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MEDICAL RECORD
A Weekly Journal of Medicine and Surgery
EDITED BY
THOMAS L. STEDMAN, A.M., M.D.
EDITORIAL STAFF
Charles A. Clouting, M.D. E. Franklin Smith, M.D.
Esther L. Jefferis, M.D. Mildred K. Smith
John E. Lind, M.D. Ralph G. Stillman, M.D.
Edward Preble, M.D. Wesley G. Vincent, M.D.
R. J. E. Scott, M.D. Susan M. Wood
IToltime 90
JULY 1, 1916— DECEMBER 30, 1916
WILLIAM WOOD AND COMPANY
1916
Copyright, 1916,
By WILLIAM WOOD & COMPANY.
_V
&
LIST OF CONTRIBUTORS TO VOL. XC.
Abbe, Robert, New York.
Abramson, H. L., New York.
Andresen, Albert F. R., Brook-
lyn, N. Y.
Aulde, John, Philadelphia, Pa.
Babcock, W. L., Detroit, Mich.
Baldwin, J. F., Columbus, Ohio.
Barber, W. Howard, New York.
Bardes, Albert, New York.
Bartholomew, H. S., New York.
Bartholow, Paul, New York.
Bartine, Oliver H., New York.
Baruch, Herman B., New York.
Baruch, Simon, Long Branch,
N. J.
Bayles, Havens Brewster,
Brooklyn, N. Y.
Bedford, E. W., Chicago, 111.
Berkeley, William N., New
York.
Bertine, Eleanor, New York.
Block, Siegfried, Brooklyn, N. Y.
Bonime, Ellis, New York.
Boudreau, Eugene N., Auburn,
N. Y.
Bram, Israel, Philadelphia, Pa.
Brewer, George Emerson, New
York.
Bristol, Leverett Dale, Univer-
sity, N. D.
Broder, Charles B., New York.
Brown, Robert Curtis, Milwau-
kee, Wis.
Browning, William, Brooklyn,
N. Y.
Bryant, W. Sohier, New York.
Bucklin, Charles Aubrey, Glas-
gow, Scotland.
Burnham, A. C, New York.
Cadbury, William W., Canton,
China.
Carpenter, C. R., East San
Diego, Cal.
Chase, Walter B., Brooklyn,
N. Y.
Clark, L. Pierce, New York.
Coburn, Raymond C, New York.
Crothers, T. D., Hartford, Conn.
Cunningham, William P., New
York.
Dabney, William M., Baltimore,
Md.
Danzer, Saul, Brooklyn, N. Y.
d'Artois-Francis, Charles F.,
Brooklyn, N. Y.
Davin, John P., New York.
Dearborn, George Van Ness,
Cambridge, Mass.
Delavan, D. Bryson, New York.
Dorrance, George Morris, Phila-
delphia, Pa.
Draper, John William, New
York.
Drennan, Jennie G., Rosebank,
Staten Island, N. Y.
Drueck, Charles J., Chicago, 111.
Einhorn, Max, New York.
Elliott, George R., New York.
Epstein, Sigmund, New York.
Fischbein, Elias C, Sonyea,
N. Y.
Fischer, Louis, New York.
Fish, J. B., Los Angeles, Cal.
Ford, James S., Wallingford, Conn.
Fordyce, John A., New York.
Forman, Jonathan, Columbus,
Ohio.
Friedman, Henry M., New York.
Frost, Lowell C, Los Angeles,
Cal.
Garbat, A. L., New York.
Gilbert, J. Allen, Portland, Ore.
Gleason, W. Stanton, New-
burgh, N. Y.
Goodwin, Henry French, Chi-
cago, 111.
Gray, Ethan A., Chicago, 111.
Greeley. Horace, Brooklyn, N. Y.
Greenberg, Geza, New York.
Greene, James Sonnett, New
York.
Grossman, Jacob, New York.
Grossman, Max, Brooklyn, N. Y
Gulliver, F. D., New York.
Haas, Sidney V., New York.
Haberman, J. Victor, New York.
Hagemann, J. A., Pittsburgh, Pa.
Hammett, Frederick S., Los An-
geles, Cal.
Hartz. H. J., Philadelphia, Pa.
Hassin, G. B., Chicago, 111.
Heise, Fred H., Trudeau, N. Y.
Herz, Lucius F., New York.
Hinsdale, Guy, Hot Springs, Va.
Hoover, F. P., Jacksonville, Fla.
Hulst. Henry, Grand Rapids,
Mich.
Jacobi, A., New York.
Jelliffe, Smith Ely, New York.
Johnson, Frank Mackie, Bos-
ton, Mass.
Johnson, J. C, Atlanta, Ga.
Johnston, Hardee, Birmingham,
.Ala.
Jones, W. Ray, Seattle, Wash.
Kahn, Alfred, New York.
Kahn, Morris H., New York.
Kapp, M. W., San Jose, Cal.
Kean, Jefferson R., Medical
Corps, U. S. A.
Kearney, J. A., New York.
Keogh, Chester Henry, Chicago,
111.
King, Clarence, Franklinville,
N. Y.
Knopf, S. Adolphus, New York.
Kreider, George Noble, Spring-
field, 111.
Landsman, Arthur A., New
York.
Lane, John E., New Haven, Conn.
Lapham, Mary E., Highlands,
N. C.
Lautman, Maurice F., Hot
Springs, Ark.
Lemchen, B., Dunning, 111.
Leszynsky, William M., New
York.
Levin, Isaac, New York.
Levy, Louis Henry, New Haven,
Conn.
Lewis, P. M., New York.
Lichtenstein, Perry M., New
York.
Lillienthal, Howard, New York.
Lintz, William, Brooklyn, N. Y.
Lloyd, Samuel, New York.
Lovett, Robert W., Boston.
Lowsley, Oswald S., New York.
Lumbard, Joseph E., New York.
Lynch, Jerome Morley, New
York.
Macht, David I., Baltimore, Md.
McGuire, Frank A., New York.
McWilliams, Clarence A., New
York.
MacDonald. H. E., Los Angeles,
Cal.
Maher, Stephen J., New Haven,
Conn.
Mallory, William J., Washing-
ton, D. C.
Massey, G. Betton, Philadelphia,
Pa.
May, Arnold H., Buffalo, N. Y.
Mead, Kate C, Middletown,
Conn.
Meltzer, S. J., New York.
Meyer, Alfred, New York.
Michie, H. Clay, U. S. Army.
Minor, Charles L., Asheville,
N. C.
Montgomery, Douglass W., San
Francisco, Cal.
Moore, S. E., Minneapolis, Minn.
IV
CONTRIBUTORS TO VOL. XC
Morgan, William Gerry, Wash-
ington, D. C.
Horowitz, B. F., New York.
Morris, Robert T., New York.
Moses, Henry Monroe, Brook-
lyn, N. Y.
Mount, Louis B., Albany, N. Y.
Myers, Samuel W., Boston, Mass.
Newton, Richard Cole, Mont-
clair, N. J.
Nice, Charles M., Birmingham,
Ala.
Nichols, John Benjamin, Wash-
ington, D. C.
Niles, George M., Atlanta, Ga.
North, Charles E., New York.
Nydegger, J. A., Baltimore, Md.
Pedersen, James, New York.
Percival, J. Barkley, Para-
maribo, Dutch Guiana.
Perkins, C. Winfield, New York.
Petery, Arthur K., Norristown,
Pa.
Philbrick, Inez C, Lincoln, Neb.
Pitfield, Robert L., German-
town, Pa.
Porter, William Henry, New
York.
Putnam, James M., Buffalo, N. Y.
RAVN, E. 0., Chicago, 111.
Reitzfeld, I., New York.
Robbins, F., New York.
Robinson, Leigh F., Raleigh,
N. C.
Rockwell, A. D., Flushing, N. Y.
Rostenberg, Adolph, New York.
Rueck, G. A., New York.
Ruiz-Arnaf, R., San Juan, Porto
Rico.
Schapira, S. William, New York.
Scheinkman, B., New York.
Scheppegrell, W., New Orleans,
La.
Schmitz, Henry, Chicago, 111.
Scott, Ernest, Columbus, Ohio.
Seaman, Louis L., New York.
Sexton, L., New Orleans, La.
Sheehan, Joseph Eastman, New
York.
Sheffield, Herman B., New
York.
Smith, J. Gardner, New York.
Smith, J. Wheeler, Jr., Brook-
lyn, N. Y.
Solomon. Meyer, Chicago, 111.
Soule, William L., New York.
Spingarn, Alexander, Brooklyn.
Stanton, E. MacD., Schenectady,
N. Y.
Stein, John Bethune, New
York.
Stewart, Douglas H., New York.
Stoll, Henry Farnum, Hartford,
Conn.
Stone, William S., New York.
Strobell, Charles William,
New York.
Sweet, A. L., Geneva, N. Y.
Synott, Martin J., Montclair,
N.J.
Thompson, W. Gilman, New
York.
Tullidge, E. Kilbourne, Philadel-
phia, Pa.
Van Baggen, N. J. Poock, The
Hague, Holland.
Verbrycke, J. Russell, Jr.,
Washington, D. C.
Voorhees, Irving Wilson, New
York.
Wade, Henry Albert, Brooklyn,
N. Y.
Ware, Martin W., New York.
Warner, Frank, Columbus, Ohio.
Wayland, C. A., San Jose, Cal.
Wayland, R. T., San Jose, Cal.
Whitman, Royal, New York.
Wile, Ira S., New York.
Williams, B. G. R., Paris, 111.
Williams, Edward Mercur, Sioux
City, la.
Williams, John R., Rochester,
N. Y.
Williams. Linsly R., Albany,
N. Y.
\\ [LLiAMSON, Llewellyn P., Med-
ical Corps, U. S. Army.
Winston, John W., Norfolk, Va.
Wittenberg, Joseph, Brooklyn,
N. Y.
Wittson, Albert J., New York.
Wolf, Heinrich F., New York.
Wright, Barton Lisle, U. S.
Navy.
WRIGHT, Harold W., San Fran-
cisco, Cal.
WYNKOOP, D. W., Babylon. N. Y.
Yarbrougii, J. F., Columbia, Ala.
Yeomans, Frank C, New York.
Zigler, M., New Y'ork.
Societies of Which Reports Have
Been Published.
American Association of Ob-
stetricians and Gynecolo-
gists.
American Association of Im-
munologists.
American Climatological and
Clinical Association.
American Electro-Therapeutic
Association.
American Gynecological So-
ciety.
American Medical Association.
Section on Medicine.
Section on Obstetrics and Gyne-
cology.
Section on Surgery.
American Medical Editors As-
sociation.
American Neurological Asso-
ciation.
American Pediatric Society.
American Therapeutic Society.
Association of American Phy-
sicians.
College of Physicians of Phila-
delphia.
Medical Society of the County
of New York.
Medical Society of the State of
New Jersey.
Medical Society of the State of
New York.
First District Branch.
Medical Society of the State of
Pennsylvania.
Section on Medicine.
Section on Surgery.
Mississippi Valley Medical As-
sociation.
Neurological Society of New
York.
New England Pediatric Society.
New Jersey Pediatric Society.
New York Academy of Medi-
cine.
Section on Obstetrics and Gyne-
cology.
Section on Pediatrics.
Section on Surgery.
New York State Pediatric So-
ciety.
Philadelphia Neurological So-
ciety.
Philadelphia Pediatric Society.
Practitioners' Society of New
York.
Medical Record
A Weekly Journal of Medicine and Surgery
Vol. 90, No. 1.
Whole No. 2382.
New York, July i, 1916.
$5.00 Per Annum.
Single Copies, 15c.
Original Arttrka.
SOME OBSERVATIONS ON CONGENITAL
AND ACQUIRED HEMOLYTIC ICTERUS.
WITH A REPORT OF TWO CASES TREATED BY
SPLENECTOMY.*
Br GEORGE EMERSON BREWER, M.D.,
NEW TORK.
The object of this communication is to report two
cases of splenomegalic hemolytic icterus, greatly
improved if not cured by splenectomy.
Before describing in detail these two cases, it
might be of value briefly to review a few facts
which have contributed to our knowledge of this in-
teresting condition.
During the past two decades a large amount of
study, both clinical and pathological, has been ex-
pended on that interesting group of diseases asso-
ciated with splenomegaly. Of these, three types,
having a number of features in common, have per-
haps received the most attention.
The first of these is that condition described
many years ago by Banti, in which enlargement of
the spleen is noted without other symptoms, often
for a period of several years. Later there occur; a
progressively increasing anemia of the chlorotic
type, with gastric hemorrhages and still later evi-
dences of cirrhosis of the liver, ascites, great weak-
ness, emaciation, pigmentation of the skin, and
death. To this condition the terms idopathic
splenomegaly, splenic anemia, and Banti's disease
have been applied.
The second of these conditions is that in which
the splenomegaly is associated with a grave and
progressive anemia. The disease advances much
more rapidly than the former type, and always in
the later stages presents the characteristic blood
changes of pernicious anemia. In this type also,
when untreated, the prognosis is fatal.
In the third type, the chief symptom is jaundice.
The disease which may be congenital or acquired
is an exceedingly chronic one, the jaundice often ap-
pearing at or shortly after birth, and may continue
with certain variations in intensity throughout life.
The jaundice in this condition has nothing to do
with biliary obstruction or bile absorption, but is
caused by a too rapid destruction of the red blood
corpuscles and is in fact a true hemolytic icterus.
The prognosis in this condition is much more favor-
able than in the first and second types, for a num-
ber of cases are on record in which a congenital
jaundice has been present throughout a long life
without causing marked impairment of health. In
perhaps the majority of instances, however, of both
the congenital and the acquired types, symptoms
*Read at a meeting of the Pracitioners' Society, Mav
5, 1916.
sooner or later appear which may result in chronic
invalidism or even death.
While these three types of disease when observed
in typical cases are quite different and distinct
from each other, cases are not infrequently encoun-
tered in which they seem to be combined, as evi-
denced by a comparatively large number of ob-
servations in which a long observed hemolytic jaun-
dice finaly presented the characteristic symptoms
and blood picture of a pernicious anemia, or in
which a definite pernicious anemia with spleno-
megaly was later associated with gastric hemor-
rhages or cirrhosis of the liver. These facts and
the additional fact that in all three, we have spleno-
megaly, excessive hemolysis, anemia, and pigmenta-
tion would lead to the inquiry as to whether we are
dealing with a single pathological entity, with varia-
tions in its symptomatology, or whether on the
other hand these three conditions should be re-
garded as three definite and distinct diseases. This
question has not up to the present time been defi-
nitely settled.
The essential features of splenomegalic hemolytic
icterus are chronic jaundice and enlargement of the
spleen. The jaundice is of a bright lemon yellow
color, which varies in intensity, but is seldom if
ever wholly absent. It is not associated with itch-
ing, torpor, slow pulse, or other evidences of in-
toxication with bile salts. The stools are never
clay colored, but are light or dark brown, always
showing an abundance of bile elements. The urine
varies in color and contains urobilin. In some in-
stances hemoglobinuria may be present. In most
but not all cases there is a definite fragility of the
red cells to the action of hypotonic salt solutions.
Enlargement of the spleen is always present, and in
the later stages of the disease may reach an enor-
mous size.
In the congenital cases, the jaundice appears at
or soon after birth. At first it is only a slight sal-
lowness or yellow discoloration of the sclerotics,
with a fainter color in the skin. As a rule there
are no other symptoms, and the child may reach
adolescence without or with but slight impair-
ment to health. In other cases the child is never
robust, the jaundice becomes more pronounced, the
appetite is capricious, there are minor digestive
disturbances, and anemia of the chlorotic type ap-
pears. The degree of anemia is often in direct pro-
portion to the degree of the jaundice; and in the
remissions in the intensity of the icterus, which
are frequent, the general health and bodily vigor
improve. In a fair number of congenital cases the
individuals live to a ripe old age without serious in-
convenience or ill health.
In the acquired cases, the jaundice is first ob-
served during adolescence or early adult life, and
while a fair proportion of these may continue for
years without other marked symptoms, in the ma-
MEDICAL RECORD.
[July 1, 1916
jority of the acquired cases and in many of the
congenital type there occurs sooner or later a series
of febrile attacks or crises, in which there may be
chills, elevation of temperature, pain in the upper
abdomen, particularly on the left side, and tender-
ness of the spleen on palpation. With these symp-
toms there is general malaise with weakness, and an
increase in the jaundice. Nausea and vomiting
may occur, occasionally diarrhea and severe pros-
tration. During these attacks there is an increased
excretion of urobilin, and the urine may become
blood red (hemoglobinuria). After each of these
attacks the patient appears more anemic, and if the
attacks are of frequent occurrence, the health rap-
idly declines. In a few recorded cases the anemia,
which at first is always of the chlorotic type, grad-
ually changes to the pernicious variety, and in these
cases if untreated the prognosis is fatal.
While a definite enlargement of the spleen is
always present when the disease is sufficiently ad-
vanced to admit of a positive diagnosis, in many
cases it is overlooked, unless the left upper quad-
rant pain and tenderness or febrile crises lead to a
careful physical examination. As a rule, the ac-
quired cases progress more rapidly and are associ-
ated with more severe crises and a graver degree of
anemia.
An interesting feature of the disease is its
tendency to appear in several members of the same
family. Graf reports a family of thirteen children,
in which the father and six of the children suffered
from the disease. Elliott and Kannavel report one
family in which three cases occurred, and another
in which four were jaundiced. In one of these the
tendency was evidently inherited from the maternal
great grandfather, six cases occurring in the sec-
ond generation, seven in the third, and two in the
fourth. The number of instances in which this
family tendency has been observed has led to the
general employment of the term familial hemolytic
jaundice, as descriptive of this condition.
Regarding the etiology of the disease it may be
stated that it is due to an exaggerated activity of
the normal hemolytic function. While Chauffard
and Widal have advanced the theory that the hemo-
lyzing agents were present or at least primarily
active in the blood and that the condition therefore
was a true blood disease, most observers now hold
to the opinion that the seat of the disease is the
spleen. This view is based upon the fact that in
these cases there is always present marked struc-
tural changes in this organ, and that careful micro-
scopical and chemical examinations always reveal
the evidences of excessive hemolysis in the spleen
with the presence of a great excess of pigment
granules showing the iron reaction, not only in the
liver but in the tissues of the spleen and in the
sinuses and tributaries of the splenic vein. These
facts and the demonstrated curative effect of
splenectomy leave little doubt as to the splenic
origin of the symptoms.
Eppinger states that the condition may be spoken
of as "hypersplenism," that while in these cases
there is at all times an exaggeration of the normal
hemolytic action of the spleen, there occurs from
time to time a "massive hemolytic activity" with
excessive destruction of the red cells, leading to the
increased jaundice, anemia, and symptoms of acute
intoxication.
In regard to the pathological changes in the spleen
in this disease, a large number of observations have
been published. While most of these simply report
on the gross changes, a not inconsiderable number
have recorded the results of careful and painstaking
microscopic study. Among these may be mentioned
those of Guizzetti, Micheli, Merkel, Kumpiess, Elli-
ott, and Kannavel. In all of these, there is substan-
tial agreement on the chief pathological changes in
the splenic tissues, although the individual spleens
show considerable variation in the extent and dis-
tribution of the lesions. Grossly the spleens show
marked hypertrophy, hyperemia, a diminution in
the number and size of the Malpighian follicles, and
in some instances, thickening of the capsule and ad-
hesions to the diaphragm and abdominal wall.
On microscopic examination the intense blood en-
gorgment of the organ is found to be chiefly in the
interstices of the splenic pulp, or the so-called
strands of Billroth, the sinuses being nearly empty.
The endothelial cells of the sinuses are greatly re-
duced in size and are oval rather than rod-shaped,
as seen in normal spleens. The pulp arteries are
occasionally surrounded by fibrous rings in a state
of hyaline degeneration, and in their fibrous coats
as well as in the surrounding fibrous tissue, are
numerous pigment granules. Phagocytosis is
marked particularly in the sinuses. Many of the
red cells exhibit an irregular outline and show a
diminished staining reaction to eosin. Many of the
follicles are atrophied or totally degenerated. As
certain of the changes in the spleen give evidence
of the presence of a chronic inflammatory process,
it is interesting to note that in a culture taken from
a removed spleen and reported by Upcott and Gib-
son, a growth was obtained of an organism of the
streptothrix group. Bunting has also obtained an
organism of the diphtheroid group. Chauffard's
report of three cases in one family, in which the
Wassermann reaction was positive, and of three
other patients in which positive signs of tubercu-
losis were present, led Kumpiess to make a critical
analysis of seventy-nine cases of hemolytic jaun-
dice, in which he was able to establish the associa-
tion with syphilis in twelve, and of tuberculosis in
five cases.
To sum up the facts so far observed in regard to
the etiology, it may be stated that the disease is
primarily due to an exaggeration of the normal
hemolytic processes of the spleen and possibly other
tissues of the body; that this excessive hemolytic
activity is in all probability chiefly due to patholog-
ical changes in the spleen, and that there is some
reason to believe that these changes may be the
result of one or more types of chronic infection.
In regard to treatment, Banti was probably the
first to employ splenectomy in the treatment of
this condition. His patient, a woman fifty years of
age, had suffered from severe anemia with tender-
ness in the hypochrondriac region for twenty-five
years. Nine years before she came under observa-
tion hemolytic icterus developed and persisted un-
til February 20, 1903, when Banti removed the
spleen. She made a prompt recovery. She was ex-
amined eight years later, in 1911, and was found
to be well with no evidence either of icterus or
anemia.
In a paper by Muhsam in 1914 (Deutsche med.
Wochenschrift, November 8, 1914), commenting on
Banti's and a number of other cases in which
splenectomy had been performed, he stated that he
had personal knowledge that the operation had been
employed for this condition in fourteen instances,
and reports the results as remarkably favorable.
In a rather hasty and incomplete review of the
current medical literature I have been able to find
no less than thirty-one operations reported, prior
July 1, 1916]
Ml DICAL RECORD.
to 1915, with one operative death, and one death
later from uremia.
Elliott and Kannavel have been more successful
in their search, and in 1915, in an article in Sur-
gery, Gynecology, and Obstetrics, they reported
forty-eight operations with two deaths. Of these,
nine were reported cured more than six months after
operation. This list includes one by Spencer Wells
twenty-seven years after operation, Banti's case
eleven years, Bland Sutton's ten years, and a case
reported by Roth six years. They also reported on
a number of cases in which postoperative blood ex-
aminations were made as follows : Seven cases dur-
ing the first two weeks, in which four had gained
from one to two million red cells ; eight cases ex-
amined from three to four weeks after operation,
in which one gained over three million cells; two
over two million, and three over one million. Nine
cases reported examined from three to six months,
with one case showing an increase of five million,
four cases an increase of over three million, and
five cases over one million.
While there are as yet very few reports stating
the remote results of splenectomy in these cases,
the records as far as they go show conclusively that
in early splenectomy we have a comparatively safe
and the only successful method yet suggested in the
treatment of splenomegalic hemolytic icterus.
The following two cases have recently come under
the writer's observation and treatment :
Case I. — C. L. A trained nurse aged 30 years. Has
suffered from jaundice for seventeen years. Several
members of mother's family have suffered from unex-
plained jaundice. During the first years practically no
symptoms. From 1899, however, she experienced a
number of attacks of moderate abdominal pain with
anorexia, constipation, and increased jaundice. In the
intervals the jaundice would lighten but it never dis-
appeared. In 1904 she had a rather severe attack with
markedly increased icterus, after which she was weak
and indisposed for three months. In June, 1906, oper-
ated upon for epigastric pain and jaundice. Gall-
bladder found normal, easily emptied, no stones. Fol-
lowing this operation she was free from jaundice for
two months, gradually regained her health and strength.
After a few days of work in the autumn she had an-
other attack of abdominal pain with jaundice. Several
months later following another attack she underwent
a second operation. Several small stones found. Gall-
bladder drained for twelve days. Jaundice decreased
but did not wholly disappear. During 1908 and 1909,
she experienced several more or less severe attacks of
pain; one with jaundice, sour vomiting, and diarrhea,
but without clay-colored stools, and another with some
pain radiating to the right shoulder. Later she entered
a hospital for severe diarrhea lasting ten days. These
symptoms continued for the next five years, pain,
nausea, fever, diarrhea, and a varying jaundice. Was
finally seen by Dr. Lewis A. Conner, who made the
diagnosis of familial hemolytic jaundice. Entered the
Presbyterian Hospital October 8, 1915. On admission
she was slightly jaundiced. Physical examination
showed chest negative; abdomen; enlargement of the
spleen, its anterior border being easily palpated for one
or two inches below the costal border. Stools, brown
color, contained urobilin. Urine negative. Blood co-
agulation time, seven minutes. White cells, 11,800;
polynuclear, 78 per cent.; red cells, 3,408,000; hemo-
globin, 75 per cent.; hemolysis test: Hemolysis begins
at .375, complete at .350. Wassermann negative. Oc-
tober 23. Splenectomy; operation without difficulty
and without shock. October 30. White cells, 31,000;
polynuclears, 88 per cent. Novembr 1. Stitches re-
moved, wound healed, primary union. November 11.
Red cells, 4,216,000; white cells, 11,000; polynuclears,
80 per cent.; hemoglobin, 85 per cent. November 14.
Hemolysis test: .550 — .400. Discharged almost free
from jaundice, gain of nearly 1,000,000 red cells and
10 per cent, in hemoglobin. May 2, six months and
nine days after operation, fragility test shows hemolysis
index .489 ; hemoglobin, 75 per cent. ; red blood cells,
4,800,000; white cells, 13,400; polynuclears, 44 per cent.;
lymphocytes, 54 per cent.; blood cholesterin, 3.61 grams
to liter.
Case II.— H. O'S. 21. Referred by Dr. Schulman. No
family history of jaundice. Three years ago noticed
gradual onset of jaundice with lassitude, but without
pain or other symptoms. Gradually grew weaker, suf-
fered from occasional pains in upper abdomen, anorexia,
and constipation. Lost fifteen pounds in past six weeks.
Admitted to the Presbyterian Hospital service of Dr.
Longcope. November 18, 1915. Sclerotics jaundiced,
skin of face pigmentated in patches. Chest normal.
Abdomen: spleen enlarged, anterior border easily pal-
pated one inch below costal border. Blood examina-
tion: Red cells, 3,064,000; hemoglobin, 70 per cent.;
whites, 9,500; polynuclears, 89.5 per cent.; lymphocytes,
10 per cent. Fragility test: Hemolysis begins at .425,
somplete at .4. Wassermann negative. November 22.
Hemoglobin, 60 per cent. Vital stain: Reticulated
cells, 27 per cent. Stools brown, no food remains, acid,
no blood, urobilin marked. Urine negative. December
4. Splenectomy without difficulty or marked shock.
Recovered from anesthetic satisfactorily. On second
and third days suffered from postoperative gastric
dilatation which, however, yielded to lavage and hot
stupes. Primary union of wound, stitches removed on
eighth day. December 18. Fragility test, .4S9-.483 ;
red cells, 3,824,000; hemoglobin, 75 per cent.; white
cells, 13,500; polynuclears, 68 per cent. December 21
Jaundice gone, pigmentation improving. May 2, five
months after operation, fragility test, .595; hemoglobin,
80 per cent.; red blood cells, 4,900,000; white cells,
15,000; polynuclears, 54 per cent.; lymphocytes, 46 per
cent.; blood cholesterin, 2.77 grams to liter; vital stain
reticulated cells, 5 per cent.
Both patients are free from jaundice, are much
improved in health, and are able to do their work
without fatigue.
16 East Sixty-fourth Street.
THE HUMAN PROSTATE GLAND IN MIDDLE
AGE.
By OSWALD S. LOWSLEY, A.B., M.D.,
NEW YORK.
The changes observed in the human prostate gland
during the period of youth have already been con-
sidered and a review of the anatomical conditions
existing during the adult stage, through the middle-
age period, and up to the time of old age are now to
be described.
By the beginning of the third decade the pros-
tate has about reached its maximum growth so it
is observed that practically the entire increase in
size occurs during the second decade. Measure-
ments in gross of specimens removed from subjects
varying in age from twenty-one to thirty, disclose
the fact that such glands vary in length between
2.8 cm. and 4.0 cm. The average being 3.3 cm.
In width the smallest one measures 3.6 cm. while
the largest is 5.2 cm., with an average of 4.16 cm.
In thickness the dimensions are always less than
the other two in this period. In this group it varies
from 2.0 cm. to 3.0 cm., with an average of 2.4 cm.
for all specimens. The trigonum vesicae, which is
generally presumed to be symmetrical, shows some
asymmetry in over 50 per cent, of the cases studied.
Extending between the apex of the trigonum and
the upper end of the verumontanum there are al-
ways found small bands of tissue which vary in
number from one or two to five. In this series 66
per cent, of the cases show one band only, in 14
per cent, there are two, and in 20 per cent, there
are three. The verumontanum averages 2.0 cm. in
length for all cases, while it is 0.41 cm. in width
and 0.3 cm. in height. The mouth of the utricle
varies somewhat in size, but it averages about 0.17
cm. The average depth of the lumen of the utricle
is 0.5 cm., but there is a variation in this measure-
4
MEDICAL RECORD.
[July 1, 1916
ment from 0.1 cm. to 0.7 cm.; 45 per cent, of the
cases show an asymmetry in the seminal vesicles of
considerable degree. The structures vary in length
from 2.3 cm. to 4.4 cm., the average being 3.45 cm.
In width the average measurement is 1.34 cm.,
thickness averages 0.78 cm.
Serial cross sections of a prostate taken from a
man aged twenty-five shows the same general ar-
rangement which characterizes the seventeen-year-
old specimen described. There is noted a very
slight increase in the size of the gland itself and
of the individual tubules. The live lobes which
make up the gland embryologically are distinguish-
able and the posterior lobe is fairly well separated
from the remainder of the gland. The tubules of
Albarran and the subtrigonal group are both pres-
ent. The verumontanum containing utricle and
orifices of ejaculatory ducts is about the average
size for this decade. Seminal vesicles and ejacula-
tory ducts show the same general characteristics
that have been described. The interesting group
of tubules occurring on the ventral wall of the
urethra at the apex of the prostate is present in
this specimen.
Serial cross sections of a prostate gland and con-
tiguous structures taken from a man thirty-four
years of age show the following: The middle lobe
is made up of seven tubules. They extend back to
the very base of the prostate at which point their
separation from the other lobes is pronounced.
There it is observed that each branch of every
tubule is surrounded by a fairly thick muscular
wall which is composed of two distinct layers. The
entire tubule in turn is surrounded by an eveD
thicker sheet and a remarkable number of branches
join and empty their contents into the prostatic
urethra through a comparatively small duct. At
the thickest portion of the middle lobe one cannot
at a glance distinguish the dividing point between
middle and lateral lobes. However, by observing
the arrangement of tubules from section to section
the division is quite apparent. As the ejaculatory
ducts and utriculus prostaticus, surrounded by
their thick muscular wall, assume their position in
the gland just above the verumontanum, the ducts
of Jhe middle lobe tubules group themselves out-
side of the ventral surface of the above-mentioned
muscular wall. At this point they are widely sepa-
rated from all other portions of the gland, and
there is a very definite layer of muscle and elastic
tissue separating them from Albarran's group. The
ducts open into the prostatic portion of the urethra
near the upper borders of the lateral walls and the
summit of the verumontanum. Their mouths are
considerably separated from other structures and
conform in this regard to their original embryolo-
gical arrangement. It is noted that middle-lobe
tubules are somewhat smaller than those of the
lateral lobes and have not nearly so many branches.
There has not thus far, with the methods at hand,
been found a difference in the character of the
mucosa. The general architectural characteristics
correspond to a certain degree in all of the lobes.
There are no particularly large intralobular blood
vessels in this specimen.
The lateral lobes of this gland are large and bulg-
ing. They compose the main bulk of the organ and
are particularly marked by the increase in the size
of the tubules composing them and the large num-
ber of branches when compared with the younger
specimens. There seems to be an increase in the
amount of interstitial tissue present and large
bundles of muscle fibers are observed at the upper
and lateral margins. The capsule is fairly thick,
and contains most of the large blood vessels. It
is an interesting fact that while there are some
blood vessels within the layers of the capsule on its
posterior surface, the major portion of them are
observed on the anterior aspect. The vessels that
extend into the gland tissue proper seem to be
Quite small, as a general rule. The tubules compos-
ing the left lateral lobe are eleven in number while
there are fifteen on the right side. It is noticed
that the branches of these tubules practically all
occur at the outer one-third of the lobe while the
inner two-thirds or that portion which is nearest
the urethra is composed mainly of muscular, elastic,
and fibrous tissue elements. These proportions do
not hold in the case of the posterior lobe although
the general principle does. Most of the ducts of
the lateral lobes have their orifices below the open-
ings of the ejaculatory ducts, very few indeed being
found above this point. The ducts proper are quite
short and run almost at right angles to the axis of
the urethra until the paraurethral region is ap-
proached, at which point they gradually bend toward
the lumen and empty into it obliquely. The area
through which the ducts pass, as described above,
is composed of muscular and elastic tissue chiefly
and the ducts themselves are surrounded by mod-
erately thick, firmly bound muscular tunics. The
entire anatomical arrangement gives one the im-
pression that they are particularly arranged for a
very rapid and complete emptying of any fluid
within their lumina. The mouths of the ducts
empty into the urethra at an angle in such a man-
ner that there is a very thin laplet of tissue cover-
ing them so that in wide distention of the posterior
urethra pressure would easily close their orifices
very effectively, particularly as a large majority of
them empty on the lateral walls of the verumon-
tanum, which is itself an easily compressible or-
gan. On the other hand, however, a number of
them open directly into the bottom of the prostatic
furrow and an effective closure of such duct open-
ings would not be accomplished.
The posterior lobe extends from its origin on the
floor of the urethra anteriorly or outward from
the orifices of the ejaculatory ducts behind them
to the point where they enter the prostate. This
lobe is fairly well separated, in this specimen, from
the lateral lobes by a layer of tissue similar in
structure to the capsule of the gland. The tubules
which compose this portion are eleven in number.
They are large and have numerous branches. Their
ducts are somewhat shorter than lateral lobe tubules
in most instances. In this specimen many corpora
amylacea occur in the posterior lobe tubules as well
as in those of the middle and lateral lobes. The
branches are more numerous near the periphery as
is the case with the lateral lobes. The mucous
membrane of the tubules is made up of the usual
cylindrical cells with the nuclei at their bases rest-
ing upon a mattress composed of delicate connec-
tive tissue threads surrounding which are quite
thick, dense layers of smooth muscle fibers. The
lumina are widely distended, and contain secretion
in most instances.
The anterior lobe. There are four very small
tubules which have grown from the anterior wall
of the urethra. These structures have few branches,
are small in size, and insignificant in appearance.
They occur at about the middle of the prostatic
urethra. The lumina are lined with low columnar
July 1, 1916]
MEDICAL RECORD.
epithelium, and there is no thick muscular layer
surrounding them. The ducts are short and small,
being about one-fifth the size of those of other
parts of the gland.
The trigonum vesica; is covered in practically
every instance by a mucosa which is free from
folds. In this instance there is a slight folding,
over the middle portion of the trigonum. There are
thirty-eight subtrigonal tubules in this specimen.
They show a considerable increase in size over all
of those previously described. This increase is no-
ticed not only in regard to the extent of the tubules,
but also there is an increase in the thickness of
their walls, and, a most unusual thing, several of
them have small branches. Although these inter-
esting structures are considerably more extensive
than in previously described younger specimens,
they retain their general characteristics and grow
down to the submucosa but not through it. Their
blind ends are situated nearer to the base of the
trigone than are their mouths, although they are
in every instance very short. Thus their course
is seen to be an oblique one. Their mouths open
directly into the bladder lumen and are not in any
sense protected by a valve-like membrane, as is
the case with the duct openings of the prostatic
tubules. There is nothing distinctive about the
histological arrangement. There are several layers
of low cylindrical and cuboidal cells disposed upon
a tunica propia. In some instances the cells are
piled upon one another, layer by layer, so that the
lumen of the tubules is very small in size. No se-
cretory substance can be made out within the
lumina of these glands as is often the case with
prostatic tubules. They vary considerably in size,
some of the largest of them having a small branch
but in no case was there found to be more than one,
and never does the structure extend through the
submucosa, although the ends of the tubule often
extend to it.
Albarran's Tubules. — Thirty-one tubules of Al-
barran are found in the subcervical region of this
specimen. They are larger and more branching
than any of the younger specimens studied. The
uppermost tubules of this large and interesting
group of structures are found under the lower part
of the trigonum vesica?. At places it is observed
that several subtrigonal glands occur in the mucosa
and below them there are seen branches of Albar-
ran's glands, which are embedded in the submucosa
and in some places have extended slightly into the
sphincteric muscle, but for the most part are con-
tained within the circular fibers making up the
sphincter, and in only a few instances do they
mingle with these fibers. A very interesting ar-
rangement is noted in that just above the lower
border of the thick, ribbon-like internal sphincter
and posterior to it there are a few of the branches
of Albarran's tubules which are very delicate in
architecture with no muscular walls and join with
other branches of the same group below the border
of the sphincter and empty into the urethra in
about the middle line above the verumontanum.
Thus we have some of the tubules of Albarran in
the shape of a letter "Y" fitting over the lower
border of the sphincter, a condition which has not
been found in any of the other specimens studied.
At no point do these tubules mingle with those of
the middle lobe, being widely separated from them.
The majority of the tubules composing this group
empty on the floor of the urethra. Their branches
are quite numerous, in some cases as many as fif-
teen being counted for one tubule. They always
extend toward the bladder and are separated from
other structures at the neck of that viscus. Most
of them are suburethral but there are a few which
empty into the urethra upon its lateral walls and
one or two on its anterior wall. These glands are
compound tubular and the mucosa is made up of
low columnar cells of small size placed upon a thin
connective tissue lining membrane. They are very
frail, being much smaller in size than prostatic
tubules and have no differentiated envelopes sur-
rounding them.
The verumontanum in this specimen measures
0.4 cm. in height, 0.4 cm. in width and contains
portions of some of the tubules of the prostate, the
ejaculatory ducts and utricle with their surround-
ing structures.
The utriculus prostaticus is quite large and deep
in this specimen. It extends from its opening in
the summit of the verumontanum almost to the
base of the prostate, and is about 1.1 cm. in depth.
In size it is about three times as large as either of
the ejaculatory ducts, and is in a more or less col-
lapsed condition, so that the mucous lining is mark-
edly folded, the lumen proper being almost entirely
filled by it. At its end, near the base of the pros-
tate, it is surrounded by a very thick wall of mus-
cular and connective tissue which is at least three
times the size of the walls of the ejaculatory ducts.
The three structures, each surrounded by its own
distinctive wall, are bound together by a compar-
atively thin envelope which contains them all. At
a point about midway between the base of the pros-
tate and the upper end of the verumontanum the in-
dividual walls of the ejaculatory ducts and utricle
are not so thick as is the case nearer the base,
but the envelope surrounding them becomes much
more prominent and is arranged far more com-
pactly. This firmly bound structure maintains its
compactness until it reaches the verumontanum, at
which point the utricle changes markedly in ap-
pearance. It is smaller in size and surrounding it
almost completely are a great many tubular struc-
tures which have in most instances a few branches.
They are lined by a mucous membrane similar in
type to that of the utricle itself and in turn have
a rather thin wall of differentiated tissue surround-
ing them. Most of these glandular structures en-
ter the utricle itself, but a number of them, near
its orifice, open directly into the lumen of the
urethra on the summit of the verumontanum and
close to the orifice. As is usually the case, the
orifice of the utriculus prostaticus opens in the
midline just a little outerward from the openings
of the ejaculatory ducts.
The vasa deferentia are unusual in a number of
ways. The mucosa is very thick and much folded,
thus making the lumen quite small. The walls are
about four times as thick as the diameter of the
lumen and mucous layers and are composed of
white fibrous connective tissue and smooth muscle
fibers very compactly arranged. At intervals there
are found, imbedded in this thick wall, small simple
tubules which communicate with the lumina of the
ducts. Some of these tubules extend quite deeply
into the walls. At the region of the ampullae of
the vasa deferentia the lumina are increased in
diameter about five times and the walls are, com-
paratively speaking, much decreased in thickness.
There are a number of folds in the ampulla which
afford an added capacity. Towards the urethra,
where the vasa deferentia become imbedded in the
MEDICAL RECORD.
[July 1, 1916
tissue of the prostate, they decrease in size until
they are a trifle smaller than above the region of
the ampullae. No accessory tubules are noted in
their walls at this point.
Well within the base of the prostate the ducts of
the seminal vesicles unite with the vasa deferentia
to form the ejaculatory ducts. The seminal vesicles
themselves extend backward so that their highest
level is farther than the base of the trigonum
vesicae. They are made up of a main lumen and
several large convoluted branches on each side and
are bound together and to the vasa deferentia by a
triple-layered fascia which I have described in de-
tail in another communication. The ejaculatory
ducts become gradually smaller in size and approach
each other more closely as they extend in a rather
oblique direction at first and then quite perpendicu-
larly to a location in the summit of the verumon-
tanum, at which point they turn sharply and run
parallel with the axis of the urethra for about 0.5
cm., where they open laterally into the urethra near
the summit of the verumontanum.
The apex group of glands is made up of nine
small tubules with many branches all of which are
contained within the wall of the membraneous
urethra just at and below the apex of the prostate.
These glands are compound tubular in type and
for the most part are found extending from the
floor of the urethra, although there are a few found
laterally and an occasional one in the ventral wall.
During the fourth decade there is no particu-
larly marked change in the gross measurements as
compared with the prostates of the third decade
at which time this organ seems to have reached its
maximum adult size. The blood vessels, most of
which are grouped in the anterior and lateral por-
tions of the capsule, are somewhat larger, and
phleboliths are more frequently found than in the
case previously observed. In size the organs ex-
amined vary from 2.4 cm. to 4.0 cm. as regards
their length, the average being 3.15 cm. In width,
which is always the greatest dimension, there is a
variance of from 3.0 cm. to 5.0 cm., the average of
4.0 cm. existing. Thickness averages 2.55 cm. The
trigonae vesicae of all the specimens being carefully
measured show that 50 per cent, of them are asym-
metrical by over 0.4 cm. Extending between the
apex of the trigonum vesicae and the upper end of
the verumontanum some of the cases have one band
of tissue, a few have two, and in over one-half
there are three such structures. In younger speci-
mens its length varies at this age from 1.1 cm. to
2.6 cm. The average is 1.8 cm. The width and
height, which are usually about the same, average
0.43 cm. in width and 0.46 cm. in height. The
utricular orifices average 0.15 cm., the variation be-
ing from 0.1 cm. to 0.25 cm., while the length of
this interesting vestigial organ varies from 0.2
cm. to 0.9 cm., with an average of 0.5 cm. The
seminal vesicles are interesting in that there is a
condition of asymmetry in about 60 per cent, of
those measured at this age. They average 4.0 cm.
in length, 1.1 cm. in width and 0.94 cm. in thick-
ness.
In the fifth decade there is only the very slightest
increase in size of the prostate compared with its
measurements of the previous period. The average
length is 3.45 cm., there being a variation of 1.6
cm. between the shortest and longest glands
measured during this period; the former is 3.0 cm.
and the latter 4.6 cm. The width, which is always
greater, varies from 3.6 cm. to 5.0 cm., with an
average of 4.0 cm. The average depth is 2.65 cm.;
the variation being from 2.3 cm. to 3.8 cm.
Sixty per cent, of all of the specimens of this
age at hand showed an asymmetry of the trigonum
vesicae of over 0.4 cm. The blood vessels in this
portion of the bladder seem to become considerably
more prominent during the middle and later years
of life, and are quite conspicuous during this dec-
ade. The verumontanum is very slightly increased
in length, the average being 1.95 cm., varying from
1.7 cm. to 2.7 cm. Its width averages 0.45 cm. and
height 0.49 cm. The mouth of the utricle varies
from 0.1 cm. to 0.4 cm., the average being 0.19 cm.
The length or depth of this interesting structure
varies from 0.3 cm. to 1.6 cm. The average is 0.7
cm. The average length of seminal vesicles is 3.9
cm., but the variation is very great. One speci-
men forty-seven years of age has vesicles which
measure only 1.8 cm. Another at forty-eight years
measures 5.0 cm. The average width and thick-
ness are 1.66 cm. and 0.9 cm. respectively.
Dr. George Walker of Baltimore permitted me
to study the prostate of a man who died at about
the middle of the fifth decade, which had been cut
in series and stained with hematoxylin and eosin.
In general this series shows characteristics similar
to those of organs already described.
The size of the prostate during the sixth decade
is practically the same as that of the fourth and
fifth decades. In length the average measurement
is 3.65 cm., varying from 2.4 cm. to 4.5 cm. The
average width is 4.37 cm., the least wide being
3.3 cm. and the greatest 5.0 cm. In thickness
there is a variation of 1.0 cm., the average being
2.75 cm.
The trigonum vesicae shows an asymmetry of
over 0.4 cm. in 80 per cent, of the specimens. The
verumontanum is about the same length as in the
preceding period, the average being 1.7 cm. It is
0.43 cm. in width and the same in height. The
mouths of the utricle average 0.13 cm. in length
while the length of the utricle averages 0.7 cm.,
varying from 0.4 cm. to 1.3 cm. The seminal
vesicles show very little change in size, averaging
3.7 cm. in length, 1.55 cm. in width and 0.8 cm. in
thickness. Thirty per cent, of the seminal vesicles
were asymmetrical comparing one side with the
other.
The human prostate gland reaches its maximum
size in health by the end of the third decade, almost
the entire change occurring during the second
period. The measurements for the adult organ as
given by Wilson and McGrath agree fairly well
with the measurements during the adult decades
in my series. They found the average adult gland
to vary in length from 3.3 cm. to 4.5 cm., with an
average of 3.4 cm. In width there is a variation
from 3.4 cm. to 4.5 cm., average 4.4 cm. Thickness
varies from 1.3 cm. to 2.4 cm., averages 1.5 cm. The
weight averages 16 or 17 grams. Cuthbert Wallace
does not quite agree with these figures. He states
the length to be 3.0 cm., the greatest transverse
diameter being 3.6 cm. and the anteroposterior
measurement 1.8 cm. He believes the average
weight to be 20.5 grams. It seems to me to be
much more preferable to consider the size of the
gland in decades in order to detect the changes that
may normally occur. Considering the matter in
this manner with a moderately large number of
specimens in each decade I have shown that the
prostate practically reaches the maximum normal
size during the third decade. During the fifth and
July 1, 1916]
MEDICAL RECORD.
sixth decades the size is very slightly increased, but they do not secrete prostatic fluid actively. The
the change is very slight, as shown by the accom- branches of these tubules are usually not as numer-
panying table. ous as those of other lobes, and are smaller in size
Table Showing Changes in Size of the Prostate Gland at Various Ages in a Series of 224 Cases
Age
Number
of Cases
Length
Width
Height
Variation
Average
Variation
Average
Variation
Average
38
10
40
33
42
29
32
1.0 cm. to 1.7 cm.
2.5 cm. to 3..") cm.
2.8 cm. to 4.0 cm.
2.4 cm. to 4.0 cm.
3.0 cm. to 4.6 cm.
2.4 cm. to 4.5 cm.
2.6 cm. to 4.5 cm.
1.2 cm.
3.0 cm.
3.3 cm.
3.15 cm.
3.45 cm.
3.65 cm.
3.23 cm.
1.0 cm. to 2.0 cm.
1 . 5 cm.
3.8 cm.
4.1 cm.
4. 1 cm.
4.0 cm.
4.37 cm.
4.12 cm.
0.7 cm. to 1.3 cm.
1.8 cm. to 2.4 cm.
2.0 cm. to 3.0 cm.
1.6 cm. to 3.0 cm.
2.3 cm. to 3.8 cm.
2.4 cm. to 3.4 cm.
2.0 cm. to 3.6 cm.
0.9 cm.
2d decade, 10-20 years
2.1 cm.
3.6 cm. to 5.2 cm.
3.0 cm. td 5.0 cm.
3.6 cm. to 5.0 cm.
3.3 cm. to 5.0 cm.
3.0 cm. to 5.0 cm.
2.4 cm.
4th decade, 30-40 years
5th decade, 40-50 years
6th decade, 50-60 years
2. 55 cm.
2. 65 cm.
2. 75 cm.
2.47 cm.
The prostate gland is in every instance divided
into five portions corresponding to the five original
groups of tubular evaginations noted in the embryo.
The division between the middle and two lateral
lobes becomes less and less noticeable as age ad-
vances, but the orifices of the middle lobe tubules
are in every instance widely separated from all
other tubular orifices and quite closely grouped to-
gether. The middle lobe tubules always grow back-
ward behind the vesical orifice outside of the broad
ribbon-like sphincter, and its tubules are never
found imbedding themselves in it or extending
within the sphincter. This is an important fact to
be noted when considering pathological conditions
at the bladder orifice, and will be discussed in an-
other paper at a later date. The lateral lobes dur-
ing the period of middle age become more and more
prominent and cause a bulging of the lateral sur-
faces to a marked degree, thus making the trans-
verse diameter of the organ proportionally greater
than the prepuberty specimens studied. The num-
ber of branches of these and other lobes of the
prostate are markedly increased but the number
of tubules is certainly not increased and seems
rather to be decreased, but that is a variable matter
which is undoubtedly determined in the embryo,
and the exact number is a personal characteristic.
The posterior lobe is fairly well separated from
all of the other portions of the gland and is divided
off by a rather firm, and in some instances, quite
thick connective tissue partition. It is always pres-
ent as is the lobe itself, and is intimately attached
to the ejaculatory ducts which are not imbedded in
this partition, but seem to be set upon its anterior
surface. This is a decidedly important matter to
the surgeon in enucleating a prostate either by
Squier's suprapubic intraurethral method in which
the enucleating finger approaches the partition and
attached ejaculatory ducts and passes along to the
upper end of the verumontanum, which is usually
removed without injuring the ducts and surely
would not be injured if the verumontanum, which
is usually torn through with some difficulty, were
cut with the scissors; or Young's perineal method
in which the two parallel longitudinal incisions
must be extended entirely through the partition,
thus preserving the ejaculatory ducts in order that
the enucleating instrument may go into the lateral
lobe cavities because otherwise it will lead into the
capsule of the gland and proper enucleation is then
an impossibility.
The posterior lobe is always present and is the
part of the gland felt per rectum. Its tubules are
in most respects similar to those of the other lobes.
In some cases, however, they seem not to be quite
so large and in most instances there is evidence that
and have a thinner layer of smooth muscle sur-
rounding them.
The anterior lobe varies greatly in different
specimens. At the time of birth it consists of two
small unimportant tubules with very few branches.
In the post-puberty specimen the anterior lobe is
quite prominent and is made up of tubules which
branch extensively and are apparently actively se-
creting prostatic fluid. A number of important
changes are noted when the pre-puberty prostates
are compared with the gland in adult life. In order
to study the various types of tissue, sections have
been stained with Van Gieson's, hematoxylin and
eosin, and Weigert's elastic tissue stains. The
mucosa of the terminal branches of prostatic tu-
bules in pre-puberty specimens is made up of cuboi-
dal-shaped cells with nuclei which are quite large
and situated in the center of the cells. They are
usually two layers thick and occasionally three.
Scattered here and there are occasional cylindrical-
shaped cells with the nuclei elongated and in the
center of the cell. The lumina are very small and
apparently devoid of secretion. The mucous cells
are placed upon a felt-like base made up of minute
connective tissue fibers, as described by Walker.
The smooth muscle layer surrounding the terminal
branches are very interesting as brought out by
Van Gieson's differential stain. Each branch is
surrounded by a definite layer of smooth muscle cir-
cularly arranged. The branches occur in groups
of 5 to 10, and the entire tubule is surrounded by
a much heavier envelope of smooth muscle, also cir-
cularly arranged. Outside of this envelope there
are several small bundles of longitudinal fibers
which occur at intervals around the tubule but not
as a definite intact sheet. The branches of tubules
all extend backward towards the base of the pros-
tate with the exception of a few of the most an-
terior tubules of the lateral and posterior lobes.
The collecting ducts are situated at the most an-
terior portion of a given group of branches and
pass quite directly toward the verumontanum so
that almost the entire duct, with the exception of
a very small portion which turns forward, may be
seen in one cross section. The ducts are lined by
a mucous membrane which resembles that already
described in practically every detail. There is,
however, a great difference noted in the arrange-
ment of the musculature. A thick layer of smooth
muscle surrounds the ducts, but it is arranged al-
most entirely in a longitudinal direction, very little
circular muscle being noted. There are practically
no branches from this portion of the tubule, most
of them occuring in the peripheral third of the
gland. In the verumontanum, the tubule turns
and runs forward for a slight distance again, and
8
MEDICAL RECORD.
[July 1, 1916
about nine-tenths of them open on the lateral walls
of the verumontanum in such a manner that there
is a little leaflet of tissue covering the orifice which
is an exceedingly important factor in protecting
the tubules of the gland from an inpouring of
urine and other foreign matter when the posterior
urethra is put under pressure. The direction of
the openings of the tubules of the prostate and
ejaculatory ducts is an important consideration also
because instrumentation will frequently cause an
infection by forcing foreign substances into them.
In the adult prostate there is noted a great change
in the mucosa. I have found in my specimens that
the tubules and their branches are lined by a single
layer of high cylindrical cells with the nuclei at
their bases. Occasionally there is inserted, between
the bases of adjoining cells, a round or conical cell,
a Krause pointed out. In some places there is a
piling up of the cylindrical cells, but I have not
found that there is a double layer of cylindrical
cells in all of the terminal branches as Langerhans
states. Near the orifices of the ducts the epithe-
lium is transitional in type, being similar to that
of the urethra itself. The muscle bundles sur-
rounding the tubular branches are very thick in
the peripheral portions of the gland, and particu-
larly in the case of middle-lobe tubules near its
base. These muscular bundles are much more pro-
nounced, comparatively speaking, in the case of the
younger specimens than in the older, and this is
probably due largely to the fact that the entire
gland becomes more compactly arranged after
puberty.
It is interesting to note the various figures
quoted in regard to the prostatic tubules. By care-
fully following each tubule from its most peripheral
terminal branches to the orifice from section to
section, I have found that in twelve specimens
studied, in this manner, the number of middle-lobe
tubules vary from 0 to 12, with an average of ten.
Right lateral lobe varies from 10 to 23, average 16.
Left lateral lobe 11 to 23, average 16. Posteri ir
lobe varies from G to 12, with an average of 9,
and the anterior lobe from 2 to 14, averaging 7. The
total number of tubules varies from 41 to 74, with
an average in all specimens of 58. This figure is
much greater than that quoted by most authors.
Kolliker states that the number varies between
thirty and fifty; Hessling 15 to 30; Luscha 16 to
25; Svetlin 15 to 32. 1 do not believe it possible
to estimate the exact number of prostatic tubules
by the examination of the posterior urethra by any
method because of the interesting manner in which
these tubules enter the urethra. In health th
are rarely visible by using any posterior urethro-
scope, but in diseased conditions their orifices be-
ae indurated and in some cases are actually held
widely open and can be seen beautifully with the
McCarthy straighl instrument.
The prostate gland seems in adull years to be
made up of concentric layers of tissue. The inner-
most or central area consists of the horseshoe-
shaped ui thra with the verumontanum. which is
made up Of the ejaculatory ducts and utricle, with
their muscular and conn me wills the ter
minal ends of the prostatic tubules with their rather
thinly disposed circular layers of muscle, and the
stroma, which is not very abundant and is made
up of connective tissue for the most part with a
moderate amount of smooth muscle fibers but prac-
tically no elastic tissue fibers. The next layer, in
the lateral and posterior direction, is made up
of stroma with practically no tubular tissue
except the ducts proper, which have very few
branches. The stroma is largely made up of con-
nective tissue with a generous sprinkling of smooth
muscle cells which are not arranged in definite
?**-
«re "
*
^,— *u
U-*--
M
1
1
JS**y
W'
I . 1. — Cross-section through the prost he level of
ihe openings of the ejacuiatory duns of a tour year old child.
' r. urethra; Ej.D, ejaculatory duels. Utr, region usually
occupied by the utriculus prostaticus Is in this case occupied
by two tubules with many branches; Str, striated muscle in
anterior portion of gland; A!., anterior lobe tubules; I.'ii .
lateral lobe tubule* I'L, posterior lobe tubules.
bundles except around the tubular ducts, as has al-
ready "been described. There are a moderate num-
ber of elastic tissue fibers here also. In the an-
terior region there are observed the tubules of the
anterior lobe with a very slight amount of smooth
muscle around them quite firmly imbedded in the
stroma. This consists in the anterior region of
the middle concentric layer of a considerable amount
of smooth muscular fibers interspersed with the
white fibrous tissue bundles with occasional fibers
of elastic tissue. Near the upper border of the
layer are seen a few bundles of striated muscle
fibers which in my specimens have not been found
to exist among the tubular branches. Cuthbert
Wallace, however, reports that he has observed
& them around some of the outermost of the branches
■of lateral lobe tubules. The outermost of these
■concentric layers is exceedingly interesting as it
/
Bk
i ■
/
•-
V
llvW'; 'M
V*
L*c
Fig 2 !.— Cn through the region of the middle of
the trigonum ve of a man S4 > eai HI., bl: i
lumen ; ML, middle lobi tubule; pai ation
from the lateral Lobes . Lat, lateral lube tubules ; \~[>. vets
rens; SV, sen ■ si< le.
contains practically all the branches of the posterior
and lateral lobes. The middle and anterior lobes
are contained, for the most part, in the middle
concentric layer. In the outer layer there is a
great preponderance of muscular tissue and mucosa.
July 1, 1916 J
MEDICAL RECORD.
over all other elements of the gland. In the pos-
terior and lateral portions the muscular tissue is
practically all smooth and surrounds the tubular
elements, as has been described. In the anterior
portion and extending down the lateral borders al-
Fig. 3. — Cross-section through the igion i th. lower por-
tion of the trigonum vesical of a uun o-i years oi age show-
ing the intimate attachment between the prostate and thi
vesical wall. BL. bladder lumen; ST, subtrigonal tubules;
ML, middle lobe tubules; hat. lateral lobe tubules: Ej.D, be-
ginning of 1 II ejaculatory ducts showing where the seminal
: I joins rn . /. f\ , n s
most to the posterior surface are found the striated
fibers which make up the so-called muscle of Henle.
This muscular tissue is so arranged that near ths
most anterior portion of the gland it is almost the
only tissue present. Looking from this point to-
ward the urethra it is seen to become less and less,
gradually shading off and being scattered by the
smooth muscle and connective tissue so that at the
edge of the middle concentric layer there are only
occasional fibers noted. There is less and less
striated muscle down the lateral borders of the
gland until it finally disappears altogether.
There are islands of lymphoid tissue scattered
here and there in the adult prostates. Rarely one
finds some of these areas in the pre-puberty speci-
mens. They seem to be most frequently met with
in specimens older than thirty years. Waldeyer has
found similar areas in the prostate of a dog and
Weski has studied them in the human and believes
them to be normal anatomical structures.
The base of the prostate is intimately attached
to the musculature of the bladder, as shown in
Figs. 2 and 3.
In regard to the internal sphincter of the human
bladder Versari concludes from his investigations
that (1) The smooth muscle sphincter of the uri-
nary bladder of man constitutes a structure by
itself, which develops independently of the middle
("circular) layer of the bladder, the circular muscle
layer of the urethra, and the musculature of the
ureters. (2) The sphincter is made up of an ure-
thral and a trigonal portion, and it is the urethral
portion only which assumes the form of a ring sur-
rounding the initial part of the urethra. The first
groups of the fibers of the sphincter arranged in
bundles correspond to the anterior arch of the
urethral portion; from there immediately follow
those of the urethral portion of the posterior arch,
and these last are apparently those of the trigonal
portion. The posterior arch of muscle extends little
by little, with new bundles either upwards to oc-
cupy part of the trigonal area or downwards along
the posterior wall of the urethra, so that it comes
to have an extent much greater than the anterior.
On the other hand, the older view held by Krause,
Hyrtl, Gegenbauer, and others is that the sphincter
is a continuation downward of the circular muscu-
lature of the bladder.
The capsule of the prostate is composed of a
structure which is made up of closely knit connec-
tive tissue fibers and surrounds the entire organ
except at the base between the entrance of the ejac-
ulatory ducts into the substance of the prostate and
the junction of the bladder wall with the gland.
Here the tubules of the middle lobe are almo ;i free
and have as a consequence very thick muscular and
connective tissue walls. The large blood vessels
which supply the prostate run in the capsule and
intralobular partitions for the most part and are
most numerous on the anterior portion of the cap-
sule. By fibrous connections adhering to the cap-
sule the prostate is fixed in position. Retzius has
termed this the ligamentum pelvic-prostaticum cap-
sulare.
A study of the secretion of the prostate gland iij
adults is very instructive. Normally it is milky in
appearance, possesses a characteristic pungent odor,
and is usually acid in reaction, but may be neu-
tral. Under the microscope it is seen to be com-
posed of a fluid containing numerous spherical re-
tractile bodies of varying sizes composed of lecithin.
There are very few leucocytes in normal cases and
no erythrocytes. Spermatozoa are not usually
found in fluid obtained by massage unless the vesi-
cles are also touched. The relation between the
lecithin bodies and leucocytes is an excellent indi-
cator for determining whether the prostate is nor-
mal or the seat of inflammation. Cells composed of
many retractile granules often brownish in color
are found. These structures have been described
by Waldeyer, who called them compound granular
cells, and are found often after the fortieth year,
and in most of the cases older than fifty. Corpora
amylacea are occasionally met with. They have a
slightly brownish color, as a rule, although they
may be colorless. They are composed of concen-
tric layers, and look more or less like an onion cut
in cross section. They are found in old age most
frequently but occur in younger specimens as well.
I remember one specimen particularly, obtained
from a man thirty-four years of age, which had
more corpora amylacea than any other that I have
seen. There are usually some loose epithelial cells
Fig. 4. — Cross-section through middle of trigonum vesica?
of 17 year-old boy. BL. bladder lumen ; ST. subtrigonal
tubule; YD. ampullae of vus diferentia; 8V. seminal vesicles:
P, lateral lobe tubules of the prostate.
which have been exfoliated from the mucosa. Wil-
son and McGrath, in their splendid review of the
literature of the prostate gland, have explained the
various views on the chemistry and physiology of
prostatic secretion.
10
MEDICAL RECORD.
[July 1, 1916
There are a number of organs which are so inti-
mately associated with the prostate gland that I
have called them accessory structures. They oc-
cupy in each instance a position contiguous to this
organ and a disturbance in their arrangement or
function is of as much importance as a disturbance
of the prostate itself. There is a member of this
group of structures which I have described and
called the subtrigonal group of tubules. They oc-
cur in the mucosa of the trigonum vesica? usually
below its central point, and are found as far out-
erward as the apex. They are for the most part
simple tubules which extend to the submucosa and
somewhat into it. In the younger specimens there
are never branches, but some of those found dur-
ing the middle-age period show one or two small
branches. There is nothing distinctive about the
structure of the membranes of the subtrigonal
group. The mucous lining is composed of transi-
tional epithelium similar in type to the vesical
mucosa. The cells are much piled up and in some
cases five or six deep. Their lumina are quite
small, as a rule. These tubules are of importance
on account of two facts. First, because their posi-
tion is such that an overgrowth or enlargement
from any cause will bring about a disturbance in
the emptying of the bladder; second, because an
enlargement of this group does occur in a small
percentage of cases. I have observed six non-ma-
lignant tumors of the trigonum vesicae intravitam
and three in post-mortem specimens. The number
of these simple finger-formed tubules increases
markedly after birth but are found in the embryo
after the fourth month. More than twenty of them
are observed in every specimen older than four
years.
Albarran's subcervical group is by far the most
important structure at the orifice of the bladder.
It is made up of many tubules which are rather
frail in structure and whose ducts open in or near
the midline of the floor of the urethra between the
upper end of the verumontanum and the orifice
of the bladder. As shown by Van Gieson's differ-
ential stain no smooth muscle fibers are demonstra-
ble around these tubules, which are much more frail
than the prostatic glandular elements. In every
case studied with one exception these tubules and
their branches grow entirely within the sphincter
of the bladder, thus occupying a most important
position. In the case of the thirty-four-year-okl
specimen a few branches of Albarran's tubules ex-
tend outside of the sphincter for a short distance.
Up to the time of birth these tubules are few in
number, but all specimens examined older than
three years have more than thirty of them. Not
only are the location and number of Albarran's
tubules important, but for some reason pathological
change in the form of enlargement in this region
is very frequent. In my series of post-mortem
specimens, I have found almost 25 per cent, of the
specimens taken from men over thirty years of age
to be enlarged sufficiently to demonstrate signs of
obstruction in the bladder. It often happens that
the passage of an instrument such as a catheter
in a patient who is suffering from a moderate ob-
struction to urination will be completely obstructed
thereafter. It seems to me that such trauma causes
an edema of both the subtrigonal and Albarran's
tubules, thereby producing a complete blocking of
the upper end of the urethra.
The seminal vesicles and the lower portions of
the vasa deferentia are bound together by a fascia
which I have called the intervesicular fascia. It
is made up of three portions, the most prominent
being the posterior leaflet, which is composed of
two layers. It extends around and between the
two seminal vesicles and posterior to the vasa defer-
entia. The seminal vesicles are thus suspended in
a sac-like structure, the posterior layer of which
extends directly across from one vesicle to the other.
The anterior layer, after circling the vesicles, joins
the posterior lamella at the border of each vesicle
and becomes intimately attached to it, thus forming
a two-layered, rather firm fibrous fascia. The mid-
dle portion is formed by a two-layered structure
which envelops the vasa deferentia in a similar
manner. The third or anterior lamella is a single-
layered fibrous structure extending from the an-
terior and lateral surfaces of one seminal vesicle
to those of the other, at which point it is attached
to the encircling portions of the posterior part of
the fascia described above. In most instances the
upper border of this fascia extends somewhat
higher than the fascia of Denonvilliers, and the two
.structures are easily separated, being in direct con-
tact only at the lateral surfaces of the seminal
vesicles. At other places the two structures are
separated by a considerable amount of fatty and
areolar tissue.
The intervesicular fascia is not nearly so firm as
that of Denonvilliers. Its posterior leaflet is the
strongest portion; the middle, or that portion which
encircles the vasa deferentia, is the weakest. The
three lamellae combined hold the seminal vesicles
and vasa deferentia in a very definite envelope,
which is of considerable importance in surgery of
this region. This structure is undoubtedly a bar-
rier to the extension of carcinoma, and may explain
why carcinoma of the seminal vesicles is usually
confined to those structures for such a long period
of time without extension to surrounding tissues
and organs. The type of pain which accompanies
acute infections of the seminal vesicles is explained
by the fact that these organs are contained within
a sacculated fascia. The intervesicular fascia cor-
responds fairly wTell to the area of the trigonum
vesicas and, reinforced by the fascia of Denonvil-
liers. forms a firm support to the bladder wall at
this area, and is an additional factor in preventing
the formation of diverticula in this region.
The epithelium of the vasa deferentia is made
up in part of simple ciliated columnar, and in part
of stratified ciliated columnar cells, with two rows
of cells. The cilia are often absent, however, and
vary a great deal. In the ampulla of the vas def-
erens the epithelium is for the most part simple
columnar in type and the cells often contain gran-
ules of yellow pigment. Besides folds there are
evaginations and tubules which occur frequently in
older specimens and extend quite deeply into the
muscular walls. The epithelium of the seminal vesi-
cles is simple nonciliated columnar in type contain-
ing yellow pigment.
The ejaculatory ducts as a rule are lined by a
single layer of columnar cells, although the mucosa
is often folded and the cells are frequently arranged
in two or three layers. These structures usually
remain attached to the upper surface of the parti-
tion separating the posterior from the lateral lobes
and pass through the prostate as a distinct body
until they arrive at the verumontanum, where their
muscular walls become quite thin and less compact,
and while they are arranged circularly, as Porosz
described, they are so frail that their sphincteric ac-
July 1, 1916]
MEDICAL RECORD.
11
tion must be very slight. Their main protective
agent seems to be the fact that they enter the
urethra obliquely in such a manner that there is a
laplet of tissue covering each orifice so that it acts
as a valve.
The utriculus prostaticus has a wide-open mouth
which is unprotected in any way. Its walls con-
tain a very great many tubules with branches that
are fairly numerous and seem to contain all the
elements which would tend to harbor infection for
a long time. The utricle varies in size in all ages
but seems to undergo a gradual increase in size up
to the third decade. It is usually contained within
the summit of the verumontanum but may extend
to the base of the prostate.
The apex group of tubules which is first observed
in a specimen seven and one-half months intra-
uterine is found in every older specimen examined.
The number of these tubules varies from 9 to 26,
with an average of 15. They occur at the apex
of the gland, are frail in architecture, but extend
fairly deeply into the coats of the urethra. They
have many branches, and are lined with a mucosa
composed of columnar cells.
LITERATURE.
Albarran et Halle: Annal. d. mal. d. org. gen. urin.
1898, p. 797.
Albarran: Maladies de la prostate, p. 526, 1902.
Cuneo: Du siege anatomique de l'hypertrophie dite
prostatique. Trav. de Chir. (voies urinaires) 4 s., p. 75.
Finger: Allgemeine Wiener medizinische Zeitung,
1893.
Von Frisch Die Krankheiten der Prostata, 1910.
Fiirbringer: tiber Prostatfunktion und ihre Bezie-
hung zur Potentia generandi der Manner. Berliner
klin. Wochenschr. 1886, Nr. 29.
Griffiths, J.: Jour. Anat. and Physiol. Vol. 23, p. 374,
1889.
Hart: A contribution to the morphology of the urino-
genital tract. Jour. Anat. and Physiol. 1901, p. 330.
Keibel-Mall : Human embryology, Phila. Vol. 1, 1910,
pp. 180-200.
Lowsley: The Development of the Human Prostate
Gland, Amer. Jour. Anat. Vol. 13, No. 3, July, 1912.
Lowsley: The Gross Anat. of the Human Prostate
Gland and Contiguous Structures, Surg. Gyn. and Obst.,
Feb., 1915, p. 183.
Lowslev: The Human Prostate Gland in Youth.
Medical Record, Sept. 4, 1915, p. 383.
Lusena: Sulla disposizione delle cellule muscolari
liscie nella prostata. Ayiatom. Anzeiger, Bd. 11, pp. 399-
406, 1895.
Pallin, Gustaf : Archiv fur Anatomie und Physiologie,
1901.
Porosz: Archiv fur Anat. und physiol. Anat. Leipzig,
1913, pp. 172-177.
Rudinger: Zur Anatomie der Prostata, des Uterus
Masculinus und der ductus eiaculatorii. Festschrift des
Arztl. Vereines Munchen. Pp. 47-67, 1883.
Tandler und Zuckerkandl: Folia urologica; Interna-
tionales Archiv fur die Krankheiten der Harnorgane,
March, 1911.
Versari: Ric. d. lab. d. Roma, Vol. 13, 1907.
Waldeyer, W.: Das Trigonum Vesica?, Sitzungs-
berichte der Akadamie der Wissenschaften in Berlin.
1897, p. 732.
Walker: Jour, of Anat. and Physiol. Vol. 40, p. 190,
1906.
Wallace: Prostatic Enlargement. London, 1907.
The Wtomino, Seventh Ave. and Fifty-fifth St.
Impromptu Diagnosis of Atropine Poisoning. — Hun-
ziker states that the picture of atropine poisoning is as
a rule quite characteristic, but it happens occasionally
that because of the attendant delirium a subject is
rushed to an asylum. In any suspected case it is best to
use the cat's eye as a diagnostic resource. If any sus-
picious drink or medicine is in evidence a drop of this
is instilled into the eye, and this failing, a drop of the
patients urine may serve the same purpose. — Cor-
respondenz-Blatt fur Schweizer Aerzte.
FROZEN LIMBS AND THEIR TREATMENT
IN THE PRESENT WAR.
By E. KILBOURNE TULLIDGE, M.D.,
PHILADELPHIA. PA.
FORMERLY CAPTAIN SURGEON IN THE AUSTRIAN ARMY ; AMD
MILITARY SURGEON. FRENCH RED CROSS.
Cold is probably the greatest hardship and most
dreaded enemy the soldiers of both armies on the
Eastern War Front experience. For the cold there is
no remedy; they must grin and bear it day after
day. We have ridden on horseback through the
blinding snow and sleet that froze to the horse's
mane and tail, standing each hair out like the quills
of a porcupine; slept in fur bags night after night
on the cold, bleak snow of the mountainside, and
trudged along the drifted roads when it v/as too cold
to snow, until the first burning sensation of frost-
bite was replaced by numbness and complete loss of
feeling in the limbs, from which the men dropped
and were forgotten by the wayside, to revel in that
overwhelming grip of tired, sleepy sluggishness that
has for hours knawed its way to the end from which
there is no awakening, a peaceful death.
We were riding with reinforcements to join that
one man-of-the hour in all Germany, Von Hinden-
berg; it had been snowing for the past week, and
our way led through the wooded Carpathians, al-
ready deep in snow. One evening I was aroused by
a voice at my elbow, and, drawing rein, I learned
after much difficulty, because of the wind and driv-
ing snow, that I was lost and alone with a medical
student attached to my staff, and that we had been
traveling aimlessly for hours on a densly wooded
slope. We took a course due north by our com-
passes, and hurrying on came upon what appeared
to be a tiny light some distance ahead. Following
this beacon we soon emerged into a clearing, where
to our delight we could distinguish what seemed to
be several men sitting about the dying embers of a
fire. I called to them, but received no response, and
throwing the bridle of the horse to the student
alighted and approached the circle. Not a soul
stirred, and as I came closer I put out my hand and
touched the nearest one of them on the arm. To
my horror, he was stiff ! Cold! Frozen to death, all
six of them — four Austrians and two Russians —
while they slept about the fire. They were bitter
foes, united against a common enemy — cold, fatigue,
and hunger; they had lost, and were there rocking
in the wind to tell the tale to others.
Frozen extremities, particularly the feet, are by
far the most common, and represent during the fall,
winter, and early spring months the majority of all
cases sent to the hospital, or treated at the front.
The frequency and common suffering of this con-
dition may be ascribed not only to the biting, in-
tense, continual cold of the mountainous districts,
but to a tendency due to the retention of the
moisture of the feet, and to the inadequate blood
supply of these points. The arteries should and
must be kept warm where they are most exposed,
and an endeavor made to prevent the occurrence
of trophic and circulatory disturbances that lead to
the more serious complications of gangrene, general
sepsis, and death. With this end in view, proper
and adequate clothing, socks, gloves, and wrist and
ankle warmers of wool and cotton should be supplied
to the troops in quantities large enough to allow of
a change at least three times a week when on active
duty, long campaign marches, and prolonged trench,
marsh, and snow maneuvers. Warm, fresh, dry
12
MEDICAL RECORD.
[July 1, 1916
socks and underclothes produce an effect both phys-
ical and mental upon the soldiers of a refreshing
ease, soothing to the tired, sore, swollen, cold, moist
feet and limbs. This necessity has been recognized
by the German medical and military authorities,
who have sent out, as the result of appeals and pri-
vate donations to the men on the front, over 15,000,-
000 marks worth of half-cotton, half-woolen under-
clothes ; 8,000,000 marks worth of cotton and woolen
socks and ankle warmers; and the special "Military
Committee for Warm Underclothing," formed at the
suggestion of the Empress, woolen goods to the
value of 20,000,000 marks.
Among the foot protectors sent by this committee
were assorted sizes of yellow oiled and waxed paper
covers shaped to go on the foot inside the boot.
Some men display a predisposition to frostbite by
pathological cardiac conditions and sluggish cir-
culation in general. This should be recognized by
the recruiting examiner or the regiment physician,
and a note made that they should not be sent to ex-
posed parts, although in the Carpathian mountain
campaign all parts were more or less exposed, and
the proper necessary care could not be taken along
this line. However, the right man in the right place
is a great medico-military secret of success toward
providing for and sustaining the health and vigor
of the troops. It must be remembered that probably
the greatest factor of sluggish circulation and a
most frequent and important one is fatigue. It is
more pronounced, and occurs more easily in cold
climates and high altitudes. Relief and frequent
changes of the men upon active duty are necessary,
and large, commodious boots, with no buttons or
laces, should be supplied to them. Unfortunately,
boots and shoes were at a premium on many occa-
sions, and we were forced to devise large easy-fit-
ting, straw-woven covers with a one to two-inch
sole that could be slipped on over the shoes. These
were of such excellent protection, keeping the feet
warm and dry, that later many thousands were
made and sent out by the government and Red
Cross.
If early measures are taken to tone up the vessel
walls and nerve supply of the legs and feet, frost-
bite may be avoided in the majority of cases. This
can be done by daily cold baths, and massage with
snow. Several officers with poor circulations treated
in this manner benefited immensely. They stripped
in the open every evening (behind a "lean-to") and
received a complete massage of the entire body ;
first with snow and later with olive oil. They be-
came so fond of the practice that it was continued
during the whole winter campaign, with a resulting
gain in weight and a marked improvement in their
muscle tone.
The conditions manifest by the effect of cold upon
the feet may progress from simple vasomotor dis-
turbances and minute blisters, to total gangren
of the toes or even of the entire foot and leg.
Soldiers standing for hours with their legs im-
mersed in snow or cold water, which many tim
formed a crust of ice upon its surface, suf-
fered mostly from a vasomotor condition, which.
left untreated, resulted in the death of
the tissues and gangrene. A great factor in
these cases is the persistent wearing by the
troops of tight ankle-bands, boots, and puttees;
swollen, water-soaked wool and cotton stockings and
socks that constrict the leg and interfere with the
circulation. The feel are swollen, inflamed, red,
and blistered, paresthesia and anesthesia being at
times present. The legs become edematous above
the water-line, and the skin may break, displaying
an open serous discharging wound. Some French
authors term this affliction "water-bite," but I fail
to disclaim its relationship as a first or primary
stage of frostbite, held in check temporarily by the
excessive moisture. We know that, if these cases
are taken out of the water and placed in a dry,
warm room the prognosis is better, and that, if they
are allowed to remain outside, the dampness aggra-
vates the condition, producing a maceration of the
tissues and causing the shoes and other coverings
to shrink still more.
The typical frostbite symptoms do not display
themselves until on or after the fourth day of water
or snow sojourn, but circulatory disturbances, if
complained of during this time, should indicate an
interference of some character, and all constricting
bands about the thigh, knee, calf, and ankle should
be removed, and massage of the entire limb ordered
with the oil preferred by the soldier himself. Some
authors, I have noticed, suggest the application, at
this stage of a solution containing collodium, alco-
hol, glycerin, and iodine, both to the feet direct and
to the sock; but I failed to obtain more benefit from
the use of any or all of these preparations alone or
in combination than that which results from appli-
cations of crude oils to the parts.
The circulation of both the blood and lymph is
most sluggish toward the ends of the limbs, and be-
cause of this, artificial aid is required to treat the
presence of extravasated blood in these regions ;
passive and active movements routinely practised
should be recommended to the men while on duty,
and prescribed even in the hospitals for bedridden
cases of this nature. I know of one surgeon who,
after elevating the affected limb, insisted that each
morning after massage with alcohol and olive oil
was given the patient lift his own extremity from
off the inclined plane, and flex and extend the knee
six times the first day, increasing daily until twenty
movements were made, and then decreasing it. He
claims that after one or two days the circulation
improved, pain was relieved, and the tissues regen-
erated, recovering their normal character without
gangrenous formations. This method I have not
tried, but am inclined to favor a seven or ten day
immobility with a daily massage, external friction,
deep-breathing exercises, and hydrotherapy before
motion is insisted upon. Hot coffee or caffeine is an
excellent remedy in treating these early cases, help-
ing to tone up the motor system with more favor-
able results than any other drugs tried.
In the later stages of frostbite there is a necrosis
of the parts involved, usually the ends of the fin-
gers, hands, feet, or toes. It may be classed as a
dry gangrene, mummification, or death followed by
inspissation if the tissues are bloodless at the time
of freezing. However, most of these cases, in fact,
practically all of 2.000 that I saw and treated, un-
derwent a mortification or moist gangrene followed
by putrefaction necrosis, accompanied by a great
septic reaction and often death if the diseased area
was not removed in time. Infection takes place very
quickly from the slightest break of the skin in the
early stages above described and spreads rapidly, ac-
companied by dysuria, oliguria, hematuria, disturb-
ances in sensation of various parts of the body, and
disorders in metabolism. The best treatment in
this stage of the affection is at first friction with
snow or cold water out in the open, where the pa-
tient should be kept for the first twenty-four hours,
the change to a warmer atmosphere being gradually
brought about. Friction or massage with oil or
July 1, 191G|
MEDICAL RECORD.
13
alcohol — some prefer turpentine, benzine, alum, etc.
— should be followed by elevation of the limb upon
soft pillows after being wrapped loosely in cotton-
wool over which is spread boric vaseline. These
coverings can be held in position by bandages ap-
plied loosely so as to avoid any danger of constric-
tion. Blisters and discoloration of the toes or other
parts show that gangrene is imminent. At this
period is the time to apply iodine tincture over the
whole surface of the limb extending it far above
and if possible below the involved area. The blis-
ters contain a dark blood-colored serous fluid, and
should be opened, carefully dried, and dressed with
dusting powder, preferably powdered borax, sali-
cylic acid, or zinc oxide. Every effort should be
made to keep the parts dry and sterile when gan-
grene sets in. Incisions at or near the beginning
of the inflammatory area may be made to allow the
escape of accumulated and retained lymph and
blood. They should be small, sometimes mere punc-
tures, and extend through to the bone. If this is
practised, a stimulating effect upon the capillary
■circulation and tissue regeneration will be noticed
with the resulting diminution and decrease in the
gangrenous involvement, thus saving as much of the
injured extremity as possible. Immediate, early or
too hasty amputation is absolutely contraindicated,
as it is impossible to say how much of the damaged
tissues will survive. It is true that a line of de-
marcation does occur, but the tissues adjoining it
become more and more healthy, forming granula-
tions significant of regeneration.
It is astonishing how an apparently serious gan-
grenous area or spot may contract and slough off,
leaving a healthy but infected granulating area.
Toes, and even completely involved feet, may re-
gain their color and former healthy appearance in
time if properly treated. Operation should, there-
fore, be delayed until at least it is evident that
flaps of skin are available and can be applied con-
veniently so that they will make a good covering
for the stump. The delay, however, should by no
means await the spontaneous sloughing of the dead
parts, because of the septic systemic infection that
invariably accompanies it. Much to my sorrow, I
followed the advice of others, among whom were
Profs. Walther, P. Thiery, and Goutley, in the early
days of my service, and waited until cicatrization
had accomplished as much repair as it could, allow-
ing spontaneous sloughing, with the result that
death carried with it five of the boys who would
probably have been saved by earlier operation at the
proper time. To operate upon these cases, the sur-
geon must know thoroughly the operations relative
to amputations and disarticulations of and about
the feet and hands, especially the former. Of these,
Lisfranc's, Chopart's, Syme's, and Pirogoff's opera-
tions are of most value and of great importance in
that a fairly presentable limb must result that will
be of some use and service in after years.
The first of these operations, Lisfranc's, is best
performed by making a short dorsal and a long
plantar flap, and disarticulating the toes and ante-
rior portion of the foot at the tarsometatarsal junc-
tion or line, the stump being composed of plantar
and dorsal tissues. The incision begins behind the
base of the fifth metatarsal bone, passes straight
down the outer side of the foot about one inch, then
around onto the dorsum and crosses the foot
with a slight downward convexity, parallel with,
and just below the tarsometatarsal joints, reaching
the inner border of the foot about one-half inch be-
low the tarsometatarsal articulations. From there
it rounds into the inner aspect of the foot and
passes straight upward, ending above the cunei-
form-metatarsal articulation of the great toe. This
completes the dorsal flap.
The plantar flap incision with the horizontal por-
tion of the dorsal incision passes down the outer
lateral side of the foot, along the plantar edge of
the fifth metatarsal to below its middle, then grad-
ually rounds onto the sole and sweeps obliquely
across the plantar surface, crossing the fifth meta-
tarsal just above its neck, and ending at the first
metatarsal-phalangeal joint. This incision is joined
to the dorsal incision by an incision running up the
mid-lateral aspect of the foot, along the border of
the first metatarsal. Care should be taken not to
make the dorsal flap too short or either flap too
pointed, allowing plenty of soft tissue on the plan-
tar flap to compensate for postoperative sloughing,
and not to mistake the scaphocuneiform joint for
the metatarsocuneiform articulation.
The incision above described should be deepened
and carried down to the bone at the line of de-
marcation, or just above, allowing enough room for
clean fresh flaps. The vessels are often already
closed by thrombus formations and rarely need
ligation. The flaps must be left open and not closed
by sutures, allowing the parts to drain. Wet sub-
limate dressings, if warm and applied twice daily
for the first four days, will soon control the septic
serous discharges, and stimulate healthy granula-
tions in the course of two weeks.
Disarticulation of the foot at the mediotarsal
joint may be done by a slight modification of Cho-
part's flaps: "a short dorsal and long plantar," and
substituting a modified oval flap as described by
Tripier, with the horizontal sawing of the os-calcis.
Chopart's, however, I found to be much simpler and
by far the quickest and best operation. It consists
of the disarticulation of the anterior portion of the
foot at the astragaloscaphoid and calcaneocuboid
joints, being somewhat similar to Lisfranc's opera-
tion.
The plantar incision begins on the outer aspect
of the foot at a point opposite the calcaneocuboid
joint, and passes down the outer side of the foot to
the middle of the fifth metatarsal, then around to
the sole of the foot along the middle of the meta-
tarsal to the inner side of the foot, passing straight
up that border to a point opposite the astragalo-
scaphoid joint. The dorsal incision begins by curv-
ing from the outer limb of the plantar incision, just
posterior to the fifth tarsometatarsal joint, and ends
by curving to meet the plantar incision of the oppo-
site side at its tarsometatarsal joint, crossing the
foot at the dorsal level of the bases of the meta-
tarsal bones.
The incision should be deepened down to the bone,
and the disarticulation performed from the dorsal
surface, while the foot is forcibly extended by an as-
sistant or by the operator's left hand. The tendons
of the tibialis anticus and posticus, peroneus tertius
brevis, and longus are cut and the extensor tendons
and tibialis anticus of the dorsal flap sutured to the
plantar flap. This will help to counteract the
tendency that exists for the displacement of the
bones of the stump by contraction of the tendo-
Achillis, which throws in many cases the head of the
os calcis downward, causing pain from pressure on
walking.
Pirogoff's operation is also necessary to resort
to when the heel of the foot has become frozen and
sloughs off with the toes. The intervening tissue on
the arch of the plantar surface of the foot that re-
14
MEDICAL RECORD.
[July 1, 1916
mains in a living condition is often so small or so
inflamed that it is not worth while saving, and the
disarticulation of the foot at the ankle joint with
the removal of the malleoli, the articular surface of
the tibia, and the anterior part of the os calcis is
necessary. A modified dorsal flap is necessary, as
a heel flap is impossible. This if tried will give
good results, although a fleshy person will produce a
better flap than a lean one. Sometimes the foot is
frozen so badly and the area of necrosis so exten-
sive that it becomes necessary to perform Syme's
operation, which is indeed a far better operation
for both the patient and the surgeon if performed
with a dorsal flap. This is a disarticulation of the
foot at the ankle joint with the removal of the
malleoli, the articular surface of the tibia and
fibula being sawed transversely at about one-quarter
inch above the inferior border of the tibia. The an-
terior tibial, external malleolar of the posterior
tibial, and internal plantar, anterior peroneal, in-
ternal malleolar of the posterior tibial and internal
and external saphenous vessels are ligated; the
nerves are all cut short, especially those of the heel-
flap bent over the ends of the sawed bones, and the
wound remains open and is dressed as above with a
wet bichloride dressing for the first four or five
days.
Watson of the British Army has devised a method
of amputation at the ankle joint when necessary
that leaves the heel intact, and in his opinion pro-
vides a more serviceable stump than obtained from
Syme's or Pirogoff's amputations. He amputates
the foot in front of the os calcis, removes the lower
ends of the tibia and fibula, and the upper surface of
the os calcis, wedging the os calcis up between the
malleoli, pinning it there with a pin that may be
removed in about two weeks, thus leaving the walk-
ing surface of the heel intact, preserving the mal-
leoli to give a firm hold to the "uppers" of the shoe
and permitting the patient to wear an ordinary
padded shoe.
If the toes or fingers alone are involved, disar-
ticulation at the first joint behind the line of de-
marcation should be performed, permitting ample
space for free tissue drainage of the open infected
stump, and sufficient tissue to form a respectable
flap when the infection has subsided. Amputations
of all the toes or fingers through the metatarsals
were frequently easily and simply performed, giving
good results. Care in these operations should be
taken to replace the tendons of the flexor and ex-
tensor muscles suturing them into the mouth of the
cut theca and periosteum or even the flap, and
thereby secure control of the stump. The operation
is a simple one, the palmar incision beginning op-
posite the saw-line on one side and carried down in
a circular curve one and one-half times the diameter
of the finger, to end on the opposite side at the same
line as the starting point. It is deepened to the
bone, and the bone should be disarticulated; the
digital artery may or may not be ligated. as the
case demands. The deep flexor will, however, be
severed and should be sutured into the mouth of the
fibrous sheath ending at the middle of the second
phalanx and into the neighboring periosteum and
soft parts if necessary. The flap is then allowed
to remain open and a wet sublimate dressing ap-
plied to facilitate drainage.
Other amputations and disarticulations are so
simple and so commonly and thoroughly discussed
by other authors that I will not mention them here.
Care and attention are required in the after-
treatment of these finger and toe amputations and
disarticulations. Exercises, passive and active,
should be commenced at the end of the first week
to keep up the strength of the muscles, particularly
the extensors, for they degenerate faster than the
flexors. The remaining fingers or parts of fingers
and toes should be left exposed or in a condition of
easy mobility so that the patient can keep them
continuously working vigorously to ward off stiff-
ness. Enough of the hand should be left if possi-
ble to permit the patient to grasp things with, as
there is no feeling and little comfort in an artifi-
cial hand, which is decidedly inferior to a muti-
lated stump that still has grasping and holding
powers. Lastly, when placing the arm in a sling,
care should be taken that the hand does or will not
drop from its own weight or receive pressure from
the edge of the supporting binder.
THE PRESENT CONCEPTION OF CONGENI-
TAL SYPHILIS AND ITS MODERN
DIAGNOSIS.*
By ADOLPH ROSTEN'BERG, M.D.,
NEW YORK.
ATTENDING DERMATOLOGIST TO THE GERMAN HOSPITAL O. P. D.
AND TO BRONX HOSPITAL AND DISPENSARY
The epoch-making discoveries of the last decade in
syphilography have along with other changes also
necessitated an important revision in our concep-
tion of congenital syphilis. Up to ten years
ago it was more or less the general belief that
germinative transmission was the common mode of
infection from parent to child, that is a trans-
mission through either spermatozoon or ovum or
both. The strongest support for this theory was
given through Colles' law, wThereby a syphilitic child
could be the offspring of an apparently healthy
mother, even transmitting an immunity to the
mother against a syphilitic infection in later life.
Matzenauer in 1903 in his Monograph, "Verer-
bung der Syphilis," guided solely by clinical and
pathological observations, doubted the correctness
of this theory and maintained that it was the mother
alone, carrying the infective agent in her placenta,
who transmitted the disease to her offspring.
With the discovery of the Wassermann test and
the finding of the spirochetes it could be shown
that Matzenauer was correct with his placental
theory, as in every specific case spirochetes were
found by all investigators in the intervillous spaces
and the maternal portion of the placenta; besides
the Wassermann was found strongly positive in
almost 100 per cent, of all these cases even when
the mother clinically did not show any specific
manifestations.
And must we not admit from theoretical deduc-
tions alone, how improbable the germinative trans-
mission of congenital syphilis appears? Does it not
seem rather impossible that the spermatozoon or
ovum could develop, if invaded by a host of living
parasites? Now that we understand Colles' law cor-
rectly, we are able to explain why syphilitic chil-
dren with frank lesions on mouth and lips, could
nurse their mothers and would not infect them,
whereas the same children would invariably infect
a wet nurse. These so-called Colles mothers un-
fortunately were infected with lues long before
their offspring was born, the disease was only latent
in their system, and therefore we find this apparent
immunity against a specific infection in later life.
*Read at a meeting of the Bronx County Medical
Society, March 15, 1916.
July 1, 1916]
MEDICAL RECORD.
15
In view of these facts it seems for all practical
purposes justifiable to assume, and most authors
take this stand to-day, that there is no congenital
without maternal lues. If so, the placenta must be
the high road through which the infection goes.
From the placental blood vessels the spirochetes are
carried to all the fetal organs. This fact explains
at once the principal difference in the dissemina-
tion of the virus in acquired and congenital lues.
In the latter we have no primary lesion as the
starting point, from which the infection travels,
first through the lymphatics and thenee in the blood
stream. In congenital syphilis, as just said, the
spirochetes are carried from the mother's placenta
into the fetal blood vessels, thus establishing a con-
dition which practically corresponds to the early
secondary stage of acquired lues. This fact
also explains why congenital syphilis acts so dele-
teriously on the fetus in a recent infection. Here
the spirochetes, which are found in greatest abun-
dance in all the internal fetal organs, will naturally
produce a severe septicemia through their toxins,
and to this the majority of these unfortunate be-
ings succumb, before they have reached their full
development. According to Kassowitz, only three-
fifths of all luetic offsprings go to full term, and
other statistics show even a higher mortality in this
respect.
After these theoretical considerations let us out-
line more in detail the various modes and possi-
bilities through which the fetus acquires its con-
genital infection.
I want to state right here that the mother may
sometimes infect her offspring without showing
manifest clinical symptoms herself. This is also
a cardinal differential point between congenital and
acquired lues, as in the latter lesions on skin and
mucous membranes only transmit the infection to
another individual. Whether the fetus will become
infected at all depends on a variety of circum-
stances, which are sometimes very complex and
often very difficult to understand.
Let us assume at the beginning that both parents
are suffering from a manifest case of lues at the
time of conception. In such a case the fetus will
hardly ever escape; a severe spirochetal septicemia
will cause an abortion or an early miscarriage, the
macerated fetus showing all the stigmata of con-
genital lues. In a few instances, especially when
some form of treatment has been instituted during
pregnancy, a living child may be born, but soon
some grave specific symptoms will develop, causing
an early death of this unfortunate being in most
cases.
If the mother alone was syphilitic at the time of
conception, the offispring will be in the same danger
as before, especially if the mother had none or in-
sufficient treatment and married during the first
two years after her infection. If the mother was
free from syphilis at the time she conceived, but
contracted the disease while already pregnant, then
the fate of the child will greatly depend upon the
period of gestation at which the infection took place.
Here different observers have come to contradictory
conclusions. Some claim that the infection is trans-
missible to the offspring only during the early pe-
riod of gestation, whereas others maintain that the
infectiousness is more intense during the second
period and increases as the pregnancy approaches
full term. Does the child ever escape infection at
all? According to the so-called law of Prof eta it
does. Unfortunately though, Profeta's law has also
been proven to be untenable in the light of our
recent investigations. The apparently healthy chil-
dren, born of mothers who became infected post
conception, remaining, according to Profeta, free
and even immune against a syphilitic infection in
later life; these children give, according to most in-
vestigators, a positive Wassermann reaction, which
shows that they do suffer from a latent form of
lues and acquired their infection during intrauter-
ine life.
A paternal infection is ordinarily not so serious
to the offspring as a maternal one. If we adhere to
Matzenauer's placental theory, the paternal infec-
tion is of no consequence at all unless the mother
becomes infected also. This positive statement of
Matzenauer seems, however, to have been somewhat
shaken recently since Finger and Landsteiner have
succeeded in inoculating monkeys with the spermatic
fluid of a syphilitic man and obtained luetic mani-
festations, thus proving the contagiousness of
syphilitic sperma, in spite of the absence of spiro-
chetes in the spermatozoon. Bab has also found a pos-
itive Wassermann reaction in the sperma obtained
from syphilitics. These findings may now explain
a few rather strange cases which were called by
Fournier infection through choc en retour, whereby
we find the following: A healthy mother conceives
from a syphilitic father, who does not show any
infectious lesions anywhere on his body at that
time. But the mother without having had a primary
lesion, develops early secondary symptoms in the
first half of her gestation ; an abortion usually fol-
lows and the fetus shows all the earmarks of con-
genital lues. In these cases, according to Fournier,
the fetus received the syphilitic virus from the
father's sperma and infected its mother through
the placenta. These cases, however, are so ex-
tremely rare, that to my mind they should not offset
the placental theory of Matzenauer and for all
practical purposes we ought to adhere to it as the
only plausible mode of congenital transmission of
syphilis.
That early and rational treatment will ameliorate
the symptoms and modify the issue in congenital
syphilis is self-evident. But even untreated cases
show, according to Kassowitz, a tendency toward
a gradual diminution in severity, ameliorating with
the duration of the disease in the parents. There-
fore we find as a rule in syphilitic families first
abortions, then stillbirths, then living premature
infants, then living syphilitic infants, born at full
term, but showing syphilitic lesions, then living full
term children, free from specific lesions or showing
them only after birth, and finally entirely healthy
children at birth and remaining so afterwards. Of
course this is not an ironclad rule and exceptions
are seen frequently, so that sometimes healthy and
syphilitic children alternate in successive preg-
nancies.
It is generally accepted and obviously seen from
the closer contact of mother and child, that a ma-
ternal syphilis will persist in its infectivity much
longer than a paternal one; therefore we see cases
in which a syphilitic woman, joined in second mar-
riage to a perfectly healthy man, bears him syphi-
litic children ; such transmissions have been ob-
served as late as twenty years after the mother
was infected. .
As to the diagnosis of congenital lues, I do not
know of any other instance where the physician's
responsibility is taxed to a greater extent than
here. It is not only the case in question, but the
16
MEDICAL RECORD.
[July 1, 1916
outcome for the future, which depends on the cor-
rect diagnosis thus leading to the correct treatment
and so offering much brighter prospects later on.
It goes without saying, that in all cases of preg-
nancy, where manifest luetic symptoms are noticed
in either or both parents or where the Wassermann
test taken as a precautionary measure, without the
presence of lesions, reveals a positive reaction, a
very prompt and intensive specific treatment should
be instituted at once. Unfortunately though such
cases are in the very small minority, the family
physician as a rule gets his first inkling of sus-
picion when he is called to attend a case of an abor-
tion or an early miscarriage, and I want to state
right here that we should suspect lues in every case
of spontaneous abortion or miscarriage, occurring in
an apparently otherwise healthy woman. Statistics
from various large obstetrical institutions will bear
out this statement. So found Ruge in Breslau, in
a series of 94 abortions in 78 cases lues as the only
causative factor. Professor Williams of Baltimore
has shown on a material of 1,000 consecutive preg-
nancies, in which 705 resulted in still-births, that
26 per cent, of these were due to syphilis.
What are the characteristic diagnostic features
in a stillborn syphilitic child? As a rule the skin
will be found macerated and peeling off; this phe-
nomenon, however, may occur in any fetus which
has died from any cause and has been retained in
utero for several days or longer, before being ex-
pelled. Tissier, however, found, on examining 155
macerated fetuses, in 99 the presence of syphilis,
and 95 per cent, of all macerated fetuses were
found to be syphilitic by Boissard. We therefore
are justified in suspecting very strongly the pres-
ence of syphilis just from this condition alone. But
all the internal organs will furnish more abundant
evidence. The thymus gland is enlarged and contains
multiple abscesses, the lungs show the so-called
white hepatization, the liver, spleen, pancreas, kid-
neys, adrenals are all greatly enlarged due to an
interstitial fibrosis and gumma formation. In all
these organs spirochetes are found in abundance.
At the ends of the long bones there is a broad zone
of ossification between the diaphysis and the epiphy-
sis with very irregular proliferations; in the bone
tissues are found islets of cartilage and in the carti-
lage islets of bone tissue, a process known as "Weg-
ner's osteochondritis." The placenta is also of
great diagnostic value in these cases. Its size and
weight are larger than normal and its consistency-
is more solid. On cutting, the tissue appears more
friable and looks like sausage meat; the weight, in-
stead of being about one-sixth of that of the
fetus, may be one-quarter or more and this latter
phenomenon alone, if not due to edema or the pres-
ence of cysts or tumors, should be looked upon in
itself as strongly suggestive of syphilis. Micro-
scopically we find the presence of gummata, vascu-
lar changes in the stroma of the villi, decrease in
the number of the blood-vessels, partly due to a
periarteritis and partly to an increase of stroma-
cells of the villi. In the decidual portion we find a
gummatous endometritis. The umbilical cord is
thick and there is a marked hypertrophy of the
connective tissues and thickening of the walls in the
umbilical veins. Spirochetes are also found in all
these different structures. It rarely happens that
syphilitic infants are born alive, snowing specific
symptoms at birth; if they are, however, the chil-
dren look puny, ill-nourished, have a shriveled
appearance, blue extremities and a hoarse, feeble
cry. The majority of congenital syphilitic children
surviving their intrauterine infection are born with
a clear skin and apparently in perfect health, but
soon our suspicion will be aroused, for characteristic
symptoms develop as a rule between the first and
twelfth week of life. Desquamating patches on the
palms and soles may be seen during very early in-
fancy and occasionally syphilitic pemphigus may
come on within a day or two after birth; if the
eruption is severe, the child usually dies. The
changes that take place within the first few weeks
in an infant, who appeared healthy at birth, are
such that it gradually seems to waste away. The
skin, which is wrinkled, assumes a dull earthy color
and there is evidence of marked anemia. The face
assumes a careworn expression, and looks like that
of a little old man. Various external lesions make
their appearance, such as pemphigus, rhagades at
the mouth, which may be so painful as to interfere
with nursing, condylomata around the anus, and a
copper-colored rash on buttocks and back. Snuffles is
a very characteristic symptom. At this time various
internal changes also take place, affecting important
visceral organs and undermining the little patient's
general health to such an extent that death soon
relieves all its sufferings, especially if no proper
and energetic treatment has been instituted. All
these clinical symptoms are characteristic enough to
enable us to make a correct diagnosis. But if still
in doubt, the Wassermann test will be of additional
value, for, as we have seen above, nearly 100 per
cent, of all mothers giving birth to syphilitic chil-
dren show a positive reaction. Therefore, it will be
our duty to examine the mother's blood in such a
case. The Wassermann test in the infant is unfor-
tunately not reliable enough, as we frequently get
a negative reaction in spite of positive lues. This
phenomenon has been explained by the fact that a
certain amount of immunizing substances have been
transferred from mother to child, sufficient to coun-
terbalance the development of a number of
spirochetes, thus weakening the formation of anti-
bodies and therefore leading to a negative Wasser-
mann. As soon as manifest lesions develop, and in
later life of the infant, the reaction will become pos-
itive and follow the same rules as in acquired lues.
In conclusion I want to make a final appeal to
the family physician, as he is the first one, as a
rule, who is called upon to make the diagnosis, to
recognize congenital syphilis or at least to suspect
it in a given case, and then to demand a Wasser-
mann test of the mother. Only then can such an
appalling waste of human life, as due to congenital
syphilis, be reduced. According to the best sta-
tistics 50 per cent, of all syphilitic children are
born dead and of those born alive 75 per cent, die
within the first year, most of them during the first
few weeks of life. The survivors, as a rule, go
through life physically and mentally damaged, a
living reproach to the misfortune of their parents.
1872 Washington- avenue.
Granuloma Pyogenicum.— C. P. Wescott reports a
case of granuloma pyogenicum occurring in a boy aged
9, and affecting the eye. It was located just above the
edge of the left upper lid and caused serious anxiety
for fear of cancer, the disease of which the child's
father had died. Wescott says the two conditions
simulating this growth are cancer and chancre. Al-
though persistent and liable to recurrence, it is usually
treated without much difficulty. The tumor in this
patient was removed and the wound cauterized; it
healed, leaving a very small scar. — Journal of the Amer-
ican Medical Association.
July 1, 1916]
MEDICAL RECORD.
17
THE IMPORTANCE OF BLOOD PRESSURE
TO THE EYE SPECIALIST.
Br F. P. HOOVER, M.D.,
JACKSONVILLE, FLORIDA.
The taking of the blood pressure in many instances
has to me been most satisfactory ; it has given me
a clearer and better understanding regarding such
cases as incipient Bright's disease, for instance,
after examination with the opthalmoscope. I
always prefer to take the blood pressure myself in
my office than to have it taken by someone else, no
matter what report may have been rendered me by
the attending physician (if one were in attendance
prior to my seeing the case) . I have come to look
upon my instrument as a necessary adjunct to my
office equipment. Time in taking these readings
should not be considered. As, however, the special-
ist rarely goes beyond his domain, the taking of
blood pressures by many is not considered to come
within their jurisdiction; it does not belong in their
line of work; it is an incroachment upon the work
of another. My ideas are at variance with those
who feel that taking a blood pressure should be left
to another entirely, but this is merely a matter of
opinion and preference. I have always felt when
a man went to a specialist on the eye, not to a "doc-
tor of optics or optometry," he does so because he
desires positive information regarding his condi-
tion. He may never have had medical attention be-
fore in his life, or since childhood, and it is fair to
that man, should the trouble be retinitis albu-
minuria, for example, to turn him loose with orders
to consult a general practitioner before seeing you
again, until you have personally investigated his
condition more fully, if for no other reason than
that of impressing, by a thorough knowledge of
the case, the great importance of prompt medical
attention, for there are men and women who, unless
you force, so to speak, a realization of what is the
matter with them, will in all likelihood leave your
office and never see a doctor until they are beyond
help. I have noticed this more especially in the less
well to do, those who in the majority of instances
have strained a point to see a specialist and cannot
afford additional expense; yet these same people
more often follow instructions implicitly than those
who are better off and have more of this world's
goods.
In taking the blood pressure the auscultatory
method is by far the easier and more satisfactory.
I used to take it by palpation, but the former meth-
od is much more reliable. The systolic pressure
alone gives too uncertain a reading to warrant a
diagnosis, for it is more easily influenced by gen-
eral conditions. In more than 90 per cent, of my
cases the pulse pressure averaged from 30 to 35 ;
my cases ranged from sixteen to seventy years of
age. Sometimes the pressure was abnormally high
in patients who were in first-class condition; for
instance, a man thirty years old came to me with a
foreign body in his eye; after its removal and see-
ing my sphygmomanometer, he asked what it was
for and, when told, said he wished his blood pres-
sure taken. This proved to be: systolic, 130;
diastolic, 100; pulse, 50, the record being taken
three times. A few days later he called again, and
I took the blood pressure once more; it was exactly
what it was at the previous visit, and yet this man
had no organic or physical ailment, spent a great
deal of time out of doors, was not of a nervous tem-
perament, had no business or domestic worries,
and was a splendid specimen of manhood 5 feet 11
inches tall and weighed 195 pounds. Nicholson says
"the diastolic pressure is between 60-105 mm. Hg. ;
a diastolic pressure above 105 mm. Hg. would be a
sure indication of hypertension, regardless of the
age of the patient."
In the aged, high blood pressure need not neces-
sarily prevail, neither should a snap diagnosis be
made in the event of a high blood pressure without
due consideration. There are many elderly people
who have had a high blood pressure for a long
time; they should be kept under observation, for
a sudden lowering of the blood pressure might be
disastrous for them, owing to its effect upon the
heart.
I have .found the blood pressures to vary some-
what in diseases of the eye: in hemorrhage of the
eye, high; in recurrent conjunctivitis with a rheu-
matic history, usually high; in retinitis albu-
minuria, high; in hysterical blindness, high; trau-
matism of the eye, in the majority of instances,
high, but we do not always see these cases until
some time after injury; in orbital cellulitis, high;
in exopththalmus, in the only case of the kind I
ever took a blood pressure, high; in optic neuritis,
high; in the nervous affections, varied; in keratitis,
retinitis, and various inflammatory conditions, va-
ried, except where there has been great pain, etc.,
as in iritis, and where there has been very little
rest or sleep, the pressure has been high, in chronic
eyestrain with more or less constant headache, pain
in or over the eye, pain in temples or on top of the
head, inflammation of the lids, the pressure is high.
We find this condition especially in bookkeepers and
those who use their eyes constantly for near work,
electricians, draughtsmen, painters on china or
those who work much on dark goods or glazed ma-
terial, those who sew for a living, proofreaders,
typesetters, cooks, etc. I do not mean to say the eye
may have been responsible for the high blood pres-
sure, for some condition in the heart, kidneys, or
nervous system in all probability was the direct
cause, but, nevertheless, in the various affections of
the eye named, I have found a blood pressure not
normal. I have said nothing regarding syphilis
or alcohol as a cause of eye trouble ; in the event of
either a high blood pressure is expected. I do not
wish to be misunderstood in this article to state the
absolute necessity of taking a blood pressure in all
of our eye cases, but I do say by so doing, many
times, one can locate some underlying cause that
plays an important part in the disease we have
under our care. In throat work in several instances
I have taken the blood pressure, and also in my
ear cases; in the former in acute bronchitis, ton-
silitis, laryngitis, asthma, also when inflammation
was accompanied by neuralgia or rheumatism or
gout, the pressure was varied, more often high. In
sufferers from anemic or run-down conditions, in
cases bordering on break down, and in diabetes, the
blood pressure was usually low. In acute otitis, in
furunculosis, in acute mastoiditis, in bulging of the
drum membrane, prior to rupture, and in cellulitis,
I have found the blood pressure high.
Mutual Life Building.
Indications for the Use of Ergot.— Sinha says that, as
ergot contracts unstriped muscular tissues in all parts
of the body and its action is not confined solely to the
organs of reproduction, it should be given when the
skin is pale, cool, and relaxed, bathed in cold, clammy
perspiration, the mucous secretions being increased,
with or without involuntary passages from bowels and
bladder. — Indian Medical Record.
18
MEDICAL RECORD.
[July 1, 1916
SOME DEFORMITIES OF THE HEAD MEN-
TIONED IN THE TALMUD.
AN HISTORICAL NOTE.
Br DAVID I. MACHT, A.B., LL.B., M.D.,
BALTIMORE, MD.
Among the most interesting malformations of the
head met with by the modern clinician are those due
to rickets, acromegaly, and osteitis deformans. The
history of these conditions is interesting and is of
a comparatively recent date. Osteitis deformans
was first described by Sir James Paget in 1877
and is sometimes known as Paget's disease.' Ac-
romegaly, the interesting condition which is now
regarded as related to disease of the pituitary
gland," was first described by Marie,3 in 1886. Even
rickets, though probably a very old condition, was
first described by Glisson1 in the seventeenth cen-
tury and is regarded as a disease of modern civil-
ized life, distinctly occidental in origin. It is the
morbus anglicus or English disease, and the term
rickets is originally from the English wrickken, to
twist. Rickets was a rare disease in the ancient
Orient.
In the course of some researches into the history
of medicine among the Semitic nations, I have come
across some passages in the Babylonian Talmud
which are of interest in connection with the above
named diseases. It is a matter familiar to every
student of the Bible that the Hebrew priests were
required to be physically, as well as morally, per-
fect— without a bodily defect or blemish — in order
to be eligible to service in the Temple.5 The Talmud,
in the tractate Bechoroth, enumerates several de-
fects which disqualify a priest from ministering
in his holy office. Among these, I was particularly
struck by three — the kilon, the lafton, and the
maqbon.
The condition of kilon is described as a person
having a peculiarly shaped head which is pointed
at the top, and broad at the bottom.
The lafton was a man with a head shaped exactly
the opposite of the preceding. To use the expres-
sion of the Talmud he had a head, very broad at
the top and narrow at the bottom, like a lefes, i.e.
a pumpkin.
The expression maqbon, derived from the word
hammer, refers to a hammer-shaped head, or as
the Talmud describes it, one with a prominent and
projecting forehead and occiput.
The terse descriptions of the kilon-head and
lafton-head, given by the Talmud, could not be im-
proved on by any modern text book in medicine.
Take, for instance, the excellent treatise on diag-
nosis by Musser. We have there a description of
the skull shapes in acromegaly and osteitis de-
formans, namely a triangle with its base below and
apex above in the one case, and the reverse in the
other, which matches exactly with the Talmudical
description. The diagrams drawn by that author
emphasize the similarity still more.
The Hebrew description of "hammer-head," as
applied to the rachitic skull is also very characteris-
tic. The classing of the rachitic deformity with
the two others, tends further to confirm the rarity
of rickets among the ancient Hebrews. That con-
dition, thanks to their dietary and other hygienic
laws, we know to have been a very rare one among
them, and was therefore probably as unusual and
striking as acromegaly or Paget's disease is among
us. It is thought that the above references to skull
deformities are of sufficient historical interest to
be worth noting, especially as the original sources
are not accessible to most medical men.
REFERENCES.
1. Paget: "Trans. Royal Med. and Chir. Soc," Vols.
LX and LXV.
2. Cushing: "The Pituitary Body and Its Disorders,"
1912.
3. Marie: "Essays on Acromegaly," New Sydenham
Soc, 1891.
4. Glisson: "A Treatise of the Rickets, Being a Dis-
ease Common to Children," London, 1651.
5. Leviticus, XXI.
iJte&inibgal Watts.
Expert Evidence in Malpractice Cases. — In an action
for damages against two surgeons for failure to
exercise reasonable care and skill in treating a
compound fracture of the bones of the plaintiff's
right arm, the evidence only showed the acts of the
defendants in getting the injured bones as observed
by the plaintiff and his wife, the nature of the treat-
ment by one of the defendants thereafter as they ob-
served it, the statements of the defendants as to their
belief that the arm would be restored to its usefuness,
and the fact that the arm was not straight when the
splints were removed. There was no evidence from any
physician to give the jury a standard to determine the
fact of reasonable care and skilfulness, and it was held
that the question was therefore one of law for the
court, as to permit the jury to determine it without
such expert evidence would be to allow them to decide
it from mere speculation and conjecture. Judgment for
thedefendants was affirmed. — Adolay v. Miller, Indiana
Supreme Court, 111 N. E. 313.
What Constitutes Practising Medicine. — On a trial
for practising medicine without a license the defendant
contended that the evidence was not sufficient to show
that he was guilty of violating the Iowa Medical Act.
or that he held himself out as a physician and surgeon,
or publicly professed to cure and heal, or that he made
a practice of healing and curing. The substance of the
evidence was that one witness went to the defendant's
house to ascertain if the defendant would treat him for
rheumatism; he said he did not remember what the
defendant told him, but he took four or five treatments,
these being performed while the witness was lying on
a sort of bench, and the defendant worked on his spine
and legs. The witness did not have any arrangement
as to charges, and never paid the defendant anything.
Another witness testified that the defendant came to
his house and gave him a treatment. This was done
by an adjustment of some of the joints of the wit-
ness's spine. He was stretched out on a bench which
the defendant had brought with him. This witness took
three or four treatments and gave the defendant $5.
Another witness said the defendant treated his wife
for goiter by rubbing the goiter and the spine; the
patient also had gas in the stomach, and the defendant
rubbed the stomach. For this the defendant received
$20 for 24 treatments.
Another witness testified that he had one of his arms
out of place, that he had sought treatment without
avail, and finally, meeting the defendant on the street,
asked him to see if he could put his arm in place, which
the defendant did.
The court thought the evidence was sufficient to take
the case to the jury on the question as to whether the
defendant assumed the duties of a physician, and that
he publicly professed to cure and heal. The conviction
was affirmed. State v. Booher, Iowa Supreme Court,
155 N. W. 167.
Prosecution for Practising Without a License. — The
Missouri statute declares that any person practising
medicine or surgery without a license from the Si
Board of Health, or after revocation of such license,
shall be deemed guilty of a misdemeanor, provided that
physicians registered on or prior to March 12, 1901, shall
be regarded for every purpose as licentiates and regis-
tered physicians. An information charging the accused
with practising medicine without a license did not nega-
tive the exception. It was held that as the exception
was not contained in that portion of the statute defining
the offence it was not necessary to negative it in the in-
formation, but to be available as a defence it must be in-
sisted on by the accused. — State v. Saak (Mo.) 182 S.
W. 1074.
July 1, 1916]
MEDICAL RECORD.
19
Medical Record.
A Weekly Journal of Medicine and Surgery.
THOMAS L. STEDMAN, A.M., M.D., Editor.
PUBLISHERS
WM. WOOD & CO., 51 FIFTH AVENUE.
See fourth page following reading matter for Rates of Subscription
and Information for Contributors and Subscribers.
New York, July I, 1916.
MEDICAL WORK AND WAR.
The threatened war with Mexico and the mobiliza-
tion of the State militia have given an opportunity
to the American Red Cross and to the medical units
attached to the National Guard as well as to the
Departments of Health to show in how far they
have profited by the experiences of the past few
years. The showing so far has been satisfactory-
In New York, for example, the State Department of
Health has on hand, as a consequence of having
foreseen the possible demand, sufficient typhoid vac-
cine to immunize every member of the New York
State National Guard against this disease, and is
now sending it out to the mobilization camps as rap-
idly as it is needed. The excessive morbidity and
mortality of the Spanish War will thus be avoided.
The first field hospital, the original of its type in
this country, and the Third Ambulance Corps, both
from New York City, the latter under the command
of Capt. L. H. Shearer, M.D., of Bellevue Hospital,
and the former of Major J. Franklin Dunseith,
M.D., of the City Department of Health, were
among the first units to reach the concentration
camp at Beekman, N. Y. The sanitary conditions
at the mobilization camp are in charge of Col. Wil-
liam S. Terriberry, M.D., of New York, who will
have each man inoculated against typhoid, and will
forbid the eating of any food except that prepared
in the camp kitchens.
Through timely gifts the New York branch of the
American Red Cross has been enabled to complete
its equipment of eight base hospitals of 500 beds
each, the hospitals being manned by members of the
staffs of the New York, Presbyterian, Mt. Sinai,
Bellevue, Lincoln, German and the Post-Graduate
hospitals. The eighth unit is the Naval Base Hospi-
tal in Brooklyn. Corresponding to these New York
units a number of other units are being planned in
other cities (thirteen in all are organized), which
will give the Red Cross a total equipment for over
15,000 beds. The New York branch is also conduct-
ing classes in first aid and the care of the sick, in
order to have volunteer helpers available, and these
courses will be continued throughout the summer.
Six thousand Red Cross nurses are holding them-
selves in readiness for mobilization orders, accord-
ing to the statement of the executive secretary of
the New York headquarters. The Preparedness
League of American Dentists has opened a registra-
tion bureau in Buffalo in the hope of enrolling
20,000 dentists who will prepare free at least one
applicant each to meet the requirements for enlist-
ment in the Army, Navy, or Marine Corps. The
standard of enlistment requires the applicant to
have at least twenty sound teeth, with four opposed
molars and four opposed incisors. Properly filled
teeth are counted as sound.
TWO VIEWS OF TOURNIQUETS.
All the devices of surgery are being tried out on
a gigantic scale in the European war, and the sur-
geons of America are awaiting the verdict of then-
European colleagues on many points, just as a half
century ago the situation was reversed. Many a
surgical procedure, beneficent in the hands of a
surgeon in the operating room and admirable in
theory, does not justify itself when put to the stern
test of the battlefield. Among the doubtful in-
stances the tourniquet may be mentioned. This ap-
pliance has a limited field of usefulness in the mod-
ern operating room and a wholly disproportionate
value in the minds of the laity who recall news-
paper accounts of persons saved from bleeding to
death by the prompt application of a tourniquet im-
provised from a handkerchief by a quick-witted by-
stander. At any rate, the European soldier is fur-
nished with a rubber one in his first-aid packet and
instructed in its use, the theory being that unneces-
sary loss of blood can thus be prevented.
Professor Albrecht of the Austrian Army,
quoted in the Wiener medizinische Wochenschrift,
calls attention to cases of gangrene resulting from
rubber tubing tied around a limb to prevent hemor-
rhage. These, he said, were usually due to the
fact that after such a bandage had been placed,
either the surgeon or the patient would be trans-
ferred elsewhere. He suggested that such cases
should be plainly labelled "rubber tourniquet."
Unfortunately in many cases only the outer dress-
ings were changed and the pressure of the tourni-
quet was not discovered until gangrene had set in.
Some cases were due to the application of the
tourniquet by the soldier himself who was later
unable to remove it or did not dare to do so.
On the other hand, Dr. R. P. Rowlands, surgeon
to Guy's Hospital, writes in the Lancet for May 13
a plea for the more thorough use of the tourniquet
in peace and war. He believes that many lives
have been lost because sufficient pains were not
taken to prevent the wounded from losing still
more blood. This extreme loss of blood causes a
secondary anemia which handicaps the patient and
also increases the risk of sepsis and other compli-
cations. The rest of Dr. Rowland's letter is chiefly
concerned with the technique of amputation, his
only allusion to the use of the tourniquet in war
being where he says, "during this war I have ten-
tatively extended the method to the septic wounds
now so common, and with very satisfactory re-
sults."
Professor Albrecht's comments on the tourniquet
seem much more pertinent, dealing as they do with
20
MEDICAL RECORD.
[July 1, 1916
his observation of cases on the battlefield where the
after-care of the patient had not been properly
carried out. The correct view would seem to be
that the tourniquet has a proper and very useful
place in battlefield surgery, but also that every case
in which a tourniquet has been applied should be
given very special attention and wherever possible
should be attended by the same surgeon for at least
forty-eight hours after the application of the
bandage.
THE BLOOD IN EPILEPSY.
It is hardly necessary to recall to the minds of the
profession the many theories that have been held
in the past regarding the nature of epilepsy. The
explanation of the ancient Romans who believed
that epilepsy was a visitation of the gods and that
of the present-day savages who think that ancestral
spirits enter the body and fight the indwelling spirit,
causing convulsions, seem to be as plausible as any.
Accompanying the varying theories, inevitable se-
quellse of them in fact, many kinds of treatment
have had their day. Nearly every drug in the
Pharmacopeia and every one reputed to be a seda-
tive, has had its trial. The bromides, opium, chloral,
cannabis indica, borax, solanum carolinense, adonis
— the list could be extended almost indefinitely.
Lately more spectacular forms of therapy have
had their vogue. The psychoanalysts, e.g. have
maintained that in the epileptic convulsion we have
a parallel to the incoordinate movements of the in-
fant when he comes in conflict with his environment,
that epilepsy in fact represents a regression of the
individual to infantile levels. Their method of
approach to the problem would be an analysis of the
convulsion itself to see how it represented the con-
flict and then an endeavor to get the patient to
adjust himself to his conflict in a way more com-
patible with social conventions. We all know some-
thing of the treatment with rattle-snake venom, or
the crotalin treatment. Then we have tried recently
a serum obtained from the blood of other epileptics.
With this latter method is associated the name of
Spangler, who reports further studies of his on the
blood in epilepsy in the Lancet for April 29. His
observations were made on 369 private patients, not
institutional cases. He finds that the hemoglobin is
high in the disorder, averaging 84 per cent., in his
series of cases. This is at variance with Facken-
heim, who found an average of not quite 60 per
cent. Of course Spangler's cases appear to be from
a somewhat higher social plant and therefore pre-
sent the factors of better nutrition, hygiene, etc.
The latter observer found no marked diminution in
the red blood cells and no degeneration of them ;
the white blood cells showed increase approximately
synchronously with the paroxysm, small lympho-
cytes and polymorphonuclears were normal, the
large lymphocytes were increased, but there was no
evidence of eosinophilia. The coagulation time of
the blood was shortened and its alkalinity lowered.
It is not obvious what deduction, if any, can be
made from the above observations, but in a disease
as obscure as epilepsy all accurate contributions to
the pathology are welcome as possible future sources
of light in the therapy.
Citrated Milk Feeding for Infants.
There has been of late a good deal of discussion
with regard to citrated milk feeding for infants.
Dr. F. J. Boynton was the first to work out and
publish a paper on this form of feeding, and in the
Practitioner for June, 1916, he has a short paper on
the subject, in which he reiterates several of his
former conclusions. He is of the opinion that it is
a practical error to advocate placing infants on
citrated whole milk from the first, as he thinks
there is too much risk in such a course. Diluted
milk should be used until the infant's reaction to
cow's milk has been tested, and then the strength
of the milk should be quickly increased. Citrated
milk is valuable for correcting milk dyspepsia.
Nevertheless, its routine and prolonged use are not
advisable. Moreover, the use of very diluted milk
with large quantities of citrate of sodium may re-
sult in general anasarca and convulsions. Some-
times it produces instant diarrhea, but Boynton re-
mains convinced that his original contention that it
has a tendency to produce constipation is correct.
The citrate should be increased in proportion to the
milk, and not to the mixture of milk and water.
Boynton especially emphasizes the point that sodium
citrate should never be given to a healthy child of
eight or nine months as a routine practice, and when
given he prefers a solution to tablets. The com-
mencement of hand feeding should always be cau-
tious. Small infants should not be started on
citrated whole milk. In short, when used judicious-
ly and discreetly sodium citrate in many instances
is valuable in the feeding of infants, but care must
be taken not to overdo the practice or to use the
drug prematurely.
2fot»a of tfc? Itek.
Medical Preparedness. — Col. Jefferson R. Kean,
Medical Corps, U. S. A., director general of mili-
tary relief for the American Red Cross, states that
the most important work which has probably ever
been undertaken by the American Red Cross for the
assistance of the medical service of the army is
now being done in the organization of base hospital
units from the personnel of the larger civil hospi-
tals in this country- These base hospitals, which
embrace much of the best professional talent in the
country, are intended to be transported on the out-
break of war to the seat of military operations,
where they will be located at the city which is
selected to be the military base. One of these
is needed for each 20,000 men brought into
service. They receive the sick and wounded
coming from the field hospitals at the front,
and in them the wounded soldier in his
journey to the rear first finds a comfortable
bed and trained nurses. Thirteen base hos-
pitals with skilled personnel are now organized and
seven more are in process of organization. Each
base hospital is equipped to receive 500 patients.
Although organized by the Red Cross, they are not
administered by it, but when called into active serv-
ice pass under the exclusive authority of the War
Department and become a part of its medical serv-
ice. The medical officers are given military commis-
sions in the Reserve Corps, and receive volunteer
commissions when called into active service. The
nurses in the same way belong to the Red Cross
Nursing Service, and in time of war become a part
of the Army Nurse Corps. The organization in
July 1, 1916J
MEDICAL RECORD.
21
time of peace of these large and complex units will
place at the disposal of the Government imme-
diately on the outbreak of war organizations which
it would require many weeks to create and equip,
and offers our soldiers from the first the finest med-
ical talent in the country. The following are the
locations of these hospitals and the heads of their
various services :
Presbyterian Hospital, New York City. — Director
and chief of surgical service, Dr. George E. Brewer ;
principal assistant, Dr. Alfred Stillman; chief of
medical service, Dr. Warfield T. Longcope; chief of
laboratory service, Dr. Karl M. Vogel; chief nurse,
Miss Anna C. Maxwell.
Mount Sinai Hospital, New York City. — Director,
Dr. N. E. Brill; chief of surgical service, Dr. How-
ard Lilienthal; chief of medical service, Dr. R.
Weil; chief of laboratory service, Dr. George
Baehr; chief nurse, Miss Elizabeth A. Greener.
Bellevue Hospital, New York City. — Director and
•chief of surgical service, Dr. George David Stew-
art; chief of medical service, Dr. Van Home Nor-
rie; chief of laboratory service, Dr. Charles Norris;
chief nurse, Miss Clara D. Noyes.
New York Hospital, New York City. — Director
and chief of surgical service, Dr. Charles L. Gib-
son; chief of medical service, Dr. Lewis A. Con-
ner; chief of laboratory service, Dr. William J.
Elser; chief nurse, Miss M. H. Jordan.
New York Postgraduate Hospital, New York
City. — Director, Dr. Samuel Lloyd; chief of surgi-
cal service, Dr. Edward W. Peterson ; chief of med-
ical service, Dr. Arthur F. Chace; chief of labo-
ratory service, Dr. Ward J. MacNeal; chief nurse,
Miss Amy Patmore.
Brooklyn, N. Y., for Navy. — Director and chief
■of surgical service, Dr. W. B. Brinsmade; chief of
medical service, Dr. Luther F. Warren; chief of
laboratory service, Dr. Robert F. Barber; chief
nurse, Miss Frances van Ingen.
Massachusetts General Hospital, Boston, Mass. —
Director, Dr. Frederic A. Washburn; chief of surgi-
cal service, Dr. George W. W. Brewster; chief of
medical service, Dr. Richard C Cabot ; chief of
laboratory service, Dr. J. Homer Wright; chief
nurse. Miss Sara E. Parsons.
Boston City Hospital, Boston, Mass. — Director,
Dr. J. J. Dowling; chief of surgical service, Dr.
Edward H. Nichols; chief of medical service, Dr.
John Jenks Thomas; chief of laboratory service.
Dr. Arial W. George; chief nurse, Miss Emma M.
Nichols.
Harvard University, Mass. — Director and chief
of surgical service, Dr. Harvey Cushing; chief of
medical service, Dr. Roger Lee ; chief of laboratory
service, Dr. Richard P. Strong; chief nurse, Miss
Carrie M. Hall.
Lakeside Hospital, Cleveland, Ohio. — Director,
Dr. George W. Crile; chief of surgical service, Dr.
W. E. Lower; chief of medical service, Dr. C. F.
Hoover; chief of laboratory service, Dr. H. T.
Karsner; chief nurse, Miss Grace Allison.
Rochester, N. Y. — Director, Dr. John M. Swan ;
chief of surgical service, Dr. C. W. Hennington ;
chief of medical service, Dr. William V. Ewers;
chief of laboratory service, Dr. C. C. Sutter; chief
nurse, Miss Emma Jones ; assistant, Miss Jessica
Heal.
Johns Hopkins Hospital, Baltimore, Md. — Di-
rector. Dr. Winford Smith ; chief of surgical serv-
ice, Dr. J. M. T. Finney; chief of medical service,
Dr. T. C. Janeway; chief of laboratory service. Dr.
T. R. Boggs ; chief nurse, Miss Bessie E. Baker.
Harper Hospital, Detroit, Mich. — -Director, Dr.
Angus McLean; chief of surgical service, Dr. C. D.
Brooks; chief of medical service, Dr. B. R. Shurly;
chief of laboratory service, Dr. P. M. Hickey ; chief
nurse, Miss Emily McLaughlin.
The names of the heads of the German and Lin-
coln Hospital units in New York have not been an-
nounced at this writing.
Mr. Irving T. Bush has relieved the embarrass-
ment of the Red Cross in regard to space for storing
the equipment of the five base hospitals now being
organized in New York in behalf of our own army
and navy by offering to provide for three of these
units at the Bush Terminal.
Death Rate in New York. — The death rate in
New York City for the week ending June 17 was
12.36 per 1,000 of population, representing a total
of 1,324 deaths, as compared with a rate of 13.28
for the corresponding week of 1915. This decrease
was due chiefly to the lessened mortality from the
acute infectious diseases — measles, scarlet fever,
diphtheria, croup, and whooping-cough — and from
lobar and bronchopneumonia. There was, however,
an increase in the number of deaths due to heart
disease, Bright's disease, and pulmonary tubercu-
losis. For the first twenty-five weeks of 1916 the
death rate was 14.92, or 0.29 lower than for the
same period last year.
Medical College Commencements.— At the nine-
ty-first annual commencement of Jefferson Medical
College, Philadelphia, held on June 3, the degree of
doctor of medicine was conferred on 162 graduates
of the school. Dr. W. W. Keen addressed the class
on "The Doctor's Duty."
The thirty-sixth and final commencement exer-
ciser of the Medico-Chirurgical College, Philadel-
phia, were held on June 9, when the medical degree
was conferred on eighty-three graduates. The col-
lege has been merged with the medical department
of the University of Pennsylvania.
Six graduates in medicine received the doctor's
degree at the 216th commencement of Yale Univer-
sity on June 21. Dr. Arthur Dean Bevan, professor
of surgery in the Rush Medical College, Chicago,
and chairman of the council on medical education of
the American Medical Association, received the
honorary degree of master of arts ; the same de-
gree was given to Dr. David Russell Lyman, head
of the Gaylord Sanatorium, Wallingford, Conn., and
on Dr. Theobald Smith of the Rockefeller Institute
of Medical Research was bestowed the honorary
degree of doctor of science. The Yale Corporation
has announced that hereafter a limited number of
graduates of approved colleges for women will be
admitted to the Yale School of Medicine.
Harvard University at its annual commencement
on June 22 bestowed the degree of doctor of medi-
cine on sixty-three graduates of the medical school,
and the degree of doctor of dental medicine on
forty-five graduates. Dr. W. G. Smillie and Dr.
Ralph Mellon received the degree of doctor of pub-
lic health, and Dr. Richard Pearson Strong, pro-
fessor of tropical medicine in the Harvard Uni-
versity Medical School, received the honorary de-
gree of doctor of science.
Personals. — Dr. Edward Perkins Carter, profes-
fessor of medicine in the medical department of
Western Reserve University, Cleveland, Ohio, re-
ceived the honorary degree of master of arts from
Williams College, Williamstown, Mass., on June 21.
Dr. Joseph A. Andrews of New York and Los
Angeles, Cal., sailed from New York on June 20 for
Labrador, on his sixth annual trip to treat at Gren-
22
MEDICAL RECORD.
[July 1, 1916
fell Mission natives of Labrador who are suffering
from eye troubles.
Dr. Allen G. Rice of Springfield, Mass., has for
the second time within four years been awarded the
prize of $200 offered annually by the Caleb Fisk
estate of Providence, R. I. The subject for this
year was "Diagnostic and Prognostic Value of
Blood Pressure Determinations."
Dr. Charles L. Gibson, director and surgical chief
of the New York Hospital Red Cross unit, sailed for
Europe on Saturday last.
Civil Service Examination. — The New York
Municipal Service Commission, Municipal Building,
Manhattan, will receive applications until July 5,
1916, from candidates for the position of pathologist
in the city employ. One vacancy exists at present
in the Department of Public Charities, Kings
County Hospital, Brooklyn, at a salary of $1,500 per
annum without maintenance. Application blanks
will be mailed upon request, but no applications will
be accepted at the office of the Commission after
4 o'clock P.M. on the date mentioned. Candidates
must be over twenty-one years of age and have the
degree of M.D. from an approved institution. The
duties of the pathologist include the performance of
autopsies, the microscopical diagnosis of tissues,
and bacteriological diagnosis and clinical pathology ;
and a practical test will be held in the laboratory
at which the candidates will be required to demon-
strate their ability to perform the work as above
outlined.
Navy Medical Corps. — The next examination for
appointment in the Medical Corps of the United
States Navy will be held on or about August 7, 1916.
The first stage of the examination is for appoint-
ment as assistant surgeon in the Medical Reserve
Corps; the successful candidate then attends the
course of instruction at the Naval Medical School,
beginning October 1, 1916, and during this course
receives a salary of $2,000 per annum, with allow-
ance for quarters, etc. At the end of the course, if
he passes an examination in the subjects taught, he
is commissioned an assistant surgeon in the navy
to fill a vacancy. Applicants must be citizens of
the United States and must submit satisfactory evi-
dence of preliminary education and medical educa-
tion. Full information with regard to the physical
and professional examinations, with instructions
how to submit formal application, may be obtained
by addressing the Surgeon General of the Navy.
Navy Department, Washington.
Grading of Restaurants Continues. — The Health
Department continued during the past week its
work of inspecting and grading the restaurants in
New York City, although no figures have been given
out, the Department having determined, in order
not to be unfair, not to grade a restaurant until
after reinspection. This will meet the objection
that minor violations have resulted in some of the
recent "bad" gradings. The Department has re-
ceived indorsements of its plan from the State Food
and Drugs Commissioners of North Dakota and In-
diana, in both of which States similar grading has
been carried out.
Poliomyelitis Epidemic. — During the past few
weeks an unusually large number of cases of
poliomyelitis have been reported, especially from the
section bounded by Henry Street and Seventh Ave-
nue, Baltic Street and First Street, and occurring
chiefly among Italians. The Department of Health
is having made a house to house canvass in each
block in which there is known to be a case of the
disease, and the Acting Commissioner has addressed
a letter to every Brooklyn physician, calling atten-
tion to the existence of the disease, the methods of
diagnosis, and the possible modes of infection, and
asking for the co-operation of the profession in con-
trolling the outbreak.
A Decision Against the American Medical Asso-
ciation.— The long-drawn out trial of the Chatta-
nooga Medicine Company's suit against the Ameri-
can Medical Association for libel has at last ended
with a verdict against the Association. The Journal
had characterized one of the products of the Medi-
cine Company as "booze," "a tipple," and "a worth-
less fraud." The trial, which was held in Judge
Landis' court in Chicago, lasted three months and
must have cost the Association a very large sum.
Obituary Notes. — Dr. Lawrence Thomas Ait-
ken of Brooklyn, N. Y., a graduate of the Long
Island College Hospital, Brooklyn, in 1908, pedi-
atrist at the Coney Island Hospital, and dermatolo-
gist at the Polhemus Clinic, died at his home on
June 18, aged 32 years.
Dr. Eugene Albert Gilman of Boston, Mass., a
graduate of Harvard University Medical School in
1872, and a member of the Massachusetts Medical
Society and the Suffolk County Medical Society,
died at his home, after a lingering illness, on
June 17.
Dr. Frederick Buell Willard of Hartford,
Conn., a graduate of the University of Vermont,
College of Medicine, Burlington, in 1900, a member
of the American Medical Association, the Connecti-
cut State Medical Society, the Hartford County
Medical Society, and the American College of Sur-
geons, and a surgeon on the staff of the Hartford
Hospital, died at the hospital, following an operation
for appendicitis, on June 16, aged 43 years.
Dr. John Owen Smith of South Canterbury,
Conn., a graduate of the Eclectic Medical College
of the City of New York in 1882, died recently at his
home, aged 76 years.
(UorrespDttlintr?.
THE SARATOGA CO, BATHS.
To the Editor of the Medical Record:
Sir: — At the annual meeting of the Saratoga
Springs Medical Society held on May 25, 1916, Con-
servation Commissioner George D. Pratt, under
whose department the management of the State Min-
eral Water Reservation at Saratoga Springs has re-
cently been placed, was a guest of the society and
addressed the meeting on the above subject. He
said in part as follows:
I have evolved certain fundamental policies with re-
gard to this reservation which I am very anxious to
make clear, not only to the members of your own so-
ciety but also to the medical profession at large. No
more fortunate time for expressing; these principles
could be found than this evening, when what I have to
say can be addressed to you personally and through you
to your brothers in the profession throughout the en-
tire United States. In full assurance that the force of
my statement will be thoroughly appreciated, I can say
to you that the highest development of the springs at
Saratoga and the greatest realization by the people of
the healing virtues in their waters can be brought about
only by whole-hearted cooperation between the physi-
cians themselves and the State commission that is
charged with the control of these natural resources.
The waters of the springs are good of themselves,
and in many cases may be taken freely without medical
direction. This is particularly true of the table waters,
of which Saratoga offers a wonderful supply. When we
July 1, 1916]
MEDICAL RECORD.
23
turn to the medicinal springs, however, we are brought
face to face with the incontrovertible medical fact that
in a large number of diseases the greatest good from
these waters can be obtained only through careful
courses of treatment prescribed and carried out in ac-
cordance with the tested principles of medical thera-
peutics. It is well understood by physicians that every
case of disease and of lowered efficiency, such as can
be benefited by the opportunities presented at Saratoga,
has its own individual characteristics, and that these
characteristics, these organic and constitutional condi-
tions, can be accurately determined only by expert
medical diagnosis. It accordingly follows that correct
application of the principles of medical therapeutics to
each individual case can be made only by a physician.
In fact, though I am no physician, I believe that I am
not far from the truth when I state that persons who
without the advice of a competent practitioner under-
take courses of treatment for the serious maladies that
bring many of them to the baths and springs at Sara-
toga are taking very grave and unwarrantable chances.
If this is true, it is clearly evident that right utiliza-
tion of the medicinal springs at Saratoga can be brought
about only through coordination of the State's admin-
istrative control with the practice of the medical pro-
fession.
It is in the highest degree important that the Con-
servation Commission, in its conduct of the great natu-
ral resources found here in such lavish abundance, shall
appreciate fully not only the material, physical require-
ments for taking the cures that these waters offer, but
also the ethical obligations that are involved in the ex-
ploitation of the springs. I speak of these ethical ob-
ligations in the medical sense. In the advertising and
sale of the purely table waters, such as the Soft Sweet
Spring water, and the other waters for which curative
qualities are not claimed, the obligations imposed upon
the commission are the usual moral obligations of hon-
est and conservative business. With the development
of the medical springs, however, whether their waters
are used for baths or for drinking, there is imposed
upon the commission a further obligation which you
physicians, if not all laymen, understand as the obliga-
tion of medical ethics. This obligation the commission
will endeavor to appreciate and adhere to. Saratoga
holds no cure-all. But for certain diseases and for cer-
tain functional disturbances, fostered by the pace of our
modern, high-pressure civilization, its springs do indeed
run with an elixir of life and hold as much of the power
of rejuvenation as any fountain of youth yet discovered.
In their more extensive development no false or ex-
travagant claims must be made for them. They need
no such exploitation. But in a thoroughly broad-
minded and ethical spirit the boons that they offer must
be made increasingly available to the entire public in
their pure and unchanged natural condition.
It is now of immediate importance that the medical
profession at large and the people of Saratoga and of
the State and nation understand the firm resolve of the
commission, and, behind the commission, of the State
administration, as vouched to you by Governor Whit-
man the other day, to work steadily and consistently,
and above all ethically, for the higher development of
this wonderful health resort. There has grown up in
the public mind, and in the minds of some of the medical
profession, an idea that the waters of Saratoga are
adulterated or altered in some degree. If this were
true it would be equivalent to an admission that the
waters of Saratoga are either not all that is claimed for
them or else they have been lessened in value by altera-
tion or adulteration. We know, on the authority of the
very highest medical opinion, that the unchanged waters
of the springs, as they flow naturally from the earth,
are equal, if not superior, in their medical qualities to
those of any other known springs in the world. To
adulterate them is unthinkable to any right-minded per-
son, and to alter their chemical content is quite unneces-
sary. I wish to state to the medical profession on this
occasion that the policy of the Conservation Commission
will be to conserve the springs in their natural state
and to give both the baths and the waters in the same
natural condition that they are in when they come out
of the ground. If any individual physician wishes to
prescribe them in altered form for an individual pa-
tient this will be entirely upon his own responsibility
and will affect no other than his own individual patient.
The waters of Saratoga are Saratoga waters. As
such they are widely and favorably known for their
efficacy in the treatment of certain disorders. To en-
deavor to identify them as to their chemical make-up
with the waters of other springs is to endeavor to make
them shine by reflected light. It is the belief of the
commission that they need no such illumination. To
change their make-up artificially in order to make them
more nearly conform to the chemical formula of springs
in other places is to assert that their established repu-
tation has been built upon no firm foundation in the
past. Such a statement would be untrue. Saratoga
offers its own gift to the world ; a gift that, in the opin-
ion of the most capable specialists, is destined to place
Saratoga still farther in the lead as one of the world's
great benefactions. Believing fully in the correctness
of this prophecy, the Conservation Commission is de-
termined that Saratoga's position shall be taken by
Saratoga herself because of the merits that it possesses,
and not because of artificial or transplanted merits or
reputation. In this endeavor the commission asks the
cooperation of the medical profession.
The force and wisdom of the policy herein out-
lined by Commissioner Pratt are most commendable.
The local medical society through many of its mem-
bers expressed sincere and hearty accord with the
Commissioner's ideas. The medical profession of
Saratoga Springs realize that the Saratoga mineral
waters have in the past with careful and scientific
administration given most excellent and decided re-
sults in pathological and functional disorders and
now with the increased efficiency of these waters and
the added facilities for their administration made
possible by state ownership and control, these thera-
peutic results have been increased several fold.
The physicians of Saratoga Springs decry most
sincerely the adulteration of these waters for bath-
ing purposes unless it be in exceptional cases where
it should be left to the judgment of the individual
physician to determine what additions shall be made
and in what quantities and these additions should
only be made on special prescription. They do not
in any sense favor the routine addition of any
chemicals to the natural Saratoga waters, believing
that these waters in themselves with their super-
saturation with carbonic acid gas are eminently effi-
cient without any addition and that they should
stand on their own merits for therapeutic effect.
The use of the term "Nauheim Bath" is some-
what misleading as every so-called "Nauheim
Bath" throughout the world varies from all the
others and the use of that name as applied to the
Saratoga waters should be discouraged. The local
profession prefer the term "Saratoga CO.. Mineral
Baths." Following the discussion of the subject the
following resolution was unanimously adopted:
"Whereas, after an experience covering a con-
siderable period, during which observations have
been made of several thousand baths administered
to a large number of patients at Saratoga Springs
with the use of unaltered natural mineral water:
"Resolved, that it is the deliberate and emphatic
expression of the conviction of the members of the
Saratoga Springs Medical Society that for series of
successive CO, mineral baths given systematically,
our natural Saratoga Springs mineral water, as now
supplied in the tubs of the State bath-houses, with
its dissolved gas retained in supersaturation, is
fully efficient; and further, that it should be used
for such series of baths without the addition of
any salts, chemicals or other substances, unless
such additions are plainly and explicitly ordered in
the prescription of the physician."
It is believed that when this matter is carefully
analyzed this position in regard to the baths at
Saratoga Springs will meet with the approval of the
profession of the State as well as of the nation.
Officers of the Saratoga Springs
Medical Society.
24
MEDICAL RECORD.
[July 1, 1916
OUR LONDON LETTER.
(From Our Regular Correspondent.)
GENERAL MEDICAL COUNCIL — EDUCATION COMMITTEE
— TEACHING ETHICS — FORENSIC MEDICINE DEN-
TAL COMMITTEE — PUBLIC HEALTH, PHARMA-
COPCEIA AND OTHER COMMITTEES GENERAL MAX-
WELL'S TRIBUTE — KILLED AND WOUNDED DIS-
TINGUISHED SERVICE.
London, June 10, 1916.
The General Medical Council has held its 103rd
session, extending over five days. Much of the
business is formal but necessary and would not
interest your readers, but there are some subjects
which may claim mention. Thus penal cases oc-
cupy a good deal of time and result in a few
names being removed from the register for "in-
famous conduct in a professional respect," the most
frequent offence being that of "covering" illegal
practice. Generally, it is a nurse who has thus been
enabled to abuse her position and the council "takes
a very grave view"- of the danger from the public
point of view of practitioners lending their names
for this purpose. Nevertheless, when cases are
proved the judgment too often only amounts to a
brief suspension which, in such circumstances, may
not be so severe as it looks, and those are not alto-
gether unreasonable who urge that the full penalty
in a few cases would be a more efficient deterrent.
The report of the Education Committee refers to
the ethical relationships of practitioners to the
State, to their patients, and to each other. At their
appointment they were directed to make such in-
quiries as they deemed advisable on these matters.
A letter addressed to all the teaching bodies elicited
the information that the subject is dealt with as a
part of the regular work in the colleges — sometimes
in the courses of forensic medicine and public
health or in other classes; sometimes in special lec-
tures. But in a number of institutions no regular
instruction has heretofore been provided on the sub-
ject. The committee consider that this neglect
should not continue though they recognize that
great variety may exist in the arrangements made
by various bodies. They propose that a general
recommendation dealing with the teaching of medi-
cal ethics be added to the resolution of the General
Medical Council in regard to professional education,
as follows: "Instruction should be given in the
courses of forsenic medicine and public health, or
otherwise, on the duties which involve upon practi-
tioners in their relationship to the State, and upon
the generally recognized rules of medical ethics.
Attention should be called to all explanatory notices
on these subjects issued by the General Medical
Council."
The report of the Dental Education and Exami-
nation Committee was received and approved after
some discussion. Reports from the committees on
Public Health, the Pharmacopoeia and Students'
Registration were also received, approved and en-
tered on the minutes.
General Maxwell has paid a striking tribute to
the doctors and nurses who rendered their valuable
services during the late disturbances in Dublin and
particularly those who exposed themselves to heavy
fire in attending to and removing the wounded. Also
to members of the Red Cross and St. John's Ambu-
lance Societies, as well as the numerous medical
men and private persons who gave assistance to
these associations or in other ways helped in the
work, especially those who placed their houses at
the disposal of the military medical staff for use as
dressing stations. In numerous instances such serv-
ices were rendered in circumstances involving great
inconvenience and even personal risk.
The war office has issued dispatches from the
commanders at the front in which a number of
medical officers are mentioned for distinguished and
meritorious service.
The King has conferred the D. S. 0. on Captain
T. Lewis Ingram, R. A. M. C, who collected and
attended wounded under very heavy fire and has
been conspicuous for bravery throughout the war;
also on Captain Brash, B. B., who, under heavy
shell fire, assisted by two men, extracted the wound-
ed at an artillery dug-out and administered first aid ;
on Captain Woodhouse, M. B., Captain Hart, M. B.,
and Lieutenant Knight, M.D., who acted in
the same courageous way. The dispatches state
that all branches of the medical services deserve the
highest commendation for the successful work done
by them both at the front and on the lines of com-
munication. The sick rate had been low and there
had been no epidemic. Enteric fever had almost
disappeared before the energetic preventive meas-
ures carried out. The results of exposure in trench
warfare in the winter were considerably restrained
by the precaution of the regimental medical officers.
The wounded were promptly and efficiently conveyed
to the base. The cooperation between officers of
the regular medical service of the army and mem-
bers of the civilian medical body who patriotically
assisted them contributed to the prevention of dis-
ease and the successful treatment and comfort of
the sick and wounded. The value of the work in
the central laboratory and of that done by the
chemical advisers with the armies in investigating
into the nature of gases and other new substances
used in hostile attacks should not be overlooked nor
should the means of protecting our troops against
them.
In the Franco-Prussian War, out of 4062 German
doctors with the army only 9 were killed and 69
wounded; but in the present war, up to January 15,
56 German doctors have been killed, 216 wounded,
40 made prisoners, and 94 are missing, while 29
have died of disease or wounds, 5 have met with
accidents, and 2 are invalided. These figures are
out of a total number of about 12,000 actually with
the army and do not include men in the military
hospitals, nor about 10,000 employed in reserve hos-
pitals, sanatoria, prisoners' camps, and ambulance
trains. As Germany has about 32,000 medical men,
if these figures are correct, it would seem that only
about 8,000 would be available for ordinary civilian
practice.
Boston Medical and Surgical Journal.
June 1.",, 1916.
I Respiratorv Exchange, with a Description of a Respiratory
Apparatus for Clinical Use. Francis C. Benedict and
Edna H. Tompkins.
\1 Studies of the Basal Metalnilism in Disease and Their Im-
portance in Clinical Medicine. .1 H. Means.
3. The Physicians and the Prevention of Industrial Acci-
dents. Herbert J. Cronin.
1 Memoria ienjamin E. Cotting.
5. Two Cases of Syphilis of the Lung. Aimer Post.
1. Respiratory Exchange, with a Description of a
Respiratory Apparatus for Clinical Use. — Francis C.
Benedict and Edna H. Tompkins call attention to the
fact that many clinicians are perhaps not aware that
a loss in weight, especially an initial loss in weight.
July 1, 1916!
MEDICAL RECORD.
25
may be largely due to a loss of water from the body,
even with patients not edematous. Furthermore, they
may have no knowledge as to whether the loss consists
of fat, muscle, or carbohydrate. A loss in weight due
to a loss of a specific material may vary in its interpre-
tation according to the character of the material; thus
a loss of muscle, and particularly a loss of carbo-
hydrate, would have a far greater significance than a
loss of fat. A definite knowledge of the character of
the loss of weight may be obtained by a study of the
respiratory exchange. In pathological cases it was dis-
tinctly of importance to know whether or not the de-
mand for nutriment, as indicated by the total amounts
of material consumed in the body, is met by the supply.
Observations of the respiratory exchange will show
very quickly the demand for energy under the condi-
tions of observation, and thus the clinician will be able
to adjust without delay the supply to the demand. The
majority of the earlier methods of studying the
respiratory exchange were, for one reason or another,
precluded from general acceptance in clinics and an
attempt was made to broaden the field of study and
increase the potentialities, by devising, constructing,
and testing a relatively simple apparatus called the
"universal respiration apparatus." With this appa-
ratus it was possible to measure the carbon dioxide out-
put and the oxygen intake with almost as high a
degree of accuracy as with the costly calorimetric
respiration chambers. Before describing the apparatus
the writers define exactly what is meant by the terms
"respiratory exchange" and "respiratory quotient,"
consider their relation to the heat production, and out-
line the fundamental principles underlying a study of
the respiratory exchange and the essentials for an ap-
paratus designed for use in pathological cases. The
detailed description of this apparatus will be published
later.
2. Studies of the Basal Metabolism in Disease and
Their Importance in Clinical Medicine. — J. H. Means de-
fines what is meant by calorimetry, and explains the
methods of calculation by which the respiratory quo-
tient and heat production are obtained. He reviews
various studies of the basal metabolism made in the
medical wards of the Massachusetts General Hospital,
a particular study having been made of thyroid disease
and obesity. He lays emphasis on the following points.
1. Basal metabolism can be readily studied in a hos-
pital clinic with a comparatively simple apparatus. 2.
The normal basal metabolism is a fairly constant affair,
and hence wide variations from it in disease are of
interest to the clinician. 3. A marked rise occurs in
hyperthyroidism. 4. A marked fall occurs in hypo-
thyroidism. 5. In regard to hyperthyroidism it seems
probable that the basal metabolism furnishes (a) The
best index as to the severity of the disease, and hence
is a quantitative means of following the course and of
judging of the effectiveness of treatment; and (6) A
valuable aid in differential diagnosis. 6. Enormous
grades of obesity are possible in the presence of a
normal basal metabolism. 7. When a reduction in
the metabolism was found in obese subjects there was
also clinical evidence of defective internal secretion.
8. A clearer conception of the food requirements in
disease is furnished by the basal metabolism than by
any other factor.
3. The Physician and the Prevention of Industrial
Accidents.— Herbert J. Cronin believes that the physi-
cian should take a more active interest in the cam-
paign for the prevention of industrial accidents. He
points out that the physician is in a position to get
the true history of how the accident occurred, look into
the physical condition of the patient and decide for
himself from the injury how it may have been caused.
The recurring cases will be strongly brought to his
attention. The youngest interne at any of the metro-
politan hospitals quickly recognizes by their frequent
occurrence the causes of the common traumatisms; he
knows the crush from the printing press, the mangling
of gears, the buzz-saw fingers, and burns from molten
metals. The doctor can inspect the site of the accident
before the real cause of the injury such as an oily
floor or a broken board, is removed. The family physi-
cian of the manufacturer can draw attention to the
reforms needed and give advice. Technical knowledge
is not necessary in giving advice for the correction of
a large number of accidents. Many of the accidents
are caused by such simple things as obstructions, un-
guarded pits, or floor openings. The writer considers
more in detail defects in machinery and other factors
that are responsible for a large number of accidents
and says it has been shown that after all the prac-
tical devices have been put on machines only about
35 per cent of accidents can be so prevented. In order
to supplement the work, every plant should start a
safety organization among its employes. He describes
a plan for such a safety organization which will not
increase the pay-roll, except in large plants where one
employe is designated to be a safety inspector and
spends his entire time at the work. In closing, it is
stated that the by-products of industrial warfare are
worse than those of real warfare and that the medical
profession should act as pioneers in this new work as
they have done in nearly every other social reform.
5. Two Cases of Syphilis of the Lung. — Abner Post
reports these two cases, both of which were syphilitic,
and in neither of which were tubercle bacilli found.
The resemblance of the radiograms in these two cases
is striking. From these cases the writer believes it is
justifiable to say that disease of the lung, in which
consolidation is found in unusual positions, or limited
entirely to one lung and in which tubercle bacilli have
not been found, may be considered suspicious of
syphilis. If the Wassermann is positive the suspicion
is much greater and may almost be regarded as a cer-
tainty. It is certain that consolidation in unusual posi-
tions, with the absence of tubercle bacilli and the pres-
ence of a positive Wassermann, does not permit the
diagnosis of tuberculosis. These cases show also the
important fact that syphilis of the lung occurs in
hereditary cases, that is, among the young, the very
individuals who are most subject to tuberculosis.
New York Medical Journal.
June 17, 1916.
1. Some of the Larger Problems of the Medical Profession.
Rupert Blue.
2. Failures in Diagnosis. William S. Uordon.
3. Focal Sepsis. Judson Daland.
4. A"-Ray Diagnosis ot Surgical Complications Within the
Chest. George E. Pfahler.
5. The Corroborative Diagnosis of Mastoiditis by Means of
the AT-Ray. Harold Havs.
6. Meningitis. Handle C. Rosenberger and David J. Bent-
ley, Jr.
7. Fleck Typhus. E. Kilbourne Tullidge.
S. Camp Sanitation. P. W. Huntington.
9. Radium in Gastric Carcinoma. C. Everett Field.
10. The Leucocyte Count of Appendicitis. J. E. Robinson.
11. Cardiac Dilatation. Max Grossman.
1. Some of the Larger Problems of the Medical Pro-
fession.— Dr. Rupert Blue. (See Medical Record, June
17.)
2. Failures in Diagnosis. — William S. Gordon gives a
comparison of physical and laboratory methods, and
sums up by stating the following: The chief causes
of errors or failures in diagnosis are ignorance or
neglect on the part of the physician ; the partial or
incomplete employment of the aids afforded by science;
26
MEDICAL RECORD.
[July 1, 1916
the failure to make routine examinations; the failure
to correlate laboratory and physical findings; excep-
tions to the laws governing diagnosis and pathology;
the limitations of scientific knowledge; the impractica-
bility at times of using all of the diagnostic methods;
the failure of the patient to submit to the requirements
of the physician; the direct or indirect influence upon
patient and physician of the erroneous expressions of
the laity. Science is rapidly advancing in all of its
branches. Diagnosis is becoming more and more ac-
curate, while the doctor is becoming more highly edu-
cated. When the public awakes to a realization of the
many difficulties which beset the pathway of the med-
ical man, and when it ceases to place him on a level
with the charlatan, it will be surprised at the compara-
tively few mistakes which the physician makes and at
the large number of successes which can be placed to
his credit.
3. Focal Sepsis. — Judson Daland considers a cause of
constitutional disease from the viewpoint of the in-
ternist and offers the following conclusions: 1. Chronic
focal sepsis is known to be one of the causes of acute
and chronic arthritis, periarthritis, arthritis deformans,
osteitis, endocarditis, pericarditis or myocarditis, en-
darteritis, acute and chronic parenchymatous nephritis,
cholecystitis, cholelithiasis, gastric and duodenal ulcer,
appendicitis, meningitis, thyroiditis, neuritis, oophoritis,
ocular diseases, furunculosis, and is the recognized
cause of other diseases. 2. The results of chronic focal
sepsis are due to the varying virulence of the micro-
organism, the duration of the focus, the quantity of
microorganisms and toxins entering the circulation,
the rapidity of absorption, the integrity of the tissues,
and the susceptibility or immunity of the patient. The
role of toxemia is not fully understood. 3. The usual
location of chronic focal sepsis in the order of fre-
quency is the mouth, the tonsils, and the sinuses. 4.
The diagnosis of chronic septic focus is sometimes
easy, but more often difficult. A common error is to
recognize only one focus when more than one exists,
and this is especially true of the teeth. Loose, dead,
capped teeth and those containing large fillings, or
those connected with bridges or artificial dentures, are
frequently septic and should be explored. The mouth
should be carefully examined for pyorrhea or pyorrheal
pockets. The diagnosis of mouth sepsis should be made
by a dentist especially trained for this work, and a
roentgenograph is always necessary. A tonsil may ap-
pear normal and yet contain an abscess or be infected.
A partial removal of a tonsil may cause a septic focus
by sealing crypts and follicles. The adenoid structure
in the supratonsillar fossa may be infected. A sinus
may appear normal and a second examination show
suppuration. This is especially true of the ethmoid
and sphenoid. The virulence of the microorganism,
rather than the size of the focus, is important. 5. Suc-
cess in treatment of constitutional diseases secondary
to focal sepsis depends upon the diagnosis and removal
of the focus or foci of infection. Temporary improve-
ment with relapses may be expected when the septic
focus is only partially removed. After removal of the
focal sepsis recovery may be hastened by personal and
general hygiene. It is believed by those having experi-
ence that an autogenous vaccine hastens recovery. I
have seen a number of patients make satisfactory re-
coveries without vaccines. The recognition of the prin-
ciple of secondary systemic infection is one of the most
important advances in medicine in recent years.
9. Radium in Gastric Carcinoma. — C. Everett Field
approaches this theme with a degree of hopefulness
that he trusts will not be considered unduly enthusi-
astic. Possibly there is no subject in medicine or sur-
gery today that is receiving more attention at the
hands of the scientific world than radium. To the
credit of this element we must acknowledge that a
large percentage of the early disappointments were
due to the fact that insufficient doses and lack of purity
of the elements were common. Radium does kill the
cancer cells and exerts its power in direct accord with
the accessibility of the mass. Superficial cancer is
controlled and cured in fast increasing percentages.
In the light of our present knowledge we place the
rays as merely an adjunct to the knife. The London
Radium Institute, in its report for 1913, says that
"tabulated data on a total of 181 cases of cancer of
the face, neck, and breast, show a total of 154 cases
healed, and seventeen discontinued. Of the 154 listed
as healed on January 1, 1911, at present 135 are still
healed." Von Czerny of Heidelberg has reported ob-
servations in several thousand cases of gastric car-
cinoma. His experiences detail the direct application
of radium, the use externally of radium compresses for
the relief of pain, and the injection of soluble salts.
With the later treatment, he avers that he has checked
for a time active congestion, relieved the pain, and
reduced stenosis to the point of allowing the passage
of food.
Journal of the American Medical Association.
June 17, 1916.
1. Some of the Larger Problems of the Medical Profession.
Rupert Blue.
2. Dispensary Abuse and Certain Problems of Medical Prac-
tice. J. Whitridge 'Williams.
3. The Duodenal Tube as a Factor in the Diagnosis and
Treatment of Gallbladder Disease. Max Einforn.
4 Acidosis in Diabetes. R. T. "Woodyatt.
■"•. Large Endothelioma of the Dura Compressing Both
Frontal Lobes. Moses Kescher. New York.
6. Trench Foot Tetanus. George G. Davis and Joseph J.
Hilton.
7. Early Death from Cerebral Syphilis, with Successful Rab-
bit Inoculation : Report of a Case. Mathew A. Rea-
soned
8. An Unusual Stomach Case, with Roentgenographic Find-
ings. George E. Brown.
9. Fecal Concretions of the Appendix Demonstrable by the
Roentgen Ray. John Douglas and Leon Theodore
LeWald.
1. Some of the Larger Problems of the Medical Pro-
fession.— Professor Rupert Blue. (See Medical Rec-
ord, June 17.)
2. Dispensary Abuse and Certain Problems of Medi-
cal Practice. — J. Whitridge Williams spoke on this sub-
ject at the one-hundred and eighteenth meeting of the
Medical and Chirurgical Faculty of Maryland. He
outlines the growth of the modern dispensary and
pleads for the maintenance of dispensaries of the high-
est type, with the knowledge that the better they be-
come, the greater will be the cry of the dispensary
abuse, which to his mind will not disappear until the
principles of medical practice in our larger cities have
undergone reorganization. As a corrective of the pres-
ent abuse of free operations by persons able to pay,
he suggests that a mechanism should be devised for
the investigation of the circumstances of the patient
and the charging of an equitable fee by the institution.
In many cases after charging such a fee for drugs and
supplies nothing would be left for the surgeon, but in
other instances a balance would be left for the pay-
ment of professional services. Naturally this would
be so small that the operator could not accept it as a
fee without a distinct loss of self respect, so that the
question would arise as to its disposition. Such money
along with other available funds could be utilized for
the payment of moderate salaries to the members of
the staff who do the work, with the understanding that
such a salary was in lieu of all fees from patients,
except those occupying private rooms at full rates.
The author endorses the "diagnostic group plan" which
is being used at the Massachusetts General Hospital,
and suggests that a fee of $10 to $25 be charged for
July 1, 1916]
MEDICAL RECORD.
27
the complete examination, and that the dispensary staff
should be compensated either by fixed salaries or by
a pro rata division of the fees after a proper deduction
has been made for maintenance charges. He then con-
siders the subject of health insurance and suggests
that each insured family be allowed to choose as its
medical attendant any physician on the panel of the
insurance organization living within a certain radius.
In cases of minor illness the patient would visit the
physician in his offices or go to the dispensary, while
in more serious cases he would go to the dispensary
for diagnosis and treatment. If the patient were ill
in bed he would be cared for at home by his medical
attendant and a visiting nurse, or sent to the hospital
if the physician deemed it advisable. Under such a
system there would be no possibility for dispensary
abuse as the expense would be borne by the insurance
fund and indirectly by those insured, no matter whether
the patients were treated at home or at the dispensary
or hospital. Nor would the doctor suffer. As probably
two-thirds of the residents of each district would be
in the insured class, large numbers of physicians would
be necessary for the conduct of the dispensary and
hospital and as they would be paid for such services,
as well as for visiting patients in their own homes,
and would have no bad bills, they would probably con-
sider it a matter of indifference where the patients
were seen. This would mean that the great majority
of physicians would become state officials and would
devote their entire time or a great proportion of it to
official duties.
3. The Duodenal Tube as a Factor in the Diagnosis
and Treatment of Gall-Bladder Disease. — Max Einhorn
emphasizes the advantages of direct examination of the
bile in diagnosing gall-bladder disease. He says he had
diagnosed probable cholecystitis by examination of the
bile in conjunction with the usual symptoms in forty
cases since May, 1914. Thirteen of these cases were
operated upon. In the majority of cases in which turbid
bile was found in the duodenum in the fasting condi-
tion, cholecystitis with gallstones is encountered. Tur-
bid bile may exist, however, without gall-bladder disease
when the liver itself is seriously diseased, or in stricture
of the duodenum below the papilla of Vater. On the
other hand clear bile may exceptionally be found in
association with biliary calculi. There are then two
possibilities: Either the gall bladder is not inflamed or
the gall bladder is entirely filled with the calculi. In
these cases no bile enters the organ and it therefore
enters the duodenum in the same state- as excreted by
the liver. In a number of patients with cholecystitis
an attempt was made to instil a weak solution of
ichthyol or argyrol into the duodenum just above
Vater's ampulla". The writer describes his method of
doing this and believes that it possesses a distinct
benefit. He has also carried out duodenal alimenta-
tion for the relief of gastric or duodenal ulcer; among
them were quite a number of patients who had gall-
stones at the same time. The latter were benefited
not only with regard to their digestive disorders but
also in reference to their gall-bladder condition. This
occurred in a striking manner with such frequency
that he felt inclined to attribute to the duodenal ali-
mentation the decidedly beneficial influence on the gall-
bladder lesion. The essayist believes that duodenal
alimentation will find an appropriate place in some
forms of cholecystitis, particularly when complicated
with ulcers of the stomach or duodenum.
4. Acidosis in Diabetes. — R. T. Woodyatt discusses
acidosis in general, the origin of the acidosis com-
pounds, conditions favoring their appearance, acidosis
in fasting, and states that acidosis in diabetes develops
under exactly the same fundamental conditions which
cause this condition in non-diabetics. There happens
in the severe cases of diabetes a rate of fatty acid
metabolism which in the absolute sense is not greater
than what might occur in health but becomes excessive
in proportion to the amount of oxidizing glucose and
so acidosis develops. In order to check a diabetic aci-
dosis, it is necessary to restore the proper ratio of
fatty acid to glucose oxidation by reducing the fatty
acid metabolism to whatever level is fixed by the ex-
isting rate at which glucose is oxidizing. In diabetes
protein alone, if metabolized in sufficient amounts, may
be productive of acidosis as well as fat, because, al-
though protein in breaking down liberates plenty of
glucose for the complete oxidation of its own ketogenic
fraction, in diabetes not all the glucose so formed can
be oxidized owing to the lessened ability of the body
to split it open. Accordingly to check a diabetic aci-
dosis it is necessary to reduce both the protein and
the fat metabolism. Fasting, rest, and warmth ac-
complish this.
6. Trench Foot Tetanus. — George G. Davis and Jo-
seph J. Hilton report a case of tetanus occurring as
a complication of "trench foot" with a fatal outcome.
In this case a prophylactic dose of antitetanic serum
had not been given, and in view of the excellent re-
sults obtained by prophylactic doses in the wounded
the writers conclude that it would be a reasonable rule
in military surgery to consider all cases of trench feet
as in a class with the wounded, and to give these pa-
tients also in every instance a prophylactic dose of anti-
tetanic serum.
8. An Unusual Stomach Case, with Roentgenographic
Findings. — George E. Brown reports this case which is
of interest not alone because of its clinical rarity, but
also from the fact that the roentgenologic findings were
deceptive. The mass on the lesser curvature resembled
the roentgenologic picture of penetrating ulcer, though
no incisura was present. The clinical findings were
also deceptive, namely, hematemesis, occult blood in
stools, gastric pain, and vomiting. The writer says he
can find no mention of any similar condition in the
textbooks.
9. Fecal Concretions of the Appendix. — John Doug-
las and Leon Theodore LeWald state that in a small
number of instances a fecalith of the appendix may
be demonstrated by roentgenographic examination and
that this fact must be taken into consideration in mak-
ing an examination. Usually the passage of opaque
ureteral catheters will be of the greatest assistance in
differential diagnosis, but the two cases reported by
Eastmond and Seelig demonstrate that even with this
assistance a mistake may be made. As a further aid
in Roentgen diagnosis, they would suggest that when
the shadow is above the crests of the iliac bones, a
lateral stereoscopic roentgenographic examination be
made, preferably with an opaque catheter in the ureter
on the suspected side. In a case recently examined in
this way they were able to distinguish what is prob-
ably a calcified lymph node from a supposed ureteral
calculus. If there is still doubt, a Roentgen examina-
tion, combined with an opaque meal or enema, may
show the relationship of the suspicious shadow to the
appendix or cecum. They call attention to the pos-
sibility of one encountering a left sided appendix due
either to a non-rotation of the colon or to a complete
transposition of all the viscera. LeWald has en-
countered the former condition in three persons, and
the latter condition in twelve. A shadow on the left
side, therefore, may represent a calculus in the ap-
pendix unless a Roentgen examination shows the cecum
on the right side.
28
MEDICAL RECORD.
LJuly 1. 1916
The Lancet.
l/.i/; 27, 1916.
1. The Chadwick Lectures on Typhus Fever in Serbia. R. O.
Moon.
2. Arrangements for the Care of Cases of Nervous and Men-
tal Shock Coming from Overseas. William Aldren
Turner.
3. Congestion in the Treatment of Epidemic Cerebrospinal
Meningitis. Duncan Forbes and Eveline Cohen.
4. The Treatment of Gunshot Wounds by Packing with Salt
Sacs. Alfred J. Hull.
5. The Anatomical Position of Localized Foreign Bodies. J.
Metcalfe and E. N. Keys-Wells.
6. Simple Tertian Malaria in French Flanders. A C. Rankin.
7. Warfare Neuroses of the Throat and Ear. John F.
O'Malley.
S. Notes on Cases of Head. Abdominal, and Joint Injuries.
H. E. Brown.
9. Notes on Camp Sanitation. A. White.
2. Arrangements for the Care of Cases of Nervous
and Mental Shock Coming from Overseas. — William Al-
dren Turner gives information with reference to the
arrangements that have been made for the care of sol-
diers sent home from overseas who are suffering from
nervous shock, neurasthenia, and nervous breakdown.
At the commencement of the war the cases of nervous
shock and neurasthenia were transferred from over
seas in company with medical and surgical cases, and
were treated in the general wards of the hospitals at
which they arrived, while the cases of mental disorder
were transferred to the established institutions for the
treatment of mental patients in the service of the army.
The increase in the number of cases of this nature
coming over in consequence of the severe fighting dur-
ing October and November, 1914, made special provi-
sion for their treatment desirable. Plans were made
so that upon the soldier's arrival at one of the British
base hospitals abroad his condition was investigated
by a special medical officer. The patient is then sent
to a section of a hospital according as his symptoms
are of a neurological or a mental character. Should
he be suffering from transitory mental symptoms, which
subside rapidly, he is transferred from the mental to
the neurological section as soon as it is advisable to
do so. In order to meet this class of cases special ac-
commodation is now being provided at the base hos-
pitals overseas, so that the patient may be placed un-
der the most suitable circumstances for recovery. The
patients are labelled for one of the clearing hospitals
at home. On arrival at one of the clearing hospitals
the patient is given treatment. If his symptoms are
slight or transitory and disappear rapidly, he is sent
on furlough and later is returned to light duty. On
the other hand should the course of the disorder be
less favorable, he may be transferred to one of the
special hospitals for nervous diseases or to a special
institution. In a general way the results of the treat-
ment of the neurological cases showed 40 per cent of
cases returned to light duty, 20 per cent invalided,
and 20 per cent transferred for further treatment to
the special institutions. The patients transferred to
the mental hospitals are mostly of the certifiable type
and include most of the severe forms of acute mental
disorder. In accordance with accepted policy none of
these patients are certified as of unsound mind. Each
patient is given a reasonable period of treatment with
a view to recovery. In consequence, however, of the
accumulation of chronic and incurable cases which was
observed a few months ago it was decided to discharge
to asylums all cases of general paralysis of the insane,
of epilepsy with insanity, and all patients who had been
in asylums prior to enlistment. The percentage of
cases of this kind returned to light duty was obviously
small, from 10 to 15 per cent.
:i. Congestion in I he Treatment of Cerebrospinal
Meningitis. — Duncan Forbes and Eveline Cohen report
five cases of epidemic cerebrospinal meningitis in which
congestion of the cerebral vessels was brought about
by raising the foot of the bed. The foot of the bed was
elevated so as to make an angle of from 14 to 23 de-
grees with the floor. The type of cases at first treated
in this way were the class of cases that almost get
over their illness, then become chronic and die. Later
congestion was found useful in the earlier stages of
the disease. If the head of the bed was raised too high
there might be severe headache and persistent vomit-
ing due to too great congestion and its results. In
such cases if the bed was lowered and the tension re-
lieved by puncture the patient usually recovered. As
different cases require varying degrees of stimulation,
no hard and fast rule can be laid down as to the height
to which the foot of the bed should be raised.
4. The Treatment of Gunshot Wounds by Packing
with Salt Sacs. — Alfred J. Hull says that the treatment
of septic wounds by a pack which is allowed to remain
in the wound for several days is so opposed to the usual
teachings of surgery that at first sight its utility may
be doubted. Nevertheless such treatment has proved
one of the most effective methods of dealing with septic
wounds during the present war. It has also been found
to be one of the most generally applicable procedures
for the treatment of secondary hemorrhages. The sacs
are made of gauze in several sizes, filled with salt,
sterilized in an autoclave, and stored ready for use.
The effect of the salt bag is to form a concentrated
solution of salt which promotes the resolution of in-
flammatory induration and aids the separation of dead
tissue by solution of coagulated lymph. If the wound
is clean the sacs are removed in from five to ten days,
and treatment by normal saline solution. This method
of treatment saves the patient the inconvenience of
frequent dressing and forms an efficient means of pre-
venting hemorrhage.
5. The Anatomical Position of Localized Foreign
Bodies. — James Metcalfe and Ernest N. Keys-Wells call
attention to the great improvements in detail and tech-
nique and the various forms of new and elaborate ap-
paratus that have been evolved in order to produce
greater accuracy in exact localization, and give their
method of localizing foreign bodies in some of the
important positions. The results have been arrived
at by the use of a long needle on a handle and meas-
uring the depth inserted when the bony point under
investigation is reached. This method was supple-
mented by taking a double image of the various regions
on one plate and estimating the depths of the body point
as for a foreign body. No attempt had been made to
give the positions in the leg or arm. A tales gives the
various parts examined. The following are examples
of anatomical depths estimated from the measurements
and given to various surgeons.
1. Rifle bullet lying in wall of pericardium, the point
2 inches and the base 1% inches from a mark on the
front of the chest. Successfully and easily removed.
2. Small metallic fragment 2 inches deep to a mark
on the front of the thigh on a level of the lesser
trochanter, stated to be lying between adductor brevis
and adductor Iongus. Removed without difficulty.
3. Rifle bullet, the point 1% inches and the base 2*4
inches deep to a mark over the scapula, stated to be
in the serratus magnus. Removed from that muscle.
4. Shrapnel bullet, 1 3/5 inches deep to a mark on
the front of the chest just below the coracoid, stated
to be immediately beneath the tendon of the pectoralis
minor. Removed from that position.
British Medical Journal.
May 27, 1916.
1. The Louse Problem at the Western Front. A 1> Ivacock.
2 Notes on Military < >rthopedics. 111. The Soldier's Foot
and the Treatment of Common Deformities of the Foot.
Robert Jones.
July 1, 19H5 1
MEDICAL RECORD.
29
3. A Case of Arteriovenous Aneurysm of the Subclavian
Artery and Vein Treated by Excision of the Sac and
the Second and Third Parts of the Artery. Comyns
Berkerley and Victor Bonney.
4. Notes on a Case of Penetrating Wound of the Heart. R.
Garside and P. McEwan.
5. White Gangrene. A. J. Hull.
6. Simple and Inexpensive Methods for Fermentation Tests
and for Obtaining Cultures of Anaerobes. J. M.
Beattie.
1. The Louse Problem at the Western Front. — A. D.
Peacock presents a morphological study of the Pediculux
humanus or common body louse and the results of an
investigation into the habits of this parasite. As a
result of his experiments it was found that the longest
period during which lice survived separation from the
human body was nearly nine days. The maximum time
during which eggs away from the body might remain
dormant was found by Warburton to be about forty
days. This was under laboratory conditions and the
temperature fell at times below the freezing point.
Similar experiments were carried out and samples
taken from a shirt exposed thirteen days did not hatch
after twenty-eight days' incubation. In applying this
knowledge the important fact is that eggs on the
clothing, particularly the outer garments, if not treated
regularly by ironing or disinfection, are a possible
source of infestation for as long as a month after lay-
ing. Also, the removal of the clothing from the body
for a few days in order to kill the eggs and lice by
exposure is not a practical scheme. The louse, there-
fore, is a parasite which is utterly dependent upon
man's blood for sustenance and man's body and clothing
for prolonged, prosperous longevity and reproduction.
The louse adds greatly to the troubles of the soldier
at the front largely because of its interference with
sleep which results in impaired vitality and mental
weariness.
2. The Soldier's Foot and the Treatment of Common
Deformities of the Foot. — Robert Jones expresses sur-
prise at the number of men with claw-feet that have
been passed into the army, and at the fact that many
such cases have found their way to the front after the
vigorous initial training which the recruit undergoes.
Sooner or later these men gravitate to the hospital
and few of them return to the ranks as efficients. A
patient with this condition of the foot is quite unfit
for military service, and should never be accepted as
a recruit. Clinically the condition presents five degrees
or stages. The progress of the development of the
deformity from one degree to another, though often
continuous, is frequently arrested in one of the early
stages.- Hallux rigidus, hallux valgus, and meta-
tarsalgia are all frequently associated with flat foot.
In connection with these conditions the author discusses
the importance of correct position and free mobility
of the great toe in marching. In young children of
all races the great toe is directed slightly inwards
towards the middle line of the body, in line with the
anterior part of the inner longitudinal arch of the
foot. In races who habitually go barefoot this posi-
tion of the great toe is preserved in adult life. In
civilized races — those, at least, who wear boots — the
toes are often cramped into boots of unsuitable shape,
so that the small muscles of the foot suffer atrophy
from disuse, and the power to spread the great toe
inwards in walking is much impaired. In a strong
foot which has not been deformed by wearing pointed
boots the great toe is spread inwards by the action
of the abductor hallucis when balancing on one foot,
when the weight of the body is on the fore part of the
foot in walking, and still more so when carrying a pack
on the shoulders. A good marching foot should there-
fore leave the foot free to adapt itself to altering condi-
tions of balance and strain. The writer discusses the
palliative and operative measures that may be employed
in correcting these deformities.
3. A Case of Arteriovenous Aneurysm of the Sub-
clavian Artery and Vein Treated by Excision of the Sac
and the Second and Third Parts of the Artery. — Comyns
Berkerley and Victor Bonney report the case of a
soldier who was wounded by a rifle bullet striking him
just outside the axillary border of the right scapula
near its inferior angle and emerging just above the
middle of the right clavicle. The wound of entrance
was healed and wound of exit practically healed, but
underlying it in the subclavian triangle was a pul-
sating swelling about the size of a double walnut.
There was a very marked thrill which could be felt
and heard even as far as the bend of the elbow. The
right arm was entirely paralyzed. A diagnosis of
arteriovenous aneurysm of the third part of the sub-
clavian artery and vein and injury to the brachial
plexus was made. As the swelling in the neck was
enlarging, and, if it continued to enlarge the diffi-
culties of operating would become greater, it was de-
cided that operation should be performed. The sac
lay between the third part of the subclavian artery
and vein, and communicated with both. The aperture
into the vein was fortunately small and was situated
about the point where the external jugular joined it.
The sac wall was very thin. Its front part was formed
by the deep cervical fascia; behind and above it ad-
hered to the brachial plexus, while the first rib and
clavicle had limited it below. There is only one other
case in which an after history of arteriovenous
aneurysm in this situation is available and this to-
gether with the successful result in the present in-
stance justifies the decision to operate. The authors
say that if they ever have to perform this operation
again they will not replace the resected clavicle, for
they think that if they had not done this suppuration
would not have occurred. It would also they acknowl-
edge, have been better not to have used silk for the main
arterial ligatures. In all cases of military surgery
where absolute asepsis could rarely be attained catgut
of an absorption rate of not more than twenty days
should be used for large arteries, a suture having this
absorption rate being used so as to minimize the dura-
tion of a ligature sinus if by chance such a complication
should happen to occur.
Calcium Sulphide an Antidote for Mercurial Poison-
ing.— B. Merrill Ricketts recently described a method
devised by him to antidote mercury in the system after
the swallowing of a lethal dose. For every grain of
mercury ingested he gives one grain of calcium sulphide
by the mouth and repeats it every two hours until five
grains have been taken. If the case is already forty-
eight hours old when treatment is begun he injects the
drug into a vein — one grain in an ounce of water for
each grain of mercury swallowed. Ricketts reported
several cases of recovery, in one of which 80 grains of
bichloride had been taken. — American Journal of Clini-
cal Medicine.
Delayed Appearance of Tetanus. — Julliard, a Swiss
■ urgeon connected with a base hospital in Lyons, states
that preventive antitoxin may sometimes delay infec-
tion, while not mitigating its severity. He saw fatal
cases which did not develop until two and three months
after injury. In one of these, two months after aseptic
healing of a wound of the os ilium, tetanus suddenly
appeared and proved fatal in eight days. The author
does not include here cases of delayed tetanus started
up by secondary operations on wounds. — Correspondenz-
Blatt fiir Schweizer Aerzte.
30
MEDICAL RECORD.
[July 1, 1916
Hunk iRmtruia.
Back Injuries and Their Significance Under the
Workmen's Compensation and Other Acts. By
Archibald McKendrick, F.R.C.S.E., etc., Surgeon in
Charge of Surgical A'-ray Department, Royal In-
firmary, Edinburgh. Blue muslin; pp. 174, with 14
illustrations. Price, $1.25 net. New York: William
Wood & Co.; Edinburgh: E. & S. Livingstone, 1916.
McKendrick shows that he fully appreciates the situa-
tion, and also that he has a sense of humor, when he
says in his preface, "Back injuries have a bad reputa-
tion. The workman looks upon them with apprehen-
sion, the insurance company with doubt, the medical
examiner with suspicion, the lawyer with uncertainty,
and the court with as open a mind as is possible under
the circumstances." As he also says, the lawyers are
puzzled by the conflicting and often contradictory re-
ports of the surgeons; and this book is offered to the
medical and legal professions as an honest attempt to
throw some light into the existing darkness and to sug-
gest some practical methods of testing the genuineness
or otherwise of the complaints made. With this end in
view the author discusses the anatomy of the spine, in-
cluding its bones, joints, ligaments, and overlying fascia
and musculature, then takes up the examination, his-
tory, and numerous other matters, tests, etc., which
should be carefully considered in order to arrive at a
correct diagnosis and separate the true from the "fake"
cases.
This book was written with the laws of the British
Isles in mind; but that interferes but little, if at all,
with its practical value, since the author is concerned
with the medical and surgical rather than the legal as-
pects of the subject. Since the Workmen's Compensa-
tion Law in this State went into effect the apparent
number of slight injuries has increased enormously,
treatment being sought for injuries so trivial that they
would have been disregarded formerly; and as real or
feigned injuries of the back have always been a fruitful
source of claims for financial balm, it is probable that
the apparent number of these cases will likewise show
an increase under present conditions. Hence McKen-
drick's book is most opportune; and as it is well writ-
ten and covers the ground quite thoroughly, it should
be of much service to those who have to do with these
often perplexing cases.
Cerebrospinal Fever. By Thomas J. Horder, M.D.,
Assistant Physician, St. Bartholomew's Hospital;
Major (Temp.) R.A.M.C, Serving with the British
Expeditionary Force. With Seventeen Illustrations.
Price, $1.25. London: Henry Frowde; Oxford Uni-
versity Press; Hodder & Stoughton; New York: Ox-
ford University Press, American Branch, 1915.
This is one of the Oxford War Primers of Medicine
and Surgery. It is a book of exceptional merit, present-
ing a complete survey of the latest knowledge of men-
ingococcus meningitis and serving at the same time as a
practical working manual for the benefit of those who
are actually treating cases of this disease. The meth-
ods of bacteriological diagnosis and the technique of
lumbar puncture are described in satisfying detail. The
chapter on diagnosis is excellent. It discusses the
subject of meningism, the diagnosis of meningitis from
toxemia merely, the acute infective processes with tox-
emic symptoms simulating meningitis, the differential
diagnosis of cerebrospinal fever from certain diseases
of the central nervous system and the differential diag-
nosis from other forms of meningitis. Considerable
value is attached to the old distinction originally attrib-
uted to Sir William Jenner, namely, that if headache
and delirium synchronize, meningitis is probably pres-
ent and not merely toxemia. The chapter on treatment
is thoroughly up-to-date. Preference is given to the
gravity method of introducing the curative serum into
the subarachnoid space, a method probably first em-
ployed in the Mount Sinai Hospital in New York. The
control of the serum administration by watching the
blood-pressure as advocated by Sophian is also dis-
sussed. The treatment by means of soamin (sodium
aminophenylarsenate) as recently reported on the basis
of successful results obtained in South Africa is fully
described. In summarizing the many good features
of this book one must not fail to mention the discus-
sion of the carrier problem in this disease, the question
of the incidence of abortive cases, and the pathogenesis,
all of which subjects have come to the forefront within
recent years. The fact is emphasized that the exact
habitat of the meningococcus in carriers is the upper
part of the nasopharynx and the posterior nares, and
there is described and illustrated a method, as advocated
by Dopter, of obtaining material from the naso-
pharynx by means of a special swab. This is a method
of examination of definite value in the case of sus-
pected contacts.
Character and Temperament. By Joseph Jastrow,
Professor of Psychology, University of Wisconsin.
Price, $2.50 net. New York and London: D. Apple-
ton and Company, 1915.
That such subtle attributes of human nature as charac-
ter and temperament should be capable of close analysis
speaks well for the progress of modern psychology. At
any rate, it is no longer considered that those elusive
traits that distinguish the so-called qualities of men
are beyond the scrutiny of science. Professor Jastrow
has attempted to gauge these qualities and the result is
a valuable contribution to psychological literature in a
volume of 596 pages. This delineates the "foundations
of human differences" and the "traits upon which edu-
cation builds, which the vocations select, and which
society encourages." One might aptly describe this
book as a treatise on human nature. Its subject-matter
is subdivided into nine chapters under the following
headings: The Scientific Approach, The Sensibilities,
The Emotions and Conduct, The Higher Stages of
Psychic Control, Temperament and Individual Dif-
ferences, Abnormal Tendencies of Mind, The Psy-
chology of Group-Traits, Character and the Environ-
ment, and The Qualities of Men. This book bears the
stamp of rare scholarship and is written in a singularly
clear and elegant style.
A Text-Book Upon the Pathogenic Bacteria and
Protozoa for Students of Medicine and Physi-
cians. By Joseph McFarland, M.D., Sc.D. Pro-
fessor of Pathology and Bacteriology in the Medico-
Chirugical College, Philadelphia; Pathologist to the
Philadelphia General Hospital and to the Medico-
Chirurgical Hospital, Philadelphia; Fellow of the Col-
lege of Physicians of Philadelphia. Eighth edition.
Price, cloth, $4.00 net. Philadelphia and London:
W. B. Saunders Company, 1916.
McFarland's text book upon the pathogenic bacteria
and protozoa is almost a household word among the
members of the medical profession in this country, and
is of course well known and esteemed by English speak-
ing medical men everywhere. The present, the eighth
edition, has been almost rewritten; so much so indeed
that the type of the entire book has been reset. The
work is remarkably full and has been brought thor-
oughly into line with all the most recent developments
of the subjects dealt with. All relating to the matter
in hand is discussed exhaustively but at the same time
in language concise and clear. The volume provides a
valuable book of reference for students and physicians.
The book is well printed and the illustrations are
excellent.
Changes in the Food Supply and Thetr Relation
to Nutrition. By Lafayette B. Mendel, Professor
of Physiological Chemistry in the Sheffield Scientific
School of Yale University. Price, 50 cents. New
Haven : Yale University Press. Loudon ; Humphrey
Milford, Oxford University Press, 1916.
The changes of the food supply and their relation to
nutrition have a very important bearing on the health
of a community. Modern methods of preparing cer-
tain staple articles of diet have resulted in various
phases of ill health. Highly milled bread, for in-
stance, is less nutritious by far than the coarser vari-
eties, while polished rice has been shown to be respon-
sible for beriberi. Pellagra and scurvy again are
what is known as deficiency diseases, due to the lack
or absence of vitamines in the article of food on which
the sufferers therefrom have subsisted. Professor
Mendel in his able essay has presented some very valu-
able facts in a very interesting manner.
Breathe and Be Well. Bv William Lee Howard,
M.D. Price, $1. New York: Edward J. Clode,
1916.
In this book, which is written for the instruction of
the laity, the author gives some very practical ad-
vice on the most important and greatly neglected sub-
ject of correct breathing, and shows how intimately it
is related to the preservation of health. He gives
directions for a number of breathing exercises, which
may be followed by those who are unable to take brisk
physical exercise in the open air. For those who ca»
and do walk at a rapid pace several miles a day the
breathing will take care of itself.
July 1, 1916]
MEDICAL RECORD.
31
j&irtrtg Skjmrts.
AMERICAN MEDICAL ASSOCIATION.
Sixty-seventh Annual Session, Held in Detroit, June 13,
14, 15 and 16, 1916.
(Special Report to the Medical Record.)
(Continued from page 1164, Vol. 89.)
SECTION ON MEDICINE.
Wednesday, June 14 — Second Day.
A Consideration of Types of Uremia. — Dr. Nellis B.
Foster of New York presented this paper. He said
that a diagnosis of uremia could not be based on demon-
strable organic changes, since the organic lesions dis-
closed at necropsy were inconstant. The clinical mani-
festations of uremia were found in association with
advanced renal disease and hence, presumably, were
due to a defect in renal function; but if the kidneys
were removed entirely the course of events leading to
death conformed but remotely to any type of uremic
state. Clinically, several types of uremia had been dif-
ferentiated, depending on the presence or absence of
group symptoms; these types might be in some in-
stances pure, not infrequently merging together. As
nephritis presented various manifestations determined
by the specific renal function most impaired, so uremia
could be divided into several groups and the primary
factor determined with a high degree of probability.
There were, according to his present conception, three
pure basic types of uremia. (1) Retention type, the
urinary poisoning of Ascoli. This was a simple re-
tention of urinary nitrogenous waste — urinary poison-
ing. (2) Cerebral edema type. This was due to de-
fective water and salt metabolism, resulting in cerebral
edema. (3) The toxic type, or epileptiform uremia.
This was a toxemia resulting from an abnormal kata-
bolism.
The Value of Recent Laboratory Tests in the Diagno-
sis and Treatment of Nephritis, with Special Reference
to the Chemical Examination of the Blood. — Dr. Arthur
F. Chase and Dr. Victor C. Myers of New York pre-
sented this paper, which was read by Dr. Chase. He
said the chemical examination of the blood in nephritis
was often of greater diagnostic and prognostic value
than the chemical and microscopical examination of the
urine, the blood pressure, phenosulphonephthelein test,
etc. The case of excretion of the three most important
nitrogenous waste products, creatinin, urea, and uric
acid, appeared to fall in the order just named, prob-
ably owing to purely physical laws of concentration
and solubility. Thus a lowered kidney activity should
become evident first by the retention of uric acid, later
by urea, and lastly by creatinin. A retention of uric
acid alone should form an early diagnostic test; an ap-
preciable retention of creatinin should constitute a
grave prognostic sign, a view well supported by their
own observations. As a gauge to the acidosis which
occurred in many advanced cases, they had found Van
Slyke's method of determining the CO; combining power
of the blood of great value. Of the large number of
methods used in the past few years to estimate the
functional capacity of the kidney, they felt that the
following were of practical use to the general prac-
titioner: Phenosulphonephthalein test, the determina-
tion of the fixation of the specific gravity and of noc-
turnal polyuria and the estimation of the blood content
of the uric acid, urea, creatinin, sugar and CO= combin-
ing power. These tests, they believed, were distinct
contributions to medicine and had come to stay. The
amount of nitrogen in the blood served as a most
excellent guide in the giving of protein. The use of
salt-free diet in cases of parenchymatous nephritis
with edema and salt retention gave prompt results.
A Comparative Study of Tests for Renal Function. —
Dr. Herman 0. Mosenthal and Dr. D. Sclater Lewis
of Baltimore presented this paper— a comparative study
of the phenosulphonephthalein, non-protein nitrogen in
the blood, blood urea, Ambard's coefficient of urea ex-
cretion, and the test meal for renal function tests had
been carried out in a series of cases. A definite scale
by which to judge the degree of impairment of renal
activity was proposed. These observations indcated
that in most instances the results obtained by the vari-
ous tests tended to be of equal degree. In a certain
number of individuals, however, they were not. This
discrepancy was not interpreted as invalidating either
one test or the other, but was regarded as evidence
that they signalized a diminution of various phases of
renal function which did not necessarily parallel one
another. When it was well understood what part of
renal function each of these and other renal functional
tests tried out, a more intelligent study of diseases of
the kidneys might be made than heretofore. In sum-
marizing they stated the following: (1) A scale of
impairment of renal function was proposed according
to which the tests might be measured. Such a grada-
tion called to the attention of the clinician the relative
degree of involvement as shown by different procedures.
Inasmuch as each of them had a significance apart from
the others, comparison according to this method was an
extremely valuable aid in the treatment and prognosis
of diseases of the kidney. (2) The lavel of the non-
protein and urea nitrogen of the blood must be esti-
mated largely as the resultant of three factors — kidney
efficiency, diet, and protein destruction. In judging of
prognosis, when these substances were high in the blood
of nephritics, due regard must be given as to whether
their accumulation was brought about by retention
alone or through retention coupled with protein destruc-
tion. The former offered a comparatively better prog-
nosis than the latter. (3) The coefficient of Ambard
was a better bethod of determining the ability of the
kidney to excrete urea than the level of this substance
in the blood. (4) The progress of renal disease was
probably followed most minutely by means of the
'phthalein excretion and Ambard's coefficient, as these
tests furnished figures in which even small variations
were of significance. (5) The test meal for renal func-
tion gave the earliest indication of diminished kidney
efficiency. It likewise reached the maximum degree of
impairment before the others. (6) Each test for renal
function covered only a limited range of the kidney's
activities. It was, therefore, a mistake to speak of any
test as measuring renal function as a whole. The aim
should be to develop a proper interpretation of the old
tests and easily applied new ones, in order to obtain a
true guide in the treatment of diseases of the kidneys.
Elective Localization of Bacteria in Diseases of the
Nervous System. — Dr. Edward C. Rosenow of the Mayo
Foundation, Rochester, Minn., briefly summarized the
results of an experimental study of the possible etio-
logical relation of localized foci of infection, especially
in and about the teeth and tonsils, to diseases of the
nervous system. A table thrown upon the screen gave
a summary of the results obtained in animals; the fig-
ures indicated the percentage incidence of focal lesions
in the various organs. Lesions of the spinal cord,
usually patchy in character, were observed in 58 per
cent, of 31 animals injected with the bacteria from the
tonsils or infected teeth in three cases of multiple
sclerosis. In one of these the lesions appeared to be
due to a staphylococcus; in the other two, to a green-
producing streptococcus. Markedly increased reflexes,
ataxia, and paraplegia were noted during the life of
some of the animals. None became paralyzed. The
duration of the symptoms ranged from three to eight
years. In two additional cases little evidence of focal
infection was found and the cultures failed to produce
lesions in the spinal cord. Lesions of the spinal cord
were noted in 78 per cent, of 36 animals injected with
the staphylococcus from the tonsil in a typical case of
sporadic anterior poliomyelitis. Lesions of the
meninges and spinal cord occurred in 50 per cent, and
66 per cent, of 21 animals injected with the bacteria as
isolated from the pyorrheal pockets and tonsils in a
case of transverse myelitis with paralysis of the lower
extremities. Partial or complete paralysis, which be-
gan in the hind extremities, developed in many animals.
The lesions of the cord consisted chiefly of hemorrhages
both in the gray and white matter and of leucocytic
infiltration of the meninges and surrounding blood
vessels. Lesions in or about one or more of the pos-
terior roots occurred in 83 per cent, of 18 animals
following the injection of streptococci from cases of
brachial, intercostal, and post-herpetic neuralgia. The
occurrence of neuritis in 28 per cent, of these animals
was noteworthy. This and the high incidence of lesions
in the skin, 28 per cent, (chiefly herpes) occurred in
animals injected with relatively large doses. As far
as could be determined, this was the first experimental
demonstration of the probable nature of this form of
neuralgia. Lesions of the peripheral nerves occurred
in 79 per cent, of the 19 animals injected with the
pneumococcus obtained on two occasions from multiple
neuritis. Lesions in or about the joints occurred in
32
MEDICAL RECORD.
| July 1, 1916
48 per cent, of the 29 animals injected, in the myo-
cardium in 28 per cent., and in the muscles in 93 per
cent., following injection of the cultures from 12 cases
of "myalgia."
Thoracic Disease — The Status of Surgical Therapy. —
Dr. Samuel Robinson of Rochester, Minn., read this
paper in which he said that the treatment of diseases
of the lung, the pleura, and mediastinum was in a
lamentably chaotic state. Several quesstions arose:
"Was it not probably that more cooperation between
the internist and the surgeon might result in better
treatment of the patient? Was the surgeon operating
on lesions which the practitioner might cure? Was the
practitioner treating some cases unsuccessfully which
the surgeon might cure?" Surgery of the pleura began
only where non-operatipe treatment failed. The sur-
geon would be found useful and safe in the treatment
of post-pneumonic abscesses; in chronic lung abscesses
he -was less successful, and would welcome the exclu-
sion of this group of cases from the surgical field. He
was watching with interest the efforts with vaccines,
climatic influences, and hygiene, but grieved at the
limited accomplishments in this direction. He believed
that early compression therapy in chronic abscess cases
would do great good. Bronchiectasis would seem to
be a chronic incurable disease. The records were hope-
lessly void of successes without surgery and painfully
attended with fatalities by operation. Artificial pneu-
mothorax had been reported as curable but grave doubts
were entertained as to the truth of this statement.
The writer warned against permitting a surgeon to
drain a case of bronchiectasis. It would do no good,
possibly much harm. Emphysema was again a
stumbling block. Surgery offered but one operation,
namely, the removal of several costal cartilages on one
or both sides. In a considerable proportion of cases
it relieved distressing symptoms, but it did not cure.
It might justly be contended that our methods of ex-
ploring the pleural cavity were inadequate. In the
management of tuberculosis the practitioner must cease
to look to the surgeon for help. The tuberculous
patient was a priori, a poor surgical risk and the out-
look for successful extirpation of tuberculous lung
tissue was particlarly discouraging. Neither was the
drainage of a tuberculous cavity a profitable surgical
measure. Of all swellings on the chest wall there were
at least two types that were curable, the so-called "cold
abscesses" and operable tumors of the chest wall. If
there were lateral bulgings suggesting mediastinal
tumor, the growth seen upon the chest wall was in-
operable. The removal of an early localized malignant
tumor of the lung was surgically possible, but the in-
ternist could not be expected to diagnose these tumors
at an early stage. It was to be hoped that within a
few years more successful extirpation of esophageal
carcinoma might be recorded.
Localized Bronchiectasis Involving the Upper Por-
tions of the Lung, with Report of Five Cases. — Dr.
Thomas McCrae and Dr. Elmer H. Funk of Phila-
delphia presented this paper, in which they reported
five cases of bronchiectasis that came to autopsy within
a period of five months and represented the only in-
stances of bronchiectasis in 80 consecutive autopsies
from the service of the Department for Diseases of the
Chest of the Jefferson Medical College. They illus-
trated particularly some of the problems of diagnosis.
The features of the marked general cases of bronchi-
ectasis were usually such that a diagnosis could readily
be made. The problem was a more difficult one iii
cases of local bronchiectasis. Of particular importance
in making a diagnosis was a history of chronic cough
for a long period with considerable expectoration with-
out marked constitutional disturbance, especially if
the sputum was fetid. The cough being paroxysmal
and often induced by changes in position was also sug-
gestive. The presence of blood in the sputum was pres-
■ M in all of these cases, but could not be considered
as diagnostic since it occurred in tuberculosis. Dyspnea
a i common, especially on exertion, and was most
marked in the cases with considerable fibrosis. The
problem of these upper lobe cases of bronchiectasis was
largely that of differentiation from tuberculosis. The
first case reported was in a man who had been in several
sanatoriums with an invariable diagnosis of tubercu-
losis. It served to emphasize the fact that when
symptoms and signs pointed to advanced pulmonary
tuberculosis and repeated sputum examinations did not
show the tubercle bacilli, the condition was not tubercu-
losis.
Another point which might aid in diagnosis was
the disproportion between the signs in the lungs and
the constitutional symptoms. Radiographic studies
should be made in every case in the hope that in the
future this diagnostic aid might be developed. The
treatment was largely palliative. The adoption of a
semi-erect posture facilitated drainage of the apical
cases. After intratracheal inflations the patient should
be placed in the recumbent position. Autogenous vac-
cines might be tried, although their value was undeter-
mined. The five cases reported had the following dis-
tribution : right upper lobe, one ; the right upper and
lower lobe, one; both upper lobes, three. Tuberculosis
was associated in four cases, three of which were bi-
lateral. Syphilis was apparently excluded as an etio-
logical factor. There was marked evidence of pul-
monary fibrosis in the bronchiestatic areas. The error
of taking bronchietasis for tuberculosis might be
avoided by careful sputum examination.
Splenectomy in Pernicious Anemia — Studies on Bone-
Marrow Stimulation. — Drs. Roger I. Lee, George R.
Minot, and Beth Vincent presented this study from
the Medical Service of the Massachusetts Hospital.
They stated that in the study of the diseases of the
blood, and particularly of the effects of therapeutic
procedures in such diseases, it was necessary that one
should be able to estimate by reliable criteria any
alteration of the relative rate and degree of destruction
and regeneration, at least of the formed constituents
of the blood. Such information was particularly de-
sirable in pernicious anemia. The methods for study-
ing the processes of destruction and regeneration were
few. Fifteen cases of pernicious anemia were studied
with reference to the effect of splenectomy on the blood
forming organs with a view of determining, if possible,
the value of this procedure in altering the activity of
the bone marrow. An analysis of the end results in
these cases certainly failed to show any permanent re-
sults from this procedure. The ultimate progress of
the disease was not changed by the operation. There
was in eight out of thirteen cases a considerable tempo-
rary improvement in two months which persisted in
some cases until six months. The study of the condi-
tion of the blood in these cases led to the conclusion
that one found stimulation of the bone marrow in per-
nicious anemia frequently occurring spontaneously. One
might find stimulation of the bone marrow usually as-
sociated with improvement after splenectomy. Splen-
ectomy seemed to result in the greatest stimulation of
the bone marrow of any known therapeutic measure.
It acted on the whole bone marrow and not only on the
portion that formed the red cells. While more constant
stimulating effects occurred after splenectomy, yet they
could roughly parallel any given case of bone marrow
stimulation after splenectomy with a case of bone mar-
row stimulation that occurred either spontaneously or
after transfusion. It was evident that from splen-
ectomy one could obtain stimulation but once. Trans-
fusion, while perhaps of less constant and less active
effect had the advantage that it was relatively simple,
and it could be repeated a number of times. Trans-
fusion did not modify the destructive agencies at work
in pernicious anemia.
Late Results of Splenectomy in Pernicious Anemia. —
Dr. Edward B. Krumbhaar of Philadelphia presented
this paper which consisted in a statistical and critical
review of the late results of splenectomy. He con-
cluded that of the 153 cases studied, 19.6 per cent, died
within six months; a distinct improvement in the clin-
ical condition and in the blood picture occurred in 64.7
per cent., and there was no improvement in 15.6 per
cent. The high postoperative mortality might be due
to the poor choice of cases in the early series. A much
greater proportion of the later cases had survived. Of
the individuals, nearly two-thirds of the total number,
that showed improvement shortly after operation, a
large number had failed to maintain this improvement,
or had since died in a relapse or from intercurrent dis-
ease. A few had continued in good condition during the
period of observation, over two years. In no case could
it been said that a cure had been effected, and the
blood of these individuals continued to show many of
the characteristic signs of pernicious anemia. On ac-
count of the improvement that followed splenectomy,
it would appear that it was not only a justifiable, but
in many cases an advisable procedure. The best re-
sults were obtained if the operation was preceded by
one or more transfusions. Those cases that relapsed
after operation might still be greatly helped by trans-
fusion. The most favorable results might be expected
in individuals who had not passed the fifth decade, in
July 1, L916J
MEDICAL RECORD.
33
whom the disease had not progressed for more than a
year, and who had a relatively good blood picture.
Individuals with enlarged spleens had done better than
those in whom the spleen was small or normal in size.
Pernicious Anemia Treated by Splenectomy and Sys-
tematic Often-Repeated Transfusion of Blood — Trans-
fusion in Benzol Poisoning. — Dr. ROY D. McClure of
Baltimore read this paper. He said that there were
many reasons why blood transfusions had not been
of more value in pernicious anemia. Chief among these
was the lack of systematic treatment. Usually about as
much good was accomplished by a single transfusion
as by a single inunction of mercury in syphilis. Dis-
credit had also been incurred by using blood which had
not stood the proper tests. The writer said that their
attention was first drawn to the great value of re-
peated transfusions in 1914 in the treatment of benzol
poisoning. The symptoms in this form of poisoning
were a severe purpura hemorrhagica with a severe
anemia of the aplastic type. Several transfusions were
performed among these cases but there was only tempo-
rary improvement, and the procedure was regarded as
of little value. In one instance, however, the family
of the donor noticed the enormous immediate value of
each transfusion and insisted that the treatment be
continued. They produced the donors so that suitable
blood was always supplied. Much to the surprise of
all this patient soon ceased to require transfusions and
made a complete recovery. This led to the conclusion
that perhaps carefully planned transfusions, persist-
ently used to prevent the anemia and its results, might
be of benefit in pernicious anemia. Repeated systematic
transfusions had been carried out only during the past
year. The result, however, had been so encouraging
that they felt that the life of a patient with pernicious
anemia might be indefinitely prolonged if the spleen
was removed as soon as the patient was in a condition
to stand the operation. Transfusion should be per-
formed until the hemoglobin was as high as 90 per cent.
or more, and this should never be allowed to fall below
75 per cent.
Premature Ventricular Systoles and Their Clinical
Significance. — Dr. John E. Griewe of Cincinnati pre-
sented this paper, which was illustrated by a number
of polygraphic and electrocardiographic tracings. He
said he wished to demonstrate the first principles in the
recognition and treatment of this form of heart irregu-
larity. While it was desirable from the standpoint of
the clinician that graphic tracings should be made
when practicable; nevertheless such abnormalities in
the heart action could be distinguished by careful pal-
pation of the pulse and auscultation of the heart sounds.
In the great majority of instances premature ventric-
ular systole was a functional disturbance. The real
seat of the trouble was usually extrinsic to the heart.
In the majority of cases auscultation of the heart would
prevent errors in diagnosis since these premature con-
tractions of the lower chamber of the heart usually
gave rise to a very characteristic sequence of heari
sounds. Cases showing premature ventricular systoles
and ho other sign of organic disease of the heart or
kidneys should not be considered a bad life insurance
risk. In a certain number of cases digitalis seemed
to have a good influence. However, in a general way
the immediate use of digitalis in premature ventricular
systoles should not be looked upon as good practice.
The prognosis should be based not on premature
ventricular systoles but rather upon the underlying
cause.
The Significance of Pulse Form. — Dr. Albion W.
Hewlett of Ann Arbor read this paper. He called
attention to two fundamental types of pulse form, the
sustained and the collapsing. The latter might be
produced by nitroglycerine and occurred frequently
in fevers and less frequently in other conditions. Low
blood pressure did not necessarily produce this type
of pulse. The writer discussed the relative importance
of the heart and blood vessels in its production.
The Relation of Changes in the Form of the Electro-
cardiogram to Functional Derangements of the Heart
Muscle. — Dr. G. Canby Robinson of St. Louis presented
this communication. He stated that the electrocardio-
gram clearly revealed disturbances of the cardiac mech-
anism, but it had not yielded many facts which might
be taken as a measure of the functional capacity of the
heart. The object of this paper was to point out cer-
tain abnormalities occurring in electrocardiographic
curves which apparently accompanied functional de-
ficiency of the ventricles. This was done with the hope
that the electrocardiographic method might sometimes
prove of value in determining changes in the functional
capacity of the ventricular musculature. The abnor-
malities in the series of cases reported consisted in
changes in the initial portion of the complexes, the
Q — R — S group, and different from those yielded by
contractions caused by the ectopic stimuli and from
those changes which occurred with bundle branch block.
These abnormalities were apparently dependent upon
derangement of the intraventricular conduction which
prevented the passage of the excitation wave either
along the usual paths or at the usual rates through-
out the ventricles. The normal spread of the impulse
was hindered because the impulse reached the ventricles
before the conducting system had recovered from the
preceding contraction, and the records indicated in
some cases that this derangement disappeared with pro-
longed ventricular rest. These observations were taken
as evidence for the belief that in cases in which the
ventricular complexes constantly showed certain ab-
normal forms there were functional changes in the
heart which prevented the normal recovery of intra-
ventricular conduction during diastole. It was shown
that changes in form of the ventricular portion of the
electrocardiogram might occur synchronously with
functional changes in the heart, and evidence was
offered for the belief that certain abnormalities in the
form of the electrocardiogram indicated functional de-
rangement of the ventricles.
Some Factors in the Production of Cardiac Dyspnea.
— Francis W. Peabody of Boston read this paper in
which he stated that a full realization of the signifi-
cance of dyspnea, and a properly adapted therapy,
could only be the outcome of a much more complete
understanding of the pathological physiology underly-
ing it than was possessed at present. Dyspnea im-
plied an element of discomfort or of difficulty in breath-
ing, which might depend on an increase in the rate
or in the depth of respiration, but usually it was asso-
ciated with an increase of both, and depended funda-
mentally on a hyperpnea or increase of the total amount
of air breathed in a given unit of time. It might there-
fore be said that in patients with heart disease a de-
crease in the vital capacity of the lungs was an impor-
tant and practically constant feature in the production
of dyspnea. Associated with this and apparently de-
pending on it, there was usually a hyperpnea in the
more severe cases. In many severe cases further causes
of dyspnea might be the presence of acidosis, and to a
less extent, an increase of body metabolism. An ac-
curate index of the degree to which the depth of
respiration was limited might be had by the measure-
ment of the vital capacity of the lungs. This was
regularly below normal in cardiac patients who com-
plained of dyspnea. In a large series of cases in all
staegs of cardiac disease the decrease in the vital ca-
pacity has been found to run almost constantly paral-
lel to the degree of physical disability.
Roentgenocardiograms — Polygraphic Strip Tracings
of Heart Chambers by the Roentgen Ray. — Dr. Au-
gustus W. Crane of Kalamazoo, Mich., presented this
communication. He stated that Roentgen-rays passing
through multiple slits would record simultaneously on
a moving film the pulsations of several chambers of the
heart. Tracings might be taken simultaneously from
the aorta and pulmonary artery. The interpretation of
such tracings was not obscured by the transmission of
the impulses through the body tissues or by instru-
mental inertia and adjustments. Roentgenograms
should be compared with electrocardiograms and
sphygmocardiographic tracings.
Contribution to the Physiology of the Stomach: the
Newer Interpretation of the Gastric Pain in Chronic Ulcer.
— Drs. Harry Ginsburg. Isador Tumpowsky and Wal-
ter W. Hamburger of Chicago presented this contribu-
tion which was read by Dr. Tumpowsky. The writers re-
viewed current theories as to the hunger pain in peptic
ulcer. They stated that there was a significant similar-
ity between the condition of the stomach in hunger and
in ulcer. The difference appeared to be largely a matter
of degree of sensitivity caused by hyperacidity and
hyperesthesia. Ten cases under the care of one of
the writers at the Cook County and Michel Reese
Hospitals diagnosed clinically as peptic ulcer were ex-
amined. The findings of strong contractions of the
stomach accompanying the pain of gastric ulcer seemed
to confirm the idea that the pain was due to tension.
It was shown that the marked hunger contractions
caused pain in a hyperirritable condition of the stomach
by increasing intragastric pressure. The conception
that gastric pain was due to tension would explain
34
MEDICAL RECORD.
[July 1, 1916
many obscure conditions simulating gastric ulcer, such
as achilia gastrica, chronic appendicitis, and gall-blad-
der disease. Hyperacidity alone might be a factor by
reflexly causing hypertonous, hyperperistalsis, and py-
lorospasm, allowing greater tension to be produced.
The subjective relief of pain by alkalies did not neces-
sarily prove that acid was the cause of pain but might
be interpreted on the basis that alkalis prevented the
development of pain producing hypertonus by neutral-
izing the causative factor of such hypertonus, namely
acid. Pituitrin stimulated contractions as was to be
expected from its property of stimulating smooth
muscle. Amylnitrite in the case reported abolished
the contractions, probably by stimulating the inhibitory
nerves or by lessening the reflex excitability. From
the results obtained hydrochloric acid, from the strength
that it might occur in the stomach, about 0.5 per cent.,
caused no appreciable effect. The authors stated that
they did not feel justified in drawing final conclusions
regarding the effect of acidity until more cases were
studied whose emptying time and condition of the
pylorus was more thoroughly observed.
Carbohydrate Restriction in the Medical Treatment of
Gastric Hyperacidity and Ulcer.— Dr. Willard J. Stone
of Toledo, Ohio, presented this paper in which he stated
that it was safe to say that in the present state of
cur information, ulceration of the stomach or
duodenum rarely occurred without long standing hy-
peracidity. Moreover the medical treatment and cure
depended to a large degree upon neutralization of the
acid secretions by the administration of appropriate
food and sufficient alkali. It seemed that in the type
of carbohydrate digestion, manifested by breads and
cereals, there existed a slightly lower hydrochloric
acidity but a more protracted secretion. Since there
was no provision in the stomach for carbohydrate di-
gestion it had seemed plausible, in this day of excessive
sugar consumption, that this common dietetic fault
might be responsible for the altered gastric secretion
found in a large majority of patients suffering with
hyperacidity, pyloric spasm, and ulcer. The point to be
made was that the excess consumption of carbohydrates
under normal digestive conditions was a different mat-
ter than excessive consumption when hyperchlorhydria
was present. In patients with pyloric spasm or ulcer
the excess was required to remain in the stomach
during the process of protein digestion of the other
constituents of a mixed meal, with the result that
bacterial fermentation followed and the symptoms of
amylaceous dyspepsia become evident. Their distress
appeared to be due primarily not to the hydrochloric
acid content of the stomach but to the bacterial elabora-
tion of organic acids from carbohydrate fermentation.
Later in the process of gastric digestion, usually after
one hour, hypersecretion of hydrochloric acid occurred
as a result of the stimulating effect of such organic
acids as butyric, lactic, acetic, and proprionic. The
Skaller meal had much to commend it. It consisted of
five grams of Liebig's extract in 200 c.c. of water. It
was more palatable and gave a truer picture of gastric
secretion than the Ewald meal. Patients with hyper-
acidity, delayed motility, and ulcer did better when
their intake of carbohydrate food was lessened. The
writer said he was also convinced that restriction gen-
erally to those articles of food which containd more
than 20 per cent., such as bread and potato, together
with sufficient alkali to limit the secretion of hyper-
chloric acid had given better results than hitherto ob-
tained. A general diet list was presented which the
writer had found useful. In addition the patient was
requested to take one glass of milk between meals and
at bedtime. After each meal and after each glass of
milk, a powder consisting of heavy magnesium oxide,
soda bicarbonate, and bismuth subcarbonate was to be
taken in from one-half to one teaspoonful doses in
one-third glass of water. If evidences of hyper-
secretion were present the powder was given every two
hours.
Syphilis as a Probable Factor in Vague Stomach Dis-
orders.— Dr. Cabot Lull of Birmingham, Ala., read this
paper. lie said that nothwithstanding modern methods
for thorough diagnosis of stomach conditions there still
was too large a class of so-called "functional diseases"
of the stomach which in reality were made up largely
of sufferers from visceroptosis, pyogenic infections,
early myocardial or valvular disease, hyperthyroidism,
latent tuberculosis, and syphilis. There was a rapidly
growing literature of organic syphilis of the stomach,
diagnoses now being based on positive clinical .r-ray
and selological findings in spite of the contention of
pathologists that the disease was rarely demonstrable
in tissue examinations after operation or post mortem.
Since Warthin found spirochetes in cardiac muscle, as
well as in other organs which showed no lesion, which
according to the older knowledge would be classed as
syphilitic, one might accept his theory for the period
of latency in persons who though free from symptoms
for decades showed abundant organisms in their tissues,
he assumed that a symbiotic relation existed between
the organisms and the body cells. This view of latency
in symbiosis would explain more satisfactorily such
phenomena as the late parasyphilitic manifestations and
the negative complement fixation test which became
positive after provocative doses of antiluetic reme-
dies. Several illustrative cases were cited and, in con-
clusion, the essayist expressed the opinion that the
recognition by laymen and physicians of the wide-
spread prevalence of syphilis, often of mild type and
non-venereal in origin, with a more definite and satis-
factory interpretation of the Wassermann reaction
would lead to the relief of many cases of functional
stomach disorder now neglected.
Syphilis in the Southern Negro. — Dr. H. L. McNeil
of Galveston, Tex., presented this communication, in
which he stated that it was the belief of the majority
of physicians working among negroes in the South
that the greater percentage of them were syphilitic.
On the other hand it was the belief of physicians work-
ing among the better class of negroes, especially in the
North, that such an estimate was not correct. Most of
these opinions were based solely upon clinical observa-
tions and not upon scientific investigation. The work
here reported was carried out on the negroes of the
city of Galveston, the majority being of the laboring
classes. The Wassermann and the luetin tests had been
employed. The series consisted of some 1200 adult
negroes, in 600 of whom both the Wassermann and the
luetin reactions could be successfully followed, while
in the remaining 600 only the Wassermann tests could
be obtained. Of these 1200 negroes, 34 per cent, gave
positive Wassermann reactions. Of the 600 negroes
upon whom both the Wassermann and the luetin tests
were done, 3!5 per cent, gave definitely positive Wasser-
manns, and 18 per cent, gave positive luetins, while the
total percentage giving positive reactions to one or both
of these tests was 42 per cent. Such statistics were of
comparatively little value in arriving at a true idea of
the prevalence of syphilis among a race of people, for
it was a well known fact that the percentage of syph-
ilis among patients applying for treatment to clinics
was always much higher than among the healthy work-
ing classes. In order to determine the actual preva-
lence of syphilitic infection among the healthy working
negro, they had made a special study of some 200 such
cases. Among these cases were included all negroes
admitted to the surgical wards of the hospital suffering
from accidental injuries, and all were ruled out who
were otherwise diseased. Of these apparently normal
cases, 24 per cent, gave positive Wassermann reactions,
12 per cent, gave positive luetin reactions, and 28 per
cent, gave positive reactions to either the Wassermann
or the luetin tests. They had also made observations
to determine what percentage of syphilis might be
hereditary and what acquired. It seemed that the ma-
jority of cases of syphilis among the negroes were of
the acquired type. Tests were made on patients hav-
ing different diseases, and these seemed to show that
certain diseases seemed to be directly connected with
previous syphilitic infection, as shown by the extremely
high incidence of positive reactions. In other diseases
moreover, syphilis, although apparently not being the
direct, or at least the sole cause of the disease, would
seem to be connected with its occurrence in some way,
chief among these being the characteristic form of acute
or sub-acute diffuse nephritis, which was one of the most
common causes of death among negroes. The occur-
rence of syphilis among whites of the same social class
as the negroes would seem to be about the same as
among negroes. In the better class of whites the
occurrence was much less, while in the best classes,
young and healthy medical students, it was almost nil.
Syphilis was undoubtedly one of the chief causes of
death and disease among negroes, ranking as high or
higher than tuberculosis, Bright's disease, and pellagra
which were the three other chief causes of death or
disability among that race in this community.
SECTION ON SURGERY.
Wednesday, June 14 — Second Day
Some Technical Features of Spinal Surgery, with Re-
July 1, 19161
MEDICAL RECORD.
35
port of Results in 150 Spinal Operations (Lantern Dem-
onstration).— Dr. C. A. Elsberg of New York read this
paper and illustrated it with lantern slides and moving-
pictures. Of the methods of approach to the spinal
cord; namely, hemilaminectomy and complete laminec-
tomy, the latter was the simpler and more reliable. He
removed the spinous processes with forceps and re-
sected the vertebrae so as to leave a tunnel 1 cm. across.
For spinal decompression, he made the opening l%-3
cm. wide. The results of spinal decompression were
as good as cranial. He recommended the removal of
the tips of the adjoining spines. The normal color of
the spinal cord was creamy white. In meningo-
myelitis, the color was pink and the veins were con-
gested. Congested veins sometimes pointed to obstruc-
tion higher up. In multiple sclerosis, the cord was thin
and pale and the vessels small. When tumors were
situated under the intraspinal portions of the nerves
it was better to sever the nerves and lift out the tumors
than to drag them out while the nerves remained in-
tact. Adhessions occasionally demanded relief. Large
tumors were soft and less injurious to the cord than
the small hard ones. He had performed 150 laminecto-
mies with 15 deaths. Of the 15, 10 were about to
die at any event. He used fine silk to suture the dura
and interrupted sutures for the fascia and skin.
Dr. Sachs of St. Louis said that Dr. Elsberg had
passed over several of his contributions to spinal sur-
gery. The approach to the anterior surface of the cord
was difficult. By severing the ligamentum denticulatum
and pulling on the stump, the cord could be displaced
to expose it. The differentiation of the circulatory dis-
turbances was of diagnostic value in determining the
nature of the cord lesion. Opening of the dura was
sufficient to produce distention of the cord veins. He
emphasized the importance of securing a dry field be-
fore opening the dura. He was accustomed to use hot
cotton to absorb the blood ; he had never tried the suc-
tion apparatus recommended by Elsberg. He made
a subperiosteal section instead of cutting the muscles
and protected the sides of the wound with gauze. He
endorsed the resection of the spines. The least possible
traumatization to the nervous system was desirable.
There was a danger, he thought, in moving-pictures
giving the impression of rough handling.
Dr. Elsberg said, in reply, that he cut the muscles
against the spines without cutting into them. Although
the spinal nerves distended when the cord was ex-
posed, the distension never equaled that of obstruction
or of meningo-myelitis.
Surgery of the Brachial Plexus. — Dr. Arthur A. Law
of Minneapolis read this paper. He said there were
many such injuries coming out of the war. He de-
scribed the mechanisms that were responsible for them.
They were not only due to direct but, as Horsley has
shown, to indirect violence. The successful surgery of
spinal nerves demanded a knowledge of the regenera-
tion of the nerves. It had been shown that nerves
grow across a gap. Wrapping the interval with fascia
or fat prevented throttling with connective tissue. Re-
generation occurred if the ganglia were intact. In
avulsion, nerves were torn and frayed, there were en-
doneural hemorrhage and fibrous tissue replacement.
There were 21 cases of avulsion of the brachial plexus
up to 1911, as proven by operation. Hartwell and
Murphy reported two cases. None of the avulsions
occurring in adult age showed complete recovery after
operation. He considered the improvement sufficient
to justify operative intervention, however. He reported
two personal cases in one of which he had repaired
a three-inch loss in the musculospiral nerve.
Dr. Dean D. Lewis of Chicago said that 36 per cent,
of nerve sutures were satisfactory. The results of sec-
ondary were about the same as primary nerve suture.
He held that the neuro-tropism did not exist in the axis-
cylinders for if it did one should get regeneration from
a severed cord. There was 5/6 proliferation from the
central and 1/6 from the peripheral end. The auto-
transplant was the best bridge. Law was to be con-
gratulated upon the results he obtained in these two
cases.
Dr. Law, in conclusion, spoke briefly upon the sub-
ject of neurotropism from an experimental point of
view.
Free Transplantation of the Omentum Subcutaneous-
ly and Within the Abdomen. — Dr. Carl B. Davis of Chi-
cago read this paper. Omental grafts did well where
transplanted. There was considerable adhesion forma-
tion about the raw edges which indicated the turning
in of the cut edges. He had lacerated the liver and
used omentum as a plug and as a flap over the lacerated
portion with the result of hemostasis. He illustrated
the results of omental grafts to stomach, intestine,
liver, and spleen by lantern slides.
Dr. Alfred Strauss of Chicago said that the advan-
tage in leaving the omental flap intact was that it was
kept alive. He drew attention to his method of pyloric
occlusion with fascial transplant. He had resected
stomachs of 26 dogs and placed fascia in the gaps. In
both series he kept the fascial grafts alive with omen-
tum layed over them.
Dr. John S. Davis of Baltimore said that Stone of
Boston had scraped intestine, applied omentum over the
scraped portion, and observed adhesions only at the
cut edges of the grafts. Senn had used omentum freely
in 1888! The use of omental grafts prevented ad-
hesions and hemorrhage and reinforced suture lines.
Dr. A. T. Mann of Minneapolis had removed a large
overian cyst and left an extensive raw surface which
developed a mass of adhesions for which he had to
reoperate within one year. He transplanted the entire
omentum over the raw area. Within a year from
the first operation, he had to operate upon the same
patient again for ovarian cyst in the remaining ovary
and found at this time the intestines free and the fat
gone. He concluded it was feasible to transplant the
omentum.
Operative Treatment for Threatened Gangrene of the
Foot, with Special Reference to Reversal of the Circula-
tion (Lantern Demonstration). — Dr. John S. Horsley
of Richmond, Va., read this paper. The essayist recog-
nized four forms of circulatory disturbance: the arterio-
sclerosis of wear-and-tear of old age, of syphilis, etc.;
intermittent claudication (arteriosclerosis with spasm
of the vessels), Renaud's disease (with spasms on the
arterial or venous or both sides of the capillaries), and
thromboangiitis obliterans (the German endarte-
ritis). Berger had shown occlusion of toxic origin.
Thromboangiitis occurs in young people between 20
and 40 and usually in Russian Poles. The treatment
is local and general. Kocher used Ringer's solution;
so did Willy Meyer. Five hundred c.c. of the solution
were given repeatedly. Carrel and Guthrie performed
an arteriovenous anastomosis and observed the circula-
tion always reversed (during a three-hour observation).
The author thought the fallacy of Carrel's observation
arose from his dependence upon the color of the blood
for the veins often carried red blood (as after con-
ditions of arterial constriction). He believed the blood
traveled down the large veins past the valves into the
small valves where after its resistance is spent, the
blood is arrested by one of the small venous valves and
forced to return by a collateral circulation. He showed
slides representing the circulations in birds and dogs
following anastomoses. He believed tying the femoral
offered as good results. In either case, the clinical
improvement was not entirely successful.
Dr. Dewitt Stetten of New York said that arterio-
venous anastomosis gave improvement by shunting the
blood back through the venous trunks but that it was
difficult to perform; the anastomosis might not remain
open, and the operation should be abandoned. Ligation
secured whatever results were obtainable by anasto-
mosis. His treatment consisted in hygiene, posture,
rest, moist dressings, and alternate hot and cold. He
believed that he causative factor was similar in nature
to that in hemophilia, an abnormality of the blood,
a hereditary character.
Dr. Charles Goodman of New York replied in favor
of arteriovenous anastomosis. He said that they had
waited 200 years for saline solution although formerly
plain salt solution was used. Still the present solution
was not identical with blood. It was not known how
much blood reached the periphery after anastomosis
but there was evidence of relief of symptoms and the
impending gangrene was averted. Bernheim had col-
lected 56 cases, 15 being successful. He reported 6
satisfactory out of 14. Others were reported since.
The experiments offered did not contraindicate the
operation of anastomosis. Endarteritis and thrombo-
angiitis were of infective origin. He had several in-
stances of 3 plus and 4 plus Wassermann reactions.
Dr. N. Ginsburg of Philadelphia had seen many
cases. They had come from Jewish people. There was
no operation indicated except in thromboangiitis ob-
literans. He believed femoral vein ligation and crossed
anastomosis palliative, only. Both procedures engorged
the extremities. He had noticed a preponderance of the
disease in male Russian Jews, many of whom were
cigarette smokers. The origin was probably toxic.
36
MEDICAL RECORD.
[July 1, 1916
Dr. Carl Beck of Chicago said that Horsley's in-
ference that Carrel depended upon the color of the blood
in tracing the course of the blood after anastomosis
was incorrect. He had worked with Carrel and knew
that he had drawn his conclusions from the position
of the vessels. He reported a case of his own with a
prompt filling of the vein. Bismuth injections were in
his opinion illusive.
Dr. La Place of Philadelphia said that thromboan-
giitis affected certain people only. Specific treatment
availed in some of these cases. Alter amputation, a
black line formed about the end of the stump. It was
wrong to sew up the wound. There was something
defective in the healing process. He found bathing the
end of the stump with serum beneficial in every case
of his.
Dr. J. F. Corbett of Minneapolis said that collateral
circulation sometimes accomplished much and deserved
some credit. The rate of flow in a normal dog differed
from that in senile gangrene of man. Animal experi-
mentation in this particular condition was of little
value. Sugar and urea increased as did the viscosity of
the blood in these cases. Viscosity increased in other
conditions as well. He could not offer anything opera-
tive but amputation.
Dr. HoRSLEY, in conclusion, replied that he had not
proposed any operation for gangrene. Ligation helped
in some instances. There might be a metabolic toxin
in the condition. He thought gelatin injection and ani-
mal study reliable.
Stab Wounds of the Chest Involving the Diaphragm
with Diaphragmatic Hernia. — Dr. Charles C. Green of
Houston, Tex., read this paper. Evisceration through
the diaphragm occurred most often on the left side, for
the liver acted as a barrier on the right. One report
of 64 cases gave 45 protrusions of the outer wounds ;
one of 13.5 hernias; one of 16, 9 protrusions at wound;
and in 190 instances there were 98 or 52 per cent,
eviscerations. He enumerated personal case-reports.
Diagnosis was often not made until obstructive symp-
toms intervened. The mortality in the complicated
cases was 64 per cent.; that in the uncomplicated was
20 per cent. In doubt, to save life, exploratory thora-
cotomy should be done.
Dr. James E. Moore of Minneapolis said that this
paper was up to the minute and that the advances in
the next decade in surgery would be in thoracic work.
With intratracheal insufflation, the thorax could be
opened with impunity. After a stab wound of the
chest, the thorax should be opened ; it would be per-
fectly safe, and might save life.
Dr. Charles C. Green of Houston, Tex., said thai
the main danger was collapse of the lung which caused
shock. But pneumothorax had already developed in
some instances. As soon as the ruptured edges of the
diaphragm could be seized and held together, there was
no danger.
Thursday, June 15 — Third Day.
This was a joint meeting with the Section on Medi-
cine.
The Immediate Effects of Splenectomy in Pernicious
Anemia. — Dr. Heinert of Boston read this paper for Dr.
Roger I. Lee of Boston. There was a typical blood
count in 15 cases of pernicious anemia. After
splenectomy, 4 improved in red cell count, 3 were un-
changed. Ten were living after 10 months. Of these
five had relapses and five did not. Three died one year
postoperative. The leucocytes varied from 2,000 to
5,000, subsided in a few days, and tended to increase.
The platelets were low after operation for 3 to 7 d tys
and increased after, which increase often persisted.
(9,000). Many showed an increase, especially in the
large platelets. Platelets were known to be increased
in thrombosis and in this series three were thrombosed
Howell-.Iollie bodies occurred in 2-10 per cent, of the
red cells after splenectomy. These bodies were sup
posed to be related to changes in the bone marrow.
blasts fluctuated. Of the red cells 0.8 per cent, were
mented. A high percentage of these indicated ac
ity of the bone marrow. There was a rise in the reticu-
lated red cells after operation. The temperature im-
proved and was associated with activity of the b
marrow and impri I in the blood picture. The
cause of stimulation of 'narrow was not known.
Operation did not alter the essential course of the dis-
ease. Evidently, such a stimulation can be obtained
but once. Transfusion did not modify the destructive
agents at work.
l.ate Results of Splenectomy in Pernicious Anemia. —
Dr. E. B. Krumbhaar of Philadelphia read this paper.
In PJ13 Eppinger and von JJecastedo independently ap-
plied splenectomy to the treatment of pernicious
anemia. The prompt improvement in the early cases
led to a widespread trial. Of 117 cases reported, 34
had died (mortality Zil per cent.). Of these, 18 died
within six weeks of the time of operation (15.2 per
cent.). In most of the other 99 cases there
was a marked improvement for a varying length
of time and in some during the whole period
of observation. Of 19 patients, alive at the end
of a year, 6 had died subsequently, 8 were still im
proved, and 5 were the same as before operation,
iiighty-four cases, studied in respect to duration of
the disease before operation, showed 11 improved and
4 deaths in 15 of six months' duration; Is improved
and 7 deaths in twenty-five one-half to one year cases;
lb improved and 10 deaths in 32 one to two-year
cases; and 6 improved and 8 deaths in 13 two-year
cases. The earlier cases gave the best results. In re-
spect to the size of the spleens, of 19 cases of large
organs, 1 died and 18 were improved; in 23 normal or
diminished spleens, 9 died and 14 improved. The diag-
nosis of pernicious anemia was not perfect, fhe aver-
age duration of all cases was one and a half years.
The most suitable for operation were the short duration
cases with large spleens (or those with marked blood
destruction showing increased unrobilin destruction).
Contraindications were cases with symptoms of spinal
cord disease, with no signs of blood destruction, or with
aplastic bone marrow.
Splenectomy in Chronic Anemia, Exclusive of Perni-
cious Anemia, and in Chronic Icterus. — Dr. Joseph L.
.Miller of Chicago read this paper. The value of
splenectomy in splenic anemia was unquestioned.
Since this disease was improved, operation improved
hemolytic jaundice and the cirrhosis of Hanot. All
were characterized by chronic icterus, chronic anemia,
or both, and splenomegaly, the siools were stained with
bile. There was an hereditary tendency in icterus, and
in splenic anemia. Anemia was not present in
Hand's Disease; this differentiated it from icterus. In
hemolytic icterus, there was a disturbed resistance of
the red cells; there were hemolytic crises. Splenic
anemia was thought by many not to be a distinct
entity; it was not a logical entity etiologically but
might be so considered for therapeutic purposes. The
anemia improved following operation. Banti's report
covering the past ten years gave 44 per cent, mortality ;
since 1910, 19 per cent. The fatality at the Mayo
clinic for eighteen cases was 11 per cent. Antisyphilitic
treatment helped some but x-rays seemed of no avail.
Splenomegaly occurred early in hemolytic icterus or
it had not occurred at all. After splenectomy the
hemolytic function (of the spleen) disappeared. Three
or four cases of the cirrhosis of Hanot had been
treated by removal of the spleen; it was impossible
to foretell the efficacy of this treatment.
Splenectomy for Hemolytic Jaundice. — Dr. CHARLES
11. Peck of New York read this paper. Splenectomy
was beneficial in hemolytic jaundice. No bile ap-
peared in the urine after operation. The symptoms of
the congenital and familial types were the same. The
author's case of congenital hemolytic jaundice was the
first American case operated upon. The patient bad
jaundice at 20 which became intermittent from 20 to
30. She had a fragility of 70 which dropped to between
35 and 40 three years after operation The
leucocytes rose, then became normal in number.
The spleen was moderate in size, its surface was
roughened, it showed interstitial hemorrhage and fol-
licles somewhat crowded out. The return to normal of
the red cell fragility was especially noteworthy. The
second case was of the acquired type. There was slight
fragility before and no change after operation. The
secondary anemia was moderate in amount. There
were urobilin and urobilogen in the urine. The spleen
weighed 800 grams. This case had been well since
operation. The third case was of the congenital type
and was operated upon by Dr. Warren. Jaundice dis
ared and improvement followed after splenectomy.
Indications for Splenectomy in Pernicious Anemia and
the Technique of the Operation. — Dr. Donald C. Bal-
ii i; of Rochester, Minn., read this paper. Of four
cases splenectomized for pernicious anemia, two im-
proved. Three syphilitic spleens had been removed.
The advocacy of splenectomy for pernicious anemia was
stronger as the anemia approached other forms with
recognizable indications for the removal of the spleen,
as hemolytic jaundice. Pernicious anemia was in-
July 1, 1916 1
MEDICAL RECORD.
37
curable. There was, however, no better therapeutic
remedy for the disease than splenectomy. The indica-
tions were (1) splenomegaly (which means overactivity,
and palpability of the spleen. Thirty-seven cases
weighed over 400 grams) ; (2) icteroid types; (3) activ-
ity of the disease (preferably the intermediate rather
than the acute or terminal stages of the disease) ; and
(4) duration of the disease (preferably short). In
separating the spleen from the diaphragm, especially
where adhesions were present and hemorrhage was lia-
ble, it was well to pack well up under the diaphragm
with hot gauze. The spleen should be drawn toward the
midline and its pedicle dissected back. The vessels were
clamped and ligated. There was no recognizable ad-
vantage in tying, first, the artery to allow more blood
to return to the body. In favor of splenectomy were
the low operative mortality, the improvement, and the
lack of superior therapeutic measures.
Pernicious Anemia Treated by Splenectomy andOften-
Repeated Blood Transfusions. — Ur. Ray McClure of
Baltimore read this paper. The essayist said that
blood might not mix, it might clump, hemolyze, or
agglutinate. In the selection of a donor, a proper test
required the elimination of such blood. It was the rule
to allow one hour for the testing of each blood, and it
was often necessary to try out eight to ten individuals
before a proper donor could be decided upon. He re-
ported one case in which syphilis was transmitted be-
cause the donor's history was relied upon instead of
waiting for a Wassermann reaction. Benzol cases were
treated by repeated transfusions; one with a hemo-
globin of 20 was raised to 95. They had performed
sixty-four transfusions in 17 cases. These were harm-
ful in seven and helpful in the others. Those harmed
suffered from the lack of good donors.
Dr. Frank Smithies of Chicago said in the past
three years they had performed multiple transfusions
and splenectomies in 27 cases. The study brought out
the toxic or infective nature of the ailment. There
were foci of infection in the blood-making organs and
in tonsils, teeth, throat, appendix, or elsewhere. There
might be foci in the blood-destroying organs as Bal-
four had pointed out spirocheta in the spleen.
Splenectomy was the less essential part of the treat-
ment. Transfusions supplied antibodies and while these
were being given possible foci of disease should be
eradicated. They had had two operable deaths. It was
their practice never to hurry. Ninety per cent, showed
active or past appendicitis, gall-bladder disease, or
perisplenitis. The average gain in the hemoglobin after
operation was 43 per cent, and over 3,000,000 red cells.
The improvement in the general condition equaled
that in the blood, the longest case remaining better
twenty-seven months.
Dr. Beth Vincent of Boston said that the amount
usually transfused was 600 c.c. The mortality in
splenectomy should be low in pernicious anemia. The
spleen should not be removed during a relapse. Cer-
tain forms did not improve after transfusions; others
did not after operation. For relapses, transfusions
were the best treatment. Both supplying new blood
and the removal of the spleen were palliative measures
which secured temporary and uncertain benefits.
Dr. H. Z. Griffin of Rochester said that thirty-nine
splenectomies gave a mortality of 7.6 per cent. There
was no reason for high mortality. Three of the deaths
were operative and four postoperative. One case lived
three years. Twenty-seven survived. The longest
time of good condition after operation was one year
(two cases). They transfused to improve the patient's
condition for operation and during relapses after opera-
tion. In thirty-three cases, examinations of the duod-
enal pigments showed high value before and low
values after operations (in pernicious anemia). The
mortality in splenic anemia was 15 per cent. Hemolytic
jaundice and syphilis should be differentiated. The
mortality in hemolytic jaundice was 10 per cent. There
was no decided drop in fragility in any of these cases
following operation. He was interested in the hemo-
lytic jaundice cases with pernicious anemia blood
counts.
Dr. W. S. Thayer of Baltimore said that the sympo-
sium was of great value. He had seen his first case
three years ago, a case with cord changes that im-
proved (although others reported none with cord
changes improved). It was important to acquaint the
patient with his chances under operation for pernicious
anemia. The disease was ultimately fatal; the re-
missions were variable in length; in one, five years,
terminating in death from another malady. In splenic
anemia, operation was advisable. In hemolytic jaun-
dice, the results of operation appeared to be beneficial.
In the congenital type, the symptoms were not grave,
life was endurable and he did not feel justified in
recommending splenectomy. In the acquired form
operation might be imperative. In splenic anemia,
splenectomy might give good results. He had waited
six months for one individual to improve and finally
operated and transfused at the same time.
Dr. G. A. Friedman of New York said that he had
seen the case at the Vanderbilt Clinic on whom Dr.
Peck operated. She was more enteric than sick. She
complained of dyspeptic symptoms. He advised send-
ing such cases to the surgeon for operation.
Dr. S. J. Meltzer of New York said the rule was for
the red cells to run in the middle of the blood streams.
Forty years ago he had seen a case with the red cells
at the periphery and thought they had been subjected to
shock (which they might have received in passing
through the spleen). In the last year Dr. Gates of the
Rockefeller Institute had splenectomized dogs and had
shown the effects of shaking upon them. He did not
wish to claim or deny traumatic effects of the spleen in
pernicious anemia. Splenic traumatism might explain
the greater resistance of the red cells after splenectomy.
Dr. W. Brem of Los Angeles gave repeated trans-
fusions. He believed by this means he could keep a
patient alive indefinitely or pull him out of a hole.
Blood-grouping for the selection of donors could now
be accomplished in a few minutes. He had performed
179 transfusions after such tests without a reaction.
He had given twelve without previous tests and with-
out reactions. In four instances where the red cells
were hemolyzed, severe anaphylactoid symptoms fol-
lowed.
Dr. Lee of Boston said that the blood picture in
pernicious anemia was the balance between blood-mak-
ing and blood-destruction. He had studied splenectomy
and transfusion from the standpoint of stimulation
of the bone marrow. The quality of the reticulated red
cells gave information as to the result of this stimula-
tion. The benefits of transfusion were the furnishing
of blood bulk and to bring about a remission through
bone marrow stimulation. Other cases not treated
showed the same changes.
Dr. Krumbhaar, in conclusion, said that much worse
results followed splenectomy associated with a low
hemoglobin (20 per cent.). There might be found a set
of splenic cases that would give uniformly good results.
Dr. Miller added that not every case of hemolytic
jaundice should be subjected to operation. There had
been three cases apparently cured as the result of
.r-rays.
Thursday, June 15 — Third Day.
Dr. F. T. Murphy of St. Louis in the Chair.
Election of Officers. — Dr. W. S. Hagard of Nashville
was appointed Chairman, Dr. A. A. Law of Minneapo-
lis, V ice-Chairman, Dr. E. H. Pool of New York, Secre-
tary, and Dr. D. Lewis of Chicago with Dr. J. T. Bot-
tomley of Boston were chosen Delegates to the House of
Delegates for the ensuing year.
Removal of (he Right Colon — Indications and Tech-
nique.— Dr. Charles H. Mayo of Rochester read this
paper. Years were required to standardize the dis-
eases that warranted colectomy. Only those who were
toxic from the intestinal contents and in whom there
was a delay of three days or more were at present con-
sidered proper subjects. The removal of the right colon
removed the absorbing surfaces of the colon and was
less fatal than the removal of the whole large intestine.
The lower ileum developed with the large colon or at
least these two parts fell on the same side of the at-
tachment of the vitelline duct. He described the
physiology of the intestine and his technique of resec-
tion. He removed the terminal ileum with the right half
of the colon and joined the terminal end of the ileum
with the side of the end of the remaining transverse
colon by means of a Murphy button. The extreme
end of the colon or the portion protruding beyond the
new iliocolic anastomosis was caught up in the closure
of the parietal peritoneum and left accessible at the
abdominal wound that it might serve as an outlet for
gas from the colon after operation, if necessary.
Tumors, granulomata, and colons of toxemic origin
were resected in this way. Few of the cases had post-
operative diarrhea. Appendicostomies might be done
to allow escane of gas in operations upon the left colon.
There were 262 resections of the left colon for malig-
nancy and 54 per cent, living or 67 per cent, alive three
38
MEDICAL RECORD.
[July 1, 1916
years after. The last twenty consecutive colectomies
were performed without a fatality. There was a 13.5
per cent, mortality in ninety-six hemicolectomies and a
14 per cent, fatality in twenty-seven ilio-colostomies.
Some Results of Colectomy and Exclusion of the Co-
lon in Cases of Chronic Arthritis. — Dr. John T. Bottom-
ley of Boston read this paper. Chronic infective
arthritis was poorly treated by the profession. The
intestinal stasis origin of the arthritis was an attrac-
tive theory. Ten of fourteen multiple, nontubercular
cases were reported relieved by operation by Dr. Rea
Smith. Anastomoses, colectomies, and other operations
were performed. The toxic symptoms were reported
relieved. There were increased joint action and im-
proved bowel evacuation. In the author's cases the re-
lief was temporary. One case remained cured three
years after; another ten months (with diarrhea) later.
Of thirty-one cases, twelve were cured. Of these twelve
five were colectomies and seven iliosigmoidostomies.
Colectomy in Lane's hands was more satisfactory than
in ours because his experience was wider and his tech-
nique better. There was diarrhea in two cases. The
joint cases that did not improve followed the natural
course of the joint disease and were not aggravated by
the operations. It was desirable to exclude infections
of the sinuses, ureters, seminal vesicles, vagina, and
other possible sources before turning to the intestinal
tract. The neuromuscular apparatus of the bowel in
intestinal stasis was at fault not the adventitious bands.
Smith advised doing colectomy or iliosigmoidostomy.
(Operations helped some and not others.) Persons to
be operated upon for stasis should first understand the
chances of a successful issue.
Dr. Rea Smith of Los Angeles said that Mayo's
operation did away with a backing-up into the colon.
In Lane's cases of" short circuiting adhesions appeared
in patches due to infection from his suture during
anastomosis. There were less such adhesions after
colectomies. Of fourteen cases there were two deaths
and three perfectly well excepting for bony ankylosis
(due to periarticular inflammation). These lived 18
months, 2 years 2 months, and 2 years, respectively,
postoperative. Of the remaining nine, two were unin-
fluenced and seven were little better. None would go
back to former condition. All were better generally,
in respect to pain if not to joints. Drainage of the
intestine seemed to influence the pain; less aspirin had
to be taken for its relief after operation.
Dr. W. R. Mac Ausland of Boston said that in ten
cases the routine measures failed. Intestinal symptoms
and the chronic arthritis were not relieved. Upon rela-
tive relief was the only basis of comparing results. The
joint cases should be taken before the advanced destruc-
tive stages. The time involved in these changes was
1 to 1% years. Deformities should be prevented or cor-
rected. Stasis was present in all.
Dr. J. M. Lynch of New York said that the time had
come when the iliocecal valve should be recognized
as either muscle or valve. If a muscle, operation was
of little value. If a valve, then operation was of some
avail. Elliott supported by Bayliss, Starling and oth-
ers, had shown that the arrangement was a muscle.
Ten minims of adrenalin shut the valve tightly as a
drum; later the same valve might relax into insuffi-
ciency. The relations of the internal secretions to the
iliocecal sphincter were to be studied. He had per-
formed twenty-eight colectomies (partial) and six
cecosigmoidostomies. All the latter had been failures.
Dr. Tucker of Cleveland asked upon what Mayo
based his operability for his colon cases. Were the
mechanical changes or the operative feasibility con-
sidered?
Dr. J. S. Horsley of Richmond, Va., said that Cannon
showed that adrenalin caused dilatation of the gut by
relaxation of the smooth musculature and did not un-
derstand why the valve should be contracted.
Dr. J. W. Draper of New York replied that the un-
derstanding was that adrenalin caused relaxation of
the gut and contraction of the valve. It was an arrange-
ment for estimating the functional disability of the
valve. He reported one case of a woman in the termi-
nal stage of polyarthritis who was unable to use her
hands to write or handle her knife and fork who was
able to turn over in bed in twenty-four hours after
hemicolectomy. The rapidity of relief suggested a bio-
chemical in place of or in addition to an infective
arthritis.
Dr. Johnson of Memphis said that all agreed the
area involved was the ilocecal region. It was due
to a regurgitation of cecal contents into the ileum,
the absorption of which caused a paralysis akin to
that of lead-poisoning. The bands over the ileum and
cecum denoted inflammation. Patients who developed
splanchnoptosis had sick headaches and toxic vomit-
ing in early life. The causes of the ptosis and of the
toxic symptoms were the same. He had performed 11
colectomies, one to the sigmoid loop. The fixation of the
end of the colon prevented sacculating or sagging. The
omentum should be saved: it prevented some of the
infection.
Dr. Mayo replied that cases hopelessly metastasized
were not operated upon. Cases of parietal fixation were
operable, as were all tumors of the colon.
Perforating Ulcers of the Stomach and of the Duode-
num.— Dr. R. P. Sullivan of Brooklyn read this paper.
He said the tenderness of ulcer was acute and easily
elicited over the ulcer site. It was in the right iliac
region in fifteen duodenal and in the epigastric region
in five-gastric ulcers. Vomiting was present and gave
relief at first and suffering later. The vomitus depended
upon the food and the site of the ulcer. Rigidity oc-
curred early. He had relied chiefly upon the pain and
rigidity. There was only one case without a preulcerous
history. Eleven diagnoses of chronic ulcer had been
made. Shock was present late in one case only. The
temperature averaged 99.4 and the respirations 34.
Appendix and gall-bladder disease should be differ-
entiated if possible, though in either event operation
was indicated. The average duration of symptoms be-
fore operation was six hours. His cases were fifteen
duodenal and five gastric ulcers. Of the gastric, three
were anterially placed, one at the lesser curvature, and
one on the posterior wall. Gibson disapproved of
gastroenterostomy for ulcer. Gastroenterostomy was
added in each of ten cases in which the lesion was
at the pylorus. He repaired the perforation and per-
formed gastroenterostomy if seen within ten hours.
Dr. C. Peck of New York said that ulcers were acute
with immediate leakage, chronic with no considerable
leakage, and of the type that leaked a little from time
to time. The leakage from an ulcer at the pylorus was
slight; gastroenterostomy should be performed for such
an ulcer at the first or at a subsequent operation. He
had seen a reperforation one year after closing an ulcer.
From 1910-1915 he had had thirty perforated ulcers,
two-thirds duodenal and one-third gastric. Gastro-
enterostomies performed mostly in the latter cases, did
not add to the operative mortality. Cases seen within
the first 10-15 hours mostly survived.
Dr. Bottomley of Boston said that he did not agree
with doing away with the drainage even in the early
cases. He had seen turbid fluid in the abdomen in 1%
hours. Drainage increased the margin of safety and
should be continued for 48 hours. Liberal diet should
not be given after operation. The source of the infec-
tion causing the ulcer should be sought and eliminated
if possible.
Dr. W. D. Johnson of New York said that a chemical
peritonitis (which was not severe) preceded a bacterial
peritonitis. Rigidity was marked. Absence of liver
dullness was a late sign and should not be included.
Dr. Sullivan replied that drainage was a matter of
opinion. The chemical peritonitis excluded the neces-
sity for early drainage. Absence of liver dullness
might be due to gas in the colon.
Plastic and Reconstructive Surgery. — Dr. J. S. Davis
of Baltimore read this paper. Dr. Davis said that the
need for reconstructive surgery had increased as a re-
sult of the war. Such surgery required special trairing
in addition to a general surgical experience. Few cases
were operated upon for cosmetic reasons, alone; many
for economic reasons.
Dr. J. S. Marvel of Atlantic City reported a case
with a large fenestra of the anterior abdominal wall
cured by skin-grafting.
Dr. J. S. Stone of Boston said much surgery was
indicated in malformations and after trauma. Knowl-
edge of the growth and of the repair of tissues was
necessary.
Sarcoma of Intraabdominal Testicle. — Dr. W. W.
Grant of Denver read this paper. Sarcoma was most
common in the undescended testicle. Ewing considered
most testicular tumors primarily teratomata. He re-
ported a case seen in 1913. He operated upon this case
when first seen, administered Coley serum, and x-ray
treatment; and removed the growth at a subsequent
operation (1915).
Dr. W. B. Coley of New York said that the essay-
ist's success was due to successful treatment with the
serum. He seldom injected directly into the tumor as
July 1, 1916]
MEDICAL RECORD.
39
the author did. Of 64 cases of sarcoma of the testicle,
twelve were undescended. He had operated upon fifty
undescended testicles and had not seen one sarcoma
among them. He believed every case of undescended
testicle should be operated upon.
Dr. Grant replied that after complete removal of the
growth the x-rays and Coley serum should be used for
prophylactic reasons.
Chronic Appendicitis. — Dr. F. G. Connell of Osh-
kosh, Wis., read this paper. He reported operating with
unsatisfactory results upon forty-eight cases of ap-
parent chronic appendicitis. There were burning sen-
sation, tenderness in the right lower quadrant, umbili-
cal region or elsewhere, general ptosis, gurgling in the
lower right quadrant, no leucocytosis, and a ptosed and
dilated ascending colon. Twenty-seven were submitted
to a second operation. Of these, fifteen were unim-
proved and one died. The pain in such cases was due
to something besides the appendix.
Dr. H. A. Black of Pueblo, Col., said that the x-ray,
test-meal, hematemesis, and the absence of pain and
tenderness did not exclude chronic appendicitis. Py-
loric spasm was often present in chronic appendicitis
and might be due to a hypertension, rather than a
hypersecretion.
Dr. LaPlace of Philadelphia said that there might
be a chronic form of transudation of the toxins through
the cecum.
Oration on Surgery — Surgical Aspects of the Indus-
trial Accident Insurance. — Dr. Emmet Rixford of San
Francisco read this paper. The principle of assessing
the employer for the surgical care of the employed was
of German socialistic origin. Most of the European coun-
tries had passed such laws. Thirty-one of the forty-
eight states had made laws for workmen's compensa-
tion. Many countries enforced compulsory insurance
to be carried by the employer, employee, and the State
in favor of the employed. He believed the movement
inevitable and that its benefits would include checks on
lodge-practice, contract-practice, hospital, and patent
medicine evils. The industrial commissions having
charge of matters pertaining to the surgical care of
injured workmen were powerful. Their tendency was to
eliminate mediocre surgery and to encourage careful
work. Sixty per cent, of the returns for injury went to
the workman and 40 per cent, to the physician. There
were only three mal-practice suits on record in the past
two years. The unions tended to favor union-chosen
physicians rather than men chosen by the State for
surgical excellency. Experts were employed by the
commissions for the special problems.
Complications and Sequellae of the Operation for In-
guinal Hernia. — Dr. Lincoln Davis read this paper.
There were 1,500 hernia? operated at the Massachu-
setts General Hospital between October, 1908, and De-
cember, 1914, by seventy-five different surgeons. There
were 1,756 distinct operations. Of these, 834 were
Bassini, 15 Halsted, and others according to Ferguson.
General anesthesia was administered in 1,309, spinal in
108, local, combined, in 6, and local alone in 75. There
were accidents to the bladder in 2, to the vas in 7, to
the bowel in 2, and 8 deaths. The mortality was 0.53
per cent. Sixty-six recurred or 3.7 per cent, (or 8
per cent, traced). These were divided about equally
between the Bassini and Ferguson methods.
Dr. H. O. Marcy of Boston was one of the pioneers
in hernial surgery. He had had about 3 per cent, re-
turns in 1000 cases.
Dr. D. N. Eisendrath of Chicago suggested using
adrenalin, one drop instead of four or five, to the
ounce in local work. He thought recurrences were
sometimes due to neglecting an occasionally present
pantaloon sac, or to leaving a direct or indirect sac
when both occur simultaneously. Pain was sometimes
caused by the inclusion of nerve fibers in the sutures.
Dr. Davis believed there was a preexisting congenital
sac in all so-called traumatic hernia. The figures for
the local operations might be too high. The infiltration
of the tissues might interfere with firm closure.
The Surgical Problem of Symptomless Hematuria, Its
Causes and Surgical Relief. — Dr. R. L. Payne, Jr., of
Norfolk, Va., read this paper. He based his report
upon eleven human and five dog instances of hematuria.
He found in those cases where the kidney was removed
and studied, inflammatory changes in the cortico-medul-
lary portion and dilated veins in the medullary por-
tions. He held that the inflammation interfered with
the venous return and forced the already distended
veins to empty into the pelves. The treatment included
nephropexy for the displaced kidney, decapsulation,
nephrotomy, and nephrectomy (too radical). The non-
operative treatment included the use of styptics, adren-
alin, and sera.
Dr. H. A. Royster of Raleigh, N. C, said a col-
league had hematuria only when he used tobacco. The
pathological changes might be those represented, or
none at all, or incipient tuberculosis. Decapsulation
was of no account. Instead of sutures, gut might
be wrapped about the kidney after exploratory
nephrotomy.
Dr. J. S. Horsley of Richmond, Va., said painless
hematuria was due to stone, tuberculosis, or hyper-
nephroma and to the changes described. The straight
suture caused less necrosis than the mattress and was
as efficient.
Dr. Payne replied that decapsulation cured probably
by setting up a thrombosis.
A Consideration of Fractures and Other Injuries of
the Hip. — Dr. A. R. MacAusland of Boston read this
paper. He divided the fractures into separations of
the upper femoral epiphyses, fractures of the necks,
and fractures between the trochanters. He favored
Whitman's abduction method for fractures of the neck.
The flexion method was not as comfortable, especially
for the old. Operative measures (nails, plates, etc.),
were not necessary for acute cases. Reduction of
fracture without an anesthetic was possible only in
those that could be speedily reduced. For the intra-
trochanteric variety, plaster fixation in abduction was
the best. Of fifty cases, he had thirty-two reports
which were satisfactory. Slides.
Nail Extension in Fractures of the Lower Extremity.
— Dr. J. C. A. Gerster of New York read this paper.
The nail extension was indicated when the usual trac-
tion or plaster methods failed or could not be employed;
in badly compounded recent fractures with extensive
abrasions and injury to the soft parts, and in old mal-
unions with much shortening. Nail extension reduced
the number of cases in which open operation was in-
dicated. Pain was prevented by drawing the skin
upwards when inserting the nail and infection was
prevented by not passing nail into joint cavity or
through the epiphyseal line. In thirty cases, the nail
holes healed completely under wet dressings.
Nails and Screws Through Joint Surfaces in Auto-
grafts and in Fractures into Joints. — Dr. A. T. Mann of
Minneapolis read this paper. In twenty experimental
cases the author had lost no knee from infection. The
dogs did so well that it was difficult to ascertain the
operated knee. The cartilage grew into the grooves
caused by the screws, appearing first as hyaline and
later as the fibrous variety. This was finally replaced
by fibrous tissue. He showed slides of the autografts,
fractures, and reactions to the nails and screws.
Dr. C. E. Thompson of Scranton, Pa., said that
fractures of the femoral necks were badly treated.
Some believed they should be left alone; others that
they would not heal as other fractures. Operation
should not be attempted at the time of fracture.
Dr. R. S. Sayre of New York said the joints pre-
sented showed evidences of erosion. The two human
cases appeared to be good results. The Steinman pin
worked well in some cases as Gerster had indicated.
THE PRACTITIONERS' SOCIETY OF NEW YORK.
Two Hundred and Seventy-Ninth Regular Meeting, Held
Friday, May 5, 1916.
Dr. John S. Thacher, Presiding.
Unusual Paralysis in Upper Spinal Region Following
Anterior Poliomyelitis. — Dr. Virgil P. Gibney pre-
sented this patient, who was a boy, 11 years of age, ad-
mitted to the Hospital for Ruptured and Crippled,
April, 1916, on account of deformity of right foot. Had
"fever" at four years lasting 24 to 36 hours. Patient
never had braces or operation. Both arms were in-
cluded in paralysis at onset, but they had so improved
that patient had some use of them, under electrical
treatment. The reactions now were — right — supraspi-
natus, infraspinatus, rhomboideus major and minor,
latissimus dorsi deltoid, pectoralis major and minor,
teres major and minor and levator scapuli, reaction of
degeneration; serratus magnus gone; left — supraspi-
natus, rhomboideus major and minor, deltoid, pectoralis
major and minor, serratus magnus, teres major and
minor, and levator scapulae, reaction of degeneration;
latissimus dorsi gone altogether; trapezius right and
left sides practically normal. The paralysis just took
40
MEDICAL RECORD.
[July 1, 1916
in the upper group of muscles. The boy now had his
foot in plaster of Paris, but would probably have to
have a piece of bone taken out of the astragalus to get
the ankle straight.
Some Observations on Hemolytic Jaundice. — Dr.
George E. Brewer read this paper (see page 1).
Dr Brewer added that both patients shown had
hemolytic jaundice. Both were jaundiced at the time
of operation. One patient had a good deal of pig-
mentation of the skin. There was very little fragility
of the blood in one case and practically none in the
other. Dr. Longcope had had the cases a long time
under observation. The second case had a blood fragil-
ity of 7 which went down to 4. The normal was 4.5.
Dr. W. Gilman Thompson said that the operation of
splenectomy used to be considered one of considerable
severity, but now it was performed very successfully
and the cases remained successful after many years.
He would like to ask the size of the spleen in Dr.
Brewer's cases. ,
Dr Brewer said he did not recall the actual size, but
it was about three times the size of the normal spleen,
and weighed 11-12 grams. It was an inch below the
costal border. One had a slight adhesion, but neither
was what would be called an adherent spleen.
Dr. J. S. Thacher asked if the veins were very large,
and if the liver was normal.
Dr Brewer said the veins were very tortuous ana
extremely friable, and the livers were slightly enlarged.
Dr. W. Gilman Thompson asked if gallstones were
usually associated with these cases.
Dr. F. S. Meara asked if the pain was usually re-
ferred to the spleen.
Dr. Brewer said that the pain was sometimes purely
epigastric, and sometimes radiated to the left shoulder.
Dr. J. W. Brannan said he would like to ask what
was meant by fragility of the blood.
Dr. F. S. Meara said that the cells were more sus-
ceptible to being broken down when the normal salinity
of the blood was changed. A very little diminution in
the normal salt content of the blood would produce
breaking down of the red cells. The severity of the
condition could be read by the susceptibility of the cell
to the changes in the saline constituents.
Dr. Brewer said the test was made by finding the
percentage of saline at which hemolysis began. The
test was best made with washed cells. The cell sur-
rounded by blood plasma was rather protected. The
normal 0.45 solution of salt would hemolyze normal
blood, whereas 0.7 showed more susceptibility.
Dr! Brannan asked what was the theory of the op-
eration. . .
Dr. Brewer said it was that normal hemolysis took
place largely in the spleen ; when the red cells had done
their work they became degenerated. The function of
the internal secretion of the spleen was to destroy red
cells. If there was a condition of hypersplenism, that
is, where the hemolysis was more rapid, a larger num-
ber of red cells were destroyed than normal. The hemo-
globin became split into two substances, hematin, which
was deposited in the liver and sometimes bilirubin,
which under ordinary conditions was taken up by the
liver and excreted in the bile, but if it occurred in
excess it entered into the intestine, and there changed
to hydrobilirubin. This later became urobilin and was
excreted in the urine.
Dr. Brannan said then was the spleen overdoing its
function? .
Dr. Brewer said yes: the pigments were not taken
care of normally and were found in the blood.
Dr. Brannan asked why this condition caused so
much harm.
Dr. Brewer said that the rapid hemolysis was the
cause of grave anemia. In some severe cases hemoglobi-
nuria occurred. Eppinger had commented upon the
hemolytic activity, and upon the intoxication by means
of products being thrown into the blood. There fol-
lowed fever, chills, and all the symptoms of an intoxica-
tion. This might quiet down and the temperature again
become normal.
Dr. Meara said that Pearce had reported decreased
fragility of the red cells from splenectomy.
Dr. Brewer said in one case reported the spleen was
removed for traumatism. In this instance the red cells
rose to 7,000,000, and the hemoglobin to 110 per cent.
Dr. Brannan said it used to be supposed that the
spleen was very necessary for the body.
Dr. Brewer said it was a good thing to have but
when it was pathological it was better to remove it.
Dr. Gilman Thompson said that there must be some
modification in the bile which produced gallstones so
frequently as a complication.
Dr. Brewer said that the condition was certainly as-
sociated with gallstones in a good many cases.
Dr. J. S. Thacher said that it used to be maintained
that the bile in cases of hematogenous jaundice was
thickened and that the jaundice was due to obstruction
of the minute bile ducts by the thickened bile.
Dr. Brewer said he had operated on the bile ducts
first, but that did not give the explanation.
Dr. Fordyce asked what was the ultimate fate of
these cases.
Dr. Brewer said that the longest record was 23 years.
The patient was perfectly well. A good many cases
were never operated on. In the later stages many cases
were reported with pernicious anemia. This also was
due to excessive hemolysis.
Dr. Brannan asked if this was a very recent pro-
cedure.
Dr. Brewer said it dated back as far as 1903. The
first operation was done for pernicious anemia. The
patient also had jaundice. The jaundice entirely cleared
up two weeks after operation.
Dr. Meara said that they had two interesting cases in
the ward, of so-called Banti's disease with splenomegaly
and anemia. The first patient was operated upon by
Dr. Hartwell. It was a very advanced case. There
was recurrent ascites and the spleen was very large.
The liver could be readily palpated. There was very
advanced cirrhosis. He believed the patient was still
living. The other case was one of very marked spleno-
megaly with marked secondary anemia, with 2,000,000
red cells. There was no change in the character of the
cells. It was now general opinion that these were early
cases of Banti's disease. In this case with ascites the
fluid was injected into a guinea pig; the result had not
been reported, but the man had evidently a tuberculous
spleen. The ascites might be from tuberculous perito-
nitis. The man was sent for operation as it was justi-
fied from the standpoint of the peritonitis.
Dr. Brewer said he had never seen a tuberculous
spleen. There were two or three in the records.
Dr. Meara said it would be called splenic anemia on
the old criteria, but this was tuberculosis.
Dr. Brewer said in another case he had to mention,
he did a gall-bladder exploration. The patient had had
jaundice 20 years, and was then 37. Health had been
pretty good until recent years. He had explored the
gall-bladder region and had found nothing. There were
spots in the liver which were supposed to be adrenal
rests, but this was later found to be incorrect. The
patient afterward came in on Dr. Evans' service. He
diagnosed the case at once as a hemolytic jaundice. Dr.
Peck operated on the natient who had been perfectly
well ever since. In some cases gallstones were found,
and the removal of these gave no relief. The cases
cleared up with splenectomy. Another case with a
peculiar history, was one where another surgeon ex-
plored the gall bladder and nothing was found. The
patient was closed up and there was no improvement.
At a second operation gallstones were found. Thus in
two cases gallstones were found on second operation and
not on the first. One case at the Presbyterian Hos-
pital, on Dr. Longcope's service had the symptoms of
obstructive jaundice, with high colored urine at times.
This patient had also an enlarged spleen. It was finally
concluded that she had obstructive jaundice. She was
operated on and the gall bladder was very difficult to
expose, as it was greatly dilated and full of bile. It
took very long to dissect out the gall bladder and the
ducts never were exposed so as to be palpated. He did
a cholecystenterostomy. The patient made a perfectly
good recovery. Bile appeared in the stools. In spite of
that for two or three weeks there was no improvement
in the jaundice. He thought perhaps it was a double
lesion. In some cases, a negative exploration, with the
handling involved, might start a small hemorrhage,
which acted as a foreign body, and this might account
for stones being found on second operation.
Dr. C. L. Gibson said that he had often not seen any
improvement in the jaundice for two or three weeks.
Dr. Brewer said that he felt that there should be an
immediate change in the jaundice.
Dr. Gibson asked what had been Dr. Brewer's experi-
ence in regard to this anastomosis.
Dr. Brewer said that he had done very few chole-
cystenterostomies. In his opinion this was a very dan-
gerous operation.
July 1, 1916]
MEDICAL RECORD.
41
Dr. Thacher asked if the patients usually died.
Dr. Brewer said yes.
Dr. Gibson said he operated in a case of this kind six
weeks ago and made a perfectly successful anastomosis.
It was a case of carcinoma of the pancreas. Six weeks
after operation the jaundice began to clear up and bile
to go through. He had had that experience two or
three times.
Dr. Brewer asked Dr. Gibson if he did not think that
chronic obstructive jaundice cases got bronzed instead
of bright yellow. There was a difference in the jaun-
dice. He knew a woman who had hemolytic jaundice
seventeen years, and was bright yellow.
Dr. Thacher asked if that was not similar to the
color of pernicious anemia.
Dr. Brewer said yes, but it was brighter. It was due
to hemolysis.
Dr. Gibson said it was a curious thing in diagnosing
cases of pelvic compression; the patient would usually
say that he had had jaundice and it had remitted.
Dr. Brewer said that he did not think one could place
much reliance on a personal record. In cases of car-
cinoma of the breast, patients would say that the tumor
varied in size. There was one other point to be men-
tioned in connection with Banti's disease. (He thought
the three lesions were closely allied.) There was the
theory that the original lesion was a phlebitis of the
splenic vein. In some cases of Banti's disease there
was a thickening and tortuosity of the veins often with
calcarous plates, originating in infection.
Dr. Meara said he had read one notice lately of such a
paper, but that was all that he had seen in the litera-
ture.
Dr. Thacher said that it had been suggested that
cirrhosis of the liver arose in pylephlebitis. Of all the
cases of hemolytic jaundice operated on, it seemed that
only two deaths occurred. Were those two attributed
to operation?
Dr. Brewer said that in one case death was directly
due to operation on a poor subject. The other case was
cited as having died from uremia, but as the death
occurred pretty quickly after operation, he thought that
it might have been post operative.
Dr. Gilman Thompson said in illustration of the dif-
ficulties of gallstone diagnosis, he saw a woman last
November who had recurrent cramps in the legs. While
under observation she suddenly developed an apparent
cholecystitis. She had pain over the gall bladder and a
distinct mass was palpable. She had fever, leucocytosis
and reflex vomiting. She was taken to Roosevelt Hos-
pital. Dr. Peck operated and found nothing in the gall-
bladder but a cirrhous carcinoma of the liver, which had
given no suspicion of its presence and the organ was
not enlarged and her nutrition was extremely good.
Since the exploration made last January the liver con-
tinued to enlarge and now reached the umbilicus, large
tumor masses being palpable, but after the patient was
sent home she got on fairly well with only occasional at-
tacks of reflex vomiting. She had had continuous high
temperature for four months ranging from 99.8° to
102°. The hemoglobin at the time of the supposed gall-
stone attack was 50 per cent., and it had gone up to
80 per cent, since. She was able to digest a variety of
food and she presented an interesting illustration of
maintenance of excellent nutrition despite a rapidly
growing carcinoma.
Dr. Brannan said she was apparently better for the
operation.
Dr. Thacher asked Dr. Thompson if he thought car-
cinomas grew more slowly in elderly people.
Dr. Thompson said it depended upon where they were
situated. He thought there was often good nutrition
for some time in a certain group of hepatic carcinomata.
Dr. Brannan asked if in this case any of the growth
was removed.
Dr. Thompson said no: there was no convenient
nodule. Dr. Peck thought the best thing was to make
the operation as short as possible. The woman had had
a recent broncho pneumonia and it was not thought ad-
visable to keep her under ether long.
Dr. Thacher asked if Dr. Brewer thought if age
made any difference in the rapidity of breast carcinoma.
Dr. Brewer said very often in elderly people it grew
slowly.
Dr. Fordyce asked was this case mentioned by Dr.
Thompson primary carcinoma?
Dr. Thompson said he supposed pathologists would
find a nodule somewhere else as a primary focus, but
clinically it was solely hepatic.
Dr. Thacher said occasionally it originated in the
liver.
Dr. Gibson said he used to teach that there was no
such thing as primary carcinoma of the liver. It was
supposed to be carcinoma of the bile ducts. He did not
see how one could get it without epithelium, and there
was no epithelium in the liver.
Dr. Brewer asked what was the origin of the liver
cells. Were they mesoblastic? He said he was much
surprised to hear Dr. Gibson say that there was no
epithelium in the cells of the liver.
Dr. Brannan asked what Dr. Thompson said to that.
Dr. Thompson said he was willing to admit that this
growth might have originated in the gall-bladder, but
there was no jaundice.
Dr. Thacher said that it might be called cancer of
the liver even if it originated in the bile ducts.
Dr. Brewer said he would like to mention one case of
obstructive jaundice due to pressure of a tuberculous
lymph node on the bile duct. He had also seen one case
due to Hodgkin's disease.
Dr. Meara asked if it was adherent to the gall-
bladder.
Dr. Brewer said it was on the junction of the bile
duct and common duct.
Dr. Thacher said he saw the autopsy of a case where
the obstruction was due to a mass of cicatrical tissue
which appeared to be of syphilitic origin.
Dr. Gibson said he operated on a case due to lym-
phosarcoma of nodules on the bile duct. He did a
cholecystenterostomy and the patient made a good re-
covery. He operated on another patient without jaun-
dice and took out the nodule for examination. The
pathologist made a similar report as on the first case.
One case got well; the other died.
Dr. Thacher said that sarcoma was often the most
difficult diagnosis to make, and especially lymphosar-
coma.
Dr. J. C. Roper said that one of Dr. Brewer's pa-
tients, Miss L.., was watched for years. She had no
free hydrochloric acid at any time.
Dr. Brewer said that she had sour vomiting, and at
one time the case simulated gastric ulcer.
Dr. Roper said that there was not so large a fragility
of the cells as in the other patient. The fragility test
depended on the amount of water used. It was a "ques-
tion of surface tension.
Dr. Brewer said that washing the cells made a dif-
ference.
Dr. Roper said the patient had an attack of jaundice
that looked like an infection. The cells dropped to two
million in a short time. She had hemoglobinuria. There
was temperature, and swollen joints, which were re-
lieved following salicylates.
Dr. Meara said the temperature might be accounted
for by the hematin.
Dr. Roper said that one patient showed no excretion
of urobilin. It was a puzzling thing how she got rid
of it.
Dr. Brewer said that Dr. Longcope had stated that if
one could have seen the patient during the febrile at-
tacks, more blood fragility might be noted.
Dr. Roper said that the patient came to the New
York hospital. He did the nitrogen partition and
never found anything abnormal. He did not believe
that the cholesterin content of the blood and the iodine
index was done.
Dr. Brewer said that he had had the cholesterin con-
tent done. It was normal. He said he would like to ask
Dr. Roper what the vital stain indicated.
Dr. Roper said that the blood might show <nore
chromophilic degeneration than normal blood.
Dr. Brewer asked if these were degenerating or new
cells.
Dr. Roper said that one man might argue one way
and one another. The normal percentage was 1.3.
Dr. Thacher asked if that indicated activity of the
hemapoietic function.
Dr. Meara said it indicated an attempt to restore the
cells to the normal.
Philadelphia Neurological Society.
At a stated meeting held April 28 Dr. William B. Cad-
walader presented a communication entitled "Occa-
sional Resemblance of Tabes Dorsalis to Disease of the
Pituitary Gland." He referred to observations of this
character in the literature, and he related the details
of a similar case under his observation. The patient
42
MEDICAL RECORD.
[July 1, 1916
was a man 51 years old, who presented diplopia, reduc-
tion in the visual fields, optic atrophy, and absence of
knee-jerks and Achilles jerks. There was, however, an
increase in fat-deposition and absence of hair in va-
rious situations, enlargement of the breasts, increased
hunger and thirst, increased tolerance for sugar carbo-
hydrates. X-ray examination disclosed changes in the
sella turcica suggestive of the presence of a new growth
involving the hypophysis.
Dr. Alfred Gordon presented "A Case of Syringo-
myelia." The patient was a colored man, 58 years old,
who presented weakness and wasting in the upper ex-
tremities, with contractures and deformity of the fingers
and loss of part of one finger by spontaneous and pain-
less amputation. Common sensibility was preserved,
while sense of pain and temperature-sense were im-
paired and the knee-jerks were increased.
Dr. John H. W. Rhein presented "A Case of Wast-
ing of the Muscles of the Left Side of the Body Fol-
lowing Injury of the Right Side of the Brain." The
patient was a man, 24 years old, who at the age of
thirteen received a bullet-wound on the left side of the
skull, the missile injuring and lodging in the right side
of the brain. Several operations were performed but
the bullet was never secured, and x-ray examination
disclosed its presence now at the base of the skull, ap-
parently in the posterior fossa. The striking feature
was the notable atrophy of the musculature on the left
side of the body, with a corresponding degree of weak-
ness, associated with slight exaggeration of the knee-
Drs. E. M. Auer and Grayson Prevost McCouch
presented a communication entitled "The Pathological
Findings in Two Cases of Paralysis Agitans." The
changes observed consisted essentially in evidences of
rarefaction of the basal ganglia of the brain, apparently
not related to the perivascular spaces.
Dr. William G. Spiller reported "A Case of Asso-
ciation of Severe Anemia with Tabes Dorsalis." The
patient had been under observation only a few days,
and he presented apparently only the ordinary symp-
tom- of tabes dorsalis. He was ill nourished and pallid,
but a blood examination was not made. On post-
mortem examination, however, in addition to the lesions
of tabes there were found the characteristic changes
associated with profound grades of anemia. The two
processes were entirely independent one of the other.
Dr. Frederick P. Clarke presented a communication
entitled "A Study of Acroataxia and Proximoataxia in
Tabes Dorsalis." He was unable to demonstrate that
proximoataxia preceded acroataxia in cases of tabes in
contradistinction to subacute mixed sclerosis due to pro-
found anemia, in which it has been maintained the re-
verse order of development takes place.
Dr. Owen Copp presented a communication entitled
"The Psychiatric Needs of a Large Community." He
pointed out that insanity is evidence of disease, and it
must be studied in precisely the same way as are other
morbid affections. To this end a well-equipped and
well-administered psychiatric clinic and hospital are
required, with abundant modern laboratory facilities
and an adequate staff of workers in the several fields
of medicine. The patients must be treated with a view
to their recovery, and after-care must be directed to
the prevention of recurrence. Prophylactic work must
be done to prevent the ill effects of toxic agents, such as
alcohol, as well as those of infectious, such as syphilis,
and segregation must be practised in a rational manner
to prevent reproduction of their kind by the mentally
deficient and the insane. Furthermore, adequate in-
struction must be given in the medical schools so that
the general practitioner shall be competent to make an
early diagnosis and promptly apply the appropriate
treatment.
Determination of Sex. — J. S. Freeborn states that as
a result of study of 1,000 obstetrical cases he was able
to foretell the sex previous to birth in 97.5 per cent.
Nearly all conceptions during the first half of the
intermenstrual period result in female offspring, boys
resulting from conceptions in the latter half. Hence
sex control should be a simple matter — the mere prac-
tice of abstinence at stated times. To formulate a law:
have marital relations only during the first ten days
after menses when girls are desired, and during the
first ten days before menses when boys are sought.
There are certain sources of fallacy which must be
borne in mind; for example, the woman may \\rongly
give the date of menstruation. — Canadian Practitioner
and Review.
STATE BOARD EXAMINATION QUESTIONS.
State Medical Board of the Arkansas
Medical Society.
November 9 and 10, 1915.
anatomy.
1. Name the articulations of the frontal and occipital
bones. What bones articulate with the radius?
2. Name divisions of the vertebral column, giving
number of bones in each division. What are distin-
guishing characteristics of cervical vertebrae?
3. What are the relations of the brachial artery?
Name its branches.
4. What spinal nerves enter into the formation of the
anterior crural nerve, and what muscles does it supply?
5. Describe the origin, course and distribution of the
renal arteries.
6. Name the cavities, openings, and valves of the
heart.
7. Name the coverings of a femoral hernia.
8. Give origin and insertion of the following muscles :
Biceps, pectoralis minor, and popliteus. Give blood and
nerve supply of each.
9. Name the arteries and nerves which supply the
duodenum. What veins drain this region?
10. What structures are severed in an amputation
about the middle third of the thigh?
physiology.
1. (a) Give composition of blood; (b) function of
blood as a whole; (c) red cells; (d) leukocytes.
2. Trace the course of the blood, (a) complete cycle,
(b) in adult, (c) in fetus.
3. Give the causations and describe the occurrence of
dyspnea.
4. Where and how are bread and butter digested?
5. Compare the work done by the liver on a protein
diet with that done on a carbohydrate diet.
6. What are the most prominent differences between
the composition of the blood plasma and that of the
urine?
7. Why is the lymphatic system so essential to the
human body?
8. Name parts of (a) the small intestines, (b) large
intestines. Give name and location of the glands found
in the small intestines.
9. How is the temperature of the body regulated and
sustained?
10. What is the function of the medulla oblongata?
chemistry.
1. (a) What is an element? (b) Name five with
symbols.
2. (a) Give two methods of preparing oxygen, (b)
Give equation of one method.
3. What is an acid, a salt, a base? Give example of
each.
4. Name the elements in the halogen group.
5. Describe Marsh's test for arsenic.
6. What do you understand by specific gravity?
7. Complete the following: NaCl + H,SO = ?
Zn + HC1 = ? AgNO, + HC1 = ?
8. Describe Fehling's test for glucose, and explain
chemical reaction.
9. What is the reaction between granulated sugar
and Fehling's solution?
10. Give the various steps in making a urinalysis.
MATERIA MEDICA.
1. (a) What arc antiseptics? (b) Disinfectants?
(c) Give an example of each.
2. Define a laxative and tell how it acts.
3. Name the alkaloids of nux vomica.
4. (a) Give the properties of chloroform, (b) Name
several preparations of chloroform.
5. What evils may result from chemical incompati-
bility in prescriptions?
6. (a) What is the source of digitalis? (b) Give
symptoms of digitalis poisoning.
7. (a) What is the source of ergot? (b) Give physi-
ologic action of ergot.
s. (a) Name six official preparations of mercury,
(b) Give briefly the properties, uses and dose of each.
9. Name the principal alkaloids of Papaver somni-
ferum.
10. Classify the following drugs according to their
physiologic action: Sodium chloride, sodium hydroxide,
July 1, 1916J
MEDICAL RECORD.
43
potassium citrate, adeps lanse hydrosus, epinephrin, fel
bovis (ox gall) , and ferri carbonas.
THERAPEUTICS.
1. How do the following drugs act in intermittent
malarial fever: Quinine, methylene blue, and euca-
lyptus?
2. What remedies should be used for hemorrhage
from mucous surfaces?
3. What are the conditions in cystitis that contra-
indicate the use of alkaline diuretics?
4. What drugs would you use hypodermically to
stimulate the heart; to produce emesis; to control hem-
orrhage?
5. Give the therapeutic application of drugs in the
different stages of pneumonia.
6. Mention the remedy which will arrest the secre-
tion of milk, and state how it should be employed.
7. What are the therapeutic uses of glycerin?
8. Describe the therapeutic uses and dangers of
chloral hydrate.
9. Differentiate the physiologic effects on the gastric
juice and on the urine of the administration of potas-
sium bicarbonate before and after meals.
10. What are the therapeutic uses of tartar emetic?
PATHOLOGY.
1. Give analysis of the urine of patients affected with
autointoxication.
2. A persistent low blood pressure is pathognomonic
of what class of diseases?
3. In what diseases do we find arteriosclerosis, and
to what conditions does it predispose?
4. What is the significance of an absence of chlorids
in the urine?
5. Explain cause and describe minutely the formation
of an epithelioma.
6. Explain the formation of pus.
7. Define leukemia, and discuss briefly the clinical
phases in its progress.
8. What pathologic condition is induced by chronic
infections of: the nose, throat, teeth, or their accessory
sinuses?
9. What is the pathologic significance of vertigo?
10. (a) When do secondary and tertiary symptoms
of syphilis appear? (b) What is the significance of
nocturnal headaches in syphilis?
ANSWERS.
ANATOMY.
1. The frontal bone articulates with: Two parietal,
sphenoid, ethmoid, two nasal, two superior maxillary,
two lacrymal, and two malar.
The occipital bone articulates with: Two parietal,
two temporal, sphenoid, and atlas.
The radius articulates with: Humerus, ulna, scaphoid,
and semilunar.
2. The vertebral column is divided into: Cervical di-
vision, with seven bones; dorsal, or thoracic, with twelve
bones; lumbar, with five bones; sacral, with five bones,
and coccygeal, with four bones.
The cervical vertebras are distinguished by possess-
ing a foramen in the transverse processes. Further,
they are smaller than those in the other regions; they
have no facets for the ribs; the spinous processes are
generally short and bifid; the spinal foramen is large
and triangular; the superior articular process is direct-
ed upward and backward, and the inferior articular
process is directed downward and forward.
3. Brachial artery. Relations. In front: Skin, fas-
cia, bicipital fascia, median basilic vein, median nerve,
coraco-brachialis, and biceps. Behind: Triceps, muscu-
lospiral nerve, superior profunda artery, coraco-brach-
ialis, and brachialis anticus. Externally : Median nerve
(above), coraco-brachialis, and biceps. Internally: In-
ternal cutaneous nerve, ulnar nerve, median nerve
(below), and basilic vein. Brandies: Superior pro-
funda, inferior profunda, nutrient, anastomotica
magna, and muscular.
4. The anterior crural nerve arises from the second,
third and fourth lumbar nerves, and (sometimes) also
from the first or fifth lumbar. It supplies the iliacus,
pectineus, sartorius, vastus externus, vastus internus,
crureus, rectus femoris.
5. The renal arteries arise from the abdominal aorta,
just below the superior mesenteric artery; they pass
out at right angles to the aorta, and cross the crus of
the diaphragm. The right is longer than the left,
passes behind the inferior vena cava, the right renal
vein, the head of the pancreas, and the duodenum. The
left passes behind the left renal vein, the body of the
pancreas, and is crossed by the inferior mesenteric
vein. Before reaching the kidney each artery divides
into four or five branches.
6.
HEART.
Cavities.
Right auricle.
Left auricle.
Right ventricle.
Left ventricle.
Openings.
Superior vena cava.
Inferior vena vaca.
Coronary sinus.
Foramina of The-
besius.
Right auriculo-ven-
tricular.
Four pulmonary
veins.
Left auriculo-ventri-
cular.
Right auriculo-ven-
tricular.
Pulmonary artery.
Left auriculo-ventri-
cular.
Aortic.
Valves
Eustachian.
Coronary.
Semilunar.
Tricuspid.
Mitral.
Semilunar.
7. Coverings of a femoral hernia, from without in-
ward, are: Skin, superficial fascia, cribriform fascia,
crural sheath, septum crurale, subserous tissue, and
peritoneum.
8. Biceps. Origin: Apex of coracoid process of scap-
ula, upper margin of glenoid cavity of scapula. Inser-
tion. Tuberosity of radius. Blood supply: Brachial.
Nerve supply: Musculocutaneous.
Pectoralis minor. Origin: Third, fourth, and fifth
ribs, and from aponeurosis of intercostal muscles.
Insertion: Coracoid process of scapula. Blood supply :
Acromial thoracic, long thoracic, superior thoracic.
Nerve supply: Anterior thoracic.
Popliteus. Origin: External condyle of femur and
posterior ligament of knee joint. Insertion: Above
the oblique line on posterior surface of shaft of tibia.
Blood supply: Popliteal. Nerve supply: Internal popli-
teal.
9. Duodenum. Arteries: Pyloric and pancreatico-
duodenal (from hepatic) and inferior pancreatico-
duodenal (from superior mesenteric). Veins: Superior
and inferior duodenal, which pass into the superior
mesenteric and portal veins. Nerves: From solar
plexus.
10. Structures severed in an amputation about the
middle third of the thigh: Skin, fascia, tensor vaginae
femoris, femoral artery and vein, profunda femoris,
external circumflex vessels, superficial obturator nerve,
external cutaneous nerve, anterior crural nerve, deep
obturator nerve, small and great sciatic nerves, ad-
ductor longus, sartorius, gracilis, pectineus, rectus
femoris, adductor brevis, adductor magnus, semimem-
branosus, semitendinosus, crureus, vastus internus,
vastus externus, biceps femoris, and the femur.
physiology.
1. Blood. Composition: Plasma and corpuscles. The
plasma consists of water and solids (proteids, extract-
ives, and inorganic salts). The red corpuscles consist
of water and solids (hemoglobin, proteids, fat, and
inorganic salts). The white corpuscles consist of water
and solids (proteid, leuconuclein, lecithin, histon, etc.).
There are also platelets, which are very small, colorless,
irregular shaped bodies, about one-fourth the size of
the red corpuscle.
Functions: The red blood cells carry oxygen from the
lungs to the tissues. The white blood cells: (1) Serve
as a protection to the body from the incursions of patho-
genic microorganisms; (2) take some part in the process
of the coagulation of the blood; (3) aid in the absorp-
tion of fats and peptones from the intestine, and (4)
help to maintain the proper proteid content of the blood
plasma. The function of the platelets is not determined;
it is possible that they take some part in the coagulation
of the blood. The plasma conveys nutriment to the tis-
sues; it holds in solution the carbon dioxide and water
which it receives from the tissues, and takes them to be
eliminated by the lungs, kidneys, and skin; it also holds
in solution urea and other nitrogenous substances that
are taken to and excreted by the liver or kidneys.
2. "The left ventricle pumps the arterial blood
44
MEDICAL RECORD.
[July 1, 1916
through the large arteries, the small arteries, and the
arterioles into the systemic capillaries. For the most
part between the capillaries and the tissues is the tissue
fluid, and across this the tissues acquire the oxygen
from the arterial blood, and return carbon dioxide to
the blood in the capillaries. The blood which leaves the
tissues is venous. The venous blood returns from the
capillaries through the small veins into the larger
veins, and the largest veins pour the blood back into
the right auricle. It will thus be seen that the right
side of the heart is occupied with the pulmonary cir-
culation, and the left side of the heart with the sys-
temic circulation. The right auricle receives the ven-
ous blood as it returns from the tissues, and transmits
it to the right ventricle. The function of the right ven-
tricle is to pump the venous blood through the pulmon-
ary arteries into the lung capillaries, where the venous
blood becomes oxygenated. The oxygenated blood re-
turns by the pulmonary veins to the left auricle, and
the arterial blood is then received into the left ven-
tricle."— (Lyle's Physiology.)
Differences between the fetal circulation and that
of the adult: In the fetus there is direct communica-
tion from the right auricle to the left auricle by the
foramen ovule; the Eustachian valves are larger, the
heart is relatively larger; there is communication be-
tween the pulmonary artery and the descending aorta
by means of the ductus arteriosus; there is communica-
tion between the internal iliac arteries and the placenta
by means of the umbilical or hypogastric arteries; and
the presence of the ductus venosus which unites the um-
bilical vein and the inferior vena cava.
3. Dyspnea may be caused by diminution of oxygen
or excess of carbon dioxide in the blood. "As soon as
the blood in the body becomes more venous than ordi-
narily, in consequence of the amount of oxygen sinking
below normal, the respiratory movements become
quicker, and both inspiratory and expiratory efforts
are increased by bringing extra muscles into play. This
condition of difficult beathing is termed dyspnea. As
the blood becomes more and more deficient in oxygen,
the respiratory efforts become more labored, the ex-
piratory movements becoming more marked than the
inspiratory. The expiratory efforts become convulsive
in character and all the muscles of the body presently
take part in the convulsions. In the last stage the con-
vulsions cease, coma sets in, the pupils dilate, the con-
junctivae are insensible, while at intervals respiratory
efforts, chiefly inspiratory, are made." (Ashby's Notes
on Physiology.)
4. Bread consists of proteid, fat, carbohydrate, salts.
and water. Putter consists of fat, a little proteid, and
water. In the mouth, the ptyalin of the saliva changes
starch into dextrin and sugar; in the stomach, the pro-
teids are changed into proteoses and peptones; in the
small intestine, the proteids are further changed into
proteoses and peptones and afterwards into polypep-
tides and amino-acids; starches are converted into malt-
ose ; fats are emulsified and saponified.
5. Action of liver on proteid: It removes the amino
group from the amino-acids absorbed, converting these
latter into oxyacids and transforming the ammonia into
urea.
Action of liver on carbohydrate: It stores glycogen,
converts it into dextrose and returns this latter to the
blood stream and thus keeps a constant percentage
of sugar in the blood.
6. Composition of urine:
( PARTS IN
1000)
Water 950.00'
Urea 28.00
Uric acid 0.60
Hippuric acid !
Creatinin 0.65
Extractives 8.00 ,
Sodium chloride 8.00
Phosphoric acid 2.00
Sulphuric acid 1.25
Lime (CaO) 0.25
Magnesia (MgO) 0.30
Potash (K.O) and soda
(Na/)) 0.60 ,
Organic
Inorganic
Total 1000.00
As compared with urine, plasma contains less water
and more solids, more organic matter, less urea, gases
(oxygen, nitrogen, carbon dioxide), hormones and en-
zymes.
7. Function of lymph: (1) It conveys nutriment to
all cells not directly reached by the blood; (2) in the
intestines, it absorbs nutrient material (chiefly fat) and
pours it into the blood stream for distribution; (3) it
takes certain waste matters to the blood to be later
eliminated by the lungs, kidneys, and skin.
Without the lymphatic system the above functions
would be in abeyance.
8. Parts of the small intestine: Duodenum, jejunum,
and ileum.
Parts of the large intestine: Cecum (with appendix),
ascending colon, transverse colon, descending colon,
sigmoid colon, and rectum.
Glands of small intestine: Lieberkiihn's glands, in
duodenum, jejunum, and ileum; Brunner's glands, in
duodenum; solitary glands, in ileum chiefly, but also
in duodenum and jejunum; Peyer's gland, chiefly in
ileum, but also in jejunum, and a few in duodenum.
9. The normal body temperature is regulated and
maintained by the thermotactic centers in the brain and
cord keeping an equilibrium between the heat gained
or produced in the body and the heat lost.
Heat is produced in the body by: (1) Muscular ac-
tion; (2) the action of the glands, chiefly of the liver;
(3) the food and drink ingested; (4) the brain; (5) the
heart, and (6) the thermogenetic centers in the brain,
pons, medulla, and spinal cord.
Heat is given off from the body by: (1) The skin,
through evaporation, radiation, and conduction; (2)
the expired air; (3) the excretions — urine and feces.
10. The functions of the medulla oblongata are: (1)
It is a conductor of nervous impulses or impressions
from the cord to the cerebrum, from the brain to the
spinal cord, also of coordinating impulses from the
cerebellum to the cord; (2) it contains collections of
gray matter which serve as special nerve centers for
the following functions or actions; respiration, salivary
secretion, mastication, sucking, deglutition, vomiting,
voice, facial expression ; it also contans the cardiac and
vasomotor centers.
CHEMISTRY.
1. (a) An element is a kind of substance out of
which we cannot, by any known means, get any other
substance.
(6) Oxygen, O; Silver, Ag; Mercury, Hg; Car-
bon, C; Calcium, Ca.
2. (a) Oxygen may be prepared by the decomposi-
tion of potassium chlorate ; also by the heating of man-
ganese dioxide.
(6) 2KC10, = 2KC1 + 30=.
3. An acid is a compound of an electronegative ele-
ment or residue with hydrogen, part or all of which
hydrogen it can part with in exchange for an electro-
positive element, without the formation of a base.
Example: Nitric acid HNO,.
A salt is a compound formed by substituting a basy-
lous element for the replaceable hydrogen of an acid.
Example: Potassium nitrate, KNOs.
A 6a.se is a ternary compound which is capable of
entering into double decomposition with an acid, to
form a salt and water. Example: Potassium hydroxide,
KHO.
4. The elements in the halogen group are: Fluorine,
chlorine, bromine, and iodine.
5. Marsh's test for arsenic: This test depends on the
fact that arsenic hydride is formed when nascent hydro-
gen acts on a compound of arsenic:
II . AsO, + 3H: = AsH3 + 3H50.
A small flask fitted with thistle funnel and a delivery
tube, as for the production of hydrogen, is used; pure
zinc and hydrochloric acid are introduced, and after a
short time the hydrogen is ignited. It is advisable to
cover the flask with a cloth before igniting the gas, as
an explosion may happen unless the air has all been
driven out. If the materials are pure the hydrogen
flame gives no deposit upon a piece of cold porcelain
brought into it, but commercial zinc usually contains
arsenic. When the purity of the gas is proved, a little
solution of arsenite may be poured down the thistle
funnel, which will produce a more rapid evolution of
gas, and the flame will become larger and perceptib y
colored. A piece of cold porcelain depressed upon the
flame will be covered with a deposit of metallic arsenic.
The films of arsenic are metallic looking in the thicker
placeB, brownish near the edges; they are easily vola-
tilized by heat, and dissolve in solution of bleaching
powder. A portion of the glass tube from which the
gas is burned should be heated to redness; the gas
decomposes and a deposit of arsenic appears on the
July 1, 1916]
MEDICAL RECORD.
45
tube, which may be identified in a similar way, or may
be converted into crystals of oxide by cautious sub-
limation in an open tube. — -(Fisher's Elementary Chem-
istry.)
6. Specific gravity of a substance is the weight of a
given volume of that substance as compared with the
weight of an equal volume of some other substance
taken as a standard, under like conditions of temper-
ature and pressure.
7. NaCl-t-H3S0,=HCl+NaHS0..
Zn+2HCi=ZnCl2+H:.
AgNOH-HCl=AgCl+HN03.
8. Fehling's test for glucose: Place in a test-tube a
few c.c. of the liquid prepared as stated below, and boil;
no reddish tinge should be observable, even after five
minutes' repose. Add the liquid under examination
gradually, and boil after each addition. In the presence
of sugar a yellow or red precipitate is formed. In the
presence of traces of glucose, only a small amount of
precipitate is produced, which adheres to the glass, and
is best seen when the blue liquid is poured out.
[The reagent must be kept in two solutions, which are
to be mixed immediately before use. Solution I con-
sists of 34.653 gms. of crystallized CuS0<, dissolved in
water to 500 c.c; and Solution II of 130 gms. of Ro-
chelle salt dissolved to 500 c.c. in NaHO solution of sp.
gr. 1.12. When required for use equal volumes of the
two solutions are mixed, and the mixture diluted with
four volumes of water.]
9. Cane sugar either does not reduce Fehling's solu-
tion, or reduces it very slowly.
10. An analysis of urine includes: Estimation of total
quantity passed in twenty-four hours, color, odor, reac-
tion, specific gravity, total solids (by aid of Haeser's
coefficient) . Then examine for albumin by Heller's test,
or by heat and nitric acid (HN03) ; then for glucose by
Moore's test, with potassium hydroxide (KHO), or with
Fehling's solution, which contains copper sulphate
(CuSO.), sodium hydroxide (NaHO), and Rochelle salt
(C406H4NaK) ; then for blood with potassium hydrox-
ide solution (KHO) ; then for bile pigments by Gmelin's
test, requiring nitric acid (HNOs) ; then for indican,
using lead acetate [Pb(C:H303):], hydrochloric acid
(HC1), ferric chloride (Fe-CU), and chloroform
(CHC13). Then quantitatively for urea, using solution
of sodium hypobromite (NaBrO) ; for chlorides, with
silver nitrate solution (AgN03) ; for sulphates, with
barium chloride solution (Bad,). Acetic acid (C;H,0:)
will be necessary to acidify alkaline urines.
MATERIA MEDICA.
1. Antiseptics are agents which prevent or hinder
the growth of microorganisms without necessarily de-
stroying them. Example: Boric acid.
Disinfectants are agents which destroy microorgan-
isms and their spores. Example: Corrosive sublimate.
2. A laxative is an agent which increases or hastens
the intestinal evacuation; it generally acts mildly, and
without causing irritation. Its action is due to a slight
stimulation of the peristalsis of the intestine.
3. The alkaloids of nux vomica are: Strychnine, and
brucine.
4. Properties of chloroform: It is a colorless, volatile
liquid, with a sweetish taste and a strong, peculiar
odor. It is a good solvent for many substances not
soluble in water. It is heavy, diffusible, of a neutral
reaction, is not inflammable, freely soluble in alcohol
and ether, but only in about 200 volumes of water.
Preparations of chloroform: Aqua chloroformi, emul-
sion chloroformi, spiritus chloroformi, linimentum
chloroformi.
5. Chemical incompatibility may give rise to: The
production of chemical substances not desired by the
prescriber; the production of effervescence or explosion
or some other process not desired by the prescriber;
evolution of gases, changes of color, formation of pre-
cipitates; deposit of some strong and lethal prepara-
tion whereby a patient's life is endangered; the de-
struction of the action of a potent ingredient in a medi-
cine by oxidation, reduction, or hydrolysis.
6. Digitalis is the dried leaves of Digitalis purpurea,
the purple foxglove. Symptoms of poisoning by digi-
talis: "Nausea, and occasionally vomiting. Sometimes
colic and diarrhea. After two or three hours, marked
diminution in the frequency of the pulse, which may
fall to 40 or even 25. Dyspnea, attended by a sense of
oppression in the chest and coldness of the extremities.
Headache, vertigo, and tendency to sleep. Usually at-
tacks of syncope occur, provoked sometimes by the slight-
est movement of the patient. Death is generally by
syncope, sometimes after several hours of coma succeed-
ed by convulsions." — (Witthaus's Essentials of Chem-
istry.)
7. Ergot. Source: The sclerotium of claviceps pur-
purea. Physiological action: Ergot stimulates and
causes contraction of involuntary muscle fibers, hence
it is a vasoconstrictor, hemostatic, and oxytocic. It is
also a cardiac sedative; it raises the blood pressure, it
increases peristalsis, and is an emmenagogue.
8. Mercury. (1) Hydrargyri chloridum mite (calo-
mel) dose gr. ss to x; used in syphilis, as a laxative or
purgative, in congested or cirrhotic liver, in diarrhea,
and as a diuretic. It is a heavy, white powder; amor-
phous; tasteless and odorless; it is insoluble in cold
water and in alcohol, and very slightly soluble in boil-
ing water; when exposed to the light it becomes dis-
colored (first yellow, then gray) and partially decom-
posed; it sublimes without fusing. (2) Hydrargyri
chloridum corrosivum (corrosive sublimate), dose gr.
1/60 to 1/30; used as an antiseptic, disinfectant, anti-
parasiticide, in syphilis, interstitial nephritis. It occurs
as heavy, colorless crystals, with sharp and metallic
taste, and acid reaction; it is soluble in 16 parts of
cold water, and 2 of boiling water. (3) Liquor arseni
et hydrargyri iodidi (Donovan's solution), dose Tljv;
used as an alterative. (4) Hydrargyrum cum creta
(gray powder), dose gr. ss to x; used in congenital
syphilis, diarrhea of children, as a cathartic and diu-
retic, and in the beginning of fevers. It is a light gray
powder, with a sweetish taste and no odor. (5) Hydrar-
gyri iodidi rubrum, dose gr. 1/50 to 1/12; used in syph-
ilis, rheumatism, and acute tonsillitis. It is a bright red
powder and has neither taste nor odor; it is almost
insoluble in water, but is freely soluble in solutions of
potassium iodide. (6) Hydrargyrum ammoniatum,
used as an ointment in 10 per cent, strength; employed
for chronic skin diseases.
9. The principal alkaloids of Papaver somniferum
are: Morphine, codeine, narceine, narcotine, thebaine,
and papaverine.
10. Sodium cldoride is emetic, purgative, and has
osmotic power. Sodium hydroxide is irritant, caustic,
and escharotic. Potassium citrate is diuretic, diaph-
oretic, and increases the alkalinity of the blood. Adeps
lanx hydrosus is emollient. Epinephrin is cardiac stim-
ulant, vasoconstrictor, and raises blood pressure. Fel
bovis is a cholagogue. Ferri carbonas is a hematinic.
THERAPEUTICS.
1. Quinine destroys the parasites of malaria. Methy-
lene blue destroys the parasites of malaria. Eucalyptus;
it is not known how this acts, or if it has any action at
all in malaria.
2. In hemorrhages from mucous surfaces, the fol-
lowing may be used: Cold, adrenalin, alum, tannic acid,
ferric chloride, gelatin, calcium chloride, opium, and
ergot (for uterine hemorrhage).
3. Alkaline diuretics should not be used in cystitis,
if the urine is strongly ammoniacal, or in advanced
cases of the disease.
4. To stimulate the heart: Strychnine, atropine, and
morphine. To produce emesis: Apomorphine. To con-
trol hemorrhage: Adrenalin.
5. The treatment of pneumonia "depends entirely on
the type of case, and the condition of the patient.
Routine treatment is the worst of all treatments. An-
swer the following questions before prescribing: Is the
patient full-blooded, and is there a full bounding pulse?
Is the pulse feeble, irregular, or intermittent?
"In the first case, in a young and previously healthy
adult, if there be cyanosis, or signs of dilatation of the
right heart, blood-letting to the extent of a few ounces
may perhaps relieve the strain, but more generally
treatment should be directed to maintaining the strength
from the outset.
"In the latter case we can hope for nothing from a
depressing treatment, so stimulants must be resorted to,
such as alcohol, ammonium carbonate, egg and brandy
mixture, quinine, ether, etc. The giving or withholding
of alcohol depends upon its effect upon the pulse; should
the pulse rate fall and the tongue become moist it may
be continued. In asthenic cases, strychnine hypodermic-
ally is necessary from the outset, and normal saline may
be given by the rectum or by the skin. Oxygen inhala-
tions are used where there is cyanosis, but it is doubtful
whether they have saved many lives. When there is
evidence of failure of the heart (weakness of the second
pulmonary sound, etc.) digitalis should be resorted to.
Many prescribe it from the outset.
"The diet should consist of milk, beef-tea or broths,
46
MEDICAL RECORD.
[July 1, 1916
white of egg, and so on. The patient should be as little
moved as possible, and the bed-pan must be used. As
in other fevers, an airy room and good nursing are
essential.
_ "Remember that narcotics are not well borne in res-
piratory embarrassment as a rule. Chloral should be
avoided, but if pain be excessive a hypodermic injection
of morphine does more good than harm, notwithstand-
ing that theoretically morphine is contraindicated. It
should not be given later than the first few days of the
illness. The pain may also be relieved by poultices,
which, however, are of doubtful use if carelessly made,
or by application of ice. Cold packs applied to the trunk
only, and frequently repeated, are very useful in re-
lieving both pain and fever. Depressant antipyretics
are to be avoided.
"The results of serum treatment are not unequivocally
encouraging, but vaccine treatment would seem to be of
better promise. Where possible, an autogenous vaccine
should be used." (Wheeler and Jack's Handbook of
Medicine) .
6. Belladonna will arrest the secretion of milk. The
belladonna plaster is generally applied to the breasts;
or the belladonna ointment may be smeared over the
breasts.
7. Therapeutic uses of glycerin: As an emollient,
laxative, and as a vehicle for other medicaments; it is
sometimes given for hepatic and nephritic calculi, for
trichinosis, and in vomiting of pregnancy.
8. Therapeutic indications for tise of chloral: As a
hypnotic (in absence of pain) ; as an antiseptic; in
cases of acute mania or delirium tremens; in nervous
dyspepsia; in fevers with high temperature, excitement,
restlessness, etc.; in seasickness; in tedious labor, to
relax a rigid os, and for uterine inertia; for nocturnal
epilepsy; for infantile convulsions, chorea, whooping
cough, and laryngysmus stridulus; in tetanus and
strychnine poisoning it is said to be antagonistic; as an
antipruritic.
Dangers are: Deep sleep, muscular relaxation, low-
ering of body temperature, lessening of sensibility and
of reflexes, and the formation of a habit.
9. Potassium bicarbonate, taken on an empty stom-
ach, enters the blood unchanged, meets the neutral phos-
phate of sodium and is decomposed, acid phosphate of
sodium being formed which renders the urine more acid.
On a full stomach it is decomposed by the acids of the
gastric juice, increases the alkalinity of the blood, and
makes the urine less acid. (From Potter's Thera-
peutics, etc.)
10. Therapeutic uses of tartar emetic: Emetic,
cardiac depressant, in bronchitis, as an expectorant, a
diaphoretic; not much used now.
PATHOLOGY.
1. The urine of patients affected with autointoxica-
tion may show either (1) the presence of acetone, dia-
cetic acid, and beta oxybutyric acid; or (2) the pres-
ence of an excessive amount of indican.
2. Apersisteni low blood pressure isfoundin: Many
acute infectious diseases, anemia, cachectic conditions,
and shock.
3. Arteriosclerosis is found in: Gout, syphilis,
chronic nephritis, alcoholism, lead poisoning, rheuma-
tism, overeating, excessive muscular work, emphysema,
cirrhosis of the liver. It predisposes to: Monoplegia,
hemiplegia, apoplexy, interstitial nephritis, myocarditis,
thrombosis, embolism, gangrene.
4. Absence of chlorides in the urine may indicate:
Starvation, lobar pneumonia; they are diminished in
many of the acute fivers, anemia, cachectic and malig-
nant conditions, extreme diarrhea and when large effu-
sions are present.
5. "Epithelioma, or squamous-celled carcinoma, may
arise on any surface covered with stratified epithelium.
It usually arises in the middle-aged or elderly, but may
also occur in the young. It often results from long-
continued irritation, and may arise in old scars or
ulcers. It may appear in one of three forms: (1) A
wart-like growth with an indurated base; (2) a small
circular ulcer with raised, rampart-like edges; (3) an
indurated fissure. The growth extends to the deeper
structures; the surface ulcerates and becomes foul from
contamination with putrefactive organisms. The near-
est lymphatic glands always become infected sooner
or later, and a fatal termination occurs rapidly unless
treatment is early and thorough. Secondary deposits,
except in the glands, are rarer than in glandular car-
cinoma. The glands sometimes undergo cystic change,
invade the skin, ulcerate, become foul, and may cause
death by secondary hemorrhage from ulceration into
large blood vessels. Microscopically, columns of cells
are seen extending from the epithelium into the under-
lying tissues, and interlacing with one another. In
some of the columns concentrically arranged masses of
flattened, cornified cells may occur ; these are called 'cell
nests.' The tissues immediately surrounding the new
growth are infiltrated with small round cells." (Aids
to Surgery.)
6. Formation of pus: "When pyogenic bacteria are
introduced into the tissues there ensues an inflamma-
tory reaction, which is characterized by dilatation of
the blood-vessels, exudation of serum, migration of
large numbers of leucocytes, and proliferation of con-
nective tissue cells. These wandering cells soon ac-
cumulate around the focus of infection, and form a
protective barrier which tends to prevent the spread
of the organisms and to restrict their field of action.
Within the area thus circumscribed the struggle be-
tween the bacteria and the phagocytes takes place, and
in the process toxins are formed by the organisms, a
certain number of the leucocytes succumb, and, becom-
ing disintegrated, set free certain proteolytic enzymes
or ferments. The toxins cause coagulation necrosis of
the tissue cells with which they come in contact, the
ferments liquefy the exudate and other albuminous sub-
stances, and in this way pus is formed." (Thomson
and Miles' Manual of Surgery).
7. Leucemia is a condition in which there is a great
and persistent increase in the number of white blood
corpuscles. There are two varieties of the disease: (1)
Spleno medullary in which the chief changes are found
in the spleen and bone marrow; and (2) lymphatic, in
which the most marked changes are observed in the
lymphatic glands.
It is possible for leucemia to be confounded with
splenic anemia and Hodgkin's disease. The diagnosis is
made by an examination of the blood. In Hodgkin's
disease there is either no increase in the number of the
leucocytes, or a very slight increase. In anemia, there
is a marked diminution in the number of the red blood
corpuscles and there is no leucocytosis. In spleno-
medullary leucemia, there is an enormous leucocytosis,
and myelocytes are present. In lymphatic leucemia, the
lymphocytes form the main part of the leucocytosis,
and there are no myelocytes. The disease is of gradual
onset, and may be accompanied by weakness, palpita-
tion, dyspnea, and dyspepsia; the face is pale or sallow;
the spleen or lymphatic glands will be found enlarged;
fever and dropsy may occur later in the disease; the
abdomen is generally swollen and emaciation is ob-
served; the urine is high-colored, scanty and may be
albuminous.
8. Chronic infections of nose, throat, and teeth may
induce: Periostitis, ostitis, caries, and necrosis of the
neighboring bones, thrombosis of the cavernous sinus,
and even so serious a condition as intracranial abscess;
infection of bones at a distance and polyarthritis may
also occur.
9. Vertigo may indicate: Neurasthenia, congestion
or anemia of the brain, eyestrain, disease of the in-
ternal ear, meningitis, tumor of cerebrum or cerebel-
lum, gout, indigestion, heart disease, arteriosclerosis,
autointoxication. It may also be caused by certain
drugs.
10. The secondary symptoms of syphilis appear at
about the end of the 45th to the 90th day; the tertiary
symptoms begin at about the end of the second year.
Nocturnal headaches in syphilis are suggestive of
cerebral syphilis.
(To be continued.)
Disturbances of Ossification in Endemic Cretinism
and Goiter. — Wegelin believes that in countries in which
goiter is endemic, a distinct arrest of ossification is
noticeable even in the fetal period, this phenomenon
being attributable to hypothyreosis, and expressed as a
lack of bone nuclei in the inferior epiphysis of the
femur in the newly born. This intrauterine arrest of
development is an inversion of conditions when there
is hyperthyroidism of the maternal organism. Thus
when gravid animals are fed with thyroid substance,
the litter is less numerous while the individual young
are better developed. In fowls thyroid feeding cause
not only larger eggs but more eggs, while after
thyroidectomy these results are reversed. This law
justifies the systematic wholesale use of thyroid feeding
for cretins and cretinoids. — Correspondenz-Blatt fur
Schweizi r .1. rzte.
Medical Record
A Weekly Journal of Medicine and Surgery
Vol. 90, No. 2.
Whole No. 2383.
New York, July 8, 1916.
$5.00 Per Annum.
Single Copies, I5c.
(Original Arturbs.
RADIUM EFFICIENCY IN NON-MALIGNANT
SURGICAL CONDITIONS.*
Br ROBERT ABBE. M.D ,
NEW YORK.
SENIOR SURGEON, ST. LUKE'S HOSPITAL.
It will refresh our minds to divert attention from
the popular hue and cry after a cancer cure by
radium, by considering a few of the interesting
list of non-malignant troubles which this remark-
able agent has helped. It will be consistent with
the aim of this most practical society that its mem-
bers should be informed on practical results.
One interesting demonstration of the prompt
curative action of radium and its permanent benefit
is in vernal catarrh, in a disease considered intract-
able by oculists, as well as physicians. This affec-
tion of the eyelids is a conjunctivitis recurring each
spring, and often lasting through the year when it
has become established. The lids are hot, swollen,
red, and itchy. Photophobia often compels the pa-
tient to stay in a semi-dark room. The lids gum up
and are glued together in the mornings with a
sticky, often mattery secretion. On everting the
upper lid there is seen a mass of granulation tis-
sue standing far out from the under surface, and
often grouped in bunches. This condition does not
occur in the sulcus above the cartilage of the lid.
By this it can be differentiated from trachoma.
I have treated in all ten cases which were re-
current for many years and can assert that the
Fig. 1. — Typical vernal catarrh ; this inveterate case had
resisted every variety of scientific treatment by specialists,
but was cured by radium.
improvement always begins soon after the first
treatment. Most cases had had extreme treatment
*Read at a meeting of the New York Clinical So-
ciety, April, 28, 1916.
by slicing off the masses, cauterization, and caustics
before I saw them, and had become the betes noires
of the oculists.
A uniform benefit and ultimate cure follow the
judicious use of radium. Technically, a fifteen
Fig. 2. — Best method of exposing the under surface of the
eyelid to strong radium ; this is placed in a groove at the end
of a long lead cylinder covered by a celluloid holder. The
cornea is protected by the lead beneath the groove holding
the radium tube.
minute application of a tube of strong radium un-
der the eyelid, moved back and forth, with a lead
device to protect the cornea, repeated every month
or two, constitutes the simple and rapidly helpful
method. With a drop of cocaine, the most sensitive
eye feels no pain. The cases I have so treated have
now remained cured up to ten years, as shown in
the case to-night. The method of its action is
specific, in altering the hypertrophied cells of the
mucous surface, which have made a veritable tumor
structure.
The second interesting condition in which radium
has no rival is in reducing lymphoid tumor tissue
such as is found in tumors of the tongue called
hemolymphangioma, and in other parts of the body.
I have reported a series of these in a paper read
before the American Surgical Association last
spring, and will not even quote further from it here,
but merely say that it is a triumph in a small group
of formerly hopeless cases. Its selective action on
the lymphoid cell growth is emphatically specific.
This overgrowth of one element of skin structure
in the scheme of tumor formation is not unlike
papillary warty growths which subside, like all
vocal cord papillomas as you have seen to-night in
the brilliant and permanent restoration of voice
with perfect vocal cords five years after apparently
hopeless conditions.
Warts, in places delicate as the edge of the eye-
lid, or the tender vermilion of a child's lip, or the
coarse skin of the sole of the foot, or under the
finger nails, or in the scalp, where scars are not
desirable, radium has cured for me a hundred times
48
MEDICAL RECORD.
[July 8, 1916
with usually no scar. 1 would class this with
specific action inasmuch as a retrograde of wrong-
growing cells takes place after this atomic bom-
bardment, causing them to return to normal growth.
Leucoplakia, considered as a simple overgrowth
of surface cells of the tongue or mucosa lining the
cheeks is not unlike the keratosis of the skin, heap-
ing up in places and making a veritable new growth,
often precancerous and tending to extend downward
and become a cancerous invasion. This is seem-
ingly as capable of cure by radium within the
mouth as it is in skin hyperkeratosis, whose dis-
appearance can be predicted with as much cer-
tainty as the treatment is easy. In the mouth,
however, the time and method of application re-
quire much more judgment and skill to attain good
results. It is associated with a transient painful
irritation which is essential to success. We face
the fact, however, that before radium was available
no cure was known. Mr. Butlin once told me that
"if radium would cure leucoplakia, it would do what
neither cutting out, or shaving off, or caustics, or
cautery had ever done in his hands."
An allied condition of the lips presents another
phase of the successful use of this energetic agent.
There is occasionally seen a weak spot of the skin
Fig. 3. — This patient with papilloma of t lit- larynx remains
perfectly cured after one rail. win application, and sang with
perfect voice five years after the treatment.
of the lip, a chronic thin surface ulcer or abrasion.
The skin refuses to heal, or if it heals with a thin
surface, it quickly breaks down and a chronic
abraded ulcer remains, not with cut-out edges, but,
as ice freezes, with a thin blue edge always looking
as if it might heal. There seems in these cases to be
a lack of force in the epithelial cells at the edge.
It often lasts for years, and is in striking contrast
to the hypertrophic conditions on the lip, both of
which I illustrate, and both are equally well cured
by radium. The same is true of the chronic painful
crack of the lip.
It seems paradoxical that the same agent can cure
an overgrowth keratosis and a deficient growth, as
in these abrasions, and until we know why cells
grow, we may not explain it. Some satisfaction,
however, may he had in a hypothesis which I offered
some years ago which argues backward from the
known output of beta radiation of radium, an enor-
mous charge of negative electron particles driven
into the disorderly growing; cells. Inasmuch as
there follows a retrograde change in the overgrown
cells, it must be due to something supplied to them
by this treatment. If, hypothetically, we surmise
that the vital force actuating a normal cell growth,
is a balance of electric action established within it.
and we conjecture that a riotous overgrowth may
be due to loss of balance, may it not be that the
preponderance of positive or negative charge is re-
sponsible for the disturbance which is corrected by
the new supply of nascent negative electrons. Sci-
Fic. •!. — Chronic abraded ulcer of the lip.
ence is about ready to concede that the actuating
force of nerve and cell activity is electrical, and
singularly enough this new agent is almost wholly a
discharge of material particles each bearing a
charge of electricity, some positive and some nega-
tive. It is not easy to explain, for instance, the
recovery of the destructive myeloid tumor of the
jaw, which I showed you to-night, as a fortuitous
reassembling of disordered cells to orderly rear-
rangement to form a normal jaw again which has
endured for twelve years. This I would designate
i Small typical true keloid of the chest; it had
been once cut out, and returned, as they all do, before coming
to me for radium treatment. This cured it with a smooth
skin 3Cai ^ed.
specific action. In what the specific action con-
sists, we cafi only speculate.
By contrast, there is an action of radium which
is curative by irritation only, as in nevus. The
endothelium of veins or arteries undergoes hyper-
July 8, 1916]
MEDICAL RECORD.
49
plasia and partly or wholly obliterates the lumen,
so as to induce a gentle fibrosis and cure of the
birthmark. Patience and discretion are needed to
keep a velvety skin and not produce a cicatricial
atrophy from overtreatment.
Fig. 6. — Extensive keloids following two years after an acid
burn.
The active irritation of these intense penetrating
rays is absolutely necessary to a successful result,
in any of its many uses. This provokes a kind of
inflammation, except that it has no bacterial origin.
Especially noticeable is this in keloids, one of the
most useful fields of its work. It was Wickham of
Paris in his early work who first showed me cases
of keloid cured by radium, and told me there was
no difference between so-called true and false keloid ;
both were equally easy to cure. I have verified this
in a great number of patients. Cases which no
surgeon would dare cut out are perfectly cured by
inducing, first, a sharp radium inflammation which
transforms the hard keloid masses of cells and
fibrous tissue. This is followed by an atrophy of
the mass as the inflammation of the fourth week
subsides. This is especially grateful in the so-called
true keloids of the front of the chest, often seen
in young women, which recur with terrifying cer-
tainty when cut out, but which invariably leave a
thin, flexible cicatrix after radiumizing properly.
In the terrible case of face keloid from acid
burns, which you have seen to-night, the condition
two years after the accident was one of progressive
very dense hard masses much as if leather were
drawn tight over a golf ball. Several sharp radium-
izations were induced in all, and each was followed
by marked softening and atrophy until now they are
all soft and pale and nearly flat.
But I come at last to speak of the most extraor-
dinary of all the remarkable effects of radium known
to me — its cure of the disease known as uterine
fibroids. It is fair to call this a disease by itself
because it has no exact counterpart that I know of,
in the body. It is essentially a tendency of the
muscular structure of the uterus to grow tumors
made up of the same muscle structure. One, or
many, they are myomata; some old and fibrosed,
some young and of juicy cell structure. Those
growing close beneath the lining membrane of the
cavity usually induce severe hemorrhages, often
very grave. For forty years surgery has had but
one answer to the appealing sufferer — "Cut them
out, usually with the whole uterus also." It would
be difficult to compute the hundreds of thousands
so treated in the hospitals of the world.
The surgical results must include not only a great
majority of satisfactory cures, but also deaths by
hundreds from operative risks and the several se-
quels of pelvic abscess, abdominal wall abscess,
hernia of the scar, cystitis from catheterization,
femoral phlebitis, and so on. Add to this the four
or six weeks of hospital care — which in private
means often a continual surgical attendance of
many weeks more, where the patient is often more
frail. The absence from work or home duties, in
women who can ill spend the time, completes a long
list of essential incidents associated with the cus-
tomary surgery of uterine fibroids.
Let us imagine, now, that a remedy for all this
is found in so simple a treatment as the introduc-
tion of a small tube of radium into the uterine
cavity, without ether, for two hours on two or three
occasions, without entering a hospital, and that,
following this, the excessive hemorrhage stops and
the tumors progressively shrink until they disap-
Fig. 7. — Same patient ;» s shown in Fig.
t rea tment
6. after radium
pear. Is this possible? It is not only possible, but
has come to the point of complete demonstration.
Accumulated cases now show that it may be de-
pended on for permanent cure, with apparently no
risks, no delay, no hospital, small cost to the patient
60
MEDICAL RECORD.
[July 8, 1916
in time and money; and to the surgeon, small cost
of time. It sounds like a Munchausen tale. It is
one of the most beneficent actions of this unique
agent.
My experience with it dates back to 1905, which
is the first case as far as I know in which it was
used to arrest a hemorrhage and for its hoped for
-good effect on the tumor. That and another which
followed soon after were recorded by me in 1906,
and have been watched ever since. The tumors
shrank year after year until they remained but very
small, inert buttons on the uterus. Since then I
have applied it in more than thirty cases and have
yet to see a case which did not shrink, some com-
pletely, some rapidly — all in large measure. It may
truly be called a specific for uterine fibroids, and
must supplant operative treatment as fast as con-
viction and the accession of radium come to oper-
ators.
Its special value shows in the many cases of
violent hemorrhages from fibroid disease. Here the
uterine lining is overgrown and highly vascular, or
stretched out thin and bleeding from open mouthed
veins. The contact of radium with these blood ves-
sels seals them up by occlusive inflammation, due to
Time has limited me in this paper to speaking of
only a few of the non-cancerous cellular growths in
which the action of this comparatively new agent —
radium — has a character of its own.
1 3 WEST Fiftieth Street.
Fig, s. To illusti iction of radium on a large
uterine fibroid. A. tumor before the application of radium-,
B, tumor ten months
the active beta rays, while the penetrating gamma
rays go through the whole disordered cell mass, and
produce a retrograde change in the conduct of each
cell so that it begins its retreat at once, and the
growth's shrinkage is measurable in from two to
six months.
The very large tumor in a desperate case of
hemorrhage, published by me last June, has shrunk
from a diameter of ten inches to four, in ten months,
and will disappear probably within a year. Mean-
while the exhausting hemorrhages ceased in six
weeks and have never recurred. The patient has
enjoyed perfect health since. This may be said or
all the cases treated.
One patient whom I have shown you to-night
with the most extensive lupus erythematosus of
the entire face, ears, and side of the neck, and of
his hands, was cured by one thorough radium treat-
ment. This case does not stand alone.
It is probable that every case will yield to proper
radiumization, judging by five cases of this disease
on the face which have yielded excellent results
which seem permanent. The first case was of a
man who had typical patches on both cheeks. He
remained cured after my treatment in 1904.
RADIUM IN THE FIELD OF LARYNGOLOGY.*
By d. bryson delavax, M.D ,
NEW YORK.
The past year has brought distinct advances in
the knowledge of the use of radium, in no depart-
ment with more encouraging results than in ours.
To-day many observers are studying its effects in
an ever increasing variety of disorders, some of
which are far beyond the limits of previous con-
jecture. Additions are being rapidly made to the
number of conditions in which the treatment is
effective, and substantial encouragement is being
given to the hope that there has been found in
radium a truly valuable therapeutic agent. Sev-
eral of our institutions, notably the General Memo-
rial Hospital, New York, have been fortunate in
acquiring amounts of radium large enough to meet
all of the probable demands of treatment, while
those in whose hands it has been placed for ad-
ministration are gaining experience in its appli-
cation and learning how it may best be utilized and
controlled.
Some contributions have been made to the litera-
ture of the subject in general, but in the depart-
ment of the diseases of the upper air passages lit-
tle has yet appeared. This is not surprising. The
study of radium is in its infancy. Few investiga-
tors at present are ready to issue formal reports
of their work, wisely refraining from announcing
results until their deductions can be placed upon
a stable basis of well proved fact. Any attempt
to drag it before the medical public at the present
time would be premature. What is needed is not
publicity, but rather the development of scien-
tifically proved data upon which, and only which, re-
liable reports of progress are possible. The secur-
ing of such data requires long-continued and pains-
taking study of the action of radium, under con-
ditions favorable for accurate observation, in the
hands of men especially qualified for the work.
When these conditions have been fulfilled, and not
until then, we may hope for the beginning of a lit-
erature at once valuable and instructive. Mean-
while, however, even the most conservative observ-
ers are willing to admit that encouraging progress
is being made. Were the actual experiences of dif-
ferent institutions devoted to the study of radium
to be quoted the truth of the above statement would
be plain.
A few fragmentary contributions and reports
have appeared, some of which are worthy of -notice.
From these it is again evident that the progress be-
ing made in the knowledge of radium efficiency in
non-malignant surgical conditions and in certain
nonsurgical affections of the upper air passages
continues to be gratifying. This is shown by the
work nf various observers in the United States.
particularly by that of Dr. Robert Abbe of New
York, and by the reports of the two leading British
institutions, the Radium Institute of London and
the Royal Infirmary of Edinburgh.1
Thus the London Institute reports excellent re-
*Read before the American Laryngological Associa-
tion at its thirtv-eighth meeting, Washington, D. C,
May 10, 1916.
July 8, 1916]
MEDICAL RECORD.
51
suits in the treatment of "vernal catarrh," patients
treated for it by radium having in a large propor-
tion of cases been cured without recurrence, al-
though under observation for a series of years.
In the treatment of nsevus by radium remarkable
results are *being obtained.2 The most brilliant of
these are seen in young children where conditions
of unusual severity in the vicinity of the lips and
nose, far beyond the limits of surgical relief, are
being successfully reduced.
Rhinoscleroma, according to Kahler,a has been
treated with good effect. Good results have been
claimed from the application of radium in goiter
and in tubercular glands.* For the latter Bissell5
of New York is particularly impressed with its
value. Under his observation proper radium treat-
ment has often and completely restored such glands
to their normal functions. Abbe believes that
leucoplakia of the tongue is not unlike a keratosis
of the skin, often pre-cancerous and tending to ex-
tend downward and become cancerous. He con-
siders that it is as capable of cure by radium as is
the skin keratosis. Delavan8 has called attention
to the same thing. Serra' reports a successful case.
Much attention is also being given to the study of
radium as applied to new growths in general and
many highly interesting and important facts are
being obtained. This is especially true of growths
of a non-malignant character. In the treatment of
nasopharyngeal fibroma the use of radium has
proved encouraging, particularly so in view of its
success in the treatment of fibromata in other parts
of the body." Abbe2 has shown a case of myeloid
tumor of the jaw, completely cured.
In the treatment of non-malignant intralaryngeal
growths many highly interesting results have been
obtained, tumors of various histological structures
having disappeared, in a number of cases with com-
plete restoration of the singing voice. The treat-
ment of papilloma of the larynx by means of radium
is one of the most interesting phases of its use.
In view of the success already attained with it, as
well as with warty growths in general, the out-
look for it is most promising.
Weil" reports a parotid tumor (adeno-cystic-
epithelioma) of seven years' standing, which was
treated for six weeks by the insertion of radium
into it. The growth disappeared, and at the end
of two years has not recurred. Freudenthal' re-
ports a case of fibrosarcoma of the right antrum
cured. He also reports a case of sarcoma of the
tonsil, in which the growth disappeared and re-
mained in abeyance for six years. Then it re-
curred and the patient died. In another similar
case the growth disappeared for six months.
In this highly specialized department, laryngol-
ogy, radium promises to occupy a wide and im-
portant field.
While the treatment of these various lesions has
been attended with interesting results, the final
value of radium in certain of the more serious af-
fections has yet to be proved. Especially is this
true of its use in carcinoma, for while a consider-
able number of cases have been placed under treat-
ment it has been claimed by some that the effect
of radium has in certain instances been unsatis-
factory; and even in some in which its influence
has been temporarily beneficial the good effect has
not always been lasting, or else too little time has
elapsed to prove its final value. In a few cases it
is said that not even temporary benefit has resulted.
while in some of these the advance of the disease
seems to have been hastened. Again, while parts of
the region exposed have undoubtedly improved,
other parts have retrogressed. Admitting that these
several objections may contain more or less of truth
it is, nevertheless, encouraging to know that the
causes of more than one of them are understood
and that diligent effort is being made to discover
the means by which they may be prevented.
In this connection, recent British experience and
opinion is interesting.
The report of the Radium Institute of London1
states that "epithelioma of the buccal, lingual, and
pharyngeal mucous membranes usually proves re-
fractory and disappointing in its response to
radium," but, it is significantly added, "under
new methods of application better results may be
expected. Thus far, the treatment does not seem
to have much effect in arresting the disease."
The report of the Royal Infirmary" gives a far
more sanguine outlook. Thus : "While in advanced
malignant cases a cure may not have been effected,
yet in practically all treated more or less benefit was
produced, through the relief of pain, the cessation
of discharges, the healing of ulcerative surfaces,
the removal of local growths, and the prolongation
of life.
"Malignant disease of the posterior nares, buccal
cavity, pharynx, and larynx seems less amenable to
radium, but this may be from the difficulty of ad-
ministering a sufficient dose in such positions."
Several cases that have come under my own ob-
servation have shown effects worthy of notice. Two
of them were epithelial carcinoma, originating in
the left side of the throat close to the wall of the
larynx and, as far as could be ascertained, extra-
laryngeal. Both patients were men in the early
fifties, hitherto in perfect health, active, vigorous,
and of excellent antecedents. When first seen, the
disease in both had invaded the interior of the
larynx, the left lateral wall of the pharynx, the
pyriform sinus, the tonsil, and the base of the
tongue. In both, ulceration was present and there
was marked aphonia and dysphagia. Operation was
impossible. Both were subjected to the radium
treatment at the same institution and large doses
were applied. In both the results have been mate-
rially the same.
The first effect of the radium locally was an al-
most immediate control of the secretions of the
throat. From having been abundant and fetid
they promptly ceased. Following this the areas of
ulceration rapidly diminished in extent, and in the
less severe of the two cases they disappeared ; while
in the other case they seemed to do so, although it
has not been possible to prove this owing to the
difficulty of examination. The swellings which had
appeared over extensive areas of the affected parts
decreased markedly, and the infiltrated tissues were
reduced in size, became soft to the touch and more
natural in appearance. Accompanying these changes
extraordinary improvement took place in the various
functions of the throat. Thus, the voice became
clearer, and deglutition, which before the applica-
tion of radium had become almost impossible,
showed such improvement that both patients were
able to swallow without pain and to largely increase
the variety of their food.
Together with these local changes, the improve-
ment in general was remarkable. Digestion be-
came normal and sleep more prolonged and rest-
ful; while with the improved nutrition a steady in-
crease of strength was apparent and a rapid return
52
MEDICAL RECORD.
[July 8, 1916
to an almost normal condition of good spirits. One
of these patients, a physician, was able to resume
his office practice and for two months remained
steadily at work.
These patients, as well as all who have seen
them, admit that even if from now on the progress
of the disease should ultimately be unfavorable the
benefit already gained in the relief of suffering and
the added comfort afforded, would well repay them
for any inconvenience the radium had caused. This
is an important concession, for the superficial burn
sometimes resulting from radium may be an un-
pleasant feature. Compared, however, with the re-
sults of any serious surgical operation, it is but a
slight annoyance. And yet how gladly will the
patient submit himself to the knife and to weeks
and perhaps months of disability and suffering fol-
lowing its use for the sake of cure, quickly forget-
ting all the harrowing details of his surgical ex-
perience and even its resulting mutilations in the
joy of being restored to life and health! Any
method which will cure carcinoma, at the same
time leaving the normal parts intact, with no worse
penalty than a slight superficial burn, should surely
be welcomed with acclaim.
The present is no time for the adverse criticism
of radium. The study of the radium treatment of
carcinoma is but just begun. Some, at the very
threshold, are already discouraged, and are an-
nouncing themselves as unwilling to believe in its
efficacy. To these we may repeat that the knowl-
edge of the use of radium in general is still in em-
bryo.
The failure to gain uniformly reliable results
in carcinoma is due to our imperfect knowledge
of the methods by which the radiations can
be controlled, of the amounts of radium which
should be used, and of the correct duration of the
exposures. The all-important basic principle has
certainly been proved, namely that, under proper
application, radium will destroy a superficially lo-
cated cancer cell. Granting this proposition, it is
by no means impossible that with increased knowl-
edge of its action, and skill in its application, deep-
ly seated cells may be successfully reached and
destroyed, while at the same time the surrounding
tissues are effectively protected.
Already, results worthy of profound considera-
tion have been obtained. Far from being discour-
aged, there is every reason why persistent and
continued effort should be made to finally solve the
existing problems and give to the world a cure for
one of its most grevious scourges. Fortunately,
there are some who, in the face of many difficulties
are earnestly and hopefully striving to obtain this
end. Let such gain inspiration from Trudeau"
that noblest of humanitarians: "Optimism is a
mixture of faith and imagination, and from it
springs the vision which leads one from the
beaten paths, urges him to effort when obsta-
cles block his way, and carries him finally to
achievement when pessimism can only see failure
ahead. Optimism may, and often does, point to a
road that is hard to travel, or to one that leads
nowhere; but pessimism leads to no road at
all.
"Let us not therefore quench the faith nor turn
from the vision which, whether we own it or not,
we carry * * and thus inspired many will
reach the goal," as have all whose hopeful imagin-
ings and courageous efforts have been the basis of
every noble success the world has ever seen.
REFERENCES.
1. British Med. Journal, June, 1915.
2. Abbe: Oral communication, 1916.
3. Wiener klin. Woch., 1905.
4. Journal-Lancet, 1915.
5. John B. Bissell: Oral Communication, 1916.
6. Trans. Amer. Laryngolog. Assn., 1915.
7. Revista Espan. de Urol, y Dermatol., August, 1915;
Laryngoscope, April, 1916.
8. Delavan: Medical Record, June 26, 1915.
9. Journal Amer. Med. Assn., December 18, 1915.
10. N. Y. Med. Journal, July 3, 1915.
11. President's Address, Eighth Congress of Amer-
ican Phys. and Surgs.. Washington, 1910.
40 East Forty-first Street.
FRACTURES IN CHILDREN.
Bt JACOB GROSSMAN, M.D.,
NEW YORK.
Fractures in children vary from those in adults not
only in severity and variety, but also in their man-
agement. The bones in children are soft and elastic,
they have in their ends cartilaginous discs which
give way to traction and bending. Where in adults
an injury will produce a dislocation, this same in-
jury in children will usually produce a fracture. The
degree or severity of the injury bears very little
relation in the production of fracture in a certain
percentage of children. At times a mild trauma as
falling on the floor and striking upon the affected
part or a slight knock against a chair will produce
a fracture. Occasionally a severe trauma such as
falling down a flight of stairs, will not produce more
than an injury to the soft parts or an injury which
is very often overlooked, namely, intraperiosteal
fractures.
A great many fractures seen by the orthopedic
surgeon are fractures which are overlooked and are
often diagnosed as "sprains," contusions, "twisted
tendons," etc. The absence of the cardinal signs of
fracture, i.e., crepitus, false mobility, deformity,
and ecchymosis probably accounts for the mistakes
in diagnosis. The absence of these signs can be
accounted for in one of the following ways :
1. An impaction of the fragments may be present.
2. One fragment may be too small or too firmly
attached to the neighboring structures.
3. Finally the fracture may be an incomplete one,
being of the fissure or torsion variety.
It is this latter cause of error which is com-
monly found in the care of children. These frac-
tures are incomplete and are known as subperiosteal
or intraperiosteal fractures. The most constant
and what can almost be called diagnostic sign, is
the localized bone or "pencil tenderness." The way
to map out this localized or pencil tenderness is to
palpate or make pressure with the back of a pen or
the rubber tip of a lead pencil. By tracing the
point of maximum tenderness one can in a vast
majority of the cases trace the line of fracture,
besides making the diagnosis. We have confirmed
our clinical findings by means of Roentgen ray pic-
tures, a few of which will be found elsewhere in
this paper. Although there is general pain in cases
of fracture, still firm pressure about the seat of
injury will, in a vast majority of cases, reveal a
definite, constant point or line of pencil tenderness
over the fracture. This tenderness is at times very
exquisite. Many parents are surprised to learn that
their children had sustained fractures, so trivial
had been the suffering, both subjectively and func-
tionally. The diagnosis in these cases was made by
tracing the line of pencil tenderness. The duration
July 8, 1916]
MEDICAL RECORD.
53
of this sign varies, sometimes persisting for weeks.
At a recent meeting of the Alumna Society of
Lebanon Hospital, the writer demonstrated several
cases of intraperiosteal fractures, all diagnosed by
tracing the line of pencil tenderness and all con-
Fig. 1. — Case I. Fissure fracture of the tibia.
The
firmed by subsequent Roentgen ray pictures,
complete reports of these cases follow.
Case I. — Dorothy E., five years of age. A few days
before coming to the Lebanon Hospital Orthopedic
Clinic, the child tripped and fell down the stairs, a
distance of a few steps. The mother thought nothing
of the injury as the child was able to get about. She
applied home remedies with very little success. For the
following few days the child complained of having pain
only when she walked. It was on account of this pain
that the patient was brought to us.
Examination: The child walked with a slight limp
on the left side. The left leg was slightly swollen,
there was no deformity or ecchymosis. Crepitus and
false mobility were also absent. A line of maximum
tenderness was traced along the shaft of the left tibia
for a distance of three inches. A diagnosis of an intra-
periosteal fracture of the tibia was made and proper
treatment instituted. The mother could not understand
how it was possible for the child to have a fracture and
still be able to get about. A subsequent Roentgen ray
picture showed an intraperiosteal fracture of the tibia,
corresponding to the line of pencil tenderness, which
we had traced. Fig. 1 is an x-ray picture of this case,
showing the location and type of fracture.
Case II. — Sarah S., nineteen months of age. A few
days before coming to our clinic, the baby fell out of
her carriage, striking upon her left leg. After the ac-
cident the child was unable to walk, and was very
tender at the site of the injury. She was brought to
us on that account.
Examination: The child was unable to bear any
weight on her left lower extremity. There were slight
ecchymosis and swelling over the site of injury. Cre-
pitus, false mobility and deformity were absent. A line
of maximum tenderness was traced along the shaft of
the lift fibula for a distance of two inches.
A diagnosis of an intraperiosteal fracture of the
fibula was made. A subsequent Roentgen ray picture
confirmed our diagnosis. (Fig. 2.)
Case III. — C. H., three years of age. One week prior
to his visit to our clinic the child fell, striking upon his
right forearm. The mother thought that the child had
only bruised its forearm, hence the delayed visit to our
clinic.
Examination: The child refused to move his right
arm. There was slight swelling and ecchymosis over
the palmar surface of the right forearm. Crepitus, de-
formity and false mobility were absent. A line of maxi-
mum tenderness was traced running transversely over
the lower end of the radius, about one inch above the
articular surface.
A diagnosis of greenstick fracture of the radius was
Fig. 2. — Case II. Fissure fracture of the fibula; another
photograph, taken in a different plane was negative. This
shows the importance of taking Roentgen-ray pictures in
more than one plane.
made and a subsequent Roentgen ray picture (Fig. 3)
confirmed our diagnosis.
The treatment of this type of fractures is the
same employed in complete fractures, differing only
in having a shorter period of immobilization.
Many authors report loosening or separation of
the epiphysis as a common occurrence in children.
In our series there were just two cases or about
1 per cent, of epiphyseal separation. In these cases
both were at the lower end of the radius, the result
Fig. 3. — Case III. Greenstick fracture of the lower end of
the right radius. ,
of a severe trauma. In a vast majority of these
so-called epiphyseal separation cases, were Roentgen
ray pictures to be taken a fracture just above the
epiphyseal line would be revealed.
These peculiarities of the bones in children make
54
MEDICAL RECORD.
[July 8, 1916
the diagnosis quite difficult, especially in intra-
periosteal fractures, when one looks to make a
diagnosis on the cardinal signs of fracture. We
must always think of fracture as a possibility when
children refuse for any length of time to use a
Fig. 4. — Case IV. Figure of eight dressing for fracture of
the clavicle.
limb, especially if they do not use it when their at-
tention is distracted from it or when they are at
play. Many cases diagnosed as contusions, twisted
tendons, or bad sprains eventually turn out to be
fractures. In this series fully twenty-five per cent,
of them were treated as sprains, twisted tendons
and contusions.
In general the treatment of fractures in children
is much simpler and easier than it is in adults.
The thick periosteum which is usually partially in-
tact prevents any considerable dislocations, nor are
the muscular tractions quite as strong and are
easier overcome than in adults. The tendency to
heal is much more intense in children and hence the
time of union is much shorter, and immobilization
is of shorter duration than that of the adult. An
exception to this is found in rachitic children, where
on account of the pathological condition in the
bones, there is interference with the healing process
and hence it takes a longer time for the fracture
to unite.
The scar which forms is usually a soft one and
only becomes solid when the rickets is cured. In
this type of cases a slight push, a jump or even a
sudden strong contraction of a muscle will suffice
to break completely a bone which is already bent.
This is also true in any process which softens the
bones, i. e., osteomalacia, atrophy of the bone
through disuse (as in paralyses and inflamma-
tions), and in osteogenesis imperfecta in which
condition the bones are very brittle.
This paper is based on the study of 200 cases of
fractures, divided as follows: Fracture of the clav-
icle, 50. Fracture of the humerus, 48; (a) surgi-
cal neck, 3; (b) shaft, 5; (c) lower end, 40. Frac-
tures of the forearm, 92; (a) shaft of the radius,
20; (b) shaft of the ulna, 5; (c) olecranon, 3; (d)
both bones, 24 ; (e) lower end of the radius, 40.
Fractures of the leg, 10; (a) tibia, 5; (b) fibula,
5. There were 130 in males and 70 in females.
The ages were between fourteen days to eleven
years. The cause in the majority of the cases was
a direct injury.
Fracture of the Clavicle. — This was a fairly fre-
quent fracture in the series of cases, there being 50
cases, or 25 per cent. The common cause was a fall
upon the shoulder and the common site was at the
junction of the middle and outer third of the bone.
Some of the cases were incomplete, being of the in-
traperiosteal variety, with no displacement of the
fragments. The diagnoses' in these cases were made
by tracing the maximum point of tenderness. The
remainder were complete and were accompanied by
severe pain and a lowering of the shoulder. The
pain was especially evident when the arm was ab-
ducted above the horizontal position. Deformity,
crepitus, false mobility, and marked tenderness
were all present.
Treatment : In treating fractures in infancy and
childhood one must always remember the differ-
ences between the infant, the child, and the adult.
The tender skin of the infant, its round, agile body,
the movable cover of fat which envelopes the soft
bones offer considerable difficulty to an exact
therapy.
In fractures of the clavicle the dressings at our
disposal are (a) the figure of eight bandage and
(6) adhesive plaster.
Figure of eight bandage: Before applying the
bandage it is very important to subject the axilke
to preliminary treatment. This consists in dusting
them with boric-acid powder and the insertion of a
pad of boric-acid lint in each to absorb the per-
spiration and keep them dry. The deformity when
present is then reduced and the fragments are re-
tained in their proper position by an assistant. A
flannel bandage about two inches wide is then ap-
plied in a figure-of-eight manner so that the figure-
of-eight is behind and the shoulders are held back
by the two loops of the eight. The forearm is then
supported by a sling about the neck.
Fig. 4 shows the back view of this dressing.
Case IV. — Josephine B., four years of age, fell and
struck her right shoulder a few days before coming to
our clinic. This accident was followed by severe pain
and disability.
Examination revealed a complete fracture of the
clavicle at the junction of the middle and outer third
Fig. 5.— Case V. Fracture of the upper part of the humerus.
of the bone. The outer fragment was displaced down-
wards accompanied by the shoulder and the inner frag-
ment was displaced upwards. There w7as complete dis-
ability, attempts at passive abduction being accom-
panied by severe pain.
July 8, 1916]
MEDICAL RECORD.
55
Adhesive plaster dressing : After the preliminary-
preparation of the axillae a strip of adhesive plas-
ter about one and a half inches wide and about
seven inches long is applied, starting in front of
the affected shoulder, continued outward around
Fig. 6. — Case VI. Fracture of the shaft of the humerus.
the shoulder and then backward and downward
over a pad (which is placed between the scapulae)
to the opposite anterior axillary line. It is impor-
tant to make traction on the affected shoulder and
draw it backward while this strip of plaster is be-
ing applied. A second strip of plaster, about the
same width and length, is then applied, starting
from the middle of the arm on the affected side
(not completely encircling it) and continued back-
ward (drawing the arm back) to the anterior
axillary line on the opposite side. The wrist on the
affected side is to be supported in a sling about the
neck.
The advantages of this dressing are: (a) Its
simplicity; (b) we can always have the parts un-
der observation without removing the dressing;
(c) there is very little danger of compressing the
blood vessels or nerves.
The dressings are usually retained for a period of
ten days, when they are removed and after-treat-
ment is begun. This consisted of massage and
passive movements of the shoulder. After a few
days active movements and exercises are begun.
In infants and younger children we usually em-
ployed the figure-of-eight dressing. In older chil-
dren it is a good plan to use the adhesive plaster
dressing previously described. The time of union
in all the cases averaged about two weeks. There
were practically no deformities or complications.
The adhesive plaster dressing was advocated by
Dr. S. Kleinberg of this city.
Fractures of the Humerus. — Fractures at the
upper end.
Of these we had three cases, all fractures of the
surgical neck of the humerus. The cause was a
fall upon the shoulder. In treating this type of
fracture one must always bear in mind that the loss
of abduction interferes most seriously with the
function of the joint. Hence we have treated these
cases with the arm in abduction and retained it
there by means of a plaster of paris bandage
spica. The spica was removed after three weeks
and the patients were discharged after a few days
after-treatment, after which time abduction, adduc-
tion, and rotation were free and painless. The fol-
lowing is a report of one of these cases:
Case V. — Yetta G., four years of age. Eight days
before coming to our clinic, the patient fell, injuring
her right shoulder. She was brought to us an account
of the loss of function of the shoulder and slight pain.
Examination : Swelling and slight ecchymosis about
the right shoulder. The right upper extremity was held
limply at the side. Marked tenderness over the upper
part of the humerus. Limitation of all movements of
the joint, especially abduction.
Diagnosis: Fracture of the upper part of the hu-
merus, confirmed by a subsequent Roentgen ray pic-
ture. (Fig. 5.)
Fractures of the shaft of the humerus: There
were five such cases in our series. Two of these
were in infants where the fractures occurred dur-
ing delivery ; one was in a child who had fallen
from a wagon, striking upon his shoulder. In the
former two the site of the fracture was near the
center of the bone, just below the insertion of the
deltoid muscle. The deformities were lateral dis-
placement, the fragments lying parallel (Fig. 7).
The lines of fractures of all three were practically
transverse. In the two infants there was an ac-
companying wrist drop, probably due to some in-
jury to the musculospiral nerve at the time of the
fracture. This wrist drop gradually disappeared
during the first two weeks.
The older child who had fallen from the wagon
sustained transverse fracture, without displace-
ment of the fragments. His history follows:
Case VI. — Sam M., eight years of age. One day pre-
vious to his visit to our clinic, he fell from a wagon
and hurt his left shoulder. He suffered very little pain
thereafter. He was brought to us on account of the
loss of function of his left shoulder.
Examination : The left upper extremity was held
limply by the side, there was swelling of the left
shoulder. Crepitus, false mobility, deformity and ec-
chymosis were absent. All the movements of the
shoulder were limited. A line of maximum tenderness
was traced running transversely across the upper part
of the humerus.
Diagnosis: A diagnosis of fracture of the humerus
was made, and a subsequent Roentgen ray picture
(Fig. 6) confirmed our diagnosis.
Treatment: Where there was a deformity (as in
Fig.
-Fracture of the humerus.
Fig. 7) it was reduced. Then strips of adhesive
plaster were passed about the chest fixing the injured
arm to the side of the body. The forearm was flexed
upon the arm, the hand brought towards the opposite
shoulder, the axilla protected by means of boric acid
lint, and the fractured humerus pressed firmly against
56
MEDICAL RECORD.
[July 8, 1916
the lateral chest wall by means of the encircling bands
of adhesive plaster.
This method prevents the usual external angular de-
formities, and has the great advantage both of sim-
plicity and security. This dressing is retained for
about a week, when it is removed and replaced by a
FIG. S. — Case VII.
Fracture of the external condyle of the
left humerus.
new one. After another week it is dispensed with en-
tirely. After-treatment was not necessary in these
cases, but it is a good plan to give massage and move-
ments to the shoulder before discharging the patients.
(c) Lower end of the humerus and in the elbow
joint. There were forty-three cases of these frac-
tures, divided as follows: Supracondyloid fractures,
10; internal condyles, 20; external condyles, 10;
olecranon process of the ulna, 3.
The supracondyloid fractures were commonly
caused by a fall upon the hand, the elbow usually
being extended. The fractures were generally
oblique, occasionally transverse. Very often there
is a displacement backward and upward of the
lower fragment. The condyles and the olecranon
process were generally fractured by direct violence,
as a fall, striking upon the elbow. The torn piece
of bone in many cases remains intact, being held
there by the periosteum; in other cases it is torn
away and displaced (Fig. 9). The fragment may be
dislocated in any direction.
The diagnosis in these elbow fractures is very
difficult at first on account of the marked swelling
and severe pain which are generally present at that
time. Motion in the joint is painful and limited,
occasionally abnormal mobility and crepitus may be
present.
There were three cases of fracture of the ole-
cranon process, all transverse, with slight displace-
ment of the fragments. All responded to the treat-
ment which will subsequently be described.
Case VII. — Anthony D., six years of age, fell and
struck on his left elbow. Complained of pain and dis-
ability.
Examination: The left elbow was held in flexion at
an angle of about one hundred degrees. Deformity,
ecchymosis, crepitus and limitation of all movements
were present. Tenderness was excruciating and local-
ized to the external condyle of the left humerus.
Diagnosis: Fracture of the external condyle of the
left humerus. A subsequent Roentgen ray picture con-
firmed our diagnosis. (Fig. 8.)
Case VIII. — Sidney E., eight years of age, fell on the
outstretched palm of his left hand. This was followed
by pain and disability.
Examination : The forearm was held in flexion of
about one hundred and twenty degrees. There were
swelling and ecchymosis about the left elbow. Deform-
ity, crepitus, and false mobility were present. Tender-
ness over the lower part of the left humerus was ex-
cruciating. All movements of elbow were limited.
Diagnosis: A supracondyloid fracture of the left
humerus, with upward and backward displacement of
the lower fragment. A subsequent Roentgen ray pic-
ture confirmed our diagnosis. (Fig. 10.)
Case IX. — Alfred M., five years of age, fell and struck
upon his right elbow. He complained of pain and dis-
ability.
Examination : The elbow was held in extension of
about one hundred and forty degrees. There were swell-
ing, ecchymosis and tenderness in the region of the
olecranon process. Slight crepitus and false mobility
were present.
Diagnosis: Fracture of the olecranon process, with a
slight upward and backward displacement. Our diag-
nosis was confiimed by a subsequent Roentgen ray pic-
ture.
Treatment: The supracondyloid and condylar frac-
tures were treated by the acute flexion position.
After the fracture has been reduced, the arm is
fully flexed, so that the hand on the affected side
rests upon the opposite shoulder and the elbow is
carried well forward on the chest. In the majority
of cases this position keeps the fragments in posi-
tion. The forearm is now bandaged to the arm by
figure-of-eight turns. Before applying the bandage
the arm should be dried and powdered and a piece
of boric acid lint placed in the erbow crease and
axilla to absorb the perspiration and keep the parts
dry. The wrist is kept in position by a sling about
the neck. It is very desirable to take a Roentgen
ray picture after a few days to see if the fragments
are in good position. Should the Roentgen ray
show a bad position the dressing should be removed
and the deformity corrected.
At the end of a week or ten days the bandage is
removed and passive movements are begun. In
performing passive movements grasp the elbow
with one hand and flex, extend, pronate, and supi-
nate the forearm to its full extent. This should be
done once only and repeated three times a week.
Massage should be given once or twice daily. Grad-
FiG. 9. — Cast- VII. Fracture of the external condyle of
the left humeri; m extended. Note the displacement
of the fragment
ually diminish the acuteness of flexion and at the
same time lengthen the sling. Flexion must be
maintained for at least three weeks. When the limb
can be used, exercise should be added. These are
described fully by the writer in a previous paper,
July 8, 1916]
MEDICAL RECORD.
57
"Fractures of the Elbow," Medical Record, Jan-
uary 15, 1916.
Treatment of fractures of the olecranon process.
— These cases were treated by mechanical means
and responded without resort to operation. The
Fig. 10. — Case VIII. Supracondyloid fracture of the left
humerus. Note the posterior and upward displacement of
the lower fragment.
method used, a very simple one, is one in which a
straight plaster of paris splint is placed along the
front of the arm and forearm, with a pad in the
elbow bend so that the limb is not fully extended.
The fragments of the olecranon are kept in posi-
tion by means of narrow strips of adhesive plaster
applied with their center above the fragment and
the ends are brought obliquely downward to the
sides of the splint below the elbow. The strapping
requires daily inspection and frequent renewal. The
marked effusion which was present necessitated the
use of an ice bag.
Subsequent treatment should be begun as early as
possible. The limb is retained in the extended posi-
tion for three weeks. From time to time the splint,
is removed and passive movements are given. Care
must be taken to avoid separation of the fragments.
In spite of this early passive movement there was
considerable stiffness, which was eventually over-
come by persistent, careful massage, baking, active
and passive movements, and exercises. It is very
important in giving passive movements to remem-
ber that one can aggravate a synovitis of the elbow
stretching the limb too vigorously, and in that way
produce fresh adhesions and more limitation of
function. A good way to prevent this is to stretch
the limb within the painful limits, that is to flex
the forearm up to the point where the patient com-
plains of pain, and to extend it up to the point
where the patient begins to complain of pain re-
peating within these limits.
Fractures of the Forearm. — There were 92 of
these cases, of which 40 were fractures of the
lower end of the radius, 20 were fractures of the
shaft of the radius, 5 were fractures of the shaft
of the ulna, 3 of the olecranon, and 24 were frac-
tures of both bones.
Fractures of the lower end of the radius. The
usual cause was a fall upon the outstretched palm
of the hand, the elbow being somewhat flexed. Oc-
casionally direct violence was the cause. The site
of the fracture was generally about three-quarters
to an inch above the articular surface. There were
very few that showed any impaction and the de-
formity in these cases was very slight. Those that
were impacted showed the characteristic deformity
of Colles' fracture, i.e., the silver forked deformity.
Case X illustrates the average type of fracture
present in these cases. The history of the case fol-
lows:
Case X. — (Fig. 12.) Daniel P., seven and a half
years of age. One day before coming to our clinic
the patient tripped and fell on the outstretched palm of
his right hand.
Examination : There was marked swelling and ecchy-
mosis on the anterior surface of the lower part of the
right forearm. Crepitus, false mobility and excruciat-
ing tenderness were present about three quarters of an
inch above the articular surface. The movements of the
wrist were all limited.
Treatment: If the fracture is an impacted one,
complete reduction is essential before any treat-
ment can be satisfactory. Subsequent adhesions
and stiffness of the wrist must be guarded against.
The adhesions and stiffness result from a teno-
synovitis of the tendon sheaths in the neighborhood
of the fracture.
Reduction : When possible reduction should be
accomplished under an anesthetic. Extension and
forcing the lower fragment forward is all that is
necessary. Where no anesthetic can be given, re-
duction is effected by grasping the hand on the
affected side, flexing and adducting it until the
impaction is undone. Care must be taken to see
that the displacement is rectified completely. After
the fracture has been reduced, the fragments can
be retained in their proper position by grasping the
lower end of the bone between the thumb and fin-
gers; the thumb is placed on the back of the wrist
and presses the lower fragment forward, while
the fingers press the lower end of the upper frag-
ment backward.
Splint: A circular plaster of paris bandage ex-
tending from the elbow to the metacarpo phalangeal
Fig. 11. — Case IX. Fracture of the olecranon process of
the right elbow. Note the slight backward displacement of
the fragment.
joints, that is to the knuckles behind and the trans-
verse crease of the palms in front, is now applied.
The fingers should be left unconfined and the pa-
tient encouraged to move them, so as to prevent
adhesions of the tendons to their tendon sheaths.
58
MEDICAL RECORD.
[July 8, 1916
The forearm should be supported in a sling. A
Roentgen ray picture should be taken as soon as
possible after the bandages have been applied, so
as to ascertain as to whether any displacement has
occurred. If any has occurred the bandages should
Fig. 12. — Case X. Fracture of the right radius.
be removed, the deformity corrected and the band-
ages reapplied.
Subsequent treatment: Where the Roentgen ray
shows no displacement the bandages should not be
removed until the end of ten days. At this time
the bandages are cut laterally, so that there are two
parts — an anterior and a posterior — which subse-
quently can be used as anterior and posterior
splints. Passive movements of the wrist, combined
with pronation and supination, are now begun.
Care must be taken to avoid displacement of the
fragments. For one week passive movements and
massage should be given every other day. After
this week has elapsed the anterior splint is dis-
pensed with and massage, passive and active move-
ments of the wrist and fingers given daily. At the
end of the third week the posterior splint is dis-
pensed with and the forearm supported in a sling
for a few days, when this is discontinued and grad-
ual use of the limb is permitted. Where marked
edema and pain remained, baking and persistent
massage usually overcame them.
The entire treatment averaged three weeks and
the majority of the patients were discharged with
no stiffness in the fingers or wrist. There was no
atrophy of the thenar muscles, which atrophy we
have found in a number of cases sent to us for
treatment to overcome the weakness and stiffness
of the wrist and fingers. To facilitate early return
to the normal, we recommend that the limb be im-
mersed first in hot water for ten minutes, then in
cold water for three minutes, followed by massage,
using olive oil while massaging. This is to be
given twice daily.
Shaft of the ulna. There were five cases. Most
of them were at the middle of the shaft and were
caused by direct violence.
Shaft of the radius. There were twenty cases
of this type, most occurring at the middle of the
shaft, the result of direct violence (see Fig. 17).
Fractures of both bones of the forearm. There
were a few of these cases that presented a fracture
of the shaft of both bones, the site generally being
about the center of the shafts. The vast majority
were lower down, about an inch above the articular
surfaces of the wrist. The former were generally
the result of direct trauma, while the latter variety
was a result of a fall upon the outstretched palm
of the hand. Figs. 13, 14, 15, and 16 illustrate the
fractures of both bones, low down, and middle of
shafts, respectively. The report of one of these
cases follows:
Case XL — Milton F., six years of age. One day be-
fore coming to our clinic he fell, striking upon the out-
stretched palm of his left hand.
Examination: Swelling, ecchymosis, deformity and
crepitus at the lower part of the left forearm. Distinct
tenderness over the lower part of the radius and ulna
about three quarters of an inch above the articular sur-
face. There was absolute loss of function in the wrist
joint.
Diagnosis: Fracture of both bones of the forearm,
confirmed by a subsequent Roentgen ray picture (Figs.
13 and 14).
Treatment: As the treatment of fractures of the
shaft of the ulna, radius, and both bones are the
same it will be discussed under one heading. After
reduction of the deformity, if one is present, apply
a plaster of paris bandage extending from the mid-
dle of the arm above to the metacarpophalangeal
joints below, leaving the fingers unconfined. The
elbow should be held at right angles and the fore-
arm midway between pronation and supination.
The patient should be encouraged to exercise the
fingers actively from the very first.
Subsequent traeatment: This dressing is re-
tained for ten days, at the end of which time it is
divided laterally, so as to form anterior and pos-
terior splints. These are removed and passive
movements and massage to the fingers, wrist, and
x I Fn
low down.
rture of both bones of the forearm
Anteroposterior view.
elbow begun, care being taken to avoid displace-
ment of the fragments. This massage and passive
movements are to be repeated every' other day for
one week. After that every day, for about a week,
active movements and Exercises being gradually
July 8, 1916]
MEDICAL RECORD.
59
added. The splints are gradually discarded and
the patient permitted to assume his normal duties.
A few words about the management of fracture
of the shaft of both bones. There are two impor-
tant points to remember in the treatment of these
fractures.
are impossible. Fusion of fractured ends can be
avoided by preventing all lateral pressure on the
bones after proper coaptation. To be successful one
must obtain proper reduction and proper immo-
bilization. A pad between the shafts of the two
bones is unnecessary as it could not separate the
bone ends without exerting injurious pressure on
the circulation.
The treatment of fracture of both bones low
down, as far as the dressing and subsequent treat-
ment are concerned, is the same as that for fracture
of the lower end of the radius alone. They have
been described fully under fracture of the radius.
Fractures of the Leg. — Shaft of the tibia. There
were five such cases in our series. All were of the
intraperiosteal variety, being the result of direct
violence. Before coming to our clinic they were
treated as contusions. The cardinal signs of frac-
ture, namely, deformity, crepitus, and false mobil-
ity, were not present. Ecchymosis was slight and
Fig. 14. — Case XI. Lateral view. Note the lateral dis-
placement of the fragments.
1. Ununited fractures of the radius are fairly
common, undoubtedly on account of improper fixa-
tion of the elbow, movements of pronation anc?
supination being insufficiently guarded against.
.
*3o
Fig. 15. — Case XII. Fracture of both bones of the forearm.
Lateral view. Note the deformity.
2. There is a tendency for the four fractured
surfaces to be drawn toward one another and union
may take place between them with complete loss of
pronation and supination. This can be avoided by
fixing the forearm so that pronation and supination
Fir., lfi. — Case XII. Anteroposterior view.
appeared late, hence it was of little value in making
an early diagnosis. The diagnosis was made by
tracing a line of maximum tenderness. There was
no loss of function in any of these cases, all having
walked to the clinic with very little difficulty, the
only complaint being of a slight pain when bearing
the body weight on the injured limb and there was
also a slight limp.
Treatment: The treatment consists of the ap-
plication of circular plaster of paris bandages, ex-
tending from the base of the toes to just below the
knees. After ten days the bandages are removed
and passive movements of the ankle begun. The
limb is then replaced in the bandages, which are
removed daily thereafter for massage and passive
movements. After four days the bandages are dis-
continued and active movements are instituted.
These active movements are continued until the
normal function of the limb is restored, which is
usually within a week.
60
MEDICAL RECORD.
[July 8, 1916
Fracture of the fibula. There were five cases in
our series. One was of the linear type. The others
showed a fracture of the lower end of the fibula; in
some cases with a displacement backward of the
foot. The fibula was fractured from an inch to an
Fig. it.
-Case XIII. Fracture of the shaft of the radius.
Anteroposterior view.
inch and a half above the base of the malleolus,
complicated in some of the cases, with a tearing
away of the internal lateral ligament and the mal-
leolus (Pott's Fracture).
Treatment: It is very important to obtain a very
accurate reduction, followed by proper retention.
Where possible, an anesthetic should be used. After
proper reduction the limb should be fixed with the
foot firmly inverted. This is best accomplished
by means of a circular plaster of paris bandage ex-
tending from the ball of the toes to a point just be-
low the knee.
We begin massage and passive movements early,
and in that way we obviate the possibility of stiff-
ness of the ankle. Owing to the readiness with
which displacement recurs, the greatest care must
be taken to fix the fragments while the joint is
moved.
After about two weeks the plaster of paris band-
ages are cut laterally so that they can be used as
anterior and posterior splints. Massage and pas-
sive movements are then begun. The limb is then
replaced in the splints, which are removed daily so
that massage and passive movements can be given.
After one week of this treatment active movements
are gradually added. The massage, passive and
active movements should be given for three weeks
before the patient is permitted to bear the body
weight on the injured limb. If the body weight is
borne too soon, the strain may produce a persistent
condition of valgus.
It is a good plan after the patient is permitted
to walk, to prescribe shoes with an eighth to a
quarter of an inch lift on the inner side of the sole
and heel. This shoe is similar to the one which we
prescribe for weak feet and has proven of value in
the subsequent treatment of Pott's fractures. These
shoes are made for us by Mr. Max Deutsch of this
city.
Where through faulty treatment a persistent
valgus results and where the valgus is not overcome
by the shoe alone, it may be necessary to supple-
ment the shoe with strapping and later with a
Whitman brace.
The patient should not be discharged until all
movements in the ankle joint are free and painless.
This is usually about six weeks after the onset of
the injury.
Summary and Conclusioyis. — 1. In treating frac-
tures in children and infants one must always bear
in mind the tender skin of the infant, its round
agile body, and the movable cover of fat which en-
velopes the soft bones.
2. The tendency to heal is much more intense in
children than in adults, the time of union is much
FIG. IS. — Case XIII. Lateral view. Note the deformity.
shorter, and immobilization should be of shorter
duration.
3. A certain percentage of fractures in children
do exist with the cardinal signs of fracture lacking,
the diagnosis being made in these cases by tracing
the point or line of pencil or maximum bone ten-
derness.
4. Where following an injury children refuse for
any length of time to use a limb, especially if their
attention is distracted from the injury, or when
they are at play, bear in mind the possibility of a
fracture.
5. One must always bear in mind the necessity of
proper retention, as it is just as important as proper
reduction in securing favorable results.
6. Early massage, passive and active movements
are very important adjuncts in securing satisfac-
tory results.
7. I wish to express my indebtedness to Dr. Sam-
uel Kleinberg for his kind suggestions, and Dr.
Jacob Bower for the Roentgen ray pictures.
1051 Boston Road.
July 8, 1916J
MEDICAL RECORD.
61
WOMAN'S DUTY IN THE ANTITUBERCU-
LOSIS CRUSADE.*
By S. ADOLPHUS KNOPF, M.D.,
NEW YORK.
PROFESSOR OP MEDICINE, DEPARTMENT OF PHTHISIOTHERAPY, AT
THE NEW YORK POST-GRADUATE MEDICAL SCHOOL AND HOS-
PITAL : SENIOR VISITING PHYSICIAN TO THE RIVERSIDE
HOSPITAL-SANATORIUM FOR THE CONSUMPTIVE POOR
OF THE HEALTH DEPARTMENT OF THE CITY OF
NEW Y'ORK.
It is not an easy task to say in fifteen minutes what
can be done in the antituberculosis crusade by the
woman, poor or rich, married or single, young in
years and experience, or rich in experience but
young in heart, because her sympathies go out to
her suffering sisters and brethren. I have, there-
fore, written down what I have to say so as not to
overstep the time limit and so as to express at least
the essential part of what I have in mind on this
subject.
Every American woman should know that her
sex does not disbar her from exercising the best
qualities as a worker for the common good. Al-
though she is not as yet privileged in all our States
to have a direct voice in making the laws, she is
required to obey. Her duty in the combat of tuber-
culosis, the disease of the masses, is primarily to
acquire knowledge; secondarily, to use this knowl-
edge for the prevention of the disease, and, thirdly,
to render whatever personal service she can for
both prevention and cure. She should know that in
spite of all our efforts we are still losing annually
well-nigh 200,000 people from tuberculosis in the
United States; that of these nearly 50,000 are
tuberculous children, and these children, figuring
their average length of life at 7% years and their
cost to the community as only $200 per annum,
represent a loss of $75,000,000. Such children have
died without having been able to give any return
to their parents and the community. Besides all
this, many a tuberculous mother has had her life
shortened because she bore one of these children.
The annual economic loss caused by the death of
150,000 adults, most of whom have died between the
ages of 15 and 45, when their earning capacity
should have been greatest, in addition to their
maintenance during their years of illness, amounts
to about $900,000,000 annually. Every woman
should know that in spite of the great prevalence
of the disease, and this fearful death rate, tuber-
culosis has been declared again and again by the
highest medical authorities to be preventable and
curable.
Women can help in the prevention of the disease
by bearing in mind that although it is very rarely
directly inherited, the tuberculous parent nearly
always transmits to his or her offspring a weak-
ness, a physiological poverty, which predisposes
the children not only to tuberculosis but also to
other diseases, particularly those of infancy and
childhood. When in addition to its inherited weak-
ness the child is exposed to close contact with the
tuberculous father or mother, postnatal infection
is sure to follow. For a tuberculous person in the
active stage of the disease to kiss a child or to ex-
pose it to the spray ejected during a coughing
spell (droplet infection) ; to have the child use the
same spoon or cup used by a tuberculous individual
before these utensils have been thoroughly cleaned ;
to expose the child to the inhalation of tubercle
*Read by invitation before the General Federation
of Women's Clubs, at their Biennial Conference in New
York City, Mav 30, 1916.
bacilli laden air, that is to say, to the inhalation of
tubercuous dust coming from the dried and pul-
verized matter coughed up by the consumptive; or
to feed the child milk from tuberculous cows, are
some of the many ways by which the child born
free from disease may surely become tuberculous.
What can women do to overcome these sources of
infection? One thing is not to marry when actively
tuberculous or in danger of becoming so, and not
to marry a tuberculous man. If tuberculosis de-
velops in either parent after marriage they should
seek the advice of a competent physician, for if
birth control ever has a raison d'etre, it seems to
me that it is when the parents are actively tuber-
culous, and particularly the mother; for in such
instances prophylaxis not only means the preven-
tion of a child coming to this world destined to in-
validism, but it also means the saving of the life of
the mother who so often succumbs as the result of
the strain of the child-bearing period when she is
herself afflicted with tuberculosis.
If there are already children in the family, they
can be protected by scrupulous care and may re-
main healthy and strong. This care must consist
not only in avoiding the above-mentioned source
of infection, but by developing the child into a
physically strong being which can resist the inva-
sion of the tubercle bacillus. The mother should
make an open-air baby of each of her children, feed
them carefully and plentifully, keep their skin
scrupulously clean, following the warm bath for the
babies with a rapid rubbing with her hands dipped
in cold water. The open-air kindergarten and the
open-air school are the only proper places to edu-
cate a child predisposed or exposed to tuberculosis.
Teach such a child breathing exercises; do not
bundle it up, but dress it comfortably according
to the season. At the time the girl grows into
womanhood do not compress the organs in the
chest and abdomen by tight lacing. It goes without
saying that the mother, in no matter what station
of life she may move, should also dress sensibly, and
never again wear the trailing skirt which collected
from the sidewalk tuberculous sputum and dirt con-
taining the germs of diphtheria, pneumonia, and
consumption, to be later on deposited on the car-
pets of the children's playroom.
A child born with a tuberculous predisposition
should always sleep, if not in the open, at least in
a window-tent or in a bed moved near the open
window. Mother and teacher must watch such a
child, and for that matter all children, to see that
they do not overdo in physical and mental exercises.
Our boards of education — and you women should
always be represented on such boards — should see
to it that the mental training of our children is not
carried on to an extent to impair their healthy,
vigorous physical development. To my mind in
many schools there are too many useless studies,
too much cramming, too much homework, and
not enough play, outdoor life, and outdoor instruc-
tion. Let singing, recitation, geology, botany,
and physical training alike for boys and girls,
weather permitting, be carried out always in the
open, and last but not least let the open-air school
become the rule and the indoor school be the ex-
ception— at least for the lower grades. You would
be surprised how much less tuberculosis, and other
infectious and communicable diseases of childhood,
we would have among children and how much bet-
ter they would be prepared for civic and, if neces-
sary, for military duty, and how much higher type
62
MKDICAL RECORD.
(July 8, 1916
of American men and women this change in our
old-fashioned curriculum in the public schools
would bring about.
Besides individual and family hygiene, outdoor
life, and physical training, we must also have
hygienic factories, workshops, stores, and offices,
and must prevent overwork and malnutrition. It is
obvious that these reforms must be obtained
through legislation. But, alas! woman is as yet
not a legislator. Nevertheless, you women of in-
fluence and power can do a great deal even before
you are legislators. Make your influence felt so
that dark bedrooms, congestion, overcrowding in
cities and country, unsanitary workshops and
sweatshop shall be done away with. Oppose with
all your might that curse of child life known as
child labor, which is still permitted in many States,
be it said to the disgrace of our nation. Do not
patronize industrial concerns when you know that
their policy is to underpay and grind down your
unfortunate sisters and brethren.
Our great Surgeon-General W. C. Gorgas was
recently asked what he regarded the most impor-
tant health sermon he could think of. I know that
I cannot honor my illustrious friend, teacher, and
superior officer better than by quoting before this
distinguished assembly of American women his ex-
act answer to this question: "I believe that all
health officers should turn their attention to those
measures which would tend to increase the wages
of the poorest class of laborers. I favor that, as
one of the basic cures of existing health evils, be-
cause it will have the effect of producing more thor-
oughly good sanitation than any more direct meas-
ures they adopt. How can the laborer earning
$500 a year learn the benefits of good sanitation?
He and his family must sleep in one little squalid
room; the wife must cook and wash and the family
must eat in the other room. It does not matter
how much you would teach the process of sanita-
tion, nor how much learning they receive on the
subject of preserving health and preventing disease,
it wouldn't do any good, because he hasn't the
facilities to carry them out. But give him a better
wage, so that he can add another room and re-
move the congestion and the breathing of the whole
family in one sleeping room, and then you go to the
very foundation of the health problem."
There is little for me to add to this message ex-
cept to say that it should have been addressed not
only to the health officers but to all physicians; not
only to them but to all the men and women of the
nation. Let me say in passing, and I believe I do
not violate any confidence by making the statement,
that our dear Major General Gorgas is a single
taxer and I, too. consider myself an humble dis-
ciple of "Saint" Henry George. Higher wages, bet-
ter feeding, and better housing will do away with
much disease and misery. I venture to say that it
will even help to combat alcoholism, for let it be
remembered that the overcrowded, underfed, and
badly housed laborer often seeks comfort and con-
solation in the cup so that he may forget his
misery. But even as things are now, a great deal
can be done by those of you who really wish to help
in the prevention of both the direct and indirect
causes of tuberculosis. The underfed school chil-
dren should be able to purchase a substantial lunch-
eon which can be furnished for very little cost;
paying even ever so little for it will prevent pauper-
ization.
Besides seeing that the underfed children re-
ceive at least one good meal while attending school
we should provide also more playgrounds, small
parks, and breathing places for them. Where land
is expensive, as, for example, in our great City of
New York, there are the thousands of acres of
roofs that could be transformed into playgrounds
and breathing places for children and tired-out
mothers. Multiply public baths and see to it that
swimming is made a part of the curriculum of
every school and catastrophes like the Slocum dis-
aster of twelve years ago will be accompanied by
less loss of lives. See to it that more comfort sta-
tions are installed in our great cities.
Now, as a last word, what can you do toward the
cure of the disease? Bear in mind that although
I have said tuberculosis is curable, it is not curable
in all stages. It is when the disease is recognized
in the early stages that the tuberculous patient
has the best possible chance of recovery. Let every
mother remember the early symptoms : a long-con-
tinued cough, loss of flesh, a little fever in the after-
noon, a little chill in the morning, frequent hoarse-
ness, easy tiring, great susceptibility to catching
colds, increased irritability, little streaks of blood
in the sputum. These symptoms are often indica-
tive of an approaching pulmonary tuberculosis.
When in addition to some of these symptoms, even
if no cough is present, you notice swelling of the
glands or joints, lameness or difficulty in walking,
running of ears, frequent nasal catarrhs, flabby
skin, a general anemic appearance and pain on
pressure over enlarged joint, the child is probably
suffering from a local tuberculosis. Early discovery
and timely and judicious treatment may prevent the
child from becoming a cripple for life.
Any one, father, mother, relative, or friend,
noticing the just mentioned symptoms in any indi-
vidual, should endeavor to bring about a careful
examination which may be the saving of a valuable
life.
What else can the woman of power, wealth, and
influence do in any community toward the cure of
a tuberculous patient? Aid the community, in
which there are not sufficient tuberculosis dispen-
saries, special hospitals, preventoria, and sanatoria
for tuberculous adults and children, to establish
these institutions and see that they are well
equipped, well managed, and the patients well taken
care of. There should be no uncared-for tuber-
culous patient in any civilized community. The un-
trained and uncared-for tuberculous individual,
whether he lives in a palace or in a tenement house,
in a first-class hotel or a lodging house, will consti-
tute a center of infection. There are not nearly
enough institutions for the care of the tuberculous
in the majority of our cities and towns. Melbourne
in Australia has given us the example by the com-
munity taking care of all tuberculous patients who
cannot be or are not properly taken care of at home,
and by enforcing all reasonable, humane, and sani-
tary precautions to prevent the further spread of
tuberculosis. This disease, heretofore considered
the most prevalent ami most fatal, the City of Mel-
bourne has succeeded in eradicating. Of course.
Australia is a country where woman does not reign
supreme, but where she is the equal of man. She
labors and works for the good of the community
side by side with man. I hail the day when her
position in this country will be the same. But in
the meantime she can do much by promoting all
movements which tend to better the condition of
the child and her less fortunate sister, the woman
July 8, 1916]
MEDICAL RECORD.
63
of the laboring class, and thus help both directly
and indirectly in the combat of tuberculosis.
I have only been able to give you some hints as
to how you can help. But I am aware that you are
all familiar with the opportunity for service which
is offered in almost every field of human endeavor
to the woman who truly wishes to be helpful. One
of our greatest philanthropists, a man who has given
away millions for the betterment of his kind, the
venerable Andrew Carnegie's favorite saying is,
"Service to man is the highest service to God.'"
To modify this for the occasion, I would wish
to say that the service which the modern woman,
that is to say, the woman of highest ideals,
imbued with the greatest desire for service to her
fellows, is destined to render to mankind, is noth-
ing less than the salvation of the human race.
Woman once in the council of city and State, there
will be less social injustice, disease, and pestilence;
woman once in the council of nations, there will be,
it is hoped, no more desolation and no more war.
16 West Ninety-fifth Street.
THE REQUIREMENTS OF THE GONOCOCCUS
FOR ITS NATURAL AND ARTIFICIAL
GROWTH.
By LEVERETT DALE BRISTOL. B.S., M.D.,
UNIVERSITY, N. D.
PROFESSOR OF BACTF.RIOLOGY, UNIVERSITY OF NORTH DAKOTA ; DI-
RECTOR OF THE STATE PUBLIC HEALTH LABORATORIES.
The successful growth of the gonococcus on arti-
ficial culture media is one of the most uncertain
procedures with which the average bacteriologist
has to deal. A few men, after careful study of the
subject, have had uniform results in obtaining
scanty growth on special media. Carrying out the
directions of these men, others have had little or
no success. From this it would seem that some
variation must exist in the different food ingredi-
ents as well as in the environmental influences re-
commended as necessary for the artificial growth
of the organism; and that up to the present time
we have found no medium which may be used by
all investigators with satisfactory results. Be-
cause of the present demand for complement fixa-
tion tests and vaccines, as well as a necessity for
further study of the organism itself, a uniformly
successful growth of the gonococcus is absolutely
essential.
This paper is based upon preliminary work which
has been done in an endeavor to answer the fol-
lowing questions:
A. Why should the gonococcus grow so rapidly
and abundantly in the human urethra, and on other
mucous membranes of the body, and not at all in
the test tube on ordinary media, and only fairly
well on special media?
B. What is the essential constituent of the hu-
man body which is necessary for the growth of the
gonococcus?
C. How can we best take advantage of this
necessary material in artificial media?
The subject is divided; the first part dealing
with the requirements of the gonococcus for its
natural growth, while the second part has to do
with the requirements of this organnism for its
artificial development outside the body.
No extended discussion is necessary as to the re-
quirements for the natural growth of this diplo-
coccus. It is common knowledge that the mucous
membranes of man or woman are the sites of pre-
dilection for the development of the gonococcus.
The mucous membranes of the male and female
genitals and their adnexa are the ones usually in-
volved, although in rare instances gonococcus in-
fection has been noted on the membranes of the
mouth, nose, ear, conjunctiva and rectum. The in-
fection is common, also, as a secondary process in
joints and tendons. The organism in the human
body, as is demonstrated by its prodigious growth,
finds what it needs in regard to moisture, uniform
temperature, proper chemical reaction, and specific
food substances. As regards the environmental
conditions of light, temperature, reaction and mois-
ture, the gonococcus should find what it needs in
the lower animals, with the possible exception that
the normal temperature of some animals may run
from one to three degress (centigrade) higher than
that of man. Growth of the gonococcus and typical
gonorrhoea have practically never been found in
the genitals of lower animals, as a result of nat-
ural infection or artificial inoculation. It hardly
seems reasonable that the slightly higher tempera-
ture in these animals is sufficient to always in-
hibit the growth of the gonococcus. It is evident
that the important thing which the gonococcus
needs for its growth and multiplication is probably
a specific food substance, and that this is present
in the human body but absent from or in a differ-
ent form in the body of lower animals. The only
other explanation is that there exists in the lower
animals some substance, or substances, of a meta-
bolic nature which antagonize and inhibit the gono-
coccus in its growth, and that these substances do
not exist in the human body.
Of the principal food substances which occur in
the human body upon which bacteria may thrive,
there is none more important than protein material.
We know that a certain amount of protein is neces-
sary in artificial media for the growth of most
microorganisms. Bacteria seem to differ as to the
kind of protein required. Most organisms are not
concerned over the special quality of protein needed
and will grow with simple proteins from various
sources as food. A few bacteria seem to require
something more than simple protein. It appears
that the chief food substance which the gonococcus
requires is protein in nature, that this protein is
more complex than simple protein, and that it has
special qualities characteristic of man and not of
lower animals. (The study of precipitation reac-
tions has demonstrated that there are definite bio-
chemical variations between even the same proteins
of man and of lower animals.)
According to recent classification, proteins may
be divided into three groups: (1) Simple proteins;
(2) conjugated proteins; (3) derived proteins.
Members of the first group are always found in the
body as constituents of muscles and blood serum,
and tissues in general. Conjugated proteins are
more complex and consist of a combination of pro-
tein and a non-protein substance. Combinations of
protein with a carbohydrate or its derivatives are
known as glucoproteins, or glycoproteins. Nucleo-
proteins are combinations of protein and nucleic
acid. The other conjugated protein of importance
is hemoglobin, a combination of globin and hemo-
chromogen, the latter being an iron-containing sub-
stance. The third group, or derived proteins, we
will not here consider.
It will be noted that the conjugated proteins are
characteristic of certain localities and tissues of
the body, while the simple proteins are much more
general in their distribution throughout the body
64
MEDICAL RECOR'D.
[July 8, 1916
tissues and cells. It has been found also that there
are specific differences between the conjugated pro-
teins of man and lower animals, as well as between
the simple proteins of man and animals.
Let us fix our attention on the exact localities
where the gonococci grow in the human body. The
mucous membrane is the best soil, and membranes
upon which the larger mucous glands open is the
best field, while small areas surrounding the open-
ings of these glands, or even inside the glands, are
the spots where these gonococci grow the most
luxuriantly and persist for the longest time.
Gonococcus infection may be classified under two
heads: (1) Primary; (2) secondary. Primary in-
fection is almost always confined to the mucous
membranes which open to the external surface of
the body, such as the urethra in the male, the vulva,
urethra, vagina in the female, and the conjunctiva,
rectum, mouth, nose, and ear in both sexes. As a
rule infection takes place by direct contact of the
diseased mucous membrane, and its infectious se-
cretions, with an uninfected mucous membrane.
Secondary infection is spread by either (a) direct
continuity of mucous surfaces and direct exten-
sion to other tissues and organs (a more or less
localized process), or (b) a general systemic infec-
tion. It should be mentioned that the usual sites
of primary infection may be involved in a secondary
way. Cowperitis, prostatitis, epididymitis, in the
male; Bartholinitis, metritis, salpingitis, ovaritis,
peritonitis, in the female; periurethral abscess,
cystitis, and nephritis, in both sexes, are illustra-
tions of the first group of secondary infections,
while septicemia, pyemia, endocarditis, and ar-
thritis are examples of systemic infection.
What specific substance in the body, common to
all these localities, serves the gonococcus for its
growth? It has been stated above that this sub-
stance is probably protein in character. What pro-
tein is characteristic of epithelial mucous mem-
brane and glands (as well as of their secretion,
mucous) and is present in variable amounts in con-
nective tissue (as found in tendons), and in carti-
lage (as found in joints), as well as in blood and
synovial fluid? Although other proteins are pres-
ent, it seems to the writer after a careful study of
the subject that human glycoproteins, especially
the human mucins and related compounds, are the
specific substances which the gonococcus requires
for its growth in the body. As mentioned above,
the glycoproteins belong to the class of conjugated
proteins and have a protein group and a non-protein
group, the latter being a carbohydrate or a deriva-
tive of a carbohydrate. This carbohydrate com-
pound was the first to be isolated from an animal
tissue and is called "glueosamin." It is a nitrogen-
containing derivative of dextrose. Of these glyco-
proteins, the mucins and mucoids are the most im-
portant for our consideration.
The mucins and mucoids are acid in character,
contain no phosphorus, have a low carbon and nitro-
gen content, a high percentage of oxygen due to the
carbohydrate group, and an increased amount of
sulphur. The amount of carbohydrate may vary to
a great extent. Unlike most of the other proteins
the mucins and mucoids are not coagulated by heat.
They may be precipitated by acetic acid and are
only slightly soluble in an excess of acid. True
mucins are derived from epithelium, while mucoids
are derived from connective tissue. "True mucins
are found." as Mann says, "in most of the slimy
fluids of the body. They are excreted by the gob'et
cells on the surface of mucous membranes and by
the larger mucous glands which are found in dif-
ferent parts of the body." Besides its presence in
the secretions of the above-mentioned cells and
glands, mucin is found in bile and a so-called
"pseudomucin" is found in ovarian cyst contents.
This pseudomucin differs from true mucin in not
being precipitated by acetic acid. Of the connective
tissue mucins, or so-called "mucoids," the ones
which most resemble true mucin, are the mucoid
in tendons, the "osseomucoid" in bones, the "chon-
dromucoid" in cartilage, and the mucoids of the
cornea, vitreous humor, and umbilical cord. Em-
bryonic and young connective tissues in general
have rather high percentages of mucoid substances.
The white of egg contains a considerable amount
of a glycoprotein called "ovimucoid." A mucoid
is also found in human blood serum and urine. In-
vestigators have found variable amounts of mucoid
in ascitic, hydrocele, and synovial fluids, and have
given to it the name "serosamucin."
Is it not of considerable significance that where
mucins and mucoids are present in greatest amount
there we find the gonococcus thriving the best? Is
it not because of the mucin or mucoid present that
the gonoccoccus grows readily on mucous mem-
branes (especially in the genital tract where addi-
tional large mucous glands are found), as well as
on the conjunctiva, cornea, and vagina in infants
(where cells are greater in number and connective
tissue is still more or less mucoid in character),
and in tendons, cartilage, and synovial fluid?
Now that the theoretical requirements of the
gonococcus for its natural growth in the human
body have been considered, let us proceed to a brief
discussion of the practical requirements for its
growth in artificial media.
It is a fact that the gonococcus will not multiply
in our ordinary culture media which contain sim-
ple animal proteins, and that our best artificial cul-
ture media for this diplococcus are largely composed
of those human fluids, such as ascitic, cystic, or
hydrocele fluids, blood-serum, or urine, in which
these human mucoid substances, of the conjugated
protein group, are found to a greater or lesser ex-
tent. Another suggestive fact is that by adding
glucose to any medium its value as a soil for the
growth of the gonococcus is considerably enhanced.
We have already stated that a carbohydrate, glueo-
samin, is characteristic of mucins. Even egg-white,
which contains considerable ovimucoid, has been
used by investigators with some success in growing
this micrococcus.
Like other bacteria, the gonococcus requires a
certain amount of moisture for its proper develop-
ment. Its resistance to drying, as well as to light,
variations in tempeature, and other external con-
ditions, is rather less than that of most bacteria.
Authorities differ as to the extremes of tempera-
ture which the gonococcus may stand. The tem-
perature of the body is probably the best for its
growth. The upper extreme is generally given as
anywhere from 38° C. to 42° C, while the lower
extreme varies from 25° C. to 30a C, according to
different workers. Most bacteria require a neutral
or slightly alkaline reaction in artificial media. A
few seem to grow best in an acid medium. Varied
advice concerning the best reaction for the gono-
coccus is met with, although the consensus of opin-
ion seems to indicate that a slightly acid react inn
to phenolphthalein. or a neutral or faintly alkaline
reaction to litmus is the most desirable.
July 8, 1916]
MEDICAL RECORD.
65
To determine further the value of human mucins
and mucoids as specific food substances for the
gonococcus, the writer has been carrying on pre-
liminary experiments, using human umbilical cords
as the source of human mucin for artificial media.
So far as the work has gone, the results are en-
couraging, though not complete enough for publica-
tion at this time.
ESOPHAGEAL STRICTURE.
By HENRY FRENCH GOODWIN. M.D..
AND
CHESTER HENRY KEOGH, M.D.,
CHICAGO. ILL.
A CASE of impassable stricture (esophageal), re-
ported in the Journal A. M. A. April 15, 1916, pre-
ceded by the caption "of interest because of the age
. . . and the medical things devised in the case,
which may be of help to others," leads us to report
the following case.
The case we present is not unknown to the staffs
of Wesley Memorial Hospital, of the Children's
Memorial Hospital, of the Charity Hospital, and of
the Chicago Postgraduate Hospital, where the pa-
tient received treatment. The case, after recovery,
was presented before the South Side Branch of the
Chicago Medical Society some years ago. The pa-
tient is alive and in good health. In stature he is
not below the average for his age.
Lawrence R., then aged three years, drank lye some
time during the summer of 1909. He was attended
by Dr. H. F. Goodwin during the month of January fol-
lowing and thereafter. Dr. A. B. Kanavel was then
brought into the case. He performed a gastrostomy.
Through the ventral opening the patient was fed liquid
food through a tube for many months, as the esophagus
had become impassable to all food solid or liquid. Even
colors in solution failed to appear in the stomach by
way of the stenosed esophagus. Men skilled in the
use of the esophagoscope were not successful in their
efforts to penetrate the stricture. Dr. Goodwin then
invited Dr. Keogh to join him in the case as his col-
league, and together they went to work to try and
save the little patient.
The child was given an anesthetic. Failing with
other methods, a Fenger flexible sound was passed by
one of us through the adventitious opening in the
stomach, through the cardiac opening and up through
the stricture to the fauces. A silk thread was tied to
the tip of the sound and drawn down and out through
the opening in the stomach. This thread was kept in
situ, until a better substitute was found — one which a
child could not sever by biting — a piece of soft flexible
rubber-covered braided tinned copper wire, in caliber
about the size of wrapping twine. The Abbe saw was
not used. Knots and small spheres were drawn through
the stricture from below upward. Later, cylinders,
modified with hemispherical ends, were used. There
was some difficulty in slowly dilating the stricture by
this retrograde method. There was also considerable
difficulty in passing the dilator through, from above
downward by this traction, even after the stricture was
fairly well dilated, and upon the whalebone or flexible
shaft commonly used all of the so-called olive tips which
were tried, from above, failed to pass the stricture. It
is to explain the form of tip then used by us, with
success, that this article is written. These tips were
home-made, of brass, plated. The mechanics of the
idea will appeal to the good sense of anyone.
It had been shown by radiograph that a small di-
verticulum above the stricture possibly impeded the
progress of the olive-shaped tips of general usage. So
(me of us made a tip in the form of a simple cylinder.
Upon a flexible shaft, from above, this made a tri-
umphal journey through the stricture to the stomach
and back again. After that the conduct of the case was
quite simple. The gastrostomy opening was allowed
to heal by granulation. From time to time, for several
months, the stricture was dilated. During the treat-
ment we used oxychloride of bismuth and olive oil.
At no time was the treatment severe enough to cause
the child discomfort. He learned to swallow the
cylinder fastened to a flexible shaft — a Fenger flexible
exploring sound was made to fit the purpose — the
cylinder passed on down to the stricture. Then a piece
of piano wire was slipped into the lumen of the sound
and the cylinder was gently forced through the stricture.
A pointed olive tip seeks the posterior wall of
the esophagus and probably engages the cul-de-sac
of a diverticulum ; while a cylinder, of proper size,
will pass through a stricture complicated by a small
diverticulum, for the reason that a cylinder
throughout its length has a bearing surface upon
the posterior wall of the esophagus and tends to
maintain its axis parallel to that of the esophagus.
The literature is replete with cases of esophageal
stricture. Perhaps the reports of Guisez in the
French literature are as complete as one would wish
to find, though the complete record of such cases is
not without value. Guisez had reported, at the time
this case was presented before the medical society,
thirty-five cases. Of these, twenty-eight strictures
were the result of caustics. The ages of his pa-
tients varied from twenty-one months to sixty-four
years.
"Electrolysis Circulaire" was his favorite method
of treatment, which, as far as we know, is not ex-
tensively practised in this country. Twenty-eight
of his reported cases were complete recoveries.
fi021 WOODLAWN AVENTE.
4346 Drexel Boulevard.
REPORT OF A CASE OF ADIPOSIS
DOLOROSA.
By CHARLES M. NICE. M.D.,
BIRMINGHAM, ALA.
PHYSICIAN TO THE BIRMINGHAM INFIRMART.
The following case seems worthy of a brief report.
S. T., a country girl, single, aged twenty-two, accus-
tomed to general housework.
She had always been robust, but at the age of sixteen
gradually took on an increase in weight. At this time
she began to have pain in the abdomen similar to that
she now complains of. She was taken to a hospital and
operated upon for gallstones and appendicitis. She had
the usual diseases of childhood. She is the oldest of six
children, all of whom are living. There was a vague
rheumatic and tubercular history on the paternal side
and a nervous history on the maternal side. Specific
history could not be ascertained.
She had been confined to her bed for six months previ-
ous to her admission in January, 1916, to my service
in the infirmary. She refused to try to sit up or work.
Her mental condition did not allow any expressions
other than pain, which she complained of day and night,
and at all times referring to her left abdomen. Her
sleep was of short duration only and she moaned almost
constantly. She refused to eat except in very modest
amounts of liquids. She would not talk.
On examination she showed a ruddy complexion and
an extreme degree of adiposity. This fat was evenly
distributed over the body, but hanging in huge folds on
either side of the abdomen, thighs, and arms. Her
weight was 262 pounds, height 5 feet, 3 inches. Her
head was constantly turned to the right side. The eyes
showd a marked exophthalmus with Stellwag's sign.
The teeth were covered with sordes and her tongue was
badly coated and breath foul. No enlargement was made
out of the thyroid, neither could there be of any other
glands.
Her abdomen showed a large scar from the appendical
region nearly to the costal margin. Nothing could be
felt through the enormous fat layers which were as
tumefactions on each side of the abdomen. On the -left
side she complained of pain on the lightest palpa-
tion. Another obvious change in her appearance was
due to the adiposity of her hands and feet, greatly en-
larging their size and giving them a fan-shape appear-
66
MEDICAL RECORD.
[July 8, 1916;
ance and especially enlarging and flattening their distal
ends.
The heart and lungs were negative. Vaginal exami-
nations showed no abnormality of the sexual organs.
The reflexes in the lower extremities were depressed.
She appeared to have full motor power, but refused to
use it, even in an effort to move herself in bed, lying
always in the same position. Some soreness was com-
plained of when pressure was made over the deep
nerves. Her blood-pressure was normal. The urinary
excretion was not increased and examination of it was
negative.
The temperature was 98.5° in the mornings; 99.6° in
the afternoons. The pulse varied from 80 to 96 and was
regular. Hemoglobin was 75 per cent., white blood
cells, 6,000; polymorphonuclear, 73 per cent.; small
lymphocytes 18 per cent., large 9 per cent.; eosino-
philes, 2 per cent.; malaria negative. Skiagraphs of
her head did not reveal anything that could be inter-
preted as a tumor or abnormality. Wassermann and
luetin reactions were negative.
When the diagnosis of adiposis dolorosa had been
made she was given increasing doses of thyroid ex-
tract, but without effect. Opiates at times were resorted
to. She was fed only by forcing.
After a time she was given daily doses of pituitary
extract hypodermically. Improvement began by the end
of the first week. The mental apathy was seen grad-
ually to disappear, the exophthalmus became less and
lesssevere, her pain was moderated, the tongue cleared,
and she began to eat with a fair appetite.
No other medication except necessary purgatives were
given and in two weeks she began to walk. At the
expiration of the seventh week she left my care, at
which time she complained of no pain.
Suggestions were given her home physician to con-
tinue the treatment and later advices received from him
inform us that she has gradually decreased in size,
works as a normal girl, and her mental condition has
greatly improved.
This case is reported because of the possibility
that she may have been operated upon six years pre-
viously for the same conditions which she has re-
cently had, namely; adiposis dolorosa with the cus-
tomary painful fatty tumors (Dercum's) and that
there were no gallstones or appendicitis as supposed.
Again there was a close relationship between the
thyroid and pituitary gland as evidenced by the
physical findings.
Finally, the administration of pituitary extract
gave almost immediate and continuous improve-
ment until the present, but the future outcome, of
course, is questionable.
Woodward Building.
Insufficient Evidence of Malpractice in Treating
Fractured Arm. — In an action for malpractice, it ap-
peared that on January 25, 1911, the ulna of the plain-
tiff's right arm was broken by the kick of a horse.
After receiving emrgency treatment he placed himself
in the defendant's care. The negligence claimed was
that owing to the defendant's lack of care and skill,
the fractured bone failed to unite, and also that he
failed to discover that the radius was dislocated at
that time or later during the treatment. On January
26, after an examination of the fractured arm with a
fluoroscope, the defendant set the arm, using splints
to retain the broken bone in place. On the following
day he discovered that it would be necessary to wire
the fractured ends of the bone and had the plaintiff go
to a hospital, where the operation of wiring was per-
formed by the defendant. After the operation, the de-
fendant dressed, bandaged, and otherwise treated the
arm until March 29, when the plaintiff consulted an-
other doctor. Dr. Rowley. The plaintiff's evidence was
to the effect that Dr. Rowley found a dislocation of the
radius; that, there had been no union of the fractured
bones; that the wire used in scouring it had broken,
and that pus had developed in the wound, all of which
conditions, except the formation of pus in the wound,
were indicated by an X-ray photograph of the plain-
tiff's arm taken on that date. At this time the plaintiff
placed himself in the care of Dr. Rowley, who treated
the injured arm until about May 1, when he and Dr.
Lewis operated by cutting off the head of the radiusr
declared necessary in order to reduce the dislocation,
and reset and wired the fractured bone, which, how-
ever, as under the defendant's treatment, from some
cause unknown to Drs. Rowley and Lewis and contrary
to their expectations, failed to unite. This evidence
merely showed what the defendant did professionally,
but there was no evidence that there had been a want
of ordinary care on the defendant's part. Not only
so, but the evidence of both Dr. Rowley and Dr. Lewis,
who were the only witnesses called for the plaintiff
competent to testify whether the defendant had exer-
cised reasonable care and skill, was to the effect that
the nature of the fracture was such as to demand the
wiring of the bone, and that the wire used was such
as surgeons generally used in such cases; that in oper-
ating upon the fracture they used like wire, which like-
wise broke in the adjusting.
No evidence was offered showing that, if the dislo-
cation of the elbow existed at the time the defendant
undertook the treatment of the fractured arm, the de-
fendant was negligent in failing to discover it. So far
as appeared, he was called upon to set the fractured
bone. No intimation was given him of injury to the
elbow. Whether or not he should, under the circum-
stances, in the exercise of ordinary and reasonable care
and skill, have discovered such condition, assuming it
to have existed, was a question for expert testimony,
and none was offered. Conceding that Dr. Rowley, as
stated by him, had no difficulty on March 29 in discov-
ering the dislocation, nevertheless this fact did not
show a want of ordinary care and skill on the part of
the defendant in failing to discover it, since Dr. Rowley,
by reason of superior learning and advantages, may
have been a man possessing far more than ordinary
skill in his profession.
It was held by the court that the evidence wholly
failed to show any lack of care and skill on the Dart
of the defendant in setting and treating the fractured
bone of the plaintiff's arm, and also failed to show when
the dislocation occurred, or that a physician in the ex-
ercise of ordinary care and skill, in treating the plain-
tiff, should under the circumstances shown, have discov-
ered the dislocation and treated it. — Houghton v. Dick-
son (Cal.) 155 Pac. 128.
Chiropractors Must Be Licensed. — A chiropractor held
himself out as being able by adjusting the bodies of his
patients to enable them to throw off disease, but sedu-
lously refrained from calling his operations treatments,
and notified his patients that he was not a doctor or phy-
sician. Texas Penal Code, 1911, Article 750, declares
that it shall be unlawful for anyone to practise medicine
in any of its branches upon human beings who has not
registered in the district clerk's office of the county in
which the resides his license for so practising, while Ar-
ticle 753 declares that any person shall be regarded as
practising medicine who shall publicly profess to be a
physician or surgeon, or shall treat or offer to treat,
any disease or disorder, mental or physical, by any sys-
tem or method, or to effect cures thereof, and charges,
directly or indirectly, money or other compensation.
The Texas Court of Criminal Appeals held that the ac-
cused, who collected fees for his adjustments, not hav-
ing procured the required license, was guilty of prac-
tising medicine without a license. — Teem v. State (Tex.)
183 S. W. 1144.
Evidence in Malpractice Cases. — The plaintiff in an
action against a surgeon for negligence in unsuccessful-
ly grafting skin to an empty eye socket for the purpose
of permitting the use of an artificial eye, has the burden
of proving that the operation was negligently and un-
skillfully performed. A verdict for the defendant was
hold to be sustained by evidence that twenty-four year?
before a similar operation had proved unsuccessful, as
did also two other operations which had been performed
after that of the defendant.— Nye vs. Clark, 193 111.
App. 505.
Liability of Charitable Hospitals. — In Pennsylvania
the law is well settled that a charitable hospital for the
care and treatment of the diseased and injured and it-
trustees charged with the management thereof are not
liable for the negligence of a nurse in administering poi
son to a patient by mistake, the nurse not being incom-
petent, nor the corporation or its officers negligent in
selecting her. This doctrine seems to be in harmony
with the decisions in the federal courts. — Paterlini v
Memorial Hospital Assn. of Monongahela Citv. 229 Fed.
838.
July 8, 1916]
MEDICAL RECORD.
67
Medical Record.
A Weekly Journal of Medicine and Surgery.
THOMAS L. STEDMAN, A.M., M.D., Editor.
PUBLISHERS
WM. WOOD &. CO., 51 FIFTH AVENUE.
See fourth page following reading matter for Rates of Subscription
and Information for Contributors and Subscribers.
New York, July 8, 1916.
ACUTE ANTERIOR POLIOMYELITIS.
The present rather serious epidemic of acute an-
terior poliomyelitis in this city again calls atten-
tion to our ignorance regarding the nature and
mode of spread of this scourge of childhood. The
disease, although its causative agency is not known,
behaves very much like an acute infectious disease,
and, indeed, it is almost universally accepted that
it is of germ origin. Inoculation experiments car-
ried out by many workers, by Flexner and Lewis
of the Rockefeller Institute and others, have been
successful in passing the disease to animals, but
not in finding the organism. It probably belongs
to a class of organisms, as yet unidentified, that
pass through the ordinary filter media.
At one time it was believed by many that this
disease is a fly-borne one, and that the large biting
stable-fly is the offending insect. It would seem that
in large cities the stable would be a negligible fac-
tor, but in the congested centers it can play quite a
part as a general nuisance and a menace to health.
It is more probable, however, that the ordinary
house fly is the culprit, yet against this is the fact
that the prevalence of the disease is not wholly con-
fined to fly time. Suspicion has also, and with some
reason, been directed 'against the flea. A more
plausible theory than that of the biting fly, and one
that does not exclude the agency at times of the
house fly, is that the disease is spread in the same
way as influenza or common colds, for it is known
that the pathogenic agent is contained in the nasal
secretions of the sick.
The high morbidity and the disastrous effects of
poliomyelitis certainly demand that every precau-
tion against its spread be taken, and therefore
among other things the regulations covering the
management of stables should be made very strin-
gent. In view, however, of the more probable
means of infection, it is very proper to consider and
to treat the disease with respect to quarantine and
isolation in the same way as the other acute infec-
tions of childhood, and this holds even though in-
stances of apparently direct contagion are rare. The
assemblage of children in epidemic localities has
been discouraged or forbidden, and although this
with the closing of moving picture shows to children
doubtless seems cruel to them, in face of the danger
now threatening nothing that has been done to con-
serve the public safety can be accounted too harsh.
The amount of infection or even the exact foci of
infection are difficult to determine because many of
the cases are believed to be abortive without para-
lytic symptoms, or so slight as to escape detection.
On the other hand, there is little doubt that many
cases of ordinary convulsions in children are diag-
nosed, in times of epidemic, as infantile paralysis in
the so-called preparalytic stage, and so the preval-
ence of the disease is made to appear greater than
it really is.
The amount of paralysis that will remain perma-
nently after an attack of acute poliomyelitis is hard
to estimate. There is usually a great deal of re-
pair, but it is often spread over a long period, even
as long as two years. Even in apparently paralyzed
muscles, if they retain their faradic irritability to
but a slight degree, there is hope of recovery under
proper treatment. A great deal of harm is often
done by commencing irritative treatment, such as
massage and electrical stimulation, too early, that is
during the acute stage of the disease. Later this
treatment must be carried out relentlessly. Even
when the paralysis is permanent the physician can
now hold out a good deal of hope if there are nearby
muscles that are intact. Transplantation of ten-
dons, so that the healthy muscles can do the work
of the paralyzed ones, is an advance in surgery that
has come to stay and will help to mitigate the evil
of infantile paralysis.
THE PARATHYROIDS.
About one year ago (May, 1915) Eugene H. Pool
contributed, as the "Collective Review" in the In-
ternational Abstract of Surgery, a summary of what
was then known regarding the anatomy and physi-
olog of the parathyroids, their relation to tetany,
and the therapeutic measures, experimental and
otherwise, which had been employed in tetany para-
thyreopriva. In view of the disappointing results
following medical treatment and homotransplanta-
tion in tetany parathyreopriva. Pool strongly em-
phasized the necessity of giving these structures as
wide a berth as possible when operating upon the
thyroid. A second publication on this subject ap-
peared in the Annals of Surgery for January, 1916,
in a paper by Pool and H. C. Falk entitled "The
Surgical Anatomy of the Thyroid with Special
Reference to the Parathyroid Glands."
In the earlier years of operation for goiter, when
the function of the thyroid was very imperfectly
understood and that of the parathyroids not even
suspected, removal of both lateral lobes of the thy-
roid at the same sitting was not infrequently prac-
tised, and this was sometimes followed by the
gradual development of myxedema, occasionally by
acute or chronic tetany. Cachexia strumipriva and
tetany were for a long time regarded as different
phases of but one condition — a condition which was
supposed to be dependent upon insufficiency of the
thyroid function. Although the normal gross an-
atomy and histology of the parathyroids were accu-
rately described by Sandstroem in 1880, their
physiological significance* was not appreciated until
Gley, in 1891, demonslrttfesbiheir relation to tetany.
While, normally, the&te-aire ftfar. parathyroids, occur-
ring in pairs, it has long been known that this
68
MEDICAL RECORD.
[July 8, 1916
number and arrangement are inconstant. Careful
examinations at autopsy have sometimes shown a
smaller number, but for reasons which will appear
later it is certain that when less than two have
been discovered some have been overlooked or the
individual has had aberrant parathyroids. Recog-
nition of the parathyroid glandules, none too easy
at autopsy, is still more difficult under the condi-
tions that obtain at operation ; and there are many
operators of large experience in this class of sur-
gery who do not hesitate to say that they have never
been able positively to identify parathyroids as such
while operating.
Under these circumstances, therefore, it is essen-
tial that the manifold relations of these bodies
to the lateral lobes of the thyroid be thoroughly
understood by the operator. In recent years, since
the relation of the parathyroids to the develop-
ment of tetany has been definitely shown, operators
have generally endeavored to avoid them; or, if
malignant involvement of the thyroid or other con-
ditions have made it necessary to disregard the
danger of removing the parathyroids in relation to
one lobe, special pains have been taken to preserve
those on the opposite side when operation upon the
other lateral lobe was necessary. Then the only
parathyroids the individual possesses may be in
relation with the lobe that is being operated upon ;
since it is usually difficult, if not actually impos-
sible, to identify these structures in the course of
operation, their safety can be secured only by leav-
ing a slice of the posterior portion of the thyroid
substance. In case of the removal of the para-
thyroids in relation with the thyroid lobes tetany
will result unless the individual is so fortunate as
to possess aberrant parathyroids. If but one para-
thyroid is left the development of tetany is prob-
able; for Iversen's analysis of the cases of human
tetany apparently showed that at least two para-
thyroids are, as a rule, essential.
Why is it that so many cases of tetania parathy-
reopriva have been reported in spite of the fact that
practically all surgeons are well aware of this dan-
ger? The studies of Pool and Falk throw consider-
able light upon this question. Under what has been
considered normal conditions the parathyroids are
sufficiently removed from the thyroid substance so
that when a lateral lobe of the thyroid is enucleated
in accordance with the usual method (splitting tha
surgical capsule anteriorly and shelling out the
lobe within this, meanwhile keeping strictly to the
line of cleavage of the true capsule during this
process) the parathyroids remain attached to the
surgical capsule or are even posterior to this, in
which latter case they should not come within the
field of operation at all. So far as Pool and Falk's
series of autopsy sections was concerned this happy
state of affairs existed in less than 50 per cent, of
the cases. In their studies the tissues of the neck
anterior to the spine were removed at autopsy in
twenty-five cases. The tissues were cut trans-
versely in thin layers and a search was made for
the parathyroid glands. As i/ustrating the diffi-
culty in identifying these bodies i- should be stated
that these were not cases of goiter, hence the num-
ber and relations of the parathyroids may be con-
sidered representative; yet in spite of extreme care
but 60 parathyroids were found out of a theoretical
100.
But it was the situation of those found with
reference to the surgical capsule that is of espe-
cial interest to the surgeon. The sixty parathy-
roids found were grouped as regards their relation
with the thyroid and its surgical capsule as fol-
lows: Twenty-six, or 43.3 per cent., lay external to
the surgical capsule at sufficient distance from the
thyroid to be safeguarded in an intracapsular ex-
tirpation of the lobe. Nine, or 15 per cent., were
so situated in relation to the capsule as to make it
doubtful whether they would be saved in an intra-
capsular removal of the lobe. Twenty-five, or 41.7
per cent., were in such a position that they would
almost certainly have been removed with the thy-
roid in an intracapsular extirpation. In the case of
unilateral intracapsular removal of the left lobe,
this examination showed that two parathyroids
would have been sacrificed twice and two would
probably have been sacrificed twice; in the case of
the right lobe two parathyroids would have been
sacrificed twice and two would probably have been
sacrificed once. Thus the operation of unilateral
intracapsular lobectomy is attended with a risk that
two parathyroids will be removed in 8 per cent., or
in 14 per cent, if the doubtful cases are included.
They also found that in intracapsular removal of
both lobes four parathyroids would have been sacri-
ficed in 4 per cent, of the cases ; four would very
probably have been sacrificed in 8 per cent., and
four would have been at least endangered in 12 per
cent.
Among the authors' conclusions are that the rela-
tion of the parathyroids to the thyroid and its cap-
sule is not of necessity the same for the whole set
of parathyroids in an individual. Also that since
usually two parathyroids lie on each side, and inas-
much as two parathyroids apparently can satisfy
the demands of the body, the chance that tetany
will develop as the result of extirpation of one lobe
is extremely remote. It is reasonably safe, there-
fore, so far as tetany is concerned, to perform com-
plete intracapsular extirpation of one lobe. It is,
however, emphasized that for the prevention of
tetany the posterior part of the lateral lobe must
always be left on at least one side; and even when
only one lobe is operated upon safety is better
assured by leaving in situ the posterior part of
that lobe.
STILL ROOM FOR IMPROVEMENT IN THE
TRAINING OF NURSES.
In the dark ages of medicine the chief instruction
students received was what they were able to absorb
from daily contact from a physician whom they ar-
companied on his rounds. Later lectures and clinics
were added where the students were brought into
touch with the practice of medicine as illustrated by
varying personalities. That was yesterday; to-day
he hears lectures for four years, the latter two of
which he also attends clinics and then frequently
takes a year or two in a hospital. To-morrow he will
have a five years' course, the last of which will be
almost wholly clinical, and following this he will be
July 8, 1916|
MEDICAL RECORD.
G9
obliged to spend at least one year in a reputable
general hospital before he is allowed to practice his
profession.
With this increase of efficiency in the training of
physicians will come, we hope, more enlightened
methods of fitting nurses for their profession. The
theory at present seems to be analogous to that
held by the parents who advocate throwing babies
into the water where they must either swim or
drown. The probationer steps from school or
counter, or whatever sphere has engaged her ac-
tivity, into the hospital, dons her uniform and rub-
ber heels, the patients are there, ill, requiring nurs-
ing, and she must nurse them forthwith, and often
the experienced nurse who is supposed to be her
preceptress hurries through a few perfunctory di-
rections to her and hastens away to duties of her
own. The bewildered probationer, left to her own
devices, potters about and usually avoids making
mistakes by doing nothing. A few days later she
is left alone on the ward for a while, the resident
physician enters, orders an alcohol sponge and is
astonished when she tells him she has not the least
idea how to give it. Or she is left in charge of a
typhoid patient who complains of a severe pain in
the abdomen but, fearful of disturbing the doctor
unnecessarily, she makes no report of it.
The above is purposely put in a somewhat height-
ened manner. In many hospitals a sincere effort is
made to give instructions in the elementals of nurs-
ing before trusting a pupil to her own resources
and in many cases the probationer is of a type
which assimilates the details almost instinctively
and displays a knowledge amounting to intuition in
emergencies.
It would seem that a course of lectures and dem-
onstrations should be given to a prospective nurse
before she is allowed to enter the wards, instead of
some time after. The powers of the superintendent
of nurses are usually much too arbitrary, moreover.
It may happen that a probationer is dropped at the
end of a few months at the pleasure of the head
nurse who often acts largely on the reports of
nurses in charge of wards, some of whom may not
have been in training themselves longer than a
year. With such a system it is easy to see how
personal animus or lack of patience with a beginner
may terminate abruptly a career which would other-
wise be successful. We all know successful doctors
who showed no great promise in their student days.
Following such a course of lectures there should
be a carefully graded series of instructions in the
wards by experienced nurses and these should follow
each other in such a logical sequence that there
would be no danger of the nurse being left to exe-
cute duties which were beyond the stage of her
training.
The nurse having been graduated, the next de-
sirable step would be the universal adoption of
laws which prevail in some States, that is, in regard
to registration. No nurse should be allowed to
practise until she has passed an examination by a
State licensing board comprising both theoretical
and practical nursing. After the system sketched
above had been in operation for a few years we
would find an R. N. as significant in its wav as an
M. D.
A PLEA FOR PURISM IN MEDICAL WRITINGS.
With his characteristic love for contention, Dr.
Charles A. Mercier, the distinguished English psy-
chiatrist, has again cast his hat into the ring. In
a letter to the British Medical Journal for May 20,
he assails vigorously the style of the average medical
writer, who, he claims, shows an extreme paucity
of vocabulary together with a lack of accuracy in
the use of words. By way of illustration he quotes
a recent article in which "marked" or "markedly"
was used twelve times in ten lines. This is of course
inexcusably tautological, but Dr. Mercier seems to
wish to exclude this unfortunate adjective entirely,
whereas it may be used quite properly to denote
anything which is noticeable, conspicuous, or em-
phasized in any way. He also objects to a patient
"developing" a disease and, strictly speaking, he is
right, although medical custom seems to sanction
the use of the word in this sense, but when he says
that " 'to develop' is not, except in photography, a
transitive verb," he is contradicted by Webster who
gives seven applications of "to develop" as a tran-
sitive verb. Dr. Mercier couches his argument in
his usual vigorous style, using such expressions as
"shockingly overworked," "vile travesty of English,"
and "repulsive jargon."
As a matter of fact, while here and there we find
instances of inaccuracies or inelegancies of style i»
medical writing we are practically never at a loss
to decide what the writer meant to convey and that,
after all, is the principal requirement of this kind
of literature. It does not seem that a report on the
result of a thousand typhoid vaccinations for ex-
ample should be judged by the same criteria which
we would apply to an essay in the Atlantic Monthly.
A medical article is valuable if it adds something to
our knowledge of disease and is not expected to be
a well of pure English undefiled. Now and then
we are fortunate enough to have writers who can
combine medical worth with elegance of diction, as
witness Oliver Wendell Holmes, S. Weir Mitchell,
and G. Stanley Hall.
Whatever be the merits of the question raised
by Dr. Mercier, who is probably not appreciated at
his true value by his colleages in England, it is
sure to set medical writers to self-examination and
even surer to arouse a storm of protest. In fact
the issue of the British Medical Journal for May 27,
which has just come to hand, contains two letters,
one taking exception to all the points made by Dr.
Mercier, as well as indicting his taste in the matter,
and the second one in the main commendatory, but
accusing him of that unpardonable crime of mis-
quotation.
The Cup That Cheers.
Among the incidental matters which are tossed
about like uneasy corks upon the stormy waves of
international affairs in Europe since the war began,
the subject of alcohol is agitated now and then. Ger-
many goes on her way serenely consuming her beer,
Russia is vodkaless, France has restricted the
heavier liquors, and England is betwixt and be-
tween. The "rum ration" still exists although many
a wordy battle has been fought over it, but two
blows have been dealt the home liquor traffic — the
70
MEDICAL RECORD.
[July 8, 1916
abolition of treating and the limiting of the hours
when liquor may be sold. Everyone reacts to alco-
hol according to his individual psychology even if
we cannot all portray our reactions as vividly as
Jack London does in "John Barleycorn." Certainly
the optimistic way to look at it is as M. C. Fies-
singer does. In a recent address before the Acad-
emy of Medicine in Paris he stated that wine ac-
tivates the internal secretions, stimulates the as-
sociation of ideas, and excites the affective states.
He says that among the moderate wine drinkers
mental originality is more constantly renewed and
impulses of the heart and active goodness are more
often in evidence. He believes that the happy
genius of the French mind is due to their national
beverage. Dr. Fiessinger's eulogy was taken excep-
tion to by some other members of the Academy,
notably MM. Linossier and de Fleury, and probably
would not be accepted unqualifiedly here. It is true
that the effect normally produced at the time of the
ingestion of alcohol is somewhat as he describes, but
it seems to be rather a question of temporary
paralysis of inhibitions and we are all too familiar
with the pathology of alcoholism to endorse the
effervescence of our French colleague.
know it may occur without hemeralopia; but in
most of the cases occurring in soldiers both condi-
tions exist in the same subject. The night blindness
is much the greater military disqualification because
a soldier is unfit for patrolling or sentry work, and
becomes fearful of a surprise.
Success of Pasteur Treatment of Rabies in the
Lyons District.
In contrast with the defective results reported from
certain Pasteur institutes throughout the world, the
failures being set down to causes beyond control, not
a patient treated in the Lyons Institute during
1913-14 was lost. The total number treated was
723. Of this number 122 received the intensive
treatment. In 446 cases the animals were proved to
have rabies, while in 277 the existence of the latter
was only suspected. The report made by Dr. Ro-
chaix in the Journal de physiologie et de pathologie
< < nerale, which was published only last April al-
though bearing the date September 15, 1915, con-
tains no comments and few control figures. A clean
score has been the rule, and but 8 patients have died
since the treatment was begun in 1900. In 1912
there were 2 deaths. The morbidity shows a dis-
tinct drop in June, while in August it seems at its
minimum. It is highest in the short month of Feb-
ruary, the antithesis of August. The biting animal
was a cat in 32 cases and a cow in 1 ; in all other
cases a dog.
Nyctalopia in Soldiers.
The European war has brought to light the exist-
ence of nyctalopia in the troops, most of which is
doubtless acquired. It seems to be largely a transi-
tory state due to fatigue or nervous depression.
The condition is frequent, about 10 per cent, suffer-
ing. The highest incidence is in the winter months
when the nights are longest. Some cases are con-
genital while others seem dependent on trench life.
Anomalies of refraction frequently coexist. No doubt
the physical fatigue, nervous tension, and moral
disquiet play a causal role. The treatment consists
in correcting anomalies of refraction, and the use
of tinted glasses. The men also improve under rest
and variety of diet. The above data are taken from
an article by Weekers the Belgian ophthalmologist,
in the Archives d'ophthalmologie, March-April,
1916. The author and others state that the condi-
tion is a new one in military medicine. Day vision
suffers but night vision more so. Nyctalopia as we
•DfemB of tip? Iw k.
Base Hospitals Promised. — As announced last
week, the New York Red Cross now has eight base
hospitals ready for service whenever they may
be called for and wherever they may be required
to go. The Red Cross has also taken charge of
the Border Hospital at Brownsville, Tex., and has
appealed for funds to enlarge, equip, and maintain
it. This hospital, which was established for the
care of the American troops patrolling the border,
treated 350 patients during 1915. many of them
wounded Mexicans. It consists at present of only
a few frame cottages without the necessary equip-
ment.
The New York State Department of Health,
through Dr. A. B. Wadsworth, director of the divi-
sion of laboratories and research, has placed its
facilities at the service of the State military au-
thorities. If it is desired, the laboratory will ship
to the surgeon of each regiment and other units in
the field, boxes containing typhoid vaccine and
serums for tetanus, diphtheria, and spinal men-
ingitis. The department has also offered to send a
bacteriologist to the State mobilization camp for
the making of diagnoses in the field.
Deaths in New York City. — The Department of
Health announces that for the week ending June 24
the death rate in New York City was 12.24, repre-
senting a total of 1,311 deaths, as compared with
a rate of 12.22 for the corresponding week of last
year, when the total number of deaths was 1,277.
Twelve deaths due to infantile paralysis were re-
ported, eleven of them occurring in the Borough of
Brooklyn, in certain sections of which the disease is
epidemic. The other contagious diseases showed a
decreased mortality ; and in the deaths due to pul-
monary tuberculosis a very appreciable decrease oc-
curred, though this was to some extent offset by
the increase in the deaths reported from other
tuberculous diseases. Owing to the inclement
weather during the week there was an increase in
the number of deaths due to bronchitis, and the
mortality of the degenerative diseases also was in-
creased. The death rate for the first twenty-six
weeks of 1916 was 14.82, as compared with 15.10
for the first half of 1915.
Poliomyelitis Still on Increase. — Up to July 5
there had been reported to the Department of
Health 623 cases of poliomyelitis, of which about
75 were in Manhattan, 3 in the Bronx, 5 in Queens,
8 in Richmond, and the remainder in Brooklyn. One
hundred and thirty-four deaths have occurred since
the first of the year, almost all of them during the
last three weeks, giving a mortality of over 20 per
cent., which is nearly four times as high as during
the epidemic of 1907. Of the deaths, all except two
were of children under ten years of age. The Com-
missioner of Health has enlisted the help of the po-
lice, street cleaning, and tenement house depart-
ments in fighting the epidemic, the police to check
violations of the sanitary code in the infected dis-
tricts, the street cleaners to pay special attention
to the streets therein, and the tenement house in-
July 8, 1916J
MEDICAL RECORD.
71
spectors to keep watch of the houses in which cases
have been reported. Placards written in English,
Italian, and Yiddish have been printed and posted
in certain parts of the city, giving warning of the
danger of infection. The Commissioner also has
the aid of the staff of the Rockefeller Institute, Dr.
Simon Flexner having addressed a meeting of
Brooklyn physicians at the Polhemus Clinic on July
1, and both he and Dr. H. L. Amoss having con-
ferred with the members of the Department of
Health. As a result of a meeting held at the office
of the Commissioner on June 30, the following or-
ders were sent out:
"All patients must be removed to hospitals
where the conditions of the home are not equal to
those found in the most modern hospitals. These
conditions must include absolute isolation, perfect
cleanliness, a special nurse who must not come in
contact with other members of the family, sun-
shine and fresh air.
"For those whose homes cannot afford these
facilities special pavilions have been set aside in
hospitals in each borough. In Brooklyn is the
Kingston Avenue Hospital, where there are now
forty patients; in Manhattan is the Willard Parker
Hospital, foot of East Sixteenth Street. A pavilion
has been set aside on North Brother Island for The
Bronx and a pavilion of the magnificent new
Queensboro Hospital at Jamaica for Queens."
The origin of the epidemic has not been de-
termined, but as the first cases occurred among the
Italians in the dock district of South Brooklyn, it
is possible that the disease may have been imported
from Italy. A special watch is being kept at Quar-
antine, but no cases have been discovered.
Open New Hospital. — The Queensboro Hospital,
representing the result of years of effort on the part
of the New York City Department of Health to pro-
vide adequate facilities for patients ill with con-
tagious disease in the Borough of Queens, was
•opened on June 28, with Dr. Charles T. Sharp as
resident physician. The hospital has accommoda-
tions for eighty patients, and has been built at a
cost of $76,000. Several interesting features have
been embodied in the construction. The ground
floor of the south wing, for instance, contains
twenty separate rooms, each opening both on a cen-
tral corridor and on a porch running around the
building. These rooms constitute "The Sieve," and
in them will be kept for two weeks all patients en-
tering the hospital, especially when there is any
doubt as to the diagnosis or as to the existence of
a complicating infection. For "The Sieve" there
is a separate diet kitchen and nurses' room, and by
an ingenious placing of windows all the patients are
under the constant observation of the nurse. The
ground floor of the north wing contains three wards
with a capacity of twenty beds, to be devoted to
diphtheria, scarlet fever, and measles, and the sec-
ond floor of the building contains two wards in each
wing, as well as a small operating room, nurses'
room, etc. The third floor contains the dormitories
for the nurses and employees. A notable feature
of the wards is the introduction of glass partitions
between the beds to prevent the reinfection of con-
valescent patients.
Dispensary Fellowships. — The Harvard Medical
School has recently established four fellowships to
be awarded to graduates in medicine and to be
known as the Boston Dispensary Fellowships. The
duties of the Fellows will be to give a portion of
their time to clinical work in the district service of
the dispensary, treating the sick in their homes,
and a portion to such study, teaching, or laboratory,
research or clinical work as may be assigned by the
Medical School. The stipend of a Fellowship will
be $500 when the physician gives part time, or $750
when he devotes his entire time to the work. Ap-
pointments will be made jointly by the authorities
of the Medical School and of the Boston Dispensary,
and the application should be made to the Dean of
the Harvard Medical School, or to the Director of
the Boston Dispensary, Boston. The Fellowships
are open to the graduates of any medical school of
good standing who have had a hospital training or
its equivalent. Negotiations are now pending be-
tween the Boston Dispensary and the Tufts Medical
School with a view of making similar arrangements
for a Fellow for next year.
Medical School Prizes. — The Yale University
School of Medicine announced on June 17 the award
of prizes for the year as follows: The Ramsay
Scholarship, established in memory of Dr. Otto G.
Ramsay, and given to a member of the junior class
of unquestioned ability and character, to Harlan B.
Perrins of Seymour. The Parker Prize, left by Dr.
Frank J. Parker, for the fourth year medical stu-
dent who, in the judgment of the Faculty, has shown
the best qualifications for a successful practitioner,
to Lloyd L. Maurer of New Haven. The Perkins
Scholarship for the first year student making the
best record, to Clifton R. Scott of Bovina Center,
N. Y. The Campbell gold medal, in memory of
James Campbell, M.D., professor of diseases of
women and children from 1866 to 1899, given for
the highest rank in examinations during the course,
to Joseph Russo of New Haven. The Keese Prize,
in memory of Hobart Keese, M.D., for the best
thesis at graduation, to Louis H. Nahum of Hart-
ford.
Vacancies in Clinic. — There is an opportunity
for two assistants in the department of diseases of
digestion and metabolism at the German Polyclinic,
Second Avenue and Eighth Street, New York. Phy-
sicians who have had some chemical training are
preferred. The hours are from 2 to 4 P.M. on Tues-
days, Thursdays, and Saturdays. Application
should be made to Dr. A. I. Ringer at the German
Polyclinic.
Must Report Tuberculosis. — The Bureau of
Tuberculosis of the North Carolina State Board of
Health is calling the attention of the physicians in
the State to the law requiring them to report all
cases of tuberculosis under their charge to the Bu-
reau within seven days after the recognition of the
disease. It is estimated that at present only one-
third of the cases of tuberculosis in the State are
being reported, and since the Bureau can accomplish
nothing without the co-operation of the physicians
and the heads of institutions for the treatment of
the disease, it is prepared to enforce the law, even
by prosecution of the delinquents.
London Red Cross Fund. — A dispatch from Lon-
don states that the Red Cross fund of the London,
Times has reached a total of $20,000,000, the largest'
amount ever raised in such a campaign by a news-
paper.
Dies at 105. — Mrs. Mary Monroe of Binghamton,
N. Y., died at her home on June 28, after a short ill-
ness, at the age of 105 years and 8 months.
Street Accidents. — The National Highways Pro-
tective Association reports that during the month
of June, 44 persons were killed by vehicular traffic
on the streets of New York, 35 by automobiles, 2 by
72
MEDICAL RECORD.
[July 8, 1916
trolleys, and 7 by wagons. During the first six
months of this year, 152 persons were killed by
automobiles, as against 137 during the correspond-
ing period of 1915, while throughout the State, ex-
cluding New York City, 100 persons were killed in
the same way.
American Hospital Units. — A dispatch from Ber-
lin tells of the departure from that city of two
American surgical units which had recently arrived
there. One unit, under the charge of Dr. Paul F.
Martin of Indianapolis, Ind., has been sent to Buda-
pest, and the other, under Dr. John R. McDill of
Milwaukee, Wis., to Cologne. It is stated that the
units had to obtain in Berlin all the necessary sup-
plies with the exception of two dozen rubber gloves,
because the British Government refused to permit
the passage of their equipment through the block-
ade. The gloves alone were passed.
Pennsylvania Commencement. — At the 160th an-
nual commencement of the University of Pennsyl-
vania, held June 21, the degree of Doctor of Medi-
cine was conferred on seventy-three graduates. Dr.
Charles Karsner Mills, formerly professor, and
now emeritus professor, of neurology, received the
honorary degree of Doctor of Laws.
Dr. Fred H. Albee received the honorary degree
of doctor of science from the University of Ver-
mont, Burlington, at the 112th commencement of
the university on June 28.
Dr. S. Lewis Ziegler of Philadelphia has been
elected a member of the Board of Trustees of
Bucknell University.
Dr. Zinke Honored. — Dr. E. Gustave Zinke of
Cincinnati, who has recently resigned as professor
of obstetrics in the University of Cincinnati Col-
lege of Medicine, was the guest of honor at a dinner
given by his colleagues in the university and among
the profession in the city. Dr. Zinke was presented
with a silver loving cup.
Broad Street Hospital. — Dr. A. J. Barker Sav-
age has been appointed superintendent of the new
Broad Street Hospital, New York, and the follow-
ing physicians have been elected members of the
Board of Directors: Dr. John F. Erdmann, Dr. L. A'.
McClelland, Dr. George Gray Ward, Jr., Dr. Ralph
A. Stewart, Dr. Charles Gennerich, Dr. W. T. Hel-
muth, Dr. W. H. Crump, and Dr. W. H. Dieffenbach.
Gifts to Charities.— By the will of the late Mrs.
Helen C. Juilliard of New York, St. John's Guild
and St. Luke's Hospital of this city receive bequests
of $100,000 each, and the New York Orthopedic
Hospital and Dispensary a bequest of $50,000. In
addition, St. John's Guild receives a contingent in-
terest of one-half of a bequest of more than
$100,000, the latter to be used for an addition to the
hospital of the guild at New Dorp, Staten Island.
An additional gift of $165,000 to Mt. Sinai Hos-
pital, New York, was recently announced by Mr.
Isaac Guggenheim and his brothers, the gift supple-
menting their previous gifts of $500,000 for the
erection of a private pavilion to be known as the
Guggenheim Memorial. It will now be possible for
the hospital to erect a pavilion having accommoda-
tions for 122 private patients, making it the largest
building of the kind in the city.
By the will of the late Charles W. Kolb of Phila-
delphia, bequests are made of $100,000 each to the
Samaritan Hospital and to Temple University.
Obituary Notes. — Dr. Everett P. Courtright
of Newark, N. J., a graduate of Jefferson .Medical
College, Philadelphia, in 1890, formerly attending
physician to St. Michael's Hospital and the Foster
Home, Newark, and a member of the Medicai So-
ciety of New Jersey and the Essex County Medical
Society, died at his home on June 28, aged 49 years.
Dr. Rudolph Kindig of Philadelphia, a graduate
of the Philadelphia College of Pharmacy and of the
Jefferson Medical College, Philadelphia, in 1887,
and for twenty-five years physician to the Swiss
Benevolent Society, died at his home on June 17,
aged 51 years.
Dr. Thomas Kirkpatrick of Garnett, Kan., a
graduate of the University of Illinois, College of
Medicine, Chicago, in 1883, died at his home on
June 11, aged 58 years.
Dr. James Edward Leary of Lowell, Mass., a
graduate of the College of Physicians and Surgeons,
Baltimore, Md., in 1894, died suddenly at his home
on June 11, aged 43 years.
Dr. Thomas Walter Long of Newton, N. C, a
graduate of the New York University Medical Col-
lege, New York, in 1885, and a member of the Medi-
cal Society of the State of North Carolina, died re-
cently at his home, aged 58 years.
Dr. Joel H. Rieger of Kansas City, Mo., a grad-
uate of Columbia University, College of Physicians
and Surgeons, New York, in 1872, died at the Ger-
man Hospital, Kansas City, on June 14, after a
short illness, aged 66 years.
Dr. Joseph E. Caviness of Lillington, N. C, a
graduate of Baltimore University School of Medi-
cine in 1890, died at his home, after a long illness,
on June 15, aged 70 years.
Dr. Grafton W. Gardner of Atlanta, Ga., a
graduate of the Oglethorpe Medical College,
Savannah, in 1861, died at his home on June 19,
aged 86 years.
Dr. John T. Sweeny of Jeffersontown. Ky., a
graduate of the Hospital College of Medicine,
Louisville, in 1906, died at his home, after a long
illness, on June 16, aged 36 years.
Mr. Joseph Ferris, pharmacologist at Bellevue
Hospital for over twenty years, during which time
he compounded nearly 500,000 prescriptions, died
at the hospital on July 1 from cerebral hemorrhage.
(Obituary.
JULIUS HAYDEN WOODWARD, M.D.
NEW YORK.
Dr. Julius Hayden Woodward of New York, pro-
fessor of diseases of the eye at the New York
Post-Graduate Medical School since 1908, and di-
rector of instruction in ophthalmology since 1913,
died at his home on July 2, aged 58 years.
Dr. Woodward was born in Castleton. Yt., and
was graduated from Cornell University in 1879 and
from the College of Physicians and Surgeons, New-
York, in 1882, the same year receiving the degree
of doctor of medicine also from the University of
Vermont, College of Medicine. After practising
for some time in Burlington, Vt., and serving as
professor of laryngology, and later of ophthalmology
in the University of Vermont, he removed to New
York in 1897, where he had since lived. He was
a member of the New York Academy of Medicine.
the Medical Societies of the State and County of
New York, the Vermont State Medical Society, the
American Academy of Ophthalmology and Oto-
Laryngology, the American College of Surgeons, and
the Society of Alumni of Bellevue Hospital, and a
life member of the Societe francai.se d'ophthal-
mologie.
July 8, 1916]
MEDICAL RECORD.
13
POLIOMYELITIS IN BROOKLYN.
To the Editor of the Medical Record :
Sir: — Perhaps at no time within the present gen-
eration has there arisen such a state of public alarm
almost bordering on panic as in the case of the pres-
ent epidemic of poliomyelitis in Brooklyn. The
newspapers have published complete reports of the
distribution of cases and of the fatalities, and these
reports together with the placards posted and the
leaflets distributed by the Board of Health have
brought home to the population a keen sense of the
gravity of the situation. The deep concern of all
parents — indeed, of all people who are interested in
the well-being of children — is intensified by the fact
that the fatal or maiming blow of poliomyelitis does
not fall merely upon weak or neglected children but
strikes with almost equal force those who are ap-
parently in perfect health and are properly cared
for in sanitary homes.
Health Commissioner Emerson is to be com-
mended for the prompt and energetic manner in
which he has faced the present crisis. There can
be no question that the removal to an isolation hos-
pital of all cases that cannot be isolated at home, as
now enforced by the Health Department, is a wise
measure and the first important step necessary in
combating the spread of this disease. At the date
of writing there are about 200 cases of poliomyelitis
in the Kingston Avenue Hospital of Brooklyn, and
there is provision for 300 more. It is to be hoped
that the spread of this disease will be checked long
before the resources of the hospital are taxed to
their limit, but unfortunately, if we are to be guided
by past experience, the ravages of this disease will
not be spent until early fall. Before another month
New York will probably face the biggest problem
which it has had to solve during the fifty years of
existence of its Health Department, namely, the
problem of providing adequate hospital accommoda-
tions for its cases of infantile paralysis.
This brings one to the subject of health prepared-
ness, a timely one indeed, and one demanding of
municipal, State, and national authorities as much
attention as any other kind of preparedness. Here
comes an unseen foe creeping with insidious step
into hundreds of homes, killing and maiming the
most helpless. The public stands aghast and a
dozen or more health inspectors and a dozen or more
nurses are added to the forces already mobilized to
deal with preventable disease. The irony of the
situation requires no comment. If one were to cal-
culate the economic loss to the body politic occa-
sioned by the ultimate incapacity of and the care
for dependent cripples, he would find that the ap-
propriation by the city for emergency purposes to
meet the present situation of a sum of money far
less than the cost of a single superdreadnaught
would result in a substantial saving to the public
treasury. Although money cannot buy public health
any more than it can buy individual health there is
an indispensable financial outlay of considerable
magnitude required in the prosecution of all public
health campaigns. Would it be too much to ask
of the metropolis of the Western Hemisphere, in-
deed, of the richest city of the world, that it sum-
mon to its service at once the best sanitary talent
that it can command?
Among the distinguishing characters of the pres-
ent epidemic are the high degree of its virulence
and the atypical character of many of the cases. The
virulence is attested by the high mortality of 20 per
cent. Within a period of two weeks the writer has
seen four fatal cases. A striking illustration of the
high degree of infectivity of the virus in the pre-
vailing series of cases is afforded by the following
experience : There have come under the writer's ob-
servation in the Children's Medical Service of Dr.
Le Grand Kerr at the Methodist Episcopal Hospital
two of the three children of a family, all of whom
were infected with poliomyelitis about the same
time. The first child, a six-year-old boy, was ad-
mitted to the hospital on the third day of his ill-
ness, in coma, with widespread paralysis of the
limbs, trunk, and diaphragm. The case was one of
typical Landry's paralysis. Death occurred within
two hours. Two days later the sister of this child,
two years of age, was admitted in the preparalytic
stage of the disease. A widespread paralysis be-
gan on the second day following admission, involv-
ing all of the limbs and the muscles of the back of
the neck. The mode of progression of the paralysis
which began in the legs and then extended to the
arms and neck made us apprehensive that we were
dealing with another instance of the Landry type
of paralysis. Fortunately, however, the disease did
not extend to the respiratory muscles. The little
patient has survived the dangerous period of her
illness. It is impossible to state to what extent, if
any, the early diagnosis in the preparalytic stage
and the various protective and therapeutic measures
instituted may have served to prevent a lethal out-
come in this case. At any rate the results empha-
size the importance of making an early diagnosis.
About the time that this patient was admitted to
the hospital, the third child in this family, a boy
seven years old, was under the care of the family
physician at home. The prominent symptoms of
his illness were fever, hyperesthesia, and delirium.
Examination of the cerebrospinal fluid showed that
this was also a case of poliomyelitis. The patient
made a complete recovery without paralysis. This
was probably an instance of the abortive type of
the disease. The above series of cases constitute
an extremely rare, if not singular, instance in which
poliomyelitis has affected three members of a fam-
ily at the same time, and in which each case has
represented a different type of the disease.
There may be more than mere accidental sig-
nificance in the fact that, with possibly one excep-
tion, poliomyeltis has tended to prevail in New York
City in epidemic type every two years since the
great epidemic of 1907 with its 2,500 or more of
reported cases. It may be noted, in passing, that
the extensive Swedish epidemic so carefully studied
by Wickman occurred in 1905. There have been
outbreaks of this disease in New York City in 1909,
1911, and 1913, and according to this apparent law
of periodicity a return of this disease was to be ex-
pected in 1915. Although a number of cases were
reported in that year from various parts of the city
they did not constitute an epidemic.
The writer had the opportunity of studying at
close range seventeen out of a total of fifty-one
cases of poliomyelitis reported in the Borough of
Brooklyn from January 1 to December 1, 1911. Dur-
ing the same period there had been 171 cases re-
ported in the Borough of Manhattan. The epi-
demic was far less extensive than that of 1907, and
slightly less so than that of 1909. But the dis-
tribution of the Brooklyn cases and the circum-
stances attending them impart considerable inter-
74
MEDICAL RECORD
[July 8, 1911J
est to them, particularly with reference to the light
they throw upon our present experience with this
disease. It was noted on comparing the different
wards of the Borough in which the cases were re-
ported that the number of cases in each ward was
directly proportionate, not to the number of people
in the ward, but to the density of the population.
Another important fact brought out was the ob-
servation that the epidemic of 1911 practically
spared the 26th ward, a thickly populated district in
which the disease had prevailed extensively in 1909.
This accorded with the observation that had been
made in other epidemics in different parts of the
world, namely, that communities that are visited by
poliomyelitis in one epidemic are spared when the
disease returns to a city in epidemic form. Polio-
myelitis provides an instance of the epidemiological
law of community resistance or immunity. Accord-
ing to this law, during an epidemic there are a
large number of individuals who suffer from mild
or latent types of the disease to which they are
thereby rendered immune. In the present epidemic
of poliomyelitis in Brooklyn the disease is preva-
lent in a section of the Borough in which only a
few scattered cases occurred during the previous
visitations.
Alexander Spingarn, M.D.
623 WlLLOUGHBY AVENUE.
Brooklyn, N. Y.
PrngrraH nf HJeMral i>rmtrr.
Boston Medical and Surgical Journal.
June 22, 191fi.
1. Movements in Medicine. Annual Discourse Before the
Massachusetts Medical Society. David L. Edsall.
2. Respiratory Exchange, with a Description of a Respiratory
Apparatus for Clinical Use. Francis G. Benedict
3. Cholecystostomy vs. Cholecystectomy. F. B. Lund
4. Report of a Case of Sacroiliac Strain Following Sym-
physeotomy.
1. Movements in Medicine. — David L. Edsall in his
address discusses the altered relation of the medical
profession to the public at large. He says that as a
result medicine has become a much more complex pro-
fession, and a new and very important character has
been added to the calling. The doctor has always been
somewhat cloistered from the world of affairs, and, as a
consequence, he has often avoided, and even resented,
anything that interfered with his freedom of action ;
and this, together with the fact that there were few
positions of dignity open to medical men in which they
were parts of a system, or were subordinate to higher
authority, has made the general idea of being a part
of a machine moving in necessary coordination with
other parts usually distasteful. But the developments
of recent decades have shown beyond a peradventure
that the broadest and most beneficent activities of
medical men in preventing and eradicating disease
have in later times, and will continue to be, not indi-
vidual researches or individual struggles with disease,
but organized systems of attack, in which every one,
whether in senior or junior positions, will be no longer
a free lance but subordinate to the system, and de-
pendent upon it for his success. The character of the
medical profession is being everywhere more or less
profoundly influenced in another way. For many years
it was customary to adopt an attitude almost solely of
defense in dealing with disease. In recent times the
attitude has become aggressive, and there has been a
massive and organized attack upon the immediate causes
of disease that are most accessible. As a part of this
movement we are now considering compulsory sickness,
invalidism, and accident insurance. The financial side
of this matter unquestionably needs especial care in
this country, not only in its relation to physicians but
in its general aspects, and particularly in justice to
the insured, because our political morals are admittedly
looser in this country than in England or Germany.
One of the most successful ways of avoiding disagree-
ments is through not forcing regulations but agreeing
upon them; and the more largely arrangements are
made with medical men through friendly understand-
ings rather than as bargains, the more successful will
they be. It would greatly help in avoiding contention
and in establishing in wise form many of the details
of the system in which medical advice is highly impor-
tant, if the local medical men involved had direct rep-
resentation on the governing bodies of these insurance
companies if they come to be formed. Many other
factors are tending to make medicine more important
as a public profession, and relatively less so in a private
relation in its main activities and emoluments. There
is already a lessened demand for the family doctor be-
cause of the increasing control of infectious diseases.
The methods that have done so much for the control
of tuberculosis can do similar things in controlling the
effects of alcohol and venereal diseases. With a decided
drift toward the control of these enormously important
causes of disease, a large effect upon the sum total of
the doctor's repair work and upon his purely palliative
treatment must be exerted. As a result of these ten-
dencies the choice of a medical career, aside from the
direct care of the sick, no longer means a distinct shift-
ing of purpose and detachment of one's self from a
medical career. The changed point of view is largely
due to the change in the character of medical teaching
and the increasing complexity of the study and practice
of medicine. The higher standards have made many
men feel that the standards of practice do not meet
what they desire, and that in confining themselves to
private practice they are taking a step downward in
regard to thoroughness and accuracy of effort. This
was probably due to the chasm that existed between
the laboratory and the clinical branches of medicine.
In order to bring the laboratory and the clinic on more
intimate relations the essayist favors the plan of having
a group of clinical teachers who practice little or not at
all outside of hospitals.
3. Cholecjstostoniy vs. Cholecystectomy. — F. B.
Lund refers to the lack of agreement among men of
experience and skill as to the indications for cholecys-
tectomy. He reviews the recognized advantages of cho-
lecystostomy upon which surgeons are very well
agreed, and believes that cholecystectomy is indicated in
the following cases: 1. In cases of very thick, acutely
inflamed, bright-red, or gangrenous gall-bladders due
to impaction of a stone in the cystic duct. 2. In cases
of chemically thickened gall-bladders. Here the thick-
ened walls cannot contract and drive out the bile, so
that what bile gets back into the gall-bladder is sure
to stagnate there; after cholecystostomy, the walls do
not contract, so that we get a mucous sinus for a long
time or forever. 3. In cases of gall-bladders very
much distended with clear fluid from impaction of a
stone in the cystic duct. 4. Whenever suspicion ex-
ists of malignant disease. 5. In chronic cholecystitis
without stones, but with moderate thickening and ulcer-
ation of the mucous membrane, giving little yellow
spots on the mucous surfaces, the so-called "strawberry
gall-bladder." These do not get well without drainage.
6, In chronic cholecystitis without stones, but with
adhesions to the surrounding organs, especially the
pylorus, which cripple the latter and cause symptoms.
Here, also, drainage alone is only temporarily efficient.
The gall-bladders is a constant focus for low-grade in-
fections and adhesions, which will continue to form and
July 8.. 19161
MEDICAL RECORD.
75
perhaps to spread until its removal, all these processes
being attended with discomfort and invalidism to the
possessor of the organ.
4. Report of a Case of Sacroiliac Strain Following
Symphyseotomy. — Charles F. Painter reports this case
because the question as to the existence of sacroiliac
mobility has so often been raised. In thsi case there
was evidence of hypermobility of the sacroiliac joints;
this was associated with severe backache, and gave
ocular evidence of its existence by the pronounced lip-
ping of the sacroiliac joints, as shown by the x-ray.
The writer says that it may be maintained that even
though one admits the validity of the claim that motion
in these joints is evidenced by the lipping of the bones
making up the joint, this is due to the fact that there
is no connection at the symphysis. There never is a
bony connection, and though the abnormal separation
in this patient may, and undoubtedly did, aggravate the
already existing mobility, still there is abundant evi-
dence that these joints are in existence and are sub-
jected to the same diseases to which other joints of
the body are subjected. No better evidence is needed
than this proof of the existence of these joints; and if
there are joints, motion must follow, in some degree
at least. Such a case cannot be of very common occur-
rence, and goes to prove that the sacroiliac joints,
though unlike other articulations, resemble them in
their essential features.
New York Medical Journal.
June 24. 1916.
1. The Value of Autoserum Injections in Skin Diseases.
William S. Gottheil.
2. Tracheobronchial Syphilis. H. Arrowsmith.
3. Nephritis in the Aged. I. L. Nascher.
4. Colonic Stasis. George H. Evans.
5. Clinical Notes from the First Surgical Division of the Sea
View Hospital. Alexander Nicoll and Michael J. Horan.
6. Adenocarcinoma of the Colon. Samuel Ross Crothers and
Robert Kilduffe, Jr.
7. A Plea for the Male Nurse. P. Samuel Stout.
8. Pathological Conditions in Hematuria and Pyuria. A. S.
Sanders.
1. The Value of Autoserum Injections in Skin Dis-
eases.— William S. Gottheil reviews the recent literature
in reference to the use of autoserums in skin diseases
and states that he has fairly complete records of thirty-
one cases of psoriasis, nine cases of various forms of
obstinate chronic eczema, seven cases of chronic urti-
caria, four cases of very bad pustular acne, five cases
of furunculosis, five cases of pemphigus and eight
cases of florid secondary syphilis, and several cases of
chronic lichen planus, leprosy, and other chhronic affec-
tions. From his experience with these cases he con-
cludes as follows: 1. In psoriasis the autoserum treat-
ment, while not in itself curative of the disease, is an
important factor in the treatment. It cuts down the
time required for the troublesome local treatment from
weeks to days, and enables us to promise to clear the
skin in from two to five days in even the worst and
most obstinate cases. It postpones relapses for a long
time, possibly indefinitely. In most cases it so influ-
ences the type of the disease that the relapsing lesions
are few and insignificant, and are readily amenable to
mild local treatment. 2. In chronic urticaria, neuro-
dermatitis, pruritus senilis, and other obstinate itchy
dermatoses it is worthy of trial. In some cases its ac-
tion is effective and brilliant. 3. It is of some value in
bad pustular acne; but in furunculosis, folliculitis, and
other pus infections I have not found it useful. 4. In
chronic eczema the same may be said as of acne; the
injections are sometimes apparently effective, and at
others fail entirely. 5. In pemphigus, lepra, and obsti-
nate lichen planus it is ineffective. 6. In syphilis it is
useless.
3. Nephritis in the Aged. — I. L. Nascher say? that
the frequent autopsy findings of interstitial nephritis in
senile cases which gave no symptoms of the disease dur-
ing life, and the frequent diagnosis of interstitial ne-
phritis in senile cases which do not show the patholog-
ical condition upon autopsy, force the conclusion that
either the pathologist or the physician was careless or
ignorant, or else that nephritis in the aged does not
present the clinical history or the pathological features
that we find in earlier life. We often get a symptom
complex in an elderly person which in a younger indi-
vidual would justify the diagnosis of interstitial nephri-
tis, yet in an aged person every one of these symptoms
may be due to a cause which is neither directly nor in-
directly traceable to the kidneys. Senile contracted kid-
ney with slightly diminished output of urine, of rather
high specific gravity and a trace of albumin without
casts, is a physiological condition. It requires no treat-
ment, and efforts to increase the output may cause a
mild irritation and inflammation, followed by degenera-
tion of the glomeruli. Chronic interstitial nephritis is
a pathological degeneration superimposed on a normal
degeneration, and by extension it will involve the glom-
eruli, producing a diffused nephritis. Parenchymatous
nephritis is always secondary, either to an acute nephri-
tis or, by extension, to an interstitial nephritis. By ex-
tension it will become diffuse, involving the whole organ.
Acute nephritis may be primary, following the inges-
tion of poisons or renal stimulants, or it may be second-
ary, the irritation arising from bacteria or products of
autointoxication or metabolism. If mild it will pass into
parenchymatous nephritis; if severe it is speedily fatal.
All pathological degenerations hasten normal degenera-
tions and are therefore incurable. In the severe form
of acute nephritis, which is always fatal in the aged,
the physician is justified in trying anything which might
increase the output of urine. In one case of parenchy-
matous nephritis with suppression of urine, the author
used sodium theobromine salicylate in 42-grain doses
three times a day for several weeks. In this case the
ordinary diuretics in the usual doses failed to increase
the urinary output, but these large doses were effective.
7. A Plea for Male Nurses. — P. Samuel Stout pre-
sents the following arguments in favor of training
young men to the nursing profession, and urges that an
educational campaign be instituted in all the high
schools informing young men of the advantages of
taking up this profession and urges that all hospitals
receiving State aid be open to them. He says that male
nurses are necessary because of the increasing scarcity
of female nurses. Male nurses are more fitted to the
work in the male wards than female nurses. Male
nurses could attend to all the orderly's duties with much
more efficiency than the ordinary orderly. Male nurses
could carry out all the operating room technique. Male
nurses would become more and more proficient, since
their work would be continued as a life work and marry-
ing would not terminate their nursing careers as it does
with the female nurse. Male nurses could be trained as
professional anesthetists. Male nurses would have a
good groundwork for the study of medicine and this
would provide a good way for the ambitious man to
work his way through medical college. A certain pro-
portion of young men should be trained for nursing in
army hospitals. In the event of war they would be in-
valuable, and could be sent to places where it would be
impossible to send a female nurse.
Journal of the American Medical Association.
June 24. 1916.
1. Further Reflections of a Medical Teacher. W. T. Council-
man.
2. The Relation of Gout to Nephritis as Shown by the Uric
Acid of the Blood. Morris S. Pine.
76
MEDICAL RECORD.
[July 8, 1916
3. The Treatment of Chronic Colon Bacillus Pyelitis by Pel-
vis Lavage. Herman Louis Kretschmer and Fred W.
Gaarde. v.,»-
4. Intracranial Treatment of Syphilitic and Parasyphilitic
Optic Nerve Affections: Physiologic Evidences: Re-
searches on Intravital Staining of the Optic Nerve.
Mark J. Schoenberg.
5. Reactions Following Intraspinal Injections of Mercury.
George W. Hall, Hayes Culbertson and Carrie Slaght.
6 The Frequency of Unsuspected Syphilis, with Special Ref-
erence to Its Incidence in So-Called Neurasthenia.
James S. McLester. „
7. Vaccine Therapy and Other Treatment in Acne Vulgaris
and Furunculosis. Harold H. Fox.
8. A Case of Granuloma Pyogenicum Affecting the Eyelid.
Cas-sius D. Wescott.
1. Further Reflections of a Medical Teacher.— W. T.
Councilman says that some years ago he gave an ad-
dress of "Reflections of a Medical Teacher"; to-day
his reflections follow along much the same lines, though
the views expressed have in some cases undergone some
alteration and repair, and in others have become deeper
and stronger. In teaching, one is concerned (1) with
the material, just as the farmer must consider first the
character of the soil he tills. Continuing the agricul-
tural simile we are (2) concerned with the tiller, his
selection and training and his ability for his job. The
(3) point is what sort of a crop he wishes to produce,
and (4) what methods of culture he pursues. In pri-
vate school teachers are selected rather on a basis of
athletics and social qualifications than on the ability
to train and inspire youth. The possession of a "Ph.D."
is also regarded as one of the desirable qualifications of
a teacher. The character of the work which the de-
gree demands in no way qualifies him to teach. How
much better it would be for him to spend the time under
a competent master in the study and practical exercise
of teaching. Every one engaged in the tillage of the
soil must study its character. Harvard having re-
quired the A.B. degree as a condition for entrance into
the medical school since 1900, so far as he has been
able to learn by careful study of results, on the whole
the A.B. men are better. The hereditary element also
favors the college man. He has been greatly impressed
with the evidence which college men often present of a
lack of thoroughness in the instruction they have re-
ceived. He believes that teaching is a calling which
if engaged in should be the paramount interest in life,
that it is a responsible, serious, and noble calling.
Teaching should not be a bar to research, and many of
the great teachers he had known have been both teach-
ers and investigators. He thought it would be well if
universities could be placed in a wilderness and with-
drawn from the environments of idleness and wealth.
Medical education must provide constant exercise in
the study of disease and practice in methods. One of
the most important elements should be the recognition
of knowledge and its separation from conjecture. The
lecture is an important part of teaching, provided its
function is understood. It should be used to expand
and coordinate the knowledge which the student has
already acquired. Next to the lecture comes the demon-
stration, a method of overrated value. Oral recitation
is also a valuable exercise provided it can be given in
such a way as to bring out the conceptions which the
student has formed and to correct those that are faulty.
The profession of medicine is a career full of interest,
the social position of medical men is on the whole good,
there is a general feeling of fellowship and comaraderie
among them, fostered by frequent meetings in societies.
2. The Relation of Gout to Nephritis as Shown by
the Urine Acid of the Blood. — Morris S. Fine presents
certain data which raise the questions: 1. Is gout
merely a stage in the developmeent of interstitial
nephritis, whose further progress may be indefinitely
delayed? 2. Is early interstitial nephritis merely po-
tential gout, in which the clinical symptoms may or may
not eventually appear? 3. Is the uric acid retention of
gout due to a specific condition, gout, or to a complicat-
ing early interstitial nephritis. The two practical
points brought out in the paper were these: (1) Since
uric acid is the first of the nitrogenous substances to
be retained in interstitial nephritis, its determination
may give the first indication of this condition when
other symptoms are uncertain or lacking. (2) Since
gout and very early interstitial nephritis are charac-
terized by essentially the same blood picture, it is neces-
sary to employ every possible test to exclude nephritis
before a high blood uric acid may be regarded as evi-
dence of gout in the absence of the typical classical
manifestations.
3. The Treatment of Chronic Colon Bacillus Pyelitis
by Pelvic Lavage. — Herman Louis Kretschmer and Gred
W. Gaarde said it was not their object to discuss the
various forms of treatment advocated for pyelitis, but
to present the results obtained by pelvic lavage in this
series of cases. This series deals only with chronic
colon pyelitis, and most of the patients had resisted
medical management. As a routine, a 1 per cent, solu-
tion of silver nitrate was used. The amount injected
varied from 5 to 7 cc. as an average. Great care should
be taken to avoid a rapid filling of the pelvis and not
to use too large amounts. In some of the cases,
catheters were passed into the pelvis and, in others,
only about one-half way. The treatments were carried
out once every five or six days until the urine was
sterile and free from pus. In summarizing the results
of treatment they reported only on fourteen patients
because they were able to follow this number to final
results. Of the fourteen cases treated by lavage, bac-
teriological cures were obtained in eleven cases. In the
remaining three it was possible to obtain positive
cultures from the ureters, although subjective symp-
toms and leucocytes in the urine had long since disap-
peared. In four cases, one injection was given; in five
cases, two injections; in three cases, three injections;
in one case, four, and in another, eight injections. They
drew the following conclusions: (1) From our results
in this series of cases we believe that pelvic lavage
gives a greater number of bacteriological cures in a
shorter space of time than any other form of treat-
ment. It is important that the urine be sterile in order
to prevent recurrences. (2) In several instances we ob-
tained sterile urine after one or two treatments of
patients who had been on internal treatment for many
months. (3) If patients fail to respond to this form
of treatment we may be dealing with a condition other
than a simple pyelitis, for example, tuberculosis, stone,
or stricture of the ureter.
5. Reactions Following Intraspinal Injections of
Mercury. — George W. Hall, Hayes Culbertson, and Carry
Slaght give a summary of the work they have done in
the Cook County Hospital, with intraspinal injections of
mercurialized serum, mercuric chloride and mercuric
succinmid. In fifteen cases treated the following symp-
toms were noted. Pain was rather severe, localized in
the back and extending down the limbs in all of the
cases. There was retention of the urine in two cases
which lasted for twenty-four hours, requiring cathe-
terization. The patients had no trouble after the first
twenty-four hours. There were insomnia and restless-
ness in four cases. There were headache and pain ex-
tending down the back in ten cases. A rise in tempera-
ture ranging from 99 to 103 Fahr. was noted during
the first twenty-four hours in all the cases. The tem-
perature began to rise about four or five hours earlier
following the injections of the mercuric chlorid and
succinimid than following the injections of mercurial-
ized serum. The cell count in the spinal fluid during
the first twenty-four hours following injection ranged
July 8, 1916]
MEDICAL RECORD.
77
from 300 to 2,000 cells per cubic millimeter. During
this period the polymorphonuclear leucocytes predom-
inated with a gradual return to the lymphocytosis later.
The period of increased cell count lasted on an average
about 72 hours. Some of the patients expressed a feel-
ing of improvement a week or two after the injections,
and requested further treatment, but no statement
could yet be made as to the ultimate results following
these injections. The writers recommend that in ad-
ministering mercuric chloride 1/100 of a grain be used
when using the spinal fluid as a vehicle. This can be
made up in a 1 per cent, solution using 20 c.c. of spinal
fluid as a vehicle.
The Lancet.
June 3, 1916.
1. On the Influence of Antiseptics on the Activities of Leu-
cocytes and on Healing of Wounds. C. J. Bond.
2. Notes en Military Orthopedics. — III. The Soldier's Foot and
the Treatment of Common Deformities of the Foot.
(Continued.) Robert Jones.
3. The Louse Problem at the Western Front. A. D. Peacock.
4. Notes on Pediculus humanus (vestimenti) and Peduculiis
capitis. A. Bacot.
5. An Investigation of the Best Methods of Destroying Lice
and Other Body Vermin. J. Parlane Kinloch.
6. Memorandum on the Treatment of Infected Wounds by
Physiological Methods. Almroth E. Wright.
1. On the Influence of Antiseptics on the Activities
of Leucocytes and on the Healing of Wounds. — C. J.
Bond has devised a method by which he uses an indigo
thread placed in a wound which serves as a trap to
catch emigrating leucocytes. In this way the cells can
be recovered for microscopic examination at various
interfals after operation, and the influence of various
antiseptics can be observed on the behaviour of the
leucocytes towards inert pigment particles, and album-
inoid and other oryanic substances introduced into the
wound. In this way the writer has made a considerable
number of observations under strict aseptic conditions
in the human subject, and many antiseptics in different
degrees of concentration have been tested by this
method of the decolorization of the indigo thread. The
outcome of the inquiry seems to be that antiseptic
solutions in moderate degrees of concentration exercise
less influence over emigration and phagocytosis than
many surgeons have supposed. There are, however,
reasons for concluding that antiseptics do exert a con-
siderable inhibitive effect on the return immigration of
living phagocytes. This aspect of the subject should
be borne in mind in descriptions of the effect of different
antiseptics in killing off pathogenic organisms in pus
and other liquids in vitro and on the sterilization of
wounds. Provided efficient drainage is ensured, the sur-
gical application of most antiseptic solutions does not
apparently materially prejudice the defensive activity of
the tissues in either infected or non-infected wounds.
If it can be shown that the use of antiseptic reagents
does at any stage inhibit the activities of the pathogenic
organisms, then, although these reagents do undoubt-
edly cause the death of a certain number of body cells
and prevent others from again reaching the tissues, this
is a small matter if the invading organisms are at the
same time materially diminished in numbers or in
offensive capacity. The occasional death of even large
numbers of phagocytes is well borne if time be given
to make up the loss. The experimental introduction of
pigmented particles into a wound also throws valuable
light on wound infection. In a general way the trans-
portation of the pigment follows the same routes and
the same lines of least resistance as those traversed
by infecting organisms. The same peculiarities are ap-
parent in the permeation of tissues and organs by
pigment granules. The liver, the spleen, the kidney
and the brain each presents its own problem in emigra-
tion, phagocytosis, and return immigration. Bearing in
mind that pigment particles are incapable of intrinsic
movement, or multiplication, or growth, any transporta-
tion of pigment, insofar as it is not due to currents in
the lymph or other fluids bathing the wound, must be
due to the action of living cells. The writer points out
that several side issues of considerable interest arise
out of this problem of the return immigration of the
phagocytes. Unless the ingested cocci and bacteria
which are carried into the tissues by the phagocytes
on their return journey are killed, or sufficiently at-
tenuated to render them incapable of further growth,
they may start into renewed activity on the death and
disintegration of the cells which contain them. It is
possible that some cases of recrudescent local sepsis
may owe their origin to this cause.
5. An Investigation of the Best Methods of Destroy-
ing Lice and Other Body Vermin. — J. Parlane Kinlock
discusses the various methods that have been employed
for the purpose of destroying lice and other body vermin
and concludes that, as Bacot has shown and as his own
experiments also demonstrate, lice do not survive im-
mersion in boiling water. Of the various insecticidal
powders that have been tested the N. C. I. (naphtha-
lene, creosote, iodoform) powder is the most destructive
to lice. Naphthalene and creosote have each a strong
insecticidal action. The insecticidal action of iodo-
form is feeble. Commercial naphthalene is more ac-
tively insecticidal than pure naphthalene and it ap-
pears that the lethal power of naphthalene for lice
is dependent in great part on the presence of hydrocar-
bons and coal tar derivatives other than pure naphtha-
lene. The immediate lethal effect of creosote when
mixed with naphthalene is less than that of some other
insecticide liquids, but the longer period during which
creosote continues to act more than compensates for the
initial disadvantage. In addition to its feeble insecti-
cidal action, idoform greatly increases the adhesiveness
of N. C. I. powder. The insecticidal power of naphtha-
lene-creosote powders gradually diminishes when they
are exposed in the open air. The moist nature of such
powders precludes their being used successfully in per-
forated tins and it has not been possible to dry the
powders and at the same time retain the moist volatile
hydrocarbons and other coal tar derivatives in which
the insecticidal effect mainly depends.
6. Treatment of Infected Wounds by Physiological
Methods. — Almroth E. Wright criticises the traditional
methods of treating wounds by a combination of anti-
septics, incision, and mechanical drainage, because it
fails to kill the infecting microbes and at the same
time fails to give the organism opportunity for ridding
itself of the infection. He says the treatment of septic
war wounds divides itself into three therapeutic pro-
cedures. In the first we have to promote the destruc-
tion of the microbes which have been carried into the
deeper tissues. We have to re-establish normal condi-
tions in the tissues, resolving the infiltration in the
walls of the wound, getting rid of infected sloughs,
prevent the corruption of discharges, and inhibit mi-
crobic growth in the cavity of the wound. During the
whole period occupied by these operations we have to
be constantly on our guard to prevent active and pas-
sive movements which would propel bacteria along the
lymphatics, and carry poisonous bacterial products into
the blood. Second, when the physiological conditions of
the deeper tissues have been restored and the wound
has been rendered to naked eye inspection perfectly
clean, the surface infection must be dealt with. Third
as soon as this has been suppressed, or all but sup-
pressed, attention must be given to promoting the
processes of repair, bringing together the tissues, and
covering over denuded surfaces. The ideal object of
78
MEDICAL RECORD.
[July 8, 1916
physiological treatment is to give intelligent aid to the
organism in combatting bacterial infection. Saline
dressings supply a means for evoking in infected
wounds certain requisite psychological reactions. Hy-
pertonic salt solution will act as a lymphagogue, draw-
ing out from the tissues lymph which has spent all its
bactericidal energy, and drawing into the tissues from
the blood stream lymph inimical to microbic growth.
It brings into direct application upon leucicytes a hyper-
tonic solution (what is in view here is a solution con-
taining 5 per cent, salt), will disintegrate leucocytes,
setting free the tryptic ferment they contain. Such a
hypertonic salt solution will also exert a number of
inhibitory actions. It will inhibit the action of the
tryptic ferment set free in the wounds. It will inhibit
coagulation and so prevent the sealing up of the ori-
fices through which lymph pours into the wound. It
will inhibit leucocytic immigration into and prevent
phagocytosis in the cavity of the wound. It will in-
hibit microbic growth. The writer discusses in detail
the various methods of using hypertonic salt solution
in the different stages of wound infection and the indi-
cations which call for the redressing of wounds.
British Medical Journal.
June 3, 1916.
1. Typhus Fever in Serbia. (Concluded.) R. O. Moon.
2. A Case of Acute Diabetes. With Comments, Especially in
Regard to Acidosis. Walter G. Smith.
3. Treatment of Septic Wounds, with Special Reference to the
Use of Salicylic Acid. Notes Based on Cases at the
Military Hospital, Kndell-street. Louisa Garrett An-
derson, Helen Chambers, and Margaret Lacey.
4. On the Ill-treatment of Genital Prolapse. W. E. Fothergill.
5. A Factor in the Treatment of Head Injuries and Allied
Conditions. T. E. Harwood.
6. A Note on Spinal Anesthesia. D. B. Gadgil.
7. A Note on the Function of the Meduallary Nerve Sheath.
C. E. H. Milner.
8. The Cockroach : Its Destruction and Dispersal. A Com-
parison of Insecticides and Methods. Joseph H. J.
Holt.
2. A Case of Acute Diabetes, with Comments, Espe-
cially with Reference to Acidosis. — Walter G. Smith re-
cords the main facts in a case of diabetes occurring in
a boy of seven years, and makes it the basis of com-
ments which he thinks justify the following proposi-
tions. There is no simple, direct test for oxybutyric
acid at our disposal. Its detection can only be effected
indirectly. Barium oxybutyric acid forms long, needle-
shaped crystals whcih are doubly refracting. Neither
oxybutyric acid nor acetone gives any color reaction
with ferric chloride; oxybutyric acid has no reactions
in common with acetoacetic acid. Hurtley's method for
its quantitative determination by extraction with ether
and estimation by titration is described by Plimmer.
For acetoacetic acid three tests are available: Ger-
hardt's, Rothera's, and Riegler's acetoaceticacid. Ace-
tone does not respond either to Gerhardt's or Riegler's
test. Its reaction with Rothera's test is similar to
that of acetoacetic acid, but is less sensitive. The sensi-
tiveness of Rothera's test is increased by the addition
of a solid ammonia salt, as the sulphate of chloride.
The writer has confirmed the value of this modification.
The amount of acetoacetic acid in urine is usually con-
siderably greater than that of acetone, according to
Plimmer from two to ten times as much. There are
two sources of acetoacetic acid in the urine, namely,
that which is preformed and that derived from intra-
vesical decomposition of ovybutyric acid. There is no
simple and reliable test at present known for the detec-
tion in urine of small amounts of acetone in association
with acetoacetic acid. Many data published in connec-
tion with acetonuria are vitiated by ignorance of this
fact. Rothera's test differentiates acetone from
creatinin. Creatinin reacts with sodium nitroprusside
and either liquor potassae or liquor ammonia?. Acetone
reacts only with nitroprusside and liquor ammonia?.
The term acetone bodies is not a happy one, for it lays
stress on the least important member of the triad.
Since acetone alone is not infrequently met with in
urine, perhaps it would be well to indicate that fact by
the term acetonuria, and to use the term acetouria for
the cases in which acetoacetic acid occur. The theory
of acidosis is still incomplete. The modes of origin of
"acetonuria" are complex and are largely influenced by
the amount of carbohydrate food assimilated. There is
no evidence that either oxybutyric acid or diacetic acid
exercise any specific toxic action apart from their acidic
character. At present all we are entitled to say is that
coma may come about by disturbance of the normal deli-
cate adjustment of acid and basic radicals in the blood
and tissues without postulating an excess of hydrogen
ions in the blood.
3. Treatment of Septic Wounds, with Special Refer-
ence to the Use of Salicylic Acid. — Louisa Garrett An-
derson, Helen Chambers and Margaret Lacey have
made observations on approximately 1000 cases of
septic wounds treated in the wards and operation thea-
ters of the Military Hospital, Endell Street, making
large numbers of cultures to determine the bacterial
growth in the wounds. From these observations they
draw the following conclusions: 1. The bactericidal
action of many of the so-called antiseptics when applied
to septic wounds is negligible. 2. The majority of
wounds heal without the application of an antiseptic,
provided free drainage is supplied and dressings are
changed frequently. Hypertonic saline, in so far as it
aids physiological processes, is preferable to many so-
called antiseptics. 3. A strong antiseptic, such as
eusol, can sterilize the surface of a wound with which
it comes in contact, and, if applied continuously, gives
excellent results. 4. Salicylic acid applied in a suitable
form can often save cases when other methods have
failed. It is particularly useful when dressings cannot
be repeated at frequent intervals. 5. In all cases
where recovery is delayed and the effect of the reagents
of doubtful value the treatment should be controlled by
making repeated cultures from the wound surfaces.
4. On the Ill-Treatment of Genital Prolapse.— W. E.
Fothergill states that some 600 plastic vaginal opera-
tions are done every year at St. Mary's Hospital, Man-
chester, and they are thus afforded an opportunity of
observing the results of many futile operations, and
suggests what he considers suitable operations for the
common forms of genital prolapse, which are four in
number. 1. In true prolapse or complete procidentia,
the operator should excise most of the anterior vaginal
wall with the front half of the vaginal roof. The
cervix should also be removed if it is unhealthy or if
the uterus is more than 3 inches long. The writer's
method of combining anterior colporrhaphy with ampu-
tation of the cervix is useful. 2. Where the uterus is
long and loose the cervix appears first at the vulva and
vaginal roof is inverted from above downward around
the elongated cervix. There is no cystocele. This is a
form of prolapse seen in virgins and nulliparous as well
as in parous women. The treatment is excision of the
front half of the vaginal roof together with the cervix,
leaving the uterus 3 inches long. 3. In cystocele the
anterior vaginal wall is everted from below upwards as
in true prolapsus, but the uterus retains its normal po-
sition. Here anterior colporrhaphy is indicated. 4. In
rectocele the posterior vaginal wall is everted from
below upwards and the anterior rectal wall is adherent
to it. This form of prolapse is seen in parous women
with torn perineum, but not in virgins or nullipara?.
In this form of prolapse most of the posterior vaginal
wall must be removed, the best method being Professor
A. Donald's colpoperineorrhaphy, which is done from
above downard so as to combine the two operations.
July 8, 1916]
MEDICAL RECORD.
79
Slock ItnrimiH.
Human Physiology. By Professor Luigi Luciani,
Director of the Physiological Institute of the Royal
University of Rome. Translated by Frances A.
Welby, with a preface by J. N. Langley, F.R.S.,
Professor of Physiology in the University of Cam-
bridge. In five volumes. Vol. III. Edited by Gordon
M. Holmes, M.D. Muscular and Nervous Systems.
Price, $5.00. London: Macmillan & Co., Limited;
New York: The Macmillan Company, 1915.
The third volume of Luciani's Human Physiology
deals with the muscular and nervous systems and
phonation and articulation. The reader will find in this
work a comprehensive, but by no means exhaustive (or
exhausting) , discussion of these various topics. The
author's method is to give an historical sketch of the
work which has been done in the past and of the differ-
ent theories which have been held, and then to criticise
and bring into their proper perspective the several
points which have been under review. It is this feature
which, combined with the author's erudition, places the
work on a higher plane than that which is enjoyed by the
average textbook. In its philosophic method and general
style, the book reminds us of Sir Michael Foster's
classical work which appeared about thirty years ago.
Appended to each chapter is a selected bibliography
which cannot fail to be of service and from which
many a reader may learn of the work of Italian scien-
tists which is not as well known as it should be. Of the
ten chapters of which the volume consists, that on the
mechanics of the locomotor apparatus is particularly
valuable because it deals with a subject which is gen-
erally either neglected or omitted by writers on physi-
ology. The chapter on phonation and articulation has
been much abridged; the author's remarks on the sing-
ing voice and the speaking voice deserve a larger audi-
ence than they are likely to receive. The sympathetic
system is discussed in a very brief chapter, but the
author makes amends by referring to the previous
volumes of this work and by the ample recognition of,
and reference to, the labors of Gaskell, Langley, and
others. Much of the pleasure experienced in reading
the volume is due to the smooth and capable work of the
translator.
Diagnostico de las Enfermedades del Coraz6n. Por
Antonio Mut, Jefe del Dispensario de Medicina gen-
eral de Instituto Rubio. Segunda edicion, corregida
y aumentada. Price, 7.50 pesetas. Madrid: Hijos de
Reus, 1915.
Perhaps in no other branch of medicine have such
signal advances been made during the past decade as
in the study of the diseases of the heart. These
advances are to be mainly attributed to two factors:
first, the use of precise physical methods of recording
the work of the heart and the condition of the cardio-
vascular apparatus as a whole; and second, bacterio-
logical studies of the blood in cases of heart disease.
Naturally, the greatest progress has been made along
the lines of diagnosis. For this reason a volume, such
as the one under review, that deals with the diagnosis
of diseases of the heart in the light of the most recent
investigations would comprise practically the entire
subject of cardiac pathology and symptomatology. The
student of this branch of medical science will find in
the second revised and enlarged edition of the impor-
tant work by Dr. Mut, a veritable digest of the most
recent knowledge of the diseases of the heart. An idea
of the extensive research upon which the text is based
may be gleaned by looking over the bibliography of 90
pages at the encT of the volume, the references com-
prising about 1.800, and all of these being contributions
subsequent to the year 1908. The text of this work is
divided into thirty chapters, which are headed as fol-
lows: Anatomy; Physiology; Subjective Symptoms;
Methods of Physical Diagnosis; Percussion: Ausculta-
tion ; Murmurs ; Examination of the Arterial Pulse and
Simple Sphygmography; Phlebography, Plethysmog-
raphy, and Tachography; Cardiography; Radiology;
Electrocardiography and Phonoscopy; Sphygmomano-
metry, Sphygmobolometry, and Viscosimetry; Arrhyth-
mias and Sinus Arrhythmias; Extrasystole; Heart
Block and Stokes-Adams Syndrome; Pulsus Alternans;
Permanent Arrhythmia; Loss of Tonicity and Cardiac
Insufficiency; Tachycardia; Bradycardia; Valvular
Lesions, Aortic and Pulmonary; Lesions of Auricu-
loventricular Valves; Congenital Diseases of the Heart;
Angina Pectoris; Endocarditis; Myocarditis; Peri-
carditis; The Heart in the Infections; Pregnancy and
Heart Disease and the Effect of Chloroform Upon the
Heart. This work may be recommended to any one
capable of reading it as an eminently up-to-day treatise
on the diagnosis of diseases of the heart.
Obstetrics. A Practical Text Book for Students and
Practitioners. By Edwin Bradford Cragin, A.B.,
A.M. (Hon.), M.D., F.A.C.S.; Professor of Obstet-
rics and Gynecology, College of Physicians and Sur-
geons, Columbia University, New York; Attending
Obstetrician and Gynecologist to the Sloane Hospital
for Women; Consulting Obstetrician to the City Ma-
ternity Hospital. Assisted by George H. Ryder,
A.B., M.D., Instructor in Gynecology, College of
Physicians and Surgeons, Columbia University, New
York; Assistant Attending Obstetrician, Sloane
Hospital for Women; Associate Surgeon, Women's
Hospital, New York. Octavo, 858 pages, with 499 en-
gravings and 13 plates. Cloth, $6.00 net. New York
and Philadelphia: Lea & Febiger, 1915.
Another very excellent and readable book on obstetrics
makes its appearance. The call for text-books of this
type naturally depends upon the needs of the student
body, graduate and undergraduate, who are pupils of
the author ; the former to refresh their memories of the
Sloane technique, the latter to obtain instruction in the
methods of their teacher. Based almost entirely upon
the figures and results obtained by the methods of this
one institution, it is a question whether the logical title
of the book had not better have been, "The Practice of
Sloane Maternity Obstetrics."
The statistics of the hospital are instructive, and
though not based on as large a series of cases as those
published by some other institutions in this country, are
quite complete and compare very favorably with figures
published both here and abroad. Grouped in one chapter
they would make a valuable collection for reference.
The sections on management of normal pregnancy,
antepartum examination, management of normal deliv-
ery, ectopic gestation, pyelitis of pregnancy, fibroids
complicating pregnancy and labor, management of lac-
tation, and artificial feeding during the first month,
have not been equaled in any recent work of similar
scope.
The Freiburg technique of scopolamine narcosis is
carefully detailed. From observation in a limited num-
ber of cases, the author concludes that the method has
its advantages in selected cases in a hospital, but that it
is inapplicable as a routine procedure in a large teach-
ing institution with an active service, as the staff re-
quirements are too great.
Pubiotomy is shown to be a competitor with cesarean
section in the moderate degrees of pelvic contraction,
but in view of the complications the author hesitates to
recommend the operation. Vaginal cesarean is described
as a valuable addition to our methods of delivery, but
one not lightly to be undertaken, especially by a novice.
In speaking of the relative value of the extraperitoneal
and the Sanger cesarean section in infected cases, the
author believes that the superiority of the extraperi-
toneal cesarean section over the Sanger incision fol-
lowed by a hysterectomy after the removal of the child
is still to be proved, and prefers the latter. Discussion
Of unsettled topics, such as the Abderhalden reaction
and the morphine treatment of eclampsia, is avoided
as far as possible. The presentation of etiology, prog-
nosis, and methods of treatment is conservative through-
out, and recommends the book especially to the under-
graduate student.
Nurse Instruction for Civil Service Examinations.
Covering Nurse, Trained Nurse, Hospital Nurse,
Visiting Nurse, Field Nurse, Tuberculosis Nurse,
School Nurse, Nurse's Assistant, Assistant Super-
intendent of Nurses, Head Nurse, Supervisory Nurse
and Superintendent of Nurses. Answers to Exam-
ination Questions and 250 Specimen Questions. New
York City, New York State, New Jersey, Chicago and
Federal Services. Price, 50 cents. New York: Civil
Service Chronicle, 1916.
The contents of this pamphlet will be evident from the
lengthy title page, transcribed above. Three sets of
questions are answered, and these answers are the
ones sent in by the candidates who obtained the high-
est marks in each case. Intending candidates can thus
see how their answers will be graded by the examiners,
and they may also observe that little eccentricities in
spelling are not seriously objected to. Indeed, the ques-
tions are not entirely blameless in this matter. Most
of the questions seem practical, and the pamphlet should
prove of service to any nurse who is thinking of apply-
ing for a civil service position.
80
MEDICAL RECORD.
[July 8, 1916
jgwipig SkporiH.
AMERICAN MEDICAL ASSOCIATION.
Sixty-Seventh Annual Session — Held in Detroit, Mich.,
June 13, 14, 15 and 16, 1916.
(Special Report to the Medical Record.)
(Concluded from page 39.)
SECTION ON OBSTETRICS AND GYNECOLOGY.
Wednesday, June 15 — Second Day.
Colonic Infections: Some Seldom Described Non-
specific Types.— Drs. J. M. Lynch and W. L. McFar-
land of New York presented this paper. They said
that in experiments on animals there were shown to be
certain fundamental principles bearing on surgery of
the gastrointestinal tract. The rate of motion of the
intestinal contents was shown to be in direct proportion
to their toxicity. It was most rapid in the duodenum.
This was important to the protective mechanism of the
animal. Thus the acid reaction in the terminal ileum
was protective in character and alimentary disease
should be interpreted in the light of this knowledge.
Digestion was shown to be a segmental process and
inflammatory conditions were most frequently found in
the caudad segment where there were great quantities
of bacteria. Twenty-one cases of purulent infection of
the colon had been studied by the writers, which ap-
peared so severe that tuberculosis was suspected in
many cases. There was severe diarrhea with early
appearance of pus, blood and mucus. The proctoscopic
picture was typical, the mucous membrane appearing
lifted from the subjacent structures and being edema-
tous and ulcerated. After recovery an atrophic ap-
pearance occurred. The lymphatics presented no change
except inflammation. Bacteriological examination was
disappointing and did not throw light on the condition,
the normal flora of the intestinal tract apparently only
being present. Conclusions were that the etiology was
unknown, the infections being acute at first and be-
coming subacute or chronic. They were segmental in
character, suggesting vasomotor origin. Cases should
be early recognized as infections and treatment should
be medical or surgical, depending upon the type. Ileos-
tomy had given very favorable results in some cases,
as in a patient who had gained 22 pounds in six weeks
after ileostomy.
Dr. J. W. Draper of New York said he wanted to
thank Dr. Lynch for this valuable paper. He had seen
a number of these cases with the reader and could cor-
roborate what he said. The involuntary system sup-
plied many nerves of the colon which had cells in the
stellate ganglion. The thirteenth thoracic supplied the
ileocecal region very largely and might account for
the reflex symptoms so often seen in the stomach in
the course of clinical disease. In regard to ileostomy,
which was the method of treatment suggested by Dr.
Lynch in his paper, Dr. Lynch had been the first to
recognize the usefulness of this treatment in these con-
ditions. Like many methods in general therapeutic use
it had been employed sporadically a number of years
and sufficient time had elapsed to prove its value. The
reason that this worked so well from the point of view
of surgical physiology was that it conformed to the
fixed rule that the stoma, to give relief, must be early
rid of the inflammatory process in the gut. Ileostomy
had immediate effect on the nervous and mental condi-
tion by reflex action upon the duodenal and jejunal
glandular secretion. To this fact also might be trace-
able the deaths in high intestinal obstruction.
Dr. J. M. Lynch said that he wanted to mention
medical treatment. All cases except the very acute
could be relieved, and it was well worth while to try
permanganate of potash. I <1 in some of the
subacute cases they had obtained good results with one
teaspoonful of peroxide of hydrogen to each pint of
water.
Congenital Inflammation. Deformation, and Defunc-
tionalization of the Caudad. Ileum and Colon. — Dr.
J. R. Eastman of Indianapolis gave this paper. He first
described the fetal colon which, he said, lay free in
the abdominal cavity to the left with its mesentery in
contact with the parietal layers of the peritoneum.
Later fusion of the layers took place, becoming con-
nective tissue, fused to the abdominal walls, as far as
the medial border of the left psoas muscle. Fusion oc-
casionally was excessive and angulation occurred as
the result. The gut itself became fused to the abdom-
inal wall causing stagnation of contents. Another
fusion took place on the right side and firm transverse
folds occurred, differing, however, from Jackson's mem-
brane. The persistence of this infantile position of the
sigmoid was often noted. Later the descending genital
glands, the ovary and testicle in descent from their
primitive position might cause deformity of the
terminal ileum and operation on internal hernia often
brought to light the persistence of a fetal fold. The
folds thus causing angulation of the sigmoid to the
left, by irregularities of embryonic fusion, could be
broken up by gauze dissection, by simple wiping of the
folds. Another point of irregular fusion was about the
cecum and terminal ileum. Fusion here often caused
a retrocecal or retroperitoneal appendix, the latter be-
ing caught between the fusing layers. Dr. Eastman
here showed diagrams illustrating the various irregu-
larities of fetal fusion and also illustrative of Jackson's
membrane, which was always associated, he said, with
chronic appendicitis, and which differed from engorge-
ment of the ileocolic artery with a hyperemic peri-
toneum and terminal ileum. The Jackson's membrane
was often confused in the minds of many with fused
membranes, but it was an entirely different condition.
Dr. Goldspohn of Chicago said that Dr. Eastman
had mentioned the extraperitoneal appendix and that
back of the cecum. Eight years ago he had operated on
a patient, a young, vigorous man, who had an extra-
peritoneal appendix lying concealed within the small
pelvis. He had an indurated mass felt distinctly one
inch inward from the right border of the ileum, which
was very painful. There was no induration beneath
this, as was usual from a ruptured appendix. The
diagnosis was very much confused by the fact that six
days preceding that time, he had been injured by a
wagon pole striking him above the symphisis pubis.
Four days after the injury, however, he was not dis-
abled and he called a doctor because he had fever,
nausea, but no acceleration of the pulse. The doctor
thought it was caused by trauma. Dr. Goldspohn
thought at first that the omentum had become strangu-
lated between the layers of the internal fold. Hernia
was present opposite the transversalis fascia, but did
not descend into the inguinal canal. Going inward
one inch from the border of the crest of the ileum, the
doctor found a small mass with about half a dram of
pus distributed into different directions; the peritoneum
had a blue appearance. Working down, extraperi-
toneally into the small pelvis, to the spermatic cord and
vas deferens toward the bladder, he got to the bottom
of the infected area and discovered a mass of gangren-
ous tissue, about as large as a man's thumb (3 inches)
that could be distinctly gathered up and had a pedicle
running upward. The appendix was not thought of.
It was tied off and taken out of the cavity, and the
cavity enlarged extraperitoneally. It was desired to
see the condition inside of the peritoneum and it was
cut into. There was some free fluid but the intestine
was not distinctly inflamed. Not wishing to infect the
peritoneum from the venomous looking connective tissue
area, the cavity was packed. There was temperature
for several days then it subsided. The patient made a
satisfactory recovery.
Dr. Gregory Connell of Oshkosh said he would like
to express his appreciation of this masterly summing
up by Dr. Eastman of the etiology of these conditions.
In the past there had been two sources considered —
inflammatory and congenital. In future the inflam-
matory could be ruled out. In corroboration of Dr.
Eastman's point relative to the ileopelvic ligament
of Lane, and also on the left side, he would like to men-
tion an instance in which there was no inflammation in
the abdomen at all but extreme ptosis and adhesions to
the round ligament on the left side. The tube was not
inflamed, but there was fusion with this ligament and
the omentum. The division made by Dr. Eastman be-
tween the excessive fusion, demonstrated by the white
line, and the vascularized layers, was a very important
one and should be kept in mind to simplify discussion.
He saw Dr. Jackson in the meeting and he hoped that
they would get some explanation of the original picture
of Jackson's membrane. As he understood it there was
a difference; Dr. Jackson's membrane being a perico-
litis, not a periceclitis. He would like to hear from Dr.
Eastman whether these conditions were a result or
merely a coincidence. The treatment of the condition
would rest upon that point.
Dr. J. M. Lynch of New York said that he thought
they were all very much indebted to Dr. Eastman for
the very excellent paper, but he believed that the kernel
July 8, 1916]
MEDICAL RECORD.
81
of the whole proposition was that there might be any
of these congenital deformities; there was, in fact, no
such thing as perfect fusion. Any two layers might be-
come separated or delaminated and become adherent
and cause deformity. He did not believe that in the
ordinary healthy peritoneum this was harmful, be-
cause it was elastic. It was the subsequent inflamma-
tion which left fibrous connective tissue. He did not
think it was necessary to operate unless there was a
change from ordinary endothelium to connective tissue.
Dr. Jackson of Kansas City said that he had con-
siderable interest in this subject, since he had described
what had since been named "Jackson's Membrane."
There had, however, been many things called Jackson's
membrane which were not so. When the structures
were considered anatomically and embryologically it
was found that there were many departures from the
normal. Many of these were due to fusion, transposi-
tions and different causes. He thought that there were
two distinct types of conditions clinically, and clinical
symptoms existed sometimes from congenital mal-
formations alone. There were angulations which pro-
duced symptoms, and the removal of which mechanical
difficulty relieved the patient. Many cases were re-
lieved by cutting adventitious bands. On the other hand,
he was" inclined to believe with Dr. Lynch that there
must be an added element, usually infection, which
made a complication to the original condition. There
were other cases, however, where correction of the
mechanical imperfection did not relieve the patient.
The patient must be treated for affection of the in-
side of the colon. In the cases of true pericolitis (Dr.
Connell was correct in so naming them) the pericolitis
never goes on to the colon. Where cases had trouble
from absorption from the outer colon there occurred a
sensitization in the portion where the absorption took
place. These cases had either to be let alone, or one
could risk another operation in the ascending colon.
Dr. J. R. Eastman said that with all respect to what
Dr. Jackson had said he would like to say that he had
seen 100 times, over the cecum and caput coli, a thin
veil that he could move about quite freely. He believed
that these anomalous membranes had been seen by
most of the gentlemen present. He did not mean to
say that these irregularities impaired the function of
the colon in every case, but occasionally it was definitely
associated with angulated fusion and with arrest of
the procession of intestinal contents, in other words,
stasis in that zone. It has been occasionally observed
that the separation of this excessive fusion would per-
mit relief of the stasis. This did not happen often,
but it was known to occur. The simple wiping away
of adhesions could restore function of the stasic distal
descending colon and proximal sigmoid, now and then.
Dr. Eastman said he had purposely omitted the dis-
cussion of associated mental states, as there was not
sufficient time to go thoroughly into the matter. He
had tried merely to bring this simple message — that
there was such a thing as excessive fusion between
the mesentery of the large intestine and abdominal
peritoneum. This might extend around and across the
normal muscle band, and such fusions might apparently
interfere with the function of the intestine, and the
fact should be borne in mind that in the case of an
oblique vascular abdominal band and folds down to
the internal abdominal ring, the appendix might be-
come arrested between these lamina? of the large in-
testine, so that when the layers became obliterated the
appendix occupied a retroperitoneal position. The ap-
parent postnatal adhesions of the omentum might rep-
resent fusion of the great omentum at the hepatic
flexure or the splenic flexure and might not represent
adult pathology at all. He was greatly indebted to
Dr. Jackson for telling them what Jackson's membrane
was (he had never known before). He did not believe
that any of them knew what membranous pericolitis
was. He could not see any reason why that should be
limited to the ascending colon. He could understand
that torsion of the cecum might pull it over from the
serosa, but this did not have the course Dr. Jackson
described. He felt that you could not do much with
a fresh separable membrane; it was like shifting
smoke. Removal gave rise to new adhesions. He felt
that this membrane was quite distinct from the en-
gorgement of the ileocecal artery.
Anterior Parietal Implantation of the Colon for
Ptosis.— Dr. Charles A. L. Reed of Cincinnati said
that it had long been axiomatic and fundamental to say
that constipation was the cause of persistent ill health.
It was, however, a new viewpoint to attribute many
anemias, rheumatisms, digestive disorders, nervous dis-
eases and kidney diseases to the effects of the toxic
state originating in constipation. Constipation could
be said to be related to any or all diseases which might
be influenced by toxemia with resulting acidosis. Treat-
ment, to be logical, must correct anatomical disturb-
ances. Causes of ptosis of the colon were numerous:
dilated ascending colon, atrophied transverse colon,
angulation of splenic flexure, adhesions to the sigmoid,
etc. Each of these were asosciated with structural
change and must be corrected by physical means. Cases
without serious distortion, and those which could be
corrected by hygienic measures were not under consid-
eration. Only those cases were considered in which
the relationship could be demonstrated between the in-
testinal condition and the constitutional state. The
idea was current that it was best to try every other
treatment before surgery, but a condition that was obvi-
ously surgical from the start should not be subjected to
delay in treatment. It was impossible in every case to
restore the status quo ante to the intestine, some condi-
tions defying functional restoration. Thus there were
two classes of operation — radical and conservative. The
former were resections, the latter plications, fixations,
and pexies. There was a rational demand for some
conservative measures, and for this reason the writer
had devised the parietal implantation of the colon, using
the preperitoneal structures, which insured maximal
support. To do this a median incison was first made
from the umbilicus to the pubis, the viscera were ex-
plored and the adhesions broken up. The peritoneal
margins were then approximated, and a liter of hy-
gienic salt solution put into the cavity, and the wound
closed by laminated chromic gut. Next the upper ab-
domen was explored, the patient being in the Trendel-
lenberg position, and the gall bladder and appendix
being examined. The incision was not extended through
the peritoneum. Dr. Reed had done this opperation 226
times with parietal implantation, and of these 96 had
been in conjunction with other operations. There was
no death from the parietal implantation alone. There
were two recurrences, one due to trauma. In 200 there
was marked functional improvement. Increase in
weight of from 30 to 60 pounds had followed in many
cases and headaches, mental symptoms, rheumatisms,
depending upon toxemia, had been overcome. Dr. Reed
showed charts illustrating the steps of the operation.
Dr. F. H. Martin of Chicago said a few fundamentals
should be emphasized: first, all displacements of the
colon and stomach, shown by pictures, did not lead nec-
essarily to serious symptoms; second, adhesions in the
abdominal cavity did not necessarily indicate that there
were pathological conditions to be relieved, in other
words, they did not lead to symptoms. This was illus-
trated by pictures shown by Dr. Ochsner at the clin-
ical congress in Boston, where there was disease but no
symptoms. Surgeons could go into the abdomen every
day and find adhesions which had not given rise to
symptoms. There were often seen displacement of the
organs causing kinks which held the viscera in disad-
vantageous positions which might interfere with func-
tion. How did nature seek to cure these difficulties?
How did nature hang up the colon when the animal as-
sumed the upright position? By peritoneal fusion. The
colon rotated, and peritoneal fusions occurred. There-
fore, if it was necessary to make a peg to hang up the
peritoneal contents, that wa,s done by nature, and that
meant that few of those cases required operation. It
was only where the viscera were caught in disadvan-
tageous positions that readjustment was required. The
advantage of pexy was that it allowed the parts to be
restored to more normal position.
Dr. R. T. Morris of New York said that surgery was
the brutal way of overcoming what the internist had
overlooked. In dealing with these cases one had to
consider two important features: first, the group of
susceptible individuals predisposed to these conditions;
second, the matter which had been overlooked by the
profession, that of sensitization, allergy or anaphylaxis.
Unless an elaborate analysis was made ruling out the
peripheral irritations and focal infections, they would
not decapitate the demon of the patient's ills by doing
any one operation. The psychic feature had to be in-
cluded. One might do almost any operation upon a pa-
tient with epilepsy and the patient would be better for
months. If one reported the cases quickly enough, one
had brilliant results. If one waited, one would post-
pone reporting results at all. The day would come
when the profession would have the Cabot system and
make a report as a lawyer would make a brief out for
82
MEDICAL RECORD.
[July 8, 1916
his client. The consultant would group together the
testimony of various specialists, relating to irritations,
focal infections, and so forth, and deduce his conclu-
sions. In some cases he would have relieved a pre-
cipitating factor, not a causative factor. In these cases
the surgeon was dealing with precipitating factors, and
his work was merely a therapeutic resource which as-
sisted the general practitioner, as the giving of a dose
of salts might assist him. The surgeon had to be re-
legated to the position of a therapeutic resource.
Dr. Emery Marvel of Atlantic City said he appre-
ciated the work of Dr. Reed on the subject of stasis.
They might well study what was the most susceptible
portion of the intestinal tract to stasis. If one took
no other means of instruction, one would conclude that
the most susceptible portion was the cecum. Dr. Reed
had mentioned inflation of the cecum. The condition
was passed over as not worthy of further mention. Ex-
ception should be taken to that. If the pictures of Dr.
Reed were followed, in cases where benefit had been ob-
tained, each picture showed stasis in the cecum. Dr.
Marvel said he had seen great benefit by reduction of
the cecum. Anywhere where one took peritoneal cov-
ering of the bowel and coapted it together there
would be distention. In studying the anatomy of
the ascending colon and cecum there were found three
bands of striae, and if sutures were applied here they
would not stretch. In the cecal pouch most of the dis-
tention was below the ileocecal valve, and the pouch had
to be reduced by making sutures in the longitudinal
direction and drawing them up. This was offered as a
consideration to Dr. Reed when cutting bands of ad-
hesions. If he would obliterate the pouch and reduce
the caliber of the cecum, additional benefit would accrue.
Prevention of the Passage of Gas Following Opera-
tions on the Colon. — Dr. A. J. Ochsner of Chicago
read this paper. He stated that aside from direct in-
terference with the circulation of the colon due to in-
jury to the vessels or to tension, there was no source
of danger to the patient so great as that which came
from obstruction to the passage of gas following the
operation. Dr. Ochsner presented charts illustrating
the various methods by which drainage could be sup-
plied to the site of operation and by which it was made
impossible for gas to accumulate above the operative
area. Various methods were as follows: (1) placing
of a drainage tube in the ileum to the abdominal wall
after removal of the colon. The mortality in these cases
had been reduced to a negligible fraction; (2) after
the removal of the ascending colon and attaching of
the ileum to the middle of the sigmoid flexure, the plac-
ing of a drainage tube to allow escape of gas from the
ileum; (3) use of a Jacob's retention catheter to drain
through the rectum into the ileum and flushing of the
openings, to prevent gas and fecal accumulation; (4)
where there was inactivity of the colon, attachment of
the ileum to the upper portion of the rectum or lower
portion of the sigmoid flexure, and application of the
Murphy proctoclysis directly to the ileum, irrigation
either from above or below ; (5) a portion of colon re-
moved, not being able to be attached; a buttonhole open-
ing was made in the abdominal wall or opening to the
ileum left open at the distal end; (6) excision of
tumor of the sigmoid, leaving enough intestine to make
an anastomosis; in this case the lumen of the lower
segment was not sufficient to carry a large drainage
tube, and a small tube was used; (7) resection of the
large intestine between the sigmoid and rectum with
insertion of a double drainage tube and fixation by a
few stutures, thus providing drainage for the gas. The
sutures would absorb and the wound would cauterize
and heal itself. In carcinoma of the colon there was
often enormous distention, and the incision should be
large enough for the entire hand. Such patients were
bad surgical risks. The obstruction had to be removed
and the tube applied.
Radical Operations for the Cure of Cancer of the
Second Half of the Large Intestine.— Dr. William J.
MAYO of Rochester. Minn., gave this paper, which was
read by Dr. Charles Mayo. The paper dealt with the
number of operations (419) from Jan. 1, 1898, to Dec.
31, 1915, at the Mayo clinic for resections of the large
intestine. The average mortality was 14.5 per cent. In
262 cases there was a five-year cure (54 per cent.), and
a three-year cure in (17. 5 per cent, of cases. In 184
cases the left half of the colon and splenic flexure was
resected with an average mortality of 17 per cent. The
right half of the colon was resected in 235 cases with
an average mortality of 12.5 per cent., the difference
being 5.5 per cent., and this was considered due to the
less septic character of the liquid contents of the right
half of the colon as compared with the more solid con-
tent of the left half of the colon and to the greater
safety of ileocolostomy, as compared with the methods
of union following resection of the left colon. The mor-
tality estimate included patients dying in hospital with-
out regard to the length of time death occurred after
operation. The mortality of resections for cancer of
the left half of the colon was based on an operability
of 62 per cent.; that is, of 100 patients 62 w:ers operated
upon. With an operability of 25 per cent, there was
a 5 per cent, mortality. There were permanent cures
in 60 per cent. A high operability with high mortality
and a low percentage of cures gave twice as many
cures to the hundred patients as a low operability and
a low mortality and high percentage of cures. This
appeared a paradox, but a greater number of patients
had been given a chance. In desperate cases the two-
stage operation was considered the best for the patient.
Metastases were often the cause of inoperability. The
patient, however, sometimes had a long rest before the
recurrence of the disease, and recent advance in technic
had extended radical operation to advanced cancers. In
conclusion patients with cancer of the second half of
the colon should be given a chance. The results were
shown to be better than in any other position except
cancers of the lip and in the fundus of the uterus.
Intestinal Obstruction: Further Experimental Studies.
— Dr. J. W. Draper of New York said that intestinal
obstruction was a many-sided problem, important to
the abdominal surgeon and to the surgical physiologist,
and important to conservative surgery and medicine.
Medicine had as yet failed to recognize that man was
but a link in the chain of animal and vegetable life and
the loosely defined syndrome known as autointoxication
was of interest alike to the surgeon and surgical physi-
ologist. This syndrome was associated with delay in
passage of intestinal contents. The relief by ileostomy,
mentioned by Lynch, could be ascribed more to bio-
chemical results than to mechanical measures. Future
progress in study would lie in considering the ali-
mentary tract as a whole rather than as cut into
arbitrary morphological divisions. Results in recent
laboratory experiments on obstruction at different
levels showed that animals died early in thoracic and
esophageal obstruction. In ileo-obstruction animals
apparently died under the influence of obstructed secre-
tion, which had been thought to be of fundamental im-
portance in causing death due to obstruction. The be-
ginning and end of the tract where shown to have
many points in common, the toxicity varying with the
digestive power. It was believed that the toxin was
not in the cell but was a product of abnormal activity.
The cells were not toxic, but their secretions were.
They apparently manufactured a substance deleterious
to the body. In duodenally obstructed animals the in-
coagulable nitrogen was double in twelve hours to
that in the controls. This might be of value in dif-
ferential diagnosis. The cause of death in obstruction
was not yet known but was apparently due to aberrant
activity of the jejunum and obstructed cells. Auto-
toxemia in the human would be better understood
when the cause of death in duodenally obstructed dogs
was known.
The Superiority of the Right Side Artificial Anus. —
Dr. John Young Brown of St. Louis gave this presen-
tation. He said that in cases of neoplasms of the
lower colon and rectum with history of chronic consti-
pation it was necessary for the surgeon to decide a
quick and safe method for relieving the patient after
the acute condition had been relieved. The cases were
usually inoperable from the rectal standpoint, although
sometimes radical work could be done. In these cases
an iliac anus, excluding entirely the large bowel, could
be rapidly made, a eecostomy being done to relieve the
tension. This measure excluded the current from the
large bowel and the continuity of the bowel could be
later restored, though this was most difficult in a left-
sided operation. The possessor of an artificial anus
was not to be envied, but he could be made comfortable
and without odor by the right procedure. The iliac
anus did away with adhesions which would follow a
left-sided anus and with the relief of acute obstruction
the large bowel could be prepared for later radical pro-
cedures when necessary. The right-sided anus enabled
the worker to work under the best conditions, and its
closure could be accomplished by simple and satisfac-
tory measi:
Dr. J. M. Lynch of New York said that he was very
triad to know that the profession were beginning to
July 8, 1916] '
MEDICAL RECORD.
83
recognize the value of ileostomy in surgery. This was
a comparatively old operation. It was first done twenty
years ago by an Italian physician, and there had been
scattered references in the literature up to the present
time. At the time Dr. Lynch had first performed this
operation it was upon a physician and he had a
multiple polyposis of the bowel. He had very severe in-
fection and was incapacitated from work. The results
of investigations on this case were read before the
Gastroenterological Society at Baltimore in 1915. The
patient was interested in the work upon him and he
was turned over to Dr. Lusk at Cornell, but he got tired
of being investigated as to sugar, although he would
have been willing, he said, to have been investigated on
beefsteak. He then went to Professor Mendel and
was investigated as to the contents of the ileum, and
Bradley of Wood's Hole investigated the enzyme out-
put of the lower ileum and found very few enzymes.
The most important lesson learned was that the patient
with an ileostomy was very comfortable and could be of
more use than the patient with a colostomy. Dr. Wm.
J. Mayo examined the patient and was convinced that
the operation was one of great value. The patient was
now practising in New Haven and had gained forty
pounds and refused to take the risk of having the
anus closed. The polyposis had disappeared but he
thought if the current were turned back he might have
a return of the trouble. It was not necessary to per-
form colostomy with ileostomy. In another case, a
woman, who had an obstruction at the lower end, a
catheter was passed through the ileocecal sphincter.
The colon was filled with water and the water remained
in. The catheter was then passed through the ileo-
cecal valve and the water tapped. There was no need
in these cases to make a cecostomy which was just as
difficult to close as an ileostomy.
Dr. J. S. Hoksley of Richmond, Va., said that he
had recently seen such an operation which had saved a
patient's life. The patient had a multiple papilloma of
the colon. It had become ulcerated and there was a dis-
charge of blood and mucus. The operation was done
under local anesthesia. He noticed Dr. Brown said he
used the lower stump of the ileum. He thought this
had a good many advantages. First it made an open-
ing in the cecum and retained the ileocecal valve. If
the flora of the large intestine had access to the small
intestine there would be trouble. There would be pro-
tection by getting the ileum to close up the cecum and
retaining the valve. If 12 inches were left from the
ileocecal valve there would be stump enough to make a
union with the ileum when it was necessary to re-
establish the current and preserve the valve.
Dr. J. Y. Brown of St. Louis said that he did not
do a cecostomy in these cases, but he simply inserted
the tube into the gut through the ileocecal valve. There
was rapid relief in the lower bowel after the upper
bowel was relieved. Where this operation was done in
a week or more one could irrigate through the tube in
the large bowel and get a relaxation where the origi-
nal obstruction was and clean out the bowel as well. It
was almost impossible to arrive at a correct diagnosis
in these cases. Dr. Crile had reported three or four
cases he considered malignant, and after the gastro-
enterostomy was done, the condition cleared up. In the
rectal eases it was necessary to get immediate relief
with as little delay and as simple a method as possible.
This method had been found absolutely invaluable in
cases of this type.
Pelvic Infection in Women. — Dr. Thomas J. WATKINS
of Chicago read this paper. He said that the subject
was a very large one and he would deal with some of
the features of its pathology. The modern treatment
of pelvic infections should be based on knowledge ac-
quired in special and general infection and immunity.
It had been changed in accordance with the apprecia-
tion of the systemic nature of infection. It was not
truly a local disease and recovery was due to systemic
immunization. In puerperal cases inflammatory exu-
date was largely accidental except in embolic infections
or phlebitis; in the nonpuerperal state the condition
was different, on account of the mode of extension of
the infection, which was by continuity of tissue, involv-
ing the Fallopian tubes. The local reaction was a con-
servative process limiting the bacterial invasion. Pres-
ence of pus was not now, as formerly, considered in-
dicative of immediate operation. Pus might be in
reality an autogenous vaccine, according to the work
of Vaughan, Jobling, Petersen and Lusk, who regarded
inflammatory products simply as reactions from bac-
terial invasion. Chronic and acute infections should be
differentiated. The acute infections were the result of
conflict with invading bacteria and the chronic dealt
with the residues resulting from this conflict. His aim
now was to deal entirely with acute infection. The
treatment, medical and surgical, in these cases was con-
fined entirely to sustaining increase of body resistance.
No remedy was of value apart from this consideration.
The outdoor treatment was of much more value in
these cases than it was in tuberculous cases, as the one
disease was more acute than the other. Patients would
sleep better and take twice as much food with outdoor
treatment, and upon this the body resistance depended.
In very acute cases of puerperal infection where leuko-
penia was present, blood transfusion was of great value.
In regard to systemic immunity, suppurations in the
pelvis became sterile more readily than in other parts
of the body, due to active reactions in the pelvis. Thus
practically all puerperal infections would be medically
treated, and it had been found that since there was
less surgical treatment, there was a lower morbidity.
Nonpuerperal infections should be also treated medi-
cally since they had marked leucocytosis. Three opera-
tions might be cited: curettage, incision and drainage,
and excision of infected parts. The first should be
condemned as dangerous and unnecessary; the second
should be practised in exceptional cases, but prolonged
operations under deep anesthesia were condemned as
lowering resistance; the third, excision, had a limited
field, i.e. with infected degenerated fibroids, with twisted
pedicles of tumors, with acute intestinal obstruction,
and with acute appendicitis.
Results Following the Treatment of Pelvic Inflam-
matory Lesions by Surgical Measures. — Drs. J. G.
Clark and C. C. Norms of Philadelphia presented this
paper, which dealt with the tubal and gonococcal type
of infection. It was stated that a few years ago, when
a patient was brought to the hospital in an ambulance
the surgeon did not know whether the tube or ap-
pendix was involved. Both were considered surgical
cases, and both were promptly operated upon. It was
recognized now that gonococcus was a slow infection
and rarely produced peritonitis. Dr. Clark then showed
lantern slides of tables showing percentages before and
since 1910 of the results of conservative treatment, with
about 71 per cent, cures. He felt that conservative
treatment showed that mortality was less and morbidity
better with this method. The employment of drainage
was always prejudicial to the patient. He would criti-
cise Dr. Coffey's recent articles on the treatment by
quarantine pack, because, in the first place, gonococcus
infection tended to quarantine itself; it did not tend to
peritonitis nor produce infection extraneous to its site.
He felt that Dr. Coffey would find that this pack would
produce hernia of the intestine and adhesions, and he
would be obliged to discontinue its use. The conserva-
tive treatment aimed at the preservation of the men-
strual function rather than at the preservation of fe-
cundity, which had usually been lost in gonococcal in-
fection. In only two of their cases had there been sub-
sequent pregnancy.
Thursday, June 15 — Third Day.
The External Signs of Diagnosis of the Attitude of
the Fetus in Utero. — Dr. E. Gustav Zinke of Cin-
cinnati read this paper. He compared the former prac-
tice of obstetrics by ignorant midwives with the present
practice in the hands of physicians. This was prac-
tically a new branch, and he felt that it was the duty
of medical colleges to provide competent teachers of
this art. A great many physicians were not familiar
with the principles of obstetrics, and the ignorant physi-
cian was as dangerous as the ignorant midwife. The
most neglected side of this art was obstetrical diag-
nosis. Questions to be answered were : Was the patient
really pregnant? If so, how far was pregnancy ad-
vanced? Would the parturient tract admit the passage
of a full-term child? Was the patient healthy? What
was the attitude of the fetus in utero after the seventh
calendar month of gestation? In regard to the first
question, the diagnosis was doubtful when signs were
indistinct, when the patient menstruated irregularly
or had never menstruated, or when she was past the
menopause. The advancement of pregnancy might be
determined by the size of the uterus or by the calcula-
tion of the last period. Thirdly, a thorough vaginal
examination would reveal sufficient evidence of pelvic
deformity to indicate instrumental delivery. Fourthly,
family history and physical examination would reveal
presence of disease. Fifthly, the attitude of the fetus
in utero was important in the last two lunar months of
84
MEDICAL RECORD.
L-July 8, 1916
pregnancy. In a patient of normal stature and attitude
a child might be born in almost any posture at the
seventh month, but at the end the position must be de-
termined. The fetal attitude must be diagnosed by ex-
ternal examination. To do this it was necessary to map
the abdomen into four quadrants, right upper and lower
and left upper and lower. To discover evidences of a
breech or vertex presentation careful notation of the
movements of the fetal heart and of the fetal move-
ments in regard to these quadrants and to the umbilicus
should be made. In vertex presentations the fetal move-
ments were in the region of the diaphragm. The head
would always select the right oblique diameter, which
was the largest. The second and fourth positions of
the vertex were most common and the first and third
least common. In breech presentations the dorso-
anterior position was most favorable for the body of
the fetus and the d.a.l. position for the head. The fetal
heart was to the left and level with the umbilicus, the
movements posterior and below the umbilicus and the
head in the upper right abdominal quadrant.
Dr. Manton of Detroit said he considered this paper
very important, because he found that on an average
not more than 50 per cent, of practitioners made a
diagnosis of presentation or position in any way. It was
a great deal easier to diagnose presentation and posi-
tion by external abdominal palpation than it was to do
so by vaginal touch. The majority of physicians ar-
rived on the scene after labor had begun, when the
pelvic bones had overlapped so that, especially in ner-
vous patients, vaginal examination was extremely diffi-
cult. The personal equation entered very largely into
diagnosis. He found that it did not make much dif-
ference how well a man was trained; if he was indif-
ferent and negligent, and if he took confinement cases
only as pot boilers, he would not in any instance make
a correct diagnosis. He could cite a case of one of his
students, a recent graduate, who was sent to assist in
a case which he diagnosed as transverse presentation.
When the case was seen it was found that the young
doctor had not even done abdominal palpation and he
had jumped to the conclusion of transverse presenta-
tion. It turned out to be a perfectly normal presenta-
tion. Any paper which would draw attention to these
diagnostic points was exceedingly valuable, and Dr.
Zinke had rendered great service by enumerating these
features.
Dr. John 0. Polak of Brooklyn said that he was very
pleased to hear from Dr. Zinke on the subject of pal-
pation. The importance of this subject could not be
overestimated. The knowledge gained in antepartem
examination in following the course of labor was ex-
tremely valuable. In ordinary cases one could follow
the advance of the course of the head and the descent
of the head through the pelvis with the hand; and also
the fetal heart in its descent and approach to the me-
dian line. In Faber's clinic the movements of the fetal
heart were followed and studied and the course of labor
determined by the descent of the heart of the fetus.
It was impressive to mark the descent of the fetal heart
every half-hour during the course of labor and to have
the student record his findings to show the direction of
the anterior shoulder of the fetal heart as the head de-
scended into the pelvis, and in that way to obtain a
practical guide of the descent of the head. In regard
to the cervix, the dilatation of the cervix was followed
through the rectum, and most of the normal cases were
conducted with no vaginal examination. The progress
was followed by abdominal palpation and by using
the fetal heart and the condition of the cervix" by pal-
pation as a guide.
Dr. Yarros of Chicago said that those of them who
had medical students to teach eight months out of the
year found themselves in a curious position. These fea-
tures were the A R C of modern training-, which had
advanced on that formerly given. These things had
to be pointed out to students day by day, and it was
necessary, because they would not remember them in
making examination. It was so with the profession;
they would not use the knowledge they had. The ABC
of modern teaching was of the highest importance. It
was not that the doctor did not know the breech from
the vertex ; it was that he did not use his knowledge.
One made a diagnosis only by using methods of diag-
nosis. In listening to the fetal heart sounds it was
important to ask the mother where she felt the baby
most of the time. In a moment she would reply on the
right side more often. The small extremity would lie
there. The fetal heart sounds, as mentioned by Dr.
Polak, were of importance. The student must listen to
them when he made his diagnosis. The examination
per rectum as to how much dilatation theie was seemed
to puzzle students a good deal, but this was one of the
important means of diagnosis to be taught them.
Dr. Zinke said that it was impossible in a fifteen-
minute paper to cover the subject entirely, as it in-
volved so many points. He had had some misgivings in
presenting such a paper to such a learned body as this,
but he had met with so many sad and serious experi-
ences in his consultation practice that he thought a
paper on this subject would be timely and would bring
these ideas anew before the profession. It illustrated
the fact that, having risen to the heights of abdominal
surgery yesterday, it was proper that they should de-
scend to the more common ground of equally useful and
important subjects to-day.
Posture in Obstetrics. — Dr. James W. Markoe of
New York read this communication. In it he gave a
brief history of the antiquity of the usage of chairs for
the use of women in labor. These were in use in the
most primitive tribes in Africa, were common in the
Orient, and had been in use in European countries
through the middle ages and down to the present day.
In Holland this formed part of an outfit of a well-
equipped bride in the last century. In 1909 Dr. Markoe
had turned his attention to the study of posture in ob-
stetrics and its effect in different stages of labor. With
the introduction of forceps in labor the importance of
this subject had been lost sight of. The obstetrician
should endeavor to make the first stage as short as pos-
sible to spare suffering to the mother. It was his duty
to teach the woman to make the best use of her pains.
In the first stage of labor the chair would allow full
dilatation to take place. It would also allow the ex-
pectant mother to rest as much as possible. A study of
the text-books showed that the physician was not ex-
pected to bother with the patient until the second stage
of labor. The primipara, however, did not know how
to use her efforts. The use of the chair would be found
to exert the pressure of the bag of waters to the best
degree. The rule of use-with-discretion applied to the
chair as to all other procedures, but Dr. Markoe had
found that since he had used the chair he had had re-
course to far fewer surgical procedures. It had been
used with 282 primipara? and 38 multipara?. Dr. Mar-
koe showed slides illustrating primitive and medieval
chairs, and also an experimental chair designed by him.
with movable footboard and back, and also the use of
the ordinary rocking chair with certain support for
the feet which could throw the axis of the uterus back.
Dr. R. W. Holmes of Chicago said that it was an in-
teresting thing that a man who was the head of one of
the largest maternity services in the country should
discuss the question of posture in labor. All the rest
of the morning had been given to the grandstand stunts
of obstetrics, but the most vitally important were these
things that every man ought to know how to carry out.
He was sorry that Dr. Markoe's paper did not go fur-
ther into the field of posture, because it was so vitally
important to obstetric work. The original chair was
the position of the woman merely squatting. This was
the most natural position of emptying of the pelvic con-
tents. It brought the axis of the uterus more nearly
into the axis of the pelvis, thereby bringing the descent
of the head into the brim. That position of crouching
often secured the same effect. The extreme lithotomy
position gave the woman the same position that Dr.
Markoe gave with his obstetric chair. He did not see,
however, how the chair could be said to shorten labor
if the average time was twenty hours and the time in
the chair was two hours. Twilight sleep had not short-
ened labor materially either. It was, however, a more
vitally important thing that patients in the early stages
of labor should have the advantages of more convenient
posture. Posture meant much in abnormal labor. It
meant the minimizing of forces. Thus in oblique pres-
entations, where the long axis of the baby was trans-
verse to the long axis of the mother, the woman should
be put on the left side, where the head was to the left,
and the fundus would gravitate and carry with it the
breech. It would be well for all to go further into the
ramifications of the subiect of posture in labor. If the
studies made in Dr. Zinke's paper and in Dr. Markoe's
paper were followed all the time they would all get
somewhere. There would not be so much indiscriminate
cesarean section and there would be an end of the
pseudo science of obstetrics.
Dr. Racon of Chicago said he had not been in the
habit of letting1 the patient be up and around the room,
mainly because of the danger of contamination. The
natient was put in a sterile bed and effort was made to
keep her in a clean condition. The contamination from
July 8, 1916]
MEDICAL RECORD.
85
the floor to the feet was avoided and walking around,
for that reason, was discouraged. The use of the chair
and letting the patient get out of bed would defeat per-
fectly sterile conditions. He would ask the doctor to
answer this point. He had been somewhat in doubt as
to the value of abdominal contractions in the first stage
of labor. It was chiefly the uterine muscle that dilated
the cervix, but the experience of Dr. Markoe would in-
cline him to try this.
Dr. J. W. Lee of New York said that, of course, the
most natural thing in our existence was to be born. It
seemed wonderful after millions of years that there
should be so much discussion on the most natural pro-
cedure that mankind could first resort to. There was
one other that was inevitable, but this was the primary
entrance to separate existence. In posture in labor na-
ture asserted itself. The most primitive posture, as
Dr. Markoe had brought out, was squatting. He wanted
to make reference to that, because it had been his for-
tune to be among primitive people. Many years ago,
when he was among the Indians, he knew of an Indian
woman about to be confined. He told the husband that
he would be glad to be of any assistance if he could.
The Indian asked him how much he would give him.
Dr. Lee said that he asked the man how much he
wanted, and the husband said he wanted a dollar. Dr.
Lee agreed to give him this sum and the man agreed
to let Dr. Lee know quickly when the birth was to take
place. Shortly after the man came running and they
both went running back and arrived in time. The
woman was in a squatting posture and she simply
pulled the baby out of the pelvis, bit the cord in two
and tied it, took some handfuls of grass and wiped off
the blood, the placenta came away, and that was all
there was to it. In advocating posture care had to be
taken not to bring on undue contraction of the muscles
of the uterus for fear of rupture, but posture stimu-
lating the first stage of labor would save no end of
trouble. Another question was how was one to manage
asepsis. He had heard a great deal about antiseptic
labor and he had seen many, many cases of so-called
puerperal fever that followed the most up-to-date,
scientific, elaborate sterilizing procedure. There was
one other condition that he had observed. In his early
days in the wilds he was called to attend upon a primi-
para. He knew very little of obstetrics. The woman
was in labor and he was beginning to be very nervous.
He washed his forceps and got ready. He had no as-
sistance but an old Irish lady who he was convinced
knew much more about the matter than he did. Pres-
ently the old lady asked, "Doctor, aren't you going to
quill her?" He said yes, perhaps that had better be
done. He did not know what it was, but he had con-
fidence in the old lady. The old lady picked out a good
sized goose quill and filled it with black snuff and put
it to the patient's nose. The patient began to sneeze
and in fifteen minutes the baby was born.
Dr. E. P. Davis of Philadelphia said that he recog-
nized the value of posture as set forth by Dr. Markoe,
and fully indorsed what he said concerning it. He
would also call attention to the value of posture in pro-
lapse of the cord when the knee chest posture and
vaginal reposition of the cord were often successful.
Voucher's position was also often of value in moderate
pelvic contraction. Dr. Davis said he was for primitive
remedies, and he had often prevented cesarean section
in the production of labor, by resorting to the posture
on the knees. If more people went upon their knees
more often no harm would be done. Lincoln had said
that often in political crises he was driven to his knees
because he had nowhere else to go. This principle would
prove of use in labor cases. In the maternity hospital
in Philadelphia where the matron was a woman of ex-
perience and sense, the patients with moderately con-
tracted pelves were often to be found scrubbing: the
stairs, in the kneeling posture and with vigorous use
of the arms. Spontaneous deliveries were the rule, and
cesarean section was rarely resorted to.
Dr. Zinke of Cincinnati said that it was not his in-
tention to unduly prolong the discussion, but he would
like to emphasize the sledge-hammer eloquence of his
friend. Dr. Davis. The question was how were they
going to prevent the necessity of performing: cesarean
sections and other operative procedures. They could
not abandon the judgment of the obstetrician. There
was no question, however, in his mind but that many
of the obstetric operations were performed too often
and without proper distinction, but at the same time
they should go slow and not express themselves entirely
condemnatory of procedures which had proven them-
selves of benefit to mankind. The doctrine of narrow-
pelves, scarcely of age, which it had taken 100 years
to develop, and which had been amply tested in the hos-
pitals of Europe within the past twenty years, gave this
result, that the cases of labor with narrow pelves had
given 80 per cent, spontaneous deliveries. Five per
cent, of cases had cesarean section with a maternal
mortality of less than 1 per cent. He would take occa-
sion here to mention one symptom, sometimes encoun-
tered, that was the "ringerbandel" or ring contraction.
It could be seen when the abdominal wall was exposed,
running transversely or obliquely, and it was always a
danger signal of rupture of the uterus. The lower seg-
ment became so excessively attenuated that there was
always danger of rupture. No man would hesitate,
when he saw this ring, to perform cesarean section or
hebosteotomy as the case might be.
The Use of Chloroform in the First Stages of Labor.
— Dr. I. L. Hill of New York said that the use of
chloroform in obstetrics was formerly widespread, and
accident was almost unknown, but that recently its use
had been criticised, largely on account of its relationship
to active degeneration of the liver cells. Some hospitals
had given up its use on this account. More evidence,
however, should be forthcoming, based on autopsy find-
ings, as to chloroform poisoning in obstetrical cases,
than had at present been produced. Careful search of
the literature failed to show sufficient evidence for
abandoning it, as 5000 chloroform anesthesias has been
performed without death, and some of these in very pro-
tracted cases. The prejudice against chloroform seemed
to have arisen largely on account of laboratory experi-
ments on dogs, in which it was found that damage took
place by liberation of hydrochloric acid with alkalis. On
this account Dr. Hill had undertaken a series of ex-
periments on animals under chloroform anesthesia. His
conclusions were that these animal experiments were
in no way comparable to human anesthesias, the ani-
mals being frightened and struggling for hours, and
requiring excessive doses, whereas a woman in labor
was suffering pain and anticipated relief, so that the
force of suggestion was added to the procedure. Dr.
Hill had found that combined with small doses of pitu-
itrin good results had been obtained. There was no
arbitrary rule for chloroform dosage; it was necessary
when the patient was unequal to the suffering. A very
little chloroform would secure tranquillity and coopera-
tion of the patient. Neurotic patients were most amena-
ble to suggestion in this respect.
Obstetric Surgery. — Dr. E. P. Davis of Philadelphia
reviewed his subject from the standpoint of modern
surgery and from his clinical experience. The scope
of obstetric surgery had become a wide one. Oper-
ation was indicated in many complications, such as
ectopic gestation, colon bacillus appendicular infec-
tion, pyosalpinx complicating pregnancy, rupture of
the uterus, ovarian tumor, fibroid tumors. All of
these were complicating problems. In soft myomata
of the uterus one distinguished surgeon had said
that he could not tell the difference from pregnancy,
but to the obstetrician Hegar's sign should always
be distinct. The question of tumors was difficult;
when they were present one had to ask how long
the woman could go on and still have a living child.
The obstetrical surgeon had also to be a vaginal and
abdominal surgeon, but in many cases the art of ob-
stetrics had been lost and a surgical monstrosity substi-
tuted. In spontaneous labor the maternal mortality
was but a fraction of one per cent, and that of the child
was largely due to asphyxiation. Abdominal cesarean
section was to be done only in carefully selected cases,
the mortality for the mother was then low, and it was
the safest way of delivering a living child. In delivery
by the vaginal route the death rate was in proportion to
the leaving by the surgeon of the uterus in good con-
dition, well drained and contracted. The fetal mor-
tality in these cases was in proportion to the distance
of the head; when the head was well in sight it was 10
per cent., with floating head as much as 33 per cent.
Clinical diagnosis was of far greater importance in
all cases than laying too much stress on laboratory
findings and centimeter measurements. There should
be constant clinical diagnosis, and the obstetrician
should perform operations, not the surgeon.
Dr. E. G. Zinke of Cincinnati said that practice was
one thing and the exercise of good judgment was an-
other. Lawson Tait had suggested cesarean section
for placenta previa, and Dr. Zinke had treated the sub-
ject in his entrance essay before this society. When
he had got through reading his paper, there had not
86
MEDICAL RECORD.
[July 8, 1916
been a single assenting voice. He had been roundly
arraigned and subsequently criticised in the journals,
but to those who had studied the subject, it was clear
that there was justification for cesarean section in cer-
tain conditions of placenta previa. Every case of
placenta previa was a surgical one, and could be recog-
nized before hemorrhage appeared and sent to the
hospital to the care of a good surgeon.
Dr. John O. Polak of Brooklyn said that there was
just one point in regard to Dr. Davis' paper that he
would like to mention. The success of the obstetrie
surgeon depended, first, upon his ability to make a diag-
nosis; second, upon the training of the individual op-
erator; third, upon asepsis. In regard to rupture of
the uterus, the speaker said that in the work of Fin-
ley sixty-two collected cases had been reported with no
rupture, except where there was definite morbidity;
that is, infection of some type. Every labor case should
be studied as to its diagnosis, measurements, and posi-
tion, and every case should be given the aseptic test,
abdominally, following rectal interpretation.
Meddlesome Midwifery in Renaissance. — Dr. DeLee
of Chicago stated that in the census of 1914 10,518 wom-
en died in childbirth. That was estimated on two-thirds
of the population of the United States, and probably,
when one considered deaths due to after effects of
childbirth, such as nephritis, endocardial disease, etc.,
it was very much higher. Probably there died annually
in the United States 20,000 mothers, and the infant
mortality was as high. The morbidity was also high;
4,654 women died of sepsis in 1914. In puerperal cases
15 per cent, had fever of some degree. Pelvic adhesions
were frequent, and many patients came back with the
same history of never having been well since the birth
of the child. Lacerated cervix was more common than
lacerated perineum because the accoucheur did not take
sufficient care of the cervix, and infections of this part
were frequent. Too many interferences with the nat-
ural processes were being practised, the efforts that
nature employed to expel the child being the best ones
and intended to insure slow dilatation of the passages
and gradual advance of the fetus. The old time watch-
ing and waiting policy in labor had been replaced by a
polypragmasia, every sort of reason being advanced for
hastening the processes of nature, including that of
saving time and sleep to the obstetrician ! One of the
most common evils was the attempt to cut short the
period of dilatation, and overstretching frequently re-
sulted in gynecological and urological disease. The
misuse of twilight sleep and of gas and oxygen had re-
sulted in increase of postpartem hemorrhage and forc-
ing the parturient to make too early bearing-down
efforts was a very common cause of procidentia uteri.
It was desirable to save the levator ani from too rapid
distention. If a desire for too rapid labor were curbed
and an extra half hour given, it would save the woman
from permanent relaxation of the pelvic floor. Other
dangers were the use of pituitrin, which should be en-
tirely condemned; too frequent cesarean section, and
the use of cutting operations instead of natural dilata-
tion of the cervix.
Dr. A. J. Rongy of New York said that he wished to
emphasize the operation of pubiotomy in protracted
labor. The use of forceps often precipitated infection,
and pubiotomy was the only choice. After a woman had
had two or three dead babies and was very anxious to
have a living baby this operation would give her a
chance. Cesarean section on the mothers gave a 30
per cent, mortality in the children. In placenta previa,
at the seventh or eighth months of gestation when
there was profuse bleeding with no signs of labor, the
operation could be tried because one did not know when
labor would take place. Another point was being able
to diagnose the size of the baby in the uterus as this
would decide whether induction of labor was desirable.
Dr. E. P. Davis of Philadelphia said that he had done
eight pubiotomies, and he had stopped. He did not like
the operation, lie was in entire accord with Dr. Holmes
in wishing to stop unnecessary cesarean section. He
hoped he would be able to do "it. To the modern ob-
stetrician fell the task of repairing injuries of labor, the
injuries to the cervix, the pelvic floor, and perineum. No
vaginal operation was complete unless these points were
attended to. With regard to the criticism of Dr. Bacon
about intrauterine gauze drainage, he had never seen
retention of lochia. He had seen 8 per cent, complete
union and 10 per cent, partial union. In regard to rup-
ture after cesarean section he had done a number and
had not had rupture, but it was an emergency pro-
cedure. He was heartily in accord with Dr. DeLee's re-
marks that injury to the genital tract produced in-
validism. He did not believe in curtailing labor. The
question of palpation was important in diagnosis. A
man should be able to tell when engagement was there
or not there. In regard to sepsis, the woman did not
die so much from the hemorrhage and sepsis as from
changes in the liver and kidneys as the result of tox-
emia. In regard to his friends Drs. Carstens and Zinke,
he asked what could he as a specialist do to make their
practice better. He could send them recent graduates,
men trained to give anesthesia properly, men who knew
when the head was engaged and when to call in the older
practitioner, men who knew how to wratch the case. He
wanted to give these men assistants who knew how to
use modern facilities. These older men had fought out
the problems single-handed, and the next generation had
had the advantage of their knowledge. All honor to the
old guard.
Dr. DeLee said that he wished to subscribe most
heartily to the last words of Dr. Davis, and if the old
guard would adopt the methods of the younger men,
they would say all honor to the young guard, too. One
important point was the rectal examination. It was a
pity that it took so long for men to learn it. If every-
one would try it out on his next case it would be aston-
ishing how much would be accomplished. With external
diagnosis and rectal examination one could get all tn<"
information necessary. Here he would say that chloro-
form was not necessary to the general practitioner. He
had been a general practitioner, and he thought one
could instruct the husband to give the patient ether as
well as one could give chloroform. Ether was more
bulky to carry, but the physician would have to carry
much more paraphernalia if he was going to do modern
obstetrical practice.
Umbilical Hernia and Lipectomy. — Dr. Walter
Lathrop of Hazleton, Pa., sketched the changes which
took place in the umbilicus after birth, resulting in the
formation of a firm fibrous scar. In hernias this was
weakened and the abdominal wall might be involved.
This condition was twelve times more frequent in
women than in men. Repair by overlapping to secure
firm fixation was the most useful operation and con-
siderable help was obtained by lipectomy where the
abdomen was large and pendulous. Lipectomy was an
easy operation to accomplish and if postoperative in-
structions as to diet and exercise were followed the re-
lief from excessive fat would last a long time. The
chances of recurrence of hernia were very much lessened
by lipectomy in very obese patients.
Sheet Rubber Superior to Gauze in Abdominal Oper-
ation.— Dr. J. W. Keefe of Providence, R. I., said that
as long as surgery remained an art sponges would be
overlooked and left in the abdominal cavity. Even very
experienced surgeons had had the misfortune to leave
something in the abdominal cavity. The human ele-
ment was always present in operating and it w-as easy
to leave a foreign body in the wound. Many cases
never came to autopsy and so the extent of these mis-
takes would never be known. The causes included a
bad light, unfavorable position, profuse bleeding, and
many cases had happened with extrauterine pregnancy,
hernia, and bladder operations. Forceps had been found
after four years and sponges after twelve. In one case
where an appendix had been removed under local anes-
thesia and a sponge was left in, the patient sued the
surgeon, who contended that the patient was looking
on and was therefore responsible. The court, however,
held the surgeon responsible. Very many devices had
been adopted to prevent these accidents, such as count-
ing the sponges, or tying the sponges to tapes. None
of these answered all objections, for if the work of
Yandall Henderson were correct, the covering of the
intestine with gauze was responsible for the loss of CO>
content of the blood. The intestine should be placed in
a bag. The use of the rubber roll would obviate many
difficulties. Part of it lay outside the wound. It was
easy to clean and sterilize and it was less irritating to
the tissues. The loss of the CO: content of the blood
would be prevented. The relief of not having to keep
count of the sponges would be immediately felt by the
surgeon.
Indications for Cholecystostomy. — Dr. Donald Guth-
kie of Sayre, Pa., gave this paper. He said that the re-
currences after cholecystostomy were from 1 to 33 per
cent. He had sent letters to a number of prominent
surgeons requesting their opinion as to the compara-
tive results in cholecystectomy and cholecystostomy.
Some advised cholecystectomy for the prevention of
systemic disease. Some thought that it was only indi-
July 8, 1916]
MEDICAL RECORD.
87
cated in malignant disease. Others, Crile, Lilienthal,
and Erdman, preferred cholecystectomy in most cases,
as affording better drainage. Counterindications for
cholecystectomy were inexperience of the operator,
desperate condition of the patient, obesity of patient,
perihepatic adhesions. Deaver, Mayo, and Crile advised
against it in empyema of the gall bladder. The latter
was to be treated by cholecystostomy followed by chol-
ecystectomy. The mortality was variously estimated as
being lower or higher than in cholecystostomy. Con-
clusions were that cholecystectomy was the better opera-
tion, but was more dangerous and required a skilled
surgeon, and that empyema of the gall bladder was best
treated by cholecystostomy and later by a second
operation.
One Hundred Consecutive Cases of Fibromyomata
Uteri Subjected to Operation. — Dr. S. E. Tracy of
Philadelphia said a study of his eases led him to con-
clude that malignancy was more frequent than was gen-
erally believed. In his series if microscopical examina-
tion six months after operation revealed a good condition
it was considered a cure. His cases showed 12 per cent.
of malignancy, and this was in accord with the general
statistics showing that cancer was on the increase (62
per cent, in 1900 as compared with 78 per cent, in
1915). The ages of his patients were from 23 to 72
years, and 88 per cent, were over 40 years of age;
sixty-three were married, twenty-seven single, and 72
per cent, had had children. In fifty-six cases there
were associated abdominal lesions. After hysterectomy
the amount of suffering from artificial menopause
was noted. There was none in 18 per cent, of cases,
other cases had varying degree, and in four it was very
marked. Forty-eight patients had both ovaries re-
moved. In these cases menopause symptoms were ab-
sent in 70 per cent. In women under forty years of
age it was found preferable to leave the right ovary,
but not unless it was absolutely normal. After forty
years of age this did not matter. Fifteen myomectomies
had been done. Of all patients two had hemorrhages
postoperative, one controlled by .r-ray. Seventy-four
were alive and in good health, mortality was 2 per cent.
He believed that all cases of fibromyomata uteri should
receive early surgical treatment, and that those
surgeons who advised women to do nothing but to await
the menopause assumed a very serious responsibility.
His list of operations included supravaginal hysterec-
tomies 64; panhysterectomies 20; vaginal hysterec-
tomy 1 ; abdominal myomectomies 9 ; vaginal myomec-
tomies 6.
Operative Treatment of Fibromyomatous Uterine
Tumors. — Dr. John B. Deaver of Philadelphia read this
paper. He stated that much harm could be done
by delay in the treatment of uterine tumors. It was
claimed that diminution of tumor growth had been
brought about by the x-ray and even more extensive
claims were made for radium therapy. He felt, how-
ever, that while it was possible for radiation to check
hemorrhage and influence tumor growth that this
therapy excited false hopes and should be considered as
malpractice. Radium should only be employed when
operation was counterindicated. There was a large
class of associated lesions in these cases, such as pyo-
salpinx, carcinoma of the appendix; ovarian cysts, der-
moid; papillitis of the rectum or ovary; cholecystitis;
hernia and other conditions. Surgery was the only safe
treatment for malignant disease and the only way to
cure cancer was to operate before it became cancer.
The operation of choice was supravaginal amputation,
and in some cases myomectomy. There was one other
operation that might occasionally be of use, that was
hysterotomy. Occasionally it was impossible to dis-
tinguish between pregnancy and a tumor symmetrically
enlarged. Richardson had said in this connection that
he could not always tell pregnancy when he had the
uterus in his hand and the obstetrician could not tell
when he was on the outside.
Recent Progress in the Surgical Treatment of
Uterine Cancer. — Dr. J. J. Jacobson of Toledo, Ohio,
read this paper. He said that the criterion of cure
in all of his studies was based on the five-year
period. The radical operation of Wertheim had given
42.5 per cent, of cures for less periods of time and 25
per cent, of cases passed the five-year limit. Cases of
recurrence after operation had usually been generally
considered hopeless, but Zweifel had reported 30 per
cent, of cures after 7.5 years for operation and recur-
rences. The treatment of Percy by diffusion of low-
degree heat throughout the cancer mass was found,
when properly performed, to raise the operability of
cases to 90 per cent. A'-ray and radium therapy were
undoubtedly powerful agents in aiding in the cure of
these diseases, as inoperable cases could be brought into
such condition as to present a good operating field for
the surgeon. The best results could then be obtained
in the radical abdominal operation. Cancer of the
uterus should receive the same treatment as cancer in
other parts of the body and undergo radical operation.
The type of cancer present should be determined and
cancers of the vaginal portion of the uterus should be
radically treated. The treatment by x-ray and radium
should be restricted to inoperable cases, and these agents
should also be used as a subsequent therapeutic measure
following every operation for uterine cancer. In this
way the patient would have been given the best pos-
sible chance against recurrence.
Dr. Henry T. Byford of Chicago said that anyone
coming there to-day would receive the impression that
there was no other treatment for fibroid tumors but
operation, but he had read a statement from the other
side of the water that no fibroid tumors should be re-
moved at all until radium and x-ray treatment had been
tried. The truth did not lie with either extreme. Know-
ing that there was a certain mortality with some of
these cases, he thought that there should be a certain
amount of individualism in certain doubtful cases. With
regard to x-ray treatment, it had the place which re-
moval of the ovaries once had. It was found that the
bleeding depended largely upon menstrual influence and
that the congestion made the tumors grow faster.
Removal of the ovaries stopped the hemorrhage and
diminished the growth, and some apparently gave no
trouble. This method had been abandoned after thor-
ough trial. The x-ray worked the same way, but one
could not get the x-ray into the tissue without destroy-
ing the surrounding tissue. If one restricted the cancer
cells with fibroid tissue there might also be dessication
of muscular tissue and the subsequent round cell infil-
tration would increase the trouble rather than diminish
it. In certain cases there was no excuse for x-ray
therapy, and this held true also of radium. It could not
go through large tumors without also destroying the
mucous membrane. Large tumors could not be treated
in this way, but there should be a certain individualiza-
tion in the cases of younger women with small tumors.
The removal of the ovaries in the case of young mar-
ried women who were to live with their husbands con-
demned them to a life of unhappiness. The social side
of this question had to be considered, for although the
woman and man stayed together on account of children
a great deal of unhappiness was bound to result. The
cure by removal of the ovaries was a doubtful one in
any case. The removal of small tumors after the meno-
pause was a more difficult matter, as a larger incision
was necessary, and one had to go further into the uterus
and one ran therefore more chance of sepsis.
Dr. Carstens of Detroit said he agreed with Dr.
Jacobson on general principles, but one point was es-
sential, and that was that one must make an early diag-
nosis. Cancer had a beginning and was so small at
first that it could not be seen, but it would get in time
to be as large as one's head. In older women it could
be recognized. What was wanted was early diagnosis.
Hundreds of women were curetted and no one ever took
the trouble to examine the curettings, but they were
thrown into the slop pail. Every curetting should be
examined, and in one hundred cases these might be
nothing but in the hundred and first case one would
catch the indications. It mattered not whether the
woman was nineteen or forty, it had been found at all
ages. He said perhaps he was dull of comprehension,
but when he heard his x-ray friends talk about getting
cancer by exposure to the x-ray he wondered why did
they use it to cure cancer. All these treatments came
and went, and he could remember when his friend
Marcy was experimenting with 200-ampere electricity;
but surgery stayed with them forever. In regard to
the other conditions, he agreed with every thing that
had been said; especially did he agree with Dr. Deaver
in regard to the operation on uterine fibroids. There
was, however, one point he would make, and that was
that fibroids did not kill the patient immediately. The
surgeon should endeavor to get the patient into the best
possible condition; and after due preparation, and
when the woman was in the proper phase, operation
could be done as soon as possible. In reply to Dr.
Deaver he was surprised to hear the doctor advocating
such an operation as hysterotomy. Personally he had
alwavs been able to diagnose pregnancy without cutting
into the uterus, but if there was any doubt in the doc-
88
MEDICAL RECORD.
[July 8, 1916
tor's mind it was easy to have an x-ray picture taken
of the uterus; if the woman was pregnant the fetal
bones would be shown. This was an easy procedure,
and he asked the doctor not to do any more hysteroto-
mies.
Dr. H. O. Marcy of Boston said that he remembered
when he was experimenting with Apostoli's electrical
treatment and he had asked him to come to his hospital
in Boston and give treatments. The singular thing was
that every patient believed that she was benefited by it.
He thought that the x-ray and radium would follow the
other tr jatment. What was there then left for the pro-
fession to do? He would advise them to follow Dr.
Deaver, but he would say that if one was in doubt an
.x-ray picture should be taken and studied and one could
find out what was in the uterus. Surgery was the only
treatment to be considered, but he would ask the pro-
fession to make themselves more perfect in the tech-
nique so that they could do better work in the future
than they, the older men, had done in the past.
Dr. Henry Schmitz of Chicago said that personally
he could subscribe to the last part of the last speech.
He had done a great deal of investigation with the
x-ray and with radium, and the question in his mind
was whether all the statements of Drs. Jacobson and
Deaver were correct, and he believed that they were
not. Cancer was operable or it was inoperable. When
it was operable it was a surgical condition, but when it
was inoperable what was there to be done? There was
the use of radium or the x-ray, or there was Percy heat
treatment. Radium was indicated when the condition
was entirely inoperable. The condition became operable
under the use of radium. When the local condition was
cleaned up the surgeon could then remove the uterus.
Not every case of myoma was operable. The patient
would probably have an advanced anemia or the myoma
was probably advanced. It would be wrong to let the
patient go as an inoperable case. Here the treatment
by x-ray or radium was of much benefit. The treat-
ment itself was easy, the patient was not required to
stay in bed, it could be used under all circumstances,
and the benefits were real and marked. Later the con-
dition had been so much improved that it was operable,
and it could then be treated surgically.
Dr. Lawrence of Philadelphia said that he simply
wanted to emphasize everything that Dr. Deaver had
said, but he wanted to add that the man who advised a
woman with a neoplasm to let it alone should be dealt
with very severely. Any neoplasm might become malig-
nant, and many of them did. Out of 100 cases of
fibroids 14 became malignant carcinomas. The mor-
tality of hysterectomy for fibroids should not be larger
than for ovarian cystectomy. There was little shock
and the hemorrhage should be absolutely nothing. The
tumor should be delivered out of the abdomen and
grasped by a ligature about the base, and an oval-
shaped incision sholud be made. By cutting out the
tumor and tying the ligature one lost no blood unless
there was venous blood in the tumor. In supravaginal
hysterectomy one shoudl leave a convex pelvic roof in-
stead of a concave one.
Dr. J. W. Lee of New York said that the subject was
a large and interesting one. A great deal of time could
be spent discussing the pros and cons, and it left them
in the state of mind of the young man who came out of
court and said, "I believe in the last speaker." Dr.
Deaver had presented a paper that took in the whole
subject. It might be called a classic. His paper cov-
ered all that had been said, and even included what Dr.
Schmitz had said, because Dr. Deaver would not dis-
I the use of radium in inoperable cases. Dr. Lee
said he had been watching this fibroid game for thirty-
five years. It used to be the custom to give large doses
of ergot, and then Apostoli's treatment was considered
a great success. He had been foolish enough to buy the
apparatus, but he had never been able to sell it. Then
came the fashion for oophorectomy. Then an ab-
dominal incision was made and the uterus was brought
out with four clamps and left, and one could see the
stump rot. Then there was hysterectomy. In regard
to the method of Dr. Lawrence, he must have fibromas
and myomas made to order. It was generally necessary
to go in further than he had described. He believed
very strongly in the work done by Dr. Deaver, and he
hoped that the style would not be altered in the next
ten years.
Dr. Kccles of Milwaukee, Wis., said that in their en-
thusiasm to cut something out he thought they were apt
to overlook the operation of myomectomy. He granted
that this was not indicated in the majority of cases, but
in a young woman desirous of having children, or at
least to menstruate, and where the tumor was not big,
there was an indication for this operation. In his stu-
dent days he had been taught that myomectomy was
more dangerous than hysterectomy. In his experience
this was not so. A considerable number of myomecto-
mies had convinced him that the indications for myo-
mectomy were often overlocked. In one case the patient
was a young woman, the wife of a prominent physician,
and she was unable to bear children, as she always
aborted because of multiple fibroids. In this case a
myomectomy was performed and seven or eight tumors
were removed. The woman was now the mother of a
four months' old baby and there was no recurrence.
Even supposing such a tumor did return, the operation
of hysterectomy could be later performed and the dan-
ger had not been increased.
Dr. Ruben of Pittsburgh, Pa., said that it would be
unjustifiable to leave this discussion with a little de-
fense for the progress of medicine. If x-ray and radium
treatment of malignant disease of the uterus could be
considered malpractice, then all new ideas must be
considered malpractice. In the old time ideal of cur-
ing cancer by the x-ray many men sacrificed their lives
in the hope of contributing to the advance of medicine.
This was due to their ignorance of the agent with
which they were dealing. Now it was known that the
rays were of different power — the soft, the medium,
and the hard ray. In the old days the rays went
through the hand, and men were burned and would
probably later die of cancer. But at the present time
men were shielded from the rays, and they did not
carry radium around without proper protection. The
rays were filtered, and the patients were given doses
measured by radiometers. Patients were given 1/40 of
a grain of strychnine, not 5 grains, and x-ray dosage
was also according to measure. There were many
young men, trained gynecologists, at the present day,
who were watching this work and its effect on the
growth of tumors, and when it was found that the
x-ray was not having effect, then surgery could be re-
sorted to.
Dr. S. E. Tracy of Philadelphia said that he did not
believe that all fibroid tumors should be treated by sur-
gery. He agreed with Dr. Schmitz that cases not suit-
able for surgery should be treated by the x-ray, but he
believed that in malignancy an early diagnosis and a
radical operation gave the best results. However, after
all that could be done by surgery had been done, the
patients should have the benefit of the x-ray. He did
not believe that any case was cured by removal of the
ovaries. A fibroid tumor without symptoms in a wo-
man under forty should be left alone; after that the
danger increased with the age of the patient. He be-
lieved that all curettings should be examined and not
thrown away. He had never seen cases where he was
afraid to operate for fibrosis. He had found it a good
plan to spend time in getting the patient into good
shape, and then operation could be successfully done.
In this the x-ray was helpful for the operability of
cases could be increased. Dr. Lawrence had spoken of
his method, and he felt with the other gentlemen that
Dr. Lawrences' cases were made to order. In all hys-
terectomies he found it a good plan to stitch the in-
fundibular and pelvic ligaments to the stump and to
pull the bladder back. It took three stitches. In re-
gard to Dr. Eccles' remark on myomectomy, the age
at which degeneration was likely to occur should be
considered. After forty, this operation was dangerous.
Dr. J. H. Jacobson of Pittsburgh said that he agreed
with Drs. Schmitz and Tracy in advocating combined
treatment. He was glad to hear that Dr. Schmitz ad-
vocated surgery in advanced cases. As a rule men who
had done much along this line of work were apt to dep-
recate surgery. He believed that in radium, x-ray, and
also Percy's heat treatment the profession had very
powerful agents to assist them in radical therapy.
Non-Inheritance of Acquired Characters. — Our belief
that acquired characters can be inherited rests very
largely on some old experiments of Brown-Sequard on
guinea pigs. These involved injuries of the nerve sub-
stance of breeding animals said to reappear in their
progeny. Even at the time it was pointed out that
sources of fallacy were present. In 1907 Wrzosek and
Maciesza began to repeat the experiments, and their
work was still in progress when the war put a stop to
it. From the first it was apparent that there was no
transmission of acquired alterations. — The Journal of
Heredity.
Medical Record
A Weekly Journal of Medicine and Surgery
Vol. 90, No. 3.
Whole No. 2384.
New York, July 15, 1916.
$5.00 Per Annum.
Single Copies, I5c.
(Original Arttrkfl.
RECENT PROGRESS IN THE OPERATIVE
TREATMENT OF EMPYEMA OF THE
THORAX.*
Bt HOWARD LILIENTHAL, M.D., F.A.C.S.,
NEW YORK,
ATTENDING SURGEON TO MT, SINAI AND BELLEVUE HOSPITALS,
AND
MARTIN W. WARE, M.D.,
NEW YORK,
ADJUNCT SURGEON, MT. SINAI HOSPITAL.
For years the primary treatment of empyema of
the thorax has been neglected. The cut and dried
methods of past decades with an appalling mor-
tality have gone on with practically no improve-
ment because of lack of investigating interest on
the part of the surgeon and because practitioners
were apparently satisfied that when an opening had
been made in the chest there was, for the time
being, nothing else to do.
In nearly one-fourth of the cases the wounds re-
quired revision and frequently the patients were
turned over to the surgeon for various deforming
thoracoplastic operations.
The original cause of the pyothorax did not seem
to matter — whether postpneumonic, metastatic, or
primarily pleuritic — the treatment was the same.
The patient was kept under observation and punc-
tured until pus was found; an opening was made
for drainage and the case was too often left to
shift for itself. In the simple and unilocular cases
in older subjects promptly operated upon there
were many recoveries, but the least complication
upset everything. When pockets or secondary iso-
lated collections formed it was hoped that they
might break into the main cavity and occasionally
they did, but sometimes there was perforation into
a bronchus, or the surgeon after many days and
much puncturing averted this calamity, the patient
meantime suffering all the dangers of sepsis.
A little more than two years ago the First Sur-
gical Service at Mt. Sinai Hospitalf took up the
study of empyema with a view to developing a line
of treatment commensurate with the therapy of in-
fectious processes in other parts of the body.
We began with the assumption that the empyema
problem was a pathological and a physiological
one and not merely a matter of the mechanical
emptying of a cavity from the most suitable point.
The behavior of the diseased tissues of the living
body had to be considered. We were aware that
the causes which originally produced the empyema
*Read May 16, 1916, before the Surgical Section of
the New York State Medical Association, at Saratoga
Springs, N. Y.
fThe operations in this series were performed by Dr.
Lilienthal, Dr. Joseph Wiener, Dr. Martin W. Ware,
and a few by the House Surgeon under supervision.
might still be operative after the chest had been
opened and even that new conditions might arise
after the operation to prevent a return to the nor-
mal.
Accordingly, we planned the therapy with two
objects in view. First, the relief of intrathoracic,
pressure which immediately threatened life andv
second, the establishment of a state which should
make possible a complete recovery with a minimum
of complications and without deformity.
Now, after two years of work and observation
we hope and believe that we may report progress.
Our mortality rate is lower than that of the
previous ten years in the same institution* and we
have succeeded in preventing the necessity for a
single thoracoplastic operation. We ourselves were
responsible for many of the failures in the decade
just mentioned and this fact appears to demonstrate
all the better that the improvement in statistics may
fairly be ascribed to changes in the methods.
We believe, too, that we have shortened the num-
ber of hospital days per patient by nearly one-
third.
General Management of the Cases: X-ray. With
few excptions all our patients were examined with
the aid of the Roentgen plate or screen, and we
have found this of incalculable value in selecting
the type of operation. Also, some interesting ob-
servations have been made in the course of these
radiographic studies. We have found that in the
encapsulated cases and also in the more chronic
general empyemata the affected side is apt to show
contraction of the chest instead of distention, the
ribs being closer together than on the healthy side.
This appearance has often been accompanied by
the presence of tough peripleuritic confining mem-
branes so that at operation the lung did not ex-
pand and required mobilization by the division or
removal of the exudate.
Encapsulation is often beautifully demonstrated
so that the most favorable point for drainage can
be determined before the operation. We have
found (Case 1, F. B.) two distinct sacs containing
pus of different appearance and consistency which
would have been overlooked without the x-ray.
Secondary collections of pus have been demon-
strated after the first operation and we have been
able to empty these sacs promptly because of the
accuracy of their localization. In two cases the
secondary abscess was in front, on the right side
close to the mediastinum near the base of the heart
I See Fig. 5). They were evacuated from the front
with the greatest ease and precision.
During convalescence the degree of pneumothorax
can be made out and its gradual disappearance ob-
served. The presence of areas of consolidation can
sometimes be determined in cases in which there is
*Wilensky, Abraham 0.: Surg. Gyn. and Obst., May,
1915.
90
MEDICAL RECORD.
[July 15, 1916
doubt between residual empyema and pneumonia.
Without the Roentgenogram unnecessary and pos-
sibly dangerous punctures would have been made.
In two instances the a;-ray enabled the diagnosis of
foreign body in the lung or trachea to be made when
Fig. 1. — The chest is open, the rib spreader in place The
scalpel is making the incision through the layer of dense
exudate which confines the lung.
clinically the case appeared to be one of atypical
empyema. These patients were bronchoscoped by
Dr. Yankauer and the foreign bodies removed. In
one case pneumonia and pneumothorax were dem-
onstrated after puncture made outside the hospital
had yielded a few drops of pus, the patient being ad-
mitted for the treatment of empyema. There was
no empyema and the patient recovered without
thoracotomy.
We do not believe that this little list comprises
all of the possibilities of z-ray diagnosis in
empyema. And we have not here gone into the
question of intrapulmonary disease.
Diagnostic Puncture. — After study of the physi-
cal signs and the radiograph the final proof, that
of the aspirating needle, should not be made until
the patient is on the operating table or within a few
hours of operation. Repeated puncture several
days before the operation may do harm. For ex-
if
#^B
■
s'
j^M
1
fi
danger of puncture is much greater in lung ab-
scess in which we believe it is absolutely contra-
indicated.
Most of our patients had been punctured before
they entered the hospital and came with the estab-
A B
^ '^
/
fWrZ
5J
Ilk I
L rH
1yi\ CJr-
SHh. .■*
n^^^
B
Fig. 3. — With the scissors incisions are made in the exudate
to permit a freer expansion of lung.
lished diagnosis of endothoracic suppuration.
These patients, however, were .r-rayed just the
same unless their condition was so precarious that
immediate relief was demanded.
Ayiesthesia. — When the empyema is secondary to
pulmonary disease, as is usually the case, we be-
lieve that ether should be avoided because of the
possibility of its irritating action upon the lungs.
We have, therefore, employed either local, regional,
or nerve-blocking anesthesia, or nitrous oxide and
oxygen narcosis.
Selection and Type of Operation. — We realized
that to obtain a final cure an active pneumonia, a
perforating subphrenic abscess, hepatic or other-
wise, or an infecting bronchiectasis, might require
medical or surgical treatment more than the con-
sequent empyema; yet a patient coming to the hos-
pital cyanotic and gasping, the heart embarrassed
by dislocation, had to be immediately relieved. His
complete restoration might be a matter for later
consideration. Accordingly, these cases were
Pig. -. — The fingers arc separating the layer of dense con-
fining exudate from the visceral pleura. The lung protrudes
below. (This is, of course, diagrammatic, 1
ample, some of our cases suffered from spreading
infection of the tissue planes of the thoracic wall
as the result of needle punctures. This, to be sure,
is often a danger avoidable by early operation and
by Roentgenography before the aspiration. The
Fig. 4. — Case 1. (F. B.) Large right sided encapsulated
empyema.
treated by what we have termed minor thoracotomy,
though in the beginning of our work there were
a few operations by the old method. (See table I.)
This table includes all cases in which primary
operation was performed, regardless of the cause
July 15, 1916]
MEDICAL RECORD.
91
of the empyema. March 25, 1914, to March 24, incision from the angle of the ribs to the anterior
1916. axillary line, more or less, and close to the upper
Table I — General Table of Operations.
Minor
Thoracotomy
Major
Thoracotomy
Resection for
Encapsulated
Empyema
Resection
(Old Metj )
Miscellaneous
Remarks.
Total.
Died.
Total.
Died.
Total.
Died.
Total.
Died.
Total.
Died.
24
4
26
5
*
0
5
1
4
3
Miscellaneous cases were: 2 liver abscesses; died. One
large lung abscess with perforation empyema; died of
hemoptysis. One old gunshot empyema; spontaneous
rupture; well.
1. Minor thoracotomy — except for its name — is
nothing new. The procedure is described as fol-
lows:
Under local anesthesia a small incision is made,
preferably in the seventh or eighth interspace, in
the posterior axillary line and carried through the
pleura. The ribs are separated by spreading the
blades of a dressing forceps or a pair of scissors
and a small tube is slipped into the chest. Or, after
the short skin incision, a trocar and cannula are
made to enter the pleura and a drainage tube is
pushed through the cannula which is then with-
drawn leaving the tube in place. There are various
devices to prevent pneumothorax. We have found
the simplest to be a permanent syphon to keep the
tube full of fluid and so arranged that the level of
the liquid in the water supply bottle is lower than
the patient's chest, while the tube leading from the
chest has its end submerged in weak antiseptic
fluid in a vessel on the floor.
border of the lower rib, to avoid nerves and vessels.
(b) Pleura entered carefully to avoid possibly ad-
herent lung, (c) Rib retractor inserted and the
ribs separated from 4 to 6 inches or more. If still
greater room is needed cut a rib or two above or
below the wound at the posterior angle, (d) Ex-
ploration. Removal by suction or sponging, of all
pus and coagula, then inspection and palpation of
lung and pleura.
Adhesions to the chest wall should not be dis-
turbed unless they separate easily. If the lung ex-
pands and fills the chest when the patient strains,
and if no sign of lung abscess or fistula is present,
the soft parts of the wound may be approximated
with chromicized gut and the skin partly closed by
suture.
Because of the division of the intercostal muscles
the ribs will not at once fall together. There will
be a space of an inch and a half or more (in adults)
which will persist for some days. Drainage open-
Table II — Operations Compared by Ages,
»
Minor Thoracotomy.
Major Th
IRACOTOUY.
Resection for
Encapsulated Empyema.
Resection
(Old Method).
Miscellan eous
Children.
Adults.
Children.
Adults.
Children.
Adults.
Children. Adults.
Children.
Adults.
IS
6
13
13
3
1
4
1
0
4
Died. ...'
Aged. . . .
4
1' ■■. 2. 3. 4
0
3
2, 3',, I
2
35, 55
0
0
1
0
0
3
25, 27. 32
Total cases . 63
Total deaths 13
Mortality rate 20.6 per cent.
Or, omitting the two liver abscesses, 61 cases, 11 deaths.
Mortality rate IS per cent
In favorable cases this operation is all that will
be necessary. The lung expands, the discharge
lessens, and recovery follows.
During the two years covered by our table we
operated in 24 cases by this method with 4 deaths
or 16 per cent. These deaths were due to pneu-
monia or general severe sepsis — often with per-
sistent diarrhea — median suppurative otitis and
metastatic abscesses, the patients being in too low
a state for more thorough surgical work. Case II.)
When these minor thoracotomy patients were im-
proved but showed no sign of prompt healing, we
considered them suitable subjects for what we have
termed major thoracotomy. This operation, how-
ever, was performed at the first sitting whenever
the case did not look absolutely desperate.
2. Major Intercostal Thoracotomy with Explora-
tion and Lung Mobilization. (The procedure has
been described in an article by Lilienthal, Ann.
Surg.. September, 1915.) Briefly, the steps of the
operation are as follows: (a) Skin and muscle in-
cision in the seventh or eighth interspace. Line of
Total children undrr twelve years.
Deaths
Mortality rate in children
Total adults
I leaths
Mortality rati- in adults
21 per cent.
25
5
20 per cent.
ings of suitable size anteriorly or posteriorly or
both may be left, but it is not often necessary to
put in tubes or gauze. Should an inoperable pul-
monary suppurating lesion be encountered — bron-
chiectasis or lung abscess — better resect a piece of
rib with the periosteum so as to permit of long-
continued drainage without a tube and without the
danger of valve formation and tension pneumo-
thorax.
If the lung is bound down by tough exudate
upon the pleura this should be divided by long ver-
tical incision (Fig. 1), when the lung will usually
try to force its way out of its confining membrane.
Peeling this away with the fingers (Fig. 2) the
lung may be further freed by incisions at right
angles with the first one (Fig. 3). Hemorrhage
is moderate, often absent. A slight wound of the
lung tissue is not serious. Tough adhesions of the
lung to the chest wall had better not be disturbed
unless they are capable of being divided between
ligatures. The loose flaps of membrane peeled from
the lung may be cut away, but there should be no
92
MEDICAL RECORD.
LJuly 15, 1916
special effort made to denude every portion of the
lung's surface.
During the procedures just described secondary
abscesses may be found and turned into the main
cavity. Sometimes the lower lobe of the lung is
Fig. ■",. — Case 1. i F. B. t Secondary antero-mesial encapsulated
pyopneumothorax. .Note fluid level.
adherent to the diaphragm. This adhesion should
be loosened with the greatest caution for fear of
entering the abdominal cavity. We have several
times encountered between lung and diaphragm col-
lections of pus which must have caused serious
complications had they not been emptied.
Having mobilized the lung the wound is closed
with tubeless drainage as just described.
We repeat that this mobilization and exploration
through the large incision — or major thoracotomy,
as we think it should be called — is not advised as a
primary procedure for the desperately ill patients.
It should follow minor thoracotomy, the operation
• for immediate relief. Doubtless, in cases without
confining membranes one of the various suction ap-
paratuses with a fixed paracentesis cannula will
prove efficient. One of the best of these is that of
Philips. (Demonstrated before the Surgical Section,
Academy of Medicine, April 7, 1916.)
We have performed in our hospital service 26
major thoracotomies with 5 deaths, or 20 per cent.
The fatal endings may be classified as follows :
1. A. S., man, 35 (one stage), gangrenous pleu-
risy.
2. Bessie T., girl, 3V2 (one stage), pneumonia.
six weeks after operation.
3. O. W., man, 55 (two stages), sepsis (avray,
suspicious of tuberculosis, but the pus showed the
pneumococcus) .
4. N. T., boy, 2 years (one stage), sepsis; diar-
rhea.
5. L. C, girl, 1 year (two stages), pneumonia;
sepsis.
The operation appears to us surgically sound. It
gives a far better opportunity than any other for
thorough exploration and rational treatment.
Pockets of pus are discovered which could not other-
wise be found. In two cases subphrenic abscesses
— evidently the determining cause of the empyema
— were discovered, though in both instances the
patients died weeks afterwards of the pylephlebitis
with the liver abscess which caused the empyema.
(Case 4.)
During the after treatment it is easy to explore
the chest digitally when retention is suspected or,
if necessary, to reopen the whole wound for more
thorough visual examination.
This operation differs from that of Fowler, De-
lorme and Lloyd in the enormous exposure with
little danger, and little hemorrhage, and, too, the
deformity following multiple rib resection is, of
course, absent. We avoid the great thoracoplastic
operations, which seek to bring a rigid chest wall
down to the collapsed lung, by mobilizing the lung
and bringing it out to the normal thoraic limits.
We repeat that out of all our cases, an unselected
series of 63 there was not one thoracoplasty.
3. Thoracotomy for Encapsulated Empyema. —
When the physical signs and the radiograph indicate
the presence of localized intrapleural abscess,
whether interlobar or not, the operation must be
planned according to the situation of the disease.
Often the costal pleura forms one wall of the ab-
scess, and in these circumstances we have resected
ribs directly over the pus, trying to avoid infecting
the general cavity. (Case 3.) The case is then
treated as an ordinary abscess. It has been found
effective to remove a section of at least one rib with
its periosteum so that this abscess can be treated
by packing with gauze and later, if necessary, by
drainage with a short tube. The removal of the
periosteum with the rib prevents the rapid growth
of deforming bony bridges which so frequently in-
terfere with proper drainage. We have dealt with
four of these cases and all the patients recovered.
This paper is not a plea for any one operation,
but for an abandonment of routine in the treatment
of empyema. Each case should be studied and its
Fig. 6. — Case 1. (F. H. Patient is well. Note cicatrix follow-
ing intercostal drainage of secondary empyema.
therapy determined according to its individual re-
quirements. We believe that the poor showing of
the results in this disease is largely due to the em-
ployment of rule of thumb methods.
CASE I. — Sacculated Empyema of Thorax; Double
July 15, 1916J
MKDK \L RECORD.
93
Sacculation. Thoracotomy with Rib Resection; Sec-
ondary Anterior Thoracotomy. On January 1!), 1916,
Frank B., 24 years old, was admitted to the medical
service of Mt. Sinai Hospital. His temperature at that
time was 103%°, pulse 100, respiration 36.
Five years before admission he had had malaria in
FltJ.
7. — Same patient as in Fig. £
cicatrix.
Shows main intercostal
South America. His present illness had begun five
days before admission, with cough, fever, and bloody
sputum. He passed through a rather sharp pneu-
monia of the right side, and on February 2 the chest
was aspirated in the fourth space posteriorly in the
axillary line, and thick pus was found. He was then
transferred to the first surgical service for operation.
The blood count was 23,600 white cells, polys 84 per
cent., lymphocytes 16 per cent., red blood ceils 5,040,000.
The x-ray showed a shadow which apparently indi-
cated an encapsulated empyema from the right apex
along the right side of the chest next to the ribs down
almost to the base. (Fig. 4.)
On February 3, 1916, in nitrous oxide and oxygen
anesthesia by Dr. Branower, an incision was made in
the seventh interspace, the lung being supposed to be
adherent at this point. The seventh rib was resected
with the periosteum and clean pleural cavity invaded
at the inner end of the wound. This opening was made
before the evacuation of the empyema and it was closed
by a suture and a gauze packing. The empyema itself
was then opened through much thickened parietal
pleura and a large quantity of pus escaped. On ex-
ploration the lower lobe of the lung was found soft
and expansile, the remainder of the cavity lined with
tough membrane. Part of this membrane was peeled
away, allowing good lung expansion, and it was thought
that the entire pus collection had been evacuated. Ex-
ploration showed the cavity to be cleanly marked, and
on completely emptying it there was no leakage, from
anywhere else. Dr. Wessler of the Roentgenological
department was present and stated that it was his
opinion that the pus extended up to the apex. There-
fore, aspiration in the axilla was practised and thick
yellowish pus of a different color from that below was
encountered. A section of the sixth rib was now ex-
cised at the site of the original wound and following a
long aspirating needle put in as close as possible to the
costal side of the chest a second large cavity was
opened with dressing forceps. The entire bilocular
cavity was now packed with gauze and patient sent
back to bed.
On February 15 he was again x--rayed because of a
rise in the temperature and a collection of pus an-
teriorly and against the mediastinum was found. There
was considerable gas above the pus. (See Fig. 5.)
Under nitrous oxide and oxygen anesthesia, a smail
anterior fourth interspace incision was made, and gas
and pus evacuated; tube drainage. Under postural
treatment this rapidly closed and the patient was dis-
charged well on March 6, 1916. The illustrations
(Figs. 6 and 7) show the sites of the cicatrices.
This case illustrates beautifully the value of the
£-ray in accurate diagnosis, pointing the way to
intelligent and prompt surgery.
Case II. — Empyema of Thorax, General Sepsis,
Double Otitis Media; Death.— On February 6, 1916,
Celia M., four years old, was admitted to Mt. Sinai
Hospital. Her temperature was 103.4°, pulse 144, and
respiration 40. For two days she was a patient in one
of the medical wards, and was transferred for opera-
tion.
When the child was fifteen months old she had some
indefinite intestinal trouble, with loss of weight and
weakness, which continued for three months.
The illness for which she entered the hospital had
begun eighteen days before admission, with cough, high
fever, and dyspnea. When transferred to the surgical
service she was acutely ill and extremely septic in
appearance. There was herpes prolabialis. great
dyspnea, both ear drums were perforated, and the ears
discharging. The left lung was apparently normal.
The right chest was full of fluid; the heart displaced;
Grocco's sign present. The day before her transfer
she had been aspirated and one cubic centimeter of
purulent fluid had been withdrawn. The blood showed
11,500 white blood cells, with 86 per cent, polys and 14
per cent. lymphocytes.
On February 8, 1916, in local anesthesia with alypin,
a short intercostal incision was made in the eighth
interspace behind the posterior axillary line, and a
large quantity of pus was evacuated. The pus was
later shown to be pneumococcal. The chest was drained
by means of a small tube and permanent suction was
arranged with the water syphon. The patient con-
tinued extremely septic, lying in a semiconscious state
and being fed with difficulty. With slight variation the
progress of the case continued for about a week, when
there developed ecchymoses of large size upon the face.
A blood culture resulted in the diagnosis of pneumo-
coccemia.
In this desperate condition a transfusion of 80 c.c.
of blood from the patient's mother was made by the
sodium citrate method, and this was repeated twice
within the next two days. Needless to say the neces-
sary tests were previously carried out. After each
transfusion there was evanescent improvement, but the
child died in coma ten days after the operation.
Pig. S. — Case 3. ( S. M. ) Large axillary encapsulated empy-
ema. Cured by resecting ribs in axillary region.
The wound showed no sign of gangrene and the dis-
charge had considerably diminished.
Carefully reviewing this case we believe that
nothing at present known to science could have
saved the patient. Her death was due, not to the
94
MEDICAL RECORD.
[July 15, 1916
empyema nor to the operation, but to the effect of
the pneumococcal bacteremia.
Case III. — Encapsulated Empyema of Thorax, Rib
Resection, and Drainage.- — Samuel M., 24 years old,
was admitted to the medical service of Mt. Sinai Hos-
pital on December 10, 1915, and was transferred to the
surgical service on January 13, 1916.
Eight years before admission he had had pneumonia,
and three years before tonsillitis. His present illness
had begun on December 8, two days before admission,
with pain in the left chest, vomiting, chills, fever, and
headache. Then with an increase of all the symptoms
there came cough, with scanty expectoration. Finally,
dyspnea and precordial pain.
Physical examination showed a very sick patient,
tongue dry and coated. In the lungs anteriorly from
the apex to second rib on the right side there was ex-
aggerated inspiration with a few rales; no dullness;
posteriorly from angle of scapula to base dullness
with bronchial respiration and voice over scattered
areas. The left side from the midscapular region to
the base showed dullness, increased tactile, and vocal
Fig. 9. — Compare with Fig. 7. This patient has had sev-
1 resections. Note deformity and rigid
■ula.
fremitus, bronchophony, numerous crepitant rales.
Urine not abnormal. The blood count was 27,000 white
blood cells, 87 per cent, polys, 13 per cent lymphocytes.
The a:-ray showed an oval shadow of large size in the
upper part of the left chest with an opacity below
connected with upper opacity by what might be called
an isthmus. (Fig. 8.)
This patient had been aspirated a number of times by
the medical men and finally, on January 4. pus was ob-
tained in the fifth space in the midaxillary line.
On January l.">. 1916, as soon as possible after
the transfer to the surgical service, the patient was
operated upon. In nitrous oxide and oxygen anes-
thesia, administered by Dr. Branower, an incision
perpendicular to the line of the ribs was made in
the left axillary region and portions of the fourth
and fifth ribs were removed with the periosteum.
At once a large collection of pus was encountered
and the anatomical conditions suggested by the
.r-ray were easily made out. There was a strong
tendency to expansion of the lung and the wound
was packed with gauze and permitted to drain with-
out a tube. The patient made an uneventful recov-
ery and was discharged well in twenty-five days.
Case IV. — Pylephlebitis Following Appendicectomy ;
Secondary Empyema of Thorax; Death. — Abraham E.,
27 years old, had been operated upon for acute gan-
grenous appendicitis, at the New York Post Graduate
Hospital, seventeen weeks before I saw him. Later the
diagnosis of pylephlebitis was made and the gall blad-
der was opened at the same hospital.
On December 29, 1915, he entered one of the med-
ical services at Mt. Sinai Hospital in a wretched condi-
tion, and eleven days later he was transferred to the
first surgical service for operation, pus having been
found on apirating the left upper chest. There was
edema of the extremities.
The urine contained albumin and red blood cells,
but no sugar. The blood showed 6,100 white cells, with
87 per cent polys and 13 per cent lymphocytes. Be-
fore the aspiration at which pus was obtained there
had been other aspirations when clear green-yellow
fluid with 89 per cent, of polymorphonuclears and 11
per cent, lymphocytes had been withdrawn. No growth
en culture. A'-ray examination showed two distinct
fluid levels in the left chest, one below, the other above.
The empyema being apparently the most urgent con-
dition, he was operated upon on January 10, in nitrous
oxide and oxygen anesthesia. A long incision was
made in the eighth interspace and the eighth rib was
widely resected with its periosteum. The rib spreader
was put in. An enormous amount of gas under ten-
sion and exceedingly foul pus was evacuated. It was
later found that this pus contained Bacillus proteus.
The lower lobe of the lung was adherent to the dia-
phragm and there were numerous other adhesions in
the chest, some of which were peeled loose, and one
which divided the chest apparently into two main cavi-
ties was divided with scissors. Dense adhesions in th«
upper chest were not interfered with. The lung was
covered with a greenish exudate, but on peeling some
of it away from the lower lobe there was no expansion.
With a very guarded prognosis this operation was con-
cluded by closing part of the wound with suture and
leaving the rest open for drainage.
By January 24 there was great abdominal distention
from ascites, and under local anesthesia a tiny trans-
verse epigastric incision was made in the hope of com-
ing down upon an hepatic abscess. Repeated puncture
through this incision revealed no pus, although the
liver was much enlarged and the abdomen contained a
quantity of seropurulent exudate. The prognosis was
now bad.
A few days later paracentesis in the left iliac region
was performed and the opening permitted to drain for
ten days. This gave considerable relief, but the fluid
reaccumulated and the patient's condition became des-
perate. Finally, intestinal obstruction developed and
the patient refused operation until fecal vomiting ap-
peared and he was almost moribund. On February 26
laparotomy under nitrous oxide and oxygen disclosed
a tough band of adhesions binding the ileum to the
anterior abdominal wall. The obstruction was relieved,
but on account of the cirrhotic condition of the liver
even the slightest adhesion between the intestine and
the abdominal wall bled furiously. The patient sur-
vived for twenty-four hours, vomiting constantly, then
died. A small piece of the liver was secured and ex-
amined by Dr. Mandlebaum, who reported a probable
healed pylephlebitis, from the history and from the fact
that there was a recent cellular cirrh
The case is reported here very briefly because of
the complication of thoracic empyema. The death
of this patient was not due to his empyema even
remotely.
There was another case which is included in our
table very similar to this one, in which a direct
perforation occurred between a liver abscess and
the right lower pulmonary lobe. At operation a
serous effusion was found in the chest and on peel-
ing away the lung from the diaphragm an abscess
was evacuated. Later the diaphragm was opened
and the main abscess drained. This patient also
died of his liver sepsis.
July 15, 1916]
MEDICAL RECORD.
95
THE CAUSE, TREATMENT, AND PREVENTION
OF HAY-FEVER.
By W. SCHEPPEGRELL, A.M., M.D..
NEW ORLEANS.
PRESIDENT. AMERICAN HAY-FEYEH-PREVENTION ASSOCIATION ;
EX-PRESIDENT. AMERICAN ACADEMY OF OPHTHALMOLOGY
AND OTO-LARYNGOLOGY', ETC.
Until recently, hay-fever was considered a disease
of varied and doubtful origin, but whose reappear-
ance was as certain as the proverbial tax-collector.
A more exact knowledge of the etiology of this
disease, however, has shown not only that it is not
inevitable, but, in view of the simplicity of its pre-
vention, is a disease whose contained existence
would be a reflection on preventive medicine.
The development of pojlinosis at the exact time of
the blooming of certain plants, and its disappear--
ance with these flowers, eventually led to the con-
clusion that a relationship existed between hay-
fever and the blooming of these plants. This was
corroborated by the fact that susceptible persons
develop a paroxysm by simply approaching such
plants at a time when their pollen is being dispersed
by the wind. It was also found that this pollen,
applied to the nostrils of susceptible subjects, could
produce a hay-fever reaction at any season of the
year.
The class of plants whose pollen may cause hay-
fever are wind-pollinated, that is, the process of
fertilization is effected by the pollen being borne by
the wind, instead of this being done by contact or by
insects. This explains the presence of such pollen
in the air. In some cases the pollen is present in
are practically all common weeds, such as the rag-
weeds, cockle bur, yellow dock, etc., which are also
a source of expense and labor to the farmer. Their
characteristics are as follows: They are wind-pol-
linated, without attractive color or fragrance, very
FIG. 1. — Common rag-weed (Ambrosia artemisicefc a). Re-
sponsible, with the giant ragweed, for S3 per cent of till hay-
fever. More common in the Middle and Northern Si
enormous quantities, as for instance in the rag-
weeds, in which it has been estimated that only one
in a hundred million pollen is actually used in fer-
tilizing the pistillate flower.
The plants that are responsible for hay-fever
Fig. 2. — Giant ragweed (Ambrosia trifida), whose pollen is
one of the chief causes of hay-fever. Grows in moist lands.
Very abundant on the Gulf Coast. (From "Hay-Fever and
Its Prevention," by W. Scheppegrell, A.M., M.D. Report of
United States Department of Public Health, June 30, 1916.)
numerous, and with abundant pollen. The lack of
color or scent is due to the fact that these plants
are wind-pollinated, the qualities mentioned being
intended to attract insects for fertilization.
The most common weeds that cause hay-fever are
the rag-weeds {Ambrosia artemisias folia and trifida,
Figs. 1 and 2), which are the causes of most cases
of fall hay-fever. The marsh elder (Iva ciliata,
Fig. 3) is also a cause of fall hay-fever and fre-
quently prolongs the attack. The early cases are
due to the yellow dock (Rumex crispus, Fig. 4),
and the mid-summer cases to the careless weed
(Amaranthus spinosus), cockle-bur (Xanthium
canadense, Fig. 5) and other wind-pollinated weeds.
In early summer, many cases are due to the various
grasses (Fig. 6), all of which are wind-pollinated.
The reaction of pollinosis is divided into the di-
rect and indirect stage. The former is influenced
by the physical conformation of the pollen. In
plants, in which the pollen is covered with spiculse,
such as the Ambrosias, Partheniums, Dracopis, etc.,
the direct reaction may develop immediately and is
usually prolonged. In those in which the pollens
are smooth, such as the Rumex, Amaranthus,
grasses, etc., the reaction is deferred several min-
utes and is milder in character.
The indirect reaction of pollinosis is partly due
to the effects of the primary irritation and partly
to the absorption of the protein contents of the
pollen, and the toxin formed by the proteolytic
96
MEDICAL RECORD.
(July 15, 1916
action of the cells. The immunity of the patient
depends upon his resistance to the initial irrita-
tion and the completeness with which the liberated
toxins are neutralized. The character of this pro-
cess establishes the degree of susceptibility of the
Fig. 3. — Marsh elder i//<i ciliata), a cause of fall hay-fever.
patient and forms an important factor in what is
called "predisposition." This is probably also af-
fected to some extent by certain general conditions
but the influence of these has not been clearly es-
tablished.
Immunity and predisposition in pollinosis are
relative terms. The person who is immune and the
one which is affected may both breathe the same
pollen-infected air, the former without apparent
discomfort and the latter developing an attack. In
each case, the pollen enters the nasal cavities, but
in the immune, the clinical symptoms are not pre-
sented.
This result is due to the fact that all cells possess
to some extent a proteolytic power which acts as a
defense against the invasion of foreign proteins,
provided certain limits are not exceeded. In ad-
dition to this, the entrance of foreign proteins by
parenteral channels results in the development of
antibodies, which are ferments which also protect
the host within certain limits. The extent to which
these processes neutralize the absorbed toxins, and
the degree to which he can resist the initial irrita-
tion, establishes the degree of immunity of the pa-
tient.
Local conditions, such as abnormalities of the
nasal passages, also act as a predisposing cause, but
much less so than is generally supposed. Operations
to correct such defects have given satisfactory re-
sults as regards hay-fever in less than 25 per cent
of the cases, and are not to be recommended unless
aiso indicated tor other reasons.
'the increased susceptibility of hay-fever after
an initial attack, is due to the anaphylactic con-
dition produced by the absorption of the pollen
protein by parenteral channels. The antibodies re-
sulting from this reaction are probably of the
anaphylactic type, and this explains the reduced
resistance to further infection.
Anti-anaphylaxis, eventually resulting in a re-
active condition of immunity, also develops in pol-
linosis, but is usually delayed for quite a long period,
and is indicated by gradual decrease of the parox-
ysms. This should not be confused witfi the disap-
pearance of the attacks due to diminution of the
supply of pollen resulting from a change of resi-
dence or the eradication of the pollinating weeds.
The effects of hay-fever are due not only to the
absorbed pollen proteins but also to the action of
microorganisms resulting from the lowered resist-
ance of the nasal mucous membrance, and from the
inflammatory reactions associated with these proc-
esses. In the treatment, these various conditions
should be considered.
The important factor in the treatment is the re-
moval of the exciting cause. In many cases, the
pollinating weeds are in the neighborhood of the
patient's residence, and the cutting of these will
frequently give marked relief. My first prescrip-
tion to such patients is "Have the weeds and grass
in your neighborhood cut and keep away from other
weeds." The result of this advice depends upon the
extent to which the pollinating weeds and grasses
can be cut or destroyed, but the results compare
favorably with the published reports of therapeutic
methods.
A method which has given relief in almost every
case, is the removal of the patient during the hay-
fever period from the infected locality. This does
not necessitate an expensive trip to the mountains
or seaside, which frequently fails to give relief on
Fig. 4 - Vellow dock [Rumex crispus). A cause of spring
hay-fever.
account of the presence of hay-fever pollens in the
air at these places. A temporary visit to a more
central part of the city will be sufficient, provided
the areas with pollinating weeds or grasses are at
a sufficient distance i • j mile or more). The new
July 15, 1916J
MEDICAL RECORD.
97
locality should, however, be carefully inspected, as
a small lot with high weeds in the same square may
be more irritating than a whole acre of weeds at a
greater distance.
For several years attempts have been made to
increase the resistance of the patient to pollen by
the injection of the pollen extracts. In all the early
attempts, mixed pollens were used without regard
to the special susceptibility of the patient, which
is probably one of the causes of their failure. In
such cases, only the pollen should be used to which
the patient reacts, as evidenced by the nasal, con-
junctival, or skin reaction. The injection of the
wrong extract may cause the patient to become sen-
sitive to the pollen from which the extract is pre-
pared.
The pollen extract is prepared by dissolving one
centigram of the specified pollen in ten c.c. of 5 per
cent, salt solution to which 10 per cent, alcohol has
been added and which is preserved in an aseptic
condition. When used, this should be diluted to
about 5 per cent., the strength to be determined by
the conjunctival reaction, this being indicated by a
hyperemia produced by the extract. The subcutane-
ous injection of the extract should be repeated at
intervals of three to five days. The object of the
injection is to increase the patient's resistance to
the pollen toxin (anti-anaphylaxis) so that the in-
haled pollen protein will no longer produce an attack.
Instead of the conjunctival reaction, the skin re-
action is frequently used. This is effected by mak-
ing a number of light scratches on the skin and rub-
bing in a drop of the pollen extract to be tested. A
positive reaction is indicated by reddening and
edema of the area surrounding the abraded surface
and accompanied by itching.
In cases in which the pollen therapy does not giva
satisfactory results, autogenous vaccines may also
be used. These are prepared from the bacteria
found in the nasal secretion of the patient. Both
of these methods have given fairly satisfactory re-
sults, whose permanency, however, still remains to
be established.
Relief has also been reported from the use of
calcium chloride, which already has been success-
fully used in asthma, the dose being 3 grams daily.
It is supposed to act as a sedative to the nervous
system.
Mercury has also been used in hay-fever, and
Barton L. Wright of the United States Navy re-
ports several successful cases. He prefers the
succinimide of mercury, 1/5 gr. in distilled water,
this being injected deeply into the gluteal muscles.
He believes that the effects are due to the fact that
patients after a mercuric treatment have a peculiar
power of resistance to infection of every kind.
In regard to treatment, however, it must be ad-
mitted that thus far none except the elimination of
the pollinating wTeeds has given very satisfactory re-
sults. The above methods are described as the most
promising thus far. Further investigations along
these lines it is hoped will eventually give sufficient
data to indicate the most advisable method of treat-
ing this disease.
As hay-fever has been shown to be a distinctly
preventible disease, it is clearly our duty to use
every effort to eradicate the cause. The investiga-
tions which we have conducted for several years
indicate that the large majority of the plants whose
pollen give rise to hay-fever are worthless weeds
which are alike an expense to the farmer and a
menace to health.
In a work of such an extensive character, how-
ever, as the eradication of hay-fever weeds, we must
have general co-operation in order to be successful.
It is therefore necessary to educate the public in
the relationship of such weeds to hay-fever and the
relief that sufferers from this disease are entitled
to by removing the caus_-. Health is one of man's
most important assets, and every one has a right
to demand that this does not suffer on account of
the neglect of his neighbor. If the hay-f<.ver weeds
are allowed to infest his neighbor's premises or
vacant lots and infect the air he breathes with
noxious pollen, he is evidently entitled to relief.
In the medical professionj the relationship of
pollen to hay-fever has been so firmly established
that it is now technically referred to as "pollinosis."
In the recent meeting of the Louisiana State Medi-
cal Society, in which I spoke of the etiology of hay-
fever, there was not a dissenting opinion expressed
regarding the relationship of these pollens to hay-
fever.
;Vw
\
"' \
Kli;
-Oockle bur (Xanthium canadenst > A great nuisance
to the farmer and a cause of hay-fever.
An important item in the eradication of hay-fever
weeds is the distance at which pollen may produce
an attack of hay-fever. It has been shown by means
of glass slides exposed to the wind that some pollens
may travel a great distance, even several miles. We
have found, however, that pollen scatters rapidly as
it is carried by the wind from the parent weed, the
decrease being estimated to be inversely as the
square of the distance. On this account, pollen is
not often a source of hay-fever at a distance of over
a half mile, and even a much shorter distance is
often sufficient to give relief. According to the
above rule, a patient at 1000 feet, or about three
ordinary city blocks, would inhale only 1/100 part
of the pollen to which he would be exposed at 100
feet.
98
MEDICAL RECORD.
[July 15, 1916
Immunity to hay-fever does not mean that the
patient is not inhaling pollen, but that the amount
is not greater than he can neutralize. In an atmos-
phere in which there is an abundance of pollen, it
is evident that all persons breathing this air must
inhale about an equal number, but only those suffer
in whom the amount of pollen inhaled is in excess
of their neutralizing power. There are probably few
who cannot inhale a certain number of pollen grains
without disturbance, hence the importance of keep-
ing this number as low as possible.
As an evidence of the importance of eliminating
the pollen in the immediate vicinity of the patient,
I have observed great relief to patients when the
hay-fever weeds in lots adjoining their residences
were cut down, although considerable pollen was
still in the air from weeds at a greater distance.
The increased susceptibility of a hay-fever pa-
Fig. 6. — Johnson grass (Sorghum halapense). Practically
all grass.s are wind-pollinated and mas cause hay-fever.
(Prom "Southern Grasses," United States i -tment of
tient after an incipient attack has already been
referred to. We have had patients living at a
distance of a quarter of a mile from a large area
of hay-fever weeds, who were entirely free for
weeks until their susceptibility was increased by an
attack from close proximity to these weeds. The
amount of pollen at a distance which had not before
been a source of irritation was now sufficient to
continue the attacks.
In order to be effective, the efforts against
hay-fever weeds should be reinforced by proper leg-
islation. There will always be persons who respect
their neighbors' rights, in health as well as in other
matters, only when compelled by the majesty of the
law. When education has reached a sufficient stage,
therefore, suitable laws should be enacted to obtain
permanent results against hay-fever.
In New Orleans where success against hay-fever
is already quite apparent, the education of the pub-
lic in the relationship of certain weeds to hay-
fever was carried out by means of articles in the
medical and lay press and in lectures before various
societies. As a result of this, when an effective
anti-hay-fever-weed law was submitted by the
American Hay-Fever-Prevention Association to the
city council it was passed without a dissenting vote.
It is now being enforced, and the results in the
reduction of the number of hay-fever cases thus
far (July 1) has surpassed all anticipations.
It is important in enacting such an ordinance
that the provisions should not be too drastic or it
will be difficult to enforce. The height of grass and
weeds should be limited to one foot on lots, side-
walks, and roads operating through a public fran-
chise. On the other hand, no preliminary notifica-
tion should be allowed, as this greatly increases the
expense of inspection and reporting, and lowers the
efficiency of the ordinance.
As the relation of weeds to hay-fever becomes
more generally recognized, adequate anti-weed laws
will be introduced in all the towns and cities. Their
proper observance will give results in hay-fever
that will fully justify the expense of their enforce-
ment.
844 Audubon Building.
HAIR-MATRIX CARCINOMA.
By FRANK WARNER, M.D., F.AC.S.,
COLUMBUS, OHIO.
Basal-celled, or hair-matrix, carcinomata occur,
with few exceptions, on the head, face, or upper lip.
They occasionally occur on the lower lip, the body,
or the extremities.
In a recent study1 of 206 cases of carcinomata oc-
curring in various parts of the body, thirteen were
found to be of the hair-matrix type; eleven being
on the upper lip or above, one over the scapula, and
one on the leg. Two of the cases were epidermoid
of the cheek.
Whenever a malignant tumor develops in this
upper face and head region, it will usually be found
to be a hair-matrix carcinoma.
Hair-matrix carcinoma, as a type of rodent ulcer,
has long been known to infiltrate broadly and
slowly, but not deeply. The general understanding
of this proposition has proved of great advantage
to the surgeon, and in turn, to the patient. Where
possible, the surgeon removes the growth with an
incision fairly clear of the infiltrating edge, which
can usually be determined by a rather abrupt mar-
gin, of different color from the balance of the
growth, being pearly in appearance.
This cancer is the least malignant of the car-
cinomata. It displays little tendency to produce
metastases, although these occasionally occur. For
all it grows slowly, and is so feebly malignant as
compared with many of the other varieties of can-
cer, as to make its complete removal easy. An oper-
ation will give the patient freedom from mutilation
and recurrence in proportion to the thoroughness
and promptness with which it is undertaken and
done after its inception. Once thoroughly re-
moved, it never recurs.
The histological picture of a hair-matrix carci-
noma is quite characteristic in most cases. At
times, however, it comes to resemble a sarcoma,
when the usual cuboidal cells, of which it is com-
posed, assume a spindle shape.
Mallory* has pointed the way to its differenta-
tion by calling attention to the fibrils which will be
July 15, 1916]
MEDICAL RECORD.
99
found on careful examination, taking the character-
istics of the cells which line the hair-matrix. Not
alone the fibrils tend to differentiate the growth
from sarcoma, but their tendency to arrange them-
selves in tubules, like the hair-matrix from which
thev are derived.
Fig. 1. — Normal hair follicles.
Adami,3 in speaking of Krompecher's work, says
that he has called these basal-celled cancers, and has
"established, it would seem, beyond any doubt, that
cells of epidermal, epiblastic origin can give rise to
tumors indistinguishable from connective-tissue
sarcomas in histological structure." Again: "We
deal with an epithelioma of the most aberrent and
anaplastic type, which, nevertheless, for long
months, and it may be, years, continues to grow
and locally infiltrate and destroy the surrounding
tissue."
Ewing* has made some interesting observations
on the resemblance of certain spindle-cell carcino-
mata to sarcomata. He says: "Epithelial tumors
may from their inception appear like spindle-cell
sarcoma, as in the spindle-cell, basal-cell carcinomas
of Krompecher. in spindle-cell carcinoma of the
thyroid, and in melanoma. It is becoming more and
more apparent that many so-called sarcomas of the
organs are in reality spindle-cell carcinomas.
Spindle tumor cells are so common in car-
cinoma that their occurrence in any carcinoma is
very strong presumptive evidence that they are
altered epithelium."
The disposition to keratinization into epithelial
pearls in basal-celled carcinomas is nowhere nearly
so frequent as it is in the epidermoid variety of
tumors, although Mallory speaks of their occa-
sional appearance in minute forms.
A rodent ulcer appears as a warty growth, and
indeed is frequently mistaken for a wart, which
may remain for a considerable time without ulcer-
ating; some authors say for several years, but this
seems rather improbable. Rather, it would appear
that the simple warty excrescence has changed its
character to a malignant type of epithelial pene-
tration and overgrowth. As has been emphasized,
hair-matrix carcinomata spread very slowly and su-
perficially.
Morrow5 pointed out long ago a prominent dis-
tinguishing feature of rodent ulcer in contrast with
an epithelioma, when he said: "The amount of
infiltration or new deposit about the base and edges
of a rodent ulcer is much less than in the usual
variety of skin cancer, while ulceration is more
marked." These are valuable points in making a
differential diagnosis.
The location of the ulceration is always sug-
gestive, in a diagnostic way, for the majority of
these ulcerations occur about the sides of the nose
and the eyelids, or on the head or face above the
lower lip.
Again, the age of the patient is helpful in making
a rightful interpretation of the character of the
ulcer, or of the warty growth before it has become
broken down into an ulcerating surface. It is pre-
eminently a disease of the advanced cancer age, or
of middle life.
Until recently many writers have confused hair-
matrix carcinomata and epitheliomata, the one with
the other. But their whole history of development
and subsequent behavior are quite different. Then
when a histological study of the two is made, there
is no longer doubt remaining as to their true char-
acter.
In contrast to many varieties of cancer which
have arisen after a prolonged period of a so-called
precancerous state, hair-matrix carcinoma is quite
as apt to develop on a part which has apparently
been free from all forms of irritation.
Some authors have attempted to explain the de-
velopment of cancer upon anatomical grounds.
Theilhaber" thought that nutritional changes, due
to endarteritis and an acellular connective tissue
that are frequent accompaniments of old age, are
responsible for their initiation. But the writer has.
shown that in a study of 206 cases of carcinoma,
obstructive vascular changes occurred in only 105'
cases, a little over one-half. So, the other half of
the cases could not have depended upon this cause
of the cancer. Likewise, the fibrotic changes were
present in only 118 cases, or 57 per cent.
These anatomical changes are hardly constant
enough to be regarded as offering sufficient causa-
tive agency for the initiation of malignant growths.
Internal causes of cancer, associated with exter-
nal irritative ones, known as precancerous condi-
tions, are more likely to result in the development
of malignant growths than where the one cause
operates alone. Perverted chemical and biological
activities of the epithelial cells seem to be sufficient
cause for the development of cancer, but just what
these changes are, or what induces them, remains
to be established. Aside from the influence that
heredity plays, and the exciting causes of the well-
known precancerous conditions, the etiology of car-
cinoma is still in the dark.
Fl<s- 2. — The tumor from the nose, showing tendency of epi-
thelial cells to form into tubules.
But whatever are the causes that start epithelial
malignancy, the disease is local at the outset, and
all that is needed to effect a cure in any one case is
to operate early enough to find the condition in its
very incipiency.
100
MEDICAL RECORD.
LJuly 15, 1916
Then, and only then, can the surgeon hope to
make his operations universally successful. This
is less true of hair-matrix carcinoma than the
others, because there is slight tendency to produce
metastases, or to infiltrate deeply; yet, even here,
Fig. 3.— Higher magnification of Fig. 2, showing the tendency
to the formation of tubules.
this form of cancer cannot always be attacked with
assurance of success when it has been in existence
for a long time, for infiltrations may have occurred
that are impossible to reach. Hair-matrix carci-
nomata are, of course, on the surface of the body,
where they can be seen in their earliest develop-
ment. If attacked as soon as observed, doubtlessly
100 per cent, of recoveries would result.
As illustrative of the results to be attained by
early operations on hair-matrix carcinoma, the fol-
lowing two cases are appended:
Case I.— Mr. J. A. C, age 53, came to mo Nov. 20,
1909, for a slight lump on his forehead, over the left
eye. This had been in existence for six months. It was
small and only slightly elevated. The edges of the ele-
vation were higher than its center, and the color was
lighter, slightly pearly in character. There was no
ulceration of the surface, but the whole appearance of
the disturbance was that of an early rodent ulcer, or
hair-matrix carcinoma. No pain was associated with
the growth. On November 24, 1909, I removed the
tumor with a rather wide incision, quite clear of the
growth. The wound healed promptly, and there has
been no reappearance up to the present time, being
nearly seven years since the operation. The tumor was
a hair-matrix carcinoma.
Case II. — D. I., age 43, male, consulted me with refer-
ence to a small lump on the right side of his nose. It
was about the size of a pea, with pearly edges, but no
ulceration. The tumor had only been observed a few
weeks previously. No pain had been experienced in the
growth. A circumstance that made one feel that
the tumor was about to ulcerate was the fact that soon
after its first appearance, or at least, since its presence
had been observed, bleeding occurred from a small vein
traversing the growth. This healed at once, so that
mo ulceration was observable at the time of the exam-
This growth was removed on October 22, 1914, by an
incision which well cleared the outermost edges of the
tumor, and the actual cautery, a platinum point heated
by electricity, was applied to both the base and the
edges of the freshly made wound. This was done as a
precautionary measure to destroy any infiltrating can
,..,, , Sn0 lis of a --pin':: i sliap.-
cot cells that po^My might have escaped the knife.
There has been no evidence of its recurrence. The his-
tological structure of the growth proved it to be a hair-
rm-iUix carcinoma.
The results in both of these cases emphasizes the
fact that we may reasonably hope for a complete
freedom from recurrence in hair-matrix carcinoma
when the operations are done early in their
progress, for it is well known that at this time these
new growths do not tend to infiltrate deeply, nor to
Fig. 3. — The tumor cells are packed closely together and
appear only as small round cells.
metastasize, nor to show a high degree of malig-
nancy.
Finally, when we come to reflect how absolutely
curable this disease is in its early inception, and
how easy it is to make a probable diagnosis at this
time, and what a slight operation is required to ef-
fect this much desired result, there seems little oc-
casion to delay these trifling operations that prom-
ise so much. As has been shown in this paper,
there is not alone this more extensive infiltration to
encounter in delayed operations, but there is the
constant danger present of an epithelioma engraft-
ing itself on the edges of the ulcerating growth.
Then a tumor of a higher grade of malignancy is
there to deal with. By this time, metastases may
have occurred in neighboring glands, or elsewhere,
and infiltration of epithelial cells into depths that
are not reached by an operation.
To obtain better results in our operations for
cancer of all forms, earlier diagnoses must be made,
and earlier opportunities given the surgeon to do
these operations.
REFERENCES:
1. Warner, Frank: Surgenj, Gynecology and Ob-
stetrics.
2. Mallory: Principles of Pathologic Histology, p.
373.
3. Adami, J. George : Principles of Pathology, Vol.
I, p. 651.
4. Ewing, James: Jour. Cancer Res., January, 1916,
p. 76.
5. Morrow, Prince A.: Dermatology, Vol. Ill, 655.
6. Theilhaber: Stirg. Gyn. Obat., November, 1914, p.
650.
in West Goodale Street.
THE ACTION OF GAMMA-RAYS OF RADIUM
ON DEEP-SEATED INOPERABLE CAN
CERS OF THE PELVIS.
BY HENRY SCHMITZ, A.M. Ml>. F.A.C.S.,
CHICAGO.
Radium therapy of malignant tumors in any part
of the body demands the discussion of the follow-
ing points: (1) The technique of the application of
radium, (2) the evidence of the histological changes
caused in the tumor tissue, and (3) the clinical
results; it also must include a discourse on all
accessory moans which will assist the action of
radium, such as 1 4 ) the application of the mas-
sive Roentgen rays, and ( 5) the use of surgical
procedures to facilitate or aid the intensity of the
gamma-rays of radium.
The Technique of Radium Applications. — The
technique of the application of radium must con-
sider (1) the amount of radium element used,
July 15, 1916]
MEDICAL RECORD.
101
(2) the method of screening, 1,3) the extent of the
time of exposure of the rays to the tumor, and
(4) the distance maintained between the radium
and the tumor mass. The quantity of radium nec-
essary to destroy growths, that reach two or three
lew...
1e
Dose h
Is^c-m.
/unit
Xs^-etn-.
%
jjSa.env-.
'll .
J+S4.em-
%
^S|«T*.
Jiur
Fig. 1. — Law of Radiation.
centimeters into the uterine, rectal, vesical and
pelvic cellular tissues, should be at least fifty milli-
grams of radium element. If the capsule cannot
be brought into direct contact with the tumor,
then a sufficient intensity of the rays must be ob-
tained by the use of larger amounts of radium
element.
To determine the dose of gamma-rays necessary
to destroy carcinoma tissue we make use of the
law of radiation and experiments carried on in
the living human body. The intensity of the
action of rays varies inversely as the square of the
distance from the source of radiation. The irradi-
ated area at a distance of one centimeter may be
considered as one square centimeter and the dose
of rays for this area as one unit. At two centi-
meters, the irradiated area is four square centi-
meters and the dose one-fourth of a unit, and at
three centimeters the irradiated area is nine square
centimeters and the intensity of the rays is one-
ninth of a unit. (See figures 1 and 2). If for in-
fifty milligrams radium element destroy a tumor
mass within one centimeter distance, in twelve
hours, then two hundred milligrams radium ele-
ment will do so in twelve hours within two centi-
meters distance and four hundred and fifty milli-
grams radium element in twelve hours within a
distance of three centimeters. However, it has been
found that more than one hundred milligrams
radium element should not be used at a given point,
and if a larger amount be used, it is better to dis-
tribute each hundred milligrams to various parts
of the tumor, as is done in the method of cross-
firing. The reasons are that large amounts of
radium cannot be properly concentrated into a suf-
ficiently small area of space, so that the law of
radiation may be correctly applied.
The experiments in the human body were carried
out in recurrent breast cancers, characterized by
the formation of multiple nodules. A nodule was
removed under local anesthesia and subjected to a
microscopic examination to determine its patho-
logical nature. Then the gamma-rays of fifty milli-
grams radium element were applied for four hours
to a given nodule, for six hours to another nodule,
for eight hours to a third, for ten hours to a fourth,
for twelve hours to a fifth, and so forth. After ten
to fourteen days, i.e. when the latency of the ac-
tion of the gamma-rays reaches its height, the
nodules were removed. We noted particularly the
distance of the growths from the skin surface. The
removed tissues were subjected to microscopic ex-
aminations. In this manner we repeatedly demon-
strated the fact that the gamma-rays of fifty milli-
grams radium element destroyed carcinoma tissue
within a distance of one centimeter from the skin
surface after a continued application of twelve
hours, i.e. six hundred milligram hours or milli-
gramage.
The receptivity or sensitization of carcinoma tis-
sue toward the gamma-rays varies, depending upon
the age of the individual and a corresponding dif-
ference in the vascularity and nucleization of the
~Radium
Ttad,
ium
KcMu
/s-l 1 \ \
\y 1 \ >
H- ' X
Ayr \
Distance.
1 cm. 2 cm.
3 cm.
Irradiated area.
1 sq. cm. 2 sq. cm.
3 sq. cm.
Dose per sq. cm.
1 unit Vi unit
1/9 unit
-Law of radiation.
4 cm.
4 sq. cm.
1/16 unit
5 cm.
5 sq. cm.
1/25 unit
stance, fifty milligrams of radium element destroy
a tumor mass within a distance of one centimeter
from the radioactive substance in twelve hours, then
the same amount will bring about the same result
within a distance of two centimeters in forty-eight
hours, and within a distance of three centimeters
in 9 x 12 = one hundred and eight hours. Or if
tissues as well as on the variety of species of the
cells composing the tumor. H. Dominici and Theil-
haber have made extensive investigations along
these two points. For practical reasons the above
dosage of milligram hours, when fifty milligrams
of radium element are used, may be considered as
lethal.
102
MEDICAL RECORD.
[July 15, 1916
If we determine by a careful examination the ex-
tent of the tumor mass and apply the radium ac-
cording to facts given, we will be able to estimate
for each case, the amount of gamma-rays necessary
to bring about a clinical cure.
The schedule of a course of radium applications,
based on these facts, is as follows: The duration
of a course of treatment varies from twelve to one
hundred and eight hours, when fifty milligrams of
radium element are employed and this depends on
the extent of invasion of the cancer into the tis-
sues. The course is divided into seances of twelve
to twenty-four hours, the interval between the sit-
tings being from twelve to thirty-six hours. We
endeavor invariably to give the total estimated
within one week.
If one hundred milligrams of radium element are
used, then the duration of the treatment is corre-
spondingly reduced. Should it be impossible to
apply the radium directly to the tumor mass, longer
exposures or large amounts must be used to cor-
rect the reduction of the intensity of the rays
caused by the increase in distance. The law of
radiation must be applied in consideration of these
facts.
The method of screening or filtering is simple as
gamma-rays only must be used in deep-seated can-
cers. The alpha-rays of radium are arrested by
the glass capsule, which contains the radium salt.
The beta-rays are absorbed by 1.2 mm. brass, silver,
or lead. The secondary or Sagnac rays, that form
in the metal screens by the arrested beta-rays, are
absorbed by a pure rubber tube free from any
metal and of 2 mm. thickness. They are also ar-
rested within a space of 7 mm. and therefore dis-
tance filtering may obviate the need of a rubber
filter.
Cross-firing should be employed whenever pos-
sible. If a carcinoma is found in the anterior
rectal wall a radium capsule should be inserted in
the rectum and another in a corresponding position
within the vagina; if in the posterior rectal wall
in the rectum and on the anal fold, if in the posterior
vesical wall in the bladder and vagina; if in the
anterior vesical wall into the bladder and on the
suprapubic region, if in the cervical canal, the
latter and the vaginal fornices, and so forth.
Special radium carriers are required for rectal
and vesical applications. For the former I use a
cup with a perforation in the center. It is held
in place by two rubber bands fastened to a belt
around the abdomen. The radium carrier is at-
tached to a brass rod which is surrounded by rub-
ber tubing. The latter arrests also the secondary
rays. The length of the rubber tubing is deter-
mined by the distance of the growth from the cup.
The brass rod passes through while the rubber tube
rests on it. The carrier by this arrangement re-
mains movable and therefore becomes automatically
adjusted to any position the patient might assume.
In vesical cancers I place the radium capsule in a
urethral catheter. Two fenestra; are made in the
catheter beneath the radium capsule. As vesical
cancers are usually located in the trigone the posi-
tion of the catheter within the bladder is indicated
by the escape of urine through the tube. The latter
is then secured in place by adhesive plaster. A
rubber tube attached to the catheter directs the
urine into a bottle. Continuous drainage is thus
secured, making long-continued applications of
radium within the bladder possible.
After the first course of radium treatment the pa-
tient is requested to return weekly for reexamina-
tion. The latent action of radium reaches its height
within twenty-one days. Should the patient at this
time not exhibit a marked improvement in the local
condition, indicated by a decrease in size of the
tumor, another course like the first one is given.
If the patient shows a marked improvement, then
the second seance is postponed for another three
weeks. Further applications are thereafter given
when indicated by a persistence or a reappearance
of the tumor.
Strictest asepsis must be observed in the applica-
tion of radium. Instruments and applicators must
be rendered sterile by boiling. The field of opera-
tion must be prepared as for any operation. The
surgeon also must adopt the same procedures as he
would for the performance of any operation.
Healthy tissue must be protected from the rays
wherever practicable. Lead sheeting 0.5 mm. thick
is used for this purpose. It is cut and shaped to
correspond to the dimensions and form of the area
to be protected from the action of the rays. The
Sagnac rays are arrested by surrounding the lead
sheeting with heavy soft rubber sheeting. The
latter also serves as a cushion to prevent undue
pressure and thereby injury to the soft tissues.
The Use of Massive Roentgen Rays in Connection
with Radium Treatment. — We cannot determine by
bimanual examination whether the regional lymph-
nodes are or are not metastatically invaded by the
carcinoma. Therefore, we apply massive x-rays
to the glands through the anterior abdominal wall
by the massive multiple field crossfire method of
Gauss. We use Coolidge and water-cooled Roentgen
tubes. As the vacuum or hardness obtainable in
the water-cooled tubes is higher than in the Cool-
idge, we prefer the former. However, the use of
the water-cooled Roentgen tube involves a greater
expenditure in the duration of the exposure, but
the higher vacuum obtainable insures a deeper pene-
tration. This, after all, determines the preference
for the water-cooled tubes.
Thirty to fifty erythema doses are necessary to
destroy a malignant growth within two centi-
meters of the surface of the abdominal wall. It
requires seven times this amount, that is three hun-
drr d and fifty erythema doses, to remove metastases
near the posterior pelvic walls, which are about ten
centimeters distant from the surface of the skin of
the suprapubic region. The Roentgen tube should
have a hardness of twelve to thirteen and a half,
as determined by a Wehnelt penetrometer. It
should carry a critical current of four to five milli-
amperes. The constancy must be maintained for
an indefinite length of time by a continuous flow
of cold water around the anode and an interrup-
tion of the current for a half second out of every
second while in use to keep the tube cool, and
thereby retain the originally indicated hardness.
The latter should be controlled by a Heinz Bauer
qualimeter. The distance of the anode from the
body should be 21 cm. The rays must be filtered
through a three millimeter aluminum screen, to
exclude the soft rays. Under these conditions, ten
to twelve erythema doses may be obtained per hour.
If three seances of one hour each are given daily,
ten to fourteen days are necessary to reach an
amount of three hundred and fifty erythema doses.
We use six fields as portals of entrance, and must
apply about sixty erythema doses to each field.
Bumm does not hesitate to apply one hundred ery-
thema doses to a field.
July 15, 1916]
MEDICAL RECORD.
103
The time of exposure may be reduced by using
a Coolidge tube. L. G. Cole states that an ery-
thema dose may be filtered in one minute using
a three mm. aluminum filter. The entire applica-
tion of three hundred and fifty erythema doses
could, therefore, be made within six hours.
The Possibility of Increasing the Intensity and
Penetration of the Gamma-rays of Radium by Ex-
cochleation and Cauterization of the Cancer Growth.
— The distance between the radium capsule and the
periphery of the tumor may be decreased by the
removal of the cancer tissue with the sharp spoon
and the cautery iron. Thereby the intensity and
penetration of the gamma-rays in the peripheral
portion of the tumor is markedly increased. This
method is especially practicable in the proliferating
cauliflower growth of the cervix. Cauterization has
been performed in every case in our series, in which
such a procedure was not otherwise contraindi-
cated. The result is a marked reduction in the ex-
tent of the new growth and a corresponding in-
crease in the penetration of the rays and a de-
crease in the duration of the exposure of the gamma-
rays. It is a purely economical question and has no
other influence on the result of the radium treat-
ment.
It is advisable to perform a colostomy in rectal
cancers. This renders the seat of the carcinoma
clean, prevents absorption of septic and putrefac-
tive material, gives the patient an invaluable relief
and makes the use of radium less obnoxious to pa-
tient and surgeon.
In vesical cancers in the male, a suprapubic cys-
totomy should be done. The radium may then be in-
serted through the suprapubic drainage tube. In-
jury to the posterior urethra by long-continued in-
sertion of a cystoscope is avoided, the use of an op-
erating cystoscope becomes unnecessary, and the ob-
jections on the part of the patient are obviated.
However, the catheter procedure, as before men-
tioned, may also be used after a preceding dilata-
tion of the urethra, so that a cystotomy can be
avoided.
The Histological Findings. — The histological
changes may be divided into four stages:
The first stage is characterized by an enlarge-
ment of the carcinoma cells, a hyperchromatosis
and a pycnosis of the nuclei. They are evident in
all the cases examined. These changes usually oc-
cur within about ten days after the first applica-
tion of radium.
In the second stage we observe caryolysis, cary-
orrhexis, cyctolysis, and cell detritus. They are
seen as early as from the first to the third week
of the treatment.
The third stage shows an absorption of the cel-
lular and nuclear debris by phagocytosis. Macro-
phages and microphages are concerned in this step.
It takes place as soon as the cells begin to de-
generate.
The fourth stage is the stage of connective-tis-
sue proliferation and scar formation. It completes
the histological cure of cancer. The places left
vacant by the dead carcinoma cells are immediately
filled by young fibroblasts derived from the con-
nective-tissue stroma of the tumor. The fibro-
blasts become differentiated. The fourth stage ap-
pears usually after the first to the third month,
but may occur much sooner.
A discrepancy frequently exists between the clini-
cal results and the histological findings. For in-
stance in case 26 of our series there was evidence
of a completely destroyed cancer tumor, yet the pa-
tient succumbed to a bowel invasion, proving that
some cancer cells either remained uninfluenced by
the radium or regenerated after the subsidence of
the action of the rays. Therefore, certain ques-
tions arise which call for definite answers before
we may positively state that radium rays cause a
degeneration and ultimate death of cancer tissue
and a simultaneous proliferation of connective
tissue.
1. Are we able by microscopic examinations to
differentiate the necrobiotic changes in the car-
cinoma cells brought about by natural and artificial
conditions from those caused by the influence of
radium rays? Cells undergo necrobiotic changes
in the course of their existence. Heat, caustics,
and alcohol, brought in contact with the tissues,
may produce the same changes, as is well known.
However, the absence of cell degeneration as evi-
denced in the first section, and the general and ex-
tensive changes as seen in the subsequent speci-
mens after their exposure to the gamma-rays, and
the regularity of their occurrence in all the tissues
microscopically investigated, even in those not pre-
viously cauterized, permit us to state that they
must be caused by the action of the gamma-rays.
2. Can we, by examination of small pieces of
tissue removed from the growth, determine the
extent and intensity of the action of radium rays?
We cannot from such an examination, but could do
so from serial sections from all the organs removed
either intra vitam during operations or, preferably,
post mortem.
I have, fortunately, seven cases in which an ab-
dominal panhysterectomy was performed after a
clinical cure of the cancer by the use of radium
rays was obtained. (Cases 26, 29, 32, 64, 128, 162,
and 165.) Serial sections were made from the tis-
sues removed. A microscopic examination revealed
that the cytolytic changes were generally present
throughout the tumor. This does not prove that
distantly located foci were not left behind. As a
matter of fact, patients 26 and 29 died subsequently
from cancer. This shows that viable cancer cells
were left behind somewhere in the pelvis. Bumm
examined tissues acted on by gamma-rays and re-
moved afterward during post mortem examinations.
He estimated that the intensity of the gamma-rays
sufficient to destroy carcinoma tissue extended into
a radius of four centimeters. Within this area
of intensity, carcinoma cells were not found pres-
ent. Beyond it, however, typical unchanged cancer
cell nests were still found to exist. In other words,
extensive carcinoma growths are only partially de-
stroyed by gamma-rays. This area of destruction,
however, has a diameter of eight centimeters and
enables us to reach tissues which a knife could
never remove.
3. Is it possible by such microscopic examina-
tions to state whether a carcinoma cell has perished
or whether it might not regenerate after the action
of the radium rays ceases? The following citation
will illustrate the answer to this question. Creron
and Rubens-Duval treated a patient suffering from
an inoperable carcinoma of the cervix with radium
during November, 1910, and January, 1911. The
patient was apparently clinically cured. She died
from an intercurrent disease (a cerebral softening)
during April, 1912, fifteen months after the begin-
ning of the radium treatment. All the internal
organs and tissues were removed post mortem, and
a careful serial histological examination of all the
104
MEDICAL RECORD.
[July 15, 1916
tissues did not reveal a single carcinoma cell at any
place of the organism. A complete anatomical cure
by radium rays had been demonstrated.
I have made a similar observation in a case of
Mrs. A. R., Augustana Hospital, number 44801,
serial number 141, who was treated with 3,600
milligram-hours radium element from October 27
to October 31, 1915, for an inoperable cancer in-
volving the cervix and the entire vagina. An ex-
amination made December 27, proved the patient
clinically cured. She died suddenly during the lat-
ter part of January, 1916, from heartblock. The
pelvic organs with the para and perimetrium and
parietal peritoneum and lymphnodes, including the
sacral, were removed en bloc. A most careful ex-
amination of stained sections in series did not re-
veal any cancer cells or nodules.
Our investigations demonstrate the uniformity
and general extent of the necrobiotic changes
brought about in the carcinoma cells by the action
of the gamma-rays. Bumm's researches fix the ex-
tent of the area of intensity of the rays within
which a carcinoma will become destroyed, and
Cheron and Rubens-Duval's case proves the capa-
bility or efficiency of the radium rays to bring
about an anatomic cure of cancer.
The Clinical Results. — The accompanying table
gives the clinical results of thirty-five inoperable,
twelve recurrent, and fifteen operable uterine car-
cinomata; seven inoperable, and three operable
rectal cancers ; and five inoperable, two recurrent,
and one operable carcinomata of the bladder. The
total number is eighty. They were treated between
April 1, 1914 and April 1, 1916.
Carcinomata of Pelvic Organs Treated With Radium
Cases Treated from April I, 191-1
April 1. 1915
TO
Cases Treated prom
April 1. 1915
3
REPORT
APRIL 1. 1915
CONDITION-
APRIL 1, 1916
REPORT
APRIL 1, 1916
S
0.
Q.
6
Z
"33 =
o
1
-a
3
Q.
|
a
"2
3
6
Z
g -
o
a
■3
3
9
0
S
Px
Inoperable
Uterine..
Rectal . .
Vesical .
18
3
2
5
1
1
1
12
2
1
2
1
2
14
2
1
17
4
3
9
1
2
2
2
6
I
1
ill 43
28 57
60 0
Total . . .
Recurrent
23
30 11',
9
0
11
7
2
2
15
5
4
2
17
9
24
:,,. ii'
6
0
2
12
3
4
1
8
2
34 04
20 0
2
Total .
9
22.22%
5
1
2
4
1
2
5
9
2
1
1
8
37.5%
7
2
0
3
5
2
3
1
2
17 66
Operable
1 terine
Rectal
3
66 67
66 67
1
Total ..
Grand total
7
39
5
11
3
2
22
3
7
i: 95
2
4
30
9
41
39
80
7
22
7
29
1
8
2
1
11
30
11
62 5
53 M
17 95
35 12
The results of the radium treatment differ de-
ponding (1) on the organ involved and (2) on the
stage of the disease. The prognosis is best in
vesical cancers, less favorable in uterine malignant
growths and least favorable in rectal carcinomata.
The value of the treatment varies depending on the
incurability, operability, inoperability or recurrence
of the disease. Some cancers are far advanced and
concealed and cannot be cured or improved by ra-
dium or any other remedial agents. The time
elapsed in all the cases enumerated is too short to
permit a discussion of the curative action of ra-
dium.
Inoperable Carcinomata. — Eleven clinical cures
were obtained in thirty-five inoperable uterine, two
in seven inoperable rectal and three in five in-
operable vesical carcinomata. A clinical cure im-
plies a complete subjective and objective cure of
the cancer as far as this can be determined by an
exact palpation and a microscopic examination. We
have a total of sixteen clinical cures in forty-seven
inoperable carcinomata, i. e., 34.04 per cent. This
percentage would have been higher if hopeless or
terminal cases had not been included. However, we
did not reject a single case referred for the treat-
ment, regardless of the general condition of the
patient. Twelve of the inoperable cases were far
advanced and are included in these statistics.
The time elapsed since the beginning of the
treatment in the fourteen clinical cures is as fol-
lows :
Serial No. 32, 26 months (hysterectomized) ; 69,
16 months; 98, 13 months; 113, 12 months; 140,
11 months; 128, 8 months (died from an intercur-
rent disease) ; 117, 2 months (died from an inter-
current disease) ; 141, 6 months; 162, 6 months;
165, 6 months; 150, 6 months; 170, 6 months; 168,
5 months ; 178, 4 months ; 70, 16 months ; 153, 6
months.
The palliative action of radium in inoperable cases
is truly remarkable. The three cardinal symptoms
— hemorrhage, putrid discharge, and pain cease
invariably within four to eight days after the
commencement of the treatment.
There does not exist another remedial agent in
our entire medicinal and surgical armamentarium,
the application of which in inoperable carcinomata
is followed by better primary and remote results.
Radium will bring about this action without imme-
diate or late danger to the patient provided the
strictest asepsis and a perfect technique are em-
ployed.
Recurrent Carcinomata. — The primary results in
recurrent cancers are: three clinical cures in fifteen
uterine, and none in the two vesical cancers, i.e. 20
per cent.
The elapsed time since the beginning of the treat-
ment is: No. 105, 12 months; 125, 10 months; 135,
9 months.
The prognosis of radium treatment in recurrent
cancers is, therefore, not as good as in inoperable
cases. Especial care is necessary in these cases to
avoid injury of neighboring organs and contiguous
tissues by the radium rays. As familiarity in the
treatment of these cases increases the results should
improve.
Operable Carcinomata. — The application of
radium following radical excision of the uterus and
adnexa for malignant disease is a purely prophylac-
tic procedure. Carcinoma cells that have become
spilled all over the wound surfaces during the
progress of the operation or carcinoma cell nests
and shoots that have been inadvertently left behind
may become effectually destroyed by the gamma-
rays. This fact has induced surgeons to increase the
percentage of operability of their cancer cases on ac-
count of the possibility of subsequent radium appli-
cations following the radical operation. It also has
rendered the operation less extensive, especially in
the regions of the rectum and bladder because of
July 15, 1916]
MEDICAL RECORD.
105
the evolution of radium-surgery. Cases No. 90,
101, 106, 133, and 188 were really inoperable, yet
subjected to an abdominal panhysterectomy and
subsequent radium treatment. Singularly enough
the first three cases have done remarkably well,
while the last two have not been benefited by the
surgery and radium.
We do not wish to render an opinion as to the
value of prophylactic radium treatment after ex-
cision of the operable cancers. The improvement or
cure must be accredited to surgery. The time
elapsed since the operations is too short to permit
an expression as to a permanent or anatomical cure.
The time passed since the operation and radium
treatment of these cases is as follows : Serial No.
32, 15 months; 41, 20 months; 90, 14 months; 101,
13 months; 106, 12 months; 107, 12 months; 134,
9 months; 163, 8 months; 173, 4 months; 174, 4
months.
Conclusions.— 1. The therapeutic action of radium
depends on the use of a correct technique, which
must be based on a careful physical examination of
the patient and the physical properties and the
biologic action of the metal.
2. The use of massive Roentgen rays, according
to multiple field and crossfire methods in conjunc-
tion with radium therapy to destroy metastases, is
an imperative necessity.
3. Certain surgical procedures must be used in
radium therapy to assist the action and facilitate
the application of the rays.
4. The action of gamma-rays on cancer tissue is
specific and suggests positive proof of the possibil-
ity of destroying malignant tumors by the applica-
tion of radium.
5. The results of radium therapy in inoperable
and recurrent cancers surpass those of any other
known therapeutic agent.
6. The prophylactic use of radium rays in oper-
able carcinomata increases the percentage of oper-
ability and probably the efficiency of the operative
procedures.
25 East Washington Street.
THE TREATMENT OF PARALYSIS AGITANS
WITH PARATHYROID GLAND.
By WM. N. BERKELEY. A.B., Ph.B., M.D.,
NEW YORK.
ATTENDING PHYSICIAN AT THE GOOD SAMARITAN DISPENSARY.
Numbers of inquiries from physicians interested
in the study of paralysis agitans continue to come
to me; and I have thought it might not be uninter-
esting to readers of the Medical Record for me to
report briefly once more my therapeutic experiences
with parathyroid gland. Since I last published any-
thing on the subject in this journal, nearly six years
have elapsed." I can perhaps offer no better intro-
duction than to repeat what I then said as to the
physiological details involved.
"It may be briefly stated that when the parathy-
roid glands are removed from a dog or other suit-
able animal, a curious and characteristic train of
symptoms follows, — hurried respiration, tachy-
cardia, profuse salivation, twitching and shivering
of the voluntary muscles, rigidity, intermittent
convulsions, rapid wasting, and death. There is
now an enormous literature on the subject. A
fairly complete bibliography may be compiled from
the writings of Jeandelise1, Pool2, Erdheim1, Berke-
ley and Beebe4, and Ochsner and Thompson5.
"MacCallum," in a further interesting and impor-
tant contribution to the subject has shown that a
suitable dose of a soluble calcium salt, injected into
the veins of a dog that has been successfully op-
erated upon in this way, will arrest the spasms
and for a few hours restore the animal to a normal
condition. He concludes that the parathyroid
glands, therefore, preside in some way over the cal-
cium metabolism of the body, and that the symp-
toms in question are caused by a deficiency of cal-
cium. S. P. Beebe and I' have successfully repeated
this experiment, which is one of the most striking
phenomena in the physiological laboratory; from a
series of additional experiments, however, we have
been disposed to conclude that in such cases the
calcium has a 'drug effect,' and that the para-
thyroid glands more likely furnish enzymes of
prime importance in the intermediary metabolism
of nitrogen. The subject is a difficult one and
awaits further research.
"Whatever the ultimate solution of the physiolog-
ical problem may be, such remarkable and charac-
teristic symptoms strongly suggest some causal re-
lation between a defective secretion of these glands
and one or more of the known convulsive diseases,
and medical men have not been backward in guesses
of various kinds. Exophthalmic goiter was long
ago proposed by Gley' and afterward given over.
Vassale proposed puerperal eclampsia.5 Epilepsy
was first suggested by MacCallum (acknowledgedly
in a tentative way),8 but further independent re-
searches by this author10 brought him to the conclu-
sion (reached about the same time by Pineles" and
Erdheim (I.e.) and rather vaguely suggested by
Jeandelise (I.e.) in 1902, four years previously)
that tetany is the final answer to this long-standing
question.
"Without going further into the extensive litera-
ture of this part of my topic, it will be enough to
say that tetany — whether associated with surgical
damage to the parathyroid glands in thyroidectomy,
with infantile rickets, with pregnancy, or with
dilation of the stomach — is unquestionably one of
the answers. But a further inquiry remains
whether this be the only disease having any rela-
tion to these glands ; and it is now some years since
the Swedish neurologist, Lundborg," and I," work-
ing along different lines, and each independently of
the other, conceived the idea that Paralysis agitans
is possibly due to some chronic disorder or disease
of the parathyroid glands.
"In support of this hypothesis I have offered
(I.e.) the following considerations: Paralysis agi-
tans has all the marks of a chronic toxemia; the
symptoms following parathyroidectomy are remark-
ably like those of paralysis agitans; in cases of
myxedema and exophthalmic goiter, paralysis agi-
tans has not infrequently occurred as a complica-
tion or sequela; of fourteen reported autopsies on
paralysis agitans, two by Erdheim (l.c) and nine
by R. L. Thompson," showed negative parathyroid
glands, but two by C. D. Camp15 and one by myself"
showed distinct pathological changes; and lastly
a remarkable percentage of cases of paralysis agi-
tans treated with properly identified fresh gland,
or a properly made extract, have been greatly ben-
efited."
As a source of supply for the remedy, the para-
thyroid glands of the horse are available in those
countries where horse meat is a popular flesh food,
and where horses are slaughtered in well-conducted
and officially inspected abattoirs. In this country
106
MEDICAL RECORD.
[July 15, 1916
the only glands generally available are those of the
bullock. As regards methods of preparation, I have
elsewhere remarked on the careless and unscientific
way in which the ordinary parathyroid of com-
merce is prepared, and I have mentioned the suc-
cessive experiments through which I have labored
in order to get a preparation which more nearly
represents the unmodified gland.
I have used fresh glands with some success. A
medical associate writing me some years ago from
Ohio told me of an elderly lady fed on fresh para-
thyroid whose improvement was quite marvelous,
and lasted over the entire time (about two years)
during which she was under observation. But fresh
glands are very expensive, are not permanently
palatable, and are, of course, not accessible to the
great majority of patients.
Later on I made a long series of experiments
with crude gland rubbed up with milk sugar, and
dried. But this was indigestible, and it was found
almost impossible to standardize it.
Much the best preparation is an acetic extract of
the fresh glands (commonly though very inaccu-
rately called a "nucleoproteid" extract), made by
treating the ground or triturated glands with cold
distilled water, filtering, and then precipitating
with a very minute amount of acetic acid. I have
fully described the process in several articles pub-
lished elsewhere.4 "
This extract, in doses of one-fiftieth grain
(either in capsule with milk sugar, or as a hypo-
dermic solution) is now for sale in a number of
New York drug stores. It is not very expensive,
and it comes nearer to the chemical constitution of
the human gland than anything I have so far de-
vised. It is absolutely without local effects of a
disagreeable nature. Among hundreds of patients
I have known of but one who either had, or thought
he had, an idiosyncrasy for parathyroid. The hypo-
dermic solution, in doses of fifteen minims, does
not even redden the skin, if it be injected with rea-
sonable care.
In the form in which I have recommended it, this
remedy has been extensively prescribed during the
last five or six years; the cases now number hun-
dreds, and it has been successfully sent, so the
dealers tell me, to all parts of the world.
Further experience seems fully to justify the
opinion I have formerly expressed, namely, that
parathyroid gland is not a "cure" for paralysis
agitans, but that 60 to 70 per cent, of the sufferers
from this dreadful disease who have given the
remedy a fair trial for from three to six months
(it takes all of this time to test it) have been
greatly benefited, and that in such patients the
progress of the disease has been arrested, or very
materially retarded.
One patient, an elderly man, relative of a med-
ical friend in the Bronx, has taken the capsules
for seven years (also the hypodermic solution at
times), and he is still in fairly good condition, but
lapses into helplessness within a few days when the
medicine is omitted.
Another recent case, woman, 52 years old,
brought to my clinic by Dr. Leon Lesser of Brook-
lyn, has done wonderfully well on my formula. Her
agitation has been entirely arrested, and her rigid-
ity greatly relieved. She had suffered with the dis-
ease for two years before I saw her. and had spent
all of her money on osteopathic and electrical treat-
ments; so that, if suggestion had anything to do
with her case, she certainly had ample opportunity
for full exercise of her imagination before under-
taking the parathyroid medication.
There are no other internal secretions which
have any specifically beneficial effect whatever — ■
either alone or in combination — in paralysis agi-
tans. Among the older patients pineal gland is a
useful stimulant to functionally failing mental ac-
tivity, and there is now on the market one extract
of pancreas which is valuable in the peculiarly ob-
stinate constipation these patients are afflicted
with. But I cannot too strongly deprecate pro-
miscuous dosing with thyroid, and pituitary, and
others of the internal glands. Thyroid, especially,
does serious harm; even massage of the neck over
the thyroid gland sometimes liberates enough of
the thyroid secretion to make the patient distinctly
uncomfortable.
Like most chronic diseases, paralysis agitans
does not do well in institutions, for reasons which
are sufficiently obvious. The most successful cases
have been in private practice, where cheerful sur-
roundings, occasional opportunities for travel, and
a varied diet contribute to the patient's comfort,
and increase his resisting power. But a fair pro-
portion even of the almshouse poor have been
greatly helped.
I am still of the opinion, as I have long been, that
paralysis agitans is caused by a deficiency of the
parathyroid glands, and that further and more
diligent study of the complicated chemical processes
involved will make it ultimately possible to cure
paralysis agitans with parathyroid in just the same
way in which cretinism is cured with thyroid.
134 East Sixty-second Street.
REFERENCES.
1. Jeandelise, P.: These de Nancy, Paris, 1903.
2. Pool, E. H.: Annals of Surgery, 1907.
3. Erdheim, J.: Mittheilungen aus dent Grenzgebiet
tier Medizin und Chirurgie, xvi, 1906.
4. Berkeley and Beebe: Journal of Medieal Research,
xx, 1909.
5. Ochsner and Thompson: "A Treatise on the Sur-
gery and Pathology of the Thyroid and Parathyroid
Glands," St. Louis, 1910.
6. MacCallum, W. G.: Johns Hopkins Hospital Re-
ports, 1908.
7. Gley, E.: British Medical Journal, 1901.
8. Vassale: Reference in Quadri, Gazzetta medica
italiana, lvii, Nos. 61 and 71, 1906.
9. MacCallum, W. G.: Medical Neivs, 1903.
10. MacCallum, W. G.: Centralbtatt f. Allgemeine
Pathologie u. path. Anat., May, 1905.
11. Pineles, F. : Mittheilungen aus dem Grenzgebiet
etc., xiv, 120, 1904-5.
12. Lundborg: Deutsche Zeitschrift f. Nervenheil-
kunde. No. 27, 1904.
13. Berkeley: Medical Ncu-s, 1905.
14. Thompson, R. L. : Journal of Medical Research,
1906.
15. Camp, C. D.: Journal of the American Medical
Association, April 13, 1907.
16. Berkeley: Article in the Presbyterian Hospital
Reports, 1906.
17. Berkeley: Medical Record, Dec. 10. 1910.
18. Berkeley: Old Dominion Journal of Med. and
Surg., 1908.
Psoriasis as a Sequel to Acute Inflammation of the
Tonsils. — Wingate has now seen six cases of this se-
quence which he is unable to explain, there being no
evidence of an infection. In four cases there was
ordinary follicular tonsillitis, and in a fifth streptococ-
cus sore throat. The sixth case followed an extirpation
of the tonsils. None of the familiar throat organisms
has ever been known to cause psoriasis. The only re-
maining view is that the balance of metabolism was
somehow disturbed, either by the fever or the state of
the tonsils. — Journal of Cutaneous Diseases.
July 15, 1916]
MEDICAL RECORD.
107
THE WASSERMANN REACTION.
By B. LEMCHEN, M.D.,
DUNNING, ILL.
With the introduction of the complement fixation
test we have obtained something valuable in diag-
nosis. It is hardly necessary for me to comment on
this. The reason I am writing this paper is to try
to make it clear that there is some misunderstand-
ing about the test, because in some cases where the
test should be positive we get a negative or vice
versa, and because the same serum or fluid gives
different results in different laboratories. Some
physicians try to disregard the test entirely. It is
with the Wassermann test, as with everything else
in medicine, the value increases with the knowledge
thereof.
First of all, it must be understood that the Was-
sermann reaction is a biological phenomena and it
confronts everything else in biology. Biology deals
with life, deals with a mystery, because the molec-
ular arrangement of the living cell is not known to
us yet. It is a question whether it ever will be
known because every living cell must be killed be-
fore it can be analyzed ; but as little as we do know
about biology we know this much, that life in high-
er planes and in animals depends on two things,
one is an attack and the other is defense. Every
higher form of life that cannot live on simple mat-
ter must attack another form of living cell to get
its food. It must also defend itself against an-
other living organism that is trying to live upon it,
and to keep up this species a third factor comes in
and that is reproduction; so I might state that
attack, defense, reproduction are the foundations
of the living organism. They are also the source
of all evils, the reason a crime is committed, be-
cause one can trace the crime to either attack, de-
fense, or reproduction. They are also the root of
insanity.
Why does a paranoiac kill? He has imaginary
enemies. It is a defense reaction. He believes that
some people are organizing against him to try to
ruin his life and his family and, after trying every
possible way of defending himself believing that he
has not succeeded, as a last resort he kills his
enemy. Why does one in delirium jump out of a
window? Practically the same thing. It is a de-
fense reaction. The patient in his delirious state
sees different animals trying to jump on him to
tear him to pieces, he has only one way of escape
and that is to jump through the window. What
else should he do? So he jumps through the win-
dow. We might also say that catatonia is also a
defense reaction, as it 's known that lower animals,
when they are in great danger of being caught as
a prey by stronger animals, lie down motionless.
Therefore, it is not strange that human beings
when they are overcome with fear are practically
paralyzed and cannot move.
Why does a dementia precox subject strike im-
pulsively? It is due to the inheritance of attack.
We can also understand mannerisms and dream
states by the inheritance reproduction. Now it is
understood always that in the animal kingdom it is
the stronger animal that attacks the weaker. It ia
the weaker that has to defend itself against the
stronger, but there might be a time when the
stronger animal was weakened either by disease or
by not having sufficient food, in which event the
stronger animal would have to defend itself against
the weaker animal. It is also known that the ani-
mal reproduction goes hand in hand with the
strength and life of that animal. An animal might
be so weakened that he could not reproduce any of
his own kind.
Now, we shall apply all these facts to the Was-
sermann reaction. It will not explain everything,
but it will explain a good deal. The Wassermann
reaction is also due to the same phenomena of
attack and defense. Here it is Spirocheta pallida
that is attacking and it is a human being that is de-
fending against the attack. The same rule is hold-
ing true here. Spirocheta pallida is an organism
that has to have albumin to live. It is also a species
that is reproducing its kind or multiplying itself.
It attacks a human being because, so far as we
know, it cannot live in any other media but the
human tissues. It produces toxin which weakens
the human beings so it can attack them more
strongly. A human being has to defend himself
against it, and nature has provided help for de-
fense against microorganism by producing some-
thing known as antibodies. Here again Spirocheta
pallida is a living organism and besides being able
to attack it is also able to defend itself. It like-
wise produces something that will neutralize the
antibodies. Here, again, the one that is infected
with this Spirocheta pallida will have to produce
more antibodies to defend himself against the
organism. The Spirocheta pallida, as regards its
growth, its reproduction, its power of producing
toxins, etc., is influenced by the food it is getting.
There might be a medium that is favorable for its
life, but it would not be favorable for reproduction.
There might be a medium favorable for its growth,
but not capable of producing toxin.
Now, let us apply all we know on the Wasser-
mann reaction and see if we cannot explain every-
thing regarding what we have said. The Wasser-
mann reaction is due to the fact that antibodies
will unite with their specific antigens; but the anti-
bodies are composed of two substances, one that is
comparatively stable, that is not destroyed by heat-
ing to 56° C, and the other known as the comple-
ment, that is unstable, and is contained in all blood
serum and is destroyed by heating to 56° C.
Wassermann takes antigens that are supposed to
be products of the Spirocheta pallida. Lately it has
been found that lipose from any organ will answer
the purpose. He takes a certain amount of this
and a certain amount of the blood serum of the
patient to be tested, after the complement has been
destroyed by heat, and a certain amount of anti-
gens. To these he adds a certain amount of com-
plement, which he takes from the aerum of a
guinea pig and incubates them for about an hour.
Then he adds to this a certain amount of red blood
corpuscles from the sheep and a certain amount of
blood serum from rabbits that have been sensitized
against the red cells of sheep, the complement of
which has been destroyed by heat. He incubates
them again for about an hour and then examines
the tube. If the patient has syphilis the comple-
ment will have been fixed at the first incubation
and there will be no hemolysis, but in case the
patient does not have syphilis there will have been
no union between the antibody and antigens and
the complement will be free to react with the red
cells from the sheep and the rabbit blood serum, and
there will be hemolysis. Now, we can readily see
why results should vary.
First, it takes some time before the patient will
react to the toxins of the spirochete. For this rea-
108
MEDICAL RECORD.
[July 15, 1916
son, at the beginning there are not enough anti-
bodies to give the reaction, but after a couple of
months, there are sufficient antibodies and we get
the reaction, generally in from three months to a
year. The Wassermann is practically positive in
syphilitic cases in more than 90 per cent. Now, as
I said before, the spirochetes are able to defend
themselves by producing something that will neu-
tralize the antibodies. If there is sufficient of that
something to neutralize the antibodies, the reac-
tion, of course, will be negative. It is a fact that
in old syphilitics we do not get more than 50 per
cent, positives, probably less. Again, there might
be antibodies still free, but not as many, and for
this reason we will get a positive reaction in
larger amounts. It is also a fact that old syphilitics
include Tabes. When we do not get a positive re-
action in the ordinary amount, which is 0.2 c.c, we
may get a positive reaction in 0.5 c.c. or 1 c.c.
Again, the patient may be so weakened by the dis-
ease or other diseases that he cannot defend him-
self or, which is the same, cannot produce anti-
bodies ; then we shall get a negative reaction even
in a syphilitic. Again, the media may be so altered
that while the organisms may still retain their power
to grow they may lose their power of attack or de-
fense. In case they lose their power to attack but
retain their power of defense, they will not liberate
anything to stimulate antibodies but will still lib-
erate substances to neutralize antibodies; or they
may lose their power to produce substances to neu-
tralize the antibodies but will liberate toxins which
will stimulate the production of antibodies. It is
also known that by treating the patient, for in-
stance, with salvarsan or mercury, a positive re-
action may become negative or a negative reaction
positive, while the spirochetes will still grow and
multiply. This will also explain why the same
serum may give different results in different lab-
oratories, as it is evident from what has been said
that antigens will vary according to the source from
which they have been taken.
Again, we know that antibodies can be trans-
mitted from the mother to the fetus, and it is also
known that children who are born from syphilitic
mothers seldom contract syphilis, although they
themselves never have signs of congenital syphilis.
Now there are some investigators who claim that
they do have syphilis because they give a positive
Wassermann reaction, but this I do not agree with.
So long as a child does not show any signs of syph-
ilis he has not got syphilis, but the positive reaction
is due to the transmission of the antibodies from
its mother either through the placental circulation
or through the milk when nursing.
I wish to state that in my opinion the reason we
never could find a substitute for mother's milk for
babies is due to the fact that nature has provided
for the helpless infant, that his mother should sup-
ply him not only with nourishment but with the in-
visible defense against infective bacteria. It i<
known that the majority of the antibodies belong
more or less to the ferments, and the ferments are
destroyed by digestion, and nature has so fashioned
the infant's stomach that it absorbs some albumins
from the mother's milk without the necessary di-
gestion, while the milk of other animals has to be
first digested before it can be absorbed. This is
the reason why we have so much trouble with
modified milk.
Again, Finger has demonstrated that the spiro-
chetes can be transmitted by the spermatozoa, so
it can easily be seen that when a woman gives birth
to a syphilitic infant that has been infected by his
father, the placenta prevents the transmission of
the organism to the mother, while the antibodies
can be transmitted, so the woman might receive
antibodies from the fetus when she, herself, may
never be infected with syphilis. It has also been
known for a long time that a syphilitic infant will
infect the strongest nurse but will never infect its
own mother; this is what is known as Colles' law.
Here again, some investigators claim that the moth-
er does have syphilis, because she often gives a
positive Wassermann. I disagree here, also. It is
known that mothers have lived for years and years
and never shown any manifestation of syphilis,
never being infected by their syphilitic children.
I say that the positive Wassermann reaction is due
to the fact that the mother has received antibodies
from the child but has never had syphilis.
In conclusion let me state that I consider the
Wassermann reaction to be of the greatest value in
the diagnosis of syphilis, but it must be taken into
consideration with the other known manifestations
of the disease. We should not make a diagnosis
entirely on the result of a Wassermann, we should
not declare a patient free from syphilis because
his Wassermann was negative, and the physician
should be careful in declaring a patient who has
had syphilis free therefrom because the Wasser-
mann is negative after treatment. If there are any
signs that the nervous system is involved, a spinal
puncture should be made and the spinal fluid exam-
ined by the cell count, globulin test, and also Was-
sermann reaction. If 2 c.c. gives a negative result,
we should try with larger amounts.
Chicago State Hospital.
The Alcoholic as Seen in Court. — Victor V. Ander-
son has made a study of 100 cases of chronic alcoholics,
those who are repeatedly arrested for drunkenness and
seem more or less unmodified by any form of treatment.
He gives statistics with reference to the number of
arrests, the economic efficiency, the mentality, and the
diagnosis in this series and finds that not more than
one-half were capable of supporting themselves out in
society. Fifty-six per cent, had the mental level of
children below the age of twelve years. They were
all suffering from conditions in general regarded as
medical problems. For purposes of treatment they, in
general, fall into two classes, namely, the steady drinker
and the periodic drinker. The mentality of the former
is either defective to begin with, or is so deteriorated
from the insidious effects of alcohol as to require that
he be confined or have prolonged care and hospital
treatment. The periodic drinker, though in many
instances he may require short periods of detention,
as well as hospital treatment, is in general to be
handled on probation and incorporation into society's
scheme of living by means of well-directed medical,
psychological and social service methods of treatment,
methods that take full account of his peculiar mental
make-up, his character defects, and temperamental diffi-
culties.— Boston Medical and Surgical Journal.
A General Plan for a Schedule of Medical Fees. — J. N.
McCormack makes some suggestions which are in part
as follows: Day visit in town, $2.50; night visit in
town, $4; ordinary office examination, $1; complete ex-
amination with advice, $5 ; advice or prescription by
telephone, SI; obstetric case, uncomplicated, not over 6
hours. $15. Cases seen in consultation, double fee.
Pees in the country are regulated as usual by mileage,
while no fees are tabulated for surgical and other spe-
cial work. — Kentucky Medical Journal.
July 15, 1916]
MEDICAL RECORD.
109
Medical Record.
A Weekly Journal of Medicine and Surgery.
THOMAS L. STEDMAN, A.M., M.D., Editor.
PUBLISHERS
WM. WOOD & CO., 51 FIFTH AVENUE.
See fourth page following reading matter for Rates of Subscription
and Information for Contributors and Subscribers.
New York, July 15, J9I6.
PSYCHIATRIC TREATMENT OF SOLDIERS.
There seems to be a certain amount of conflict of
opinion as to the effect on the nervous system of
soldiers fighting in Europe, of the unprecedented
conditions of warfare existing there. It was freely
predicted at the outset of the war that the present
generation of young men and especially of those of
England and France whose vital energies were said
to be sapped by city life and self-indulgence would
inevitably break down under the fearful strain of
war. The conditions of war have been worse than
anticipated and it appears on the whole that the
fighting men have borne up very well under them.
Some say that affections of the nervous system have
been infrequent, while others declare that a large
proportion of soldiers are incapacitated by such dis-
orders. Perhaps the truth lies in the mean.
In a special bulletin issued in April, 1916, by the
Military Commisson of Canada, Dr. C. R. Clarke of
Toronto discusses the psychiatric treatment of sol-
diers. According to this authority, the question of
caring for returned soldiers suffering from mental
and nervous troubles has engaged the attention of
the Canadian medical profession in a marked way
since the actions of last year. He points out that
new conditions have arisen since the use of high ex-
plosives and the mental strain during action seems
to be of the most severe character, with the result
that numerous such cases are encountered requir-
ing special treatment.
With regard to the manner in which such patients
should be treated, the writer emphasizes the fact
that neither convalescent homes, general hospitals,
private houses, nor asylums are appropriate places
in which treatment may be carried out. As conval-
escent homes and general hospitals are obviously un-
suitable for the treatment of these cases, under the
present conditions cases of marked mental trouble,
although curable in the majority of instances, have
to be sent to asylums. Of course, this is most unfair
and, in a manner of speaking, a tragedy, for not
only does it place upon the men the stigma of being
certified inmates of a hospital for the insane, but
perhaps in the majority of cases it precludes the
possibility of successful treatment. In the large
proportion of cases proper and intelligent treatment
will cure,whileitis equally as obvious that unintelli-
gent and careless treatment will tend to aggravate
the mental state, and life in an asylum is apt to
have the most dire results.
As Clarke says, modern methods demand that re-
cent cases of mental disease should receive just the
same attention that cases in a general hospital se-
cure. What should be done is to acquire a house of
suitable structure which will afford accommodation
for a certain number of patients. The necessary
staff is best lodged in a separate building. This hos-
pital should be equipped with the most modern
scientific, hydrotherapeutic, and electric apparatus
demanded in the care of such patients, and especially
should the medical attendants be men who have
been well trained in the diagnosis and treatment of
mental disorders. This, after all, is the most im-
portant point. If a correct diagnosis be not made,
the patient will not be treated as he should be
treated, and a medical man to be able to make a cor-
rect diagnosis must be an expert. Also nurses
should be specially qualified and should be women
of the highest type, as on the sensible nursing of
psychiatric patients the outcome largely depends.
During recent years it has been increasingly evi-
dent that in order to treat mental disorders intelli-
gently new methods must be devised. Some men are
peculiarly fitted by temperament and order of brain
to deal with such cases, and these men should be
rendered as skillful as possible by long training. We
are only now on the eve of managing mental affec-
tions in a sensible manner, and the war in Europe
will, it is to be hoped, tend to develop a really
scientific system of differentiating between the va-
rious kinds of mental aberrations and of treating
each kind on its merits, or rather in the way that its
peculiarities call for.
SWIMMING-POOL SANITATION.
IN large cities the question of supplying adequate
swimming-pool facilities, and their sanitation, is a
very^pertinent one. Because of the mode of living,
especially in the congested districts, this offers
really the only means of sufficiently cleansing dur-
ing weather when this seems most necessary, be-
sides offering the readiest, though temporary, re-
lief from the depressing heat of the summer months.
It is for them a stimulant of first value in over-
coming the relaxation and the exhaustion accom-
panying such weather. At least for bathing and
cleansing purposes, the pool — or its prototype in
miniature, the bathtub — method is entirely unsat-
isfactory because it entails rewashing in the water
contaminated by the very materials one desires to
get rid of by the bath. At best, this method is
unsanitary, and the sooner all pools and tubs are
replaced everywhere by the shower bath the better.
If this is properly and not extravagantly used, the
consumption of water may be very small.
In cities like New York, situated on tidal water,
the use of stream pools for bathing purposes in
the summer is a universal practice. The question
of the safety of these stream pools is most im-
portant, especially when the waters are depositories
for sewage. Even the tidal waters surrounding
such a city as New York are not sufficient to re-
move the enormous amount of sewage deposited.
While ordinarily the typhoid-colon element in water
is not a large one, because usually so soon and so
much diluted, where there is bathing at the very
110
MEDICAL RECORD.
[July 15, 1916
points of discharge of the sewage, the danger to
health is great, especially in respect to the spread
of typhoid where there is a large carrier popula-
tion. Moreover, the whole gamut cf pathogenic
bacterial infection can be spread by pool water.
Epidemics of vulvovaginitis, venereal disease, aural
and ocular conditions have been reported as hav-
ing been spread by swimming pools.
As a later development in swimming pools, the
indoor pools offer a great many advantages, and
obviate the prolific source of infection carried by
live sewage. The usual drinking water being used,
the opportunity for infection is only that of drink-
ing water, and to a much lesser degree if the water
is kept fresh and wholesome by one method or
another. The element of colon contamination is
supplied almost entirely by the bathers themselves,
the dilution depending upon the amount of fresh
water added, and the frequency of the addition. In-
vestigations carried on by Manheimer (Public
Health Report No. 229) showed that this element of
pollution was quite appreciable. He made the
amount of the bacterial content of the water and
the presence of colon bacilli as his bacteriological
index of the purity of the water, and the clearness
and the ability to see the bottom of the pool as his
practical index, being especially the index of the
amount of solid matter suspended in the water. The
larger the pool capacity in relation to the daily at-
tendance, and the greater the frequency of the
change of the water the safer is the pool. The least
expensive and the best method of maintaining pool
sanitation is by refiltration of the water used, com-
bined with some chemical treatment, usually a coag-
ulent like alum or calcium hyperchlorite. When the
latter is used, a trace of chlorine must always be
present in the water to make it adequate.
The installation of indoor swimming pools, as
recommended by the New York Department of
Health, will soon take the place of the highly un-
sanitary stream swimming pools. But the installa-
tion must be along proper lines as to capacity, at-
tendance, refiltration, and chemical treatment, else
all the good that might accrue from the indoor pool
will be lost.
THE COLD FEET OF LEGISLATORS.
The Romans did not believe that a man possessed
the capacity for making laws to govern other men
until he had learned to govern himself, i. e. until he
was long past the follies of youth, or until he was
what we would call aged. It is not recorded, how-
ever, that their laws were any the less just or their
public policy any the less martial because their cir-
culation was less vigorous than in youth. Cold feet
may exist actually then without their supposedly
concomitant mental attitude.
In an article dealing with "colds," in the British
Medical Journal for April 15, Dr. Leonard Hill calls
attention to the ventilation of the House of Com-
mons, where the ventilating current is driven up
through the floor in such a way as to cool the mem-
bers' feet, while their heads are exposed to more
stagnant air. As a result, Hill says, they suffer
from cold feet and stuffy heads; he does not say
whether or not he uses these expressions figura-
tively. In the May 13 issue of the same periodical Dr.
E. Lloyd Owen takes exception to Dr. Hill's theory.
He believes that, warm feet and a cool head being
the ideal conditions to promote sleep, cool feet and
a warm head must necessarily make one wide
awake, which is ingenious, but savors too much of
sophistry. Dr. Owen says that he finds difficulty
in thinking after spending eight hours in a warm
bed; that is, if he remains in bed. This is sus-
ceptible of another explanation. Having spent eight
or nine hours in a warm bed, the apposite idea
would naturally be to arise, hence the disinclination
to think at all.
Whether, then, we believe with the pacifists in
cold feet for legislators, or think that, come what
may, a lawmaker should have a cool head at all
times, whether his feet be frying or freezing, we
will all agree that the subject of ventilation of
legislative halls should be given enough attention
so that the soporific effect of carbon dioxide is not
added to the somnolence of the spoken word.
THE PRESERVATION OF CERTAIN
ANTIGENS.
There are a number of difficulties which arise in
the attempt to produce anti-human precipitin rabbit
serum, a procedure which may be of the greatest im-
portance in a medicolegal connection. The need for
haste may be imperative, the rabbit may die at the
critical moment, from anaphylaxis, from peritonitis,
or, from the toxic effects of the serum, and it may be
difficult to obtain the human serum in the desired
quantities at the desired time. Efforts to preserve
the serum in fluid form have not been very success-
ful since it shows a tendency to precipitate a portion
of its protein content even though sterile and kept
at a low temperature. It would doubtless be pos-
sible to keep it unchanged when frozen and dried
in vacuo, but the technique of this method is quite
laborious and requires special apparatus.
In order to avoid, as far as possible, most of the
difficulties above mentioned, Smith (Jour. Med. Re-
search, 1916, xxxiv, 169) has made use of the pre-
cipitate obtained by treating the human blood with
ammonium sulphate. The sediment thus obtained
is freed from the solution by prolonged and vigor-
ous centrifugation. The precipitate is then dried,
powdered, and put up in tubes each of which con-
tains 0.5 gram, representing the sediment from
10 c.c. of blood. Before use the powder is taken up
in 2 c.c. of sterile salt solution and is then ready for
injection. The small amount of ammonium sulphate
remaining proved slightly irritating when the ma-
terial was injected intraperitoneally and markedly
so when it was injected into the vein. It would
probably be necessary to remove this salt by dialysis
before using the preparation intravenously. This
material proved to have active antigenic properties,
even when nine months old, and the serum produced
from its use was uniformly of good value. It is
necessary to use a very small bulk of the substance
and its administration is apparently without danger.
Such a preparation would be of great help at times
and it offers a convenient way for the storing of the
antigen. The author used placental blood and thus
July 15, 1916]
MEDICAL RECORD.
ill
was able to obtain a large volume with but little dif-
ficulty. It is probable that a similar method may be
applied to a number of the immunological reactions
for the preservation of the reagents.
Medical Preparedness.
There has recently been organized a Committee of
American Physicians for Medical Preparedness,
representing the American Medical Association, the
American Surgical Association, the Congress of
American Physicians and Surgeons, the Clinical
Congress of Surgeons of North America, and the
American College of Surgeons, which in coopera-
tion with the Federal Government is formulating
plans for the purpose of ascertaining, organizing,
and utilizing the civilian medical resources of the
country in accord with the comprehensive plans
for national defense which are now being carried
out in all lines of endeavor. The chairman of the
committee is Dr. William J. Mayo, and the secre-
tary, Dr. Frank F. Simpson, Jenkins Arcade Build-
ing, Pittsburgh, Pa. The first duties of the com-
mittee will be to aid the medical departments of the
United States Navy and Army by making a com-
prehensive inventory of the qualifications of indi-
vidual civilian physicians throughout the country,
and to cooperate with the American Red Cross in
bringing that organization up to the highest stand-
ards of medical ideals and in forming Red Cross
units throughout the country. As it is the desire
of the Surgeon-General of the army greatly to in-
crease the number of medical men in the Reserve
Corps, the committee will also endeavor to interest
the medical profession in that branch of the service,
if Congress will permit it to survive. The organi-
zation will include, in addition to the national com-
mittee, committees of nine members in each State.
Fancy-work for Surgeons.
Who of us has not sat admiring the deft way in
which a wife or sister or one who has not promised
as yet to be either makes a needle fly back and forth
through a piece of linen until the line of stitches
seems actually to grow under our eyes by leaps and
bounds? And then we have contrasted mentally the
surgeon at the next operation we witness, excellent
workman though he may be, watching him crunch
down upon a needle with a needle holder, push a
needle the size of a darning needle through the tis-
sues, release the needle-holder, seize the needle again
on the other side and so on, wishing that a little of
the seamstress's dexterity might be communicated
to him. Or perhaps we are surgeons ourselves and
have often wondered what an efficient expert would
say to the countless lost motions in the sewing up
of an abdomen.
And yet the answer is easy. Simply a course in
sewing, plain and fancy, but above all a few lessons
in the correct way to use a thimble. Sit at the feet
of some good housewife and learn the fundamentals.
Dr. Edward Harrison, in an article in the British
Medical Journal for May 6, gives this excellent ad-
vice, illustrating by his own experience. He began
six or seven years ago to learn to sew with a thimble
and gradually advanced until he was able to hem a
fine cambric handkerchief accurately and fairly
rapidly. Applying this accomplishment to his sur-
gery, he found his needle much more easily directed
and managed almost entirely with one hand, leaving
the other free to expedite the work in some other
way. Dr. Harrison found that he could use a
straight needle for many kinds of suturing where it
was generally supposed only a curved one could be
used.
In these days when our patients, especially those
who affect decollete, demand the invisible scar and
other cosmetic results of operations, the suturing of
the wound plays a much greater part than it did
years ago, and a suggestion such as that of Dr.
Harrison is worthy of serious attention, in spite of
the smile it may evoke at first. Let us not forget
also that the beneficent effect of the operation itself
may in some cases depend almost entirely on the
skill with which the parts are approximated and not
neglect anything which might enhance that skill.
A Question of Anatomy.
As was to be expected the Journal of the American
Medical Association has attacked editorially Dr.
H. H. Rusby of this city because of the testimony
he gave in favor of the plaintiff in a libel suit re-
cently decided against the Association. We are not
going to defend Dr. Rusby, who needs no defense,
for a lifetime of honorable service in the cause of
science speaks for itself. It pains us, however, to
find our esteemed contemporary wrong also on an
anatomical point. It speaks of "Dr. Rusby's weird
conception of the anatomy of the female pelvis," be-
cause he referred to "the unstriped muscular fibers
of the broad ligament!" (mark of astonishment the
Journal editor's), and advises him, when he gets
back to Columbia University to "ask a freshman
student in the anatomy class to make a dissection
of some of the unstriped muscles in the broad liga-
ment." The funny point here is that the broad
ligament does contain unstriped muscular fibers, as
Cunningham, Gray, and all anatomists, as well as
De Lee and many obstetricians, testify. Whatever
the wants of others may be, Dr. Rusby evidently
needs no freshman to teach him anatomy.
Sfatifi of tfo? Wetk
Troops' Health Cared For.— Three of the best
sanitarians of the army, Lieut.-Col. Edward L.
Munson, and Majors R. B. Miller and W. N. Bisp-
ham, have been sent from Washington to San
Antonio to take charge of the organization of the
sanitary forces along the Mexican border. Dr.
Thomas Darlington of New York also has been
sent by the National Civic Federation to the bor-
der to investigate and report on the health of the
enlisted men. The work of the Red Cross and
of the army medical organizations has continued
unabated during the week in spite of the loosen-
ing of the tension in the Mexican crisis. It is re-
ported that a large percentage of the men who
were in the organized militia at the time of the
President's call have been rejected by the army
surgeons for failure to meet the physical require-
ments.
Another Base Hospital Unit. — A letter has been
received at the American Red Cross Headquarters
in Washington from Dr. William J. Mayo, of Roch-
ester, Minn., stating his willingness to organize
a base hospital, the personnel and equipment of
which will be furnished by the Mayo Clinic. The
number of medical officers in a base hospital is 23;
the number of beds 500, and the cost of the equip-
ment is estimated at $25,000.
Camps for Doctors. — General Wood has an-
112
MEDICAL RECORD.
[July 15, 1916
nounced that two training camps, both for medical
men, will be held in connection with the regular
Military Training Camp at Plattsburg, N. Y., dur-
ing July. The course of instruction will cover
camp sanitation and military hygiene, and the
camps will be commanded by medical officers of
the regular army. Enlistment blanks will be fur-
nished by the Military Training Camp Associa-
tion, 31 Nassau Street, New York.
The Poliomyelitis Epidemic. — Two hundred and
eighty-seven deaths and 1440 cases was the record
in New York City in the present epidemic of
poliomyelitis up to July 12, by far the greater num-
ber of the cases and deaths having occurred in
Brooklyn, where the first case was discovered. In
its efforts to combat the disease the New York
City Department of Health has received the help
of all of the other city departments as well as of
the State Department of Health and of the United
States Public Health Service. The facilities of the
last, offered by the Secretary of the Treasury, are a
great assistance in the fight, and are being used
largely to determine if possible the means by
which the contagion is spread and the ways in
which it can be controlled. The hospitals through-
out the city have also responded to the call and
practically all have offered to care for patients or
to supply doctors and nurses for work outside. On
July 9 the Kingston Avenue Hospital, Brooklyn,
was filled to its capacity, 301 patients, and the
Willard Parker Hospital, New York, with 139
patients had almost reached its limit. The use of
the hospital on Swinburne Island containing forty
beds was given by the Health Officer of the Port,
Dr. L. E. Cofer, who also offered to supply doctors
and nurses for twenty patients. The quarantine
laboratory will undertake the routine diagnosis
of all cases on Staten Island. By the passage of a
special resolution through Congress it will be pos-
sible for the authorities of the city to use also
the contagious disease ward of the Ellis Island
Hospital in which 400 beds are available; doctors
and nurses for the care of patients there, however,
must be supplied by the city. In order to cover
all this emergency work, the Mayor has authorized
the sale of bonds up to $80,000. Practically all
public places, moving picture theaters, etc., have
been closed to children, the play streets have been
abandoned, and the playgrounds have been thor-
oughly disinfected and will be kept as clean as
possible. Parents are being advised by visiting
inspectors and nurses as well as through the me-
dium of moving pictures to keep their children as
much as possible from other children. Cases of
the disease have also been reported from many
places in the State outside of New York City and
also from Pennsylvania, Illinois, Missouri, Ken-
tucky, Massachusetts, Wisconsin, Kansas, Iowa,
and Indiana.
Brooklyn Dental College. — The committee which
is soliciting funds for the establishment of a new
college of dentistry in Brooklyn, to be conducted
in cooperation with the Long Island College Hos-
pital, announces that one-half of the necessary
amount has already been subscribed; it is hoped
that the college may be prepared to receive stu-
dents and patients by next October. A dental in-
firmary for children and a clinic in oral surgery
will lie included. At present, Brooklyn has no
dental college.
Medical Advance in China. — A public health de-
partment has recently been organized in the
province of Kiangsu, China, in which Shangai is
situated. The department will regulate food,
drug, and sanitary inspections, as well as control
home sanitation and medical education.
Floating Hospital Opens Season. — The first trip
of the Helen C. Juilliard, the new floating hospital
of St. John's Guild, was made on July 5, and a num-
bers of mothers and babies from New York and
Brooklyn were taken down to the Lower Bay, where
the boat anchored off the Seaside Hospital, New
Dorp, S. I. The boat will continue to run each week
day during the summer on a regular schedule. Tick-
ets for the trips, which are absolutely free for sick
babies, mothers, and children, are distributed
through the various hospitals, dispensaries,
nurseries, and like institutions.
Aiding the Red Cross. — A number of prominent
physicians of New York City are serving on a special
committee for the purpose of assisting the Ameri-
can Red Cross in its campaign to attain a member-
ship of 1,000,000 throughout the United States. An
appeal to the medical profession to join the Red
Cross is signed by Dr. G. D. Stewart, Dr. G. E.
Brewer, Dr. G. L. Gibson, and Dr. N. E Brill, repre-
senting the Red Cross Units of Bellevue, Presbyte-
rian, New York, and Mt. Sinai Hospitals, respec-
tively.
Home for Nurses. — A six-story home for the
nurses of the Manhattan Eye, Ear, and Throat Hos-
pital, New York, is to be erected on East Sixty -third
Street, directly in the rear of the hospital building.
The structure will have a frontage of 125 feet and
a depth of 40 feet, and will, it is estimated, cost
$300,000.
Merger of Journals. — The New Orleans Medical
and Surgical Journal, which with the July number
began its sixty-ninth volume, announces that the
American Journal of Tropical Diseases has been in-
corporated with it, and that the combined journal,
which will continue under the title of the former,
will be the official organ of the Orleans Parish
Medical Society and of the American Society of
Tropical Medicine. One effect of the consolidation
of the two papers will doubtless be to widen the
area of circulation of the New Orleans Journal,
which will be to the advantage not only of the
journal itself but also and especially of the new
readers of this old established and excellently con-
ducted periodical.
Bequests to Charities. — By the will of the late
Mr. Fredrick K. Trowbridge of this city the Flower
Hospital, New York, receives a bequest of $5,000.
The Brooklyn Hospital and the Long Island Col-
lege Hospital, Brooklyn, receive bequests of $2,500
each by the will of the late Miss Mary Baylis of that
city.
Personals. — Dr. Harry Plotz and Dr. George
Baehr of the staff of Mt. Sinai Hospital, New York,
who have for over a year been studying the sani-
tary conditions, especially as regards typhus fever,
in Eastern Europe, returned to this city on July 6.
Dr. E. V. Morrow of Portland, Ore., returned to-
this country recently, after having spent eighteen
months as chief operating surgeon at the hospital
at La Panne, Belgium. Dr. Morrow received from
King Albert the decoration of King Leopold.
American Hay Fever Prevention Association. —
The annual meeting of this association was held
in New Orleans on June 15, when Dr. William
Seheppegrcll of New Orleans was re-elected presi-
dent. Dr. Rupert Blue, surgeon-general of the Public
Health Service, honorary vice-president, and Dr..
July 15, 1916]
MEDICAL RECORD.
113
N. L. Thiberge of New Orleans, corresponding sec-
retary. The president reported that thirty-four of
the State boards of health had co-operated with the
association in its campaign against hay fever, and
that the research department had done excellent
work in completing a list of the hay fever weeds
for the Southern, Middle, and Eastern States, and
was now preparing a similar list for the Western
and Pacific States.
Pacific Coast Oto-Ophthalmological Society. —
At the closing session of the annual convention held
in Portland, Ore., on June 23 and 24, the following
officers were elected: President, Dr. Clarence A.
Veasey, Spokane, Wash. ; Vice-Presidents, Dr. P. A.
Jordan, San Jose, Cal., and Dr. Frank A. Burton,
San Diego, Cal.; Secretary-Treasurer, Dr. L. D.
Green, San Francisco.
Kentucky Valley Medical Association. — Officers
were elected at the annual meeting at Richmond on
June 29 and 30, as follows : President, Dr. Clarence
H. Vaught, Richmond; Vice-President, Dr. Wilgus
Bach, Jackson ; Secretary-Treasurer, Dr. John H.
Evans, Beattyville.
Women's Dental School. — The first dental school
to be devoted exclusively to the training of women
in dentistry will, it is now announced, be opened
next month in connection with Hunter College (the
New York City free college for women). There
will be three terms of instruction, extending over a
year, the first term beginning on July 10, and under
the Seeley bill passed last April by the New York
State Legislature, the students will be graduated as
dental hygienists. Graduates of the school will be
eligible for employment as dentists' assistants, as
assistants in dental clinics, and as school inspectors
under the Department of Health, in which case they
will instruct the school children in the essentials
of dental hygiene.
Conference on Eugenics. — The annual meeting
of the Eugenics Research Association and the con-
ference of the Eugenics Research Office were held at
the Carnegie Station for Experimental Evolution,
Cold Spring Harbor, N. Y., on June 23. Dr. Adolf
Meyer was elected president of the association.
Philadelphia Medical Club. — At a recent meet-
ing of the club a reception was held in honor of Dr.
Charles A. E. Codman, president-elect of the Medi-
cal Society of Pennsylvania; Dr. John B. McAlister,
the present president; Dr. George I. McKelway,
president of the Delaware State Medical Society,
and Dr. Alexander Marcy, representing the presi-
dent of the Medical Society of New Jersey.
Hospital Sued. — Charging that six inches of
rubber tubing was left in his body, after an opera-
tion three years ago, and that as a consequence he
has suffered greatly, a former patient of Christ
Hospital, Jersey City, N. J., has brought suit against
the hospital for $20,000 damages.
Maine Homeopathic Medical Society. — The fif-
tieth annual convention of this society was held in
Augusta, Maine, on June 12 and 13, when the fol-
lowing officers were elected for the ensuing year:
President, Dr. Luther A. Brown, Portland ; Vice-
Presidents, Dr. Franklin A. Ferguson, Portland, and
Dr. W. H. Walters, Fairfield; Treasurer, Dr. W. S.
Thompson, Augusta; Secretary, Dr. Carrie E. New-
ton, Brewer.
Obituary Notes. — Dr. Charles S. Wood of New
York, a graduate of the College of Physicians and
Surgeons, New York, in 1886, died at his home on
July 6. aged 52 years.
Dr. William Blundell of Paterson, N. J., a
graduate of the College of Physicians and Sur-
geons, New York, in 1861, and a member of the
American Medical Association, the Medical Society
of New Jersey, and the Passaic County Medical So-
ciety, died at his summer home in Allendale on
June 30, aged 79 years.
Dr. Andrew Jacob Koontz of Independence, Va.,
a graduate of the College of Physicians and Sur-
geons, Baltimore, in 1887, and a member of the
Medical Society of Virginia and the Grayson County
Medical Society, died suddenly at his home on June
20, aged 57 years.
Dr. John F. W. Whitbeck of Rochester, N. Y.,
a graduate of the University of Pennsylvania, De-
partment of Medicine, Philadelphia, in 1870, presi-
dent of the medical staff of the Rochester General
Hospital, and a former president of the Medical
Society of the State of New York, died at his home
on July 3, aged 72 years. Dr. Whitbeck was a
fellow of the American College of Surgeons and a
member of the American Medical Society, the Medi-
cal Society of the State of New York, the Monroe
County Medical Society, the Rochester Pathological
Society, and the Academy of Medicine.
Dr. Walter Jay Bell of Atlanta, Ga., a graduate
of the Medical Department of the Tulane University
of Louisiana, New Orleans, in 1891, died at his
home on June 17, aged 47 years.
Dr. I. R. Aultman of Meigs, Ga., a graduate of
the University of Georgia, Medical Department,
Augusta, in 1893, died at his home on June 22.
Dr. Robert J. Gilliland of Easley, S. C, a grad-
uate of the University of Maryland, School of
Maryland, Baltimore, in 1883, and a member of the
South Carolina Medical Association, and the Pickens
County Medical Society, having at one time served
the latter as secretary, died at his home, after a
short illness, on June 26, aged 56 years.
Dr. Luther B. Etheredge of Wagener, S. C, a
graduate of the University of the South, Medical
Department, Suwanee, Tenn., in 1900, and a mem-
ber of the South Carolina Medical Association, and
the Aiken County Medical Society, died at his home,
suddenly, on June 24, aged 42 years.
Dr. John P. Corrigan, formerly of Pawtucket,
R. I., died at the Providence Hospital, Providence,
from heart disease, on July 6, aged 59 years. Dr.
Corrigan was graduated from the New York Uni-
versity Medical College in 1883, and practiced in
Pawtucket until a few years ago, when he retired
to join the Dominican Order, in which he was known
as Brother Vincent. He was at one time a member
of the American Medical Association, the Rhode
Island Medical Society, the Providence District
Medical Society, and the Rhode Island Ophthal-
mological and Otological Society.
Dr. Paul Paquin, formerly of Asheville, N. C, a
graduate of the University of Missouri, Medical
Department, Columbia, in 1887, and a member of
the American Medical Association and the Medical
Society of the State of North Carolina, died at his
home in Kansas City, Mo., after a long illness, on
June 23, aged 55 years.
Dr. Heber Wheat Jones of Memphis, Tenn., dean
emeritus and professor of clinical medicine in the
University of Tennessee, Medical Department, and
president of the Tennessee State Board of Health
for twelve years, and of the Memphis Board of
Health for eight years, died at his home, after a
long illness, on June 26, aged 68 years. Dr. Jones
was graduated from the University of Virginia.
Department of Medicine, Charlottesville, in 1869.
114
MKDICAL RECORD.
[July 15, 1916
(Enmapimltew*.
OUR LONDON LETTER.
( From Our Regular Correspondent. )
GENERAL MEDICAL COUNCIL — D.S.O. AND OTHER HON-
ORS— CANADIAN ARMY MEDICAL CORPS — A GIFT TO
LONDON CHARITIES — SILVANUS THOMPSON — NA-
TIONAL HOSPITAL FOR EPILEPSY AND PARALYSIS.
London. June 17, 1916.
The General Medical Council in its five days' sitting
disposed of a large amount of business, much of
which, though necessary, possesses but little inter-
est to the profession at large. Some of it, however,
demands careful consideration by those who pay at-
tention to it in this respect as well as to its rela-
tion to the public. The report of its education com-
mittee is of this nature. To it had been remitted
the subject of the ethical relationships of medical
practitioners, to the state, to their patients and to
each other, with power to make any inquiries
deemed advisable. A letter was sent to the teach-
ing bodies which elicited the information that in
most cases the subject is included in the courses of
forensic medicine and public health, also to some ex-
tent in special lectures, but in many instances no
attempt to deal with the subject has so far been
made. The committee is of opinion that this neg-
lect should not continue, though special arrange-
ments may naturally vary among the different
bodies. Accordingly they suggest that a general
recommendation should be added to the resolutions
of the General Medical Council dealing with the
matter. Further, attention should be called to all
explanatory notices issued by the Council on the
subject.
Reports were also submitted by the University of
St. Andrews, by the dental committee, the public
health committee, the examination committee, the
pharmacopoeia committee, and the students' registra-
tion committee.
Capt. T. L. Ingram, R.A.M.C, has been awarded
the D.S.O. in recognition of his gallantry and
devotion to duty on the field. He collected and at-
tended to the wounded under heavy fire, and from
the beginning of the war has been conspicuous for
his personal bravery on every opportunity.
The Military Cross has been conferred for gal-
lantry and duty on the field on Capt. J. C. Brash,
M.B. He went to an artillery dug-out which had
had a direct hit, extracted the wounded and admin-
istered first aid under heavy shell fire. Capt. H. F.
Percival Hart, M.B., Capt. Randall Woodhouse,
M.B., and Lieut. W. J. Knight, M.D., for similar
devotion under fire. The cooperation between the
regular army medical service and members of the
civil medical profession who have given their serv-
ices to the army has largely contributed to the pre-
vention of disease and the successful treatment of
the sick and wounded.
A number of honors have been distributed on the
King's Birthday. Among them some are of the
profession. A P.C. goes to Dr. Christopher Addi-
son. There are three Knights — F. Mark Farmer,
Armand Ruffer, Nestor Tirard. K.C.M.G. is con-
ferred on Baldwin Spencer; C.M.G. on Montizam-
bert, Director-General of Public Health, Canada ;
Major Fred N. White, I. M.S., and Captain Mac-
Ilwaine, R.A.M.C. The Kaisar-I. Hind gold medal
goes to H. M. Newton. F.R.C.S., Rev. P. Cullen,
Brigade-Surgeon, I. M.S., retired, and Robert Geo.
Robson, MA., M.D. Several additions to the Order
of the Bath and the Royal Victorian Order have also
been made.
All branches of the medical services have lately
received the highest commendation for their work
both at the front and on the lines of communication.
The sick rate has been low, no enteric fever, no epi-
demic. The results of exposure in the trenches in
the winter were to a great extent checked by the
precautions carried out. The Canadian army medi-
cal corps rendered most valuable assistance. The
central laboratory and chemical advisers with the
army took prompt action in investigating the gases
and other new substances employed in hostilities and
devising means of protecting the troops against
their effects. The value of this work has been rec-
ognized in all directions.
A sum of £25,000, free of legacy duties, has been
bequeathed by Mr. Frank Daniels to be distributed
by the Lord Mayor of London among such charitable
and benevolent objects as he may, in his absolute
discretion, select, and in such proportions as he may
think proper. Gifts to charity which are so abso-
lutely free from restrictions are sufficiently rare to
call for approving comment.
Prof. Silvanus Thompson died on the 12th inst.,
aged 65. He took B.A., London, in 1869, and pro-
ceeded later to the D.Sc., taking honors in science
during the course. In 1879 we find him professor
of physics at Bristol University College. In 1893
he was a delegate at Chicago Electrical Congress, at
which he read a paper on Ocean Telephony. In this
he put forward the idea of accelerating the speed
of signaling in cables by the use of inductive shunts.
He contributed many papers on a great variety of
scientific subjects to the Royal and other societies,
in some of which he served as president. He was
honorary vice-president of the Electrical Exhibition
at Frankfort in 1891. He was an able linguist;
gave a lecture in Italian before the Volter Centenary
Congress at Como, 1899, and one in German before
the Urania Society in Berlin in 1901. He was
author of "Lessons in Electricity and Magnetism"
and other valuable works. He wrote the life of
Faraday and of Lord Kelvin.
The National Hospital for Paralyzed and Epilep-
tics has 68 beds for those suffering from shock and
they are pretty constantly occupied by patients com-
ing direct from the Expeditionary Forces and from
Red Cross and military hospitals.
TREATMENT OF POLIOMYELITIS.
To the Editor of the Medical Record :
Sir: I make so bold as to offer the following sug-
gestions regarding the treatment and prophylaxis
of infantile paralysis:
Treatment — Local applications of 10 per cent,
silvol or argyrol to the nose, with hexamethylena-
mine in large doses internally. The performance
of lumbar puncture.
Prophylaxis — Silvol or argyrol to nose and hexa-
methylenamine in moderate doses internally in the
case of all children who have come into contact with
a positive case.
I base these suggestions upon the facts that the
nose is probably the portal of entrance of the infec-
tion and that hexamethylenamine when taken in-
ternally will be found in the cerebrospinal fluid.
Also, on the supposition that lumbar puncture will
carry off some of the infecting organisms and their
toxins. Samuel W. Myers, M.D..
Boston. Mass.
July 15, 1916J
MEDICAL RECORD.
115
graQrpBa of iftrMral ^rintrv.
The Boston Medical and Surgical Journal.
June 29, 1916.
1. The Shattuck Lecture. The Etiology of the Diseases of
the Circulatory System. Theodore C. Janeway.
2. Respiratory Exchange, with a Description of a Respira-
tion Apparatus for Clinical Use. Francis G. Benedict
and Edna H. Tompkins.
3. Diagnosis of Periosteal Sarcoma with the X-ray. Fred-
eric J. Cotton.
4. Further Experience in the Treatment of Intracranial
Hemorrhage in the Newborn. Robert M. Green.
1. The Etiology of Diseases of the Circulatory System.
—Theodore C. Janeway discusses this subject under the
tentative classification of known bacterial infections;
probable, but unproved bacterial infections; syphilis
(a) of the aorta, (b) of the heart, (c) of the smaller
arteries; rare infections; parasites and tumors; in-
toxications, exogenous and endogenous; nutritional dis-
turbances; mechanical disorders; nervous disorders; de-
fects of development; hereditary disease and the rela-
tive importance of the various causes of myocardial
insufficiency. He has tabulated the histories of his
series of hypertensive patients previously reported with
reference to past infections. The outstanding fact in
this group is the frequency of a history of typhoid
fever compared with pneumonia. A study of the
statistics of Johns Hopkins Hospital from September
21, 1914, to April 2, 1916, leads him to the conclusion
that no evidence has been brought forward to place
hypertensive cardiovascular disease in the category of
the direct results of syphilis, and that syphilis plays an
indirect role, if any, in its causation. In discussing
the role of alcohol in the production of disease of the
heart or vessels he says there can be no doubt that the
death rate from circulatory disease is considerably
higher in those occupations where habitual drinking is
the rule. However, a study of his own cases showing
hypertension lends no support to the view that alcohol
has an important influence in the production of this
type of arterial disease. He has tabulated the histories
as to tobacco of 226 men with angioid pain and com-
pared them with 285 men with hypertension, and of
300 other male patients and says that no important in-
fluence of tobacco is seen in these figures. In the ma-
jority of cases of cardiorenal disease he is convinced
that the disease is essentially one of the circulatory sys-
tem, involving the kidney through its vascular appara-
tus, and sometimes sparing it entirely. Hypertensive
arterial disease must be looked on to-day as the type in
which heredity plays the largest role. The essayist
states that his whole group of private patients gave
the cause of death as cardiovascular for both parents
or one parent, or one parent and other members of the
family in 22 per cent., for one parent or brother or
sister in 28 per cent., while 50 per cent, had no cardio-
vascular heredity at all. He has tabulated all his cases
having myocardial insufficiency observed during the
period mentioned and finds that one-third of their myo-
cardial failures are associated with hypertension. As
another large group of these patients die of apoplexy,
hypertensive cardiovascular disease assumes a first
place as a cause of circulatory death. Chronic endo-
carditis stands next, with syphilis of the aorta just
behind, each accounting for about one-sixth of the fail-
ing hearts. To these may be added the deaths from
syphilis of the cerebral arteries and ruptured aneurysms.
The clinically primary myocardial insufficiencies, a
motley group etiologically, but largely arteriosclerotic,
follow with about one-eighth of the blame. Emphysema
and its congeners are not far behind, then true bac-
terial endocarditis, then thyroid intoxication, and vari-
ous minor causes. The practical conclusions are drawn
that reduction of the mortality from circulatory diseases
is attainable through the diminution of syphilitic in-
fection and the early and intensive treatment of primary
syphilis; the further reduction of preventable infec-
tious diseases; the education of the public to consider
"rheumatism" a serious disease, particularly in child-
hood ; the provision of suitable employments for cardiac
patients and of convalescent hospitals for the neces-
sarily protracted after care of cases of acute inflam-
matory disease of the heart and of patients recovering
from myocardial insufficiency, and through general
hygienic measures including the promotion of temper-
ance. The essayist states that no large reduction of
the mortality from circulatory diseases is likely to oc-
cur until the problems of the ultimate causes of hyper-
tension and chronic nephritis and the infectious agent
of rheumatic fever and its portal of entry have been
discovered.
4. Further Experience in the Treatment of Intra-
cranial Hemorrhage in the Newborn. — Robert M.
Green recalls that he reported seven cases of intra-
cranial hemorrhage in the newborn in the issue of the
Journal for April 30, 1913, and discussed the classifica-
tion of cases, and methods of diagnosis and treatment.
Since that time he has observed two further cases of
this condition which illustrate those methods. He con-
cludes that intracranial hemorrhage in the newborn
may be most conveniently classified clinically under
two groups, infratentorial and supratentorial. In the
infratentorial type of hemorrhage the symptoms and
signs are primarily respiratory in character and are
probably dependent on the pressure of accumulating
blood about the respiratory center in the medulla. In
the supratentorial type of hemorrhage the symptoms
and signs are primarily convulsive and are probably
dependent on the irritation of the motor area by ac-
cumulating blood over the cerebral convexity. In any
case of doubt, diagnosis should be confirmed by explora-
tory lumbar or cranial puncture, or Doth. In the infra-
tentorial type of hemorrhage repeated lumbar puncture
is probably the best palliative treatment and may
prove definitely curative. In the supratentorial type of
hemorrhage, the best treatment is incision along the
coronal suture at one or both lateral angles of the
anterior fontanelle followed by brief drainage with
rubber tissue. More extensive procedures than these
are unnecessary and likely to prove fatal. Early diag-
nosis and operation within the first two or three days
of life are essential for the best results. The prog-
nosis becomes steadily worse as time progresses and
clotting takes place.
New York Medical Journal.
July 1. 1916.
1. Conservation In Obstetrics. Edwin G. Cragin.
2. Bone Sarcoma Treated by Radium. Joseph B. Bissell.
3. Stricture of the Ureter. Guy L. Hunner.
4. Congenital Syphilis. J. P. Jones.
5. Intradural Nerve Anastomosis in Selected Cases of Polio-
mvelitic Paralvsis. Norman Sharpe.
6. The Contents of Ovarian Cysts. J. T. Leary, H. J. Hartz
and Philip B. Hawk.
7. Dementia Prseeox. Morris J. Karpas.
S. Autoserotherapy. Francis Huber.
1. Conservation in Obstetrics. — Edwin B. Cragin
questions whether in our enthusiasm over radical ob-
stetric surgery we are neglecting the fundamentals of
obstetrics, the routine precautionary measures which
may make a resort to radical obstetric surgery un-
necessary. He says the consultant still sees cases of
puerperal sepsis; of ruptured uteri; of undiagnosed pos-
terior positions of the occiput. He sees cases in which
the forceps have been applied too early, cases in which
version has been attempted too late. The importance
of pelvimetry, uranalysis. and blood pressure readings
in the pregnant woman should not be overlooked. He
116
MEDICAL RECORD.
[July 15, 1916
questions whether the fetal heart is watched as closely
as it should be and pleads for the early diagnosis of
occipito-posterior positions, and as elements in this
diagnosis he emphasizes: (1) The absence of the
smooth broad fetal back from the front of the mother's
abdomen; (2) the location of the greatest intensity of
the fetal heart sounds outside of the line joining the
umbilicus and either anterior superior iliac spine;
(3) the character of the labor pains, the uterine con-
tractions being often feeble, far apart, and ineffectual.
This type of labor is so often found associated with a
persistent occipito-posterior position and the diagnosis
should at least be suggested and should be either veri-
fied or excluded by careful examination. The writer
regards cesarean section as a conservative procedure when
delivery of a living child through the natural passage is
shown to be impossible provided the following condi-
tions are present: 1. Labor of short duration or not
begun. 2. Unruptured membranes, or membranes only
recently ruptured. 3. No recent vaginal examinations,
or only one or two under the strictest asceptic pre-
cautions with sterile gloved hands, etc. In the writer's
opinion placenta praevia, eclampsia, accidental hem-
orrhage, etc., furnish an indication for a section only
as a rare exception. In certain cases of complete
placenta praevia with marked loss of blood and cervix
not easily dilatable, a section offeis the best prospect
to mother and child. The same may be said of certain
cases of accidental hemorrhage with complete prema-
ture separation of the placenta, but it is the writer's
custom to deliver most of these women in some other
way, usually after preliminary dilatation with the
elastic bag.
3. Stricture of the Ureter. — Guy L. Hunner states
that he has records of fifty cases of stricture of the
ureter since November 1, 1915; in the same period he
has treated forty-nine cases of tuberculosis of the
kidney and thirty-nine cases of stone in the ureter. He
is firmly convinced that the majority of ureter stric-
tures, excluding those of tuberculous and stone origin,
should be classified as simple chronic strictures and
that they have their origin in an infection carried to
the ureter walls from some distant focus, as diseased
tonsils, sinuses, or teeth. This conception of stricture
postulates that in the majority of cases ureter infiltra-
tion is primary and that other urinary tract lesions so
often associated with stricture are secondary, such as
hydronephrosis, pyelitis, and pyelonephrosis. An an-
alysis of these fifty cases seems to support this view.
Another argument for a systemic infection is the pre-
ponderance of cases in which the stricture occurs in
the broad ligament region where the ureter has its chief
blood and lymphatic connections. While the ideal treats
ment for stricture of the ureter is by dilatation from
the vesical approach, and in cases without infection
and without much renal disturbance we can look for
cure by this method, there are cases in which methods
for vesical approach fail and retrograde dilatation may
be employed. This method consists in exposing the
ureter by an extraperitoneal incision; then making an
incision into its dilated portion above the site of the
stricture, after which increasing sizes of the French
gum elastic bougies or metal sounds are passed until
the stricture is dilated to a diameter of from 0.5 to
1 cm. The ureter incision is then closed with catgut
and reinforced, if necessary, with silk or linen. The
writer has treated eight cases by this retrograde
dilatation and the results have been perfect in six, so
far as measured by relief of symptoms and ability to
catheterize easily from below.
5. Intradural Nerve Anastomosis in Selected Cases
of Poliomyelitic Paralysis. — Norman Sharpe has carried
on a series of experiments upon animals in nerve anas-
tomosis in the spinal canal with the object of caudal
root anastomosis in marked cases of paralysis of the
lower extremities following poliomyelitis. He reports
three cases, but states that it is too soon to give the
final results. He says that operation of intradural
nerve anastomosis of the cauda equina roots is not
more formidable that the frequently performed opera-
tion of haminectomy with opening of the dura. The
operation is performed in two stages as, for instance,
in the first case reported a laminectomy was performed;
the spinous processes and lamina? of the twelfth dorsal
and the first, second, and third lumbar vertebras were
removed, exposing the dura. The wound was closed
with catgut and silk. Two weeks later the wound was
reopened and the arachnoid incised. The right twelfth
dorsal anterior root was isolated, cut near its passage
through the dura, and united by single fine silk suture
to the fourth lumbar right anterior root which was
severed near the conus. In a similar manner the first
and second lumbar right anterior roots were united to
the first and second sacral anterior roots respectively.
6. Contents of Ovarian Cysts. — J. T. Leary, H. J.
Hartz, and Philip B. Hawk have made a study of the
toxicity of several varieties of cysts, namely, three
multiple proliferating cyst adenomata, one papillary
proliferating cyst, one multiple follicular cyst, and one
simple cyst of the ovary. They found that the con-
tents of the different cysts were sterile in each case.
The cysts examined showed no toxicity, regardless of
the nature of their contents. No rise of temperature
nor loss in weight was noted in any guinea pig after in-
jection. The animals were killed about twelve weeks
after injection, and no lesions could be determined
macroscopic-ally. In two cases the physical nature of
the contents was mucilaginous in the extreme, having
the physical appearance of a mucin substance. That
this property was due to the globulin content and not
to a mucin substance was shown by the precipitation
properties and coagulability of the substance in ques-
tion accompanies by the lack of viscosity in the re-
sulting filtrates. A slight amount of pseudomucin was
obtained in each case, but the trace present could in no
way account for the physical characteristics of the
contents.
Journal of The American Medical Association.
July 1, 1916.
1. Resuscitation Apparatus. 1'andell Henderson.
2. A Study of Ophthalmoscopic Changes in Xephritie.
George Slocum.
3. Parenchymatous Disease of the Liver a Cause for Rise
in Portal Blood Pressure. C. F. Hoover.
4. Proteose Intoxication : Intestinal Obstruction and Acute
Pancreatitis. G. H. Whipple.
5. The Use of the Desiccation Method in Ophthalmology.
with Special Reference to Epitheliomas of Lids. Canthi
and Conjunctiva: Report of Cases. William I.. Clark.
6. Bismuth I'aste in Chronic Suppurative Sinuses and
Empyema: Incorrect Technique as a Cause of Failure
in Its Application. Emil G. Beck.
7. Subluxation of the Head of the Radius : Report of a Case
and Anatomical Experiments. C. A. Stone.
S. Seven Unerupted Teeth in the Superior Maxilla. E. P. R.
Ryan.
9. Orthopedic Treatment in Hemiplegics of Long Standing.
George R. Elliott and Samuel W. Boorstein.
10. Report of a Case of Bantl's Disease. Karl C. Eberly.
11. Knee Block from Avulsion of Bone Fragment by Pos-
terior Crucial Ligament. Roscoe II. Kahle.
12. Sudden Blindness Associated with Choked Disk and N';is:il
Sinus Disease. Edward J. Brown.
1. Resuscitation Apparatus. — Yandell Henderson
describes the various forms of resuscitation apparatus
now on the market and points out that the mechanical
requirements are easily met. The important thing is
that the apparatus should be of such simple character
as not to impose on the credulity of the ordinary man.
All that any apparatus can accomplish is artificial res-
piration with air enriched with oxygen. The superiority
of a mere pump lies in its simplicity. Universal train-
July 15, 1916]
MEDICAL RECORD.
117
ing in the prone pressure manual method of artificial
resuscitation will accomplish more for resuscitation
from drowning, electric shock, and asphyxia than is
possible by providing any amount of apparatus. Arti-
ficial respiration with apparatus is superior to the
manual method, in that the apparatus is capable of giv-
ing a normal volume of pulmonary ventilation, while
the manual method is not. Nevertheless the imme-
diate application of a poor method is far more im-
portant than the application of a perfect method after
a delay of even five minutes. The knowledge that ap-
paratus is available is liable to result in a neglect of
immediate manual treatment in order to have the ap-
paratus brought from a distance. The Resuscitation
Commission, after considering the matter in the light
of such evidence as is available, concludes that prob-
ably ten minutes is the extreme limit of time beyond
which restoration is practically impossible. Oxygen in-
halation should be used immediately in gas and smoke
cases, but the apparatus employed should be such as
will allow the oxygen to reach the lungs in efficient
concentration. Such apparatus should go with every
artificial respiration device. It has been shown that
the oxygen concentration obtained by the pulmotor is
not very considerable. The writer expresses the opin-
ion that investigation of the use of artificial respira-
tion apparatus in asphyxia neonatorum is needed.
3. Parenchymatous Disease of the Liver a Cause for
Rise in Portal Blood Pressure. — C. F. Hoover says that
in attempting an explanation of ascites in hepatic cir-
rhosis we must consider the blood pressure and minute
volume of flow in the aorta and cava. If the pressure
and flow in the aorta and cava are unchanged, then
obviously the only hydraulic considerations are those
which may affect blood pressure within the portal vein.
From clinical experiences in the study of pylephlebitis
and portal anastomoses with tributary to the cava, it
seems clear that a rise in pressure in the portal vein
must precede ascites. Here, however, experiences are
encountered which are very disconcerting to this view
of ascites if a rise in portal vein pressure is regarded
as only an expression of obstruction to portal flow from
fibrous tissue formation. Every clinician sees patients
with typical alcoholic cirrhosis who have ascites which
accumulate very rapidly. The ascitic fluid is drawn off
one or more times, and, in spite of the fact that there
is no demonstrable change in the hepatic signs, the pa-
tient will live for some years without a return of as-
cites. Two cases are reported. In the first there was
the clinical picture of recovery from an acute hepatitis.
An acute toxic hepatitis causing an increase in the
parenchymatous volume under such conditions would
create a higher pressure within the enclosure of Glis-
son's capsule than would the same degree of parenchy-
matous enlargement when it occurs within the enclosure
of a normal Glisson's capsule with normal and less re-
sistant interstitial tissue. The behavior of the audible
hum and palpable thrill in the caput medusa; in this
case is clear and direct evidence of elevation of portal
pressure due to parenchymatous hepatitis in the pres-
ence of an old interstitial hepatitis. In the second case
there was insufficient direct evidence of an elevation of
portal pressure, and this suggested two possible sources
of the ascites, namely, either an elevation in portal
pressure on account of an acute hepatitis, or merely a
hydrops peritonei which happened to be the only col-
lection of extravascular serum because of some modi-
fication of the chemistry of the blood. Whatever the
cause may be in this second case, the two cases show
how important it is to consider the part parenchymatous
disease of the liver may play in the diagnosis and treat-
ment of ascites of hepatic origin.
5. The Use of the Desiccation Method in Ophthal-
mology, with Special Reference to Epitheliomas of the
Lids, Canthi. and Conjunctiva; Report of Cases. — Wil-
liam L. Clark describes the technique for the application
of the desiccation method to eye lesions, and reports on
a series of eighty-four cases of localized epitheliomas.
The desiccation method consists in the application of
heat just sufficient to desiccate but not to carbonize.
This heat is best generated by means of a high fre-
quency electric current, which is subject to accurate
regulation. The writer concludes that desiccation is a
successful treatment for localized basal cell epitheliomas
of the lids and canthi, both from a curative and cos-
metic standpoint. In advanced epitheliomas of these
regions, when sinus or orbit is involved complete suc-
cess is not certain because of the inaccessibility of the
diseased tissue, and is applied for palliative reasons
when operation fails or is contraindicated. The results
thus far in round cell and melanosarcoma of the lids
and conjunctiva have been good, but a sufficient time
has not elapsed in any case to determine ultimate re-
sults. Success is assured in benign growths of the lids,
such as angiomas, warts, moles, xanthoma, and lupus
erythematosus. Desiccation may be used to advantage
for the treatment of pterygium, granular conjunctiva,
and corneal ulcers. Symblepharon usually does not fol-
low desiccation. There is no danger of applying the
desiccation treatment to growths on the cornea, as it is
under perfect control.
6. Bismuth Paste in Chronic Suppurative Sinuses
and Empyema: Incorrect Technique as a Cause of Fail-
ure in Its Application. — Emil G. Beck believes a dis-
cussion of this subject is warranted, because the present
war in Europe will result in a tremendous increase in
this class of cases. He presents statistics of 527 cases,
exclusive of nose and throat cases, from a wide range
of sources, and finds an average of 80.64 per cent, of
cures. The failures he attributes pincipally to faulty
technique. Some of these errors are as follows: The
bismuth may not be sufficiently incorporated with the
petrolatum and may contain lumps. A little water
dropped into the mixture will curdle the solution and
make it unsuitable for the treatment. The instruments
used are often improvised and not suitable for this form
of treatment. Undue force is used in the injection. An
incomplete filling of the entire sinus tract is the most
common error, which is responsible for more failures
than any other cause. The sinuses are injected too fre-
quently by some practitioners. Some patients are al-
lowed to dress their own wounds, reinfection usually
following. Physicians at times do not give the paste
sufficient opportunity to do the work. The writer con-
fidently states that this treatment has passed its ex-
perimental stage, and the results obtained by surgeons
all over the world warrant its more general employment.
Stereoroentgenograms should be employed to control the
treatment and to prevent useless operations. Bismuth
poisoning can be avoided and is now of rare occurrence.
Should toxic symptoms appear the paste must be re-
moved by washing out the cavity with warm olive oil
and injecting sterile oil, which should be allowed to
remain for from twelve to twenty-four hours.
7. Subluxation of the Head of the Radius. — C. A.
Stone reports a case and describes some experiments
which he believes throw some light on the production
and maintenance of this deformity. From his experi-
ments on twelve arms that were practically free of
muscle but on which the ligaments were intact, he con-
cludes that subluxation of the head of the radius can
occur while the biceps are contracted, with the forearm
flexed and without adduction. It occurs only while the
hand is pronated. The line of traction is parallel to
118
MEDICAL RECORD.
[July 15, 1916
the shaft of the bone. Supination is resisted, because
the tense lateral ligament forces the flattened side of
the radial head against the anterior edge of the lesser
sigmoid articulation and the inner attachment of the
annular ligament. Attempts at this motion throw the
exposed two-thirds of the long axis of the head against
an already tight ligament, making it more tense. Com-
plete pronation is possible, because the short part of the
long axis is behind and moves outward against the
loose posterior portion of the lateral ligament.
9. Orthopedic Treatment in Hemiplegics of Long
Standing. — George R. Elliott and Samuel W. Boor-
stein say that it has generally been accepted that if a
hemiplegic has not improved within a short time he will
never improve; but, on the contrary, contractures de-
velop and he becomes a chronic invalid. They report a
case which disproves this and indicates that there is no
time limit for improvement in hemiplegia. This case
further suggests that a patient with hemiplegia should
receive proper orthopedic treatments as soon as he re-
gains consciousness. Light massage should be used, and
active and passive exercises should be begun early. As
soon as the patient is able he should be urged to stand
up. Even in old and neglected cases great improvement
can be obtained, especially in walking; hence one should
work patiently on any hemoplegic who comes under his
professional care.
The Lancet.
June 10. 1916.
1. The Chadwick Lectures on Typhus Fever in Serbia. R. O.
Moon.
2. Intestinal Disorders Arising from Protozoal Infection.
B. R. G. Russell.
3. Lamblia Intestinalis Infections from Gallipoli. Alex.
Mills Kennedy and D. D. Rosewarne.
4. Remarks on the Nature and Distribution of the Parasites
Observed in the Stools of 1,305 Dysenteric Patients.
H. B. Fantham.
5. An Enumerative Study of the Cysts of Giardia (Lamblia)
Intestinals in Human Dysenteric Feces. Annie Porter.
6. Spinal Anesthesia: With Reference to Its Use in the
Trendelenburg Position and for the Prevention of
Shock. H. M. Page and Harold Chappie.
7. Observations on the Treatment of Anaphylaxis. Albert S.
Leyton and Helen G. Leyton.
8. Prevention of Fly-breeding in Horse Manure. S. Monck-
ton Copeman.
2. Intestinal Disorders Arising from Protozoal In-
fection.— B. R. G. Russell reports three cases of infec-
tion with Entameba histolytica s. tetragena and one
case with an infection of Lamblia intestinalis. The
former three cases showed nothing unusual. The
fourth case, however, failed to respond to two courses
of emetine and a chronic dysentery was established.
Alternate views have been advanced to explain this
phenomenon, the first an anatomical and the second a
biological. It is possible to conceive a few amebic cysts
locked up in a fragment of more or less dried intestinal
content, perhaps lodged in a crypt, where the emetine
cannot gain access. The other possibility is after the
analogy of certain trypanosomes, easily killed by a par-
ticular organic compound of arsenic, which may after
exposure to this drug, under conditions not exactly de-
termined, become insusceptible to the action of this very
arsenical compound. This insusceptibility or arsenic
fastness becomes a character of the trypanosome
through subsequent generations. The ameba of dysen-
tery may in like manner become immune to the
action of emetine. In the third case the relapse oc-
curred after long treatment with emetine and the con-
ditions for the establishment of an emetine-fast ameba
were present. Fortunately, however, the cause of the
relapse did not lie in the presence of a permanently
emetine-fast ameba. Hence it seems that the whole
question why certain cases relapse demands further re-
search. In conclusion the author states that the prob-
lem for the clinical pathologist is to recognize the causa-
tive organisms in the stools. Accurate measurements
must be made of these by a micrometer eyepiece whose
value has been reckoned out for the various objectives
by means of a ruler slide. For a study of active amebae
from an acute case of dysentery a warm stage is in-
dispensable. In detecting the encysted forms of E.
histolytica double-strength iodine solution, as recom-
mended by Dr. Wenyon, has proved of great service.
The solution is made up similarly to Gram's solution,
only double quantities of iodine and potassium iodine
are measured out. The writer gives the technique for
a further cytological study and the permanent preserva-
tion of interesting specimens.
6. Spinal Anesthesia: With Reference to Its Use in
the Trendelenburg Position and for the Prevention of
Shock. — H. M. Page and Harold Chappie express the
opinion that for all ordinary uncomplicated cases in-
halation anesthesia as improved at the present day is
still the method of choice, but that there remain many
cases in which great advantages may be obtained by
the use of spinal anesthesia. The operations in which
these advantages may be of special importance are
those for acute abdominal conditions, especially if septic
in nature; any prolonged abdominal procedure likely to
be followed by shock; amputations; operations of the
bones of the lower limbs, especially when the patient's
vitality is lowered by exhaustion, sepsis, or hemor-
rhage; and certain genitourinary operations. The
writer reports seventy cases in which the patient was
placed in the Trendelenburg position after the intra-
thecal injection. He states that he might have re-
ported many more cases in which the patient was put
on a slight incline, with the head lower than the body,
without any trouble occurring, but he included only
those placed in the Trendelenburg position. When this
position is used it is better to combine a general anes-
thetic with the spinal injection, for the small quantity
of ether or chloroform mixture required to keep the
patient unconscious when there is no reflex disturbance
has no necrotic effect on the tissues and practically has
very little effect on the after condition of the patient.
The administration of nitrous oxide and oxygen for
prolonged periods is quite easy, either after a spinal
injection or in conjunction with satisfactory local in-
filtration with novocaine. In twelve cases in this se-
ries, however, no general anesthetic was administered.
In three cases there was a partial failure, and more or
less deep inhalation anesthesia was required. No pa-
tient died on the table or before recovery from paral-
ysis. There was no case of surgical shock in the se-
ries. In some cases there was a fall in blood pressure
without quickening of the pulse rate, remediable by rais-
ing the legs to a level with the rest of the inverted body.
Harold Chappie adds a note to this article in which
he states that he has been using spinal anesthesia dur-
ing the past four years in operations on the female pel-
vic organs and is thoroughly in agreement with the
author as to the value of this method. He finds it spe-
cially indicated in operations in which great surgical
shock is anticipated, as in a Wertheim operation for
carcinoma of the cervix. By this method of anesthesia
this operation can be safely performed, especially if
normal saline be at the same time introduced into the
axillae after the method of Arbuthnot Lane. From the
surgeon's point of view the great advantage it affords
is in the complete relaxation of the abdominal muscles.
Novocaine with adrenalin was used in the majority of
the cases, the dose varying from 2% to 3 c.c.
7. Observations on the Treatment of Anaphylaxis. —
Albert S. Leyton and Helen G. Leyton record their ex-
periments on the excised rabbit's heart, and believe that
anaphylactic phenomena is mainly due to a toxic com-
July 15, 1916]
MEDICAL RECORD.
119
bination of horse serum and patient's or animal's serum
and that it is dangerous chiefly on account of the effect
on the central nervous system and the cardiac muscle.
These observations led the writers to investigate some
possible remedies or prophylactics. The problem was
attached by a modification of the serum so as to elimi-
nate the toxic element, or by treatment of the patient,
either before or after the onset of symptoms. Efforts
to effect a modification of the serum have thus far
been attended with little success. Nevertheless, the
treatment of anaphylaxis, at least in the guinea pig, is
not entirely hopeless, if due preparation is made.
Rosenau and Anderson state that untreated guinea-pigs
never recover if the anaphylactic condition has pro-
ceeded to the convulsive stage. This has also been the
experience of the writers but they have found, in addi-
tion, that the injection of alcohol or of spirit of camphor
has in some cases averted death even after convulsions
have begun. Inasmuch as the nervous element is almost
certainly involved in anaphylaxis, they have tried cer-
tain drugs alone and in combination, acting both cen-
trally and peripherally on the nervous system. The
drugs which they have successfully used in averting
anaphylaxis in a large percentage of instances are
hyoscine, scopolamine, morphine, and atropine. In
combination both hyoscine and scopalomine have a dis-
tinct influence in preventing anaphylactic shock, but
only hyoscine will do so by itself. This the observers
atribute to the more central action of the hyoscine.
Morphine and atropine by themselves do not possess
any noteworthy protective power, but appear to coun-
teract the dangerous properties of hyoscine. In con-
cluding, the writers strongly recommend the use of
hyoscine previous to the injection of serum for a sec-
ond time in any case in which the interval since the
previous injection has exceeded one week.
British Medical Journal.
June 10, 1916.
1. Notes on Military Orthopedics. On Malunited and Un-
united Fractures. Lieutenant-Colonel Robert Jones.
2. Observations on Spirocheta Eurygyrata, as Found in Hu-
man Feces. H. B. Fantham.
3. Perforating and Penetrating Wounds of the Chest with
Severe Hemorrhage : A Suggestion for Treatment.
A. Don.
4. A Suction or Vacuum Bougie for the Treatment of Chronic
Gonorrhea. Captain A. Cambell.
2. Observations on Spirochaeta Eurygyrata, as
Found in Human Feces. — H. B. Fantham, in examining
the feces of soldiers who had contracted various forms
of dysentary or diarrhea in Gallipoli or Flanders, found
23 cases of single infection with spirochetes within
three months. He found that the spirochetes were
seen to be more numerous in a preparation and to occur
more frequently in stools if dark-ground illumination
is used. Also if stained smears of stools are made,
many more infections will be found, perhaps in as many
as 50 per cent, of the cases. The same spirochetes
were found in the stools of some apparently healthy
persons. The organism, which has pointed ends, meas-
ures from three to fifteen microns in length and about
0.25 of a micron in breadth. The so-called spirilla men-
tioned by some of the earlier workers as occurring
occasionally in cholera motions are included under the
name Spirochseta eurygyrata. The number of coils
in a spirocheta is not a specific character but is vari-
able, and is primarily an index of the rate of motion,
being also partially dependent upon the rate of thick-
ness of the organism.
3. Perforating and Penetrating Wounds of the
Chest with Severe Hemorrhage. — A. Don offers a meth-
od of treatment for this class of wounds which he
thinks is worthy of trial by surgeons at the front. He
says the severer cases almost all die of hemorrhage
within the first few hours, and so far there has been
little attempt to check this mortality. A study of the
mechanism and physics of respiration show that the
suction in the pleural cavity is exerted strongly from
the commencement of the act of inspiration to that of
expiration, and more feebly during the whole expira-
tion. A bleeding point thus has a suction pump applied
to its open rent and a clot is prevented from forming.
The same process takes place throughout the lung tissue
and there is added the elasticity of the lung tissue it-
self which pulls apart and keeps open any rent. To
overcome both the suction and the elastic forces and
to allow the lung a complete rest until hemorrhage has
been arrested the idea occurred to the writer of making
a temporary opening into the pleural cavity, allowing
the lung to contract quickly, and, if necessary, washing
out the blood clot. In most of the cases of chest
wounds, especially from shells, the hemothorax has
later become septic and death from empyema has
supervened. This infection of the blood clot is almost
certain to occur. The risk, then, of causing by oper-
ation an infection which would not otherwise occur is
almost infinitesimal, and on all grounds this suggestion
wisely used in selected cases seems sound. In the only
case in which the writer has done this operation great
relief was experienced in breathing; there was a
marked diminution of pain and, though the hemorrhage
could not be said to have been severe, it was still going
on and stopped quickly after the operation. The oper-
ation may be done under a general or a local anesthetic,
and in any of the usual sites for empyema, preferably
the mid-axillary line. Percussion localized the hemo-
thorax and a stab is made with a scalpel through the
intercostal space, close to the lower rib. Even if the
point of the scalpel wounds the lung, which is most un-
likely, the consequence is negligible. The knife is then
withdrawn and the center piece of a tracheotomy tube
put in. If air has not entered it will now do so, with
a hissing noise, and the blood will be coughed up. The
whole operation does not occupy a minute and the tube
may be removed after twenty-four or forty-eight hours.
The patient upon whom this operation was performed
went to the base hospital on the third day in quite fit
condition.
Statistics of Death Due to Childbirth.— Zinke states
that during the past fifty years Germany has lost
400,000 women from puerperal causes, while in the
United States, during the same period, the loss is esti-
mated at 1,000,000. During the past forty-five years
our population has increased by 40,000,000, while in
Germany the increase is about one-half this figure.
With a like increase in population during the next
fifty years, the death rate from puerperal affections-
remaining unchanged, the mortality will be appalling
and the morbidity is computed now at three or four
times the mortality. To show how much of this is
really preventable, we only have to bear in mind the
absence of mortality in well-conducted maternities when
all conditions can be controlled. — Bulletin of the Lying-
in Hospital of Neiv York.
Contraindications to the Karell Diet. — E. H. Goodman
states that there are cases which do not respond to
this restricted milk diet, in which the latter is no longer
recommended. Patients exhibiting symptoms of uremia
should not be put on the Karell regimen, since the latter
restricts to a minimum the intake of fluids. It has
been shown by Senator and others that in a uremic
crisis the fluid intake should be greatly augmented for
the purpose of flooding from the system the unknown
toxic substance or substances believed to be the causa-
tive factor in uremia. Wittich states that the Karell
cure in two cases of uremia left him absolutely in the
lurch, and the patients were made materially worse.
The treatment of such individuals should be that well
known to all practitioners of medicine, and the Karell
regimen has no place whatever in the management of
such cases. — Archives of Internal Medicine.
120
MEDICAL RECORD.
[July 15, 1916
Cooperation of Medical Director and Local Ex-
aminer.— Dr. B. L. Jenkins read a paper before
the Section on Life Insurance, State Medical As-
sociation of Texas, on this subject. In the course
of his remarks he pointed out that the duty of the
local examiner is not alone to the company : the
applicant also has rights to be considered. So ac-
curately have mortality statistics been calculated,
correlated and tabulated, that the expectant period
of life, at all ages, and under all the varied con-
ditions and environments, has been reduced mathe-
matically to hours. This being true, all or prac-
tically all men and women are entitled to life insur-
ance of some form at some rate. To accurately
arrive at just what that form and that rate should
be, the local examiner should be able, and it should
be his purpose, to furnish to the medical director
a pen picture, with the perfectness of the artist's
brush, not alone the physical finding and measure-
ments resulting from a careful, painstaking, and
competent examination, but the habits, environment
and life of the applicant. After such a picture has
been transmitted to the medical director, and he has
carefully reviewed it from its every angle and
studied its every phase, as the art critic should, if
in any doubt about any point it is his duty, not
only to the company but to the examined and the
applicant, and it should be his invariable rule and
custom, to at once confer with the examined in an
effort to gain more complete information. Or if
he does not concur in the recommendation of the
examiner, he should at once confer with him, giv-
ing specific reasons for such non-concurrence.
A local examiner who would not truly paint is
unworthy; and the medical director who fails at
any time in dealing frankly and freely with his
local examiner is a misfit in the position he occu-
pies.— Texas State Journal of Medicine.
Diseases of the Circulatory and Hematopoietic
Systems in Relation to Obesity. — In a paper on
disease in relation to obesity, Dr. F. Parkes Webber
said that it was well known that many obese per-
sons had slight edema about the ankles when they
were up and had not been recently lying down. In
most cases he believed the edema was not a sign
of particularly bad prognostic significance. Occa-
sionally, however, it rapidly increased and became
associated with shortness of breath on exertion,
out of all proportion to the obesity. It then might
constitute an early sign of cardiac failure. Es-
pecially was this to be feared in persons who had
been formerly addicted to excess use of beer and
alcoholic drinks, even when by auscultation of the
heart no murmur of valvular disease could be dis-
covered. In such cases signs of so-called "myo-
carditis" might suddenly arise, accompanied by the
characteristic "irregular inequality" of auricular
fibrillation. In other cases the slight edema in ques-
tion might be due partly to varicose veins, and it
was only the varicose veins that had to be consid-
ered in regard to the assurance. Occasionally a
plethoric type of obesity might to some extent mask
the presence of arteriosclerosis and commencing
aneurysm of the aorta. Symptoms such as shortness
of breath and thoracic discomfort might at first
be wrongly attributed to the obesity, but more
act examination would probably reveal quickly
complicating disease. In very rare cases in p;
obese individuals, pallor and slight edema might
be due to some hematopoietic disorder, or, for in-
stance, to pernicious anemia or to an atypical form
of leucemia. — The Assurance Medical Society of
London.
"Accident" — Anticipated Consequences. — In an
action on an accident indemnity policy it ap-
peared that the insured had been out horseback
riding, and, coming home, took a cold plunge, as
he had frequently done before, the shock of which
cause an acute dilatation of his heart for 29 weeks.
The insured had been a well and active man, and
had no organic trouble with his heart. The plaintiff
recovered a verdict and judgment in the trial court,
which was reversed on appeal. "It can hardly be
asserted," the court said, "that the act of voluntar-
ily entering a bathtub filled with cold water is an
accident. If some one had pushed the insured into
a tub so filled, or, for that matter, into a pond of
cold water, and the results had followed which en-
sued when he voluntarily committed his body to the
water, then the act would have been an accident in
the ordinary acceptation of the term. It is not an
accident for which an insurance company would be
liable if one so insured, while in a state of lively
perspiration, stand before an open window, take
cold, and die; nor if, by some gross immoderation
in eating, acute indigestion be occasioned, and
heart failure result ; nor yet if in taking a dose of
strychnine, aware of its poisonous nature and know-
ing that in certain sized doses it is a heart stimu-
lant, and not deadly, but mistaking the effect of a
given quantity, death ensues. It is urged that
heart dilatation is not usually attendant on the tak-
ing of a cold bath. When it does occur, it is unex-
pected, unusual, and unforeseen, and therefore an
accident. Undoubtedly an accident, in both its
technical and commonly accepted meaning, is an
event which occurs without one's foresight or ex-
pectation and wholly undesigned; yet it is not true
that every unusual, unforeseen, and unexpected
event is an accident within the true meaning of the
term as used in insurance policies. * In
this particular instance the weakened heart failed to
do its work properly ; the sudden contraction of the
surface blood vessels must have necessarily and
correspondingly increased the blood pressure, thus
throwing an additional burden on the heart. It
failed to respond to the work of propelling the
blood over the body, and acute dilatation occurred.
The court is constrained to hold that the
result which followed the taking of the bath by the
insured was not an accident upon which recovery
can be had under the wording of the policy (which
insured against bodily injuries effected solely and
exclusively by external, violent, and accidental
means). A case is cited where recovery was had
by reason of a ruptured blood vessel occasioned by
the mere lifting one's self naturally out of a chair.
It is felt by this court that in such a case, as in
the case at bar, such a conclusion would be unduly
pressing the construction of the language univer-
sally employed in naked accident policies. It would
amount to an unfair and unjust enlargement of the
company's liability and would convert accident com-
panies into both sick-beneficial and life insurance
companies; and, worse than this, the apparent vice
of it is that, if countenanced, it would inevitably
result in the necessity of requiring constantly in-
creasing premiums from the vast multitude of the
laboring classes as well as people of moderate means
who chiefly buy this character of insurance." — New
Amsterdam Casualty Co. v. Johnson, 91 Ohio St.
Rep. 155, 110 X. E. 475.
July 15, 1916]
MEDICAL RECORD.
121
Maak Srotpuia.
El Problema de la Meningitis. Por el Dr. Cesar
Juarros, Medico primero de Sanidad Militar, Profes-
sor de Psiquiatria del Instituto espanol criminologico,
Jefe de la Consulta de enfermedades nerviosas del
tercer Dispensario de la Cruz Roja; Professor agre-
gado del Instituto de Medicina legal. Price, 4 pesetas.
Madrid: Hijos de Reus, 1915.
Those who are interested in the subject of meningitis
and who are able to read the Spanish language will
find this volume a valuable digest of the latest knowl-
edge of the various affections of the meninges. This
knowledge has grown rapidly during the past few years,
chiefly through the contributions of French clinicians.
The author has made a thorough survey of the liter-
ature of meningitis and has succeeded in presenting
an epitome of it in a form that is no less interesting
than instructive. Chapter I deals with lumbar puncture
and ventricular puncture; Chapter II, with the symp-
tomatology of meningitis; Chapters III and IV with
laboratory data; Chapter V, with tuberculous menin-
gitis; Chapter VI, with meningococcus meningitis, and
Chapter VII, with syphilitic meningitis, and the types
of meningitis caused by the pneumococcus, the typhoid
and influenza bacilli, the gonococcus, the streptococcus
and other microorganisms, and the meningitis associated
with parotitis. In Chapter VIII there is discussed the
so-called toxic meningitis, including the uremic and
serous, and those caused by salvarsan and carbon
monoxide. The types of meningitis of difficult classifi-
cation are described in Chapter IX : these types are the
otitic and traumatic meningitides, and the meningitis
associated with zona, insolation, Pott's disease, cysticer-
cus, and trichinosis. The meningeal reactions are
dealt with in Chapter X. The author believes that
the term meningism should be discarded, for in all
cases in which the meningeal syndrome is present he
believes there are distinct pathological changes in the
meninges. Chapter XI deals with the localized types
of meningitis: the spinal and the cerebral. A most
important topic constitutes the subject-matter of the
following chapter, namely, the meningeal hemorrhages,
the various types of which may be differentiated by an
examination of the cerebrospinal fluid. The treatment
of meningitis is exhaustively discussed in Chapters XIII
and XIV. Various important points are summarized
in Chapter XV, and Chapter XVI deals with meningo-
coccus meningitis as it has been observed in Spain.
An idea of the thorough manner in which the author
has elaborated his theme may be gleaned by noting the
subdivisions of the type of meningococcus meningitis
as observed in the newborn. The following varieties
are mentioned : the typical, the abortive, the prolonged,
the fulminant, the hypersthenic, the posterior basilar,
the tetanic, the type accompanied by paralysis of the
neck muscles, and the uremic. The book on the whole
is one of the most impoi-tant contributions that have
been made within recent years to the literature of
meningitis, a contribution out of all proportion to the
modest size of the volume.
A Handbook of Colloid Chemistry. The recognition
of colloids, the theory of colloids, and their general
physicochemical properties. By Dr. Wolfgang
Ostwald, privatdozent in the University of Leipzig.
First English edition translated from the third Ger-
man edition by Dr. Martin H. Fischer, professor
of physiology in the University of Cincinnati, with
the assistance of Ralph E. Oesper, Ph.D., instructor
in chemistry, New York University, and Louis
Berman, M.D., staff physician, Mount Sinai Hos-
pital, New York. Price, $3.00 net. Philadelphia: P.
Blakiston's Son & Co.
The first part of Wolfgang Ostwald's textbook on col-
loidal chemistry has passed through a number of edi-
tions in German, and has been generally accepted as a
standard presentation of the physics and chemistry of
bodies whose surfaces are very large in proportion to
their other dimensions. Unfortunately, the second part
has never appeared, and it is to be regretted that the
translators of the present volume have not deleted
references to this proposed continuation, as on pages 39
and 82. In some instances, also, as at the bottom of
page 28 and the end of the second paragraph on page
158, the statement is made that a matter will be dis-
cussed in detail later; as the details are not to be found
in this volume in connection with some of these refer-
ences, it is to be presumed that they refer to the un-
published volume. The only other errors noted are
the use of "exterpolations" for "extrapolations" on
page 58, and the inclusion on page 98 without criticism
of some highly improbable statements on the increased
radioactivity of substances in colloidal form. If there
is anything we know about radioactive substances it is
that they are not influenced in their energy emission by
any physical or chemical means at our disposal. These
minor defects, however, in no way diminish our obli-
gations to Dr. Fischer and his collaborators in the,
production of a very admirable translation of an ex-'
tremely valuable book. While the results of the study
of colloidal chemistry are important in commercial life,
applying to many processes of manufacture, especially
dyeing, they are also fundamental in many biological
reactions, as substances of large molecular weight,
such as proteins, soaps, and some of the carbohydrates
of the body are subject to mechanical laws which gov-
ern colloidal suspensions. It is generally held, also,
that the reactions between the various antibodies and
antigens are best explained by supposing that their
condition is colloidal. While the details are highly
technical, the physician will find much of interest in
this volume, for there is no question that in the future
a much fuller use of the methods of analysis here pre-
sented will be made in physiology and pathology. At
the present time the science is not advanced sufficiently
far to result in important practical applications to
medicine, though general biology has greatly benefited.
Principles and Practice of Physical Diagnosis. By
John C. DaCosta, Jr., M.D., Assistant Professor of
Medicine, Jefferson Medical College, Philadelphia.
Third edition, thoroughly revised. With 243 original
illustrations. Price, $3.50. Philadelphia and Lon-
don: W. B. Saunders Company, 1915.
Though progress in diagnosis has of recent years been
effected rather through developments in laboratory
procedures than by innovations in the methods of im-
mediate examination of the patient, still in this field,
as in all other departments of medicine, there have been
advances of some importance. Accordingly there has
been no lack of new material to incorporate in the third
edition of this most excellent treatise on physical diag-
nosis. Electrocardiography naturally is one of the most
important of the added subjects and is discussed clearly
and explicitly, with its practical applications indicated
as far as present knowledge permits. Radiography in
gastroenterological diagnosis and also in the study of
thoracic disorders receives much new space, as well as
the recent lore in regard to cardiac irregularities,
auricular flutter, fibrillation, etc. Especial attention
must be called to the very numerous and unusually use-
ful illustrations which form so vital a part of any
book on physical diagnosis and are particularly well
chosen in the present admirable volume.
A Treatise on Medical Practice Based on the
Principles and Therapeutic Applications of the
Physical Modes and Methods of Treatment. By
Otto Juettner, A.M., Sc.M., Ph.D., M.D. Price, $5.
New York: A. L. Chatterton Co., 1916.
This is a one-man cyclopedia, the matter being ar-
ranged alphabetically. From the numerous affiliations
of the author, which are too many to reproduce, we
gather that he is well qualified to write on the physical
and dietetic treatment of disease. But it is strange to
find a reference work comprising such subjects as
radiography, electrotherapeutics, Swedish movements,
etc., without a single illustration! And this, too, in an
era when pictures seem to count for more than text.
Manual Practico de Anestesia (General, Local, Re-
gional y Raquidea), por J. Blumfeld, M.D., Cantab,
Primer, Anestesiador del Hospital de San Jorge y
Profesor de Anestesia del de Santa Maria en Londres.
Traducido directamente de la tercera edicion inglesa
y completado con un apendice por D. Julio Ortega,
Doctor on Medicina. Prologo del Dr. D. Juan Bravo
Coronado Cirujano de numero de la Beneficencia pro-
vincial. Price, 3.50 pesetas. Madrid: Hijos de Reus,
1914.
This work is a translation of the third edition (1912)
of Blumf eld's "Anesthetics: A Practical Handbook."
The translator has added some text on somnoform and
liquor somniferus, which substances appear to be in
favor in Spanish and Portuguese speaking countries ;
also on intravenous and conduction anesthesia. A brief
critical summary completes the text.
122
MEDICAL RECORD.
LJuly 15, 1916
l§>flrtoy Stejrorta.
MEDICAL SOCIETY OF THE STATE OF NEW
JERSEY.
One Hundred and Fiftieth Annual Meeting, Held in
Asbury Park, June 20, 21 and 22, 1916.
(Special Report to the Medical Record.)
Tuesday, June 20 — First Day.
The President, Dr. William J. Chandler of South
Orange in the Chair.
House of Delegates. — After the call to order by the
President, the presentation of credentials by the dele-
gates, and the adoption of the minutes of the last meet-
ing the following reports were presented.
Report of the Recording Secretary. — Dr. Thomas N.
Gray of South Orange presented this report, which
showed that the membership of the Society on June 1,
1915, was 1,649; that there had been a gain of 187 new
members; that after deducting the losses occasioned by
death, resignation, and failure to pay dues there was a
net gain of 51 members, making the membership at the
present time 1,700.
Report of Committee on Publication. — Dr. AUGUST A.
Strasser of Arlington reported for this committee. He
stated that for the first time in the history of the State
Journal it had shown a profit, a little over seven dol-
lars. This was small indeed, but it held much that was
promising for the future. They had found that co-
operation with the Advertising Bureau of the American
Medical Association had been greatly to their advan-
tage. Their advertisements were all ethical and they
recommended that when members could conveniently do
so they patronize those who had contributed by their ad-
vertisements to the financial success of the Journal. It
should be remembered that medical defense in malprac-
tice suits was only given to subscribers to the Journal.
The July, August, and September numbers of the Jour-
nal would be of special value and would constitute a
memorial of the One Hunderd and Fiftieth Anniversary
of the Society.
Report of Committee on Legislation. — Dr. Henry B.
Costill of Trenton presented this report in which he
cited the principal measures which had come before the
Legislature during its past session which affected the
welfare of the medical profession. Among these were
bills aiming to relieve the physician of his obligation to
guard professional secrets on the witness stand, and
bills legalizing the practice of osteopathy and chiroprac-
tique. All of these bills were defeated, the osteopathy
bill not before it had passed the lower House and the
chiropractique bill not until after it had passed both
Houses of the Legislature. This committee urged
stronger co-operation on the part of the county socie-
ties in the efforts to influence legislation affecting the
practice of medicine and public health. In view of the
amount of time that was required of those who attended
hearings at Trenton it was recommended that a tax of
one dollar be levied on every member of the Society to
defray the expenses of such men as should be chosen to
assist the Legislative Committee of the State Society.
It was pointed out that the members of the county soci-
eties frequently could exert greater influence on the
assemblymen and representatives from their localities
than could be brought to bear at Trenton by physicians
who were unknown to the assemblymen.
A lengthy discussion on these recommendations em-
phasized the need of sending men before the State Leg-
islature who were familiar with the problems of the
medical profession and who were able to present their
viewpoint in a way that would carry conviction. The
various cults when they wished to secure the passage of
legislation favorable to their interests hired the best
legal talent available to present their side and had their
supporters flood the mails of assemblymen with letters
urging the special measure in which they were inter-
ested. It was further pointed out that the family phy-
sician of a representative was in a position in which he
could do a great deal to enlighten that representative
and to bring a direct influence to bear on him; it was
his duty to exert this influence. After a lengthy discus-
sion as to the advisability of levying an additional tax
of a dollar on each member this question was referred
to the Business Committee for further consideration.
Resolutions on Stream Pollution. — Dr. Luther M.
IIalsey of Williamstown stated that the New Jersey
State Department of Health was in session and has
passed resolutions opposing the discharge oi partially
purified sewage into the streams of the State and that
they would like to have the State Medical Society endorse
these resolutions. The resolutions were endorsed by the
Society, but it was pointed out that it should have speci-
fied more definitely what was meant by partially purified
sewage.
Report of the Treasurer. — Dr. Archibald Mercer of
Newark presented this report, which showed the
finances of the Society in thriving condition, there hav-
ing been $5,194 in the treasury on January 1, 1916.
Report of Board of Trustees. — Dr. John M. Ward of
Trenton presented this report, in which satisfaction was
expressed with the reports of the officers. It was an-
nounced that Dr. Edward J. Ill of Newark had been
appointed Chairman of the Board of Trustees and Dr.
David C. English of New Brunswick had been re-elected
Editor of the Journal.
Report of Special Committees. — Committee on Stand-
ardization of Hospitals. — Dr. JOHN C. McCoy of Pat-
terson made this report. He stated that this committee
had inspected forty-iliree hospitals in the State of New
Jersey. The importance of standardizing hospitals was
evident since the Board of Medical Examiners of New
Jersey required that every applicant for a license to
practice medicine should have had one year's hospital
experience. In this inspection notice had been taken of
the physical plans of hospitals, the conditions with ref-
erence to financial management, and the provisions for
the care of patients. A great deal of information had
been collected and analyzed. The facts which had most
impressed the committee were the lack of uniformity in
the essentials of hospital management and the failure in
some instances to achieve the main object of the hos-
pitals, the proper care of the patient. The hospital
must be judged by its results and many hospitals failed
to give value received for the money expended. The
statistics of some of the hospitals gave very little in-
formation as to the efficiency of hospital management.
There was a lack of attention in the medical department
to historical data, and the management had failed to
require such data. The committee suggested that a
blank form should be incorporated and that the use of
such forms should be made compulsory and introduced
into the annual reports of all hospitals. The reports
from the hospitals should give the wages of all em-
ployees, the average stay in the hospital of the patients,
the average cost of maintenance of each patient, etc.
The State Board of Medical Examiners had given their
hearty co-operation in this investigation and had as-
sisted the committee in deciding upon the minimum re-
quirements in the way of equipment for a pathological
laboratory. It was found that a hospital laboratory
could be equipped at a cost of $600. The detail of such
equipment was given in the full report. The results of
this effort at hospital standardization had been given to
the American Medical Association. This organization
had congratulated them on their work and had stated
that this was the first instance in which a hospital
standard had been submitted to them. It was difficult
to make the standard as high as it should be at the pres-
ent time, but with a minimum standard once established
the standard could gradually be raised. This investiga-
tion had also shown them that co-operation between the
boards of managers of the different hospitals, if it could
be brought about, would offer great economic advan-
tages.
Report of the Judicial Council. — Dr. William H. Is-
zard of Camden presented this report, in which he em-
phasized the advantages of medical defense and cited a
number of cases which had come up during the past
year. In several instances the mere fact that the physi-
cian against whom action was brought applied for medi-
cal defense was sufficient to bring about a withdrawal
of the case.
Report of Committee on Economics. — Owing to the
death of the chairman of this committee, Dr. Frank N.
Gray of Jersey City, one of the members of the commit-
tee presented this report. This report stated that it
had been conservatively estimated that the illegal prac-
tice of medicine cost the people of the State of New
Jersey $7,000,000 annually. It had also been estimated
that the illegal practice of medicine cost the people of
the United States $400,000,000 annually. There was a
book published called "The Druggist's Manual," which
contained 2,800 prescriptions, of which 1,400 were so-
called "cures." With such a state of affairs it was not
to be wondered at that the members of the Society would
not stand a further tax of one dollar a year.
July 15, 1916]
MEDICAL RECORD.
123
Report of Committee on Tuberculosis in Childhood. —
Dr. Gordon K. Dickinson of Jersey City presented this
report, which embodied the results of the work of a
special committee appointed by the Society to investi-
gate the prevalence of tuberculosis in children and to
make suggestions. This report emphasized the well-
known fact that infection with tuberculosis in childhood
was responsible for the large majority of cases of tuber-
culosis in adults. Future generations would wonder
why, when we possessed this information, we had not
acted upon it in such a way as to control this disease.
This committee recommended that resolutions be passed
to the effect that the State Board of Health be called
upon to look to the sanitary condition of the schools in
regard to the prevention of tuberculosis; this meant
open air, not open window, schools, for tuberculous and
anemic children. It was further recommended that the
influence of this Society be brought to bear on legisla-
tive bodies in order that sanatoria or preventoria might
be established for the care of tuberculous children.
This action was urged as a fitting memorial of the One
Hundred and Fiftieth Anniversary of the Society.
Election of Honorary Members. — The following were
elected honorary members of the Medical Society of the
State of New Jersey: Dr. J. K. Mills of Philadelphia,
Dr. Hugh Cabot of Boston, Dr. George W. Crile of
Cleveland, and Dr. James B. Deaver of Philadelphia.
Report of Publicity Committee. — Dr. James Hunter,
Jr., of Westville made this report. He stated that in-
asmuch as the general public were showing great inter-
est in matters pertaining to public health and inasmuch
as the newspapers published articles on these subjects
which were incorrect and misleading, they had selected
125 papers and had sought to co-operate with the editors
in the publication of suitable articles. Seven such arti-
cles had been prepared and published without the names
of their authors in a considerable number of news-
papers. Later inquiry was made as to how they had
been received; the replies received showed that the
newspapers would be glad to continue to print articles
of this kind provided they were short, were on subjects
of general interest, and preferably, if possible, had some
local coloring.
Report of Business Committee. — Dr. Theron T. Sut-
phen of Newark reported for this committee, to which
the reports had been referred for consideration. The
committee approved the recommendations made by the
Committee on Tuberculosis in Childhood. The recom-
mendations of the Legislative Committee were referred
to the house for decisive action. After long discussion
it was decided to leave the matter of paying the ex-
penses of delegates sent to appear before the Legislature
to the county societies. The resolutions presented by
the Women's Christian Temperance Union asking that
the Society endorse resolutions calling attention to the
harmful effects of alcoholic beverages and to the grow-
ing disuse of alcohol as a therapeutic remedy by mem-
bers of the medical profession. This resolution was
then referred to the Committee on Public Health for
further consideration. With reference to the subject of
prize essays, the committee recommended that the Trus-
tees be empowered hereafter to choose a subject, since
no essay had been presented under the present way of
allowing anyone to choose his own subject. The House
of Delegates had been asked to endorse a resolution rec-
ommending the reporting of venereal diseases. In the
opinion of the committee this was a matter that should
be left to boards of health under present conditions.
The House of Delegates acted in accordance with the
suggestions of the Business Committee on these matters.
GENERAL SESSIONS.
Tuesday, June 20 — First Day
Invocation. — Rev. A. E. Ballard of Ocean Grove made
this invocation.
Address of Welcome. — Mayor C. E. F. Hetrick made
a brief address welcoming the Society to Asbury Park.
Indications for Surgery. — Dr. Edward J. Ill of New-
ark made this address. He said that a foreign surgeon
visiting this country had expressed his admiration of
the technical qualifications of American surgeons, but
regretted that about 50 per cent, of the cases were oper-
ated upon without indications. If the object of surgery
was to get rid of a diseased organ, or organs, or tissues
which gave the patient no inconvenience, if it was for
the purpose of getting a rare or interesting specimen,
if it was for the purpose of doing an operation, if it
was for an imaginary danger to the patient, or, though
one hesitated to say it, If it was for the exaction of a
fee. it should not be done. Operation should be consid-
ered only when it was necessary to save the patient
from a real or impending danger or to restore him to
health, that was, to remove certain symptoms which in-
capacitated him from enjoying life and which interfered
with his usefulness as a member of society. In the
former instance the indication was absolute; in the lat-
ter the choice should be left to the patient. Indications
for operations must never be based on laboratory or
x--ray findings, though these might be of incalculable
value as corroborative evidence. These were no longer
the days when one said the patient had recovered from
the operation ; the question now was "Will he be well
and free from symptoms?" With a good surgeon at
hand it might be well to err on the safe side and oper-
ate; with a poor surgeon it was better to take one's
chances with nature. Among the diseases calling for
prompt surgical interference were perforation of the in-
testinal, biliary, urinary tract, or intestinal obstruction.
The lower down in the intestinal tract the perforation
had taken place the more urgent the indication for oper-
ation. Nowhere was this more forcibly illustrated than
in cases of intussusception in children. No condition of
the kidney except fracture or wound called for immedi-
ate attention. Other operations on the kidney should
be done only after careful estimation of the functional
capacity of the kidney by laboratory methods. Delib-
erate and time taking consideration should precede all
stomach, intestinal, and intra-pelvic operations. The
essayist protested against the removal of ovaries con-
taining small cysts due to simple thickening of the
albugenia or simple adherent or displaced ovaries. All
ovarian neoplasms, however, he believed should be re-
moved. Fibroids of the uterus should be removed only
for good and sufficient reasons. In over five hundred
operations on fibroids he had never seen an instance of
malignant degeneration. Acute simple inflammatory
or suppurating diseases of the genital tract rarely
needed operation. Cesarean section in many instances
of abnormal labor had become the least mutilating and
the safest of any obstetrical operation. Labor should
never be induced before term for the convenience of the
patient, the nurse, or the doctor, but only with all the
indications and care of a major operation.
Education of the Nurse. — Dr. Gordon K. Dickinson
of Jersey City presented this paper, in which he stated
that an increasing number ..of well-educated young
women had entered the profession of nursing with the
result that they had idealized the profession, and as a
consequence the nursing profession had exerted an in-
fluence on hospitals, allied institutions, and legislatures.
Laws had been enacted which affected more or less
severely the source from which the nurses were ac-
quired. The work of the nurse in general practice was
uncertain, irregular, and sometimes very tiring; this
together with the high standard of educational require-
ment afforded the reason for the small number of girls
applying to the training schools. An investigation of
twenty-two hospital superintendents, seventeen physi-
cians, and seven nurses showed that the large majority
felt that the present demands were not exorbitant, that
they should be lived up to, and that the present condi-
tion did not warrant change. The time had come for
a reconsideration of the whole matter. The question
arose as to whether it was fair to the applicant who
came to the hospital to be trained to use her as much as
she was used for the convenience of the institution and
to neglect so largely the bedside training. Too often
the nurse's training was left to a subordinate nurse,
while those paid for that purpose were seldom seen at
the bedside. Gross errors were too often controlled by
severe discipline instead of being remedied by precept
and example. The essayist, in closing, requested that
the Society should appoint a committee to investigate
the methods of instruction and training in the training
schools of the State, the principles underlying hospital
training schools, to consult with the nurses who had
graduated and those who were in training, and to report
at the next annual meeting as to whether the nresent
method of training nurses was the most satisfactory, or
whether it would not be more wise to take the young
woman from the grammar school, give her two years
intensive training at the bedside, supplemented by book
instruction, and then with hospitals standardized, to in-
quire whether a diploma from such an institution would
not be sufficient without compelling a second examina-
tion at Trenton. It must be remembered that nurses
were needed for homes, and for physicians, and surgeons
in their general practice, and that preparation for
124
MEDICAL RECORD.
[July 15, 1916
higher positions might be left to a post-graduate course.
Dr. Edward J. Ill of Newark said he agreed with
much that Dr. Dickinson had said. The average life of
active service for a nurse was about ten years. If for
this ten years she spent three years of preparation in a
hospital one need not look long for the cause of the
diminishing supply. A nurse could learn all she need
know in two years. An instance had come to his atten-
tion in one institution where ten lectures were given the
nurses on the care of special accidents and eight on
scarlet fever. Dr. Ill thought he could tell a nurse all
she would need to know about scarlet fever in fifteen
minutes.
President's Address.— Dr. William J. Chandler of
South Orange delivered this address in which he re-
viewed the history of the Medical Society of the State
of New Jersey. He said, in part, that compared with
the zone of time since the crust of this sphere began
to harden or from the earliest signs of animal life, one
hundred and fifty years seemed like a mere point in the
cycle of time, but to us, living from day to day and
from year to year, it seemed quite venerable and in
this latter conception they had met to ce'.ebrate the
sesquicentennial of the Medical Society of the State of
New Jersey, the oldest medical society in this country.
Conditions of life in 1776, when New Jersey was a
province in the colonial possession of Great Britain,
were quite different from what they were to-day. The
geographical boundaries of New Jersey were at that
time coterminous with those of to-day. The early set-
tlers settled along the Hudson and Delaware rivers
while between these streams lay dense forests of the
oak and cypress so that communication between East
Jersey and West Jersey was difficult. There were also
essential differences in the characteristics of the people.
In the east the doctrine of John Calvin prevailed; in
the west the Quakers largely predominated. In those
days it took more days to make the journey from Phila-
delphia to New York than it took hours at the present
time. The physician of 1776 relied upon his horse and
saddle and took not the road but the trail through the
forest, fording rivers and streams, and thus travel was
only possible during daylight. Danger beset him from
bandits, horse thieves, and Indians. The country was
overrun with itinerant doctors, mountebanks, fakirs,
natural bonesetters, etc. French and English military
establishments brought with them educated physicians,
and young men of this country either studied with them
or went abroad to receive academic or medical training.
Many clergymen took medical courses so that they could
minister to the body as well as the spiritual needs of
the people. The first president of the society was the
Rev. Robert McKean of Amboy. He came to this coun-
try as a missionary from the Society for the Propaga-
tion of the Gospel in Foreign Parts. On his tombstone
was inscribed the following: "An unshaken friend, an
agreeable companion, a rational divine, a skillful physi-
cian, and in every relation of life an honest man." A
number of physicians devised a plan for bringing to-
gether all the physicians of the province into a society.
An advertisement asking them to assemble was placed
in the New York Mercury calling the meeting for June
'27, 1766, in New Brunswick. One of the early and im-
portant matters that came before the society was the
arrangement of a suitable fee bill for medical and sur-
gical services. Those fees were small in comparison
with the fees of the present day, but it was to be re-
membered money had a greater purchasing power
at that time and the doctor furnished medicine and
blisters, cups, bleeding, enemata, etc., for all of which
he charged extra. The fee for an ordinary visit was
one shilling sixpence, and about one shilling a mile for
mileage; above fifteen miles it was one shilling six-
pence per mile, and above twenty-five miles two shil-
lings. Consultations were fifteen shillings; phlebotomy,
one and sixpence; extracting a tooth, one and six-
pence; amputating an arm. three pounds; delivery in
natural labor, one pound and a half. In conformity
with the provisions of the constitution local or "infe-
rior" societies were at once established which were to
meet every two months and were to report their pro-
ceedings to the General Society at its semiannual meet-
ings. The second meeting of the society was held in
Elizabethtown, November 4, 1766. At this meeting Dr.
Kean reported a recipe given to him by Dr. Ayres of
Newport, R. I., of which the main ingredient was pow-
dered glass. In order to be effective this was to be ad-
ministered in quantities sufficient to cause violent pain
in the stomach and contractions of the extremities.
After discussing this remedy the consensus of opinion
was that they could not rely too much on this new rem-
edy until they knew something more about it. It was
not to be expected that a society having as its object
"the advancement of medical science, the elevation of
professional character, and the rendering of efficient
service to mankind" could be established in a community
full of professional jealousies and overrun with irregu-
lar practitioners without arousing antagonism. Con-
siderable opposition was encountered and the society
finally published its legal instruments in the lay papers
and explained its purposes. The fee bill was a constant
bone of contention and it was years before one was
evolved satisfactory to the members of the society. At
the third meeting of the society the subject of medical
education was taken up. The society agreed that for
the advantage of youth and the honor of the art of
medicine no man should be taken as an apprentice who
was not competent in Latin and did not have some
knowledge of Greek, and no man could take less than
four years preparation as an apprentice and one year
in some school of medicine in this country or abroad.
This work of raising the standard of medical education
had been going on ever since and allied with it had
been the labor of endeavoring to suppress quackery and
all forms of irregular practice. This work would be
continued until the laws of New Jersey were inferior to
none and applied alike to every practitioner of medicine
in this State with justice and equality. The meetings
of the society were interrupted during the Revolution-
ary War, not enough members having been left in their
homes to hold a meeting. They gave their services and
their lives freely for their country at that time. Meet-
ings were convened in 1781 and in 1783 application was
made for a charter of incorporation or such other act
as might seem proper to regulate and restrain the prac-
tice of medicine and surgery in the State. There seemed
to have been some difficulty in getting what they wanted
for the charter was not issued until 1793, fifty-two
names appearing as incorporators. This charter ex-
pired by limitations in 1815. The new charter obtained
in 1816 provided for the establishment of a district so-
ciety in every county and placed the control of the State
society under the control of fifteen managers. This
arrangement was not satisfactory and in 1818 a sup-
plement was passed making the State society to be
composed of four delegates from each of the district
societies. The officers of the State society were ex-officio
members and the ex-presidents were ranked as fellows
and given the rights and privileges of delegated mem-
bers. The society was conducted on practically the
same basis to-day. The American Medical Association
found practically nothing to change in the charter and
only a few changes in the phrasing of the constitution
and by-laws of the society in order to make them con-
form to their models for State societies. In 1820 the
society established a standing committee which did the
work of the present committee on scientific work, the
judicial council, the committee on publication, and a
large part of the work assigned to the board of trustees.
The power of examining candidates for medical prac-
tice and the conferring of the degree of doctor of medi-
cine was given to the society in 1816. For many years
candidates were examined and licensed to practice medi-
cine by the society. This power as still vested in the
society through the State Board of Medical Examiners
did the work. Some of the examination papers were
still available and showed that certain applicants even
in those days did not come up to the standard set. Of
this the following was an example: Question — "What
do you mean by an hour-glass contraction?" Graduate,
embarrassed and slow in answering, so the examiner
asked: "What would you do in a case of hour-glass con-
traction?" Answer — "I would pass a wire." The fol-
lowing was another example: Que.it ion — "What causes
the secretion from the bronchial tubes?" Embarrassed
student did not answer. Question — "What do you mean
by expectoration?" Answer — "I can't exactly tell."
Question — "What would you prescribe as an expecto-
tant?" Answer — "James' expectorant; it always works
well." Question — "What are the constituents of James'
expectorant?" Answer — "I do not know; he won't tell."
These applicants were not granted a degree. Of the
recent changes in the constitution and by-laws of the
society two were worthy of passing attention, the estab-
lishment of permanent delegates and the enrollment of
all active members of county societies as associate dele-
gates of the State society. This plan had worked
greatly to the advantage of both the State and the
county societies. Dr. Chandler said he regretted that
time would not permit him to review all the activities
July 15, 1916]
MEDICAL RECORD.
125
which the society had engaged in for the benefit of the
medical profession and for the state at large, such as
the institution of insane asylums, founding a relief fund
for physicians, prize essays, the State Journal, etc.
Oration in Surgery. — Professor John G. Clarke of
Philadelphia delivered this address which he prefaced
with a quotation from Samuel Sharpe's treatise on "The
Operations of Surgery," published in 1758. He said
with reference to the removal of the breast for cancer :
"The success of the operation is exceedingly precarious
from the great disposition there is in the constitution
after an amputation to form a new cancer in the wound,
or in some other part of the body. When a scirrhus
had admitted a long relay before operation the patient
seems to have a better prospect of cure without danger
of relapse than when it has increased very fast and
with acute pain." When it was realized that it had
been one hundred and fifty years since these lines had
been printed and took into consideration the widespread
skepticism as to the benefits accruing from the surgical
extirpation of cancerous growths among many physi-
cians and laymen, one realized most vividly that small
progress had been made in the great majority of cases.
Little was known of the exact etiology of cancer. Noth-
ing thus far had been accomplished in preventing it and
each decade witnessed a steady increase. Each year
the number of deaths from cancer in the United States
approximated 75,000 and in the civilized world 500,000.
All we had to pin our hope on at the present time was
the motto of the American Society for the Prevention of
Cancer. "In the early recognition and treatment of can-
cer lies the only hope of cure." The layman must be
taught that cancerous growths in no part of the body
were painful in the earlier stages and therefore a lump
in the breast or abdomen, a small ulcer on the tip of the
tongue, or cheek, or on the cervix, was the one condi-
tion which should have immediate attention on the part
of a competent physician. Any ulcer that did not heal
had cancer potentialities. Usually when the patient
was stricken with cancer of so advanced degree that
there was persistent pain, and when emaciation and a
bad sallow color were present, she had passed the possi-
bility of cure. Two fallacies of former years had been
cast into the waste basket; first, that cancer was a gen-
eral blood disease, and second, that it was of hereditary
origin. Agnew, in what proved to be his valedictory
address- (for he died a few months later) given before
the speaker's class of the University of Pennsylvania
twenty-five years ago, said he could not count one sin-
gle cure following the removal of the breast in his many
years of surgical practice. Since that time methods had
so far improved that skillful surgeons of the present
era confidently count 30 to 50 per cent, of permanent
cures from thorough removal of the disease by radical
operation. So long as the theories of former days were
held the surgeon could soothe his feelings of profes-
sional inadequacy by the theory of incurability. That
day had passed and soon the laity would hold the physi-
cian to as strict accountability who allowed a patient to
drift beyond the safety zone in cancer as they did now
when the agonizing pain of appendicitis was falsely
diagnosed as acute indigestion or ptomaine poisoning.
The essayist stated that in his twenty years' experience
he had found nothing to convince him that cancer had
an hereditary tendency. A study of all the combined
statistics showed that cancer was a disease of middle
life, occurring between forty and fifty years of age, and
therefore women in the critical period of their lives
should be especially alert to bring to the attention of
their physicians any decided change in the way of ex-
cess. Childs of England had well pointed out the dan-
ger signals of cancer. (1) A small lump or thickening
of any kind in a woman over thirty-five years of age
was a starting point of cancer in 90 per cent, of the
cases and the finding of a lump in the breast should be
followed by its immediate removal. (2) The danger
signal in cancer of the uterus was irregular bleeding,
especially after the menopause. (3) The danger signal
in cancer of the lip, mouth, or tongue, or skin was a
wart or sore that would not heal. (4) In cancer of the
stomach and intestines the danger signal was not so
apparent; obstinate, persistent diarrhea, vomiting or
the passage of blood were danger signals that should be
heeded at once. In speaking of cancer of the uterus.
Dr. Clarke said that in less than two years he had
treated forty-nine cases of inoperable cancer of the
uterus with radium and during the same period only
twelve cases had been considered as within the radical
operative limit. During the preceding ten years about
sixty radical operations were performed. Although
radical operation had given the best ultimate statistics
the primary death rate was unavoidably high and seri-
ous operative sequelae occurred. The essayist said they
had abandoned extensive glandular dissections because
they added to the hazards and did not increase the per-
manent cures. There was no middle road in cancer of
the cervix; the surgeon had better perforin a simple
vaginal hysterectomy or a high amputation of the
cervix with extensive cauterization than to attempt the
radical operation if he was not prepared to execute de-
tails. If the growth had invaded the parametrium to a
point beyond the outer limits of the ui-eters or if it had
found lodgment in the iliac glands the case must, with
rare exceptions, be regarded as hopeless so far as surgi-
cal extirpation was concerned. In cancer confined to
the fundus, recurrence did not take place in more than
50 per cent, of the cases while in cancer of the cervix
in only about 30 per cent, of the cases was there no re-
currence. The crux of the matter was that surgery
should be attempted only in clearly operable cases, leav-
ing the large remainder to secure relief from therapeu-
tic efforts. Radium offered the most hopeful outlook of
any remedy thus far presented in the palliative and
even the curative treatment of the borderline and in-
operable cases. In the gynecological clinic of the Uni-
versity of Pennsylvania during the past two years forty-
four cases of carcinoma of the uterus, vagina, and ure-
thra had been treated. These cases were practically all
classed as inoperable. From 85 to 100 grams of radium
were applied in a platinum capsule shielded by rubber
for twenty-four hours; this was repeated at the end of
six weeks. The results of too intensive treatment with
radium had in some instances been even worse than the
disease itself. In this series, with the excepttion of two
cases, there had been no disagreeable effects. They had
adhered to the rule never to attempt to operate in any
case that had been healed by radium. Radium as shown
by this series of cases was by no means u universal
panacea for cancer, even when the growth was strictly
localized. In operative cases the average stay in the
hospital was three weeks, while for the application of
radium not more than three days was required. Dr.
Clarke discussed the Percy method of treating cancer of
the cervix and expressed the opinion that the results
fell far short of those obtained by the use of radium.
Removal of the uterus in cases of cancer of the fundus
had yielded such good results that taking chances with
radium was not justified in these cases. His attitude
toward cervical cancer was just the opposite. In the
borderline cases of cancer of the cervix they employed
radium. Dr. Clarke illustrated his paper by lantern
slides.
(To be concluded.)
COLLEGE OF PHYSICIANS OF PHILADELPHIA.
Stated Meeting, Held Wednesday, April 5, 1916.
Dr. J. William Taylor, Vice-President, in the Chair.
Dr. A. C. Abbott read a Memoir of the late Surgeon-
General Sternberg.
A New "Muscle Substitution" Operation for Congen-
ital Palpebral Ptosis. — Dr. John B. Roberts presented
this contribution from the Surgical Laboratory of the
Philadelphia Polyclinic. In November, 1914, a three-
year-old girl had been sent to him by Dr. H. A. Stout
of Wenonah, N. J., for operative treatment of very
marked double ptosis and a moderate degree of epi-
canthus of both eyes. The child had been taken previ-
ously to an ophthalmic hospital but no operation had
been performed. Because of the generally unsatisfac-
tory results in operation for ptosis Dr. Roberts devised
an operation which he had suggested in 1912 based on
the myoplastic methods used in traumatic and ortho-
pedic muscular deficiencies. Believing it best, however,
to try at first one of the already recognized ophthalmic
procedures the Tansley method was followed in an
operation upon both eyes. Following this the child
couM uncover the eyeball so that in the right eye about
one-half the cornea was visible. The left eye was not
so satisfactory in result, although the lid could be
lifted somewhat better than before the operation. In
March of this year the child was returned for further
treatment. It was determined upon the present oc-
casion to lessen the epicanthus by an arrowhead-shaped
excision of skin and superficial fascia by Berger's
method to get rid of the deformity at the inner canthus
of the eye, and to try the author's previously devised
"muscle substitution" method which he had employed
126
MEDICAL RECORD.
[July 15, 1916
only upon the cadaver, to -elieve the ptosis of the left
upper eyelid. The left eyeb-ow was shaved and an in-
cision carried from the root of the nose along the super-
ciliary ridge almost to the external angle of the frontal
bone. From the nasal extremity of this cut a vertical
incision was made through the tissue of the forehead
almost to the hair line. The flap was turned upward
and outward so as to expose the occipitofrontal muscle
and tendon. Just beneath the upper orbital margin an
incision down to the fascia of the upper lid was made
from the nasal to the temporal side following the curve
of the bone. The skin flap was turned downward and
the tarsal plate exposed and its upper edge identified. A
tunnel was then cut beneath the soft tissues about half
an inch in width extending under the orbicular muscle
to the incision made through the shaved eyebrow. From
the muscular belly of the occipitofrontal muscle, im-
mediately about the tunnel opening, was cut a strip of
muscular fibers about a third of an inch wide and an
inch and a quarter long. The parallel incisions, making
this strip, diverged a little at their upper ends so as to
make the muscular band wider near its upper ex-
tremity. A cross incision was made at the upper end
converting the strip into a long flap. This flap was
turned downward, thrust through the tunnel, and at-
tached to and upon the upper edge of the tarsal plate
by three silk sutures. The two corner sutures were put
in as mattress stitches and held the flap on top of it —
that is, superficially to the tarsal fibrous plate. Re-
turning to the frontal region, the operator cut on each
side of the turned down flap two strips of muscle, each
half the width of the inverted flap, having their at-
tachment to the muscle above. These were drawn to-
ward the fold of the inverted flap, attached to it on its
superficial surface, which formerly had been the under
surface, by a mattress suture at each edge, and were
united in the middle line by a third suture, also put
through the turned over portion of flap so as to make a
mattress suture. An additional suture was inserted at
one edge where the first flap was bent over to keep it
thus folded. The skin and superficial flap of the fore-
head were then replaced and sutured in position by
worm gut sutures. The result of the operation was
sxcellent, although the time has been but four weeks.
Subsequently the Berger operation with arrowhead ex-
cision on each side will be performed for the epicanthus.
The sutures were so placed as to lift a little the canthus
of each eye. The wound all healed by first intention.
In addition to the ability to raise the eyelid a satisfac-
tory result of the operation was the making of a normal
furrow in the lid at the seat of the upper edge of the
tarsal plate. It was suggested that if the incision
through the eyebrow to that at the middle line of the
forehead for any reason seemed to be undesirable, the
flap might be turned outward and downward instead
of outward and upward by making the horizontal in-
cision within the hair line instead of in the eyebrow.
Birth Traumatisms of the Upper Extremity; The
So-called Birth Palsies. — Dr. G. G. Davis in this paper
stated that until comparatively recently injuries of the
upper extremity, commonly called birth palsies, had
been regarded by him as true nerve paralyses. Even
at the present time the pathology of the injuries and
their treatment were perhaps not definitely settled, al-
though much had been accomplished. To his mind the
greatest advance had been made by Dr. T. Turner
Thomas, who, while not denying the occasional ex-
istence of distinct nerve lesions, had claimed that the
main element of the lesion was articular, and to be
treated by operative means. Dr. Davis had long been
convinced that the essential element was an articular
lesion and that the most successful treatment must be
based upon this fact. He was not yet convinced, how-
ever, that the luxation described by Duchenne, treated
by manipulation by Whitman, and operation reduction
by Thomas, was the essential lesion of disability.
While treatment of the luxation had been of value, he
attributed the improvement in function to the changes
produced in the soft parts by the operation. From his
experience he believed that the condition consisted usu-
ally of lesions of the nerves, muscles, and ligaments
about the affected parts, the extent and character of
which varied with the mode of production of the origi-
nal injury and the length of time after birth that the
patient came under observation. Operations upon the
brachial plexus have shown that absolute rupture of
some of the nerves did take place, although rarely. The
paralytic symptoms observed were usually due not to
a rupture, but to a contusion or stretching of the nerves,
under which circumstances the probability of recovery
was excellent. There was too often the tendency in a
young infant to consider the nerve lesion the prominent
factor, when the quietude of the arm was due almost
or quite entirely to the articular lesion, the remaining
disability after healing of the contused nerves, was due
to the cicatricial and damaged condition of the articular
structures. This fact, unfortunately, was not generally
recognized and the necessity of treating the condition
was consequently ignored and a crippled arm might re-
main through life. In treatment obviously efforts
should be made at the earliest possible moment. Delay
in operative treatment in the very young, because of
the problem of nourishment, might have no effect upon
the nerve lesions but was decidedly harmful to the
articular lesions. The essential part of treatment was
said to be first to stretch or manipulate the parts that
they might be placed in their normal positions by
passive motion, with restoration of muscular power by
training and exercise. Operative measures which might
later become necessary because of fibrous obstructions
and continued abnormal position of the limb would, of
course, vary with individual cases. The good results
following operation upon so-called luxations in these
cases Dr. Davis attributed to the free division of the
restraining tissues and the placing of the parts in bet-
ter position and not to replacement of the head of the
humerus. To his mind, conditions which had been
termed luxations were rather sub-luxations, and the
malposition in itself seemed scarcely of sufficient extent
to account for the disability or to justify the expecta-
tion of much functional improvement by its correction.
For the restricted motions in the shoulder joint, those
of abduction and external rotation the operation em-
ployed by Dr. Davis was described and in the few cases
in which he has used it marked improvement was
obtained. He regards it as neither crippling nor
dangerous. Operation upon the elbow for increasing
flexion or extension was not regarded as advisable. In
one patient aged about twenty, in whom supination
was impossible, an incision was made over the middle
of the radius and the insertion of the tendon divided.
This allowed an additional degree of supination but
not enough, and another incision was then made over
the head of the radius, the external lateral and orbicu-
lar ligaments divided and the tissues detached for a
short distance down the inner side of the neck and
shaft. Upon supinating the hand, the head of the radius
rose directly out of its bed and projected forward.
Apparently the radius in its growth had become twisted
so that when supination was performed the head was
thrust forward. Therefore, the head and neck were re-
moved nearly or quite down to the insertion of the
biceps muscle at the radial tubercle. Dr. Davis urged
the use of the greatest care in this procedure not to
wound the posterior interosseous nerve. After closure
of the wounds the forearm was dressed on a splint
with the hand in extreme supination. In the one case
in which the author had done this operation the results
were extremely satisfactory. Attention was called to
the possible prevention of many cases of injuries at
birth and to the responsibility of the attendant:
further, that the profession, since these injuries and
their treatment are better understood, should cease to
ignore them, and see that they receive efficient treat-
mnt.
Dr. T. Turner Thomas, remarking upon the etiology
of birth palsies, said that it had been but a few years
since there was hut the one view that they were due
to injuries of the brachial plexus; to-day many believed
them due to injuries of the skeleton; thus was the
profession reverting to the position of Duchenne in
the beginning of his work upon this subject.
Dr. A. P. C. Asmn BST, relative to the frequency of
the condition, said that in addition to the cases seen
with Dr. Davis in his clinic, he had within the last two
or three years nearly forty cases under his care. Of
this number a large proportion had been shoulder dis-
locations. It was the dislocation of the shoulder to
which Dr. T. T. Thomas called particular attention
which had first aroused Dr. Ashhurst's interest in these
conditions and given a clue to the best means of their
treatment. In a child of three months in whom a pos-
terior dislocation was confirmed by .v-ray treatment was
instituted as would be indicated in the same condition
in the hip. Reduction was done under ether, and the
shoulder held in a plaster dressing in abduction and
external rotation. Dislocations, however, were not the
only lesions occurring, and the dispute at present was
whether the dislocation was caused by the original
injury at birth, or followed a traumatic paralysis of
July 15, 1916J
MEDICAL RECORD.
127
the shoulder muscles. Up to three years of age Dr.
Ashhurst had secured permanent reduction without
open operation, but in cases over this age recurrence
had followed bloodless reduction. In none of the live
cases in which he had operated by bloody reduction had
dislocation recurred. In all he had used the approach
to the shoulder joint described by Kocher with Senn's
modification of the skin incision. In Dr. Ashhurst's
opinion, if patients were treated from the time of
birth, as emphasized by Dr. Davis and in the way he
advised, most would recover with little permanent dis-
ability; that in a few of these cases at a later period,
and in almost all seen for the first time a number of
months after birth (especially if dislocation of the
shoulder were present) it would be necessary to treat
the upper extremity in plaster of Paris in abduction
and external rotation for a period of not less than three
months; that dislocation should be reduced, if necessary
under anesthesia, as soon as practicable after its recog-
nition;, that in patients over three years of age, blood-
less reposition seldom would be permanently success-
ful; that operative treatment must secure anatomical
reposition of the humerus in the glenoid, with restora-
tion of free external rotation and abduction, which
should be maintained by fixed dressings for a period of
not less than three months; that in the vast majority
of cases nerve lesions were insignificant, requiring no
special treatment.
Dr. Davis, in closing, observed that while at the
present the matter of pathology and treatment was un-
settled much could be done for the improvement of
cases. In spite of the fact that some of his cases
exhibited were not brilliant from a demonstrative stand-
point, from a utilitarian standpoint they were well
worth the time and effort expended upon them.
The Use of the Karell Cure in the Treatment of
Cardiac, Renal, and Hepatic Dropsies. — Dr. Edward
Harris Goodman regarded drugs, physical therapeutics,
and diet in the treatment of these conditions as the
triad upon which reliance was usually placed, and be-
lieved that, generally speaking, in the lay as well as
in the professional mind, the greatest of these was
drugs. In many dropsical cases all three agents were
indicated; in many, physical measures might be safely
dispensed with ; and, in very many cases of severe
renal and cardiac breakdown, drugs as well as physical
measures might be disregarded. There were no cases,
however, in which diet had not earned a well-deserved
fixed place. The majority of cardiac dropsies and a
large proportion of dropsies of renal origin he believed
would improve under rest in bed and an appropriate
diet. The diet which had served him best, and which
he had employed successfully for the past seven years,
was that known as the Karell diet or Karell cure.
Although half a century had elapsed since Karell had
published his paper, this diet seemed to be but little
known and but rarely used. Under the technique of
the treatment the patient should receive daily at 8.
12? 4, and 8, 200 c.c. of raw or boiled milk, warm or
cold, and no other food. Thirst formed the greatest
cause of complaint during the first three or four days,
and it might be necessary to allow the patient to rinse
out his mouth with water. If hunger were urgent a
small piece of toast or zwieback might be given with
each portion of milk. The rapid loss of weight en-
couraged the patient to persist with the treatment
Continuance of the diet depended upon the diminution
of edema and the patient's plea for more food. Usually
the diet might be increased at the end of a week by
giving a soft boiled egg (without salt or pepper) at
10 a.m. and a piece of zwieback at 6 p.m.; the next day,
an egg at 10 a.m. and at 2 p.m. with a piece of white
bread. Following this the food should be increased
gradually to a full diet. Such "full diet," however,
was a misnomer, since it should be salt poor and com-
prised of selected foods. Until the patient received
the full diet the daily amount of liquid (which should
be milk) must not exceed 800 c.c. Entering upon the
full diet cocoa, or tea might be substituted for the
milk, limited to the same amount, however; such limi-
tation was to be continued for from two to four
works after the disappearance of edema. During the
treatment the patient should be in bed. The bowels
should be kept open; preferably by laxatives in pill
form, since no water was required for their adminis-
tration. Improvement should be noted at the end of
three days. If this did not cure, drugs and other
measures were indicated. Twelve illustrative cases
of the effect of the Karell cure in edema were reported.
The first three charts showed only loss of weight; the
fourth, a rapid increase of diuresis, then a decrease
indicating the need of other therapeutic measures; the
fifth and sixth, loss of weight and increase of diuresis
amounting to 531 ounces in four days with unusually
rapid loss of weight; the eighth, the effect of the milk
diet in hepatic cirrhosis; ninth, the failure of the cure;
tenth, lowering of blood pressure, systolic and diastolic;
the eleventh, retention of chlorids on a salt poor diet,
with prompt elimination of chlorids and increased
diuresis on Karell cure plus caffein and hot packs;
twelfth, curves of body weight, chlorids and urine.
The minimum amount of work given to the human or-
ganism was regarded by Dr. Goodman as the most
important feature of the Karell cure. The good effects
were seen by the patient almost before being noted
by the physician, and these effects were the reward of
strict observance of the cure, viz: the taking of only
200 c.c. of milk at 8, 12, 4, and 8, the purpose of the
treatment being immediately defeated were the milk
taken at the pleasure of the patient, or in larger
quantity. While an attempt had been to ascribe the
benefits following the Karell cure to reduction in the
amount of fluid, the minimum of salt contained in the
milk, and to the melting of body protein, it would seem
more probable to the author that several problems were
involved: (1) Absolute rest in bed; (2) the tow
amount of fluid and food which also limited cardiac
effort; (3) the low amount of sodium chloride; (4) a.
combination of the salt-poor diet and the low amount
of fluid. To whatever factors the results were due, in
dropsical conditions of renal, cardiac, and perhaps
hepatic origin, the Karell milk diet given as taught
by Karell was in Dr. Goodman's opinion the diet par
excellence. While in the majority of cases drugs in
combination with the Karell cure would be found un-
necessary, in marked dyspnea, cyanosis, frequent and
irregular pulse, such drugs as camphor, digitalis,
strophanthus, caffeine, and morphine were indicated
in emergencies. In the prognostic significance of the
Karell cure a positive chloride balance was of un-
favorable import. The. treatment was regarded as
contraindicated in the presence of symptoms of uremia
since it had been shown by Senator and others that in
such crisis the fluid intake should be greatly augmented
to eliminate the toxic substance causative of uremia.
Dr. James Tyson recalled that fact that some of the
early work of Dr. S. Weir Mitchell included the use of
the Karell diet, which possibly was also the foundation
of his little book on "Fat and Blood." In 1884 Dr.
Tyson had read a paper on "The Milk Treatment of
Disease."
Dr. James M. Anders observed that the Karell cure
was much more used abroad than in America. In the
opinion of His the cure was not only effective in renal
and cardiac dropsy, but alleviated the disturbance in
breathing and other distressing symptoms not depend-
ent upon the edema present in many of these cases. Dr.
Anders agreed with other authors upon the value of
the treatment before actual decompensation had taken
place; for example, in cases of aortic valvular disease
showing simply premonitory symptoms, associated per-
haps with a mild grade of arteriosclerosis. After posi-
tive involvement of the kidneys and the presence of
uremia it would be altogether contraindicated. Dr.
Anders did not advocate the use of the treatment in
valvular disease with dropsy in which the kidneys were
intact, but in all such cases felt there should be al-
lowed more food of a higher caloric value with aid to
elimination by other means such as rest, cardiac stimu-
lants, etc. It seemed to him that the use of iron could
be utilized to advantage in connection with the Karell
cure, particularly in the lengthened periods of its em-
ployment recommended by Dr. Goodman. Following
the recommendation of His, Dr. Anders' custom had
been to give 1,000 c.c. for five or six days at intervals.
He hoped that Dr. Goodman's paper would bring this
subject to the attention of the profession.
Dr. Clifford B. Farr remarked that one of the
chief theoretical objections to the treatment was the
insufficiency of the diet even for a patient in bed, and
suggested the possible advantage of the addition of
sugar of milk or cream to the measured amount of
milk. This would bring the nutritive value more nearly
to the proper level and add nothing to the amount of
fluid or chlorides.
Dr. Goodman in closing said that some food was
given after three to six days, during those days, how-
ever, the diet was limited to 800 c.c. of liquid in the
form, preferably, of milk. He thought the addition of
cream or sugar of milk would be of advantage.
128
MEDICAL RECORD.
[July 15. 1916
STATE BOARD EXAMINATION QUESTIONS.
State Medical Board of the Arkansas
Medical Society.
November 9 and 10, 1915.
(Concluded from page 4(i.)
bacteriology.
1. (a) Give method of blood staining, (b) What is
the normal blood count, and how is it affected by dis-
ease?
2. (a) What is the value of Widal's test for typhoid
fever? (b) At what stage of the fever is it most re-
liable?
3. What general conditions predispose to bacterial in-
fections?
4. (a) Give general method of procedure for staining
bacteria, (b) What are counterstains?
5. (a) What is the most effective method of steriliza-
tion? (b) How are culture mediums sterilized?
6. (a) Describe in detail the process of finding tu-
bercle bacilli in the urine, (b) Give method of de-
termining the location of the infection. (c) From
what other bacilli would you have to differentiate them?
7. Name some of the diseases of which the pneumo-
cocci may be the chief etiologic factor.
8. What culture-medium is essential in the growth of
the organisms producing the following diseases: Cere-
brospinal meningitis, gonorrhea, and diphtheria?
9. Mention five general or systemic diseases produced
by microorganisms, and in connection with each give
name and chief morphologic characteristic of organisms
concerned.
10. What is the cause of difference in the virulence
of diphtheria?
practice.
1. Name four types of malarial infection, and give
treatment of remittent fever.
2. Give the etiology and treatment of acute tonsillitis.
3. Give the treatment for habitual constipation.
4. Differentiate between pleurisy with effusion and
acute lobar pneumonia, giving treatment of the latter.
5. Give the treatment of facial erysipelas.
6. How would you make an early diagnosis of tubercu-
losis?
7. Give the treatment of ophthalmia neonatorum.
8. Give the treatment of convulsions caused by ne-
phritis.
9. Give the medical treatment of ulcer of the stomach.
10. Give the symptoms and treatment of pellagra.
obstetrics.
1. Into what stages is labor divided, and where do
these stages begin and end?
2. Give diagnosis and management of a breech pres-
entation. What are the dangers?
3. Give indications for the use of forceps, internal
podalic version, and cesarean section.
4. What are the causes of hyperemesis gravidarum,
and the clinical features and the treatment of the con-
dition?
6. What is placenta prsevia? Name its causes, va-
rieties, symptoms, dangers, and treatment.
6. Eclampsia: etiology, premonitory symptoms, and
treatment?
7. Describe the delivery of the placenta after the
method of Crede.
8. Give two indications for the induction of prema-
ture labor, and describe one method of performing it.
9. What are the symptoms of inevitable abortion, and
how should a case be managed?
10. How would you manage a case of primary post-
partum hemorrhage?
gynecology.
1. (a) Name two causes of sterility in the male,
(b) Name three of sterility in the female.
2. Name the objective signs of extrauterine preg-
nancy.
3. Name two most common causes of dysmenorrhea.
4. What symptoms of cystitis are first noted?
5. Name the indications for the use of uterine tam-
pons following abortion.
6. Name three varieties of fibroids of the uterus.
7. Name three etiologic factors in acute endometritis.
8. Give treatment for inoperable carcinoma of cervix.
9. Would you remove in toto an ovary with a small
cyst?
10. What are the objections to ventral fixation of
uterus?
SURGERY.
1. Define inflammation, septicemia, and pyemia.
What organs are most prone to pyemia?
2. What general term denotes control of hemorrhage?
State all the methods which may be used to stop the flow
of blood from a wound.
3. What would be the proper treatment for backward
dislocations of the femur at knee, with rupture of the
popliteal artery?
4. Give causes, symptoms, diagnosis, and treatment
for acute suppurative osteomyelitis.
5. Define shock, and state how you would treat same.
6. If called to a patient with a compound fracture of
leg in lower third which had been produced by kick of
horse in a barnyard, state in detail how you would
treat such case. .
7. Define ankylosis; give varieties; also describe a
surgical method for restoration of joint function in case
of bony ankylosis of the knee joint.
8. Give points of differential diagnosis between py-
loric (or duodenal ulcer) and cholecystitis.
9. Give varieties of ileus, and state some of the causes
of each.
10. Give symptoms, diagnosis, and treatment of stone
in ureter.
HYGIENE.
1. Name four points in personal hygiene to prevent
acquiring or imparting tuberculosis.
2. Name some special precautions a child should ob-
serve at school in order to avoid contracting disease.
3. What is the hygiene of pregnancy, and what- ad-
vice would you give a pregnant woman from a hygienic
standpoint?
4. Give prophylaxis of filth diseases.
5. What are the dangers from (a) the house fly?
(b) The mosquito? (c) How would you exterminate
them from a community?
6. (a) Name the chief sources of contamination of
drinking water, (b) Give several methods of purifying
drinking water.
7. Name some diseases that are communicated to man
through cow's milk.
8. (a) Name all diseases due to microorganisms,
(b) Methods of transmission.
9. What hygienic precautions should be employed
around a patient with scarlet fever and diphtheria?
10. What necessarv precautions should be taken to
insure healthy sleep?
ANSWERS.
BACTERIOLOGY.
1. The film is properly made and fixed. It is then
stained for five minutes with 0.5 per cent, alcoholic
solution of eosin diluted with water; it is then rinsed
in water, and dried with filter paper; it is then stained
for half a minute with a saturated aqueous solution of
methylene blue; and again it is rinsed and dried, and
then mounted. The normal blood count is about 5,000,-
000 red corpuscles to the cubic millimeter, in women the
number is about 4,500,000. The colorless corpuscles are
about 6,000 to 10,000 to the cubic millimeter. The red
corpuscles may be increased in: Chronic heart dis-
ease, with cyanosis; and in conditions in which the
blood is concentrated owing to a severe watery diarrhea.
The red corpuscles are decreased in : Anemia (particu-
larly pernicious anemia) and leucocythemia. The color-
less corpuscles are increased in: Leucocythemia, leuco-
cytosis (due to inflammation, suppuration, toxins, etc.).
The colorless corpuscles are decreased in conditions of
starvation and malnutrition, and sometimes in perni-
cious anemia.
2. The diagnostic value of the Widal reaction is be-
lieved by some to be great; others place little reliance
on it. It may be absent in cases of typhoid fever;
it may be present for several months after an attack
of typhoid; the reaction may not be obtained till the
third week of the disease; it may be present in other
diseases or in perfectly healthy persons. The above
have all been urged as objections; certainly only posi-
tive results have any value at all. Enthusiastic advo-
cates of it have asserted that it is present in over 95
per cent, of all cases of typhoid. It is probably most
reliable during the second week of the disease.
July 15, 1916]
MEDICAL RECORD.
129
3. Conditions which predispose to bacteria! infection:
The bacteria must be sufficiently virulent, must enter in
sufficient numbers and by the appropriate avenue, and
the host must be susceptible to their action. The latter
condition is aided by anything which depresses or
diminishes the general physiological activity of the host,
such as depressing hygienic conditions, old age, weak-
ness, extreme youth, fatigue, disease, exposure to cold,
insufficient diet, intoxications of all kinds, the inhala-
tion of harmful vapors, and traumatism.
4. General method of staining bacteria: "Nearly all
the known bacteria are readily stained by the watery
solutions of any of the basic anilin dyes. The film
on the slide or cover-glass, properly prepared, is cov-
ered by a few drops of the stain, or the cover glass,
film-side down, is floated in a watch-glass full of the
staining solution ; at the end of from one-half to two
or three minutes the staining fluid is poured off, the
slide or cover-glass washed rapidly in water and then
allowed to air-dry; after which, in the case of cover-
glass preparations, they are inverted upon a drop of
Canada balsam on a slide and examined with the oil-
immersion lens; or, when slides have been prepared,
after washing and drying a drop of cedar oil is put over
the preparation, and the same is examined with the
oil immersion objective, without the use of a cover-
glass." — (Archinard's Bacteriology.)
A eounterstain is a stain used to bring into contrast
bacteria or parts of tissues colored by another stain.
5. Heat is the best sterilizer; hot air or steam may be
employed. Culture media are sterilized by steam in an
autoclave, at a temperature of 110° C, at 6 pounds
pressure, for half an hour. If an Arnold sterilizer is
used the intermittent plan must be adopted, otherwise
the spores will not be destroyed.
6. To find tubercle bacilli in the urine: "Withdraw
the urine by a sterile catheter into a sterile conical
urine glass. The urine so withdrawn is allowed to
stand until the sediment collects. The supernatant fluid
is poured off and the sediment is centrifuged. The
supernatant fluid is poured out of the centrifuge tube,
the tube filled with distilled water that is free from
tubercle bacilli, shaken so as to wash out the urinary
salts, which interfere with the staining, and centrifuged
again. This process is repeated once or twice. The
sediment remaining after the third centrifugation is
smeared on clean glass slides and allowed to dry in
the air. The smears are fixed by passing three times
through the flame, and then stained for five minutes
with warm carbolfuchsin, washed in water, submitted
to the action of the acid-alcohol solution for one min-
ute, washed in water, counterstained with Loffler's alka-
line methylene-blue for thirty seconds, dried, and ex-
amined under a 1/12 inch oil immersion objective. If
acid-fast bacilli are found by this method, a second
smear should be decolorized in the acid solution over-
night, washed in water, and counterstained in the
Loffler's alkaline methylene-blue in order to be sure that
they are not smegma bacilli. Urine obtained by the
catheterization of the ureters may be treated in the
same way." — (Anders and Boston's Medical Diagnosis.)
If tubercule bacilli are only found after ureteral
catheterization, the lesion is not in the bladder, but in
ureter or kidney. The eystoscope may show lesions in
bladder or urethra. The tubercle bacilli must be differ-
entiated from the smegma and leprosy bacilli.
7. Pneumococci may cause pneumonia; they may be
found associated with other microorganisms in diph-
theria, tonsilitis, otitis media, endocarditis, lobular
pneumonia, pericarditis, meningitis, arthritis, osteo-
myelitis, and conjunctivitis.
8. Cerebrospinal meningitis is caused by the Diplo-
coccus intracellul-aris meningitidis; it grows well on
blood serum, ascitic fluid, and culture media containing
meat infusion.
Gonorrhea is caused by the Diplococcus gonorrhx; it
grows on blood serum, or mixtures of meat infusion
agar with blood serum or hydrocele or ascitic fluid.
Diphtheria is caused by the Bacillus diphtheria"; it
grows upon blood serum and meat infusions.
9. Typhoid fever is caused by the Bacillus typhosus
of Eberth. This organism is rod shaped, with rounded
ends, is from 2 to 4 mikrons in length, and about three-
fourths of a mikron in breadth; it does not stain by
Gram's method, but stains with all the anilin dyes; it
has flagella, no spores, is aerobic and facultative an-
aerobic, and is motile.
The characteristics of the bacillus of diphtheria : The
bacilli are from 2 to 6 mikrons in length and from 0.2
to 1.0 mikron in breadth; are slightly curved, and often
have clubbed and rounded ends; occur either singly or
in pairs, or in irregular groups, but do not form chains;
they have no flagella, are non-motile, and aerobic; they
are noted for their pleomorphism ; they do not stain
uniformly, but stain well by Gram's method and very
beautifully with Loffler's alkaline-methylene blue.
The cause of syphilis is the Treponema pallidum. It
is a very slender spiral, about 4 to 20 mikrons in length,
with very close and regular turns, the curves vary in
number from three or four to twelve to twenty. At
each pole is a fine flagellum. It can move forward and
backward, and also rotate on its axis. It is not settled
whether division is transverse or longitudinal. It has
not yet been cultivated on artificial media.
Plague is produced by the Bacillus pestis. This is non-
motile, with rounded ends, is about 1% mikrons in
length and a little more than half a mikron in breadth ;
it stains readily with all the anilin dyes, but not by
Gram's method ; it has no spores, and is not encap-
sulated.
Tetanus is produced by the Bacillus teta/ni. This is a
small, slender rod with rounded ends; at one end is a
spore, which gives the bacillus the appearance of a pin
or a drumstick; it is from 2 to 4 mikrons long and from
hi to Vz mikron in breadth; it is slightly motile, is an-
aerobic, and stains with the ordinary anilin dyes and by
Gram's method.
10. The difference in the virulence of diphtheria may
be due to the difference in the number of bacilli pres-
ent, or to the variation in the tenacity with which they
retain their virulence, or to variations in the body de-
fenses and general vitality of the patient affected.
PRACTICE.
1. Four types of malarial infection: — Tertian (inter-
mittent), quartan (intermittent), estivoautumnal (re-
mittent) , and malarial cachexia, or chronic malaria.
Treatment: "In the remittent estivoautumnal type it
is often impossible to anticipate the paroxysms. The
quinine must then be given at regular intervals and in
sufficiently large doses to produce physiological effects
in the shortest time possible. It often happens, particu-
larly in the pernicious form, that the remedy is not
retained, or, if retained, it fails to produce the desired
effect, more especially when it is administered in capsule
or cachet. It is then better to administer it hypoder-
mically in the form of the hydrobromide, hydrochloride
or bisulphate, in doses of 15 to 30 grains once or twice a
day. The method advocated by S. Solis-Cohen is to give
but three subcutaneous injections of 10 or 15 grains
(0.65-1.0) during seven days following the last par-
oxysm, repeating the injection, however, after each
paroxysm, in the event of recurrence. Unfortunately
there is great liability to cause abscesses by this
method.
It is of the utmost importance in this form of infec-
tion to get the gastrointestinal canal into a condition
favorable to the absorption of quinine. A calomel or
blue-mass purge, followed, if necessary, by a full dose
of magnesium sulphate, often seems to double the effect
of the previously ineffective doses of quinine, and War-
burg's tincture often arrests a remittent fever on which
much larger doses of quinine in other forms have had
no influence. It should be given in doses of 3 ss every
two or three hours. In some instances the use of one
of the more soluble salts by internal administration
will be found more effective than that of the sulphate."
— (French's Practice of Medicine.)
2. Acute Tonsillitis. Etiology: The Staphylococcus
pyogenes and Streptococcus pyogenes are the chief
organisms found; acute rheumatism is often associated
with the disease. Predisposing" causes are exposure to
cold and wet, and poor hygiene. Treatment: Rest in
bed; a calomel purge followed by a saline; salicylates
gr. x-xv every three hours, or tincture of aconite;
liquid diet; antiseptic sprays, and cold applications.
3. Treatment of chronic constipation: "The cultiva-
tion of habits of regularity is of the utmost importance.
The patient should go to stool at the same time every
day, whether there is a desire to evacuate the bowels
or not, and every such desire should be immediately
gratified. The diet should comprise considerable fruit
and vegetables (which leave a residue). A glassful of
cold water before breakfast, an orange or oatmeal at
breakfast, and stewed fruits and salads at dinner sub-
serve a useful purpose in many cases. Persons of
sedentary habits are often benefited by exercise; ab-
dominal massage is useful in some cases, and an
abdominal binder is of value to those with a pendulous
flabby abdomen and visceroptosis.
130
MEDICAL RECORD.
[July 15, 1916
Drugs should be dispensed with as long as possible.
Medicinal measures when necessary vary with the na-
ture of the causal factor, -which must be diligently
searched for. At the beginning of the treatment it is
often advisable to clear the intestine thoroughly with
castor oil, a blue mass pill or calomel followed by a
saline aperient. In many cases the best results are
obtained by a daily injection of tepid water with or
without soap; in other cases injections of oil are much
better; but enemas should not be too long continued.
Some patients are much benefited by a saline aperient
water, sodium phosphate, or other saline, taken a half
hour before breakfast. Should a course of medicine be
necessary, the desired results may usually be secured
by the use of cascara sagrada, which has the advantage
that, having been continued for some time, the dose
necessary to secure a daily evacuation may be grad-
ually reduced, and the drug ultimately dispensed with,
should the patient continue habits of regularity. The
pill of aloin (Va grain), strychnine (1/40 grain), and
extract of belladonna (1/10 grain), though much
abused, is very useful in many cases." — (Kelly's Prac-
tice of Medicine.)
4.
PLEURISY WITH EFFUSION.
Onset marked by chilliness
persisting for a few
days.
Cough is irritating; no ex-
pectoration, or, if pres-
ent, catarrhal in char-
acter.
Sputum negative; tubercle
bacilli rare.
Moderate fever of continu-
ous type; declines by
lysis.
Prostration moderate.
Unilateral distention of
the thorax.
Countenance pale and
anxious.
Limited expansion at base
of chest on the affected
side.
Tactile fremitus dimin-
ished or absent.
Interspaces bulging at
base of chest.
Percussion shows flatness,
with great resistance to
the pleximeter finger.
Diminished or absent
breath-sounds over effu-
sion the rule. Respira-
tion murmur diffuse,
distant, and generally
unaccompanied by rales.
Bronchial breathing may
lie present over the en-
tire affected side of the
chest.
Friction sound heard in
early and late stages.
LOBAR PNEUMONIA.
Onset acute, with rigor,
lasting one hour or
longer.
Cough more marked, and
accompanied by rusty
or bloody, tenacious ex-
pectoration.
Dense aggregations of
pneumococci present.
Fever, 102° to 104° F.;
falls by crisis.
Prostration extreme.
Absent.
Mahogany-colored flush of
cheeks.
Degree of expansion
slightly, if at all, in-
hibited.
Increased over area of
consolidation.
Absent.
Dullness with less resist-
ance, and sometimes a
tympanitic note.
Harsh bronchial breathing
and presence of rales
in first and third stages,
unless a bronchus is
plugged.
No friction murmur; rales
present.
(Anders and Boston's Medical Diai nosis.)
The treatment of pneumonia "depends entirely on the
type of case, and the condition of the patient. Routine
treatment is the worst of all treatments. Answer the
following {questions before prescribing: Is the patient
full-blooded, and is there a full bounding pulse? Is the
pulse feeble, irregular, or intermittent?
"In the first ease, in a young and previously healthy
adult, if there be cyanosis, or signs of dilatation of the
right heart, blood-letting to the extent of a few ounces
may perhaps relieve the strain, but more generally
treatment should be directed to maintaining the
strength from the outset.
"In the latter case we can hope for nothing from a
depressing treatment, so stimulants must be resorted to,
such as alcohol, ammonium carbonate, egg and brandy
mixture, quinine, ether, etc. The giving or withholding
of alcohol depends upon its effect upon the pulse; should
the pulse rate fall and the tongue become moist it may
be continued. In asthenic cases, strychnine hypodermic-
ally is necessary from the outset and normal saline may
be given by the rectum or by the skin. Oxygen inhala-
tions are used where there is cyanosis, but it is doubtful
whether they have saved many lives. When there is
evidence of failure of the heart (weakness of the second
pulmonary sound, etc.) digitalis should be resorted to.
Many prescribe it from the outset.
"The diet should consist of milk, beef-tea or broths,
white of egg, and so on. The patient should be as little
moved as possible, and the bed-pan must be used. As
in other fevers, an airy room and good nursing are
essential.
"Remember that narcotics are not well borne in res-
piratory embarrassment as a rule. Chloral should be
avoided, but if pain be excessive a hypodermic injection
of morphine does more good than harm, notwithstand-
ing that theoretically morphine is contraindicated. It
should not be given later than the first few days of the
illness. The pain may also be relieved by poultices,
which, however, are of doubtful use if carelessly made,
or by application of ice. Cold packs applied to the trunk
only, and frequently repeated are very useful in re-
lieving both pain and fever. Depressant antipyretics
are to be avoided.
"The results of serum treatment are not unequivocally
encouraging but vaccine treatment would seem to be of
better promise. Where possible, an autogenous vaccine
should be used." (Wheeler and Jack's Handbook of
Medicine.)
5. Treatment of facial erysipelas includes isolation of
the patient, and antisepsis; light and nutritious diet,
and tonics and stimulants are indicated; tincture of the
chloride of iron, n^xv in water, thrice daily; ichthyol
ointment, 15 to 20 per cent, may be applied; antistrepto-
coccus serum has been tried.
6. The early manifestations of pulmonary tuber-
eulosis are: (1) Physical signs: Deficient chest expan-
sion, the phthisical chest, slight dullness or impaired
resonance over one apex, fine moist rales at end of in-
spiration, expiration prolonged or high pitched, breath-
ing interrupted. (2) Symptoms: General weakness,
lassitude, dyspnea on exertion, pallor, anorexia, loss of
weight, slight fever, and night sweats, hemoptysis.
7. The treatment of ophthalmia neonatorum is: (1)
Prophylactic: Whenever there is the possibility of infec-
tion, or in every case, wash the eyelids of the new-born
child with clean warm water, and drop on the cornea of
each eye one drop of a 1 or 2 per cent, solution of nitrate
of silver, immediately after birth. (2) Remedial: Wash
the eyes carefully every half hour with a saturated solu-
tion of boric acid; pus must not be allowed to accumu-
late. Two drops of a 2 per cent, solution of nitrate of
silver must also be dropped on to the cornea every night
and morning. The eyes must be covered with a light,
cold, wet compress. The patient must be isolated, and
all cloths and compresses used must be burnt.
8. Treatment of convulsions caused by nephritis:
Chloroform during convulsions, wet cupping, venesec-
tion if patient is otherwise robust, hot pads, free pur-
gation, pilocarpine to produce sweating (only if there is
no edema) ; the food must be nutritious (chiefly milk),
but nitrogenous food in general must be avoided; salt,
stimulants, and diuretics are prohibited; the patient
should have sufficient water to drink.
9. Medical treatment of gastric nicer: Rest and a
light and easiiy digested diet are absolutely essential.
Abstinence from food by stomach and gastric lavage
with feeding may be necessary for a time. Sodium bi-
carbonate, bismuth subnitrate, silver nitrate and opium
are the most frequently used drugs. Pain, vomiting, and
hemorrhage are treated as they arise; perforation de-
mands prompt operative interference.
10. In pellagra "the symptoms develop insidiously,
the earliest manifestations usually being gastrointes-
tinal— anorexia, stomatitis, salivation, epigastric pain
or distress, diarrhea and a gradually increasing anemia,
disinclination to exert inn. and psychic depression. The
fully developed disease is characterized by cutaneous,
digestive, and nervous symptoms. There is at first a
characteristic pellagrous erythema that usually comes
on first in the spring, tends to subside and recur (in the
fall and spring) . It develops bilaterally especially on
the exposed surfaces, the hands, arms, face, and neck;
that is, it seems to be related to the action of the actinic
rays of the sun; it may be dry (usually early) or wet;
the lesions become pigmented (liver yellow or chocolate
color) and usually progress to desquamation, exfolia-
tion, and gangrene of the skin, which are followed by
cicatrization. The characteristic digestive symptoms
consist of stomatitis, the cardinal red tongue the bald
tongue or the stippled, bluish black tongue; salivation,
pyrosis, and diarrhea (fetid, slimy, greenish stools),
sometimes bloody stools, may occur. The nervous symp-
July 15, 1916.]
MEDICAL RECORD.
131
toms consist of neuromuscular pains in the back and
legs, spinal tenderness, headache, vertigo, unilateral or
bilateral mydriasis, muscular spasms, exaggerated re-
flexes, later paralysis with lessened or absent reflexes,
mental depression delusions, hallucinations, melan-
cholia, and insanity. Mild cases may be afrebile, but
fever (102° to 105° or more) is not uncommon. Im-
provement may occur after the lapse of several months,
but recurrences especially in the fall and spring are
common." — (Kelly's Practice of Medicine.)
The treatment is mainly symptomatic; liberal diet,
and proper hygienic surroundings are indicated; fresh
fruit, milk, eggs, fresh peas or beans, lean meat. The
drug which has given the best results is arsenic (Fow-
ler's solution, soamin, salvarsan, or atoxyl). Change of
climate may bring about improvement.
OBSTETRICS.
1. Labor is divided into three stages: The first stage
begins with the commencement of labor, and ends with
the complete dilatation of the os uteri. The second stage
begins with the complete dilatation of the os uteri, and
ends with the birth of the child. The third stage imme-
diately follows the second, and ends with the expulsion
of the placenta and the beginning contraction of the
uterus.
2. Diagnosis of breech: Abdominal palpation reveals
the head above and the breech below. The heart-sounds
are heard above the umbilicus. Vaginal examination
shows high position of the presenting part, and
when the os is dilated the characteristic features of the
breech may be detected. Meconium is evacuated.
Management: First stage. — Keep the patient in bed
and at rest, so as to preserve the membranes as long as
possible. Warn the relatives of the risk to the child.
Second stage. — Prepare warm towels to wrap around
the child's body and limbs, and a warm bath, and every-
thing likely to be required for the treatment of as-
phyxia. Allow the breech to be born without hurrying
it. Support the perineum as in a vertex case. As soon
as the body is born as far as the umbilicus, draw down
a loop of the cord, at the same time maneuvering it to
the corner of the pelvis, where it is least likely to be
compressed. This loop by its pulsations is an index of
how it is faring with the child. Wrap the limbs and
trunk in a warm towel, and hold them slightly towards
the mother's abdomen so as to aid the lateral flexion of
the body. At the same time exert suprapubic pressure
upon the fundus which aids expulsion and promotes
flexion. When the elbows appear the hands may be
gently disengaged with the finger. Meantime carefully
watch the pulsations of the cord. Provided it is beating
regularly and the child is not making convulsive move-
ments, there is no need for anxiety. Wait for the next
pain and with the aid of suprapubic pressure expel the
head in a fully flexed attitude. Extraction of the head.
— If the head be delayed more than a few minutes after
the birth of the trunk as far as the umbilicus, it will
almost certainly require to be artificially aided. The
two best methods of doing this are (1) the Prague seiz-
ure, and (2) the Mauriceau-Smellie-Veit grip. Both
are designed to extract while at the same time promot-
ing flexion. Therefore aid the latter by making the
nurse or assistant exert suprapubic pressure while the
extraction is being performed. Either method is more
easily performed if the mother is in the cross-bed posi-
tion on her back. This position can only be maintained
by the aid of assistants, but if such aid is available it is
often desirable to place the mother in this position as
soon as the breech reaches the vulva. Anesthesia is
also required. Prague seizure. — Seize the feet and legs
by one hand and carry them well forward between the
mother's thighs. Place the first and second fingers of
the other hand over the child's shoulders to steady the
head. Pull upon the legs in a direction at right angles
to the mother's abdomen. This forces the occiput
against the pubes and so increases flexion, while it also
effects extraction, which is controlled by the fingers over
the shoulders. In a primipara this method may require
such force that the head comes out with a suddenness
that causes severe tearing of the perineum. In these
cases the second method is perhaps better. Mauriceau-
Smellie-Veit grip. — Place the child astride upon the
left forearm, and slip the two first fingers of the left
hand into the vagina and apply them to the superior
maxilla on each side of the nose. With these fingers
try to draw down the chin and nose, and so promote
flexion. At the same time the two first fingers of the
right hand are passed over the shoulders and traction
made by them in an upward direction. An alternative
is to pass the left forefinger into the mouth, but this is
apt to cause injury to the jaw." — (Johnson's Midwif-
ery.)
The danger to mother and child in a case of breech
presentation are: (1) Compression on the umbilical
cord; (2) premature respiration; (3) asphyxiation of
the child; (4) the child may suffer from fractures, dis-
location, hemorrhage, or paralysis; (5) extension of the
head, or of the arms over the head; (6) increased ten-
dency to rupture of the perineum.
3. Indications for the use of forceps are: "1. Forces
at fault: Inertia uteri in the presence of conditions
likely to jeopardize the interests of mother or child.
(a) Impending exhaustion; (6) arrest of head, from
feeble pains. 2. Passages at fault: Moderate narrow-
ing 3M to 3% in., true conjugate; moderate obstruction
in the soft parts. 3. Passenger at fault: A. Dystocia
due to (a) oecipito-posterior, (6) mento-anterior face,
(c) breech arrested in cavity. B. Evidence of fetal ex-
haustion (pulse above 160 or below 100 per minute.) 4.
Accidental complications: Hemorrhage; prolapsus fu-
nis; eclampsia. All acute or chronic diseases or com-
plications in which immediate delivery is required in
the interest of mother or child, or both.— From Jew-
ett's Practice of Obstetrics.)
The indications for podalic version are: (1) In trans-
verse presentations; (2) in placenta praevia; (3) in
malpresentations of the head; (4) in simple flattened
pelvis, and in minor degrees of pelvic contraction; (5)
in prolapsus funis; (6) in sudden death of the mother;
and (7) in any case where speedy delivery is impera-
tive.
The absolute indications for cesarean section are:
Extreme pelvic contraction or deformity in which deliv-
ery by forceps or version or symphyseotomy is impossi-
ble, and in which craniotomy is either impossible or
would be more dangerous to the mother ; the presence of
extreme atresia of the vagina; rupture of the uterus;
sudden maternal death.
4. Hyperemesis gravidarum, is occasionally seen in
pregnancy, and becomes "so excessive as to threaten the
patient's life. It may arise from a variety of causes.
The most common are: Reflex disturbance, caused by
the rapid growth and distension of the uterus; some
pathological condition of the uterus or its adnexa; some
pathological condition of the gastrointestinal tract; ex-
cessive sexual intercourse; kidney insufficiency. The
principal symptom is continuous vomiting, which results
in exhaustion and death unless relieved. The outlook
is very grave. The treatment consists in rest in bed in
a quiet, darkened room and the administration of easily
digested foods, such as milk, broths, eggs, etc. A care-
ful search must be made for some local exciting cause,
and if any such condition is found it should receive ap-
propriate treatment. Sexual intercourse should be in-
terdicted. The bowels should be kept freely open. So-
dium bromide, camphor, cocaine, silver nitrate, cerium
oxalate, hyoscine, hydrobromide, antipyrin, etc., are
among the drugs used internally. Rectal alimentation
may be necessary, and. as a last resort, dilatation of
the cervix and internal os. or abortion may be per-
formed."— (Pocket Encyclopedia.)
5. Placenta prasvia is the condition in which the pla-
centa is attached in the lower uterine segment and may
be near or over (partially or completely) the internal
os. The causes are unknown; multiparity, frequent
pregnancies with subinvolution, and abnormalities of
uterus, placenta or cord are said to predispose to this
condition. Varieties: (1) Central, when the placenta
completely covers the os. (2) Partial, when the pla-
centa overlaps the os. (3) Marginal or lateral, when
the placenta reaches the margin of the os but does not
overlap it. Symptoms: Sudden hemorrhage, accom-
panied by syncope, vertigo, restlessness, and feeble
pulse. Dangers: Hemorrhage, sepsis, death of the
mother, death of the fetus. Treatment: Stop the
hemorrhage by a tampon; this must be tight and
thorough. Accouchement force is indicated; this con-
sists of dilatation of cervix, version and immediate
extraction of the child.
6. Puerperal eclampsia is an acute morbid condition,
occurring during pregnancy, labor, or the puerperal
state, and is characterized by tonic and clonic convul-
sions, which affect first the voluntary and then the
involuntary muscles; there is total loss of consciousness,
which tends either to coma or to sleep, and the condi-
tion may terminate in recovery or death. Etiology:
Uremia, albuminuria, imperfect elimination of carbon
dioxide by the lungs, medicinal poisons, septic infection ;
predisposing causes are renal disease and imperfect
132
MEDICAL RECORD.
[July 15, 1916
elimination by the skin, bowels, and kidneys. Premoni-
tory symptoms: Headache, nausea, and vomiting, epi-
gastric pain, vertigo, ringing in the ears, flashes of
light or darkness, double vision, blindness, deafness,
mental disturbance, defective memory, somnolence;
symptoms easily explained by the circulation of toxic
blood through the nerve centers. These may be pre-
ceded by lassitude, and accompanied by constipation, or
by diarrhea. Headache is perhaps the most significant
and common warning symptom. In bad cases the urine
is reduced in quantity (almost suppressed), very dark
in color, its albumin greatly increased, so that it be-
comes solid on boiling. Next comes the final catastrophe
of convulsions. For preventive treatment: (1) The
amount of nitrogenous food should be diminished to a
minimum; (2) the production and absorption of poison-
ous materials in the intestines and body tissues should
be limited and their elimination should be aided by im-
proving the action of the bowels, the kidneys, the liver,
the skin, and the lungs; (3) the source of the fetal
metabolic products and the peripheral irritation in the
uterus should, if necessary, be removed by evacuating
that organ. The curative treatment includes: (1) Con-
trolling the convulsions (by chloroform, veratrum, or
chloral) ; (2) elimination of the poison or poisons which
are presumed to cause the convulsions; (3) emptying
the uterus under deep anesthesia, by some method that
is rapid and that will cause as little injury to the
woman as possible.
7. Creole's method of delivering the placenta "is to
reinforce the expulsive strength of the uterine contrac-
tions by grasping the fundus through the abdominal
wall, with the thumb in front and the fingers behind,
and, at the acme of the pain, not sooner, compress the
fundus firmly downward in the axis of the birth canal.
The fundus should be carried well back during the
manipulation to bring the uterine axis more into the
line of the vaginal axis. This process may be repeated
with each pain, at the acme of the contraction, until the
placenta is delivered. Vaginal bleeding will appear in
the interval between contractions when the placenta
begins to separate. This bleeding is from the placental
site which cannot retract until the placenta is com-
pletely detached. No traction should be made on the
cord to assist the delivery of the placenta. Occasionally
when the placenta is in the vagina or in the grasp of
the lower segment, funic traction is admissible. The
separation and expulsion of the nlacenta from the
upper, contracting segment of the uterus may be rec-
ognized by an upward movement of the fundus, as the
placenta passes into the lower segment and vagina." —
(Polak's Obstetrics.)
8. Two indications for the induction of prematur*
labor: — Placenta prasvia, and toxemia of pregnancy.
It may be accomplished by introducing a catheter,
under proper aseptic and antiseptic percautions, between
the membranes and the lower uterine segment; care
must be taken to avoid rupturing the membranes; more
than one catheter may be inserted; the instrument is
left to be expelled with the child.
9. Symptoms of inevitable abortion: — Hemorrhage,
severe cramps, dilatation of cervix, uterus soft and en-
larged, the discharge consists of dark blood, clots, and
portions of the ovum.
Management of inevitable abortion: "Two methods
of treatment have been advised for these cases. The
first is the expectant plan: Place the patient in bed, and
if the bleeding is profuse insert a tampon of iodoform
gauze (one yard) well up against the cervix. If this
fails to control the hemorrhage, reinforce it by another
yard or two of gauze and a perineal pad and binder.
Small doses (5%) of the fluidextract of ergot should
now be given every two or three hours. At the end of
from eight to twelve hours remove the tampon, when
the ovum may be found extruded from the cervix; if
not, a vaginal douche of mercuric chloride (1:4000)
must be given, and another tampon introduced. If, upon
the removal of this second tampon at the end of ten or
twelve hours, the ovum is not discharged, then more
vigorous methods to secure its expulsion must be
adopted. Active ]>lun : The physician's hands and in-
struments are sterilized; the patient is etherized and
placed on an approprite table; the genitalia are thor-
oughly cleansed and a vaginal douche of mercuric
chloride (1:4000) is given; the anterior lip of the cer-
vix is brought down to the vulvar orifice; the cervix is
dilated if necessary; the placental forceps is introduced
into the uterus, and as much as possible of the ovum
is removed; the uterus is thoroughly curetted, and an
intrauterine douche of sterile water is given. A light
tampon of iodoform gauze is placed in the vagina; the
patient is then returned to bed. A strip of gauze may
be placed in the uterus in cases of sharp retroflexion,
to secure free drainage, and occasionally an intrauterine
tampon will be necessary, when the uterus refuses to
contract and hemorrhage persists after the use of the
curette." — (Pocket Cyclopedia.)
10. Treatment of postpartum hemorrhage. — Grasp
the uterus at once, through the abdominal wall, and
massage it firmly. Anything in the uterus should at
once be cleaned out. Pass one hand into the uterus, and
with the other on the outside make firm pressure. A
hypodermic of ergotin, or ergot can be given by an as-
sistant. An intrauterine douche of hot sterilized water
(about 115° F.) may be given. Sometimes a very
thorough packing and plugging of gauze of uterus and
vagina may be necessary. Whatever is done must be
done promptly; and everything likely to be needed for
this emergency should be prepared beforehand in every
labor.
GYNECOLOGY.
1. Two causes of sterility in the male: — Abscess of
virile spermatozoa, and hypospadias.
Three causes of sterility in the female: — Abscess of
uterus, tubes or ovaries; atrophy of uterus or ovaries;
and gonorrhea.
2. Objective signs of extrauterine pregnancy: —
"When extrauterine pregnancy exists there are: (1)
The general and reflex symptoms of pregnancy; they
have often come on after an uncertain period of ster-
ility; nausea and vomiting appear aggravated. (2)
Then comes a disordered menstruation, especially
metrorrhagia, accompanied with gushes of blood, and
with pelvic pain coincident with the above symptoms of
pregnancy; pains are often very severe, with marked
tenderness within the pelvis ; such symptoms are highly
suggestive. (3) There is the presence of a pelvic tumor
characterized as a tense cyst, sensitive to the touch,
actively pulsating; this tumor has a steady and pro-
gressive growth. In the first two months it has the size
of a pigeon's egg; in the third month it has the size of a
hen's egg; in the fourth month it has the size of two
fists. (4) The os uteri is patulous; the uterus is dis-
placed, but is slightly enlarged and empty. (5) Symp-
toms No. 2 may be absent until the end of the third
month, when suddenly they become severe, with spas-
modic pains, followed by the general symptoms of col-
lapse. (6) Expulsion of the decidua, in part or whole.
Nos. 1 and 2 arc presumptive signs; Nos. 3 and 4 are
probable signs; Nos. 5 and 6 are positive signs." —
(American Text-Book of Obstetrics.)
3. Two common causes of dysmenorrhea: — Pelvic
congestion and underdevelopment or lack of develop-
ment of the genital organs.
4. Early symptoms of cystitis: — Vesical tenesmus, fre-
quent urination, pain, urinary changes.
5. A uterine tampon may be necessary after an abor-
tion if the uterus does not contract, and if the hem-
orrhage continues after curettage.
6. Three varieties of fibroids of the uterus: — Inter-
stitial, submucous, and subperitoneal fibroids.
7. Three etiologic factors in acute endometritis: —
Sepsis following labor or abortion, gonorrhea, and in-
strumental interference with the uterus.
8. Treatment for inoperable carcinoma of cervix: —
Careful nursing, scrupulous cleanliness with douches
containing potassium permanganate or bichloride of
mercury; morphine for the pain; the dead tissue may
be removed by scissors or curette; tonics and nourish-
ing food are indicated.
9. "The treatment of an ovarian cyst is ovariotomy
by the abdominal route. The tumor should be removed
at once, as there is less danger in operating upon a
small pelvic tumor than a large abdominal growth which
has undermined the general health and formed adhe-
sions with adjacent organs." — (Ashton's Gynecology).
10. The objectimxs to ventral fixation of the uterus
are thus given by Hermann (Students' Handbook of
Gynecology) :
"(1) Its risk. Oversights will occur in the practice
even of the most careful; but the risk is very small.
(2) Adhesions within the peritoneum are sometimes
absorbed. They are absorbed often enough to make
stitching of peritoneum to peritoneum unsatisfactory.
After abdominal section ventral hernia may first de
velop after the scar has held firm for twelve years; and
nossiblv the new attachment of the uterus may also,
after many years, give way. t3) The operation lifts
up the uterus. If the vulval orifice is very large there
July 15, 1916]
MEDICAL RECORD.
133
may still be a protrusion of the vaginal mucous mem-
brane. It is well, therefore, to precede ventral fixation
in women past child bearing by posterior colporrhaphy.
(4) It is said to cause difficulty in labor, should the
patient become pregnant. It does not always do so;
and in many cases reported as illustrating such diffi-
culty, the ventral fixation was not the cause of the
difficulty. Ventral fixation after colporrhaphy, if the
result be permanent, relieves the patient of any neces-
sity for the continual readjustment of a pessary, and
lifts the uterus up effectually. Ventral fixation is not
advised in cases in which the womb can be comfortably
kept up by a pessary."
SURGERY.
1. Inflammation is the name given to the succession
of changes occurring in a part after an injury, pro-
vided the injury does not at once destroy its vitality.
Septicemia is an acute surgical infection caused by
the absorption and development of bacteria in the blood
of the patient.
Pyemia is an acute surgical infection caused by the
diffusion of septic emboli throughout the circulation;
metastatic abscesses are thus produced. The organs
most prone to pyemia are the lungs, kidneys, spleen,
liver, brain, and large joints.
2. The term denoting control of hemorrhage is hemo-
stasis. The methods of controlling hemorrhage are:
Pressure, forced flexion, forceps, clamps, torsion, liga-
ture, cold, heat, cautery, elevation, styptics, suprarenal
extract, ergot.
3. The popliteal artery should be ligatured and the
dislocation reduced. The leg must then be carefully
observed for some time, and if loss of vitality of the
limb becomes evident amputation above the knee will
be necessary.
4. Acute suppurative osteomyelitis. "Causes. —
The general vitality is lowered, and there is some focus
of ulceration in the mouth or throat, by which organ-
isms enter and circulate in the blood. All that is now
necessary is that some part of a bone should have its
vitality depressed by a blow, strain, or exposure to cold,
and the organisms then attack it. The bacteria most
commonly found are the staphylococci, but streptococci
are present occasionally. The disease usually begins
in the new growing bone at the end of the diaphysis,
rarely in the epiphysis. The lower ends of the femur
and radius, the upper ends of the tibia and humerus,
are the commonest seats.
"Symptoms. — The disease begins with a rigor, high
temperature, and severe pain. The part becomes
swollen, infiltrated, and congested, with distended veins
over it. The pulse is rapid and small and the tongue
dry, and delirium soon comes on. It should be dis-
tinguished from acute rheumatism by the fact that the
interarticular and not the articular region is affected.
Fluctuation can be detected if the bone be superficial,
or the abscess may burst on the surface. The bone is
then found to be bare over the extent of the abscess
cavity. When the bone is deeply seated or the disease
confined to the medulla, the swelling is later in evidence,
but the pain and toxemia are very severe, and the child
may die from this before local signs show themselves.
When the epiphysis is attacked, septic arthritis often
quickly follows, and a loose flail joint may result.
"Treatment must be very prompt. A free incision
must be made through the periosteum and the pus
evacuated. In any case, whether pus is found or not,
the surface of bone must be gouged away to expose the
medulla freely, and any gangrenous tissue scraped out.
The cavity must then be washed out and freely drained.
The wound in the soft structures is not closed in any
part- If symptoms of pyemia occur, it may be neces-
sary to amputate the limb through the joint or bone
above, so as to cut off the source of emboli. When a
large portion of or the whole diaphysis is necrosed,
there are two courses; either to cut short the disease
by removing the dead portion at once, or to leave the
sequestrum to stimulate the formation of an involu-
crum. Where there is a single bone, as in the arm and
thigh, the sequestrum is left; where there is a double
set of bones, as in the forearm and leg, the sequestrum
is removed at once. Celluloid, zinc, and ivory rods hav»
been inserted to stimulate osteogenesis. In most cases
it is doubtful how much bone is actually dead, so that
it is better to open up the cloaca? in the newly formed
involucrum to remove the sequestrum. The cavity heals
by granulation." — (Aids to Surgemi.)
It is to be diaqnosed frjm (1) Rheumatism, in which
more than one joint is affected and the tenderness is in
the joint, and not near it. (2) Tuberculous arthritis, in
which the onset is slow and the trouble starts in the
epiphysis rather than in the diaphysis. (3) Cellulitis, in
which the bone and periosteum are not affected, and in
which there is always a wound.
5. Shock is the name given to a sudden and general
depression of the vital powers due to some strong stimu-
lation (such as injury or emotion) acting on the vital
centers in the medulla, and producing vasomotor paral-
ysis.
Treatment of shock/ Place the patient in the recum-
bent position, with the head low, apply warmth to the
body, administer a stimulant and give a hot saline in-
fusion ; morphine hyperdermically, may be necessary for
the relief of pain. Adrenalin solution is administered
into the arterial system.
In surgical operations shock may be largely prevented
by reassuring nervous patients, keeping the patient
warm, the avoidance of the excessive catharsis and
semi-starvation that often prevail before operations, the
administration of strychnine and atropine before oper-
ation, the avoidance of delay and undue handling of
parts during the operation, prompt checking of hem-
orrhage, and by using the utmost gentleness.
6. "In the treatment of compound fractures the main
object is to render the wound aseptic and to give effi-
cient exit to the discharges. For this purpose the
patient should in all cases be anesthetized, the limb
shaved, and thoroughly purified, and the wound en-
larged and thoroughly washed out with some reliable
antiseptic. It may be advisable to excise torn and dirty
fragments of skin, muscle, and tendon, especially when
dirt has been ground into them. Loose fragments of
bone are removed and portions denuded of their perios-
teum may be taken away lest necrosis should ensue;
where fragments retain any considerable connection
with the soft parts they may be left without fear. When
a sharp end of one of the fragments is protruding
through a small opening in the skin it is first purified
thoroughly before attempting its reduction and then
replaced after enlarging the wound in the skin, or a
portion sawn off. Hemorrhage is dealt with in the
usual way, and the fragments are placed as nearly as
possible in their normal position. If the fragments can
be brought accurately into position it is well to fix them
by some mechanical appliance; but where the ends of the
bone are much comminuted the small portions must be
arranged in position as well as possible, and no attempt
made to wire them. A good-sized drainage tube is in-
serted, and, if need be, counteropenings are made; the
external wound is closed or not, according to circum-
stances, and dressed, and suitable splints are then
applied. Under such a regime the majority of cases do
well. Immovable apparatus may be used after a time,
windows being left in the plaster casing to allow wounds
to be dressed." — (Rose and Carless' Manual of Sur-
yery.)
7. Ankylosis is the condition in which the mobility of
a joint is restricted or abolished. True ankylosis is
caused by intra-articular lesions; false, by extra-articu-
lar lesions. The true ankylosis may be bony or fibrous.
Ankylosis is also said to be complete or incomplete.
In bony ankylosis of the knee joint, if in false posi-
tion, resection of a wedge-shaped piece of bone is nec-
essary to make the limb straight. This is followed by
extension, massage, and passive movement.
8. In duodenal ulcer there will be pain in the right
hypochondriac region occurring about 3 hours after
meals; intestinal hemorrhages which produce tarry or
red stools; and anemia.
In cholecystitis, the pain is in the right hypochondriac
or epigastric region, and occurs in paroxyms and with-
out reference to time of eating; nausea, vomiting and
jaundice may be present; constipation is common; and
there is generally severe prostration.
9. Ileus. Varieties: — (1) Strangulation, due to
bands or adhesions or apertures; (2) Volvulus, due to
twists on the axis of the mesentery or bowel; (3) Intus-
susception, due to excessive mobility and irritability of
the intestine; (4) Stricture, due to cancer or scar tissue;
(5) Obstruction by tumors, foreign bodies, fecal accu-
mulation, or following an operation ; the latter may be
due to paralysis of the bowel or diminished peristalsis.
10. Stone in the ureter. Symptoms: — Severe colic,
with pain radiating along the ureter; tenderness over
the ureter; hematuria; the stone may be felt through
rectum or vagina; a skiagram may show the stone;
ureteral catheterization through the cystoscope may
allow of the stone being touched by the catheter, and
a waxed tip may receive a scratched impression.
It is diagnosed from cystitis (in this the urine is
134
MEDICAL RECORD.
[July 15, 1916
alkaline, and pus is found at the beginning or end of
urination) ; from tuberculosis of bladder (in this there
are tubercle bacilli in urine, frequent urination, and
the symptoms are not relieved by rest) ; from prolapsed
inflamed ovary (the ovary is further from the vaginal
wall, and the stone is felt in the antero lateral fornix).
Treatment: — Except when anuria is present, observe
the case to see if the stone is fixed or moving; if it is
moving, allow time for it to pass into the bladder. If
it is impacted near the kidney, attempt to push it back
and remove it through pelvis of kidney; failing this,
incise ureter and remove it, and then suture ureter. If
impacted lower down, it should be removed by lumbar or
sacral incision. In the renal colic, morphine, with hot
fomentations is given. In case of anuria, nephrolithot-
omy is indicated.
HYGIENE.
1. Four points to prevent acquiring or imparting
tuberculosis: (1) Compulsory notification of the dis-
ease; (2) prohibition of spitting except in proper re-
ceptacles, the sputum should be burnt or disinfected;
(3) proper disinfection of houses or rooms occupied by
tuberculous persons; (4) proper sanitary supervision
of dairies, farms, cattle, milkshops, and workshops.
2. The principal means of preventing the spread of
contagious diseases in schools are: Regular and effi-
cient inspection by physicians; prompt exclusion and
isolation of anyone suffering from a contagious dis-
ease, or coming from a house where such disease is;
compulsory notification of all infectious and contagious
diseases; individual towels, drinking vessls, and other
implements; children who have had a contagious or
infectious disease or who have come from a house
where such disease prevailed should not be readmitted
to school until sufficient time has elapsed since the
occurrence of the last case to insure safety.
3. By the liygiene of pregnancy is meant the care
which should be observed by the pregnant woman for
the preservation of health and strength both of herself
and of the fetus. The pregnant woman should take
moderate exercise in the open air; in the last month
massage may take the place of exercise. Daily bathing
in tepid water, care of the teeth, regularity of the
bowels, ample sleep in a well-ventilated room, plenty
(but not too much) of simple, nourishing and easily di-
gested food, at regular hours, clothing not too tight,
especially about the abdomen and breasts; attention to
the nipples, regular examination of the urine, and the
restriction of marital relations are the main points to
which advice should be directed.
4. Prophylaxis of filth diseases consists in the pre-
vention of the ingress and accumulation of dirt, proper
methods of removal by cleaning, and of destruction by
burning; by having proper, tight receptacles for waste
matter; by having proper plumbing and water supply;
by proper ventilation of and sunlight in living and
sleeping rooms; by not keeping domestic animals in the
house, and by keeping such animals clean ; by keeping
oat rats, mice, flies, mosquitoes and other insects as
much as possible, and by personal cleanliness.
5. The dangers from the housefly are: Transmission
of diseases, such as typhoid, tuberculosis, cholera, dys-
entery, diarrhea, anterior poliomyelitis, and possibly
other diseases. The mosquito may transmit malaria,
yellow fever, dengue, and filariasis.
To exterminate flies: "Since flies breed only in filth,
the first thing to do is to render it impossible for the
fly to reach any of the accumulations unavoidable
around habitations. This is done: (1) By destroying
filth wherever found. (2) By rendering it distasteful
or poisonous to flies or their larvae by the use of lime,
kerosene, oil of pennyroyal or cresol. (3) By excluding
light from the receptacle or by screens which the flies
cannot pass. The most difficult part of an anti-fly cam-
paign is teaching the people to dispose of their garbage
properly. No amount of screening, trapping or poison-
ing will make up for careless disposal of filth and
waste. All such materials must be promptly destroyed
or buried. If a really good suspension of milk of lime
(calcium hydrate) is mixed with the garbage or refuse,
the eggs and pupae or maggots of the fly are at once
destroyed, but it must be made to come in contact with
the eggs or maggots to do any good. Kerosene oil is
more effective, but more expensive. Where crude oil
or low grade distillates are procurable, the expense is
much lessened. Oil of pennyroyal, in the proportion of
1 ounce to 1 quart of kerosene, is very distasteful to
the adult fly, as well as fatal to the young, and a
small quantity sprinkled around the garbage can is
sufficient to keep away all flies. The greatest draw-
back is the expense. Cresol is not expensive, and may
be used freely in 2 per cent, emulsion. Privy vaults,
manure bins, and similar places must be made and
kept perfectly dark. Screens must be made auto-
matically self-closing, otherwise they are sure to be left
open and to fail of their object." — (Gardner and
Simond's Practical Sanitation). Fly poisons, flytraps
and fly papers may also be used.
"The most efficient way of getting rid of mosquitoes
is to make it impossible for them to breed. The eggs
of a mosquito are laid in water, and water is abso-
lutely necessary for the larval and pupal stages, which
must be passed through before the adult mosquito is
produced. Fish destroy developing mosquitoes and
large sheets of water are too rough for them; so mos-
quitoes must have, for breeding, rather small collec-
tions of fresh water free from fish. Mosquitoes will
soon disappear from a locality if all such collections of
water within a quarter of a mile of it are filled up,
drained, or covered with a film of coal oil so as to make
it impossible for the mosquitoes to breed in them. Those
who live in a malarious district should protect them-
selves from mosquito bites by the careful use of mos-
quito netting.". — (Marshall's Microbiology.)
6. The chief sources of contamination of drinking
water are: Sewage, including not only solid and liquid
excreta, but also house water and waste water; manu-
facturing refuse, such as from dye works, bleaching
works, tanneries, and numerous other industrial places;
improper storage or service of water.
Drinking water may be purified by: Distillation,
boiling, filtration, precipitation, and various chemical
methods.
7. Diseases specially liable to be conveyed by the in-
gestion of milk: Tubercolosis, typhoid fever, scarlet
fever, diphtheria, tonsilitis, cholera, and gastrointestinal
disorders.
8. Diseases due to microorganisms: Typhoid, trans-
mitted by food, water, milk, fingers, flies, and "car-
riers"; dysentery, transmitted by water, milk, vege-
tables, direct contact with patient and his discharges,
flies; cholera, transmitted by food, water, and flies;
smallpox, method of transmission is not known, pos-
sibly by air, flies, mosquitoes; scarlet fever, transmitted
by secretions from nose, throat, and ear (suppurating),
and scales from skin; measl.es, transmitted by direct
contagion, fomites; diphtheria, transmitted by infected
articles, "carriers," milk, fomites, domestic animals,
secretions from throat or nose or ear; influenza, trans-
mitted by "carriers," sputum; mumps, transmitted by
contact; plague, transmitted by the flea, rats, squirrels,
marmot; Malta fever, transmitted by milk of goat and
possibly by biting insects; anthrax, transmitted by ani-
mals, wool, skin, rags; glanders and farcy, transmitted
by inoculation; foot and mouth disease, transmitted by
secretions of infected animals, and milk, butter, and
cheese made from milk of such animals; hydrophobia.,
transmitted by saliva and bite of dog or wolf; yellow
fever, transmitted by Stegomyia mosquito; malaria,
transmitted by Anopheles mosquito; dengue, trans-
mitted by Culex mosquito; pellagra, perhaps transmit-
ted by Simulium (sand-fly) ; erysipelas, transmitted by
inoculation; tetanus, transmitted by inoculation; tuber-
culosis, transmitted by inoculation, inhalation and in-
gestion ; leprosy, transmitted by inoculation, contagion
with secretions; typhus, transmitted by body lice and
bedbug; relapsing fever, transmitted by bites of in-
sects; kala a:ar, transmitted by bite of bedbug; an-
terior poliomyelitis, transmitted by secretions and flies:
cerebrospinal meninaitis, transmitted by nasal secre-
tions and "carriers"; syphilis, transmitted by sexual
contact, kissing, instruments, and inoculation; gonor-
rhea, transmitted by sexual contact; fingers or towels
may also convey the virus.
9. The patient must be isolated; no one but the physi-
cian and nurse must enter the room; the physician
should put on a large washable gown when he goes in
and remove it on leaving, at the same time washing his
hands in a disinfectant; the nurse, when she leaves the
sick room, should also remove her clothes and put on
others, at the same time disinfecting herself. At the
termination of the disease everything should be disin-
fected: toys and books, etc., are better burned.
10. Healthy sleep is more apt to occur when the per-
son is healthy and of correct habits; bodily comfort,
mental repose, sufficient warmth, proper ventilation, a
slight amount of fatigue, perfect quiet, and a comfort-
able bed are more or less necessary. Sometimes, in ad-
dition to the above, an evening walk, a warm bath at
bedtime, and a light repast before retiring may be
necessary.
Medical Record
A Weekly Journal of Medicine and Surgery
Vol. 90, No. 4.
Whole No. 2385.
New York, July 22. 1916.
$5.00 Per Annum.
Single Copies, 15c.
©rujinal Ariirka.
ANIMAL EXPERIMENTS UPON THE AC-
QUIREMENT OF ACTIVE IMMUNITY BY
TREATMENT WITH VON RUCK'S VAC-
CINE AGAINST TUBERCULOSIS.
By FRANK J. CLEMENGER, M.D.,
ASHEVILLE, N. C.
FORMERLY ASSISTANT, IMMUNIZATION DEPARTMENT, ST. .MARY'S
HOSPITAL ;
AND
F. C. HARTLEY, M.A., M.D. (Cambridge).
LONDON.
INSTRUCTOR AND ASSISTANT, IMMUNIZATION DEPARTMENT,
ST. MARY'S HOSPITAL.
(From the Laboratory of the Department for Therapeutic
Immunization, St. Mary's Hospital; London, W., England.)
The following experiments were undertaken for the
purpose of independent observations in respect to
the immunizing power of a specific vaccine made
from extractives of the tubercle bacillus, as pre-
pared and described by Dr. Karl von Ruck' of Ashe-
ville, N. C, at whose request one of the authors
(F. J. C.) applied to Sir Almroth E. Wright, his
former chief, for his consent to have the work done
under his direction in his laboratory at St. Mary's
Hospital in London. This request being granted by
Sir Almroth Wright, arrangements were made ac-
cordingly.
In order to expedite the necessary studies, Dr. von
Ruck supplied thirty-six guinea-pigs which had been
immunized in his laboratory, to be taken to London.
Through an unfortunate accident, thirty-two of the
animals were drowned on shipboard. In fifteen
of the autopsies, the animals showed lesions to
which Dr. von Ruck had called the attention of one
of us, as seriously interfering with his own experi-
ments, which he then considered as spontaneous
tuberculosis. Sections from tissues of two of these
animals showed acid-fast bacilli. The four remain-
ing animals were excluded from our experiments.
It was not intended to be within the scope of
these experiments to undertake any work with the
idea of establishing proof of the clinical value of
this vaccine; but the interim caused by the neces-
sity of immunizing a new lot of animals, was util-
ized for treating a few clinical cases selected by Sir
Almroth Wright with this end in view. Realizing
the long period of time which would be required to
study a comparative series of cases under treat-
ment with Tuberculin BE in routine use in the
clinic of the Department at St. Mary's Hospital. Sir
Almroth decided to select only cases for treatment
with this vaccine, which had failed to show improve-
ment under treatment with Tuberculin BE. and to
note any changes that might become manifest
through its influence.
Eight cases were assigned for this purpose, being
of the type predominating in this clinic, namely six
cases of lymph gland affections characterized by
chronic sclerotic lesions, in which the enlarged
glands varied in size from masses one to four inches
in diameter, and two cases of lupus of long stand-
ing, one of which had existed for fifteen years and
involved nearly all parts of the body; the second
case had developed upon scar tissue forming after
the removal of tuberculous glands from the neck;
the lesions covered a patch one by one and one-half
inches in size.
These cases were treated for three months with
varying doses administered subcutaneously and, in
some instances, intravenously. At the end of that
time the clinical experiments were given up on ac-
count of the necessity of proceeding with the ex-
periments upon animals. During the course of the
treatment, forty-eight observations were made to
ascertain the relation between the opsonic contents
and the specific precipitins of the sera of these pa-
tients; but no uniformity could be established in
their inverse proportions, as had been observed by
Dr. von Ruck.2
In the course of treatment of these cases no per-
manent changes could be noted in the local lesions;
but in four out of six cases of the glandular type,
an improvement became manifest in the general
condition of the patients, which suggests that the
treatment had been beneficial. The other two of
the glandular cases had presented no general symp-
toms and, from the fact that 1 c.c. of the vaccine
was administered intravenously, without causing
any reaction, it is possible that the lesions were not
tuberculous.
The extensive case of lupus had been treated with
other specific products for several years, during
which periods of improvement and relapses had been
noted; consequently no conclusion could be drawn
when the treatment was discontinued. In the other,
less extensive case, while presenting no definite
changes in the local lesions, such a remarkable gen-
eral improvement occurred that the change was
noticeable to any one.
Considering the fact that all these c;is< which
had been assigned, were of a character which im-
plies a minimum circulation in the affected tissue,
it is possible that, no matter how much immune sub-
stances might be elaborated in response to a given
vaccine, an influence upon the local lesions could
hardly be expected by this means alone.
Animal Experiments. — Great difficulties were en-
countered in obtaining guinea-pigs free from
pseudotuberculosis and, as will be shown later, a
large number of the animals used in the experi-
ments were found to be affected with various types
thereof.
In our search for normal animals suitable for our
experiments, a dealer was found who claimed that
136
MEDICAL RECORD.
[July 22, 1916
he had never had any infection among his animals,
either acute or chronic. From his stock, 104 male
guinea-pigs were chosen, and their active immuniza-
tion was undertaken by the subcutaneous adminis-
tration of successively increasing doses of the vac-
cine. A number of these animals died, especially
during the early part of their treatment, and on
autopsy they were found to present lesions which
resembled tuberculosis. Captain Stewart R. Doug-
las, I. M.S., assistant director of the department, was
consulted and suggested that we were dealing with
a chronic form of pseudotuberculosis. In our fur-
ther investigations we isolated a short coccobacillus
from some of the lesions, and also a Gram-negative
bacillus whic hseemed to be identical with the Ba-
cillus pseudotuberculosis rodentium described by
Pfeiffer.
It was decided, however, to proceed with the im-
munization of the remaining animals, because it
was doubtful whether a perfectly reliable source of
animals could be found. After a certain number of
doses of the vaccine had been administered, the sera
of the animals were tested by a technique of comple-
ment-fixation described by Dr. von Ruck.5 At this
time there remained fifty-one animals of the origi-
nal lot. In six of these, Dr. von Ruck's criterion
in complement-fixation was reached with antigens
supplied by him. In the remainder the results were
only partial or negative.*
It appeared after many attempts, that the binding
power of the antigens for complement was very vari-
able and unstable, especially in the presence of
hemolytic amboceptor of high titer, and it became
necessary to employ amboceptors of low titer, in
order to obtain any results at all. The hemolytic
system used was rabbit hemolysin for calf-cells,
with' either guinea-pig or rabbit serum for comple-
ment. The rabbit complement frequently proved so
weak and variable, that it had to be abandoned, and
the partial results that were obtained occurred
when guinea-pig complement had been employed.
To eliminate the possible adverse influence of
pseudotuberculosis, in the sera used for complement,
a further search for normal guinea-pigs was under-
taken. A lot was purchased from a guinea-pig fan-
cier who bred his animals exclusively for purposes
of exhibition. These animals were young and, from
all outward appearances, they were perfectly
healthy. A point was made to autopsy, with great
care, each of the guinea-pigs of this lot, that had
been killed for the purpose of securing fresh serum
for complement, and pseudotuberculous lesions were
found in every one of them, over thirty in number.
We are not prepared to express an opinion on the
exact relation of sera from animals affected with
pseudotuberculosis upon the variability and unre-
liability in complement-fixation tests. We have
thought of non-specific fixation, or of deviation of
complement through the presence of a large amount
of amboceptor for the organisms of pseudotubercu-
losis; but we did not have the time and opportunity
to study the subject critically.
The amazing point about these infections with
*The antigens were four in number: (1) a fat-free
emulsion of tubercle bacilli; (2) a lipoid, neutral in re-
action; (3) a fatty acid; (4) a water-soluble protein.
The double guide indicating successful resistance to in-
fection, which was conditioned by Dr. von Ruck as
essential, was that the sera should give complete fixa-
tion in strum dilutions of 1:8 with all antigens; and
that 0.2 c.c. of the active serum should cause marked
morphological changes upon 0.01 mgr. of virulent tuber-
cle bacilli of human origin, in vitro, after incubation
for twenty-four hours at 37° C.
pseudotuberculosis is the large amount of tissue in
vital organs, which can be involved in the local
processes and yet permit the animals to live in ap-
parent health. The assumption of a certain degree
of an acquired immunity against the bacteria caus-
ing the pseudotuberculosis, which prevents gen-
eralization through the blood, possibly may account
for these observations and also for the earlier
deaths which took place after the administration of
anti-tuberculosis vaccine, or after infection with
tubercle bacilli, which would then cause a dis-
turbance of this acquired immunity. In any case,
the presence of an infectious disease, which in its
course has caused such extensive involvement of
vital organs, may well be considered a hopeless bar-
rier to the successful immunization of the affected
animal against tuberculosis or against any other in-
fection.*
Bactericidal Experiments. — Our bactericidal ex-
periments will be considered first, because they, pre-
ceded the infection of treated animals. Their ob-
ject was to demonstrate a difference in the germi-
cidal action of human sera, accordingly as they were
taken before or after the administration of the vac-
cine. If such a difference could be clearly estab-
lished in a sufficiently large number of cases in fa-
vor of the sera taken after one or more doses of the
vaccine, such a result would have to be accepted as
conclusive.
For preliminary experiments, the sera of nine
persons were obtained, who had not before been
treated with the von Ruck vaccine or with any other
product of the tubercle bacillus.
The technique for these and for the bactericidal
experiments with sera taken after vaccination, was
as follows: Two drops of the person's serum were
mixed with two drops of an emulsion of living
tubercle bacilli, containing 0.01 mgr. of the bacilli.
This mixture was agitated in a test-tube and then
placed in an incubator at 37° C. over night. The
mixture was then injected subcutaneously into a
guinea-pig. For the infection of control animals,
an equal amount of normal serum was substituted
for the human serum in one group, and normal salt
solution in another group of animals, all control
test-tubes being otherwise treated exactly like those
intended for the principals. +
The results of these experiments are given in
Table I.
Apparently the human serum had a slight inhibi-
tory effect, increasing the average duration of life.
It is readily seen that the purpose of the experi-
ment has been accomplished in the above group.
Guinea-pig No. 1 (Dick) shows some modification of
virulence, and justly so. The serum had given posi-
tive results in the complement-fixation test, indicat-
ing that its donor had developed a fair amount of
immunity to the tubercle bacillus. At a later date
♦Aside from the disappointing and inseparable com-
plications of infection with pseudotuberculosis in our
experiments, the possibility of error in utilizing guinea-
pigs for diagnostic experiments became manifest in the
course of our studies. The inoculation of a guinea-pig
with suspected fluids or tissues may lead to serious
error, unless the results are studied and controlled in a
more critical manner than is the usual custom. Our
observations also raise the question of the reliability of
some of the experiments in tuberculosis recorded in
literature, in which such critical studies were omitted.
f All emulsions used in these experiments were made
by Dr. Achard of Dr. v. Ruck's staff, who placed thorn
in the hands of Dr. Parry Morgan of the staff of the
Department. Dr. Morgan put up the serum and bac-
terial mixtures in this and in subsequent experiments
and witnessed their use for the infections.
July 22, 1916 j
MEDICAL RECORD.
137
he responded to the vaccine with a sharp reaction and
manifested a decided improvement in his physical
condition during the weeks following. Excluding
guinea-pigs Nos. 6 and 14, on account of the short
time they lived after infection, it will be found
that 100 per cent, of the sera which are left show
no modifying action upon the virulence, except in
the duration of life; or, if the result in G. P. No. 1
is interpreted as manifesting a modifying influ-
ence, 85.7 per cent, will be left in which no modi-
fying action upon the virulence was evident.
Table I— Animal Experiments with Human Sera Taken Before Vaccination
Animal
Name
No.
Hayman . . .
15
Storrer .....
13
Francis
6
Duff
14
Hardy
5
Menereau . .
33
Henry
2
Edwards. . .
4
Dick
1
Controls.
Normal salt
9
Normal salt
10
Normal salt
11
Normal salt.
12
G.P. Serum .
8
G.P.-Serum .
16
G.P.-Serum.
17
G.P.-Serum.
18
G.P.-Serum.
7
Death
Lived,
Days
Found dead in cage
Found dead in cage
Killed
103
109
29
Found dead in cage
1
Killed
117
117
117
102
103
Killed.
Killed.
Found dead in cage.
Found dead in cage.
Found dead in cage.
Found dead in cage.
Found dead in cage.
Found dead in cage.
80
80
80
109
Killed.
117
Found dead in cage.
Found dead in cage.
Found dead in cage.
Killed
80
30
101
Autopsy
Disseminated lymph gland tbc.
Generalized tbc.
Excluded, having been killed
through error.
Excluded on account of early
death.
Disseminated lymph gland tbc.
Generalized tbc.
Disseminated lymph gland tbc.
Generalized tbc.
Tbc. of regional lymph glands.
Generalized tuberculosis.
Generalized tuberculosis.
Generalized tuberculosis.
Disseminated lymph gland tu-
berculosis.
Disseminated lymph gland tu-
berculosis.
Generalized tuberculosis.
Apparently pseudotuberculosis*
Apparently pseudotuberculosis.*
Tuberculosis of regional lymph
glands.
•Serum controls Noe. 17 and 18 are excluded on account of early death.
After these infections had been made, the indi-
viduals who had supplied the sera for this group
were given each one dose of the vaccine. Excepting
one infant (Duff) and a child (Francis), all re-
acted to its administration, the reactions being at-
tended by fever. The sera of these persons were
tested after five days. Bacteriolysis in vitro, of
tubercle bacilli, could not be demonstrated in any
of them* and the same is true for the sera obtained
from animals which had been treated with the vac-
cine, in the subsequent experiments. In the latter
sera an obstacle to the demonstration of bacterio-
lysis was encountered also in the gross contamina-
tion of the specimens, which was unavoidable on
account of having to bleed the animals from the ear.
The difficulties in the complement-fixation test,
which we encountered, have already been described.
It was agreed, because of these difficulties, to take
specimens of serum from the vaccinated individu-
als, on three successive days, hoping that a posi-
tive serum would be secured on one or more of these
three occasions. Two drops of the respective serum
were then placed in a sterile test-tube, and 0.01
mgr. of tubercle bacilli in emulsion added, the tubes
being placed in the incubator over night. The con-
tent of each individual tube was then used for the
subcutaneous infection of a guinea-pig. Control
experiments were made in a certain number of ani-
mals with the contents of tubes containing a like
quantity of tubercle bacilli, while the immune hu-
man sera were replaced by normal human serum or
*When decolorization of slides, made for the purpose
of demonstrating bacteriolysis in vitro of tubercle ba-
cilli, was done with 25 per cent, sulphuric acid, no lysis
was demonstrated. Slides decolorized with lesser per-
centages of acid were not accepted by Captain Douglas,
on account of possible retention of stain by contami-
nating bacteria.
by normal salt solution.* The results of the bac-
tericidal experiments with sera taken after vaccina-
tion with a single dose in four adults, two children
and one infant, and with sera from two other adults
who had received two doses of the vaccine before
the present studies were undertaken, are given be-
low, t
Bactericidal Experiments with Human Sera talcen
after the Administration of Vaccine.
Adults. Dick. Serum taken vii/20/14. G.P. No. 6,
infected subcutaneously in left axilla; weight 500
grams. Killed 124 days after infection; weight 530
grams.
Autopsy: Infection site open lesion. Left axillary
glands 3x3 mm., caseous; 3x4 mm., caseous; right axil-
lary gland 2x3 mm., caseous.
Liver, 1% times normal size; several patches of fibro-
caseous degeneration.
Mesenteric glands from a caseous mass, 10x3 mm.
Spleen, 8 times normal size; a mass of fibrocaseous
degeneration.
An omental gland under spleen, 2x3 mm., fibrous.
Lungs, numerous greenish tubercles; some caseation.
Mass of bronchial glands, 6x4 mm., caseous.
Smears made for tubercle bacillus: positive, left axil-
lary gland; mesenteric gland; spleen; bronchial glands;
retrosternal gland; negative lung and liver.
Cultures for microorganisms of pseudotuberculosis,
positive for liver; negative for spleen and lung. Gen-
eralized Tuberculosis.
Dick. Serum taken vii/21/14. G.P. No. 16; infected
subcutaneously in left axilla; weight 330 grams. Killed
122 days after infection; weight 465 grams.
Autopsy: Infection site not found. Spleen normal
size, mottled. Mesenteric gland lxl mm. Lungs slightly
mottled.
Smears from spleen and mesenteric gland negative.
No Tuberculosis.
Dick. Serum taken vii/21/14. G. P. No. 23. In-
fected subcutaneously in left axilla; weight 345 grams.
Died 38 days after infection; weight 430 grams.
Autopsy: Infection site, nothing abnormal noticed
except an axillary gland 3x5 mm., normal in consist-
ency. Abdomen : Exudation and free feces found in
peritoneal cavity; quantity 2 c.c. Mesentery, injected
at gastroenteric margin. Kidneys, normal; left supra-
renal injected. Spleen, size normal, with dark red
borders ; otherwise normal. Testicles normal. Retro-
peritoneal glands normal. Liver normal. Diaphragm
injected. Lungs, normal.
Smears: No tubercle bacilli found in smears from in-
fection site and from peritoneal exudate.
Cause of death, probably injury. No Tuberculosis.
Excluded on account of early death.
Achard. Serum taken vii/20/14. G.P. No. 8. In-
fected subcutaneously in left axilla; weight 520 grams.
Killed 122 days after infection ; weight 590 grams.
Autopsy: Left axillary glands 3x2 and 2x2 mm.,
caseous. Mesenteric glands 2x2 mm., fibrous. Liver:
normal size; many small miliary patches scattered
throughout central and left lobe. Two large areas of
miliaries on border of left and central lobes, 3x2 mm.
Spleen: Nine fibrocaseous nodules. Lungs: 8 or 10
small gray tubercles scattered through lung.
Smears from left axillary glands, mesenteric glands,
liver, spleen, lung, all negative as to T.B.
Cultures for organisms of pseudotuberculosis, from
liver, spleen, lung, all negative. No Tuberculosis.
Achard. Serum taken vii/21/14. G.P. No. 12. In-
fected subcutaneously in left axilla; weight 365 grams.
Killed 122 days after infection; weight 560 grams.
Autopsy: Infection point not found. Mesenteric
lymph gland or fat, 2x1 mm. Liver apparently normal.
Spleen normal, dark. Lungs normal except for small
patch of consolidation in middle right lobe.
*For this group of principals and controls still an-
other source of guinea-pigs had been utilized. Two of
the animals were killed when first received; they were
found entirely normal on autopsy, and we were fortu-
nate in finding very little pseudotuberculosis among the
rest of these animals. It was a matter of great dis-
appointment that it was not possible to obtain enough
animals from this source for all our subsequent experi-
ments.
fSeveral of the persons who had furnished serum for
the preliminary experiments (see Table I.) were not
included in the present tests, because it was not prac-
ticable to obtain specimens of their blood.
138
MEDICAL RECORD.
[July 22, 1916
Smears for mesenteric gland or fat, from liver,
spleen, lungs, negative as to tubercle bacilli. No
Tuberculosis.
Achard. Serum taken vii/22/14. G.P. No. 21. In-
fected subcutaneously in left axilla; weight 405 grams.
Killed 123 days after infection; weight 600 grams.
Autopsy: Infection point not found. Spleen mottled.
Smears from spleen negative as to tubercle bacilli. No
Tuberculosis.
Storer. Serum taken vii/20/14. G.P. No. 7. In-
fected subcutaneously in left axilla; weight 480 grams.
Killed 122 days after infection, weight 480 'grams.
Autopsy: Left axillary lymph gland 3x2 mm., case-
ous; another 2x2 mm. normal. Spleen 3 whitish nod-
ules, 2x1 mm. Lungs normal except for 2 smail gray-
ish spots, Vixl mm. Smears from left axillary gland,
tubercle bacilli found; from spleen and lungs, no tuber-
cle found. Cultures for organisms of pseudotubercu-
losis, from spleen and lungs, negative. Tubercle bacilli
at Infection Point.
Storer. Serum taken vii/21/14. G.P. No. 14. In-
fected subcutaneously in left axilla; weight 350 grams.
Killed 122 days after infection; weight 510 grams.
Autopsy: Infection point not found. Mesenteric
gland, lxl mm. normal. Liver normal except for 1
small whitish patch on outer border of lefc lobe, and
1 on inner border of left lobe. Spleen mottled. Lungs
some intense mottling. Smears from mesenteric
glands, liver, and spleen negative as to tubercle bacilli.
Cultures for organisms of pseudotuberculosis from liver
and lung, negative. No Tuberculosis.
Storer. Serum taken vii/22/14. G.P. No. 19. In-
fected subcutaneously in left axilla, weight 340 grams.
Killed 123 days after infection ; weight 430 grams.
Autopsy: Infection point not found. Liver normal.
Spleen normal, dark. Lungs normal, a little mottled.
Smears from spleen no tubercle bacilli found. No
Tuberculosis.
Colebrook. Serum taken vii/20/14. G.P. No. 4.
Infected subcutaneously in left axilla; weight 510 grams.
Died 119 days after infection; weight 370 grams.
Autopsy: Enormously distended bladder. Infection
site: 2 lymph glands 4x3 mm., caseous. Spleen, 2
white patches, 4x2 mm. and 2x2 mm. Lungs intensely
mottled; one small greenish surface, lxl mm. on pos-
terior surface of lower left lobe; lower right lobe in-
tensely congested.
Smears: Tubercle bacilli found in axillary lymph
glands and spleen; none found in lung.
Culture for organisms of pseudotuberculosis from
spleen, Gram-negative coccobacillus found; lung nega-
tive. Generalised Tuberculosis.
Colebrook. Serum taken vii/21/14. G.P. No. IS.
Infected subcutaneously in left axilla; weight 415 grams.
Killed 121 days after infection; weight 500 grams.
Autopsy: Infection point not found. Spleen normal,
dark. Lungs slight anthracosis. Smears from spleen,
no tubercle bacilli found. No Tuberculosis.
Colebrook. No serum available on vii/22/14.
Henry. Serum taken vii/20/14. G.P. No 5. In-
fected subcutaneously in left axilla; weight 470 grams.
Killed 123 days after infection; weight 560 grams.
Autopsy: Open lesion at infection site; caseous.
Left axilla, lymph gland 2x1 mm., normal consistency.
Spleen normal size and appearance, except a slight line
across one end, 3 mm. long, whitish, suggesting scar
tissue. Mesenteric glands 6x4 mm., fibrocaseous.
Lung, 1 green spot, lxl mm., border of left upper lobe.
Smears: Infection site, axillary gland, spleen,
mesentric gland, no tubercle bacilli found.
Cultures for organisms of pseudotuberculosis, from
lungs negative. No tuberculosis.
Henry. Serum taken vii/21/14. G.P. No. 17. In-
fected subcutaneously in left axilla; weight 450 grams.
Died 119 days after infection; weight 420 grams.
Autopsy: Infection point not found. 1 mesenteric
gland, %xl mm., apparently normal. Liver normal
except for 2 minute whitish spots, %x% mm. Snleen
normal, mottled. Lungs: Top of right lung, nafch
%x2 mm., white; area of congestion in lower lobes
(marked).
Smears: Mesenteric gland, liver, spleen, lung, no
tubercle bacilli found.
Culture for organisms of pseudotuberculosis, from
liver and lung, negative. No tuberculosis.
HENRY. Serum taken vii 22 14. G.P. No. 20. In-
feeted subcutaneously in left axilla; weight 375 grams.
Killed 121 days after infection: weight 480 grams.
Autopsy: Left axillary lymph gland 4x3 mm. Spleen
slightly mottled.
Smears: Tubercle bacilli found in left axillary lymph
gland; none found in spleen. Regional, lymph-gland
tuberculosis.
F. J. C. Serum taken vii/20/14. G.P. No. 2. In-
kcted subcutaneously in left axilla; weight 450 grams.
Died 119 days after infection; weight 330 grams.
Autopsy: Infection site, 2 lymph glands, 2x2 mm.,
caseous. Mesenteric gland, lx% mm., fibrous. Spleen
normal in size; 2 fibrous nodules, 2x2 and lx% mm.
Liver normal except for 1 small whitish patch, lxl mm.
Lungs intensely mottled; 1 small gray nodule at base
of left lower lobe; 1 on lower border of upper lobe.
Smears: Mesenteric gland, spleen, axillary lymph
gland, tubercle bacilli found. Lung, no tubercle bacilli.
Cultures for organisms of pseudotuberculosis, spleen
and liver negative. Gram negative coccobacillus in
lung. Generalized Tuberculosis.
F. J. C. Serum taken vii/21/14. G.P. No. 11. In-
fected subcutaneously in left axilla; weight 375 grams.
Killed 121 days after infection; weight 495 grams.
Autopsy: Infection point not found. Spleen normal,
dark. Lungs a little anthracosis. Smears: Spleen, no
tubercle bacilli found. No Tuberculosis.
F. J. C. Serum taken vii/22/14. G.P. No. 24. In-
fected subcutaneously in left axilla ; weight 340 grams.
Killed 121 days after infection; weight 460 grams.
Autopsy: Infection point not found. Liver normal
except 2 minute whitish spots, under surface of left
lobe. Spleen normal size, mottled. Lungs, pneumonic
patch, central portion of upper right lobe.
Smears: Liver, spleen, lungs, no tubercle bacilli
found.
Culture for organisms of pseudotuberculosis: Liver
and lungs negative. No Tuberculosis.
Children.
Edwards. Serum taken vii/20/14. G.P. No. 3. In-
fected subcutaneously in left axilla; weight 570 grams.
Killed 123 days after infection ; weight 625 grams.
Autopsy: Left axillary lymph gland 4x3 mm., case-
ous. Spleen normal size, mottled; whitish patch at tip
3 mm. Mesenteric gland 2x3 mm., fibrous. Lungs in-
tensely congested; 1 minute greenish spot on lower
left lobe.
Smears: Left axillary gland, tubercle bacilli found,
spleen, mesenteric gland, lungs, no tubercle bacilli
found.
Cultures for organisms of pseudotuberculosis: Spleen
and lungs negative. Regional Lymph Gland Tubercu-
losis.
Edwards. No serum available vii/21/14.
Edwards. Serum taken vii/22 /14. G.P. No. 22. In-
fected subcutaneously in left axilla; weight 370 grams.
Killed 122 days after infection; weight 480 grams.
Autopsy: Infection point not found. Spleen normal,
slightly mottled. Lungs slightly mottled. Smears:
Spleen, no tubercle found. No Tuberculosis.
Francis. Serum taken vii/20/14. G.P. No. 9. In-
fected subcutaneously in left axilla; weight 540 grams.
Died 120 days after infection; weight 430 grams.
Autopsy: Infection point not found. One retroperi-
toneal lymph gland 1x2 mm., apparently normal.
Liver normal except for a few whitish spots %x%
mm. Spleen normal, mottled. Lungs intense conges-
tion.
Smears: Retroperitoneal lymph gland, liver, spleen,
no tubercle bacilli found.
Cultures for organisms of pseudotuberculosis: Liver
and lungs negative. No Tuberculosis.
Francis. Serum taken vii/21 ,'14. G.P. No. 15. In-
fected subcutanously in left axilla; weight 500 grams.
Killed 121 days after infection; weight 515 grams.
Autopsy: Infection point not found. Spleen normal,
very blackish. Smears: Spleen, no tubercle bacilli
found. No Tuberculosis.
Francis. No serum available vii/22/14.
Baby Duff (Infant). Serum taken vii/20 14. G.P.
No. 1. Infected subcutaneously in left axilla; weight
490 grams. Killed 123 days after infection; weight 610
grams.
Autopsy: Infection point not found. Liver normal
except for 1 minute spot, %x% mm., central lobe.
Spleen dark mottled. Mesenteric gland 3x2 mm.
Smears: Spleen, mesenteric gland, liver, no tubercle
bacilli found. No Tuberculosis.
Baby Duff. Serum taken vii/21 14. G.P. No. 10.
Infected subcutaneously in left axilla; weight 470 gms.
Killed 121 days after infection; weight 565 grams.
Autopsy: Infection point not found. Spleen normal
size, mottled. Lungs a little anthracosis. Smears:
Spleen no tubercle bacilli found. No Tuberczilosis.
July 22, 1916]
MEDICAL RECORD.
139
Baby Duff. Serum taken vii/22/14. G.P. No. 18.
Infected subcutaneously in left axilla; weight 365 gms.
Killed 120 days after infection; weight 525 grams.
Autopsy: Left axillary lymph gland 2x1 mm., appar-
ently normal. Liver normal except for 3 small whit-
ish patches, a2xl mm. Spleen normal, dark. Lungs
mottled, irregular anthracosis.
Smears: Liver, spleen, lungs, left axillary lymph
gland, no tubercle bacilli found.
Cultures for organisms of pseudotuberculosis: Liver,
gram negative cocco-bacillus. No Tuberculosis.
Controls for Virulence. — Normal Salt Control.
vii/20/14. G.P. No. 34. Infected subcutaneously in
left axilla; weight 385 gms. Killed 121 days after in-
fection ; weight 640 grams.
Autopsy: Open wound at infection site. Left axilla,
2 glands, 2x3 mm., caseous; cervical gland, 3x4 mm.,
caseous; Mesenteric gland 6x6 mm., caseous. Liver a
mass of small whitish patches. Spleen 3 times normal
size, a mass of fibrocaseous areas. Lungs a mass of
small tubercles. Mass of bronchial glands, 1 0x15 mm.,
caseous. Retrosternal 4x3 mm., caseous.
Smears: Mesenteric and retrosternal glands tubercle
bacilli found, liver, spleen, lungs, axillary glands, no
tubercle bacilli found.
Cultures for organisms of pseudotuberculosis: Liver,
spleen, lungs, negative. Disseminated Lymph Gland
Tuberculosis.
Normal Salt Control, vii/20/14. G.P. No. 33. In-
fected subcutaneously in left axilla; weight 335 gms.
Died 117 days after infection; weight 355 grams.
Autopsy: Left axilla, 2 glands, 7x4 mm., caseous;
right axilla, 1 gland, 2x3 mm., one 3x5 mm. Right in-
guinals, one 5x7 mm., one 2x3 mm., caseous. Left in-
guinals enlarged. Two cervicals 2x4 mm. Mesenteric
gland 2x3 mm., caseous, one 3x5 mm. Retroperitoneal
gland lxl mm., normal. Liver fibrocaseous masses,
2x2 to 4x7 mm., all lobes. Spleen 3 times normal ; fibro-
caseous masses throughout. Lungs a mass of tuber-
cles, all lobes. Bronchial glands, mass 4x6 mm., fibro-
caseous.
Smears: Infection point, mesenteric, inguinal and
bronchial glands, liver, spleen, lungs, tubercle bacilli
found.
Cultures for organisms of pseudotuberculosis: Liver
and lungs negative; spleen, a Gram-positive coccus.
Generalized Tuberculosis.
Normal Salt Control, vii/21/14. G.P. No. 30.
Excluded on account of leaky syringe, losing part of
contents.
Normal Salt Control, vii '21/14. G.P. No. 29.
Infected subcutaneously in left axilla; weight 350 gms.
Killed 120 days after infection ; weight 530 grams.
Autopsy: Open lesion at infection site. Left axilla,
mass of glands, 40x15 mm., caseous. Right axilla,
gland 6x6 mm., caseous. Mesenteric mass of glands,
10x15 mm., caseous. Liver, central lobe several areas
of fibrocaseous degeneration. Spleen four times nor-
mal; a mass of fibrocaseous nodules. Lungs, base
shows number of small tubercles and fibrocaseousi
areas. Mass of bronchial glands, 12x8 mm., caseous.
Smears: Left axillary lymph glands and bronchial
glands, tubercle bacilli found. Liver, mesenteric
glands, spleen, lungs, no tubercle bacilli found.
Culture for organisms of pseudotuberculosis: Liver
and spleen, negative. Disseminated Lymph-Gland Tu-
berculosis.
Normal Salt Control, vii/22/14. G. P. No. 26.
Infected subcutaneously in left axilla; weight 370
grams. Died 58 days after infection ; weight 490 grams.
Autopsy: Axillary glands 4x6 mm. caseous. Spleen,
5 areas 4x4 mm., caseous. Lungs, few white tubercles
at base, right lobe: otherwise normal. Peritoneal ex-
udate, 2 c.c, bloody. Left axillary gland, 2x2 mm.
Retrosternal gland caseous.
Smears: Axillary and retrosternal glands, tubercle
bacilli found. Peritoneal exudate, spleen, liver, lungs.
No tubercle bacilli found. Disseminated Lymph Gland
Tuberculosis.
Normal Salt Control, vii/22/14. G. P. No. 25.
Infected subcutaneously in left axilla; weight 335
grams. Died 97 days after infection; weight 320 grams.
Autopsy: Left axilla, mass of glands, 10 x 5 mm. case-
ous. Gland below left ribs 10 x 20 mm. caseous. Left
inguinal glands, 10 x 5 mm. caseous; 3x2 mm. caseous.
Adhesions small intestine to parietal peritoneum; omen-
tum adherent to stomach and spleen. Mesenteric gland,
3x2 mm. fibrous. Retroperitoneal, fibrocaseous gland,
3x5 mm., two 5x2 mm. fibrous. Intestines adherent
to liver. Liver, under surface, several whitish patches
up to 3 x 3 mm.; top surface all lobes similar. Spleen
mass of whitish nodules up to 3 x 3 mm., twice normal
size. Pancreas 2 x 11 mm. hibrocaseous. Peritoneal
exudate 2 cc. serous. Lungs, upper lobes deeply con-
gested; all lobes several (base) greenish patches lxl
mm. ; middle right lobe many greenish patches, lxl
mm.; few on right lower lobe. Left lung covered with
greenish patches, lxl mm. Mass of posterior medias-
tinal glands, 5x3 mm. caseous. Mass of anterior
mediastinal glands, 10 x 15 mm. caseous.
Smears: Left axillary glands, gland on margin of
ribs. Liver, pancreas, no tubercle bacilli found. Left
inguinal, mesenteric, retroperitoneal, posterior medias-
tinal, retrosternal lymph glands, lungs, tubercle bacilli
found.
Cultures for organisms of pseudotuberculosis. Liver:
Gram-negative coccobacillus. Spleen negative. Gener-
alized Tuberculosis.
Serum Controls.
Normal Human Serum, vii/20/14. G. P. No. 36.
Infected subcutaneously in left axilla; weight 355
grams. Died 117 days after infection; weight 400
grams.
Autopsy: Open lesion at infection site. One cervical
lymph gland 2x3 mm. caseous. Left axilla, mass 8 x
4 mm. caseous. Right axilla, 2x2 mm. fibrous. Omen-
tum 3 tubercles, 2x1 mm. Mass of mesenteric glands,
3x4 mm. Liver full of white fibrocaseous patches.
Spleen three times normal size; numerous fibrocaseous
nodules. Lungs a mass of small grayish tubercles.
Mass of bronichial glands, 6x8 mm. caseous.
Smears: Spleen, bronchial glands, left axillary
glands, tubercle bacilli found. Liver and lungs, no
tubercle bacilli found.
Cultures for organisms of pseudotuberculosis, liver,
spleen, lungs, negative. Generalized Tuberculosis.
Normal Human Serum, vii 20 14. G. P. No. 35.
Infected subcutaneously in left axilla ; weight 360
grams. Died 112 days after infection; weight 360
grams.
Autopsy: Open lesion near infection site. Two left
axillary glands 6x4 mm. caseous; right same, and one
fibrous. Left inguinal 6x4 mm. caseous. Peritoneal
exudate 2 cc. Omentum several small whitish tubercles.
Mesenteric gland, 6x6 mm. caseous. Liver, mass of
irregular whitish areas. Spleen mass of fibrocaseous
nodules. Pleural exudate 2 cc. Lungs, mass of small,
fibrocaseous tubercles. Left lower lobe, large fibro-
caseous area, 2x3 mm. Mass of retrosternal glands,
caseous. Mass of bronchial glands, 10 x 5 mm. caseous.
Smears: Right axillary, mesenteric glands, lungs,
tubercle bacilli found. Liver, spleen, brochial glands,
no tubercle bacilli found.
Cultures for organisms of pseudotuberculosis; liver
and spleen, negative. Generalized Tuberculosis.
Normal Human Serum, vii/21/14. G. P. No. 32.
Infected subcutaneously in left axilla; weight 375
grams. Killed 120 days after infection; weight 570
grams.
Autopsy: Left axilla, mass, 20 x 30 mm. caseous.
Right axilla, 3x2 mm. normal in consistency. Right
inguinals, 6x4 mm. fibrocaseous. In front of sternum,
gland 4x6 mm. Cervicals 3x4 mm. Mesentery,
mass 10 x 15 mm. caseous. Liver several small whitish
areas. Spleen 3 times normal; a mass of fibrocaseous
nodules. Lungs, base shows numerous small grayish
tubercles. Retrosternal glands, two, 4x4 mm., caseous.
Bronchial glands, mass 5x10 mm.
Smears: Mesenteric glands, tubercle bacilli found.
Left axilla, liver, lungs, retrosternal gland, spleen, no
tubercle bacilli found.
Cultures for organisms of pseudotuberculosis: Liver,
spleen, negative. Disseminated Lymph Gland Tubercu-
losis.
Normal Human Serum, vii/21/14. G. P. No. 31.
Infected subcutaneously in left axilla; weight 335
grams. Killed 120 days after infection ; weight 540
grams.
AutoDsy: Infection point not found. Mesenteric
Erland, 3x4 mm., fibrocaseous. Spleen normal, mottled.
Lun^s whitish nodule, 2x2 mm., in ri?ht upper lobe.
Smears: Mesenteric gland, spleen, lungs, no tubercle
bacilli found.
Culture for organisms of pseudotuberculosis: Lung,
Gram-positive thick bacillus. No Tuberculosis.
Normal Human Serum, vii/22/14. G. P. No. 28.
Infected subcutaneously in left axilla: weight 340
e-rams. Killed 120 days after infection ; weight 630
grams.
Autopsy: Infection point not found. Mesenteric
140
MKDICAL RECORD.
[July 22, 1916
gland, %xl :r,m., apparently normal. Spleen normal,
■nottled. Lungs normal except for one small congested
spot on left upper lobe.
Smears: Mesenteric gland, spleen, no tubercle bacilli
found. No Tuberculosis.
Normal Human Serum, vii 22 14. G. P. No. 27.
Infected subcutaneously in left axilla; weight 395
grams. Died 115 days after infection ; weight 450
grams.
Autopsy: A few cervicals, 2x3 mm., fibrous. Axilla?,
one on each side, fibrous. Peritoneum full of exudate,
20 cc. Liver, mass of fibrocaseous areas all lobes.
Spleen 8 times normal size, a mass of fibrocaseous areas.
Lungs intensely congested, full of small gray tubercles.
Mass of bronchial glands, 20x15 mm., caseous.
Smears: Liver, lungs, bronchial glands, tubercle
bacilli found. Spleen, no tubercle bacilli found.
Cultures for organisms of pseudotuberculosis: Liver
and spleen, Gram-negative coccus. Generalized Tuber-
culosis.
Twenty-three human sera are to be considered in
this experiment, and of this number, seven were
without lesions, eight had slightly discolored
patches or a questionable gland which proved to be
of non-tuberculous nature, and two had lesions
which can justly be interpreted as pseudotubercu-
lous, since no tubercle bacilli could be discovered in
them. Three proved to have generalized tubercu-
losis, while bacilli could be demonstrated only in the
regional lymph glands of the remaining three. This
summarizes a resistance to infection with tubercle
bacilli in seventeen animals of this group. If we
wish to exclude the two with pseudotuberculosis, we
have fifteen animals which totally resisted infec-
tion.
The salt controls designed to show the virulence
of these infections, all acquired tuberculosis,
whereas of the normal-serum controls designed for
comparison with the results obtained with immune
sera, four showed tuberculosis and two did not ac-
quire tuberculosis.
Our autopsies show that the sera from one of the
vaccinated individuals had resisted infection on the
three days, four on two out of the three days, and
four on one of the three days on which the sera
had been taken.
Active Immunization. — The treatment of the an-
imals to be considered consisted in the subcutaneous
administration of vaccine in doses of 1 to 5 milli-
grams, at intervals of about seven days, the doses
being increased or repeated, not under five days, ac-
cordingly as they appeared to be well borne. The
total number of doses varied from twelve to six-
teen and averaged fourteen for all animals which
outlived their treatment.
We have referred to the frequent deaths from
pseudotuberculosis, which occurred during the
treatment of the animals. We started with 104
guinea-pigs, and only 51 remained living and in
good condition when we proceeded to test their sera
with a view of determining their contents of spe-
cific amboceptors for the several antigens, and the
degree of morphological changes upon virulent
tubercle bacilli in vitro, with a view of selecting
those of the animals for infection, which would com-
ply with the standard heretofore mentioned as a
guide.
We have stated the difficulties which we encoun-
tered in the complement fixation tests. After several
attempts to overcome them, we had found only six
sera in which the titer reached the requirements ; in
the sera of the other animals, the results were only
partial or negative. But, inasmuch as no better
preparations of antigens were available, and the
presence of infection with pseudotubercle bacilli
might also stand in relation to our failures in ob-
taining satisfactory results, further tests were
abandoned and no additional serological studies
were undertaken.
An attempt was made to demonstrate lysis in
vivo by the reproduction of the Pfeiffer phenome-
non. Two guinea-pigs, Nos. 43 and 53 of the group,
that showed a complete complement-fixation, and
one, No. 14 of the group that showed a partial com-
plement-fixation, were selected for the experiment.
Each animal with a separate control was infected
with 200 times the supposed lethal dose of the cul-
ture employed in all these experiments. Exudate
was taken from the peritoneal cavity of each pig
and of its control, at intervals of two, four, six
and twenty-four hours after the infections were
made. The slides of this experiment were studied
and examined by Capt. S. R. Douglas who reported
that he could find no appreciable difference between
the exudates of the immunized animals and those of
their controls. These animals all died later;
tubercle bacilli were found in all lesions; no cul-
tures for bacilli of pseudotuberculosis were made.
Before infecting the treated animals, eight were
killed which had shown negative results in the com-
plement-fixation test, in order to ascertain the prob-
able prevalence of pseudo-tuberculosis. Five of the
eight showed lesions which were undoubtedly of
pseudotuberculous origin and the related organisms
were obtained in pure cultures from two of them.
This gave little prospect for a sufficient number of
unobjectionable experiments, inasmuch as we con-
sidered it but just to comply with Dr. von Ruck's
condition that normal animals were necessary in
order to resist infection, and that failures in ani-
mals which are diseased or have pseudo-tuberculo-
sis, must be eliminated from consideration.
The remaining forty-three animals were never-
theless all infected, together with controls, as will
appear in the following tabulation, because we
hoped that something of value might be shown on
their autopsies, to compensate us for the time and
labor expended upon their treatment.
In our tabulation it will be observed that we re-
cord our findings only in regard to the presence or
absence of tubercle bacilli, to the exclusion of the
examination of sections. In this respect we are
fully conscious that the simple presence of acid-fast
rods is, in itself, not an absolute proof of tubercu-
losis, and that it is essential to demonstrate typical
histological tubercles, in order to establish such a
diagnosis. For this purpose, specimens of all
doubtful lesions were preserved at the time when
the autopsies were made, but, in view of the great
prevalence of pseudotuberculosis, as found during
the course of the experiments, and because of the
fact that it would be necessary to exclude such ani-
mals from consideration, it was doubtful whether
the large amount of labor required for preparing
and examining sections was justified at all. The
question, which had been previously discussed with
Sir Almroth Wright, was decided by limiting the
examination to the search for tubercle bacilli in
smears made from caseous or macerated tissues, in
loth principals and controls.
Our results in these experiments are given in
three groups, corresponding with the degree of
complement-fixation observed in testing the respec-
tive sera.
It will be noted that our infections failed entirely
in several of our controls for the treated animals,
which obscures the results in the principals. The
July 22, 1916]
MEDICAL RECORD.
141
Table II.
GROCP I. COM.'LEMF.NT-FIXATION TEST POSITIVE.
Infection.
De*th.
TCBERCTLOSIS FOUND IN LESIONS.
PsErDOTTBERCULOSIB
Mode*
Dose.
Mgr.
Weight.
Gm.
Weight,
t'.m.
Lived.
Days
Infest. Site:
Reg.L.Glds.
Distant
L. Glands
< irgans
Degree
Culture
32 Principal
Control
50 Principal
Control
54 Principal
Control
73 Principal
Control
Intratracheal
Intratracheal
Intratracheal
Intratracheal
Intraperitoneal
Intraperitoneal
Intratracheal
Intratracheal
0.02
0 02
0 02
0 02
0 01
0.01
0 01
0.01
600
390
790
505
605
380
575
590
f.00
950
650
Mill
MHI
71.5
Died
Chloroform
' 'form
Chloroform
' 'MiTofonn
Chloroform
Died
Chloroform
73
73
111
111
111
111
10
91
0
Positive
(1
0
0
Positive
0
0
0
Positive
0
0
0
Positive
0
0
fi
Positive
0
0
(I
Positive
0
0
No record
0
No record
0
0
0
Slight
Slight
No record
0
No record
0
0
0
No record
Positive
» ' "VPLEMENT-FIXATION TEST PARTIAL.
1 Principal.
Control, . .
3 Principal.
■ ■
31 Principal
Control. . ,
42 Principal .
Control. ..
51 Principal. .
Control . . .
57 Principal. .
Control .
72 Principal .
Control
101 Principal .
Control . . .
Intratracheal
Intratracheal
Intraperitoneal
Intraperitoneal
Subcutaneous
Subcutaneous
Intratracheal
Intratracheal
Subcutaneous
Subcutaneous
Subcutaneous
Subcutaneous
Intratracheal
Intratracheal
Intraperitoneal
Intraperitoneal
1 0.01
540
690
0 01
430
510
0.01
550
770
0.01
340
660
0.01
4ii4
680
0.01
370
475
0 01
647
460
0.01
365
570
0 01
742
770
0 01
350
570
0 02
517
420
0.02
490
540
0 01
880
0 01
520
0 02
455
660
0 02
85
490
Chlcri
Chloi
Chlor.
Pseudotu i i
Chlor.
Died
Chloroform
Chloroform
Chloroform
Died
Chloroform
Chloroform
Chloroform
I 'hlorofonn
Chloroform
10S
ins
112
112
12
12
1C6
106
11:'
112
'4
104
11:1
113
104
104
0
Positive
0
0
0
0
0
0
0
0
0
0
0
Positive
0
Positive
0
Positive
(i
0
0
0
0
II
0
II
0
0
II
0
0
0
0
0
0
0
0
0
II
0
II
0
II
Positivl
II
Slight
flight
Slight
Slight
0
0
0
0
Slight
Slight
li
Slight
0
Marked
Marked
Positive
n
0
0
Positive*
0
0
0
0
0
!'. i'i\.
II
0
0
0
Positive
GROUP 3. COMPLEMENT-FIXATION TEST .NEGATIVE.
2 Intratracheal
5 Intratracheal
12 i Intratracheal
If. Intratracheal
20 [intratracheal
33 [Intratracheal
75 [Intratracheal
63 [Intratracheal
27 Intratracheal
37 Intratracheal
i.2 Intratrachela
65 [ Intratracheal
67 [intratracheal
on Intratracheal
102 Intratracheal
24
25
21.
30.
66..
70..
71
74
44 .
45..
16
52..
55..
56..
50
61..
Subcutaneous
Subcutaneous
Subcutaneous
Subcutaneous . .
Subcutaneous
Subcutaneous
Subcutaneous
Subcutaneous
Subcutaneous
Subcutaneous
Subcutaneous . .
Subcutaneous
Subcutaneous. .
Subcutaneous
Subcutaneous
Subcutaneous
0 02
465
550
0 02
560
.mi
0.02
S25
Ml)
0.02
Animal
lost
0.02
417
5S0
0.02
550
720
0 02
570
460
0.02
760
790
0.01
500
650
0.01
412
750
0 01
745
710
0.01
700
700
0.01
625
780
0.01
617
770
0.01
580
520
0.02
572
560
li 112
640
620
0.02
525
650
0 02
445
695
0.02
567
520
0.02
580
690
0.02
890
910
0.02
460
435
0.01
680
630
0.01
645
660
0.01
537
750
0 01
529
580
0.01
610
660
0.01
702
770
0.01
717
910
0.01
640
820
■ ''I
< 'hloroform
Died
I 'hloroform
Chloroform
PseudouibtTcuIosis
Chlonifnrai
Chloroform
Clili-Toform
Died
No cause
Chloroform
Pse udotuberculosis
Died
?
Chloroform
Chloroform
Chloroform
Pseudo and genuine tuberculosa
?
Chloroform
Pseudo and Pennine tuberculosis
No cause
V cause
Chloroform
Chloroform
Chloroform
Chloroform
Chloroform
Chloroform
S4
Posith .
Positive
Positive
Marked
Ot
85
0
0
ii
Slight
Positive
61
Positive
I'., itive
Positive
Mark! .1
Positive
84
Positive
0
o
Marl -1
Positive
84
0
0
II
Slight
57
Positive
ii
Marked
Positive
84
Positive
0
Positive
Marked
114
0
0
li
0
0
114
Positive
0
0
Slight
0
70
0
0
(I
Slight
Positive
70
Positive
0
0
Marked
0
117
0
0
0
Marked
0
114
Positive
0
0
Marked
0
61
Positive
Positive
Positive
Marked
0
121
No record
121
0
Positive
ii
Marked
0
114
0
I'.
Positive
Marked
0
114
Positive
Positive
Positive
Marked
0
91
Positive
Positive
Positive
Marked
Positive
102
0
Positive
0
Marked
ot
114
Positive
Positive
0
Marked
0
56
Positive
Positive
Positive
Marked
Positive
71
Positive
Positive
0
Slight
Positive
71
Positive
0
0
0
0
117
Positive
0
0
Slight
Positive
114
Positive
0
0
0
0
117
Positive
0
0
Slight
0
114
Positive
II
0
Marked
114
Positive
0
0
Slight
Positive
114
Positive
Positive
0
Marked
0
ONTROLS FOR GROUP 3
1 ! Intratracheal
2 Intratracheal
8 Intratracheal
9 Intratracheal
10 Intratracheal
4 Subcutaneous
7 Subcutaneous
11 Subcutaneous
3 Subcutaneous . .
5 , Subcutaneous
6 Subcutaneous
0 02
345
430
0.02
315
320
0 02
450
440
0 01
355
410
0 01
475
658
II H2
435
470
0.02
315
320
0 02
475
610
0 01
395
650
0 01
370
470
0.01
445
Chlor. ■
Tuberculosis
Tuberculosis
Chloroform
Chloroform
T;il'i'rculosis
No cause
Chloroform
('!>!,,roform
Pseudo and genuine tuberculosis
"i form
85
82
70
103
in.:
93
109
103
107
107
103
Positive
Positive
Positive
0
Positive
Positive
0
Positive
0
Positive
Positive
Positive
Positive
Positive
0
Positive
0
0
Positive
0
0
0
0
Positive
Positive
0
0
0
0
0
0
Positive
Marked
Marked
Marked
Marked
Slight
Marked
Slight
Slight
Slight
Slight
0
Positive
Positive
0
0
0
6
o
Positive
Positive
VIRULENCE CONTROLS
"Pseudo organisms cultured from blood.
fOnly fibrous lesions in internal organs .
^Tuberculosis in fibrous mesenteric gland.
^Cultured an anerobic bacillus from pleural exudate.
culture from which the emulsion was prepared, was
the same as the one used for the bactericidal ex-
periments, in which the infections with 0.01 mgr.
0 02
0 01
0.01
0.02
0.02
0.01
460
545
500
515
480
525
560
705
650
670
670
630
Doubtful
Form
form
Chloroform
Chloroform
Chloroform
15
63
122
93
93
122
0
0
0
II
Po itivi
Positive
e
0
Marked
0
0
0
Positive
0
0
2
3
4
5
6
Subcutaneous
Subcutaneous
Not exam
0
Positive
0
0
ined
0
Positive
0
appeared to have been very near to the minimal
fatal dose. Less than one week intervened, how-
ever, between these infections, and the only factor
142
MEDICAL RECORD.
[July 22, 1916
that we can consider as most likely to account for
the lack of virulence in some of the controls is,
that there was a difference in the number of living
tubercle bacilli contained in the respective emul-
sions. These were made in the same manner for
both series of infections, a sterile physiological salt
solution being used in their preparation, and the
emulsion was examined microscopically to assure
uniformity of distribution of the tubercle bacilli.
The bacilli were, however, weighed on different
chemical balances. Those for the emulsion used in
the bactericidal experiments were weighed on the
balance of the Inoculation Department, which ap-
peared to lack in accuracy. Consequently the more
sensitive balance in another department was re-
sorted to for weighing the tubercle bacilli for pre-
paring the next emulsion. Further, while the dose
of 0.1 c.c. of the emulsion, equalling 0.01 mgr. of
tubercle bacilli, for the bactericidal experiment, was
apportioned to the several tubes for incubation on
the same day on which the emulsion was made, that
employed for the infections under consideration
was made on the preceding day and stood for twen-
ty-four hours before it was used. It is therefore
possible that the number of tubercle bacilli was
less, because of more accurate weighing, or that
the normal salt solution favored the clumping and
spontaneous agglutination of the tubercle bacilli;
or then both conditions may have obtained and in-
fluenced the results. The emulsion was, however,
well shaken each time before the syringe was filled.
Under the circumstances we submit these experi-
mental results in guinea-pigs treated with vaccine
without other comment than that, as a whole and
irrespectively of dosage or mode of infection and
of the influence of pseudotuberculosis, they seem
to show a difference in favor of the treated animals,
which does not, however, appear decided enough to
warrant positive conclusion.* On the other hand,
our results in the bactericidal experiments were
clear in their import, and they appear to confirm
Dr. von Ruck's claims that active sera, taken after
one or more doses of vaccine, reduced the virulence
of tubercle bacilli in vitro sufficiently to prevent in-
fection in guinea-pigs, whereas in like experiments
with sera taken before vaccination, and in the vir-
ulence-controls of both series the animals acquired
tuberculosis.
We owe many thanks to Sir Almroth E. Wright,
who so kindly permitted the attempt to ascertain
the facts in regard to this work. His earnest co-
operation and desire to see at first hand the evi-
dence on which these claims are based was a source
of great satisfaction. It had been hoped that he
might add some personal comment on the results
and conclusions of this work. His journey with
the Expeditionary Force in France, from which he
has not yet returned, seemingly makes this impos-
sible. We also tender our thanks to Dr. Parry
Morgan who assisted during the earlier work, and
to Capt. S. R. Douglas whose continued interest,
and counsel were of great value to us.
*It is but fair to state that, on the conclusion of the
autopsies, a cable was sent to Dr. von Ruck, stating
that the experiments had been successful in about 43
per cent, of the treated animals, a conclusion which had
been arrived at by comparison with the controls, with
reference to the presence of absence of tubercle bacilli
in the lesions found on autopsy. It is on this account
that we believe the result to be in favor of the vaccine
and that, in order to obtain unobjectionable results, the
experiments should be repeated upon normal animals,
with infections in which the virulence of the cultures
is even and uniform.
REFERENCES
1. Karl von Ruck: A Practical Method of Prophy-
lactic Immunization against Tuberculosis; with Special
Reference to Its Application in Children. Pamphlet,
Asheville, N. C. 1912; Medical Record, 1912, LXXXII,
369.— also Journal Amer. Med. Assoc, 1912, LVIII,
1504.
2. K. v. Ruck & S. v. Ruck: Journ. Amer. Med. Assoc.
1910, LIV, 954.
3. K. v. Ruck & A. E. v. Tobel: Laboratory Technic
in Experimental Immunization against Tuberculosis.
Pamphlet, Asheville, N. C, 1914.
THE DIAGNOSIS AND TREATMENT OF
POLIOMYELITIS*
BY WALTER L. BARBER, M.D.,
WATERBURY, CONN.
A FEW years ago if I had been asked to prepare a
paper on this subject, it would have consisted of the
following sentence: The diagnosis of poliomyelitis
is not recognized until paralysis appears and, when
known, no treatment is of benefit. To-day, after
close study and experimental research, much has
been discovered and can be written on the subject.
The term poliomyelitis is in use because, on ex-
amination after death, it gives the method of classi-
fication, based on the lesion found. It is still popu-
larly known as infantile paralysis, probably because
it is more frequently seen in infants and young chil-
dren, although it does occur in adults.
As a preliminary to my paper, and that it may
serve the purpose of bringing before you the symp-
toms of the disease, I will give briefly the history
of a case.
D. C, the little seven-year-old daughter of one of our
wealthy men, was taken ill three days after her return
from her summer home at the shore. Previous to her
seizure, she had been in the best of health. From the
best information I could obtain, there had been no polio-
myelitic infection prevailing either there or in our city.
The onset came suddenly while she was at school. It
began with a chill, severe headache, a temperature of
102° or more, nausea and vomiting, muscular tenderness,
dilated pupils, and a little mental confusion. The symp-
toms were much like those of intestinal toxemia or acute
indigestion. By the fifth day I began to fear typhoid
fever and took the blood for a Widal test. She was then
suffering severe pain in her left arm and leg. The re-
flexes were normal at that time but I noticed a strabis-
mus of the muscles of the left eye and, when I asked her
to draw up the lower limbs, only the right one could per-
form the function. On the sixth day, the diagnosis was
evident from the partial paralysis of the muscles of the
left shoulder group and complete paralysis of the glu-
teals, quadriceps, and peroneals of the lower extremity
of the right side. The child could not sit up in bed or
move the leg. The faradic irritability was lost, as were
the reflexes of the patellar tendon. There was no im-
pairment of sensation or incontinence of urine. Marked
atrophy of the muscles did not occur. Improvement
soon began and continued. As time went on the muscles
of the arm regained their normal function. Her gen-
eral health was excellent and she began to play and to
use the muscles. Three months after the onset, a slight
spinal curvature was noticed and a limp, when walking,
was evident, showing cessation in the growth of the
bone. Soon after, at Christmas time, she developed
pneumonia and was very ill for six weeks, during which
time all treatment was suspended. As she began to get
about again, the improvement in her muscle tone was
very marked, all due, I believe, to the enforced quiet and
rest that was absolutely necessary for her while under-
going recovery from the lung affection.
In these days, the increasing prevalence of polio-
myelitis makes it one of the most important and
practical diseases for our investigation and discus-
sion. Each year, since 1907, has seen its epidemic
*Read at the meeting of the New Haven County
Medical Society, Oct. 2, 1915.
July 22, 1916]
MEDICAL RECORD.
143
somewhere which has left behind it hundreds of
victims. Massachusetts had 234 cases that year. In
1908 the disease raged in New York City, and more
than two thousand children were attacked. In 1914
it prevailed in epidemic form extensively in Ver-
mont. I am convinced that sporadic cases often oc-
cur with symptoms so mild and transient as not to
be recognized.
How helpful to the medical profession, then,
by way of the nasopharynx and along the lym-
continued work of Flexner and his co-laborers. In
their laboratory, through experiments with monk-
eys, they have discovered :
1. The disease is due to a germ, one of the filter-
able organisms, so minute that it can pass with
readiness, and with no loss of energy, through the
pores of a porcelain filter — the smallest one ever dis-
covered by the microscope.
2. By the action of this germ the disease be-
comes infectious and may, or may not, produce
cases, sporadic or epidemic in form, severe or mild
in type, depending on its activity and virulence.
3. The entrance of the virus into the system is
by way of the nasopharynx and along the lym-
phatics which follow the filaments of the olfactory
nerve to the cerebrospinal fluid.
4. The same portal of entry can, and probably
does, act as the pathway of exit for the germ, to be
transmitted by contact or carrier to new fields for
reinfection.
5. An early diagnosis of the disease, by the find-
ing of organisms in the spinal fluid, is possible but
not very probable.
6. One attack tends to afford protection from the
disease in the monkey, but up to the present time,
with any mixture of virus or serum, immunity in
the individual has not been accomplished.
Having stated these important and decisive facts,
we can briefly elucidate on the development of
poliomyelitis and its attendant results. When the
germ reaches the spinal cord by way of the spinal
fluid it at once begins active work on the lymph and
blood cells of the gray matter of both the anterior
and posterior horns, but chiefly the anterior. The
arterial supply is greater and richer at the lumbar
and cervical enlargements of the cord; which ac-
counts for the lesions found in these zones. When
the former is involved the muscular group of the
lower extremity is impaired, and when the inflam-
matory process impedes or destroys the cells of the
cervical ganglia the muscles of the upper extremity
are paralyzed. The irregularity in the branching of
these vessels of supply determines the question as to
left or right side paralysis. Of course, at the onset,
no one can foretell the result of the infection. It
may, or may not, affect the nerve cells. It will all
depend on the virulence of the organism and the re-
sistance of the patient. No doubt, many cases are
mild and abortive because of the small area con-
gested, the cell function being only incapacitated.
Paralysis generally follows the stage of invasion
within three or four days. The loss of motion may
be rapid or slow. With a severe attack, a large
number of voluntary muscles of one or both extrem-
ities are simultaneously affected. When the paral-
ysis is gradual, the muscle impairment extends from
one group to another, covering several days. The
leg muscles are often affected. Cases of partial
paralysis occur about twice as frequently as those
of complete paralysis. Loss of function in the mus-
cles of the spine is rare, and greatly to be deplored
because of its relationship to spinal curvature.
Muscles that have not improved in three or four
months will never entirely recover. Marked
atrophy then exists. The muscle is changed into fat
deposit and slowly disappears. This is due to the
degeneration of the cells in the anterior horn of the
gray matter of the cord, thus interfering with the
proper nutrition and function of the nerve and
muscle.
Having devoted a few minutes to the end results
of this insidious and much-dreaded disease, we will
take up one of the divisions of our theme — its diag-
nosis. Generally, the attack is so sudden — like a
flash out of a clear sky — that poliomyelitis is not
recognized until the paralysis makes plain the local-
izing of the infection in the spinal canal. Often, in
the morning, after only a restless night, the useless
member is discovered. If the onset is of three or
four days' duration and the cerebral symptoms are
unimportant, intestinal toxemia or the beginning of
typhoid fever may be suspected. Many abortive
cases or those unattended with cell destruction are
never diagnosed. Of course, the disease can be,
and often is, confounded with cerebrospinal menin-
gitis. Until more knowledge has come to us, I can
not see how, clinically, such a diagnostic mistake
can be avoided. The two diseases attack children
alike; are caused by organisms that reach the nerve
centers through a common portal of entry, the naso-
pharynx; and in both the infectious virus is elimi-
nated from the same site. Epidemic cerebrospinal
meningitis occurs generally in the winter months,
while epidemic poliomyelitis is said to prevail more
often in summer ; but neither one will prevail unless
the germ is at hand to convey it. In both cases the
spinal fluid should be withdrawn and examined.
The Kernig symptom — that is, an inability to extend
the leg on the thigh when the latter is flexed on the
trunk — is obtained in all cases of cerebrospinal
meningitis at some period of the disease; so, also,
are marked rigidity, petechia?, and opisthotonos,
which symptoms, as a rule, are never found in polio-
myelitis, except possibly in some of the bulbar
forms. As a matter of fact, the diagnosis probably
will not be made until the malady is self-evident.
The treatment of poliomyelitis, as in all diseases
due to germ infection, may be divided into two va-
rieties: first, the specific treatment directed to the
specific cause; second, the symptomatic, directed to
the morbid changes and their manifestation as
brought out by the symptoms. We now know posi-
tively— what had been for a long time suspected —
that the cause of the disease is an invasion into the
spinal canal of a horde of virulent organisms so in-
trenched that we are unable to destroy them or
lessen materially the damage they may inflict. In
our desire to assist the patient, increase his power
of resistance, and diminish the action of the infec-
tion, we must not forget those in health beside the
patient, who are quite liable to contract the infec-
tion. Every effort must be made toward prevention.
Isolate the patient and his surroundings; notify
the quarantine authorities; make the nurse and fam-
ily understand the absolute necessity of destroying
or sterilizing all articles that have come in con-
tact with the virus, which we now know emanates
from the nose and throat; keep the parts well
sprayed with solution of hydrogen peroxide; adopt
rigid precautions against the spread of the disease
such as have been essential in other infectious dis-
eases, and administer hexamethylenamine to the
unaffected members of the family. We believe, to-
day, that not only the patients are contagion car-
144
MEDICAL RECORD.
[July 22, 1916
riers, but the well ones who have come in contact
with the disease. It adds to the difficulty of pro-
phylactic measures, but it seems desirable to keep
the patient in quarantine for at least five weeks.
No organisms have been found, as yet, in the fecal
or urinary excretions, but I am convinced it is
wiser and much safer to disinfect them carefully
throughout the disease, at any rate at the onset, as
we are accustomed to do in typhoid fever.
There is no known specific or remedy for polio-
myelitis. Flexner and his associates, to whom the
writer is greatly indebted for some of the essen-
tials of this paper, have not, up to the present time.
succeeded in producing therapeutic serum that will
neutralize or destroy the effect of the virus, when
once the system becomes infected. Dr. Flexner
says: "Finally, the serum treatment of poliomye-
litis must, at the present time, be regarded as
strictly in the experimental stage, and it cannot be
predicted how soon, or whether ever at all, such a
form of specific treatment of the disease will be
applicable to the spontaneous epidemic diseases in
human beings." Personally, I have faith to believe
that, having discovered the nature and type of the
virus and so many important points in regard to
the phenomona of immunity, it will not be long
before a serum will be secured which will possess
sufficient therapeutic value to mitigate the end re-
sults of the disease or, at least, to prove of some
help in its prevention.
After accomplishing all that is possible in the
way of prevention, and having no measure of specific
treatment of value to offer, we must rely entirely
on the symptomatic medication. Naturally, the
bowels should be thoroughly evacuated — my favor-
ite drug being calomel, not alone for its bile-stimu-
lating effects, but also for its germicidal and anti-
septic qualities. An icebag should be applied along
the spine. The occurrence of convulsions would call
for the use of chloroform carefully administered.
The headache, tenderness of muscles, and extreme
restlessness require acetphenetidin in sufficient
doses to relieve and make comfortable the patient.
For these symptoms, however, in place of drugs, I
prefer to use heat in some form — the electric heat-
ing pad always when the house is wired for the
current. I know of nothing so valuable in that
form of muscle pain. Just how much good heat
does in thwarting the progress of atrophy that is
present in the later stage of the disease is a ques-
tion, but it is a helpful method of supplying warmth
to the affected parts which are generally from one
to two degrees of temperature lower than the un-
affected member. For a few days it is always best
to administer large doses of hexamethylenamine,
combined with benzoic acid for its germicidal
action. The use of this medicine is also based on
the fact that it is found in the cerebrospinal fluid,
and has already given some evidence of a favorable
action on inflammatory processes in the brain and
spinal canal. Flexner's experiments with this drug
showed that it had some immunizing effect, but was
of no value after the infection had occurred. Chil-
dren are not monkeys, however, and drugs may
operate on them differently. For example, Dr.
Lovett says: "In July, 1911, three children in
family were affected at intervals of three or four
days with fever, prostration, and gastrointestinal
disturbance. The diagnosis of the first case was
made only after the second child was in the height
of her attack and before the third was affected.
The first child received no hexamethylenamine, the
second had a little, and the third had large doses
from the beginning. The first child was severely
paralyzed from the waist down, the second had
weakness of the legs and back for a few months,
and the third had no muscular involvement. All
were equally sick." After such an observation, its
use early in suspected cases seems highly desirable.
Another drug that I want to mention is strych-
nine, to be given only after all inflammatory effects
have subsided. It acts directly by stimulating the
motor ganglin, thus counteracting the increasing
tendency to muscular atrophy. The consensus of
opinion is that its use favors nutrition of the para-
lyzed parts by its effects on the sympathetic nerve.
It should be given at first in small doses, increased
week by week, and continued over a long period.
It is just as beneficial when given internally as by
the subcutaneous method.
As regards the use of electricity in poliomyelitis,
authorities disagree, and quite emphatically too.
Last winter I asked Dr. William B. Pritchard of
New York to see a case with me (the one I have
reported), and he suggested the use of galvanism
in doses of five milliamperes for ten minutes every
day. This was continued for several months, or
until the muscles began to respond to the inter-
rupted current ; then both were used for months.
As a matter of fact, the child still continues to have
electricity, though away at the shore and under the
care of Dr. Wallace. Whether the treatment was
helpful, or in the least beneficial in improving the
muscular tone, or whether the condition — which has
been slow enough — follows the stimulation of
strychnine and the added nutrition to the impaired
muscles from good food, fresh air, and delightful
circumstances, I am unable to state. There are,
however, real doubters of its efficacy. Dr. Lovett
of Boston has this to say in regard to it: "Elec-
tricity is less highly regarded in the treatment
than was formerly the case. The unintelligent use
of it, month after month, to the exclusion of other
measures, has been one of the handicaps which has
stood in the way of the best progress in many cases.
It is quite possible that it may improve the muscu-
lar condition. Statements of its value rest, as a
rule, on bare personal assertion or on the un-
usually rapid improvement of the individual cases;
but cases vary greatly in their rate of improvement,
and the only way to judge of the value of electricity
is to use it on one side of the body in bilateral cases,
and use the other side as a control. In the winter
of 1913-1914 some cases in private practice were
given daily treatments of galvanic electricity on one
side and none on the other, while daily muscle-
training was being given by my assistant, who was
not told which side was receiving the electrical
treatment. At the end of some months she was
asked if either side had showed more rapid improve-
ment than the other, and no difference had been
noticed. This simply confirmed my general experi-
ence of many years of less careful observation." I,
myself, feel that the use of electricity is too often
left to the nurse or some other inexperienced per-
son. Applications, when used too long or misdi-
rected, fatigue the muscle and do harm.
Massage should go hand in hand with the elec-
tricity. It induces a better blood supply; hastens
the lymph along the channels; promotes a warmth
of the parts, thus preventing muscular deteriora-
tion. I have little knowledge of muscle-training or
the manner in which it is taught, but I do know that
such orthopedists as Lovett of Boston and Wallace
July 22, 1916]
MEDICAL RECORD.
145
of New York speak of this method with increasing
favor, especially in partial paralysis. Dr. Ruhrah,
in "Progressive Medicine," reviews the method, and
I quote: "The last part of the treatment consists
in muscle education. This is best done before a
mirror — the patient trying to move the muscle, and
when this cannot be done voluntarily, having the
person superintending the treatment make the nec-
essary motion. This is difficult in young children,
but can be tried in all children over three years of
age. This should only be continued for a short
time at one sitting. In the correction of deformi-
ties one should be particularly careful to avoid ex-
ercising the healthy muscles by improperly used ex-
ercises. The healthy muscles may be developed very
much more rapidly than the deformed ones, thus de-
veloping a worse deformity than when the treat-
ment was started. It is therefore necessary to ex-
plain to the one directing the treatment just what
should be done, and he should not deviate from the
directions given. . ." One voluntary contraction
of a muscle is now thought to be of greater value
than any produced by electricity.
In conclusion, I want to add that, for the de-
formities that must and will occur in all severe
cases, tendon transplantations and bone repair have,
by our steady advance in knowledge, reached a
stage of perfection never before equaled ; to an
expert orthopedist I commend early your case, if
improvement ceases.
*Child still employing slight support and using- elec-
tricity, July 16, 1916.
TREATMENT OF UNSTABLE SEMILUNAR
CARTILAGES OF THE KNEE JOINT.*
By ROYAL, WHITMAN, M.D.,
NEW YORK.
The disability first classified as internal derange-
ment of the knee joint is now recognized, as caused
in the great majority of cases, by displacement of
the internal semilunar cartilage.
The injury is comparatively common, but I am
inclined to think that its characteristics are more
familiar to those interested in athletics than to
physicians, many of whom have but the vaguest
ideas as to its causes and consequences. I shall,
therefore, describe briefly its anatomy as a basis for
argument in favor of effective treatment.
The semilunar cartilages are similar in structure
and function to the glenoid and cotyloid ligaments
that enlarge and deepen the articulating surfaces
about which they are attached. They differ, how-
ever, in that they are separated into two parts, and
being loosely bound to the margin of the tibia move
upon its surface through a range of about one cen-
timeter. In adaptation to the movements of the
joint, they change also in contour, becoming longer
and thinner in full extension, and correspondingly
shorter and thicker in flexion.
The internal cartilage, following the border of
the tibia, is more properly semilunar in outline as
compared to the external. It is more closely con-
nected with the lateral and capsular ligaments, and
is subjected to greater strain by the lateral mobil-
ity of the joint. At 30 degrees of flexion, for exam-
ple, the tiba may be rotated outward on the femur
through a range of 30 degrees, or until it is checked,
chiefly by tension on the internal lateral ligament.
Internal rotation, on the other hand, is limited to 5
or 10 degrees by the resistance of the crucial liga-
ments.
*Read before the Orthopedic Section of the New
York Academy of Medicine, April 21, 1916.
Displacement of the internal cartilage is
usually caused by external rotation of the tibia on
the femur, or by internal rotation of the femur
upon the fixed tibia while the knee is flexed. The
sudden strain upon the internal lateral ligament,
whose deeper layer is attached to the cartilage,
tears the latter loose from the margin of the tibia
and displaces its anterolateral portion backward
toward the interior of the joint, so that it is caught
between the bones when the limb is extended. The
general impression seems to be that the displace-
ment is in the other direction, and that the carti-
lage projects beyond the margin of the tibia, where
it may be detected on palpation. This, however,
must be very unusual.
In typical cases the injury occurs during violent
exercise, as in athletic contests. Thus in England
it is known as the "footballer's knee." There is a
sensation of sudden strain, and often of something
slipping within the joint, usually severe pain and
immediate disability, the characteristic symptom
being inability to extend the limb completely. Re-
placement may be spontaneous, but manipulation is
usually necessary. An effective method is to place
the patient on the back, and to flex the knee on the
thigh and the thigh on the trunk. One then abducts
the tibia on the femur to separate their inner mar-
gins, then rotates the tibia outward and inward and
extends the limb. During the manipulation the pa-
tient usually feels something slip, and free motion
is regained. Effusion often follows the accident,
and sensitiveness about the inner side of the joint
persists for several weeks.
The immediate treatment after reduction should
be fixation for a time sufficient for the repair of
the strained or ruptured ligament and reattachment
of the cartilage to the tibial margin. Apparently
for want of treatment, or in spite of it, such se-
curity is not often established, since recurrence is
the rule under predisposing conditions. If it oc-
curs at infrequent intervals the reaction is usually
severe. If it occurs often the joint becomes more
tolerant, the patient learns some effective method of
readjustment, or there may be no so-called locking
of the joint, the disability being rather from a sense
of insecurity than from the direct consequences of
the displacement. This insecurity limits activity,
not only in athletic contests but under ordinary
conditions as well. The patient instinctively avoids
predisposing attitudes and movements, and usually
knee caps, bandages, and even apparatus are worn
to assure security.
The injury is most common in young men, but it
is by no means rare in young women, and although
the immediate cause is injury, weak feet, weak
muscles, and bad attitudes must be recognized more
often as predisposing factors in this sex.
Occasionally, the consequences are more serious,
when, for example, the cartilage remains displaced,
so that limited motion, pain, and synovitis persist
indefinitely. In these cases partial recovery is ex-
plained by disintegration of the obstruction or ac-
commodation to its presence. In other instances,
the cartilage may be broken, or crushed by direct
violence without actual displacement, and there are
others in which injury or displacement is a com-
plication of degenerative changes in the joint.
This paper is chiefly concerned with the ordinary
cases in which the symptoms are recurrent, and are
directly dependent on the displacement. In this
class, although complete restoration of the function
of the cartilage may be possible, it is probably
uncommon, the so-called cure being in most in-
146
MEDICAL RECORD.
[July 22, 1916
stances simply an accommodation to the weakness.
A sense of insecurity is in itself a serious handi-
cap, while recurrent displacement endangers the
function of the joint. Repeated injury to the
synovial membrane which covers the cartilage leads
to hypertrophy; effusion to weakness; distention to
laxity of the ligaments; and the secondary mus-
cular atrophy which is almost always present in-
creases the functional disability. In cases of the
more serious type, changes characteristic of chronic
arthritis follow, which may serve as a predisposing
cause of tuberculous disease.
In cases, therefore, of persistent instability, in
which the inconvenience is at all serious, particu-
larly if a bandage or other support must be worn
constantly, removal of the cartilage is indicated.
The operation would be advisable even if the
cartilage were essential to normal function, since
if it is loose it is practically a foreign body. It is
not, however, thus essential. Experimentally, its
removal does not affect the movements of the joint,
nor is function impaired in those cases that have
been operated on.
It is true that stability may be assured in most
instances by a brace that prevents lateral mobility,
but the treatment is somewhat burdensome, the
outcome uncertain, and, if successful, the result no
better than that which is practically assured by the
removal of the unstable cartilage.
What may be classed as relatively early opera-
tive treatment is, I find, not usually advised or ap-
proved either by physicians or surgeons. The op-
eration is thought to be dangerous, requiring pro-
longed convalescence, and resulting in a weakened
or possibly stiffened joint. From practical experi-
ence, however, it may be stated that the immediate
discomfort and the succeeding disability are usually
no greater, and often are less, than when caused
by the occasional displacement. In fact, functional
recovery is far more often delayed by relaxed liga-
ments, atrophied muscles, and hypertrophied syno-
vial membrane — the results of persistent irritation
and injury — than by the operative removal of the
cause.
The only reasonable argument for delay when the
diagnosis is clear and the disability recurrent is
the danger of infection, and this may be reduced to
the most remote possibility by the simplicity and
directness of the operative procedure. In favorable
cases the cartilage may be removed in a few min-
utes. There is no necessity for exploration of the
joint, and the only assistance required is for re-
traction of the tissues.
Particular attention is, of course, paid to cleanli-
ness. If time permits the part may be shaved,
washed, and protected by gauze for several days be-
fore the operation, when it is prepared with iodine
in the usual manner. An Esmarch bandage is
usually applied in order to avoid swabbing and the
like. The patient is then drawn down to the edge
of the table, so that the leg, flexed to a right angle
at the knee, hangs dependent, as suggested by
Jones. In this attitude an incision, slightly convex
forward, is made midway between the border of
the patella and the condyle, its base being just in
front of the internal lateral ligament. The joint is
then opened. In most instances the displacement of
the cartilage is evident, since the tension on the
capsule of the dependent leg draws it upward and
away from the tabia. Not infrequently it is de-
tached anteriorly and displaced backward. It may
be fractured, or thickened and pedunculated, but in
the ordinary case it is not greatly changed in
shape. It may be normal in appearance or yellow-
ish in color if the disability is of long standing.
By extending the incision downward the cartilage
may be divided into two parts ; the anterior or free
half is then easily detached by a slight pull with
the forceps. The posterior part is attached to the
capsule, and often to the tibia, and must be sep-
arated with the scissors. It is the rule, apparently,
to cut away only the loose anterior portion, but I
have always removed the entire cartilage, and thus
a possible cause of further trouble. In most in-
stances, the evidences of previous irritation and
injury may be seen in congestion of the tissues, and
particularly in the hypertrophy of the synovial
membrane.
After removal of the cartilage the synovial mem-
brane is closed with fine catgut, and the capsule
and other tissues in layers with stronger sutures.
No drainage is used. The knee is firmly bound with
a gauze roller, and a light plaster splint holding the
limb in slight flexion is applied. Apparently the
bleeding after suturing is insignificant, since no in-
convenience has been noted from this source. The
plaster splint is of service in lessening the discom-
fort caused by sudden movements during the sensi-
tive stage. The patient usually remains in the
hospital for a week, though not necessarily in bed,
activity being regulated by the sensations.
The plaster splint is retained for about two
weeks, in order to permit of repair of the capsule.
The knee is then strapped to replace the support,
and to guard against strain.
The patient is instructed to cultivate an elastic
gait in walking. If, as is often the case, there is a
tendency toward valgus, the soles are thickened on
the inner border, or arch supports are applied if
the deformity is more marked, and appropriate ex-
ercises are prescribed.
In cases of a favorable type cure is practically
complete in a few weeks. In those of long standing,
in which the muscles are atrophied, the ligaments
relaxed, and the internal structure of the joint dis-
organized, recovery is slower, and a supporting
apparatus may be indicated, but the improvement is
immediately apparent and progressive and the re-
sult is satisfactory to the patient.
The characteristics of the varieties of the injury
and disability may be illustrated by selected cases.
Case I. — The unreduced type. A vigorous young man,
25 years of age, an acrobat by profession, was seen in
May, 1914. Three months before, while seated in a
chair with the left leg flexed beneath the seat, on turn-
ing suddenly he felt something snap in the knee. The
pain was acute, and he was unable to extend the limb.
The next day a physician attempted to reduce the de-
formity, but the pain caused the patient to faint. He
used crutches for a month, and had since limped about
with the aid of a cane. There was marked atrophy of
the thigh, slight limitation of extension at the knee,
slight outward rotation of the tibia, and the character-
istic sensitiveness to pressure on the inner side of the
knee. Operation was advised, but the patient was not
seen again.
Case II. — Illustrating secondary, or arthritic changes
following displacement. A woman 50 years of age was
seen in April, 1914. Apparently the knee had been
normal until injured by a misstep about 18 months be-
fore. The accident was followed by pain, swelling, and
inability to extend the limb. Apparently, although the
history was indefinite, flexion had since persisted. Nine
months after the accident an attempt had been made to
reduce the displacement, but without success. The patient
had since suffered much discomfort in the knee, and
the gait was very awkward because of the flxion to 140°.
The joint was infiltrated and sensitive to movement and
pressure. Degenerative changes in the joint were ap-
July 22, 1916J
MEDICAL RECORD.
147
parent in the a--ray picture. On operation, the internal
cartilage was found to be displaced, and of a yellow
color. The synovial membrane was thickened. The
articular cartilage of the femur was hypertrophied at
the margins, suggesting arthritis deformans. Flexion
contraction was so resistant that complete extension was
not attempted. In this case it was by no means cer-
tain that the arthritis was dependent on the injury, and
the prognosis was very guarded, but under rest, mas-
sage and protection, practically complete recovery fol-
lowed.
Case III. — Severe and disabling symptoms persisting
in spite of protective treatment. A colleague, 43 years
of age, displaced the internal cartilage in April, 1911.
This was treated by the most approved conservative
methods — by a plaster support, by a protective brace,
by strapping, massage, and the like for 6 months. He
was meanwhile never free from discomfort, and was
frequently disabled by recurrent displacements when
support was removed. Eventually he became seriously
alarmed because of the possibility of tuberculous dis-
ease, and consented to operation. In this case the car-
tilage was displaced and broken into two parts. Com-
plete and permanent functional recovery followed.
Case IV. — Illustrating persistence of disability for
many years. A man 39 years of age was seen in March,
1914, the disability dating from his school days. The
knee was weak, and he was constantly solicitous of it.
It gave way, and the displacements, which he reduced
himself, were becoming more frequent, and were fre-
quently accompanied by synovitis. He had worn various
appliances without permanent benefit. The cartilage
was removed June 16, the interior of the joint showing
the usual congestion. In three weeks the condition of
the knee was what the patient considered normal before
the operation. Recovery was practically complete in
6 months.
Case V. — A case of the favorable type. An athletic
girl of 19 was seen in October, 1913. About a year be-
fore, the cartilage had been displaced while she was
playing basketball. In August, displacement again oc-
curred, and also on three occasions since then, the pain
being so extreme that the patient's health has been im-
paired by it. The cartilage was removed in November,
1913. In three weeks she was practically well.
Case VI. — Removal of both cartilages. An athletic
girl of 20 was seen on April 6, 1911. She had injured
the left knee at basketball five months before. There
had been some pain and stiffness at that time, but no
limitation of motion or swelling. Conservative treat-
ment relieved the symptoms, but 6 months later high
kicking induced a severe attack. Since then the dis-
comfort had been constant, and the patient was often
conscious of something moving in the joint. The opera-
tion was performed on February 1, 1912. To my sur-
prise there was almost complete detachment of the ex-
ternal as well as of the internal cartilage, and both
were removed. Recovery was rapid, and practically
complete.
Case VII. — Illustrating occupational disability. A
man of 32 was seen on December 12, 1912. He was an
expert marksman, but the danger of displacement pre-
vented the necessary kneeling position. Removal of the
cartilage gave complete relief.
Case VIII. — Occupational disability. A young foot-
ball player who often displaced the cartilage when kick-
ing the ball. In this case the cartilage was very much
hypertrophied, and could be palpated by the patient him-
self. Removal relieved the symptoms.
Case IX. — Occupational disability. A school bey six-
teen years of age had been unable to engage in athletics
because of recurrent displacement during a period of
two years, and on this account desired relief. He was
practically well three weeks after the operation.
Case X.- — Illustrating the distinction in symptoms be-
tween displacements of the internal and external car-
tilages. A boy of sixteen was seen in August, 1914.
For three years a peculiar snapping sensation had been
noted whenever the knee was flexed. There was no lock-
ing, swelling, or local sensitiveness — only, as he de-
scribed it — a deadened feeling in the limb. On opera-
tion the external cartilage was found to be detached and
displaced backward, obstructing movement, and caus-
ing a peculiar jar and displacement of the tibia when
it was overcome. Recovery was complete and perma-
nent in three weeks. Several similar cases have been
seen in which a "snapping knee" was the most notice-
able symptom.
In my experience there is no operation more uni-
formly successful than this, or in the confirmed
cases more directly indicated, since a loose cartilage
is of no functional value, but is a dangerous en-
cumbrance to which the habits of the individual
and the structure of the joint must accommodate
themselves to their mutual disadvantage.
283 Lexington Avenue.
THE NATURE OF THE LEUKEMIAS; THE
PATHOGENESIS OF ACUTE LYM-
PHATIC LEUKEMIA.
By RICHARD STEIN. M.D..
NEW YORK.
VISITING PHYSICIAN TO THE GERMAN AND LEBANON HOSPITALS.
In this study I will attempt to bring the subject of
the nature of the leukemias to a clearer clinical
understanding by discussing some phases of this
large subject, partly as the result of personal ex-
perience, partly as the fruit of the study of the
large amount of material which has been gathered
together since Virchow's first description.
Virchow spoke of the affection as leukemia, the
disease with white blood, naming it from its most
charactertistic symptom. He noticed that in one
group of cases the most predominant clinical symp-
tom is a marked splenic engorgement, while in an-
other group multiple glandular swellings dominate.
Thus Virchow was led to differentiate a splenic form
of leukemia presenting a saturation of the blood
with white corpuscles containing polynuclear cells
from a lymphatic form of leukemia in which the
blood contains the lymphatic cells in large excess.
In consequence, Virchow speaks of a splenemia and
a lymphemia. Even at that date Virchow recog-
nized the universal implication of the lymphatic
tissue in the lymphatic type of the disease, as well
as the concomitant anemia, the oligocythemia.
Neumann's discovery of the hematopoietic func-
tion of the bone marrow and of the changes found
in the marrow in leukemic disease were of a nature
to modify the views originally held of the histo-
genesis of the leukemias as referred to above; the
splenic form of the disease was now shown to be
characterized by a myeloid metaplasia of the spleen
as well as of the bone marrow. Thus lymphemia
and myelemia were now recognized as characteristic
of distinct types of leukemia. Thus it already be-
comes apparent at this point that in the leukemias
we do not see diseases of distinct organs, but of
special types of tissues, the lymphatic and the mye-
loid. To study the pathology of the leukemias sat-
isfactorily, it becomes necessary to investigate the
changes in all the tissues, but especially those of
the hematopoietic organs. In them we shall find
the myeloid or the lymphatic metaplasia, according
to the character of the leukemia. The proliferations
are of a uniform character and easy of interpreta-
tion. Of late a number of chemical tissue reactions
have been devised which serve to differentiate the
lymphoid and the myelogenous tissues.'
The blood has been looked upon by some as a
tissue in which the various corpuscular elements
can be compared to the cellular structures, and the
serum looked upon as the intercellular structure,
just as if the blood were a stable woven tissue, not
simply an aggregation of cells suspended in a men-
struum. Following up this idea, the blood is imbued
with certain formative qualities of a developmental
as well as of a regressive quality. Led on by this
theory, as well as by the hope of incidental patho-
genic findings, many investigators of the diseases
of the blood have tried to find the solution of the
148
MEDICAL RECORD.
[July 22, 1916
mystery of leukemia in some special formation in
the blood itself. Invariably these investigators
have been misled by the will o' the wisp of the fas-
cinating polychrome blood morphology.
By many investigators leukemia was early looked
upon as a tumor formation, and the term metasta-
sis, which is still current in speaking of leukemic
proliferation, has been persistently used up to our
own time. Among modern authors, Banti, Rib-
bert and Benda are inclined to the tumor theory on
account of the seemingly aggressive character of
the leukemic proliferation into the surrounding
healthy tissues. This apparent malignancy, how-
ever, on close study proves to be nothing but a meta-
plastic overgrowth. Since we are still in ignorance
of the essential nature of malignant growth, a fur-
ther discussion of the theme, is leukemia a malig-
nant growth or not? seems fruitless. At the same
time it is advisable to discard the term metastasis
in this connection, as this term is associated exclu-
sively with the idea of malignant tumor growth;
this, however, is extraneous to the conception of
leukemic disease generally held at the present day.
This question of the tumor nature of leukemia
has more than a theoretical interest for the reason
that there is a class of cases which resemble the
leukemias in their clinical aspect, but which, as
soon as a blood examination is made, at once appear
as diseases of a totally different nature. The blood
in these cases is not leukemic and shows no special
characteristics more marked than those encoun-
tered in clinical conditions of various kinds. Since
Cohnheim cases in this group have been called the
pseudoleukemias. Lately cases of this kind have
been described which have stood for the first stage
of true leukemias. Then there are forms of pseudo-
leukemias which are of a tuberculous, granuloma-
tous or sarcomatous nature. Then there are cases
described from time to time which it is necessary to
group with the pseudoleukemias, their etiology be-
ing as yet undetermined, and because they are
surely distinct from the leukemias proper. By a
careful study of these cases we arrive at a certain
delimitation of the leukemias toward allied clinical
states, and incidentally widen our knowledge of the
pathogenesis of the leukemias.
Ehrlich's color analytical studies of the blood,
undertaken with a novel technique of fixation and
stain, have contributed a form of research which
can be employed to investigate with finesse the
morphological characteristics of the cellular ele-
ments of the blood. This method, as applied to the
study of leukemia, has given brilliant results.
It has been stated, in connection with this very
subject, that morphological hematology has been
very much overdone.' Morphological hematology
has been used in a one-sided, routine fashion; the
attempt is made to solve the pathological or biologi-
cal problems by the exclusive use of Ehrlich's
methods of color study of the blood constituents.
No doubt a great deal has been learned by this
method in leukemia and other so-called blood
diseases. But at the same time mention should be
made of the fact that some of the broad conclusions
which were drawn by Ehrlich himself in his original
studies of the granulations had to be considerably
modified. And as to the solution of some of the
problems of the origin, development, and course of
the conditions under discussion — just as in other
investigations — these can only be reached by im-
proved histological, bacteriological, and experi-
mental studies, w^hich, until recently, have not held
pace with morphological blood studies. Thus, for
instance, the theory of the evolution of the leuco-
cyte, based, as it largely is upon the study of mor-
phological hematology alone, can be seriously ques-
tioned. And with all the infinite pains which have
been expended upon the investigation of the his-
togenesis of this disease, the springing points from
it are still unsettled, and little or nothing has been
added to our conception of the pathogenesis and the
etiology of the leukemias. This is also in part
due to a preconceived notion still held by some of
the foremost hematologists, that leukemia — in view
of the phenomenal blood changes — are different from
all other known diseases. We shall see that this is
unfounded. By the empirical method of observation
the clinicians have brought the subject near to a
solution. Leukemia is based on well-known path-
ological and clinical processes.
What then is leukemia? In order to be as brief
as possible, I have cut the question in two or rather
in four, and will confine myself on this occasion to
the question: What is acute lymphatic leukemia?
Ever since Ebstein's3 publication of a case of
acute lymphatic leukemia and of his monograph, it
seemed more than probable that in acute lymphatic
leukemia we are dealing with an infectious dis-
ease. Subsequently Albert Fraenkel's* series of
cases could only tend to strengthen this view in the
unbiased observer.
It is not the purpose of the writer to describe in
detail all the clinical features of acute lymphatic
leukemia with a view to demonstrate the infectious
nature of the disease by analogy. For this purpose
Ebstein's work may be studied with profit. The
writer will attempt to prove the infectious nature
of the disease by selecting one or the other strik-
ing phenomena commonly observed in well known
forms of infectious disease which are similarly ob-
served in acute lymphatic leukemia — first then, the
phenomenon of leucocytosis, in this instance of
lymphocytosis. Furthermore, he will point out
certain clinical group characteristics observed in
leukemic disease which are invariably found in
the course of infectious diseases. Thirdly, he will
describe certain cases which have all the cardinal
signs of infectious disease and which are clinically,
hematologically and pathologically analogous to, if
not identical with, acute lymphatic leukemia. These
cases range through various degrees of severity,
from the comparatively mild type of infection to the
severer and the fatal cases. Hitherto leukemia was
invariably considered a fatal disease. By the study
of this group of cases it is made evident that the
light cases are nothing more or less than a phase
of the severe and fatal cases of leukemia. And
lastly by a short discussion of the status thymo-
lymphaticus, which presents an important element
in the pathogenesis of lymphatic leukemia.
Lymphocytosis. — According to Virchow, leukemia
is a progressive leucocytosis. This definition holds
good for all cases with rare exceptions. Now, aside
from certain well-defined physiological states like
hunger, digestion, pregnancy, lactation, and aside
from certain variations of the leucocyte count due
to stimulation or inhibition of the endocrine organs
and the phenomenon of anaphylaxis, leucocytosis is
exclusively and constantly associated with infection.
The phenomenon of leucocytosis moves in definite
cycles, varying in kind, number, and relative pro-
portion according to the nature of the infection —
according to certain principles of chemotaxis.
Thus, thanks to the labors of Ehrlich and his fol-
July 22, 1916]
MEDICAL RECORD.
149
lowers, we are now able to diagnosticate and prog-
nosticate infectious disease, according to the nature
of the accompanying leucocytosis. Thus in a well
marked infectious condition we are led to expect
a certain well-defined leucocyte count, which, in
conjunction with other signs, will indicate the char-
acter, phase, or stage of that case of infection. If
this count varies in the kind, number or proportion
of the leucocytes, we at once look for complications
to explain the atyphical or anomalous blood-count.
This rule is as invariable as a mathematical law.
In the present state of our knowledge it is not
easy to translate the formulas of the various leu-
cocyte counts into the formulas of the biological
blood reactions which give rise to the characteristic
leucocytosis under varying conditions. Clinical ex-
perience has shown empirically, that some of the
well-known infectious diseases instead of being ac-
companied by the usual polynuclear hyperleucocy-
tosis, exhibit a marked degree of lymphocytosis.
Among these may be mentioned variola, lues,
tuberculosis, typhoid fever, malaria, pertussis, and
some others. The infectious agent of each of the
diseases named produces in all subjects who are
successfully infected by them, not the ordinary
polynucleosis, but a lymphocytosis, absolute or
relative. There are certain infectious diseases on
record in which the lymphocytosis induced by some
special lymphotactic agent reached excessive figures.
How can this be explained? Primarily by the
character of the infective agent. All individuals
react in the same way — in a general chemotactic
sense — when infected with certain pathogenic bac-
teria. BergeF has shown that the lymphocytes con-
tain a fat-splitting lipolytic ferment. Applying
this lipolytic property of the lymphocytes to the
phenomena of infection, lymphocytosis may be de-
fined as an antagonistic reaction of the blood
(Abwehr reaction) against antigens of a lipoid
character. Thus it is possible to induce local lym-
photaxis by injecting fat into the peritoneal
cavity. The lymphocytes take it up and split it
up, by means of the lipase; the fat laden lymphocytes
are transported into the spleen. In looking into
the properties of the infectious agents of some of
the diseases mentioned above in which lymphocytosis
occurs, the bacillus of tuberculosis, the spirochete
of lues, we find that both of these germs have a
fatty covering; the lymphocytosis accompanying
these diseases may be explained on this basis. It
may be noted in this connection that as far back
as our knowledge of leukemia extends it has been
asserted that the disease develops on the basis of
certain forms of cachexia due to severe infection of
lues, malaria, or typhoid fever. We may infer that
severe infections of a lymphotactic nature may pre-
pare the foundation of a leukemic invasion — prob-
ably of a lymphatic nature — by unsettling the bal-
ance of the lymphatic and myelogenous tissue sys-
tems of the body. I will not dwell on the character
of the cells encountered in acute lymphatic
leukemia. It is not always the large lymphocyte
as Ebstein and Fraenkel thought. In children and
young individuals, the small so-called ripe lym-
phocyte may be the feature of the histological as
well as of the blood picture.
The infectious nature of acute lymphatic leu-
kemia must further gain support by drawing at-
tention to the clinical grouping of the cases recorded
hitherto, according to clinical type characteristics.
There is first the enteric type described by Mosler,
which is heralded by severe enteritis accompanied
by bloody stools. This suggests a primary infec-
tion of the intestinal tract. Then there is the pur-
puric or Werlhof, or scorbutic type with hem-
orrhages from mouth and nose and hemorrhages into
the skin purpuric enanthemata and exanthemata.
Then a type frequently observed starts with an
angina accompanied by glandular swelling of the
neck. Again we have an aggravated form of the
same type with ulceration and necrosis of the
mucosa of the throat and nasopharynx, occasionally
noma of the buccal membranes. In some of these
cases the Klebs-Loeffler bacillus, in others the bacil-
lus and spiral of Plant- Vincent's disease were found.
Although it must be conceded that catarrhal, ul-
cerative and necrotic changes in gums, fauces, and
nasopharynx may partake of a secondary constitu-
tional leukemic nature, the appearance of these
lesions at the time or shortly after the inception of
the disease with the accompanying infiltration of
the lymphnodes of the neck and jaw make it more
than probable that the tissues of the mouth, throat,
and pharynx serve as the portal of entry of the
leukemic infection, as they do in so many other
cases of infectious disease.
Through the kindness of Dr. F. E. Sondern I am
in the position to mention a noteworthy series of
cases of Vincent's disease which have been studied
by Dr. Sondern but not published as yet. Dr. Son-
dern has observed fifteen cases in children and
adults in which the bacteriological examination of
the throat demonstrated the bacillus and spiral of
Vincent's disease, and the blood showed a very high
grade of lymphocytosis. In fact, in cases which
were clinically diagnosed as acute lymphatic leu-
kemia and were subsequently investigated with
especial reference to the throat, the bacillus and
spiral of Vincent were found in the large majority
of cases (15 cases). These highly interesting ob-
servations call for further study. They seem to
me to be highly suggestive in demonstrating the
connection between a peculiar throat infection and
leukemic disease. On searching the literature I
find a similar case published by Beltz,1 from Frid-
rich M tiller's Klinik (Case VII). This was a case
of Vincent's angina, with an apparent acute lym-
phatic leukemia. The study of the organs, how-
ever, showed a myelogenous metaplasia. The
author is therefore inclined to consider it a case
of myeloblastic leukemia.
Acute Lymphatic Leukemic Disease; a Clinical
Form of Infection of Mild, Severe, and Fatal Type.
— -Above we touched upon the subject of lymphocy-
tosis as a specific positive chemotactic reaction,
against certain well-known infective agents. We
ascribed this phenomenon to which all infected sub-
jects react in the same manner to certain properties
of the pathogenic germs which come into play. I
will now deal with a group of infections accom-
panied by a remarkably high lymphocytic blood
count, often identical with the leukemic lymphatic
blood count. Sui-prisingly little is known of this
phase of the subject, either because the condition is
rare, which is not unlikely, or perhaps because little
attention has been paid to the subject. These in-
fections are caused by the ordinary germs of
catarrhal or purulent inflammation; they are the
well-known infections which nearly invariably go
hand in hand with the ordinary polynuclear leu-
cocytosis. Richard C. Cabot" has described some
of these cases under the heading of "The lymphocy-
tosis of Acute Infection." Clinically they may ap-
pear under the guise of an ordinary wound infec-
150
MEDICAL RECORD.
[July 22, 1916
tion, an angina, or enteritis. They are accom-
panied by a swelling of the spleen, liver, and lymph
glands and by high temperature. Kothe reports
cases of appendicitis with a very high lymphocytic
blood count from Sonnenburg's clinic. Dr. Chas.
A. Elsberg was kind enough to report to me twq
such cases. Evidently certain individuals in attacks
of appendicitis and other enteritic infections react
by a very high lymphocytic blood count. This fact
is not generally known.
A short time ago, the following remarkable case,
which at first looked like an ordinary head cold, came
under my observation: Male child, seven years old;
only child. Mother has chronic hyperthyroidism.
Child is subject to head and chest colds. Large
lymphatic tonsils at birth. Tonsillotomy and removal
of adenoids at five. Vaccination when six months.
Measles at four. Pertussis soon after. Milk grade of
anemia. Differential blood count normal when in
good health.
Present history: All members of household have
colds. Patient has head and chest cold. Remittent
temperatures 101° a.m., 101°-103° p.m. Enlarge-
ment of spleen, continuous, rapid. Liver can also
be distinctly felt. Moderate swelling of lymph
nodes all over the body, especially cervical and in-
guinal. At end of second week, lower border of spleen
at niveau of navel. Marked prostration. Duration of
illness three weeks. Blood examinations.
11
OS
Haemo-
globin,
per Cent
6
6
CO
a a.
-3-c OJ
11°
►J =•
111
.31*
J- O i-
Mi
o EJl
(0-g.S
p,
7th
21,900
19^
65
12' j
S
1 i
9th
73
3,744.000
22,500
36
45
16
i%
V,
12th
64
3,920,000
19,700
26«
62
8
H
3
22nd
74
3,880,000
10,200
38
38
16
3
4 1
Remarks: Red cells show some irregularities in size
and shape. They stain poorly. Widal test made on the
seventh day of illness absolutely negative. Blood culture
of same date also negative. Blood examination made
some months after illness shows normal blood. During
a severe cold, one year later, without fever, there were
6400 W. B. C, small lymphocytes, 21 per cent large
mononuclears, 16 per cent. The blood was examined
by Dr. A. L. Garbat. The case was twice seen in con-
sultation by Dr. Isaac Adler.
This child was one member of a family, all of whom,
at the same time had the usual winter's cold. The illness
started in with rhinitis, pharyngitis, subsequently a
light bronchitis developed. What first attracted my at-
tention was the considerable and progressive swelling
of the spleen, and the enlargement of the lymphnodes
which was generalized. The blood was then repeatedly
examined ; the blood-picture was typical of an acute
lymphatic leukemia in a child. It is true the degree
of lymphocytosis was not that of a full-fledged case,
but the condition having been discovered quite early it
gave promise of developing into a fully developed acute
lymphatic leukemia. Accordingly we were inclined to
make a serious prognosis. However, the symptoms
subsided, the lymphocytosis completely disappeared in
the fourth week, as also the swelling of spleen, liver and
lymph glands.
About the nature of the case, there can, I think,
be but one opinion. To speak of it as a catarrhal
fever with a severe lymphocytosis would not be an
adequate description, or give to the case the dis-
tinction it merits. It was more than that. The
case bore all the earmarks of an early stage of
acute lymphatic leukemia. It ended in recovery.
To designate it according to the usual clinical terms,
we were dealing with a primitive or abortive type of
acute lymphatic leukemia. Turk reports a small
number of similar cases, which also occurred in
children and young individuals. He speaks of these
cases as representing examples of the "lymphocytic
biological blood reaction." Inasmuch as these cases
are due to an apparent infectious cause, and end
in recovery, it is inferred that they are not cases
of true leukemia. For so far the infectious
origin of lekemia has not been demonstrable; the
cases of cryptogenetic leukemia have invariably
ended fatally. Long remissions may occur just as in
anemia perniciosa, but the outcome is invariably
fatal, except in one case of undoubted chronic
lymphatic leukemia reported by Turk which has
been well more than twelve years. Turk remarks:
It is a question whether these cases of lymphatic re-
action are identical with leukemia; but, he con-
tinues, they present the key to the whole question of
the nature of leukemia.
In addition to these comparatively mild and typical
cases, which clinically are analogous to, if not iden-
tical with what is usually looked upon as leukemia,
there is a record of a considerable number of cases
which clinically assume the form of sepsis asso-
ciated with changes in the blood and tissues of a
more or less typical leukemic character. The in-
fective or septic nature is at once apparent. The
course of the infection is also generally known, hav-
ing entered by way of the mouth, throat, internal
organs, bones, etc. Often to the surprise of the
observer, a typical or atypical blood find is inci-
dentally made. The combination of infection and
leukemia is generally looked upon as accidental, and
the observers are loath to accept the theory that the
leukemia is the consequence of the infection — all
the more so, as preliminary blood examinations be-
fore the advent of the present illness — are missing.
In the blood findings of the cases cited above
there happens a rather sudden and increasingly
complete absence of all but the smallest percentage
of leucoytes, other than the lymphocytes, with the
preponderance of the so-called large lymphocytes.
Turk interprets these cases as a complete inhibition
of the granulocytic elements ( Verkeummerung des
Granulocyteusystems). By that he means to imply
that under the influence of the septic poison the
myologenous tissues lose their ability to generate
new cells, thus very few or none are thrown into
the circulation, and complete lymphemia develops,
and with that the power to cope with the infection
ceases, and the patient dies of toxemia. I have gone
very carefully over the protocols of the autopsies
and the histological examinations of the tissues of
the cases of this class. Each of these cases is a
study. Any generalized statement as to histological
findings would be incorrect. The findings vary ac-
cording to the nature and the degree of the infec-
tion— the preponderance of the leukemic process in
this organ or that, and lastly the effect of the mixed
or terminal infection upon the blood forming and
other organs. In a general way it may be stated
that here, too, is found a uniform leukemic meta-
plasia pervading the tissues, just as in the crypto-
genetic forms of the disease.
In this connection I may be allowed to cite a
short history of a case — incomplete though it may
be, which possibly belongs here, from Dr. Waldo's
service in the Lebanon Hospital:
Young woman, family and personal history negative.
One child living and well. No history of abortus.
Menstrual history regular. Patient says that one week
before admission she felt weak and chilly. She then
noticed swelling of the face and gums. The last two
days, bloody flow from the vagina. Examination :
Swollen gums, enlarged glands of neck. Uterus not en-
larged, no signs of extrauterine pregnancy. Blood
exudes from the uterus. Pulse very rapid. Remittent
temperatures for four days. Between the fifth and
sixth day the temperature rises from 103° to 107".
Exitus. The following blood counts are significant:
July 22, 1916J
MEDICAL RECORD.
151
On entrance:
Hemoglobin.
"B.C.
R
55 per cent
2,690,000
10,000
75 per cent
25 per cent
55 per cent
2,5(10,000
25,000
3 per cent
97 per cent (mostly large)
30,800
99 per cent (mostly large)
1 per cent
W.B.C
Polynuclears
Lymphocytes .
Second blood examination:
Hemoglobin
R.B.C
W.B.C
Polynuclears
Lymphocytes ...
Third blood examination:
W.B.C
Lymphocytes.
Polynuclears
Status Lymphaticus and Acute Lymphatic Leu-
kemia.— So far we have tried to indicate the in-
fluence of infectious processes in the etiology of
leukemic disease, and although our knowledge of
the cause, the immediate and remote effect of the
pathogenic element upon the tissues is still dis-
connected and fragmentary, it now seems more
than probable, that certain infections which ordi-
narily are accompanied by lymphocytosis, may exert
an overwhelming lymphatic influence upon the
affected individuals. There follows a suffundation
of the tissues and generally of the blood too, by the
lymphatic cells of various stages of development,
and lymphatic leukemia results. And furthermore, it
seems that the most ordinary bacteria, those caus-
ing the commonplace infections and suppurations,
may, under peculiar circumstances, produce a lym-
phatic instead of a myelogenous blood reaction, a
lymphotaxis, instead of a myelotaxis.
Now every individual being exposed at all times
to the ordinary infections and very frequently also
to the diseases accompanied by lymphocytosis men-
tioned above, the question naturally arises, what
additional factor, exceptional though it may be,
is necessary to initiate leukemic disease — which,
after all is a comparatively rare affection. There
must exist some basic condition in the leukemic in-
dividual, in all probability some inborn character-
istics without which it is impossible for the leukemic
disease to take root.
This theory seems especially plausible in acute
leukemic disease, in which the symptoms of in-
vasion become apparent at the turning of the hand.
Acute lymphatic leukemia, the majority of which
cases occur in the very young, calls for an inherent
congenital disposition. Does this exist?
In his original description of lymphatic leukemia
Virchow points to the conspicuous enlargement of
the thymus. Since then we have learned, that in
children, lymphatic leukemia, which is always acute
in childhood, is regularly accompanied by thymic
overgrowth and by considerable enlargement of the
lymph glands of the neck, the submental and sub-
sternal region. In other words, acute lymphatic
leukemia in children and young subjects is regularly
grafted upon — the condition known as status thym-
olymphaticus. In the true interpretation of this fact
lies, I think, the solution of the other half
of the mystery of leukemia. Given a consti-
tutional basis — in this instance the thymic or
thymolymphatic state— then by the impetus of in-
fection an overwhelming stimulation to lymphatic
proliferation is created. We assume at the same
time, with Turk, an inhibition of the myelogenous
tissue reaction, partial or complete. The signifi-
cance of this extreme aberrant reaction is not
understood. It may be defensive in its nature. The
system succumbs to the leucotoxic influence upon
the blood and tissues, and to secondary or terminal
infection.
From a clinical point of view, the importance of
the recognition of the various forms of constitu-
tional deficiency can hardly be over-estimated. The
status lymphaticus is only one phase of develop-
mental insufficiency of interest in this connection.
Virchow taught us the significance of the hypoplas-
tic constitution and the Vienna school of patholo-
gists and clinicians, Rokitansky, Kolisko, Bartel,
Neusser, and many others have worked out the
various forms and combinations of constitutional
deficiency which form the pathogenic basis of leu-
kemic and other diseases hitherto wrapped in mys-
tery. I mention this to indicate that in leukemic
subjects other forms of constitutional deficiency
have been found besides the lymphatic state.
The function of the thymus being unknown, the
theory that in lymphatic leukemia a revivification of
the thymus takes place is hypothetical. In the
thymic state we do find a hyperplasia of the lym-
phatic tissue of that organ; in fact, the thymus
may become very prominent and has often been
looked upon as a tumor formation. What has been
said above regarding the tumor conception of leu-
kemic hyper- or metaplasia also applies to the en-
larged thymus;* there is no reason why it should
not be considered simply in the light of a hyper-
plasia of the lymphatic tissue, stimulated during
the leukemic process by some infection. What in-
terests us here specially is the influence of the
thymus on tissue growth and blood formation
(lymphocytosis), a question which is in the center
of discussion at the present time, as regards the
various aspects of thyroid disease. I will conclude
by mentioning a very interesting clinical observa-
tion : the influence of revaccination in the path-
ogenesis of acute lymphatic leukemia. In the first
case given in detail by Neusser," there was a very
strong general and local reaction, the lymphocytes
ran up to 90 per cent. The same author describes
another case after vaccination — with a sublymph-
emic blood count. Both individuals belonged to
the hypoplastic type. Wilbur' describes a similar
case. Evidently the patient belonged to the same
class, having 54 per cent lymphocytes in 8800
leucocytes. One week after vaccination there were
252,000 leucocytes and 94 per cent lymphocytes,
mostly large. The case ended fatally. We know
that variola is regularly accompanied by a pro-
nounced lymphocytosis. The pathogenic agent of
vaccinia is probably also a lymphotactic germ. To
sum up: The nature of lymphatic leukemia can
best be studied not so much by means of the hem-
atological method as from the broad standpoint of
clinical observation and pathological research.
Acute lymphatic leukemia is an infectious disease:
It may develop as the result of infection by patho-
genic agents, producing an overwhelming chemo-
taxis of a lymphocytic nature. But it can also be
produced by the staphylococcus and streptococcus,
and other pathogenic germs in individuals belong-
ing to the thymolymphatic type and other forms
of constitutional deficiency.
REFERENCES.
1. Beltz: Leukaemie mit besonderer Berricksichtigung
der akuten Form. Deutsche Archiv. f. klin. Med. 113.
1913-1914. Bengel und Betke: Myeloblastenleukaemie,
Frnnkf. Zeitschrift f. pathotoq. Anatomic, 1910, Bd.
IV., p. 87.
2. Discussion on hematological subjects, N. Y. Acad-
emy of Medicine, Jan. 15, 1916.
3. Ebstein : Ueber d. akute Leukaemie u. Pseudoleu-
kaemie D. Arch. f. klin. Med. Bd. 44, 1889, p. 343; and
Die Pathologie Therapie der Leukaemie, Stuttgart,
1909.
4. Fraenkel: D. wed. Woch., No. 39-43, 1895, p. 639.
5. Bergel: "Die Klinische Bedeutung der Lymphocy-
152
MEDICAL RECORD.
[July 22, 1916
tose," Verhandlungend. XXX Deutschen Congresses f.
innere Med., 1913, p. 334
6. Cabot, R. C. : "The Lymphocytosis of Infection,"
Am. Jovru. Med. Sc, 1913, CXIV, 335.
7. Wilbur: Leukemia — an Infection. Jour. A. M. A.,
Oct. 9, 1915, Vol. 65. No. 15, p. 1255. Nearly all the
literature on this phase of the subject can be found.
Some additional references are:
Turk: Klinische Haematologie, II; Theil, p. 222 and
p. 259.
Turk: Bezielungen der acuten Leukaemie zu den In-
fectioskrankheiten. Mittheil. d. Gesellschaft f. innere
Med. u. Kinderheilkunde, 1909, p. 89.
Eppenstein: Acute Leukaemie u. Streptococcusepsis
Deutsch. med. Woch., 1907, 332, p. 1984.
Hoist: Folia ha?matologica, I, 736.
Marchond, F. D.: Arch f. klin. Med.. 110. 1913, p.
359.
8. Warthin: Pathology of Thymic Hyperplasia,
Archives of Pediatrics, 26, 1909, p. 617.
9. Neusser: "Ausgewaehlte Kapitel d. Klin. Sympto-
matologie u. Diagnostik"; 4, Heft, Statisthymicolymph-
aticus, p. 212.
FURTHER OBSERVATIONS ON THE VALUE
OF SCARLET RED IN THE TREATMENT
OF GASTRIC AND DUODENAL ULCER*
By JULIUS FRIEDEXWALD, M.D.,
PROFESSOR OF GASTROENTEROLOGY,
AND
T. F. L.EITZ, M.D.,
ASSOCIATE IN GASTROENTEROLOGY.
UNIVERSITY OF MARYLAND SCHOOL OP MEDICINE AND COLLEGE OF
PHYSICIANS AND SURGEONS, BALTIMORE, MD.
IN a paper published two years ago1 we reported the
result of treatment of thirty-seven cases of peptic
ulcer with scarlet red, advocating the use of this
drug not as displacing the time-honored rest cure
treatments of Leube or the more recent cure of
Lenhartz, but simply recommending its employment
as a useful adjuvant in the treatment of this affec-
tion.
In this paper we noted the fact that John Staige
Davis was the first to suggest the use of this drug
in the treatment of ulcer of the stomach and to
prove its usefulness experimentally in animals.
"Scarlet red has the scientific name tolueneazotol-
ueneazo-betanapthol and is made by a combination
of amidazotoluol and betanapthol and has the for-
mula,
CH3 CII
/
C,.H, — N = N — CH — N = N — C10H„OH
(Beta).
It is a reddish-brown powder and gives a scarlet
red color. in oil solutions. The powder as well as the
oil solution is tasteless. Scarlet red is insoluble in
water, but is soluble in alcohol, ether, and olive oil."
Davis's conclusions as to the effect of this sub-
stance are as follows: "The dyestuff used in this
series of experiments is not toxic and apparently
has no deleterious effect on either dogs or rabbits.
When given by the mouth it is a fat-selecting vital
stain. In the course of months the stain is grad-
ually eliminated. Subcutaneous and intraperitoneal
injections stain only the fat in actual contact with
the scarlet-red oil solution. It is difficult to say
from these operative experiments whether the scar-
let red has, or has not, a definite stimulating action
on the epithelium of defects in the gastric mucosa.
However, the scarlet-red oil solution caused a more
rapid and better developed growth of epithelium in
the group in which it was used than occurred in
the duplicate group where plain olive oil was used.
*Read at the annual meeting of the Medical and
Chirurgical Faculty of Maryland, April 26, 1916.
The results with dry powder were not so favorable
experimentally, but this may have been due to the
fact that the material was not continuously in con-
tact with the denuded area. We were unable to
determine the relative effect of the scarlet red on
chronic gastric ulcers, as it was impossible to pro-
duce chronic ulcers in dogs with controls of exactly
the same size. Our experiments are suggestive, and,
as this dyestuff may be safely administered, we feel
that it is worthy of a thorough clinical trial."
According to our observations scarlet red may
be administered in doses of from 15 to 20 grains,
three or four times daily, without producing the
slightest toxic effect, provided a pure preparation
be employed (.Biebrich). It is best given in 71--
grain cachets, 2 of which may be taken three or
four times daily before meals. It may, however, be
administered in much larger doses, and only after
very large continuous doses can the odor of camphor
be detected in the urine. Not the slightest toxic
effect of this drug could be observed in any instance
during its employment in over one hundred patients.
We reported the results of treatment of thirty-
seven cases of ulcer in which scarlet red was em-
ployed in the course of treatment. In the largest
proportion of these cases a most beneficial effect
seems to have been obtained from its use. From
the use of the remedy the following conclusions
were drawn:
1. Scarlet red is a useful adjuvant in the treat-
ment of peptic ulcer.
2. While it cannot replace the usual forms of
treatment, when it is administered in conjunction
with them it frequently renders the cure more
effective.
3. As a help in the treatment of ambulatory cases
it is of great service, and its effect seems to be even
more favorable than that obtained from bismuth.
4. Its use need not in any way interfere with the
administration of other remedies, such as the alka-
lies or belladonna, when indicated, and, in fact, the
effect of the combination is at times most bene-
ficial.
Since this publication, the use of this remedy has
been noted by other observers. Zeublin1 found it of
value in a case of gastric ulcer with hemorrhage.
Einhorn3 points out its use in gastric and duodenal
ulcer and Jones' has employed it along with the
duodenal tube feeding, a daily close of scarlet red
in capsule being given by mouth, along the side of
the tube with apparently good results.
We have since employed this remedy in forty-five
more cases of ulcer with equally favorable results.
As in the last report we have not included those
cases in which the Leube or Lenhartz cure had been
undertaken and which have made uneventful recov-
eries, inasmuch as most of such cases would have
recovered without the help of any drug whatsoever;
but have included only those in which the result
of the rest cure was unsatisfactory and have added
the ambulatory cases of ulcer, which remained un-
benefited by the usual treatment.
Of these cases in which the remedy was em-
ployed sixteen were treated by the Leube rest cure,
eighteen by the Lenhartz treatment and eleven were
ambulatory cases. Of those treated by the Leube
cure thirteen or 28.8 per cent, were cured; two or
4.4 per cent, were relieved and one or 2.2 per cent,
was not relieved. Of those treated by the Len-
hartz method fourteen or 31.1 per cent, were cured;
two or 4.4 per cent, were relieved and two or 4.4 per
cent were not relieved. Of those given ambulatory
July 22, 1916]
MEDICAL RECORD.
153
treatment four or 8.8 per cent, were cured; four or
8.8 per cent, were relieved and three or 6.6 per cent,
were not cured.
When we consider the fact that all of these
cases resisted the usual treatment (that is, were
treated by the usual methods first and were not re-
lieved until the scarlet red had been administered),
the result is most encouraging. The results ob-
tained are much like those noted in our first report.
The results of treatment in the forty-five cases in
which scarlet red was utilized are illustrated in the
accompanying table. In it are noted respectively
the location of the ulcer, the dose of scarlet red ad-
ministered, the duration of treatment and its
effect.
Table Illi'strating the Effect of Scarlet Red :s the Treatment of Fortt-
fia'E Cases of Peptic Ulcer
Monthly Cyclopedia and Medical Bulletin, June, 1913.
2. Zeublin : Transactions of the American Thera-
peutic Society, 1913, p. 114.
3. Einhorn: Medical Record, July 18, 1914.
4. Jones : Transactions American Gastro-Enter-
ological Association, 1915.
Dosage
Duration
Form of
in Graias
of Treat-
No.
Name
Age
Sex
Diagnosis
Treatment
per
Diem
iii'"!' in
Results
1
J.S.
22
M.
Duodenal
Leube
45
4
Cured
2 T. F.
34
M
Gastric
Lenhartz
30
6
Not relieved
3 C.L.
26
M.
Duodenal
Lenhartz
60
4
Cured
4
H.T.
20
F.
Duodenal
Lenhartz
45
3
Cured
5
I.. P.
52
M.
Gastric
Leube
45
4
Cured
G
P. A.
64
F.
Gastric
Leube
60
5
Cured
7
J.J.
58
F.
Duodenal
Lenhartz
45
4
Cured
g
J.S.
44
M.
Gastric
Ambulatory
30
6
Cured
9
F.B.
49
M.
DuodenaJ
Lenhartz
40
4
Cured
10
K.S.
62
M.
Duodenal
Leube
45
5
Cured
11
T.M.
.'.7
F.
Duodena!
Lenhartz
60
3
Cured
12
N.P.
61
M.
Gastric
Ambulatory
45
5
Relieved
13
B.K.
47
M.
Duodenal
Lenhartz
40
4
Cured
14
O.T.
29
F.
Duodenal
Ambulatory
60
6
Not relieved
15
R.M
38
F.
Gastric
Leube
45
4
Cured
Mi
M.F.
17
F.
Duodenal
Lenhartz
60
5
Cured
17
K W
52
M.
Duodenal
Lenhartz
45
4
Relieved
18
F.P.
59
M.
Gastric
Leube
30
3
Cured
19
J.H.
28
F.
Duodenal
Leube
45
6
Cured
20
u C
71
M.
Duodenal
Leube
60
4
Relieved
21
L.D.
42
M.
G a? rric
Ambulatory
40
5
Cured
22
P.B.
'.-1
F.
Duodenal
Lenhartz
40
5
Cured
23
A.F.
54
F.
Gastric
Ambulatory
60
7
Relieved
24
T.B.
49
M.
Duodenal
Leube
60
s
Cured
25
L.K.
;
F.
Duodenal
Ambulatory
45
4
Not relieved
26
0. F.
.52
M.
Duodenal
Lenhartz
45
6
Not relieved
27
B.C.
40
M.
Gastric
Ambulatory
40
5
1
28
D.M.
47
F.
Duodenal
Leube
60
4
Cured
29
E.P.
69
M.
Duodenal
Lenhartz
60
3
Cured
30
G. C.
43
F.
Gastric
Leube
40
6
Not relieved
31
M.F.
38
M.
Duodenal
Lenhartz
45
6
Cured
32
O.L.
54
F.
Duodenal
Leube
60
8
Cured
33
R.S.
56
F.
G a? trie
Leube
45
7
Cured
1
S.V.
37
F.
Duodenal
Lenhartz
60
3
Cured
35
B.B.
68
M.
Duodeoal
Lenhartz
45
4
Cured
36
G. K.
44
M.
Duodenal
Leube
40
6
Cured
37
L.G.
47
M.
Gastric
Ambulatory
40
2.
Cured
38
K.B.
52
M.
Duodenal
Lenhartz
60
4
Relieved
39
J.S.
38
F.
Gastric
Ambulatory
45
7
Not relieved
40
M.R.
62
M.
Duodenal
Lenhartz
60
6
Cured
41
F.S.
56
F.
Gastric
Leube
45
8
Relieved
42
O.P.
29
M.
Gastric
Ambulatory
45
4
Cured
43
N. K.
31
M.
Duodenal
Leube
40
4
Cured
44
B.C.
i
F.
1 hiodenal
Ambulatory
60
6
Relieved
45
C. F.
2'.
M.
1 ruodi i a]
Lenhartz
45
7
Cured
From our experience with this remedy in the
treatment of the forty-five cases of peptic ulcer just
noted, together with the results in the thirty-seven
cases already reported, we believe we are justified
in drawing the following conclusions:
1. Scarlet red still remains a useful adjuvant in
the treatment of peptic ulcer and while it cannot by
any means replace the usual forms of treatment,
when administered in conjunction with them, it
adds materially to the effectiveness of the cure.
2. It is of great help when administered in the
ambulatory cases, the effect being even more fa-
vorable than the usual remedies, such as bismuth.
3. Inasmuch as scarlet red in no way interferes
with the administration of other remedies, such as
the alkalies or atropine, these may be administered
when indicated at the same time and in fact, the
effect of the combination is at times most beneficial.
REFERENCES.
1. Friedenwald and Leitz: On the Effect of Scarlet
Red in the Treatment of Gastric and Duodenal Ulcer,
A STUDY OF THE NORMAL BACTERIAL
FLORA OF POSTAGE STAMPS.
By ROBERT A. KEILTY, M.D.,
A N ! i
MR. PHILIP D. McMASTER,
PHILADELPHIA. PA.
(From the McManes Laboratory of Pathologv, University of
Pennsylvania.)
The purpose of this study was to determine the
normal bacterial flora of postage stamps, that is, to
get some idea of the general character of bacteria
found on stamps with especial emphasis in the
search for tubercle bacilli. Bacillus tetani, the colon
group, and diphtherial forms.
The literature on this subject is surprisingly
meager and but little record is made of the bacteria
of stamps. The subject is usually approached from
the viewpoint of the spread of infection by the
postal service as a whole, the infection by letters
and the fumigation of letters, and but little record
is made of infection by stamps or of the bacteria
of stamps.
In order to determine this fifty stamps were
bought in various stores in Philadelphia, including
the central office, branch offices, almost all the large
department stores, many drug stores, and some of
the small general stores. Most of the stamps were
bought from sheets and a few (3) from stamp
books. The character of the place was noted, its
general cleanliness, the clerk and his appearance,
and whether the stamps were placed on the counter
with the change or not. In almost all cases they
were presented with the glue side up showing that
the precepts of public hygiene have had this much
effect.
The clerk was then asked to place the stamp in a
sterile tube in which it was taken to the laboratory.
Each stamp was then smeared over blood serum,
agar, and a bouillon tube was inoculated and finally,
incubated in sterile water in a centrifuge tube for
twenty-four hours. This was centrifuged and the
sediment used to inoculate tubes of bouillon, Pet-
roff's medium, and smears made and stained for the
tubercle bacillus.
The first fifteen stamps were treated in this man-
ner, and among other growths, two which appeared
to be Micrococcus aureus were obtained, but as it
was believed that many more like these would be
found their pathogenicity was not tested. It later
appeared that on the remaining thirty-five stamps
no similar growths were found.
The other thirty-five stamps were treated in a
different manner. Each was cut in half, one-half
treated as were the first fifteen smeared on blood
serum, agar, and in bouillon, then centrifuged in
sterile water and the sediment used to inoculate
Petroff's medium, bouillon and smeared on slides
which were stained for the tubercle bacillus. The
other half was incubated in a centrifuge tube with
3 per cent, sodium hydrate for twenty minutes,
neutralized with normal hydrochloric acid and cen-
trifuged. The sediment was used to inoculate tubes
of Petroff's medium and smeared and stained for
tubercle bacillus. This method rendered two smears
stained for tubercle bacilli, two tubes of Petroff's
154
MEDICAL RECORD.
[July 22, 1916
medium and five of the ordinary media for each
stamp.
Concerning the growths found; all were nega-
tive with respect to tubercle bacilli, colon and
diphtherial forms. A surprisingly small number of
moulds were found, only six in all, with practically
the same number of Bacillus subtilis. A great num-
ber of non-pathogenic cocci were found of which a
large light yellow form and a small white glistening
form were most common. The pathogenicity of
these was tested in guinea pigs and found to be
negative, not even producing a swelling at the site
of inoculation. From their cultural characteristics
they were believed to be Micrococcus citreus Stern-
berg or M. flavus Flugge and M. dissimilis or M.
descidens for the small white form. Other micro-
cocci were found, small yellow forms which were
non-pathogenic and from their cultural characteris-
tics and behavior were believed to be M. luteus and
M. versicolor.
Five rod forms were obtained but these were
found to be of only two different forms, one a long
slender curved organism, the other a shorter and
broader form. These were found to be non-patho-
genic for guinea pigs. It is interesting to note that
two stamps were found to be completely sterile.
A summary of the results giving the probable
kinds of organisms found is as follows:
/■pmo11 .,.. f .1/- disHmilia
wu-. -,i smau --\M. decidens
r White iZ i l
1 I large 11 M. candidus or candidam
Micrococci 53
M. luteus
Yellow
(M.
\M.
{small t U, Versicolc
, „ < M. citreiis S
large 10 \M fiavus F
Sternberg
Flugge
Micrococcus aureus, possibly two growths.
Micrococcus auranti/as, one.
Moulds, six.
Bacillus subtilis, four.
Percentages :
Micrococci (non-pathogenic), 81.
Moulds. S.
B. subtilis, 5.5.
Other bacteria (non-pathogenic), 5.5.
The majority of the stamps showed one or more
organisms but in no single instance were they found
to be pathogenic in type. This does not exclude
the fact, that under favorable conditions certain
pathogenic types, which would resist drying to a
certain extent, might not be carried on a postage
stamp. On the other hand the work proves the
stamp to be a carrier of organisms and these could
readily be transferred from one individual to an-
other. This would only be of importance where the
organism was pathogenic. We have in mind a drug
store where one of the members of the druggist's
family had advanced tuberculosis. His sputum as
well as his feces contained may bacilli, he had a
hacking cough and was in the habit of protecting
his mouth with his hand while coughing. During
busy times he often served customers, and not in-
frequently dispensed stamps to children who would
immediately moisten them with their mouths and
paste them to letters. A single exposure in this
case might prove negative, but the constant ex-
posure in some cases would undoubtedly end in
infection.
We are in debt to Mr. H. McC. Miller for much
valuable assistance in the routine work of this paper.
Conclusions.
1. A study of fifty stamps obtained from as
many different sources, clean, dirty and indifferent,
showed bacteria in every instance except two.
2. With the possible exception of two cases no
organism pathogenic in type was encountered.
3. Aside from hygienic reasons it Is dangerous to
lick postage stamps on the ground that the stamps
are bacteria laden and under favorable conditions
might easily convey pathogenic types, especially
colon, diphtheria and tubercle bacillus.
4. We would therefore advocate a movement to
have installed in all places dispensing postage
stamps a moistening device of some type. This
movement could be started with beneficent results
in the post-offices of the United States Government.
jH?frrol*r.al Notes.
Incompetent Hypothetical Question — Whether Acci-
dent Caused Disease. — In an action for injuries re-
ceived in a street car collision, claimed to have resulted
in a tumor on the breast and traumatic neurasthenia,
an expert witness for the plaintiff was asked: "Doctor,
referring to the suppositions or hypothetical patient
and taking into account the elements of the hypothesis,
have you an opinion, as a medical man, and based upon
reasonable certainty, as to what was the cause of the
neurasthenia and the tumor in the hypothetical pa-
tient?" A. — "Yes, sir." Q. — "What is your opinion
as to the connection between this disease and the
tumor or growth in the breast?" A. "That the tumor
resulted from the bruise — the injury to the breast. The
neurasthenia resulted from the shock of the accident,
and was kept alive by the breast condition." The Illi-
nois Supreme Court held that the questions were im-
proper, as invading the province of the jury and calling
for an opinion on an ultimate fact. Where there is a
conflict in the evidence, as in this case, as to whether or
not the party suing was injured in the manner charged,
it is not competent for witnesses, even though testifying
as experts, to give their opinions on the very facts the
jury is to determine. Whether or not the collision in
this case caused traumatic neurasthenia in the plaintiff
or caused the tumor in her breast were ultimate facts
upon which the jury must make their findings. It is no
more proper legally for physicans to settle these ques-
tions for the jury by their direct answers than it would
be for a motorman of another street-car company to set-
tle the question of negligence by testifying in broad
terms that the defendant was guilty of negligence be-
cause the motorman failed to cut off the power by use of
the canopy switch in time to prevent the collision. The
rule in such cases is not different where hypothetical
questions are put to the expert witnesses. A physician
may be asked whether the facts stated in a hypothetical
question are sufficient to cause a certain condition, or he
may be asked whether a given condition may be caused
by the facts stated in the hypothetical question. But he
should not be asked whether or not such facts did cause
such condition or malady. In cases where there is no
dispute as to the manner and cause of the injury, and no
dispute that there was an injury sustained by reason of
the acts of which compaint is made the Illinois Supreme
Court has held that a physician may then testify that a
later malady was or was not caused by the accident or
original injury, upon the same principle that he may tes-
tify that death resulted from a certain wound. The phy-
sicians having stated that the plaintiff's tumor and
neurasthenia were caused by the collision, the jury had
to award large damages under this evidence. Judg-
ment for the plaintiff was reversed and a new trial
granted. — Fellows-Kinbrough v. Chicago City Rv. Co.
(111.) Ill N. E. 499.
Malpractice — Evidence. — In an action for malpractice
in diagnosing and treating the plaintiff's dislocated
shoulder as a sprain, the evidence conflicted as to wheth-
er the defendant applied the usual tests by inserting the
fingers in the armpit and placing the patient's right
hand on the opposite shoulder with the elbow pressed
against the side or chest. The injury was sustained on
February 3, 1912, at which time the plaintiff alleged the
shoulder was dislocated. It was held that evidence of
physicans that they found on March 25 following that
there was a dislocation was admissible when considered
in connection with evidence of a sufficient cause of dis-
location on Feb. 3, and the evidence of the plaintiff and
his wife that the shoulder had suffered no injury be-
tween February 3 and March 25. It was held that the
evidence of dislocation and of the defendant's failure to
properly diagnose the case was sufficient to take the
case to the jury. — Hoffman v. Watkins, Washington
Supreme Court, 155 Pac. 159.
July 22, 1916]
MEDICAL RECORD.
155
Medical Record.
A Weekly Journal of Medicine and Surgery.
THOMAS L. STEDMAN, A.M., M.D., Editor.
PUBLISHERS
WM. WOOD & CO., 51 FIFTH AVENUE.
See fourth page following reading matter for Rates of Subscription
and Information for Contributors and Subscribers.
New York, July 22, 1916.
IS THE PRESENT ILL-REPUTE OF SPINAL
ANESTHESIA DESERVED?
The sudden vogue attained by spinal anesthesia
several years ago is still fresh in our minds, but we
search in vain for like popularity to-day. The
method, in this country anyway, appears to have
fallen into desuetude, in spite of the ardent claims
formerly made for it. The reason for this abrupt
decline from favor would probably be summed up
by the average physician as three in number: Un-
reliability of action, disagreeable after-effects, and
a high mortality. And yet we get reports from
anesthetists who have used the intrathecal method
in large numbers of cases which deny the first and
the last of these reasons and report the second as
practically negligible. The suspicion naturally
arises then that perhaps some error of technique
has been responsible for the lack of success reported
hitherto.
Several hundred cases were reported by Dr. C. G.
Holman in the Lancet for May 6, with no bad re-
sults other than severe temporary headache in a
few cases, readily relieved by aspirin. Holman be-
lieves that novocaine is less toxic than stovaine,
being led to that opinion by experiments which he
made on rabbits; the maximum dose is 0.075 gm.
Apropos of this dosage he comments on the
fact that an example of the bad results pub-
lished was in a case in which 0.15 gm. was
given to a patient 68 years old. The posi-
tion recommended by this writer is lying on
the side with the knees drawn up and the back
rounded. In the same periodical for June 10, Dr.
Page, who not long ago reported a series of pro-
statectomies under spinal anesthesia, and Dr. Chap-
pie speak a good word for this form of anesthesia in
those cases where a more complete muscular relaxa-
tion is desired than can be obtained under the ordi-
nary "deep"" anesthesia, and where it is essential to
minimize shock. Seventy cases of pelvic operations
were reported with nine deaths, none of which could
be attributed in any degree to the anesthetic. These
were for the most part cases in which a general
anesthetic was contraindicated — heart and kid-
ney cases, alcoholics, excessively obese persons, etc.
Dr. Page's practice was to put the patient in the
Trendelenburg position after the injection of the
anesthetic, a procedure which is not generally known
in this connection. A complete flaccid paralysis of
the lower half of the body was obtained, extending
sometimes as high c.3 the second rib; this dis-
appeared shortly after the operation. Dr. Chappie,
who did the operation in nearly all of these cases,
remarks that some of the patients could not have
been operated on at all except by this method.
These writers also report an occasional headache
lasting a short time.
With these favorable reports at hand, it would
seem that a recasting of some of the opinions of
spinal anesthesia currently held would be necessary.
It is quite evident that the method should not be
attempted except by one who is thoroughly versed
in its technique, as an incorrect position of the
patient, a failure to reach the spinal canal, a with-
drawal of too much or too little fluid, an injection
of too small or too large a dose, may cause either a
failure to obtain anesthesia or collapse during the
operation.
THE DISTRIBUTION OF TETANUS TOXIN.
It is the general belief at the present time that
tetanus toxin, elaborated at the point of infection
and growth of the organism, passes up along the
axis cylinders of the motor nerves to the central
nervous system where it combines with the cells for
which it apparently has a special affinity, and, as a
result of this combination, changes take place
which produce symptoms.
In the course of his extensive studies upon this
disease, Robertson has devoted a certain amount of
time to an effort to determine how the toxin is dis-
tributed in the body and how it makes its way from
the periphery to the brain. He reasons very clearly
(American Journal of Medical Sciences, clii, 1916,
31) that theoretically it is difficult to understand
how tetanus toxin, which admittedly has a high
degree of affinity for nerve cells, may travel along
an axis cylinder without combining with it. The
axis cylinder is merely the process of a cell, and
logically the toxin would be expected to combine
with it and therefore remain in place. He asks
very pertinently if this is "a hitherto unknown
affinity to travel?" He points, however, to the
demonstration of lymph channels in the substance
of nerve trunks, and records several of his own suc-
cesses in injecting them. It is naturally difficult to
trace them, for the usual methods of section and
ligature of the nerve would, of course, obliterate the
lymph channels, and moreover these spaces are
blocked by degenerating myelin material whenever
a nerve is cut. Given, therefore, the existence of
this lymph stream, it would certainly be the natural
path for the passage of any substance in fluid form.
Robertson goes carefully into the experimental evi-
dence on hand and shows that none of the results
exclude the possibility of transmission in this way.
He then cites some experiments of his own which
he considers to have weight in the support of his
side of the discussion.
The author of this interesting paper makes out a
very strong argument. The theory which is now
dominant has always been a difficult one to accept
upon philosophical grounds, and Robertson's is much
more plausible. There are still points which need
elucidation, and it is desirable that the lymphatic
156
MEDICAL RECORD.
[July 22, 1916
system be studied more intensively. Weed and
Wegefarth have shown that the spinal fluid drains
out, to a very slight extent, through the perineural
lymph channels, but were unable to demonstrate any
influx of fluid into the cerebrospinal cavity except
from above. The existence of lymph channels with-
in the substance of the nerves trunks and of a cur-
rent in them carrying fluid toward the brain, is a
fact of considerable importance if it can be fully
demonstrated. It would be interesting to know the
destination of this fluid, for it has been the experi-
ence of most investigators that very few substances
find their way into the cerebrospinal fluid in spite
of this apparently easy pathway. Thus this work
is of considerable importance not only in its con-
nection with the treatment of a dangerous disease
but also because of its relation to the physiology of
the nervous system.
A PHILANTHROPIC POSSIBILITY.
Probably we have all indulged in that most agree-
able of all phantasies, the picturing of what we
would do with boundless wealth. Some of us would
erect model hospitals, some pattern medical schools,
give scholarships to needy but earnest disciples of
iEsculapius, send them abroad to study, etc., etc.
Nevertheless it is sometimes very difficult to know
just what to do with all of the unearned increment.
After the organized charities have been appeased,
the poor relatives made comfortable for life, and
religious duties recognized, the question arises as
to the proper disposition of the remaining thou-
sands destined for charity.
Let us then suggest for the relief of these dis-
tressed millionaires a scheme by which they can
help to reduce infant mortality at small cost. To
explain it fully we must go back some ten years to
the time when one Benjamin Broadbent was elected
Mayor of the Borough of Huddersfield, England.
Having always taken a strong interest in the prob-
lem of infant mortality, and having viewed with
alarm its prevalence in his community, he offered a
birthday gift to every child born within the village
of Longwood, in his borough. This took the form
of a promissory note for one pound sterling, pay-
able when the child should become one year old. The
natural consequence was that parents awoke to the
fact that the survival of their babies depended
somewhat on the care they received. Their pride
and interest were aroused, and they determined to
keep their children alive through that first year, not
only because of the five dollars, although that was
a large sum to many of them, but for the sheer
sake of winning. Best of all, Mayor Broadbent's
unique scheme attracted so much attention to the
subject of infant mortality, especially in his own
borough, that it became a kind of headquarters for
the study of the subject.
Why, then, does not some philanthropist set in
motion a similar scheme in some district in the
United States where the mortality of babies is
high? There is little doubt but that he would be
doing good, and the only drawback to the proposi-
tion would seem to be the almost certain result that
about 50 per cent, of the fortunate babies would
bear their benefactor's name for life.
Twlight Sleep Again.
Little has been heard recently of that form of am-
nesic analgesia known as twinght sleep, it is only
a few months ago when it was a fruitful theme for
discussion, not only in medical journals but in the
lay press. At first it was heralded, chiefly in maga-
zines, as one of the most beneficent procedures ever
introduced and its good features were so lauded out
of all proportion that it was difficult to take an un-
prejudiced view of its distinctive points. However,
one is able now to consider the method judicially and
to pass upon the drawbacks or merits in a sane man-
ner. In Surgery, Gynecology and Obstetrics for
June, Dr. Charles B. Reed has a paper on the sub-
ject in which he reviews his experiences in the use
of the method. He states that from observation of
cases treated by himself and others the belief has
been reached that the morphine-scopolamine anal-
gesia is entirely harmless to both mother and child
when properly administered. He regards the treat-
ment as successful in his hands, since 29 per cent
of his cases were practically, and 56 per cent en-
tirely, free from pain, or 85 per cent in all. The
strength is conserved and the convalescent period
shortened. Whether or not the woman gets up ear-
lier is a question of uterine involution rather than
one of days or strength or treatment. The main
thing is that she feels better much sooner. It is
Reed's opinion that primary pain, weakness, hemor-
rhage, prolapsed cord, and a lack of correlation be-
tween the size of the pelvis and the child make con-
ditions that are unfavorable for twilight sleep. He
does not believe that twilight sleep can be produced
in every case, but it does no harm, he says, when
properly used and he is convinced it will act hap-
pily in about 85 per cent of the cases selected with
due regard to contraindications. He regards it as
a valuable and permanent addition to the resources
of the obstetrician, and says that much of the
antagonism to it arises from an inability or an
unwillingness to bestow upon a woman in labor the
uremitting attention and the higher technical pro-
ficiency which these cases demand. The above is
interesting testimony in favor of a mode of over-
coming some of the unpleasaut features, notably
pain, of parturition, and is not altogether in har-
mony with the experience of many other observers.
Spontaneous Chronic Nephropathy of the Dog.
Although chronic nephritis in the dog is quite a
common disease, and the fact has been recognized
by many investigators, nevertheless it has appar-
ently been overlooked to a certain extent and no
really adequate study of the subject has been under-
taken. The matter is very important, for the dog
is an easily obtainable animal which has been used
largely for experimentation and the question of
proper controls is an essential one. MacNider has
undertaken an investigation of the subject and re-
ports his findings in a recent paper (Jovr. Med.
Research, 1!" 16, xxxiv, 177). Out of a total of two
hundred and thirty-seven dogs, forty-two had con-
stantly or intermittently an albuminous urine with
various types of casts, and at autopsy showed un-
questionable evidence of kidney injury which was
farly diffuse in its distribution. Eighteen other
animals showed localized areas of kidney injury but
were excluded from this series. Of the forty-two
animals studied, the changes in eighteen were con-
fined very largely to the glomeruli. In the remain-
der the changes were of the same type but in a more
advanced stage. In several there was sclerosis of
July 22, 1916]
MEDICAL RECORD.
157
the renal arteries. No acute inflammatory changes
were observed. There was apparently very little
effect upon the tubular epithelium. When these ani-
mals were made acutely nephropathy by uranium it
was found that the action of the drug was practic-
ally the same as upon the normal kidney while the
regenerated epithelium which was formed in the
course of healing of a uranium nephritis was more
resistant to the action of this drug than was normal
epithelium. The work is very interesting and the
article will bear careful study. Careful controls
are even more essential in animal experimentation
than in many other varieties of research and in this
special instance the controls are apparently rather
difficult to obtain.
Visceral Inversion.
So-called heterotaxia has now been placed on
record at least 170 times. Many cases are autopsy
finds, while of the clinical material not much has
been radiographed. Simple dextrocardia is ex-
tremely rare and has been encountered as a familial
affection. Much the greater part of the material
is made up of complete heterotaxia. Electrocardio-
grams have been obtained in both forms, naturally
accompanied by skiagrams. A. de Castro of Rio de
Janeiro with two colleagues has been able to place on
record three cases of complete heteroataxia within a
very brief period. This would of course suggest
that the condition cannot be so very rare (Archives
des maladies du occur, etc., May, 1916). All three
subjects had pulmonary tuberculosis. The heart's
action was normal (in simple dextrocardia, on the
contrary, the heart's action shows modification). In
none of the patients was there evidence of morpho-
logical anomaly of any sort. All of them were right
handed. The spleen could be recognized on the right
by physical exploration. In one of the patients the
heart, stomach, liver, and spleen were transposed,
but not the intestine.
Sfoum of ifo? Wnk
The Poliomyelitis Epidemic. — There has been a
progressive increase in the number of new cases
in this city during the few days preceding the
present writing, but it is hoped, nevertheless, that
the height of the epidemic has been reached. The
total number of cases reported up to July 20 is
2,327, the deaths being 455. Dr. C. E. Banks of the
United States Public Health Service has been or-
dered here from Milwaukee to take charge of the
work for prevention of the spread of the disease
outside of the city. The Rockefeller Foundation
has donated $50,000 to aid in the work of dis-
covering and keeping under observation su
carriers of the disease. Dr. Alvah H. Doty, for-
mer quarantine officer of the port of New York,
has been appointed administration officer in
charge of this work and he has under him a con-
siderable staff of physicians and nurses. The
laboratory investigations are under the supervision
of Drs. Lavinder and Frost of the U. S. Public
Health Service. The use of adrenalin, as recom-
mended by Dr. Meltzer at the special meeting of the
Academy of Medicine on July 13, a report of which
is presented on page 167 in this issue, has been tried
this week with apparent success in a number of
cases at the Throat, Nose and Lung Hospital. The
remedy was given in 2 c.c. doses every six hours,
and was followed by marked improvement in the
paralysis as well as in the general condition.
Cuban Quarantine Against the United States. —
The Cuban sanitary authorities have adopted
quarantine restrictions against United States chil-
dren on account of the epidemic of infantile pa-
ralysis. In the future children arriving from
American ports who have an abnormal tempera-
ture will be isolated until the trouble is diagnosed,
while children in normal health will be kept under
surveillance until the danger of developing infan-
tile paralysis has passed.
Poliomyelitis Clinics. — The Department of
Health, through the cooperation of various hos-
pitals which are treating a large number of cases
of poliomyelitis, has arranged a series of clinical
lectures to physicians. These clinics are to be
conducted during the week commencing Monday,
July 24, at the following hospitals: Willard Parker
Hospital — Dr. Philip Van Ingen and associates, 4-5
P. M., Monday, Tuesday, Wednesday, Thursday, and
Friday. Kingston Avenue Hospital — Dr. Louis
Ager and associates, 4-5 p. M., Monday, Tuesday.
Wednesday, Thursday, and Friday. Mf. Sinai Hos-
pital— Dr. Herman Schwarz, 4-5 P. M., Monday,
Tuesday, Wednesday, Thursday, and Friday. Belle-
vue Hospital — Dr. J. S. Ferguson, 4-5 p. M., Tues-
day, Thursday, and Saturday. Babies' Hospital —
Dr. Charles Gilmore Kerley, 4.30-5.30 p. M. Tuesday
and Thursday. S/cinburne Island — Dr. Frank Clark,
4-5 p. M., Thursday and Friday.
New York State Commission for Boy Train-
ing.— At the recent session of the Legislature of
this State a bill was passed providing for physical
training of not less than twenty minutes each day
by all pupils eight years of age and over in the
public and private schools in New York State.
The program to be followed is to be determined
by a commission composed of the Major General
commanding the National Guard (Gen. John F.
O'Ryan), a member appointed by the Board of
Regents of the University of the State of New
York, and one appointed by the Governor. The
choice of the Regents fell upon Dr. John H. Fin-
ley, Commissioner of Education, and the Governor
has appointed Dr. George J. Fisher chairman of
the Committee on Awards and Scout Require-
ments of the Boy Scouts of America.
Prize for the Best Artificial Hand.— The Royal
Surgical Society of London, according to The Sun.
has received a gift of a large sum of money to be
offered as a prize to the inventor of the best arti-
ficial hand. Competitors will have to exhibit per-
sons who have worn the hands for at least six
months.
The American Field Ambulance in France,
which now has 150 cars in service, has been made
an independent unit and separated from the am-
bulance organization at Neuilly. A. Piatt Andrew
will continue as chief inspector and will be assisted
by Stephen Gallatin of New York. Of the cars
now in service 125 are on the Verdun front. New
cars are being fitted out, and young men are coming
from the United States to drive them, so that by
the end of August 200 cars will be in service, or
five times as many as a year ago. The Field Am-
bulance will have a suburban villa, where the
drivers can rest when on furlough.
Death of the Kaiser's Laryngologist. — It is re-
ported from Amsterdam that Dr. Friedrich W. K.
von Ilberg, to whose care was intrusted the man-
agement of the chronic throat affection from which
the German Emperor suffers, died in Berlin on
July 9.
American Hospital Unit in Bohemia.— The
158
MEDICAL RECORD.
[July 22, 1916
American hospital unit, consisting of four surgeons
and four nurses from the American Physicians'
Relief Association, has been assigned to Pardowitz,
Bohemia, where one of the largest and most up-to-
date hospitals in the empire, with a capacity of
10,000 patients, is located. The surgeons are Drs.
Martin, Moore, Corby, and Mincke.
Another Red Cross Hospital Ship Torpedoed. —
The National Headquarters of the American Red
Cross in Washington announces that they have
just received the following cablegram from the
Central Committee of the Russian Red Cross in
Petrograd: "On July 8 about 9.00 o'clock in the
morning the hospital ship V'Peryod of the Russian
Red Cross having all the external marks required
by the Hague Convention was torpedoed and sunk
about thirty-two leagues from Batum, near the vil-
lage of Vitse (on the Black Sea) by an enemy sub-
marine. There were eight deaths and seven
wounded among the crew and sanitary personnel
of the ship. All hostile governments had been
notified of the equipment of the V'Peryod as a
hospital ship. All possibility of a mistake is ex-
cluded. We protest with most profound indig-
nation against this new crime."
American Physicians Wanted in London Mili-
tary Hospitals. — Sir William Osier has sent word
to a number of American surgeons that there are
vacancies for 120 young American medical grad-
uates in the military hospitals of London and its
immediate neighborhood. The term of service is
six months. There will be a small salary and pas-
sage will be paid both ways. Applications will be
received by Dr. Richard Cabot and Dr. Henry A.
Christian of Boston; Dr. W. S. Thayer of Balti-
more; Dr. Dean Lewis of Chicago, and Dr. Karl
M. Vogel, 437 West Fifty-ninth Street, New York.
Another Base Hospital Unit for the Mexican
Border. — The American Red Cross Headquarters
announce that a base hospital unit at the German
Hospital in New York is being organized under
the American Red Cross. Its director is Dr. Fred-
erick Kammerer, who has just withdrawn from
active service with the German army and brings
to his new task the very valuable knowledge
gained at the German front in the European war
zone.
Camps for Medical Men at Plattsburg. — Major
General Leonard Wood, commanding the Eastern
Department of the Army, has announced that two
training camps for medical men will be held in
connection with the regular Plattsburg Military
Training Camp this month. The first camp began
on Wednesday and the second will begin on July 24.
The course of instruction will emphasize camp sani-
tation and military hygiene. The camps will be
commanded by medical officers of the regular army.
Psysicians desiring to attend one or both of these
camps should communicate with the Military Train-
ing Camps Association, 31 Nassau Street, where
enlistment blanks will be furnished on application.
Goggles for Troops in Texas. — Mr. Oliver Iselin
has sent a check to the Red Cross to pay for goggles
for use by the New York National Guard on duty
on the Mexican border to protect them from the
alkali dust and glare of the sun.
Dr. Cecil D. Gaston has been elected by the
Jefferson County Medical Society health officer of
the city of Birmingham. Ala. Dr. Gaston has
served as city physician for several months. He
is a graduate of Jefferson Medical College, Phila-
delphia.
Dr. Franklin C. McLean, assistant resident
physician in the hospital of the Rockefeller Insti-
tute, New York, has accepted an appointment by
the trustees of the Union Medical College, Pekin,
to the professorship of Internal Medicine. The
appointment carries with it the headship of the
Union Medical School. This is one of the insti-
tutions of the China Medical Board of the Rocke-
feller Foundation.
Mr. Hardolph Wasteneys, associate in the De-
partment of Experimental Biology in the Rocke-
feller Institute, New York, has accepted an appoint-
ment as associate professor of pharmacology in
the University of California.
A Symposium on Acidosis. — The June number
of American Medicine, recently issued, is devoted
largely to papers dealing with acidosis in its vari-
ous aspects, the contributors being some of the
best known clinicians and laboratory workers in
this country and Great Britain. Among them are
P. J. Cammidge, Eric Pritchard, Frederick Lang-
mead, Herbert Williamson, and Edward Gillespie
of London, England; Robert T. Morris, Heinrich
Stern, Robert Coleman Kemp, Anthony Bassler,
A. C. Burnham, William P. Cunningham, George
Dow Scott, Louis Fischer, Samuel Floersheim, and
John W. Wainwright of New York; George W.
Crile of Cleveland, Alfred C. Croftan and Bayard
Holmes of Chicago, J. H. Kellogg of Battle Creek,
Stephen H. Blodgett of Boston, and W. S. Gordon
of Richmond, Va. It is unusual for a single issue
of a journal to contain so many notable contribu-
tions, and the editor, Dr. H. Edwin Lewis, is to be
congratulated upon having produced such an in-
teresting and instructive contribution to the liter-
ature of this very live subject.
Kentucky Valley Medical Association. — At the
annual meeting of this association, held at Rich-
mond, Ky., June 29 and 30, the following officers
were elected : President, Dr. Clarence H. Vought
of Richmond; Vice-President, Dr. Wilson Bach of
Jackson; Secretary-Treasurer, Dr. J. H. Evans of
Beattyville.
The Connecticut State Board of Health, at a
recent meeting in Hartford, re-elected its present
officers as follows: President, Dr. Edward K. Root,
Hartford; Secretary-Treasurer, Dr. John Torring-
ton Black, New London; Sanitary Engineer, J.
Frederick Jackson, New Haven; State Bacteriolo-
gist, Prof. H. W. Conn, Middletown.
The American Association of Immunologists. —
At the recent meeting of this association held in
Washington, D. C, May 11 and 12 the following
officers were elected: President, Dr. Richard Weil,
New York; Vice-President, Dr. John A. Kolmer,
Philadelphia, Pa.; Treasurer, Dr. Willard J. Stone,
Toledo, Ohio; Secrtary, Dr. Martin J. Synnott, "4
South Fullerton Avenue. Montclair, N. J.; Council
(1918), Dr. William H. Park, New York; (1921),
Dr. Arthur F. Coca, New York.
The Status of the Officers of the American Med-
ical Association. — Quo warranto proceedings were
filed recently by Illinois State's Attorney Home
seeking to declare the charter of the American
Medical Association forfeited in consequence of the
holding of elections elsewhere than in the State of
Illinois and of denying to the fellows of the Asso-
ciation the right to vote for officers.
Obituary Notes. — Dr. Francis Sorrel, formerly
of Savannah. Ga.. died at his home in Washington,
D. C, on June 30, at the age of 89 years. He was
born in Savannah and was graduated from the Uni-
July 22, 1916 J
MEDICAL RECORD.
159
versity of Pennsylvania in the class of 1848. He
was in the medical corps of the U. S. Navy from
1849 to 1856, when he retired from the service and
began practice in Savannah. During the Civil War
he served as surgeon with the Georgia troops, and in
1865 was appointed medical director of the General
Hospital in Richmond, Va. At the end of the war
he returned to Savannah and lived there until two
years ago, when he went to Washington.
Dr. Thomas A. Ashby of Baltimore, Md., a grad-
uate of the University of Maryland, School of Medi-
cine, Baltimore, in 1873, a member of the American
Medical Association, the Medical and Chirurgical
Faculty of Maryland, the Baltimore City Medical
Society, and the American Gynecological Society,
and a fellow of the American College of Surgeons,
died at his home, after a lingering illness, on June
26, aged 67 years. Dr. Ashby was the founder of
the Maryland Medical Journal, and its editor from
1877 to 1892, and had been professor of gynecology
in the University of Maryland since 1897.
Dr. Archibald M. Glass of Booneville, Ky., a
graduate of the University of Louisville, Medical
Department, in 1885, and a member of the Ameri-
can Medical Association, the Kentucky State Medi-
cal Association, and the Owsley County Medical So-
ciety, of which he was secretary for some years,
died at his home after a long illness, on June 21,
aged 53 years.
Dr. James T. Roan of Wayness, Ga., died at
Jones, near Savannah, on June 30, at the age of 64
years. He was a graduate of the Southern Medical
College, Atlanta, in the class of 1882. He had been
in ill health for several vears.
©bttuarg.
ELIE METCHNIKOFF, M.D.
PARIS, FRANCE.
Professor Elias Metchnikoff, the last of the
pioneers in bacteriological science, died of heart
disease on Saturday in the Pasteur Institute, Paris,
at the age of 72 years. He had been ill for several
months, and his death had been expected mo-
mentarily. He was born in Russia May 16, 1844,
and began his scientific career as a naturalist. It
was while studying cellular embryology in the
young of marine organisms that he discovered the
phagocytic action of the leucocytes. From this fol-
lowed his theory of inflammation that the hyperemia
and pus formation were due to the rush of the leu-
cocytes to the injured part in their effort to de-
stroy the invading microorganisms. His theory of
immunity was also based upon this discoverv, the
antibodies being products of the attacking leu-
cocytes. He came from a short-lived family, and
this fact turned his attention to the subject of lon-
gevity, from which followed his theory of the in-
testinal origin of arterial and other degenerations
which shorten life and of the action of the lactic-
acid bacilli in destroying the noxious intestinal flora.
He entered the Pasteur Institute in 1888, and in
1895 was appointed its director. The Nobel prize
in medicine was awarded him in 1908. It is impos-
sible in a short notice to recount all that Metchnikoff
has done for science, for he was working pro-
ductively in this field for forty-five years, and will
rank with Pasteur, Lister, Ehrlich, Behring. and
Koch as one of the giants in the practical applica-
tion of bacteriology to the saving of human life.
GJurrrsjimtDntre.
THE TREATMENT OF INFANTILE PAR-
ALYSIS.
To the Editor of the Medical Record:
Sir; — In the discussion following the papers on
infantile paralysis read at the special meeting of
the Academy of Medicine on July 13, I made some
remarks which were reproduced in the daily press.
This brought results which compel me to ask you
for some space in your journal. In the first place
I am receiving many letters, telegrams, and tele-
phone messages asking for exact information as to
how to use adrenalin, etc., and would therefore re-
quest you to publish an exact reproduction of my
remarks which I purposely read from notes. [See
under the report of the meeting of the Academy of
Medicine, pages 171 and 172.]
Regarding the two apparatuses mentioned, I ex-
pect to publish soon a detailed description of both
of them and their working. However, I wish to
add that I would gladly demonstrate the action of
these apparatuses at the Rockefeller Institute if
there should be a number of physicians who would
signify their desire to witness such experiments ; a
definite appointment could then be arranged.
As I have said, the metropolitan press took notice
of my statement regarding the use of adrenalin in
infantile paralysis. This was resented by the
Health Department. "The medical importance of
this is not so great as the space in the newspapers
would indicate." "... his (Dr. Meltzer's)
suggestion was purely theoretical." "It is unfor-
tunate that the newspapers have seized on this one
small detail." While I am confident that Dr. Emer-
son, who is an old friend of mine, did not intend to
offer an affront to me personally, or to suppress
the use of adrenalin in the treatment of infantile
paralysis, the undertone of the various statements
emanating from him as well as from Dr. Ager could
not fail to discredit the value of my suggestions and
to imply that I have been guilty of some impro-
priety. " Permit me to deal here with both points in
question. In the first place, as to the propriety of
my actions. I received a call at my house from two
competent physicians from the Kingston Avenue
Hospital who wished to learn my views of the treat-
ment of poliomyelitis. I spoke to them at length
and promised to bring out the two respiratory ap-
paratuses to the hospital and to demonstrate their
use. Next morning I called up Dr. Emerson to find
out whether my going there would meet with his
approval and asking him at the same time to exert
his influence that my activities there should not be
ventilated in the public press. I then learned that
there would be a meeting of the Academy of Medi-
cine which would deal with infantile paralysis. I
asked the president to put me upon the list of those
who would discuss the papers. At the meeting I
found that anything I wished to say had to be with-
in five minutes or less. As the last participant in
the discussion of that meeting I had to speak very
briefly, but I spoke as a medical man, on a medical
subject, to a medical audience. I was certainly
within my rights. I could not be held responsible
for the fact that the newspapers thought that what
I said was worth a wide circulation. I gave no in-
terviews.
Now, as to the merits of the treatment. The first
requirement of a new treatment is that it should
do no harm. On the basis of my extensive experi-
160
MEDICAL RECORD.
[July 22, 1916
ence I was, and am, sure that a cautious intraspinal
injection of adrenalin does no harm. As to the good
it may do, I have given in my brief statement full
reasons for the justification of my expectations.
Will adrenalin accomplish a real cure? Anyone who
is trained in experimental and clinical criticism can
readily see that this question can not be answered
for some time to come. On the one hand, it is
quite certain that in many cases it will be of no
value on account of the frequent occurrence of a
steady ascending progress of the chief inflammatory
focus to the origin of the phrenic nerves and to the
respiratory and the vasomotor centers. The failure
of adrenalin to help in some cases does therefore in
no way speak against its possible usefulness in some
other cases. On the other hand, the recovery of
some cases does not speak definitely for the useful-
ness of adrenalin, since 75 per cent, of the patients
recover without this treatment. This criticism is
applicable to any kind of useful remedy in a dis-
ease in which the mortality is comparatively low.
However, there is one form of evidence which is of
actual value, and that is when an improvement is
observed which has to be ascribed to the remedy.
That kind of evidence we have unmistakably seen
in the experimental poliomyelitis of monkeys, and I
may say now that similar evidence has already been
obtained in the treatment of human beings. One
competent physician wrote to me July 12 the follow-
ing: "So far have made observations on three cases.
on the effect of intraspinal injection of adrenalin.
In one case, in particular, the results certainly were
good and resembled those obtained by Clark experi-
mentally." Dr. J. C. Regan, resident physician of
the Kingston Avenue Hospital, stated to me ex-
pressly that he is sure that the intraspinal injec-
tion of adrenalin and the administration of oxygen
under pressure exert a good effect. In one case,
complicated with pneumonia, recovery took place
under this treatment. The immediate effect of the
oxygen administration upon the cyanosis was un-
mistakable, and he wished me to let them keep both
apparatuses for the administration of oxygen for
some time until they could obtain their own. Under
these circumstances I am of the opinion that the
treatment of poliomyelitis by the measures I sug-
gested is not only permissible but it would be nearly
bordering on criminal neglect not to use them. This
la<t statement is perhaps exaggerated, but at any
rate, it was my perfect right and duty to bring for-
ward my therapeutic suggestions.
I would like to take issue with several statements
of Dr. Emerson ; i.e. if he was correctly quoted. He
stated that the treatment of the sick children is
not one of the duties of the administrative part
of the Health Department. It seems to me that
this position is entirely untenable. If the Health
Department has a right to compel people to give
up the sick children to its care, it is a positive
duty of that department to look out for the propi r
treatment of these children and to try any method
of treatment which promises to do some good. Fur-
thermore, the holding out of hopes of a cure for the
sick babies would make the task of the Board of
Health in taking the children away from their
homes a good deal easier. The department there-
fore should not discourage such hopes. Finally, if
all the children, sick with infantile paralysis are to
be treated exclusively in the hospitals under the
jurisdiction of the Health Department it is the
duty of these hospitals to study new methods of
treatment, if any are offered, and are sound; other-
wise there would be no therapeutic progress pos-
sible for the disease of infantile paralysis. Dr.
Emerson is further quoted as saying that adrenalin
is not a specific, and therefore does not come within
the province of the Board of Health, and he defines
a specific as that which offers a cure in every in-
stance. It seems to me that both statements are
unsupportable. The antidiphtheritic, antitetanic,
and antimeningitic sera surely do not cure in every
case. They are, nevertheless, unquestionably spe-
cific methods of treatment. On the other hand, it
is undoubtedly the duty of the hospitals under the
jurisdiction of the Board of Health to apply any re-
liable method of treatment to the patients entrusted
to their care, whether the methods of treatment are
specific or not.
The views ascribed to Dr. Emerson, who is prob-
ably the best informed medical man who in recent
years has presided over the Health Department, are
so obviously wrong that I am convinced that he was
incorrectly quoted. I discuss these points here
merely to impress upon those in power that it is
their duty to treat the patients entrusted to them
by any available method, specific or non-specific; to
study diligently new methods of treatment which
are certain not to do any harm and offer some pros-
pect for doing some good, and to manifest to the
public rather a hopeful attitude toward the success
of any form of treatment.
S. J. Meltzer, M.D.
New York.
A SUGGESTION IN POLIOMYELITIS.
To the Editor of the Medical Record :
Sir: — As the remedy for the prevention or cure
of poliomyelitis must be found in the use of a
serum, can there be a valid objection to the use
of high-grade antidiphtheritic serum as a cura-
tive agent during the initial stage of this affec-
tion, and is there a valid objection to the use of
high-grade antidiphtheritic serum as a prevent-
ive agent for adults and children living in close
relations with the one afflicted? This serum pre-
vents the onset of paralysis in diphtheria. It
modifies the course of scarlet fever.
Furthermore, to prevent the spread of this dis-
ease thorough disinfection of each and every
house in which it occurs should be enforced, pref-
erably with chlorine gas, as was done in the
cholera epidemic of the last century. This dis-
infection should be undertaken immediately after
removal of the patient and when the house is com-
pletely empty.
The above serum is as near a cure as we have,
and disinfection should prevent the spread of the
disease. The term infantile paralysis should not
be used, unless there be paralysis, the proper
term for this disease being poliomyelitis.
Justin Herold, M.D.
i Grand avenue, Bronx.
THE RIGID OR THE ELASTIC TOURNIQUET?
To the Editor of the Medical Record:
Sir:— These remarks are inspii in editorial
in the Medical Record, July 1, 1916. If the reader
will refer to that, brevity is possible here, for that
editorial contains timely and practical lessons on
tourniquets and on points concerning them that are
often misinterpreted or ignored.
Some years ago, at an editor's request, the present
writer wrote upon the text "Hemorrhage and a
July 22, 1916J
MEDICAL RECORD.
161
Wire." At present he cannot recall where it was
published. At any rate, the late Dr. Dawbarn
shortly before his death came across that article
which happened to be printed a few pages removed
from something of his own, and of which he was in
rch. He telephoned at once in about the following
words: "Why on earth did you not put that in the
Record or somewhere where it could be seen. Wh\ !
Everybody is fussing and mussing with elastic
tourniquets. I have wasted years in experimenta-
tion and you here, in this article, make clear that
we have only been taking steps to make gangrene
and slough ; and you show that the force for evil
is the follow-through and bruise of elasticity, but
what is required is the non-cumulative and set pres-
sure of rigidity." He came to my office, and partially
disrobed, and at his request I shut up various arter-
ies. This aroused both his commendation and en-
thusiasm. He planned to do great things with
"Stewart's Wire Tourniquet." He experimented on
dogs, horses, and people, and was quite provoked at
me because the matter was so absurdly simple in my
opinion. His comment was: "That is just it, you
think it is of small value because a man may carry
the makin's of it in his pocket, or like a wrist watch;
but to me, therein lies its great value."
The ordinary bloodless method is a series of bruis-
ings, from the firm application of the rubber band-
age to the strangulation by the encircling rubber
tubing. Pressure from a rigid source will not result
in the same amount of damage as that from an
elastic one, a rigid ligature will not cut out as
rapidly or as completely as will an elastic one;
because the rigid loop surrounds a mass of living
plastic matter which it does not kill by contractility
and by an ever-shrinking circumference.
One great handicap to any tourniquet is the
dawdling habit which often possesses its manipula-
tor, for slow application insures well-filled veins,
therefore an aftercoming operation is very bloody
indeed. Speed is a valuable factor in obtaining
the best results from a tourniquet.
The manipulation of the wire tourniquet may be
varied to suit almost any circumstances. Suppose
an arm and an emergency amputation were in ques-
tion; then elevation of the limb for three minutes,
omission of bandages, non-disturbance of germs,
mud, etc., and leaving out the usual stripping proc-
ess will empty the veins, will slow down the ar-
terial current and will do no damage. Gravitation
will traumatize but it takes years to spread a vein.
While the arm is held in its elevated position a dozen
turns of a three-inch gauze bandage (twelve yards
long) should be made around and around and ex-
actly superimposed.
To stop the bleeding from a main artery at its
branches, put the hard roll of such a bandage upon
the gauze turns which it has furnished, press it
down directly, upon the artery and wire it firmly into
place. To influence main, collateral and anastomotic
circulation, cut off the roll and make a sort of wire
collar over the bandage. Ordinary covered or in-
sulated electric lighting wire is good for such a
purpose, but a pair of handles is indispensable for
obtaining sufficient traction and its resultant con-
striction.
The principle involved is that of wiring a garden
hose, the tool for that purpose might be employed,
but it is too powerful and in undiscerning hands
could become almost like a Jarvis snare in effect.
I use the handles of a Gigli saw, but Dr. Dawbarn
used a couple that he fashioned out of a broom-
stick, and I am informed that in his research work
on surgery of the arteries he could take either one
of the two old horses on his farm and open and sew
up almost any artery that he chose. Certainly any
that would come under the control of a tourniquet.
He told me that he never had any slough or
gangrene; and jokingly gave as the reason — "The
horses are hired for $5 a year, for experimental
purposes during my vacation, at the end of which
they are returned to their owner. If I should kill
them or harm them materially then I am to buy
them, or it, at full value."
Three tight encircling wires should be placed, and
this is a minimum. Whether spaced an inch apart
and holding a roll of bandage against an arterial
trunk, or whether a whole limb is to be made blood-
less, or whether a perfect collar of wires spaced a
quarter of an inch apart, are questions to be settled
by the surgeon's judgment. It is important that
they be placed upon an empty, elevated, blood-
drained by gravity limb, that the distal turn should
be applied both first and speedily, and that the skin
of the limb should be properly protected by folds or
turns of bandage or by a thick folded towel.
Upon such a protection make a loop of wire and
give it the first turn of a reef knot. Pull this as
tight as you deem necessary, give a couple of twists
to your hands and your constrictor is firmly placed.
A collar may be made by fastening the first turn,
carrying the wire round and round, bandage-
fashion, and twisting the ends together securely at
the finish. Separate wires spaced (% inch) apart
are best, and may be released by severing with wire
cutter, with bandage scissors or by twisting with
pliers. Wire is too cheap to call for the exercise of
any economy, it takes up but little room in pocket
or satchel, is not perishable as rubber is, and may
be made to serve different purposes, such as cord-
ing the extremities or wiring splints. It is hardly
fair to patient or method to try any manipulation
for the first time in an operating room. And there
have been men who could not tighten the wires at
all on a first attempt. But a quarter or a half hour
spent with one's own leg or thigh as clinical ma-
terial will smooth out any difficulty for those who
are not accustomed to handling wire.
When using pieces of wood or any make-shift
handles, the wire must be carefully fastened in
order to produce an efficient pull. The Gigli handles
may be used as cleats are, and a few turns of the
wire about them suffices.
Douglas H. Stewart, M.D., F.A.C.S.
12S West Eighty-sixth Street.
OUR LONDON LETTER.
(From Our Regular Correspondent.)
ALEXANDRA DAY — ROSE FESTIVAL — VICTORIA CROSS FOR
CONSPICUOUS BRAVERY ; SINTON, SINGH — SICK AND
WOUNDED ABROAD METROPOLITAN HOSPITAL — SIR
JAMES GOODHART'S DEATH.
London, June 24, 1916.
Wednesday last was "Alexandra Day," and happily
the weather permitted the festival to be successful.
It is also called "Rose Day" and is celebrated by
almost everyone wearing a little artificial rose on
coat or dress front. When London takes up some
such movement it is usually done with enthusiasm.
This year 15,000 "rose girls" took up their posi-
tions at the corners of streets and other likely places
as sellers of the flower, and you could buy at any
price from a penny to a pound or as much more as
you were disposed to contribute. Thirty millions of
the little emblems were ordered to meet the demand
162
MEDICAL RECORD.
[July 22, 1916
in London and other cities. The chief depot in the
city was the Mansion House, where the Lady
Mayoress superintended 200 vendors. No little
amount of trouble is required to command success
by enlisting sellers, examining their qualifications
and arranging the part to be undertaken by each.
But there is always a supply of ardent workers ready
to carry out any branch of the service. The money
raised goes partly to the hospitals in which Queen
Alexandra is particularly interested and partly to
homes for cripples. Two of the latter are practic-
ally supported by these institutions in which the
little cripples are occupied all the year round in
making the flowers. They delight in the work.
Some who have lost a hand or their lower limbs can
do this work and are wheeled or carried into the
factory, as may be necessary, and rejoice to meet
others engaged in the same way. The oversea do-
minions join in the celebration. Queen Alexandra
takes great interest in the occasion and this time
drove round London in an open carriage into which
showers of flowers were continually thrown by the
loyal crowds.
The King has been pleased to award the Vic-
toria Cross to Capt. John Alexander Sinton, M. B.,
I. M. G., for "most conspicuous bravery and devo-
tion to duty." Although shot through both arms
and through the side, he refused to go to the hospital
and remained as long as daylight lasted, attending
to his duties under heavy fire. In three previous
actions Captain Sinton displayed the utmost bravery.
His Majesty also conferred the Cross on Sepoy
Chatta Singh, Ninth Bhopol Infantry, in the Indian
Army, for his most conspicuous bravery and devo-
tion to duty in leaving cover to assist his com-
manding officer, who was lying wounded and help-
less in the open, where Singh bound up the officer's
wound and then dug a cover for him with his en-
trenching tool, being exposed all the time to very
heavy rifle fire. He remained until nightfall — five
hours — beside the wounded officer, shielding him
with his own body on the exposed side; then, under
cover of darkness, he went back for assistance and
brought the officer into safety.
Owing to foreign requirements the relatives of
sick and wounded officers cannot visit France ex-
cept under conditions which the Army Council feels
compelled to impose. A telegram granting permis-
sion to visit an officer in a dangerous state can be
obtained from the War Office when no military or
medical objection is present.
At Cambridge the Senate has been discussing the
question of throwing open the 1st and 2d M. B. ex-
aminations to women. The usual procedure of pub-
lishing a report and recommendations and discus-
sing them before taking a vote has not been fol-
lowed; a vigorous protest signed by the heads of
several colleges has been issued. There has been
no discussion of the recommendations. The Senate
is asked to vote without information, without de-
bate on this controversial question which involves
complex problems with serious issues. It seems an
undesirable time to bring forward such proposals,
for many members of the Senate are away on na-
tional service. It is objected by some that instead
of invitation to discuss the matter, they have been
presented with recommendations without any re-
ports to justify them, but simply told that they have
been approved by the General Board of Studies and
of the Local Examinations Syndicate. But the Sen-
ate has no power of delegating its authority to these
bodies. A more natural procedure would be for the
special Board for Medicine to present a report for
discussion in the Senate, and for any proposals or
amendments to be further considered by the Council.
At the annual meeting of the Metropolitan Hospi-
tal it was reported that the in-patient accommoda-
tion had been increased to three times its size in
order to meet the demands for wounded and sick
sailors and soldiers. Of the 300 beds, 260 are for
military patients. This includes the Howard de
Walden wards, which are provided at a cost of £2000
by Lord and Lady Howard de Walden. The year
had been a trying one financially, and closed with
a deficit of some £3000.
Sir James F. Goodhart died on the 28th ult., aged
70. He was consulting physician to Guy's Hospital,
in connection with which one will remember his life's
service. He was on the committee of King Edward
VII Sanatorium, a Fellow of the Royal College of
Physicians, of the Royal Society of Medicine and
other societies. In 1898 he filled the presidency of
the Harveian Society. His "Common Neuroses"
was perhaps his most successful work, but his
"Diseases of Children" was equally popular. He was
created a baronet in 1911 and is succeeded in title
by his son Ernest, honorable secretary to Princess
Mary's Sailors and Soldiers' Fund.
Boston Medical and Surgical Journal.
July 6, 191G.
1. Leonardo Da Vinci's Scientific Research. Arnold C. Klebs.
2. The Menace of Syphilis of To-day to the Family of To-
morrow. J. Harper Blaisdell.
3. Vaginal Hysterectomy for Procidentia. P. E. Truesdale.
4. The General Practitioner's "Apologia pro Vita Sua." An-
drew F. Downing.
5. Anesthesia. Edward L. Young, Jr.
S. The Treatment of Paresis by Intraventricular Injections of
Diarsenolized Serum. Philip Coombs Knapp.
2. The Menace of Syphilis of To-day to the Family
of To-morrow. — J. Harper Blaisdell has tabulated 30
families according to their medical and social histories
as they appeared for treatment at the Skin Department
of the Boston Dispensary. Of the husbands in this
series less than 10 per cent, escaped the infection. Four
died with syphilis a contributing factor. Two suffered
with insanity. Twelve out of a possible 25 are not tak-
ing any treatment. Of the wives 28 out of 30 were in-
fected, and the remaining two probably had the disease.
The women were usually the first members of the fam-
ily groups to come to the clinic and the number under
treatment is relatively large when compared with the
number of men. There were 132 definite pregnancies in
these 30 families. These resulted in only 23 healthy
children, the large majority of whom were born before
infection entered the family. Of the 53 living children
syphilis claims at least 24, or 45 per cent. In the cases
of the 79 deaths syphilis may be credited as the probable
cause in at least 59 or 74 per cent. The writer also
tabulates the age and marital status at the time of en-
trance to the clinic of 500 consecutive cases of adult
syphilis. Of these 500 cases 23b' were single men. Two
hundred and twelve had early or secondary syphilis and
172 contracted the disease before their thirtieth year.
There were only 35 single women who came for treat-
ment during the same period. Yet the 23t> men prob-
ably represent as many women who are active foci. The
bringing under medical supervision of the relatively
large number of single women, now apparently under no
control, would go a long way toward removing active
foci of infection and minimizing the danger to their
future husbands and children. A study of the series of
single men and women who were syphilitic shows that
syphilis is usually acquired by the unmarried of both
sexes in early adult life. In closing the essayist states
July 22, 1916J
MEDICAL RECORD.
163
that the meance of syphilis in the home is one of the
greatest problems of preventive medicine and that the
early syphilis of to-day can well be depended upon to
furnish the family syphilis of to-morrow.
4. The General Practitioner's "Apologia pro Vita
Sua." — Andrew F. Downing writes of the lack of unity
among the members of the medical profession and of
the excess of organization which threatens to become
pathological. Division into specialties and subdivision
into the branches of the specialties have resulted in a
chaotic mass of antagonistic smaller bodies that seem
to have nothing in common but contempt for the man in
the ranks. The general practitioner rightfully feels
that any successful and honest attempt to uplift the
rank and file must be accompanied and even preceded
by a similar movement to rid the field of specialism of
its many mushroom growths. The solution of the prob-
lem does not consist in giving to the public the untruth-
ful impression that the general practitioner represents
only mediocrity or inefficiency and that the magic word
"specialist" always connotes education, training, experi-
ence, competency, skill, culture, and intellectuality. The
essayist believes that if group medicine is to be what it
now pretends to be — better medical service and not
medical panhandling — it is an important instrument for
the welfare of the people and its success will be linked
in a large part with the efficient supervision maintained
over it by wise and impartial medical leaders. The
general man's idea of efficient group medicine is consul-
tation with — what now seems to be considered an old-
fashioned institution — the learned internist. For him it
is the original, most serviceable, true and tried method
of seeking light in dark places. The good internist is
worth a dozen groups and more. The misfortune is that
there is not enough of him. Never was he so much
needed as he is to-day to deliver some of our specialists
and surgeons of pride and covetousness and envy and
to encourage the general practitioner to stifle his bit-
terness and keep "his heart still pregnant with celestial
fire." What the general man then demands is that sur-
geon and specialist be held up to a high standard of
efficiency, a standard at least half as high as they would
demand of him.
6. The Treatment of Paresis by Intraventricular
Injections of Diarsenolized Serum. — Philip Coombs
Knapp says that a fairly large experience with the
treatment of syphilitic affections of the central nervous
system by intraspinal injections of salvarsanize<i
serum by the Swift-Ellis method and its modifications
has shown him that in no other way can he so con-
stantly obtain good results. This opinion is reached
from the study of about 500 injections on over a hun-
dred patients. His experience, like that of most ob-
servers, has led him to accept the hypothesis that the
action of salvarsan and its substitutes, neosalvarsan and
diarsenol, is most pronounced when it is exerted most
directly upon the spirochaetes. He has seen tabetics,
who could stand only by the support of two nurses when
treatment was first begun, who after a few injections
would walk several miles with an approximately nor-
mal gait. He has seen patients completely paraplegic,
with total loss of control over the bladder, leave the hos-
pital walking normally, with complete control over the
bladder, and with normal sensibility and reflexes, after
three injections. Such brilliant results, however, he had
not seen in cerebral cases. He considers the operative
procedure fairly safe and feels encouraged to continue
with this method.
New York Medical Journal.
July S, 1916
1. Exophthalmic Goitre. W. H. B. Aikins.
2. Vaginal Hysterectomy. Joseph C. Taylor.
3. Radium. Sinclair Tousey.
4. Syphilitic Aortic Disease. G. W. McCaskey.
5. Transmissible Diseases in War. P. W. Huntington.
ti. Syncope Immediately After the Administration of Diar.-
senol. Sylvan H. Likes and Herbert Schoenrich.
7. Chronic Interstitial Nephritis. Francis E. Park.
fs. A Trustworthy Nonpoisonous Antiseptic. William M.
Gregory.
1. Exophthalmic Goitre.— W. H. B. Aikins reports
five cases which serve as examples of the benefit to be
derived from the use of radium rays in exophthalmic
goitre. He states that his clinical experience shows
that, when applied over the thyroid, the more penetrat-
ing radium rays diminish the vascularity and reduce
the secretion of the gland. It possesses two definite
advantages as compared with the .r-rays; these are, the
possibility of giving definite doses, and the fact that it
can be applied without noise or excitement, while the
patient remains in bed. In view of the fact that injury
to the nervous system is an important factor in the
etiology of exophthalmic goitre, and as a rule symptoms
referable to it predominate in the clinical picture, it
follows that one of the essential objects in treatment
is to endeavor to relieve these nervous symptoms and
that therefore psycotherapy plays an important role
and consequently physicians who have not had much
experience in treating neurotic and neurasthenic people
should refrain from undertaking the medical treatment
of cases of this kind.
2. Vaginal Hysterectomy. — Joseph C. Taylor says
that vaginal hysterectomy is efficient in intraligamentous
and retroperitoneal growth, for small fibroids situated
near the endometrium in women who have passed the
menopause, in complete prolapse after the menopause,
in cancer of the cervix where the disease is so far ad-
vanced that a Wertheim is likely to result in a cure and
is deemed desirable for the relief of pain and the nause-
ous discharges, and in cancer of the fundus which can
be treated equally as well by the vaginal as by the
abdominal method. The writer describes his technique
of performing hysterectomy based on the technic of
division of the uterus into two parts and clamping pro-
gressively from above downward. This operation has
the advantage that there is never any fear of vaginal
hernia owing to the fact that the base of the broad liga-
ment becomes agglutinated to the vault of the vagina
and serves as traction to keep the vagina of normal
length. The writer has measured the vaginae of many
women before this operation and two years after has
found the length to be the same. Painful scars in the
vault of the vagina are out of the question inasmuch as
the main nerve supply of these parts is cut off during
the excision of the cervix. The method described serves
in all ordinary cases, but in cases of multiple fibroids
the technic has to be modified, and also in cases of
complete prolapse. In a series of over 300 vaginal
hysterectomies the writer has had but three deaths and
none of these could be traced to the operation itself.
6. Syncope Immediately after the Administration of
Diarsenol. — Sylvan H. Likes and Herbert Schoenrich
state that they have had occasion during the last three
months to administer numerous intravenous injections
of a preparation made in Canada which the manufac-
turers claim is identical with the German salvarsan and
to which they have given the name diarsenol. They find
that the powder seems to dissolve less readily than
salvarsan, requires a greater degree of heat for its solu-
tion, and gives off a rather strong, garlicky, disagree-
able odor. The precipitate which forms after the addi-
tion of the alkali is darker, which is also at times the
case with the solution when ready for administration.
The therapeutic efficacy of the drug does not differ ma-
terially from that of salvarsan. On the whole the reac-
tion did not seem to differ very materially from that of
salvarsan, although it was observed in a greater percent-
164
MEDICAL RECORD.
[July 22, 1916
age of cases, and when present came on earlier, was
more severe in character, and in three cases it was
alarming. In these cases, after the administration of,
0.6 diarsenol, the patients went into profound syncope,
with profuse sweating and extreme pallor; the wrist
pulse was not palpable and in two of the cases there was
nausea and vomiting. The writers are of the opinion
that these reactions were due to some variation in the
form of the drug.
8. A Trustworthy Nonpoisonous Antiseptic. — Will-
iam M. Gregory thinks that the failure of modern anti-
septic treatment to meet the exigencies of military
surgery in Europe makes it worth while to remind the
entire medical profession that they have in calendula a
drug that will kill all pus germs. General knowledge of
the power of calendula as a germicide and its general
use in hospitals and in surgery, would prevent thou-
sands of cases of suppuration and infection every year.
This remedy has stood the test of years and is abso-
lutely sure death to all pus germs, but it must be the
right calendula. There is much on the market that
is almost worthless. The reliable fluid extract is so
concentrated that it is almost of the consistence of
syrup. In erysipelas, calendula, lead acetate, and a
saturated solution of boric acid will be found affective.
In leucorrhea, non-alcoholic calendula, non-alcoholic
hydrastis, and glycerin are exceedingly efficient. Burns
dressed with calendula and saturated solution of boric
acid will remain perfectly clean and sterile till healing
is complete.
The Journal of the American Medical Association.
July 8, 1916.
1. Standards for Determining the Suitability of Patients for
Admission to a Free Dispensary. Borden S. Veeder.
-. A Critical Analysis of Outpatient Work from the Point of
View of Efficiency. Lovell Langstroth.
3. Immunity Conferred by the Transfer of Immune and of
Mixed Immune and Sensitized Serums. Henry Sewall,
W. C. Mitchell and Cuthbert Powell.
4. Simple Tic Mechanism. C. P. Oberndorf.
5. The Fatigue of Accommodation as Registered by the Ergo-
graph. Lucien Howe.
G. A Primary Intradural Tumor of the Optic Nerve : Re-
moval with Preservation of the Ball. E. C. Ellett.
7. Condyloma Acuminatum of the Anal Region in the Male
A. Ravogli.
8. The Desirability of Using Miotics as Adjuvants to Mydri-
atics. Harold Gifford.
9. Angina Epiglottidea Anterior. Report of a Case Caused
by the Bacillus Influenza?. Sam X. Kej .
1. Standards for Determining the Suitability of
Patients for Admission to a Free Dispensary. — Borden
S. Veeder, as a member of a committee appointed to in-
vestigate and establish standards for the admission of
patients to the new Dispensary of the Washington Uni-
versity in St. Louis, has communicated with a large
number of clinics in this country to obtain their stand-
ards of admission. This inquiry has shown that a defi-
nite standard of financial suitability for admission to
free dispensaries has not been based on a study of eco-
nomic principles involved. There are two more or less
distinct purposes for which dispensaries have been es-
tablished, namely, for purposes of medical education
and as a means of furnishing free treatment to the indi-
gent poor. Although it is natural to consider whether
the same standard of admission is suitable for each
type of dispensary, no such difference has been used
in working out the standard prescribed in this paper.
A basic income has been worked out for various types
of families and individuals below which patients should
receive free medical services, and a classified scale of
family, consisting of father, mother at home and three
children under fifteen years of age, the annual income
of which is less than $800 a year. is considered as suit-
able for free medical treatment. Men or women living
independently but with family aid to fall back on are
included in the family group. Men, living independ-
ently, at labor in which there is steady employment,
are entitled to free treatment with a weekly wage rate
below $9.50 per week. Women under similar conditions,
are entitled to free treatment with a weekly wage rate
below $8.75 a week. Men living independently, at work
in an industry in which there is much unemployment,
are entitled to free treatment with a weekly wage below
$11, and women under similar conditions if the weekly
wage rate is below $10. The writer finds that the prob-
lem of dispensary abuse is in reality not so big as it is
generally considered. Investigation shows that the
actual percentage of abuse, where an effort is made to
eliminate it, is small, being at the Washington Univer-
sity Dispensary but 2 per cent, of the patients treated.
The various means so far suggested to eliminate this
2 per cent, are impractical.
2. A Critical Analysis of Outpatient Work from the
Point of View of Efficiency. — Lovell Langstroth has
made a statistical study of 348 records from the Dis-
pensary of the University of California Medical School
in the hope that a consideration of the end results ol
the various examinations and diagnostic procedures
might make for greater efficiency in the outpatient de-
partment. An examination of the figures makes it
obvious that the number of cases is too small to deter-
mine the value of the different laboratory procedures.
Among the facts brought out are that 38 per cent, of
the patients failed to return after diagnosis; 11 per
cent, of the patients did not return a sufficient number
of times to justify making a diagnosis; in 7 per cent,
of the cases it was impossible to make a definite diag-
nosis; 75 per cent, of the patients sent to the hospital
for further examination or treatment had a correct
admission diagnosis. Only 38 per cent, of the patients
in this series were benefited by their visits to the clinics.
Eighty-three per cent, of the patients did not return to
the clinics after three months. This study emphasizes
the need for the same careful attention to detail and ef-
fectiveness in dispensary work that is given to hosiptal
work, which it appears is rarely given. The figures
show that this work, when considered from the stand-
point of end results, is disappointing.
3. Immunity Conferred by the Transfer of Immune
and of Mixed Immune and Sensitized Serums. — Henry
Sewall, W. C. Mitchell and Cuthbert Powell. (See Med-
ical Record, June 17, 1916, page 1111.)
4. Simple Tic Mechanism. — C. P. Oberndorf reports
three cases of habit spasm which serve to show that
the tic is essentially a defense reaction elaborated by
the censor against a primarily autopleasurable act. It
constitutes when regarded as an entity, a compromise,
just as most other neurotic symptoms are compromises,
to retain and at the same time abandon an act which
originally yielded satisfaction but which has become in-
tolerable because it cannot be brought to harmonize
with the individual's idea of adult or adolescent pro-
priety. The mechanism in the tics reported are all very
simple, and all disappeared, not because of their analy-
sis, but because more vexing problems harassing the
patients were solved and the necessity for such supple-
mentary compromise defense reactions no longer ex-
isted. The cases thus illustrate the theory that these
tics originally represented purposes, that the purpose
had been suppressed, and how the apparently senseless
movement, when resumed, constituted a simple defense
compromise which afforded relief to the patient.
7. Condyloma Acuminatum of the Anal Region in
the Male. — A. Ravogli comments on the rarity of the
occurrence of condyloma acuminatum in the anal region
of the male and reports two cases which have come
under his observation in his hospital service. In both
of these cases it can be said that the condyloma has had
its origin on the skin and mucous membrane injured
July 22, 1916]
MEDICAL RECORD.
165
by syphilis and that the constant presence of normal
and abnormal secretions and lack of cleanliness have
caused the proliferating acanthosis. The syphilitic base
is only accidental, however, and not necessary for the
production of the condyloma. On a mucous membrane
or on the delicate skin of the genitals, excoriated from
the irritating secretion of the gonorrhea, or an excori-
ated surface left so by the presence of chancroids, papil-
lary hpertrophy may develop with the formation of
condylomatous growths. In the cases in which the
acanthosis has a syphilitic base, the growths are pro-
duced on a base hard and infiltrated, and in this case
very likely the presence of the spirochete is capable
of causing vegetation. When the syphilitic infiltration
has been removed through local antisyphilitic treatment,
the proliferations also gradually disappear. In the case
of cyndylomata, on the contrary, no application stops
the growth of the tumors and the treatment rests en-
tirely on the destruction and removal of the papillary
growths. The writer uses the sharp dermal curette to
scrape the growth from its roots, and then touches
the bleeding wound with ferric chloride. In the two
cases reported the whole mass was removed with most
satisfactory results.
9. Angina Epiglottidea Anterior. Report of a Case
Caused by the Bacillus Influenza?. — Sam N. Key says
that in spite of the conflicting evidence on the question
of whether angina epiglottidea anterior is a separate
pathological process, or only a part of a general involve-
ment of the adjacent structures, it is an undeniable fact
that a curious inflammation of the epiglottis in which
there is remarkably little involvement of the rest of the
throat does occur. In the case reported the ulceration
and edema of the anterior surface of the epiglottis was
caused by the Bacillus influenzse. It occurred during an
epidemic of grip in the patient's community. In his
case all the evidence of active inflammation was con-
fined to the epiglottis, the process seemingly being pri-
marily in the epiglottis. It is suggested that the
B. influenza; may, under certain conditions, have a se-
lective activity for the epiglottis and that it is possible
that this may be of more frequent occurrence than has
been supposed.
The Lancet.
June 17. 1916.
1. Memorandum of the Treatment of Infected Wounds by
Physiological Methods. Almroth E. Wright.
2. A Contribution to the Etiology of Shell Shock. Harold
Wiltshire.
3. Failure of the Right Side of the Heart as a Result of Ex-
tensive Pulmonary Disease. F. J. Poynton.
4. The Effect of Ferrivine and Intramine on Syphilis. L. W.
Harrison and C. H. Mills.
5. A Case of Erb-Duchenne Paralysis Due to a Bullet Wound
of the Fifth Cervical Nerve. Spinal Accessory Anas-
tomosis : Recovery. George L. Preston.
6. The Diagnosis of Dextrosuria and Pseudo-Lasvulosuria.
P. J. Cammidge.
2. A Contribution to the Etiology of Shell Shock. —
Harold Wiltshire states that the functional nervous
affections of modern warfare are essentially the same
as the functional nervous affections of civil life, and
in consequence should be of great value in helping to
elucidate problems connected with the etiology of the
functional nervous diseases in general. He points out
that a*- che present time the etiology of shell shock is
buried in confusion owing to three main difficulties,
namely, bad terminology, dubious clinical histories, and
rapid changes in clinical condition. In view of this
confusion he discusses the possible etiological factors
under the following headings: 1. Wounds. 2. Possible
physical causes. 3. Possible chemical causes. 4. Pos-
sible psychic causes. 5. Causes of relapse. His prac-
tical experience with this class of cases leads to the
following conclusions: 1. The wounded are practically
immune from shell shock, presumably because a wound
neutralizes the action of the psychic causes of shell
shock.' 2. Exposure and hardship do not predispose to
shell shock in troops who are well fed. 3. While it is
theoretically possible that physical concussion resulting
from a shell explosion might cause shell shock, it is
certain that this must be regarded as an extremely
rare and unusual cause. 4. Chemical intoxication by
gases generated in shell explosions cannot be more than
a very exceptional cause of shell shock. 5. Gradual
psychic exhaustion from continued fear is an important
disposing cause of shell shock, particularly in men
of neuropathic predisposition. In such subjects it may
suffice to cause shell shock per se. 6. In the vast ma-
jority of cases of shell shock the exciting cause is
some special psychic shock. Horrible sights are the
most frequent and potent factor in the production of
this shock. Losses and the fright of being buried are
also important in this respect. Sounds are compara-
tively unimportant. 7. A consideration of the causes
and frequency of relapses favors an original cause of
psychic nature. 8. Any psychic shock or strain may
cause a functional neurosis, provided it be of sufficient
intensity relative to the nerve resistance of the indi-
vidual. Such shock or strain need not have any con-
nection with "sex complexes."
3. Failure of the Right Side of the Heart as a Re-
sult of Extensive Pulmonary Disease. — F. J. Poynton
cites two cases, one of chronic pulmonary tuberculosis
and a second of extensive pulmonary sclerosis and bron-
chiolectases, in which the pulmonary condition had
fallen into the background and a series of symptoms,
apparently cardiac, had become predominant. Dyspnea
had increased; a very striking lividity of the whole
integument, and notably of the face and extremities,
had become permanent; dropsy and ascites had at-
tained a high grade, and the liver in both cases was
greatly enlarged. Venous engorgement was conspic-
uous, but the pulses — a point of importance — though
strikingly rapid (120 to 140 per minute) were not
arrhythmic; and the quantity of urine passed was con-
siderable. These, together with the tricuspid systolic
mumur, were the features which attracted attention
and made it clear that some very definite change had
taken place in the course of these illnesses. Radio-
graphic examination showed that the enlargement of
the heart was symmetrical owing to the disproportionate
size of the right side. The outline is not so circular,
as in failure the result of mitral disease and the trans-
verse measurement is not so great. The left border of
the outline is not so circular as in mitral disease with
failure of compensation, but makes an obtuse angle,
the apex of which is formed by the junction of the
upper limb constituted by the left ventricle with the
lower formed by the right ventricle. The writer thinks
these facts should be borne in mind in connection with
the progress in thoracic surgery in recent years, espe-
cially the possibility in performing artificial pneu-
mothorax that, in putting out of action a considerable
portion of functioning lung which disturbs the balance
of pulmonary circulation and throws considerable strain
on the right ventricle, the reserve power in weakly
subjects may be rudely shaken and secondary heart
failure encouraged.
4. The Effect of Ferrivine and Intramine on Syphilis.
— L. W. Harrison and C. H. Mills have tested the action
of ferrivine and intramine in three cases of syphilis
and have found that these agents have entirely failed
to cause the S. pallida to disappear from the lesions of
three well marked cases of secondary syphilis. After
the failure of ferrivine to cause the diappearance of
Spirochseta pallida from a mucous patch a single dose
of salvarsan effected this in 18 hours. Clinically they
166
MEDICAL RECORD.
[July 22, 1916
were unable to detect any influence of either or both
of these compounds on syphilitic lesions, although each
of them was of the variety which heals in a week or
ten days under salvarsan treatment. These investi-
gators also find that intramine and ferrivine are ex-
tremely unpleasant in their effects. They have no
specific effect on early syphilis.
6. The Diagnosis of Dextrosuria and Pseudo-Laevu-
losuria. — P. J. Cammidge emphasizes the clinical impor-
tance of distinguishing between these two conditions.
He finds Benedict's test for sugar in the urine more
sensitive and reliable than the test with Fehling's so-
lution. With 0.3 per cent or over, of dextrose it gives
a characteristic reaction on boiling, but with smaller
quantities the precipitate forms only on cooling. A
similar delayed reaction is characteristic of pseudo-
larvulose (iso-glucuronic acid), which does not reduce
alkaline copper solutions as readily as dextrose. The
formation of a precipitate as the solution cools is sugges-
tive, therefore, of pseudo-laevulose or a small quantity
of dextrose. To differentiate the two, Borchardt's
modification of Seliwanow's test is employed. A mix-
ture of 4 cc. of the urine and 1 cc. of Seliwanow's re-
agent (resorcin, 0.5 gm.; hydrochloric acid, sp. gr. 1.195,
30 cc; distilled water 30 cc.) is heated to boiling in
a water bath for a few minutes. If pseudo-laevulose or
true laevulose is present the solution assumes a purple-
red color, but dextrose alone gives no color change.
To differentiate pseudo-laevulose from true laevulose the
solution is cooled, made alkaline with solid sodium car-
bonate, and extracted with 2 or 3 cc. of ethyl acetate.
If true laevulose is present the ethyl acetate extract is
red or pink, but if the positive result was due to pseudo-
laevulose the watery solution retains the pigment, and
the extract is yellow or brown. The diagnosis may be
confirmed by preparing the para-bromphenylosazone and
taking its melting-point. The osazone of pseudo-
laevulose melts at 256° C, that of true laevulose at
197c C, and the osazone of dextrose at 220 C, while
the hydrazone of glycuronic acid melts at 236° C.
British Medical JournaL
June 17. 1916.
1. The Fastinir Treatment of Diabetes. E. I. Spriggs.
:'. A Simple System of Skeleton Splinting. C. Max Page.
3. A "Cage" Splint tor Fractures of the Humerus. E. M.
C'owell.
i. The Inhibitory Action of Saliva on Growth of the Menin-
gococcus. M. H. Gordon.
5. The Behavior of Hypochlorites on Intravenous Injection
and Their Action on Blood Serum. H. D. Dakin.
1. The Fasting Treatment of Diabetes. — E. I.
Spriggs relates his experience with the fasting treat-
ment of diabetes which he used before he became ac-
quanted with Dr. Allen's work. He reports five typical
cases and outlines his procedure which consists in a
two days' fast, allowing nothing but a cup of weak tea
with 10 cm. of 20 per cent, cream at breakfast and
tea-time. After the first two days 150 cm. of clear
meat broth is added at lunch and dinner time. If
acidosis is present after two days of fasting, alcohol
may be allowed, 0.12 gram per kilogram of body weight
being given in the form of whiskey four times a day.
In the cases reported no alcohol was used. When the
urine has been sugar-free for twenty-four hours, 7.5
grams of carbohydrate is added in the form of vege-
tables which contain low percentage of carbohydrate.
On the second day of feeding 30 cc. of cream is allowed
with each cup of tea, and three eggs are added. On
the third day a feeding, and on each alternate days
subsequently, 5 grams of carbohydrate is added. Vege-
tables containing higher and higher percentages of
carbohydrate are used, and finally porridge, oatcake,
macaroni, bread, and fruit. The addition of carbo-
hydrate is continued until sugar appears or the
tolerance reaches 3 grams of carbohydrate per kilo-
gram. At the same time 15 grams of protein in the
form of meat and fish are added daily up to one gram
per kilogram, or, in certain cases, more. When the
protein has reached the desired amount, fat is added
until the patient stops losing weight or is getting 40
calories per kilogram. If sugar at any time recurs in
the urine ti.e patient is again fasted until the urine is
sugar-free for twenty-four hours. The diet is then re-
sumed at the point where it was left off, but on only
one-half the amount of carbohydrate is given until the
urine has been sugar-free for two weeks. In summing
up his observations the writer says that fasting up to
several days is well borne by cases of mild and severe
diabetes of ages ranging from 24 to 79 years. The
urine was made free from sugar, the blood sugar was
reduced, and acidosis greatly diminished. In most
cases the food could be increased gradually without
glycosuria. The rapid abolition of sugar had an ex-
cellent effect on the patients. It shortened tedious
treatment, and enabled more time to be given to find-
ing out what food should be taken and in what quan-
tity. For the majority of diabetic patients Dr. Allen's
treatment offers great advantages. There is evidence
enough that such patients, though not cured, may be
freed from the signs and symptoms of their complaint.
2. A Simple System of Skeleton Splinting. — C. Max
Page calls attention to the value of skeleton splinting
in the treatment of gunshot fractures and describes a
system which he finds superior to the aluminum stapled
strips which he described some time ago. He has found
that the aluminum strips are not always sufficiently
rigid for prolonged treatment and that, furthermore,
the supply of aluminum for surgical purposes is limited.
He finds annealed steel the most satisfactory material
available. The stock material consists of five foot
lengths of annealed mild steel % inch by % inch. The
strips are drilled throughout their length at one inch
intervals with holes of 1, 6-inch diameter. Split steel
rivets are required to couple the various lengths after
they have been bent to form the splint required. The
writer describes in detail the tools required, the method
of cutting, bending and coupling the strips, and gives
the measurements and details of constructing some of
the more commonly used splints. Modifications in size
and designs will often be necessary, but can readily be
carried out. The splints can always be reinforced if
exceptional rigidity is required by the addition of
arches or by riveting extra lengths on the main frame.
4. The Inhibitory Action of Saliva on Growth of the
Meningococcus. — M. H. Gordon describes experiments
which have shown that normal saliva and saliva from
meningococcus carriers inhibits the growth of the men-
ingococcus upon solid artificial culture medium (nas-
gar) . The nasal mucosa from normal persons has no
such inhibitory effect on the growth of meningococcus.
A quantitative experiment showed that fresh saliva does
not lose this inhibitory influence when diluted a hun-
dred-fold. This antimeningocoecal action of saliva is
due to its living bacteria. A young broth culture from
saliva is at least as efficacious as fresh saliva in anti-
meningocoecal action. This effect is due to the living
and multiplying bodies of bacteria in the broth. When
they have been separated off by a Berkefeld filter, or
killed by heat, the broth has lost its meningococcal
power. This inhibitory action of saliva appears to be
due chiefly to mixed salivary streptoccoci. Pure cul-
tures of predominant streptococci, when tested indi-
vidually, were found to exert comparatively slight in-
hibitory influence on the growth of meningococcus.
These observations demonstrate the practical impor-
tance of avoiding contamination with saliva when swab-
bing the nasopharynx of suspected carriers.
July 22, 1916]
MEDICAL RECORD.
1G7
NEW YORK ACADEMY OP MEDICINE.
Special Meeting, Held July 13, 1916.
The President, Dr. Walter B. James, in the Chair.
This meeting was held in Aeolian Hall as the Academy
of Medicine could not accommodate the large number in
attendance. The meeting was called to discuss the
subject of Poliomyelitis.
Infantile Paralysis: What We Know About the Trans-
mission of the Disease. — Dr. Simon Flexner presented
this communication. He said that infantile paralysis
was caused by the invasion of the central nervous sys-
tem by a minute, filterable microorganism which had
now been secured in artificial culture and as such was
distinctly visible under the higher powers of the micro-
scope. The virus of infantile paralysis existed con-
stantly in the central nervous organs and upon the
mucous membrane of the nose and throat and of the
intestines in persons suffering from the disease; it oc-
curred less frequently in other internal organs and had
not been detected in the circulating blood of patients.
The difficulties attending the artificial cultivation and
identification of the microorganism of infantile paral-
ysis were such as to make futile the employment of
ordinary bacteriological tests for its detection. Never-
theless the virus could be detected by inoculation tests
upon monkeys. The virus had an apparently identical
distribution irrespective of the types or severity of
cases of infantile paralysis. The virus was known to
leave the infected human body in the secretions of the
nose, throat, and intestines, and also escaped from con-
taminated healthy persons in the secretions of the nose
and throat. The virus entered the body, as a rule, if
not exclusively, by way of the mucous membrane of the
nose and throat. It multiplied in these localities and
then penetrated to the brain and spinal cord by way
of the lymphatic channels which connected the upper
nasal membrane with the interior of the skull. As the
virus was thrown off from the body mingled with the
secretions, it withstood for a long time even the highest
summer temperatures, complete drying, and even the
action of weak chemicals, such as glycerin and carbolic
acid. Hence mere drying of the secretion was no pro-
tection ; on the contrary as the dried secretions might be
converted into dust, which was breathed into the nose
and throat, they became a potential source of infection.
The survival of the virus in the secretions was favored
by weak daylight and darkness and hindered by bright
daylight and sunshine. It was readily destroyed by ex-
posure to sunlight. The blood-sucking insects had been
suspected of conveying the disease. Certain experiments
did indicate that the biting stable fly could both with-
draw the virus from the blood of the infected and recon-
vey it to the blood of healthy monkeys. More recent
studies had failed to confirm these earlier ones. Do-
mestic flies experimentally contaminated with the virus
remained infective for forty-eight hours or longer.
While our present knowledge excluded insects from
being active agents in the dissemination of infantile
paralysis, they nevertheless fall under suspicion as be-
ing mechanical carriers of the virus of that disease.
The animals that had especially come under suspicion
as possibly distributing the germ of infantile paralysis
were poultry, pigs, dogs, and cats. Experiments had,
however, excluded these animals from being carriers
of the virus of infantile paralysis. Studies carried out
in various countries in which infantile paralysis had
been epidemic all indicated that, in extending from
place to place, the route taken was that of ordinary
travel. In other words the evidence derived from this
class of studies confirmed the evidence obtained from
other sources in connecting the distributing agency in-
timately with human heines and their activities. The
virus of infantile paralysis was destroyed more quickly
and completely in the interior of the body than, in
some instances, in the mucous membrane of the nose
and throat. It had been found in monkeys that the
virus might disappear from the brain and spinal cord
within a few days to three weeks after the appearance
of the paralysis, while at the same time it was present
on the mucous membranes mentioned. The longest period
after inoculation in which the virus had been detected
in the mucous membrane of the nose and throat of.
monkeys was six months. In an undoubted case of the
human disease the virus was detected in the mucous
membrane of the throat five months after its acute onset.
This was conclusive evidence of the occurrence of occa-
sional chronic human carriers of the virus of infantile
paralysis. A study of the virulence of the virus in
various epidemics showed that it was subject to great
fluctuations of intensity. Not all children and relatively
few adults were susceptible to infantile paralysis. Young
children were more susceptible, generally speaking, than
older ones. The light or abortive cases indicated a
greater susceptibility to the disease than had generally
been recognized. The period of incubation might be
as short as two days or as long as two weeks or more;
the usual period, however, did not exceed about eight
days. Probably the period at which the danger of com-
munication was greatest was during the very early
and acute stage of the disease. (This statement was
made tentatively.) Cases of infantile paralysis that
had been kept under supervision for a period of six
weeks from the onset of the symptoms might be re-
garded as practically free of danger. One attack of in-
fantile paralysis conferred immunity. Protection had
been afforded monkeys against inoculation with effective
quantities of the virus of infantile paralysis by previ-
ously subjecting them to inoculation with sub-effective
quantities of the virus. This method, however,
had not been successful in all instances. Passive
immunity had been conferred on monkeys, but
it was somewhat uncertain and its brief duration
rendered it useless for purposes of protective im-
munization. However, a measure of success had
been achieved by the experimental serum treat-
ment of inoculated monkeys. For this purpose blood
serum from recovered or protected monkeys or human
beings had been injected into the membranes about the
spinal cord, and the virus was inoculated into the
brain. The injection of the serum must be repeated
several times in order to be effective. The results from
this treatment were said to be promising. Unfortunately
no other animal than the monkey seemed capable of
yielding an immune serum, and the monkey was not a
practicable animal from which to obtain supplies.
Hexamethylenamin was the only drug which had shown
any useful degree of activity. Experiments on monkeys
had shown this drug to be effective only very early in
the course of the disease, and only in parts of the ani-
mal treated. From our present knowledge certain prac-
tical deductions might be drawn. Since the chief mode
of conveyance of the virus was through human beings,
either those ill with the disease or healthy carriers, and
since the domestic fly might be grossly contaminated
with the virus and might deposit it on the nose or
mouth of a healthy person, or upon food or eating
utensils, our efforts must be directed to the control
of these sources of infection. Protection to the public
could best be secured through the discovery and isola-
tion of those ill of the diesease, and through the sani-
tary control of those who had associated with the sick
and whose business called them away from home. Par-
ents should consent to the removal of children ill with
the disease to a hospital both in the interest of the
sick child and in the interest of other children. This
removal must include not only frankly paralyzed cases
but also other forms of the disease. In concluding, Dr.
Flexner said it was too early to calculate the death
rate in the present epidemic; it might prove to be con-
siderably lower than it now appeared to be. Of those
who survived, a part made complete recoveries and
this number was greater than was usually supposed.
The knowledge regarding infantile paralysis was now
far greater than in 1908 and the forces in the city
which were dealing with the epidemic were better or-
ganized than ever before. The outlook, therefore, should
not be regarded as discouraging.
The Clinical Types of the Disease. — Dr. Henry Kop-
lik read this paper. He said that poliomyelitis was pri-
marily an epidemic disease and as a sporadic condition it
had attracted very little notice. All the epidemics which
had thus far been recorded resembled each other very
closely. An attempt to connect this disease with the
occurrence of cerebrospinal meningitis had developed
into a belief that poliomyelitis was an entity, clinically
occurring in epidemics in the late spring to late autumn
and following the regular sporadic occurrence of the
disease in limited numbers in the months following the
winter and reaching into the late spring up to the
time of the epidemic outbreaks. Epidemics of this dis-
ease had been known to skip a year and to always crop
up again in the place of the original occurrence which
should give the thoughtful hint as to the possible cause
of its epidemiology. In all the epidemics thus far re-
corded, the symptomatology and clinical types had been
much the same. Though most of the scientific knowl-
168
MEDICAL RECORD.
[July 22, 1916
edge of the clinical types of poliomyelitis was borrowed
from Swedish and .Norwegian observers, Medin and
Wickman, the first inkling of the epidemic nature of
the disease was voiced by Colmer, an American physi-
cian, who in 1841 observed some form of paralysis in a
child and obtained the history that in the locality in
which the patient lived several similar cases had oc-
curred and most of them had recovered. Following
him, Caverly in 1894 described the epidemic in Vermont;
Taylor and Chapin later on observed the epidemic
nature of the disease. Aside from these observers,
much of the clinical knowledge at present was due to
Medin who described the clinical types of acute epidemic
poliomyelitis in 1884 before the International Congress,
much to the astonishment of most pediatricians who still
retained the simple picture of poliomyelitis anterior as
retained in older text books — as a simple infantile
paralysis. In all, 42 epidemics had been observed in
American and the Continent and this alone should
establish the tendency of poliomyelitis to occur in epi-
demic form at certain seasons and remain sporadic
until the time arrived for a new outbreak. This dis-
ease selected the young as its victims. Out of 886 cases
in the epidemic of 1907, 571 were below 3 years of age,
771 below 5 years, and 3 were under 6 months of age.
In the present epidemic the youngest case Dr. Koplik
had seen was four and a half months old and absolutely
breast-fed. The most susceptible period was from 1 to
3 years of age. There were four principle types which
could be clinically described and proven by laboratory
methods: (1) the abortive; (2) the bulbospinal; (3)
the cerebral and meningeal, and (4) the bulbopontine
types. Wickman had described a neuritic type. These
types could all be understood when poliomyelitis was
regarded from the standpoint of an acute, infectious
disease, involving certain parts of the general nervous
structures, causing certain definitely marked pictures
and there stopping, or going on at one stroke to involve
the whole cerebrospinal axis and in this way causing
a debacle of the whole substratum of the nervous
economy.
J. Tin Abortive Type. — It was through the abortive
type of the disease that these cases were spread to
others. This type was that which did not go on to
paralysis, recovered, and did not leave the host injured
so as to leave no doubt as to its distinct identity. A
child of 5 years of age was attacked with a headache,
slight malaise, and an attack of vomiting lasting five
days, intense pain in both lower extremities radiating
to the soles of the feet and worse at night, slight pain
in the nape of the neck, lassitude, cerebellar gait on
walking, increased reflexes in the lower extremities,
rectal temperature above 100.5 deg. Fahr. In ten days
the pains had disappeared, the child was well and
wanted to go out and play. The abortive cases pre-
sented prodromata such as headache, weakness, dimin-
ished reflexes and pains in the nape of the neck, with
or without vomiting and fever, and still did not present
paralysis and recovered.
2. The Bulbospinal Type.- — This was the most com-
mon type and gave the disease its name. The patient
would have an attack of vomiting and slight fever and
within twenty-four hours the mother would observe
that the child could not move one or the other extremity.
These forms might have no fever, but it was possible
in giving the history the mother might have overlooked
the symptoms of fever, malaise, and such indisposition
as peevishness, which might have preceded by a
few days the paralysis. In other cases the paralysis
appeared gradually. Pain might continue to be quite
severe, especially when the extremities were moved.
The paraylsis might spread and involve not only the
remaining lower extremity, but the upper extremities,
the muscles of the back, the respiratory muscles of the
thorax, and possibly the muscles of the abdomen. As a
rule, in the purely spinal cases, the paralysis appeared
and did not spread in the great number of cases. In
others, it might spread from the extremities and in-
volve the whole trunk, even to causing bulbar paralysis
of the respiratory centers. But after the tenth day,
paralysis was not apt to spread to the bulbar medulla,
though cases had been known to die after the fifteenth
day.
'■'>■ T -Roth the
meningitis and cerebral types should be combined be-
cause of the cerebral symptoms which irave rise to a
picture closely simulating meningitis. The meningitic
form of poliomyelitis ran its course with cerebral symp-
toms. A child of three was taken with vomiting for
forty-eight hours, followed by rigidity of the neck with
pain on flexion of the head, Brudzinski's sign and re-
flex, Kernig's sign, sopor, and Macewen's symptom
which might be slightly marked; also diminished re-
flexes. Some patients migh improve after a day or two,
the fever might abate and they might even be about
and then have a recrudescence of fever, sopor, rigidity,
delirium, irritability, extreme hyperesthesia, and pain
in the nape of the neck. In some cases the only palsy
•night be ocular; in others a slight facial palsy might
be present which might be combined with a weakness
in one or other extremity. After a week the patient
became brighter. There was still, however, marked
ataxia and Romberg's sign. As convalscence was es-
tablished, the ataxia was the last symptom to disappear.
The hydrocephalus and abnormal mental state might
remain for some time after the temperature was
normal. On recovery, there was a slight strabismus,
ataxia, or optic neuritis. In one group of cases he had
seen unilateral ophthalmoplegia with hemorrhages into
the retina. In lumbar puncture lay the differentiation
of this form of poliomyelitis from cerebrospinal
meningitis.
4. The BulbojX>ntinc Type. — The bulbar or pontine
form of the disease deserved notice as a distinct form.
An infant, breast-fed, thirteen months of age, was at-
tacked with fever and vomiting. The fever continued
into the afternoon of the following day. when the
mother noticed a flatness on the right side of the
face. The temperature continued at 102.4°, the infant
was bright, laughed, and played in the crib, but there
was a tired look about the face and eyes. The knee
reflexes were increased; otherwise there was no
paralysis that could be demonstrated. In another case,
ten days before the patient, aged twenty-one months,
was seen, he was taken with high fever and vomiting
and there were some green movements. The fever con-
tinued, in a less degree, to the ninth day when the
mother noticed that the right side of the face was
flat; there were tremulous movements of the head and
arms and the patient was restless. There was constant
jactitation of the head and insomnia; there was rigidity
of the neck, but no palsies of the extremities; on the
contrary, the patient exhibited great strength in both
the upper and lower limbs. In other cases, the outcome
was not so favorable; there was an involvement of the
nuclei which controlled deglutition and respiration. In
these cases the patient might be lost by paralysis of the
respiratory centers. The neuritic type included those
cases in which pains in the extremities became a leading
feature of the clinical picture. Some of these cases
developed paralysis; others did not. They were re-
ferred to under the head of abortive cases. The symp-
toms given justify a lumbar puncture in order to es-
tablish the character of the fluid which in poliomyelitis
showed a lymphocytic cytology and an increase of globu-
lin. The examination of the blood was very uncertain.
As to prognosis, the low mortality of 10 per cent, ap-
plied to children below eleven years of age, and 27 per
cent, among older children and adults. Twenty per
cent, of all cases completely recovered and the younger
the child the better the prognosis.
Abortive and Nonparalytic Cases. Their Importance
and Their Recognition. — Dr. George Draper discussed
this phase of the subject. He took exception to the
term "abortive." He said this term had been used
when attention was centered on the paralysis as the
chief symptoms of poliomyelitis. As our knowledge had
grown it had became increasingly evident that in acute
anterior poliomyelitis we were dealing with a general
infection that presented a great variety of manifesta-
tions. The cases that escaped paralysis were just as
important from the standpoint of the spread of the
infection as the paralyzed cases. In fact they were
infinitely more dangerous. These cases that were called
"abortive" should be called "atypical," if those that de-
veloped paralysis were considered as typical. There
was no possible way at the present time of determining
the number of cases that were not paralyzed. Such
figures as had been collected varied greatly and un-
doubtedly the number of cases that were not paralyzed
varied greatly in different epidemics. There were cer-
tain indications, however, that lejd to the belief that
the number of these cases was considerable. Investiga-
tion had shown that frequently where there had been
one case of poliomyelitis in a family another child had
shown mild symptoms, as fever, general malaise, and
vomiting. Pathological studies had shown that there
might be not only lesions in the spinal cord, but that
the entire lymphatic apparatus and the viscera might
be involved. Palpably enlarged lymph nodes might be
July 22, 1916]
MEDICAL RECORD.
169
observed. This furnished further evidence that poli-
omyelitis was a general infectious disease. Cases of
infantile paralysis fell into the following groups: (1)
Gastrointestinal. (2) Respiratory. (3) Febrile. (4)
Meningismic. (5) Paralytic. In the first three types
there might be slight transient paralysis. In the type
showing paralysis one might find any or all the prodro-
mal symptoms seen in the other types. The intensity
of the symptoms was no guide to the prognosis. In
fatal cases more extensive lesions of the cord had
sometimes been found than were indicated by the symp-
toms. That there should have been this general degen-
eration of the cord without clinical manifestations sug-
gested that in the milder cases there might be cord le-
sions that gave no clinical evidence of their existence.
In times of epidemic every one was alive to the symp-
toms of poliomyelitis, but it was not enough for a physi-
cian to say that a given case was or was not one of
infantile paralysis. In suspicious cases lumbar punc-
ture should be done, and the spinal fluid examined.
There was usually an increase in the lymphocytes and
a very large percentage of polymorphonuclears, which
changed within twelve hours to mononuclears, and in
three or four days there was a leucocytosis. The alhumin
and globulin content of the fluid were increased but
less so than in tuberculosis meningitis. Reduction with
Fehling's solution was good. The diagnosis was based
on the finding of gastrointestinal respiratory and febrile
symptoms. Gastrointestinal symptoms were of course
present in many conditions and infections. The respira-
tory symptoms might resemble those of influenza, such
as lung signs and pains in the bones and joints. Where
the above-mentioned symptoms were found a search
should be made for transient weakness and mild de-
grees of paralysis and for local muscle tenderness. One
point of value in the diagnosis was the anterior spinal
flexion sign. Before paralysis set in this sign was
definitely present. It could be elicited by having the
child place his hands under his thighs and then flexing
the trunk forward, doubling the child up. There was
no longer any question but that these atypical cases of
poliomyelitis existed. They must be recognized and
herein lay the problem. In learning to recognize them
a double advantage would result. The cases as moving
sources of contagion would be controlled and those that
were destined to be paralyzed would be recognized in
the preparalytic stage and could be treated early when
a remedy was discovered, and thus possibly saved from
oncoming paralysis.
The Present Epidemic: The Types Which It Presents.
Dr. Louis C. Ager spoke more particularly of his per-
sonal experience at the Kingston Avenue Hospital. He
stated that it would be generally understood that the
amount of clinical work that they had had to accom-
plish during the epidemic had left no time in which to
write a paper or to digest the large amount of clinical
data that had accumulated. This data would be put in
shape for presentation at some future time. When it
was recalled that from June 20 to July 12 they had
cared for 320 patients with poliomyelitis in the Kings-
ton Avenue Hospital, the fact would be appreciated that
the resident staff were brought face to face with a
large number of serious problems. He wanted the peo-
ple of New York to get some idea of what they had
accomplished. On July 3 there were eighty-nine pa-
tients admitted to the hospital, and on that day the
ambulance surgeons had only three hours sleep and
no meals. A most striking feature in connection with
this work was the great degree of comfort experienced
by the patients after they were brought to the hospital
from homes unsuited to the care of children sick with
an infectious disease. The best feature in the scheme
of hospitalization of these cases was the beneficial ef-
fect on the children themselves. Dr. Draper had spoken
of the large number of abortive cases, and in this class
of cases they have had more proof of the infectivity
of poliomyelitis than had been evident before the pres-
ent epidemic began. In this connection such examples
as the following might be cited : On July 2 a child was
taken ill with convulsions, vomiting, and fever, but
recovered. On July 3 another child in the same family
was stricken with the acute fulminating type of the
disease and died within forty-eight hours. On July 4
an older member of the family developed the disease.
At least eight instances had come under their observa-
tion at the Kingston Avenue Hospital in which there
had been two or more eases in the same family. That
there are practically no cases of poliomyelitis among
colored people is borne out by our experience at the
Kingston Avenue Hospital. Investigations having for
their object the detection of a racial susceptibility had
not revealed any racial predisposition to the disease.
With reference to the affection of the liver and spleen,
they had found no material enlargement in these organs
except in some fulminating cases. In a series of sixty-
seven cases they found oniy two with enlarged livers.
The age incidence was practically the same in the
present epidemic as in the epidemic of 1907. The epi-
demics in this country seem to show a lower age inci-
dence than those abroad. In one group of eighty-seven
cases, forty-six occurred between the ages of 2 and 5
years; twenty-two between the ages of 1 and 2 years;
eight between the ages of 6 and 12 years; three be-
tween 1 and 6 months. They had two adult cases in
this group, one in a woman of 2S years of age and
one in a pregnant woman of 21 years. They had found
as usual that the lower extremities were most fre-
quently paralyzed. In a group of sixty-four cases
examined, the lower extremities were involved in thirty-
nine instances; the upper in seven; there was facial
paralysis in five cases, and in thirteen the only definite
symptom was marked paralysis of the muscles of the
back. There were two typical ataxic cases. A few
special types had been seen. There was one peculiar and
unusual case in a boy of 11 years. He was a well-
nour.ished, well-developed child. When brought to the
hospital his only symptom was markedly labored breath-
ing. He asked for a drink of milk and it was noticed
that there was a slight blur to his speech. When he
tried to drink he was unable to do so because of pharyn-
geal paralysis. His diaphragm was completely para-
lyzed. He was able to use his arms and hands, could
stand up in his crib, and his back showed no evidence of
paralysis. He gradually became weaker and died five
hours after entering the hospital. Another case of the
fulminating type showed a general paralysis; practi-
cally all the skeletal muscles were affected and there
was marked respiratory paralysis. In neither of these
cases was the heart affected. They had tried artificial
respiration with Dr. Meltzer's apparatus, and in some
instances had succeeded in bringing back the color after
death. had apparently occurred. They still hoped that in
some cases something might be accomplished by this
method. They had also observed a meningitic type of
the disease. They had had one older boy who was
wildly delirious. He had complete paralysis of one leg
and one arm, and was totally blind. There was an
alternation in his condition from deep meningeal coma
to active maniacal delirium. During the epidemic they
had received six calls to see croup cases for the purpose
of intubating and when they had reached the patients
found respiratory paralysis and poliomyelitis. It was
sometimes extraordinary to see the rapid improvement
that took place in some cases. Some bottle-fed babies
who were unable to take their milk at first were now
able to hold the bottle and feed themselves. In closing,
Dr. Ager emphasized the fact that their experience had
absolutely convinced them that the only place in which
to take care of children with poliomyelitis was in a
hospital, unless the conditions of the hospital could be
reproduced in the home.
Laboratory Aids in the Diagnosis of Poliomvelitis. —
Dr. Josephine B. Neal said that it was well known
that sporadic cases of poliomyelitis were frequently seen
when no epidemic existed. Because of this fact, during
the past six years it had been the lot of the Miningitis
Division of the Department of Health to study, both
clinically and by means of laboratory methods, many
cases of this disease before the present epidemic oc-
curred. Most of the cases seen by them, both before
and during this epidemic, had been atypical, and they
had, therefore, been compelled, when endeavoring to
make a diagnosis, to consider their laboratory findings
with more than ordinary care. As with most such pro-
cedures, the answers which the laboratory returned to
their questionings furnished them with evidence that
was corroborative only, and by no means absolutely
diagnostic. Perhaps one of the most interesting exper-
iments employed in the study of poliomyelitis had been
the inoculation of monkeys by means of washings from
the respiratory and alimentary mucous membrane. This
was first successfully performed by Kling, Petterson,
and Wernstedt in 1911. It had since been repeated
fpveral times. Dr. DuBois. Dr. Zinsrher. and Dr. Neal
obtained washings from the nose and throat from an
abortive case two weeks after the incidence of the
disease. With these washings they produced typical
poliomyelitis in monkeys. In sections of the brain from
one of these monkeys a few globoid bodies similar to
those described by Flexner and Noguchi were found.
170
MEDICAL RECORD.
[July 22, 1916
Another laboratory method of some diagnostic value
was the so-called neutralization test. In this, serum
from the suspected case, in the stage of recovery, was
mixed with an old fatal dose of an active virus. These
were incubated, and later injected intracerebral^' into
the monkeys. Failure of. the disease to develop indi-
cated that the virus had been neutralized. This test,
however, did not furnish conclusive evidence of polio-
myelitis, for sera from noses known to have been free
from a recent attack of the disease had sometimes
successfully neutralized the virus. It was, however,
quite obvious that laboratory methods requiring the use
of monkeys were both too complicated and too expensive
for ordinary diagnostic use. A study of the blood pic-
ture was exhaustively made by Peabody, Draper, and
Dochez of the Rockefeller Institute. It was shown that
there existed a varying increase in leucocytes and a
polymorphonucleosis. This was characteristic of so
many other diseases that it was of little value in diag-
nosis. The procedure which they found to be their
most, reliable and valuable aid in the recognition of
poliomyelitis was the examination of the spinal fluid.
In the first twenty-four to forty-eight hours after its
onset, poliomyelitis must be differentiated from the
early stages of epidemic meningitis or mild purulent
meningitis, and aiso from a meningism accompanying
pneumonia or other infection. The clinical picture pre-
sented by these diseases were quite similar, and it was
in the distinguishing between them that the examina-
tion of the spinal fluid afforded them the most valuable
information. In the early stages of poliomyelitis, the
spinal fluid was clear, or rarely it might be slightly
cloudy. It often showed a good fibrin web formation.
There was a slight to moderate increase of albumin
and globulin, and also of the cellular elements. The
reduction of Fehling was prompt. Those poliomyelitis
fluids which were cloudy presented a polymorphonucleo-
sis which might run as high as 90 per cent., but which
they usually found to be about 60 per cent. As a rule,
however, 80 per cent, or more of the cells were mono-
nuclears. In examining such fluids, they had frequently
observed the presence of large mononuclear cells, which
they believed to be, in a measure, characteristic of
poliomyelitis. They were now studying these by means
of the various differential stains, in the hope that their
research in this direction might develop something of
positive diagnostic significance. Two rare types of
spinal fluids sometimes occurred in poliomyelitis when
hemorrhagic process had been more than usually exten-
sive. The first of these was of the true hemorrhagic
character, the red blood cells being evenly diffused
throughout the field. When collected in successive
tubes, the specimens were all hemogeneous, showing no
change in the intensity of the hemorrhage. This served
to differentiate it from bloody fluids obtained by the
accidental puncture of a vein. The second of these
rarer fluids illustrated the so-called syndrome of Froin.
It had the characteristic yellow color, and coagulated
spontaneously. The spinal fluid from early cases of
purulent meningitis showed a varying degree of cloudi-
ness, except in very rare instances when it might he
clear. A greater increase in albumin and globulin
was usually found here than occurred in poliomyelitis
with a poorer reduction of Fehlings. The cells in these
fluids of purulent meningitis were 90 per cent, or more
polymorphonuclears, and the etiological organism was
found except in the mildest cases. In certain mild
cases of meningitis, probably of epidemic variety, the
meningococci might never be positively demonstrated in
the fluid. In purulent meningitis due to other organ-
isms, these practically always appeared later. In one
instance, she had seen a clear fluid from an early case
of epidemic miningitis. This was of about eighteen
hours' standing. Although the cellular reaction was so
slight, the meningococcus was demonstrated to be pres-
ent in the fluid by smear and culture. The fluid in
meningism was increased in amount but practically
normal in character. When seen a week or more after
the onset, cases of poliomyelitis, especially if presenting
cerebral symptoms, must be differentiated from tuber-
culous meningitis. The spinal fluid in both these con-
ditions was clear, and increased in amount. The albu-
min and globulin content of both was also increased;
but usually in poliomyelitis the increase of both these
last-named elements was not so great as occurred in
tuberculous miningitis. The reduction of Fehling's so-
lution was usually better, and Dr. Neal said that many
tuberculous fluids gave a good reduction of Fehlings
though the contrary had been stated. The cellular ele-
ment was also usually less in poliomyelitis. In hoth
conditions, at this stage, there was ordinarily a mono-
nucleosis, although in some acute cases of tuberculous
meningitis there was a polymorphonucleosis. If, how-
ever, as might occassionally happen, the increase of
albumin and globulin was greater than usual, and the
reduction of Fehling's solution was not so prompt, then
the determination of the disease must wait upon the
results of animal inoculation if it had been impossible
to demonstrate tubercle bacilli in fluids. In brief, then,
a spinal fluid increased in amount, and chowing a slight
to moderate increase in albumin and globulin, a good
reduction of Fehlings, and a varying cellular increase,
mostly mononuclear, made the diagnosis reasonably
certain in fairly early cases of suspected poliomyelitis.
A slightly cloudy fluid occurring very early in the dis-
ease must be differentiated from a similar fluid in an
early purulent meningitis. Fluids from the cerebial
or encephalitic type of poliomyelitis sometimes might
be differentiated from fluids of tuberculous miningitis
only by animal inoculation.
The Importance of the Present Epidemic. — Dr. Haven
Emerson said that the Health Department was not able
at the present time to present statistics in a complete
form. The records showed the date on which the cases
were reported, and not the date of onset. For instance,
in May only five cases were reported; since May. fifteen
additional cases had been reported that had their onset
in May. In June, the incidence of the disease rose rap-
idly. The increase in the number of cases was observed
about June 20, and rose rapid iv until Ju;y 11, when the
highest point was reached. Since that time there ap-
peared to have been a recession, but it could not be
said, as yet, that it was permanent. Dr. Emerson pre-
sented the statistics for diphtheria, scarlet fever, meas-
les, and diarrheal diseases during the past six years,
and the first six months of the present year, for New
York City, and contrasted them with the number of
cases and deaths reported from poliomyelitis. They
showed that both the morbidity and mortality rates of
poliomyelitis were low in comparison with the above-
mentioned diseases. During the first six months of
191G there were 884 deaths from diarrhea and 57
from poliomyelitis. The community looked with com-
placency on the former while it was panic stricken in
the presence of the latter. The psychological state of
the lay public was interesting at this time. The panic
that had resulted from reports with reference to infan-
tile paralysis was probably due to the fact that this
was the first epidemic of this disease in which it was
reportable in New York City. It was also the first
time that there had been a concerted effort at hospitali-
zation of the disease. The present method was frankly
an experiment. At the onset the Health Department
was confronted with two alternatives. The one was to
attempt quietly the medical control of the cases; the
other was the method of publicity. They had decided
in favor of the latter as offering the better prospect
of real control of the disease. This method also offered
the opportunity of giving the city a lesson in cleanli-
ness and the control of infection. This was the first
epidemic of poliomyelitis in this city that had been
studied while it was in progress. The epidemic of 1907
was not studied until in November, when the Neurologi-
cal and Pediatric Sections of the New York Academy
of Medicine appointed a committee to investigate that
epidemic. In that epidemic there were probably 2,500
cases. The average mortality, as estimated in foreign
epidemics, had varied from 7 to 10 per cent. During
the epidemic of 1907 the mortality was 5 per cent. Dur-
ing the present epidemic about 2,600 cases have been
reported. Investigation showed about 1,600 of these to
be true poliomyelitis. The mortality thus far in this
epidemic was estimated to be 18.7 per cent. The most
important factors in dealing with infantile paralysis
were early diagnosis and the institution of methods
by which they were able to prevent the spread of the
virus among the healthy, and putting all cases under
neurological and orthopedic observation. This might
save the individual and the public from the future
burden that permanent crippling implied. Infantile pa-
ralysis was essentially a disease of early childhood. At
least 99 per cent, of the children affected had been born
since the last epidemic. Of the cases of true polio-
myelitis reported it was estimated that 917 have been
under five years of atre. and that 99 per cent, have been
under ten years. About 403 cases have shown paraly-
sis. In 50 per cent, of the eases the paralvsis made its
appearance in the course of a few days after the onset
of the disease. The longest period after the onset at
which paralysis made its appearance was sixteen days.
July 22, 1916]
MEDICAL RECORD.
171
In from 5 to 8 per cent of the cases, secondary or sub-
sequent cases have occurred in the same family. When
one gets a second or third case in the course of three
or four days after the onset of the first one it is safe
to classify it as a secondary case. These facts were
important, since the public had not previously been
impressed by the infectious nature of the disease. The
person suspected of being; a carrier of infantile paraly-
sis presented a difficult problem, since they could not
prove definitely that a person was a carrier, as could be
done in diphtheria or typhoid fever. This epidemic has
also presented the opportunity for concerted action on
the part of hospitals. This would probably result in
some definite plan for dealing with such emergencies
in the future that would greatly benefit the public and
would favor scientific study of the disease. The expe-
rience in this epidemic had shown the necessity of
having a staff suited to meet the needs of cases of in-
fantile paralysis. Dr. Emerson said he would like to
urge that hospitals that were likely to have cases of
infantile paralysis organize a staff consisting of a
laboratory diagnostician, an orthopedist, a neurologist,
and a pediatrician. There would be a great field for
social-service work for many years to come among these
patients. There was another point of importance in
connection with this epidemic, and that was that it
had shown the extent to which medical men would sac-
rifice themselves and their financial interests to the
public welfare. Many instances had come to his knowl-
edge where physicians who had been taking care of
these cases of infantile paralysis had, for the time
being, lost their practices, and were actually suffering
in consequence, their patients being afraid to come to
their offices. Other physicians should do all in their
power to discourage this attitude on the part of the
patients and to see that such physicians did not suffer
because of their willingness to sacrifice themselves. Fi-
nally, it should be remembered that no health depart-
ment, however efficient, could control an epidemic and
secure proper police enforcement of its regulations
without the support of the medical profession. There
must be early diagnosis and a willingness to report
cases, and it was to be hoped that as a result of this
meeting many undetected cases would be promptly re-
ported to the Department of Health.
Dr. William H. Park said that Dr. Flexner and
Dr. Noguchi had added so much to their knowledge of
infantile paralysis that there was little for him to add.
He would like, however, to emphasize one or two points
along the same lines that Dr. Flexner had spoken. At
the present time they knew that the sick person was
the source of most of the contagion, and that the per-
sons in attendance to the sick person, or the carrier,
spread the disease. There was no known carrier, as a
fly or insect, but the fly or filth that had been contami-
nated by the sick person or the carrier might spread
the infection. If an insect was found to convey the
contagion, it would probably be in a subordinate degree.
If we could detect the carrier of poliomyelitis as we
can the carrier of diphtheria or pneumonia or typhoid
fever, we would not act much differently than we were
doing. We possessed the knowledge necessary for the
detection of diphtheria and pneumonia carriers, and yet
we had done but little to control these diseases by con-
trol of the carriers. From what had been done in other
lines it was possible that more might be done in the
treatment of poliomyelitis by vaccines and serums, but
at the present time Dr. Park said he had no new knowl-
edge to offer. They had iust begun to study and work
along this line, and possibly six months from now they
might be able to announce some new discoveries.
Dr. Walter B. James said that two questions had
been asked. Some one asked whether it was safe to
admit and treat cases of infantile paralysis in a general
hospital. A doctor from an infected district asked what
the modern treatment for poliomyelitis was.
Dr. Haven Emerson said that it was considered
perfectly proper to treat these cases in a general hos-
pital. Experience had shown that in hospitals where
sanitary precautions were strictly carried out, infection
did not take place. The doctors, nurses, and attendants
in the hospitals did not contract the disease.
Dr. Henry Koplik said it was very difficult to speak
about the treatment of a disease the cause of which
was still under investigation. The treatment of the
disease could at this time be only symptomatic. The
patient should be isolated and kept absolutely quiet.
This was most important. Any one in attendance on
the patient should wear a gown and cleanse his hands
after leaving the patient. Together with absolute quiet,
the patient should have plenty of fresh air and an
easily assimilable diet. The bowels should be attended
to. Dr. Koplik said he had no particular remedies ex-
cept those supposed to have an effect on the general
nervous system. Liberal doses of urotropin had been
employed, but the utility of this drug had not as yet
been definitely established. Lumbar puncture offered
certain advantages. In the first place, the mere me-
chanical removal of a certain amount of toxic spinal
fluid might be of some benefit. In the second place, it
gave an opportunity to make a diagnosis; and in the
third place, it relieved pressure. This was of benefit
because the fact that we got the Macewen sign showed
the presence of pressure. If paralysis started in the
patient's limbs, they should be kept absolutely quiet,
and in some instances a cast might be applied to pre-
vent contracture of the muscles. When the ease was
removed it could sometimes be seen that it had been
instrumental in diminishing contracture. This con-
tracture might return later when the patient should
be referred to the orthopedist. Chloral and bromides
might be administered for symptoms referable to the
nervous system. Opium should not be used unless ab-
solutely necessary. Charcot had recommended the in-
tramuscular injection of strychnine as soon as the pain
and fever had stopped. One-fortieth of a grain might
be given daily for thirty days, different groups of mus-
cles being selected for the successive injections. Many
cases, however, had regained their power without the
injections, and many did not, so that it was very diffi-
cult to give an accurate judgment as to their value.
Warm baths sometimes proved a great blessing, if they
could be given without moving the patient too much.
Massage sometimes seemed to aggravate the condition ;
in other instances it seemed to relieve the pain. Iodide
of potassium in large doses seemed to relieve the pain
to a grater extent than any other remedy. In a few
cases its effect was almost miraculous. There should
not be too much activity in the treatment of these cases.
No attempt should be made to increase the tonicity of
the muscles until the active stage of the disease was
passed.
Dr. Leon Louria said there was nothing to be said
that had not been laid before them. He wished, how-
ever, to emphasize what had been said with reference
to the cases that did not show paralysis. The epidemic
could only be stopped by a recognition of the cases that
did not lead to paralysis. In a few instances he had
noticed a very interesting occurrence. A child would
be taken ill with indefinite febrile manifestations, sore
throat, and general malaise; he would be treated by
the usual remedies for such conditions, and would ap-
parently recover. In the course of three or four days
the symptoms would recur, and one wou:d also get defi-
nite symptoms of poliomyelitis and definite paralysis. If
the disease was recognized early, and the child placed
in bed and given the rest that the nervous system re-
quired, and the nervous system was not exposed to
additional trauma, the virus would not exert as great an
effect. The same treatment should be applied to the
abortive form of the disease as was given the paralytic
form and in this way the development of paralysis
might be prevented. In two instances which had come
under his observation the disease appeared to be of the
abortive type and two weeks later the symptoms became
more severe and a definite paralysis with permanent de-
formity resulted. Scientists were agreed that infantile
paralysis was carried from the sick to the healthy
child. It was possible for a healthy person to travel
into an infected district, to be contaminated with the
virus of infantile paralysis and then to implant it in
another locality. Children who were slightly ill and
whose illness was not properly interpreted were a
prolific source of this disease and if they were assembled
this evening that they might be prepared to assist the
health authorities in their endeavor to control this
disease, medical men should be called upon to njake an
early diagnosis and not to take lightly those silments
that might be abortive types of poliomyelitis.
Dr. Samuel J. Meltzer said that the several papers
presented failed to cover one essential phase and that
was the treatment of the disease. The reason for it
was to be found, perhaps, in the discouraging fact that
there was, at present, practically no treatment for polio-
myelitis. He wished to bring forward three promising
therapeutic measures based essentially upon personal
work. Since he had only five minutes at his disposal,
his remarks must of necessity be dogmatic and very
'irief. His practical suggestions had to be introduced by
the following considerations. Any inflammatory focus:
172
MEDICAL RECORD.
[July 22, 1916
was surrounded at the periphery by zones of hyperemia,
exudation, and edema. Thirteen years ago, in experi-
menting upon rabbits' ears, he found that an injection
of adrenalin reduced the entire inflammatory swelling:
to a very small focus in the center, consisting mainly
of paralyzed blood-vessels (passive hyperemia). The
peripheral zones of edema and active hyperemia disap-
peared completely for some time. Several years ago Dr.
Auer and he found further that an intraspinal injection
of adrenalin into monkeys produced a long-lasting effect
upon the blood pressure, longer than by any other method
of administration; more than one hour might pass be-
fore the blood pressure returned to normal. On the
basis of these observations and on the further plausible
assumption that the early stages of the paralytic ef-
fects in peliomyelitis were not caused by the chief in-
flammatory focus but by the peripheral zones of active
hyperemia, exudation, and edema, he induced Pr. Clark,
then working under Dr. Flexner at the Rockefeller
Institute, to make the following experiments. Monkeys
dying from experimental poliomyelitis received intra-
spinal injections of adrenalin. The beneficial effect was
most striking. Animals which were paralyzed and mori-
bund at the time of the injection were seen several
hours later eating bananas which they held themselves.
The paralytic conditions were strikingly improved and
the life of the animal was prolonged in some cases for
several days. The animals finally died; but in this series
of Dr. Clark's experiments, all had received reliably
fatal doses of the virus. It was important to bear in
mind that the mortality in human infantile paralysis
was generally not more than 25 per cent, and was
usually due to respiratory paralysis. It was probable
that often the respiratory paralysis was not produced
by the chief inflammatory focus, but by the preceding
extensive peripheral zones of exudation and edema,
which were surely capable of interfering with the
vitality of the nerve centers controlling respiration.
If the exudation and edema could be removed for
some time, the lives of a few or of many of the cases
might be saved, for it frequently happened that the
ascending progress of the actual inflammation came
to a standstill. On the basis of these facts and
considerations he recommended the injection of adre-
nalin intraspinally in every case of infantile paraly-
sis, the injections to be repeated in from four to six
hours. The procedure might save life, and in surviving
cases it might reduce the extent of the final lesion.
There was no danger in this procedure. Monkeys
stood well as large a dose as 2 c.c. in a single injection.
However, in human infantile paralysis the injections
should be begun with a dose of 0.5 c.c. of adrenalin, until
more was learned about the effects. There were two
other suggestions he wished to make. One was to ad-
minister artificial respiration by means of his appar-
atus for pharyngeal insufflation as soon as the patient
showed a degree of unconsciousness and respiratory in-
sufficiency. It was an easy and reliable procedure. The
second suggestion was to administer oxygen under pres-
sure in a respiratory rhythm by an apparatus which
he had recently devised and used on human beings in
several instances. It abolished rapidly cyanosis and
might save life. It might even act specifically on the
virus of poliomyelitis.
MEDICAL SOCIETY OF THE STATE OF NEW
JERSEY.
One Hundred arid Fiftieth Annual Meeting, Held in
Asbury Park, -lime 20, 21, and 22, 1916.
(Special Report to the Medical Record.)
(Concluded from page 125 i
Wednesday, June 21 — Second Day.
Reception of Delegates and Guests from Other States
«eith Responses by Presidents of State Societies and
Delegates from Other States. — Dr. W. W. Palmer of
Boston, President of the Medical Society of the State
of Massachusetts, said he was not prepared to make a
formal address, but would present the greetings and
congratulations of the Medical Society of the State of
Massachusetts, which was fifteen years younger than
the Medical Society of the State of New Jersey, having
been organized in 1781. The charter of the Massa-
chusetts Society bore the names of Samuel Adams and
John Hancock. There were records showing that Dr.
Chrystopher Elmer of the New Jersey Society had
written to Dr. John Warren of the Massachusetts So-
ciety asking him for a copy of the act of incorporation
of the Massachusetts Society. While the Medical So-
ciety of the State of New Jersey had been organized
longer than that of Massachusetts, the latter was the
first to have been incorporated by an act of Legislature.
The records of the Massachusetts Medical Society had
been collected and published by Dr. Henry I. Bowditch
and made very interesting reading. In closing, Dr.
Palmer said that not only was the Medical Society of
the State of New Jersey ancient and honorable, but it
had many honorable members who had been in the
practise of medicine for more than fifty years. He
had just met such a man who told him that he had
practised medicine for fifty years and that without a
vacation ; the society should appoint a conservation
committee who should see that he and others of his
kind were compelled to take a vacation.
Dr. H. B. Earle of Greenville, South Carolina, said
he accepted the invitation to be present not only in
order to congratulate the members of the Medical So-
ciety of the State of New Jersey on the attainment of
so venerable an age, but to see how the oldest medical
society in the United States conducted its affairs. The
Medical Society of the State of South Carolina was
one of the youngest in the country, having been in ex-
istence only six or eight years, but they were doing
good work. While South Carolina had not had a State
medical society it had produced some famous medical
men, Marion Sims, Chisholm, and Thomas. In their
society they had been having fifty or sixty papers and
holding their meetings until late at night. He thought
the custom of the New Jersey Society of having fewer
papers, having them of a high character, and placing
emphasis on the social side was worthy of emulation.
Dr. Edward Y. Davidson of Washington, D. C,
President of the Medical Society of the District of
Columbia, after expressing his appreciation of the
depth and wholesomeness of the hospitality that the
guests had received at the hands of the society, said
that the history of the Medical Society of the State of
New Jersey overlapped that of the United States; it
antedated by ten years the birth of this republic and
had given great men who had contributed to the mak-
ing of the history of this republic as well as having
been an important factor in American Medicine. The
society was born of hardy parentage bred on rugged-
ness in a critical period and it was to be expected that
their offspring would carry out the high mission which
they had undertaken for the advancement of medicine.
They were to be congratulated not only for their
seniority, but for their high achievements in medicine.
Dr. J. R. Brown of Tacoma spoke for the Medical
Society of the State of Washington. He said that the
Medical Society of the State of Washington was one
of the youngest State societies, but was proud to boast
of its youth. They would hold their twenty-seventh
annual meeting next month. There were at the pres-
ent time 1,500 physicians in the State of Washington
and 900 were members of the State society. They were
organized on practically the same lines as the New
Jersey State society. Some of the work they were
doing might be of interest. Washington was a manu-
facturing State and there were many accidents, and
they had come to the conclusion that it was advisable
to have an accident insurance. Formerly the doctors
had many damage suits as the results of fractures
and other injuries; now the employees received com-
pensation and there few damage suits. The doctors had
combined for protection and had a medical defense fund
against malpractice suits. There had been more than
100 suits and in none had a judgment been secured
against a physician. This had been a means of unify-
ing the medical profession so that they now stood prac-
tically as one man. Every three years the physicians
of Washington, Idaho, and Oregon met together and
had formed a great Northwestern Medical Empire
which was doing much for the uplift of the medical
profession. They had only one first-class medical col-
lege for 4,000,000 population and they did not want any
more.
Dr. George I. McKelway of Dover spoke for the
Medical Society of the State of Delaware. He said the
Delaware society was incorporated in 1789, and he be-
lieved it was the third oldest medical society in the
United States. He said he had lived in Delaware but a
short time; most of his early associations were con-
nected with New Jersey. His grandfather had settled
in Trenton where he lived until he was ninety years of
age and practiced almost up to the time of his death
so that the early conditions of the practice of medicine
in this State were particularly interesting to him.
July 22, 1916]
MEDICAL RECORD.
173
The Morbidity of Childhood and the Mortality of the
Second and Following Decades. — Dr. Thomas N. Gray
of East Orange presented this paper, in which he stated
that the success attending- the efforts to conserve infant
life gave warrant for the exploitation of another line
of child welfare work, namely, that of giving the child
a chance to grow into robust adult life and to live the
allotted years of man. His object in presenting this
subject was the prevention of those deaths which oc-
curred in later years due to those diseases of childhood
which were preventable through the prophylaxis of
non-communicable diseases made possible by proper
equipment for diagnosis, thorough foreknowledge and
thoroughness of examination and thorough control of
epidemics and immunization against communicable dis-
eases. Another reason for the conservation of child
life had come to them and that was the vital need for
preparedness. The essayist discussed the cause of later
year deaths from organic heart disease, chronic nephritis
and pulmonary tuberculosis and sought in the diseases
of childhood a possible relationship with these, especi-
ally with reference to rheumatism, diphtheria, scarlet
fever, measles and whooping cough. He said that no
figures were extant, showing the percentage of deaths
at ages from ten to forty years of age from organic
heart disease and nephritis traceable to first decade
rheumatism, diphtheria or scarlet fever, but it was
known that scarlatinal rheumatism was the cause of
many cases of endocarditis and damaged heart valves,
that in a child a typical polyarthritic manifestation of
rheumatic infection was a common occurrence, that the
cardiac complications of rheumatic infection were not
only more common in the child than in the adult, but
as a rule were more severe. There was a definite con-
nection between heart lesions and "growing pains," at-
tacks of tonsillitis and a history of a fever lasting a
week or ten days. His experience which had covered
the lives of patients from birth to the fourth decade
had demonstrated such a connection many times. It was
his belief that a large percentage of deaths in later
years from the disease mentioned were due to the pre-
ventable diseases of childhood. Many opportunities of
forestalling damage to the heart valves were lost
through the failure to make an early diagnosis of
rheumatism and to follow it by treatment with the
salicylates. In diphtheria many physicians waited for
the report from the laboratory before giving antitoxin,
and too many discarded their suspicions as to the pres-
ence of diphtheria on the receipt of a negative report.
Until the time came when research workers would place
at their command the means for immunization against
all infections, and even after it we must look to our
health boards to prevent epidemics of scarlet fever,
diphtheria, measels, and whooping cough as effectively
as they now controlled smallpox. Dr. Gray said he had
asked a health officer the following question : "Would
not the same isolation, strict quarantine, with immuni-
zation in diphtheria and pertussis, limit and control
these diseases?" He had also asked whether the health
boards did not have the same control over other com-
municable diseases that they had over smallpox and
why. if they had such control, they did not exercise it?
The health officer replied: "Because public opinion
would not sustain us and it would bring about a furious
storm of protest." In discussing the control of tubercu-
losis, the essayist said that this disease could be con-
trolled only by the removal of open cases to sanatoria
and by placing infected children in preventoria. To do
this would require an adequate sanatorium and pre-
ventorium in every county. There was only one reason
for inadequate county sanatoria in this State with its
ample enabling act for their establishment, and that
was the failure on the part of freeholders to appropri-
ate enough money. This failure was due partly to lack
of appreciation of the need and partly to the deterring
fear of a raise in the tax rate. Sanatoria without pre-
ventoria would lead to an endless chain of expenditure
with no hope of controlling the disease. In discussing
the problem of bovine tuberculosis the essayist said
that the fact that the tuberculous cow remained in the
herd was not the fault of health boards, but was due
to the injustice of the law which allowed the dairyman
but a nominal price for his slaughtered cow and took
from him the value residing in hide, hoof, fat, and meat
if it was salable.
Dr. Johnson of the New Jersey State Board of
Health said that the question was often asked why so
much attention was paid to infants and so little to the
young adult. Dr. Gray had pointed out the need of
more thorough examination and diagnosis in the dis-
eases of children and had urged that more care be
taken in the reporting of communicable diseases. Dr.
Louis I. Dublin had recently published a study of 1,153
cases of scarlet fever in reference to their sequela;. In
this series there were ninety deaths, and eleven of these
showed distinct kidney involvement. He found that
either the impairments of the kidneys which were so
common in scarlet fever were severe enough to cause
immediate death, or that in the survivors the injurious
effect was not sufficiently great to kill wiihin the next
five years. He said that it was quite possible that
ultimately there might be an increase in the expected
number of deaths from kidney lesions, although such a
consequence might not manifest itself until ten or
more years had elapsed after the initial incidence of
the scarlet fever. Although the sequela of scarlet fever
were apparently not an appreciable factor in the mor-
tality of the survivors, it should not be overlooked that
the disease itself still constituted an important factor
in child mortality. Dr. Johnson said she would like
someone to express an opinion as to whether there was
any relation between nephritis and cold baths, whether
it was possible that the intense chilling resulting from
cold baths might result in nephritis. She did not be-
lieve they could effectively control communicable dis-
eases until they had well trained, full time health
officers and good nurses to assist these health officers.
It was important that parochial schools as well as
public schools should be inspected. The truant officers
should also cooperate in reporting communicable dis-
eases. Teachers sometimes kept children in school when
they ought not to be there. In Princeton the Board of
Health notified the school nurses of every case of com-
municable disease and the nurses notified the Board of
Health of any case they encountered, and in this way a
closer watch could be kept over cases of communicable
disease. Accurate records as to the prevalence of
tuberculosis could not be obtained, but it was estimated
that for every fatal case there were eight or twelve
living cases. On such a basis it would seem that the
hospitals were accommodating only about 3 per cent,
of the cases. With such figures it ought not to be
necessary to point the moral. The speaker also em-
phasized the importance of pasteurization of milk as a
preventive of bovine tuberculosis and said that all
communicable diseases should be as rigidly quarantined
as smallpox now was, and then they might be as effec-
tively controlled.
Dr. Henry H. Davis of Camden said they wanted
local health boards to do better work, but they did not
want the tax rate raised. If there was an epidemic of
smallpox they had no trouble in getting an appropri-
ation to control it, yet among all the communicable
diseases there was none so easy to stamp out. The
great problem in the control of communicable diseases
was how to get the money.
Dr. Gordon K. Dickinson of Jersey City said the
dollar was the great thing. When people looked at the
dollar and saw the dollar sign on one side and "In God
we trust" on the other they decided to trust to God to
take care of the contagious disease. It seemed to him
that the only thing to do was for the profession to get
together and organize, to send out a man of personal
magnetism who was interested in this subject to stir up
the profession and get them to organize a campaign of
education, and then when they asked for an appropria-
tion from the State or a municipality for the control of
communicable diseases they would get it.
Dr. Alfred F. Hess of New York said that Dr.
Gray had brought up one of the most important public
health problems of the day. It was recognized that
most of the ills of adult life were contracted during
infancy and childhood. That tuberculosis was the most
important of these ills was recognized by everybody
since von Behring brought out the facts with reference
to the large number of infections with tuberculosis in
childhood. Dr. Hess said he happened to be in charge
of the first preventorium for infants in the United
States. This preventorium was located at Farming-
dale, about ten miles inland from Asbury Park. The
institution accommodated about 180 to 200 children of
tuberculous parents. Their experiment of taking the
infants of tuberculous mothers before they became in-
fected might also be of interest. They had been told
that it would be impossible to get these babies, as the
mothers would not give them up. They had thus far
taken twenty-five babies who gave negative von Pirquet
reactions; that was, they were taken before they be-
came infected. They took some of these babies from
mothers who were in tuberculosis sanatoria. They had
174
MEDICAL RECORD.
[July 22, 1916
established the fact that the mothers were willing to
give the children up. Another problem was with ref-
erence to returning the child. That bothered them
some at first. In about one-half the cases the mothers
had died after a year or so and the children were then
returned to a safe home. In some instances the mothers
were cured and it was safe to send the babies home.
In other instances they kept the children, and these
were a problem. Dr. Hess said it seemed to him that
this was an important way to attack the tuberculosis
problem. Most of the speakers had referred to the
financial side of the problem. He had just attended a
meeting at Long Branch, a city whose financial budget
amounted to $250,000 a year, and last year they gave
$25,000 to health work. This year they had a new gov-
ernment and it was decided to cut down the appropri-
ation for health work to $15,000. Finally a com-
promise was made and $19,000 was decided upon. They
did not think a visiting nurse very important, while in
reality she was the keystone of public health work be-
cause she found out and brought to the doctor's atten-
tion the various needs of the individual. If the doctors
wanted to organize and do some work, Long Branch
was an interesting example which they might take as a
starting point.
Dr. Julius Levy of Newark expressed the opinion
that they could not affect the problem of tuberculosis
in New York to any great extent by a preventorium
that took care of twenty-five children. This was only
an experiment. He believed real prevention would
come not through preventoria, but through bettering
living conditions. The effort to control tuberculosis by
sanatorium treatment would only present the problem
of the continued increase of accommodations in insti-
tutions. It was said that nearly everyone contracted
a little tuberculosis and everyone is exposed to the dis-
ease to some degree, and the problem was to minimize
the danger of this exposure. The infant should be left
with the tuberculous mother if it could be nursed and
at the same time protected from infection. Breast-fed
babies were much less liable to contract infection and
possessed a higher resistance than bottle-fed babies.
This was shown by the fact that there were fewer eases
of measles among breast-fed babies, and when they did
contract the disease they had it in a milder form. The
medical profession should be taught that nursing was
possible in 99 per cent, of the cases and that it in-
creased resistance. Some children had a myocardial
degeneration due to the fact that they did not get
enough rest during an infectious disease. Such a
child might not be definitely ill but merely under par.
The child might not seem sick enough to put to bed, yet
a week's rest in bed was what was needed. This was
frequently the case when a child had an infectious dis-
ease in a mild form. No matter how mild the infec-
tious disease might be the child should be kept in bed
for a week.
Dr. Alexander Marcy of Riverton said that public
health work was something entirely different from the
practice of medicine. If men to do efficient public
health work were wanted they must be trained to that
work. In the State of New Jersey every health or-
ganization must have a licensed health officer and the
State Health Board provided for these examinations by
an act of Legislature. Many of the men taking these
examinations who had practised medicine knew less
about public health work, judging from the results of
the examinations, than those who had never studied
medicine. They had the cart before the horse; the first
thing to be done was to find some way of training men
to become sanitary officers. A man who wished to do
public health work should go to some institution and
take a course and graduate as he did from medical col-
lege. The need was for trained sanitarians, trained
health officers and trained medical inspectors. As to
the medical profession becoming a unit; if that condi-
tion could be realized it would be impossible for any
body politic to stand before a united profession. They
now went before the Legislature with half a dozen men
from different parts of the State and nearly every indi-
vidual had an idea of his own; there was no con-
sensus of opinion and the politicians say, "Great
Heavens! there come the doctors and they have not the
slightest idea what they want."
Dr. Linn Emerson of Orange expressed the opinion
thai what was needed most was sanatoria for advanced
and incurable cases of tuberculosis. All sanatoria were
conducted on the idea that the percentage of cures was
the one thing to be considered, and if an individual was
in the advanced stage and could not be cured he was
sent home, and the result was that he infected everybody
in the family. All the money spent on preventoria was
as good as wasted so long as communicable cases were
turned loose, and it was a surprise to him that people
interested in tuberculosis did not realize this fact when
they went about endeavoring to improve conditions.
Dr. Herman Gross of Metuchen called attention to
the working conditions in factories which were respon-
sible for a great deal of tuberculosis. He told of one
factory where the women went to work early and
worked late, working ten and twelve hours daily, and
then going home and doing their house work and said
that within three years after they began this work
50 per cent, of them came down with tuberculosis.
When the inspectors came around the employees were
told to tell them that they worked only fifty-five hours
a week, which was the limit the law set for women fac-
tory workers. Something should be done to limit the
working hours and control conditions in the factories.
In this factory only ten minutes was allowed at noon.
Abroad employees were given an hour at noon.
Dr. B. D. Evans of Morris Plains said that if any-
thing was to be done of a practical character it would
have to begin with a campaign of education; every
large project, whether in medicine or law or muni-
cipal government or national government, in the
sciences, the arts, or the crafts, was brought about by
educational work. In a case of measles the doctor too
often told the family that the diseases did not amount
to anything; that the child should be protected and it
was nothing serious. The general public had come to-
look upon measles as of no more consequence than a
slight attack of indigestion. Children should be told
of the dangers of measles in the public schools as they
were now told of the dangers of alcohol, tobacco, small-
pox, and tuberculosis. If the people were made to under-
stand the gravity of the sequelae of the communicable
diseases a public sentiment would be created, and when
there was a request from State or local health boards
for funds they would be forthcoming. It was right that
this society should be behind such a campaign of edu-
cation.
Dr. Thomas N. Gray of East Orange said he agreed
with Dr. Levy that the underlying problem was that of
economics, but they must deal with present conditions,
and if they could not do anything to remedy the eco-
nomic conditions they must have sanatoria, they must
have better isolation and better protection on the part
of the boards of health. Tuberculosis was not con-
tracted in the open air but was essentially a home
disease. They should have a sanatorium in every
county with accommodations for every open case of
tuberculosis, but he wished to emphasize what he had
said, that sanatoria without preventoria would never
stop the spread of tuberculosis.
Reception of Delegates. — Dr. MARTIN I. TINKER of
Ithaca, President of the Medical Society of the State of
New York, spoke for that organization. He said that in
listening to the discussion he had come to the conclusion
that the state societies did not differ essentially from
one another. He had hoped to learn something of the
organization and methods of the New Jersey State So-
ciety. The New York Society did not have all that was
good in organization ; they had much to learn from
other societies. Progress in medicine was not the work
of a few brilliant men ; progress did not come from a
community where the average intelligence was low but
where the average standards were high.
Pennsylvania Delegation. — Dr. Chandler then wel-
comed the twenty-five delegates from Pennsylvania.
Dr. John McLean of Philadelphia, President of the
Philadelphia County Medical Society, said he believed
the Philadelphia County Medical Society was the larg-
est county medical society in this country. They had
done their part in influencing education. They were
not obstructionists but constructionists and when they
went before a governing body they knew what they
wanted and they went with definite recommendations.
Dr. E. A. Crueger of Philadelphia said the problems
confronting health officers were complex and perplex-
ing. It was very hard to make families recognize that
the rights of the individual ceased where the rights of
society began. Mention had been made of the relation-
ship of legislative bodies to health departments. He
thought a great deal could be done by diplomatic pro-
cedure and here the first step was the education of pub-
lic sentiment. He told of some of the difficulties that
Philadelphia had encountered in getting proper hospital
accommodations for tuberculous patients and for the
insane and the struggle they had encountered in get-
July 22, 1916]
MEDICAL RECORD.
175
ting a new municipal hospital so that they wanted to
sympathize with the New Jersey Society in its trials
and to share in its triumphs.
Dr. William Duffield Robinson of Philadelphia told
of the intensive health work they were doing in Phila-
delphia. They took one block at a time and made a
study of every individual in that block and kept records.
They had proved that the intensive method of doing
public health work was the most effective. They had
physicians, visiting nurses, social workers and all the
newer methods and they were getting better results in
this way.
Address of the Third Vice-President. — Organotherapy.
Dr. Thomas W. Harvey of Orange, N. J., delivered this
address. He stated that many tissues of the body had
internal secretions, that was, they elaborated during
the process of metabolism, either in response to stimuli
from the central nervous system or excitant agents
from the secretions of their tissues, a substance which
they poured into the blood stream and which had impor-
tant functions in the body. Certain internal secretions
were essential to the maintenance of life, notably that
of the suprarenal capsules and the pituitary body.
These regulated the amount of blood supply, determined
growth, inaugurated chemical changes in the body nec-
essary to nutrition, stimulated phagocytosis, antagon-
ized infections, and antidoted toxins that resulted from
errors in the chemistry of life. Extracts of internal
■organs did not represent the entire effect of the internal
secretions that were elaborated in these glands. The
ductless glands were all interdependent. When there
"was a deficiency in some ductile gland it was often im-
possible to determine which one and often the same
symptom complex found threatening life was traceable
to deviation from the normal of quite dissimilar organs.
The essayist had seen cases of status lymphaticus in
which recovery took place from very serious attacks
and the subsequent history indicated the involvement of
other organs than the thymus; one patient was found
to have Addison's disease, and another Graves' disease.
There seemed to be no success attendant upon the use
of adrenalin in Addison's disease associated with lesions
of the suprarenal capsule. From the use of the secre-
tions of the ovary much could be expected in the amelio-
ration of disturbances of the nervous system consequent
upon the establishment of the menopause whether nat-
ural or artificial. It was well in the present state of
our knowledge to accept the terms "hyper" and "hypo"
as expressing different forms of disease caused by dis-
turbance of function of these glands without committing
oneself to the theory that there must be an excess or a
deficiency. Thymus extract was useful in many cases
of exophthalmic goiter, particularly those occurring
about the period of puberty. The writer discussed the
relationship of the pituitary gland to abnormalities of
growth and development and called attention to the
usefulness of this agent in obstetrical practice and after
laparotomies. In pneumonia pituitary extract might
be used as adrenalin had been to sustain the heart and
circulation during the crisis. It was also useful in
shock, surgical or emotional. Thyroid extract had a
number of indications. It was useful in obesity, though
injudiciously administered it might be productive of
harm. In arteriosclerosis it lowered blood pressure.
Oration in Medicine — The Classification, Prognosis,
and Treatment of the Nephritides. — Professor Martin
H. Fischer of Cincinnati presented this communication
which was illustrated by graphic charts and brought
out several new ideas in reference to nephritis. He
stated that the effect of water and sodium chloride in
nephritis could only be determined with authority on
the basis of the cause of the clinical entity called ne-
phritis. It might be said that nephritis was an edema of
the kidney and this brought up the problem as to the
cause of the edema of the kidney, which might and did
affect other organs and tissues as well as the kidney.
The question might be asked: "Why do the cells and
tissues of the body hold any water at all?" "Why does
the body hold so constant an amount of water from
month to month and from year to year?" Even the
osmotic theory lacked a good many facts to support it.
One must get at the laws that governed the absorption
and excretion of water by simple colloids, and of these
the protein colloids were the most important. They had
found that the more acid that was added to a protein
colloid in the presence of water the greater the degree
of swelling, and that if this acid was neutralized one
got a shrinking of the protein colloid. If to the pro-
tein colloid swollen by acid solution any salt was added
there resulted a reduction of the swollen fibers. Sodium
chloride had less activity in this respect than other salts,
such as sodium nitrate, sodium acetate, etc.; the most
powerful salts were sodium tartrate, sodium citrate,
and sodium sulphate. Magnesium sulphate was very
much more powerful than the same concentration of
sodium or potassium. The action that this agent had in
extracting water from the bowel was well known but
the explanation had been lacking. If an ox's eye was
placed to soak in an acid solution an experimental
glaucoma was produced; the eye would become swollen
to the point of rupture. If one then added sodium
citrate to the solution the eye would shrink. Glaucoma
was entirely an edema of the eyeball. Tissues suffered
changes accordingly as they held more or less water
and the amount of water sucked up was determined by
the cells themselves and not by something outside. If
one applied these facts to nephritis which was an edema
of the kidney the general conclusion would be reached
that nephritis was also a composite of a number of
chemical changes occurring in the whole or in parts
of the kidney; they were all due to a common cause,
namely, the abnormal accumulation of acids or other
substances that acted like acids, urea, etc. This having
been proven one ought to be able to do something for
the nephritic patient. The evidence of the accumula-
tion of acids in nephritis was well established and when
there was a sufficient acid concentration albumin, casts,
and blood appeared in the urine. If water was ingested
it was retained and one got edema and thus one saw
developed parenchymatous nephritis. It was well
known that muscular contractions during violent exer-
cise produced lactic acid and when violent exercise was
continued the acids accumulated faster than the blood
could oxidize them and one would find albuminuria with
casts. In some instances in young healthy athletes as
much as several grams of albumin to the liter had been
found after violent and prolonged physical exercise.
The same thing might be observed in warm-blooded
animals after exposure to cold. In considering ne-
phritis one should not concentrate his attention on the
kidney but should look outside for the principle that
should guide him in the treatment of nephritis. The
cause of the abnormal production of acid must be
sought. One might have a patient with pneumonia and
convulsions due to the large amount of acid produced
in which one could not neutralize the acid for hours
after the convulsions. Again about 50 per cent, of the
eclampsias occurred, not during, but after delivery,
this being due not only to the accumulation of acids
before delivery but to the additional accumulation due
to the muscular contractions and strain during labor.
In such cases one had an acidosis and the indications
were for the administration of alkalies and also for the
administration of salts in more than physiological con-
centration. A third rule was to give sugar; a high con-
centration of sugar also dehydrated. A fourth rule
was to give water but this was not an unmixed bless-
ing; there should be enough alkali and salt to neutralize
the effect of the water. The idea had been prevalent
that to administer salt to a nephritic was to kill him;
this was incorrect, and sodium sulphate possessed ad-
vantages over sodium chloride. Dr. Fischer objected to
the elaborate classification of nephritides in vogue and
stated that so little was known of the physiology of the
kidneys that there was no warrant for such classifica-
tion. The kidney was all parenchyma and therefore
there could be only one kind of nephritis and that was
parenchymatous nephritis. There might be two varie-
ties of parenchymatous nephritis, general and "spotty."
That was the entire kidney might be involved or the
process might go on in small foci of infection. In the
latter condition after the acute attack the prognosis was
good in nephritis due to infection, anesthesia, etc. The
prognosis on the other hand was much less favorable if
the condition of the kidney was dependent upon arterio-
sclerosis, the reason being that one was dealing with
necrosis of an irremovable and irremediable type. When
a patient with parenchymatous nephritis developed gen-
eral edema the idea was that the edema was due to a
cessation of kidney function. This was wrong, for the
operative removal of a kidney did not produce edema.
Edema was not due to loss of kidney function but to
something that produced the disease, to a general
toxemia affecting all the tissue cells, including the cells
of the kidney. The symptoms that had been attributed
to the kidney were signs and symptoms of edema of the
brain, an intoxication by the same poison that had
affected the kidney. The headache of so-called uremia
told us that the brain was swollen to the danger point.
It was not true that high blood pressure was a conse-
176
MEDICAL RECORD.
[July 22, 1916
quence of kidney disease; high blood pressure was de-
pendent upon the cardiovascular system and was a com-
pensatory mechanism.
The following questions were asked: "In the use of
organic acids of fresh fruits do the acids oxidize to
carbonates? In glaucoma should one use the citrates
to control the edema? What effect had the intravenous
injection of colloidal sulphur? What is the diet in the
condition known clinically as chronic interstitial ne-
phritis? What would be your treatment for so-called
uremia? Has the Karell treatment any advantages?
Is a blood pressure of 140 normal in a man of sixty
years? If we use dextrose does it prevent the oxidiza-
tion of the tissues of the body? What do you mean by
a clinical uremia? Does a child make a complete recov-
ery from the nephritis of scarlet fever? Is there any
permanent damage from the violent exercise indulged
in by athletes?"
. Dr. Fischer, in closing the discussion, said that or-
ganic acids were of two types; one type was readily
oxidizable and fruits containing this type led to a
decrease of water. This was true of most fruits and
vegetables, with the exception of strawberries, cran-
berries, and grapes. On the whole, fruits and vege-
tables made for alkalinity and not for acidification. In
twenty-two cases of nephritis investigated, nine were
due to an underlying arteriosclerosis and as a rule the
prognosis of these cases was bad. He could not answer
the question with reference to the effect of colloidal
sulphur. This was a suspension and did not come in
the group studied. As to the diet in so-called chronic
interstitial nephritis he said he supposed the one who
asked that question meant the condition associated with
cardiac hypertrophy and vasomotor disturbance. They
did not confine these patients to an extremely limited
diet but gave them rest and decent food, not merely slop
foods, fie allowed the patient to eat vegetables which
yielded about 25 per cent, alkali, a certain amount of
meat was permitted, and enough alkali was adminis-
tered to keep the urine neutral. As to the treatment
of uremia, he did not call the condition uremia; he
called it edema of the brain due to a toxin or to a car-
diovascular condition. All edemas did not have the
same mechanism and one must get at the mechanism in
each case. The question was asked as to the advantages
of the Karell treatment. This treatment was based on
the reduction of sodium chloride and restriction of the
intake of fluid, 500 c.c. of milk being allowed daily.
The loss of fluid through the lungs and skin was so
much more than through the kidneys that he did not
think the restriction of fluid made a great deal of dif-
ference in the amount of fluid retained in the body,
while the restriction of fluids favored the accumulation
of toxins. The edema was not due to lack of secretion
on the part of the kidneys. He gave alkali and salt to
cause dehydration and allowed water, but the effect of
the water was controlled by the alkali and salt. A blood
pressure of 140 mm. was high. When in any man past
the age of forty years the blood pressure went above
130 it was time for him to look after himself. Dex-
trose did two things. Many of these patients were
sugar starved and where there was sugar starvation
one got acid intoxication. Dextrose dehydrated as did
the salts but in a different way. It was quite impos-
sible to analyze the clinical case that had been referred
to, but dyspnea meant increased hydrogen ion concen-
tration and probably edema of the brain; whether this
was secondary to an aortic lesion in the case cited
could not be stated. When one had acidosi;, dyspnea,
and clinical edema, the case was not at it a
cardiovascular one. In scarlet fever the toxin that
ed the kidney lesion was not carrie.: here
were no traces of such an occurrence, but there might
be a lowered resistance and one might get a reinfei
■ E the kidney and a new attack of nephritis with a new
organism. As to the danger from violent i foot-
ball and rowing matches put too great a strain on the
process of oxidation. If such work was dons regularly
it could be carried on all right. The Chinese coolies all
had clinically hypertrophied hearts and went through
life comfortably with them, but it was different where
the strain was temporary; after the strain was over the
individual lapsed into a less active life, took on flesh,
and degeneration followed.
Klcction of Officers. — The following officers were
elected to serve during the ensuing year: Dr.
Philip Marvel of Atlantic City; First Vice-President,
William G. Shauffler of Lakewood; Second \
'. Dr. Thomas W. Harvey of Orange; Third I
President, Dr. Gordon K. Dickinson of I
Recording Secretary, Dr. George N. Gray of East
Orange; Corresponding Secretary, Dr. Harry A. Stout
of Wenonah; Treasurer, Dr. Archibald Mercer of New-
ark. Delegates to the American Medical Association,
Drs. William S. Lalor of Trenton and Luther M. Halsey
of Williamstown.
The Banquet. — The banquet given on the evening of
June 21 was the most largely attended of any in the
history of the society. At that time letters of congratu-
lation and felicitation were read from President Wood-
row Wilson and from the presidents of many of the
State societies who were unable to be present. The
treasurer of the society, Dr. Archibald Mercer of New-
ark, was presented with a loving cup as a testimonial of
appreciation of his services to the society during the
twenty-five years he had been treasurer.
Thursday, June 22 — Third Day
After the completion of the work of the House of
Delegates and the inauguration of the incoming Presi-
dent, Dr. Philip Marvel, the morning was given over
to the Centennial Exercises of the Essex, Middlesex,
Monmouth, Morris, and Somerset Component Societies.
Dr. Alexander Marcy, Sr., of Riverton, who had
attended the Centennial of the Medical Society of the
State of New Jersey and had attained the ripe age of
87 years, was introduced to the members of the Society
and congratulated them on the progress they had made
during the past fifty years. Representatives from each
of the above societies reviewed the early history of his
society and gave such reminiscences as he could find of
the organizers of these societies. The Essex was the
oldest county society in this country, having been or-
ganized June 4, 1816. Its charter members were Peter
I. Stryker, Ferdinand Schenck, William McKissack,
James Elmendorf, William D. McKissack, August R.
Taylor, Ephraim Smith, Moses Scott and Henry Schenck.
The other counties above mentioned all organized within
a very short time after the Essex County Society in re-
sponse to an act of the State Society requesting such
organization. The history of these societies showed
that they had been interested in the suppression of
quackery, in the elevation of the standard of medical
education, in the study of diseases that seemed to be
epidemic in their midst, and in elevating the standards
of the profession. That they took these societies very
seriously was shown by the fines imposed for absence
from meetings.
The Disease Carrier on Train and Steamboat. — Wil-
bur A. Sawyer cites certain reasons for increased
disease incidence in travelers. One of these is in-
creased contact with healthy disease-carriers. As these
men travel, infection cannot be traced to them. Contact
is closer and objects of common use are handled in rapid
succession. The abolition of the common cup has doubt-
less prevented considerable morbidity. Diphtheria has
been spread on shipboard by a carrier, or at least
numerous carriers were identified during the epidemic,
and cerebrospinal meningitis in like manner. In both
cases the vessels were overcrowded. These were iso-
lated instances, perhaps, but typhoid carriers are almost
ubiquitous. For every 100 cases of typhoid which sur-
vive, 7 are reckoned as carriers. On trains the chief
danger is in the dining car service, as both cooks and
waiters may convey the disease, but on shipboard the
carrier is more dangerous — not only cooks and waiters,
but stewards, stewardesses and others are a source of
danger. This has been realized in lumber steamboats,
in which an ordinary passenger acted as carrier. The
men drank from the water cask from their cupped
hands. — Journal of Sociological Medicine.
Prognostic Significance of the Trine in Puerperal In-
fection.— Schaefer states that after the temperature be-
comes high in puerperal infection the urine will be
found of high specific gravity, dark colored and con-
taining in solution indican and ethereal sulphates. If
we can cause the disappearance from the body of all
the phenol derivatives, the prognosis should improve.
Catharsis and diuresis are indicated, and the density
of the urine may be brought down below 1015. A low
density, when associated with high temperature, is in
itself a good prognostic, and the eliminant treatment
will not be required. The obstetrical or rather surgical
management, of course, goes ahead as usual, but the
author believes that the bacillus coli communis plays a
great role as a determining cause, and that intestinal
hygiene and sanitation must be guaranteed in all puer-
peral disorders. — The Medical Fortnight!)/ and Labora-
tory News.
Medical Record
A Weekly Journal of Medicine and Surgery
Vol. 90, No. 5.
Whole No. 2356.
New York, July 29, 1916.
$5.00 Per Annum.
Single Copies, J5c.
(Original Arttrba.
NITROUS OXIDE-OXYGEN, THE MOST DAN-
GEROUS ANESTHETIC.
By J. F. BALDWIN, M.D., F.A.C.S.,
COLUMBUS, OHIO.
SURGEON TO GRANT HOSPITAL, PROFESSOR CLINICAL SURGERY,
OHIO STATE UNIVERSITY.
Whenever any new line of treatment is proposed
it is universally recognized as incumbent upon its
sponsors to show that it is better than prevailing
lines of treatment, its superiority consisting in a
larger percentage of cures, a more prompt recovery,
or a diminution of morbidity.
This rule most certainly should apply to the in-
troduction of any new anesthetic agent. Chloro-
form has its advocates, and for certain purposes
its advantages, but ether may be accepted as the
standard of safety the world over. Every new
anesthetic must, therefore, be weighed in the bal-
ance with ether.
If the sponsors of the new anesthetic are actuated
purely by scientific motives, every unsatisfactory
experience, and certainly every death, would be
promptly reported, so that the profession at large
could judge as to the relative value of the new
anesthetic ; while if such adverse experiences are
not reported, but attempts are even made to cover
up and deny their occurrence, then only mercenary
motives can be attributed to the advocates. Teter
of Cleveland, in a personal letter, reports that he
knows of twenty-six nitrous oxide-oxygen fatali-
ties, nine of which have occurred in Cleveland. Dr.
A. H. Miller of Providence, R. I., has collected ref-
erences to eighteen deaths. Rovsing was able to
get track of thirteen deaths, several of which had
been suppressed. (This author1 in his chapter on
anesthesia gives a death rate of one in 2,000 for
chloroform, and one in 50,000 for ether.) Gwath-
mey (personal communication) knows of from
twenty to forty unreported deaths.
Practically all of the anesthetists who have writ-
ten on nitrous oxide-oxygen state most positively
that death occurs only from asphyxia, and that if
the anesthetist watches the color and pushes the
oxygen death cannot occur. If that is the case, it is
certainly very important that the anesthetist shall
know what are the symptoms that indicate asphyxia.
Turning to Gwathmey5 (p. 134) we find the follow-
ing statement : "The fourth stage, or stage of over-
dose, supervenes through some error of technique
by which asphyxia becomes the predominant fea-
ture of the narcosis. Breathing becomes embar-
rassed usually through convulsive muscular spasm.
The interference with respiration is first marked
through hyperpnea (excessive breathing), then by
dyspnea (difficult breathing) . Violent or convulsive
expiratory efforts, sometimes accompanied by gen-
eral muscular spasms, mark the second stage of
asphyxia. Following this there is a stage of ex-
haustion, in which the muscular spasm is super-
seded by muscular flaccidity. The pupils become
more widely dilated, the lids are widely open, the
conjunctivae are insensitive, the pulse becomes im-
perceptible, respiration is marked by prolonged
sighing inspirations which gradually cease. Paraly-
sis of the respiratory center is complete and death
supervenes. Marked cyanosis accompanies this
condition of affairs."
In none of the cases detailed in this paper was
death the result in any way whatever of asphyxia,
but in all of them the death occurred without warn-
ing, in the midst of an apparently smooth anes-
thesia, and with the startling suddenness of an
overdose of chloroform.
Gwathmey states, as the natural effect of nitrous
oxide-oxygen administration, that the pulse becomes
rapid, from 140 to 160 per minute, and in pro-
longed operations the temperature goes up from
y2 to 2 degrees (p. 109).
According (Gwathmey) to the experiments of
Buxton, and later of Wood and Cerna, "nitrous
oxide-oxygen exerts a direct action upon the heart
itself, having little or no direct influence upon the
vasomotor centers of the brain cortex" (p. 130).
"Buxton . . . found that . . . nitrous
oxide produced so great an enlargement (of the
bulk of the brain and the cord) as to force out the
cerebrospinal fluid" (p. 131).
"The most natural inference, from the study of
the reflexes and other effects upon the nervous sys-
tem, is, according to Kemp, that nitrous oxide acts
especially upon the brain cortex" (p. 131).
It is inconceivable to think that any agent capa-
ble of producing the constitutional disturbances in-
dicated above should not be pregnant with manifold
possibilities of evil; and yet, in a calendar just re-
ceived from a manufacturer of nitrous oxide-oxy-
gen, we are told that this combination "Does not
affect the heart; does not affect the kidneys; does
not produce nausea; decreases danger of postopera-
tive pneumonia."
Connell,3 who writes the article on anesthesia in
Johnson's new work on "Operative Therapeusis,"
says of the nitrous oxide-oxygen anesthesia that
"since the extensive introduction of this gas into
general surgery, the reported and unreported
deaths have probably far exceeded those from
ether," and aside from its death rate it is evident
from his entire chapter on this subject that he re-
gards its disadvantages as far outweighing its pos-
sible advantages.
Luke, anesthetist to St. Luke's Hospital, New
York, reports4 one death out of about 200 adminis-
trations of nitrous oxide-oxygen. The patient was
dead six minutes after entering the operating room.
He also reports another case in which the patient
ITS
MEDICAL RECORD.
[July 29, 1916
was resuscitated with great difficulty. Dr. Roy Mc-
Clure, now of the Johns Hopkins, reports to me two
deaths which occurred while he was connected with
the New York Hospital. These occurred in the
service of Dr. Frank Hartley, and took place while
gas was being given as a preliminary to ether. Dr.
McClure was resident surgeon at this time, and is
entirely familiar with the facts.
From inquiry as to nitrous oxide-oxygen at the
Mayo clinic, I find that this anesthetic was used in
about 1,400 cases as a preliminary to ether. I
can learn of no mortality, but the result was not
satisfactory and it was dropped. Miss Henderson,
the anesthetist, under date of January 16, 1915,
wrote that on the day before Dr. E. J. Burch of
Carthage, Mo., reported to her a case which he had
lost under nitrous oxide-oxygen. The anesthesia
had been a brief one for a rectal examination. The
examination was completed and the surgeon left the
room, but was called back hurriedly and found the
patient dead. She says of the nitrous oxide-oxygen
anesthesia : "We have investigated its merits at
various times, but the surgeons have not seen fit
to make any change from 'drop ether,' which has
been used here for many years." A personal com-
munication from Dr. Burch affirms this report.
In conversation recently with two of the best
known surgeons of Cleveland, Drs. Bunts and Skeel,
I found that no thorough investigation of nitrous
oxide-oxygen deaths had ever been made in that
city ; numerous instances were known, but the de-
tails had never been published. Both of these sur-
geons used ether by preference, but because of the
newspaper prominence given nitrous oxide-oxygen
they were obliged in some cases to yield to the re-
quest of their patients and use that anesthetic.
Gwathmey' (p. 109) reports three fatalities out
of 2,500 cases. In the first case death occurred
suddenly before operation was commenced. In the
second it also occurred suddenly, but the operation
had begun and the anesthesia up to that point had
been normal. In the third case the pulse became
very rapid, and at the close of the operation went
up very rapidly. Color became cyanotic and could
not be cleared up with oxygen, the breathing be-
came weaker and weaker and finally ceased. Be-
cause at the autopsy an enlarged thymus was found,
with hypertrophy of the lymphatic tissues in gen-
eral, the pathologist gave status lymphaticus as the
cause of death.
Recently (December 5, 1915) Dr. T. G. McCor-
mick, now of Portsmouth, Ohio, formerly of De-
troit, told me that they had had either seven or
eight deaths at Grace Hospital, Detroit. He was
resident physician there during that time, and one
of the deaths occurred while he was giving the an-
esthetic. He could give no particulars of any of
the other cases, but his own patient died suddenly
and without any warning.
The following is the Columbus death list for
nitrous oxide-oxygen:
1. The first death in Columbus from nitrous
oxide alone occurred some years ago at the Dental
Clinic of the Ohio Medical University. The gas was
given for the extraction of teeth, and the patient
died suddenly and without any warning. Efforts at
resuscitation were made as usual, but were unavail-
ing. My authority is Dr. A. O. Ross, then dean of
the dental department.
2. Probably the first death in this city from
nitrous oxide-oxygen took place at Mt. Carmel Hos-
pital, the anesthetist being a physician who was
considered an expert, and who is among the best
known anesthetists of New York City. The pa-
tient, according to the anesthetist's statement to
me, died suddenly in the midst of a somewhat pro-
longed abdominal operation.
3. Dr. G. W. Mosby of Columbus reports to me
that he had a patient die from nitrous oxide-oxygen,
also at Mt. Carmel Hospital, the anesthetic in that
case being given by Dr. Jones. The operation was
for pelvic infection. The operation, he says, had
lasted about forty-five minutes, and was proceeding
satisfactorily apparently, when the patient sud-
denly died. He unhesitatingly attributes the death
to the anesthetic.
4. Dr. R. B. Drury reports that last year at the
St. Clair Hospital a woman was being put under
nitrous oxide-oxygen anesthesia by Dr. Jones, for
the removal of a fibroid by the late Dr. Leach, whom
Dr. Drury was assisting. Just at the beginning of
the incision the woman suddenly expired without
the slightest warning.
5. Dr. Drury also reports a death from nitrous
oxide-oxygen in a man aged 65, whom he operated
upon at Washington Courthouse. A year before
the same patient had had a suprapubic prostatec-
tomy under ether by the late Dr. Leach, and went
through the operation nicely. Further trouble com-
ing on, Dr. Drury decided to operate through the
perineum. Nitrous oxide-oxygen was given by Dr.
Rice. In the midst of the operation, which had been
going on all right, the patient suddenly expired.
6. Dr. George Williams reports that at the St.
Clair Hospital he gave nitrous oxide-oxygen for a
hysterectomy for fibroid tumor, about one year ago.
The patient went through the operation very satis-
factorily, and the surgeon was about to close the in-
cision when the patient suddenly died without any
warning whatever; had been doing well up to that
moment.
7. Dr. G. L. Saunders tells me that about four
years ago, while waiting for a patient of his own
to be operated upon at Mt. Carmel, he witnessed an
operation on a colored woman, probably 35 years of
age, who was suffering from a small fibroid.
Nitrous oxide-oxygen was being given, and just as
the abdomen was being opened, and before any
work on the inside had commenced, the patient sud-
denly died without any warning. All efforts at re-
suscitation failed. Dr. Saunders was a stranger in
the city, and did not know the anesthetist.
8. Dr. Goodman reports that on March 13, 1913,
he opened through the vagina a cul-de-sac abscess.
The case was a puerperal one of two weeks' stand-
ing. Nitrous oxide-oxygen anesthesia was given by
Dr. Rice. The opening of the abscess took but a
moment, but the patient suddenly died on the table.
9. Dr. Goodman reports the case of a young
woman, mother of a child two years of age, upon
whom he operated for the removal of fibroids. The
husband, against the wishes of the surgeon, in-
sisted on the use of nitrous oxide-oxygen. A supra-
vaginal hysterectomy was made in the usual way,
the operation being exceedingly easy. There were
no adhesions, and the operation took about twenty
minutes. The patient had taken the anesthetic
beautifully, breathing quietly, and with good color.
As the last stitch was being inserted the patient
ceased to breathe and the heart stopped. Dr. Rice
was giving the anesthetic. Dr. Goodman at once
opened the abdomen, massaged the heart through
the diaphragm, giving deep injections into the heart
of adrenalin, besides using oxygen and artificial
respiration, dilating the sphincter ani, etc., but the
patient was dead.
July 29, 1916]
MEDICAL RECORD.
179
10. This patient was a woman operated upon by
Dr. Howell for abdominal tumor. She had had one
kidney removed some time before, and was known
to be suffering from nephritis. Nitrous oxide-oxy-
gen was used. After the operation there was bloody
urine, then suppression of urine, then death from
uremia. (.Had this suppression of urine occurred
under ether, the death would undoubtedly have been
attributed to the ether; by a parity of reasoning it
should be attributed to the nitrous oxide-oxygen,
though it is possible that the anesthetic had nothing
to do with the death.)
11. Dr. J. M. Thomas reports that about two
years ago Dr. Howell operated upon a patient of
his, 22 years of age, for chronic appendicitis; had
suffered from infantile paralysis, and had some
functional heart trouble. Dr. Rice gave the anes-
thetic. The operation was completed, and Dr. How-
ell had left the room, when suddenly the patient
went bad, and apparently died on the table. Dr.
Fletcher and several others were present. Artifi-
cial respiration was kept up, he says, for justy sixty
minutes, when she breathed herself for about ten
minutes. The abdomen had been reopened by Dr.
Howell, the heart massaged, and adrenalin injected
into the heart substance. After breathing for ten
minutes respiration stopped and further resuscita-
tion was impossible. He is positive that the death
was due to nitrous oxide-oxygen.
12. Mrs. McC, aged 37, had a simple abdominal
hysterectomy October 28, 1914. In spite of my own
protests and those of her attending physician, she
insisted on taking nitrous oxide-oxygen. Dr. Rice
administered the anesthetic, which she took beauti-
fully, but just at the completion of the abdominal
work, without the slightest warning, the heart's
action suddenly ceased and the patient was dead.
The heart was at once massaged through the open
abdomen, and all the usual measures for resuscita-
tion instituted, but in vain.
13. Mr. B. of Degraff, aged 62, was operated upon
February 26, 1914; had been having severe attacks
of pain in the region of the gall bladder, and his
physicians thought that he had passed gall stones.
He had had some bronchorrhea for several years;
no kidney trouble. Because of the history and local
conditions a gall-bladder operation was advised, and
because of the bronchorrhea I advised nitrous
oxide-oxygen. There was hypertrophy of the heart,
but no valvular lesion could be detected. Pulse reg-
ular, and of good volume. The diagnosis was a mat-
ter of doubt, but malignancy could not be positively
excluded. An incision was made over the gall blad-
der, which was found distended. At this time the
patient was reported by Dr. Rice to be doing badly,
and an instant examination showed a pulseless
aorta. The heart was at once massaged through
the diaphragm, artificial respiration kept up, etc.,
but all efforts were without avail. Autopsy showed
an enlarged heart, but no dilatation.
14. Mr. L., aged 62, was brought to the hospital
May 14, 1912, with a diagnosis of peritonitis from
appendicitis. His condition when he reached the
hospital was bad, as he had got chilled on the train
coming up. In the course of an hour this condition
improved, so that he had a good color, and a good
heart's action. His condition was such as to indi-
cate extensive infection, and I planned to make a
nuick incision and put in a drain. For this purpose
I thought nitrous oxide-oxygen safer than ether.
He took it nicely, but just as the incision was made
he died suddenly. After death was determined the
incision was extended somewhat, and it was then
found that there had been a plugging of the supe-
rior mesenteric artery, all the intestines supplied
by the artery being black and devitalized. Of
course, death would have occurred within a few
days, so that the anesthetic death was of no special
importance. Within a few months of this time,
however, I had two similar cases, one in a young
woman of about 30, the other in a man of about 60.
Ether was given in both cases, the abdomen opened,
the condition determined, and the abdomen at once
closed. Both survived the exploration by a day or
two.
The above list shows that we have had twelve, or
more properly perhaps thirteen, deaths from nitrous
oxide-oxygen when given for major operations.
Careful investigation seems to show that there have
been not to exceed twelve or thirteen hundred ad-
ministrations of this anesthetic for major opera-
tions, in Columbus, so that the death rate has been
practically 1 per cent.
Without persistent effort on my part, few of the
nitrous oxide-oxygen deaths in Columbus would
have been unearthed. I have made no canvass of
the situation in other cities of the State, but inci-
dentally know of several deaths in Cincinnati,
Cleveland, Toledo, and Akron. In one of the Cin-
cinnati cases the anesthetist was a specialist of
twenty years' experience, who had spent two weeks
at Lakeside to familiarize himself with the details
of the nitrous oxide-oxygen anesthesia. He had ad-
ministered the combination successfully in a num-
ber of cases, but in this particular case (nephrot-
omy for stone) he had objected to the giving of the
gas as he preferred ether, but the surgeon insisted
and he complied. The anesthesia went off beauti-
fully, the operation had lasted about thirty minutes,
and was just about completed when the patient sud-
denly died. (Personal communication from the an-
esthetist, Dr. Leroy S. Colter.)
Under date of June 1, 1916, in response to a let-
ter of inquiry following a newspaper announcement,
Dr. H. H. Wiggers of Cincinnati writes me that
the death of a married woman in his practice "oc-
curred suddenly, without any warning. There was
simply a cessation of the heart beat. We cannot
account for the death." No details of operation
given, but the anesthetist was a specialist, with an
experience of about eleven hundred cases of nitrous
oxide-oxygen anesthesia.
Gwathmey, concerning whose skill and experience
there can be no doubt, under date of November 6,
1915, gives me a personal report of a death which
he had had a few days before, and which he expects
to report at an early date. This death under nitrous
oxide-oxygen, he says, "was absolutely uncalled for,
and has changed my ideas of the safety of nitrous
oxide-oxygen entirely. ... I believe if I had
given him ether the man would have been alive to-
day."
In commenting on autopsy No. 3394, Dr. Hugh
Cabot, of the Massachusetts General Hospital
("Case Reports" received January 16, 1916), says
in regard to a death from nitrous oxide-oxygen,
that "during the operation the anesthetist remarked
that the breathing was slow, but the color of the
skin normal. The color of the blood was at no time
observed to be unusual. At the point last described
the anesthetist observed that the respiration had
stopped. Artificial respiration was started and
kept up for forty minutes steadily, with the libera!
use of oxygen. . . . This was an anesthetic
death due to gas and oxygen anesthesia." The an-
esthetist in this case was Dr. Freeman Allen, chief
180
MEDICAL RECORD.
[July 29, 1916
of the department of anesthesia, and consulting
anethetist to the Massachusetts General Hospital
and Children's Hospital.
Ochsner'' says that he made a careful test with
one hundred successive cases of nitrous oxide an-
esthesia, compared with a similar number of ether
anesthesias by the drop method. He says he "found
no difference in the course of the anesthesia, nor in
the comfort of the patient, but there was a little
more bronchial irritation following operation when
nitrous oxide-oxygen gas had been used." (Absence
of bronchial irritation is one of the strong claims
made by those who advise this anesthetic.) The
method, he says, he found cumbersome, and, there-
fore, permanently abandoned it. The only special
value that he attributed to it is a "slight advertis-
ing value which the method undoubtedly possesses."
He then speaks of the addition of oxygen to the
nitrous oxide gas, and claims for it the same ad-
vertising value as for the other, but "possibly to a
somewhat greater degree." He then speaks of some
of the disadvantages which it has, and finally con-
cludes as follows : "For some time to come there will
be a certain amount of advertising advantage, but
as soon as this has been dissipated through the fact
that every one will be prepared to administer this
form of anesthesia, its drawbacks must become ap-
parent as compared with its advantages."
In Columbus nitrous oxide-oxygen deaths have
occurred at the hands of three administrators, all of
whom are looked upon by their friends as thor-
oughly competent specialists. Deaths have occurred
to each in frequency just about in proportion to the
number of administrations for major operations.
Dr. Rice has lost the largest number, but has un-
doubtedly had more administrations in major work.
Dr. Howell, who has made a personal study of
nitrous oxide-oxygen anesthesia, and has watched
many such administrations at Lakeside, Cleveland,
and who has until recently used nitrous oxide-oxy-
gen almost exclusively, tells me that he regards Dr.
Rice as the most skillful nitrous oxide-oxygen anes-
thetist in the State. The anesthetist who had but
one death had given this anesthesia in about fifty
cases.
We are told by many that while deaths on the
table are exceedingly rare from ether, many deaths
occur later from pneumonia, which should be
charged up to ether. Those who make these state-
ments should certainly read Rovsing' (p. 85), who
considers this matter briefly but very forcibly: "It
is astonishing, moreover, that the misconception
that ether has a harmful influence on the pulmonary
passages still exists, because in reality the correct-
ness of this view has long since been refuted, both
clinically and experimentally. From a clinical point
of view it was Mikulicz's report in 1898, which
drove the nail home. Mikulicz, on account of the
somewhat frequent occurrence of postoperative
pneumonia, had deserted ether and taken up chloro-
form, in the belief that the pneumonia was due to
the irritating effect of the ether. To his surprise,
however, it appeared that the cases of chloroform
narcosis were followed by a still greater percentage
of postoperative pneumonia. He, therefore, decided
to prive up narcosis by inhalation entirely, and
thereafter employed local anesthesia in all opera-
tions, even the major ones. But, to his yet greater
surprise, the result was that the lung complications,
far from decreasing, increased to a considerable ex-
tent: with 114 laparotomies he had no less than
twenty-seven lung complications. Naturally, this
experience overthrew the old conception that post-
operative cases of pneumonia were 'narcosis pneu-
monia.' One curious fact should long ago have
aroused the surgeon's suspicions; namely, that al-
most every 'narcosis pneumonia' manifested itself
after laparotomy, while it is extremely rare to find
pneumonia following operations on the extremities,
thorax, and head. To what was this strange oc-
currence due? Surely, in the main, to two circum-
stances: (1) That peritoneal infection is conveyed
to the lungs partly by way of the lymph vessels
and venous blood, and partly by embolism, and (.2)
that a patient with a laparotomy wound dares not
cough or breathe freely, inasmuch as this involves
pain in the wound. If, therefore, the patient is al-
ready suffering from bronchitis, or if an infection
of the lungs sets in, the development of pneumonia
is greatly favored by the deficiency in expectoration
and lung ventilation.
"It has been proved experimentally with animals
— and I myself have substantiated the fact by ex-
periments— that ether does, indeed, occasion in-
creased salivation in the salivary glands of the
mouth, but that the air passages — larynx, trachea,
and bronchi — are not irritated at all, even when the
animals are killed by administering ether through
a tracheotomy tube until they are dead. Therefore,
the only way in which ether narcosis per se can
cause pneumonia is by aspiration of accumulated
saliva in the throat. This, however, is always due
to some technical error in the narcosis, for saliva
should not be allowed to accumulate in the throat
to any extent. ... If, therefore, it is proved
that the ether fumes do not in any way irritate the
main air passages, one should admit that the other
assertion must also be wrong. I mean the asser-
tion that ether is contraindicated in patients suf-
fering from lung disease: emphysema, bronchitis,
bronchiectasis, abscess of the lung, etc."
I have had ether administered in very many
thousands of cases; years ago by use of the old-
fashioned cone, then the Allis inhaler, and now for
a number of years by some form of the drop
method. I have never had a death on the table from
its administration. I cannot recall a single death
from postoperative pneumonia. I have had two or
perhaps three deaths from suppression of the urine.
It is possible, perhaps probable, that this suppres-
sion was the result of the action of the ether on the
kidneys, and yet we all know that deaths from sup-
pression occur in cases in which no anesthetic what-
ever has been given, and earlier in this paper I
have referred to one death in which suppression of
the urine followed the administration of nitrous
oxide-oxygen.
Nitrous oxide-oxygen has a field of usefulness to
which it should be strictly limited. It can be used
for very brief operations, as it has been for many
years in the extraction of teeth. It is also proba-
bly the safest anesthetic to use, as suggested by
Ochsner, in cases of acute pulmonary congestion, or
of acute nephritis. With these exceptions, which
make its field a very limited one, nitrous oxide-oxy-
gen should be looked upon as the most dangerous
anesthetic that can be used, even in the hands of
the most experienced.
REFERENCES.
1. Rovsing: Abdominal Surpery, 1914.
2. Gwathmey: Anesthesia, 1914.
3. Connell : Art. Anesthesia in Johnson's Operative
Therapeusis.
4. Luke: N. Y. Medical Journal, January 20, 1915.
5. Ochsner: Manual of Surgery, 1915.
lir. South Grant Avenue.
July 29, 1916]
MEDICAL RECORD.
181
PELLAGRA— A CRITICAL STUDY.
Br JOHN AULDE, M.D.,
PHILADELPHIA. PA.
Introduction. — The object of the present article is
to make a critical survey of the dietary defects re-
sponsible for the appearance of pellagra, a mys-
terious malady which now prevails throughout the
Southern states. Such a study is made possible
through the information contained in two publica-
tions'= recently issued by the United States Public
Health Service. Like scurvy and beriberi, attacks
of pellagra have generally been regarded with sus-
picion, because of their insidious, seasonal develop-
ment, with apparent recovery and persistent re-
currence. Fortunately, the data at hand is of such
a character that we can bring to bear upon this
disorder the modern searchlight of scientific in-
quiry— which gives promise of arousing wide-
spread interest. This favorable outlook is not de-
pendent upon relief from pellagra alone, nor is it
limited to scurvy and beriberi, these disorders being
rare in this country. On the contrary, the princi-
ples underlying the successful treatment of these
diseases by diet alone are universally applicable in
all diseases, acute, subacute and chronic, functional
and organic, infectious and non-infectious, because
in every instance we have to contend with the ef-
fects, direct and indirect, immediate and remote,
arising from dietary deficiency, evidence, complete
and in detail, being supplied in the accompanying
tabulations.
Historical References. — In view of the very un-
satisfactory results attending the investigations of
many learned men, physicians, chemists, and bac-
teriologists, for the past two hundred years, it
would not be profitable to review the long campaign.
The recent history of attempts to conquer the
malady can be briefly stated. By way of explana-
tion, it should be mentioned that there has always
been two sides engaged in the controversy — one
party claimed that it resulted from some occult
dietary fault, corn meal being blamed, while the
other party insisted it must be due to an infection.
Several years ago a commission was organized
in London, three experts (physicians) were em-
ployed, but in their latest published report they
say, "their efforts to discover the essential, pella-
gra-producing food, or the essential, pellagra-pre-
venting food have not been crowned with success."
Substantially the same conclusion faces the Public
Health Service, in the attempt to demonstrate the
infectious organism, this bacteriological work hav-
ing been under way now for several years in dif-
ferent places throughout the South. In this con-
nection it should be stated that no claim is set up
that the pellagrin is free from bacterial infection —
far from it; but there is no specific microorganism
by which the disorder may be transferred to man
or animals, as is the case with diphtheria, tuber-
culosis, and other infectious diseases.
Two years ago an entirely new theory was
launched, which assumes that this disorder must be
due to the "over-milling" of corn, by which process
of refinement certain vital elements essential to
maintain the activity of the various digestive func-
tions are removed, such, for example, as the polish-
ing of rice.
The United States Public Health Service has re-
cently issued an interesting report on vitamines,'
showing their efficiency in preventing and curing
polyneuritis in pigeons fed on polished rice. In
this instance, the vitamine was obtained from
brewer's yeast, the source of yeast nuclein, first
advocated by Vaughan in 1893. While the evidence
in favor of yeast vitamine is decidedly favorable, it
remains to be seen whether yeast nuclein will pro-
duce equally satisfactory results. Thus, "A pigeon
kept on polished rice without the yeast filtrate be-
gins to lose weight usually within the first five days,
and dies with the typical paralysis of polyneuritis
within about twenty days. If 1 c.c. of the yeast
filtrate is given to completely paralyzed pigeons, a
relief of the paralysis will occur within an hour,
and to all outward appearances the pigeon will be
restored to a normal condition within twelve hours."
The author also refers to the experimental work of
Chamberlin and Vedder (1911), who showed "that
the neuritis-preventing substance of extracts of rice
polishing is removed by filtering through bone-
black."
In this connection it should be added that the
polyneuritis and paralysis, as occurring in pigeons
from polished rice, are a counterpart of the symp-
toms witnessed in beriberi. In addition, the writer
has frequently traced neuritis to excessive rice eat-
ing, but has invariably relieved the condition by
reorganizing the dietary together with administra-
tion of lime salts.
Another important item relates to the laboratory
method of concentrating the yeast filtrate for con-
venience in administration to humans — by using
aluminum silicate to secure adsorption. The daily
dose of this latter substance for adults amounts to
5 grams (75 grains), and since Dr. Seidell suggests
the employment of vitamines for pellagra, we must
bear in mind that both silica and aluminum have
been held responsible for this disease.
Preceding the "vitamine" theory several specious
theories have been advanced within the past few
years, one of which deserves attention, viz., that
silica in the food eaten and water drunk can pro-
duce the disease. The plausibility of this concep-
tion seemed at first a deduction fully warranted,
when it was shown that guinea-pigs, rabbits, dogs,
and monkeys fed upon silica developed the charac-
teristic symptoms recognized as belonging to pel-
lagra. The fallacy of this theory was shown by the
writer1 in a short article in which it was indicated
how silica became a factor in experimental work.
Thus, pellagra is a disorder characterized by a
diminished alkalinity of the blood (acid excess),
and as a result of this chemical deviation there fol-
lows depletion of the lime salts, magnesium salts
taking their place. By or through this substitution
there is an excess of magnesium salts in the tissues
— then the addition of silica, which has an affinity
for magnesium, gives rise to a new combination,
magnesium silicate. Like sodium silicate, mag-
nesium silicate shows a tendency to harden when
it is cooled, and that accounts for the various
"rheumatic" affections which involve principally the
smaller joints. The sponsor for silica, Alesendrini,
an Italian, had previously written a book to prove
that pellagra was an infectious disease, but this he
renounced when he took up silica, a marked illus-
tration of the uncertainties attending medical in-
vestigations.
Along about this period came another specious
theory, namely, that pellagra was caused by the
presence of aluminum in the food— and that the
injurious effects arising therefrom might be coun-
teracted by adding fresh animal meat to the
dietary, ah amusing and ridiculous suggestion to
the confirmed vegetarian. The fallacy of this
182
MEDICAL RECORD.
[July 29, 1916
theory will be appreciated by recalling the objec-
tions offered to silica as the causative factor — the
latter has an affinity for magnesium and aluminum
has a double affinity for silica. This accounts for
the pellagra symptoms produced by either silica or
aluminum in laboratory work, when employed ex-
perimentally in animals, usually in massive doses,
to study the effects, physical and physiological.
Such experiments in this instance have no practical
bearing upon the case, since neither silica nor
aluminum are taken into the system with our daily
food or otherwise in such quantities as would or
could produce the characteristic symptoms of the
disease.
About a year ago, a thoughtful and industrious
Italian, Dr. A. Cencelli, published an incisive paper'
giving an account of his efforts to counteract the
injurious effects of silica in the drinking water.
Small pieces of lime were placed in the pipes and
reservoirs, and the treatment was applied not only
to animals in which the disease had been induced,
but also to human beings who had been suffering
from pellagra for longer or shorter periods of
time, and "the results were in the highest degree
satisfactory. Persons who had been ill for a long
time immediately improved and were cured in a
relatively short space of time, without any change
having been made in their mode of life, surround-
ings or diet."
Evidently, Dr. Cencelli had overlooked my contri-
bution0 published more than six years ago, from
which the following extract will show my trend of
thought at that time: "In the opinion of the writer,
the underlying, causative factor is to be found in
magnesium infiltration, a pathological condition in
which there is a depletion of the lime content of the
nuclear proteid, being the counterpart of that which
occurs in plant life when magnesium salts in ex-
cess cause destruction and death of the protoplasm,
since magnesium acts as an insulator, impeding the
uninterrupted transmission of nerve impulses."
At the time this paper was written serious
complaints had been lodged against all corn prod-
ucts employed throughout the South, and it was
shown beyond question that the letting of contracts
to the lowest bidder had deluged that section ot the
country with deteriorated grain, the principal
sufferers being the inmates of asylums. Indeed, in
several instances, charges were brought against the
managers for negligence on the part of attendants —
it was assumed that the hands and feet of the vic-
tims had been scalded, the skin eruptions being
so marked as a result of the disease.
In this connection another quotation may be per-
mitted, as follows: "A significant, factor in this
connection relates to the normal acidity of corn
meal ; that is to say, when corn meal of good qual-
ity is submitted to the usual chemical tests it shows
a relative acidity varying from 13 to 25 per cent.
When corn meal of an inferior quality — due to de-
composition from various causes — is tested, the
acidity is found notably increased, in some cases
running as high as 95 per cent."
The questions relating to magnesium infiltration
and acidity will be better understood from the
analysis of the dietary studies, and need not be
taken up at this point, but one more reference
should not be omitted. Fifty years ago, a French-
man, Roussel,: published a book, from which the
following extracts are copied: "Without din
measures, all r< medies fail. . . . When drugs
and good food are simultaneoi I it is to
iatter that the curative action belongs; the
former simply exercises an adjuvant action and is
without proved efficacy, except against secondary
changes or accidental complications."
The Public Health Service Reports. — These re-
ports are skeletal in character, and yet they furnish
a substantial basis upon which to erect the super-
structure^— they merely supply the daily bill of fare
or menu without any details as the nutrient values
of the various food materials. Upon the assumed
theory that pellagra is due to a dietary deficiency,
lack of protein with a superabundance of starchy
food-stuffs, the experimental work was taken up
with the understanding that it should be continued
for a period of two years. The results proved so
favorable that a report was made at the end of the
first year, and it is this data which we have under
consideration. There were really three operations,
one embracing two orphanages situated near Jack-
son, Miss., another located in the grounds of the
State penitentiary, with eleven volunteers, while
the third was confined to two wards of the Georgia
State Sanitarium, an asylum for the insane, where
72 insane women (36 white and 36 colored;, all
pellagrins, were placed under treatment. As a re-
sult of care in the diet there was but one case de-
veloped in the orphanages, and all who had the dis-
order at time of beginning made complete recovery.
Altogether, there were more than two hundred cases
under observation — and a point worth noting in this
connection is that the history of the disease in both
institutions showed that it had been confined ex-
clusively to children between the ages of six and
twelve years. This peculiarity is readily suscept-
ible of explanation — up to six years of age the chil-
dren were provided with milk three times a day, but
none allowed after that age. This will partly antici-
pate the value of diet, more fully elaborated in the
analysis. The "Pellagra Squad" was confined to
criminals who volunteered to take the diet which
was supposed to produce the disease, on condition
that they receive a pardon from the Governor of the
State.
Only two of the operations are included in this
paper, the dietary of the orphanages not being
available for tabulation — and the accompanying
tables are self-explanatory. Thus, to produce the
disease a liberal supply of starchy food-stuffs were
given, no meats being allowed; to prevent and cure
the disease a dietary was provided which included
a half pound of beef daily, along with legumes and
little of the starchy food. Each dietary study is pre-
ceded by the data furnished by the Public Health
Service, the computations being worked out by the
writer — to show as a whole and in detail the nutri-
ent value of the dietary selected — and special atten-
tion should be directed to the importance of the
mineral constituents, a computation not usually in-
cluded in dietary studies.
Dietary Studies. — The object of a dietary study
is to determine with mathematical accuracy the
nutrient value of the various foods eaten from day
to day, or month to month. Sufficient evidence has
accumulated to enable us to determine the mi' -
mum demands of the system for rebuilding mate-
rials and for fuel, or heat-producing materials, so
that it is comparatively easy to make computations
for different persons employed at different tasks
— and allowance must also be made for the season
of the year, less fuel material being required in hot
weather than during winter. The minimum de-
mand is based upon the needed repairs, sixty grams
about two ounces I of protein being required for
this alone. Starting with this, the demand for
July 29, 1916]
MEDICAL RECORD.
183
carbohydrate is estimated at four times the amount,
while one-fifth of the whole (about two and one half
ounces) should be fat. Food materials taken in
excess of the above amount (about twelve and one-
half ounces), should be in like proportion to main-
tain good health. Slight variations may be made
from time to time, but when long continued the
evidences of debility become well marked and may
be readily detected by the skilfull physician.
These nutrient elements, protein, fat and carbo-
hydrates all produce heat, while at the same time
serving other purposes ; thus, the protein of meat
or potato produces the same amount, 4.1 per cent,
per gram, but the fat eaten produces more than
twice as much, 9.3 per cent, per gram, a gram weigh-
ing a little over 15 grains, or one-fourth of a tea-
spoonful. Meats contain both protein and fat, but
no carbohydrate, while legumes (potatoes, etc.), and
cereals contain all of the elements — in varying pro-
portions.
The computations to determine the amounts of
protein, fat and carbohydrate have been made from
Atwater's tables' which are generally accepted as
authoritative, while the percentages of calcium and
magnesium are taken from my book,9 the data hav-
ing been compiled from the monograph by Sher-
man, Mettler, and Sinclair," Department of Chem-
istry, Columbia University, New York.
The amounts of the various food materials are
given in the table, together with the computations,
and with the exception of the rates for brown
gravy are approximately correct. As there was no
heading for brown gravy in Atwater's tables, meat
stew was substituted as being nearest in point of
protein, fat and carbohydrate and the percentages
of calcium and magnesium have been omitted, but
this omission will not affect the general results. The
probability is that brown gravy would affect the
caloric value, since the fat content would be greater,
but it would not involve the mineral constituents.
In addition it should be mentioned that fried mush
is rated as corn bread.
Table 1 — Dietary Study — Experimental Pellagra (Camp Study).
Food
Materials
Weight,
Lbs.
Biscuits
Corn bread
Grits (hominy)
Rice
Fried mush
Brown gravy
Sweet potatoes
Cabbage
Collards
Cane syrup
Sugar
Totals
Food eaten per man per
day .
Food utilized per man
per day
41.81
24 56
27.06
24 2.5
33.87
37 81
23.62
4 25
23 75
5.94
8.75
255.67
3.32
1.33*
3 637
1 940
.595
679
2 675
1.739
708
.06S
I IKs
142
.172
Grams
1 087
1 154
.054
024
1 591
1.625
.496
012
.142
6 1S5
080
Grams
36
Carbo-
hy- I Calor-
drate, 1 ies
Lbs.
23 120
11 371
4 SI6
5.917
15 681
2 079
9 944
.238
1 496
4 116
s 7.-.II
S7 52S
1 . 136
Grams
515
Cal-
cium
Oxide,
Ml 'tr
sium
i Ixide,
Grains Grains
628
076
370
B56
959
905 41 :::i.i
6221 17 255
61 160 55.580
15 472 226 B70
17 047 250 033
20 :i7l) 101 S50
21 338 312 958
,368
.919
. -'7:.
213.335
2,770
2,766
96.425
147 609
31 414
6 247
34 912
73 ISO
Calories as computed from Atwater's tables. 2,767.
As a result of the "Camp Dietary" no less than
six of the inmates developed symptoms pertaining
to pellagra. At first, there was intestinal irrita-
tion (diarrhea), and this was accompanied by lack
of appetite, loss of strength and weight. Later,
mild nervous symptoms appeared, but it was not un-
til five months after beginning treatment that the
"typical" skin eruptions developed.
The "Asylum Dietary" is thus described in the
report: "A cup of sweet milk, about 7 ounces, is
furnished each patient for breakfast and one of
buttermilk for both dinner and supper. About half
a pound of fresh beef and two to two and one-half
ounces of dried field peas or dried beans enter into
the daily ration. Oatmeal has almost entirely re-
placed grits as the breakfast cereal ; syrup has been
entirely excluded. Corn products, though greatly
reduced, have not been entirely eliminated."
The menu for Tuesday, selected for this study, is
as follows :
Breakfast. — Grits, sweet milk, sugar, broiled
steak, hot rolls, biscuits, coffee.
Dinner. — Beef stew, potatoes, rice, bread, but-
termilk.
Supper. — Baked beans, light bread, coffee, sugar,
buttermilk.
As the exact amounts of oatmeal, sugar, bread,
potatoes and rice are not given, it was assumed
that they had one portion, the weight of each being
added in the proper column. Thus, the total amount
of food eaten for the day is 51.5 oz., or 3.21 lb., two-
fifths of which is milk and buttermilk.
Table II — Dietary Study — Georgia State Sanitarily (Asylum). Selected to
Prevent and Cure Pellagra.
Food Materials
(Breakfast)
Oatmeal
Milk
Sugar
Hamburg steak
Bread
Coffee
Totals
Food value, each person
(Dinner)
Beef stew
Potatoes
Rice
Bread
Buttermilk
1 portion
1 cup
3 teasp.
1 portion
1 portion
1 portion
1 portion
1 portion
1 portion
1 cup
Totals
Food value, each person
(Supper)
Baked beans
Light bread
Coffee
Sugar
Buttermdk
Totals
Food value, each person
1 portion
1 portion
3 tease
1 cup
6
7
1
4
1 5
4
I
4
1 5
7
20 5
0105
0144
Hi Mil
00S2
1021
Grams
46
.0655
0062
0040
00S2
0131
0970
Grams
44
00S6
O0S2
11031
0299
Grams
13
►J
001 s
0174
l!.',,ll
01114
a "3
0431
02 IS
.0625
Grams
40
0872
0002
0002
0014
0021
0911
Grams
41
.0031
.0014
1755
Grams
80
0522
.0610
0482
0210
1824
Grams
82
.0245
.0482
Illi25
0210
0066 | .1562
Grams i Grams
3 70
*= '.=;-T3.=
•I r§*2
5 goo
2 047
267
!jfl
536
551
059
124
023 059
280 700
210 1 050
1371 124
5.267 | 551
5.917 2 484
1.8S1
137
372 7 2S5
367!
2 205
121
Summary.
Breakfast
Dinner
Supper
Totals
Food value, each per
son (lbs. 3.21)
Food utilized, lbs
19 5
46
40
80
20.5
44
41
82
11.5
13
3
70
51 5
103
84
232
Grams
Grams
Grams
103
84
232
Lbs.
Lbs.
Lbs.
Lbs.
929
2290
.1863
5l;:;:i
888 7.474 7 270
902 5 917 2 1S4
372 7 Js.5 2 880
2162 20 676 12.634
|
215*20.676 12 634
215! 20 676 12 634
Table No. Ill, "Comparison of Dietary Values,"
has been added for the purpose of showing the
"one-sided" character of the dietary selected in-
stead of a "balanced ration" — it shows at a glance
just how the two dietaries could be readjusted to
meet the normal demands of the system.
Analysis of the Tabulations. — By comparison and
contrast we may arrive at definite conclusions, at
least from a mathematical viewpoint, but there are
physiological and chemical questions to be brought
into consideration. For example, it is easy to make
the calculation and find that each dietary carries
184
MEDICAL RECORD.
[July 29, 1916
about two pounds a day more than is utilized; that
the protein content of the "Camp Dietary" is 30 per
cent, above the minimum, while the protein content
of the "Asylum Dietary" is 70 per cent, above the
minimum; that both dietaries were lacking in the
fat content of a "balanced ration" ; that the "Camp
Dietary" had a surplus of carbohydrate of about
200 grams while the "Asylum Dietary" had a de-
ficiency of like amount. Most important, however,
is the notable discrepancy in the mineral content —
the "Camp Dietary" contains about two and one-
half times as much magnesium as lime, while the
lime content of the "Asylum Dietary" is one and
one-half times the magnesium content. Now comes
the question as to which has the greater influence,
the discrepancy in the fat and carbohydrate, or the
reversal in the proportions of the calcium and mag-
nesium? Vegetarians live a normal life without fat,
animal fat, so that question is settled. Hard work-
ing men will consume food which produces twice as
many heat units (calories), as these men in the
camp, who worked four and a half days per week,
enjoy life and apparently suffer no bad effects from
the increased intake of carbohydrates. Again., the
absence of carbohydrate from the dietary is not at
all serious, as shown by the freedom of the asylum
inmates from recurrences of the disease, several of
whom had experienced two or more attacks. Fur-
ther, there were more than 72 patients under treat-
ment at the beginning of the course, but some of
them so far recovered under the treatment that they
were permitted to go to their homes. It is doubtful
if the excess of protein in the "Asylum Dietary"
could have exercised such a marked change, since
the "Camp Dietary" contained 30 per cent, above
the minimum requirement.
Table III— Comparison of Dietary Values.
Actual Ration
"Balav ED R '.71
n"
Is
, i
■SS
8
■c
o
3
e" g
£5
4
, i
• J
O g
412
o
78
103
36
84
515
2768
2154
7^
103
93
2501
i Lictar}
3301
This leaves for consideration the function of min-
eral constituents, but that harks back to the protein
element in the dietary. It is not an accumulation of
fat which gives a man mental ability and physical
strength ; nor can either be claimed for carbohy-
drate. Hence, the necessity for interrogating
nature.
In the "Asylum Dietary" nearly 16 of the 20
grains of lime were derived from the milk and but-
termilk, while the magnesium came chiefly from
oatmeal, rice and baked beans — in fact, when a child
gets 7 ounces of sweet milk and 6 ounces of oat-
meal, the mineral balance is in favor of lime bj
more than one grain. But a child twelve months
of age will take a quart of milk a day and thrive
.1 by which he gets about 24 grains of lime
daily.
Now, le< us examine the "Camp Dietary" — the
lime was derived principally from biscuits, sweet po-
tatoes, ci Hards and cane syrup, while the magnesium
contenl came from corn products almost exclusively
— with the rice content, it make up nine-tenths of
the whole. Had it not been for (he cane syrup the
"pellagra symptoms" would have appeared much
earlier and shown greater severity. Then, if we
add to this a decomposed or deteriorated corn
preparation with an excessive relative acidity, we
have a fairly complete picture of the conditions
which precipitated this malady in the first place and
kept it alive for two centuries.
In the usual dietary of the ordinary home in this
country, Langworthy has calculated that the average
intake of calcium ranges from 10.5 to 15 grains
daily, the magnesium content being estimated at
half this amount — and this apparently accounts for
the prevention of the recurrence of the disease in
the two wards of the Georgia State Sanitarium.
Deductions from the Evidence. — The general
reader must concede that we have a pretty good
case, but the evidence is not all in. For example,
as soon as the camp subjects began to suffer from
intestinal irritation, an examination of the blood
would have shown that they were suffering from
calcium depletion incident to the acid excess; that
the normal alkalinity of the blood was diminished,
interfering with its oxygen-carrying capacity; that
the heart action was enfeebled as a result of the
chemical deviation ; and finally, that nerve conduc-
tion was impaired — in consequence of the calcium
depletion and in the coincident substitution of mag-
nesium. It is precisely on the same principle that
a farmer would not permit the use of lime on his
land where it contained a large percentage of
magnesium, because he knows that such a combina-
tion would be fatal to his crops.
The essential factor in the production of pellagra,
scurvy and beriberi, and in fact, all chronic dis-
eases, is the mineral deficiency in the protein mole-
cule. The protoplasmic cell is the unity of which
the body is made up, just as the bricks are the unit
in a solid brick wall, except that these cells are
living organisms, possessing all the characteristics
and properties of life, nutrition (absorption), excre-
tion, motility, reproduction and response to stimuli,
and to this should be added the psychic. These cells
are made up of the food taken into the system; they
are composed of molecules — of fat, carbohydrate
and protein molecules, and the functional activity
and physical energies of the protoplasm are de-
pendent upon the proper distribution of the mineral
salts, not in the fat and carbohydrate molecules, but
in the protein molecules. It is the protein mole-
cule which enables the protoplasm to perform its
special or specific functions in muscular tissue,
kidney structure, in the liver, the lungs, the brain,
the reproductive organs, and finally, maintains
correlation with all the organs through the
medium of the nervous system. When illness super-
venes, there is at once an acidity, or diminished
alkalinity of the blood, and lime being a stronger
base than the others, this substance combines with
the acid and is eliminated. Thus, a person living
on crackers and water for three days will lose more
lime than the intake — and he will begin to lose it
during the first day of the experiment, all of which
goes to confirm my contention that calcium deple-
tion is responsible for pellagra.
Bacterial Infection. — This claim is further con-
firmed by a study of bacterial infection. Under nor-
mal conditions it is the protein molecule which en-
ables us to ward off disease, by maintaining an anti-
septic condition of the blood; by promoting or
favoring the production of bacteriolysins, sub-
stances which dissolve the bacteria; by the produc-
tion of poisons (bactericides), which kill the in-
vading hosts of bacteria; by augmenting . and
July 29, 1916]
MKDICAL RECORD.
185
strengthening the functional activity and physical
energies of the phagocytes, which surround and di-
gest the bacteria when found in the blood stream
and in the tissues, this peculiar feature of defense
being regulated by chemotaxis. In none of the con-
ditions can we depend upon nature when the blood
and lymph and tissues are surcharged with mag-
nesium salts, because bacteriologists have shown
time and again that when the blood is charged, sur-
charged, with a considerable percentage of mag-
nesium sulphate (Epsom salts), it loses its bac-
tericidal properties.
On the other hand, the presence of magnesium
salts in excess seems to favor the growth and mul-
tiplication of bacteria, the constitution of which is
substantially the same as the protoplasm, simply
because magnesium salts in excess are debilitating
— as in the case when they are substituted for the
calcium salts in the body tissues, their function is
impaired. Normal nucleoproteins are converted into
magnesium nucleoproteins and these latter lack the
property of imbibition (absorption), and this ex-
plains why the wise farmer refuses to put lime salts
surcharged with magnesium on the soil ; he knows
that the tiny rootlets will shrivel up, turn black and
die and that his crop will be a failure — and such is
substantially the picture we see when the search-
light of scientific inquiry is thrown on the disease
known as pellagra.
REFERENCES.
1. Experimental Pellagra in the Human Subject
Brought About by a Restricted Diet. Bulletin of the
U. S. Public Health Service.
2. The Prevention of Pellagra, a Test of Diet Among
Institutional Inmates. Bulletin of the U. S. Public
Health Service.
3. Vitamines and Nutritional Diseases, by Atherton
Seidell, Bulletin of the U. S. Public Health Service,
1916.
4. Aulde: Treatment of Pellagra, Lancet-Clinic,
June 12, 1915.
5. Cencelli: New Theories and Investigations Con-
cerning Pellagra, Lancet, April 17, 1915.
6. Aulde: Pellagra — An Inquiry, Netv York Medical
Journal, Dec. 4, 1909.
7. Roussel, Theophile: "Traite de la Pellagra et des
Pseudo-Pellagres," Paris, 1866.
8. Atwater: The Chemical Composition of American
Food Materials, Washington, D. C, 1906.
9. Aulde: The Chemic Problem in Nutrition (Mag-
nesium Infiltration), Philadelphia, 1912.
10. Sherman, Mettler and Sinclair: Calcium, Mag-
nesium, and Phosphorus in Food and Nutrition, Wash-
ington, D. C, 1910.
1305 Arch Street.
THE DRUG HABIT.
By FRANK A. McGUIRE, M.D.,
AND
PERRY M LIGHTEN STEIN. M D ,
NEW YORK.
PHYSICIANS TO THE CITY PRISON (TOMBS).
So much has been recently written on this sub-
ject, and so many different views of it have been
taken by the different writers, that it would seem
that we owe an apology for writing the present
article.
We are, however, convinced that this subject as
herein discussed will be of interest to all who read
its contents. As physicians to the City Prison
( Tombs ), Manhattan, it has been our opportunity
to come in contact with and treat approximately
twelve thousand cases within the last twelve years.
This is a conservative estimate. We have observed
and studied people so addicted, and we have insti-
tuted a definite treatment, which has proved ef-
fective The drugs most often used are opium and
its derivatives and cocaine.
Opium is the concrete milky exudation obtained
in Asia Minor from the unripe capsules of papaver
somniferum, by incision and spontaneous evapora-
tion. It is usually put on the market in subglobu-
lar, flattened, irregular cakes, chestnut brown or
somewhat darker in color. The mass is plastic,
but on keeping a harder external crust is formed.
The cakes weigh from 4 ounces to 2 pounds. Opium
has a heavy, sweetish odor and a disagreeable bit-
ter taste. At present the use of this drug by ad-
dicts is restricted, owing to the increase in price.
This fact has resulted in causing opium users to
resort to heroin, the latter being more readily pro-
cured. Opium smokers may be divided into two
classes: (1) Pleasure smokers; (2) Fiends. The
pleasure smokers are usually found among the
well-to-do and business men, actors and actresses,
and the sporting element. They smoke only oc-
casionally and are not confirmed addicts. On the
other hand, the fiend is one who practically lives
in the opium dens. Such people lose all ambition
and simply smoke and sleep.
Pleasure smokers usually are possessed of most
elaborate layouts. They have costly jeweled pipes
and dens fitted accordingly. The fiend usually
craves to smoke in company and is not very par-
ticular in choosing his company. Usually men and
women smoke together. A mattress is placed on
the floor. The man who pi'epares the opium lies
down, the second smoker places his head upon the
abdomen of the first; the third will assume a simi-
lar position, and so on with the others, forming a
circle. The man who prepares the pill then takes
the yen hok, which is shaped somewhat like a probe,
having one pointed end. He places a small piece
of opium on the point of the yen hok and heats
it over a tiny flame of a small lamp, used for
that particular purpose. The lamp is filled with
an oil which will not smoke when burned. This
prevents spoiling of the flavor. It requires an
expert to cook the pill. When the mass is heated,
it softens and is then shied. By this is meant
the stringing or pulling of the mass. The shied
mass is again rolled on the yen hok and heated.
Next, the bowl of the pipe is heated and the warm
mass quickly applied around a small opening of
said bowl. The smoker quickly draws on the pipe.
Only one or two pulls may be taken from a pill.
The bowl must be kept warm. When all are smok-
ing, the group resembles a wheel, with the pipes
as the spokes.
After smoking, a cake is found in the pipe which
is dark brown in color and brittle in consistency.
This mass is known as yen shi or opium ashes.
It is bitter in taste and has a peculiar sweetish,
sickening odor. It is eaten by some addicts and
is also used by the Chinese to flavor raw opium.
Morphine is derived from opium and heroin is ob-
tained from morphine. Addicts of opium and its
derivatives use the drug only for its effect upon
the nervous system.
Briefly the action is as follows: Opium stimulates
the intellect, imagination, associations, all of pleas-
urable character. The reality of life in its sterner
phases, is viewed and interpreted from an illusive
standpoint, creating a subjective and objective
reality where cares and sorrows are submerged,
a self-contentment, a mental Utopia — in other words,
the euphoria of the poppy. This is followed by a
dreamy state, due to suppression of external
186
MEDICAL RECORD.
[July 29, 1916
stimuli, resulting in sleep. The subject has fantas-
tic dreams, often of an impossible nature. The
sleep is deep and the person is not easily aroused.
The pupils are contracted and react very suggishly
to light and accommodation. After a person has
taken the drug for years, there may not be a con-
tracted, pin-point pupil. The muscles seem to be-
come inactive and do not react to the drug any
longer. For this reason, the pupillary condition is
not a reliable diagnostic sign in older cases. All
other reflexes are first stimulated and then de-
pressed. After the cessation of the action the in-
dividual is dull, restless, and unable to concentrate
his thoughts. Such individuals lose all ambition.
Perversion of the moral sense is a marked symp-
tom. Delusions may occur and some prisoners
show marked hallucinatory excitement. The re-
flexes are exaggerated, due to the removal of the de-
pressant action of the drug upon the spinal cord.
The action of morphine and heroin is similar to
that of opium, but greater in degree. This is par-
ticularly true of heroin. This latter drug is sev-
eral times as powerful as morphine. The chemical
name of heroin is morphine diacetic ester.
Cocaine is a white crystalline powder, inodorous,
which has a slight acid reaction and is bitter in
taste. When placed on the tongue, it produces a
tingling sensation, which is followed by numbness.
Cocaine hydrochloride is derived from Erythroxy-
lon coca. Its action on the nervous system differs
from that of morphine. This drug stimulates all
the mental faculties and produces a great increase
of bodily power. As in the case of morphine, all
external occurrences are ignored. All care and
sorrow are forgotten and the person is supremely
happy. Cocaine, however, does not stimulate the
imagination as much as does morphine, nor is
there any tendency to sleep. On the contrary,
cocaine causes insomnia. One habitue told us that
it was a common occurrence for him to go without
sleep for seventy-two hours after taking cocaine.
At the end of that time he was practically in a
condition of collapse. The stimulating effect of
cocaine is followed by physical and mental exhaus-
tion, enfeeblement of the intellect, and headaches.
Cocaine acts upon the sympathetic and causes a
dilatation of the pupils. Habitues, when in need
of the drug frequently complain of a feeling of
foreign bodies crawling under the skin. As re-
gards the reflexes, these are increased or exag-
gerated during the period of stimulation. When
the action of the drug ceases, a decrease in reflex
activity is noticeable. The pupils react to light.
The pathological changes resulting from these
drugs are worthy of mention.
Gastrointestinal system. — As is well known,
opium causes a decrease of all secretions excepting
the sweat. It may readily be assumed that a con-
tinuation of such action for any prolonged period
will result in atrophy of the gastrointestinal glands.
Opium also decreases peristalsis, thereby causing
constipation. Taking both the decrease in secretion
and interference with peristalsis into considera-
tion, it is obvious that absorption and assimilation
are interfered with and that stagnation occurs.
Consequently toxic substances are absorbed, giving
rise to headaches, dizziness, and dulled mentality.
People addicted to opium and its derivatives usually
eat less than normal individuals. Opium appeases
hunger. This, of course, is a factor to be remem-
bered when we consider the great loss of weight
that occurs in fiends. We have noticed that yen shi
chewers lose weight more rapidly than opium
smokers. This is also true of morphine and heroin
fiends, particularly of individuals addicted to the
latter, said drug being several times more powerful
than morphine.
Respiratory system. — Narcotic addicts at the
present period prefer to administer heroin and co-
caine by sniffing. This method of administration
leads to definite pathological changes in the nose,
often resulting in perforation of the nasal septum
at the union of the cartilaginous and bony portion.
Upon beginning to sniff either cocaine or heroin,
the nose feels clogged up when the effect of the
drug wears off. The action of the drug when ad-
ministerd by sniffing produces a sensation of numb-
ness and coldness. This is due to the shrinking or
temporary constriction of the blood-vessels of the
nasal mucosa. Therefore, when the action of the
drug wears off, there is a dilatation of the blood-
vessels and swelling of the mucosa, resulting in
clogging the nose. In order to feel relieved, the
fiend takes another sniff. Later, there is no swell-
ing after the action of the drug wears off. The
mucosa becomes anemic and an ulceration forms
at the union of the bony and cartilaginous septum.
Continuation of sniffing eventually leads to per-
foration. We have seen several cases where com-
plete destruction of the cartilaginous septum has
occurred, with resultant caving in and deformation
of the nose, somewhat resembling the saddle nose
of syphilitics. Cocaine will produce a perforation
in onj year's time. A combination of cocaine and
heroin will produce a perforation in less time.
Heroin will produce a perforation when used for
several years.
It is also noticed, as a rule, that drug fiends suffer
from bronchitis. It is safe to say that at least
three-quarters of all the drug fiends who have
come under our observation and treatment have
presorted this condition. The explanation thereof
is as follows : When morphine or heroin is taken,
in physiological, or rather therapeutic, doses, the
action is to depress the sensibility of the respira-
tory tract to reflex stimulation and to diminish the
amount of bronchial secretion. The old law that
over-stimulation results in depression is true in
this instance. When a person takes these drugs
continually for a long period, the above-mentioned
action ceases. Consequently the drug acts as an
irritant to the respiratory system, resulting in
bronchitis with abundant expectoration. It is a
well-known fact that fiends usually die of either
tuberculosis or acute cardiac dilatation. We know
that opium and its derivatives in large doses slow
the respirations to four and six per minute. It is
evident that a continuation of the administration of
large doses of the drug can have only one effect,
viz., weakening of the lung tissue. The amount of
air taken in is diminished. The CO, of the blood
therefore rises; CO, is a poison and results in
diminishing the resistance. Taking into considera-
tion the fact that fiends are usually neglectful of
all else but the procuring of the drug, in conse-
quence not eating regularly, etc., it is evident that
they are more prone to tuberculosis than others.
Circulatory system. — The following diagram
taken from Sollman's textbook of Pharmacology is
illustrative of the action of the opium group on
circulation. The late Prof. John H. Ripley used
the official solution of morphine in attacks of
diphtheritic paralysis of the heart. This restored
the action of the heart to a great extent.
July 29, 1916]
MEDICAL RECORD.
187
From the following diagram it is easy to see what
large doses accomplish. A continuation of the ad-
ministration of large doses can have only obvious
results upon the circulatory system. Large doses
result in paralysis of the heart muscle. When a
fiend is deprived of the drug and suffers severe
withdrawal symptoms (vide infra), he may die sud-
denly from an acute dilatation.
Genitourinary system. — Morphine is eliminated
in the urine in the form of morphine-glycuronic
acid. We have noted in several cases that there
was a suppression of urine. Usually, however, no
marked pathological symptoms referable to this
tract occur.
Generative symptoms. — The action of the opium
group on the system is marked. In males taking
the drug the general rule is a loss of sexual desire.
An erection may occur, but there is not much sex-
ual inclination. If sexual intercourse is attempted,
the act is usually futile, and where emission of
semen does occur, it is usually accomplished after
several hours' effort. When the drug is withdrawn,
the sexual desire often becomes intense. People
addicted to the drugs, upon withdrawal of same,
have nocturnal emissions, and these are sometimes
so frequent as greatly to weaken the individuals.
Women are usually more strongly affected than are
men. They also suffer frc-m nocturnal emissions.
One woman begged for bromides to quiet her, stat-
ing that she could not keep her hands from herself.
Cocaine habitues are usually sexual perverts, and
in them the sexual desire is extreme. In females
when taking the drug ( opium and its derivatives)
habitually there usually occurs a cessation of men-
struation. We have known women to give a his-
tory of cessation extending over years. The menses
usually return when treatment is begun, and are
sometimes very profuse and attended with severe
abdominal and lumbar pains. What is the effect of
addiction upon pregnancy? The following facts
have been ascertained from the histories obtained
of prisoners coming under our observation. Where
both mother and father are addicts and under the
influence of the drug, sexual intercourse is without
result. Where both are temporarily off the drug
and are sexually excited, impregnation may occur.
If both return to the drug, one of two things may
happen: (a) miscarriage; (6) birth of a child
which may be dead or else if it lives, is of a weak-
ened constitution. The addicted mother should not
nurse the child. If she does the child will become
addicted through the milk. We have the history of
a case where a child, eight months of age gave all
the symptoms of drug addiction. It seems that
heroin does not decrease the secretion of milk as
much as does morphine. So long as the mother
took heroin the amount of milk secreted was plenti-
ful, but as soon as morphine was taken the amount
secreted diminished rapidly. We have failed to
find reference to sexual changes in the literature
treating with drug addiction. The effect upon the
generative organs we believe to be of evident im-
portance.
Mentality. — Drug fiends as a rule are neurotics.
The psychoses noted in addicts are often similar to
those seen in alcoholics. In the latter, the charac-
teristic features are delusions of marital infidelity
and of persecution. The following cases will illus-
trate this point:
People vs. C. H. C. H. was a woman and a confirmed
addict. While under the influence of opium she killed
her husband, whom she accused of marital infidelity.
These delusions were also present while she was in the
Tombs. She was sent to Matteawan, and is there at
the present time. This woman showed marked sexual
hyperesthesia and begged for bromides to quiet her
passion. After killing her husband she attempted
suicide while suffering from the above-mentioned de-
lusions.
People vs. N. C. N. C. was also a confirmed addict.
He also had delusions of marital infidelity. While in
the Tombs these delusions were inhibited as far as
could be ascertained, by talking with the man. However,
our attention was called to these delusions by letters
written to his wife by him, said letters being referred
to us. These showed the trend of his delusions. In
fact, all these accusations were written by the prisoner
in red ink, whereas the other part of the letter was
written in black ink.
Several of our cases showed marked delusions of
persecution. One prisoner in particular became
very violent and required several hypodermic in-
jections of morphine to quiet him.
Are all drug addicts of lowered mentality? Ab-
solutely not. It is true that opium and its deriv-
atives dull the mentality. However, all addicts are
not placed in the same position socially, nor are
all addicts fiends (vide supra). The addict who
has plenty of money and many friends, and in con-
sequence better social surroundings, cannot be com-
pared to the fiend who hangs out in the dens and
just lives to smoke. The first mentioned are usually
well nourished and take just enough of the drug to
satisfy them. The latter are never satisfied. If
any mental defectives are to be found they are
found in the latter class. Obviously, immediately
after awakening from sleep produced by opium, the
mentality is clouded, but this soon wears off.
Krafft-Ebing, in speaking of the action of poisons
on the mentality, says: "Morphine never injures
so profoundly the psychic organ as alcohol does,
but I have never seen a morphine addict who was
psychically intact. Intelligence it is true, is prac-
tically spared, character and ethica* feeling, the
highest mental functions, also mental energy and
force always suffer. The fully developed morphin-
ist is an individual weak in character and will, and
without energy, who would receive under criminal
prosecution, the benefit of the extenuating circum-
stances, and who in the care of his interests and
duties should always be given help."
In a letter written to the Hon. John J. Freschi,
then a magistrate (September 19, 1912) on the sub-
ject relating to a proposed amendment of the sec-
tion in the Inebriate bill with reference to the dis-
position of drug addicts the above-mentioned state-
188
MEDICAL RECORD.
[July 29, 1916
ment of Krafft-Ebing was included. We must,
however, differ from the author when he states that
he never has seen an addict that was psychically in-
tact. Our experience teaches us differently. Mental
energy and force may suffer in fiends, but to say
that this is also true of addicts who smoke for
pleasure is contrary to our experience.
In discussing the mentality of addicts we must
not forget to mention that these individuals are un-
believable. Former Deputy Commissioner Wright
describes a man who was brought to his notice by
the warden. The prisoner was accused of trying
to procure drugs from outside sources. When ques-
tioned he swore he never had used drugs and in
fact did not know what heroin and morphine looked
like. The man was searched, and in the seams of his
trousers was found concealed a deck containing
enough heroin to satisfy his craving for several
days.
Drug addicts may be dulled mentally in some in-
stances, but when the problem is one of obtaining
the drug, these people are the cleverest and most
cunning of all people. As is well known, it is
almost impossible to smuggle opium or its deriv-
atives into the Tombs. In spite of all precautions,
some does get through. Some of the attempts made
are as follows : On one occasion two books were
sent to an addict ; the keeper searching the pack-
ages examined the pages from cover to cover and
could find no signs of drugs. Deputy Commission-
er William J. Wright happened to be in the build-
ing and saw the books. He picked one up and
noticed a white powder on the desk. He then
searched the book but could find nothing. Taking
out his pocket knife he ripped up the binding of the
books and discovered a package of heroin concealed
in each. On another occasion a woman came to
visit a drug user. She was searched by the matron,
all her clothes being stripped from her. Nothing
could be found. And handing the woman her hat,
the matron noticed the rubber end of a pen filler on
the end of the hat pin, the same having been con-
cealed beneath the plumes. This contrivance, when
examined, proved to contain a large dose of mor-
phine.
On still another occasion a woman was arrested,
charged with having drugs in her possession. When
searched, no drugs were found. She was then
turned over to the doctor, who upon vaginal exam-
ination discovered a case containing an entire hypo-
dermic outfit, including several tubes of morphine
tablets. On many occasions drugs have been found
concealed in the vagina. On others we have found
condoms full of heroin or morphine concealed in
the vagina, and on one occasion a finger cot with
morphine in the rectum, with a string attached,
protruding from the anus.
Another mode of smuggling the drug is in food.
Oranges have been sent to users of the drug which
upon examination proved to be loaded with a solu-
tion of morphine. The drug had been injected by
means of a hypodermic. One addict attempted to
send the drug into the prison in a can of condensed
milk. We have in our possession two packages of
cigarettes, which are leaded with morphine tablets.
Finally, in speaking of the effect upon the men-
tality, we must not forget to mention the yin yen.
By this is meant the periodical craving for the
drug. This, of course, is purely a psychic phenom-
enon, and is most often noticed in individuals when
they are "getting off" the drug. At such times
they will beg piteously for the drug.
Other changes produced by the opium group. —
It has come to our notice and has been demon-
strated to other physicians by us that many of the
women habituees present a wonderful growth of
hair. On one occasion a prominent physician vis-
ited the Tombs and while discussing this subject
said physician seemed sceptical as to this fact. We
took him to the female prison and had two addicts
brought out, who let down their hair and dispelled
all doubt as to our statements. It is no exaggera-
tion to state that these women each had hair which
extended to the calves of the legs. Not alone was
their hair long, but thick and oily. We can think
of only one explanation of this fact. As is well
known, opium and its derivatives decrease all secre-
tions excepting the sweat. The sweat glands are
stimulated. Histology of the scalp teaches us that
numerous sweat glands are distributed to the scalp
and the roots of the hair. Opium and its derivatives
by stimulating the glands increase the moisture of
the scalp, thus causing a greater growth of hair. It
is purely a nutritive process.
Hypodermic fiends at times present frightful skin
lesions. The body appears to be covered with a
rash, due to the use of the needle. At other times
abscesses are noticed, filled with foul pus. Fiends
do not sterilize the skin and needle before injection,
and in most cases inject the liquid through the
clothes. In the Tombs, the fiend manufactures his
own hypodermic. The rubber portion of a fountain
pen filler is attached to a hypodermic needle. This
makes a very serviceable syringe. The fiend passes
the syringe to the others on the tier. I have known
syphilis to have been transmitted to four individ-
uals by this means.
Drug addicts, when unable to obtain the drug,
suffer severely, as in the withdrawal stage. We
usually find them lying in bed and yawning very
frequently. Lacrymation and running of the nose
are invariable signs. Sometimes the individuals
cannot stop sneezing. They seem to be itching all
over, and are continually rubbing the arms and
legs. In some of the severer cases the patients
vomit and are affected with diarrhea, which is at
times bloody. The body is covered with a clammy
perspiration. The pupils are dilated and react
sluggishly to accommodation and light. The pa-
tient may be unable to void urine. Women often
have profuse menstrual discharges and severe ab-
dominal pains. Abdominal pains are also present
in the men. The pulse varies between 100 and 140,
is of low tension, and sometimes irregular. In-
somnia is present in all cases. In both males and
females sexual excitement may be intense, and noc-
turnal emissions may occur. Some patients present
delusions and hallucinations. The reflexes are all
exaggerated excepting the pupillary.
Cocaine fiends show no withdrawal symptoms.
Opium smokers seldom show any withdrawal symp-
toms excepting the yin yen. The withdrawal symp-
toms are usually noticed only in morphine and
heroin addicts.
In cocaine fiends the following are usually
noticed: loss of weight, mental fogging, exhaustion,
insomnia, spasmodic contractures of muscles of the
extremities and acceleration of pulse. These in-
dividuals are usually anemic, have a dry, sallow
skin, and a peculiar glistening look in the eyes. The
withdrawal symptoms in one who has used both
cocaine and heroin are more severe than in one who
has used heroin only. The combination of cocaine
and heroin is very destructive as regards both the
July 29, 1916J
MEDICAL RECORD.
189
physical and the mental condition of the individual.
How is the habit acquired? From the histories of
the prisoners we have ascertained the following:
Very few drug fiends traced their addiction to
physicians' prescriptions. In fact it is a rare oc-
currence for us to obtain such a statement. Those
who do give such a history are most often women
who have suffered from tubal disease or severe
burns and cancer. Among men giving such a his-
tory the majority are affected with locomotor-
ataxia or cancer. The majority of prisoners, how-
ever blame their addiction to friends. Drug addic-
tion has become so prevalent that there is scarcely
a poolroom or saloon that may not be termed a drug
fiend's "hang out." The profit reaped by dealers
in narcotics is so enormous as to warrant certain
conspiring individuals to chance arrest. Almost
always, the addict is fooled. When he buys a deck
"60-grain powder," he is sure to receive three-fourths
sugar of milk. Janitors, cabdrivers, and bar-
tenders have become agents, for certain individuals
have found that drug selling is a very profitable
business. These men are known as go-betweens.
Some people take the drug for insomnia. This
is particularly true of nurses and physicians.
Such cases have come under our observation and
treatment. Others take the drug to ward off sor-
row and care, while some are compelled to take the
drug because of the severe pains caused by loco-
motor ataxia, cancer, etc.
It is a noticeable fact that most of the addicts
coming under our treatment are young indivduals.
It is not uncommon to find boys and girls sixteen
and eighteen years of age who give a history of
having taken the drug for two years. We have
treated one child, who became a confirmed drug fiend
through the mother's milk.
Concerning addiction among the different races,
we have ascertained the following:
Yellow race: Compared to all other races ar-
rested for various crimes, the Chinese are prob-
ably the fewest of criminals. However, those who
are arrested are for the most part addicts. The
particular drug used is always opium and its ashes,
yen shi. We have never seen a Chinese hypodermic
fiend or sniffer.
White race: Next to the yellow race in the pro-
portion of prisoners is the white race. These are
chiefly Hebrews and Italians. The former compose
from 30 to 50 per cent, of the addicts, the latter
from 20 to 30 per cent. The remainder are chiefly
Irish. The drugs used by the white race are heroin,
morphine, opium, and cocaine, in order of fre-
quency. From 80 to 90 per cent, use heroin.
Black race: Prisoners of this race are mainly
addicts of heroin, cocaine, and opium smoking, in
order of frequency. It is rare to see a colored hypo-
dermic fiend. Down south the negro is addicted
mostly to cocaine.
As to the occupation of individuals addicted to
drugs, we have ascertained that none of the hab-
itues are engaged in what may be termed laborious
work. The occupations given among them are ac-
tors, clerks, chauffeurs, artists, and song-writers.
Among the females we find solicitors, actresses,
nurses, and stenographers.
As regards nationalities, we must state that it is
rare to see a foreigner, with the exception of the
French, who takes the drug. By foreigner? we re-
fer to those individuals who have been in this coun-
try but a short while. We have, however, treated
several Syrians and Greeks. Most of the addicts
are American born, or have been in this country for
years.
As regards social standing, it may be stated that
addiction exists among all classes. Individuals from
Fifth Avenue often mingle with those of the Bow-
ery, and when under the influence of the drug are
on the same moral and mental plane as are the
fiends of the underworld.
In conclusion we wish to state that we do not
desire to discuss any particular form of treatment.
We wish to state most emphatically, however, that
having taken the physiological action and patho-
logical changes incurred by the drug into consider-
ation, we are compelled to state that we do not
sanction any treatment that employs depressant
drugs, to gain what is commonly advertised as a
cure. The individual may be taken off the drug
by any of the advertised methods, but at what cost?
The treatment sometimes acts like a torch applied
to a barrel of gunpowder. If the patient before
being treated, has a slight tuberculous focus, he is
sure to have an extensive one following some of the
widely advertised treatments. If he has a latent
nephritis, this is certain to become a very active
disease. If a cardiac condition with compensation
exists before treatment, the individual may die
during the treatment, and if not, is left with an in-
competency following the "cure." Such individ-
uals when dismissed and turned onto the street in
their weakened condition, will follow the line of
least resistance, i.e. they will go to the first place
they can reach to get some "dope" to strengthen
themselves with. The treatment we have employed
consists in rapid reduction, accompanied by sup-
portive treatment. In all our experience we have
never had a single death and have never had a
patient who did not gain some weight. In fact, we
have had patients who gained from 40 to 50 pounds
in two months' time, this period including the actual
treatment and after-care. We wish to state most
emphatically that one cannot cure a drug fiend in
two weeks or in two months. All one can hope to
accomplish is to take him off the drug. Following
the treatment, the patient should be sent to a farm
or some institution, outside of the city where he
will be away from bad company and from sources
where he may obtain the drug. He should stay
away for a period of from six months to one year.
This is the only method that can lead to perma-
nent and good results.
We advocate that the following facts be ascer-
tained before actual treatment is begun : (1)
Physical condition of the individual. (2) Kind of
drug used by the individual. (3) Daily amount
taken. (4) Social condition.
No physician should be allowed to treat a patient
outside of a sanatorium or hospital. The so-called
reduction cures given by physicians, allowing the
fiend to work and attend to all business, permitting
contact with evil associates, are of no value and
should be prohibited by law.
The reduction treatment is the oldest and in our
opinion the best treatment. The Chinese have em-
ployed a reduction treatment for many years. This
consists of two bottles containing red coated pills.
One bottle contains opium pills and the other are
plain pills. The Chinaman is told how many to begin
with and gradually reduces the amount until "off the
drug." This treatment is not carried out in a sana-
torium, and therefore very good results have not
resulted. Osier, in speaking of the treatment of
drug addicts, states : "Isolation, systematic feeding.
190
MEDICAL RECORD.
[July 29, 1916
and gradual withdrawal of the drug, are the essen-
tial elements. As a rule the patient must be under
control in an institution, and should be in bed for
the first ten days. It is best in a majority of cases
to reduce the morphine gradually. Usually within
a week or ten days the opium may be entirely with-
drawn. In all cases the pulse should be carefully
watched and if feeble, stimulants should be given.
It is essential in the treatment of a case to be cer-
tain that the patient has no means of obtaining
morphine."
In connection with the last statement we refer
our readers to the early part of the article. When
drug fiends enter the Tombs every bit of clothing is
taken from them and thoroughly searched. All mail,
clothing, and food are thoroughly searched. Fe-
male addicts are in addition given a vaginal exam-
ination by the physician.
Forchheimer (Prophylaxis and Treatment of In-
ternal Diseases) states: "In order that the best
results be obtained the patient must be confined to
bed and have a trustworthy attendant. Where the
conditions are proper, the patient may undergo the
weaning from morphine at home. This is not a
favorable way. For even in hospitals and institu-
tions the patient frequently circumvents all pre-
cautions taken to prevent his obtaining morphine.
A morphinomaniac has lost his moral sense; he can
never be believed, and besides, on account of the
suffering attending the withdrawal of the drug, he
will try to get morphine at any cost, using all his
ingenuity to this end in the most unscrupulous man-
ner. Before he enters the room in which he is to
be treated, he should be carefully examined. Clos-
ets, bed clothing, indeed every nook and corner; the
patient himself must be stripped and all his be-
longings searched for morphine."
This author also advocates the reduction treat-
ment, the patient being under constant observation.
Among others recommending the reduction treat-
ment are Dieulafoy and Strumpel. Almost every
textbook on medicine recommends this method.
Being in the city employ we have frequently been
asked for recommendations as to methods advocated
for curbing the drug habit. We cite the following
and hope that our recommendations will receive
the earnest attention of our readers.
It is an evident fact that a State law will never
in any way curb the drug habit. The Boylan law
is a failure in this respect. People who want
the drug simply go to New Jersey or Connecticut
and obtain as much of a supply as is desired. At
present a State law is being recommended, and we
venture to state that it will meet with just as much
success as did the Boylan law. The Harrison law
has also proved a failure. Unscrupulous physicians
have added greatly to their material interests while
strictly adhering to this law. The law is full of
loopholes. The one dollar tax imposed on physicians
practically places us on a level with saloonkeepers.
The imposing of such a tax does not act as a de-
terrent upon drug addiction. If a proper Federal
law be enacted we will be doing something to curb
the drug evil. We believe the following would be
such a law: 1. All narcotic drugs and their deriv-
atives coming into the United States to be placed
under the supervision of the United States Public
Health Service. 2. The United States Public Health
Service is to sell or dispense of these drugs to the
State Health Service of each State, record to be
Kept of same. 3. The State Health Service is to
sell or dispense of the dru±:* to the Board of Health
of each city, record being kept of same. 4. The
Board of Health to have stations in each district,
open day and night, at which places physicians and
druggists may obtain the drugs, a record being
kept of same. 5. The establishment of dispensaries
or receiving stations, where addicts may apply for
treatment without fear of arrest and from which
place they may be sent to certain designated hos-
pitals to take the treatment. 6. The establish-
ment of farms to which these addicts may be sent
after being taken off the drug, and where they can
remain for at least six months. 7. To make it a
criminal offense for physicians to treat patients
outside of a sanatorium or while at large, without
constant watching.
The Hon. Katherine B. Davis, also the Hon. Bur-
dette G. Lewis and the Hon. David Kelly have tried
their utmost to establish farms for drug fiends,
and have been successful in obtaining a farm at
Warwick.
What is the percentage of addiction in the
Tombs? Undoubtedly our statement will cause sur-
prise in view of the fact that so many hysterical
statements have recently been made and published.
Those actually giving a history of addiction and
requiring treatment comprise 5 per cent, of the in-
mates. This is a liberal percentage. We do not
count those as addicts who are arrested for selling
the drug or those who have taken the drug on one
or two occasions, but have never made a habit of it.
Two years ago our percentage was only approx-
imately 3 per cent., showing that addiction is on
the increase.
People have also entertained the belief that all
homicides are drug users. We have found the fol-
lowing to be the crimes committed by addicts: In
order of frequency these are petit larceny, grand
larceny, attempted suicides, exposure of person,
forgery.
Pleasure smokers rarely commit crimes which
may be traced to drug influence. Fiends commit
the crimes above mentioned, and usually the reason
given is that the money stolen was to be used to ob-
tain the drug. In regard to Krafft-Ebing's state-
ment (vide supra) we wish to state that we par-
tially agree with the statement which says, "The
fully developed morphinist is an individual weak in
character and will, and without energy, who would
receive under criminal prosecution the benefit of
the extentuating circumstances and who in the care
of his interests and duties should always be given
help."
We feel also in discussing its medicolegal rela-
tions that the line should be drawn sharply between
those addicts who had borne a previous good char-
acter and who had become addicts from physical
causes i.e. insomnia, locomotor ataxia, etc., to aid
them at their work, as they say, and where some
degree of relationship can be established between
the act charged and the drug addiction, not legal
insanity as we understand it, but a lesser degree of
responsibility, as implied by the mental state in-
duced by the drug. We differ from Krafft-Ebing
in the general application of the above to all ad-
dicts who commit crime, but would confine it to
the class as above described, who are essentially
distinct from those who acquire the habit through
criminal associations.
In conclusion, we wish to state that the present
article is based entirely on our observations and
treatment of cases, and we feel that we have demon-
strated several facts hitherto unpublished. To re-
capitulate:
Opium and its derivatives and cocaine lead to the
July 29, 191GJ
MEDICAL RECORD.
191
following: (1) Perforation of the nasal septum.
(2) Impairment of the sexuai organs and of the
power of generation. (3) Impairment of moral
sense. (.4) Impairment of the mentality. In hypo-
dermic fiends we find multiple lesions of skin and
formation of abscesses. Opium addiction is a
causative factor of tuberculosis and bronchitis. It
affects the cardiac muscle leading to cardiac dilata-
tion. It influences the nutrition of the scalp, caus-
ing increased growth of hair.
We take this opportunity to thank Warden John
J. Hanley and the keepers of the city prison for
their courtesy and aid in obtaining the data above
quoted.
104 West Eightt-fifth Street.
7S9 Dawson Stf.eet.
THE PHYSICS OF PERCUSSION AND
AUSCULTATION OF THE CHEST.
By FRED H. HEISE, M.D.,
TEUDEAU, N. T.
RESIDENT PHYSICIAN, TRCDEAU SANATORIUM.
Percussion and auscultation are based primarily
on the production and interpretation of changes in
sound; consequently these two methods of diag-
nosis are intimately connected with, or governed
by, the physical laws applying to sound. And it
will not be amiss to define sound briefly and to state
some of the simpler laws governing its character,
production, conduction, etc.
Sound is the sensation produced through the ear
by vibrations, either of a vibrating body itself or
the surrounding medium. Sounds may therefore
be said to be wave vibrations interpreted by the ear,
just as light is wave vibration interpreted by the
eye. Sound waves may differ in three ways: (1)
the rate of propagation or number of waves per
second; (2) the amplitude of each wave; (3) the
form, that is whether simple or compound. In
other words, sound waves as heard by the ear may
differ in pitch, intensity, and quality.
The number of waves per second determines
pitch. If the waves are long and few in number the
pitch is low, and as the number increases per second
the pitch becomes higher and higher, until the sound
is very shrill and piercing and finally becomes in-
audible. It has been found that to be perceptible
as sound the vibrations must be no fewer than 16
to 24 per second, nor more numerous than 30,000
to 40,000 per second.
Intensity or loudness is dependent upon wave
magnitude or amplitude, and diminishes with the
square of the distance of the sounding body and also
as the density of the medium through which it
passes decreases.
Quality depends upon wave form, that is whether
simple or compound, and distinguishes between the
same tone when sounded upon two different musical
instruments, such as a piano and a violin. It de-
pends upon the number and intensity of the over-
tones or harmonics which blend with the funda-
mental note. These overtones are higher notes of
small intensity as compared with the fundamental.
Sound waves are conducted, and may be reflected,
refracted, diffracted, and interfered with or broken,
giving rise to beats.
Sound waves are not conducted in a vacuum. A
medium for conduction must be present. In this
medium the waves travel in all directions, with a
velocity or facility depending upon its physical
nature and temperature. In air the velocity is about
1090 feet per second at 32; F., and increases as
the temperature increases. In other cases the ve-
locity varies inversely as the square root of the
density. In liquids the velocity is greater than in
air (in water 4 times greater). In solids the ve-
locity varies greatly, being small in inelastic sub-
stances such as lead and wax, and quite great in
substances like wood and steel (2 or 3 miles per
second, or about 10 to 15 times as rapid as in air
and 3 to 4 times as rapid as in water.)
The laws governing reflection and refraction of
sound are the same as those governing light. The
echo is a sample of reflection. Owing to the rapid-
ity with which sound travels in air, 1090 to 1125
feet per second, and to the fact that approximately
1 9 to 1 16 of a second must elapse between sounds
for them to be appreciated as distinct and separate
sounds, the hearer must be at a distance of approxi-
mately 60 feet from a reflecting body to appreciate
an echo. For this reason echo plays no prominent
part in auscultation and percussion.
When a sound wave meets the surface of another
medium of greater density it is in part reflected,
travelling back from that surface into the first
medium with the same velocity with which it ap-
proached. When a sound wave travelling through
one medium meets a second medium of a different
kind the sound waves are communicated to the sec-
ond medium with a velocity and direction depend-
ing upon the density and elasticity of this medium.
Sound may be amplified or increased in intensity
by resonance. By this is meant the prolongation
of sound by reflection, or the prolongation and
increase of sound by sympathetic vibration or other
bodies. This sympathetic vibration is in unison
with the fundamental tone or one of its harmonics.
The pitch and quality of the resulting sound are
largely dependent upon the shape and size of the
resonant chamber.
Having considered in a general way a few of the
laws governing sound, let us now consider the
anatomical construction of the chest and see what
bearing this has on sound as produced by percus-
sion and as heard upon auscultation.
The chest is a bony and cartilaginous framework
covered by muscle tissue, fat, and skin, and enclos-
ing the lungs, heart, and mediastinal tissues and
structures. Separating the chest from the abdomen
is the movable diaphragm. Between the ribs are
interlacing muscles, allowing considerable move-
ment. Covering the ribs according to physical de-
velopment and nourishment there is a varying
amount of muscle tissue and fat. Lining the ribs
on the inside is a smooth reflecting surface, the
pleura, and enclosing the lungs is another such sur-
face.
The lungs are made up of spongy, elastic tissue,
the air cells and bronchial tubes of various calibre
and size, the more minute ones not having any carti-
lage in their walls and the larger, from the fourth
division upward, having cartilage (Learning) and
being more rigid. These tubes are set at all angles
to one another, and are therefore not arranged ac-
cording to acoustic principles. Accompanying the
bronchi and around the air cells are also many blood-
vessels of varying sizes. Connecting the lungs with
the mediastinum are the larger bronchi and blood
vessels. And the larger bronchi terminate in the
trachea, which leaves the mediastinum and ends
in the voice-producing larynx. At the base of the
chest is the diaphragm, which permits considerable
variation in chest or lung volume. Owing to the
conical shape of the chest and the presence of only a
192
MEDICAL RECORD.
[July 29, 1916
little cartilage in the apex, this part is much less
movable than the base.
Percussion. — The chest in health is a very good
resonator. It is said that the violin was fashioned
after it. Certainly the air contents when set in
vibration amplify the sound and give it a quality
dependent upon the physical state of the lung at the
time being. What is the percussion note? It is
the resulting sound we hear when striking the outer
covering of the chest or the walls of the resonator.
This sound is produced by vibrations originating in
the chest wall, travelling through it to the resonat-
ing chest, reflected backward through the wall and
into the surrounding air. It is true that a part of
the sound travels only through the air to our ear,
but this part necessarily lacks chest resonance.
Originating in and travelling through the chest wall,
the sound upon percussion must be modified by the
physical state of the various tissues comprising the
wall. Considering the resonating chest as a con-
stant, that is having a constant volume of air, what
external causes affect the note heard on percussion?
The thickness of the chest wall, the quantity of
fatty tissues and the state of contraction of the
muscle tissue and skin. If the chest wall is very
thick a hard blow is necessary to cause vibrations
to reach the lung with sufficient intensity to be re-
flected again. So that with ordinary percussion
no resonance results. Fatty tissue is a poor con-
ductor of sound because the rate of propagation is
slow. Therefore a large proportion of fat will suc-
cessfully block vibrations unless the force originat-
ing them is great. When the muscles and skin are
much relaxed, density diminishes and conduction is
diminished. The vibrations may not reach the lung.
Also, as in the case of a violin string too loosely
strung, the vibrations may be too slow to be appre-
ciated. On the other hand, when the muscles and
skin are contracted and tight the resulting vibra-
tions are rapid and the note is high pitched, just
as the violin note is higher pitched when the string
is tight than when it is loose. Some of ' the per-
cussion note variations caused by the physical state
of the muscles covering the chest are used by some
men as an aid in diagnosis (Pottenger, etc.).
With the wall of the chest constant, how may in-
ternal chest conditions alter the percussion note?
By alteration of the volume of air in the lung, by
replacing a portion of the air set in vibration by
a more solid substance and by interposing non-air-
containing substances between the source of vibra-
tion and the lung. In other words, by destroying
a part of the resonating chambers or by making
them inaccessible to vibrations. These conditions
may be brought about by ordinary inspiration and
expiration, emphysema, atelectasis, infiltration, con-
solidation, new growth, thickened pleura, effusion,
etc. In addition to these, air may be interposed be-
tween chest wall and lung. In each condition, ac-
ding 1o the amount of air accessible to the vibra-
tions, the resulting note will be low and resonant
or high and less resonant, or not resonant at all.
since the larger the resonating chamber the lower
its fundamental, and it is the fundamental note
with its overtones which is consonated.
Cornet states that on the surface of the lung
irculosis areas cause an impairment of note only
after reaching a size of 4 to 6 cm. and a depth of
2 cm.; dullness is produced only when the depth
reaches 5 cm.: and that areas lying deeper than
5 cm., in other words having more than 5 cm. of
normal lung between them and the chest wall, may
easily escape detection by percussion. With this
in mind and also the various causes influencing the
pitch and resonance of the percussion note, it is
difficult to see how minor changes can be of as
great significance as some would lead us to believe.
Auscultation. — During auscultation we listen for
what we term the breath sounds. These come to us
from the lung through the walls of the chest. As
we inspire, air is taken through the larynx and
trachea into the larger bronchi and then through the
smaller bronchi to the alveoli or air cells of the
lungs. Coming through the larger tubes and those
of smaller calibre which have rigid walls the fric-
tion of the air against the sides of the tubes causes
vibrations and these are carried with the current of
air into the lung. The air, in passing an open tube
and by being impinged on angles of bifurcation,
likewise give rise to sound and this is carried and
conducted. It is said that after the air reaches the
fourth division of bronchi no friction is caused,
since the tubes of smaller calibre possess no carti-
lage, nor have rigid walls, and that the interchange
of air further in the lung is by diffusion. During
its course to the alveoli the air is warmed, causing
an increased power of wave propagation. The
alveoli or air cells are elastic. Each is in itself a
small resonator. As it dilates it gives rise to sound,
and within certain limits as it dilates the sound
is proportionately amplified. It is the combination
of sounds caused by friction, conducted along the
tubes and the dilating air sacs, which makes up the
inspiratory sound. When the air sacs collapse sound
is again produced and friction sounds are caused
in its outward passage, but here the current of air
is in the opposite direction from inspiration.
According to Baas the breath sounds are modifi-
cations of the laryngeal and tracheal sounds only.
According to Laennec they are caused only by the
friction in the bronchioles and infundibula. Ac-
cording to Bueri they result from the friction of
central and peripheral air volumes.
It is said that conduction within the lung takes
place only in the direction of the tubes. The air
in the lung not in the tube current is a poor con-
ductor. The chest is a resonator. Helmholtz,
Midler, and others have determined its fundamental
note as a low one. Air conducts the lower sounds
more readily than the high ones. The spongy lung
dampens high tones more than the air alone. The
tracheal and bronchial pitch is high, so that a layer
of normal lung deadens these sounds almost com-
pletely. On the other hand, solids conduct the high-
er tones better than air tubes of the same length,
consequently when the lung approaches solidification
better conduction of tracheal and bronchial sounds
takes place. Vesicular breath sounds are of low
pitch only. Heart sounds are dampened by normal
lung tissue in all areas except where the heart lies
in close proximity with the chest wall. However,
there the sounds are conducted by the mediastinum.
The shape of the chest partly determines the qual-
ity of sound. But inasmuch as respiration is largely
a voluntary act intensity, and to a less degree pitch,
must be relatively dependent upon the character of
the respiration. However, other things being equal,
intensity is dependent upon force or respiratory
rate, and pitch upon the physical state of the lung
(Quimby).
What are the modifications in breath sounds that
may be experienced when alteration in the function
and physical state of the lungs and adjoining struc-
tures takes place? These may be briefly sum-
marized in the following:
Alterations in the intensity of inspiration and
July 29, 1916J
MEDICAL RECORD.
193
expiration, alterations in the relative duration of
inspiration and expiration, alterations in pitch and
quality of both sounds.
Alterations in intensity may be brought about
voluntarily or involuntarily. When the change is
involuntary it is due to a change in the function
of breathing or to a change in sound conduction.
In the first instance there may be a partial atelect-
asis which does not permit the lung to take in as
much air as is otherwise possible, or on account of
partial obstruction in one of the larger tubes
respiration is more labored. This last occurs also
when the air sacs are dilated and kept so through
spasm of their muscles and degeneration of their
elastic tissue. In the second instance, that is when
due to change in sound conduction, intensities be-
longing to the larger tubes may be transmitted more
readily than normal and add to the intensity
normally heard at the periphery. Or conduction of
the sounds may be impeded by interposing media be-
tween the ear and the source of sound, as in pleurisy
with effusion.
Normally inspiration is longer than expiration.
The ratio has been variously estimated as low as
2 to 1 or as high as 4 or 5 to 1. The air in enter-
ing the lung travels toward the ear of the ausculta-
tor, and impinges itself on the angles of bifurca-
tion. Inspiration is consequently more intense and
of longer duration than expiration, during which
latter act the column of air travels from the ear and
impinges itself only with another column of air on
the sides of the tubes. Anything which delays the
normal collapse of the air cells or obstructs the out-
ward passage of air will prolong expiration. This
may occur in emphysema, or in partial paralyses of
the air cell walls as in tuberculosis, or by foreign
bodies having a valve-like action.
I have said that the normal vesicular breathing
was low in pitch and the tracheal and larger
bronchial pitches were high. Theoretically this
should not be so. The trachea is large in lumen
and longer than any of the tubes further along the
respiratory course. Its note should be low. And
as we proceed further into the lung the note should
become higher and higher, reaching its highest
pitch in the terminal bronchioles. The sound heard
at the periphery of the lung should therefore be
high in pitch. However, most observers state that
the vesicular murmur is low and bronchial respira-
tion high in pitch. Why this should be so I am
unable to state positively. However, it may depend
upon the fact that air conducts lower tones better
than high ones and that the spongy lung dampens
higher tones more than low ones. In this way pos-
sibly the higher tones are lost except when by in-
creased direct conduction through solids which
transmit high notes readily we hear them as hap-
pens when we listen directly over the trachea or
bronchi, making the latter respiration relatively
higher than the vesicular. Certainly we know that
intensity diminishes as we proceed from the trachea
to the bronchioles, in part because the force is di-
vided and in part because conduction becomes
poorer. Solids conduct higher notes better than air,
so that when air has been replaced by congestions,
new growth, etc., higher pitch should predominate in
respiration.
As a general working basis we may say that in-
tensity and pitch as heard at the lung margins are
largely dependent upon sound conduction. In-
tensity diminishes as density diminishes and high
notes are proportionately dampened and low notes
relatively increased. Anything which increases the
density along the respiratory channel will increase
intensity and relatively increase the dominance of
high notes in the lung margins.
However, intensity may be increased when cavita-
tion is present. Here air is the conducting medium
and amplification takes place in the cavity. The
resulting pitch depends on the greatness of the re-
sonating space, being low in large and high in small
cavities.
Vocal Resonance. — Increase or diminution of vo-
cal resonance depends largely upon sound conduc-
tion. Here the sounds formed in the larynx travel
along the tubes to the periphery of the chest. Any-
thing along the course of the bronchi affording in-
creased conduction will give increased vocal re-
sonance at the periphery of the lung. This con-
dition is best brought about by an increase in
density, as in infiltration, consolidation, new growth,
etc. Or it may be caused by amplification within
a cavity. On the other hand, conduction from the
periphery of the lung to the chest wall must also be
borne in mind since the interposition of certain
media may interfere with or increase sound con-
duction. The first may be due to pleurisy with
effusion, thickened pleura, air, etc., and an in-
creased conduction to adhesions, new growth, etc.
In considering auscultation, that portion of the
chest above the plane of bifurcation of the trachea
must be considered in a different light from the por-
tion beneath this plane, for in this upper portion
lies the large trachea. And the anatomical posi-
tion of the trachea, the acuteness and point of
origin of the angles of bifurcation, and the length
of each first bronchus — right and left — must be
considered. These factors have a bearing on the
sounds heard at the apices of the lungs. The
trachea lies closer to the right apex. Trie angle
of the (first) bronchus to the trachea is more acute
and rises higher on the right than on the left And
the right first bronchus is shorter than the left. All
of these factors would give to the respiratory sounds
on the right more of the tracheal character, hence
they are slightly broncho-vesicular. Also, vocal re-
sonance therefore should be and is more intense.
Pleurisy with effusion reaching to this plane may
give rise to increased vocal resonance throughout
the area of dullness. And when the fluid falls be-
low this level the increased vocal resonance disap-
pears (Sewall). In a case of pneumothorax of the
right side, with the lung entirely collapsed and with
a small amount of effusion, breath sounds and in-
creased whispered voice were heard by me when the
patient was so inclined posturally as to bring the
fluid into the apex.
Above the plane of bifurcation of the trachea,
breath sounds from the trachea are well conducted
by the bony structure of the chest. In two in-
stances breath sounds could be heard above the sec-
ond rib, and in one of these also above the third
vertebral spine, after complete pneumothorax, as
shown by ar-ray, had been attained.
Bronchial breath sounds can normally be heard
over the sterum to just below Louis angle, over the
acromion processes (Barraeh) and along the
cervical and upper three dorsal spines. Increased
whispered voice is also heard here, as well as far
up on the cranium. This is in part due to bone
conduction.
Rales and Adventitious Sounds. — These are pro-
duced upon and within the chest wall, upon the
pleural surfaces and within the lung. We will speak
only of those which are produced within the bronchi
and air cells.
194
MEDICAL RECORD.
[July 29, 1916
Within the lung these sounds are vibrations
caused by a current of air passing along the respira-
tory passages to the air cells and meeting a partial
resistance. The resistance may be due to partial or
complete obliteration of the air cell or bronchus by
means of collapse, mucus or fluid. Thus, for in-
stance, the walls of the air cells or bronchioles may
through atelectasis be in apposition, or they may
be the seat of exudates, serum, etc. A forced in-
spiration will separate the walls of the air cells
or bronchioles or set in vibration the serum or
exudate; a sound is the result.
The resulting sound will vary in pitch according
to the diameter and length of the air space in
which the sound occurs. Vibrations within the
smallest bronchioles will be high in pitch, and as
the larger bronchioles and bronchi become the seat
of origin the pitch will become lower.
The intensity of the sounds will vary with the
force causing the vibrations and also with the
quantity of the medium set in vibration.
The quality of the sound depends upon the phy-
sical state of the medium set in vibration and the
resonance of the chamber in which the vibration
takes place. Dilatation of the bronchi, or cavities,
may give added resonance by reason of their in-
creased air ^'-ntent. And by reason of the variable
fluid level, increasing or decreasing the air space,
pitch may be also changed.
Bubbling sounds are produced by the passage of
air through a liquid medium, as happens in the
case of cavities where the entrance of air is below
the level of secretion.
Vibration within air spaces may also be produced
by sudden changes in the position of the vibrating
medium, caused by gravity or by pressure from
without. Whatever may be the cause, intensity,
pitch, or quality of the sound originally produced, it
must before it reaches the ear be modified by the
rules governing sound conduction which have al-
ready been referred to.
The definition of sound was given as "vibrations
interpreted by the ear." The ear is a part of the
individual, and by reason of anatomical or patho-
logical variations the same sound may not be con-
ducted alike to the brains of two individuals, or
the two brains may vary in experience or educa-
tion in their interpretation of sound, and conse-
quently, although physics governs sound production
and conduction, the personal equation governs sound
interpretation — the one an exact science, the other
a variable quantity. For this reason, percussion
and auscultation are exact methods only within the
limits of the human personal equation.
REFERENCES.
Cornet, G.: Pie Tuberkulose, 1907.
DaCosta, John C: Physical Diagnosis, 1915.
Duff, A. Wilmor: A Text-Hook of Phvsics, 1913.
Forbes, John: Laennec's Chest. 1827.
Learning. J. R.: Acoustics Apnlied to the Humai
Chest in Phvsical Diagnosis. .V. )'. Med. Jr.. .Ian. 26,
1880; also transact. N. Y. S. Med. Soc, February.
1889.
Miiller, Friedrich: Principles of Percussion and
Auscultation. Lancet, March 8, 1913. No. 4671, I
674. Zur Physikalischen Diagnostik, Vol. 28, 1911.
Sewall, llv.: Amer. Jr. Med. Sciences. Vol. CXLV,
page 'J". 1. 1913.
Sewall and Childs: Arch. lv>. Med., Vol. X, page 45.
Sobotta-McMurrich : Atlas and Text-Book of Human
Anatomy. 1914.
Spitzka, E. A.: Gray's Anatomy, 1913.
Quimby, Charles E.: The Applied Physics of Phys-
:-al Diagnosis — Acoustics. MEDICAL RECORD, March 25,
13: Some Points in the Acoustics of Respiration
Jr. A. M. A.. Oct. 1. 1904.
A NOTE ON POLIOMYELITIS, WITH ITS PRE-
PARALYTIC SYMPTOM.
By LOUIS FISCHER, M.D.,
NEW YORK.
In the early stages of poliomyelitis we frequently
have a sudden onset with a high temperature last-
ing several hours or days. There are headaches,
pains in the back and limbs, and sometimes rigidity
of the trunk and neck. The patellar reflex and
plantar reflex may be exaggerated, diminished, or
even absent.
As the pathological lesions are confined to the
anterior horns, the pia mater, and the spinal cord,
drainage of the spinal fluid is indicated as a means
of diagnosis. The fluid of poliomyelitis so obtained
is colorless. To differentiate the symptoms of polio-
myelitis from those of an acute cerebrospinal men-
ingitis, simple meningitis, or tuberculous meningi-
tis, we should resort to a lumbar puncture. The
spinal fluid should be carefully examined as to its
color, its transparency, or turbidity. The presence
or absence of pathogenic bacteria will aid in ex-
cluding poliomyelitis. Thus the tubercle bacillus
will be found in tuberculous meningitis, and a
staphylococcus, diplococcus, or influenza bacillus, in
acute meningitis, or in cerebrospinal meningitis.
There is an increase of the leucocytic element,
especially the polynuclear percentage, in the earlier
stages of the disease, later a mononuclear increase.
Still later we find 100 per cent of leucocytes. The
globulin reaction in the beginning is negative, later
it is positive.
A symptom of great importance, described by
Dr. Draper of the Rockefeller Institute, is that
flexion of the spine anteriorly produces pain and
stiffness of the neck. The lymph glands of the
body are enlarged.
An important symptom has been described by
Culliver as a peculiar twitching, tremulous, or con-
vulsive movement. It usually affects a part or whole
of one or more limbs, the face or jaw. It may also
affect the whole body. In the beginning, the symp-
toms may last less than one second, and do not recur
oftener than every hour or so. Later, the spells
lengthen to a few seconds, and recur at shorter
intervals. The condition is sometimes accompanied
by a peculiar cry, similar to the hydrocephalic.
During the convulsive movement the child is appar-
ently unconscious, with eyes set for a few seconds.
A similar symptom has been described by Prof.
Arnold Netter,1 of Paris. This preparalytic symp-
tom, if noted, will serve as a warning of the ap-
proaching paralysis, and, when observed, the limb
should be strengthened by support to remove the
weight.
The following case,
Jerome H., five years old, was seen in consultation
with Dr. D. Paul Waldman on July 12, 1916. He was
a fairly well nourished boy with a history of congenital
syphilis. He was in apparent good health until six days
ago when he was frightened by a dog. The dog did not
bite him but licked his hand. The following day the
child became languid and complained of headache. There
was slight constipation. The appetite was fair. A
slight papular and erythematous eruption was noted
over the thorax, back, and upper and lower extremities,
very little on the face. The temperature ranged be-
tween 103° and 104°. There was marked hypers-
thesia of the skin with nervous quivering and twitch-
ing (preparalytic symptoms).
At miduight on July 12 the right arm became para-
lyzed, showing involvement of the brachial plexus. No
other etiological factor could be made out. The sani-
'British Jour, of Children's Diseases, Dec, 1913.
July 29, 1916]
MEDICAL RECORD.
195
tary surroundings are perfect. Hygienic supervision of
the child's body and food could not be better. There
had been no exposure to poliomyelitis as far as the
family know. Xor could the family physician, Dr.
Waldman, shed any more light on the etiology.
Whether or no the susceptibility of the patient was in-
creased because of its congenital syphilis is worth con-
sidering.
Examination showed the generalized eruption con-
fined to the boay — very little on the face. On stroking
the skin with the fingernail a marked hyreremie flush
remained visible for over ten minutes (the so-called ta-
che cerebrale). The pupils responded to light and ac-
commodation. There was an exaggerated plantar re-
flex, also exaggeration of the patellar reflex, and
marked hyperesthesia of the skin at the slightest strok-
ing of various parts of the body. There was an ab-
sence of rigidity of the sternocleidomastoid muscle. The
right arm and forearm were limp, the surface tem-
perature normal. A lumbar puncture made between
the 4th and 5th lumbar vertebra; showed increased
pressure of the spinal fluid and yielded a perfectly
transparent fluid; 40 c.c. was obtained without diffi-
culty. This fluid was examined by Dr. Abrahams at the
Research Laboratory of the Health Department who
reported as follows: mononuclears 80 per cent; albu-
min, 1 — ; Fehling's 3 -(-.
The child rested comfortably after the puncture and
the temperature came down to normal. Five grains
of urotropin were given every four hours. Very light
gentle massage was given once daily. A light soft nu-
tritious diet consisting of milk, vegetables, fruits, ce-
reals, and eggs was given.
Flexner has suggested the use of hexamethylena-
mine (urotropin), 3 to 5-grain doses every four
hours, as a prophylactic to children in congested or
infected districts. In all cases seen by me I have
advised 3 grains, given morning and evening for
several weeks, as it liberates formalin in the tis-
sues.
There are three types most commonly met with :
the catarrhal, the gastrointestinal, and the cere-
bral.
In the catarrhal type there is nasopharyngeal in-
volvement, or bronchial catarrh, or symptoms re-
sembling the onset of a pneumonia.
In the gastrointestinal type we have symptoms of
overfeeding, or disordered nutrition, vomiting, con-
stipation or diarrhea, and always fever. We should
always suspect an abortive form of the gastroenteric
type if a child, in spite of having its diet carefully
supervised, suddenly shows gastroenteric derange-
ment, with anorexia and a general apathetic condi-
tion.
The cerebral type is seldom met with in the abor-
tive forms. I have never seen a case with convul-
sions and rigidity of the neck muscles that was not
followed by paralysis.
The reflexes will be found slightly exaggerated,
especially the patellar, plantar, and ulnar. In some
cases seen by me the reflexes were greatly dimin-
ished for one day and found normal the following
day.
The abortive type is the most common form, and,
unfortunately, the one overlooked by the laity, be-
cause of the mildness of its symptoms. In many
instances, the onset of slight sneezing, nasal dis-
charge, and a temperature of 100D may be all the
evidence of the poliomyelitis. Children convalesc-
ing from the abortive type are responsible for the
spread of this disease. The symptoms being mild,
the disease is overlooked.
155 West Eighty-fifth Street.
Constitutional Effects of Deep Roentgen Therapy. —
According to G. E. Pfahler in a small proportion of
patients who receive large doses of rays, there develop
constitutional symptoms consisting of nausea, occa-
sional vomiting and a certain amount of prostration.
HYPOCHONDRIA.
By CLARENCE KINO, M.D.,
FRANKLINVILLE, N. Y.
EX-PRESIDENT CATTASAUQUA COUNTY MEDICAL SOCIETY ; LATER
ATTENDING PHYSICIAN. CATTASAUQUA COUNTY HOSPITAL
AND LOCAL SURGEON B. R. & P. RAILROAD.
Twenty-five or thirty years ago the word hypo-
chondria was very much in evidence in medical
nomenclature, but more recently it has had to give
way to the trend of modern terminology. Beard's
epoch-making neurasthenia has absorbed some of
the symptoms formerly attributed to hypochondria,
while melancholia includes some, and hysteria still
others. In this paper I shall retain the nearly ob-
solete term as being old-fashioned enough for me
and expressing just the condition I wish to de-
scribe.
No one who has been long in general practice has
failed to meet with cases of nervous people whose
minds were wholly taken up with magnifying their
own ailments, either trivial or imaginary. These
people are the terror of the doctor. It makes but
little difference what is said cr done for them, they
are still ailing and are always in a deplorable con-
dition, despite the failure to find anything of a
tangible nature to account for their bad feelings.
The main characteristic with them is the firm grasp
which their ailments have upon the mental equi-
librium, amounting almost to a self-centered insanity
of the melancholic type. And indeed it has usually
been considered that hypochondria should be classed
with the mental disorders, rather than with the
purely nervous or physical diseases.
Hypochondria is a disease of either s?x, occurring
in my experience with nearly equal frequency among
men and women, the preponderance, if any, probably
being in favor of the latter. It is a disease of adult
life and occurs most often about the time of the
climacteric in either sex. Mental worry with a
natural pessimistic disposition, combined perhaps
with overwork and some slight physical indispo-
sition, are the usual precursors. A low-ered state
of health from any cause may undoubtedly predis-
pose to it which only needs some strong mental in-
fluence to apply the finishing touches. Once de-
veloped it may continue a few weeks or it may pass
over into a true melancholia and persist as long as
life lasts.
Dubois, in his Psychic Treatment, states that
"there is no longer any malady called hypochon-
dria," and then immediately proceeds to Jevote more
than two pages to its description. He gives as his
definition of it "that conditio.; of the patient in
whom his naturally melancholic preoccupations are
centered chiefly upon his health, and upon the work-
ings of his organs." Thus it will be seen he classes
it as a special form of melancholia, but it appears
to me much may be said in favor of its being a dis-
tinct entity.
Hypochondria, as I see it, is a hybrid, a cross
between melancholia and neurasthenia, but differing
decidedly fron- either. Thus, with hypochondria it
is often possible to get the patient to talk rationally
and with a certain amount of cheerfulness on some
subjects, or even to smile, but if left to his ow^n
inclinations his mind soon reverts tc me melan-
choly aspect of his health; and in neurasthenia the
condition is much the same. But in true melan-
cholia the poor unfortunate cannot show much in-
terest or any enjoyment in any subject even for a
brief period. The gloomy forebodings as to busi-
ness, social, or religious matters present with each
196
MEDICAL RECORD.
[July 29, 1916
disease are much more decided in melancholia and
predispose to suicide; but this danger is also pres-
ent to some slight degree in hypochondria. On the
other hand, in neurasthenia the patient seems to
experience a certain amount of actual pleasure in
dwelling upon and "doctoring" his imaginary ills,
and self-destruction is therefore an almost unknown
termination in uncomplicated cases. These, in my
opinion, constitute the principal mental characteris-
tics of the three diseases, although it must be con-
ceded the line of demarcation is on all sides vague
and indefinite and the discrimination between them
in a given case is a matter of terms almost as much
as of judgment.
Hypochondria, when it comes to the physician, is
generally a chronic disease and has already run
the gamut of home treatment, patent medicines,
sympathetic neighbors, and often other doctors.
But this may also be said of the other diseases,
especially neurasthenia. On account of this there
may be some anemia and general deterioration of
the health, but a careful examination of the various
organs and their functions will show little if any-
thing out of normal. But the neurasthenic is sick
physically as well as mentally, although the physical
ailments are secondary to and dependent upon the
mental weakness. The neurasthenic suffers much
from nervousness, probably has disturbed sleep or
insomnia, a poor appetite, functional inactivity of
the abdominal and pelvic organs, especially of di-
gestion, and a general loss of strength and weight.
There is also apt to be dysmenorrhea or amenor-
rhea, a furred tongue, constipation, hemorrhoids,
vertigo, exaggerated reflexes, various paresthesias,
and often neuralgia of different nerve trunks, gen-
erally the sciatic, the vagus, or the intercostals.
Melancholia, if it has lasted for any length of time,
is marked by a peculiar facies of a dull and more or
less idiotic type which we do not get with the other
diseases. These, then, are the earmarks by which
we must make our discrimination and which must
guide us in our management of the case and our
prognosis.
At this point I would like to bring this paper to
a close but I know something should be said of
treatment. This is difficult and usually unsatisfac-
tory. Very often the patient drifts along as a
chronic drug taker, unable to do any work or per-
haps leave his bed, and finally develops some or-
ganic disease which closes the scene or makes a
true physical invalid. I know of nothing better for
these cases than change of environment ; and travel
with a cheerful and intelligent companion as chap-
eron or attendant will sometimes work wonders for
them. This is for tho purpose of occupying their
minds and giving them something to think about
outside of their own feelings. Suggestion holds a
valuable place in treatment and the doctrine of good
health or early improvement should be constantly
preached to them by doctor and attendants. They
should not be allowed to talk of themselves or refer
to their ill health, but to circumvent this will re-
quire much tact and good sense. The late Dr. Gray
of New York advised hypnotism as a valuable meas-
ure but of this I have no knowledge. If there was
any way of instilling Christian Science belief by
serums or other means it would be the ideal treat-
ment, but as yet we have not quite reached that
desideratum. Hydrotherapy in the form of colon
fluskings in the knee-chest position for the purpose
of freeing the large intestine of putrefactive ma-
terial or the cold spinal douche preceded by hot
water fomentations, as advised by Baruch, may be
of some benefit when it can be employed. These
measures, together with high-frequency currents,
general tonics, nerve sedatives, and placebos (and
most drugs are placebos in this disease) constitute
our only means of treatment.
One point of practical importance which I would
mention in closing is this: Hypochondriacs are very
apt to think that this and that article of diet "hurts
them" and they keep cutting out the really valuable
foods, one by one, until they have little left to sub-
sist upon. When possible it is best to humor their
whims to a certain extent, but they should not be
allowed to half-starve themselves under any false
notions about diet. Ordinarily, some simple stomach
remedy or digestive, if prescribed with explicit di-
rections as to its use and results expected, will make
them more tolerant of food and do much to aid
nutrition.
A CONSIDERATION OF THE OPSONIC TECH-
NIQUE AS A POSSIBILITY OF EVIDENCE
OF LEUCOCYTIC INHIBITION.
By ARNOLD H. MAT, M.D.,
BUFFALO, X. Y.
The work of Sir A. E. Wright has been instrumental
in the practical application of ideas of the greatest
value to humanity. It is, however, of scientific in-
terest to review the opsonic technique with a con-
sideration of another possibility being responsible
for the phenomenon, which may be as potent in the
production of it as is the presence of opsonius, and
which may lead to the question of its infallibility
as regards the proof of opsonius. The writer is not
a laboratory man, and presents this merely because
of the scientific interest it may hold.
The opsonic technique is performed in the fol-
lowing manner: (1) Serum of the patient + washed
leucocytes + suspension of microorganisms.
Serum of normal individual (s) -f- washed leu-
cocytes + suspension of microorganisms.
Mixtures of each of the above are made in spe-
cially provided tubes, and are incubated at 35° C.
for about 15 minutes. Microscopic examination of
stained slides of each of the above preparations is
made to ascertain the phagocytic function of the
leucocyte. The difference manifested in the pha-
gocytic activity of the leucocytes Wright ascribes
to the presence or diminution of bodies termed
opsonius, which by their action upon bacteria facili-
tate phagocytosis. In the technique the effect of an
immune serum upon a bacterial leucocytic combina-
tion not being included, it is not necessary to con-
sider this phenomenon here.
In a consideration of this problem the funda-
mental nature of the leucocyte must be considered.
The leucocyte primarily is a protoplasmic body,
whose evident function is phagocytosis. Being a
protoplasmic body it necessarily possesses the proto-
plasmic properties of irritability, metabolism < in-
gestion, digestion, and excretion) motility, repro-
duction, etc. It is not in appearance unlike the
ameba, and many of its peculiarities lead to the
name of amebocyte being early ascribed to it.
Thus there is a marked resemblance between the two
in the manner of locomotion, and the ingestion of
particles, and it may be assumed that they likewise
resemble each other in the matter of irritability.
The protoplasm of the leucocyte is highly special-
ized, and it possesses an innate, very likely an
evolutionary, predilection for these cells (bacteria),
July 29, 1916]
MEDICAL RECORD.
197
whose existence in the body is inimical to the host.
This faculty, which implies function, illustrates a
higher degree of protoplasmic resistance to bacterial
toxins than visceral cells functionating differently.
However, not to transgress the object of this paper,
and to bring in interesting but irrelevant facts, it
may be said that the leucocyte is an irritable body,
and is not always successful in its combat with bac-
teria, oftentimes succumbing or being devitalized
by the bacteria. This could be anticipated from the
fact that it is a protoplasmic body. Evidence of the
fact that it is an irritable body, and that its func-
tion may be determined by its environment are
easily obtainable. Thus non-virulent pneumococci
are susceptible to phagocytosis, whereas virulent
ones are not. The leucocytes not only succumb to
but may be devitalized by toxins. This fact is illus-
trated by the work of Neisser and Weichsberg, who
were able to prove by the reducing power of methy-
lene blue by live leucocytes the injury wrought the
leucocytes by a toxin called leucocidin, obtained
from staphylococci filtrates. Various degrees of
injury are wrought the leucocytes by this toxin.
In short, then, the leucocyte is an irritable body, and
may be adversely effected by environmental condi-
tions in the same manner as any other cell, or as
any combination of cells, which comprise the vari-
ous manifestations of life.
Now, then, there remains to be examined the
blood serum, which is the remaining factor in the
technique. In disease there occurs a contamination
of serum which is a factor proportional to the char-
acter (virulency, diffusibility) of the infection. The
serum then obtained from the patient represents a
contaminated serum, and proportionally as is the
diffusibility and virulency of the disease process.
The serum obtained from the healthful individual is
normal noncontaminated serum. There are here,
then, two essentially different sera, and into these
are placed irritable, protoplasmic bodies, whose life
and function, as has been shown, is directly depend-
ent upon environmental conditions. Exclusive of
any other factor, may not 'the inhibitory effect of a
contaminated serum upon a body which is as sensi-
tive as any other protoplasmic element be the de-
termining factor in the slight deviation manifested
in phagocytic capacity of these sets of leucocytes?
To maintain that it may not be so effected is to
deprive it of its property of irritability, which is
amply attested to. Therefore may not another fac-
tor, exclusive of opsonius, the factor of a proto-
plasmic body reacting to its environment, be con-
sidered in an explanation of the technique.
Whereas these facts may seem trivial and unim-
portant to many, anything that seeks to contribute
to the absolute truth in science is of value.
177 Walnut Street.
The Spinal Fluid Syndromes of Nonne and Froin and
Their Diagnostic Significance. — F. M. Haines concludes
that compression of the spinal cord and its meninges
from whatever cause leads to the formation of a cul-de-
sac more or less complete distal to the site of compres-
sion. This leads to characteristic changes in the spinal
fluid. The earliest characteristic change has been de-
scribed by Nonne as an increase of proteid without cell
increase. As the condition of cord compression persists,
the fluid gradually becomes yellow in color (xantho-
chromia), the proteid content increases enormously, and
the fluid, when removed, coagulates spontaneously
(Froin's syndrome). Pleocytosis may or may not be
present, depending on whether or not the meninges are
inflamed. Xanthochromia must be distinguished from
erythrochromia due to hemoglobin staining. The
Nonne-Froin syndrome when present always indicates
a compression lesion of the cord. — American Journal of
the Medical Sciences.
Liability of Railroad Hospital Association. — In an ac-
tion by the father of a deceased employee of a railroad
company against a hospital association for the neglect
ff its physicians and attendants in failing to give the
on suitable care and attention, it appeared that the de-
fendant was an association maintained by the railroad
for the treatment of the employees while sick, and was
Supported by the monthly contributions of all its em-
ployees who, so long as they remained in the service of
the company and contributed to the fund, were entitled
to the benefits of the hospital free of charge. The Kan-
sas Supreme Court applied the rule that charitable as-
sociations conducting hospitals are not liable for the
negligence of their physicians and attendants resulting
in injury to patients unless it is shown that the associa-
tion maintaining the hospital has not exercised reason-
able care in the employment of its physicians and at-
tendants.— Nicholson v. Atchison, Topeka & Santa Fe
Hospital Assn. (Kan.) 155 Pac. 920.
Inference That an Insured Physician Knew of Disease
Affecting Him. — The Colorado Supreme Court holds that
an insurance company cannot avoid its contract
of insurance upon a mere inference that the insured,
solely because of the fact that he was himself a phy-
sician, knew he was afflicted with a particular disease.
To justify such avoidance upon the part of an insurance
company, the testimony should so satisfy the mind of
the court as to be conclusive in that respect. North-
western Mut. Life Assn. v. Farnsworth (Colo.) 153
Pac. 699.
Illegal Prescriptions for Intoxicants. — The Missouri
statute, Rev. St. 1909, Sec. 5784, declares that any
physician who shall make any prescription to any per-
son for intoxicating liquors to be used other than for
medicinal purposes shall be deemed guilty of a mis-
demeanor. Section 5781 provides the character of pre-
scription which will protect a druggist in making sales
of intoxicants in quantities of less than four gallons.
A physician who unlawfully issued a prescription for
intoxicating liquor wrote the prescription in such a
manner that the druggist who filled it was not pro-
tected. In a prosecution against the physician under
section 5784 it was held that nevertheless he was guilty
of a violation of that section ; the word "prescription"
as there used meaning a direction of remedy or remedies
for a disease and the manner of using them, and not
necessarily a valid prescription which would protect the
druggist that filled it. State v. Nicolay (Mo.) 184 S. W.
1183.
Licensing of Chiropractors. — The California statute of
1913, regulating the practice of healing arts,
makes any one who shall practice any system of
healing, or who shall diagnose, treat, operate for,
or prescribe for, any disease, without a license,
guilty of a misdemeanor, while section 22 omits
persons treating by prayer. A drugless healer, of the
class known as chiropractors, contended that the act
was discriminatory, as it made greater requirements of
such healers than it did of spiritual healers. It was
held that the statute was not subject to criticism on
the ground that it was discriminatory and lacked uni-
formity of operation, for a drugless healer who adjusts
his patient's anatomy might well injure him, while the
prayers of an ignorant person would be of no injury.
It was argued that to require no diagnosis from those
who profess to treat disease by prayer while prohibiting
all other unlicensed persons from diagnosing various
ailments is an unjust and unconstitutional regulation,
favoring one class of citizens unduly. The court said
that those who believe that divine power may be in-
voked by prayer for the healing of the body believe also
that God is all-powerful. Patients receiving their min-
istrations know this, and therefore no fraud or injury
may be practiced upon such persons by reason of any
lack of skill by the healers in determining the nature
of the diseases to be treated. But those who elect to
depend upon some other system of treatment have a
right to protection by the State from the ministrations
of unskillful, uneducated persons. For example, a suf-
ferer from a fever, who summons a licensed physician
holding himself out to the public as one qualified to treat
the sick, is entitled to the services of a doctor who has
been taught to discriminate between typhoid and small-
pox. In other words, the right to practice medicine
should carry with it some assurance to the public that
the licensed practitioner possesses reasonable proficiency
in the technique of his profession. — People v. Jordan,
California Supreme Court, 156 Pac. 451.
198
MEDICAL RECORD.
[July 29, 1916
Medical Record.
A Weekly Journal of Medicine and Surgery.
THOMAS L. STEDMAN, A.M., M.D., Editor.
PUBLISHERS
WM. WOOD & CO., 51 FIFTH AVENUE.
See fourth page following reading matter for Rates of Subscription
and Information for Contributors and Subscribers.
New York, July 29, 1916.
THE SIGNIFICANCE OF THE APICAL
SHADOW IN DENTAL ROENTGENOGRAMS.
Roentgenological examination of the teeth and
jaws, with the interpretation of the roentgenograph,
has without question come to be a permanent addi-
tion to the methods of detecting possible chronic
focal infection as the causative factor in certain
cases of systemic disease. It is thus seen that the
significance and interpretation of the apical shadow
about the apex of a tooth so frequently found in the
roentgenogram are of the greatest importance. A
brief consideration of this subject is not without
interest to every practitoner of medicine.
The dark shadow found around the apex of a tooth
means the lessening of density in that particular
area, due to decalcification in the bone. Clinically
it may result from infection (generally from a dead
tooth) or from a blind abscess; and, if cyst and pres-
sure atrophy are excluded, it may mean a devital-
ized tooth through the apex of which the infection
had spread to form an abscess, or a healthy tooth
with a blind abscess. In all cases appropriate clini-
cal tests should be employed to determine whether
the tooth under investigation is dead or healthy. In
some cases a tooth may be proven to be dead by
objective tests and subjective symptoms, and still
no abnormality may be demonstrable roentgeno-
logically, for the reason that the alveolus may not
at all be involved as a result of the infection or the
degree of decalcification is insufficient to produce
visible changes in the roentgenogram. In fact, sub-
jective symptoms may make their appearance before
changes can be detected in the roentgenographic ex-
amination.
Mackee and Remer, in an interesting paper on
this.subject in the American Journal of Roentg
ology i March, 1916), call attention to the fact that
very slight apical shadows should lead to decided
care in interpretation, particular consideration being
given to the exclusion of anatomical shadows, photo-
graphic defects, artifacts, and overlapping shadows.
For example, the authors point out that the antrum
of Highmore, the foramen of the inferior dental
canal, and the nasal cavity may form overlapping
shadows in the region of the superior molars, lower
bicuspids, and superior central incisors respectively.
They insist, however, that a persistent apical
shadow, found in a number of radiograms taken
from different angles, is most certainly suspicious.
It is true that lack of study of this subject has led
to the belief quite common among physicians that
an apical shadow means pus and cavity formation in
the alveolus. Now, although it is true that a very
dense shadow and complete loss of bone detail indi-
cate the presence of a cavity, still, as a general
proposition, one must realize that a cavity cannot
with positiveness be said to exist in cases in which
nothing more than a dark shadow with bone detail
is found in the roentgenogram. Mackee and Remer
properly assert that an apical shadow does not neces-
sarily mean a cavity or the presence of pus. In
fact, pus should not be diagnosed by the roentgen-
ologist but by the dentist. Apical shadow does, how-
ever, mean decalcification, which may be from many
causes — atrophy or absorption due to prolonged irri-
tation or pressure, acute infection, or the remains
of former disease (scar tissue).
It is important to remember that "a shadow can
be made lighter or darker, smaller or larger, by vary-
ing the exposure, the quality of the ray, the depth
of the development, the photographic emulsion, the
developer, the angle, etc." When examining the pa-
tient roentgenologically for evidence of dental sepsis
in cases referred by physicians who suspect it as a
cause of systemic disease, the alveoli of both jaws,
with the apex of every tooth, should be included in
the examination. Conservatism in interpretation
should be the rule for the roentgenologist. In every
instance the findings of the dentist should be taken
in conjunction with those of the roentgenologist.
Ottolengui, in the same journal, directs our at-
tention to the fact that the physician (whether as
clinician or roentgenologist) is too frequently apt
to label as pathological and declare to be a focus of
infection any area which seems to be rarified in the
roentgenogram. He makes the following declara-
tion which it would be well for all of us to keep in
mind constantly when doing this sort of work: "The
radiograph is not a picture of disease. It is a rec-
ord only of the varying resistance to the passage of
the ray offered by the parts pictured. The interpre-
tation of the meaning of these shadows, and a de-
cision as to whether they are caused by pathological
conditions or not, require on the part of the radio-
graphic diagnostician a full knowledge of the clini-
cal expressions of the various affections, and of the
varying shadows cast in consequence thereof."
SOME PHASES OF ACIDOSIS.
Acidosis is now held to include a good many condi-
tions which formerly were not classified under this
head, and in fact it is now believed that acidosis
plays a part, sometimes predominant, in the causa-
tion, or rather the progress of various diseases and
affections. Within the past few years the question
has been studied minutely and from several stand-
points, and our knowledge in this direction has in-
creased very considerably. Of those who have con-
tributed to the attainment of this knowledge none
has been more earnest in his endeavors nor more
successful in his results than Cammidge, and it is
therefore of interest to find his most recent views
on this subject in the special acidosis number of
American Medicine for June.
July 29, 19161
MEDICAL RECORD.
199
Cammidge defined acidosis as a condition in which
there is an accumulation of acid products of metab-
olism in the body owing to an excessive production,
or to defective elimination, or to both together, and
he goes on to say that it is now generally agreed
that the clinical symptoms of acidosis are not de-
pendent upon any specific toxic properties possessed
by these metabolic products, but arise from the im-
poverishment of the body in bases that occurs as
a result of the acid character of these products.
Thus, considered from the standpoint of a defi-
ciency of bases, the term acidosis may be extended
to include conditions in which there is an excessive
primary loss of bases, or an inadequate absorption
of base-forming substances through the intestinal
mucosa to meet the ordinary requirements of the
body.
Consequently the possible causes of an abso-
lute or relative acidosis are numerous and to a
greater or lesser extent are encountered in a wide
variety of conditions. Cammidge confines himself
to a consideration of diabetes mellitus in which
acidosis assumes the dominant role and is often the
determining factor in a fatal issue. It is impossible
in limited space to recount at length Cammidge's
interpretation of acidosis in diabetes mellitus, and
it must suffice to say that he points out that as a
result of clinical experience a vegetable diet has
come to be an important feature of most modern
methods of treating diabetes, and that casein has
been employed empirically in recent years as the
chief constituent of many so-called "diabetic" breads
and biscuits. He further points out that a vegetable
diet, or at least a system of dieting that contains
a large proportion of "vegetable days," has other ad-
vantages, not the least of which is the preponder-
ance of base-forming over acid-forming elements
that it furnishes.
In the same journal a good deal of attention is
paid to that condition of childhood known as cyclic
vomiting. Eric Pritchard discusses this phase of
acidosis in an original manner, and among the con-
clusions at which he arrives are that the measure
of the severity of an acidosis is not to be estimated
on the basis of the amount of acetone or other acid
bodies in the urine, but on the degree of carbonate
depletion, and that one of the effects on the system
is to cause a serious hemolysis. Hence there must
be an active regeneration of red blood corpuscles or
a profound anemia will result. This is probably the
explanation of the enlarged ends of long bones in
rickets.
The more chronic effects of acidosis are observed
in rickets, cyclic vomiting, recurrent bilious
attacks, and the troubles connected with dentition.
The treatment, both preventive and remedial, con-
sists in the adjustment of the food to the physio-
logical requirements in each individual case, com-
bined with the administration of alkalies as may be
indicated.
There is little doubt that our knowledge of acido-
sis is very much clearer than formerly, but it may
also be said, without much fear of contradiction,
that there is yet much to be learned on the subject.
While we may be well on the way, we are by no
means at our journey's end.
DISEASE IN THE GERMAN ARMY.
Not a great deal of information has filtered through
to the outside world from the Central Powers about
health conditions in their armies. This is due part-
ly to the iron rings about their troops and the
amount of censoring each item of news receives
before it reaches America, but partly also to the
secretiveness of the German authorities in their
handling of military problems. It can hardly be
imagined, however, that they deal with the medical
problem other than efficiently when we consider
their capacity for organization and their scientific
attainments.
In one of the last issues of the Berliner klinische
Wochenschrift which the British censor has al-
lowed us to read. Dr. Goldscheider, who has been in
the field with the German army, notes a few of the
conditions which he found there. He has some
criticism to make of the methods used for trans-
porting the sick which seemed to him to be inade-
quate. Discussing typhoid fever, he says difficulty
was experienced in making an early diagnosis on
account of the fact that the bacteriologists were
not near enough to the front. He mentions Weil's
disease at one point and a few other infectious
diseases, but they did not seem to occur in large
numbers. Heart trouble appeared to be one of the
most serious problems and this corresponds with
the experience of the English, who report a condition
which has been referred to as the "soldier's heart"
by Sir James Barr and has given rise to a great deal
of discussion, not devoid of acrimony. Dr. Gold-
scheider deplores the lack of accuracy in diagnosis
of affections of the heart in recruits, the distinction
between organic and hemic murmurs and between
myocarditis and cardiac neurosis being especially
faulty. In fact, he says, a great many soldiers were
invalided who should never have been accepted for
service.
Dr. Stadelmann. at a meeting of the Berliner
Medizinische Gesellschaft, also lays stress on the
large number of heart cases; he says that 50 per
cent, of all soldiers were neurasthenic and of this
number 50 to 70 per cent, complained of heart
symptoms while in reality only 5 per cent, had
organic heart trouble. These men were formerly
removed from the front, given prolonged rest in
bed and medication, but they failed to improve under
this regime so that now they were kept in con-
valescent quarters behind the front and given light
work to do, their minds being kept off their symp-
toms. The real trouble with these patients was that
they did not want to return to the front.
ANEMIA AND CHLOROPHYLL.
One occasionally sees statements that certain green
plants, such as spinach, leeks, etc., have special
dietetic value because of an iron content, but so far
as we know the claim that chlorophyll, wherever it is
found, is a hematopoietic substance, is of recent
origin. Professor Biirgi in the Correspondenz-Blatt
fiir Scluveizer Aerzte, April 16, endeavors to show
that the green coloring matter of vegetation is not
only the most nowarful regenerator of the blood, but
a valuable stomachic and regulator of assimilation.
200
MEDICAL RECORD.
[July 29, 1916
In the same journal for June 3 Maillart of Geneva
attempts to demonstrate the same thesis from an
economic-historical viewpoint. True chlorosis is
notably rare in Geneva, and this may be due to the
fact that the town is surrounded by a vast acreage
of market gardens. These in turn have been made
possible by the great fertility of the land, which has
made the industry profitable for centuries. Green
herbs are produced in the greatest variety. So
much in use are legumes that the Genevese have been
termed "legumivores," and legume soup, which also
contains leeks, lettuce, and carrots in the winter, and
salad vegetables in the summer, is a characteristic
Genevese dish which is famous as an appetizer.
Aside from the soup, great quantities of green
vegetables are consumed: green beans, green peas,
watercress, chervil, dandelion greens, artichokes,
asparagus, sorrel, spinach, and other chlorophyll-
containing vegetables. On the other hand, the de-
mand for vegetables poor in chlorophyll, such as cab-
bage and cauliflower, is not greater in Geneva than
elsewhere in Switzerland. When the Genevese emi-
grate they invariably miss this abundance of green
stuff. Maillart advises the daily use of green
legumes, not only for the anemic and dyspeptic, but
for the healthy as well. Chlorophyll has been given
as such to the anemic, but doubtless cannot replace
the fresh vegetables. The author does not allude to
the value of tinned beans and peas in this connec-
tion, but it is evident that from the dietetic stand-
point they cannot replace the fresh articles.
Rubber Tissue Tendon Sheaths.
The old adage "Necessity is the mother of inven-
tion" has been exemplified many times during the
present European war when lack of time or of
materials has forced surgeons to improvise instead
of following the beaten track in matters of tech-
nique. One instance of this, a device which may
be worth utilizing in selected cases in the future,
is found in the report by M. Petit of Chateau-
Thierry (Revue de Chirurgie, January, 1916) of
two cases where the tedious dissection of a fat-
fascia flap was avoided by using sterile rubber
tissue to prevent tendons from becoming adherent
to the skin. In the first case there had been a
wound of the forearm which had cicatrized with
fusion of the flexor tendons to the skin, bringing
about a tnain en griffe. Petit freed the tendons and
interposed a rectangle of sterilized rubber tissue.
The skin wound was then entirely closed, healing
was by first intention and function of the tendons
was perfect. Later the sheet of rubber tissue
worked out at one portion of the wound but
the perfection of the functional result was main-
tained. In the second case there was adherence of
the flexor tendons to the skin of the lower third
of the forearm, again with main en uriffe. The
same technique was employed with perfect result
in every way ; for in this instance not only was
function perfect but there has been no evidence
that the rubber tissue is to be extruded.
value in the treatment of paresis, but something
must depend on what is meant by a prolonged treat-
ment. If a cure faithfully kept up for a year "be of
no avail in one case this does not straightway jus-
tify the assumption that another case would not
show improvement after two years of exhibition.
But to-day we have authorities who mean by pro-
longed treatment not less than ten years. In a
recent number of the Annales des maladies vene-
riennes (May, 1916), Gaucher cites several cases in
point. Thus a man contracted syphilis in 1892 and
showed the first symptoms of paresis in 1896. He
was at once placed on mercurial injections with io-
dide of potassium inwardly which were maintained
year in and year out. For about ten years he remained
free from pupillary disturbances and changes in the
reflexes. He showed some of the ordinary evidences
of constitutional syphilis despite the treatment. The
leading symptoms suggestive of paresis were limited
to headache, crises of aphasia, vertigo, staggering,
diplopia, etc. At the expiration of ten years the
psychic-somatic picture of paresis appeared quite
suddenly and completely. The mercurial treatment
was not in any way modified. Now, 1916, after
20 years of paresis the man still lives, still re-
ceives his injections of benzoate of mercury with
iodide inwardly. Not all symptoms progress and
some of them subside. He is able to take care of
himself and his personal affairs. His family no
longer wish to have him committed. Years ago such
men as Brissaud, Raymond, and Joffroy pronounced
the patient incurable. The author looks upon the
case as a real cure, although he thinks it unwise to
stop the treatment. A parallel case is also related.
foa of % Wnk,
Necessity of Very Prolonged Mercurial Treat-
ment in General Paralysis.
It has generally been understood that a thorough
course of mercurial treatment has no permanent
The Poliomyelitis Epidemic. — There were fewer
new cases of infantile paralysis reported in this
city during the first part of the week than there
were in the same period last week, though the
deaths had proportionally increased. That the
disease is not declining, however, was shown by
the fact that the number of new cases (150) re-
ported on Tuesday was greater than on any previ-
ous day. Outside of the city the number of cases
has increased, a total of 237 cases being reported
in New York State from the beginning of the epi-
demic to July 24, and 274 cases in New Jersey.
In this city up to July 26, the total number of cases
was 3,260 and of deaths 682.
Great Britain Bans Red Cross Shipments. — The
appeal of the American Red Cross that supplies
be allowed to be sent from here to Germany has
been refused by Great Britain on the ground that
they are not needed. In support of this contention,
Professor Hochenegg of the medical corps of the
Austrian Army is quoted as stating that there is
no shortage and no prospect of shortage in medi-
cal supplies of any kind or of materials for surgi-
cal dressings. The British Government therefore
holds that if supplies of rubber and other materials
were admitted to Germany it would not conduce to
the welfare of the sick and wounded but would
merely set free an equal amount of such materials
for belligerent purposes.
A Warning to Turkish Hospital Ships. — The
Russian Government has given notice that all
Turkish hospital ships will be sunk on sight in
reprisal for the sinking of the two Russian hos-
pital ships, Portugal and Y'Pmjod by the Turks.
Dr. Charles D. MacCarthy. Jr., of Maiden, Mass.,
July 29, 1916J
MEDICAL RECORD.
201
has received the cross of the Legion of Honor in
recognition of his work with the American Am-
bulance in France.
Sir Victor A. H. Horsley died on July 16 at
Amora in Mesopotamia of a heat stroke. He was
born in 1857 and was knighted in 1902. He was
emeritus professor of clinical surgery and consult-
ing surgeon at the University College Hospital,
London. At the outbreak of the war Sir Victor
went to France with the Red Cross. Then he ac-
cepted a commission as a colonel and went to Egypt
as consulting surgeon. Learning of the great need
of medical officers in Mesopotamia he requested to
be transferred and reached the Tigris last March.
An Army Hospital Train. — A hospital train of
ten Pullman cars, designed by the Army Medical
Department is in course of construction. Five of
the cars are to be equipped with regular hospital
beds and have large side doors for loading and un-
loading stretchers, two will be of the regulation
sleeper type, equipped with extra fans, medical
cabinets, and ice tanks, one will carry a complete
operating room, and another a kitchen large enough
to care for over 200 sick. In addition to the regu-
lar army personnel, the train will carry a special
corps of army nurses to serve in the wards and
operating car. The train will be painted maroon,
with the insignia of the Army Medical Department.
Army Hospitals on the Texas Border. — Secretary
of, War Baker announces that the Department is
constructing a number of small hospitals at minor
posts along the border with base hospitals at Fort
Sam Houston and Fort Bliss, Texas. Base hospi-
tals have been authorized and are now being com-
pleted, supplied with personnel and equipment, at
Brownsville, Eagle Pass, Laredo, Nogales, and Fort
Crockett. There are seven field hospitals with the
troops on the border, each having a capacity of 216
beds. This does not include the field hospitals of
the organized militia now on the border.
Medical Care for Soldiers' Families. — A number
of Detroit physicians have volunteered to give med-
ical service free, in case of need, to the families of
the members of the National Guard who have been
sent to Texas.
Psychological Laboratory at Bellevue. — A psy-
chological laboratory has recently been estab-
lished at Bellevue Hospital, in New York City,
under the direction of Dr. Menas S. Gregory, chief
of the Psychopathic and Alcoholic Services. Fa-
cilities will be provided for both clinical and re-
search work. As these services admit about 15,-
000 patients annually, the opportunities for re-
search will be exceptional. Dr. Leta S. Holling-
worth, formerly psychologist in the Department of
Public Charities in New York City, has been
placed in charge of the laboratory.
A Two-Year Pre-Medical Course. — A bill has
been introduced in the Georgia Legislature requir-
ing a college course of two years as a preliminary
for admission to any medical school in the State.
The bill also provides that there shall be no appeal
from the decision of the Board of Medical Examin-
ers when the license of a physician is revoked.
Rockefeller Institute. — Dr. Alphonse R. Dochez,
hitherto an Associate in Medicine has been made
an Associate Member. Dr. Henry T. Chickering
has been appointed Resident Physician in the Hos-
pital to succeed Dr. Dochez. The following have
been made Associates: Dr. Louise Pearce (Path-
ology and Bacteriology") ; Dr. Frederick L. Gates
(Pathology and Bacteriology). The following have
been made Assistants: Dr. Oswald Robertson
(Pathology and Bacteriology), Mr. Ernest Wild-
man (Chemistry). The following new appointments
have been made: Dr. Rhoda Erdmann, Associate
in the Department of Animal Pathology; Dr. Rufus
A. Morrison, Assistant in Medicine ?nd Assistant
Resident Physician; Dr. John Northrop, Assistant
in the Department of Experimental Biology; Dr.
Jean Oliver, Assistant in the Department of Path-
ology and Bacteriology; Dr. Ernest W. Smillie, Fel-
low in the Department of Animal Pathology; Dr.
William D. Witherbee, Assistant.
Dr. A. A. Eisenberg, formerly pathological anat-
omist in the U. S. Army Medical Museum and
School, Washington, D. C, has been appointed path-
ologist at Charity Hospital, Cleveland.
A Memorial to Major Walter Reed. — It is
planned to erect a memorial to the late Major Wai-
ter Reed, head of the Army Commission which con-
firmed Finlay's mosquito theory of the transmission
of yellow fever, on the campus of the University of
Virginia, of which he was a graduate.
Dr. James A. Lyon, assistant Superintendent of
the Rutland, Vt, State Sanatorium, who recently
entered the service of the government in the 2d
ambulance company, was the recipient, in leaving
for the front, of a loving cup from the patients of
the institution.
Vehement Vegetarianism. — An ardent advocate
of the moral and hygienic beauties of vegetarian-
ism, who has been arrested eighteen times for cre-
ating a disturbance by his uncontrolled enthusi-
asm in the cause, was sentenced in a police court
in this city the other day to a two year term in the
workhouse for attacking a woman who was coming
from a butcher shop.
The Broad Street Hospital. — The trustees of
this institution have bought a plot at the corner
of Broad and South Streets, New York, as the site
for a new hospital. The building with 100 beds
will be ready for occupancy in the autumn.
A Psychopathic Clinic at Sing Sing.— Warden
Osborne announced recently that a psychopathic
clinic under the direction of Dr. Bernard Glueck
has been established at Sing Sing Prison. The
object of the clinic is not only to determine the
mental status of the present and future inmates
of that institution, but also to inaugurate a study
of the underlying causes of crime along the lines
suggested at a meeting of the New York Academy
of Medicine held last winter. The Rockefeller
Foundation has contributed the necessary funds
for the clinic. Dr. Glueck, who will be appointed
resident psychiatrist, was formerly on the staff
of the Government Hospital for the Insane at
Washington. The general supervision of the work
will be under an Advisory Board consisting of
Drs. August Hoch, William Mabon, William L.
Russell, George H. Kirby, L. Pierce Clark, and
Thomas W. Salmon.
Obituary Notes. — Dr. William Evans Cassel-
berry of Chicago died at his home in Lake Forest
on July 11. He was born in 1858, and was gradu-
ated in medicine from the University of Pennsyl-
vania in 1879. He began practice in Chicago in
1883. He was professor of laryngology at the
Northwestern Medical College and laryngologist to
St. Luke's Hospital. He was a member of the Chi-
cago Academy of Science, the National Association
for the Study of Tuberculosis, the American Acad-
emy of Ophthalmology and Oto-Laryngology, the
American Laryngological Association, the Chicago
202
MEDICAL RECORD.
[July 29, 1916
Laryngological and Otological Society, the Illinois
State Medical Society and the American Medical
Association.
Dr. Samuel D. Booth of Oxford, N. C, died on
June 29 at the age of 75 years. He was a graduate
of the Medical College of Virginia, Richmond, in
1867.
Dr. ROSCOE Smith of Auburn, Me., died on July
8 at the age of 80 years. He was born at Peru,
Me., and was graduated from the Harvard Medical
School in the class of 1870. The following year he
began practice in Turner, living there until 1889,
when he retired, and five years later moved to
Auburn.
Dr. John P. Corrigan, for over 25 years a prac-
ticing physician in Pawtucket, R. I., died in Wash-
ington, D. C, on July 6, of ptomaine poisoning. He
was born in Ireland in 1856, and was a graduate of
the Bellevue Hospital Medical College, New York
City. He had recently retired from medical prac-
tice and was about to be received into the Order of
St. Dominick, having just completed his novitiate.
Dr. Joseph W. Henry of San Francisco died in
San Jose on June 28 at the age of 47 years. He
was born in Ireland, and was a graduate of the
Medical Department of the University of Southern
California in the class of 1897.
Dr. Harry Carter of Manchester, N. H., died in
the Hartford (Conn.) Hospital on July 4 at the age
of 40 years. He had for many years been engaged
as surgeon in the mercantile marine, and had had
several very trying experiences, including shipwreck
and fire at sea.
Dr. S. G. Popplewell of Milo, Mo., died of cancer
of the stomach on July 5 at the age of 69 years. He
was a graduate of the College of Physicians and
Surgeons, Keokuk, Iowa, in the class of 1876.
Dr. Arthur Cleveland Cotton of Chicago died
of heart disease on July 12 at the age of 69 years.
He was born in Grieggsville, 111., and was gradu-
ated from Rush Medical College, Chicago, in 1878.
He was pediatrist to the Presbyterian Hospital and
professor of pediatrics in Rush Medical College. He
was a member of the Chicago Medical Society, the
Chicago Pediatric Society, the Chicago Medical Ex-
aminers' Association, the American Pediatric So-
ciety, the Illinois State Medical Society, and the
American Medical Association.
Dr. Charles Hamilton Hughes of St. Louis, for
many years editor of the Alienist and Neurologist,
and professor of nervous diseases in the Barnes
Medical College, died on July 13 at the age of 77
years. He was born in St. Louis, and was gradu-
ated from the Washington University Medical
School in 1859. For a short time after graduation
he served in the Marine Hospital Service, and then
began practice in Warren County, Mo. He served
as surgeon in the Federal Army during the Civil
War, and at its close became superintendent of the
Missouri Asylum for the Insane at Fulton. In 1871
he began practice in St. Louis and soon acquired a
wide reputation as a neurologist and alienist. He
was no "brain-storm" theorist, but held in many of
the murder trials in which he gave expert testimony
that the murderer was sane enough to be respon-
sible fur his acts.
Dr. Edward N. Flynn of Jeffersonville, fiid.,
died of Bright's disease on July 9 at the age of
49 years, lie was born in New Bedford. .Mass.,
and was graduated from the Louisville Medical Col-
lege in 1897. He served for four years as mayor of
Jeffersonville.
(EflrrffijHmtonrp.
INTRASPINAL INJECTION OF ADRENALIN
CHLORIDE IN ANTERIOR POLIOMYELITIS.
To the Editor of the Medical Record:
Sir: — I desire to present the following brief re-
port regarding the use of adrenalin chloride, in-
traspinally, as suggested by Dr. S. J. Meltzer in the
treatment of infantile paralysis at the New York
Throat, Nose and Lung Hospital. There are 51
cases under my observation at the present time. It
is unnecessary to give in detail the routine treat-
ment other than that of the adrenalin injections.
All the patients received urotropin in moderate
doses.
Not knowing the dose of adrenalin in these con-
ditions I began the injection of 3 minims of a 1-1000
solution, but soon increased the dose to 30 minims
without any deleterious results. The injections are
given every six hours as a routine. The reaction
upon the part of the patient from the procedure is
practically unnoticeable except that in a few cases
where a high intraspinal pressure has been relieved
before the injection of adrenalin, headache and
vomiting may follow. These phenomena are prob-
ably due to the sudden relief of the high intraspinal
tension and not to any action of the adrenalin. From
a clinical point of view, it is well to state that a
vast majority of all the cases have a notable • in-
crease of intraspinal pressure. Usually the spinal
fluid is allowed to run off through the needle, but
in some cases I have drawn off with the syringe
from 1 to 15 c.c. It is noted that the intraspinal
tension decreases as the injections are continued.
I would not advise the use of adrenalin in larger
doses than 2 c.c. since pulmonary edema may be
produced by large doses of the drug. However, the
slow absorption from the spinal canal will allow the
injection of large doses without any deleterious
results.
As to the physiological action of adrenalin in
these conditions further work must be done, for up
to the present the explanation of its action is only
theoretical. In the cases where voluntary move-
ment of various parts of the body was lost for a
period of time and regained, the loss could not have
been due to any degenerative changes in the neurons
from pathological lesions. The probability is that
the path of the lower motor neurons in the spinal
canal was blocked from pressure caused by the exu-
date produced at the area of inflammation which is
in the neighborhood of the ventral horns of the gray
matter of the cord, thereby disturbing the contin-
uity of the reflex arc and the free passage of im-
pulses from the upper motor neurons. It has been
shown experimentally that adrenalin will relieve.
to a marked degree pressure around an inflam-
matory area and reduce the focus of inflammation.
Should the motor disturbance in infantile paralysis
be due to pressure, then intraspinal injections of
adrenalin given before there are degenerative
lesions in the nerve tissue might well produce bene-
ficial results in progressive malady impeded.
The following cases are reported that some idea
may be gained as to the condition of the patients
before and after the injection of adrenalin. Sev-
eral other cases showing equally gratifying results
are under observation.
Case I. — J. K., male, aged three years. Admitted to
the hospital July 15, lillG. General condition very low.
July 29, 1916]
MEDICAL RECORD.
203
Unable to swallow food or drink; extremities cold; ab-
sence of radial pulse; heart block of a 5-4 rhythm;
auricular fibrillation at times; respirations slow and
principally diaphragmatic. No voluntary motion of
limbs; legs flexed upon the thighs; absence of all skin
and tendon reflexes. Hyperextension of spine. July 22 :
Patient raises himself up in bed; good control of all
voluntary muscles; respirations normal; normal rigidity
of spine, and force and rhythm of heart excellent. All
skin reflexes present except the left plantar. Right
knee jerk and both elbow tendon reflexes present.
Case II. — S. D., male, aged five years. Admitted to
the hospital July 15, 1916, in a very restless condition.
Marked hyperextension of spine; unable to move either
the left arm or right leg; complained of severe pain in
back and lower extremities. All the skin and tendon
reflexes absent. July 22 : Normal flexion and rigidity
of spine; able to flex, extend, and move the left arm in
any direction ; raises right ieg about 6 inches off the
bed; all skin reflexes present except the plantar. Right
knee jerk present.
Case III. — J. L., male, aged three years. Admitted
July 14, 1916, in a very stupid condition. Entire mus-
culature in a marked state of hypotonicity; no volun-
tary motion ; absence of both skin and tendon reflexes.
Sensation of pain hyperacute. July 22: Muscular tone
much improved ; very good flexion and extension of
both arms and left leg; right leg is in a passive state.
Both plantar and cremasteric reflexes present. Left
knee jerk present.
In each of the above cases adrenalin was admin-
istered in doses of 2 c.c. every six hours.
P. M. Lewis, M.D.
House Surgeon.
Xew Yokk Throat, Xose, and Lung Hospital.
TREATMENT OF INFANTILE PARALYSIS.
To the Editor of the Medical Record:
Sir: — The paper of Dr. Meltzer in the issue of
the Medical Record for July 22 emboldens me to
publish a suggestion I made a week ago by tele-
graph to Surgeon General Blue, Commissioner Em-
erson, and a prominent neurologist in Brooklyn.
The first referred the matter to his representative
in New York, Dr. Lavinder, who has written that
he would give attention to the matter so soon as his
work was organized.
I ask a modicum of space to call further atten-
tion to the matter. In the February report of the Hy-
gienic Laboratorq, Atherton Sidell published some
remarkable data on polyneuritis of pigeons that had
been fed on polished rice that may give a valuable
clue to the treatment of poliomyelitis, despite the
fact that the pathological lesions are quite different.
Therapeutics is, after all, but empirical; our most
valued drugs like quinine and digitalis having been
discovered and successfully used before their ra-
tionale was known. Dr. Meltzer's probable ration-
ale of the action of adrenalin in poliomyelitis may be
applicable to my suggestion for its therapy derived
from Sidell's experiments, who found that pigeons
suffering from induced polyneuritis are in an hour
relieved from paralysis and entirely restored to
health within twenty-four hours, also that pigeons
fed with polished rice for the purpose of producing
polyneuritis do not contract the disease at all if at
the same time given 1 c.c. of a waste product de-
rived from brewers' yeast.
Would not a trial of this agent be demanded in
view of the utter helplessness under which the phy-
sician now labors? Sidell claims that this waste
material of breweries may be concentrated so that
5 grams would suffice for a man. The quantity
for a child may be calculated in the usual way. In
view of the fact that the preparation is odorless,
almost tasteless, and harmless, the experiment is
worth trying.
Simon Baruch, M.D.
Long Branch, X. J.
TYPHOID VACCINE IN POLIOMYELITIS.
To the Editor of The Medical Record:
Sir: — In a recent number of the Journal A. M. A.
appeared an article by Drs. Miller and Lusk on the
treatment of arthritis by the injection of foreign
protein usee Medical Record, June 17, page 1100),
in which the authors advocate the use of typhoid
vaccine intravenously. I can speak well of this
non-specific treatment of arthritis, and from per-
sonal trial and observation can endorse its use in
infectious arthritis. It must be given cautiously
and carefully in selected cases. It produces a vio-
lent reaction, and in some cases an increase of pain
in all the affected joints temporarily. Mention is
made in the article of the experiments of Vaughan,
whereby a certain amount of immunity against spe-
cific infections by non-specific bacteria was ob-
tained. Animals were immunized against typhoid
and cholera by dead cultures of B. prodigiosus and
B. subtilis. A moderate and transitory immunity
against colon infection was obtained by injecting
egg albumin into animals. Many years ago Klein in
England immunized animals against B. pyocyaneus
infection by using killed cultures of B. prodigiosus.
In view of the widespread epidemic of poliomyelitis
in the East, with the mode of infection as yet un-
discovered and with a mortality rate of 20 per cent.,
it seems that some non-specific immunizing meas-
ures might at least be experimented with. By im-
munizing children with typhoid vaccine, typhoid
fever can be prevented, and it is possible that by the
various antibodies thus mobilized another bacillary
infection may be prevented or defeated.
The two schools, that of Ehrlich and of Bordet,
long contended as to the specficity of antibodies,
Bordet and Metchnikoff holding that there was but
one, the substance sensibilitrice. Leucocytosis is
produced by injections of typhoid bacilli, and
antibodies also; the natural defenses of the body
might overflow and destroy the bacilli of anterior
poliomyelitis. It would be interesting to learn if
anybody who had recently been immunized by vac-
cines of any sort, but particularly typhoid vaccine,
developed poliomyelitis. It seems that the pro-
cedure can do very little harm, and it might do a
great deal of good.
Robert L. Pitfield. M.D.
Germantown, Pa.
A HANDY BANDAGE ROLLER.
To the Editor of the Medical Record:
Sir: — Apropos of a suggestion in a recent edi-
torial article in the Medical Record, the following
description of a handy bandage roller, made in an
emergency at the home of a patient, may be service-
able to others under similar circumstances.
My patient had a brawny swelling of the breast
about two weeks after a difficult labor. The same
breast had been badly riddled by a deep abscess after
her other child was born, and it seemed as if an
abscess was now inevitable. It was in March, 1885,
and I had just been reading the valuable contribu-
tions of Dr. Philander A. Harris of New Jersey to
the American Journal of Obstetrics, upon the treat-
ment of mammitis by bandaging and rest, and I de-
termined to use the long, wide bandage over a cot-
ton compress, as he had recommended. But this
called for a bandage at least 15 or 20 yards in length
and about 3 inches wide. We made it from six or
seven lengths of a sheet, lapped and stitched to-
204
MEDICAL RECORD.
[July 29, 1916
gether, and to wind it I extemporized a crank and
spindle from an umbrella rod with its brace at-
tached, that met my eye, simply bending the slim,
square brace, near the outer end of it, at a right
angle, and leaving 2 or 3 inches of the rod still at-
tached to serve for a handle.
A stout little salt-box — 3 x 4 x 9 inches — with two
holes at each side, very near together, at one end to
receive two short pieces of the rod, and other holes
near the other end to receive the crank shaft, and
the machine was ready for use. The bandage was
passed over the end of the box, under the first rod,
over the other and then to the crank, and by moist-
ening the end of it slightly and pinching it snugly
to the crank shaft, while the first few turns were
made, our bandage was quickly and firmly wound.
The wrinkles in the cloth were smoothed out as they
passed by the rod at the end of the box, and pressure
or traction there, as the bandage was fed into the
machine, made the bandage, when finished, as firm
and hard as might be desired.
The improvised machine worked so well I brought
it home, smoothed the edges and rough places, had
the whole thing enameled in black, and have used
it and Dr. Harris's long bandage from time to time
ever since, and both of them always with satisfac-
tion. C. H. L.
SARATOGA SPRINGS FOR CARDIOVASCULAR
DISEASES.
To the Editor of The Medical Record:
Sir: — In the interest of sufferers from organic-
heart diseases who cannot avail themselves of the
unique waters of Nauheim, which have made that
resort the Mecca of these unfortunates, I desire
to comment upon your editorial on this subject in
your issue of June 3, and upon the letter of the
officers of the Saratoga Springs Medical Society,
published July 1, which opposes the accepted views
of heart specialists and eminent internists the world
over. The officers of this society have by resolution
stated "their deliberate and emphatic conviction
that for series of successive CO, baths given sys-
tematically our natural Saratoga Springs mineral
water, etc., is fully efficient," meaning, of course,
in cardiac cases in which alone such series are pre-
scribed. And our colleagues display commendable
catholicity and courtesy by, adding, "and further,
that it should be used for such series of baths with-
out addition of any salts, unless such additions are
plainly ordered in the prescription of the physi-
cian."
Whether the American profession will be guided
by this resolution of a small number of colleagues
whose unpublished observations extending over a
brief period of a few months in a resort that is
still in its infancy so far as CO. baths for cardiac
disease are concerned, or by the published observa-
tions of physicians and eminent specialists all over
the world extending over a period of twenty-five
years on a material of over a million recorded baths
for heart cases alone, is not for me to point out.
I desire to call attention to the fait that the
officers of this society have written: "The physi-
cians of Saratoga Springs decry most sincerely the
adulteration of these waters for bathing purposes
— except when made on special prescription." The
Century dictionary define "adulteration" to be "the
debasing by substitution of an inferior article for
the genuine." Surely they would not suggesl such
a thing to their colleagues or permit them to do it!
The zeal of the Saratoga physicians for purism is
commendable, in view of the real adulteration of
the famous drinking waters of that spa long ago
abandoned. But this does not in the least apply to
these waters for bathing purposes, which have not
yet established a reputation by reason of their very
early youth. In fact, the publication of two cases
is all the literature I could find upon these baths
contributed by a Saratoga practitioner outside of
propaganda by an official of the reservation in the
shape of papers with lantern slides. The paper of
Dr. Baruch in your issue of June 17 is really the
first rational explanation of the action of the salines
in the Nauheim bath, since he has fortified the
opinions established on reliable clinical evidence by
physiological data and chemical experiment.
It is now clearly demonstrated that the tempera-
ture, which is the chief element (according to
Groedel and others) in the Nauheim bath, is made
bearable and effective for the depreciated heart
patient by supersaturation of the water with CO.;
that the CO., locally and by absorption, enhances
cardiac tone ; that the salines facilitate absorption
and prevent loss of C03 from the water; that CO.
is the normal stimulant of the respiration, and that
this combination of demonstrated physiological ac-
tions trains the insufficient heart to better function
anl prevents lethal complications.
Dr. Baruch gave the reasons of the superiority
of the natural CO. water over the artificial, and
demonstrated clearly that the Saratoga CO., waters
combined with the calcium and sodium chloride,
which are equal in therapeutic effect to the natural
chemicals, offers the closest possible approximation
to the far-famed Nauheim waters. It is therefore
fortunate that we have the opportunity to send our
chronic heart cases to Saratoga Springs.
For all other purposes the natural CO. Saratoga
water is fully effective. I agree with Dr. Baruch's
conclusion that no plain CO, bath can with advan-
tage be substituted for the natural CO. water when
combined with the salinefc in the treatment of cardio-
vascular insufficiency. This fact is so well recog-
nized in Europe that in resorts having fine CO,
water, e.g. Kissingen, the waters are always rein-
forced by salines in baths for cardiovascular dis-
eases. I agree with our Saratoga colleagues in their
preference for the term Saratoga CO. mineral baths,
and in the abolition of the term Nauheim baths in
prescriptions. Any additions should, as they very
properly insist, "be plainly and explicitly ordered
in the prescription of the physician."
Albert J. Wittson, M.D.
273 West Seventy-third Street.
OUR LONDON LETTER.
(From Our Regular Correspondent.)
OPHTHALMOLOGICAL NOTES — PITUITARY TUMORS —
TYPHUS IN CAMP OF PRISONERS OF WAR IN GER-
MANY— DESERTION OF DUTY BY GERMAN SUR-
GEONS.
London-, July 1. 1916.
In the section of ophthalmology (R. S. M.) last
week. Dr. F. R. Yelland showed a case of visual
orientation, following a wound of four months dura-
tion, which was first perceived soon after an epilep-
tic fit. The patient had been improving recently
after having had right hemiplegia and erroneous
visual projection. A similar case was reported to
the B. M. A. last March. Mr. Paton had carried
out certain tests on the present case which satis-
July 29, 1916J
MEDICAL RECORD.
205
fied him that the faulty projection was not due to
defective eye movements, but rather to complete de-
struction of the right occipital cortex, the left being
but slightly affected. It looked as if there had been
complete severance of the superior longitudinal com-
misural fibers. Afterward a case of "retinitis pig-
mentosa" of an unusual character was shown by
Captain Carruthers in a young man who had been
a soldier for three months. He came under notice
as he could not see to drive on the approach of
dusk. A younger brother and an elder sister had
suffered from night-blindness. Comments were
made on the case by the president and several mem-
bers. A giant perimeter was shown by Captain
Hudson, who invited suggestions for improving it;
some were offered by Lieut.-Colonel R. H. Elliot,
who related some experience he had had with an
instrument of his own make.
Dr. A. S. Cobbledeik read a papar on four cases
of pituitary tumor, all in women, three of them
over 60 years old. The first showed contraction of
the visual field, 10 to 20 degrees in extent, and a
scotoma for color upward and outward from the
central fixation point. This troubled her in reading,
and people's faces seemed tinged with blue. There
was contraction in the temporal half of the field.
Later drowsiness with violent headaches came on
with Cheyne-Stokes breathing, but the pupils were
not affected. The urine was normal. At the post-
mortem examination a pituitary tumor as large as
a walnut was found, which Dr. Buzzard regarded
as a cyst. Gland-substance enough remained to en-
sure normal metabolism during the sixty-three years
the symptoms lasted. In the second case there was
right homonymous hemianopia and myxedema.
Memory had begun to fail and speech was indis-
tinct. There was lesion of the left optic tract,
probably due to pituitary growth. Thyroid extract
was given and there was some improvement of mem-
ory and also of numbness which had been present.
The discs seemed normal. Little change was
noticed in the patient's condition for three years,
but after that there was rapid deterioration of vis-
ion; the nervous state increased, vertigo and flick-
erings before the eyes were complained of. The
face and hands swelled and later the symptoms were
in some degree like Meniere's disease, but without
deafness or sickness. In the third case there was
optic atrophy, obesity, myxedema and diabetes.
The sight had been deteriorating for four years,
and in the last year drowsiness was on the increase.
No tendency to hemianopia. Skiagrams showed en-
larged and lobulated sella turcica. The fourth case
was diagnosed as early optic atrophy, myxedema,
and pituitary tumor. There was defective memory,
falling hair, suffocating feelings, and heart attacks.
A year ago life was despaired of. The discs were
normal, but vision for white contracted in every
direction.
You have probably some information as to the
epidemic of typhus in the camp of the British
prisoners of war in Germany. We had a committee
of six surgeons sent over to take up duties which
had been abandoned by the German surgeons-in-
charge. This abandonment seems almost incredible,
so contrary is it to the practice of the profession in
all countries — Germany included. But on this occa-
sion the desertion of duty was only part of the of-
fence. For these German surgeons not only stayed
away from the camp, but made no effort to
secure a supply of medical necessaries for their de-
serted patients. When asked for such by British
surgeons on the spot, the answer was insult to the
"English swine." We may hope these men were ex-
ceptional, but it is a matter of surprise that so far
such conduct has not brought condemnation from
their professional brethren in their own country.
frugrrBs of iH*iiiral %tvnw.
Boston Medical and Surgical Journal.
July 13, 1916.
1. Certain Occupations as Contributing Factors to Diseases
of the Skin. Charles H. White.
2. Leonardo Da Vinci's Scientific Research. (Concluded.)
Arnold C. Klebs.
3. Hematocele of the Tunica Vaginalis. Charles M. Whitney.
4. A Statistical Study of the Mortality from Diabetes Melli-
tus in Boston. H. Morrison.
5. The Treatment of Chronic Disease as a Problem of Applied
Physiology. Francis H. McCrudden.
6. Acute Arthritis Experimentally Produced by Intravenous
Injection of the Staphylococcus Pyogenes. E. C. Stein-
harter.
1. Certain Occupations as Contributing Factors to
Diseases of the Skin. — Charles H. White mentions some
46 or more diseases of the skin apportioned among
approximately 120 different occupations. He says that
he has personally treated all but one of these diseases
and has treated in all probability representatives of
a very large proportion of the many occupations. He
warns against the assumption that these diseases fall
to the lot of all men and women who engage in these
multifarious pursuits. There are no available statistics
covering the whole subject of occupational skin dis-
eases, but in the case of eczema we have more or less
reliable figures. The writer cites a number of ob-
servers who practically agree that about one-fourth of
all the cases of eczema which they treat are directly
attributable to the occupation of the patient, and asks
the question: "Granted, therefore, that a certain pro-
portion of the community is susceptible to the dangers
inherent in its chosen occupation, can anything be
done to mitigate or abolish these dangers?" This he
answers strongly in the affirmative and believes the
desired end may be accomplished by the education
of the employer and the employed. Physicians who
spend their lives among contagious and often danger-
ous diseases are fortunately usually spared from shar-
ing the fate of their patients, mainly because of their
knowledge of self-protection, and this same knowledge
must be disseminated among all classes of human
beings. He believes it will not be as difficult a task
to educate the employer as many think, since it is not
for his interest in any way to have his men incapaci-
tated.
4. A Statistical Study of the Mortality from Dia-
betes Mellitus in Boston from 1895 to 1913, with Spe-
cial Reference to Its Occurrence Among Jews. — H.
Morrison finds that during the period of 1895 to 1913
there were in Boston 1775 deaths from diabetes mellitus
out of a total of 229,468 deaths. In Boston, as else-
where, there has been a steady rise in the death rate
from this disease; it was 7.1 per 100,000 in 1895 and
21.3" in 1913, or 3.1 per 1000 total deaths in 1895, and
13.3 in 1913. The death rate from diabetes has been
relatively very high among Jews in Boston, occurring
about two and one-half times as frequently among
Jews as among their neighbors. A similar analysis
shows that the death rate from this cause was very
high among those of German, English, and American
parentage, so that death from this disease occurred
about two times as frequently among them as through
the community in general. The largest number of
deaths from diabetes occurred among those of Irish
parentage, 656 out of 1775, or more than one-third of
the total. This death rate, however, was not out of
proportion to their population. There were only 11
206
MEDICAL RECORD.
[July 29, 1916
deaths from diabetes among negroes in Boston from
1895 to 1913. This series of 1775 deaths from diabetes
was made up of 958 females as against 817 males.
This is contrary to the general observation that dia-
betes occurs more frequently in the male sex. The
largest number of deaths occurred among persons of
the seventh decade. The duration ol this disease could
not be estimated from this study, for nearly half the
death returns did not answer at all this question or
gave it in indefinite terms. This is a point to be
borne in mind in making out death certificates. The
author believes the reason for this increase in the
death rate from diabetes mellitus is due to the in-
creasing complexity of civilization. It is particularly
prevalent among Jews, not because of ethnic pecu-
liarities, but because a severe environment during
many centuries has developed a nervous type easily
thrown out of balance.
6. Acute Arthritis Experimentally Produced by In-
travenous Injection of the Staphylococcus Pyogenes. —
Edgar C. Steinharter recalls that he has previously
pointed out that the staphylococcus organism of shift-
ing grades of virulence localized on intravenous inocu-
lation in different structures of the body, and within
certain limits a selective localization of this micro-
organism for special organs could be developed by
cultivation of the organism in functionating tissue.
He has also shown that when the staphylococcus at-
tains an affinity for a certain structure of the body, a
fresh subculture of the organism obtained from a
focus of infection was apt to possess properties lead-
ing to its localization in that tissue. The strain used
in the experiments now reported was the one used in
the gastric ulcer series. It was obtained from blood
culture in a case of septicemia in man. Following
the intravenous injection of the organism into the
general circulation of rabbits, the joints showed no
gross pathological changes except a very occasional
slight hyperemia of the periarticular tissues. How-
ever, cultures of the apparently negative joints very
often yielded a pure growth of the staphylococcus.
Further experiments showed that with a more virulent
strain of the staphylococcus it localized in the joints
and produced typical lesions of arthritis. The or-
ganism recovered from the arthritic joints had a tend-
ency to again localize in joints. In some eases the
arthritis was the only lesion found at autopsy, but in
other cases it was associated with one or more other
lesions, namely, duodenal ulcer, appendicitis, cholecys-
titis, myocarditis, pericarditis, endocarditis, nephritis,
colitis, and myositis. The results of localization ob-
tained in connection with the studies of staphylococci
are singularly suggestive of Rosenow's experiments
with the streptococci. If these facts apply in these
cases of streptococci and staphylococci, it would seem
possible that they may apply to still other organisms,
for so far as we can determine, the essential factor
governing localization is growth in the tissue. After
an organism has grown in a certain environment, it
tends in later generations to select that environment,
or at least, to thrive he?t in that environment.
New York Medical Journal.
July 15, 1916.
1. Syphilis <>f tli.- [Nervous System. ESugene !' Bondurant
i i • Fisher and Jones.
i and Its Modern Revival. Norman D. Matti-
4. Tul. :il Sterilization. Alfi -im i
tary Preparedness and thi
ti. Rubella or Gei M < ■ I i fray.
7. The .Min oscop D 0 I . Levin.
8 i lonnellan King I1 i James
epl Kii
9. Maj >' Solution \ N'oncaustic !■ ihlorite Douslas
H. Stewart
1. Syphilis of the Nervous System. — Eugene D. Bon-
durant claims that one in five of the inhabitants of the
United States has the taint of syphilis in his blood,
and that one in five of those who contract syphilis
receives some material injury to the nervous system
therefrom. One in five of the patients in our insane
asylums is placed there by syphilis, this disease rank-
ing first as a cause of insanity. Most of the organic
nervous disease met with in practice is a result of
syphilis. As a contribution toward facilitating the
recognition of involvement of the nervous system in
the syphilitic process in its early as well as late stage,
he reminds his readers of the following: The neuras-
thenia syndrome is often present as the earliest evi-
dence of cerebral or meningeal syphilis involving the
convexity. The psychasthenic syndrome likewise gives
early warning of a diffuse syphilis cerebri affecting the
vertex. The occurrence of either of these forms of
neurosis in one who has had syphilis indicates danger
of subsequent general paresis. Ptosis and other ocu-
lomotor palsies are usually diagnostic of meningeal
syphilis of the base. Most atrophy of the optic nerve
is syphilitic in etiology. Many headaches and neural-
gias are caused by syphilis. Most of the pupillary light
reflex abnormalities seen are of syphilitic etiology.
Chronic neuritis of sensory type is usually syphilitic.
Symptoms of spinal sensory root irritation — stabbing
pains, anesthesia, disorder of position sense, delay in
rate of transmission of nervous impulses, etc., are
usually symptoms of syphilitic disease. The onset of
epilepsy after the age of thirty-five years means a
syphilitic infection. The occurrence of arteriosclerosis,
cerebral hemorrhage, softening, etc., before the age of
thirty-five years, is seen only in those previously in-
fected by syphilis. Nearly all spastic paralysis is
syphilitic in origin. Nearly all disturbances in gait are
due to syphilis. Most aphasias and other speech defects
in adults are due to syphilis. Most of the abnormali-
ties of the deep reflexes, with the exception of those
seen in acute non-specific infectious diseases, are evi-
dences of syphilis. A large percentage of the cases
of acute and chronic mental diseases are primarily
syphilitic in causation. Syphilis of the nervous system
is in its early stages curable by any and all measures
which will cure syphilis. In its later stages, after the
death of the nerve cells, it is incurable by any means
whatsoever.
2. Vertigo and Seasickness, Their Relation to the
Ear. — Lewis Fisher and Isaac H. Jones state that all
vertigo of whatever cause, be it from stomach, kidneys,
eyes, or what not, is directly due to a disturbance along
some part of the vestibular paths. It should be borne
in mind that the static labyrinths always act in unison.
They continuously keep sending out an equal flow of
tonic impulses to the whole body. When, however, a
pathological process impairs or exaggerates the action
of one of the labyrinths, there results a definite dis-
turbance of this nicely adjusted mechanism with ver-
tigo as a symptom. Impairment or stimulation of both
sides to exactly the same extent produces no vertigo
whatever. Seasickness is therefore an ear phenomenon,
by which is meant that the end organ of equilibrium,
namely, the static labyrinth, is disturbed by the un-
accustomed movement of the boat or ship. Disturb-
ances of the vestibular apparatus can be definitely
analyzed by means of the new ear tests. Cases of
vertigo, therefore, need no longer be regarded as vague
or mysterious, but should be cleared up by means of
these ear tests.
4. Tubal Sterilization. Pregnancy Following Bilat-
eral Salpingectomy: A Report of Two Cases and a
Complete Review of the Literature.— Alfred Heineberg
July 29, 1916]
MEDICAL RECORD.
207
reports two cases in which this unexpected sequel
emphasized the fact that if sterility had been the object
sought by the operations in these cases they would
have been classed as failures. He says that pregnancy
has unexpectedly occurred in many patients after oper-
ations upon the Fallopian tubes performed for the ex-
press purpose of producing sterility and in others who
were subjected to bilateral salpingectomy for the relief
of tubal disease. He gives a resume of the literature
of the clinical and experimental experience with tubal
sterilization from which he finds that one may fairly
arrive at the following conclusions: 1. There is no meth-
od of tubal sterilization which affords absolute security
against conception. 2. Simple ligation of the Fallopian
tubes with either single or double ligatures has been fol-
lowed by the largest number of reported failures. 3.
Excision of a wedge-shaped section from each cornu of
the uterus, followed by careful closure of the opening
with musculomuscular and seroserous sutures has yield-
ed better results than any other method. 4. In the light
of our present knowledge it seems unwise to advocate
any other method than cornual resection. These conclu-
sions are in accord with those arrived at in previous re-
views of this subject by Charles (56), Geissler (57),
Gunther (58), Mironow (59), Offergeld (60), Perdrizet
(61), Pestalozza (62), and Sarwey (63.
8. Connellan-King Diplccoccus Infection of the Ton-
sils.— James Joseph King has observed about 100 cases
of arthritis at the Hospital for the Ruptured and Crip-
pled in New York from which he concludes that every
case of septic arthritis, commonly called rheumatism,
is caused by a focus of infection somewhere in the
body. It may be found in the tonsils, ears, accessory
sinuses, gastroenteric tract, genitourinary tract, and
in and around the teeth. The most frequent focus is
found in the mouth and the tonsils. A very simple
tonsillitis may be followed by complications such as
nephritis, endocarditis, myocarditis, arthritis, so seri-
ous as to endanger life. The infection may become
latent and produce serious trouble weeks or months
later at a point far removed from its original site.
Where the focus of infection in arthritis exists in the
tonsil, the treatment should consist of autogenous vac-
cines until all infection is cleared up and then the
removal of the tonsils by enucleation. In the Con-
nellan-King diplococci infections the blood changes
seem to be a simple anemia and in a few cases a
slight increase in the number of eosinophiles, four to
six per cent. In some cases symptoms other than
those for which treatment was instituted have disap-
peared. For instance, in one patient with arthritis
and marked ethmoiditis the culture was obtained from
the throat. After two weeks of treatment the arthritis
was only slightly improved, but the ethmoiditis and pus
in the nose had entirely disappeared. The essayist
has found the vaccines eminently satisfactory in a high
percentage of the cases treated.
Journal of the American Medical Association.
July 15. 1916.
1. Pityriasis Lichenoides Chronica : A Clinical and Micro-
scopical Study of a Case Mistaken tor Lichen Planus.
Fred Wise.
2. Traumatic Pulsating Exophthalmos. William Zentmayer.
3. Some Technical Features of Laminectomy for Spinal
Disease and Injury, Based on 150 Spinal Operations.
Charles A Hlsherg.
4. Some Bodily Changes During Anesthesia : An Experi-
mental Study. Frank C. Mann.
5. Xitrous-Oxid-Oxygen Anesthesia in Major Surgery- A.
B. Cooke.
G. Stab Wounds of the Chest Involving the Diaphragm, with
Diaphragmatic Hernia or Evisceration. Charles C.
' ir.^en.
7. The Factor of Fear in Nervous Cases. Hugh T. Patrick.
S. Heterophoria in Children. "Wendell Reber.
9. Blood Transfusion, with Special Reference to Group Tests.
Walter V. Brem.
10. The Etiology of Nonparalytic Ocular Imbalance : Some
Original Conceptions and Interpretations Based on the
Physiology and Psychology of Ocular Movements. Will
Walter.
11. Cast of Mastoiditis Complicated by Purulent Cerebro-
spinal Meningitis ; Operation and Recovery. W. H.
Huntington.
1. Pityriasis Lichenoides Chronica. — Fred Wise pre-
sents a clinical and microscopical study of a case mis-
taken for lichen planus. The eruption exhibited by
this patient so closely resembled a widespread lichen
planus that a number of dermatologists, even after
careful scrutiny, held the opinion that it was, indeed,
an unusual example of that dermatosis. The localiza-
tion and distribution of the lesions, their color, con-
sistence, burnished surface, configuration, occasional
grouping and linear arrangement, together with the
fact that the patient complained of considerable itching
of the affected skin, were determining factors in the
diagnosis. There were, however, certain points of de-
parture from the typical picture presented by a dis-
seminated eruption of lichen planus. The papules, in-
stead of being predominantly polygonal, were for the
most part oval and round in outline; umbilication was
seen in only a small proportion of the lesions, most
of them presenting a smooth, glistening surface, with-
out a trace of delling; the fine, whitish, adherent,
linear scaling — Wickham's striae — so characteristic of
lichen planus papules, were lacking. Finally, the ab-
sence of lingual and buccal mucous-membrane lesions,
in a case presenting an eruption so extensive in its
distribution, contributed an added element of doubt
to the diagnosis of lichen planus. (In Werther's case,
however, the buccal mucosa? were affected by the dis-
ease.) From the histological standpoint, the minute
structure was seen at a glance to be quite different
from the characteristic picture of lichen planus, and
to conform to that which, when correlated with the
clinical appearances, left no other diagnosis open for
consideration than that of parapsoriasis. It is well
known that the microscopical changes in this group
of affections are by no means pathognomonic, in the
same sense that the histopathology of lichen planus is
pathognomonic, for the various pathological altera-
tions peculiar to parapsoriasis may also obtain in many
other cutaneous diseases, or may at least play a minor
part in the general morbid process of other derma-
toses. A diagnosis of parapsoriasis based on the micro-
scopical findings alone is considered to be, as pointed
out by Arndt, a rather uncertain procedure, and should
be made with circumspection. Such a diagnosis is
fully justified, however, when the clinical and histo-
logical data are considered side by side and are cor-
related to one another, as was done in the present
instance.
2. Traumatic Pulsating Exophthalmos. — William
Zentmayer says there can be little doubt that in the
majority of cases of traumatic origin the lesion is a
rupture of the internal carotid in the cavernous sinus,
and that the dilatation of the ophthalmic veins and of
the nasofrontal and angular veins is the result of the
venous stasis thus created. It therefore seems logical
to seek to prevent the stasis rather than to remove
the end-result. An analysis of the 29 cases collected
in this paper shows that the common carotid was
ligated 16 times, resulting in a cure in 7, improve-
ment in 5, and failure in 4. Common ligation of the
common carotid and the ophthalmic vein was done
once, resulting in a cure. Combined ligation of the
internal carotid and facial vein was done once, result-
ing in a cure. Ligation of the orbital veins was done
once, resulting in slight improvement. Slow ligation of
the carotid was done twice, resulting in one cure and one
slight improvement. Ligation of both carotids was done
once, resulting in failure. Compression of the carotid
208
MEDICAL RECORD.
[July 29, 1916
and internal treatment was followed in four cases, re-
sulting in cure in two cases, improvement in one, and in
one the result was unknown. Gelatin injections were
used in one case, resulting in a cure. There was no
treatment in six cases.
3. Some Technical Features of Laminectomy for
Spinal Disease and Injury. — Charles A. Elsberg. (See
Medical Record, July 1, page 34.)
4. Some Bodily Changes During Anesthesia. — Frank
C. Mann presents an experimental study and states
that a study of the blood of dogs subjected to etheriza-
tion demonstrated the following facts: The amount
of circulatory blood is diminished about 10 per cent,
after from six to nine hours of light etherization.
There are variations in the cholesterin values, but the
changes are not uniform. The specific gravity does
not change under light etherization, and under deep
anesthesia increases only as asphyxia becomes a fac-
tor. The number of red corpuscles, the amount of
hemoglobin, and the fragility of the red cells do not
change. There is always a leucocytosis in ether anes-
thesia. The degree of leucocytosis varies from a very
slight increase in the number of cells to more than
double the normal number. The increase is usually
present after from three to four hours of etherization,
and is due mainly to cells of the polymorphonuclear
form. The leucocytosis is not dependent on the spleen
and is not prevented by atropin. It is probably the
result of a direct action on the bone marrow. Phago-
cytic action is certainly not depressed by an etheriza-
tion period of from five to six hours.
6. Stab Wounds of the Chest Involving the Dia-
phragm with Diaphragmatic Hernia or Evisceration. —
Charles C. Green. (See Medical Record, July 1, page
36.)
8. Heterophoria in Children. — Wendell Reber sub-
mits figures which would indicate that one in 18o of
all refractive cases will represent a child with an
essential heterophoria, and that one child in 10 that
exhibits muscular imbalance will need some manner
of treatment for its abnormal muscular status. An
analysis of 35 cases is reported. He concludes that
heterophoria in children is in a certain proportion of
cases an entity which must have some kind of atten-
tion. Painstaking consideration of all the general
physical factors is most imperative. Thorough-going
correction of the refractive status is imperative, but in
some cases it is merely "first aid." Exophoria when
intrinsic will probably be best met with weak prisms
(from 1 to 2 degrees), bases out, plus lateral rotation
exercises. Exophoria when intrinsic will often re-
spond to training alone, frequently will need prisms,
bases in (from 1 to 2 degrees), for permanent use,
and rarely comes to operation. Hyperphoria when in-
trinsic almost always demands vertical prisms of from
one-third to one-half the total infinity deviation, and
when paretic will more frequently than any other mus-
cular anomaly justify operative interference.
9. Blood Transfusion, with Special Reference to
Group Tests. — 'Walter V. Brem describes the technique
and rationale of the method of blood grouping and pre-
sents the following conclusions: The practical work-
ing out of our group tests and method of transfusions
has proved most satisfactory. We have determined
the groups of numerous donors and have made Was-
sermann tests on their bloods. Our laboratory keeps
in touch with these donors, who are glad to give sev-
eral hundred cubic centimeters of their blood for a
small amount of money. They come to the laboratory.
and, by the needle and vacuum flask method, we with-
draw the quantity of blood desired, having first co-
cainized the skin over the vein. Some of these donors
have been used many times during four years. They
lose no time from work, the procedure is practically
painless, they feel that the money is easily earned,
and the patient is under no obligation to the donor.
Having our donors classified and knowing their Was-
sermann tests are negative, we are in a position to
give transfusions quickly. A group test of the pa-
tient's blood requires only a few minutes after the
blood is obtained, and then we can summon the correct
donor. The method is simple and easy for everyone
concerned, and the results, as far as I can judge from
the literature, are as satisfactory as from other
methods of transfusion. The defibrinated or citrated
blood is injected intravenously through a needle with-
out previous incision of the skin. The skin is cocainized
at the time of injection.
The Lancet.
June 24, 1916.
1. An Address on Injuries of the Eye and Orbit. Arthur D.
Griffith.
2. Address on Diseases of the Throat. Nose ami Ear. and
Their Treatment in Hunter's Time. W. H. Kelson.
3. The Removal of Adenoid Growths. J. L. Ayraard.
4. Operative Treatment of Osteoarthritis. W. I. deC.
Wheeler.
5. On the Agglutination Reaction of the Bacilli of the
Typhoid-Dysentery Group with Normal Sera. T. R,
Richie.
6. The Causation and Cure of Certain Lunacies. Rupert
Farrant.
7. Annual Report for 1914 of the Registrar General. (To
be concluded.) John F. W. Tatham.
1. Injuries of the Eye and Orbit. — Arthur D. Griffith
says that in analyzing 350 consecutive cases from
active service he finds that 25 per cent, are cases of
active injury to the eye or orbit and 15 per cent, are
cases of a condition that is a rarity in peace practice,
and which may be called "shock amblyopia." This term
is applied to diminution or loss of vision following a
shock in which no structural change is produced in
the eye or optic nerve. The shock is usually from the
explosion of a shell or grenade near the patient,
though it may be due to other causes. In discussing
wounds of the globe the author states that if one eye
is ruptured it should be removed. If both eyes are
ruptured, as a rule, they should be left. He would
rather remove many damaged eyes unnecessarily than
allow one patient to become blind through his fault.
Where one eye is injured, the signs to look for in the
sound eye are photophobia, lacrymation, and circum-
corneal injection. These constitute the picture of sym-
pathetic irritation. If it is decided to remove an eye
there are two ways of doing this, by evisceration or
by excision. The operation which the writer has per-
formed in the majority of cases is an amputation of
the anterior part of the eye, leaving the longest stump
which can be covered by the flap of conjunctiva. Con-
junctiva and Tenon's capsule are divided circularly,
going behind the wound if possible, otherwise excising
it. These membranes are turned back as a cuff for
at least one cm., and the anterior part of the eye
amputated at this level, or farther back if that is ren-
dered necessary by a scleral wound. The contents of
the sclera are turned out and every trace of choroid
removed. An operation which has some place in war
ophthalmology is exenteration of the orbit. This con-
sists of removing the whole of the contents of the
orbit except the periosteum. The object is to provide
the fullest possible drainage for the orbit. The writer
has done this in two instances.
4. Operative Treatment of Osteoarthritis. — W. I.
deC. Wheeler describes the operations which he per-
formed for the relief of crippling osteoarthritis of
knee and the hip joint and shows .r-ray pictures illus-
trating the condition of the patient three years after
the operation. The first operation was performed on
July 29, 1916]
MKDICAL RECORD.
209
the knee joint, the lipping of the tibia being care-
fully removed through a well-marked line of cleavage.
A weight and pulley were attached to the limb for
ten days and massage was administered for a short
time subsequently. A few days after the operation the
joint could be extended and flexed without pain. A
month after the first operation the right hip joint was
opened through Kocker's posterior incision. The cap-
sule was freely opened and, while the hip was rotated
freely in all directions, the newly formed bone was
chiseled away from about two-thirds of the circum-
ference. On the following day pressure on the heel
caused no pain. Eight months afterward the patient
walked without crutches and with perfect comfort.
There are three classes of patients that receive benefit
by operation. Cases in which there is a line of cleav-
age between the new and old bone; cases in which
irregular osteophytes form in connection with the joint
in such a way as to produce ossification in the fibrous
layer of the capsule, and cases of rheumatoid arthritis
in which there is destruction of the joints without
osteophytic outgrowths. This form of the disease is
common in young people and much can be done for
them by the administration of vaccines if the focus
can be found. If the cases are cryptogenic attention
should be directed to the condition of the large in-
testine.
5. On the Agglutination Reaction of the Bacilli of
the Typhoid-Dysentery Group with Normal Sera. — T.
R. Richie states that since the appreciation of the
actual facts regarding "normal" agglutination of the
organisms in the group under discussion is a very
pressing matter in view of the many enteritis cases
to be investigated at the present time, in association
with Dr. Rajoman and Dr. Western, he undertook the
examination of a series of normal, so as to determine
the normal mean agglutination for the bacilli in ques-
tion when examined with the technic in use in their
laboratory (Bacteriological Laboratory of the London
Hospital). The blood of 792 persons was tested, and
none of them, so far as they were aware, had suffered
from any infection by any organism against which the
sera were being tested. The writer describes the
technique which he and his associates used and gives
the following general summary of his conclusions:
1. B. Typhosus. — (a) Complete agglutination in a
dilution of 1-16 should be looked upon with considerable
suspicion. (6) Complete agglutination in a higher
dilution (1-32 or above) should be looked upon as diag-
nostic. B. Paratyphosus A and B. — Complete agglu-
tination in a dilution 1-16 is suspicious, and in 1-32 or
higher may be looked upon as diagnostic. B. Dysen-
teric (Shiga). — Complete agglutination in a dilution
of 1-64 and above should be regarded as diagnostic.
B. Dysenterise (Flexner). — Complete agglutination in a
higher dilution than 1-128 should be looked upon as
diagnostic, but in a dilution of 1-128 or lower it cannot
be relied upon for diagnostic purposes. 2. In the case
of medical students, laboratory workers, and the hos-
pital class of the population, the tables given show that
a larger percentage respond to the test in higher dilu-
tions than do "normal" members of the population.
This must be taken into consideration in applying the
above conclusions.
British Medical Journal.
June 24, 1916.
1. Clinical Lecture on the Right Side of the Heart and Its
Relation to Overstrain. William Russell.
2. The Theory of Blood Pressure Measurement. Leonard Hill
and James M. McQueen.
3. Systolic Pressure in Acute Nephritis. Rodolf G. Aber-
crombie.
4. Congenital Cystic Kidney with Local Diffuse Peritonitis ;
Surgical Destruction of Part of the Kidney ; Recovery.
John D. Malcolm.
5. Memorandum on the Prevention of Amebic Dysentery. J.
I Jordon Thomson and D. Thomson.
6. Causation and Cure of Certain Forms of Lunacy. Rupert
Farrant.
7. The Treatment of Backward Displacements of the Uterus.
(To be continued.) Frederick J. McCann.
2. The Theory of Blood Pressure Measurement. —
Leonard Hill and James M. McQueen call attention to
the difficulties and disagreements met with in the study
of blood pressure measurements and state that in order
to give accurate information on the factors concerned
in blood pressure measurements a scheme must permit
of compression being applied to an artery in a pulsable
and not rigid manner, and a rise of a peripheral re-
sistance pari passu with increasing compression must
be arranged for. When an armlet or bag of Hill's
pocket sphygmomometer is made to compress an artery
where it lies on bone or with little tissue around it —
for example, temporal, dorsalis pedis, aberrant radial —
it deforms the artery and prevents the passage of the
pulse at a pressure less than diastolic. The finger of
the physician acts in the same way, and therefore can-
not estimate the systolic pressure accurately. Com-
pression of the tissues surrounding the artery so as to
block the venous outlets is essential to accurate blood
pressure measurement. This congests the blood be-
neath and beyond the armlet or bag. The pulsing of
the congested mass of tissues renders armlet or bag
capable of delivering a circular compression to the
artery, and one which yields to the pulse and prevents '
deformation of the artery until the systolic pressure is
overtopped. Sufficient area of veins must be blocked
if the blood pressure measurement is to be an accurate
one, consequently the bag or armlet must be broad.
The bag, together with the observer's hand, inclose the
forearm, and so makes the bag of Hill's instrument
equivalent to the armlet. Failure to make the bag
broad enough accounts for many of the inconsistencies
in the literature of blood pressure measurement.
3. The Systolic Pressure in Acute Nephritis. — Rodolf
G. Abercrombie has recently treated at a base hospital
in France several hundred cases of nephritis occurring
among the soldiers, and has taken advantage of the
opportunity thus afforded for the study of the blood
pressure during the acute phases of this disease. He
has found that the blood pressure is always raised
during some stage of the course of the disease, although
not to so great a height as in the case of chronic
nephritis. Wide diurnal variations in the pressure
were usually present, the pressure being highest in the
evening. Associated with this evening rise of tem-
perature there has been paroxysmal dyspnea and head-
ache. Usually the amount of albumin diminished pari
passu with the fall in pressure, although residual albu-
min often pei-sisted after the pressure had fallen to
normal. Sometimes, however, the two curves bore no
relation to each other.
6. Causation and Cure of Certain Forms cf Lunacy. —
Rupert Farrant publishes a summary of his study of
the causation and cure of certain forms of lunacy car-
ried on during the last seven years. He states that it
is a continuation of that previously published on the
thyroid gland in the elucidation of goiter and exoph-
thalmic goiter. This work consists of the microscopic
examination of sections taken from the pineal, pituitary,
thyroid, and sexual glands — first at different ages and
periods of life; secondly, the effect induced in these
glands by the acute and chronic toxemias, and, thirdly,
the changes found in cases of lunacy. From the ex-
amination of some 3,000 specimens it is found that
these glands differ at different ages and periods of
life; with advance of life they tend to atrophy. It is
found that the pineal and pituitary react to certain toxe-
mias, the ultimate result of which is fibrosis. The re-
210
MEDICAL RECORD.
[July 29, 1916
lation of the thyroid to certain toxemias with the in-
duction of hypertrophy, cysts, and adenomata the
writer has already described in a former article. In
primary and secondary amentia, atrophy of the pineal,
pituitary, and thyroid were found in three main groups
of cases. In dementia praecox and other cases of de-
mentia an alteration was found in the glands which
varied with the duration of the case. In some cases of
acute confusional mania, melancholia, manic-depressive,
and other forms of insanity, changes were found
in the thyroid, pituitary, and the sexual glands. The
changes varied from hypertrophy to atrophy. The
pituitary gland was found sometimes to have given
rise to symptoms of hyperpituitarism and ranging to
apituitarism, in idiocy, dementia prascox, and other
forms of insanity. The thyroid gland was frequently
found to be abnormal in children, adolescent, and adult
lunatics. Signs of alteration in the pineal were found
especially in children and adolescents. Alteration was
found in the sizes of the testicles associated with duct-
less gland changes. Pyohhea and carious teeth were
found to be a frequent accompaniment of lunacy in
adults. The writer has deduced that many cases of
lunacy may be classified according to the toxemia pres-
ent and the change that it has induced in the ductless
glands. Alteration in the sexual glands, whether
primary or secondary, leads to altered mentality up to
insanity. The lines on which treatment may be car-
ried out based on this view of the pathology is that
toxemias, if present, should be removed by medicinal
or surgical measures and the glands allowed to involute
if they are hypertrophied, or if they are degenerated
with deficient secretions these secretions should be sup-
plied. Good results may be expected before cortical
brain lesions have taken place.
Berliner klinische Wochenschrift.
March 20, 1916.
Isolated Sclerosis of the Pulmonary Artery. — Hart
states that isolated genuine sclerosis of this vessel in
the young is undoubtedly rare. Not many cases are
on record. Romberg was the first to show that the
lesion may be isolated and unaccompanied by symp-
toms. In 1912 Schneller and Schumacher attempted to
collect the recorded cases, but included numerous cases
which were not strictly isolated. The author recognizes
but five cases, with possibly a sixth, in which there was
a slight sclerosis of the aorta. These agreed not only
pathologically, but clinically — cardiac disturbances
ending in insufficiency, edema, and cyanosis, increased
cardiac dullness to right, murmurs over all valves, with
predominance of mitral, and small and rapid but regu-
lar pulse. The diagnosis was congenital heart lesion,
presenting especially mitral insufficiency. Autopsy
showed a high degree of hypertrophy of the right ven-
tricle, but with fully intact valves and marked sclerosis
of the pulmonary artery. To these five (six?) cases
the author has the rare good fortune to add two more.
1. A woman of 30 came to autopsy with the diagnosis
of myodegeneratis cordis. She was highly dyspneic
and cyanotic and murmurs were heard over the entire
greatly enlarged heart. Xo history was available.
The second case was in a young woman of 25. The
cardiac troubles had begun a half year before and had
rapidly increased until three weeks before she had be-
come bedridden with cyanosis, dyspnea, and marked
palpitation. The symptoms were typical, as L-iven
above, but the diagnosis at the time was stenosis and
insufficience of the mitral. Death soon supervened.
In both cases the autopsy finds were startling, espe-
cially in the second case, in which a positive diagnosis
had been made. The right heart in both cases was
hypertrophic while the left was atrophic and appeared
like a rudimentary appendage. Elaborate studies in
some of the recorded cases showed that the sclerosis of
the pulmonary artery, albeit isolated, differed in no-
wise from the same lesion when part of a generalized
arteriosclerotic process. As for the etiology one pa-
tient had been a heavy beer drinker who had suffered
originally from beer-drinker's heart, a condition which
would throw strain upon the pulmonary artery of a
purely mechanical character. Had some toxic factor
been present other vessels would probably have suf-
fered. An entirely different causal nexus must have
been present in the author's case, in which the left
heart had become atrophic, as is sometimes the case in
mitral disease. Apparently the left heart withers be-
cause of a blood scarcity. The relation of pulmonary
sclerosis to hypertrophy of the right heart is not clear.
Which is primary and which secondary ? The author
holds that the vascular lesion occurs first.
Cystoscopy and Radiation in Inoperable Cancer of
the Uterus. — Heimann states that cystoscopic control
in the radiation treatment of uterine cancer has become
an accepted procedure. The latter is best shown in cer-
tain cases. Thus in a woman of 49 the portio has been
transformed to a cauliflower the size of a hen's egg,
which bleeds freely on contact. Both parametria are
infiltrated, worse on the right. The cystoscope shows
a small bladder, markedly bulging over at the trigon.
Marked transverse folds, tumefied. Mucosa injected.
Ureteral openings cannot be brought into view. After
the combined use of mesothorium and deep radiation,
the cancer vanished, the vaginal walls came together,
the bladder had improved so that both ureteral orifices
could be brought into view. In a second case a similar
condition of the bladder became almost normal after
the disappearance of the cancer. The improvement in
the situation, size, and condition of the bladder does not
always run parallel with the improvement in the can-
cerous growth. When the condition of the bladder is
one of parietal edema the viscus may return to its
normal condition save when the growth of the cancer
has caused deep-seated changes in the vascular ap-
paratus. When these are severe we find the so-called
bullous edema, as the lymph, no longer able to escape,
causes a detachment of the epithelial layer. Beyond
this comes actual perforation. All kinds of results are
seen in the course of radiation. The edema may dis-
appear, remain unchanged, or grow worse. Bullous
edema has been seen to disappear after radiation. As
is known, the state of the bladder is a factor in deter-
mining operability. In regard to the infiltrated para-
metria these become softer after treatment in favor-
able cases. In one of the author's cases an initial suc-
cess was not maintained and matters rapidly changed
for the worse. But whether treatment is of benefit or
not cystoscopic control is equally serviceable.
Old Substitutes for Scarce New Remedies. — Servoss
thinks that the scarcity of syntheties is not an un-
mixed evil. Some old forgotten resources may now be
profitably revived, such as cok-hicum for rheumatic af-
fections, which with alkalis can in part replace the
salicylic derivatives. Aconite and veratrum have been
neglected for coal tar antipyretics, and the same is
true of henbane and lobelia as antispasmodics. We no
longer use conium or gelsemium, although they can
often replace morphine, while hyoscine properly given
is a better hypnotic than sulphonal or veronal. The
author sees no harm in borrowing from the selective
materia medica under the circumstances. We should
make a trial of it, at least, and if any remedies are
dependable credit should be given where it is due.
lie makes this suggestion fully realizing that it will
not be popular with the profession, who, however, are
slavish in their attitude toward foreign manufacturers.
— Indianapolis Medical Journal.
July 29, 1916]
MEDICAL RECORD.
211
£<irirtjt Sfejinrta.
AMERICAN NEUROLOGICAL ASSOCIATION.
Forty-second Annual Meeting, Held at Washington,
D. C, May 8-10, 1916.
The President, Dr. Lewellys F. Barker of Balti-
more, in the Chair.
Monday, May 8 — First Day.
War and the Nervous System. — Dr. Llewellys F.
Barker of Baltimore delivered this address, saying
that as the result of the studies which had been made
during the present European war our knowledge had
been enlarged in reference to organic nervous lesions,
functional nervous disorders, psychiatry, and normal
psychology. So far as wounds of the brain and spinal
cord were concerned, the accepted views regarding top-
ical diagnosis were being corroborated, it had been
established that certain organic lesions of the central
nervous system might be caused by modern high ex-
plosives without external wound. Surgeons were unan-
imous in urging the thorough investigation of every
head wound, no matter how trivial it might at first
seem to be. As regarded the peripheral nerve injuries,
it had been shown that loss of power due to section of
tendons or muscles might sometimes be confused with
paralysis due to lesions of the nerves themselves. Con-
trary to what many had expected, nervous states not
due to organic lesions, though fairly numerous, had in
reality made up but a very small proportion of the total
number incapacitated by the war. All the well-known
types of the functional nervous disturbances had been
met with. While the number of simulators and ma-
lingerers was large, those more experienced in the psy-
choneuroses believed that the number of true, or vulgar,
simulators was very small. It had been pointed out
that malingering was itself a psychological symptom.
As regards the psychoses, it was surprising that such
a small number of cases of insanity had been reported.
It was asserted that the majority of soldiers in whom
psychoses had been observed either had had symptoms
of the diseases before the war or had given definite
evidence of predisposition to mental disorder. The evi-
dence seemed to favor the view that the human ner-
vous system was to-day better able to stand strain than
ever before in its history.
The Differentiation and Organization of Sensations.
— Dr. Stewart Paton of Princeton, N. J., read this
paper, in which he said there were two points he
wished to emphasize as the result of observations upon
the embryos of some of the higher vertebrates: First,
the great necessity of looking at the neurological phe-
nomena from a broad biological standpoint. Second,
he wished to emphasize, if possible, the great value that
came to us from a study of comparative neurology.
In the chick embryo of 55-57 hours of incubation
he had found the motor half of the reflex arc de-
veloped far in advance of the sensory half. This
tract was developed from the lower caudate quarter of
the cord up to the level of the third nerve. At 120
hours one could follow the development of the third
nerve to its tei-minal distribution. Evidently this was
an ancestral inheritance. The sensory half of the arc
was very gradually superimposed upon the motor sector.
When the embryo first responded to stimuli from the
outside world we found that the first organ to come in
and modify our responses was the thyroid; a little later
the adrenals. At this period, 120-125 hours, there was
a perfectly enormous differentiation in the sympathetic
nervous system. Only very much later did the sex or-
gans apparently come into the neural circuit.
Neuraxial Differentiation of the Fibers from the
Horizontal and the Fibers from the Vertical Semi-
circular Canals, Demonstrated by Means of the Barany
Tests. — Drs. Charles K. Mills and Isaac H. Jones
of Philadelphia prepared this paper, which was read
by Dr. Jones, who said that no matter where the pri-
mary seat of the affection which caused vertigo might
be situated, whether in the stomach, kidney, liver, pan-
creas, tonsils, or the brain outside of the vestibular ap-
paratus, the resulting toxemia, the abnormal nervous
stimulus, or the cardiovascular did not produce vertigo
until the vestibular apparatus — the labyrinth and its
associated pathwavs and encephalic centers — was in-
volved. The Barany tests furnished them with the
means for studying this vestibular apparatus. These
tests enabled them to say with more positiveness that
an intracranial tumor, abscess, or other lesion was
situated in the third ventricle, the cerebellopontile
ang.e, was limited to the pons or the cerebellum, or was
labyrinthine. Cajal had shown histologically that fibers
from the vestibular portion of the eighth nerve en-
tered Deiter's nucleus and continued from the inferior
cerebellar peduncle into the cerebellum itself. This
tract had been generally recognized and accepted. The
writers believed (1) that this path included the fibers
from the horizontal semicircular canals exclusively, and
(2) the fibers from the vertical canals had an entirely
different course. The former were confined to the ob-
longata, while the latter ascended into the pons. In
thirty-two cases in which the labyrinths themselves and
the eighth nerves were normal and the horizontal canals
gave normal reactions, the vertical canals failed in some
or all of the well-known responses. That the labyrinths
themselves were normal was made probable by the
presence of perfect hearing, and corroborative evidence
of neuraxial lesions was additional confirmation. In
five cases stimulation of the vertical canals produced no
nystagmus, no vertigo, and no falling, and yet violent
projectile vomiting occurred. This showed that the
vertical canals themselves were functionating; in fact,
there was even a hyperactive response of the tenth
nucleus to the stimulation of the canals. In one case
in which the lesion was clearly thrombosis of the right
posterior, inferior cerebellar artery the right horizontal
canal failed to respond normally, whereas reactions
from the right vertical canals were normal. They be-
lieved that the ear stimulus which produced vertigo
passed to the cerebrum through the cerebellum. While
the paths which carried vestibular stimuli through the
cerebellar to the cerebrum were not demonstrated abso-
lutely in all their extent, the facts at their disposal ap-
peared to indicate that they were received by the cere-
bellum through the inferior cerebellar peduncle from
the horizontal canals and the middle cerebellar peduncle
from the vertical canals, and after completing their
cerebellar itinerary pass to the cerebrum by way of the
superior cerebellar peduncles. In the experience of the
writers interruption of the impulses from the vertical
canals was produced by tumors of the cerebellopontile,
internal hydrocephalus causing pressure on the floor of
the fourth ventricle, and intracerebellar tumors causing
pressure on the pons. Finally, they were confident that
the fibers from the horizontal canal and the fibers from
the vertical canals had separate pathways in the neu-
raxis. That the horizontal canal fibers were confined
to the oblongata and entered the cerebellum through the
inferior peduncle and that the vertical canal fibers as-
cended into the pons and entered the cerebellum through
the middle peduncle, however, they believed to be highly
probable, but felt that their evidence to date was not
sufficiently large to indicate with confidence the exact
course of these fibers.
Sensory Disturbances of Cerebral Origin. — Dr.
Alfred Gordon of Philadelphia read this paper, in
which he presented the records of nine anatomoclinical
cases distributed as follows: Four cases of cortical le
sions, three of capsular, one of thalamic, and one of
pontine lesion, and called attention to the special char-
acteristics of each of these groups and the differentia!
features in regard to the sensory disorder. He found
that the generally adopted views concerning sensory
disturbances of cerebral origin did not always present
the real condition. For example, in one of his cases
there had been a large hemorrhage strictly limited to
the parietal lobe, nevertheless there had been a hemi-
plegic condition on the opposite side. Also in a case
with involvement of the very posterior portion of the
internal capsule which was supposed to be purely sen-
sory in function there had been no sensory disturbances
at all during life. His conclusions from this study were
that, in spite of the generally accepted views concerning
sensations of cerebral origin, certain conservative reser-
vatons should be made whenever diagnostic deductions
were to be made.
Dr. David I. Wolfstein of Cincinnati said that a
colored man had come into the receiving ward but had
not been admitted because nothing could be recognized
He had come a week later, and it had been found that
he had localized convulsions of the face and arm and
there was very complete arteriosclerosis. He also had
a loss of the position sense and impairment of the lo-
calizing sense. The ;r-rays showed that he had been
stabbed in the head with a penknife and that a piece of
the blade was extending into the precentral convolu-
tion. The blade was extracted and the man recovered
promptly from the convulsions, but the arteriosclerosis
and the disturbance of the sensations remained as be-
fore.
212
MEDICAL RECORD.
[July 29, 1916
Dr. Herman H. Hoppe of Cincinnati said that he re-
called a case of tumor in the arm center in which the
first manifestation had been pain in the tip of the
tinger, this disturbance of sensation preceding the Jack-
sonian seizures. The tumor had been located in such a
way as to cover both the ascending and the parietal
lobe. It was impossible to tell where it originated.
Some Unusual .Features of Jacksonian Convulsion. —
Drs. Samuel Leopold and E. Murray Auer of Phila-
delphia, in a paper prepared by them and read by Dr.
Leopold, reported a number of cases showing unusual
features of Jacksonian epilepsy. Diphtheria had been
the etiological factor in one case. Unilateral sensory
phenomena associated with hydrocephalus had been
noted in one of the cases. The presence of thalamic
pains, together with Jacksonian convulsions, verified by
necropsy, constituted one of the unusual manifestations.
Jacksonian convulsion had occurred in cases with the
lesion located at a distance from the motor cortex. The
peculiar manifestations of Jacksonian attacks in syph-
ilis were noted in two cases.
Spasmodic Tic Produced by Cerebellopontine Tumors.
— Dr. Harvey Cushing of Boston read this paper, stat-
ing that a patient had been sent to the Brigham Hos-
pital with the diagnosis of right parietal tumor pro-
ducing Jacksonian attacks of the left face. His assistant
arrived at the same conclusion on seeing the patient.
It seemed typical. The patient was conscious and could
turn his head, even though the attack was going on.
He was very certain on two or three occasions that the
attack and spasm, with the sensory disturbance which
he said came with it, had spread into the arm and side.
In going over him carefully it became evident that this
was a cerebellopontine tumor of the usual type, and
upon operation a tumor had been found relatively early
and removed in so far as one was justified in removing
these things, leaving the capsule. In a series of fifty
to sixty pontine cases this had been the only case in
which he observed these definite attacks, and this began
originally as nothing but a little blepharospasm of the
left eye. He had been having attacks every ten minutes
when he came in. They subsided after operation. Here
was a peripheral lesion which caused weakness in the
face, but less commonly produced spasmodic tic, which
might be mistaken for Jacksonian attacks. Since that
he had seen one other example of almost exactly the
same kind.
Dr. J. Ramsay Hunt of New York said that he had
in his papers upon the sensory route of the facial nerve
emphasized the production of reflex spasms of the face.
He had had a series of cases of reflex quiverings and
spasms of severe degree. In one case there had been
spasm of the auricular mechanism only. Evidently only
certain cells of the facial nucleus had been in a state of
excitability. Therefore he did not think these cases
necessarily depended upon pressure upon the pons.
Dr. W. G. SPILLER of Philadelphia said that some
years ago Dr. Mills had had a case of spasm confined
to one side of the face which at necropsy showed tumor
of the cerebellopontine angle. Dr. Spiller had had a
case of a man struck on the right side of the forehead.
He said that the eyelids of both sides were affected.
Dr. Jones concluded that there was a tumor of the cere-
bellopontine angle, and this was confirmed by necropsy
Dr. W. B. Cadwalader of Philadelphia remarked
that in a case which he had observed there were clonic
movements of one side of the face without loss of con-
sciousness. It was decided that there was probahlv a
cerebellopontine growth, and autopsy showed an endo-
thelioma a short distance anterior to the eighth nerve.
Stock-Brainedness. The Causative Factor in the So-
Called Crossed Aphasias. — Dr. Foster KENNEDY of
New York presented this paper, in which he said that
the cause of the indecision in regard to the location of
the speech centers, and, therefore, the causation of the
aphasia, lay in the fact that apparently irrefragable
evidence could be produced by the protagon'sts of each
of the different views. The cases used to disprove th"
validity of Broca's area only impugned tic theo
constant conjunction of riirht-braincdness and left-
handedness. or vice versa. The conviction had grown,
therefore, that there was truth in both dogmata,
that adequate explanation of many anomalous cases
could not be given without the iniection into the argu-
ment of some new factor not .-is yel brought under
tiny. The author desired in the most tentative fashion
to suggest that, the simple statement that a given n:i-
tient was right- or left-handed was no' adeanate i;
light of some cases to be mentioned later. No more in-
formation than was contained in this somewhat bald
announcement had been given by any of the writers on
this topic saving Byrom Bramweil, yet it would appear
that not only by investigating the question of a patient's
handedness but also the prevalent type of handedness
in his stock would throw light on a very obscure chap-
ter of neurological medicine. In the literature of
aphasia one found that but few cases disagreed with
tlie general hypothesis that in right-handed persons the
centers of language were situated on the left side of
the brain. In the few instances where aphasia had re-
sulted from injury to the right brain, some anomalous
and adventitious circumstance had usually been brought
forward to account for the situation. It would appear,
then, that from the cases reported in this paper this
trend, when present in the stock, might produce in the
few right-handed individuals of the sinistral stock a
condition of brain similar to their collateral relatives
and ancestors, with the result that the speech area in
such persons came developed in an ectopic position.
Dr. Hugh T. Patrick of Chicago said that about
thirty-three years ago, when he was a medical student,
Dr. janeway gave a sort of rule of thumb in deciding
on who was right-handed and left-handed, a rule which
seemed to work pretty well; that is, that a left-handed
person must be a left-handed writing person. All other
activities were of less importance.
Dr. Joseph Collins of New York City said that it
was currently reported or spoken of in literature that
the majority of children were left-handed. That was
widely believed. However, credible statistics showed
that only about 5 per cent, of adults were left-handed.
There must be a serious mistake on one side or the
other. He was inclined to think that it was on the side
of those who believed that children were all left-handed
or that the majority of them were left-handed. Second,
to all rules there were exceptions. It was quite pos-
sible that some of these cases referred to by Dr. Ken-
nedy were exceptions to the rule, which was that the
speech area of left-handed individuals was on the right
side of the brain. Third, if Dr. Patrick would sub-
stitute fighting for writing he would agree with him.
If a man fought with his left hand he was left-handed.
If a man did the primitive things of life, the things
that were necessary in order for him to continue his
activities, he was a left-handed individual. Dr. Collins
said that he was left-handed, but did all such things
as writing, golf, and drawing with his right hand ; in
striking, at least in doing any of the fundamental
things, he was left-handed. He was inclined to believe
that the executive speech area might be vicariously as-
sumed by areas of the brain adjacent to the injured
part of the brain, which would explain the majority of
cases which were exceptional to the generally estab-
lished rule.
Dr. E. B. Angell of Rochester, N. Y., said that some
years ago a woman of thirty-two had come to autopsy
for brain tumor. As a child of five she had thrombosis
of two-thirds of the operculum and part of the motor
tract of the left side. As a child she had been right-
handed. As the result of the hemiplegia and loss of the
power of the right arm she had to develop the left hand.
She regained the power of speech. At the autopsy were
found the remains of the destructive process of the old
thrombosis. The right side corresponding to the right
operculum and the right motor hemisphere were much
enlarged. The cortex was much thickened, showing the
influence of the change from right to left as she grew
up to womanhood.
Dr. Charles K. Mills of Philadelphia said that he
felt more like responding to the discussion by Dr. Col-
lins than to the paper by Dr. Kennedy, although both,
of course, vent together. There was nothing he dis-
liked so much as to disagree with Dr. Collins, as every-
body knew, but he thought Dr. Collins was altogether
wrong about this thing of the primitive instinct of
preservation. This did not have to do with the facultv
of speech and development of one or the other hemi-
sphere. It was the educational acquirements of the
brain that had to do with this. It was very true that
Dr. Collins might be able to hit nit with his left hand,
but he would say that the probabilities were that he hit
out with both sides of his brain, with speech as well as
in other ways. He believed Dr. Kennedv had really the
right explanation. If you had the inheritance of speech
through many generations with the inheritance of right-
handedness, the left-handedness in a given generation
was then sort of an accidental deviation, so to speak.
and it didn't have the force that it would have had if
the left-handedness had been inherited through many
generations.
July 29, 1916J
MEDICAL RECORD.
213
Dr. J. Ramsay Hunt of New York City said that, in
the interest of harmony between Dr. Mills and Dr.
Collins, he would suggest that Dr. Collins was both
ngnt una wrong; that some of his functions he per-
formeu Willi tne cortex ana some with the globus pal-
iiuus. Many ox the acts, for instance fighting, must be
referable 10 ihe automatic mechanism. So we saw that
a man could be rignt-sided in regard to the globus
pallidus.
Dr. Bernard Sachs of New York City said that it
was a fact that the majority of children weie, in the
ordinary sense, born ambidextrous, and the important
thing was that most people became later in life abso-
lutely right-handed. Another point was that the loss
of speech defect was associated with loss in both hemi-
spheres about equally, and it was jnly later in life that
liie preponderance of the left hemisphere had become
well established. He believed there were different
groups of cases. The ordinary child born ambidextrous
could be made a right-handed child. There were some
individuals who never could be made right-handed. He
positively beneved that the larger number of people
were rignt-handed because they were made so by edu-
cation.
Dr. W. G. SP1LLER of Philadelphia said that he had
had occasion to examine a child bearing out Dr. Saeh's
statement. A child born right-handed had been burned
in a gas flame and had been unable to use the right
hand for five or six weeks. During that time he used
the left hand, and when the bandage was removed con-
tinued to use the left hand. It required training to in-
duce the child to resume the use of the right hand.
Undoubtedly, if the effort had not been made to train
the right hand the child would have continued using the
left hand.
Dr. FRANCIS X. DERCUM of Philadelphia remarked
that if his recollection served him correctly, the right
side of the child was larger at birth. He thought there
was more muscle tissue in the right side than in the
left. It could not be merely a matter of training, but if
the right hand was injured the left hand was trained.
Dr. Harvey Cushing of Boston said that he thought
it might be of interest to call attention to a fact that
was well known that right- and left-handedness wen;
back into other forms of life than mammals. It was a
matter that was of interest even to Leonardo da Vinci,
who made a study of spirals. Occasionally there was
a left-handed reversal of this form. In certain shells,
perhaps one out of ten thousand, there was a left-
handed spiral, all the remainder being right-handed.
Then, too, he believed that parrots were right-handed,
or right-clawed, as a rule, and whether or not any ex-
periments had been made to ascertain whether this
could be altered by removal of speech he did not know.
Dr. Alfred Reginald Allen of Philadelphia stated
that the blood supply of the human being and most
mammals and vertebrates was not symmetrical with the
vertical axis. It was probable that the left S'de of the
brain might get a better blood supply than the other
side of the brain.
Dr. Isaac Adler of New York said that he had been
making some cranial measurements and ran across a
peculiar relation of the right hemisphere. In the right-
handed person the right parietal lobe was more promi-
nent than the left. In the left-handed person it was
not so. It was about equal. The conclusion was that
most left-handed people, therefore, were ambidextrous.
The Effects of Laminectomy and Simple Exposure
of the Cord Upon the Reflexes and Upon Some Symp-
toms of Spinal Disease. — Dr. Pearce Bailey and Dr.
CHARLES A. Elsberg of New York City prepared this
paper, which was read by Dr. Elsberg, who stated that
in a large number of spinal operations remarkable
changes in the skin and tendon reflexes had been ob-
served. Laminectomy and exposure of the spinal cord
frequently had a marked influence upon the symptoms
and physical signs of spinal disease. In some instances
complete and permanent relief had followed the opera-
tion.
Dr. E. Sachs of St. Louis said that there were two
points which struck him forcibly; that was, that these
changes lasted only at most forty-eight hours, fre-
quently only twenty-four hours, and in the second place,
that, with one or two exceptions, most of the changes
he recorded were changes in which spasticity improved
to the point of normal reflexes or in which normal re-
flexes subsided and became really subnormal. He would
like to ask Dr. Elsberg whether a possible exDlanation
might be that it was due to a temporary loss of cerebro-
spinal fluid. He thought that it had been demonstrated
pretty conclusively that it took from welve to forty-
eignc Hours for cerebrospinal fluid, if it had been lost
in a considerable quantity, to reform. In the second
piace, these symptoms that he had described migut be
uue to a cutting of the inhibitory influence of the cen-
tral nervous system. Might it not be that the tempo-
rary removal of the cereDrospinal fluid opened these
central paths again and in consequence the inhibition
of the central nervous system came into play again?
Dr. James J. Putnam of Boston said that he should
like to call attention in the first place to the fact that
mtzig many years ago reported certain effects due to
laying bare the cortex of the brain. Simpie exposure
had a very considerable effect. A great many years
ago Dr. Putnam had had under his care a patient with
an intramedullary spinal tumor which had been operated
upon by Dr. Keen of Philadelphia, with the result of
tnuliiig that nothing could be removed. Then the pa-
tient went on with complete paralysis of his leg and
then he developed very intense, almost unbearable pain
in the arms. Dr. Warren then operated again. He
could not say exactly whether the operation had been
done in the cervical region, but he thought not. He
thought that the idea was that a free exit should be
obtained for the cerebrospinal fluid and the other opera-
tion had been done in the dorsal region. At any rate,
the spinal canal had been reopened and, to their great
pleasure and surprise, the patient's pain went away
and never came back again as long as he lived. He had
done, as Dr. Putnam dared say others had, quite a
good many lumbar punctures for the relief of dizzi-
ness. In trying to explain the favorable result in these
cases he could not find any better way to account for it
than that it broke up the habit of the nervous system.
He thought there was distinctly such a thing, and knew
there was as regards functional nervous disorders, and
he thought there might be as regards the organic
processes of what we might call state or habit; and it
happened now and then that, when some considerable
influence came into temporary play changing this, the
set character of the process that was going on might be
altered. At any rate, in a great many kinds of con-
ditions one saw results that could not be explained
under any other hypothesis.
Dr. Foster Kennedy of New York said that he would
ask if Dr. Elsberg did not consider that in an operation
done on the spinal region or any operation a great many
factors entered into the procedure. One of them was
essentially the anesthetic. He thought he had seen in
cranial cases, as well as in spinal cases, when the pa-
tient was coming out of the anesthetic, that the reflexes
were abolished, and he had seen an extensor plantar re-
flex and so-called Babinski sign not change to flexor
but become absent and later reappear as before. He
would suggest to Dr. Elsberg the question as to whether
or not the anesthetic had any influence.
Dr. Francis X. Dercum of Philadelphia said that thi=s
discussion recalled to his mind some experiences he had
had with the late J. William White at the Philadelphia
Hospital quite a number of years ago, in which they
noted a quite persistent improvement in several of their
cases for which they could not account. They had found
no lesion in the cord and the patients simply got better
after the laminectomy. Dr. White and himself wrote
a paper upon the subject, entitled "The Value of Opera-
tion Per Se." They thought it due to some unexplained
improvement of nutrition, something that brought more
blood in the healing process to the wounded cells, and
that the nutrition of the cord itself was raised and some
restoration of function followed.
Dr. E. W. Taylor of Boston said that some work
that he had been doing for a couple of years might per-
haps throw some side light on this question. In cases
which had been anesthetized, no matter what the op-
erative procedure, invariably the acetone and diacetic
acid varied anywhere from 36 to 72 hours, and the mus-
cular and mental activity of these patients was pretty
near parallel with the persistence and amount of aci-
dosis, and he would feel that the change noted in these
cases was one of depression and that perhaps an inves-
tigation along the line of acidosis in the changes in the
reflexes would be fruitful.
Dr. Joseph Collins of New York said that he
thought that the explanation that Dr. Taylor had just
given was the proper explanation and the one that
would stand the test. He would suggest, therefore, and
would put this in practice in his own cases hereafter,
that the bicarbonate of soda be given in moderate sat-
uration, as he understood that that was the surgical
procedure in order to diminish the acidosis. He thought
214
MEDICAL RECORD.
[July 29, 1916
he ought to say that in a considerable number of cases
of laminectomy done by Dr. Elsberg for him there had
been no improvement whatsoever in any of the morbid
manifestations of disease.
Dr. Charles A. Elsberg of New York City said that
they had also a theory to explain these symptoms, but
did not think it was worth very much more than the
other theories proposed. It was purely theorizing. They
had investigated these cases from various viewpoints.
They had, for example, watched the condition of the re-
flexes in a considerable number of patients who had
been under prolonged anesthesia not only after opera-
tions on the cerebrospinal system, but other operations,
and had seen suppression of the reflexes for a few hours
until the patient was fully awake, but never after that.
They thought very much over the question of whether
the escape of cerebrospinal fluid had anything to do
with it. One must remember that in opening the dura
he is exposing the cord to a higher pressure than it had
before. In addition to that he had injected considerable
amounts of saline solution just before the cord was
closed in order to have it full of cerebrospinal fluid, and
it showed nothing different from those in whom the
spinal fluid had escaped. The question of acetone was
one that he was unable to speak about. He had exam-
ined a number of patients who had acetonemia and that
had regularly a depression of normal reflexes.
Progressive Atrophy of the Globus I'allidus. A
Special Form of the "Paralysis Agitans Syndrome"
Occurring in Early Life and Associated with Atrophy
of the Cells of the Globus Pallidus.— Dr. J. Ramsay
Hunt of New York City read this paper, stating that
paralysis agitans undoubtedly included a variety of
types which were related clinically but which must pre-
sent differences in the localization and character of the
underlying pathological lesion. In the present study an
effort was made to isolate a special group of paralysis
agitans cases, namely, the juvenile type, on the basis of
certain definite changes in the motor cells of the corpus
striatum. In one case which was studied the sole lesion
was atrophy and disappearance of the large motor cells
of the globus pallidus system. The globus pallidus sys-
tem was the motor center proper, while the neostriatum
(caudate and putamen) formed an inhibitory and co-
ordinating cortical mechanism. The mechanism which
was involved in this disease was the motor or afferent
system of the globus pallidus. A destructive lesion in
the case of the globus pallidus produced not only pa-
ralysis of certain automatic and associated movements,
a slowness of movement and loss of motor initiative but
a great increase in muscular tonus as well. An affec-
tion of the small-cell system of the neostriatum released
the motor mechanism of the globus pallidus from con-
trol, and there resulted the phenomena of the chorea of
Huntington. A destructive lesion of both types of cells
produced chorea, athetosis, spasms, rigidity, and tremor
in various combinations.
Dr. B. Sachs of New York said that he was abso-
lutely in sympathy with Dr. Hunt's efforts to separate
some of the groups of paralysis agitans. One of Dr.
Hunt's cases he had had an opportunity to study. The
case of this boy had impressed him at the time by the
fact, and he had made the statement, accordingly, that
here was a case of paralysis agitans appearing in early
life and with some of the symptoms that we ordinarily
associated with disseminated sclerosis. In other words,
when the disease occurred in early life, it had some
of the symptoms which we knew always occurred in
early life, although the other disease appeared later in
life. He had no right, nor had he the desire, to deny
that it might be due to changes in the globus pallidus
and that there might be some explanation for the lesions
in other cases of paralysis agitans. These changes in
the globus pallidus were the only changes that Dr. Hunt
was able to put his finger on. There was danger of
making that the seat of the chief pathological lesion.
The question arose whether they were not simple ter-
minal changes? Had they any actual causative rela-
tion to the disease which had lasted twenty years? In
a case cif this sort it wou'd be absolutely necessary to
see tin- anterior pole of the brain and the very lowest
part of the spinal cord in order to be sure that we had
ally got at the chief changes underlying the disease.
Dr. J. Ramsay Hunt of New York said that, of
course, this was only one case; but one case, if thor-
oughly studied, was as good as a thousand, and he felt
that he was right. As to the diminution of cells, he
had been very careful in making comparison with the
normal count, not just guessing. Then the cells showed
all the changes of chronic atrophy. Now, of course, if
he had suddenly presented such a case and asked his
hearers to believe that it was because of paralysis agi-
tans, they might wonder. Wilson had come very near
it with Wilson's disease. Here was a disease involving
the caudate nucleus that immediately threw a light on
that reflex. There were two great cell groups here, the
large cell group of the globus pallidus and a smaller
group. Then the phylogeny and anatomy all favored
such an idea. These tracts of the system developed very
early in the life of the fetus.
Werdnig - Hoffman, Early, Infantile Progressive
Spinal Muscular Atrophy. — Dr. M. A. Bliss of St.
Louis read this paper, stating that an apparently
healthy and intelligent child, who had made the normal
progress of an infant for the first few weeks or months
of life, began without sudden onset, and without obvious
cause, to lose power. The weakness was first noticed
in the legs and in the hips ; as the disease progressed
the lower portion of the back became so affected that
the child was no longer able to sit up. The disease pur-
sued a progressive course, the shoulders, thighs, upper
arms, forearms and legs being successively involved,
and finally the muscles of the hands and feet. Fibrillar
twitching of the muscles might be present in some cases.
The limbs were usually absolutely flaccid, and the deep
reflexes were abolished. There was no pain or tender-
ness, and no disturbance or sensation. The disease ran
a slowly progressive course, death taking place from
failure of respiration or bronchopneumonia. Although
pathologically these cases closely resembled the pro-
gressive muscular atrophy of adults, they presented
considerable differences. The disease started in the
proximal muscles, and only later affected the hands.
The atrophy was not so striking as in adult cases; in
fact, the infant often appeared well nourished. Cases
with spastic condition of the legs were rare. He re-
ported in detail the cases of three children by the same
mother, all apparently normal and healthy at birth, but
who fell victims to this disease at the age of about nine
months and died as the result of it before they reached
the age of three years.
Amyotrophic Lateral Sclerosis. — Dr. John H. W.
Rhein of Philadelphia read this paper, in which he
stated that the subject of his report was aged 56. The
symptoms were atrophy of both arm muscles, including
the small muscles of the hand, the flexors and the ex-
tensors of the forearm, biceps, triceps, shoulder girdle,
pectorals, and serratus magnus. There were fibrillary
tremors of both arms. Both sides of the tongue were
atrophied, the knee and arm jerks were exaggerated,
but there was no Babinski sign or spasticity. The Was-
sermann reaction was positive. Death occurred about
a year after the onset. The pathological study was
made of the cord, medulla, pons, internal capsule, basal
ganglia, corpus callosum, and cortex with Marchi as
well as other methods. The results of this study were
presented.
Dr. F. R. Fry of St. Louis said that some years ago
he had reported a classical case of Friedreich's ataxia
in a girl of twelve or fiftten years of age. At a later
period the mother of this girl, who was then about
forty-two years of age, developed amyotrophic lateral
sclerosis. He simply mentioned that little coincidence
as possibly interesting from an etiological standpoint as
to whether this syndrome did not represent the same
kind of amyotrophic tendency that Friedreich's disease
itself was clinically considered to be.
Dr. Samuel Leopold of Philadelphia said that he had
reported on this same subject. In his case the individ-
ual had died within two years. He found some round-
cell infiltration, and, on looking up the subject to see
what relation syphilis had with this condition, found
that in about one-third of the cases syphilis played a
very important role. So that might be "a dominant fea-
ture in these very rapid cases.
Tuesday. May 9 — Second Day.
Familial Spastic Paralysis. — Dr. C. Eugene RlGGS
of St. Paul, Minn., read this paper, saying that the
classical syndrome of this disease was spastic paralysis
of the lower extremities, often involving the trunk mus-
cles, occasionally the upper extremities and sometimes
the face muscles as well. The muscles of the upper and
lower extremities, as in his cases, were hard and re-
sisted passive movements. Reflexes were increased;
ankle-clonus and Babinski were commonly present. Pes
equinus and adductor contractions occurred. Some pa-
tients soon became bedridden, while others might walk
for some time. Optic atrophy might occur; as might also
weakness of the eye muscles, nystagmus, vertigo, idiocy,
July 29, 1916|
MEDICAL RECORD.
215
speech defects, bulbar symptoms, atrophy of the small
muscles of the hand, bodily defects, hyphosis, and scoli-
osis. Sensation was normal, and there were usually no
involuntaries. He reported three cases of the same pa-
rents, in which neither parent was alcoholic or neu-
ritic. They had three other children which did not be-
come affected. The familial characteristics were
clearly evidenced in these patients although no definite
fault could be discovered in the racial line of either
parent.
Dr. John H. W. Rhein of Philadelphia said that
about two years ago before the Philadelphia Pediatric
Society he had described a family very much the same
as that described by Dr. Riggs. There were five mem-
bers, all of whom were affected in the same way. One
child escaped. All these children had developed the dis-
ease in the fourteenth year of age. One of these chil-
dren had died at the age of 14, after a serious convul-
sion. The Wassermann reaction of the father and
mother of the children had been negative. This was the
only generation in which this had occurred. He had
looked up the literature and found the disease reported
in 111 families by some ninety observers.
On the Diagnosis of Subacute Combined Sclerosis of
the Spinal Ccrd Associated with Severe Anemia. — Dr.
William B. Cadwalader of Philadelphia read this pa-
per, in which he stated that in 1913 Dejerine had pub-
lished an article in which he called attention to a certain
type of sensory dissociation observed by him in three
cases of posterolateral sclerosis of the spinal cord, one
of the cases coming to autopsy. The type of combined
sclerosis ran a subacute course and had its origin in an
infection or a toxic process, the nature of which had not
been definitely determined, or was referable to perni-
cious anemia. The author recorded the notes of the his-
tories and the results of examination of nine cases that
he believed conformed to the type of combined sclerosis
of the spinal cord associated with anemia. In each of
these cases there was more or less disturbance of volun-
tary motor power of the lower extremities, with ataxia
and moderate spasticity. The tendon reflexes were ex-
aggerated, and in all but one the presence of a typical
Babinski sign was demonstrated. Two types of sensory
phenomena were recorded, subjective and objective. The
patients all complained of subjective disturbances of
sensation, variously described as numbness, burning,
tingling, coldness and heaviness of the lower extremities
or of the hands. Examination showed that tactile sen-
sation and sensations for heat, cold, and pain were nor-
mal in all but one case. Bone sensation, as tested by
the appreciation of the vibrations of a tuning fork, was
lost or modified in the lower limbs in every case. The
inability to recognize posture of the toes, associated
with diminished appreciation of passive movements of
the toes or fingers, was present in all cases. It was
known that the various deep sensations and stereog-
nostic perceptions passed through only the long fibers of
the posterior columns, and it was the long fiber system
alone that was involved in this type of combined sclero-
sis. It was clear, therefore, that by applying these
known pathological and physiological facts it was pos-
sible in most cases, accurately to determine the location
and extent of the sclerosis when it occurred within the
posterior columns, and, by determining the location and
extent of the sclerosis, a positive opinion as to the
nature of the condition that had produced it could be
given.
Dr. James J. Putnam of Boston said that he was
fortunate enough a good many years ago to see eight
cases and to have four postmortem examinations in
rapid succession and then for many years he took great
interest in this very striking trouble. In the first
place he was rather surprised that Dr. Cadwalader
spoke of a reflex condition, the knee jerks, etc., as ex-
aggerated. That was to say, he spoke of the whole
picture as of being of a spastic trouble even in the
early stages. Certainly in almost all the cases he had
seen, and Dr. Taylor and he at one time reported
fifty, that had not been the case, and, whether it was
that they missed the early stage, he did not know, but
he did not see how that could have been, for he had
seen these patients from the very earliest moment. The
microscopic changes were certainly very striking. He
had seen a very considerable improvement in at least
one of these patients through training similar to that
one used in tabes.
Dr. C. Eugene Riggs of St. Paul said that as to treat-
ment, he had in one or two instances noticed very
marked improvement from the intravenous iniection of
salvarsan. He remembered a patient who had died
recently in which he was able to get the blood count up
io noimal; although the cord symptoms remained the
same. The patient left his observation and some time
ago died. He presumed there had been a return of the
anemic state. He remembered a patient two or three
years ago who could not walk. That patient walked in
a somewhat unsatisfactory manner when he left the
hospital and he had heard of no recurrence of the
trouble. Bramwell stated that he had one case of re-
mission in pernicious anemia which lasted nineteen
years; therefore he thought the patient still needed
watching.
Dr. Charles L. Dana of New York City said that
this seemed to be a disease which was increasing in
this country. Certainly he saw many more cases than
he did a few years ago and not long ago he had re-
ceived a letter from a gentleman in charge of a large
sanatorium in the Middle West in which he said, though
not a specialist himself, that he had a great many cases
of this type coming to his sanatorium. If you saw these
cases very early and recognized their character, not
necessarily by any distinct evidence of pernicious
anemia, for you often don't get that, you could hold
them and sometimes keep them well for years. He had
a patient of this kind now in the fourth year and dis-
tinctly better than when he first saw him. If the cases
went on until they were really established, the patients
almost always died in two or three years. Hence, it
was a matter of extraordinary importance to the neu-
rologists and to the general profession to detect these
cases early.
Dr. L. F. Bakker of Baltimore said that in his ex-
perience there were two extremes of clinical symptoms.
Sometimes the extreme was on the ataxic side, some-
times the spastic side. In other words, sometimes the
degeneration was more marked in the lateral funiculi
and sometimes in the posterior funiculi. The emphasis
on cases occurring without anemia seemed to him im-
portant. He believed it made clear that the cord lesion
was not due to anemia but that the cord lesion and
anemia probably had a common cause. It was a disease
of the whole body. There was another factor which
should always be kept in mind. None of these patients
had acid in the stomach juice. It was a disease, there-
fore, which probably involved the whole body, a very
extensive distribution of lesions and disturbance of
function. It looked as though it were a toxic affair.
Another point he would emphasize was the occurrence
sometimes in families. He remembered distinctly two
instances in which two brothers were affected. He had
seen the best results from large doses of hydrochloric
acid after meals and arsenical preparations internally,
through salvarsan, together with a period of rest and
general upbuilding. He had one man who had been
very well for several years; his hemoglobin had gone to
108 and he was a very robust man. His brother had
died. The patient's hemoglobin was down below 30
per cent, at one time. He could not believe he would
continue well. He thought he would ultimately die of
the disease.
Dr. Hugh T. Patrick of Chicago, presented this
paper, saying that in 1908 Laurans collected nineteen
cases of facial diplegia in multiple neuritis. To this
list the author has added twenty-nine, including his
own, but perhaps two or three of these might be con-
sidered doubtful besides half a dozen that he had taken
at second hand, the original reports not being accessible.
Perhaps the most frequent type was a not very severe
multiple neuritis beginning in the legs, affecting the
arms less, with total facial diplegia. The combination
of complete double facial palsy with less intense involve-
ment of the extremities was the striking feature. In
only one rare instance was the facial palsy partial. But
the degree of quadriplegia was exceedingly variable.
Assuming that multiple neuritis was always caused by
a poison and knowing that certain tissues were pe-
culiarly vulnerable to certain poisons, perhaps it was
equally reasonable to say that certain poisons had a
special predilection for certain tissues. This could not
confidently be answered in the affirmative. But the
negative aspect was interesting. Apparently the most
frequent causes of multiple neuritis did not cause
facial diplegia. No case had been due to a metallic
poison (except probably one of plumbism) and he be-
lieved no case due to alcohol, although one patient had
been a wine dealer. He had found no typical case due
to diphtheria, though of 171 cases of diphtheritic par-
alysis collected by Ross, five showed more or less facial
diplegia and of fifty cases of precocious palatal par-
alysis in diphtheria collected by Rolleston, two had had
216
MEDICAL RECORD.
[July 29, 1916
labial palsy. There was no case following typhoid
unless his first case was one. The most frequently
surmised cause had been influenza but in no case wras
the definitely ascertained and in only four out of thirty-
four cases was it thought highly probable.
Dr. Sidney I. Schwab of St. Louis said that he had
had two cases, one of which died and the other re-
covered, in both of which the bladder and rectal reflexes
were lost. That brought up two points of particular
interest: one was the diagnostic side of these cases,
that was the differentiation from so-called myelitic
processes and, second, the mechanism of the process
itself. It seemed almost a clinical proof, it appeared
to him, of the work of Rose, the experimental work in
regard to which, through the sheath of the sciatic
nerve, material could be carried in certain instances to
the spinal canal. He thought the method by which the
spinal cord was finally attacked was through the sheath
of some of the peripheral nerves. He believed it was
impossible anatomically to procure bladder and rectal
insufficiency purely through the peripheral mechanism.
It was too complicated and there were too many col-
lateral branches and we must conclude that in these
cases there was some definite process which got to the
cord along the nerves which happen to be attacked.
The other feature he happened to know about was the
curious emotional state of these patients. The neuritis
itself might be somewhat insignificant, but in the midst
of this neuritic complication the sudden or even gradual
paralysis caused in these patients, at least in two he
knew about, a most profound emotional disturbance.
The last patient he had became very emotional and very
depressed, slightly maniacal, and with the disappear-
ance of the facial diplegia these symptoms disappeared.
Dr. William G. Spiller of Philadelphia said that he
might add another case of facial diplegia which oc-
curred in neuritis. He had been interested in alcoholic
neuritis. A year or two ago he had had a man in his
service with marked neuritis of the Landry type. There
had been ascending paralysis. He had had marked
diplegia facialis. It was purely alcoholic. He had
been admitted to the "drunk" wards many times. In re-
gard to Dr. Patrick's statement regarding the pos-
sible toxic factor, during the past winter there had
been an interesting case in the Philadelphia Hospital,
that of a boy recovering from tetanus. During the
latter period he had developed facial paralysis. Facial
palsy was fairly common in tetanus. The facial palsy
had developed during the fourth or fifth week from a
draft. He thought that the tetanus intoxication pre-
disposed the lad to the effect of the draft.
Dr. Archibald Church of Chicago said that there
had been admitted to the neurological service at
Michael Reese Hospital last November a young man
who presented the condition Dr. Patrick had outlined,
rather mild multiple neuritis with diplegia. He had
made a searching investigation for the cause of the
disease, although the condition had appeared some two
weeks before his admission. There had been a most
painstaking search of the secretions of the body, spinal
fluid, blood and everything else which was open to
laboratory investigation, but these had been entirely
negative. The causation therefore was obscure, but the
had been excessively fond of candy, to which he had
access, and had eaten one to two pounds a day. After
the onset of symptoms, which were largely sensory at
first, a severe diarrhea developed. He had recovered
rapidly and was discharged in ten weeks able to walk
and feeling quite comfortable. Another case he had
seen many years ago and which had occurred with
acute intestinal disturbance.
Dr. Charles L. Dana of New York City said that
he had watched cases of neuritis in alcohol wards for
twenty-live or thirty years, and there had never oc-
curred a case of facial diplegia. He had been accus-
tomed to look out for that phenomenon because many
years ago he had had a case which fell definitely into
the group that Dr. Patrick had described. This had
been a case of a young man quite well known, a tennis
player, very active, athletic and a moderate drinker,
who had gone down to North Carolina and, while there,
had been exposed to a good deal of cold and wet,
possibly canned food, and had developed a slight degree
Multiple neuritis and very complete facial diplegia.
He had gradually but slowly recovered from his neu-
ritis and almost completely from the diplegia. Dr.
Schwab had spoken of the mental state. Rather curi-
ously, though this patient had been somewhat de-
pressed, he had apparently gotten well. About ten
years afterward he had developed melancholia and shot
himself. He thought the suggestion Dr. Patrick had
made that these things were toxic in character was in
harmony with what we had been believing in regard to
the pathology of paralysis. He had for a long time
considered that it was an infectious neuritis and he did
not see that the fact that a neuritis was unilateral
would exclude infection. We got infectious herpes. It
seemed to him that along that line we should discover
the cause of the disease.
Dr. Smith Ely Jelliffe of New York City asked
what lay behind the individual susceptibility in these
cases? It certainly was recognized that the toxic factor
might be one of the links in the chain, but what about
the nervous system itself? What about the variations
in the nervous system? What about the condition which
Adler had called specific attention to and from that
attitude of mind one must interpret the hysterical
monoplegia of toxic origin, the diplegic cases of bac-
terial origin. In such cases one must go to the hys-
terical side of the mechanism.
Dr. S. Leopold of Philadelphia said that he wished to
place on record a similar case in which the etiology
was clear. It showed the typical facial diplegic and
multiple neuritic phenomena, in which the origin was
given as quinsy. It was known that quinsy was asso-
ciated with streptococci. The etiology might be fairly
closely associated.
(To be continued.)
COLLEGE OF PHYSICIANS OF PHILADELPHIA.
Stated Meeting, Wednesday, May 3, 1916.
Dr. William J. Taylor, Vice-President, in the Chair.
Mental Disease and Mental Defect; Their Magnitude
and Import. — Dr. Owen Copp, Physician in Charge,
Pennsylvania Hospital for the Insane, observed that .t
was a common fallacy of the public mind and especially
of the mind of the legislator, that mental disease and
mental defect might be neglected without serious con-
sequences, which fallacy was grounded upon a deep un-
consciousness of the magnitude of the matter. Mental
disease, though multiform, affected three classes of in-
dividuals: (1) the insane; (2) the feeble-minded, and
(3) the epileptic. Percentages taken from the last
United States census, while not necessarily signifying a
relative increase in the prevalence of insanity, proved
the public burden to be increased by accumulation of in-
sane in institutions more than twice as fast as the gen-
eral population. Figures presented only the average for
the whole country, a wide variation obtaining in dif-
ferent States; for example New York had a ratio of
74 per cent, larger than Pennsylvania in institutions,
and an admission rate of 59 per cent, in excess of Penn-
sylvania, while Massachusetts ratios in excess of Penn-
sylvania's were 75 and 114 respectively. The de-
ficiency of enumeration and provision for the feeble-
minded and epileptic was shown to be greater than for
the insane. The annual cost of the burden of insanity
alone at the conservative estimate of $175 per capita
of insane in institutions in 1910 was presented as
$32,863,425 in all the States of the Union. This, how-
ever, did not show the cost of home care, the loss of
income from productive labor, the handicap of the wage
earner by a dependent in the family, nor the conse-
quences of stress upon relatives with similar inherit-
ance predisposing to mental breakdown. It ignored also
the collateral burden of inefficiency, vagrancy and
pauperism, delinquency and crime, of alcohol and drug
inebriety and associated evils upon the present gen-
eration, to say nothing of the future. Goddard's tragic
story of Martin Kallikak illustrated the possibilities of
harm to succeeding generations. There should be in the
writer's opinion a militant attack upon the whole prob-
lem, the first step in advance should be a definition of
the problem itself and its exact relations to social and
economic conditions. Progress already made by public
and private agencies was noted. There was needed in
every large community a psychiatric hospital, free to
the poor, the center of investigation and diagnosis of
mental abnormalities for the guidance of educators,
juvenile courts and charitable agencies; for short in-
tensive treatment of acute mental conditions on the
plane of the hospital for physical diseases; in affiliation
with the medical school and university for clinical teach-
ing of psychiatry and abnormal psychology that the
future family physician might be retained to foresee,
prevent, and afford early treatment of incipient mental
disease; with its outpatient department to facilitate-
July 29, 1916]
MEDICAL RFXORD.
21?
home tieatment through a social service arm reaching
out inio tne community to promote mental hygiene and
supervise tne after care of the mentally aitected re-
stored Liy treatment in institutions.
Dr. 1'. X. Jjekcum emphasized the importance of the
practical questions in the field of insanity and called
attention to tne lack of facilities for the care of the
mentally defective. The victory of the therapeutics
of insanity was to be gained by an increased knowledge
of its pathology, notably of the role of the internal
secretions and of the autonomic and sympathetic nerv-
ous systems. A still greater victory was to be found
in the prevention of insanity by physiological and moral
living. All causes damaging the germ plasm of the
parent impaired the structure and metabolism of the
descendants. The role of syphilis and alcoholism was
obvious.
Dr. George E. Price observed that it was curious
that the branch of medicine having to do with the
most vital element — reason, had been the slowest in
scientific development. It was scarcely more than 100
years since the first attempt at rational care of the
insane had been inaugurated. He felt that Dr. Copp
in speaking of prevention through education had struck
trie keynote of the problem. The great mass of people
referred to by Dr. Copp, apparently normal, but who
are the victims of an unstable nervous system because
of poor heredity formed the class to be helped by an
understanding of normal living.
Dr. Copp, in closing emphasized the necessity of a
mental patient receiving the same study as that given
any other form of disease, and as a case in point
cited an instance of a young girl who had developed
some mental trouble said to be dementia prajcox, but
in whom by a thorough examination such as would be
made in a general hospital juvenile paresis was re-
vealed. The history showed that the father had died
of general paresis in a hospital for the insane, that
the mother and five brothers were syphilitic. The dif-
ference between the hospital attitude toward mental
disease and the simple care attitude was observed to
be that in the latter, effort ceased with the care of the
father; while in the former, the attempt was made
to prevent infection and to bring others under treat-
ment. That much cou'd be done for the mental pa-
tient was demonstrated in that during the last year
55 per cent of a large admission rate at the Pennsyl-
vania Hospital for the Insane recovered; or, were so
far improved that they could live under ordinary con-
ditions of life. Not only was it not humane to neg-
lect the chronic case, but not economical. Partial re-
generation of nerve centers and development of dormant
energies were possible, thus reducing the cost of care
of the patient and contributing materially to his sup-
port.
Splenectomy as a Therapeutic Procedure. — Dr. Ed-
ward B. Krumbhaar, in an historical outline of splen-
ectomy, said it was one of the oldest abdominal opera-
tions of which the profession had definite knowledge.
It had undoubtedly been practised by the Greeks and
Romans and was continued at rare intervals through
the Middle Ages. With the advent of anesthesia and the
greater surgical skill of the nineteenth century the use
of the operation had been extended to the removal of
the chronically diseased organ. In the past three years
a more active study of the surgical treatment of cer-
tain so-called primary anemias had led to the much
wider application of splenectomy, which type of case
the paper chiefly dealt with. Diseases in which re-
moval of the enlarged spleen was definitely contraindi-
cated included the various forms of leucemia, malaria,
atrophic cirrhosis of the liver, and most cases of tuber-
culosis and syphilis. Too much emphasis he felt could
not be laid upon the necessity of ruling out atypical
forms of leucemia before splenectomy was undertaken.
The presence of a hemorrhagic diathesis should usually
be sufficient to prevent operation, although the repeated
hemorrhages from varices, or other mechanical cause,
as in Banti's disease, were rather indications for opera-
tion than otherwise. In the severer anemias if the
bone marrow were found to be aplastic splenectomv
should not be attempted. The operation had met with
surprising success in Banti's disease, Gaucher's dis-
ease, the congenital and acquired forms of hemolytic
,-aundice, and to a lesser extent pernicious anemia. The
cause of improvement or cure in these diseases he said
was but little understood and was probably different
in different disease. In Banti's disease it was impor-
tant that the operation should be undertaken before the
disease had progressed beyond the first of the three
stages. Before undertaking the operation, however, all
possible causes for the syndrome presented should be
i uied oul so far as possible by a complete, but not
necessarily prolonged, study of the course of the dis-
ease, witn frequently repeated blood examinations.
Prom an observation of reported cases it would seem
wiser to restrict splenectomy in Gaucher's disease to
those cases unusually handicapped by the results of
the disease but which were still good surgical risks,
1 he fieid in which splenectomy had been practised with
the greatest success was undoubtedly that of hemolytic
jaundice. The most important disease to which splen-
ectomy had been applied, on account of its greater
frequency and greater severity, was pernicious anemia,
Altnougn it was still too eariy to promulgate any de-
finite decision upon the value of the operation in this
disease it was possible to base views upon substantial
evidence; although great improvement might be said
to persist in a certain number of cases, in the majority
the effect of the operation was to produce a remission.
The time of operation and the determination of the
case to be subjected to operation were questions which
must be decided after the lapse of time and the ac-.
quisition of more evidence. The operation had already
proved of sufficient value to form the prediction that
such an accumulation of evidence would in time be
forthcoming.
Dr. Edwin E. Graham asked if Dr. Krumbhaar could;
give any information upon the difference in the prog-
nosis in the three grades of Banti's disease, as he had
distinguished them.
Dr. Krumbhaar, in replying to Dr. Graham, recalled
one record in which very good results were found after
splenectomy late in the third stage of the disease when
the patient was very anemic, and with an advanced
degree of cirrhosis and ascites. Further than this he,
could not say.
Dermatitis Caused By Cosmetics and Wearing Ap-
parel, Particularly Those Containing Paraphenylene
Diamin. — Dr. Frank Crozer Knowles observed that it
had been only of recent years that dermatitis of the^
scalp, face, neck, and wrists could be positively ascribed
to irritants, the exact formula; of which were known.
In 1901 Mewborn reported a case of severe, dermatitis
of the face caused by the use of a French hair dye the
active principle of which was paraphenylene diamin.
Apparently the major portion of hair dyes depended
for their action upon this element. The frequency of
the eruption from this chemical could be judged from
the report in the Journal of the American Medical'
Association of eight cases during the first six months
of 1909. Heimann had reported six instances within
the last month. The distribution of a dermatitis in,
the upper third of the face, the swollen eyelids, the.
vesiculation of the rims of the ears were suggestive
of the cause. The reaction frequently occurred several-
days or even weeks after the last application of the
dye. The symptoms of intoxication from paraphenylene
diamin and other poisonous aniline dyes, it was said,
might be divided into (1) Toxic skin eruptions, der-
matitis and urticaria, with great burning and itching;
(2) Gastrointestinal symptoms, such as nausea; (3)
Nervous symptoms, sleeplessness, dizziness, weakness,
of the legs, epileptiform attacks, and syncope. In sev-
eral instances death had resulted and cases had been
reported in which retrobulbar neuritis with impair-
ment of central vision and a central scotoma for red
and green were observed. Damianos had recorded an
instance of chronic poisoning from a hair dye con-
taining this substance used over a considerable period.
Paraphenylene diamin was not the only chemical re-
sponsible for a dermatitis of the scalp and the con-
tiguous parts; instances had been reported in which
resorcin, and "triple extract of heliotrope" had caused
a dermatitis. Foerster had reported a case caused by
the use of a proprietary mouth wash containing forma-
lin; Heimann, an interesting case in which a dermatitis
was caused by the use of a bust developer, the out-
break extending to the extremities, neck and face.
Aurantia or hexanitrophenylamin, used in the staining
of cheap yellow shoes, might also cause an outbreak of
dermatitis. Anilin dyes were often also causal of an
eruption. Attention was called to the danger of der-
matitis from the use of fur dyed with paraphenylene.
The apparent immunity shown by some persons might
be explained by the resistance of the individual or the
perfection of the dyeing process. Since the hair dye.
mentioned was prohibited from sale in France, Austria,
and Germany its toxic properties could be readily ap-
preciated. Olson had made the reasonable suggestion
that if the selling of fur dyed with paraphenylene
diamin were not prohibited by law there should be at-
218
MKDICAL RECORD.
[July 29, 1916
tached a label stating that this dye had been employed.
Since the wearing of fur was so universal it was urged
that the laity in general should be cognizant of the at-
tendant dangers and physicians constantly on the
watch for this etiological factor. As a prophylactic
measure it should be recognized that dyed fur should
not touch the skin.
STATE BOARD EXAMINATION QUESTIONS.
The University of the State of New York.
May, 1916.
Answer a total of ten of the questions on each paper,
but no more.
ANATOMY.
1. Define the following terms: (a) diploe, (b) epi-
physis, (c) medullary cavity, (d) Haversian canal,
(e) tuberosity.
2. Give the origin of the muscles inserted in the
tuberosities and bicipital groove of the humerus.
3. In what vessel does each of the following termi-
nate: (a) lateral sinus (sinus trans versus) , (b) in-
ternal saphenous vein (vena saphena magna), (c) bra-
chial vein (vena brachialis), (d) hepatic vein (vena
hepatica) ?
4. Give the minute anatomy of lung tissue.
5. Name the spinal nerves entering into the forma-
tion of plexuses and state the plexus with which each
is connected.
6. Name and describe (a) the lobes of the liver, (b)
the fissures that divide them.
7. Describe the intercostal arteries and give their
relations.
8. Describe the development of the femur, and state
when (at what time of life) the epiphyses join the
shaft.
9. Describe the endocardium.
10. Describe the spermatic cord (funiculus sper-
inaticus).
11. Name three layers that are differentiated at the
embryonic area in the development of the ovum, and
mention the structures developed from each.
12. What is (a) the cauda equina, (b) the foramen
of Winslow, (c) the optic thalamus, (d) the trigonum
vesicae, (e) the Eustachian tube?
PHYSIOLOGY.
1. Name the automatic centers located in the medulla
oblongata.
2. What is the ratio between the respiration and the
pulse? What is the average measurement of the adult
male chest in (a) deep expiration, (b) complete in-
spiration?
3. Name the superficial reflexes. Describe a test that
may be applied to ascertain the integrity of each of the
superficial reflexes.
4. Explain the physiology of the accepted fresh air
and dietetic treatment of tuberculosis.
5. Name, in order of importance, the avenues through
which the heat of the body is lost.
6. Describe in detail the changes undergone by food
in the stomach.
7. Give in pounds the normal quantity of blood in an
individual weighing 150 pounds.
8. Name the chemical elements that are constant in
the human body.
9. State the function of the secretions of the prostate
and Cowper's glands.
10. What changes take place in the composition of
the blood as it passes through the kidneys?
1 1 . What are the general functions of fat within the
body?
12. Describe the physiology of the contraction of a
muscle fiber.
CHEMISTRY.
1. What are the alkali metals? Give the valences and
the general characteristics of the alkali metals.
2. Describe iodine giving (a) its occurrence in nature,
(b) its properties, (c) its therapeutic uses.
3. What is amy] nitrite'.'
4. Describe a test for lactic acid in the stomach con-
tents.
■r). What are proteins? Where in the body are pro-
teins found? Name the chief proteins.
6. Give a test for (a) glucose in the urine, (b) uric
acid in the urine.
7. Define water of crystallization. Distinguish be-
tween deliquescence and efflorescence.
8. Describe a method of preparation of hydrogen
sulphide. What are the properties of hydrogen
sulphide?
9. Differentiate between alloy and amalgam.
10. What is wood alcohol? Give the formula and the
properties of wood alcohol.
11. What are fatty acids? Name three fatty acids.
12. Give the formula for (a) saltpeter, (b) Chile
saltpeter, (c) blue vitriol, (d) green vitriol.
HYGIENE AND SANITATION.
1. What are the first two duties of a physician when
called to attend a case of communicable disease?
2. What principles must be observed in the safe stor-
age of rain water for a drinking supply?
3. What features should be considered in locating and
constructing a privy on the premises of a village school-
house?
4. Give the maximum period of incubation in each of
the following diseases: (a) smallpox, (b) scarlet fever,
(c) whooping cough.
5. What diseases may be conveyed through cow's
milk?
6. Give the theory of the application of vaccination
against smallpox.
7. Name five diseases that may be contracted by eat-
ing uncooked meat.
8. What five common metallic substances are factors
in the production of occupational diseases?
9. Give in detail the method used in the United States
for accomplishing the registration of marriages.
10. How may Vincent's angina be positively diag-
nosed? With what communicable disease is it most
frequently confused?
11. What are the purposes for which the Binet-Simon
test is employed?
12. What are the two most important factors to be
observed in preventing the occurrence of bubonic
plague?
surgery.
1. Describe gangrene of the foot due to diabetes.
2. Give the symDtoms and the surgical treatment of
the early stage only of tuberculosis of the hip joint.
3. State two effective methods of controlling hemor-
rhage from the popliteal artery, when without access to
surgical instruments.
4. Give the technic of lumbar spinal puncture.
5. Describe the operation of thoracotomy for em-
pyema.
6. Describe a radical operation for epithelioma of the
lower lip (omit aseptic technic).
7. Give the clinical picture of an acute osteomyelitis
of the tibia.
8. What is the treatment of impacted fracture of the
head of the femur?
9. Give the clinical history of a case of chronic ap-
pendicitis.
10. Discuss the surgical management of gunshot
wound of the abdomen.
11. State the most common form of dislocation of the
shoulder, and give Kocher's method of reduction.
12. Describe and diagnose femoral hernia.
ANSWERS.
ANATOMY.
1. Diploe is the cancellous tissue found between the
outer and inner layers of the flat bones.
Epiphysis is a bony process which was developed
separately from the bone and afterwards joined the
bone.
Medullary cavity is the hollow part in the center of
a long bone, and which contains the marrow.
Haversian canal is the central canal of a Haversian
system.
Tuberosity is a non-articular, rough, broad promi-
nence of a bone.
2. To the greater tuberosity of the humerus, there
are attached, the Supraspinatus (origin from Supra-
spinatus fossa of scapula and supraspinatus fascial,
infraspinatus (origin from infraspinatus fossa of
scapula and infraspinatus fascia), and Teres minor
(origin from dorsal surface of axillary border of
scapula). To the lesser tuberosity, the Subscapularis
gin from subscapular fossa and axillary border of
scapula). To bicipital groove, the Latissimus dorsi
(origin from six lower thoracic vertebras, lumbar fascia,
July 29, 1916]
MEDICAL RECORD.
219
crest of ilium, and from lower three or four ribs).
3. The lateral sinus terminates in the internal jugular
vein ; the internal saphenous vein terminates in the
femoral vein ; the brachial vein terminates in the axil-
lary vein; the hepatic vein terminates in the inferior
vena cava.
4. The structure of the lungs. — "In the lungs the
bronchi branch in a tree-like manner, the final ramifi-
cations opening into the pulmonary cells. The larger
intrapulmonary bronchi are lined by columnar ciliated
epithelium resting on a basement membrance. Lying
under this basement membrane are longitudinally dis-
posed elastic fibers with loose connective tissue. More
externally is a layer of smooth muscle fibers arranged
circularly, the bronchial muscle. External to the bron-
chial muscle is a fibrous coat containing scattered, ir-
regular plates of hyaline cartilage. The smaller bronchi
(bronchioles) have no cartilaginous plates, but their
muscular coat is well marked. Each bronchiole leads
into a small number (three or four) of wider thin-
walled spaces, lined by flattened epithelium, and called
atria. Out of each atrium open two or three blind
diverticula, each of which is called an infundibulum.
The walls of the infundibula are studded with hemi-
spherical sacs known as alveoli, which are lined by flat-
tened, non-nucleated, epithelial cells. Between adjacent
alveoli there is a dense network of capillaries, supported
by a small amount of fine connective and elastic tissue;
the network of capillaries is thus common to the two
adjacent air cells, and the blood in the capillaries is
separated from the air in the alveoli merely by two thin
layers of epithelium. In birds, even the alveolar epi-
thelium appears to be absent, the blood and air being
separated solely by the capillary wall." — (Bainbridge
and Menzies' Essentials of Physiology.)
5. The first four spinal nerves enter into the forma-
tion of the cervical plexus; the fifth, sixth, seventh, and
eighth cervical and the first thoracic nerves enter into
the formation of the brachial plexus; the first four lum-
bar nerves enter into the formation of the lumbar
plexus; the fourth and fifth lumbar, first, second, third,
fourth, and fifth sacral, and the coccygeal nerves enter
into the formation of the sacral plexus.
6. The lobes of the liver are: Right lobe, left lobe,
lobus quadratus, lobus caudatus, and Spigelian lobe
(the last three are subdivisions of the right lobe). The
fissures of the liver are: Umbilical fissure, fissure for
the ductus venosus, transverse fissure, fissure for the
gall bladder, and fissure for the inferior vena cava.
"Right and left lobes are separated from each other
by the umbilical fissure on the under surface, and pos-
teriorly by the fissure of the ductus venosus. The right
is the larger, and contains the transverse fissure and
fissure for the vena cava; is subdivided into the three
following lobes:
"The lobus quadratus: bounded by the umbilical and
transverse fissures and the fossa of the gall bladder.
"The lobus Spigelii is on the posterior surface, and is
the projection between fissures for the inferior vena
cava and ductus venosus, behind the transverse fissure.
"The lobus caudatus connects the preceding lobe with
the main mass of the right lobe, and lies behind the
transverse fissure.
"The longitudiiuil fissure is occupied by the round
ligament, and divides the organ into right and left
lobes; it is separated into two parts by its union with
the transverse fissure.
"The anterior part or umbilical fissure contains the
remains of the umbilical vein, and lies between the left
lobe and the lobus quadratus. The posterior part or
fissure of the ductus venosus lies between the left lobe
and the lobus Spigelii, and contains the remains of the
ductus venosus.
"The transverse or portal fissure is placed at right
angles to the longitudinal fissure, between the lobus
quadratus and the lobus Spigelii, and lodges the hepatic
duct, artery, and portal vein, nerves, and lymphatics.
The artery lies between the duct in front, and the vein
behind.
"The fissure for the vena cava is placed obliquely at
the posterior margin of the liver, behind the gall blad-
der, lying between the right lobe and the lobus Spigelii,
and separated from the transverse fissure by the lobus
caudatus. The hepatic veins enter the vena cava at the
bottom of this fissure." — (Aids to Anatomy.)
7. "The superior intercostal artery arises from upper
and back part of the subclavian, behind scalenus anti-
cus, bends backward over pleural dome in front of neck
of first rib to first and second intercostal spaces, sup-
plies small branches to cord and deep spinal muscles.
On the neck of the first rib, the first intercostal nerve
is external, and first thoracic ganglion of sympathetic,
internal to artery.
"The thoracic intercostals (nine pairs) arise from
posterior part of aorta, run transversely outward on
bodies of vertebra?, and behind pleura to intercostal
spaces. The right ones, crossing over front of spine,
supply the bodies of vertebra? and pass behind the
esophagus, thoracic duct, and azygos veins. The ar-
teries of both sides are crossed by sympathetic chain
and its splanchnic branches. On reaching intercostal
spaces, they divide into anterior and posterior branches;
the anterior branch crosses the space obliquely upward
so as to get to lower border of the upper rib near the
angle: at first it lies between external intercostal and
fascia, subsequently between two intercostal muscles;
anastomose with anterior intercostal of internal mam-
mary, thoracic branches of axillary. Above the artery
is a companion vein, and below the intercostal nerve.
The posterior branch passes backward between vertebrae
and superior costotransverse ligament, sending inward,
spinal branch through intervei'tebral foramen to cord,
membranes and body of vertebra;, and backward, mus-
cular branch which divides into inner and outer
branches to muscles of back. A branch, the collateral
intercostal, is given off near the angle of the rib, which
runs along the upper border of the lower rib. Branches
accompany the lateral cutaneous nerves of the thorax
from the main trunks of the intercostals. The three
lower branches pass forward between muscles of ab-
dominal wall; anastomose with epigastric and phrenic."
— (Aids to Anatomy.)
8. "The femur is developed by five centers: one for
the shaft, one for each extremity, and one for each
trochanter. Of all the long bones, except the clavicle,
it is the first to show traces of ossification : this com-
mences in the shaft, at about the seventh week of fetal
life, the centers of ossification in the epiphyses appear-
ing in the following order: First, in the lower end of
the bone, at the ninth month of fetal life (from this the
condyles and tuberosities are formed) ; in the head at
the end of the first year after birth; in the great tro-
chanter, during the fourth year, and in the lesser tro-
chanter, between the thirteenth and fourteenth. The
order in which the epiphyses are joined to the shaft is
the reverse of that of their appearance: their junction
does not commence until after puberty, the lesser tro-
chanter being first joined, then the great, then the head,
and, lastly, the inferior extremity (the first in which
ossification commenced), which is not united until the
twentieth year." — (Gray's Anatomy.)
9. "The endocardium is a serous membrane that cov-
ers the inner surface of the heart. Histologically it
consists of two layers, an inner lining of simple squa-
mous epithelial cells (endothelium or mesothelium), and
an outer layer composed of connective-tissue fibers,
connective-tissue cells, and smooth muscle cells. The
endocardium is reflected over the heart valves where the
smooth muscle is particularly abundant." — (Hill's His-
tology.)
10. The spermatic cord consists of the vas deferens
with artery to the vas, spermatic artery, and pampini-
form plexus of veins forming spermatic vein above,
sympathetic nerves, the cremasteric artery, the genital
branch of the genitocrural nerve, lymphatics, together
with some areolar tissue; it extends from the internal
abdominal ring to the testis, passing in its course along
inguinal canal, from which it emerges by the external
abdominal ring, and thence in front of the pubes to the
scrotum. The vas deferens is placed at the back of the
cord.
11. The three layers of the blastoderm are: The epi-
blast, mesoblast, and hypoblast.
From the epiblast are derived: The skin, and its ap-
pendages (hair, nails), and glands (including the mam-
mary glands) ; the nervous system (brain, spinal cord,
ganglia and nerves) ; the epithelial parts of the organs
of special sense.
From the mesoblast are derived: The skeleton, con-
nective tissues, muscles and bones, heart, blood-vessels,
lymphatics, and spleen; the urinary and generative
organs.
From the hypoblast are derived: The epithelial lining
of the alimentary canal and its glands; the epithelial
lining of the respiratory tract, Eustachian tube, thyroid
and thymus.
12. The cauda equina is the lower part of the spinal
cord, consisting of the roots of many nerves.
The foramen of Winslow is a foramen connecting the
two sacs of the peritoneum ; it is situated behind and
below the transverse fissure of the liver.
220
MEDICAL RECORD.
[July 29, 1916
The optic thalamus is one of the basal ganglia of the
brain ; it forms the side of the third ventricle and part
of the floor of the lateral ventricles.
The trig ovum vesicas is a triangular surface at the
base of the bladder, immediately behind the urethral
orifice; it is bounded behind at each angle by the orifice
of a ureter.
The Eustachian tube is an osteocartilaginous chan-
nel connecting the middle ear with the pharynx.
PHYSIOLOGY.
1. The centers situated in the medulla oblongata are
those for: Respiration, salivary secretion, mastication,
sucking, deglutition, speech production, facial expres-
sion ; it also contains the cardiac and vasomotor centers.
2. The normal respiratory rate is about 18 per min-
ute; the normal pulse rate is about 72 per minute. Hence
the ratio between the respiration and pulse is about 1:4.
The average measurement of the adult male chest is
about 32 to 35 inches, in deep expiration, and about 34
to 38 inches in complete inspiration.
3. Superficial reflexes. 1. Plantar; elicited by strok-
ing or scratching the sole of the foot, which causes at-
tempts to withdraw the foot from the source of irrita-
tion. 2. Gluteal; a contraction of the gluteal muscles
en masse when the buttock is gently pricked or
scratched. 3. Cremasteric; when the thigh is irritated
on its inner surface by grasping, stroking, scratching,
etc., the homolateral testicle is distinctly retracted. 4.
Erectile reflex of penis; produced by gentle friction of
the glans penis, especially of the frenum, resulting in
turgidity of the organ and erection. Its analogue in the
female pertains to the erection of the clitoris. 5. Ab-
dominal; consists of a retraction of the anterior abdo-
minal walls when the skin is slightly irritated. 6.
Mammary; in women, a retraction of the epigastrium
when the mammary region is tickled. 7. Palmar; cor-
responding to the plantar, usually less developed than
the latter." — (Hall's Physiology.)
4. "The objects of climatic treatment are to furnish
a complete change of environment, to withdraw the pa-
tient from the influences under which he contracted the
disease, to subject him to a climate which will promote
healing in the lungs by increasing the activity of the
digestive functions and thus stimulating nutrition, by
improving the tone of the nervous and circulatory sys-
tems, either by invigoration or protection, and by lessen-
ing exposure to secondary infections. Further climatic
treatment may have for its object palliation of distress-
ing symptoms in patients whose diseases may not prove
fatal for months.
The main object of dietetic treatment is to enable the
patient to regain his lost weight but not to make him a
"flabby, breathless mass of inert fat." A patient who
eats and digests well is a patient half-cured. The teeth
should receive careful attention and be placed in order
at once. The preparation and serving of meals should
receive the strictest attention, as the kitchen is the only
pharmacy that many patients should know. The meals
should be carefully chosen and each planned in relation
to the preceding. The physician should carefully scruti-
nize the diet and lay down broad general rules. It is
a wise plan to vary the articles of diet as much as pos-
sible, and special dishes on special clays of the week
should be avoided when possible. The table should be
attractively arranged and the food well and quickly
served (not quickly eaten). Many patients will eat
well if the courses follow one another in rapid succes-
sion, whereas if long delays occur cough or fatigue may
prevent the eating of the desired amount. To pile up
a plate with large amounts and to expect a patient who,
especially at first, has little or no desire for food to
consume it is a mistake. Repeated helpings until the
desired amount is eaten is preferable."— (Lawrason
Brown, in Osier's Modern Medicine.)
5. Unit is lost to the body through the skin, the lungs,
and in the urine and feces.
6. In the stomach the food is mixed with gastric iuice,
more thoroughly triturated, moved around the stomach,
and finally expelled into the duodenum. In the stomach
the proteins are split up into proteoses and peptones by
the pepsin of the gastric juice, and certain bacteria are
killed bv the hydrochloric arid; starches are not af-
fected; fats are split up by a gastric lipase.
7. Formerly the quantity of blood in the body was
said to be about on th of the body weight. Just
now it is said to be about one-twentieth of the body
rht, According to the former of these, an individual
weighing L50 pounds would have about 11% pounds of
blood: on the latter basis he would have about 71'-
pounds of blood.
8. The chemical elements in the human body are:
Carbon, hydrogen, oxygen, nitrogen, chlorine, sodium,
potassium, sulphur, calcium, iron, phosphorus, mag-
nesium, fluorine, iodine, silicon.
9. The function of the secretions of the prostate and
Cowper's glands is not understood. These secretions
are essential to or aid in maintaining the motility of
the spermatozoa ; perhaps they render the seminal fluid
more fluid and so aid in its ejaculation. According to
Dearborn, "the secretion of the prostate seems to pre-
serve the vitality of the spermatozoa, while that of
Cowper's gland is a mucus which prevents their too
wide dissipation in the vagina."
10. The blood on its passage through the kidneys
loses water, salts, urea, carbon dioxide, and extractives.
11. Functions of fat in the body. — (1) It helps to
maintain and regulate the body heat; (2) it acts as a
protection to certain delicate structures; (3) it gives
form and roundness to the body; (4) it acts as a reserve
substance which the body can draw upon for nutrition
in case of emergency; (5) it probably plays a part in
the maintenance of the life and nutrition of the cells of
the body.
12. To produce contraction of a muscle fiber a certain
stimulus is necessary. A nerve impulse is generally the
stimulus, but mechanical, chemical, electrical, and ther-
mal stimuli will do as well. The time that elapses be-
tween the application of the stimulus and the contrac-
tion of the muscle is called the latent period. During
contraction the following changes take place in a
muscle: (1) It becomes shorter and thicker, but the
volume remains the same; (2) it consumes oxygen;
(3) it sets free carbon dioxide; (4) it forms sarcolactic
acid; (5) it becomes acid in reaction; (6) it becomes
more extensible and less elastic; (7) there is an in-
crease in heat production, and consequently a rise oif
temperature; (8) the electrical reaction becomes rela-
tively negative.
CHEMISTRY.
1. The alkali metals are sodium, potassium, lithium,
rubidium, and cesium. They have a valence of one.
Each of them makes a single chloride, a hydroxide, and
one or more oxides. The hydroxides are more or less
alkaline and are basic in character.
2. Iodine is a solid, occurring in bluish-gray crystal-
line scales; it has a metallic luster, is volatile, and has
a peculiar odor: it is slightly soluble in water, but is
very soluble in alcohol, ether, carbon disulphide, and
benzene. It is a weak bleaching and oxidizing agent.
Iodine is a disinfectant, parasiticide, irritant, and
counterirritant.
3. Amyl nitrite is a liquid containing C.-H,,NC>2 and
other nitrites.
4. Test for lactic acid. — Put three drops of concen-
trated solution of phenol and three drops of an aqueous
solution of ferric chloride in a little water; to this add
a little of the filtered gastric contents (after a test
meal) ; if lactic acid is present the blue color turns to
a canary-yellow.
5. Proteins are nitrogenous organic substances of
complex composition and unknown constitution. They
are found in every cell and tissue of the body, and are
indispensable to the "life" of these cells and tissues.
The chief proteins are: Albumins, globulins, nucleo-
albumins, histons, protamins, albumoses, peptones, hem-
oglobins, nucleoproteids, glycoproteids, keratins, col-
lagen.
6. Test for glucose. — If albumin is present it should
be removed. The urine is then tested for sugar as
follows: Render the urine strongly alkaline by addi-
tion of Na-CO-. Divide about 6 c.c. of the alkaline
liquid in two test tubes. To one test tube add a very
minute quantity of powdered subnitrate of bismuth, to
the other as much powdered litharge. Boil the con-
tents of both tubes. The presence of glucose is indi-
cated by a dark or black color of the bismuth powder,
the litharge retaining its natural color.
Test for uric acid. — To a few drops of the urine add
a little dilute nitric acid and evaporate to dryness; a
yellowish-red residue is left; add a little ammonia; a
violet color results.
7. Water of crystallization. — Many substances, upon
assuming the crystalline form, take with them a cer-
tain number of molecules of water which are necessary
for the maintenance of the form (and often of the
color) of the substance. This water is called wafer of
crystallization.
liquescent substance is a solid which has such a
tendency to unite with water that it absorbs it from the
air. becoming damp and finally liquid.
July 29, 1916]
MEDICAL RECORD.
221
Efflorescence is the property of certain crystalline
bodies whereby, on exposure to air, they lose their
water of crystallization and fall to powder.
8. Hydrogen sulphide may be prepared by the action
of dilute sulphuric acid upon ferrous sulphide:
FeS + H2S04 = FeS04 + H=S.
Hydrogen sulphide is a colorless gas with a disgusting
odor and taste (like rotten eggs) ; soluble in alcohol,
slightly soluble in water; it is used as a reagent in the
chemical laboratory.
9. An alloy is a substance composed of two or more
metals.
An amalgam is an alloy containing mercury.
10. Wood alcohol is methyl alcohol, CH,OH. It is a
colorless liquid, with a sharp, burning taste and an al-
coholic odor; it burns with a pale flame, giving less heat
than that of ethyl alcohol ; it is a good solvent for
resins, sulphur, potash, and other substances. It is
poisonous.
11. Fatty acids are monobasic acids, of the acetic-
series, with the general formula CnH~nO=. Acetic acid,
CH,.COOH; valerianic acid, CHXOOH; palmitic acid,
C„H„.COOH.
12. Saltpeter, KNC\; Chile saltpeter, NaNO,; blue
vitriol, CuS04; green vitriol, FeSCv
HYGIENE AND SANITATION.
1. In case of communicable disease, the physician
should isolate the patient and inform the local health
authorities.
2. "In collecting rain from roofs, it is very necessary
to insure cleanliness of the supply, by allowing the first
flow to run to waste, thereby avoiding contamination by
dirt, leaves, bird-droppings, soot, and other matters de-
posited upon the roof and collected in the gutters. A
number of automatic devices are in use for the purpose
of diverting the first washings away from the conduc-
tors. After this has been done, they change position,
so that the subsequent fall is saved and stored. . . .
Cisterns for storage of rain should be so constructed
and arranged as to admit of easy inspection and clean-
ing. They should be kept covered so as to exclude
dirt and dust of all kinds, insects, mice, and other ani-
mals, and to shut off light as well, for the presence of
light is an important aid to the development of lower
plant forms. The best materials for their construction
are bricks, stone, cement, and slate. Cement makes a
good lining if one is desired; mortar, however, is objec-
tionable on ac^i'int of the solvent power of water upon
lime, which will cause progressive increase in hardness.
Cisterns should be provided with overflow pipes dis-
charging into the open air rather than into the house
sewer, and their exits should be protected by wire net-
ting against the entrance of leaves and small animals."
(Harrington's Hygiene.)
3. "The privy must be at least six feet away from
any dwelling, and fifty feet away from any well, spring,
or stream ; ready means of access must be provided for
the scavenger, so that the contents need not be carried
through a dwelling; the privy must be roofed to keep
out the rain, and be provided with ventilating apertures
as near the top as possible; that part of the floor which
is not under the seat must not be less than six inches
above the level of the adjoining ground and moreover
be flagged or paved with hard tiles having an inclina-
tion toward the door of the privy of one-half inch to
the foot, so that liquids spilt upon it may run down
outside and not find their way into the receptacle under
the seat; the size or capacity of this receptacle may not
exceed eight cubic feet, by which limitation a weekly
removal of its contents is necessitated; the sides and
floor of this receptacle must be of some impermeable
material, the floor being at least three inches above the
adjoining ground level; the seat of the privy should be
hinged so as to allow of the ashes being readily thrown
in, and the receptacle unconnected with any drain or
sewer. — (Notter and Firth's Hygiene.)
4. The maximum period of incubation of smallpox
is twenty days; of scarlet fever is twelve days; of
whooping cough is ten days.
5. Diseases which may be conveyed through co
milk: Tuberculosis, typhoid, scarlet fever, diphtheria,
measles, foot and mouth disease, milk sickness, cholera,
tonsillitis, and gastrointestinal disturbances.
6. Theory of the application of vaccination against
smallpox : "The more recent view of the immunity con-
ferred by vaccination against smallpox is based upon
the demonstration that the disease variola in man and
the disease vaccinia in the bovine species are of the
same nature and not different, as was formerly believed.
This has been established by numerous inoculation ex-
periments. The disease in the cow is a modified form
of the human disease. The effect of the passage of the
unknown microorganisms through the insusceptible bo-
vine is to diminish the virulence of the germ, that by
its subsequent inoculation in man immunity is secured
without the profound disturbance which infection with
a germ of unmitigated virulence would involve." —
(Delafield and Prudden's Pathology.)
7. Five diseases that may be contracted by eating un-
cooked meat: Trichinosis, tape worm, echinococcus dis-
ease, tuberculosis, anthrax.
8. Lead, zinc, mercury, arsenic, and antimony may
produce occupational diseases.
9. It is impossible to answer this question. There is
no method used; each State does as it pleases, and in
some States there is no law on the subject.
10. Vincent's angina may be positively diagnosed by
the finding of the fusiform bacillus and the spirocheta
darticola in the membrane; it is most frequently con-
fused with diphtheria.
11. The Binet-Simon test is employed to test the men-
tality of children and feebleminded persons.
12. Two most important factors in preventing the
occurrence of bubonic plague are: (1) Complete de-
struction of rats and keeping them out of buildings;
(2) persons exposed to infection should receive a pro-
phylactic vaccination with Haffkine's vaccine.
SURGERY.
1. Diabetic gangrene "is prone to occur in persons
over fifty years of age who suffer from diabetes melli-
tus. The vessels of these patients are often markedly
atheromatous. In some cases the existence of the dia-
betes is unsuspected before the onset of the gangrene,
and it is only on examining the urine that the cause of
the condition is discovered. The gangrenous process
seldom begins as suddenly as that associated with em-
bolism, and, like senile gangrene, which it may closely
simulate in its early stages, it not infrequently begins
after a slight injury to one of the toes. It but rarely,
however, assumes the dry, shrivelling type, as a rule
being attended with swelling, edema, and dusky redness
of the foot, and severe pain; the dead part remains
warm longer than in other forms of senile gangrene;
there is a greater tendency for patches of skin at some
distance from the primary seat of disease to become
gangrenous, and for the death of tissue to extend up-
ward in the subcutaneous planes, leaving the overlying
skin unaffected. The low vitality of the tissues favors
the growth of bacteria, and if these gain access the
gangrene assumes the characters of the moist type and
spreads rapidly. There is usually a peculiarly offensive
odor about the patient, which differs from that of other
forms of moist gangrene." (Thomson and Miles' Sur-
gery.)
2. The early symptoms of hip-joint disease are:
Night cries (in a child) ; lameness in the morning; a
slight limp; tendency to become tired on slight exertion;
wasting; spasm; pain; swelling, and deformity (either
real or apparent) .
Treatment : In the early stages, rest in bed is indi-
cated, with extension ; also, tonics, restoratives, fresh
air. If necessary, the limb should be straightened and
put up in plaster of Paris, or a brace or other mechani-
cal appliance should be used. Intraarticular injections
of iodoform have been recommended. Resection of the
hip may be necessary.
3. Hemorrhage from the popliteal artery may be
controlled by: (1) Placing a pad in the popliteal space
and then keeping the leg in forced flexion by means of a
bandage; (2) pressure on the femoral artery.
4. Lumbar puncture: "The back should be carefully
sterilized and through asepsis must be preserved in
every detail. The patient may lie on the right side with
the left knee well drawn up, may lie prone with a pillow
under the belly, or may sit in a chair with the body bent
forward. The site of the intended puncture may be
frozen with ethyl chloride, but no general anesthetic
is required. A Pravaz syringe is employed. The
needle, which should be three inches in length, is
guarded by the surgeon's index-finger and the point is
inserted one-half inch to the right of the median line
and between the third and fourth lumbar vertebras. It
is pointed upward and a little inward under a spinous
process. In a child the needle enters the canal at a
depth of from two to three centimeters; in an adult, at
a depth of from four to six centimeters. The fluid is
permitted to fall drop after drop into a sterile test-
tube." (DaCosta's Surgery.)
5. Empyema. "Treatment should be undertaken
without delay. Aspiration seldom cures, but may be
222
MEDICAL RECORD.
[July 29, 1916
undertaken where the dyspnea is great, and an anes-
thetic given afterward for the excision of a piece of rib.
Drainage is always necessary, and is best, done by excis-
ing a portion of the fifth or sixth rib in the midaxillary
line. The patient should be allowed to come round
quickly from the anesthetic, so that the coughing which
occurs will expel the masses of coagulated lymph and
help to expand the lung. A big drainage tube is then
inserted. Daily dressings are necessary, but irrigation
of the cavity is seldom needed." (Aids to Surgery.)
6. The treatment of epithelioma of the lower lip con-
sists in early and free removal of the affected portion
of the lip and of the infected glands. In comparatively
small growths which do not involve the angle of the
mouth, a V-shaped incision is carried through the entire
thickness of the lip so as to include the disease and an
area of healthy tissue beyond it. In larger growths,
particularly when situated at the angle of the mouth,
it is necessary to carry an incision transversely into the
cheek to enable the lip to be repaired without leaving
deformity. When it is necessary to remove the greater
part of the lower lip, the defect may be filled up by flaps
of skin taken from below the jaw (Syme's operation).
When the tumor is adherent to the lower jaw, it is nec-
essary to resect a portion of that bone along with the
lip. The frequency with which recurrence takes place
in the lymphatic glands below the jaw renders it ad-
visable to remove these in all cases, whether they are
palpably enlarged or not. J. Hutchinson, Jr., recom-
mends that the submaxillary and submental triangles
on both sides should be cleared out as a routine pro-
cedure." (Thomson and Miles' Manual of Surgery.)
7. Acute infective osteomyelitis. Causes: The gen-
eral vitality is lowered, and there is some focus of ulcer-
ation in the mouth or throat, by which organisms enter
and circulate in the blood. All that is now necessary is
that some part of the bone should have its vitality de-
pressed by a blow, strain, or exposure to cold, and the
organisms then attack it. The bacteria most commonly
found are the staphylococci, but streptococci are present
occasionally. The disease usually begins in the new
growing bone at the end of the diaphysis, rarely in the
epiphysis. The lower ends of the femur and radius,
the upper ends of the tibia and humerus, are the com-
monest seats.
"Symptoms. — The disease begins with a rigor, high
temperature, and severe pain. The part becomes swol-
len, infiltrated, and congested, with distended veins over
it. The pulse is rapid and small and the tongue dry,
and delirium soon comes on. It should be distinguished
from acute rheumatism by the fact that the interarticu-
lar and not the articular region is affected. Fluctua-
tion can be detected if the bone be superficial, or the
abscess may burst on the surface. The bone is then
found to be bare over the extent of the abscess cavity.
When the bone is deeply seated or the disease confined
to the medulla, the swelling is later in evidence, but the
pain and toxemia are very severe, and the patient may
die from this before local signs show themselves. When
the epiphysis is attacked, septic arthritis often quickly
follows, and a loose flail joint may result.
"Treatment must be very prompt. A free incision
must be made through the periosteum and the pus
evacuated. In any case, whether pus is found or not,
the surface of bone must be gouged away to expose the
medulla freely, and any gangrenous tissue scraped out.
The cavity must then be washed out and freely drained.
The wound in the soft structures is not closed in any
part. If symptoms of pyemia occur, it may be neces-
sary to amputate the limb through the joint or bone
above, so as to cut off the source of emboli. When a
large portion of or the whole diaphysis is necrosed,
there are two courses; either to cut short the disease
by removing the dead portion at once, or to leave the
sequestrum to stimulate the formation of an involu-
crum. Where there is a single bone, as in the arm and
thigh, the sequestrum is left; where there is a double
set of bones, as in the forearm and leg, the sequestrum
is removed at once. Celluloid, zinc, and ivory rods have
been inserted to stimulate osteogenesis. In most cases
it is doubtful how much bone is actually dead, so that
it is better to open up the cloacae in the newly formed
involucrum to remove the sequestrum. The cavity heals
by granulation." (Aids to Surgery.)
8. "In impacted fractures in' the old, liable to break
neck close to head, it is unwise to attempt forcible re-
duction to secure better position of the fragments.
These cases should be handled as carefully as possible,
and if there are no contraindications the patient should'
be placed upon a firm level mattress, the foot of the bed
slightly elevated, and the leg immobilized either by sand
bags placed on both sides or by the application of a long
external T-splint. If there is muscular twitching, it is
advisable to supplement this dressing by the application
of a Buck traction apparatus with from three to six
pounds fastened to the stirrup." This weight steadies
the part and often gives considerable comfort. This
dressing should be used for from four to eight weeks.
It may be removed at this time and a short spica of
plaster of Paris perhaps applied from the waist to mid-
thigh, and the patient allowed upon crutches. In the
aged it is better to remove all apparatus at the end of
about five weeks and allow the patient to get up, at first
sitting up a short time daily, later resting in a chair,
and at the end of about ten weeks walking with
crutches.
"Exception to the above rule in the treatment of im-
pacted fractures is in cases occurring in early childhood
or middle age, which, if left uncorrected, may result in
a deforming coxa vara with considerable subsequent
deformity and loss of function. In these cases it is
advisable perhaps only after consultation with another
surgeon to correct the deformity under ether, place the
part in extreme abduction and traction, and while in
this corrected position to apply a gypsum spica splint
from chest to toes of the affected side after the method
of Whitman." (Roberts and Kelly's Fractures.)
9. Chronic appendicitis may follow an acute attack,
but "eases are sometimes met with in which the patient
has never had an attack which would suggest acute
appendicitis; he complains of impairment of his general
health, of abdominal discomfort, sometimes amounting
to pain, and inveterate constipation. There may be
discomfort in the right side of the abdomen on bending
the body or on lifting weights. In some cases the chief
complaint is of disturbance of digestion (appendicular
dyspepsia). Physical examination is often inconclusive,
as there may be no localized tenderness, and nothing can
be made out on palpation of the right iliac fossa. The
diagnosis is necessarily difficult, and may only be ar-
rived at by a process of exclusion. In many cases it is
only cleared up on opening the abdomen, when there is
found a kink, stricture, concretion, or twist of the ap-
pendix, or adhesions in its neighborhood. Removal of
the appendix and liberation of adhesions usually bring
about a cure." (Thomson and Miles' Surgery.)
10. Gunshot wound of the abdomen. "The treatment,
even without symptoms of visceral injury, is immediate
enlargement of the wound, in order to explore the abdo-
men, check hemorrhage, and close such visceral perfora-
tions as may be found. The abdomen is then flushed
with salt solution, and closed or drained, according to
the amount of soiling present. If the omentum pro-
trudes it should be ligated and removed, while coils of
intestine should be carefully washed with salt solution
and returned to the cavity. In cases in which there is
doubt as to whether or not a wound enters the peri-
toneal cavity, such wound should be enlarged and the
diagnosis positively made, preparation being made at
the same time to treat any visceral injuries that may be
found. In gunshot wounds on the battle field an excep-
tion has been made to the rule of immediate exploration,
because it has been found that the chances of recovery
are better without operation." — (Stewart's Surgery.)
11. The most common form of dislocation of the
shoulder is the subcoracoid. Kocher's method of reduc-
ing is: To flex the forearm, press the elbow to the side,
rotate the arm outward. Bring the arm forward and
upward to a right angle with the body, then rotate in-
ward, while the elbow is brought down over the body so
that the fingers sweep the opposite shoulder.
12. "A femoral hernia protrudes through the crural
canal, and presents through the saphenous opening. The
coverings are: (1) Skin and subcutaneous tissue,
(2) cribriform fascia, (3) anterior layer of the femoral
sheath, (4) septum crurale and extraperitoneal fat.
The Signs are usually characteristic, viz., a more or
less reducible swelling, with an impulse on coughing,
and a neck which runs into the abdomen by way of the
saphenous opening. From inguinal hernia it is dis-
tinguished by the neck being below Poupart's ligament
and external to the pubic spine. A psoas abscess
pointing through the saphenous opening is reducible,
and has an impulse on coughing; but fluctuation can be
felt between the swelling at the saphenous opening and
the swelling always present in the iliac fossa in these
cases. A pouch in a varicose saphenous vein close to
the saphenous opening has a characteristic thrill on
coughing which should prevent mistakes." (Aids to
Medical Record
Vol. 90, No. 6.
Whole No. 2387.
A Weekly Journal of Medicine and Surgery
New York, August 5, 1916.
$5.00 Per Annum.
Single Copies, 1 5c.
G&rujutal Arttrbfl.
CLINICAL METHODS OF MEASURING
ACIDOSIS.*
By JOHN R. WILLIAMS, M.D.,
ROCHESTER, N. Y.
Recent advances made in medical research have
led clinicians to attach greater significance than
formerly to the acid content and output of the body.
Notably in diabetes and nephritis is it important to
have some measure of these facts. The past few
years have witnessed the development of several
methods of determining with approximate accuracy
and reasonable facility the degree or amount of
acid intoxication of the body.
A comparative study of the value and
limitations of these various methods may
be helpful to those clinicians who are not
in touch with research or well-equipped
clinical laboratories. The phenomenon
of acidosis may be estimated either ac-
curately or approximately by the follow-
ing methods: (1) By a study of the
urine in which (a) the total acid excre-
tion, (b) the total ammonia, and (c) the
output of ketone bodies have much sig-
nificance. (2) By a study of the carbon
dioxide tension of the alveolar air. (3)
By determining the carbon dioxide com-
bining power of the blood. (4) By meas-
uring the hydrogen ion concentration of
the blood.
The more practical of these methods
will be discussed in detail and illustrated
by case records, while the difficult and
extremely technical procedures will be
but briefly noticed.
The study of the urine, while affording
extremely suggestive information, does
not necessarily yield a true measure of
the body acidity. It tells us only how
much acid is excreted. When the pro-
duction of acid in the body is increased,
the outgo in the urine is likewise in-
creased, but there is no definite relation-
ship between the two. Furthermore,
there is no simple, accurate way of esti-
mating the total acidity of the urine.
In the metabolism of food and in the
tissue changes which accompany work
and other energy manifestations, car-
bonic, sulphuric, phosphoric, oxalic, lactic,
hippuric, uric, amino, and other acids are
formed. With the exception of the vola-
*Address, in part, before the George
Washington Medical Society, Washington,
D. C, February 19, 1916.
tile carbonic acid gas, which is eliminated through
the lungs, these acids or their various salts, which
are non-volatile, are excreted in the urine in varying
amounts. According to the laws of physical chem-
istry, they are dissociated into electrical units, the
positive or hydrogen ions and the negative acid
radical ions. According to this conception these
two sets of ions float about in the solution except
when attracted by the poles or electrodes of an elec-
tric current. Some acids possess thi's power of dis-
sociation to a greater degree than do others, hence
are known as strong acids, examples of which are
sulphuric and hydrochloric acids. Other acids dis-
sociate to a very slight degree and are known as
weak acids, examples of which are carbonic and
acetic acid. The true acidity of a fluid depends
|TotalAcidSait5^L CC
Jfl„22 2324 25 28 27 2829 30 31^
i ase 1512. — Male. Age, 48 years. Severe diabetes complicated with car-
buncle and deep cellulitis in neck, and myocarditis. Operation followed
by death from exhaustion without coma, it will be noted that this patient
had a severe acidosis evidenced by the excessive excretion of urinary acid
and ammonia and by the low carbon dioxide tension.
224
MEDICAL RECORD.
[Aug. 5, 191G
not on the amount of acid but on the amount of
hydrogen ions in solution. The measure of these
can be determined only by elaborate and extremely
technical electrical methods uuite beyond the scope
of the average clinical laboratory.
The study of the urine by chemical titration
methods yields quite different information. By
this we determine how much acid hydrogen can be
replaced by an alkali or base of definite strength.
Thus we attempt to determine the total amount of
replaceable hydrogen, which is not the true measure
of acidity, for, as above stated, the acidity of a
fluid depends upon the amount of dissociated hydro-
gen ions. Furthermore, in the chemical determina-
tion of urine acidity we assume that the turning
point from acid or alkali to neutral is definitely re-
vealed by indicators, and this is untrue. No two
indicators have the same end-point, hence the de-
terminations by chemical titration means are more
or less arbitrary. Notwithstanding these technical
difficulties and defects the titration method of esti-
mating urinary acidity is of considerable value
when properly done.
The method suggested by Folin is recommended.
Decinormal sodium hydrate is used as the alkali
and phenolphthalein as the indicator. Neutral
potassium oxalate is added to pre-
cipitate certain calcium salts which
tend to obscure the end-point. It
may be done as follows: Place 25
c.c. of urine in a beaker or flask. Add
about two teaspoonfuls of finely pul-
verized neutral potassium oxalate and
two drops of a 1 per cent, phenolphtha-
lein solution. Stir or shake vigor-
ously for a few seconds, then titrate
with a N10, or decinormal, sodium
hydrate solution until a faint but per-
manent pink appears. Having thus
ascertained the number of cubic cen-
timeters of decinormal alkali required
to neutralize 25 c.c. of urinary acid,
the acidity of the entire 24-hour quan-
tity may be readily calculated. It is
better to state this total acidity in
terms of decinormal alkali; but, if it
is desired to convert it into grams of
sodium hydroxide, this may be done
by multiplying the total number of
cubic centimeters of decinormal alkali
by 0.004, the number of grams of so-
dium hydroxide in 1 c.c. of decinormal
solution; or, if it is desired to express
it in terms of oxalic acid, multiply by
0.0063, the number of grams of oxalic
acid in 1 c.c. decinormal solution.
Having thus neutralized the 25 c.c.
of urine, from this same specimen one
can easily determine the amount of
ammonia present. For clinical pur-
poses, the formalin titration method
is sufficiently accurate. This is done
as follows: To the 25 c.c. of neutral-
ized urine add 10 c.c. of neutral 40
per cent, formalin. Then titrate again
with decinormal alkali. This reading
will represent the number of cubic
centimeters of decinormal ammonia in
the 25 c.c. of urine, from which the
amount in the 24-hour specimen may
be estimated. The acidity of the urine
and that represented by the am-
monia are additive. Their sum gives the most ac-
curate expression of titratable urinary acid excre-
tion. For purposes of clinical research Folin's
method of estimating ammonia should be employed.
In a preceding paragraph it was mentioned that
in the body metabolism two types of acid, volatile
and non-volatile, are formed, and that the former
is eliminated through the lungs while the latter is
excreted by the kidneys. The amount of volatile
acid or carbonic acid in the blood bears a constant
relationship to the non-volatile acid present. It has
been established that the acid content of the body
remains practically constant even in the presence
of increased production, and that death will super-
vene before a measurable increase occurs. The
body protects itself against this increased produc-
tion by withdrawing bases or alkali from the tis-
sues, by a remarkable physiochemical property of
combining the newly formed acid with neutral salts
and proteins in the blood in such way that these
substances still remain neutral, by the formation
of ammonia from neutral substances, that is the
breaking down of proteins, and further by dimin-
ishing the amount of carbonic acid in the blood by
increased ventilation of it through the lungs. It
follows that if the acidity of the blood is repre-
L , ' ill l
:::
II i
::: ::: : •" ••" ::: :::
::: II: :::! ::: ::: ::: :::
i:::- II: ::: :•• ••: ::: ::i
:::
lii
II:
|
::: :::
lllj II!
Si »:
ill »:
;... i... ...
••• jjj; ;;;
*•• ::: ::: ... *** --■ • •*
□ IACETIC ^liirfiA
Arm +1+2+3+4
MM
•45
COzTENSION 40
/
AcidSaiteiAmmon.
jTotalAmmonia % 500
_ 250
|Tora!AcidSalte% CC
JAtC
6 29 30 31 J 2
EB.
3 4
Case L513. — Male. Ago, 71 years. Severe ed by ad-
erosis and gangrene. Operation. Ether anesthesia. Death
istion ami without coma. For four days after operation patient
ited only a mild acidosis, as will he seen from the carbon dioxide tension
and urine arid and ammonia output. Following this a severe acidosis
mi: i i.- tration - copious doses of soda, water, etc., raised I
tei ion (" practically normal limits two days before death.
This case illustrates tremendous acid production with the body eliminating
iefly as urinary arid, if acid ha
ding death, a much lower carbon dioxide tension would be expe< :
Aug. 5, 1916J
MEDICAL RECORD.
225
sented by the sum of its volatile carbonic acid con-
tent and the various other non-volatile acids, that
a determination of one enables us to estimate the
other; furthermore, if the sum of the two remains
constant and one increases in amount, the other
must correspondingly diminish. Therefore, a low
per cent, of carbonic acid in the blood means a high
per cent, of non-volatile acid; conversely, when the
non-volatile acids are diminished the carbonic acid
content is increased. These facts may be directly
ascertained by a determination of the carbon di-
oxide combining power of the blood, using the un-
published method of Van Slyke, or by taking ad-
vantage of the fact that the percentage of carbon
dioxide in the lung air is practically the same as
that in the arterial blood and employing the much
simpler and more practical test of estimating the
percentage and barometric tension of carbonic acid
gas in the lung air.
Fredericia's Method for Determining the Car-
bonic Acid Tension of the Lung Air. — Numerous
methods for determining the carbon dioxide tension
of the lung air have been suggested, but for one
reason or another most of them are too complicated
or difficult for practical clinical work. The chief
objection to many of the methods that have been
1
| 1
ssj
:::
|
S3
ill
iii
in
ii!
:::
:::
I::
ESS
::!
it
•!•: ••*
jj|
iii
:::
:::
■5!
:::
DIACET1C J.l4.,a>,*4
ACin + 1+2+3+4
MM
45
COzTENSION 40
ALVEOLAR AIR
35
30
25
V
4000
V
3500
CA
5E
NO
. 1;
!9I
3000
Z500
2000
I7SH
1500
'"'
"3
1250
j
\\
MaxNormal Total moo
:
§S *§r Si
AcidSalts&Mmnon
t .■
s : ■ 11 - ■
■■^-
" 750
1
fe l '
;:■'.':'
JTotalAmmonia % son
1
|frf|jf| ,|$
H
j 2511
jTotBlAcidSalteffi CC
28
21
23
24
25
2S
27
;?3
30
31
1 2
Case 1291. — Female.
AUG
Age, 30
„rs. Acidosis of severe diabetes, fatal.
Patient had been fasted for 72 hours preceding,- Aug. 21. Fir 4S hours she
had been vomiting almost constantly. Aug. 21 had severe diaphragmatic
pain, slight air hunger and drowsiness. Aug. 23. more deeply comatose.
Difficult to swallow. Note that urinary acid, diacetic acid, and ammonia ex-
cretion very small, indicating retention. Aug. 24. 25, 26, 27 patient given
140+ grams carbohydrate, chiefly levulose, daily. Comatose symptoms less
severe. Note marked acid retention. Aug. 2S to Sept. 2. Note the very
small acid and ammonia excretion compared with the low carbon dioxide
tension, and that the ferric chloride test was practically negative on Aug. 2S,
29, although patient was quite comatose. Urine not examined Aug. 30, 31.
proposed is that two sets of apparatus are required,
one for the collection of the air sample, the other
for its analysis. Fredericia's* apparatus was de-
signed to overcome this objection, and his instru-
ment may be used for both purposes. The appa-
ratus, as will be seen from the accompanying cut, is
essentially a U-shaped gas-collecting tube, with stop
cocks so arranged that a sample of air may be con-
fined in one portion of it and subjected to such
chemical treatment as is desired.
The tube is so constructed that that portion of it
from stop cock C, when closed, to and including the
bore of stop cock G contains 100 c.c. The section
of the tube from F to E is graduated in tenths of
1 per cent of the total volume of this part of the
gas chamber. The scale reads from 2 to 8 per cent.
Stop cock C is of straight bore, as is seen in the
illustrations. Stop cock G is of three-way bore.
In one position, one arm of the tube communicates
with the other; in a second position, communication
between the arms is closed ; in a third position, the
bulb portion of the tube is closed while the
other arm communicates with the outlet tube; in
a fourth position, these are reversed and the
bulb portion communicates with the outlet and the
other arm is sealed.
In carrying out the test the follow-
ing apparatus and reagents are re-
quired: (a) the Fredericia gas tube,
(b) a large glass cylinder of sufficient
capacity to hold the gas tube (a stock
battery jar 21 x 30 c.mm. is admirably
suited for the purpose) (c) an ordi-
nary 100 c.c. laboratory wash bottle
filled with id) a 5 per cent, solution
of sodium hydrate and a 1 per cent,
solution of acetic or a saturate solu-
tion of boric acid.
Before making the test, the battery
jar or cylinder should be filled with
water at the temperature of the room ;
greater uniformity of readings may be
had if water at a temperature of 20°
C. or 68° F. be used. The purpose of
the water is to cool to a constant tem-
perature the gas or lung air of the pa-
tient after it has been collected in the
tube. This is very important, because
the volume of gas varies inversely
with its temperature. Each variation
of 1° in temperature will cause a vari-
ation of 0.4 per cent, in the volume of
the carbonic acid.
The person whose lung air is to be
examined should sit quietly in a chair
and breathe in a natural manner for
several minutes. Observations should
be made in either a sitting or lying po-
sition, preferably the former, as read-
ings vary slightly with the posture of
the body. At the end of a normal ex-
piration the mouthpiece of the appa-
ratus (A1 is put in the patient's
mouth. The stop cocks should be ar-
ranged as in Fig. 1. The patient is in-
structed to expel through the tube as
much as possible of the air remaining
in his lung, without first talking,
coughing, inhaling, or exhaling air.
*Fredericia: A Clinical Method for the
Determination of Carbonic Acid Expan-
sion in Lung Air. Berl. klin. Wochen-
schr., July 6, 1914, pp. 1268-1271.
srp
226
MEDICAL RECORD.
[Aug. 5, 1916
Most people will thus expel during such an expira-
tion approximately 1500 c.c. of air of which at
least 1000 c.c. is alveolar air. Inasmuch as the
apparatus contains only about 130 c.c. it will be
hydrate solution will absorb no more gas, which is
readily told when the liquid ceases to rise in the
bulb arm. The apparatus is once more immersed
in the jar of water to restore the gas to a constant
no. 2
F/G.Z
FIG.3
PIG. 1 — Showing Fredericia apparatus and the position of the
stop cooks at different stages of the test.
seen that the air which is recovered at the end of
the expiration will be a representative sample of
the air from the lung alveoli. Immediately after
the close of this forced expiration and before re-
moval of the instrument from the patient's mouth,
stop cock C must be closed and remain closed until
the end of the test. Stop cock G, however, must
remain for the present in the
same position as in Fig. 1.
The apparatus* is now im-
mersed for from 3 to 5 min-
utes in the water in the glass
jar. The water must extend
over stop cock C, but must
not reach tube K. The gas
is thus cooled and contracts.
For this reason a small
amount of air enters the tube
at K but it does not reach
that portion of the tube con-
taining the air to be examined
so the result is not affected.
The apparatus is then re-
moved and the sodium hydrate
solution in the wash bottle is
forced into the tube at K
until the column of liquid in
HK is on a level with the top
of the bulb in the other arm.
Stop cock G is then closed as
in Fig. 2. A small amount of
the fluid will have entered the
bulb portion of the tube. The
apparatus is then tipped,
turned, and gently shaken so
as to bring the sodium hy-
drate solution in contact with
all parts of the bulb portion,
and the carbonic acid con-
tained therein which it ab-
sorbs. Stop cock G is then
opened again as in Fig. 1 so
as to allow more sodium
hydrate to enter the bulb
arm, the stop cock is then
closed and the process of
shaking repeated. This oper-
ation is repeated several
times until the sodium
'Apparatus made by Emil
Greiver Companv, New York
City.
-Showing Fredericia tube and other apparatus needed
for the lung air test
temperature and it should be left therein for at
least three minutes. It should then be quickly re-
b— ic 250
MTotalAcidSalls^ CC
NAll
Cask 1569 Female. Age, 31
19 20 2! 22 23 24
years.
Acidosis of severe acute diabetes. Recoverv.
to hospital patient had vomited frequently for 4S hours. On March 15
me Ha in, air hunger, and drowsiness. Loss of fluids from bodv
probably was chief cause of severe symptoms. Note the greatly increased excretion of
urlnarj i imonia on March 15 and 16. brought about by the administration
ol large amounts of fluid and alkali, and the beneficial effect of this evidenced bv the
rise in the carbon dioxide tension.
Aug. 5, 1916]
MEDICAL RECORD.
227
moved and stop cock G so turned as to drain tube
HK, or as shown in Fig. 3. In this way the liquid
in HK should be brought down to the same level
as in the bulb arm. The apparatus should again
be immersed in water for a minute or two, and the
leveling process repeated if the column in HK is
higher than in the bulb arm. The apparatus should
then be returned to the glass jar and the height of
the column of liquid in the bulb should be read,
the observer looking through the jar. The height
of this column represents, in cubic centimeters or
per cent., the amount of carbonic acid that was ab-
stracted from 100 c.c. of alveolar air at a tempera-
ture of 20° C. It has been established that the
percentage of carbonic acid in the alveolar air
closely approximates that in the arterial blood.
The percentage of gas dissolved in a liquid de-
pends not on the amount present but upon the
barometric pressure, hence it is necessary to de-
termine the pressure of that portion of the alveolar
air which was carbonic acid gas. If a given per
cent, of the lung air is carbonic acid then that per
cent, of the barometric pressure represents the ten-
sion of the carbonic acid gas. If a sample of lung
air contained 5 per cent, of gas and the barometer
at the time read 29.0 in. or 760 mm., then the ten-
sion of the gas would be 0.05 of 760 mm. or 38 mm.
less a slight correction for water vapor. The table
!::
rss
•••
S3
:::
;-'
::i ::: «i
::: ::: '•'•'•
— vrl :::
DIACETIC ......j
Ann +1+2+3+4
MM
45
COzTENSIQN 40
ALVEOLAR AIR 35 /
30
25
4000
3500
CA<
5EJI0, 1518
3000
Z500
2000
1750
1500
1250
MaxNormal Total idoo
1
iTotalAmmorua^a 500
1
i 250 ^
^
'
|TotalAcidSalt5& CC
h 69 st 1
29
30
3
AP
may:
Case 151S. — Female. Age, 21 years. Severe nephritis. Marked anemia, pal-
lor, and general edema. Kidney function, three phenol-sulphonephthalein, two
hour tests. (1) 11 per cent., (2) 20 per cent.. (3) 13 per cent. Chloride reten-
Uon. Systolic blood pressure ranges between 15."; and ISO mm. No dyspnea ex-
cept on exertion. Note the low urinary acid output and slight evidence of aci-
dosis in the carbon dioxide tension.
on page 229, prepared by Dr. Edgar Stillman
in which is shown the tension of different percent-
ages of carbonic acid gas at various barometric
pressures, will facilitate the test.
Certain precautions should be exercised in mak-
ing the lung air test. The apparatus should be
clean and dry, because water absorbs its own vol-
ume of carbon dioxide. The apparatus should be
inserted in the mouth at the end of a normal ex-
piration. If the patient takes a full breath before
making the test, as beginners are apt to do, the
alveolar air will be diluted by the deeply inspired
air and the carbon dioxide output will be ap-
preciably reduced. This is illustrated in Table
No. 1.
Explanation of Charts.- — These are records of
cases exhibiting severe acidosis. They are plotted
so that the daily excretion of diacetic acid, total
urine acid, and total ammonia, may be compared
with the carbon dioxide tension of the lung air.
Of these methods the carbon dioxide tension is the
most reliable index of acidosis. This is plotted
in millimeters of mercury barometric pressure. The
commonly accepted normal limits are from 38 to
45 mm. Diacetic acid is estimated by the usual ap-
proximative quantitative, ferric chloride method, in
which varying intensities of the test are repre-
sented by from one to four plus marks. The total
urine acid and ammonia are both
plotted in terms of decinormal
alkali, as will be seen by the key.
These two excretory products are
additive, therefore one is super-
imposed on the other. Together
they afford a very reliable measure
of titratable urine acid excretion.
The normal individual rarely ex-
cretes more than the equivalent of
900 c.c. of decinormal alkali daily.
It is not the purpose of the au-
thor to discuss the treatment of the
terminal stages of diabetes, but
rather to present the measurable
phenomena of severe acidosis, and
a comparison of the best practical
methods of study.
Case 1641. — Female, Age, 60 years.
Patient was found unconscious by
family physician. Coma of acidosis
was suspected. A lung air test was
made in the manner above described
and 5.2 per cent, of carbon dioxide
or 36.8 mm. tension was obtained.
This tended to exclude coma of aci-
dosis. Later it was discovered that
patient was unconscious from over-
doses of veronal.
Case 1587. — Female. Age, 44 years.
Gastrojejunostomy. Persistent vom-
iting. For 12 days patient did not
receive or tolerate more than 200
calories of food daily. For 48 hours
semi-comatose. Compulsory lung air
test made. The carbon dioxide
equaled 2.3 per cent., or 17.4 mm. ten-
sion. Patient died in coma, due
probably to acidosis of starvation and
exhaustion.
Case 1568. — Female, Age, 35 years.
Primioara, 8 months pregnant. In-
tense headache and vomiting. Patient
conscious. Lung air test made in
usual manner. Carbon dioxide equaled
4.4 per cent., or 32.4 mm. tension,
suggesting severe acidosis of eclamp-
sia. Two hours later there followed
the severe convulsions of puerperal
eclampsia. Uterus emptied. Recov-
228
MEDICAL RECORD.
[Aug. 5, 1916
rrotalAddSaltefo CC
HARI2 13 14 IS 16 17 18 19 20 21 22 2324 25 26 27 28 29 30
Case 1o67. — Female. Age. 20 years. Severe diabetes complicated by acute appendicitis and marked lipoidemia. Patient
exhibited all tlie early stages of coma, as vomiting, diaphragmatic pain, air hunger, and drowsiness, from March 13 to March
IS. Note the striking relationship of excessive urinary acid and ammonia output with the low carbon dioxide tension of lung
air; also that the ordinary ferric chloride test affords only a crude index of the severity of acidosis.
1250
MaxNormal Total ioqo
AcirtSalte^Ammnn
TotaiAmmanii!
|TotfllAcirtSalt5t5 CC
\ge,
NAB
7 8 9 10 II 12 13
nr
■ •' ' years. Mild diabetes complicated bj syphilis. Note the persistent mi.«
acid in the urim th< slighUj excessive urinarj acid and ammonia output
me normal when antisyphilitic I
14 IS 16 17 18 19 20 2 I 22 23 24 25 26 27 28 29 30 31
APR.
Id acidosis evidenced
It will
Aug. 5, 1916]
MEDICAL RECORD.
229
ery of both mother and child. One week later lunj; air
carbon dioxide was 5.6%, or 40.7 mm. tension.
TABLE FOR THE CONVERSION OF THE PERCENTAGES
OF CARBONIC ACID OAS IN THE LUNG All: [NTO
TERMS OF BAROMETRIC PRESSURE OR TENSION
Percentage
( 'itrbonic
730 Mm
741) Mm
750 Mm
760 Mm.
." Mi
780 Mm
790 Mm
Acid Gas
28.7 In.
29.1 In.
29.5 In
.'"s l„
30.3 In.
30.7 1n.
31.1 In.
:: 0
20.9
21.2
2i 5
21.8
22.2
22.4
3.1
21.6
21 9
22 2
22.6
22.8
23 2
23.5
3.2
22.2
22 6
23 'l
23.2
23.6
23.9
24 2
3.3
23.0
23 4
23 7
24 0
24 3
24.7
25 .0
3.4
23.7
24.0
24 4
21 7
25.1
25 4
25.8
3.5
24.4
24 8
25.1
25.4
25.8
26.2
20.6
3.6
25.0
25.4
25.8
26.2
26 6
26 9
27.3
3.7
25.8
26.2
26.5
26 !i
'.'7 3
27.6
28 0
3.8
26.5
26 .8
27.2
27.6
28.0
2S 4
28 .8
3.9
27 2
27.6
2* II
28.4
28 s
29 2
29.6
4 0
27 8
28 2
28.7
29.1
29 5
29 9
30 3
4 1
28.6
29.0
29.4
29. S
30 2
30 6
31 1
4 2
_„, .,
29 7
30.1
30.6
31.0
31 4
31 S
4.3
30.0
30.4
30.8
31.3
31 .7
32 2
12 6
4.4
30.6
31.1
31 5
32.0
32.4
32 9
33 4
4 5
31.4
31.8
32 2
32.7
33.2
33 Ii
34 1
4.6
32.0
32 5
33.0
33.5
33.9
34.4
34 9
4 7
32.8
33.2
33.7
34.2
34.6
35 2
35.6
4.8
33.4
33 9
34 4
34.9
35.4
35 9
36 4
4.9
34 1
34.6
35.2
35 6
36.2
36.6
37 1
5.0
34.8
35 3
35.9
36 4
36.9
37 4
37 ''
5 1
35.5
36 0
36.5
37 1
37 Ii
38 1
38 7
5 2
36.2
36.7
37.2
37.7
38 3
38.8
39 3
5.3
36 9
37 .5
3.8.0
38.5
19 1
39 6
411 2
5 4
37.6
38.2
38 7
39.3
39.8
40 4
in 9
5 5
38.3
38.9
39 3
40 0
40 5
41 1
41 7
5.6
39.0
39.6
40.1
40.7
41.3
41 8
42 4
5.7
39.7
40.2
40 8
41.4
42 0
42 6
43.2
5.8
40.4
41.0
41 5
42.1
42 7
13 3
43 9
5.9
41 1
41 7
42 3
42 9
43.5
44 i
44 7
6.0
41 S
42 4
43 ii
43.6
44.2
44 9
45 -">
6.1
42 .5
43 1
43 7
44.3
45.0
45.6
46 2
6.2
43.2
43 8
44 4
45 1
45 7
46 3
47 0
6 3
43 9
44.5
45 1
45.8
46 4
47.0
47 7
6.4
44.6
45.2
45 9
46 5
47.1
47.8
In s
6.5
45.3
46.0
46 6
47.3
48:0
4S 6
19 .;
6.6
45.9
46.6
47.3
48 0
18 ii
1:1 ;
50 1.1
6.7
46.6
47 4
48.0
48.7
49.4
.-■II 1
50 i
6.8
47.3
48.0
48.7
49.4
:,ll l
50 -
.il 7>
6.9
4s M
48 8
49.5
50.1
50 '•
51 6
Summary and Conclusions. — The tests described
in this paper can be carried out by any well trained
physician. They are simple, require very little time,
are fairly accurate, and afford information of much
value in cases of severe metabolic disturbance.
Table No. 1.
Comparing the carbon dioxide in the lung air after a nor-
mal expiration with the exhalation following a forced in-
spiration.
C02 After Normal
Expiration.
Sllliln t
Per rent.
Tension.
in. Atteb Forced
Inspiration.
PerCent.
A
1
A
Ii
C
54.7
54.7
54 7
54 7
52.2
5.9
6 0
:, 1 1
6.2
5 9
42 ii
4) II
42 6
44 6
42 'i
Table No. 2.
Showing the percentage of carbon dioxide and barometric
tension of the lung air in a series of normal individuals.
First Observation Second Observation
Subject
Age
Per On I.
Tension.
Per i •ii'
Tens M|,
Girl
8
6 0
44 0
i 1
37 1
Boy
5!
5.9
43 5
6 0
41 ,1
iirl
4
5 4
39 8
5 II
:;ii 4
Man
32
i. 2
45 5
Man
28
6 4
47 1
\V oman
28
5 1
19 1
Comments.— It will be observed that file carbon dioxide tension of the lung air
DI normal individuals may \ary Iroirj 36 in lit) nil, i. Reading in children ar,
ticalty the same as in adults.
The measure of the urinary acid and ammonia
excretion may throw light on the acid production.
elimination, or retention by the body. If the
urinary acid output is high, production must be
high. If low, there may be retention or defective
elimination by the kidnevs.
Table No. 3.
Showing the effect on the carbon dioxide output of the
lung air of compulsory breathing through the tube in a
series of normal individuals.
Subject
Norhai,.
i im; M Two Minutes.
Per Cent.
l
Per Cent.
Tension
!', , 1 , ,,
! , 0 .,.,
Man (41 yrs.)
Man (41 yrs.)
Woman (28 yrs.).
Girl(6yrs>
8 0
7.1
.5 1
5.1
7 2
mi 8
5.) 11
39 3
37 1
.-.2 2
6.3
5 5
6.3
i. 7
45.8
in ii
45 2
48 7
7 8
7 n
5 6
5 3
7 5
59 2
53 2
40 7
.Is 5
Woman (40 yrs.'.
57 0
Conditions of test. — Subject sitting quietly in chair, air tube in month with lipB
closed tightly about it. Nose pinched shut. Sample of air taken at end of exhalation
at end of time limit.
Comments. — It will be observed that when compared with the normal output, the
lung air obtained in the Fredericia tube at the end of 1 minute's compulsory breathing
contains less carbon dioxide, but that at the end of 2 minutes the readings are prac-
tically the same. Therefore the F'redericia used in this way affords a fairly accurate
measure of the carbon dioxide tension. This method may be useful when dealing
with patients who cannot or will not assist in performing the test in the normal or
previously described manner. Thus in stuporous or comatose patients a fairly
accurate reading may be obtained by forcibly holding the apparatus in the path ui
mouth, at the same time pinching the nose and compelling him to breathe through the
tube for two minutes. The following cases seen in consultation illustrate the useful-
ness of the test when employed this way:
If acid production is high, and there is good elim-
ination, the carbon dioxide tension of the lung air
may be high, indicating that the body is protecting
itself by kidney elimination alone. If the carbon
dioxide tension is low with high urinary acid elim-
ination, it suggests a more profound acidosis for
which the body is trying to compensate by lung
ventilation. If urinary acid elimination is low and
the carbon dioxide tension is also low, increased
acid production and retention are suggested and an
acidosis and coma of grave prognosis are likely to
follow.
The ordinary tests for diacetic acid are of much
less value to the clinician than are the urinary acid
and ammonia determinations taken in conjunction
with the carbon dioxide tension of the lung air.
In the experience of the writer these tests are of
greater value in diabetes than in other metabolic
disturbances or diseases.
In the preparation of this paper the studies of
Higgins, Peabody, Henderson, Stillman, and Fred-
ericia have been freelv used.
CONNECTICUT, A STUDENT OF TUBERCU-
LOSIS.*
By STEPHEN J. MAHER. 11 F> .
NEW HAVEN, CON'N.
CHAIRMAN STATE TUBERCULOSIS COMMISSION OF CONNECTICUT.
Some years ago, as a member of the State Tuber-
culosis Commission, I wrote a rather widely
circulated paper on "Connecticut, a Doctor of
Consumptives." In that paper I told of Connecti-
cut's method of treating the three hundred patients
in her three tuberculosis santaoria. Since then
Connecticut's practice as a tuberculosis specialist
has increased considerably. She now has four
tuberculosis sanatoria and every day she treats
more than five hundred tuberculous patients. If
she could afford it she would have even more pa-
tients. We who have had charge of this practice
of hers have long recognized that although in giv-
*Read before the Meriden Medical Society, April 27,
1916, and in part before the Stamford Medical Socioty,
February 19, 1916.
230
MEDICAL RECORD.
[Aug. 5, 1916
ing to these five hundred patients the modern
hygienic dietetic treatment of the disease we were
doing justice to the patients, we were not doing
entire justice to Connecticut. Why not? Because
justice to Connecticut demanded that we not only
treat these patients but that we study them to such
purpose that in the future there should be less
tuberculosis in Connecticut.
We realized that, like the rest of the world, we
were unable to answer many of the important
questions that hover like Zeppelins over our pres-
ent theory of tuberculosis. Of course, many of the
enthusiastic leaders of the anti-tuberculosis cam-
paign deny the importance of the questions and
profess to see no threatening shadows or shapes
in the clouds that pass over the trenches of the
anti-tuberculosis armies. But most physicians,
and even the laymen who have given the subject
proper study, realize that tuberculosis is still a
mysterious disease, and that we must conquer the
mystery before we will be able to conquer the
disease.
Now where could there be better opportunities
for attacking both the mystery and the disease
than in our State sanatoria? In these sanatoria
are more than five hundred patients, in all
stages of the disease, drawn from the million or so
of people who look to Heaven from the compara-
tively few square miles of Connecticut. In these
sanatoria are good physicians and nurses, good
microscopes, and a sufficient, if small, laboratory
equipment.
"Then why not do some scientific research
work?" That is the question we have been asking
the superintendents of the various sanatoria for
some years. "You know the great need of this
research work. You have the ability, have you
not? You have the material and the instruments.
And we promise you public recognition of any
good work that you may do."
Several of the physicians responded to our ap-
peal by making a few rather desultory and incom-
plete experiments, but nothing satisfactory was
accomplished until 1915.
In March of last year the commission voted to
hold a medical conference once a month at one of
the State sanatoria, and to require the medical
staff of the sanatorium at which the conference was
held to be ready at the conference to present
to the commission and to the physicians of the
other sanatoria some interesting new work or some
studies of the especially interesting cases in the
institution. It is only a year since this rule went
into effect, but it has already worked wonders.
The superintendents and their assistant physicians
have taken up the idea with the heartiest enthusi-
asm. A rivalry, keen but friendly, has developed
between the four institutions for the credit of hav-
ing the best conference. I must confess that I have
been astonished at the fine quality of many of the
papers and demonstrations. Some of the confer-
ences were good enough to command the time and
attention of the best doctors anywhere. Here are
a few of the topics. Of course, I will not go into
enough detail- to spoil the publication value of the
original work.
1. At the Hartford Sanatorium, Dr. Wagner
gave interesting avray demonstrations of many of
the difficult cases, and thus brought up for discus-
sion the whole subject of x-ray diagnosis in tuber-
culosis. He also applied the luetin test to 160
patients in the sanatorium. He found that
an astonishingly large proportion of the patients
gave a positive reaction, but the results, as
was brought out in a sharp general discussion,
were largely nullified because of the fact that most
of the patients had received iodine medication
within a few days or weeks of the test. Neverthe-
less, his report of the reactions and his searchings
of the patients' bodies and histories for stigmata
of syphilis were very stimulating and did much to
increase the interest of all of us in the question of
the frequent coincidence of the two diseases, syph-
ilis and tuberculosis.
At the Hartford Sanatorium, Dr. Strobel pre-
sented a most interesting study of the possible re-
lation of the pneumococcus to hemoptysis in pul-
monary tuberculosis. He isolated from the bloody
sputum of all of a short series of cases of pul-
monary hemorrhage a typical pneumococcus which
was pathogenic to rabbits. He is still at work on
this problem.
2. At the Norwich Sanatorium, Dr. Campbell and
Dr. Lynch have demonstrated that the preliminary
injection of guinea pigs with a very slightly viru-
lent type of the human tubercle bacillus, did not in-
terfere in any way with the action of a highly
pathogenic strain of human tubercle bacilli injected
after some months into these same guinea pigs.
They died at exactly the same time as the controls.
Dr. Lynch also presented a study of the bacterial
findings in the mouths of fifty consumptives in the
later stages of the disease. In only four of the
cases could he demonstrate tubercle bacilli in the
wipings or washings of the teeth, gums, tongue,
tonsils, or pharynx. These four cases were all in
extremis and were all dead within ten days of the
examinations. Other subjects presented at the
Norwich Sanatorium conference were: "The
Source of the Infection in Tuberculosis," by Dr.
Campbell, and "The Pre-Bacillary Forms of the
Tubercle Bacillus," by Dr. Lynch.
3. At the Meriden Sanatorium, Dr. Dinnan has
carried out two interesting bits of work. One
concerned the question of heliotherapy. Of course,
everybody knows that sunlight properly applied
benefits patients suffering from bone or glandular
tuberculosis, but the question of whether the con-
tinued exposure of the skin of all the body to the
direct rays of the sun benefits cases of pulmonary
tuberculosis has not been satisfactorily answered.
Dr. Dinnan's work has not answered it; but of the
six second-stage cases that formed his class last
summer five showed marked improvement, three
have gone back to work with the disease arrested,
and one has died. His reports at two of the confer-
ences included full reports of blood counts and blood
pressure, and hemoglobin indices, as well as the
ordinary sputum and urine and temperature and
pulse and respiration records.
His other investigation related to blood pressure
before, during and after hemorrhage in cases of
pulmonary tuberculosis. His findings have been
the surprising and important ones: (1) That hem-
orrhage from tuberculous lungs is never due to
high blood pressure: but (2) that the bleeding con-
sumptives have lower blood pressure than the aver-
age consumptive, and (3) that blood pressure for
the hemorrhage case, just before the hemorrhage,
is lower than the normal of that case; that (4) the
blood pressure rises during the hemorrhage, and
(5) that the blood pressure remains high for a
Aug. 5, 1916]
MEDICAL RECORD.
231
short time after the hemorrhage and then slowly
falls to what it was before the hemorrhage. Dr.
Dinnan is still working on this problem. His con-
clusions in this matter, considered in connection
with Dr. Strobel's finding of a pathogenic pneumo-
coccus in the sputum of all his bleeding consump-
tives, open up a wide field for speculation and study.
Because of my desire not to offend Dr. Dinnan's
well-known modest disposition, and because I un-
derstand that most of you have seen the cases that
composed the class in heliotherapy last year and
are more or less familiar with his studies on the
blood of the tuberculous, I will not dwell on his
work at any greater length. That such work is im-
portant I need not tell you. I need not tell any
doctor.
I will spend a little more time on the work done
at the Shelton Sanatorium. You probably know
less about the Shelton Sanatorium than about any
in the State. I want to introduce you to it.
4. At the Shelton Sanatorium, Dr. Stockwell's
best work has been on streptothricosis. A most
difficult problem of sanatorium management is
one that perhaps you would consider easy.
It is none other than the problem of diagnosis.
Has the patient tuberculosis? Of course, most of
the patients that come to the State sanatoria have
not only the physical signs of tuberculosis, but they
also have easily demonstrable tubercle bacilli in
their sputum; yet I think it is safe to say that in
every tuberculosis sanatorium everywhere a vary-
ing percentage of the inmates have no tubercle ba-
cilli in their sputum. They may have areas of con-
solidation or softening, or even cavitation in the
lungs, and yet the most diligent search will fail to
reveal a single tubercle basillus. Even guinea-pig
inoculation may be negative. In these cases the
various tuberculin tests may give unsatisfactory
or contradictory evidence.
The State sanatoria are maintained for the ben-
efit of residents of the State who have tuberculosis,
and not for the benefit of persons who have not
tuberculosis, even if they have suppurating cavities
in their lungs. Nor are the sanatoria preventoria.
A patient must have tuberculosis to be legally ad-
missible. But when a patient with the physical
signs of consumption has been sent to a sanatorium
with a diagnosis of tuberculosis made by a physi-
cian of good repute, or by the staff of one of the
best hospitals in the State, the sanatorium physi-
cian who takes it upon himself to pronounce that
patient non-tuberculous must be very sure of his
ground. The easy and ordinary way is to keep the
patient and say nothing. Dr. Stockwell's way has
been to study the patient and report his findings.
At the conference held at the Shelton Sanatorium
he has already demonstrated twelve cases of strep-
tothricosis, and in nine of the twelve cases there
were no tubercle bacilli. All of these cases were
severe progressive cases ; they were all hemorrhage
cases. The little granules of the fungus were
shown at the conferences in the sputum of all
twelve cases. The streptothrix was displayed in
pure culture on glycerin and glycerin-agar. Under
the microscope hanging drops of the live organism
were shown, as well as many stained smears of the
pure cultures, and of the streptothrical sputum.
Then the twelve patients were exhibited and exam-
ined, and their treatment explained. Their treat-
ment consisted in the administration of the iodides
up to tolerance, usually 30 or 40 drops of the sat-
urated solution three times a day. One patient re-
ceived 70 grains three times a day. Remember,
these were hemorrhage cases, and yet they received
ihese heroic doses of the iodides. Now as to the
results: Two died; one left without treatment; one
remains unimproved ; six have gone home without
any symptoms left of their former serious lung
trouble, and one has gone home improved but with
some activity left in the lung lesion. One remains
at the sanatorium slightly improved. And all of
these cases were doing badly when Dr. Stockwell
began his intensive study of them.
In order to persuade you that the subject is of
importance to you as well as to us, let me relate
briefly the history of one of these cases, the last
one mentioned above, the one that remains at the
sanatorium slightly improved. The patient, a
husky man of middle age, had an attack of pleurisy
in September, 1913. Several ribs were resected in
November, 1913. A sinus persisted. In March,
1914, his left knee began to swell. At one of the
best hospitals in the State various measures were
adopted to cure the supposedly tuberculous knee;
even a resection was tried. Nothing helped.
Finally, in September, 1914, the leg was amputated
above the knee. In January 1915, an abscess de-
veloped in the right hip. The surgeons in the hos-
pital threw up their hands and notified the patient
and his friends that the hospital could do no more
for him, and that, as he had tuberculosis of the
lungs and of the bones, the proper place for him
was at one of the State tuberculosis sanatoria;
therefore he was brought to the Shelton Sana-
torium.
Routine examinations of sputum showed no
tubercle bacilli in his sputum. After a while Dr.
Stockwell's attention was directed to this fact. He
immediately found the streptothrical granules, not
only in the man's sputum, but also from the pus in
the discharging sinuses in his hip and chest. The
iodides have stopped the progress of the disease.
The patient has gained in weight. The streptothrix
cannot now be found in either sputum or pus.
He has no more hemorrhages, but his bones are
badly hurt; he has lost a leg. His future use-
fulness to himself or the community is very doubt-
ful. It is distressing to observe his pathetic cheer-
fulness and to consider how different his circum-
stances would be to-day if any one of the many
eminent physicians and surgeons who treated him
during the last two years had known as much about
streptothricosis as Dr. Stockwell knows now.
Here is another investigation pursued at this
sanatorium and reported at a recent Shelton con-
ference by the first assistant, Dr. Stilphen. It
concerned the von Pirquet test. You all know the
common judgment on the von Pirquet test: "It is
of the greatest value in very young children, but it
is of less and less value as the child grows older,
and it is of no value in adults, because practically
all adults have had tuberculosis at some time, and
the positive reactions that practically all adults
give to the von Pirquet test are of no assistance
to us in determining whether the patient has now
active tuberculosis."
Well, here is what they learned on that sub-
ject at Shelton, and how they learned it. They ap-
plied the test to all the patients in the sanatorium,
one hundred and thirty-three in number. They ap-
plied the test to every patient at first with two
kinds of Mulford's tuberculin, one made from
human tubercle bacilli and one from bovine tubercle
bacilli. They were so surprised with the results
232
MEDICAL RECORD.
[Aug. 5, 1916
that they wrote to Alexander for bovine and human
tuberculin, and explained to Alexander that it was
for a very important series of tests. They received
special guarantees as to the quality of the tubercu-
lin sent to them. They then went over all the
patients again with the new bovine and new human
tuberculin. And to their consternation the results
with the second test were practically the same as
with the first. Here are their results: Of the 133
patients tested, only 61 reacted. Of the 16 incip-
ient cases tested, 10 were positive and 6 negative.
Of these 10 positive incipient cases, 2 were positive
only to human tuberculin, 2 only to bovine tuber-
culin, and 6 to both human and bovine.
Of the 55 moderately advanced cases tested, 26
were positive and 29 negative. Of these 26 posi-
tive moderately advanced cases 6 reacted only to
human tuberculin, 5 only to bovine tuberculin, and
15 reacted to both bovine and human tuberculin.
Of the 58 advanced cases tested, 23 were positive
and 35 negative. Of the 23 positive advanced cases,
3 reacted only to human tuberculin, 4 only to bovine
tuberculin, and 16 to both human and bovine tuber-
culin. Of 4 cases of surgical tuberculosis tested, 2
were positive and 2 negative. Of the 2 positive
cases of surgical tuberculosis, 1 reacted only to bo-
vine.
It was only last December that Craig's article on
the complement fixation test in tuberculosis ap-
peared in the American Journal of the Medical
Sciences. Those of you who have mastered the
technique of the Wassermann test, and who have
read Craig's article, will realize with what a love of
work Dr. Stockwell and his assistants must be
possessed when I tell you that at the conference
held at Shelton last March Dr. Stockwell reported
his findings in 31 cases, 26 tests and 5 controls.
All his controls were negative, and 24 of his tests
surely positive. His two negative tests were his
first two experiments, and were probably negative
because of poor antigen. Some of his tests gave a
positive complement fixation test, although the
patient had been negative to the von Pirquet test.
This splendid result has been accomplished during
the winter in spite of the fact that at the time of
the appearance of Craig's article neither Dr. Stock-
well nor his assistants had more than a reading
acquaintance with complements, antigens or ambo-
ceptors. Isn't that interesting and important?
The medical staffs of all the sanatoria are study-
ing the questions of the relation of typhoid to
tuberculosis and some other fascinating problems
that I am not at liberty to discuss to-night. At
all of the sanatoria there is new interest in the
patients and all that concerns tuberculosis. That
is the cheerful verdict of doctors, nurses and
patients.
In conclusion may I not fairly claim that Con-
necticut, as represented by those in charge of her
State tuberculosis sanatoria, has begun a really
serious and unusual and valuable study of the great
problem of tuberculosis? If you consider the claim
a fair one, I would ask you to show your sympathy
with it by keeping in touch with us, by visiting
the sanatoria, by giving us the benefits of any con-
structive criticisms that may occur to you as the
results of your visits, by informing your people
and your representatives in the Legislature of the
importance to the present and future generations
of Connecticut's dual role of Doctor and Student of
Tuberculosis.
in 2 Orange Street.
COMPLEMENT-FIXATION IN PULMONARY
TUBERCULOSIS.*
SOME CLINICAL OBSERVATIONS.
By ALFRED MEYER. M.D.,
NEW YORK.
Numerous reports have appeared during the last
few years upon the value of complement-fixation in
the diagnosis (or exclusion) of tuberculosis, espe-
cially the pulmonary form. The conclusions reached
by various authors all seem to agree that there is
some value in the test, both in confirming the exist-
ence of tuberculosis, either active or inactive, and
in excluding it if the reaction is negative. There
is, however, very considerable variation in the per-
centages of reliable results obtained in both positive
and negative cases. This does not necessarily indi-
cate the unreliability of the method, because it must
be remembered that the different laboratory work-
ers have employed different antigens, and for pur-
pose of comparison the method used in all cases
must be identical down to the minutest detail. At
the same time, the widest publicity possible must be
given to that method which seems to offer the high-
est percentage of reliable results so that the work
may be repeated on the largest possible scale by
many independent observers.
The object of this communication is (1) to give
a short summary of work done on my cases this
winter by Dr. H. R. Miller of New York with a new
antigen; (2) to compare the results with similar
work done by others, and (3) to illustrate the prac-
tical value by a few detailed clinical histories. The
serological work was done by Dr. Miller at the
Bacteriological Laboratory of the College of Phy-
sicians and Surgeons, Columbia University, New
York City. Up to the present time he has examined
the sera of a thousand cases obtained from many
different sources. The material reported upon here
was furnished by me from my service at the Bed-
ford Sanitarium of the Montefiore Home, from my
tuberculosis and general services at Mt. Sinai Hos-
pital, and from cases in my private practice.
The method used by Dr. Miller was recently de-
scribed by him as follows:
"The bacilli which so far have been used for the
production of the antigen have been of the human
type, some of them isolated by Miller, some of them
obtained from Prof. Theobald Smith, some from
the laboratory of Prof. William H. Park, and some
from the laboratory of Parke, Davis & Co. They
have been grown mainly on the gentian violet
medium of Petroff, and on Miller's modification of
this medium; also on Petroff's potato broth. It is
at present the impression of the writer that the
medium on which the bacilli are grown plays no
great part in determining the usefulness of the an-
tigen. It seems, however, to be important that a
number of different strains should be used — that is,
that the antigen should be polyvalent — and the use
of relatively young cultures is advisable. So far,
in most of the reactions, unheated bacteria have
been used.+ Inasmuch as the method of produc-
tion, under these circumstances, is fraught with a
not inconsiderable element of danger, we have re-
cently begun to use bacteria heated to 60° for a
half hour, and in the one series so carried out no
*Read at the Twelfth Annual Meeting of the National
Association for the Study and Prevention of Tubercu-
losis, Washington, May 11, 1916.
fin a few of these eases the sputum was found posi-
tive only subsequent to the serological test.
Aug. 5, 1916]
MEDICAL RECORD.
233
Table I
Case
Age
Clinical Diagnosis
Von Pirq.
X-Ray
Comp. Fix.
Remarks
M. A.
34
Doubtful pulm. tuberculosis
Pos.
Thickened left pleura
+ + +
10 wks. later neg.
H. B.
20
Pulmonary tuberculosis
Typical tuberculosis bilat.
Feb. + + + +
April
Always afebrile.
B jp. exam. Wass. neg.
L. D.
1 Bilat. apic. tuberculosis
Pos.
Infilt. both apices.
+ + +
Afebrile.
J. F.
.Slight rt. apic. tuberculosis
+ + + +
30 sputa. 3 laryngeal.
G. F.
Consolidation rt. upper lobe
SI. pos. and neg.
Tumor?
Aneurysm?
Feb. 12 + + 4- +
Feb. 24 + + + +
April 25 neg.
Wass. neg. 16 sputa. (More
details in text.)
D. G.
19
Pulmonary tuberculosis rt. cav-
ity
Rt. tuberculosis
+ + +
19 sputa. Guniea-pig inoc:no
tuberculosis. Febrile.
J. G.
56
Slight old mitral stenosis; pleu-
Rt. apic. tuberculosis. Pleural
+
Recurrent hemoptyses.
1 ral thickening
thickening
A.H.
Doubtful tuberculosis
No definite evidence
+
Afebrile; probably arrested
H. I.
64
Doubtful tuberculosis
:fc
Bilat. chron. apic. tuberculo-
+ +
Afebrile; recurrent si. hemopt.
sis
+ + + + (same date}
5 yrs.
D. M.
50
Pulmonary tuberculosis suspect Neg.
+ +
Subfebrile.
J. S.
15
Hodgkins?
Old lesion 1. apex. Bron.
nodes, large
+
Path. ex. gland; tuberculosis
adenitis.
K. S.
31
Bilateral apical tuberculosis
Marked bilat. fibrosis
+
31 sputa. Febrile many weeks.
Guinea-pig neg.
s. s.
Doubtful tuberculosis
SI. dense rt. apex; peribron.
infiltration
+ +
Admits lues; Wassermann
posit.
a. r.
DoubtfuJ tuberculosis
POS.
SI. infilt. left apex.
+ + +
9 sputa.
I. w.
Doubtful tuberculosis
Pos.
Pulm. cavity
+
Afebrile. Only 3 sputa ob-
tainable.
*In a few of these cases the sputum
deteriorating effect of the heating was apparent.
These problems of detail, as well as many others,
are being thoroughly investigated.
"Twenty mgm. of the moist tubercle-bacillus mass
was weighed out, placed in a conical 15 c.c. centri-
fuge tube, and to it are added 90 mgm. of table salt.
With a glass rod filed to roughness at the end, this
paste is ground by hand for about one hour. Dis-
tilled water is then added to isotonicity ; that is, 10
c.c. to the quantities above described. That is the
antigen. Just before using, it is shaken up and
the heavier particles are allowed to settle in the
course of a few minutes. Except for the removal
of these larger elements, the suspension is used as a
whole without centrifugation and without filtration.
"The antigen so prepared has hardly ever been
found anti-complementary in quantities as large as
1 c.c, and has given fixation with positive sera
(the sera used in quantities of 0.1 c.c.) in amounts
as low as 0.02 c.c. The titrations as well as the
reactions have been done with one-half the original
Wassermann quantities, using a sensitization of
two units of amboceptor and two units of comple-
ment. So far we have used the anti-sheep rabbit
hemolytic system. As a routine, the 37° one-hour
water-bath incubation has been employed. A num-
ber of parallel series have been done by the four-
hour ice-box method, but since this seems to make
little difference in the results, the time-saving 37°
method was decided upon as a routine procedure.
The antigen appears to be quite stable. We have
used with satisfaction antigens as old as six or
seven weeks kept on ice."
Summary. — Of forty-eight cases with positive
sputum, all but two reacted positively, equivalent
to 96 per cent.* This result is even more favorable
than appears on the surface, for one of the two ex-
ceptions (A. W.) had had negative sputum for
seven months (eighteen examinations), had gained
33 lbs., and was in all probability an arrested case.
The other exception (H. S.) was also in all proba-
bility an arrested case, having been afebrile for a
year, and having gained nearly 18 lbs.
"This applies to all my cases.
Table II.
Case
Age
Clinical Diagnosis.
Von Pirq.
X-Ray.
Remarks
A.B.
Chr. bronch.; polvcythemia
Pos.
Infil. both upper lobes
Afebrile; 5 sputa.
A. B.
20
Pleurisy with efTus.
Neg.
Guinea-pig negative.
P. C.
36
Lues. Indefinite apical signs
Wassermann + -+- + +
M. E.
50
Diabetes
±
Reaction apex, percussion neg.
A. E.
50
Chr. nephritis
SI. +
Febrile
J. F.
Pleuro-pneumonia with serous effus.
±
Temp. 106 deg.
A. H.
42
Py opneu moth or ax
Neg.
Neg.
Guinea-pig neg.
Operation; death.
M.J.
43
Duodenal ulcer, healed tuberculosis
Suspect tuberculosis 14 years
before.
M. K.
37
Spontaneous pneumothorax (right)
Probably old left apical lesion, rt. pneumo-
thorax
Afebrile, Wass. neg., P. S0-92,
R-20-24.
L. K.
Infiltration both apices, pleurisy both
bases
7 sputa neg. Always afebrile ;
gained 23 lbs. in 9 wks.
J. L.
21
Sexual neurasthenic
Pos.
Negative
O. L.
Post-pneumonic pleurisy
Neg.
Infiltration rt. base
Afebrile.
I. L.
Chronic nephritis and uremia
*
6 sputa neg. one antiformin.
Death.
F. P.
17
Mitral lesion, well compensated. Tuber-
culosis suspect.
Neg.
Calcareous bronch. lymph nodes
Afebrile.
I.. K.
49
Malignant tumor testicle.
Confirmed by operation.
J. R.
43
Pulm. abscess; rapid cavity formation
Neg.
Neoplasm?
Wassermann neg. Sputa f 14>
neg. Once, 2-acid fast bacilli.
WBC 29,000.
M.S.
28
Phthisiophobia; slight nephritis
Negative
6 sputa negative; 1 antiformin.
I. S.
34
Old pneumonia; pleural adhesions
Neg.
Shadow left base; cause uncertain
Afebrile. Wassermann negative.
A. S.
40
Carcinoma of stomach.
Wassermann negative.
S. W.
38
Chr. nephritis; chr. endocarditis; lues
Neg.
Wassermann -+- + + +
s. s. w.
n
Old pleurisy; healed tuberculosis
Peribronch. infiltration; calcareous bron.
nodes; slight infiltration apices.
Question of permitting marriage
R. Z.
19
Doubtful pulm. tuberculosis
Pos.
Dense, irreg. shadows around hilus and in 4th
r't interspace. Great number dilated
bronchi.
Repeated hemoptyses.
234
MKDICAL RECORD.
[Aug. 5, 1916
It is necessary to go a little more into detail with
regard to fifteen strongly suspect cases with nega-
tive sputum that reacted positively. The sputum
in these cases had been examined from three to
thirty times, some with antiformin.
The group of cases in Table I, not proven bac-
teriologically, represents a very common type for
which clinicians are seeking additional reliable aid
for a correct conclusion ; and this need applies both
to cases in which the interpretation of undoubted
physical signs is uncertain, and to suspect cases
without any physical signs at all, or is needed to
corroborate exclusive skiagraphic findings, or to act
as substitute for skiagraphic evidence if this is not
available. Everyone of the above cases, with the
exception of S. S., justified the positive complement-
fixation test, either from the clinical or skiagraphic
point of view, equivalent to 93 per cent. S. S. had
a positive Wassermann, and although he had x-ray
findings that might have justified including him
among the proven tuberculosis cases, it was thought
wise to exclude him for reasons which will appear
later under my remarks on syphilis.
The case of G. F. is of especial interest because
of the original x-ray diagnosis, the Von Pirquet
findings and the change from two four-plusses to
negative. It must be stated, however, that he had
had a tuberculin injection of 0.005 with marked
febrile reaction on Feb. 2, ten and twenty-two days
respectively before his two positive complement-
fixation reactions. As has been shown by Citron,
tuberculin injections may cause the appearance of
antibodies in the serum, which soon disappear. The
subsequent course of this case, clinically and skia-
graphically, indicated that his condition was one of
chronic fibrosis with bronchiectases, and the sus-
picion is confirmed that the first and second positive
complement-fixation reactions were due to the tuber-
culin injection, and that he had no active tubercu-
losis.
In two of the cases (M. A. and H. B.) a decrease
in complement binding corresponded strikingly with
clinical improvement. I leave it an open question
whether there is any relationship between these two
facts, and therefore of its prognostic significance.
This can only be decided after the accumulation of
a very large number of observations.
I wish to report also twenty-two cases of various
diseases with negative reaction.
An analysis of Table II shows that in at least
15 cases out of the 22, equalling 68 per cent., the
negative complement-fixation agreed with the clini-
cal findings.
Of the remaining seven, M. J., L. K., F. P. and
S. S. W., if ever tuberculous, were apparently healed
cases ; hence we may reasonably include them among
the cases in which a negative complement-fixation
reaction is reliable, which increases the percentage
to 86. In three cases, however, M. K., J. R. and
R. Z., the serological findings are not absolutely ac-
ceptable. M. K. and J. R. are sufficiently explained
in the table.
The case R. Z. was a young girl of nineteen whose
first hemoptysis had occured nine years before, after
falling down stairs (traumatic tuberculosis, so-
called?) ; again, hemoptyses four years before and
two weeks before admission to my service at Mt.
Sinai Hospital. According to her story, all these
hemoptyses had been very large. While under my
observation she had fresh hemorrhages on eight
different days, as much as 11 ounces on one day. and
totaling about 23 ounces, finally necessitating the
induction of an artificial pneumothorax on the right
side. The selection of the side for lung compression
was somewhat difficult because there had been a
complete absence of physical signs, with the excep-
tion of very slight crepitation on that side in the
axillary region, and at that time radiography was
not advisable because of the hemoptyses. From
that date on, now five months ago, there has been
no recurrence of bleeding, and she is much improved
in general health ; she has no cough, no expectora-
tion, has gained a great deal in weight, and a
guinea-pig inoculation with the blood proved nega-
tive, so I am still in a quandary as to the nature
of her case.
In discussing tuberculosis complement-fixation in
his recent work on "Pulmonary Tuberculosis," Fish-
berg says: "Most writers obtain positive reaction
in patients with syphilis." On the other hand, Craig
{Am. Jr. Med. Sci., Dec, 1915) has reported that
out of 150 syphilitics examined, only two cases gave
positive tuberculosis complement-fixation, and in
these two the symptoms of a coincident tuberculous
infection were present. My own series shows two
cases of syphilis, P. C. and S. W. (Table II), each
with Wassermann four plus and each with negative
tuberculosis complement-fixation. On the other
hand, S. S. (Table I), a doubtful tuberculosis, ad-
mittedly luetic, had a positive complement-fixation,
but also a positive Wassermann and x-ray findings
that might be interpreted as confirmative of either
or both of these diseases.
In a verbal communication, Dr. Miller tells me
that he has examined fifty-four other cases with
positive Wassermann and they were all negative for
tuberculosis with his antigen, with the exception of
one case, which was positive, and proved to be com-
plicated by tuberculous peritonitis. This evidence
strongly supports the view that with this antigen
there is no confusion between the two tests, but that
a positive tuberculosis complement-fixation in a
luetic is simply proof of the coexistence of the two
diseases.
The limited time at my disposal precluded my
going extensively into the literature of the subject.
Radcliffe (Jour. Hygiene, Cambridge, 1915, XV)
had 89 per cent, positive results in 568 cases in all
stages of pulmonary tuberculosis. In 11 cases other
than tuberculous, mostly malignant growth, all were
negative; in 20 suspect cases with negative sputa,
75 percent, were positive; 45 apparently normal in-
dividuals, examined on 204 occasions, were invaria-
bly negative.
Craig (loc. cit.) found 96 per cent, of positive
reactions in active tuberculosis and 66 per cent, in
inactive. The test was negative in normal indi-
viduals, and also in patients suffering from other
diseases.
Baldwin, of Saranac Lake, in a private communi-
cation, reports 56 per cent, positive in 32 suspicious
cases and 90 per cent, positive in 10 known first
stage; 25 per cent, positive in 32 healed cases, from
four months to ten years. He also makes the re-
markable statement that there were 30 per cent,
positive in 20 supposedly healthy persons who had
been long exposed to tuberculosis.
In conclusion, I would say that in my judgment
the evidence offered by my cases, examined with
Miller's antigen, compares most favorably with the
results obtained elsewhere with other antigen; that
it is in all probability no exaggeration to say that
the method equals in value the Wassermann test for
syphilis. It is most important that complement-
Aug. 5, 1916]
MEDICAL RECORD.
235
fixation tests, with Dr. Miller's antigen, be made on
as large a scale as possible in sanatoria and, so far
as practicable, in private life.
785 Madison Avenue.
SYPHILIS OF THE BLADDER.*
Bt JAMES PEDERSEN, M.D.,
NEW YORK.
The progressive pace set during the past twelve
years by laboratory research workers, leading to
precision in the diagnosis of syphilis in all its
stages and to greater efficiency in its treatment,
has been fully equalled only lately by the avidity
with which practitioners have seized upon the there-
by attained solution of many problems in medicine
and surgery. An example of testimony to this
fact is Dr. Barker's paper, presented at the New
York Academy of Medicine's recent symposium on
syphilis. It recalls to mind the keen clinician who,
less than a generation ago, predicted that most ills
of mankind could be traced to syphilis recently ac-
quired or remotely inherited, and makes of him a
seeming prophet, at that time without honor both
within or without his own country. We are rap-
idly coming to know how much more general and
occult is syphilis than was ever suspected.
The induction of Dr. Barker's paper, read on
that occasion, contains an interesting chronological
compilation of the research attainments and their
dependent clinical facts. These attainments and
facts are to-day so essential to precision in medi-
cine and surgery that, closely summarized, it is
permissible to repeat them here. Most of them
fall within the past decade.
1. The discovery of Treponema pallidum as the
cause of syphilis, followed later by success in grow-
ing the organism in pure culture.
2. The discovery that many animals are suscept-
ible to syphilis, not only by transmission, but also
by inoculation from pure culture.
3. The discovery of simple, easy methods of dem-
onstrating the organism obtained from all sorts of
syphilitic lesions, the chancre, the secondary erup-
tions, and gummata; the walls of aortic aneurysms,
the brain in general paresis, and the cord in tabes;
the organs in children dead of congenital syphilis,
and the placentas of mothers of syphilitic children.
4. The discovery of the Wassermann reaction, ap-
plicable alike to the blood serum and the cerebro-
spinal fluid, and, through its clinical use, the proof
that unsuspected syphilis is more widely spread
than has been estimated ; that the majority of cases
supposedly well-treated before the Wassermann re-
action control was known, still harbor infection;
that many of the wives and children of supposedly
cured luetics are infected, even though they show
no symptoms; that the reason why a syphilitic
child of a syphilitic father can be nursed by the
mother without giving the disease to the mother
(Colles' law) is that the mother is already infected
(the child having been infected by placental trans-
mission from the mother rather than by direct in-
heritance from the father) ; and that the reason
why the apparently healthy child of luetic parents
seems to be immune from infection, say, from an
infected wet nurse (Profeta's law), lies in the fact
that the child is already infected.
5. The advent of salvarsan, and by its use the
proof that in many cases syphilis can be cured in
*Read before the Medical Association of the Greater
City of New York. April 17, 1916.
reality and the Wassermann reaction be made nega-
tive permanently; that this cure is much more cer-
tain by intensive treatment in the early stages than
by any form or measure of treatment late in the
disease.
6. That the disease does not bequeath an im-
munity, and that reinfection can and does occur.
For the development of the infrequent topic this
paper is to present, we have an extended thesis by
Durceux (Paris, 1913), obviously covering all the
cases recorded down to that date ; certain references
to works on cystoscopy ; cases from the recent liter-
ature in this country; and five cases from my own
observation.
From the Durceux thesis, it is apparent that
syphilis of the bladder, as a lesion, either is rare
or has been frequently overlooked or incorrectly
diagnosticated. On the other hand, the thesis
teaches us not to be surprised at the failure of the
cystoscopists to identify the pathologic condition
heretofore, for the reasons now to be described.
The forms under which secondary syphilis of the
bladder appear are very similar to, often practi-
cally identical with, those non-specific and formerly
commoner lesions — namely, simple hyperemia, sim-
ple ulcer, and papillary growths. To differentiate,
the classical hyperemia of bladder syphilis is said
to appear as discrete reddish spots, like macules,
sometimes referred to a roseola of bladder; it may
be symptomless. The characteristic ulcer is like
the specific ulcer on any mucous membrane — more
or less elevated on an area of edematous and in-
jected mucous membrane, the edges definite, prom-
inent, and firm, the base grayish with necrotic or
hemorrhagic debris. They are usually multiple in
clusters, rarely disseminated, and often grouped
about or adjacent to one or both ureter mouths.
When so situated, they may readily be mistaken
for tubercular ulcers, especially if the appropriate
symptoms of tuberculous cystitis be present — fre-
quency of urination, more or less urgency, pain,
tenesmus, and hematuria. The papillary growths
of secondary syphilis have no features recognizable
by cystoscopy that will differentiate them from the
ordinary papillomata nor from the villous growth
surmounting a malignant base.
The tertiary lesion of bladder syphilis — the
gumma — is equally difficult of diagnosis by inspec-
tion. There is nothing about it to suggest syphilis.
Whether ulcerated or not, it resembles either an
infiltrating or a salient malignant growth.
By cystoscopy alone, therefore, the diagnosis of
bladder syphilis — no matter what the stage — can-
not be made. It must be supported by at least one
of the corroborating essentials — the history, the
Wassermann reaction, syphilitic signs elsewhere in
the patient, the somewhat despised treatment test.
Removing through the operating cystoscope a sec-
tion of an ulcer margin or of a growth for the
microscope, is no longer allowed by the best authori-
ties. It is liable to promote dissemination and
metastasis. The difficulties surrounding the cysto,
scopic diagnosis of bladder syphilis give that most
available examination a regrettably negative value,
in view of the fact and all our evidence would show
that the incidence of bladder syphilis preponder-
ates in the tertiary stage, when corroboration is
least ascertainable.
Duroeux's thesis points out this deficiency and
displays the scepticism of the literature. He re-
cites that Fournier, in 1899, ignored the subject in
his first edition : that Guyon, as late as 1903. in
236
MEDICAL RECORD.
[Aug.
1916
his fourth edition, denied the existence of syphilis
of the bladder; that in 1906 Nogues doubted all
the alleged cases reported up to that time; and
that Desnos and Minet, in 1909, did not accept
syphilitic ulcer of the bladder. Kaposi is men-
tioned as alluding to rare but indisputable gum-
matous ulcers and cicatrices in the post-mortem
bladder; while Caspar and other authorities on
cystoscopic diagnosis are silent, non-committal, or
unconvinced. The only French authors conceding
syphilis of the bladder (though they refer to only
rare tertiary lesions) are Legueu (Treatise on
Urology, 1910), and Hallapeau and Fouquet (Treat-
ise on Syphilis, 1911). Proksch, in his great bib-
liography, accepts as clearly authentic only some
of the occasional post-mortem ulcerations of the
bladder, reported as specific.
A glimpse into still earlier history is interest-
ing. According to Durceux, the earliest mention
of bladder syphilis was made by Morgagni in 1767,
in the form of a specimen corroborated by lesions
in the glans, epiglottis, and tongue. The next rec-
ord is a specimen presented by Follin in 1849.
Ricord, in 1851, described in great detail and illus-
trated two cases, proven later by autopsy. Close
upon him follow Virchow and Vigal de Cassis.
Beginning with 1899, the observers and cases. begin
to count up, though very slowly. Matzenauer
(1900) seems to be the first who used cystoscopy
in these cases.
Of the twenty-six tertiary cases thus brought
together by Durceux, the incidence of the chief
features was as follows (expressed in percentage) :
Cystitis 50
Hematuria 35
Lesions elsewhere 62
) positive 54
History ( negative 8
fPapillomata 16
?'&*&&' i Ulcer 1 mufupie".:: :::::::::::::::::::: :lt
m the bladder Gummata . . . 27
lUndefined 4
Wassermann reaction (positive) 8
Of the fourteen secondary cases collected by him,
two are incompletely reported post-mortem cases
(Fenwick, 1; Neumann, 1) and one is the case of
a four year old child who died of syphilis con-
tracted from a wet nurse. The lesions were chancre
of the mouth, a skin eruption, and ulcers of the
pharynx, urethra and bladder.
Three cases by Pereschiwkin and five by Frank
(1909) seem to have been put on record to negative
the claim made by Nitze in 1907 that there existed
no cystoscopic picture of a syphilitic bladder. The
eight cases of these two observers seem not to have
been reported in detail. Asch's one case (1911)
had developed sharp cystitis eighteen months after
a vulvar "abscess," with adenopathy, and twelve
months after a gonococcus infection. Multiple
bladder ulcers were found. One other case gave
a positive history and had a bladder ulcer.
Counting the case of the four year old child, the
only other satisfactory report in this group of
fourteen cases is that made by Durceux with Levy-
Bing (1912). Making cystoscopy a part of the
routine examination of 100 luetics, they discovered
ten small vesical ulcers in a patient without symp-
toms of cystitis, but having confirmatory syphilitic
signs and a positive Wassermann.
Examining recent works, we find the French well
in the lead with both plates and text, practically
all based on the cases collected by Durceux.
The Germans are a close second, through Frank
of Berlin, who exhibited a series of illustrations
from two cases at the German Neurological Con-
gress in 1909.
The English come third, with Thomson-Walker's
good description of syphilis of the bladder, though
he quotes only Asch, apparently not knowing of
the French thesis.
Our country follows in a minor fourth place;
our recent books either make no mention of the
subject or allude to it only casually. In our jour-
nals, where we make a better showing, the follow-
ing cases are found:
The one reported by Rush (Mobile), in 1913, is
interestingly suggestive. The patient, 66 years
old, had contracted syphilis when 24, and it had
been thoroughly treated. He had had symptoms of
cystitis for many years and presented a notably
enlarged prostate. The case had been variously
diagnosticated as Bright's disease, carcinoma of
the rectum involving the prostate, senile enlarge-
ment of the prostate, and vesicle calculus. The
existing nephritis was held to bar prostatectomy.
Owing to hemorrhage, cystoscopy was impossible.
Wassermann reaction, weakly positive. After the
second intravenous salvarsan, all his symptoms be-
gan to improve and the Wassermann became nega-
tive. Then twenty-six injections of salvarsan were
given, resulting in an almost total disappearance
of the symptoms and a marked reduction in the
prostate. The fact that the cystitis had long ante-
dated the prostatic obstruction, appears as ground
for the inference that a gumma of the prostate and
bladder was the pathologic condition.
Simons ( 1913) reported a twenty-four year old
man who, denying syphilis, presented vesical symp-
toms suggestive of tuberculosis. Cystoscopy
showed clean cut ulcers posterior to the trigone.
Local treatment aggravated the symptoms. The
Noguchi test was then found positive, and intra-
muscular injections of mercury promptly affected
a cure. Eventually the blood became negative and
the bladder normal.
Buerger, the same year, described two cases of
ulcer of the bladder; Simons later commented that
the second case may have been syphilitic, as the
ulcer healed under mercurial treatment, although
the Wassermann was negative.
Hunner (Baltimore, 1915) enumerated eight
cases of chronic ulcers of the bladder, neither
tuberculous nor malignant. Five were treated by
excision. The other three did not improve under
non-operative treatment. He does not seem to
have suspected syphilis, and Cones calls attention
to the fact that syphilis was not excluded.
Finally, Schapira (1915) described a case of
probable re-infection, the first infection occurring
in 1907, the second in 1912. In 1914, within four
or five months after five injections of salvarsan,
when the Wassermann was negative, bladder symp-
toms developed. The cystoscope showed a con-
gested trigone, two ulcers recognized as syphilitic,
and a gumma. Another administration of salvar-
san acted as a provocative; the Wassermann became
strongly positive. Under continued treatment,
complete recovery occurred.
The cases from my own experience are as fol-
lows:
Case I. — A married man, 71 years old, in moder-
ately good sreneral condition, with two apparently
healthy children, aged 13 and 11 years respectively.
(The patient did not marry until his 56th year.) Un-
doubted syphilis in his 21st year. Month medication
for only one mouth. Ten years thereafter, he began
to have so-called "liver attacks." These seem to have
recurred frequently, with increasing severity, finally
Aug. 5, 1916]
MEDICAL RECORD.
237
culminating in a grave condition in 1905. He was seen
by a gastroenterologist, who soon changed his tentative
diagnosis of carcinoma to syphilis of the liver. Six
weeks of intensive treatment effected a cure.
At this time (1905) there appeared the first bladder
symptoms usual to any 66 year old man — painless fre-
quency of urination. Later on, hematuria was added.
Two trifling attacks in the course of the intervening
five years were followed by sudden, almost profuse,
hematuria, with clots sufficient to cause intermittent
retention. He had been obliged to use a catheter off
and on for a week before he was referred for treatment.
The clots and rapid oozing made cystoscopy difficult;
but a growth (taken to be a probable malignant neo-
plasm) was made out, apparently involving a large
area of the bladder base and the lateral walls to a
small extent. Cystoscopy was protested until after
antisyphilitic treatment had been tried. This was car-
ried out in the hospital and forced. Though favored
by rest in bed, the bleeding only slowly abated; but by
the end of the month a clear view of the bladder lesion
was had and the patient could go about almost at will
without greatly increasing the then minimal oozing.
The lesion is correctly described as a "fleshy" or com-
pact growth, with a few moderately villous formations
and an unusual amount of necrosis. By continuous
sloughing, the growth gradually decreased in size until,
nine months later, only a small mass with a narrow
villous margin was left near the right ureter mouth.
Posterior to the trigone, one area, originally hidden if
not involved, now presented a reddish-brown, finely
striated appearance, such as might be formed by a
recent scar in the mucous membrane of a partially
distended bladder.
It is admitted that the course of this case during
the second half of the two years and nine months
the patient was under observation, creates the sus-
picion of an underlying or resultant true neoplasm,
as opposed to an unconditioned gumma; the ne-
crosis ceased, nevertheless the tumor did not dis-
appear wholly, and the tendency to hemorrhage
after over-exertion was ever present, though slight.
Occasionally considerable bleeding occurred. To
offset the suspicion, however, is the fact that con-
stant treatment was not possible, owing to the
patient's distance from the city and other contin-
gencies. He died in December, 1912, of an ex-
tensive erysipelas.
An interesting and not wholly irrelevant query
would be whether this patient's practically neglect-
ed syphilis, contracted when he was twenty-one,
was still communicable at fifty-six when he mar-
ried, and whether it had anything to do with a
chronic joint trouble for which his wife was under
the care of an orthopedic surgeon. To further
complicate the matter, is his history of several
attacks of urethritis, prior to marriage.
Case II. — March 11, 1915. A man, aged 34, married,
came to the Post-Graduate Clinic, complaining of
hematuria, apparently the result of traumatism. He
had been accustomed to pass a more or less flexible
bougie at intervals, to dilate urethral strictures that
dated from boyhood. Their cause could not be ascer-
tained. Cystoscopy showed thickening and diffuse con-
gestion of the mucous membrane (the usual picture of
a long-standing, chronic cystitis) , and, in addition, a
marked but flattened infiltration of the right anterior
wall, with an open lesion posteriorly, supposed at that
time to be the wound made by the patient's bougie.
The infiltration was so marked and circumscribed that
malignancy was suspected.
The patient now called attention to a reddened, semi-
fluctuating swelling, occupying the right supra-spinous
fossa. When cut down upon, it proved to be neither
an abscess nor an infected lipoma, but a full-fledged
gumma, in spite of a negative history and a negative
Wassermann. The fossa was cleaned out and drained.
Under intramuscular injections, it healed well, though
not without further necrosis and suppuration. Within
four weeks after treatment was begun, cystoscopy
showed a general improvement in the bladder.
The patient so appreciated his improvement that he
disappeared, only to report again at the end of nine
months that hematuria had returned. Cystoscopy
(about four weeks ago) revealed much less chronic
"cystitis," the first infiltration about half the original
size, a peculiar tesselated appearance of the membran-
ous urethra posterior to the trigone — due apparently
to the contraction of superficial scars — but no discov-
erable ulcer to account for the hematuria. The man
is again under antisyphilitic treatment.
Case III. — June 23, 1915. A robust looking woman,
44 years of age, married. Her only child, now 25 years
old, developed an eruption soon after birth that was
diagnosticated congenital syphilis. He was treated
successfully.
Apparently this patient, the mother, had good, if
not perfect health, throughout and down to her thirty-
seventh year, when frequent and painful urination de-
veloped. Hematuria, with clots, supervened. The blad-
der was variously treated by many physicians the world
over; repeated cystoscopic examinations disclosed "ul-
cers." Finally, in January, 1915, while in Paris, the
diagnosis was made. Intramuscular injections every
two days resulted favorably at once, and she continued
in fair comfort for nearly five months, though the
treatment had not been concluded.
When she came under our observation, she was again
urinating every fifteen minutes during the day and
every half hour at night. The urine was turbid and
slightly blood-stained. Gross hematuria had not oc-
curred since the treatment in Paris. Cystoscopy, with
only two ounces of fluid in the bladder (its maximum
capacity at that time), (no anesthesia) revealed an al-
most general thickening of the mucous membrane, with
here and there areas of sharply defined congestion set
with ulcers to which mucus-like pellicles were more
or less adherent. From approximately the left ureter
mouth, a narrow ridge — its free edge marked by a
linear ulcer — curved upward across the vault of the
bladder, gradually narrowing, and vanished into the
wall at the corresponding landmark on the right side.
The ridge would probably have been less salient had
full distention of the bladder been possible. No bleed-
ing point was seen, nor did the urethra bleed, though
it was very sensitive. Under intramuscular injections,
she improved rapidly. My notes state that within ten
days she was retaining her urine three hours. The
unfortunate woman had suffered so long and patiently
that, as she demurred, I did not insist upon a control
cystoscopy when she was about to leave the city.
Though the following case is chargeable with a
positive history and positive Wassermann reaction,
the bladder factors therein were so minor and
ceased so promptly under the intensive treatment
given that only a summary will be necessary.
Case IV. — A 62 year old man, with a prostate sur-
prisingly small and soft for his age, and with only
a drachm of clear residual urine, complained of fre-
quency and an urgency so great that he was liable to
incontinence during sleep. He could not always wake
up promptly enough to control the urinary impulse.
Under antisyphilitic treatment alone, improvement set
in at once and progressed. His day intervals now are
normal; during the night he urinates but once. The
assumption is that his lesion was a specific hyperemia
of the bladder. His rapid improvement precluded the
necessity for a confirmatory cystoscopy.
Case V. — November 16, 1911. A married woman,
30 years of age. Never pregnant. Two gonococcus
infections by her husband; the first when twenty, the
second when twenty-six. Apparently the distressing
frequency and pain of urination date from the first
urethritis. She has never been free from these bladder
symptoms since. Undoubtedly, they are aggravated
by the colon bacillus infection present. Cystoscopy,
negative. Urethra deeply congested. Eight months
later, however, an ulcer and punctate spots were dis-
covered in the bladder.
Intermittent treatment based on those diagnoses and
continued over a long period gave considerable relief
at times, but only temporarily. Two urinations at
night and a three-hour interval during the day was
the best result obtained. In addition to local measures,
the treatment included two courses of colon bacillus
vaccine (autogenous and stock), and finally removal
of the infected (right) kidney (May 22, 1913). At
this time there was stricture of the right ureter and an
ulcer at its mouth. The first pelvic examination, made
early in the course, excluded any abnormality, but the
second disclosed a marked retroversion. This is said
238
MI.DICAL RECORD.
[Aug. 5, 1916
to have been corrected by her physician. No benefit
resulted.
Last November, after she had been absent for nearly
eighteen months, the Wassermann was found -| — \- ; the
Schwartze, negative. Her family physician is carry-
ing out the antisyphilitic treatment. Both he and the
patient report that she has less pain and frequency,
as a rule. She now urinates only once during the
night.
Though the last two cases may not be accepted
as conculsive, they nevertheless present a reason-
able, if not a strong, probability, on the basis of
which they are believed to have a place under the
title of this paper. In any event, Case IV serves
to point out that bladder hyperemia may be re-
lated to syphilis in the same way that it is to sev-
eral other conditions; and Case V helps fix the fact
of occult syphilis as a contributing cause in some
highly complex cases.
The conclusions to be deduced are these:
1. Syphilis of the bladder is an entity often over-
looked or not recognized.
2. It may manifest itself in one or more of sev-
eral possible pathologic lesions, only one of which —
the punctate hyperemia in multiple spots, the so-
called "macule" — is pathognomonic.
3. The other lesions, having the same general ap-
pearances of benign or non-malignant lesions not
due to syphilis, cannot be differentiated cystoscopi-
cally ; some corroboration is necessary to the diag-
nosis.
4. Suspected, recognized and treated, the prog-
nosis seems uniformly good.
in Kast Forty-first Street.
DRUG ADDICTS AND THEIR TREATMENT.
Bt T. D. CROTHERS. M.D.,
HARTFORD. CONN.
Within the last few months a number of very
elaborate papers have appeared concerning drug
taking and the methods of treatment. These papers
indicate an increasing interest, and show that the
profession has at last awakened to the responsibility
of being better able to treat and counsel such cases
than the empirics who have largely occupied this
field.
In July, 1915, there were forty-one homes, sana-
toriums and institutions for the treatment of drug
addicts. A very large number of them were ob-
viously empirical, from the fact that they advertised
new and secret drugs. They claimed to have dis-
covered some process, unknown to the regular pro-
fession. Four of these concerns used remedies that
had been found in foreign countries, and they evi-
dently had the monopoly of the importation of these
drugs. Others claimed not only the discovery of
new drugs, but combinations of drugs, never made
before, and new methods of using them that would
produce most unusual effects.
Evidently a great many persons are treated in
these various institutions from the fact of their
number and variety. The profession recognizes this
very clearly by the increasing number of victims
coming for help who have tried these various ad-
vertised cures and relapsed, and their condition is
more serious than ever before. Hence the profes-
sion is greatly concerned to know what to do, and
how to treat these poor victims, who are in a large
proportion of cases members of good families and
among the patrons who are quite able to pay for
medical attention. In consequence of this, during
the last few- months a number of papers have ap-
peared from writers who supposed they had at-
tained a degree of certainty in their methods of
treatment. An outline of what may be termed the
general principles which are to be followed in the
care and treatment of these addicts will give a little
wider view of the problem that is becoming more
urgent every day.
Hospital treatment is found in most cases to be
the first essential. The patient must leave his sur-
roundings and home life and go where all these
conditions can be directed and controlled. The
first object is to remove the drug, and this can best
be done in exact surroundings and conditions of
living. The after-treatment may be conducted at
home, under the care of the family physician, but
at first the patient is far too weak and neurasthenic
to be able to take care of himself in any particular
way. In the hospital the physician will determine
what plans to follow, whether the withdrawal of
the drug will be rapid or slow, and how far the
patient will cooperate in the treatment. In some
instances a rapid withdrawal is called for. In
others a long, slow removal gives a chance for
building up the mental and physical conditions of the
patient. The theory that shock will follow from
the rapid removal is not sustained; no matter what
quantity the patient may be taking it can be re-
duced greatly without the patient being conscious
of it. Below that many symptoms will develop,
mostly of a mental character, that require treat-
ment. Experience shows that substitutes of the
narcotic family are not only dangerous, but often-
times worse than the original.
The claims of irregulars that the original drug
has been removed and they are cured, and the fact
that preparations of belladonna, hyoscyamus, and
other drugs are being substituted, are absurd and
misleading. The removal of the substitutes pro-
vokes the return to the original drug, or something
equivalent to it. The various theories of shock,
depression, and functional disorders are largely
mental, and are overcome by natural methods and
the recuperative powers of nature.
The condition of the morphine addict is an as-
semblage of toxemias and autointoxications, obses-
sions, delusions, and various forms of functional
and transient paralysis. These are most readily
removed by eliminative measures through the
bowels and skin, together with hydropathic appli-
ances of every description.
Fatigue, weariness, and morbid consciousness or
absence of consciousness of his real condition are
always present. The arterial tension is extremely
variable, rising and falling alternately from condi-
tions unknown, associated with unstable heart's
action and extreme susceptibility to a great variety
of conditions that seem to be governed by sur-
roundings. Irritation of every description is regis-
tered by the tension. Drugs and spirits or any-
thing that will relieve this irritation is most grate-
ful, and sought for. Tobacco, coffee, tea. and tinc-
tures, patent drugs or anything containing alcohol
seem to be very suitable for the occasion, and yet
all are dangerous and complicate the real conditii n.
The short cures in which excessive purgation,
bathing, rubbing, and drinking large quantities of
water give very pronounced hints of the actual re-
quirements. The supposed shock from withdrawal
does not appear, and the patient is buoyed up with
hope that the drug will never be resumed again,
because there is no possible desire for it. This is
accomplished by the sudden overwhelming appeal
Aug. 5, 1916J
MEDICAL RECORD.
239
to the organism, which is certain to be followed by
reaction.
The week or two weeks' treatment in which the
patient is put to sleep by another drug, on the sup-
position that the substitute can be dropped and the
original craving will be gone, depends on so many
unknown conditions as to be practically unreliable.
The mental state of the patient, who on awaking
from the chemical stupor realizes that he has es-
caped the former drug, becomes a literal obsession
that overcomes a great variety of symptoms for a
time, but sooner or later there is reaction, and the
hope of permanent recovery goes down in relapse.
He has nothing permanent on which to build, ex-
cept the fleeting suggestion of cure, which trie
organism is unable to sustain.
The fatigue, pains, and aches which are overcome
by morphine must be treated, as also the conditions
of the brain and organism that call for relief and
appeal for help. The withdrawal of the drug which
gives this help is only a small part of the treat-
ment. The very unusual histories of cases reported
give the best evidence of this. Thus in one in-
stance a morphine addict went to the mountains,
under the care of a physician, and drank immense
quantities of water every day. He lived on a grain
diet, took a hot bath every morning, and lived prac-
tically out of doors. The doctor, who had great
faith in medicines, gave at short intervals a solu-
tion of skull-cap. In a short time the patient gave
up the morphine voluntarily, and in a few weeks
was discharged cured. The doctor attributed the
cure to this particular drug. In another instance a
chronic addict was put on a spare diet of grains ;
he walked four times a day a mile or more to drink
large quantities of mild mineral water. He re-
covered and the mineral water was given credit for
the cure. A third instance reported was of a
woman who had been addicted to morphine two
years. She lived a life of great ease, without any pur-
pose or object. Suddenly she was called to Colo-
rado to take charge of her brother who was dying
from consumption. She went up to a mountain
shack and was forced to do a great deal of nursing,
preparing of foods, carrying of water, and other
duties that she had never done before. She grad-
ually gave up the use of the drug and substituted
hypophosphites which her brother was using, and
in this way she remained for nearly a year, actively
engaged in this mountain cottage, and returned en-
tirely restored. The doctor reported the case as
one restored from hypophosphites. These three
are examples, of the removal of causes which were
unknown at the time, but really were the largest
contributors to the continuance of the drug addic-
tion.
Whenever the states of irritation, exhaustion,
and depression are removed, the desire for the drug
dies out. This gives a most significant hint of
what the cure of drug addictions really means.
Treating symptoms complicates the case, and is far
from being scientific. Elaborate details of what
means or measures remove the discomfort and
ps.vchical symptoms, which follow when the drug
is taken away, of themselves are of very little value.
The theory that opium produces a toxin which
circulating through the blood increases the demand
for it, and that of the products of acids that in-
tensify the present conditions, sound very learned,
but somehow they do not go back to the original
causes. A great many cases have been reported
where the removal of some sharp irritating cause,
such as a spicula of bone pressing on a nerve, a
neuralemma from a contused nerve, a depressed
bone of the skull, a tapeworm, or a great variety of
active sources of irritation, has been followed by
the giving up of opium in any of its forms.
It is not uncommon in the general practice of
physicians to find persons who are taking opium or
its alkaloids secretly, with or without any particu-
lar cause. The ordinary physician is satisfied with
the patient's statement, as to why he began the
drug, and beyond this there is a range of moral
causes which the physician acquiesces in. It would
seem absurd to concentrate all efforts on the re-
moval of the drug and neglect the causes. It is
simplicity itself for one to go here and there for
two or three weeks and have the drug removed by
substitute methods of all sorts and kinds, and then
come out buoyed up with the faith that he has
escaped and will never more relapse.
The family physician who has charge of these
cases soon discovers a great variety of complicating
symptoms which did not appear before. The patient
apparently is free from the drug, but other symp-
toms break out of a more aggravating character —
insomnia, periods of restlessness, of excitement, or
unusual elation or depression.
If he is in business circles he will complain of
exhaustion that is most unusual and does not yield
to the ordinary remedies. He will have symptoms
of so-called rheumatism, muscular stiffness, neuritic
pains, and his digestion will be impaired. His eye-
sight will be weakened and a great variety of other
general and local symptoms will appear. The
original causes have not been touched. In addition,
there have been drug complications and drug in-
juries which are more or less traceable. Thus the
person treated with hyoscine and belladonna com-
pounds will develop a class of symptoms that seem
to have some connection with these drugs. The
delirium and delusion from hyoscine leave some
vestige and conditions that linger long after the
drug has been taken. The defective eyesight that
calls for readjustment of glasses, where belladonna
has been given freely in the treatment, suggests
drug injury. In cases where bromides have been
given for a long period, there are degrees of dull-
ness and loss of energy that give the same intima-
tion. All these are hints that the condition treated
in the withdrawal stage by narcotic drugs is full of
peril and possible future disturbances.
When the physician discovers the use of morphine
in his patient a very active study should be made
to find the original cause and the contributing con-
ditions. A reckless physician may give morphine
to a toxemic case for some little time as the most
simple way of removing the symptoms. Later the
patient continues the drug. The fact that the
morphine was given for toxic conditions, and that
it produces a toxic state, outlines the treatment
clearly.
In the nerve-exhausted, care-distracted men and
women, who find relief in morphine, another set of
suggestive causes indicate the methods of treat-
ment. There is often a common-sense viewpoint
which is not recognized; most of the modern writ-
ers give great emphasis to the withdrawal of the
drug and consider the after-treatment a matter of
small moment.
The psychical treatment, which considers the ef-
fects of mind on the body and the influence of sur-
roundings and occupations, opens the widest road
for practical results. The frequent relapse of such
240
MEDICAL RECORD.
[Aug. 5, 1916
persons with the loss of faith in the patient and of
confidence in the physician in his permanent restora-
tion, all come from the absence of exact psychical
and physical study and treatment.
The drug-taker is always aged physically, and is
subject to a great variety of conditions, which can
be removed as positively as any other disorder. He
may have inherited defects, and he certainly has
acquired some of them, but with proper means and
study, they can be overcome, and to a large extent
removed.
I have found in my long experience that a form
of re-education and mental change, or to use a larger
term, reclamation, which signifies a complete change
in mind and body and a new consciousness of how
to live. I have noted many persons who
were cured, in the sense of never using the drug
again and living many years a useful life. I have
seen instances where it would seem that the drug
addiction was self-limited and after a time would
die out in ordinary favorable conditions. Its very
intimate association with alcohol of course com-
plicates and increases the degeneration, but even
here, there is not unfrequently seen a recuperative
power that is startling.
The so-called incurable cases are in persons who
use any sort of drugs or spirits that have narcotic
effects, going from one to another as circumstances
demand, but even these persons are curable by ways
and means that seem astonishing at present.
One such person is recorded in medical literature
as having made a permanent recovery from the use
of alcohol, a second recovery from opium, a third
from chloral, and a fourth from cocaine. The phy-
sicians who treated this man, spoke very positively
of the effects of certain drugs or combinations of
drugs and believed their means and methods to be
responsible for the cure. In all probability each
one of these physicians was not aware of the
patient's cures in other institutions. He was a man
of some property and prominence and moved about
from place to place and was secretive to the last
degree. After the last cure, he was killed in an
accident, or he might have furnished other details
for the literature on this subject. Experience
brings out one fact as basic of all others. The
patient should go under the care of a scientific phy-
sician; scientific in the sense of being careful, con-
scientious, and exact in his work and a student in
the sense of studying each case by itself, and not
according to the theories or traditions of others.
The patient should be made to understand that
the removal of the drug is by no means the whole
treatment, that there are other very serious de-
rangements that must be found and corrected, and
that his full cooperation is required covering a long
period of time. He must recognize that the use of
morphine is only a blundering effort to cover up his
real condition. He resembles the ostrich who in
times of danger buries his head in the sand.
The continuous use of morphine not only covers up
the pain signals but creates other centers of dis-
tress and so adds to the degeneration and decay, or
rather aging of the patient to an extent beyond any
possible conception. The patient's viewpoint is a
very dangerous one and in many instances it is
practically an insane one, meaning by this a per-
version and reversion of natural reasoning and
thought, and an absence of correct judgment of
cause and effect. Many of the morphine addicts
show a degree of mental vigor in other respects, but
concerning themselves and the use of the drug they
are practically dements, full of delusions and illu-
sions, and are utterly unable to judge correctly of
what should be done. The more intellectual the
patient, the more dangerous and subtle the delusions
are.
When the patient realizes this thoroughly and
puts himself implicitly under the care of a wise
physician, the beginning of a permanent cure is
made. The physician should then have no diffi-
culty in studying the case and determining the
causes and exact conditions present; then apply-
ing the best means and methods for their removal.
All this is along the line of every day practice and
training. There are no specifics or mysterious
drugs with unknown effects and nothing in the na-
ture of a miracle here. The patient's conception of
what he wants is one thing, which is very likely to
differ widely from that of the physician, but through
it all, there must be a degree of confidence and
positive deference to medical judgment and skill.
Details of how this can be done and the exact
means to be used can only be stated in the most
general terms, because no two cases are alike. The
presence of toxemias and autointoxications is uni-
versal to all cases, and therefore suggests the first
question of treatment; then follow all degrees of
physical and psychical palsies which require their
special distinctive treatment.
Eliminative measures, which include appeals to
the skin, bowels, and kidneys through baths, cathar-
tics, massage, and various other measures depend-
ing on the history and habits of the patient, are
necessary. Baths in mineral water seem to supply a
most practical demand. Of these the soda, salt and
gas baths are the best. Where the skin is very in-
active a mineral bath in hot water is useful. Where
the skin has been very active and perspiration
marked, salt baths and acid baths are excellent.
The hydropathic measures must be determined from
the previous habits of the patient, his occupation
and diet, in the same way that cathartics given
should be studied and adapted to the person. The
next question is that of nutrition and sleep. The
previous history and present conditions will usually
furnish the best hints of what measures are practi-
cal. Then occupation, exercise, and regular habits
of living are to be treated in the same exact way.
Psychically the patient's consideration of his own
condition and his reasoning as to what he needs and
what is lacking often give most important clues for
restorative measures. The study of the patient's
mentality is as important as his physical condition.
If he has lost faith and courage and becomes pessi-
mistic where he was the opposite before, this is a
physical hint of importance. If he has suffered
from injuries, shocks, and mental changes that pro-
foundly influenced his nervous system, they are dis-
tinct conditions to be overcome. The chronic addict
always exhibits mental lowering and defects of
ordinary reasoning that are of course incident to
the continuous anesthesia of the drug. These are
questions for study, quite as important as the exact
dosage necessary to keep him comfortable.
Stretching out from this point there is a great un-
known field of symptoms, dating from distinct
causes which should be understood and treated with
as much exactness as the pain symptoms for which
the drug is taken. As to what drugs may be given
or depended upon for relief, there can be no abso-
lute certainty of uniform effects. There are many
drugs called tonics and alteratives that serve a
good purpose, and there are many mild narcotics of
Aug. 5, 1916]
MEDICAL RECORD.
241
the vegetable class that are extremely useful and in
some instances have a decided value, but all this
must depend on the condition of the patient and the
good judgment of the physician.
There is always a degree of complexity in the
symptoms and a certain sudden shifting of mental
and functional activities of the patient that require
the highest kind of skill to meet and overcome. The
attempt to do this by drugs alone is crude and
usually a failure. It should be understood that the
effects of long addiction to narcotic drugs have very
seriously impaired the adjusting centers of the
brain and its capacity to accommodate itself nor-
mally to the exigencies of the present, hence there
is a degree of degeneration and impairment that
must be recognized and provided for.
While the removal of the drug is the important
part of the treatment it often uncovers a great va-
riety of symptoms which are really worse than
slavery to the narcotic. The specialist can treat
the former most practically, but he rarely has the
opportunity to carry on the after-treatment other
than by advice and counsel, and in this the family
physician has a larger field for the exercise of his
best skill and judgment.
The central fact should never be forgotten that
drug addictions are distinct neuroses and psychoses,
amenable to treatment and curable to an unknown
extent. Preventive measures here are pronounced
and physicians recognize susceptiblities and often
exercise judgment in preventing the development of
these nueroses by discretion in the use of opium.
When the addiction is fairly formed the com-
plexity of the symptoms and general control of the
case present so many obstacles in the treatment
that physicians hesitate, and not unfrequently per-
mit such cases to fall into the hands of irregulars.
Later when they relapse and come back for active
treatment, the difficulties increase and in the ab-
sence of text-books and authorities telling exactly
what to do, there is more or less confusion. All
this reflects on the training of the physician and
the disposition to accept theories and traditions
from unknown sources and to neglect the same exact
scientific study and treatment of such cases as are
given in other departments of medicine.
Another fact should be emphasized. Physicians
should discourage patients from expecting help
from irregular and mysterious sources and depend-
ing on specifics and specific treatment. Here as in
every other department of medicine, it is cause and
effect and a study of the exact laws and conditions
which control the growth, development, and termi-
nation of narcotic addictions.
Medical colleges should make the study of these
neuroses a part of their training. Post-graduate
schools would find instruction in this department
welcomed by an increasing number of physicians.
It is obvious that the treatment of drug and spirit
addicts, now largely in the hands of quacks, must
be brought into the range of scientific studies, the
demand for which is apparent in every section of
the country.
Treatment of Syphilis at the Providence City Hospi-
tal.—H. P. B. Jordan states that 606 and 914 have prac-
tically the same therapeutic value and that too much
reliance is put upon these drugs by the laity. All
patients should receive mercury treatment after 606
treatment as efficiently as they did before the intro-
duction of the latter, and in latent and tertiary cases a
good course of mercury should be given before salvar-
san. — Providence Medical Journal.
PAINLESS AND SHOCKLESS CHILDBIRTH.
TWILIGHT SLEEP.
By II. W. KAPP. M.D..
SAN JOSfi, CAL.
In the Medical Record for November 14, 1914, I
gave a short report of my success with a new
method of modifying the pains of parturition. I
beg space for a more extended report after another
year of experience with the method.
Fear is one of the greatest inhibitors of normal
functioning. Fear retards mental, physical, and
spiritual development. How can a mother develop
mentally and physically and give the correct develop-
ment to a child in utero when her mind is filled
with thought of fear of the distress of the pregnant
state and the agony of the accouching chamber.
For ages, from the depths of their agony have
parturient mothers said, "For God's sake, doctor,
do something to relieve me." We can now answer
that appeal.
Very recently, within a few days of each other, I
had three primiparous cases and in each one, before
I left the house after the confinement, the woman
planned for the next baby as coolly as if the having
of babies was a mere joyful occasion. I considered
that the best compliment for my method that I
could have.
When we can make womankind know that the
pains of parturition can be made bearable and even
easy then we shall be laying the foundation of a
new consciousness where fear does not enter and
motherhood will be glorified anew. I used to dread
my confinement cases, but do not dread them now,
for I feel master of the conditions. When an ex-
pectant mother comes to me now and engages me
for her confinement I can assure her that her pains
will be bearable and that she will receive her baby
in her arms joyously. The very fact that I can tell
her truthfully that she will not have the severe pains
lulls her fears and puts her in a better attitude to
take the pains.
I have seen many a woman enter the pangs of
labor with dread and fear and when I proved to her
that the pains could be and were modified so the
agony was eliminated then she would bless me and
put forth her best effort and assist gladly in the
expulsion of the child.
Probably the first case where I used my present
method will illustrate what I have had told me
dozens of times. I was confining a quadripara. I
had confined her twice before and she was no
shirker and her pains were very hard at each con-
finement. As the head was entering the upper brim
of the pelvis she would be almost in a frenzy with
each pain. She would not bear down. She begged
piteously for me to do something to relieve her.
It was too early to give her chloroform and besides
I did not like to give her chloroform as she had a
history of very severe hemorrhage at each confine-
ment. I was almost desperate for I knew her so
well that I knew her pains were all that she said
they were. Why I gave her what I did I do not
know only that there was some vague impulse for
me to try it. I gave her hypodermically 1/12 gram
heroin hydrochloride. In about fifteen minutes she
turned to me and said, "Now I can bear down.
My! what a relief." She then took hold of the
straps and the way she could bear down and the
manner that she hustled that child into the outer
world was a revelation to me. And this time there
242
MEDICAL RECORD.
[Aug. 5, 1916
was no hemmorrhage though that may have been
due to the fact that for a week previously to the
confinement I had given her ten drops of adrenalin
chloride twice a day.
After the baby was born the mother turned to me
and said, "Doctor, give that hypodermic to every
woman having a baby. It's the greatest blessing
that I have ever known."
The above case occurred in August, 1911. I used
the drug in practically all my cases for three years
when I went to New York City for post graduate
work and to study the Freiburg method of "twilight
sleep." I at once saw the uselessness of that method
for the general practitioner, though a study of it
has helped me to modify and perfect my methods
of procedure.
In my opinion amnesia is not the most desired
object to be attained in confinement. Analgesia is
the desideratum. With drugs that produce amnesia
the patient does not use her voluntary forces to as-
sist in the expulsion of the child. With a condition
of analgesia the patient can employ all the forces
that nature has given her to hasten the progress.
A mother has all the joy of knowing when her child
is born. And it is a joy when the pains have not
outweighed all else.
My method is a practical one adapted to use in
the humblest home as well as in the most elaborately
furnished home or hospital. Heroin intelligently
used is the best aid yet found for general use.
Heroin does not bring babies without the help of
the mother and the doctor. Heroin is a blessing
if used with brains. Some people seem to think,
when you offer them an aid in parturition, that it
will be something vague or mysterious that relieves
the mother of all effort or responsibility. I explain
to the prospective mother that the laws of nature
demand that the child be born through the efforts of
her voluntary and involuntary forces. I aim to
help her use her natural forces by using a simple
analgesic that does not destroy the involuntary
forces and by its mild anodyne effect allow her to
increase her voluntary effort and thus make labor
less in length of time and very much less as to
suffering and pain.
When I am called to a case in labor and the
woman is a multipara, I satisfy myself that the
pains are real labor pains and strong enough, I give
a heroin at once as labor is usually short and the
mother has known from previous experiences what
the real pains are. In a primipara I always wait
until the pains become severe enough that the pros-
pective mother may know what real pains are like.
I do not care what stage of labor the patient is in —
the pain is my guide for the giving of the heroin.
I then wait for the effect and while doing so
attend to the asepsis and preparation of the patient
if that has not been attended to before. I watch
to see if the effectiveness of the pains lessened or
changed in any way. In from 10 to 20 minutes
the patient often complains of a dizziness or a
slight feeling of intoxication, and almost always a
sleepy feeling. Right there is one of the most im-
portant moments of your work. Explain in a very
firm manner that now the hurting pains will be les-
sened and it is the time for her to make all the
progress that she can by using all her expelling
forces that she can summon. Teach her to take deep
breaths and hold them firmly while pulling on the
straps, and keep doing so as long as she feels the
contraction of the uterus. The primipara often
needs some coaching in the matter.
The patient may become sleepy and shirk the
effort, if you do not insist on her doing her part,
and thus prolong labor. I have had a few cases
that I had to cure of the laziness by letting the
heroin wear off and letting the pains come back with
all their force. When I gave them heroin again
they were more than ready to do their part. As I
said before, some patients think when you offer
them help that you must do all.
Remember that heroin produces analgesia and
does not retard labor nor hasten labor itself. Get
all the parturient forces to work and when you
have once taught the patient to use those forces
correctly then you can sit calmly by and watch the
progress of the case. If dilatation is not far ad-
vanced I usually go and make calls if it is in the
day time. At night I often lie down and rest. I
come back to the case as often as my judgment tells
me. If dilatation is nearly complete and labor well
advanced I do not leave the case.
The effect of one injection of 1 12 grain heroin
hydrochloride will usually last from two to three
hours; I have had it last more than three hours.
I have had cases that needed another injection in
half an hour. When the head is dilating the vulva
and perineum I aim to have all the effect of the
heroin that the patient can stand without retarding
the pains. A few times I have been so eager to
produce perfect analgesia that I gave so much heroin
that it retarded the pains. One-third or one-half
ampule of pituitrin will start the pains if they be-
come retarded. For a long time I was very positive
that heroin did not stop the action of pituitary ex-
tract. Several of my friends told me that it did.
They had given the latter frequently after heroin
and other quieting drugs, and had found it of no
assistance. A short time ago I had a few cases
that I had well under control with heroin, and I
wanted to hasten matters and I got no results even
with a full dose of pituitary extracts. I was puz-
zled for a time, but on investigating I found that
my druggist had given me another make. I sent
for some of the old kind that I had used at first
and I have been able to prove that it will work
when I am having the patient under the full dose
or heroin and does it properly. A few cases to illus-
trate my method :
Mrs. R., primipara, called me at 5 a.m., reported that
membrane had ruptured, but that she had no pains. I
told her to go to bed and call me when the pains started.
At 7 a.m. she phoned that the pains had started. I
saw her at 9 a.m. The pains were regular but not
severe. Os rigid no dilatation (just such a case as I
used to insert rubber bags). I toid them to call again
when the pains became more severe, and left to make
other calls. At 11 a.m. I was called, and at that time
found the pains very severe, and every 4 and 5 minutes
in frequency. I gave !_- gr. heroin hydrochloride hypo-
dermically. An examination revealed the os softening
slightly. Again I made calls until 1:30 p.m., when I
received word that the pains were severe again. I
found the os as large as a 25-cent piece and softening
very nicely. I gave another % gr. heroin and went to
my office. At 4 p.m. I was called again. I found the
os nearly dilated. I gave another 14 gr. heroin and
instructed the patient to use her full parturition forces.
She responded intelligently and labor progressed
normally. At 6 p.m. gave 1/24 gr. heroin, and at 6:30
p.m. I delivered the child without laceration, either in
the cervix or in the perineum. As I was leaving the
patient I congratulated her upon standing the pains so
well. She laughed and said, "Doctor, that was no pain
at all. I am ready to have another baby at any time
if that is all there is to it," yet she complained bitterly
of the pains before I gave the heroin.
Mrs. W. By all the data and examinations she was
nine and a half months parturient; she would have
Aug. 5, 1916J
MEDICAL RECORD.
S43
slight pains almost every day but they were not last-
ing. I had confined her twice before — each time very
slow but normal labors. Examination showed os soft
and slightly dilated. I decided to induce labor. I gave
1/3 ampule pituitary; within fifteen minutes pains
started vigorously every three or four minutes. When
the pains became very severe I gave her 1/12 gr.
heroin, which in this instance increased the frequency
of the pain, but the analgesia effect was perfect. The
patient was delivered in an hour and a half, absolutely
normal, and with but very slight sense of pain.
Just after writing the above notes I was called to
Mrs. C. Tripara; the membranes had been ruptured
for two days. She had very slight pains once an hour
or less often. I gave \'z ampule pituitary. Pains be-
came hard and regular within ten minutes. After two
hours the pains died down again. I then gave another
xk ampule pituitrin. Labor then progressed normally,
and at the end of another two hours the os was fully
dilated and the head passing down into the bony pelvis.
As the head was passing the lower brim of the pelvis
the patient began to complain of the pain. I gave her
the usual 1/12 heroin and soon had perfect analgesia.
The pains seemed of good quality but the progress was
a little slow, so I gave another % ampule pituitary, and
in fifteen minutes I delivered normally a 7 Mi-pound
child without laceration, and without the least outcry
from the patient.
Mrs. S., primipara, had albuminuria for two weeks;
some swelling of the feet and legs. No head symptoms.
Pains off and on all night. At 7 a.m. I called and
found the os slightly dilated. Pains not severe. Went
away and came back again at 9 A.M. When the pains
were very severe and dilatation was about two-thirds
complete, I gave the usual 1/12 heroin hypodermically.
In fifteen minutes she said she was dizzy but the pains
did not hurt badly. I explained to her how to use her
breath control and pull on the strap. She made very
fine progress until the head engaged in the lower brim
of the pelvis. I tried for an hour to make her deliver
the child, but she could not. I put on the instruments
and delivered the child at 12 m. had a very slight
laceration of the fourchette. I gave her the first dose
of heroin, Ma, at 9 a.m. The next one at 10:30, an-
other at 11 and another at 11:30. The last one slowed
the pain some, but I had decided to use the instruments
and wanted as perfect an analgesia as I could have.
At the very last I gave a few whiffs of chloroform.
I have repeatedly delivered with forceps and used
no chloroform, depending upon the analgesia from
the heroin and had no outcry from the patient
either. I rarely have to give an anesthetic to do
repair work on the perineum if I have good anal-
gesia at delivery from the heroin. The beauty of
instrument delivery under the heroin analgesia is
that the patient can and does assist in the expulsion
of the child.
While writing the above sentences I was called in a
hurry to a confinement case. Found the patient a
primipara, yelling like a Comanche Indian on the war-
path— with each pain. I gave 1/12 heroin at once. The
head was just beginning to dilate the vulva. In fifteen
minutes the patient took the pains without an outcry,
and in twenty-five minutes I delivered an 8% -pound
baby. Had a very slight laceration that required three
stitches. Took the stitches without an anesthetic. The
patient laughed when we had finished and said, "Those
last pains were nothing at all compared with the pains
I had when you came." I had given the hypodermic
without an explanation, as the patient was a "Scientist,"
but her "healer" had not arrived to take care of the
case and evidently absent treatments were not suf-
ficient for the pains thereof.
If there is inertia of the uterus, quieting medi-
cines will be of no use. I have made some good
cases of inertia cases by using pituitary extract
and when the pains got severe using small doses of
heroin. I have never had a severe case of oligopnea
where I used heroin. Last month I had a slight case
of oligopnea, but in a few minutes the child cried
lustily. I have had but one case of hemorrhage
where I use heroin and that was instantly controlled.
I have had ample opportunity to observe confine-
ment cases where no drugs are used, as I am fre-
quently called by members of two religious sects
that forbid the use of drugs during confinement,
and all the work must be done without anesthetics
or any analgesics.
My observations have convinced me that oligop-
nea is most often produced by the head lying low
in the pelvis for too long a period. The worst
case that I ever had was in a Japanese woman
where the Japanese midwife failed to deliver and I
wzi called to deliver the child after the head had
been low in the pelvis for several hours. I delivered
without drugs of any kind and yet I worked a half
hour before I could get the child to breathe well.
My labor cases are shortened by the use of heroin
for the mother uses better expulsive forces and
dilatation takes place easier when under the use of
this drug.
The shock after confinement is vastly less where
heroin is used. In fact, shock is almost absent
where the analgesia has been good. Patients rarely
feel exhausted. I have given heroin in cases of
valvular trouble of the heart, in albuminuria cases,
in normal and abnormal cases. I have not had one
bad result that I could trace to the drug.
Porter Building.
iHpfctrnlpcai Nates.
Undertaking to Cure Incurable Disease. — The Okla-
homa State Board of Medical Examiners revoked a
license for being guilty of unprofessional conduct in
undertaking, for a fee, to cure an incurable disease. On
appeal, the Oklahoma Supreme Court held that the
words "incurable disease," in the second clause of sec-
tion 6905 Rev. Law, 1910, defining "unprofessional con-
duct" of a physician as "the obtaining of any fee, or
the assurance that an incurable disease can be perma-
nently cured," mean any disease which has reached an
incurable stage in the patient afflicted therewith, ac-
cording to the then general state of knowledge of the
medical profession. A document was introduced in evi-
dence headed, "Absolute Guarantee," in which the de-
fendant agreed to refund all moneys paid by the patient
should the latter fail to receive a complete cure by the
treatment, and the patient agreed to follow the defend-
ant's directions through a period sufficient as deemed by
the defendant to effect a complete cure; failing his fol-
lowing the directions so given, the agreement to become
null and void. The defendant claimed this was not a
guaranty of cure, but only a guaranty to refund the fee
in the event the treatment proved unsuccessful. The
court considered this contract to be a mere subterfuge,
probably drawn to protect the defendant in such pro-
ceedings; and that it in effect held out to the patient
an assurance of a permanent cure. — Freeman v. State
Board (Okla.) 154 Pac. 56.
Drugless Practitioners. — In a California court the ar-
gument was made that because the law includes such
subjects as histology, elementary chemistry, toxicology,
physiology, elementary bacteriology, and pathology in
the examinations to be taken by applicants for certifi-
cates to practice as drugless healers, it is unfair, be-
cause these are standard courses of study in the prepa-
ration of physicians and surgeons, but are not needed
in the art of those who intend to alleviate human suf-
fering by manual and mechanical means only. The
answer of the court was that to the Legislature is com-
mitted the duty of determining the amount and quality
of scientific education necessary for the individual to
possess before he may hold himself out to practice the
healing art; but, while it was not for the court to sub-
stitute its discretion and judgment for those of the
Legislature, the wisdom of some of these requirements
for practice would strongly appeal to it, if it did possess
a broader power than is given to it. For example, the
importance of a study of toxicology is evident to every
one. Without it the drugless practitioner might apply
his manipulations to one suffering from the effects of
a poison, and might continue his efforts until time for
the successful administration of an antidote had passed.
—People v. Ratledge (Cal.) 156 Pac. 455.
244
MEDICAL RECORD.
[Aug. 5, 1916
Medical Record.
A Weekly Journal of Medicine and Surgery.
THOMAS L. STEDMAN, A.M., M.D., Editor.
PUBLISHERS
WM. WOOD & CO., 51 FIFTH AVENUE.
See fourth page following reading matter for Rates of Subscription
and Information for Contributors and Subscribers.
New York, August 5, 1916.
MORTALITY FROM ALCOHOL.
Any estimate of how many deaths in a given com-
munity are due to alcohol must necessarily be open
to question, in fact, the result must be taken after
all as merely a guess, more or less shrewd according
as the guesser is more or less clever. It is obvious
that we must look elsewhere than on the death cer-
tificate for the information sought, for rare indeed
is the occurrence of the word alcohol on one of these.
Replacing it are more euphemistic names and ones
less likely to involve the physician in unpleasant
scenes with relatives or even possible libel suits.
Even in the lowest class of patients there is a hesi-
tancy about ascribing the death to alcoholism for
it is just this class of patients which might sue a
hospital or a physician with means, having every-
thing to gain and nothing to lose.
Of course one way of guessing at an estimate of
this sort is by ascertaining in what percentage of
cases of a given disease alcohol is supposed to be
a factor by clinicians. Then the number of deaths
caused by that disease can be ascertained and it
may be assumed that the same percentage of these
deaths was due directly or indirectly to alcohol.
This is the method adopted by Dr. Norman Porritt'
in estimating the number of deaths in England and
Wales during the year 1913, due directly or indi-
rectly to the abuse of alcohol, which he places at
77,416. Conclusions arrived at in such a way are
hardly worth putting on paper, but they will no
doubt be widely quoted by the propagandists, in
fact, have already appeared in one of their hand-
books.
Among other diseases Dr. Porritt assumes that
alcohol must have contributed to a varying propor-
tion of the deaths due to cirrhosis of the liver,
heart diseases, cancer, tuberculosis, and epilepsy.
Without discussing any of these here except the
last named, it may be said that we now speak of
epilepsies rather than of epilepsy and that the old
disease entity known as classical epilepsy is grad-
ually shrinking to a comparatively small number
of cases. There is absolutely no connection be-
tween alcoholism and idiopathic epilepsies.
The fundamental error in dealing with the prob-
lem of alcohol is the conception of it as a habit-
forming drug, the abolition of which would mean
'The Alliance Year Book and Temperance Reform:
Handbook for 1916. Manchester: United Kingdom
Alliance.
the automatic regeneration of all inebriates. As
a matter of fact, the inebriate is not normal and,
deprived of his alcohol, would drift to some elee-
mosynary institution. This has been proved by the
experience of prohibition States. We must not ex-
pect, however, to find any scientific view of the sub-
ject taken by publications such as the one in which
Dr. Porritt's article appears, but instead the bran-
dishing of such imposing arrays of figures as he
has marshaled by not too critical calculations. The
suggestion he makes that death certificates should
be made confidential is one which admits of a wide
discussion, but, while it might enlarge the number
of reports of death due to alcoholism, it would still
in all probability be far from accurate in this
regard.
THE HOME TREATMENT OF TUBERCULOSIS.
One of the best results to be achieved by the cam-
paign for the prevention of tuberculosis is the
improvement in the sanitary conditions especially in
such homes as are the most likely to have tubercu-
losis developed in them. With this in view there
has in fact been everywhere created a demand for
better, more cleanly, better ventilated, and better
lighted homes. This demand has been making
steady progress and the reduction of the new case
incidence can well be attributed in large measure
to this improvement of the home. But not so much
in the prevention of the spread of one case to an-
other has the improvement shown its strongest
point, as in the creation of an atmosphere which
reduces to a minimum the likelihood of the incipi-
ent cases rapidly passing on and through the other
and final stages. It has the effect in curing a great
many of the incipient unrecognized cases. Since
Virchow enunciated his dictum of the universality
of tuberculosis the fact has been brought home
that many of the transient cases of influenza, com-
mon colds, attacks of bronchitis, and even "run-
down" conditions are merely the evidences of the
presence of mild transitory infections with the
tubercle bacillus ; and that the little extra care en-
forced during this period in the shape of rest, free-
dom from all forms of dissipation, good food, and
the like soon overcomes these cases of mild, though
masked, tubercle infection.
Because of the home conditions the treatment of
the poor for tuberculosis has heretofore been an
especially difficult problem. To treat them in un-
cleanly, congested, unventilated, and unlighted
homes was out of the question; the private sana-
torium was out of the question because of the very
economic conditions which brought on the tubercu-
losis; and to wait for the public sanatoria to make
room meant for most of them the arrival of their
turn some time after death. In tuberculosis, even
if nowhere else, does money mean life; for even if
a sanatorium is attained the worry regarding the
means to pay for this form of extravagance quite
overbalances any good that might have been
obtained through this form of treatment. The
exiling of tuberculous patients to distant wilds and
distant climes, away from every encouraging influ-
ence, and to be a burden upon strange communi-
ties, is a crime no longer countenanced by the pro-
Aug. 5, 1916]
MEDICAL RECORD.
245
fession or by the public at large. The superstition
that a mad scramble to the farthest point away
from home gave the surest and the most speedy
hope of cure has no foundation in fact. On the
contrary, it can be the greatest factor for harm.
The overcrowding of certain communities having
reputations as health resorts has a depressing influ-
ence on everyone. Healthy influences and the pres-
ence of healthy people seem to be among the best
stimulants to the recovery from illness.
Whether from necessity or from other causes,
medical men are fast seeing the possibilities of
treatment with better results in nearby sanatoria,
in domestic camps, or in the homes of the patients.
The conversion of a previously insanitary home into
a suitable one for treatment is not always an easy
task, but with persistence and co-operation it can be
done. The possibilities of the home treatment have
been well illustrated by the results obtained by the
Home Hospital established by the New York Asso-
ciation for Improving the Condition of the Poor.
Their figures for cures are better than those of the
best sanatoria. For the poor, the home hospital idea
has decidedly the advantage over other methods be-
cause it adds to the well-being of the patients by
permitting them to be near their dear ones, and
often by giving them an opportunity to take advan-
tage of any light occupation, when not contraindi-
cated by their condition. Besides, one successful
case of home treatment carrying out all the re-
quired hygienic demands of the disease is a factor
of no mean proportion in furthering this campaign
for the prevention of tuberculosis.
The addition of the day camp to the home treat-
ment of tuberculosis has been a great improvement
in such instances especially where home conditions
could not be made acceptable. And when the night
camp idea for patients in the incipient stage, who
must do some form of work for their support, is
added to the home idea in the treatment of tubercu-
losis, the results will nearly approach the ideal.
When cases are diagnosed early the physician is
now in position to advise against exile or expensive
sanatorium treatment, and to assure a cure by home
treatment of greater speed, more substantiality, and
longer duration than he could hope for in any other
way. There is no doubt that with proper home sur-
roundings modelled especially for this purpose, with
care exercised against infecting others, with the in-
fluence of home and friends, with proper food at the
lowest cost, and with the addition of the day and
night camps, cure and rehabilitation of the tubercu-
lous by the home method may be obtained. And,
particularly, the method encourages the main-
tenance of the highest sanitary ideals in the home
after cure; where each case by the example set is
rather a help to the community than a menace.
eries. The view has even been hazarded that a
periodical devoted to mistakes would prove a huge
success. This conception comes at once into violent
clash with the principle that confession of failure
is a weakness, and that prestige of the individual
and profession would be irrevocably lowered by such
a course. Upon such a foundation all the "antis"
and others who are at odds with the profession
would hasten to build. It is also evident that ordin-
ary medical literature contains an abundance of
data in reference to mistakes, introduced in their
proper connection. No case could be properly re-
ported without due mention of errors, timely recog-
nition of which often leads to a successful outcome
of the case; while proven neglect in recognition
leads many to profit by the mistake of one. To
raise the subject of errors to a special discipline
is at least uncalled for.
The occasional publication of a series of errors
upon a background of successes such as appears
from the pen of Baetz in the Journal of Tropical
Medicine and Hygiene for June 15, 1916, is always
pertinent. The author covers five years of autopsy
work, and arranges his material, with the excep-
tion of infections and neoplasms, by organs. Un-
der the head of neoplasms, disseminated sarcoma
was overlooked in four cases, masked respectively
as dysentery, Pott's disease, syphilis of the liver,
and congenital heart disease with visceral conges-
tion. Under the head of renal disease we find that
uremic eclampsia due to chronic diffuse nephritis
masqueraded as epilepsy. A diagnosis of uremia
ending in fatal coma was correctly made, but cer-
tain severe pains had received no explanation until
autopsy revealed that the kidney mischief had all
been due to an impacted calculus. A diagnosis of
pyonephrosis was correct as far as it went but au-
topsy showed that the patient had but one kidney.
In another correct diagnosis of chronic nephritis,
it was found that the principal pathological condi-
tion was abdominal tuberculosis. Perforated duo-
denal ulcer with rupture passed in one case for
lead colic, apparently a full fledged technical error.
Another ulcer was overlooked in the presence of
notable advanced cardiorenal disease.
It is hardly necessary to multiply these instances.
The patients were negroes living in an environment
of tropical diseases. The errors were seldom of
the sort which cause death. The chief lesson to be
drawn from them is not that of diagnostic falli-
bility, but of the great value of autopsies in all
complex cases. These would greatly benefit the
public if only they were made mandatory under
a greater variety of conditions than that of sud-
den death.
MISTAKES REVEALED BY THE
PATHOLOGIST.
It has been conceded that the publication of diag-
nostic and therapeutic mistakes has much more
teaching value than the narration of cures which
may not have been cures at all but simple recov-
The Infectivity of Poliomyelitis.
The epidemic of poliomyelitis which is now present
in New York City and neighborhood is exciting un-
due alarm in consequence, no doubt, of the wide-
spread publicity which has been given to it. To
judge from the almost hysterical quarantine meas-
ures instituted in various localities — in staid old
Connecticut of all places — one would think it as con-
tagious as smallpox among the unvaccinated, or
as yellow fever two decades ago. To quiet the ap-
246
MEDICAL RECORD.
[Aug. 5, 1916
prehensions of these timorous health officers the
publication of authoritative articles, such as one ap-
pearing in Public Health Reports for July 14, 1916,
is commendable. Dr. Wade H. Frost, past-assistant
surgeon, U. S. P. H. S., writes here of the infec-
tivity of infantile paralysis, summarizing in part
as follows: "The rapid spread of epidemics over
wide areas, their spontaneous decline after only a
small proportion of the inhabitants have been at-
tacked, and above all the preponderating incidence
in young children, have not been satisfactorily ex-
plained by any hypothesis other than that the in-
fective agent during epidemics is widespread, reach-
ing a large proportion of the population, but only
occasionally finding a susceptible individual, usually
a young person, in whom it produces characteristic
morbid effects. Assuming this rare susceptibility,
the well-established facts collected by epidemiological
students are compatible with the evidence of labora-
tory experiments that the disease is directly trans-
missible from person to person." On the whole, per-
haps, this is the most reasonable manner of regard-
ing the infectious nature of poliomyelitis. Only
a comparatively few persons are susceptible and
these are, with few exceptions, children, the sus-
ceptibility being generally greatest in the first half
decade of life, thereafter progressively diminishing
until in adult life there is a very general immunity
to natural infection.
Autotherapy.
The general principles of autotherapy, as first de-
scribed in the Medical Record, are formulated by
Dr. Charles H. Duncan as follows: "When the
pathological exudate, or the end product, or a dilu-
tion of the same, of any localized (and possibly non-
localized) infectious disease is filtered with a Berke-
feld filter and the filtrate injected hypodermically,
or placed in healthy tissues, antibodies specifically
corresponding to the disease, will tend to be devel-
oped." A corollary of this general rule is: "In ex-
tra-alimentary and extra-pulmonary diseases, if the
crude pathological end products are placed in the
mouth specific resistance to the disease will tend to
be developed." This method is reviewed at length
in a recent issue of the Southern Medical Journal
by Passed Assistant Surgeon John C. Parhafh, U. S.
Navy, who points out that in many cases of infec-
tion and especially in some types of skin infection
autogenous filtrates act almost magically. Par-
ham is of the opinion, judging chiefly from his own
experience in treating cases of infection by auto-
therapy, that in surgical as well as in medical fields
its range of application is wide, and, what is to the
point, it is effective. It is obvious that the secre-
tion of a wound upon which an antiseptic or germi-
cide, such as bichloride, phenol, etc., had been used
would be unsuitable. However, he believes that
the day of these agents so generally employed in
surgical practice is on the wane, and that the almost
universal use of salt solution, salt solution and
sodium citrate, or Wright's solution will supplant
them. These solutions, not being antiseptics or
germicides, are not contraindicated where the em-
ployment of autotherapy is anticipated. If by
means of autotherapy active immunity can be ac-
quired in cases of infection, then there can be little
doubt that as a method of treatment it will quickly
make headway, although there are still many points
in connection with the method which require further
study and elucidation.
Vincent's Method of Prophylaxis and Infantile
Paralysis.
Vincent of angina lame once published a thorough
method of disinfection of the upper air and food
passages which has been used extensively in the
prophylaxis of cerebrospinal meningitis, grip,
anginas, etc. Quite recently Coulomb applied it to
600 soldiers, each of whom rinsed his mouth and
gargled his throat with iodized water or Labar-
raque's solution 50 to 1,000. Under a couple of days'
use the daily number of anginas reported fell to zero.
When cerebrospinal meningitis was epidemic and
all other methods had failed to arrest the outbreak,
that of Vincent was applied intensively with great
success. The particular antiseptic used is apparently
less essential than the manner of using. Three
times a day after meals a preliminary douching of
the entire mucosa with 10 per cent, hydrogen perox-
ide was carried out. The tonsils and pharynx were
afterwards painted with iodine 10 parts, potassium
iodide 10 parts, and glycerin 300 parts. Further,
three times a day each soldier inhaled the follow-
ing: Iodine 20 gm., guaiacol 2 gm., thymic acid 0.25
gm., alcohol (60 per cent.) up to 200. The inhalation
should last two minutes. At a later period the dis-
ease reappeared, and 107 suspects were isolated, 15
of whom were found to be meningococcus carriers.
Vincent's method was used for four consecutive
days and after two days of intermission the throats
of all the men were found sterile, while not a
case of meningitis had developed. These data are
taken from an article by Lefas in La Presse Medi-
cate, June 29. There is no mention of acute an-
terior poliomyelitis, but it would seem that the
article ought to be timely in connection with the
present local epidemic of the latter. The combina-
tion of douching, brush application, and inhalation
should sterilize all ports of entry. On account of the
tender age of most of the victims the method would
perhaps have to be modified.
SfettiB of tto Wttk
The Poliomyelitis Epidemic. — There has been
little change in the epidemic of infantile paralysis
in New York and vicinity during the past week, ex-
cept that the number of new cases in Brooklyn
where the epidemic began is decreasing, showing ap-
parently that the susceptible material in that region
is nearly exhausted. Health Commissioner Emer-
son has called a conference of pathologists and bac-
teriologists for Thursday of this week to study the
epidemic and suggest possible measures for its con-
trol. Those invited are: Drs. Victor C. Vaughan,
University of Michigan ; Milton J. Rosenau, Har-
vard; Dr. J. W. Jobling, Vanderbilt University;
Paul A. Lewis, University of Pennsylvania; John
Howland, Johns Hopkins University; C. C. Bass, Tu-
lane University; Theobald Smith, Princeton; John
F. Anderson, New Brunswick, N. J.; Richard M.
Pearce. University of Pennsylvania; Francis W.
Peabody, Peter Brent Bingham Hospital, Boston;
Ludwig Hektoen, University of Chicago; John G.
Adami. McGill Medical College, and the following
from New York City: Drs. Simon Flexner, Hideyo
Noguchi, Hans Zinsser. George Baehr. Francis
Carter Wood. William J. Elser, William H. Park,
and C. H. Lavinder and Wade A. Frost of the
United States Public Health Service. The total
number of cases up to August 2 was 4.123 and of
deaths, 898.
Aug. 5, 1916J
MEDICAL RECORD.
247
An Experiment in Tuberculosis Control. — The
National Association for the Study and Prevention
of Tuberculosis is about to institute an experiment
on a large scale for the control of tuberculosis. It
is proposed to select a town of from four to ten
thousand inhabitants and then to discover with the
aid of the local physicians, through careful medical
examinations every case of tuberculosis, every in-
dividual who has been exposed directly to the dis-
ease, and particularly all children up to sixteen who
have had close relations with persons ill with tuber-
culosis during their lifetime. It is proposed that
every known case of tuberculosis and every exposed
case of whatever nature should be under some sort
of supervision during a three-year period, either
in the home, in an open air school, in a tuberculosis
clinic, or in a hospital or sanatorium. In this way
and by keeping in close contact with all new families
and new babies born into the community the com-
mittee hopes to be able to prevent the spread of
tuberculosis, to stop the development of any new
cases in the community, and to determine the abso-
lute and relative worth of the various methods
usually employed in fighting the disease.
Anthrax in Western New York. — A meeting of
representatives of the dairy industry of Erie Coun-
ty and officials of the State Agricultural Department
was held recently in Buffalo to discuss methods to
check the outbreak of anthrax among herds in sev-
eral of the towns of Erie County. About thirty
authentic cases of the disease have been found. The
animals were slaughtered and buried in quicklime.
One farm hand is known to have contracted the dis-
ease.
A Large Sanatorium Planned for Hot Springs. —
It is announced from Hot Springs, Ark., that capi-
tal is being raised in New York for the erection of
a large sanatorium at that place. The building and
grounds will occupy ten acres and will cost
$9,000,000.
Trouble in a Pittsburgh Hospital. — A disagree-
ment between the medical staff and the superinten-
dent of the Presbyterian Hospital in Pittsburgh has
resulted in the resignation of three of the attend-
ing physicians. The superintendent also resigned,
but her resignation was not accepted by the trus-
tees, who passed a resolution of confidence in her
and satisfaction with her work. The medical men
assert that the management of the hospital was
more anxious to make money for the institution
than to help the sick poor, and that the wards were
filled with pay patients to the exclusion of those
who could not pay. The trustees declare that these
charges are unfounded.
More Hospitals Needed in France. — William P.
Hollingworth, Vice-President of the American
War Relief Clearing House for France and Her
Allies, who recently returned to this country, re-
ports that there is an urgent need for more hospital
and ambulance groups for the French Army manned
by American volunteer drivers. The French Gov-
ernment has shown high appreciation of what has
been already done in this direction. The work of
relieving the refugees and the distribution of hos-
pital supplies undertaken by the War Relief Clear-
ing House has reached enormous proportions.
About 40,000 cases of clothing and supplies have
been shipped to France and distributed through the
Clearing House in Paris, besides many thousands of
dollars in money.
Dr. Straw Honored. — Dr. A. Gale Straw, a mem-
ber of the Harvard medical unit on active service
at the trout in the European war, has been pro-
moted from the rank of captain to that of major for
efficient service.
Dr. Albert Neisser, Professor of Dermatology at
the University of Breslau, and discoverer of the
gonococcus, died on July 30 in his sixty-second year.
Milk for German Babies. — The State Depart-
ment at Washington has received a cable from Dr.
Taylor of the American Embassy in Berlin, stating
that the report published in New York that the
babies in Germany are suffering for lack of milk
is not true. He has made a special investigation
throughout Germany, at the request of our Gov-
ernment, and finds that, instead of a diminution,
there has been an actual increase in the milk sup-
ply. As further proof that the babies are not starv-
ing it is stated that the infant death rate in Ger-
many is now lower than it was before the war.
Praise for American Red Cross Nurses. — Mr.
William Warfield, formerly an attache of the Ameri-
can Embassy in Petrograd, and now charge d'af-
faires for the United States in Sofia, Bulgaria, has
written to Miss Jane A. Delano, chairman of the
National Committee on Red Cross Nursing Service,
as follows: "While acting as an attache of the Em-
bassy in Petrograd, specially assigned to war relief
work, I had occasion, as you know, to see a great
deal of the members of the American Red Cross
units in Russia. It gives me great pleasure to take
advantage of this opportunity to say that the nurses
attached to these units have been the greatest credit
to the organization and to the country they repre-
sent. Their professional efficiency is not only un-
questioned, but has excited a great deal of comment
in medical circles, having been mentioned to me fre-
quently by the Russian surgeons. Personally, by
their devotion to duty and their splendid organiza-
tion and discipline, these ladies have been a credit
to American womanhood and its ideals. I do not
hesitate to say that they have had an influence for
good quite apart from mere professional services."
Lecturers on Dentistry for Medical Students. —
Announcement is made of a special series of
lectures on dental subjects to the students
of Columbia's Medical Department during the
coming year. The course of lectures will
aim, to furnish the medical student with a
knowledge of the fundamental principles in the
proper care of the teeth and will emphasize the
close relation between the diseases of the body and
defective teeth. The lectures will be given by Drs.
Arthur Merritt, Leuman M. Waugh, W. B. Dun-
ning, H. S. Vaughan. and Henry S. Dunning.
New Naval Surgeons. — At the recent examina-
tion the following named medical men successfully
passed for appointment as assistant surgeons in
the Medical Reserve Corps, with a view to subse-
quent examination for appointment in the Medical
Corps of the Navy: Drs. James A. Halpin, Wash-
ington, D. C; William D. Heaton, Wahoo, Neb.:
Aubrey M. Larsen, Salt Lake City, Utah; Lincoln
Humphreys. Argenta, Ark.; Theo. Edward Cox,
Cleveland, Ohio; Arthur W. Hoaglund. Minneapolis.
Minn.; Carroll H. Francis, Camden, N. J., and
Harold L. Jensen. San Francisco, Cal.
American Electrotherapeutic Association. — The
next annual meeting of this association will be held
at the Hotel Martinique, New York City, on Sep-
tember 12-14. under the presidency of Dr. Jeffer-
son D. Gib=on of Denver. The secretary is Dr.
Byron S. Price. 65 Central Park West, New York.
The Northwestern Medical Society of Nebraska
248
MEDICAL RECORD.
TAug. 5, 1916
held its annual meeting in Canyon Park, Long Pine,
on July 18, at which time the following officers were
elected: President, Dr. G. O. Remy, Ainsworth;
Vice-President, Dr. E. T. Wilson, O'Neill; Secre-
tary, Dr. J. M. Tische, Wood Lake; Treasurer, Dr.
Thomas J. Lawson, Long Pine. Wood Lake was
selected as the place for holding the next meeting,
the last Tuesday in October.
The Montana Medical Association held its an-
nual meeting on July 12 and 13 at Miles City, elect-
ing the following officers: President, Dr. J. A.
Donovan, Butte; First Vice-President, Dr. Arthur
Morrow, Kalispell; Second Vice-President, Dr. R.
H. Beach, Glendive; Third Vice-President, Dr. Ar-
thur Jones, Butte; Secretary-Treasurer, Dr. E. J.
Balsam, Billings. The next annual meeting will be
held at Kalispell.
The Study of Inebriety. — A Research Founda-
tion has recently been organized at Hartford,
Conn., for the purpose of making an exact scien-
tific study of the causes of alcoholism and in-
ebriety. It will be endowed and become a perma-
nent work. Preliminary studies have already
begun, and practising physicians from all parts
of the country are appealed to for the records
and histories of cases which will be compiled and
tabulated for the purpose of determining the laws
which control and govern them. Dr. T. D. Croth-
ers of Hartford writes that this is the first scien-
tific effort to take up the subjects of alcoholism
and inebriety and determine the causes which
produce them outside of alcohol. Science has
shown that these conditions are governed by exact
physical and psychical laws, which if known and
understood would indicate the most practical
means and measures of relief. The Foundation
will be practically a laboratory or clearing house,
where persons can come for examination, counsel,
and advice. To a large class of persons who want
something more than pledges, appeals, or sana-
torium treatment this will open a new field of
means and measures for relief that will be most
welcome. Among the questions, an answer to
which will be sought, are the following: Why
are certain periods of life more favorable for the
outbreak of the craze for alcohol than others?
Why does the desire to drink break out suddenly
in diverse conditions and then subside from
causes inadequate to explain the change? What
is the explanation of the exact periodicity of these
drink excesses that are as certain as the rise and
fall of the tide? What are the causes in sur-
roundings and conditions of living that provoke
these paroxysms? Why do men drink after in-
juries, diseases, shocks, losses, disappointments,
business reverses, and great successes in life?
What degenerations are transmitted from the
parents to the children that create susceptibility
or immunity to the effects of alcohol? Why are
some persons able to drink in so-called moderation
for years and why do others quickly become dis-
eased and die? Why do some men drink in early
life, then abstain, and in middle or later life turn
to alcohol again and drink until death? Why are
some persons susceptible to the contagion of sur-
roundings and companions, while others are im-
mune? What physical and psychical causes pro-
duce the drink craze?
Obituary Notes. — Dr. William McKELVY of Den-
ver died July 13 at the age of (52 years. He was
a graduate of the medical department of the Uni-
versity of Pennsylvania in the class of 1875 and
practised in Breckenridge, Colo., from 1880 to 1900,
when he removed to Denver.
Dr. E. W. Dean of Hiram, Ga., died in Atlanta on
July 4. He was a graduate of the Medical Depart-
ment of the University of Georgia in the class of
1883.
Dr. David William Edgar of Ames, Iowa, died
suddenly in Marshaltown on July 8 at the age of
71 years. He was born in Wisconsin and was
graduated from Rush Medical College, Chicago, in
1874. He practised at various times in Monroe and
Dayton, Wis., and Gowrie and Fonda, Iowa. On
account of heart trouble he retired in 1911 and went
to Ames to live.
Dr. Roscoe Smith of Auburn, Me., died on July
8, after a month's illness, at the age of 80 years.
He was born in Peru, Me., and was graduated from
the Harvard School in 1869. He practised for
many years in Turner, retiring in 1889, and subse-
quently removing to Auburn.
Dr. Louis Augustus Woodbury of Groveland,
Mass., died July 17 at the age of 72 years. He was
born in Salem and was graduated from the Harvard
Medical School in 1872. He was a member of the
Harvard Alumini Association, the Haverhill Medi-
cal Club, the Massachusetts Medical Society, and
the American Medical Association. He retired from
practice about five years ago.
Dr. James Smiley Bush, Jr., of Colquitt, Ga.,
died in Albuquerque, N. M., on July 13, at the age
of 31 years. He was born in Colquitt and was
graduated from the Atlanta College of Physicians
and Surgeons in 1912. He was obliged to give up
practice about a year ago on account of ill-health.
Dr. Thomas C. Elmendorf of Port Chester, N.
Y., died recently at his home in that place at the
age of 64 years. He was a graduate of the New
York Homeopathic Medical School and Hospital in
the class of 1875.
Dr. James F. Heady of Glendale, Ohio, died on
July 24, after a long illness, at the age of 64 years.
He was born at Vevay, Ind., and was graduated
from the Miami Medical College, Cincinnati, in
1878. After an interne service in the Cincinnati
General Hospital he began practice in Glendale.
Dr. Thomas Alphonzo Kenefick of New York
and Newport, R. I., died at the home of his brother
in Lawrence, Mass., on July 30. He was born in
1858 and was graduated from the Medical Depart-
ment of Columbia University in 1885. He was a
member of the Rhode Island Medical Society, of the
Medical Societies of the County and State of New
York, of the American Medical Association, and of
the New York Academy of Medicine.
Dr. Herman G. Tarter of Chilhowie, Va., died at
the residence of his father, Dr. J. E. Tarter of
Wytheville, on July 15, at the age of 31 years. He
was a graduate of the Medical College of Virginia
in Richmond in the class of 1911.
Dr. Price Emerson Murray of Atlanta died July
20 at the age of 63 years. He was a graduate of
the Atlanta Medical College in the class of 1886.
Dr. William LOVETT of Norman Park, Ga., died
after a brief illness on July 21, at the age of 34
years. He was born in Sparks, Ga., and was a
graduate of the Atlanta College of Physicians and
Surgeons in the class of 1913.
Dr. Adolfo Lamar of Havana, Cuba, died in New
York City last week, from disease of the heart, at
the age of 47 years. He was a native of Havana
and a graduate in medicine of the University in that
city.
Aug. 5, 1916]
MEDICAL RECORD.
249
(dnrrcspandHur.
MERCURIC SUCCINIMIDE IN
POLIOMYELITIS.
To the Editor of the Medical Record :
Sir: — Owing to the continued and virulent epi-
demic of infantile paralysis in New York, a condi-
tion that demands the use in the treatment of the
disease of any method which has the remotest pos-
sibility of being of value, I venture to suggest that
the method advocated by me since 1910 for the
treatment of many of the acute infectious diseases,
namely, deep intramuscular injections of large
doses of mercuric succinimide, should be tried.
Barton Lisle Wright, M.D.,
Surgeon, U. S. Navy.
U. S. S. Delaware.
OUR LONDON LETTER.
(From Our Regular Correspondent.)
HONORS FOR MEDICAL SERVICE IN THE FIELD —
STRANGULATION OF THE UTERUS BY TORSION — ■
FIBROMA — SUPRACERVICAL HYSTERECTOMY.
London. July S, 1916.
Among the recent honors for services in the field
the C. B. has been conferred on Col. F. W. G. Gor-
don-Hall, M. B., A. M. S., and Lieut.-Col. R. J. W.
Mawhinery, R.A.M.C. and the C.M.G. on Major A. C.
Valadier, A. M.S. The distinguished service order
is awarded to Major Robert Tilbury Brown and
Lieut.-Col. A. E. Conquer Keble, and the Military
Cross to Corporal Morton Peto and J. Swinburn
Townley. The Commander-in-Chief, East African
Force, Lieut. -Gen. the Hon. J. C. Smuts, has
transmitted a list of officers recommended for serv-
ices in the field, a considerable proportion being in
the Royal Army Medical Corps, the South African,
and the Indian Medical Services.
There is a shortage of medical recruits for the
army which is expected to continue for some time
and perhaps increase. Under the new act calling-
up notices are not being sent to men who have two
or more children. This will apply to 178 officers,
of whom 93 are on the panel. It is said that of
these 31 are entitled to exemption, but it is hoped
that they will remain and that others who have so
far kept off will come forward to help in the present
emergency.
The act came into operation on the 24th ult.
and makes every medical man under 41 years old
a soldier unless he has enrolled with the Central
Medical War Committee. An appeal by the authori-
ties for more men even up to 45, has been readily
responded to and it is expected that a further ap-
peal will be made — probably up to 50 or even 55,
and it is certain that many of that age are capable
of effective service. There has been some hesita-
tion on the part of practitioners on account of the
inadequate statement as to what was to be the
duties undertaken. A physician is not willing to be
put over a surgical ward and vice versa, and the
Central War Committee should see that every one
they induce to come to their help should be assigned
to the work with which they are most familiar.
At the Obstetrical Section (R. M. S.) Mr. J. D.
Malcolm showed a case of strangulation of the
uterus by torsion of the body on the cervix. A frail
lady of 70, married but never pregnant, was seized
with pelvic pain after dinner. Next morning took
breakfast as usual, .but could not get up as the
pain increased and vomiting came on. Temperature
by evening reached 101° F. Seen by three doctors
late that night, a hard, round, pelvic tumor about
4 inches in diameter was felt in the median position.
Behind this was an irregularly oval mass about 3V£
inches from above downward by 1% inches from
side to side, uneven in consistence, but most of it
fairly soft. Below was a soft short cervix uteri.
The rectum was firmly compressed, but slightly
movable as a part of the pelvic mass. A fibroma
had existed before menstruation ceased and it
seemed as if something had twisted, but the con-
dition behind the hard tumor was a puzzle. The
abdomen being opened a fibroma was seen attached
to the left anterior upper part of the uterus. This
and the uterine body had revolved a full turn on the
cervix; the lower end of the body was tightly
twisted, the parts above being of a deep, blue-black
color, and although it was only 28 hours from pain
being felt and only 16 hours after it became severe,
there was a distinctly offensive odor. Supracervical
hysterectomy was performed; the left ovary and
tube were raised by the new growth above the con-
striction and they were removed ; the right were be-
low it and were not taken away. The recovery was
slow but otherwise good. The specimen was ex-
hibited, the uterus body was obviously enlarged by
congestion, was soft from age and the softness with
its attenuation permitted the strangulation by tor-
sion. Dr. Cuthbert Lockyer was glad the case
was brought forward, as it demonstrated a rare con-
dition which presented great difficulties in diag-
nosis. As to the torsion, it was known that a twist
of the corpus on the cervix through as much as 90°
could occur without producing symptoms suggest-
ing the condition. In eight cases of torsion re-
corded by Kelly and Cullen not one set up special
symptoms, and in one of them the corpus was ro-
tated through 180°. The torsion usually is through
the isthmus which gradually atrophies and forms a
sort of pedicle for the body above it. This pedicle
may become severed from the cervix, as shown in a
case of Bastinelli of Rome. Dr. Lockyer referred
to five recorded cases of acute torsion, the causation
of which is still a subject of speculation.
OUR LETTER FROM ALASKA.
(From Our Special Correspondent.)
"SEE ALASKA FIRST."
St. Michael. July 6, 1916.
This letter is written with the view of inviting the
attention of the professional man who is thinking of
a trip to the fact that Alaska offers some very in-
teresting features for the professional man and its
scenery stands in a class by itself. The transpor-
tation companies have so perfected their means of
travel that a trip through Alaska is now a luxury
instead of a hardship as in former times.
The average person of the United States knows
very little of the vastness of this territory which in
square miles is said to equal New York, New Jer-
sey, Pennsylvania, Illinois, Indiana, Ohio, Michi-
gan, Wisconsin, North and South Dakota, and all
of New England combined. If a map of the terri-
tory was superimposed upon that of the United
States — drawn to the same scale — it would extend
from Charleston, S. C, to San Francisco. This vast
country extends from about 55° to about 71° North
latitude, or more than 4C north of the Arctic circle,
and with this vastness is a great diversity of cli-
mate, scenery, flora and fauna.
250
MEDICAL RECORD.
[Aug. 5, 1916
The climate of Southeastern Alaska is much like
that of Oregon while the climate of Northwestern
Alaska more nearly resembles that of northern
Montana, but even in this comparison the extremely
short days in winter and the extremely long days
in summer mark quite a contrast. In summer this
truly is "The Land of the Midnight Sun." The
winters are pleasant, but as the only means of
transportation is by the dog sled, winter is a poor
time to visit Alaska; but with the advent of sum-
mer the geese, duck, swan, crane, and many
varieties of smaller birds return by the millions and
there is probably no place where more game can be
seen to the square mile than in Alaska from May
until October. The flora too is interesting. The
surface snow and ice disappear and the fields that
are at first bleak and barren looking, soon take on a
very picturesque appearance with wild flowers of
every color and many varieties.
The glaciers, rivers, plains, seas, islands, vol-
canoes, mountains, tundras, forests, fishing, hunt-
ing', and mining (especially for gold) will keep the
average tourist's attention from the time he first
sights southeastern Alaska until he passes through
the Unimak pass of the Aleutian Islands, on his
homeward journey. But for the professional man
there is still more of interest! The Eskimo, as the
native is called who lives on the coast, and the In-
dian, who lives in the interior, offer a vast field for
medical study. On account of the climatic con-
ditions, isolation, and environment, the native has
acquired many habits that are unknown within the
United States. Of the many interesting things that
these people offer, the following seem most strange:
Their method of burial in improvised boxes above
ground, covered with logs on which are fastened
the belongings of the deceased, their method of
dress, what they eat, their houses, their methods of
transportation in summer (kyack) and winter (mal-
amute dogs and sleds), the council house (kashim),
the "medicine man" and a talk with him and pos-
sibly seeing him "make medicine" (treatment of
the sick by song and dance), or possibly the wit-
nessing of some festivity as "The Feast to the
Dead."
When a doctor visits a native village for the first
time he will most probably say or think "My! I had
no idea that these people were in such great need
of medical and surgical treatment! What a vast
field this offers for some missionary or other kind
of benevolent society." "How dirty they are," will
probably will one of the first remarks made. The
doctor will be struck with the large number of per-
sons who present evidences of tuberculosis both pul-
monary and of the spine, also with the large num-
ber of cases of skin diseases, the large number of
persons who live in each house (which house is usu-
ally of one room), and the large percentage of chil-
dren. If possible, he should go into some of these
In. ii e and try to see some of the natives al meal
time. It is not customary to knock, but to walk
1 in and say "wah-kah ing "How do you
do?" He will almost always find the women or
iws at work, but will verj rarely find the men
lining anything.
Sonic of the most interesting things that the doc-
tor will see in southea tern Alaska are the totem
poles which are records of family deeds and achieve-
ments and vary from small sticks to enormous poles.
Some of the most interesting things that he will
see in northwestern Alaska are the beautiful and
useful things thai the natives carve from walrus
ivory and mastodon ivory. In fact he can get al-
most anything he desires made of this material, and
if the time will permit can have it made to order.
Of course Alaska is noted for its furs; mink, mar-
tin, otter, swan's down, eider down, lynx, red fox,
white fox, cross fox, ermine, and beaver are on the
market and handled by the fur traders and mer-
chants. The price will be about the same as paid in
the United States but one will have a greater selec-
tion to choose from. All furs seem high this sea-
son.
In making out an itinerary I would suggest the
following: Purchase a round trip season ticket
from your home to Seattle, arriving in Seattle about
two days before the ship is scheduled to sail. Pro-
cure a round trip ticket to St. Michael reading
through the Inside Passage and down the Yukon
river to St. Michael, from St. Michael to Seattle via
Nome. This will give an ocean trip to Skagway
through the beautiful inside passage. Take the
train at Skagway for Whitehorse (Canada) over a
railroad that stands in a class by itself, and connect
with a river boat for Dawson and Tanana and
change for St. Michael. This gives a river voyage
of about 2,000 miles touching at many points and
usually long enough for passengers to go ashore
and see what is to be seen.
It is estimated that the trip above outlined will
take about thirty days and cost approximately $270
including transportation, meals, and berth, but
$400 should be allowed for the trip to cover the cost
of incidentals and for the purchase of interesting
and useful souvenirs. This is the complete trip,
but there are many shorter trips, in fact any point
along the line may be used as the turning point and
thus shorten the time for the busy professional
man. There are good accommodations for ladies and
children and nurses. The summer temperature
varies from about 50° to 68° Fahr. and along with
the ocean trip it is thought that such a trip will
prove to be helpful to children suffering from in-
testinal troubles as well as possibly many others.
The professional men of Alaska are cosmopoli-
tan, interesting, and cordial and I believe will be
pleased to devote a portion of their spare time to
meet our professional brothers and to show them
points of local interest. One need have no hesi-
tancy in introducing oneself and feeling sure of a
welcome in the office of any physician who practises
in Alaska.
JJrngrfBB nf iftrfttral ^rmtn*.
Boston Medical and Surjjical Journal.
July 20, 1916.
l. David Williams Cheever. (Memorial Address). Ge
w i !aj and .1 I '"lims Warren.
i'. . [alius Clarke White (Memorial Address.) Abner
i Frederick i ' Shattuck.
3. Epidemic Poliomyelitis. The Symptomatology and Diag-
nosis in the Acute Sta ■<■ Francis R. Fraser
i Anatomic Form and Posture, Important Factors in the
Treatment of Pulmonary Tuberculosis. Joel E,
Goldthwa
5. The Teaching of Therapeuti Bi inch of App
Physioli ' lei 'i udden
6. Exfolial ititla Following Ncosalvarsan Injections.
Eli ne
7. A Review "i 127 Cll a "i Ataxia 1'araplegia.
■ ; ii
3. Epidemic Poliomyelitis; The Symptomatology and
Diagnosis in the Acute Stages. — Francis R. Fraser sta
that in the preparalytic period and in abortive cases
the diagnosis of poliomyelitis depends, to a <rreat ex-
. on the presence of an epidemic and association
with other cases. Under these circumstances, a history
of sudden onset, with fever, gastrointestinal symptoms,
Aug. 5, 1916]
MEDICAL RECORD.
251
and perhaps pain, would indicate a careful examination
for signs of stiffness of the neck and back. If any sus-
picion of a meningitic lesion is entertained, lumbar
puncture must be performed, when the condition of
the spinal fluid will clear the diagnosis in most cases.
The differentiation from a gastrointestinal upset is
most difficult, but in gastrointestinal disorders the spi-
nal fluid is normal. Other common infectious diseases
commence similarly, but in them the pain and hyperes-
thesia are usually absent. Skin lesions in poliomyelitis
have been described, but are not constant in character,
and are present in only a small number of cases. Acute
rickets is easily mistaken for poliomyelitis because of
the fever, the prostration, and the tenderness. The
spinal fluid, however, is negative, and in poliomyelitis
pronounced enlargement of the liver is not found. Tu-
berculosis of the hip can be differentiated by the his-
tory of onset. Acute rheumatic arthritis may com-
mence acutely, and the fever, pain, and disinclination
to move, be very similar; but the tenderness is local-
ized to the articular structures, and in poliomyelitis
there is no swelling of the periarticular structures and
no synovial effusion. Meningitis due to the meningo-
coccus, the pneumococcus, the influenza bacillus, to
streptococci and staphylococci, give a spinal fluid with
increased cell count, due to polymorphonuclears, and the
causal organism can be found in the smears and can
be cultivated. In tuberculous meningitis and syphilitic
meningopyelitis, the spinal fluid is very similar to that
of poliomyelitis, and the clinical findings do not differ-
entiate it until the case has been watched for a few days.
A positive Wassermann in the blood is not sufficient
to differentiate syphilitic meningitis, as it may be found
in acute poliomyelitis, as in other acute infections. Even
when evidence of paralysis, or of involvement of the
motor system, is found, the diagnosis may not be clear.
Acute poliomyelitis is probably more often mistaken
for cerebrospinal meningitis than for any other dis-
ease, especially as paralysis may occur in both; but
the rash, the photophobia, and characters of the spinal
fluid, should differentiate them.
4. Anatomic Form and Posture Important Factors in
the Treatment of Pulmonary Tuberculosis. — Joel E.
Goldthwait calls attention to the different anatomic
types that exist, and to the fact that each type has
its own more or less definite potential of disease, and
of these the congenital visceroptotic, the carnivorous,
the hyper-onto-morph, is commonly tuberculous. This
type, during development, acquires habits of carriage
in which the ribs are lowered and the chest is used
in the position of full expiration. In this position, tho-
racic breathing must be very imperfect and full ex-
pansion of the chest rarely occurs. The writer de-
scribes several defective anatomical types, and shows
how they interfere with the mechanism of breathing
and the function of the heart. From these he draws
the practical suggestion that if we are to do the best
we can to insure health we must see that the body
is so used that the rhythm of respiration, both as it
refers to the thoracic and the diaphragmatic move-
ment, is as nearly normal as possible. With the facts
thus brought out, the use of a back brace for a case
of pulmonary tuberculosis may seem unusual, but is
not irrational. In the treatment of tuberculous pa-
tients, the importance of posture must be borne in
mind at all times, and particularly as the patients are
put out in the open to get the fresh air. If improp-
erly propped up in bed, obviously little air can get
in to the individual, and this is also true of some of
the reclining chairs which are used in our sanato-
ria, especially the canvas steamer chair. If such chairs
are used, their harmful features should be appreciated.
and corrected. The simple use of a board placed at
the back of a canvas steamer chair makes the chair
much less objectionable. The aim in treating these
patients should be to make the full excursion of the
chest in inspiration and expiration possible with the
least effort.
5. The Teaching of Therapeutics as a Branch of Ap-
plied Physiology. — F. H. McCrudden expresses the opin-
ion that the teaching of therapeutics is one of the
weakest points in the training of the medical student.
He thinks that a division of medical science dealing
with the aims and methods of therapeutics, and filling
in the gap between physiology, chemistry, physics, phar-
macology, and the other fundamental sciences which
underlie the methods of treatment, on the one hand,
and the actual details of treating individual patients
from day to day, on the other, should be recognized,
and a course on this subject should be added to the
medical curriculum. This instruction should aim to
give the student a point of view regarding these pur-
poses and principles of treatment, so that these details
may be contemplated not as a vast number of empiri-
cal and unrelated elements, but as mutually dependent
parts of a whole. It should continue the emphasis
on scientific habits of thought, which is one of the
objects of instruction in physiology and other funda-
mental branches of medical science, and bring out
the fact that therapeutics is not an empirical art, but
an applied science. The writer emphasizes the im-
portance of impressing students early in their medical
career with an optimistic and hopeful attitude toward
the result of treatment. The less optimistic attitude
of many physicians is due not to the poor results of
treatment, but to discouragement at the difficulties of
having treatment carried out in private practice, a
distinction that should be brought home to the stu-
dent. For an understanding of rational therapeutics
a study of the treatment of chronic disease forms the
best basis.
7. A Review of 127 Clinical Cases of Ataxia Para-
plegia.— G. H. Bigelow bases this study on the records
of the Neurological Clinic of the Massachusetts Gen-
eral Hospital, from 1903 to 1915. He finds that of
these 127 cases of ataxia paraplegia, 70 per cent, were
males, whereas in the whole Out-Patient Department
approximately 58 per cent, are males. In 83 cases, a
possible etiology was established. This was as fol-
lows: Syphilis, 43; following accident, 10; following
acute infections, 6; hemiplegia, 5; alcoholism, 5; mal-
formations or irregularities of the spine, 3; hyperten-
sion, 3; chronic disease, 2 (gout and sepsis) ; exhaus-
tion, 2; anemia, lead poisoning, neurotic family history,
exposure, heredity, tumor, pellagra, each 1. In 44 cases
no possible etiology could be found. Of the 47 syphilitic
cases, only 7 showed positive laboratory findings. The
essayist concludes that, contrary to the observations
of several other authorities, it would seem from an
analysis of these cases that syphilis is an important
etiological factor in ataxia paraplegia.
New York Medical Journal.
July 22, 1916.
1. The Diagnosis and Treatment oi \<ui Anterior Polio-
myelitis in the Preparalytic and Postparalytic Stages.
M. N. Neustaedter.
2 Diagnosis and Treatment Adam H. 'Wright.
:;. An Analysis of Certain Neurotic Symptoms. C. P. Obern-
dorf.
> Percussion in Early Tuberculosis Julius Schneyer.
5. Syphilis of the Larynx. Joseph Weinstein.
6 Iniraperitonv.il Vdhei B R .1 I a \V. A. Nealon.
7. Laboratory Aids in thi Diagnosis of Poliomyelitis. Jose-
phine B. Neal
4. Percussion in Early Tuberculosis. — Julius Schneyer
says that there is no doubt that some change of reso-
nance to gentle percussion accompanies very early
252
MKDICAL RECORD.
[Aug. 5, 1916
lesions in the apex; indeed, it is his experience that
some alteration to skilled percussion can be found in
every diagnosticable lesion, and that diagnosis can
rarely be made without it. He concludes that impair-
ment of resonance in one apex can be discovered by
the softest percussion, having in mind the possibility
of hypersonance on the opposite side. Reinforcement
by expiratory percussion may be tried in doubtful
cases. These cases are often overlooked or missed if
ordinary percussion is used. The degree of impair-
ment may be determined by increasing the weight or
force of percussion in order to see if it still persists,
or at what point it stops. The most important evi-
dence for diagnosis is the finding whether there is any
impairment at the other "seats of election" for tuber-
culous deposits, for instance, in the opposite side or
at the apices of the lower lobes. Topographical per-
cussion may supply us with the following information:
a, Equal resonant areas and of normal extent are evi-
dences of normal lungs. The areas of normal measure-
ment, but one being displaced, is a condition described
by Kroenig under the name of "physiological heteroto-
pia." It was this condition which led Kroenig to dis-
cover his outer boundary, 6. There may be a blurring
of one or the other, or both margins of the resonant
area, with or without some general loss of resonance,
a condition very suggestive of early tuberculosis, c.
A difference of the areas and especially in the width
of the "isthmus" may be due either to expansion of
one side, or retraction of the other, or both conditions
may be present. Auscultatory percussion, as practised
by the writer, has proved of notable value for the con-
firmation of the findings by gentle percussion in out-
lining Kroenig's areas, or mapping out the respiratory
excursion of the lung borders, especially when external
noise prevents appreciation of the delicate shades of
difference in sounds by gentle percussion. The dimi-
nution of the respiratory excursion of the lower border
of one lung is an early sign of tuberculosis, emphysema,
old age, pleurisy, pain, inability to breathe, or other
conditions interfering with the free movement of the
lung in the pleural space without active disease having
been excluded. As a measure of the extent of pleurisy
in any case of phthisis, in order to decide as to the
advisability of artificial pneumothorax, the measure-
ment of the degree of movement or expansion of the
lung is of notable value.
6. Intraperitoneal Adhesions. — R. J. Behan and W.
A. Nealon present the results of a study made to de-
termine the cause of the intraabdominal formation of
adhesions and the manner of their prevention. They have
made observations to determine if alcohol, glycerin,
denudation, infection (mild or severe), or toxins or bac-
teria passing out from the intestines, can form ad-
hesions. They have also made studies to determine if
petrolatum applied over raw areas will retard adhesive
formation; whether wool fat, an organic fat alone, or
mixed with some inert or soluble substance as boric
acid, inhibits adhesion formation, and whether olive oil
or Russian oil prevents or hinders adhesive formation.
In the course of their investigations it became apparent
that something more than traumatism was necessary
to the production of adhesions between two adjacent
peritoneal surfaces. This additional factor may be
infection of a mild type. The previous methods of pre-
venting adhesions apparently did not take sufficiently
into consideration either the possibility or the presence
of this infection; and also discounted another im-
portant factor, namely, that in using olive oil or min-
eral oil, such as petroleum, a foreign substance was be-
ing introduced into the peritoneal cavity, the reaction to
which would be the throwing out of an exudate with
fibrin deposit and subsequent adhesive formations. In
the hope of deriving some information along these lines
experiments were performed with wool fat and boric
acid as an antiseptic to counteract any mild infection
which should occur in the abraded peritoneal cavity.
The results of these experiments on animals were so
encouraging that these observers decided to try wool
fat boric acid paste in the human abdomen. Thus far
they have used it in fifteen cases with good results. Up
to the present time none of these patients have com-
plained of symptoms which could be traced to adhesions,
though sufficient time has not elapsed to determine
whether the tendency to adhesive formation has been
entirely obliterated. In all of these cases there has
been a postoperative elevation of temperature. The
pulse as a rule does not increase in rapidity. The pa-
tient complains of but little postoperative pain. It has
become the writer's routine practice to use this prepa-
ration in all cases in which there is a possibility of
postoperative adhesive formation.
7. Laboratory Aids in the Diagnosis of Poliomyelitis.
— Josephine B. Neal. (See Medical Record, July 22,
1916, page 169.)
Journal of the American Medical Association.
July 22, 1916.
1. Epilepsy, with Special Reference to Treatment. Francis
X. Dercum.
2. The Preparation of the Patient for Operation. Walter B.
Lancaster.
3. The Transplantation of Ductless Glands, with Reference
to Permanence and Function. O. T. Manley and David
Marine.
4 Amino Acid Nitrogen jn the Systemic Blood of Children
in Health and Disease. C. J. V. Pettibone and F. W.
Schlutz.
5. Strabismus Produced by Operation for Strabismus: A
Consideration of Causes Producing Deformities Fol-
lowing Strabismus Operations, with Suggestion for
Corrective Operative Procedures. Frank C. Todd.
6. A New Shortening Technique, with Report of Forty-Two
Operations. Roderic O'Connor.
7. Linitis Plastica : With Report of Case. Gilbert M. Barrett.
8. The Effect of Activity on the Histological Structure of
Nerve Cells. R. A. Kocher.
9. The Nature, Manner of Conveyance, and Means of Pre-
vention of Infantile Paralysis. Simon Flexner.
1. Epilepsy, with Special Reference to Treatment. —
Francis X. Dercum says that after we review the facts
that have been hastily7 summarized, one fact stands forth
with striking prominence, namely, that epilepsy is not a
specific clinical entity. Under the caption of epilepsy are
included many symptom groups which differ widely as
to their origin and pathology. A specific treatment of
epilepsy is obviously out of the question, and the first
step must be an intensive study of each individual case.
The first indication in the treatment is that the or-
ganism shall lead as physiological a life as is com-
patible with its structure. To attain this end, a life
without physical or mental strain, close to nature, in
camp or on the farm, should be adopted by the epileptic.
This, indeed, is the principle applied in the various
epileptic colonies. In addition, three points should be
borne in mind: 1. The diet should be so modified that
in this organism, already toxic, as little strain as pos-
sible be placed on the liver, the thyroid and other de-
fensive glands. For this reason the red meats are to
be partaken of sparingly. The carbohydrates also are
to be diminished. To take the latter in large amount
is to hamper the oxidation of the tissues, an oxidation
which for the obvious reason of the autotoxicity of the
patient should be maintained at as high a level as pos-
sible. In the diet, emphasis should be laid on the white
meats, the succulent vegetables and milk; eggs also may
be permitted. Stimulants of all kinds are, of course, to
be excluded. 2. The various avenues of elimination
should be kept freely open. If the diet does not of it-
self counteract the constipation frequently present, a
moderate dose of a simple saline or laxative water may
Aug. 5, 1916]
MEDICAL RECORD.
253
be given daily. The patient should drink water freely
between meals to promote the action of the kidneys, and
should take a lukewarm sponge bath daily to promote
the action of the skin. The bath should not be such as
to promote an active reaction, but merely to favor
elimination. 3. Resort to medicines must, of course, be
had in many cases to influence or control the seizures.
Experience teaches that chief reliance must be placed
on the bromids. Regarding their efficient administra-
tion, however, one important point must be borne in
mind, namely, the principle of sodium chloride with-
drawal introduced by Richet and Toulouse. If table
salt is withheld, the bromids instead of being eliminated
are retained and are effective in much smaller dose.
The writer has been in the habit for many years past
of administering the bromids in the form of sodium
bromide, at the same time instituting as rigid a with-
drawal of the sodium chloride as possible. He says
there can be no doubt that under these circumstances
the sodium bromide takes the place, in a measure, of
the sodium chloride in the tissues. If, in a case so
treated, the sodium bromide be discontinued and sodium
chloride resumed, the bromide is rapidly eliminated in
the urine. In a given number of instances, the physio-
logical level of the patient may be distinctly raised by
the administration from time to time of small doses of
thyroid extract; say from an eighth to a quarter of a
grain three times daily, seldom more. Thyroid in small
doses, long continued, stimulates the chain of glands of
internal secretion, increases oxidation and promotes
metabolism generally.
3. The Transplantation of Ductless Glands, with Spe-
cial Reference to Permanence and Function. — 0. T. Man-
ley and David Marine say that in the course of their
work during the past three years, they studied the
transplantation of ovary, suprarenal (cortex and
medulla), spleen, parathyroid, and thyroid of rabbits.
Because the thyroid has several advantages such as ac-
cessibility, wide range of morphological changes, and
its specific iodin reaction, the following summary is
based for the most part on their experiments with the
thyroid gland: Concerning autografts we have been
able to confirm the conclusions of others that thyroid
when transplanted shows all the evidence of growth,
function, and permanence, and to the same degree, as
does the non-transplanted thyroid. This work also
shows that specific nerves, whether secretory or regu-
latory, are not necessary for the control of growth or
of function in the case of the thyroid. Concerning the
behavior of thyroid homograft, it seems established that
both the host and the tissue used for the grafts modify
their duration. These two factors may be quite inde-
pendent, antagonistic to, or helpful to each other. In
the case of the thyroid this reaction may be modified
by iodine. Lastly, the future of tissue transplantation
as a therapeutic means rests on a solution of the prob-
lem of the homograft, and it is also certain that what-
ever headway is made in overcoming the obstacles to
homografting will to an equal degree be applicable to
the solution of the tumor problem.
4. Amino Acid Nitrogen in the Systemic Blood of
Children in Health and Disease. — C. J. V. Pettibone and
F. W. Schlutz. (See Medical Record, June 24, 1916,
page 1156.)
6. A New Shortening Technique. — Roderic O'Connor
tells of the development of the method, gives the tech-
nique in details and makes a report on 42 operations.
He says the mechanical factors that operate against
successful results in advancement are the constriction
of tissues by sutures or ligatures, the tension on point
of union by the operated muscle and its opponent, the
anatomical formation of the tendons with their
parallel fibers but loosely held together, the stretching
of the operated muscle, causing paresis, and the retrac-
tion of the globe into the orbit. In the operation de-
scribed the points essential to success are: A clear
field of operation with the entire tendon in view, plac-
ing the catgut loop the proper distance from the in-
sertion, and sliding the tendon loops into close contact
and retention in that position by the ligature of fine
catgut. Out of 42 operations in 35 cases there were
but three absolute failures as follows: In one case,
owing to gonococcus infection several days after
operation; in another case on inferior rectus,
owing to the use of too small a catgut, and thus
being an error of judgment excusable when it is re-
membered that it was his first operation on that muscle
and he had no previous experience to guide him ; in the
third case, owing also to too small a catgut. If this
had been a case under cocaine the error of judgment
could have been corrected at once. In future in such
cases he said he would allow the patient to come out of
the anesthetic to see if enough effect had been secured,
and if not, remedy the failure at once.
8. The Effect of Activity on the Histological Struc-
ture of Nerve Cells. — R. A. Kocher says there is the ut-
most divergence of opinion as to the nature of the
changes taking place in nerve cells following activity,
and one who tries to correlate the findings of the dif-
ferent workers in this field is utterly confused. The
chief findings relate to (a) size of cell body and nucleus,
and (b) amount and distribution of chromatic mate-
rial. In conclusion he states that there could be found
no constant difference in the size of the nerve cells or
nuclei resulting from activity. An apparent difference
in size which appeared here and there on counting a
small number of cells was shown on enlarging the series
to be counterbalanced by a similar variation on the part
of the controls. Hence it must be concluded that any
difference in size of cells found was within the limits
of normal variation. Furthermore, in no experiment
did the histological structure of the nerve cell following
activity, even to the point of exhaustion, show any con-
stant deviation from that of the corresponding resting
cells of the controls. Some very sweeping generaliza-
tions have been drawn from the conclusions of previous
workers; namely, that fatigue, fear, shock, and exhaus-
tion may lead to permanent damage and even disinte-
gration of nerve cells. Crile's present theory of sur-
gical shock and of certain aspects of exophthalmic
goiter, based essentially on these assumptions, may be
cited to show to what extremes these deductions have
led.
9. The Nature, Manner of Conveyance, and Means of
Prevention of Infantile Paralysis. — Simon Flexner. (See
Medical Record, July 22, 1916, page 167.)
The Lancet.
July 1. 19K5.
1. The Cavendish Lecture on the Fate of Patients Who Have
Had Stones Removed from the Kidney. John Bland-
Sutton.
2. An Address on the Prevention and Treatment of Cholera.
(An Abstract.) Stafford M. Cox.
3. Remarks on the Cause and Nature of the Changes Which
Occur in Muscle After Nerve Section. J. N. Langley.
4. The Diagnosis of Cancer of the Stomach. James Alex-
ander Lindsay.
5. On a Substitute for Peptone and a Standard Nutrient
Medium for Bacteriological Purposes. Report to the
Medical Research Committee. Sidney W. Cole and
H. Onslow.
6. The Shockless Operation. P. Lockhart-Mummery.
7. Intestinal Toxins and the Circulation. D. T. Barry.
8. Kala-azar in Soldiers Returning from Malta. Gordon
R. Ward.
9. Abdomino-perineal Resection of Rectum bv Coffey's Modi-
fication of the Two Statge Operation. L. C. Panting.
10. Annual Report for 1914 of the Registrar-General. John
F. W. Tatham.
11. A Portable Fracture Box for Use in Field Ambulances
and Field Hospitals. St. J. Dudley Buxton.
254
MEDICAL RECORD.
[Aug. 5, 1916
2. Prevention and Treatment of Cholera.— S. M. Cox,
in an address before a Medical Conference in Malta,
says there is little hope of treating cholera successfully
by a bactericidal serum, when it is fully developed. The
best hope of combating the disease is through prophy-
lactic inoculation. He has treated over 2000 cases since
1907 and has found that at the collapse stage of the
disease a continuous intravenous saline infusion offers
certain advantages. After the infusion of five pints a
reaction rigor sets in. The continuance of the infusion
up to eight or ten pints results in a dilution of the
blood; elevation of blood pressure, with reestablishment
of supressed renal flow; elimination of the endotoxins
from the blood and later from the stools, thus obviating
the onset of febrile reaction stage of cholera, the re-
mainder of the illness being usually apyrexial. The
essential features of the apparatus used, apart from
the heat-regulating apparatus, can be easily impro-
vised. The procedure and requirements for doing this
are detailed.
3. Cause and Nature of the Changes Which Occur in
Muscle After Nerve Section. — J. N. Langley reviews the
theories to account for the fact that section of a nerve
causes atrophic changes in the muscle it supplies. By
experiments in electrical stimulation he has tested the
theory that the maintenance of nutritive conditions of
the muscle depends upon its contracting at intervals,
so that when the normally occurring contractions are
prevented by nerve section the nutritive condition of
the muscle suffers, and it gradually loses weight and
decreases in irritability. If this theory were true a
certain degree of contraction brought about by elec-
trical stimulation would keep the denervated muscles
in a normal condition. The author points out that this
does not occur in clinical practice. He relates his ex-
periments on rabbits from which he concludes that the
changes which take place after nerve sections are not
due to absence of contraction, and the term "'disuse
atrophy" is a misnomer. It therefore becomes neces-
sary to look for some other cause of the atrophic and
degenerative changes. Professor Kato and the writer
noticed that muscles from about the fourth day after
section of their nerves are in a state of continuous fib-
rilation, i.e. the separate muscle fibers contract rhyth-
mically, but with different rhythms; the muscles pre-
sent a shimmering appearance when viewed by light
reflected from their surface. The contractions cause no
movements of the muscle as a whole and are easily
overlooked. As each fiber contracts many times a
minute the total expenditure in a day must be con-
siderable. It is then reasonable to suppose that this
continued activity of the muscle fibers must cause fa-
tigue and that the atrophy of the muscle is due to too
great rather than too little functional activity. The
changes in reaction which occur in denervated muscle
are, in fact, like those caused by fatigue.
1. The Diagnosis of Cancer of the Stomach. — James
Alexander Lindsay presents an analysis of 40 cases of
cancer of the stomach which have occurred in his prac-
tice at the Royal Victoria Hospital. A history of pre-
vious gastric ulcer was obtained in only five cases, or
12% per cent. Only 4 patients gave a history of al-
coholic excess. The symptoms which first attracted the
patient's attention were as follows: Painful dyspepsia,
15 cases, or 37% per cent.; vomiting and pyros
cases, or 22% per cent.; loss of weight. 6 cases, or 15
per cent.; progressive weakness and anemia, 4 cases,
or 10 per cent.; hematemesis, 3 cases, or T'L. per cent.;
anorexia, 2 cases, or 5 per cent.; melena, 1 case, or LML>
per cent. A tumor was detected in 15 cases in this
series. Its value as a signal symptom the writer does
not consider great. Enlargement of the liver was noted
in 9 cases in this series. In discussing the early symp-
toms the author states that loss of appetite may be
early and marked, and may be the first symptom to
attract attention. Oftener it develops gradually. It
is usually a prominent feature in established cases.
The dyspepsia of gastric cancer is attended by dis-
comfort and pain, sense of fullness in the epigastrium,
nausea, sickness, eructations of offensive gases, and in
most cases vomiting. These symptoms are at first re-
lated to the ingestion of food, but at a later stage they
become more or less constant. The differentiation of
gastric cancer from chronic gastritis, non-malignant
gastric ulcer, non-malignant pyloric growth, pernicious
anemia, and phthisis are discussed.
5. On a Substitute for Peptone and a Standard Nu-
trient Medium for Bacteriological Purposes. — Sidney W.
Cole and H. Onslow have been conducting experiments
for the purpose of finding a substitute for the peptones
the supply of which has been cut off from Germany dur-
ing the war. In the process of this work they have
found a sharp criterion for a standard nutrient medium.
If a medium containing a fermentable carbohydrate be
sown with a specific organism a definite final hydro-
gen-ion concentration is reached. This is dependent to
a remarkable degree upon the constitution of the fluid,
a very slight change in which may cause a consider-
able variation in acidity. This effect is most clearly
seen if more than one organism be employed. In fact,
it was often noticed that the degrees of acidity produced
by two organisms might actually be inverted. With
these views and facts in mind the authors made experi-
ments with various media containing an abundant sup-
ply of these amino-acids. The growth on such media
of a large number of pathogenic organisms is so rapid
compared with their growth on the recognized standard
media that the method of preparing this media is pre-
sented in the hope that it will be found a cheap and
effective substitute for peptone and nutrient broths.
The authors also describe a simple method of standard-
izing the reaction of media, based on Walpole's prin-
ciple of eliminating the color of the broth by use of a
special tintometer. They state that the supply of free
amino-acid is best obtained by the tryptic digestion of
casein, and to secure uniform results a pancreatic ex-
tract is used, prepared by a method which follows a
formula given by Mellanby and Woolley. The details
of its preparation are presented.
7. Intestinal Toxins and the Circulation. — D. T.
Barry has been following up the investigation of the
action of excretory toxins on the neuromuscular mecha-
nism of the heart and has tried to ascertain approxi-
mately the level at which the alimentary toxin begins
to be formed. As in the previous experiments the
toad's heart was perfused through the inferior vena
cava, using the intestinal contents, which were mixed
with Ringer's solution in a mortar, and the solution
rapidly filtered with the aid of a water pump. Extracts
were used from the upper, middle, and lower third of
the small intestine. The effects on the blood pressure
and heart beat of intravenous injections of the intes
tinal contents of the animals themselves was also in-
vestigated. These experiments indicate that there is
little doubt that substances having a deleterious action
on the heart musculature and nerves are formed both
in the small and large intestine, even under apparently
normal circumstances. It is quite conceivable that such
products, whether of bacterial or ferment action, may
on occasion exist in excessive quantity and find access
by absorption to the circulation ; or that certain con-
ditions may determine undue absorption when they
exist in ordinary amounts. Peptone has a depressing
effect on the blood pressure, but practically no peptone
Aug. 5, 1916]
MEDICAL RECORD.
255
is shown to exist in those regions of the gut where the
toxicity is most marked. If the contents of the lower
end of the ileum are acidified and boiled, then filtered,
and to the filtrate alcohol or tannic acid is added, no
appreciable precipitate is formed. The writer thinks it
is reasonable to assume that prolonged absorption of
even minute quantities of toxins would produce effects
on the mammalian heart similar to those immediately
produced in the toad's heart by comparatively strong
concentration; that many conditions of irregularity and
block in the human heart in Stokes-Adams and other
affections seem to fall into line with the action of these
substances, and that a systematic course of treatment
of the alimentary canal antiseptically and otherwise
should be of the greatest service in some of these cases.
British Medical Journal.
Julii 1, 191fi.
1. Notes on Military Orthopedics. V. Transplantation of
Bone, and Some Uses of the Bone Graft. Robert Jones.
2 On the Life-History of Ascaris Lumbricoides. P. H.
Stewart.
3. Disinfection of the Nasopharynx of Meningococcus Car-
riers by Means of Air Saturated with a Solution of
Disinfectant. M. H. Gordon.
4. Paralysis of the Intestine After Resection for Gunshot In-
juries. Owen Richards and John Fraser, with Note by
Cuthbert Wallace.
5. Postoperative Paralytic Ileus. H. T. Hicks.
6. The Treatment of Backward Displacements of the Uterus.
(Concluded.) Frederick J. McCann.
1. Transplantation of Bone, and Some Uses of the
Bone Graft. — Robert Jones, in concluding an account of
his experience in the grafting of bone says that what-
ever particular theory of osteogenesis may be the true
one, he has found the following points valuable in prac-
tice: The area of the graft must be kept scrupulously
aseptic, and free from unnecessary blood clot. Ade-
quate blood supply is necessary to the growth of the
graft. The graft must be placed in close apposition to
raw surfaces of the bone with which it is to unite. The
whole region must be kept fixed for a long period for
undisturbed organization to take place. The bone p-^nft
should be autogenous, and it is better that it should
include both periosteum and medulla wherever this is
possible, for both these aspects of the bone afford
facilities for the growth of new blood vessels. Surgeons
should have patience, for union is often delayed, and
hasty conclusions that union is not going to take place,
and consequent relaxation of strict fixation of the part,
may convert a case of delayed union into one of non-
union. After any procedure of bonegrafting it is essen-
tial to fix the limb absolutely to let new vessels grow
undisturbed by chance movements, for the idea of the
operation is that all the transplanted bits of bone shall
become vascularized. As a general rule, the limb should
be kept fixed and undisturbed for at least twice the
time necessary for union of the same bone in an ordi-
nary simple fracture since there is no definite time
within which a fracture will unite. It is difficult to
formulate an exact rule as to when a bone grafting
operation should be performed, for the danger of re-
crudescent sepsis seems never to be absent. It is the
essayist's habit to wait for at least six months after a
sinus is closed, during which time and for a variable
period afterwards efforts should be made to improve
the general nutrition of the limb. Early operation is
to be discouraged from every point of view, and failure
to observe this fact has resulted in many a tragedy.
2. On the Life History of Ascaris Lumbricoides. — F.
H. Stewart describes his experiments on pigs and rats
which apparently show that, contrary to the generally
accepted theory, the life history of Ascaris lumbri-
coides presents an alternation of hosts. Eggs develop
mature embryos in the outer world in a damp atmos-
phere, preferably at a temperature of 25° to 30 C
When ripe eggs reach the alimentary canal of the rat
or mouse they hatch. The larva? liberated enter the
bodies of their host, a few only escaping in the feces.
Between four and six days after infection they are
found in the blood vessels of the lungs, liver, and
spleen. The host is seriously ill with symptoms of
pneumonia. On the sixth day they have passed from
the blood vessels into the air vesicles of the lung caus-
ing hemorrhage into them. On the tenth day they are
found only in the vesicles of the lung and in the
bronchi. If the disease does not prove fatal the host
recovers on the eleventh or twelfth day. On the six-
teenth day the host is free from the parasite. It is
obvious that the transfer of the parasite from the
bronchi of the rat or mouse to the intestine of man
and of the pig could be readily effected. The writer
concludes that the further course of the life history of
this parasite requires additional study for its elucida-
tion.
3. Disinfection of the Nasopharynx of Meningococ-
cus Carriers. — M. H. Gordon has made observations to
ascertain whether the air of a room when saturated
with water vapor containing chloramine exerts bacte-
ricidal properties, and if so to what extent such air can
be tolerated by human beings. He describes the pro-
cedure which he has followed in a number of experi-
ments which he finds warrant the following conclu-
sions: 1. The air of an ordinary room, when brought to
the point of saturation by means of a steam spray con-
taining 2 per cent, of chloramine, acquires pro-
nounced bactericidal properties for Staphylococcus epi-
dermidis. 2. Such air can be tolerated by human be-
ings for a period varying from six to twenty minutes
without marked discomfort and without harm.
3. When inhaled through the nose, this air succeeds
temporarily in destroying the meningococcus in the
nasopharynx of carriers. Its sphere of usefulness in
this and other respects is being more closely investi-
gated. In view of the simplicity and convenience of
the method and its obvious suitability for the purpose
of dealing with a large number of carriers at a time,
the above results are encouraging.
4. Paralysis of the Intestine After Resection for
Gunshot Injuries.— Owen Richards and John Fraser ob-
serve that this complication seems to occur only in the
small intestine, the segments of the intestine above the
union becoming distended, while the segment below re-
mains contracted. The writers report several cases
from which they conclude that in cases operated on
is probably mainly due to some interference with the
within a short time after the receipt of the injury this
nervous mechanism, caused by the injury itself and
the resultant shock, and increased by other causes — for
example, local peritonitis. In cases operated on after
a considerable interval, a further cause is that con-
tinued obstruction, and consequent septic absorption,
render the bowel above incapable of rapid recovery.
A case in which this complication has occurred may
possibly be saved by subsequent short-circuiting of the
affected coil. Cuthbert Wallace comments on two of
the cases reported in which resection and circular en-
terorrhaphy were performed, one in the lower ileum
and one in the upper jejunum. A short circuit operation
was performed in both to relieve a distention which
was limited to the small gut above the line of the cir-
cular enterorrhaphy. The cause of the obstruction was
a paralysis of the bowel below the site of the operation,
which was not due to septic peritonitis but to some ac-
quired defect. It would be advisable in these cases to
make the anastomotic opening at a considerable dis-
tance from the lesion, or to short circuit into the trans-
verse colon, as suggested by Sampson and Handley.
256
MEDICAL RECORD.
[Aug. 5, 1916
The International Medical Annual. A Year Book
of Treatment and Practitioner's Index. 1916.
Thirty-fourth Year. Price, $4 net. New York:
William Wood and Company.
The International Medical Annual has had a long and
honorable history as a publication of service to all
English-speaking practitioners. Among its contributors
this year are two New York men, Lewis A. Conner,
who has written on Pulmonary Diseases, and J. Ramsay
Hunt, who presents the Diseases of the Nervous Sys-
tem. It is but natural and right that a very important
portion of this issue should be given over to the con-
sideration of naval and military surgery, and this has
been done very thoroughly. It should not be thought,
however, that any of the other branches of medicine
have on this account been neglected. This number is
as interesting and instructive and as complete as any
of its predecessors and will serve admirably to main-
tain the position of the series in medical literature.
No other publication quite fills the position of the
Annual and we are sure that no other will ever succeed
in doing so.
A Treatise on the Principles and Practice of Med-
icine. By Arthur R. Edwards, M.D., Professor of
the Principles and Practice of Medicine and Clinical
Medicine and Dean of the Northwestern University
Medical School, Chicago. Third edition, thoroughly
revised. Price, $6. Philadelphia and New York: Lea
and Febiger, 1916.
While one-volume treatises on the practice of medicine
must inevitably have many faults they also may
possess definite advantages, and that there will always
be a demand for them is certain. The present example
of the class is distinctly meritorious, and that it has
found favor with many readers is shown by the fact
that it is in its third edition. Features of especial in-
terest are the very many diagnostic tables, in which
conditions sometimes difficult to differentiate are con-
trasted, and the sections on treatment which are much
more satisfactory than is usually the case in similar
works. The text is modern in its presentation of most
subjects, and though some readers may be disappointed
at not finding such topics as the significance of the
nitrogen partition in the blood, the fasting treatment of
diabetes, or the present conceptions of acidosis fully
discussed, such matter is hardly to be expected in a
book of this scope. It is a pleasure to commend it as
most excellent of its kind.
International Clinics. A Quarterly of Illustrated
Clinical Lectures and Especially Prepared Original
Articles on Treatment, Medicine, Surgery, etc.
Edited by H. R. M. Landis, M.D. Vol. I, Twenty-
sixth series, 1916. Price, $2. Philadelphia and Lon-
don: J. B. Lippincott Company.
This number of the "Clinics" contains seventeen articles
on Treatment, Medicine, Neurology, Public Health,
Pathology, Gynecology and Surgery. In an article on
chorea by E. E. and W. H. Mayer the treatment by
the intravenous administration of phenol is recom-
mended and seven successful cases are reported. This
treatment is used apparently because of the authors'
belief that chorea is an infection and that the phenol
acts as a disinfectant. Whether there is any analogy
between this and the well-known Baccelli treatment of
tetanus cannot be said, but it is to be hoped that other
observers will be able to confirm their results. They
have adopted what is apparently an unnecessarily
scornful attitude toward the bacteriological work which
has been done on the streptococcus group of infections.
Satterthwaite's article on Drug Therapy in Cardiovas-
cular Diseases embodies many ideas in regard to digi-
talis which are at variance with the views held gen-
erally to-day. There are several other articles of in-
terest which make this number conspicuous. The
"Clinics" starts out well under its new editor and there
is every indication that its present success will follow
it in the future.
A Textbook of Nervous Diseases for Students and
Practising Physicians, in Thirty Lectures. By
Robert Bing, Dozent for Neurology at the Univer-
sity of Basel. Only Authorized Translation by
Charles L. Allen, M.D., Los Angeles, Cal.; with
111 illustrations in the text. Price, $5. New York:
Rebman Company.
Nervous diseases for many reasons bulk large now-
adays. The manner in which we live has the tendency
not only to keep our nerves at a high tension, but to
find out the weak spots in the armor of our nervous
system. Moreover, neurology has now been brought to
a more or less scientific basis and no medical student's
education is considered complete unless he knows some-
thing of this branch of medical knowledge. The great
teachers of neurology have been and are inhabitants
of Continental Europe and among these Robert Bing,
whose book is being noticed, is by no means the least
distinguished. The subject matter in this work is pre-
sented in the form of lectures, which have been system-
atically arranged for publication in book form. In the
arrangement of the material, the customary topograph-
ical and pathologico-anatomical classification has been
subordinated almost entirely to the etiological and
pathologico-physiological. This was done in order to
condense the work to a suitable size. The author states
in his preface that he has refrained from forcing to the
front the views of any particular school, but has en-
deavored rather to exercise a certain eclecticism which
is justly considered as the scientific signature of
Switzerland, in which the German and the Latin man-
ner of thought and investigation blend and reinforce
one another in harmonious fashion. This work may be
regarded as a thoroughly useful, practical, up-to-date
book, and as such of great value to students and prac-
titioners.
Painless Childbirth, Eutocia and Nitrous Oxid-
Oxycen Analgesia. By Carl Henry Davis, A.B.,
M.D. Associate in Obstetrics and Gynecology, Rush
Medical College in affiliation with the University of
Chicago; Assistant Attending Obstetrician and Gyne-
cologist to the Presbyterian Hospital, Chicago. Price,
$1. Chicago: Forbes & Co., 1916.
The recent lay agitation in regard to Twilight Sleep
has called forth numerous articles on analgesia in
obstetric practice. The first articles dealt with the
value or difficulties of scopolamine and morphine admin-
istration. Later, reports from several hospitals ap-
peared, where nitrous oxide and oxygen had been used
during labor with excellent results. Dr. Davis' book
discusses these two methods of obtaining painless child-
birth. After reviewing the introduction of anesthetics
into obstetrics, he takes up the pharmacology and toxi-
cology of the drugs whose use he afterward considers —
scopolamine and morphine, nitrous oxide and oxygen.
The advantages of nitrous oxide and oxygen analgesia
are given in a report of results in 104 cases at the
Presbyterian Hospital, Chicago. Dr. Davis found that
labor was shorter, tears were fewer, the babies lost less
weight, and the women were able to leave the hospital
earlier. Cumbersome apparatus will largely limit the
use of this method in private practice, except among
the wealthy, but this will be only an added argument
for hospital care of obstetric cases.
Instinct and Intelligence. By N. C. Macnamara,
F.R.C.S. Price, $2.00. London: Henry Frowde,
Oxford University Press. Hodder & Stoughton. New
York: Oxford University Press, American Branch,
1915.
Macnamara in his preface says, "In the following pages
we have endeavored to give an outline of the evidence,
and the reasons upon which we rely to prove that the
instinctive behavior of human beings depends on work
performed by definite parts of the brain ; consequently,
education has not only to deal with the training of
something immaterial which we call mind or conscious-
ness, but has first and foremost to deal with the proper
development of the nervous substance of that part of
the brain the orderly working of which is essential for
the occurrence of instinctive and intellectual phenom-
ena." He traces the development of the nervous sys-
tem from atoms, molecules, and energy in amebas, in-
sects, amphioxus, apes, idiots and finally intellectual
beings. He shows how instinctive response to stimuli
becomes more elaborate with higher forms, and how
with the development of the cerebrum, intelligence, de-
fending an association of ideas, somes in. Then, he
says, "If the evidence referred to in this and the pre-
ceding chapters is trustworthy, and the hypotheses
founded on it reasonable, it follows that any effort
made to develop the moral and intellectual capacities of
young people should be directed towards the efficient
training and nurture of the nervous substance upon
which this manifestation of these faculties depend; to
be more precise, our efforts should be directed towards
developing the nervous instinctive basic substance of
the basal ganglia, and of the association areas of the
neopallium."
Aug. 5, 1916]
MEDICAL RECORD.
257
gwietg fifrjiflrtB.
AMERICAN NEUROLOGICAL ASSOCIATION.
Forty-second Annual Meeting, Held at Washington,
D. C, May 8-10, 1916.
The President, Dr. Lewellys F. Barker of Balti-
more, in the Chair.
(Concluded from page 216)
Obstetrical Paralysis. — Drs. John Jenks Thomas and
James Warren Sever of Boston prepared this paper,
which was presented by Dr. Thomas, who said that there
was no evidence from their experimental work or clin-
ical observation to support the theories of Lange and
T. Turner Thomas that the primary cause of obstet-
rical paralysis lay in an injury of the capsule of the
shoulder joint or a dislocation, with secondary dam-
age to the nerve trunks. This theory got no support
from experimental work, and in addition did not ac-
count for the distribution of the paresis of muscles
generally seen, such as the spinati, supplied by the
suprascapular nerves, nor the frequent involvement of
the sympathetic fibers going to the pupil and eyelid,
often seen in cases of paralysis of the whole arm, and
of the lower arm group. The partial dislocation of the
head of the humerus backward, the bending down of the
tip of the acromion, and the forward dislocation of the
upper end of the radius were all secondary changes, due
to the formation of contractures in the stronger or un-
affected muscles. Dislocations of the shoulder, separa-
tion of the epiphyseal end of the humerus, or fractures
of its shaft, like fractures of the clavicle, were infre-
quent accidents, and, while they might be unaccom-
panied by an injury of the plexus, more frequently
they were complicating injuries which rarely caused
permanent difficulties. The treatment to be effective
must be adapted to the conditions in the individual
case. Treatment by massage of the paralyzed muscles
and development of them as they recover through edu-
cational exercises were necessary in all cases where the
plexus had been injured to more than a very slight ex-
tent. Resection of the plexus and transplantation of
torn nerve roots of the plexus were to be reserved for
cases which did not show evidence of recovery of func-
tion in definite groups of muscles within a reasonable
time, generally not less than six months, though fre-
quently this time needed to be extended to a year, a
year and a half, or occasionally even longer. The late
complicating deformities about the shoulder and elbow-
joints should be treated on orthopedic principles. The
writers presented a new operation for this deformity at
the shoulder joint by division of the tendon of the sub-
scapular muscles outside the joint. These cases needed
careful after-treatment by passive movement massage
and educational exercises to bring about free and natu-
ral movement in the joints and use of the extremity.
Dr. Charles K. Mills of Philadelphia said that he
had seen many cases of obstetrical paralysis and had
also published a small amount of matter with regard
to traumatic brachial palsy. One thing seemed to him
to have been omitted entirely, or else he did not listen
with sufficient attention. He believed that these ob-
stetrical palsies were due in a large percentage of the
cases not to the direct lesion of the brachial plexus or
of the shoulder, although these were present, but that
they were due to an avulsion of the nerve roots of the
plexus. It seemed to him this should be understood.
He worked sometimes with T. Turner Thomas, and they
had had this matter up in connection with one of the
cases of injury to the shoulder and plexus, with regard
to which he contributed a paper to one of the journals.
However, it did not take away from the value of these
observations and these experimentations for relief.
Traction on the plexus, which frayed the nerves, always
occurred: the avulsion of the nerve roots or a certain
part of the nerve roots of the plexus, and therefore a
total and permanent destruction which could never be
very fully or largely relieved except by adaptation or
compensatory operation.
Dr. Taylor of Boston said that there were two or
three points he would like to make in regard to brachial
palsy injuries; in the first place, in regard to the eti-
ology. In a paper which he had presented to this so-
ciety in Baltimore it had been stated that there were at
least twenty experimental productions of this lesion on
new-born babes who had died a few hours after birth.
In every one extraspinal. In sixty operative cases, in
only 10 per cent, was it fair to presume that there had
been an intraspinal lesion. In a case which had not
been published he was called upon to deliver a woman
with a badly deformed pelvis. It was necessary to do
version, in which the extraction was a breech extrac-
tion, and, feeling that this type of lesion was exceed-
ingly apt to occur, he put most of the traction on the
lower extremities of the child until they were damaged
so that he did not dare continue; then the pressure was
exerted over the shoulder and a lesion of the brachial
plexus occurred where he had stated before the delivery
of the child's head that such a lesion would occur.
After delivery he found it had double hemorrhage from
both hemispheres. If one explored a child in the early
weeks of its career and one did not find damage to the
plexus requiring surgical repair, he had done nothing
more than make an incision 2 inches in the skin, sub-
cutaneous fat, and fascia. That gave one an oppor-
tunity to observe the brachial plexus. On the other
hand, if one found a serious surgical damage to that
plexus, then he could do the repair at the time most
favorable to the child and the risk one had run was
justified by the improvement that took place.
Dr. John Jenks Thomas of Boston said that he
thought Dr. Taylor had given us fully what Dr. Mills
had alluded to. We know that the lesion in these cases
was not a constant one. It varied in severity and in the
situation of the injury. Occasionally avulsion of nerve
roots was seen. Some of their cases had shown separa-
tion between the nerves of the plexus. He could not
agree with Dr. Taylor on the advisabilty of early ex-
ploratory operation in all cases. Certainly he thought
that should never be done in cases where at the time,
soon after birth, we found the injury limited to the
upper arm group of muscles. These cases practically
all showed partial recovery after operation. The ques-
tion was somewhat different when we came to total arm
paralysis. He thought their work had given them a
clue as to why this was so. In the upper arm paralysis,
although the nerves were stretched, there was fraying
out of the fibers and hemorrhage within the sheath ;
there was no complete separation or tear of the plexus.
The only complete injury we found then was the tearing
off of the suprascapular nerve. To suture the supra-
scapular nerve, which was very small in the infant, he
thought was practically impossible. His plea was that
we should make our treatments suit the individual case.
Further Contribution to the Treatment of Syphilis
of the Nervous System.— Drs. B. Sachs, I. Strauss,
and D. J. Kaliski of New York City prepared this
paper, which was read by Dr. Sachs. Two years ago
they reported 120 cases; to-day they reported 100 other
cases, twenty treated by the intraspinous method, the
others by the intravenous method. Omitting all the un-
necessary detail, they were forced to conclude that the
intravenous method was the one that they preferred by
all odds to the intraspinous method, for the reason that
the intravenous method had given absolutely satisfac-
tory results and by the intraspinous method they had
not obtained a single result that they could not have
obtained by the intravenous method. The intraspinous
method was attended by all sorts of disagreeable com-
plications and discomfort of the patient, which increased
the risk enormously. They had evolved a system of in-
tensified intravenous treatment which was even more
intensive than the form of treatment originally sug-
gested by Dreifus. In some of the cases intravenous
treatment was given by small doses daily, sometimes for
five or ten days. Then a period of rest of four or five
days, or a week; then followed a series of intensive
mercurial treatments. The intravenous treatment of
salvarsan should be observed most carefully, with spe-
cial reference to the effect on the kidneys.
Dr. Joseph Collins of New York said that he was
now in the position of holding no brief for the Wasser-
mann reaction per se. He had no faith in it compared
with other methods of diagnosis of syphilis. The Was-
sermann reaction meant nothing more than that we
should be suspicious of syphilis. If a person came in to
him and had only a plus Wassermann, he would say,
"You marry." That was a different state of mind from
two years ago. He believed that the Wassermann test
has been far overrated in its value to the clinician.
A few months ago, when this matter had been under
discussion before the New York Academy of Medicine
and he had made the statement that he was quite un-
willing to pin much faith to the Wassermann reaction
unless he found some chang-es of the biological reac-
tions, all the speakers had said in closing that they were
sure he was mistaken. He agreed with Dr. Sachs that
the intravenous method of administering salvarsan or
258
MEDICAL RECORD.
[Aug. 5, 1916
arsenobenzol was preferable to the intraspinal. During
the last two years Dr. Craig and mmself had devoted
themselves to tne use of salvarsan intraspinousiy. They
were convinced this had no advantage over the intra-
venous method.
Dr. C. Eugene Riggs of St. Paul, Minn., said that
during the last two years he had closely watched the
effects of the intravenous as compared with the intra-
spinous method, and his experience had not been in
harmony with that of Dr. Sachs. In between 400 and
500 cases he had had no unpleasant experience with the
intraspinous method aside from one case of cerebro-
spinal meningitis, which had made a good recovery.
Dr. E. E. Southard of Boston said that in respect to
Dr. Collins' remarks in reference to marriage he would
say that if anyone came to him with a doubtful Wasser-
mann reaction he should regard that his desire to marry
was a psychopathic one, and he should at once counsel
lumbar puncture. He would rely upon the results then.
He would have repeated Wassermann tests. He re-
garded it as a medical crime for a person with a posi-
tive Wassermann and any mental symptoms not to re-
ceive a lumbar puncture.
Dr. B. Sachs of New York said that in reference to
what Dr. Southard had said, he thought he was in gen-
eral agreement with him, although he did not think
every candidate for marriage should be penalized by a
lumbar puncture. In order not to be misunderstood, he
would say that in all of their work they had endeavored
to obtain negative reactions as regards the cerebro-
spinal fluid. In regard to the Wassermann reaction of
the blood, they allowed that one condition to persist
without insisting that the antisyphilitic treatment must
be coninued to the extreme until a change in the Was-
sermann reaction of the blood was effected. As re-
garded the intraspinous form of therapy, they had a
right to speak authoritatively so that the general prac-
titioner should not be made to feel that here was the
great solution to the question of antisyphilitic treatment.
The attention of the general practitioner should be di-
rected to the far greater dangers of the intraspinous
as compared to the intravenous method, and the fact
that it accomplished nothing that we could not accom-
plish by the far safer intravenous method.
Dr. I. Strauss of New York said that to show that in
the last two years there had been a change in opinion
and that we were not altogether wrong in our stand
he would call attention to the fact that the very indi-
viduals who used the salvarsanized serum had turned
to what they called the method of salvarsan plus salvar-
sanized serum. In other words, finding the salvarsan-
ized serum contained no antibody, they had added this
amount of salvarsan, which was practically 1 mgm., to
their fluid to obtain their results. Regarding the dan-
gers of this intraspinous method, there were two cases
in his experience which showed that this method was
not so harmless as generally portrayed. Unfortunately,
he thought medical men were a little careless in report-
ing the sad results of therapy.
Types of Neurological Cases Seen at a Base Hospital.
— Dr. John Jenks Thomas of Boston read this paper,
saying that injuries of the peripheral nerves were fre-
quent, but many that appeared total were, on careful
examination, found to be partial. Immediate interfer-
ence except for the suture of obviously severed nerves
and to prevent their retraction was seldom advisable,
as all wounds were septic. When an operation was
necessary it should be done after the wound was healed,
and followed the usual lines of those for other injuries
of peripheral nerves. The spinal cord might be in-
jured directly by fragments of bone or muscle, but not
infrequently also indirectly through concussion, pro-
ducing hematomychia. At first almost all these case*
showed complete sensory and motor paralysis, and the
true extent of the damage could be determined only
after a time. Injuries of the brain from bullet wounds
were fairly frequent at base hospitals, and many of
these did surprisingly well. Primary operation except
for checking hemorrhage should be avoided. In a good
many instances with bullet wounds they found tan-
gental wounds because of the high velocity, but in these.
even though they found no extensive fragmentation of
the inner table of the skull, the bullet very frequently
lacerated the dura as it channeled the bone. Therefore,
all of these bullet wounds of the head which were so
located that an injury of the brain might have oc-
curred should be explored. Functional disturbances of
the nervous system were seen quite frequently at the
base hospital-. Curiously enough, these functional case-
seemed to develop most often, at least during the first
few weeks after being incapacitated, in the men who
had not been wounded, being mostly in those who had
been thrown down by the concussion produced by the
bursting of high explosive shells of large caliber or
who had been buried in the dirt, as when a trench or
dugout had been blown in by such shells.
Syringoencephalomyelia; Uhe Function of the Pyram-
idal Tract. — Dr. William G. Spiller of Philadelphia
read this paper, in which he stated that it had been
asserted that syringomyelia did not extend above the
lower part of the pons and no term was employed in
medical literature to indicate the implication of the
brain in the syringomyelic process except syringobulbia,
a term applicable only to the lower part of the brain.
He showed in 190(5 that the syringomyelic process might
extend upward through the brain into the uppermost
part of the internal capsule and almost into the lateral
ventricle. He now proposed the terms syringoencephalia
and syringoencephalomyelia for those conditions con-
fined to the brain or implicating the brain as well as
the spinal cord and of the same character as syringomy-
elia. Syringomyelia was a term applied to cavity for-
mation in the spinal cord. The methods in which these
cavities were formed vary. A common way was by de-
fective closing in of the posterior columns, leaving a
space which later enlarged. A similar defective closing
in might occur in the brain. The aqueduct of Sylvius
at one period of embryonic life was relatively large.
In 1902 he reported a case of hydrocephalus caused by
almost complete obliteration of the aqueduct by ex-
cessive closing in, and in this report he mentioned that
the closure of the aqueduct resembled in the changes of
tissue produced by it the condition often seen in the
region of the central canal of the spinal cord, leaving
nests of ependymal cells about it. He had now studied
the aqueduct in microscopical sections from thirty-
eight cases taken at random, and had found that the
character of this opening varied greatly. It might have
a long, narrow slit at its lower part lined by ependymal
cells, and frequently had nests of ependymal cells about
it. Possibly from these, as in the cord, tumors might
have their origin later in life. He had recently studied
a case in which the fissure existing in the embryo be-
tween the optic thalamus and the corpus striatum had
failed to close in entirely to form the opto-striate notch
and had left a fissure extending from the lateral ven-
tricle into the brain, destroying the anterior half of the
posterior limb of the internal capsule. This fissure was
surrounded by thickened neuroglia and some nests of
ependymal cells. The upper extremity of the opposite
side had been moved freely during life, except that iso
lated movements of the fingrs had been impossible bu*
no paralysis of the face had been detected, and yet the
fibers supposed to furnish motor power to the upper
extremity and face had been destroyed.
A Consideration of Some Selected Problems in a
Year's Neuro-Surgical Service. — Dr. E. Sachs and Dr.
Sidney I. Schwab of St. Louis prepared this paper,
which was read by Dr. Sachs, who said that it was im-
portant to study neuro-suigical cases from two point*:
of view, the neurological, which placed its emphasis on
the production of symptoms in relation to a definitely
placed lesion, and the surgical, which emphasized the
question of the adaptability of a given lesion to sur-
gical procedure. It was this shifting of emphasis at
the hands of two differently trained observers which
they believed would eventually satisfy the broadest de-
mand of neuro-surgical cases. Each case was therefore
studied independently by the neurologist and surgeon ;
the resulting data were gathered and discussed before
it finally became either a strictly surgical problem or
was discarded into the neurological class with no sur-
gical outlook. Among the many problems that had
arisen during the past year the following seven were
selected for presentation and comment: 1. The re-
liability of the Barany observations as tested on stimu-
lation of the cerebellum in a conscious patient. 2. Sig-
nificance of albuminuria in intracranial pressure.
3. Multiple lesions. -1. The place of lumbar puncture
in intracranial pressure. 5. Pseudo-optic neuritis.
R. Tumors of the Gasserian ganglion in sinus condi-
tions. 7. Disappearance of cord tumor symptoms after
lumbar puncture.
Acroparesthesia. — Dr. James J. Putnam of Boston
read this paper, stating that the object of his paper was
to seek a more adequate explanation of the nature and
pathogenesis of the affection which Schultze had de-
nominated acroparesthesia (recurrent numbness of the
hands, etc.). the first thorough description of which had
been given by the speaker in 1880 on the basis of the
Aug. 5, 1916]
MEDICAL RFXORD.
259
analysis of thirty cases. He called attention particu-
larly to the following points: 1. The tendency of the
numbness to recur toward the latter part of the night
and at first to be present only then. 2. The slight
changes of coloring or consistence of the fingers. 3. The
frequent changes of sensibility during the attacks.
4. The presence (as a predisposing cause?) of other
neurotic tendencies. 5. The relation of the symptoms
to the use of the hands, or their position, or to slight
stimulation of the skin with hot or cold water, and in
other ways. The best view to take of such a neurosis
as this, and perhaps of all specific neuroses, was ( 1 i
that they pointed to a failure of the coordinated ad-
justments of the nervous system (relation to the neu-
rotic temperament as a whole, etc.) ; (2) that they
pointed to an attempt on the part of the organism to
assert itself through some new dynamic and quasi-
coordinatory effort as if seeking for some new equi-
librium. But the new coordinatory equilibrium thus
established was always a relatively poor one (substitu-
tion of vascular cramp for coordinated contraction and
dilatation, etc.). The aim of the treatment should be,
first, to restore the tone of the nervous system; second,
to eliminate emotional complexion at variance with
health ; third, to remove accessory causes, such as tox-
emias (note the arthritic tendencies and digestive
troubles present in many cases) ; fourth, to remove
specific excitations, such as exposure of the hands to
hot and cold water ; fifth, to adopt means calculated to
encourage adequate vascular reflexes (exercises of spe-
cific sorts) . Quinine is often useful, especially for short
periods and in large doses, perhaps acting as a vascular
stimulant. Local heat and electricity also had a place,
and the same might be said of occupational training of
the patient.
Wednesday, May 10 — Third Day.
Intramedullary Tumor of Cervical Cord. Probable
Diagnosis. Removal in Two-Stage Operation: Gradual
Improvement. — Drs. F. X. Dercum and J. CHALMERS
DaCosta of Philadelphia prepared this paper in
which they stated that they placed on record a case
which had to do especially with the recognition and
interpretation of pain of spinal origin. The signifi-
cance of such pain was frequently overlooked. At times
it was incorrectly ascribed to a visceral origin and had
led to futile abdominal and other operations. The case
was interesting because of the relatively rapid and
extensive development of symptoms, suggesting a mye-
litis rather than a local lesion, because of the sero-
logical findings and finally because of the diagnosis of
tumor and its successful localization and removal. The
first symptoms of illness appeared in the latter part
of October, 1913, namely, some vague pain or numb-
ness in the left shoulder which did not hurt when moved
or handled. Numbness gradually made its appearance
in the left arm and later there was distinct weakness
of the left arm. When the patient coughed or jarred
himself, he had a sensation as of a "thrill going through
his body." Soon numbness, weakness and pain ap-
peared in the right arm. About a month later there
was weakness in both legs and in the bladder. Walk-
ing became difficult and soon there was loss of sensa-
tion and paralysis in both legs. When admitted Janu-
ary 27, 1916, the patient was completely paraplegic
and there was absolute loss of sensation of all forms
as far as the level of the second rib. A slight plus
patellar reflex was elicited upon both sides. No ankle
clonus, but Babinski upon both sides. Marked general
wasting of the hands, forearms, arms and shoulders,
as well as of the trunk and of the lower extremities
was present. The lumbricales, both the thenar and
hypothenar eminences, and to a smaller extent the in-
terossei were wasted in both hands. The pupils
were equal, average in size and reacted to light. The
Wassermann reaction was negative. On February 21,
1916, an exploratory operation was undertaken. In-
cision over the fourth, fifth, sixth, seventh cervical and
first dorsal vertebra; and the processes and lamina of
the seventh cervical and first dorsal vertebra; removed.
Immediate on opening the dura a dark, bluish-red mass
began to extrude. It was evident that dissection would
damage the cord and it was decided to follow Elsberg's
plan of allowing the tumor to extrude. The patient
reacted well from the operation and was comfortable.
After five days the wound was reopened and the cord
was again exposed. The edges of the incision had be-
come considerably separated, the tumor had extruded" in
part, and it was now gently coaxed or teased from its
bed m the cord with the aid of small pledgets of gauze.
The tumor was exceedingly friable and soft and came
away only in small fragments. The subsequent sur-
gical course was without incident. Within twenty-four
hours after the operation, the patient became cog-
nizant when the left leg or foot were touched. He
felt the touch as something hot or burning but he could
not localize the impression save to say that it was the
left limb which was touched. Within a few days the
hypesthesia of the hands and arms grew markedly less
and soon disappeared. This was followed by a rapid
gain in power over the movements of the fingers, hands,
wrists, forearms and indeed of the upper extremities
generally. The improvement in the right upper ex-
tremity was somewhat more rapid than in the left.
Twelve days after operation the patient was able to
distinctly abduct the left thigh. Once or twice slight
movements were noticed in the toes. Patient was able
to flex and abduct the thighs, slightly, but the improve-
ment in this respect had not kept pace with the im-
provement in sensation. When examined on April 27,
1916, his improvement as regards the sensory findings
were less manifest than at the previous examination.
In other respects the improvement had continued,
though it had been slow.
The Rising Tide of Disabilities Following Trauma
and Their Relation to Our Compensation Laws. — Dr.
B. Sachs of New York read this paper, saying that in
ten cases there was only one case in which he could say
that there was a permanent disability following in-
jury. That was a distinct brachial plexus neuritis
which had not been recognized. Thus far he had not
seen anything in this country comparable to the trau-
matic neuritis, as it had been established by Oppen-
heim many years ago. In the main, we as neurologists,
should insist that the evidence should point to organic
changes of the nervous system, central or peripheral,
and that we should limit so far as possible the purely
psychic element. Much more important than estab-
lishing the fact that there was or was not an organic
change in the nervous system is the ruling out of or-
ganic nervous symptoms. A man who had a distinct
spondylitis as the result of trauma a year before added
to his regular symptoms any number of disabilities
which could not possibly fit into the general conception
of a spondylitis or traumatic myelitis in association
with spondylitis. Simulation and malingering were very
infrequent. In this country the attempt at simulation
is not made as in Europe. There was a peculiar
mental attitude in all these cases and the fear of hav-
ing the earning capacity limited by the accident be-
came a perfect obsession with the individual. Dr.
Sachs had given the opinion that that mental attitude
was to be considered as a disability following injury.
He urged that the profession give due allowance to the
mental attitude of the person who has been injured.
The workman should be given the benefit of every
doubt. Do not exaggerate. Rely upon the basis of the
symptoms known to be connected with both the organic
and the peripheral nervous system.
Dr. Smith Ely Jelliffe of New York City said that
he was m very thorough sympathy with Dr. Sachs' re-
marks relative to the compensation material that is be-
ing thrust upon us. He thought that we could get a
great deal of light upon the subject of malingering if
we made tests upon the autonomic and sympathetic
systems. They were very definite tests for definite
organic conditions.
Dr. Hugh T. Patrick of Chicago ventured to make
a very unscientific but, he believed, practical sugges-
tion. He believed that these groups creep over into
each other. He was sure we all had had the experience
of being unable to place a given case in a given group,
and we had been driven to trying various remedial pro-
cedures and agents in the hope that we might cure or
relieve the patient. Some of these patients were very
promptly and, he believed, progressively relieved by a
very simple procedure, the suggestion of which he got
from Dr. Moyer, which was elastic constriction. The
application of the rubber tubing or elastic rubber
bandage about the extremity two or three times a day
ior two or three minutes would absolutely and com-
pletely relieve some of these cases in a very short time
Dr. Charles L. Dana of New York City said that
he presumed there was a psychogenic side, although he
had never seen it. Aside from that group there was
a large number due to the causes stated. One rather'
unusual case he had seen recently in which he thought
he had discovered a cause not mentioned. He had had
•j:ray pictures made of the arms, and had found a very
distinct evidence of thickening of the arteries of the
260
MEDICAL RECORD.
[Aug. 5, 1916
more affected arm. One arm was more paresthetic than
the other. The history of the case, the character of the
symptoms all indicate that it was a paresthesia due to
vascular involvement. He thought the vasomotor sys-
tem and the vascular system were behind the majority
of the ordinary cases. There was one other group of
cases which he thought ought to be watched very
carefully, that was the kind of acroparesthesia with
the beginning of combined sclerosis, associated with
anemia.
Diffuse Endothelioma Enveloping Spinal Cord in its
Entire Length.— Drs. Peter Bassoe of Chicago and
C. L. Shields of Salt Lake City prepared this paper,
which was read by Dr. Bassoe, who said that the pa-
tient, a girl of sixteen years, had been taken with head-
ache, vomiting and dizziness eight months before death.
Later, failing vision, two weeks of strabismus, and
finally complete blindness. Hearing also had been lost.
The optic disks showed secondary atrophy, and the
tendon reflexes were lost. The spinal fluid showed lym-
phocytosis and increased albumin. There had been
convulsive seizures during the last two weeks before
death. The necropsy revealed the unusual condition of
a diffuse grayish-white thickening of the pia along the
entire cord, most marked posteriorly. Histologically,
this tumor proved to be of connective tissue.
Dr. Harvey Gushing of Boston said that he thought
that in a series of about 100 cases of certified tumors
that had been calkd endothelioma, there had been many
examples of endotheliomatous effects. Many of these
endotheliomas had heretofore been called sarcomas, and
whether this tumor of Dr. Bassoe's should be called sar-
coma he did not know. It was his feeling that these
tumors were not dural tumors. He thought they were
really arachnoid tumors and that they originated from
the endothelial cells which covered the arachnoid tufts.
He surmised that, if this original tumor was an en-
dothelioma, this meant a sarcomatous degeneration in
the tumor with invasion of the cerebrospinal space.
Dr. Bassoe said that in this case the dura had not
been involved anywhere. As to the sarcoma and en-
dothelioma question, that was a very long question. He
would simply say if he were shown a slide with cere-
bellum without being familiar with the history of the
case, that it was a fibrosarcoma, and a slide from any
other part of the pia would pass for a round-cell sar-
coma.
Preliminary Report on the Use of I he Abderhalden
Reaction in Mental Diseases.— Drs. Henry A. Cotton
of Trenton, N. J.; E. P. Corson White of Philadelphia,
and W. W. Stevenson of Trenton, N. J., prepared this
paper which was read by Dr. Cotton, who said that,
since Fauser in 1912, with the assistance of Abderhal-
den, had begun to apply the principle of the Abder-
halden reaction to psychiatry, very little had been ac-
complished. Simon had shown that uniform results
could be obtained in various psychoses, and Ludlum and
White had also reported results with certain psychoses.
In this preliminary report of the work at the New-
Jersey State Hospital they would merely present the
results of the Abderhalden tests in 289 cases, including
the various psychoses and some normal individuals. It
was not their purpose to discuss the nature of the re-
action or to take up the various theories that were rep-
resented by the various investigators. The original
method of Abderhalden had been used in all cases, and
in thirty-one cases the reaction was confirmed by the
ice-incubation method of Bronfeubremer. It was im-
portant to remark that in the hands of one who had
had considerable experience the reaction not only was
of value as shown by the uniform reaction obtained in
the same case on repeated examinations, but also that
certain definite types of psychoses apparently had given
uniform findings in a number of cases. We could con-
clude that the Abderhalden reaction gave certain defi-
nite and uniform results. That these results were prac-
tically negative except in dementia precox and epilepsy.
That in dementia precox 81 per cent, of the cases
showed a positive reaction to sex gland, and in three
cases out of fifty-five gave a positive reaction to thy-
roid and sex; two of them were the catatonic type. Dif-
rential count of the blood showed rather charac
istic conditions in dementia precox ; Le. high red blood
cells, very low white cells, and high lymphocyte count
and low polymorphonuclear. That in epilepsy prac-
tically all cases, sixty-nine, gave a positive reaction to
adrenal gland. That the value of these reactions was
to lay the foundation for therapy, based upon the facts
deduced. In epilepsy the feeding of pancreatic gland
had produced some remarkable results.
Injuries to the Spinal Cord Produced by Modern
Warfare.— Drs. Joseph Collins and C. Burns Craig
of New York prepared this paper, which was read by
Dr. Craig, who said that these observations were based
on ten months' service with the American Ambulance in
France. Contrary to what might be expected, the in-
juries to the nervous system were not different from
those occasionally seen in civil practice. The great dif-
ference was quantitative rather than qualitative. All
wounds to the nervous system might be grouped under
three heads: concussion, contusion or laceration, and
compression. Injuries to the peripheral nerves were
practically all lacerations, compression from scar-tissue
formation also playing a role. The lacerations of the
brain and spinal cord presented a prognosis almost
hopeless. Such cases showed little improvement in
symptoms after the initial shock had passed off. Over
90 per cent, of the lacerated wounds of the brain, being
infected, developed meningitis and died. Cases with
cord lacerations remained paraplegic and died of sepsis
following pyelonephrosis within nine months. Con-
cussion injuries to the brain and cord cleared up in a
most remarkable manner. Concussion with hematomy-
elia of the cord, causing paraplegia or quadriplegia,
might follow the impinging of a bullet or shell frag-
ment upon the vertebra without fracture of the latter.
Such cases recovered almost completely.
Dr. Charles L. Dana of New York said he also felt
in sympathy with Dr. Sachs' presentation, and it would
be a great satisfaction if we as neurologists held some
attitude which, as Dr. Sachs suggested, is one of full
sympathy with the attempt to find organic conditions.
He thought the association ought also to keep in mind
the fact that before many years the whole situation
would be changed by the enactment of laws of health
insurance which would give compensation to every
working man who earns less than $1,000 a year when-
ever he fell ill from any cause during his employment.
We did not know exactly what the conditions would be,
but it would revolutionize the activities of our dis-
pensaries and hospitals andi it wouldi make great
changes in methods of examining and compensating
those who were injured nervously as well as from
other causes.
Dr. F. R. Fry of St. Louis said that in regard to what
Dr. Dana had been saying there was a better outlook
for adjusting all these things between the profession
and the laity by this industrial insurance feature than
we had ever had. The difficulty had always been to
have the general laity grasp the situation or have some
means of handling it. He could not help feeling that
that was going to be the solution of the whole thing.
Dr. L. F. Barker of Baltimore said that we must
distinguish between cases of incontestable organic and
functional disease. There could be no doubt that there
would be just as great disability from functional as
from organic disease. He believed that in this matter
psychiatry would help us. He thought that the organic
neurologists were very apt to go too far in the direction
mentioned, and that the psychiatrists would help us to
get matters straight. He believed that the phobias and
ideas of damages were very important, as they act on
the susceptible nervous system. There was no doubt
that when there was a single capital payment for dam-
ages the disease might last a shorter time than when
payment was made by instalments. If invalid insur-
ance should be adopted it seemed to him there might
possibly be different rates of insurance for people who
had a tendency to psychopathic conditions and thos.*
who are healthy and w-hose stock is healthy.
Dr. E. D. FISHES of New York City said that he
would agree with Dr. Sachs in saying that not many
of the cases were malingerers. They were honest in
their statements. They were disabled; they were un-
able to do work; they would like to work, and he thought
that was something we ought to consider.
Dr. B. Sachs of New York City said that the difficul-
ties were extraordinarily great. He believed the neu-
rologist and psychiatrist would have to co-operatf in
order to determine the exact mental attitude. He had
brought to his notice cases of distinct chronic psychosis
in which the disease antedated the time of the accident.
For instance, one was a case of paranoia with delusions
of persecution. It was the claim that the accident had
made thai paranoia worse.
The Report of the Cancer Control Commission. —
Dr. HARVEY CUSHING of Boston said that at the meet-
ing of this congress held in 191:1 the American Gyneco-
logical Society presented to the other branches of the
congress an identical resolution requesting the appoint-
Aug. 5, 1916]
MEDICAL RECORD.
261
ment of two or more delegates to co-operate in forming
a national organization to conduct an educational propa-
ganda regarding the prevention and cure of cancer. Of
all the validated societies probably the Neurological
Society had least interest in this, as cancer of the ner-
vous system was of less immediate interest than cancer
such as the laryngologist or the general surgeon or the
gynecologist might encounter. Nevertheless it seemed
to him that it would be just and fair and co-operative
if that society would be willing to express its interest
and sympathy in that movement and express its desire
to co-operate and affiliate with it in any way in its
power.
Dr. Charles L. Dana of New York City said that
there was just one line of inquiry in connection with
cancer of the nervous system which would be extremely
interesting. He had seen, and probably all saw at
times, cancer of the brain following operation upon the
breast. This had come within his observation so often
that he viewed with trepidation operation on the breast.
If we sent in our experiences of metastatic cancer of
the brain and spinal cord it would be helpful.
Dr. Alfred Reginald Allen of Philadelphia said
that in compiling some statistics a few months back
he and Dr. Frazier had been very much interested and
not a little surprised to receive statistics from a well-
known surgeon who made the statement that of all cases
of cancer of the breast he had seen, a good many (70
per cent.) had given metastasis to the spinal column.
We saw not only metastasis to the brain, but we quite
frequently saw cord involvement through metastasis
from the bone.
Dr. Archibald Church of Chicago said that it had
been his misfortune to see a number of women who had
had cord metastasis from the breast during the last
three years.
Dr. L. F. Barker of Baltimore stated that he wished
to speak of a practical point about the relief of root
pain. We all knew how often morphine wore out and
how big the dose had to be made. Schlesinger had put
out a formula that had been used in the Johns Hopkins
Hospital with great satisfaction. Two doses a day
would usually keep the patient easy. The formula was
as follows:
Scopolamine hydrobrom., 0.0025.
Morph. hydrochlor., 0.2.
Dionin, 0.4.
Distilled water, 10.
M. Sig. : Seven drops hypodermically every
twelve hours or oftener.
It was a very small dose of scopolamine and of mor-
phine, but it was remarkable how it relieved the pain.
Officers. — The following was the result of the elec-
tion of officers: President, Dr. E. W. Taylor, Boston;
secretary-treasurer, Dr. Alfred Reginald Allen, Phila-
delphia.
ASSOCIATION OF AMERICAN PHYSICIANS.
Thirty-first Annual Meeting, Held in Washington, May
9, 10 and 11, 1916.
The President, Dr. Sewall of Denver, in the Chair.
Tuesday, May 9 — First Day.
President's Address. — Dr. Henry Sewall of Denver
made a brief address in which he referred to the in-
fluence and the records of the Association and believed
that their best interests were to be had in casting out
the weak and letting in the strong. In their ranks were
a large number of men, rich in potential forces, men
who were greatly to be welcomed. They should seek a
broader intercourse with men and especially with those
men who had recently entered their ranks. The Asso-
ciation had at present an issue which they should en-
courage, the plan for establishing a National Board
of Examiners and he hoped that the work that the
late Dr. Rodman had begun would be carried out. The
menace which now confronted the race was that children
in general seemed less and less imbued with the respect
for truth; if this was a fact it was time for them to
make some suggestions and consider methods for the
correction of this. Scientific investigations were all
desirable; truth itself demanded that they should seek
the limitations of science. Faith, hope, and charity
might add to what they were after — truth. So-called
pure science was the indispensable servitor of truth.
In all schools and colleges it had been agreed that the
atmosphere that was surrounded by truth was ideal.
Truth would rule the mind and the conduct of people.
Biochemistry of Acidosis. — Dr. Lawrence J. Hender-
son of Boston read this paper by invitation. He said
that whatever the causes might be there was a common
result which involved the normal chemical equilibrium.
It was not at all difficult to discover the changes, or
the largest change in the body. The great change
was a diminution in the bicarbonates in the blood.
The three elements to consider in the body with re-
spect to the topic under discussion were (1) water,
(2) sodium chloride, and (3) the bicarbonates. To
understand how any diminution in the bicarbonates
came about was not a difficult matter. It should be
remembered that everything was related in the body
to every thing else, and nothing was more far reach-
ing in adjustment than this. The equilibrium to be
maintained between acidosis and bases involves bases
which could yield alkalies. The alkali was split off from
the base, or probably from an unknown source, and
the alkalies became mobilized. To treat a nephritis
with large amounts of sodium chloride he believed was
malpractice. On the other hand, nothing was easier
than to treat acidosis with moderate quantities of an
alkali. Small quantities of sodium chloride alone
might render the urine neutral or faintly alkaline;
then there would be no difficulty or ill effects from the
acidosis.
Acidosis in Infants and Children. — Dr. John How-
land of Baltimore said that acidosis in children was a
dangerous condition, for after treating infants and
children with this condition they must as a rule treat
some chronic disease and with the constant fear that
the acidosis might return. He divided acidosis into
(1) that due to acetone bodies in excess, and (2) that
not due to the formation of acetone bodies in excess.
In acidosis, there was nearly a complete anuria; the
body could not rid itself of the acids and so developed
an acid equilibrium. In nephritis in children acidosis
might develop as it did in adults. It was quite gen-
erally assumed that the acetone bodies were abnormal
and that their presence signified an unusual complica-
tion in the course of disease, whereas one might liken
the mere presence of acetonuria to fever, for it oc-
curred in most of the infectious diseases of childhood
with much the regularity that fever did. The quantita-
tive difference between the mere presence of the acetone
bodies and their production in sufficient amount to
threaten life was an enormous one. To guard against
the deleterious influence of acids formed or introduced
into the body, a most efficient mechanism was available.
It was only necessary to consider the mechanism from
the standpoint of the blood since this served to regu-
late the reaction for the entire body. The important
constituents of the blood influencing this regulation
of the reaction were sodium bicarbonate, occurring
chiefly in the plasma; the acid and alkaline phosphates
of potassium, found almost entirely within the red
blood cells, and the proteins. Acids, whether formed
in the body or introduced from outside, displaced the
carbonic acid from the sodium bicarbonate and set
carbon dioxide free. This excess of carbon dioxide
was removed by the increased pulmonary ventilation,
leaving a neutral salt, sodium oxybutyrate, or chloride,
or what not, to be removed by the kidneys. Such a
mechanism allowed relatively large amounts of abnor-
mal acids to be at once rendered innocuous and removed.
Thus dyspnea, or more properly hyperpnea, under ab-
normal circumstances, was an agent of the greatest
value in ridding the body of carbon dioxide and keeping
the reaction within normal limits. Hyperpnea was the
best evidence of acidosis to be obtained by physical
examination alone. The second defense of the body by
which acids were removed was elimination by way
of the kidneys; these have the capacity to excrete an
acid urine from a nearly neutral blood. The third
method of defense was offered by the proteins and
depended upon their amphoteric character. These three
means of defense acted synchronously and resided in
the blood itself. The body possessed a further means
of defense in that it was able to neutralize acid by
the production of alkali in the form of ammonia. In
childhood acidosis resulting from the production of
abnormal acids was found chiefly in diabetes and re-
current vomiting. A study of diabetes in children
showed very well the enormous amount of acid that
might be taken care of with no disturbance of the
reaction of the blood and with no effect upon the
respiration. In recurrent vomiting the conditions were
more_ obscure and less understood than in diabetes.
Acidosis in Acute and Chronic Disease. — Dr. Chan-
ning Frothingham of Boston said that with the im-
provements in the methods now employed in detecting
262
MEDICAL RECORD.
[Aug. 5, 1916
acidosis the subject had increased tremendously in
interest in recent years. The occurrence of acidosis
in diabetics had long been known. Recently one of
the profession had shown and demonstrated to us
that in a great many of the acute infections and dis-
eases of childhood this condition was present. During
the past winter in Boston the cases had been studied as
they came in and it was learned that acidosis occurred
among adults as it did in children.
Investigations in Diagnosis and Treatment of Acidosis.
— Dr. L. G. Rowntree of Baltimore, Md., described a
method of diagnosis which he said was very simple
and rapid, fifty demonstrations having been made in
one afternoon. He thought the nomenclature of this
disease should be considered by the Association. With
regard to acidosis in diabetes he reported briefly one
case in which all known methods of treatment had been
applied. Alkalies were given in sufficient quantity to
correct the hydrogen-ion concentration, in other words,
the blood became alkaline; but in spite of this the
hydrogen-ion concentration (the acetone bodies) in the
blood persisted in twice the normal amount, and then
the patient died in an attack of typical diabetic coma.
This went to show that one could correct the acidosis
without changing the patient's condition.
The Etiology of Pellagra. — Dr. Edward J. Wood of
Wilmington, N. C, presented this subject from the
standpoint of a deficiency, but this deficiency was re-
garded as more specific than had been generally
thought. Corn was thought by the writer to bear the
same relation to pellagra as rice to beriberi. The evi-
dence of the correctness of this view was proven both by
experimentation on the pigeon and by evidence found in
the literature of outbreaks of pellagra brought about
by eating highly milled meal which were promptly con-
trolled and corrected by feeding whole meal. The fault
lay in two factors. The first was the heating of corn
in the kilns above 120° C, which was enough to destroy
the vitarnine. The second was the removal of the fat
containing germ from the grain. The remedy con-
sisted in feeding the victims the whole grain and this
plan was also prophylactic.
The Treatment of Typhoid Fever by Intravenous In-
jections of Sensitized Typhoid Vaccine Sediment. — Drs.
Frederick P. Gay and H. T. Chickering of the Uni-
versity of California presented this communication.
This report dealt with slight amplifications of the cases
already given by the authors. It included a number of
additional cases and also a continuation of the labora-
tory studies. The series consisted of between 75 and 80
cases of typhoid fever in which the diagnosis had been
verified by blood culture and the Widal tests. In these
cases the majority had been treated with intravenous
injections of polyvalent, sensitized typhoid vaccine sedi-
ment as already recommended for prophylactic use by
Gay and Claypole. The routine treatment of these
cases, apart from this specific treatment, had varied
somewhat, as the cases occurred in the practice of a
large number of physicians, and both in hospitals and
private houses. The mortality had been about the
same as the best hospital normal, from 9 to 10 per
cent. Very distinct benefit, however, had been pro-
duced by the vaccine treatment in cutting short the
duration of the disease. Over 40 per cent, of the cases
had been abortively cured, that is to say, the tempera-
ture had returned to normal within a week following
the first use of the vaccine. In 25 per cent, more of the
cases each injection of the vaccine had been followed
by a successive fall in the temperature level and a more
gradual return to the normal temperature in periods
that had been distinctly affected by the treatment. The
nature of the reaction produced by these injections and
the correlation of the severity of the disease and the
blood findings in relation to the results produced, would
be considered as well as suggestions that might be use-
ful in still further perfecting this method of procedure
in the near future.
The Physical Signs and Svmptoms of Wounds of the
(host. — Dr. C. P. Howard of the University of Iowa re-
ported a series of 107 cases, of which 87 were thor-
oughly studied. The wounds were produced by rifle
or machine-gun bullets (45) or by .-hell as shrapnel,
high explosive, or hand grenades (42). In one group
(15) no signs could be found. In Group II either
pneumonia (4) or simple serous effusion (2) was
found. In Group III mediastinitis (one case). In
Croup IV a hemothorax was found which was either
infected (9 cases) or non-infected (56 cases). The in-
fecting organisms varied. The symptoms were cough,
pain, hemoptysis of varying degree and dyspnea. There
was usually fever present. The physical signs sug-
gested rather a consolidation than fluid owing to the
great compression of the lung. The cardiac displace-
ment was often striking. In eight cases unequivocal
and in five others suggestive signs of pneumothorax
were present. In four cases a pneumonia existed on the
side opposite the hemothorax. Secondary hemorrhage
into the pleural cavity was rare, only one case being
noted. Simple fibrinous pericarditis occurred in three
cases and in one a pneumopericardium. The treatment
consisted of free drainage in the infected cases and
of simple aspiration or of oxygen-replacement. The
mortality was only 7 per cent, in the entire series.
Wednesday, May 10 — Second Day.
Election of Officers and Members. — President, Dr.
George Dock; Vice-President, Dr. Francis H. Williams;
Secretary, Thomas McCrae; Recorder, Dr. Thomas R.
Boggs; Treasurer, Dr. J. P. Crozier Griffith; Councillor,
James B. Herrick; Representative on the Executive
Committee of the Congress of American Physicians
and Surgeons, Dr. Theodore C. Janeway; Alternate,
Dr. Richard P. Strong.
Elected to Honorary Membership. — Dr. William C.
Gorgas, Surgeon General, United States Army; Dr.
George M. Kober, Washington.
Elected to Active Membership. — Dr. Charles C. Bass
of New Orleans; Dr. Nellis B. Foster of New York;
Dr. J. Ramsey Hunt of New York; Dr. James W.
Jobling of Nashville; Dr. Howard T. Karsner of Cleve-
land ; Dr. Francis W. Peabody of Boston ; Dr. Peyton
Rous of New York; Dr. Walter R. Steiner of Hart-
ford, Conn.; Dr. Albert E. Taussig of St. Louis, Mo.;
and Dr. Rollin Turner Woodyatt of Chicago.
Elected to Associate Membership. — Dr. Frederick M.
Allen of New York; Dr. Alphonse R. Dochez of New
York; Dr. Charles W. Edmunds of Ann Arbor; Dr.
John H. Eyster of Madison, Wis.; Dr. Arthur D.
Hirschf elder of Minneapolis; Dr. Arthur S. Lovenhart
of Madison; Dr. Herman O. Mosenthal of Baltimore;
Dr. Edward Carl Rosenow of Rochester, Minn. ; Dr.
George C. Shattuck of Boston, and Dr. Gerald B. Webb
of Colorado Springs.
Lipase in the Urine of the Tuberculous. — Dr. William
Charles White read this paper. He undertook a study
of the lipase in the urine in tuberculous patients and
found that there was a disappearance of fat in the
animal body, and also an accentuation of the destruc-
tive process itself in the animal bodies succumbing to
this disease. The fact that lipase act on the tubercle
bacillus itself had also been shown. In all 194 separate
tests had been made and the very useful method of
Hulet was used; this method was published years ago.
In order to rule out the possibility of the influence of
food, etc., he took all the urine passed at each time
for six days. In one case 19 separate tests were made,
in another, 28; in another, 42, and in another 9. All
were distinct cases of tuberculosis and in a dying con-
dition. There were 73 tests made in the early cases,
cases that were improving and those that had no fever.
In one case of pneumonia with high fever and in one
case with typhoid fever, a number of tests were made.
In conclusion Dr. White said that in the urine of normal
individuals, apparently normal, with tuberculosis and
without fever, there was no lipase. They were practi-
cally normal individuals. In the urine of the advanced
cases with fever and oncoming fatality, there was a
marked variation in the lipase content. The increase
in the lipase content preceded the accompanying fever.
There was no lipase in the cases of pneumonia when
there was a high fever.
Leucemia, Lymphosarcoma, and Hodgkin's Disease. —
Drs. C. H. Bunting and J. L. Yates presented this com-
munication, and called particular attention to the diffi-
culties encountered in making the diagnosis. There
was a group of diseases in which the gland enlargement
was a feature of the disease. To summarize the com-
mon factors there was the presence of the history of
primary infection as well as some trouble in the buccal
cavity. There was this progressive glandular enlarge-
ment with or without tumors. There were moderate
anemia and a late fever. There was a fatal termina-
tion in all the cases. There was the occurrence of a
true course of the disease, Hodgkin's blood picture or
the leucemic blood picture. Bacteriologically the con-
dition was characterized by considering the presence
of tho diphtheroid organism. Pathologically they might
place the disease into one of three groups. First, the
Hodgkin group proper; here they met with a marked
destruction of the lymphocytes and a proliferation of
Aug. 5, 1916]
MEDICAL RECORD.
263
the endothelial cells and fibroblasts. In this group they
often found the leucemic blood picture. Secondly, this
was the group of the so-called large-celled lymphoma,
a group commonly called pseudoleucemia. Thirdly,
there was the group of small-celled proliferation, a
lymphocytoma. The evidences all pointed to the etio-
logical value of the diphtheroid organism.
Renal F'unction in Serum Disease. — Drs. W. T. LoN-
cope and F. A. Rackemann presented this report.
During the past two years they had made a careful
study of renal function in ten cases and the method
employed was placing the patients on a diet consisting
of a certain amount of sodium chloride and then de-
termining the output in the urine. The charted results
were very interesting.
Studies of the Actual Constituent, in Crystalline
Form, of the Thyroid. — Dr. E. C. Kendall of Rochester,
Minn., read this paper. He said that the investigation
of the iodine compound isolated from the thyroid, had
shown that it possessed the characteristic activity of
the gland and was its actual constituent. Its isolation
in pure crystalline form had been perfected, and pre-
liminary experiments suggested that its function was
concerned with the metabolism of amino acids.
The Pathological Changes in the Sympathetic System
in Goiter. — Dr. Louis B. Wilson of Rochester, Minn.,
presented this paper, which was illustrated with lantern
slides. The paper was based on a study of cervical
and other sympathetic ganglia removed at operation
and from patients with goiter, the results being con-
trolled by a study of the ganglia from non-goitrous
patients. Sections of the ganglia, stained by various
methods, showed extensive histological changes, con-
sisting of various stages of cell degeneration, viz., hy-
perchromatization, hyperpigmentation, chromatolysis.
and atrophy or granular degeneration. So far as
might be determined from the small number of speci-
mens examined (25 cases), the pathological changes in
the ganglia were paralleled to the stage and intensity
of the symptoms of hyperthyroidism and to the hyper-
plastic and regressive change in the thyroid.
Dissociate Jaundice. — Drs. C. F. Hoover and M. A.
Blankenhorn of Cleveland presented this communica-
tion in which they told of the methods employed in de-
tecting bile pigment in plasma and in the urine, the
method of isolating the bile salts in the urine, etc.
Dissociate cholemia and dissociate choluria might be
correlative in many cases, and not the consequence of
dissociate biliary retention. Pigmental jaundice with-
out bile salts was invariably hematogenous and never
originated from dissociated hepatic retention of bile
pigment. Pigmental choluria without bile salts was
frequently a survival of complete biliary retention. Pig-
mental choluria without bile salts occurred only in
hematogenous jaundice. Bile salts were not present
in hematogenous cholemia. Bile salts unaccompanied
by bile pigment might have occurred in the blood of
primary anemia and lead poisoning. Bile salts unac-
compar::d by bile pigment might occur in the urine
as a consequence of dissociated retention of bile salts
in primary anemia and lead poisoning. The presence
of bile salts in the urine without bile pigment was (with
primary anemia and lead poisoning excepted) always
due to renal dissociation of complete cholemia on ac-
count of the absorption of bile pigment in the plasma
and the escape of bile salts through the renal filter.
The maximum cholemia (pigmental) without choluria
might be both hematogenous and hepatogenous. Ob-
structive jaundice yielded only moderate cholemia and
choluria. When cholemia was pronounced from ob-
structive jaundice, choluria would develop. In hemol-
tvic and infectious jaundice there might be pronounced
cholemia without choluria.
Pancreatic Changes in Latent Syphilis. — Dr. A. S.
Warthin of Ann Arbor, Mich., read this paper, which
he illustrated with lantern slides. The histological
study of the material from seven autopsies in deaths
from diabetes showed in all syphilitic lesions in the
myocardium and aorta, the presence of spirochetes
being demonstrated in five cases. In all of these cases
marked changes were found in tiie pancreas of the
nature of interstitial pancreatitis, both interlobular and
intra-acinar. This led to the study of the pancreas
in a large number of other cases of latent syphilis with
the result that in no case was a normal pancreas found.
In all cases of latent syphilis this organ showed marked
changes in tbe form of a diffuse or patchy fibrosis with
active inflammatory foci corresponding to the localiza-
tion of the spirochetes. The relationship of these
changes to diabetes was discussed.
The Control of Malaria by Treating Malaria Carriers.
— Dr. C. C. Bass of New Orleans presented this paper,
which was illustrated by lantern slides. Where
malaria prevailed there were many more malaria car-
riers who were not known to be infected than there
were persons who had acute symptoms of malaria. In
much of the country where malaria prevailed it was
not practical at present to install and maintain meas-
ures that would prevent the breeding of mosquitos, nor
to protect all the inhabitants, including the carriers,
from their bite. Koch advocated the possibility of con-
trol and eradication of malaria by finding and treating
all infected persons in the community. Experiments
and a demonstration of this method on a large scale
were now being made in Bolivar County, Miss., in the
heart of the malarial section of the South. The work
had advanced sufficiently to show that in this county,
which was believed to be representative of a large part
of the South in which malaria was most prevalent, the
cooperation of all the people could be secured to the
extent of making a complete malaria survey and in-
ducing all to take quinine as directed. The cost of the
control of malaria by such a method would be very-
small compared to the cost of controlling it by the
known methods of mosquito control. Lantern slides
were presented showing the prevalence of malaria, the
importance of the malaria carriers, and some of the
results obtained in this experiment.
Clinicai Observations on Intestinal Autointoxication,
Especially as Regards the Specificity of Toxin. — Dr.
Thomas R. Brown of Baltimore presented a study of
two cases of chronic eczema and urticaria of long stand-
ing, with definite hypersensitiveness to various proteins,
and of a case of choroiditis apparently due to definite
infection of intestinal origin.
The Bile Content of the Blood in Pernicious Anemia. —
Dr. A. M. Blankenhorn of Cleveland presented this
paper. He said that while investigating the nature of
the jaundice in pernicious anemia, the observation was
made that many patients, although distinctly jaundiced,
showed no bile in the urine. The blood plasma, however,
in every case showed a corresponding jaundice. These
plasmas when presenting a jaundice of certain in-
tensity all gave a chemical test for bilirubin. Urobilin
was found in the plasma of none. There was often a
higher concentration of bilirubin in the plasma, coinci-
dent with the absence of bile from the urine, than was
found in the plasma of patients with certain lesions of
the liver which were always characterized by bile in
the urine. Bile salts were found in the plasma in
ten out of thirteen cases. The eases showing the high-
est concentration of bilirubin in the plasma were those
showing evidence of the most active blood destruction,
that was, anemia, jaundice, and increased urobilin in
the stool and urine. The cases showing highest con-
centration of salts were those in which the nerve lesions
predominated.
Anatomical Approaches to the Problem of the Func-
tional Psychoses, Including a Particular Study of Five
Brains. — Drs. E. E. Southard and M. M. Canavan of
Boston presented this paper, which they illustrated with
lantern slides. They stated that at the bottom of all
work with the functional psychoses should be a series
of cases anatomically verified. Massachusetts institu-
tional material had been culled to secure such a series,
and a summary of previous published work was offered.
New York with Boston State Hospital material was
offered from which by successive refinements and elim-
inations a series of five cases was obtained from an
initial group of over 150, in which five cases a number
of somewhat equivocal microscopic appearances were
found, sometimes in remote parts of the cerebral cortex
not often examined. These cases were all of long-
standing, yet had brains of approximate normality in
the gross (systematic photography available). The
problem of the essential functionality of these five
cases was then considered. Were there cases of severe
chronic mental disease in which the brains were in-
trinsically normal?
The Roentgen Ray in the Diagnosis of Cancer of the
Stomach. — Drs. Julius Friedenwald and F. H. Baetjer
of Baltimore presented this communication, which they
illustrated with lantern slides. In the x-ray study of
cancer of the stomach, they said it was important to
recognize the varying positions and functions of the
stomach under normal conditions. The greatest diffi-
culty arising was that the stomach was not a hard
fixed subject, for they knew that a perfectly normal
stomach might present great variability, not only as to
position, but as to motility and expulsion of contents.
264
MEDICAL RECORD.
[Aug. 5, 1916
We might divide the various types of stomach into three
classes — first, the stomach of the fleshy individual; sec-
ond, the stomach of the medium weight individual, and
third, the stomach of the thin individual. We had no
hard and fast rule, therefore, according to which the
stomach could be said to empty in a certain number of
hours and that if this time was prolonged, that the
conclusion was reached that we were dealing with some
pathological condition. In the first class, the stomach
emptied in about three hours. In the third class it took
about six hours, and so that the question of any be-
ginning obstructive lesion was dependent very largely
on the character of the stomach with which we were
dealing. A third difficulty was to be encountered in
the fact that the motility of a normal stomach might
be naturally affected by conditions outside of the stom-
ach itself. In dealing with carcinoma of the stomach
their determination of the special lesion was dependent
upon the study of several conditions. Namely, the
peristaltic waves of the stomach and the many irregu-
larities or filling defects in the stomach itself. We
might divide the carcinomatous lesions of the stomach
into three classes: first, lesions in the cardiac end of the
stomach ; second, lesions in the body of the stomach,
not affecting the orifices; third, lesions at the pyloric
end of the stomach. The carcinomatous lesions of the
various portions of the stomach varied materially and
had their characteristic .r-ray pictures. Differential
diagnosis between carcinoma and ulcer was often most
difficult. The a--ray often furnished important evidence
as to whether the tumor was or was not operable in as
much as it definitely established the location and extent
of the growth and degree of obstruction.
The Main Factors Affecting the Intensity of the
Sounds as They Pass from the Interior of the Lungs to
the Periphery "of the Chest. — Drs. George W. Norms
and C. M. Montgomery of Philadelphia presented this
paper which they illustrated with lantern slides. They
stated that the main factors diminishing the intensity
of sounds as they passed from within the bronchi to
the external chest surface were reflection and diffusion.
Reflection might be a potent factor where vibrations
passed between media of different densities as air and
fluid or air and tissue. Sound was not much affected
in its passage between fluid and tissue because the
differences in density were not sufficiently marked.
Marked vocal resonance occurred over solid lung be-
cause the parenchyma was airless, thus eliminating re-
flection in this part of the lung. The vocal resonance
might also be increased when fluid separates a solid
lung from the chest wall. In the normal lung, on the
other hand, reflection took place between the bronchi
and the surrounding air, between the tense membranous
tissues of the parenchyma and the adjoining air, and
between the air in the lung and the chest wall.
Diffusion, while more or less a constant factor in all
conditions, plays a special part in pleural effusion, the
sounds becoming spread out or diluted as they pass
from the lung surface in contact with the fluid to the
point on the chest revealing diminished vocal resonance.
(To he continued.)
Sllprapfutir l^ittta.
Sonka iRrrritirD.
The Medical Record is pleased to receive all new
publications which may be sent to it, and an acknowledg-
ment will promptly be made of their receipt under this
heading; but this is with the distinct understanding that
it is under no obligation to notice or review any publica-
tion received by it which in the judgment of its editor will
not be of interest to its readers.
Rules for Recovery from Pulmonary Tuberculosis.
A Layman's Handbook of Treatment. By LAWRASON
Brown, M.D. Published by Lea & Febiger, Philadel-
phia and New York. Second Edition. Thoroughly re-
vised. 184 pages. Price, $1.25 net. Cloth.
Profilaxis del Thus EXANTEMATICO. Por el DR. I».
MANUEL Martin SALAZAR. Published by Enrique
Teodoro, Madrid. 59 pages.
Transactions of the Thirty-seventh Annual
Meeting of the American Laryngological Associa-
tion. Held at Niagara Falls, Canada. June 1, 2, and
'■'■■ 1915. Published by the Association, N. Y. 402
pages.
On Modern Metj s of Treating Fractures. By
Ernest W. Hey Groves. Published by William Wood &
Company, New York. Illustrated. 286 pages. Price
.T'li.Tf) net.
Roentgentherapy of Venereal Bubo. — E. Kil-
bourne Tullidge mentions a good and efficacious
treatment for venereal bubo which he says was
accidentally discovered by a German medical offi-
cer in charge of a mobile Roentgen apparatus in
the field. He treated the inflammatory swellings
^ymptomatically with roentgentherapy (10-20 X
with a 0.5 mm. aluminum filter) with the result
that fluctuation, pain, redness, and swelling grad-
ually disappeared and the retrogressive changes
that followed left only a small pigmented spot on
the scar.
Calcium Sulphide in Bichloride Poisoning. — In
the Medical Record of July 1 ip. 29) reference
was made to Rickett's recommendation of calcium
sulphide as an antidote to bichloride of mercury.
For every grain of mercury which has been taken
he gives one grain of calcium sulphide by the
mouth and repeats it every two hours until five
doses have been taken. In the item referred to
this was erroneously written five grains instead of
five doses.
Purgative Rendered More Palatable. — One-half
teaspoon of aromatic spirit of ammonia added to a
dose of salts improves the taste and removes the
nauseating effect for most patients. — The Xurse.
Orange Peel as a Cholagogue and Peristaltic
Stimulant. — Rosenthal, a medical officer on active
service with the French army, has been using plain
orange peel prepared in the following manner as a
means for improvement of the intestinal conditions
of the soldiers in his charge: Fresh orange peel is
boiled in about a pint of water for half an hour;
this water is removed and may be used for a tooth
wash. The softened peel is then boiled for another
half hour in fresh, slightly sweetened water, re-
moved and dried, when it is ready for use. The
peel of one orange is an average dose. While the
intestine is acted upon mechanically, there is also
an increased flow of bile which may continue for
several hours.
Ammonia as an Enema. — T. A. Black offers the
following prescription for an enema to be used in
the treatment of postoperative abdominal conditions
where ileus and intestinal paresis may be present:
Liquor ammonia? fortior, 1 dram; water, 1 pint; a
hypodermic of pituitary extract, 1 c.c, given half
an hour before the enema produces an increased
effect. The enema must not be used too frequently
or in succession, or any stronger than the prescrip-
tion above given, as otherwise injury to the intes-
tinal mucous membrane is liable to occur. The
enema produces a large movement and discharge of
flatus. — The Lancet.
Another Use for Epsom Salts. — A saturated
solution of Epsom salts applied to linen stained by
iodine entirely eradicates the stain without injury
to the material. — The Trained Xurse.
A Harmless Antiseptic Dressing. — Where per-
sonal idiosyncracy contraindicates the use of bi-
chloride as a dressing for wounds, erysipelas, etc.,
the following answers as a general antiseptic:
1{ Sodium citrate. 0.5.
Sodium chloride, 3.0.
Distilled water. 100.0.
Prevention of Bed Sores. —
K Sodium chloride, "iij.
Whiskey. Oj.
M. sjg. : Apply to parts twice daily. — Western
Medical Times.
Medical Record
Vol. 90, No. 7.
Whole No. 2388.
A Weekly Jotirnal of Medicine and Surgery
New York, August 12, 1916.
$5.00 Per Annum.
Single Copies, 1 5c.
OJrtgmal Artirks.
CULTIVATION OF THE ORGANISMS OF
VACCINIA, VARIOLA, AND
VARICELLA.
BY HORACE GREELEY, M.D.,
BROOKLYN, N. Y.
In the Medical Record of Aug. 1, 1914, I gave an
account of a diplococcus-like organism which I had
"found to be constantly present in vaccinia virus,
in vaccine vesicles, in varicella vesicles, and in the
vesicles and pustules of such cases of variola as had
been available." Since this time I have been study-
ing the behavior in cultures of the organisms, and
investigating various serological and immunological
factors in connection therewith. In the present
article I will recount some cultural experiments that
may be easily performed by anyone, and detail other
work which I have completed.
Appearances in Vaccinia Virus. — -If a dilute smear
be made of any specimen of commercial vaccinia
virus or of Noguchi's rabbit-testicle preparation,*
or of lymph from a human vaccine vesicle, and the
smear be fixed and stained by one of the ordinary
methods — preferably first "clearing" the specimen
with 50 per cent, acetic acid- — and care be used to
avoid the formation of dye precipitates, a good
many distinct, though minute, bipolar bacilli may
be seen with aid of the usual oil immersion (1/12)
lens and a magnification in the neighborhood of
1000 diameters. After one has detected these or-
ganisms and has made out that portion of their
bodies, usually non-stain-taking, lying between their
well staining poles, many oval non-stain-taking in-
volution forms* may be seen, which in view of the
cultural history (to be detailed), are probably in
the process of "spore" formation or discharge.
These latter are commonly very numerous in lymph
from human vaccine vesicles.
Cultures from Vaccinia Virus. — Originally, cult-
ures were made in pure hydrocele fluid, completely
filling the hollow between a hanging-drop slide and
its cover glass, the margin of the latter being sealed
with paraffin. In such a culture, after two days,
with the ordinary 600 magnification, a great many
minute bipolar bacilli may be seen (as tiny
globules) and clumps of branching organisms are
numerous at the end of six days. In such fluid
media all the organisms show a greatly exaggerated
Brownian movement which tends to separate all
daughter cells from their parents. Subcultures
from such slides on ordinary solid media show no
developments.
*Specimens of "strains No. 86 and No. 100" were
used.
tin the Noguehi preparation such "spores" are not
in evidence. This explains the relative short life of the
rabbit testicle virus as compared to the skin produced
In testing the suitability of various strengths
of hydrocele fluid, several series of cultures were
made, with the average results shown in the follow-
ing table:
TABLE I.
Hydrocele-fi.uid-Dilution Media Tests.
Each tube contained approximately 2 c.c. of total fluids ;
each was planted with one drop of one-in-ten vaccine virus
(in saline solution, and taken from a market tube of virus) ;
each had a blank control, and all were incubated, aerobically,
at 37.5 deg. C.
Results— End op Six Days.
Hydrocele Fluid Strength
i Diluted with Salt Solu-
tion), per Cent.
10, 15 and 20
25 and 30
35,40,45,50,55, B0.
65,70, 75, SO, 85, 90, 05, 100
Macroscopic
0
Faint precipitate
Slight precipitate
Faint precipitate
Occasional bipolar bacillus.
Few bipolar bacilli.
Many bipolar bacilli.
I Few bipolar bacilli.
With 50 per cent, hydrocele fluid as a constant,
and allowing for the saline contents of hydrocele
fluid, the salt concentration of the media was in-
creased in multiples of 0.9 per cent sail strength,
with results as in the following table:
TABLE II.
Saline Concentration Effects.
Salt (0.9 per Cent.)*
Concentration,
Per Cent, of Total.
Rbsui/
, Fnti ck Six Days.
Macroscopic.
Microscopic.
20
Very slight sediment
Moderate sediment
Heavier sediment
Slight sediment
Slight sedimeot
Faint sediment
Faint sediment
0
33
50
100
127
160
200
Few very pmall bipolar bacilli.
Few very small bipolar bacilli.
250
♦Made from tablets each containing: sodium chloride, 2.250 gm.; calcium chloride,
0.075 gm.; potassium chloride, 0.025 gm. Four tablets to the liter used to make all
the salt solutions. Same tablets were used in making bouillon. It is not thought,
however, that the results would be any different with a 0.9 per cent, salt base of nure
sodium chloride.
From the results given in Table II it was judged
that a salt concentration of 50 per cent, was most
suitable as a diluent. Therefore, using sterile dis-
tilled water in place of the saline recorded in
Table I, a similar series of tests was carried out,
with a similar result, only that the growth of organ-
isms in each dilution was considerably greater (par-
ticularly so in tubes containing 50 per cent, hydro-
cele) than in the tubes of the series of Table I, and
corresponded in development to "50 per cent." of
Table II. To the last described favorable medium
(50 per cent, hydrocele in distilled water) was then
added glycerin in percentages from 0.1 to 50, and
the same general procedure gone through with as
before; and, while it was found that the addition
of glycerin in all proportions exercised a slightly
266
MEDICAL RECORD.
[Aug. 12, 1916
unfavorable influence, still a few bipolar forms ap-
peared in all strengths up to and including 5 per
cent, glycerin. (It should not be forgotten that
this applies to direct cultivation from vaccinia
virus.)
In the course of many trials of various culture
media it was found that after washing the surface
of an ordinary Loeffler blood serum tube with lime
water, a plant of vaccine virus would often yield a
faint growth, which, though barely discernible
macroscopically, supplied many bipolar forms to
smear examination. On this account a series of
cultures was made, as before, in 50 per cent hydro-
cele and distilled water, to which latter calcium
oxide had been added in amounts to make the series
of tubes contain a lime water (0.17 per cent, cal-
cium oxide) strength running from 1 to 50 per
cent.
After three days incubation, it was found that
tubes containing lime water equivalent strengths
between 1 and 20 per cent, showed heavier growths
than controls without the calcium oxide. (It should
be noted that tubes holding a lime water equivalent
of 25 per cent, and over showed a distinct precipi-
tate immediately after preparation.)
Bouillon was then substituted for the distilled
water, and a series of tubes (containing 2 c.c. each
of total fluid) was inoculated, and the same gen-
eral procedure followed. After six days' incuba-
tion the results were as shown in Table III.
Dextrose added to the fluid media, even to the
extent of 0.1 per cent., proved to have an unfavor-
able influence upon growth of the organism (on
direct cultivation from virus).
TABLE III.
Limed Htdrocej.e-Bouilj.on' Tests. |]
Lime-water-equivalent strength of media, 10 per cent.
Hydrocele
Fluid,
per Cent.
Bouillon,
per Cent.
Macroscopic appears
:
0
50
62 5
75
87 5
100
100
50
37 5
25
12 5
0
Faint precipitate
Marked precipitate
More marked precipitate
Still more marked precipitate
As nevt ^bove
None
Few bipolar bacilli.
(Irc-at nu
Great many bipolar acilli
acilli.
Few bipolar bacilli.
From Table III it is seen that media consisting
of about 70 per cent, hydrocele fluid and 30 per cent,
bouillon, and containing a lime water equivalent of
10 per cent. (i.e. 0.017 per cent, calcium oxide) was
quite suitable for the growth of the organism in
question. Wishing to exclude more positively possi-
bilities of the presence of organisms contaminating
the hydrocele fluid, equal parts of bouillon, and the
distilled water with various percentages of lime wa-
ter, were tried and it was found that approximately
50 per cent, of bouillon, with 50 per cent, of dis-
tilled water — water from 10 to 100 per cent, sat-
urated with calcium oxide — was very suitable for
cultivating the bacillus.*
*In hanging-drop slide cultures, in medium composed
of diluted hydrocele and sterile powdered guinea-pig
skin, branching groups were observed in which no seg-
mentation of central filaments could be seen, while ter-
minal projecting filaments commonly developed spore-
like bodieo. This gave rise to the belief that the organ-
isms wen, of the sporothrix variety. Subsequent free
cultivation, however, showed their true nature.
TABLE IV.
General Results — Fluid Media (As Shown by a Series of Cultures Sown with Vaccinia Virus).
After
Three
Fifth Day Retlan't. Two Days Growth
DlLCKN'T
Days Incubation
ON' I.OF.FFLF.K
ond
Cul-
Hydro-
Rouil-
After
Das'
cele,
lon,
T.il'H-
Five
Replant,
No.
per
per
0.9
U ., in
Days
I ive
Cent.
Cent.
Distilled
!
Equiva-
Macro-
Mil 1 .-
Days,
Macro- Microscopic
u ater
lenl . per
scopic.
scopic.
1
Solution.
Cent.
1
100
Clear*
Few bipol-
ar bacilli
50
50
Few bipol-
ar bacilli
3
25
75
*
Cloudy
Many bi-
polar bac-
cilli
I.arue bipo-
lar bacill-
li. sur-
tax e gr't b
Profuse Small ami large bipclar bacilli
4
50
50
Clear
Many
5
25
75
( Icar
Great
many
Fev.
bipolar
bacilli
6
100
10
Cloudy
Great
many
As 3
7
iO
50
10
Clear
As 4
V- .'.
B
25
75
hi
Clnudv
As 5
As 3
Profuse
Sporulating bipolar bacilli
9
50
50
10
Clear
\- 3
10
25
75
10
Clear
\- :i
\- '.
11
75
25
Cloudy
\- 6
\ 8
12
25
25
0
Few bipo-
lar bacilli
As 3
\ .:
\- s
13
50
0
Clear
\> 1
14
•■7
13
Cloudy
\- 3
\- .;
15
7
50
( lear
\s 12
16
13
50
* leai
As 4
17
50
Clear
As 12
is
25
50
10
Clear
\s 12
19
75
25
10
Cloudy
As 12
20
37
13
50
10
Clear
\- I
many
L>1
87
13
in
As 3
22
43
7
10
Clear
\- 1
23
33
31
33
**
Clear
\- 1
'21
33
33
\i
**
Cloudv
\- .
\- 3
25
0
**
Cl,.:lr
\- 12
-V,
33
10
Cloudy
As 5
\ 3
As 3
■27
■
As 4
28
50
50
Clear
\- 5
\- :.
29
100
10
Clear
\- -'.
Sporulatinp
bipolar
bacilli
50
50
10
Clear
A* 12
U :i!l tubes showed some precipitate.
Ided,
Aug. 12, 19161
MEDICAL RECORD.
267
In preparing this medium, calcium oxide (Merck)
was used, a small quantity being recalcined on a
piece of platinum foil and dumped into a test-tube
containing bout 4 c.c. of distilled water, the latter
having just been boiled to expel the carbon dioxide.
This tube was then centrifuged and the required
proportion of the clear lime water was added to a
tube containing bouillon, also just boiled with the
same object.
Table IV is useful mainly to show in what varied
media the vaccinia organism may be grown, and
also that for a particularly successful transplant
the sporulating stage must have been reached.
Further, that this latter can be reached only under
TABLE V.— AGGLUTINATION TESTS.
Serum Tested
TWENTY-FOUR HOUR BOTJILI.ON
Giictvth
Patient.
Disease.
Period.
Dilution.
VARIOLA ORGANISM
\ AC) INI V ORGANISM
VARICELLA
}ROANI?-M
Half Hour.
Hour.
Half Hour.
Hour.
Half Hour,
Hour.
S. A
Variola
Eruption
1-10
C.
c.
p.
c.
1-20
C.
c.
s.
c.
1-40
P.
c.
c.
0
p.
1-80
s.
c.
c.
0
s
1-160
0.
s.
c.
(>.
0.
S.A
Variola
Convalescence
1-10
c.
c.
P.
c.
1-20
c.
c.
s.
p.
1-40
c.
c.
0.
s.
1-80
c.
(
0.
1-160
0.
s.
p.
c.
M. D
Variola
Erupt'on
1-10
1-20
c.
c.
c.
c.
P.
c.
s.
1-40
c.
c.
0.
0.
1-80
p.
c.
c.
1-160
0.
0.
p.
, p.
C. W
Variola
Eiuption
1-10
1-20
c.
c.
c.
c.
P.
s.
r.
P.
1-40
c.
c.
0.
0.
1-80
c.
s
s.
1-160
0.
0.
o.
0.
Four adult?
Normal
\(.; vaccinated since infancy
110
1-20
1-10
1-S0
1-160
0.
0.
s.
p.
s
0.
o.
0 .
Normal
Ni't vaccinated since infancy
1-10
1-20
1-40
1-80
0.
0.
c.
p.
s.
c.
c.
c.
0.
o.
8.
1-160
Four adults
Normal
Successfully vaccinated within 1 months
1-10
1-20
1-40
1-80
s.
c.
0.
c.
s.
c.
c.
c.
c.
0.
0.
1-160
0.
I.E. andM-E. . .
Varicella
Convalescence
1-10
1-20
1-40
1-80
1-160
0.
0.
c.
c.
0.
0.
('.
p.
0.
0.
0.
M. M
Varicella
Convalescence
1-10
1-20
1-40
1-80
1-160
s.
p.
s.
c.
p.
o.
c.
c.
p.
0.
0.
p.
s.
0.
Call
Normal
Before use for vaccine production
1-10
1-20
1-40
1 -80
1-160
0.
(>
('.
0.
c.
('.
p.
0.
o.
s
0.
Call
After use for
vaccine production
1 10
s
s.
o.
c.
c.
c.
c.
1-20
0.
1-40
('.
c.
! 80
p.
c.
p.
c.
1-160
o.
s.
o.
0.
Normal
1-10
1-20
1-40
1-80
1-160
o.
0.
o.
0.
c.
p.
<).
c
0.
Fourteen rabbits . .
After use for
vaccinia "seed"
1-10
1-20
1-40
1-80
1 160
0.
0.
c.
c.
c.
c.
p.
c."
c.
c.
p.
II.
c'
0.
1-10
().
0.
c.
c.
1-20
p.
c.
('.
1-40
0.
s
0.
p.
1-80
0.
s
1-160
II.
One rabbit
After uee for
i :.. i inia "seed"
1-10
1-20
1-10
1-80
1-160
0.
0.
p.
0.
c.
p.
0.
c.
c
c.
s.
o.
p.'
0.
Note. In this table the extent of agglutination is indicated as follows: No agglutination, O; slight, S: partial, P ; complete, C.
268
MEDICAL RECORD.
[Aug. 12, 1916
aerobic conditions (note cultures 3, 6, 8, 11, 14, 19,
24, 26, from which highly successful transplants
were made, and also cultures 5, 7, 10, 17, 28, whose
transplants produced no macroscopic growth.
It is also apparent from this and the preceding
tables that there is some element in both hydrocele
fluid and bouillon that needs to be neutralized, or
at least diluted, before much growth (primary
plant) of the organism can take place. (In Table
IV compare cultures 1, 3, and 6; 27, 28, and 29.)
It was some time before the appearance of large
bacilli among the minute bipolar affairs was un-
derstood, since the temptation was to regard them
as but contaminations, and it was not until the
method of cultivating the organism upon solid
media was discovered that any certainty was felt
as to their role.
As a result of attempts (some successful and
some not) to transplant the fluid cultures to solid
media, direct cultivation of vaccinia virus upon
solidified blood serum was essayed. Remembering
the role of the limed bouillon in fluid cultures, and
knowing the necessity of keeping cultures from dry-
ing; besides thinking of imitating the natural
process by which the host's circulation carries off
what may be called a parasite's sewage, the follow-
ing procedure was adopted: The surface of an
ordinary Loeffler blood serum tube was inoculated
with a loopful of 10 per cent, vaccinia virus (in
saline solution or distilled water) and upon this
was dropped one or two drops of limed bouillon
(bouillon 50 per cent, in distilled water from 10
to 100 per cent, saturated with calcium oxide).
Tube was incubated at 37.5° C, and each day a drop
or two of freshly prepared limed bouillon was made
to flow over the surface of the media. In any case
in which bouillon accumulated sufficiently to
threaten to drown the culture it was pipetted off.
In cultures so treated there appears in about ten
days, sometimes earlier, sometimes much later, a
crop of low lying (flat) mucus-like, glistening col-
profuse growth which usually covers the entire sur-
face of the media and sometimes becomes wrinkled
and curdy. Peptonization, with replants, begins
quite uniformly within 24 hours. Transplanted to
nutrient agar growth is uncertain but sometimes
„ ] "■ culture ol vaccinia virufl on Loeffler.
"li day. Organism "sporulating." Stained bv alkaline
methylene blue. Magnification 1650.
onies which, usually within 24 hours after they ap-
pear, begin to cause rapid peptonization of the
media.
Transplantation from such colonies on ordinary
Loeffler serum gives rise, within 24 hours, to a
Fig. 2 — Smear from pustule of S. A., a negro patient of the
Kingston Avenue Hospital. Made at the height of a general-
ized variola eruption. Smear cleared with 50 per cent acetic
acid, and then stained by alkaline methylene blue. Magnifi
cation 1650. It is seen that only the poles of many of the
bacilli are stained.
(after extended artificial cultivation commonly)
similar. Transplanted to bouillon, within 24 hours
the medium is clouded, and sometimes a white
matted growth appears a day or so later upon the
surface. From the minute, bipolar, poorly stain-
ing bacillus of vaccinia virus we find in the fluid
primary cultures described, after some three days,
besides the same minute forms, large well staining
bacilli, and others of intermediate size.
In the colonies which have developed upon solid
media, as described, only the largest forms are to
be seen, in various stages, either not distinctly
showing the bipolar effect or with this very marked.
Within 24 hours (after the first appearance of these
solid media colonies) the organisms begin to "sporu-
late" (simultaneously with their peptonization of
the media) when they show as non-staining cen-
trally, oval-shaped bodies with a tiny "spore" in
each end.* After the peptonization of the media is
well advanced (within two or three days) nothing
but the "spores" can be found, many appearing like
the primary minute bipolar bacillus of vaccinia
virus and young primary fluid cultures. These
"spores" when planted in concentrated hydrocele
fluid media usually develop only the minute form,
so that by this procedure the organism can be re-
stored to its vaccinia virus stage, or rather, develop-
ment.
Appearances in Variola Virus. — Smears made
from the vesicles and pustules of cases of variola
show uniformly, and much more distinctly than vac-
cinia virus, small bipolar bacilli. When carefully
stained, in a similar way to that recommended for
vaccinia virus, these bacilli are very distinct and
numerous. In the microphotograph of a variola
♦Throughout this article I have put the word spore
in quotation marks, since by it I mean one of the polar
bodies that escapes from the involution oval shaped
bacilli and grows into new bacilli, and not the involution
form itself.
Aug. 12, 1916]
MEDICAL RECORD.
269
pustule smear, reproduced herewith, the outlines of
most of the bacilli are poorly defined owing to the
failure of photography to distinctly record lines de-
pending mainly upon differences of refractility, such
as surround the non-standing areas; but this is not
Fig. 3 — Variola bacillus from culture on Loeffier's blood
serum. Virus taken from pustule of S. A., a negro patient of
the Kingston Avenue Hospital, at the height of a severe
generalized variola eruption. Smear stained with alkaline
methylene blue. Magnification 1650.
the case in direct observation of smears. As a case
progresses to recovery, oval involution forms, simi-
lar to those of vaccinia virus, appear.
Cultures from Variola Virus. — Primary cultures
from vesicles and pustules, made in limed bouillon
(with or without hydrocele fluid) within 3 to 5 days
show many of the small bipolar bacilli. Cultures
made on Loeffler and regularly watered with limed-
bouillon (as described in connection with vaccinia
cultures) show within about ten days numerous low
lying greyish colonies of very mucilagenous con-
sistency.
Unlike the colonies of the vaccinia organism, de-
veloped under similar circumstances, there is but
moderate tendency to subsequent liquefaction of the
media, and the first few transplants usually refuse
to grow on Loeffler unless it be "watered." After
several generations, however, the organism will
grow on plain Loeffler and will often partially di-
gest it.
The appearance of the full grown bacillus from
variola is very similar to that of the organism of
vaccinia. In the microphotographs, actual differ-
ences seem very marked, owing mainly to different
ages of the cultures used.
Cultures from Blood of Variola Case. — In one
case, blood smears were examined at the height of
the eruption and fever, and small bipolar bacilli
were observed lying free in the serum and in about
the same proportion as the leucocytes. It may be
interesting to note that the latter had increased to
about 24,000 per cubic millimeter, and were
lymphocytes to the extent of about 50 per cent.
Cultures made from the blood of this case gave
exactly similar growths (by the same methods) as
were obtained from the pustules.
Appearances in Varicella Virus. — The contents
of the average varicella vesicle is usually very
watery and organisms are correspondingly scarce.
Yet every one from which a smear can be obtained,
shows minute bipolar bacilli. The organisms are
very numerous in smears made from severe cases.
They resemble closely the bacilli of the variola
vesicles.
Cultures from Varicella Virus. — Cultures from
varicella vesicles, made and treated identically as
those from vaccinia virus, give similar results.
After two or three days in limed bouillon (with or
without hydrocele) minute bipolar bacilli are nu-
merous, and on solid media (Loeffler) "watered," as
before, in about ten days a profuse development of
grayish low lying mucilaginous colonies, which, in
another 24 hours, liquefy the media. Replants from
such liquefying colonies are very vigorous and grow
very easily on plain Loeffler, liquefying it actively
by the end of the first 24 hours.
The full grown bacillus from varicella cases is
very similar to the vaccinia organism. In an epi-
demic of varicella this spring in a Brooklyn institu-
tion, smears were made of nasal and tonsillar mucus
from three children who had been exposed to the
contagion, and in two of the three cases bacilli
exactly similar to the full grown varicella culture
organisms were found. Both these children de-
veloped a varicella eruption two days later. Similar
bacilli are uniformly present in the nasal mucus of
active cases of varicella.
In the table which follows, the complete morphol-
ogy of the organisms is given, as well as such differ-
ences between the three varieties as have been
observed :
TABLE VI. — DETAILED CHARACTERISTICS OF THE THREE
ORGANISMS COMPARED.
(Description applies to all except when it is stated
otherwise) .
I. Morphology.
Vegetative Cells (a)
Medium: Loeffler blood-serum, wet daily with "en-
livened" bouillon. Temperature: 37.5° C. Age: 7-10
days. Form : Long rods, quite variable in size — from
0.3 by 0.7 microns (as in virus smear) to about 0.6 by
3.5 microns (as in full development on Loeffler). Vari-
cella organism is usually the longest. Ends: Rounded.
Fig. 4 — Varicella bacillus. Primary culture from vesicle,
10 days on Loeffler. Stained by alkaline methylene blue.
Magnification 1.G50. This smear was made as soon as visible
colonies developed, and just before organism began to
"sporulate."
Arrangement: Small fluid-media forms — singly and in
branching clumps; large solid media (aerobic) forms —
commonly parallel and at acute angles (as diphtheria
bacilli) sometimes in chains, especially the varicella
bacillus.
270
MEDICAL RECORD.
[Aug. 12, 1916
Sporangia (b)
These involution forms appear in primary cultures,
made as above, in about ten days; in replants in
about three days. Form: Elliptical. Size: Slightly
broader and shorter than fully developed bacilli. Lo-
cation of "Endospores" : Bipolar, sometimes unipolar.
"Endospores" (c)
Forrn: Round; many, so soon as they escape, seem
to divide and produce the minute bipolar form, as seen
in the virus. Size: Round form, 0.3 microns; bipolar
form, 0.3 by 0.7 microns (approximately). Germina-
tion: Bipolar, "spores" escape through rents in ends of
cell wall.
Flagella (d)
Full grown bacilli, propagated in bouillon, are ac-
tively motile. The variola bacillus (full grown) does
not develop active motion until after several genera-
tions in bouillon of a replant from primary solid media.
Carefully stained by Gram's or Van Ermengen's
method, a single short terminal flagellum may be seen.
Capsules (e)
Usually noticeable.
Staining (/)
Virus and vesicle smear forms, particularly, and
those of primary cultures in "enlivened" bouillon are
very difficult to stain, except at the poles. Full de-
velopment forms stain easily with all the usual dyes.
Gram's: Results vary somewhat with age of organ-
isms; "spores" and polar areas are always positive.
2. Cultivation.
Loeffler's Blood Serum: Virus, vesicle, pustule (and,
with variola — as found with the one case tried — blood,
taken during the early stage of the eruption) plants,
watered daily with "enlivened" bouillon, show, after
24-48 hours, the minute bipolar bacilli — usually there
is no macroscopically visible growth. After 7-10 days,
primary cultures usually show many round, glistening,
greyish, low lying, viscid colonies. (I have seen a de-
velopment appear, in a tube protected from drying out
by a paraffined plug, as late as a month after sowing
with vaccinia virus. Sometimes, when no macroscopic
growth has appeared after a ten day incubation, a re-
plant to a fresh tube will give prompt results) Lique-
faction: This begins within 24 hours of the appearance
of the viscid colonies described, and reaches its maxi-
mum within three days. Replants: If made from fully
developed colonies of either the vaccinia or the varicella
bacillus, replants on Loeffler usually produce abundant,
flat, cietaceous growths, often wrinkled. Variola
bacillus replant cultures, have, so far, invariably re-
produced the original colony development, and usually
show slight liquefaction of the surface of the media
within three days. Vaccinia and varicella replants al-
ways produce liquefaction of nearly the entire medium.
Odor: Distinct after liquefaction, especially in the
cases of the vaccinia and the varicella organisms never
putrefactive.
Bouillon: (limed, "enlivened") Primary cultures,
during the first 48 hours, usually show no macroscopic
change, but many minute bipolar bacilli may be found
in the sediment. After 3-5 days these cultures often
become cloudy, and show numerous bipolar bacilli of
the small form, of intermediate size, and some of the
full development. Replants from the cloudy cultures,
and also replants from solid media (Loeffler) made in
plain bouillon show diffuse clouding within 24 hours, or
else, in the cases of the vaccinia and the varicella
bacilli, a surface growth similar to the replant develop-
ment described in connection with Loeffler's medium.
Sometimes these two organisms will give the surface
growth (without clouding of the bouillon) and some-
times a general clouding without the appearance of a
scum. I have seen no surface development appear in
the case of the variola bacillus.* In such transplants,
the medium from which taken and the stage of develop-
ment, seem to be the determining influence (with the
vaccinia and varicella organisms) in respect to the
form of growth in plain bouillon. The first few gener-
ations of the variola bacillus, replanted in bouillon, per-
sist in the minute non-motile form but later develop,
and continually reproduce, the large motile form.
Serum, diluted with broth or water, effects a reduction
of the variola bacillus (large form) to the minute non-
motile form, when a transfer is made to it. The same
may be effected in the cases of the vaccinia and the
varicella bacilli (large forms) but is more difficult, since
the large-bacillus form of growth tends to persist.
Nutrient Agar: Replants from profuse surface
growth of the vaccinia and of the varicella bacilli
sometimes show a growth similar to that which appears
on Loeffler within 24 hours. The variola organism
grows feebly or not at all, when so transferred.
3. Physical and Biochemical.
Gas Production : In bouillon containing 1 per cent, of
dextrose, 48 hours, at 37.5°C. vaccinia bacillus: (2nd
generation) produced no gas. Growth poor; variola
bacillus: (8th generation) produced no gas. Growth
poor. Varicella bacillus produced considerable gas.
Acid Production: In bouillon the growth of all three
organisms (large forms) produce acid. In 48 hours the
varicella bacillus, growing in 2 c.e. of this medium,
developed acidity in it which required 0.07 c.c. of deci-
normal sodium hydroxide to neutralize.
Indol Production : In 0.5 per cent. Witte's peptone,
after 72 hours at 37.5°C, the Salkowski test indicated
a feeble production of indol by the vaccinia bacillus,
a very feeble production by the variola bacillus, and a
moderately large production by the varicella bacillus.
Vitality on Culture Media: All three organisms may
be cultivated indefinitely under conditions described.
Drying: All three organisms are readily killed by
drying.
Ferments : "Sporulating" forms liquefy Loeffler
variola bacillus much less readily than the others.
*Since writing this, a slight surface growth on
bouillon, of the variola bacillus, has been observed. It
seems that the longer this organism is cultivated the
nearer does its relationship become to the vaccinia or-
ganism.
TABLE VII.— COMPLEMENT FIXATION" TESTS.
Serpm Tfsted
Patii "'
I i.
__
\< riod
S \ Variola I i;ition
S. \ \ ariola
M. I) Variola I rupt
CM \ ariola Eruption
l Normal adult Not vaccinated
- Ni rmal adult Not vaccin ted ii
Normal adult Not vaccinated since in
_' Normal adult Nol t accinati d it
Normal adult Not vaccinated
'j Noi mal adult Not ^ accii ■'
Normal adult N'ot vaccinated since infancj
v Normal adult Success! ully vaccinated with
Norma! adult 1 With-
months
I ' Normal adult Successful!; vaccinated with-
'■■ ■ Normal adult Su ssfully vaccinated with-
in 3 month*
!■ I- Moderately severe vai- Convalescence
1 Moderate^ severe vai i nee
ieclla
v vaccination
Call uter use 1 i rod inia virus
Thret tun)
Sixrabbita v .. (,f- vaccinia "seed*' -iru=
Vahiola Antigen.
Vaccinia Antigen.
Yaricell\ Antigen.
Scrum 0.01
+ + + +
+ + + +
+ + + +
+ + + +
Serum 0.02 Serum 0.O1 Serum 0.02 Serum 0.01
+ + + +
+ + -f +
+ + + +
+ + + +
+
+ +
+
+ +
•
+ + + +
+++
+ + + +
+++
Serum 0.02
+ +
+ + + +
+ +-"- +
+ _
-
- ■
+ + + -I + + + +
Not t ested
Not
+ + ->- -r i + + + +
+ + + +
+ + a .
+ + +- +J-+-t-
+ f-i- + + + +
++ ++++
Not
Not I
Not •
+ + +- + + - +
+ + -■- I + + + +
-*- + + + - r+ +
Aug. 12, 1916]
MEDICAL RECORD.
271
Filtration: Cultuies of all three organisms at the
sporulating stage passed through Berkefeld filter (No.
5) give a filtrate from which new cultures (replants)
may he reauily obtained, on media described.
4. Pathogenicity.
Work in connection with pathogenic properties of
these organisms, and natural and artificial immunity
to them, is incomplete and will be the subject of a later
publication.
Agglutination Tests. — In examining the table of
agglutination tests we note that the variola organ-
ism was agglutinated, within one hour, in variola
sera dilutions as great as 1-160, while with all of
the six normal controls practically no agglutination
developed. The sera of the recently vaccinated
showed considerably greater agglutinating power
over this (the variola) organism than that of the
average adult; the varicella sera were totally lack-
ing in this power. With the animal sera the results
were inconclusive.
The vaccinia organism was clumped even more
markedly' than that of variola by variola sera. This
organism was most specifically clumped by the ani-
mal sera tested, as is seen in the table in the case
of both the calf and the rabbits.
The varicella organism was irregularly affected
by all except the varicella sera which, strange to
say, were the only ones totally without influence
upon it.
From the standpoint of the sera examined ws find
indication from the table that specific value can be
attached to the agglutination test in the case of
variola.
Also that, in the case of vaccinated animals, their
sera have specific agglutinative power over the vac-
cinia organism.
Complement Fixation. — It was found that the
growth from the surface of Loeffier serum, before
peptonization of the media had begun, was unsuit-
able for antigenic purposes since no filtered extract
could be obtained which would give an anticomple-
ment unit. If, however, peptonization had com-
menced ( and this, as stated, is coincident with the
breaking out of "spores") a definite anticomplement
unit was easily found.
The antigen in the case of each of the organisms
was prepared as follows :
The growth from the slant surfaces of four
Loeffler serum tubes (usual 4-in. size) organisms of
respectively, 3, 5, 7, and 14 days' growth (replants),
was washed into 8 c.c.'s of normal salt solution,
sealed in a tube and heated for one hour at 68° C.
It was then filtered through Berkefeld filter No. 5
and tested.
Anticomplement units in the sheep-rabbit-guinea-
pig hemolytic system (bulk of test 0.5 c.c), were
found to be as follows:
Vari la antigen
0 15
\ accuiia .
0 0-5
\ arirella ....
... II 10
Therefore, according to the usual procedure, one-
fourth of these anticomplement units, made up to
be contained in 0.15 c.c, were used in the tests de-
tailed in Table VII.
Reviewing the table mentioned, we note that the
variola antigen gave strikingly specific results with
its corresponding serum. (The results were the
same when half the antigen unit was used.) This
antigen gave negative results with practically all of
eleven sera taken at random from normal adults,
four of whom had been successfully vaccinated
within three months. Of these four, however, one
gave a (-| — Y-) and two a (+) reaction. Negative
results were also obtained with sera from two chil-
dren convalescent from varicella.* Results with
animal sera are seen not to have been distinctive —
possibly through failure to properly control the
known anticomplementary action of such sera.
The vaccinia antigen gave irregular results with
the normal adults, with the exception of those re-
cently successfully vaccinated. The negative re-
sults, when tested with variola sera, are most in-
teresting as contributing to the establishment of
distinctions between the organisms in question.
(The three cases of variola from which the sera
came had never been vaccinated.)
Except, perhaps, with that from the calf in the
case of the vaccinia antigen, the results with ani-
mal sera were generally unsatisfactory.
The varicella antigen, curiously enough, while it
gave negative results with both variola and vari-
cella sera, gave positive tests with most of the nor-
mal adult sera tried, as it did likewise with the
animal sera.
Examining the same table for the results ob-
tained with specific sera we note that the only clean
cut results were from the variola sera. In the case
of the others (with the exception of the inexplicable
instance of the varicella sera) various plausible in-
terpretations will suggest themselves to the reader.
Thanks are due to Dr. W. T. Cannon, resident
physician, in charge of the Kingston Avenue Hos-
pital, for opportunities to get material from cases
of variola; to Dr. F. S. Fielder, in charge of the
Department of Health Vaccine Laboratory, for
blood from rabbits used to produce "seed" vaccine;
to Dr. G. W. White, in charge of the Otisville Sana-
torium Laboratory, for calf serum. Also to Dr.
H. A. Reque, for material from varicella cases; to
Dr. F. M. Sharpe, Dr. J. C. Kennedy, and to many
other Brooklyn physicians, for the same.
140 Clinton Street.
A PRACTICAL METHOD OF TREATMENT FOR
"INOPERABLE" CANCER OF THE BREAST.+
By CHARLES WILLIAM STROBELL, M.D.,
NEW YORK.
VISITING GYNECOLOGIST, WEST SIDE GERMAN DISPENSARY AND
HOSPITAL.
The purpose of this paper is to make known to the
medical profession a method of removing the can-
cerous breast, which, as regards results, has as
yet shown no subsequent remanifestation or re-
currence of the disease within the limits of the
operated area. Work and observation along this line
now cover a period of seventeen years — my first
operation having been performed in October, 1898.
In all, sixteen patients have undergone the opera-
tion. The first eight cases were reported in the
American Journal of Surgery, Nov., 1912. With
two exceptions, the eight previously unreported
cases herewith presented were operated upon at the
Memorial Hospital for the treatment of cancer and
allied diseases; the two exceptions at the West Side
German Dispensary-Hospital.
The technique has undergone important modifi-
cations since 1912. It is earnestly hoped that the
*Results from these sera are offered with reserve,
since they were negative throughout the series of tests
for some unknown reason.
fRead by invitation, at Newark, N. J., January 25,
1916, before the sections of Surgery, Gynaecology and
Obstetrics: under the auspices of the section on Gynae-
cology and Obstetrics, of the Academy of Medicine of
Northern New Jersey.
272
MEDICAL RECORD.
[Aug. 12, 1916
method will not be brought into disrepute through
inadequate technical preparation; it is a surgeon's
task; wherefore without the especial qualifications,
it were better not undertaken.
Absolute removal of all cancer cells has been,
and still is, the goal of all progressive surgical
technique, with the result of gradually improving
statistics. These statistics are, however, still far
from holding out hope of ultimate absolute relia-
bility along purely surgical lines, limits having been
reached which may not safely be transgressed. The
fatal defect lies in the inability of the operator to
know at the termination of the operation whether
or not all cancer cells are included in the removed
tissue. Neither macroscopic nor microscopic ex-
amination permits of such a conclusion. Thus the
only reliable proof of the removal of all cancerous
cells in any operative area lies in the hazardous
test of time.
These considerations, especially the frequent re-
currences in the line of incision, have led me to
proceed in an entirely different direction in the
hope of avoiding local recurrence ; and the striking
fact of non-recurrence in the sixteen patients op-
erated upon to date, indicates that there is a sound
basis underlying the method. Yet I am not on that
account here urging this treatment in the place of
the usual surgical removal of mammary cancer in
operable cases. Neither is it my intention to claim
priority in the use of any of the agents employed
in this work, or of any combination of them; the
knowledge of their nature and use is common, and
"old as the hills." Starting out with well-founded
convictions as to the cause of local recurrence, fol-
lowing cancer operations in general, my idea was
to develop in accordance therewith a simple and
practical technique for the removal of the cancer-
ous breast, to be, if possible, as extensive in scope
as is the knife, but with the added advantage of an
inflammatory reaction in the floor of the wound
capable of destroying infected cells ordinarily re-
sponsible for local recurrence; also to accomplish
this without possible further dissemination of the
disease by manipulation or incision.
Theoretical Basis.- — Theoretically, proliferating
cancer cells scattered about in the tissues, compris-
ing the floor of the usual amputation wound and
commonly responsible for recurrence, are destroyed
by a chemically induced inflammatory reaction at-
tendant upon the formation of a "line of demarca-
tion." This intense inflammatory reaction, pene-
trating deeply these floor tissues, constitutes a pro-
tective process, absent in other methods. The phe-
nomena are:
1. Destruction by chemicals of the entire cancer-
ous breast and isolated cancer cells, in situ.
2. Absolute avoidance of manipulative displace-
ment onward of loose proliferating cells through
vascular channels beyond the limits of the opera-
tive field.
3. Leisurely and safe necrotization of the con-
demned tissues to any necessary extent.
4. Phagocytic walling-off process of offense and
defense, sealing all vascular channels preparatory
to nature's own amputation at the line of demarca-
tion.
5. Intense inflammatory reaction within the zone
of tissues underlying the terminal or separated
layer of necrotized tissue, followed by vigorous
healthy granulations.
6. Regression, in varying degree, of enlarged
axillary nodes.
7. Repair always vigorous and rapid, facilitated
by autoplastic skin grafts, and resulting in a per-
fectly functionating, freely movable skin surface.
8. Unimpaired arm movement.
9. Absence of recurrence in the operated area.
This process is lethal to cells in that the active
chemical agent is absorbed by the dormant tissues
upon which it is spread. Cancer cells are not dis-
turbed, but perish where they are overtaken.
Avoidance of manipulation is ideal, as the destruc-
tion and daily removal of layers of devitalized tis-
sues proceeds from above downward — the last layer
being removed by natural processes. Leisurely the
operation certainly is, as there is never occasion
for haste.
Pain in the breast tissues in some degree there
may be both before and during removal. Pain in
the surrounding skin there would be, should one
fail to protect the outlying or surrounding surfaces
from the action of fluids draining away from under
the dressings. This latter is, however, avoidable,
while pain in the operative field is readily con-
trolled. The method is free from shock, and there-
fore a perfectly safe operative procedure. It is
particularly well borne by those well advanced in
years, and by poor operative risks in general.
The inflammatory reaction is the key to the sit-
uation and solves the problem of local recurrence.
The "walling-off" by an intense leucocytic exudate
obviates the sudden severance and consequent ex-
posure of defenseless tissue to possible reinfection.
Diminution of Axillary Nodes. — Where axillary
lymph nodes are enlarged and there is no evidence
of mediastinal involvement, as shown by a Roent-
genogram, the nodes may be simply inflamma-
tory, in which case they tend to rapid disappear-
ance. When, however, the nodes have undergone
hyperplastic, or fibrous changes, neither rapid nor
total retrogression could of course be expected. My
second case — still living — has carried such a node,
unchanged, for nine years.
It is, of course, generally recognized that when
the axillary nodes are invaded by cancer the prog-
nosis for any form of treatment becomes very un-
favorable. Greenough (Annals of Surg., Vol. 46)
reports that of 236 cases with palpable axillary
nodes, only 12 per cent, were cured by operation,
while of 275 similar cases, Finsterer (Zeit. f. Chir.,
bd. 89) reports only 4.3 per cent, cured. With in-
volvement of supraclavicular nodes, the condition
is much more unfavorable. When the axillary nodes
alone are involved, the chemical removal of such
nodes cannot be- claimed to be as thorough or rad-
ical in its operation as the dissection of the axilla
by the knife. When both axillary and supraclavicu-
lar nodes are involved, the patient will probably
sooner or later succumb to the coincident internal
metastases, and the removal of nodes would not
materially influence the prognosis. This at least is
my observation.
Indications for Chemical Operation. — The exact
scope of the applicability of the chemical operation
is as yet difficult to determine. In a general way,
to a believer in the "lymphatic permeation" theory
of Handley regarding the mode of dissemination of
cancer, it would seem reasonable to suppose that
the "microscopic growing edge" could, with more
certainty, be overtaken by the penetrating destruc-
tive action of zinc chloride and subsequent inflam-
matory reaction than by methods not accompanied
by such phenomena.
At present, it is at least clear that the operation
Aug. 12, 1916]
MEDICAL RECORD.
273
has a definite field in the several groups of cases
classed as inoperable. Particularly so in:
1. Cases of advanced inoperable carcinoma in
which the local condition is intolerable to the pa-
tient and attendants by reason of ulceration, hemor-
rhage, suppuration, necrosis, fetor, and pain. Here
the chemical operation speedily changes the intol-
erable condition to one of wholesomeness and com-
fort and restores the patient to her home and
friends. (See Figs. 2 and 3.)
2. Cases of advanced or of operable carcinoma in
which there exists a contraindication to operation
by reason of general debility, valvular disease of the
heart, or nephritis.
3. Cases of advanced carcinoma with invasion of
axillary and supraclavicular nodes, in which ex-
perience shows that postoperative recurrence is
practically certain.
In the above groups of cases the results of chem-
ical removal have been so much better than might
be expected that I naturally feel inclined to employ
the method in all breast cases in which the outcome
of surgical removal is distinctly unfavorable. Only
inoperable cases have thus far been treated.
As to recurrence of the disease, within the limits
of the operated area, following chemical removal, it
has yet to be noted.
Active agents employed in the operation are :
Potassium hydroxide (KOH) U. S. P., long
crayons, employed only in the first stage, or stage
of denudation. The substance absorbs water from
the tissues and diffuses quickly. Its effect is to dis-
organize and liquefy tissues, which it does to a con-
siderable distance.
Zinc Chloride Compound. —
J$. Zinci chloride, U. S. P., §vi.
Sanguinariae radicis, pulv., §ii.
Carbonis salicis alba?, pulv., 3i.
M. Employed only in the second stage for the
destruction of gross breast tissue.
The action of this compound may be fittingly
designated : : the chemical drive. Zinc chloride is
a safe escharotic in this operation, in that it is not
absorbed by the system to the extent of reaching
vital parts. Its "drive," so far as observed, is about
three-fourths of an inch in depth. The outer third
of this "driven" tissue dies a rapid death, becomes
hard and leathery, and may be removed; while the
inner two-thirds successfully resists its attack.
This remaining two-thirds undergoes inflammatory
reaction, theoretically fatal to cells of lower degree
of vitality than the normal.
The compound is prepared by trituration in a
Wedgewood mortar. The sanguinaria — a vegetable
escharotic and adjuvant — is combined with the
given quantity of zinc, to make a mixture of the
consistence of vaseline, or cold cream, when water
is added. Powdered willow charcoal is added to
blacken the mixture, which serves to identify it.
The coloring of the mixture is important, since thus
is made practicable the strict confinement of the
active agent within prescribed limits, which is ab-
solutely essential to a painless operation. Where-
ever the least "speck" of this black mixture settles
and is allowed to remain on the adjacent skin, there
it will destroy tissue and cause needless pain.
Armamentarium. — A well-lighted operating room
is essential. Besides the anesthetist, two assistants
will be required; long crayons of KOH; a wedge-
wood mortar, containing the zinc compound ready
for applications; a half dozen hemostatic forceps;
bandage shears, scissors, and scalpel; tincture of
iodine; steel spatulum; two six-inch thumb forceps;
ten-yard spool of surgeons' zinc oxide adhesive
plaster; good supply of gauze sponges, 6x6 inches,-
and 2-inch canton flannel strips; one pound of ab-
sorbent cotton; rubber gloves, gowns, etc. Pro-
tective compound:
K. Boracic acid, 2 parts.
Starch, 20 parts.
Zinc oxide, 20 parts.
White vaseline, 58 parts.
Anesthesia is employed in the first and third
stages only, according to the case. It may be pri-
mary, general, or local.
If primary, the production of analgesia, amnesia,
and anociassociation alone is aimed at. Agents thus
used are morphine with hyoscine or scopolamine,
combined or not, with inhalants; if general, mor-
phine, followed in a half hour with ether, or nitrous
oxide gas and oxygen ; if local, only by nerve block-
ing at the spinal roots.
Technique of primary anesthesia: One and a half
hours before starting the operation, grain 1/128
of hyoscine hydrobromate, grain 1/128 of scopola-
mine hydrobromate, and grain Vk of morphine
sulphate (or gr. 1/128 of scopolamine hydropbro-
mate, and gr. % of morphine sulphate) are admin-
istered hypodermically.
The operation starts one hour and thirty minutes
after the hyoscine-morphine injection, coincidently
with the administration of inhalants. As the work
proceeds, the patient is gently aroused from time
to time by the anesthetist, the ability of the patient
to respond being the guide to dosage.
Operative Plan. — First stage, denudation ; second
stage, removal; third stage, skin-grafting; fourth
stage (occasional only), lymphangectomy, radium,
a'-rays.
The object to be accomplished in the first stage
of the operation is the destruction and removal of
all skin layers overlying the mammary gland, to-
gether with its attached underlying fascia, and in-
cluding the nipple structures.
The object aimed at in the second stage is the
destruction and removal of all mammary and ad-
jacent infected tissues from the midsternal and
midaxillary lines, horizontally, and from the second
to the seventh ribs, vertically. This removal in-
cludes all accessible fascial structures and the major
portion of the great pectoral muscle. It may also
if required include the costal periosteum.
The object of the third stage is to facilitate re-
pair of the granulating surface by grafting it with
healthy skin taken from the patient's thigh. This
hastens convalescence and insures a functionating,
freely movable skin. It also minimizes contrac-
tures.
Persistence of enlarged axillary lymph nodes at
the conclusion of the healing process constitutes a
fourth stage in which these glands may be treated
by physical methods, or dissected out en masse.
(The role of the lymph nodes in this operation has
not yet been worked out. My experience is that in
a large percentage of cases they regress in varying
degree, or remain stationary without further mani-
festation.)
Preliminary Precaution. — A limiting or boundary
line should be drawn on the skin with moistened
lunar caustic twenty-four hours before the opera-
tion, following as closely as possible the circum-
ferential basal outline of the breast. This, by then,
blackened line must not be crossed the following
day in the process of denudation, as it provides a
274
MEDICAL RECORD.
[Aug. 12, 1916
margin of safety for the spreading action of the
chemical in the second stage, wherein the diame-
ters of the held are extended. Wide removal of the
skin is always indicated.
Operative Technique. — First stage, denudation.
— The operator may begin his work immediately the
inhalation of gas and oxygen or ether is started.
The surrounding skin .surface is first protected
from the action of the chemical by a liberal appli-
cation of the protective compound.
The destructive agent employed at this stage is
potassium hydroxide, which liquefies tissues more
or less rapidly. The commercial long crayons are
used, the holding end being wrapped about with
gauze for protection of the operator's hand. The
free end of the crayon is dipped in water and made
to pass gently to and fro over the skin surface,
within the limits previously marked. Any liquid
excess of the potassium hydroxide must be con-
stantly wiped away as it forms, to prevent its con-
tact with the skin outside the limiting silver line.
Sponges of absorbent cotton, dipped in water and
wrung out nearly dry, are best for this purpose.
Soon, a multitude of small brownish necrotic spots
appear all over the breast; these later coalesce until
the entire surface is of a light brown color. The
epithelial layers then successively peel off. Later,
the necrosis extends to the fascia. Openings appear
here and there, through which can be seen the fat
lobules. With the removal of the fascia is encoun-
tered the network of superficial mammary veins.
As the walls of these veins are destroyed, venous
oozing begins, but this is easily controlled by clamp-
ing and pressure.
The removal of the skin fascia nipple, and its
areola accomplished, the remaining portion of the
breast presents as a mass of fat lobules, exhibiting;
the characteristic concentric arrangement of the
mammary gland with its radiating vertical septa.
This process occupies on an average about the spac
of an hour, varying with the texture of the skin and
the size of the breast.
The Second Stage. — The second stage, or stage
of removal of the mammary gland proper, may be
begun, if primary anesthesia has been employed,
when denudation is completed and before the pa-
tient leaves the table. //, however, general anes-
thesia has been employed, the application of the
zinc compound would better be delayed for six
Ikiihs, or until there is certainty that the dressings
will not be shifted to adjacent skin surfaces, where
they would cause discomfort, by the restlessness of
tin patient. In either case, the protective com-
pound is removed, and strips of cotton cloth, rather
thinly spread with the zinc compound, are applied
to the breast. Care must be taken to have the zinc
compound of just the right consistence, or the agent
will "run" over the adjacent skin and cause severe
pain. The zinc compound must be kept absolutely
within the bounds set for it, and for this reason
the operation is best done at hospitals where the
nurses are familiar with the work. Proceeding
spirally from the base upward, the zinc-cotton strips
are then securely fastened into position by inch-
wide tapes of surgeon's adhesive plaster, forming a
cap when completed. At the expiration of twenty-
four hours the plaster and zinc cap is lifted off,
and the layer of devitalized tissue removed by care-
ful dissection. In doing this the operator must be
mindful not to traumatize the living and sensitive
tissue beneath, or pain and hemorrhage will follow.
Removal of the mummified layer completed, a fresh
application of the active agent is made, as well as
of the skin protective, and so on from day to day
until the deep fascia is removed and the fibers of
the pectcralis major are exposed. Upon this, the
final application of the active agent is made for
from 24 to 48 hours, according to indications.
This last layer of devitalized tissue is not to be
disturbed, but is, in a variable period of time, cast
off by an intense reactive exudative inflammation,
which extends deeply into the underlying tissues
and forms a line of demarcation. The resulting
slough leaves a finely granulating level area which
discharges a profuse lymphorrheic exudate ( see Fig.
1 ) . Febrile disturbances accompany the operation
throughout, but more especially so during the sep-
aration of the final layer or devitalized tissue, when
the temperature, pulse, and respiratory fluctuations
attain the maximum. Fluids forming under the
Fio. 1. — Character of the tissue reaction in the opei
area; thrombosis oi vessels with rich polynuclear leuoocytic
exudate into stroma ami gland alveoli.
last layer of the slough must be given early and
free exit by means of dependent drainage openings,
mainly approximating the axillary edge. The
amount of absorption is never alarming. Through-
out this second stage the nursing is of the utmost
importance both by day arid by night. The indica-
tion is best met by the application of absorbent cot-
ton sponges, changed hourly, to prevent the zinc
compound "drainage fluids from running down over
the axillary edge, and coming in contact with tin
adjacent >kin. Frequent bathing of this skin S
is of greatest benefit. The nurse should at all til
be sure that the dressings are absolutely in pi:
and not allowed to shift from their moorings. Also
she must scrupulously remove and keep off any
black "speck" or stain from the skin outside th2
line of demarcation. All the- . pracauti
may, of course, be discontinued when the final zinc
application is removed.
Aug. 12, 1916]
MEDICAL RECORD.
275
Irregular loosening or separation of the slough
will cause some discomfort, especially from the re-
sisting nerve fibers. Prompt removal of loosening
portions is best in some cases; in others, it is better
to support them and allow all to come away en
masse. Pain manifesting itself at any stage of the
operation is always readily controlled by the judi-
cious employment of morphine or codeine. Usually
none is requred.
Much might be written on the technique of this
stage of the operation. In the daily removal of de-
vitalized tissues good judgment is required to know
just how deep to cut, and in what direction, in or-
der to avoid pain and hemorrhage. Danger signals
must be respected, and these things can come only
with experience and observation. As to hemostasis,
tincture of iodine has proved to be of greatest
service. It is an ideal antiseptic as well, and should
be applied upon the slightest appearance of color.
For any obstinate oozing, such as may occur in the
removal of indurated tumor tissues or when en-
countered in the soft abscess walls, or hematomata,
the most reliable hemostatic is the zinc chloride
compound, applied to the site on a small patch of
cotton cloth and moderately compressed by means
of a wad of absorbent cotton, for a short space of
time. The action of this agent thus quickly con-
trols the situation. The application of hemostatic
forceps is not very useful in the stage of removal,
owing to the friability of the devitalized tissues,
yet occasions will arise where it can best control
the situation.
During the period of separation or sloughing,
and up to the time of skin grafting, a cerate com-
posed of: Pinus canadensis, ,-,i ; white wax and
zinc oxide, of each, ,-,iij, and white vaseline,
,",xii, is spread thickly on a square of cotton cloth,
large enough to cover the wound and three inches
beyond in all directions and applied. This dressing
should be changed every eight hours. No other will
be required throughout.
At times it will be desirable to facilitate separa-
tion of the slough when the vitality is low and re-
pair processes slow, by the application of dry or
moist heat. This is most readily and neatly accom-
plished by the employment of an electric pad 6x8
inches, with or without an interposed wet compress.
Skin Grafting. — The third stage consists of cov-
ering the granulating area with skin grafts from
the patient's thigh, by the well-known method of
Thiersch. These thin tissue paper-like grafts
should be immediately transferred to the waiting
breast surface. They should overlap the edges of
the wound. The grafts are covered with a sheet
of asceptic rubber tissue, and over this several
layers of gauze, all strapped securely into position.
This dressing need not be changed for a week,
when the grafts will all be found to have "taken."
The thigh is similarly dressed, but these dressings
are renewed every second day. The thigh surface
speedily heels over and causes no inconvenience.
The new skin soon becomes as freely movable as on
the back of the hand, and functionates perfectly.
(Pee Fig. 2.) A dusting powder of boracic acid,
following the daily cleansing or dressing, is the best
treatment for some time after the dismissal of the
patient.
Advances will continue to be slow, from the very
nature of the work. However, that progress has
been made is evidenced by the fact that at the Me-
morial Cancer Hospital, where for the past
eighteen months this method has been under ob-
servation, it has been conceded that the author's
chemical operation has a definite field in surgically
inoperable cancer of the breast.
The following six case reports from the records
of the Memorial Cancer Hospital, as also this paper,
are published with the approval of the committee on
publications, Drs. James Ewing, Wm. B. Coley, and
Richard Weil.
Case I. — Mrs. C. J., age 79, widow. Admitted May
20, 1915. Ad. No. 21418. Chief complaint, tumor of
left breast. Grandmother and aunt died of cancer.
Present illness began two years ago. First noticed
that the left breast became swollen, but no pain. About
a year ago, consulted physician, who told her that there
was a large lump in her breast. Shortly afterward she
noticed letraction of the left nipple and some discharge
therefrom. About six months ago, noticed some blisters
appearing on the skin of the breast, which broke down,
leaving a yellowish scab. This had continued up to
the time of admission, when it involved the entire breast.
Status Praescns: There is some discharge exuding
from the ulcerating surface. Clinical Diagnosis: Can-
cer of the breast. Pathological report on specimen from
lymph node: Metastatic alveolar carcinoma. (Ewing.)
X-ray of chest: Glands of hilum of lung much en-
larged and represent probable metastasis (Holding).
Operated upon by chemical method, May 27. Opera-
tion completed and ready for skin grafting, June 14.
Postponed. Patient died a week later of uremia. The
autopsy showed an advanced chronic interstitial ne-
phiitis. The temperature range from time of ad-
mission was between normal and 102°; pulse between
normal and 100; respirations between normal and 40.
Notation. — The operation was done to relieve an
intolerable necrotic local condition. Trie influence
of the operation in hastening death is problematical.
For the sake of statistics, had the renal condition
been known, the operation would better not have
been done, as it was only a matter of days, at the
best. — (Author.)
Case II. — Mrs. E. T., widow, age 64. Admitted
September 11, 1914. Ad. No. 21603. Chief complaint.
— Tumor of the breast. Mother died of cancer of breast.
She had an operation for tumor of right breast at 18 ;
and one for tumor of left breast at 28. Present ill-
ness began fifteen years ago with small nodule in re-
gion of left nipple. The nodule remained small until
three months prior to admission. It was tender but not
painful. Two months ago noticed a large lump in the
breast; pain became more constant, nipple retracted,
reddened. General condition of patient good.
Status Praesens: Left breast the seat of a large,
irregular, indurated growth, the size of an orange, not
very firmly attached to the fascia ; skin adherent, nipple
retracted. (Axillary nodes were enlarged. December
18,1915. C. W. S.) Patholigical report: Alveolar car-
cinoma; mucoid changes in certain areas (Ewing). No
X-ray examination of chest was made before opera-
tion.
Operated upon by chemical method September 12,
1915; skin grafting, September 28. Discharged, Oc-
tober 8, 1915. Temperature fluctuations between
normal and 101°; pulse, normal and 116; respirations
between normal and 24.
Notation. — The breast was removed, together
with half an inch in thickness of the pectoral mus-
cle. The resulting smooth healthy granulating sur-
face was covered with skin transplants from the
thigh. Good operative results; fine movable func-
tionating skin surface. This patient is alive and
without sign of local recurrence. X-ray examina-
tion of chest, taken February 3, 1916, shows en-
larged glands in right side of chest extending
from mediastinum out into lung tissue, apparently
along the bronchial tube. — (Holding.)
Case III.— E. ('.. age 59. Admitted Mav 21, 1915.
Ad No. 22296. Chief complaint. — Ulcerated tumor of
the rin-ht breast. Trouble began about twelve years
9<*a, when a lumr* the size of a hickory-nut was noticed
phove the rif*ht breast. This gave no trouble for nine
years, remaining the same size, movable, not tender
276
MEDICAL RECORD.
[Aug. 12, 1916
and not painful. Three years ago this nodule began
to grow rapidly larger; the skin over it became re-
tracted, puckered (pigskin), and pain and tenderness
were first noticed. One year later, the skin over the
tumor broke down, and the ulcerated area has since
increased in size until it is 4 x 3 inches in diameter.
There was never any discharge from this nipple. There
is no history of injury to the breast. Past and family
history, not important. Constant excruciating pain for
past two years.
Status Praesens: The upper inner quadrant of the
right breast is the seat of the disease. Ulcerated area
involves half of the breast. It is above the main mass
of the mammary tissues. Edge, hard and elevated;
base of ulcer is gray; purulent discharge, with foul
odor. There is a deep contraction furrow between the
breast and anterior axillary fold. There are no pal-
pable axillary nodes. Pectoral gland at margin of
breast, distinctly involved. Very corpulent female;
left leg shorter than right from old fracture of femur,
which is constantly painful. There is a pigmented erup-
tion over the upper abdomen and lower chest. X-ray
shows probable extensive metastasis in the chest
(Holding).
Clinical diagnosis, based upon physical examination,
— carcinoma of breast with metastasis in chest. Patho-
logical diagiwsis: Alveolar carcinoma
Operated upon by chemical method, June 3. Skin
grafted, June 30, 1915. Temperature range between
normal and 101°; pulse between normal and 100
respiration between normal and 24. Discharged,
August 1, 1915.
Notation. — The patient presented a very bad
physical condition generally. There was constant
sciatic neuralgia at and above the site of fracture —
almost helplessly crippled. Right brachial neuritis
streaking down into arm and breast complicated
the far-advanced condition, which was absolutely
inoperable surgically. Some avoidable pain was en-
countered during the removal. The breast was re-
moved along with a half-inch layer of pectoral mus-
cle and a large pectoral node. Later, small tuber-
cles appeared an inch beyond the inner border in
the skin. These were destroyed with KOH. The
patient made a good recovery, and is well at this
time of writing. The new skin surface is in fine
condition. X-ray examination of chest, taken Jan-
uary 17, 1916, shows adventitious tissue in medias-
tinum, very marked on the right side. No metas-
tases in lung parenchyma. — (Holding.) This op-
eration was done at the request of the medical staff,
for a demonstration of the method, the case being
surgically inoperable. A pectoral node the size of a
cherry persists.
Case IV. — Mrs. R., age 42, married. Admitted Au-
gust 12, 1915. Discharged September 2, 1915. Ad-
mittance No. 22384. Chief complaint, tumor of right
breast. Twelve months ago, patient first noticed a
bloody discharge from the nipple. Several hard lumps
developed around the nipple, and she experienced occa-
sional sharp darting pains. The discharge continued
and became more profuse in the later months. No other
history of cancer in the family. The patient had a
tumor of the right leg, which was removed at opera-
tion eight years ago. It was pronounced sarcoma. It
recurred, broke down, and finally healed, giving no
further trouble. Three months following the operation
on her leg, an abscess in her left side (flank) devel-
oped. This was opened, drained, and healed.
Status Praesens: Thorax; left breast normal; right
breast has nodules in lower outer quadrant, skin slighly
involved, nodules hard. No X-ray of chest taken. Clini-
cal diagnosis of carcinoma by five General Memorial
surgeons. No pathological examination made.
Operation by the chemical method, August 12. 1915.
Skin grafting was done August 2G, 1915. Temperature
fluctuations from normal to 101°; respirations from nor-
mal to 24; pulse from normal to 104.
Notation. — The patient was greatly debilitated
and emaciated. The breast was small and in-
durated. Removal of the breast was rapid and
painless. Skin grafting was done at the end of
the second week. Three weeks from the begin-
ning of the operation the patient was discharged.
No axillary glands were palpable. The case was
referred to me for the chemical operation by her
physician. Mrs. R., who lives in the South, reports
herself perfectly well; new skin surface soft,
smooth, flexible, and functionating; no arm stiff-
ness; general health improving. — January 15, 1916.
Case V. — Mrs. G., age 57, widow. Admitted August
12, 1915. Ad. No. 22450. Chief complaint, tumor of
breast. Five years ago noticed a small lump, the size
of a marble, in right breast. Not much growth was
noticed for the first two years. A short time later, the
skin became discolored; no discharge from nipple.
Never had any pain from breast. The mass continued
to grow, and about eight months ago the skin broke
down over the tumor. Menopause, ten years ago. No
injury to the breast; no complications during the nurs-
ing period; no other case of cancer in the family.
General appearance: Large, stout, florid woman. Sur-
gical condition. — There is a large bleeding mass, a little
larger than an egg, in the upper portion of the right
breast. It involves the nipple and is firmly adherent
to the chest wall. There are no palpable axillary or
supraclavicular nodes. The left breast is the seat of a
transverse scirrhus cancer. There is a slight indura-
tion of a portion of the scar, — it passes through the
nipple. Scar is from an ancient traumatism. Axilla,
negative. X-ray of chest, taken September 21, shows
Fig. 2. — Case VI.
Inoperable carcinoma of the breast in
woman aged 47 years.
probable metastases to both lungs. General condition,
fair.
Chemical operation begun August 30. Both breasts
were removed. Fine recovery. Skin grafting was done
September 18. Temperature fluctuations between nor-
mal and 102.8°; respiration between normal and 26;
pulse between normal and 101. Pathological report,
alveolar carcinoma.
Notation. — This patient's general condition was
very good. Notwithstanding both breasts were re-
moved, there were no complications. The nursing
was excellent. The active agent being kept wholly
within bounds, there was no pain. The breasts,
together with a half-inch layer of pectoral muscle
and a large right pectoral gland, were removed.
The patient was discharged four weeks from the
beginning of the chemical operation; no palpable
axillary glands. Last report: patient perfectly
well; has gained fifteen pounds in weight. X-ray
of chest, taken February 3, 1916, still shows proba-
ble metastases to both lungs.
Case VI. — Mrs. T., age 47, married. Nursed her
children. Admitted October 22, 1915. General history,
negative. Chief complication, large ulcerating tumor of
the left breast. Four and a half years ago, noticed
small lump in breast, gradually increasing. Shooting
pains for last six months. Systolic bruit all over chest.
Aug. 12, 1916]
MEDICAL RECORD.
277
Description of tumor: The left breast is immensely
enlarged. (See Fig. 2.) On the outer surface, are ir-
regular ulcerations that are sloughing. The general
color is purple, the surface is irregular, due to separate
bosses fixed to underlying tissue. Foul discharge from
ulcerations. Tumor surface, irregular in contour. Skin
is smooth and shiny. There are large (glandular)
masses extending toward the axilla. The induration
extends upward to the clavicle, outward to the mid-
axillary line, and internally to the costal margin.
Parallel (or nearly so) to left clavicle, is a varix-mul-
tiple enlarged vein. Ulcerations are in region of nipple.
These have sloughing bases and foul discharge. Tumor
is fixed to the skin above and to the chest wall be-
neath, is non-sensitive, and very vascular. Approxi-
mate measurements of tumor mass are 7x7x3 inches.
Pathological report, from tissue from edge of ulcera-
tion.— Large alveolar carcinoma, somewhat resembling
adenoma malignum. General hemorrhagic pigmenta-
tion (Ewing). X-ray of chest taken October 25, 1915,
shows diffuse shadow of a very large mass over the
right side of the chest which obliterates all detail at
the hilum of the lung on that side (Holding).
Operated upon by chemical method on October 29,
1915. On account of the extreme vascularity and mag-
nitude of the growth, progress was slow. Skin graft-
ing was done January 30, 1916. Temperature fluctua-
Eig. 3. — Result of the chemical operation and skin grafting in
the case of mammary carcinoma in Fig. 2.
tions ranged between normal and 102°; pulse between
normal and 120 ; respirations between normal and 26.
This patient seems perfectly well and does her usual
housework.
The two following case reports are from the West
Side German Dispensary-Hospital, where the oper-
ations were performed:
Case VII. — Mrs. J. S., married, age 64. Admitted
June 4, 1915. Multipara; menopause passed at age
45; mother died of carcinoma of stomach. Three
months ago, first noticed a "lump" in the outer part
•of the right breast. This was at first neither tender
nor painful. The tumor grew rapidly, at the same time
becoming painful. The breast was greatly enlarged;
the outer half being distorted and irregular in out-
line from the presence of an indurated mass which
was adherent to both under- and overlying fascia. The
skin, also adherent to the tumor, was unbroken, smooth,
and tense; the nipple was sunken below the general
level. There were no ulcerations. Axillary glands in-
dicated metastasis, there being a lymph node, the size of
a robin's egg, under the edge of the pectoralis major
muscle, and smaller ones near the vessels. Clinical
•diagnosis, carcinoma. Pathological diagnosis, adeno-
-carcinoma. No Roentgenogram of chest taken.
Operation by the chemical technique, June 5, 1916.
'The entire breast, a half inch in thickness of the pec-
toral muscle, and the enlarged pectoral node were re-
moved. Skin grafting was done June 20. The patient
was discharged about four weeks from admission. The
axillary glands had subsided so that they were scarcely
appreciable.
Notation. — Examination of the patient, June 15,
1916, shows the chest wall smooth ; skin soft, mova-
ble, and freely functionating. Slightly enlarged
fibrous glands in dome of axilla. No restrictions of
arm movement other than she has had for several
years, from an old dislocation. The patient was
doing her housework, and declares herself perfectly
well. She has gained twelve pounds in weight, and
is the picture of healthy old age.
Case VIII.— Mrs. D. A., age 66, married forty-one
years. Admitted October 31, 1915. Had two children,
nursed but one; always in good health; weight, 210
pounds. Menopause began at forty-eight and ceased
at fifty-two years. First noticed a hardening of the
right breast in the vicinity of the nipple in June, 1915.
Growth was quite rapid. There has been no pain, but
an occasional "stitch" runs through it. The right
breast is very greatly enlarged and distorted by the
presence of a growth the size of a large orange. This
growth is of irregular contour, hard, non-sensitive, ad-
herent to the fascia below and the skin above. The
mass occupies almost the entire breast, but mainly the
upper outer quadrant. The nipple was deeply de-
pressed, ulcerated, and discharged a foul exudate. The
axillary glands were enlarged, but not greatly so. A
large pectoral node at the outer edge of the great
pectoral muscle presented, the size of a medium horse-
chestnut. There was also a large supraclavicular node,
rather painful to pressure and of the size of a large
hazelnut. The arm was somewhat swollen and at times
painful. The surrounding skin was dotted with brown-
ish, flattened papules, ovoid in shape, and covering the
upper half of the body above the umbilicus and mid-
axillary line laterally. Pathological report, fibro-carci-
noma (Ewing).
Operation by chemical method was begun October 1,
1915. On account of the great size of the breast, the
removal occupied time in proportion. All the skin lay-
ers and the fascia or capsule of the breast were re-
moved with caustic potash under primary anesthesia,
and the zinc compound was applied. Skin grafting was
done in the third week, the grafts all taking The
patient was discharged December 1, 1915. No .r-ray
examination of chest was made.
Notation. — This patient was seen July 1, 1916,
at which time the breast area was level with the'
chest, covered with soft, movable, functionating skin
transplants. The feeling of constriction of the
chest was lessening. The arm was greatly swollen,
while the nodes in the axilla were still perceptible.
The supraclavicular node was also still palpable.
The patient's general health was improving, and
she felt well.
Mrs. A.'s condition was absolutely inoperable
when she consulted me. Surgical relief had been
denied her by other surgeons. The operation was
done as a palliative measure, since internal metas-
tasis was quite probable, as indicated by her gen-
eral condition.
17 East Thirty-eighth Street.
EPIDEMIOLOGY AND PREPAREDNESS.
By CHARLES E. NORTH. M.D.,
NEW YORK.
War, earthquake, fire and pestilence are more stim-
ulating to the public mind than any other kind of
events. The consciousness of the civic body is
aroused to a realization of the common interest and
the necessity for self-preservation by the common
danger. An epidemic of infectious disease is like
a conflagration in that it starts from a small begin-
ning, and if unchecked may spread like a fire
through a municipality or state.
278
MEDICAL RECORD.
[Aug. 12, 1916
Through the centuries, time after time, epidemics
have swept through human communities, but in
spite of their frequent occurrence and the tempo-
rary panics caused thereby, there remains a strange
lack of preparedness, and each epidemic seems to
catch the community it attacks unprepared. Re-
cently the mayor of one city remarked to the writer:
"Cities must have epidemics once in a while, and
the only way is to let them burn themselves out."
Thus the epidemic is still in most minds a periodic
dispensation of Providence which suffering human-
ity must accept. The chronic indifference of the
community to its own self-preservation has prevent-
ed the development of the science of epidemiology
and of expert specialists able to qualify as epidemi-
ologists. While it is true that there is an abundant
supply of bacteriologists, chemists, pathologists,
physicians, sanitary inspectors, and other special-
ists, yet at times of epidemic it is difficult to dis-
cover men of ripe experience in the control of epi-
demics who can qualify as specialists in epidemi-
ology. Experience with more than one epidemic as
a qualification would reduce by one-half any group
of experts called in for consulting purposes, and,
perhaps, eliminate the health officer himself. More
than two epidemics' experience would reduce the ex-
pert list another 25 per cent., and three or more
epidemics would probably reduce the list to one
man. Such is the limitation of expert practice in
this special science. In America it is doubtful
whether there are more than one-half dozen men
who can personally qualify as experts in the science
of epidemiology. As a consequence, the majority of
epidemics are handled by inexperienced persons, and
the death rate and morbidity rate are correspond-
ingly higher than they would be if standard meth-
ods in the control of epidemics in every community
were immediately applied.
Epidemiology is not bacteriology. It is not
chemistry, or physics, or medicine, or pathology. It
is not vital statistics, or sanitary science, or any
of the special branches of medical or public health
knowledge. It is a science of sciences. It partakes
of all of the other branches of medical and public
health work. Epidemiology is an overhead sci-
ence, in which the other sciences are used as instru-
ments. It co-ordinates not only the knowledge se-
cured through the special medical and sanitary sci-
ences, but it plays upon them as upon an instru-
ment, laying the emphasis when necessary on the
one hand or on the other, as the particular prob-
lem to be solved demands.
For this reason the chemist, the bacteriologist,
and the other specialists in the various special sci-
ences are not necessarily epidemiologists. The spe-
cialist with his nearby point of view may not have
the comprehensive view necessary to play the part
of a good epidemiologist. The first essential of a
good epidemiologist is a point of view which is
remote and detached so that he can view the field
from a sufficient elevation to give values which are
not distorted to the various facts and data col-
lected. The epidemiologist must not overestimate
or underestimate the value of the facts brought to
him. His view, in short, must be macroscopic,
rather than microscopic.
The science of epidemiology itself is so new that
even a definition has not been formulated. It deals
primarily with the investigation and control of epi-
demics of infectious diseases. Such epidemics can
be dividea into two great classes. The first includes
the annual or seasonal epidemics, such as infant
diarrhea and dysentery in the summer ; typhoid
fever in the fall; grippe, bronchitis, and pneumonia
in the winter, and scarlet fever, whooping cough,
chickenpox, measles, etc., in the spring. These an-
nual waves of infectious diseases sweep through
all communities with clocklike regularity each year.
The second class are those which visit communi-
ties at irregular intervals and unexpectedly, includ-
ing smallpox, cerebrospinal meningitis, typhoid
fever, septic sore throat, infantile paralysis, plague,
etc. Strange to say, the annual or seasonal epi-
demics are accepted as a matter of course and
looked upon by many health officers as unavoidable.
While the death rate from the seasonal epidemics
is far greater than from the irregular epidemics,
yet the irregular epidemic is sufficiently unexpected
to be dramatic and to cause a much greater sensa-
tion in the community mind.
Though the science of epidemiology is new, medi-
cal, literature and public health records furnish
abundant material for the establishment of certain
definite principles of action. While the collection of
data is still incomplete, and some infectious diseases
are not fully understood, yet many of the principles
are sufficiently clear to make it possible for the stu-
dent of epidemiology to recognize the action which
communities must take to put themselves in a state
of preparedness.
The work of Bentham, Chadwick, and Southwood
Smith from 1833 to 1848 resulted in a recognition
of the necessity of a centralized control by public
officials over sanitary conditions, so that the state
became a party to the health of the individual.
The Chadwick agitation brought about the estab-
lishment of a central statistical department in Lon-
don, known as the Central Register's Office, and the
history of registration of cases of disease dates
from this time. This registration was the basis of
the elementary sanitary laws established for Lon-
don, and eventually for other parts of England.
Since 1875 three fundamental principles of public
health control have been recognized in England.
Notification, meaning the reporting of cases to
municipal health authorities, was applied to London
and adopted by over eleven hundred provincial dis-
tricts. This notification is interesting because the
law provides that, "Diseases must be reported by
any one of seven persons, the duty falling in the
following order: The head of the family, the near-
est relative in the building, the person in charge of
the patient, the occupiers of the house, the attend-
ing physician, and the assistant attending phy-
sician. A notice by any one of these relieves those
who come later in the list, but not those who come
earlier. Penalty for failure to report is forty shil-
lings.'"
A second provision in the early English law is
that, "Whenever any part of England or Ireland ap-
pears to be threatened with an epidemic, the local
government board may make regulations for guard-
ing against the spread of the disease within the
whole or any part of the district of any local au-
thorities." This fixes supreme power with supreme
authority in the case of emergency.
A third important principle established by this
law is that it prohibits "illegal exposure of an in-
fected person without proper precautions against
the spread of said disorder in any street, public
shop, public conveyance, etc." This refers to walk-
ing cases of infectious diseases, and establishes con-
trol over such persons by public health authorities.
The demonstrations of Pasteur and Koch threw
Aug. 12, 1916]
MEDICAL RECORD.
279
great light on the direction which must be taken by
the science of epidemiology. For many years after
bacteria were demonstrated to be the cause of in-
fectious diseases there existed a widespread belief
that germs could live out of doors for considerable
lengths of time, and that dirt, garbage, air, dust,
rags, clothing, streets, walls, and floors were the
common means for the transmission of infectious
disease. In short, external agencies were believed
to be the means for carrying disease from person
to person. This meant the environment of human
beings rather than the human beings themselves.
As a consequence, sanitation was looked upon as
the most important weapon for the control of epi-
demics, and sanitary science, dealing with the de-
struction and prevention of external infections, was
developed as a special department of knowledge
treating with the proper cleaning up of this en-
vironment. The cleaning of streets, the disposal of
garbage, the disposal of sewage, the purification of
water supplies, the disinfection of dwellings, pas-
teurization of milk, have all been developed as a re-
sult of this era of sanitation. Faith in sanitation is
so widespread that it still remains the chief weapon
in the hands of public health authorities, and a
"clean-up" campaign is the first measure to be ap-
plied in times of epidemic diseases.
A more intimate study of the nature of infectious
disease has brought about startling revelations dur-
ing the past ten years and has created a new and
powerful influence which marks a distinctly new
era in the methods for the control of epidemics.
This may be called "the era of contact infection"
as contrasted with the older "era of sanitation."
Contact infection recognizes the bacteria of disease
as primarily parasites of warm-blooded animals,
unable to live for any great length of time outside
of living bodies. It recognizes that occasionally the
environment may be responsible for the transfer-
ence of infection, but that most of the time infec-
tion is transferred directly from person to person
by contact.
The discovery that persons in apparently perfect
health may be the carriers of infectious bacteria of
a number of well-known infectious diseases has en-
tirely changed our point of view regarding the pre-
vention of these diseases. Not only carriers, but
mild cases and missed cases are now known to be
the means of spreading infection. The picture of
an epidemic has been changed from that of a series
of sick persons, transferring disease through ex-
ternal things, to a picture of sick persons, each of
whom is surrounded by a group of those with whom
they have come into contact, and this group of con-
tacts is now recognized as the chief source of dan-
ger to the community. It is out of this group of
contacts which surrounds each recognized case that
the next crop of cases may be expected. The trans-
ference of infection frequently occurs before dis-
ease is recognized. Thus each case becomes a focus
and the center of a small, localized epidemic all its
own.
In the year 1916, however, the health authorities
even of our largest cities still cling to sanitation as
their most important weapon, and make the control
over carriers, mild cases, missed cases, and persons
who have come into contact with the recognized
cases a secondary and incidental matter. This fact
justifies us in attempting to weigh the merits of this
new principle of control by a brief survey of the
opinions of leading investigators of this subject.
Chapin, in his epoch-making book entitled
"Sources and Modes of Infection,"2 gave a powerful
impetus to the recognition of infection by contact.
He states that "Municipal cleansing is of little use
in the prevention of disease. Mild, atypical cases
and unrecognized cases of infectious diseases are
often extremely common. . . . They may be
more numerous than recognized cases. . . . Any
scheme of prevention which fails to take into ac-
count carriers and missed cases is doomed to partial
and perhaps complete failure. I have sometimes
been told that I lay too much emphasis on contact
infection, but if it is the principal way in which dis-
ease spreads, too much emphasis cannot be placed
upon it, and it seems to me that the evidence is
that it is the chief mode of infection."
Doty,3 in his book entitled "The Prevention of In-
fectious Diseases," says: "The popular fomites the-
ory is unsupported. Fomites are not the cause of
disease, but persons, insects, food, and drink. . . .
The control of disease consists in an investigation
to discover the whereabouts of those who are in-
fected and to secure their strict isolation. Also, to
detain, or in some manner keep under observation,
those who have been exposed to infection and who
are known as 'suspects,' and to detect irregular and
unrecognized cases which are largely responsible for
the outbreaks of infectious diseases."
Wassermann4 says: "In practically all infectious
diseases the existence of persons has been estab-
lished in the surroundings of all cases who are ap-
parently perfectly well, but are, nevertheless, the
carriers of the corresponding germs. These, be-
cause they go about at will, become a source of fur-
ther distribution of the epidemic."
Rosenau5 says : "The practical value of isolation
varies with each disease . . . with the exist-
ence of latent infections, missed cases, carriers and
other factors which influence the spread of the in-
fection."
Kirchner8 says : "The basis for the control of epi-
demics in war time and in peace consists in the de-
termination of the cases themselves as well as in the
establishment of germ carriers from those surround-
ing the patient. At the outset of an epidemic it is
necessary to ascertain how many apparently healthy
individuals in the patient's surroundings harbor dis-
ease germs."
Kiefer' says: "The first necessary step in the con-
trol of epidemics is a campaign of education to teach
the public something about contact infection."
Neufeld' says: "The modern fight against epi-
demics consists in the rapid, accurate discovery not
only of the patients, but also of all persons capable
of transmitting the disease germ. Experience has
repeatedly shown that excellent results were ob-
tained when undoubtedly only a portion of the dis-
ease transmitters have been checked."
Hune" says: "The number of healthy germ car-
riers is small at a time free from epidemics, in the
beginning as well as at the end of epidemics, but it
is enormously high at the height of the epidemics.
For this reason early measures alone are appropri-
ate and practicable."
MacNutt,"' in a review of epidemiology, says:
"Carriers, missed cases, and incipient cases have
within a few years been shown greatly to aggravate
problems of control and to add an entirely new chap-
ter to epidemiology, revolutionizing our views in im-
portant respects. A study of every epidemic should
include a careful consideration of the activity of this
class of cases."
The pendulum has swung too far in favor of
280
MEDICAL RECORD.
[Aug. 12, 1916
sanitation, and it is now, after many years, swing-
ing back again to contact as the chief means of the
transmission of infectious diseases. The word "con-
tagion" in its original means contact, and contagious
diseases have been called such because in the
earliest times it was believed that they were trans-
mitted by contact. We have been mistaken in get-
ting too far away from this idea, and we are now
getting back on to solid ground and a full recogni-
tion of the vital importance of contact, not only on
the part of severe cases, but on the part of carriers,
mild cases, and unrecognized cases, as the chief
means of transmitting the majority of infectious
diseases.
It is possible to draw up a list of the measures
which experience has shown are effective in the sup-
pression of epidemics, as follows:
General Measures
Legal powers
Notification
Inspection and diagnosis
Registration
Field investigations
Tabulation
S[ucial Measures
Water purification
Pasteurization
Destruction of animals
Destruction of insects
Vaccination
Serum therapy
Medical treatment and nurs- Diphtheria antitoxin
ing Nose and throat disinfection
Isolation Disinfection of discharges
Hospitalization Personal hygiene
Quarantine
Sanitation
Control of contacts
Disinfection
Education
Each measure in the list is capable of special
modification to meet the conditions created by a
special epidemic. The selection of the correct
measure and its application to the community at
the right time and in the right place requires of
the epidemiologist not only a familiarity with the
special epidemiology of the disease he is combating,
but a peculiar intuition which can be obtained only
from experience.
The application of the science of epidemiology to
American municipalities has been inefficient for a
number of reasons. The majority of communities
have not yet elevated the health department to a
position of sufficient importance. Even where finan-
cial appropriations are considerable, there is com-
monly a tendency to look upon public health service
as a political matter. Frequent changes of health
officers and appointments to such positions of men
with no particular qualifications other than political
qualifications, or with no experience, means lack of
preparedness.
Real students of the science of epidemiology are
so scarce that standard methods for handling epi-
demics are not fully recognized. As an illustration
of this uncertainty, one American author says that
"In America, when the number of cases of measles
amounts to one in one thousand of population, there
is an epidemic. In England, measles is epidemic
when there are 1.2 per thousand. In New Orleans,
measles is epidemic when there are between 2000
and 5000 cases, or 22 per thousand population ; and,
mark you, any disease is epidemic when there are
ten cases in close proximity to each other." An-
other prominent health authority administers com-
fort to the inhabitants of his community by com-
paring the number of cases of epidemic disease with
the total population, and showing how infinitely
small the percentage really is. It is a question
whether such arithmetic conveys any real comfort
to that portion of the population living in the af-
flicted locality. The addition of large groups of
healthy persons to vital statistics is hardly an ade-
i uate means for offsetting the seriousness of an
i tbreak in a limited locality.
In America seasonal epidemics are too largely
accepted as a matter of course, and no such thing
as preparedness is undertaken. In the fall the an-
nual typhoid epidemic is a distinct surprise. The
grippe epidemic in January is always unexpected.
Scarlet fever and measles in the spring is a startling
novelty. Yet such a thing as preparing this year
for the epidemics of next year is unheard of, be-
cause these surprises are chronic.
I will mention for illustration one thing which is
not done, but which might be done to reduce the
annual number of cases and deaths from in-
fectious disease. Assume a class of thirty school
children. One of them contracts measles and is sent
home. Two weeks later fifteen others in the class
come down with a rash and are sick with measles,
to the great surprise of their parents, who were not
notified by the school authorities or by the health
department that their children had been exposed.
Two weeks later in the homes of the fifteen chil-
dren, among their brothers and sisters, and in the
neighboring homes among playmates, over one hun-
dred cases of measles are discovered. Here we have
a third crop of measles cases entirely due to a need-
less exposure, because the parents were not notified,
either by school authorities or health authorities
that such exposures had taken place. Only a little
notification to parents and only a little education re-
garding the meaning of contact would have pre-
vented this third, and largest, crop of cases. Many
parents are sufficiently intelligent to understand the
importance of keeping exposed children separate
from unexposed children. The condition cited above
is not imaginary, but really exists to-day in all
American cities not only in regard to measles, but
scarlet fever, whooping cough, chicken-pox, mumps,
and all the infectious diseases of childhood con-
tracted in the public schools. The neglect of school
authorities and health authorities to inform parents
of the exposure of children to these diseases, and
to point out the value of isolation for the protection
of other unexposed children is directly responsible
for three-quarters, and perhaps a higher percent-
age, of the cases of infectious disease among chil-
dren.
Proper preparedness for the occasional and irreg-
ular epidemics which occur is also lacking. There
is no such thing as a first-class bureau of epidemi-
ology in America. No municipality employs a
specialist in epidemiology, qualified by experience to
take active control of epidemics. Municipalities de-
pend for their protection on such incidental experi-
ence and incidental organization as their health de-
partment may possess. It is small wonder, in view
of the circumstances, that epidemics, whether sea-
sonal or irregular, catch municipal health depart-
ments napping, and almost panic stricken.
New York City illustrates by its own career in-
stance after instance of this sort of unpreparedness.
A review of the epidemics from which the city has
suffered shows the imperfection of methods of in-
vestigation and control. Where the department of
health has not entirely missed the discovery of the
true cause of an epidemic, the outbreaks recorded
have pursued their course uninterrupted, and in
some instances for weeks, and even months, unan-
nounced. A health department which in other re-
spects is excellent has been peculiarly weak in its
control of epidemics.
As an illustration of this deficiency may be men-
tioned the current epidemic of infantile paralysis.
The records show that from April 13 until the last
Aug. 12, 1916]
MEDICAL RECORD.
281
day of May, 1916, there were only nine cases of
infantile paralysis in the greater city, but from
June 6 to 10 there suddenly appeared ten new cases.
From June 10 to 15 nine more appeared, making
nineteen cases in nine days. From that time on the
epidemic increased by leaps and bounds, and still
continues. The record up to this writing, tabulated
below, shows 3098 cases and 647 deaths.
Date
Cases
April 13 to June 1
9
June 2 to 10
10
June 11 to 15
19
(epidemic evident)
June 16 to 20
35
June 21 to 25
121
June 26 to 30
279
July 1 to 4
463
July 5 to 10
1.0S2
Julv 11 to 17
2,124
(control of contacts)
July 18 to 20
2.446
Julv 21 to 26
3.098
The New York City Department of Health un-
dertook emergency measures to suppress this epi-
demic the first week in July. It laid emphasis on
the cleaning of streets, disposal of garbage, and
sanitation. The reporting of cases and the isola-
tion of discovered cases seems to have been carried
out so far as possible. But a most remarkable
omission was the failure of the Department to take
any steps for the control of contact cases until
July 14. On that date, the special committee ap-
pointed by the mayor passed a resolution stating
that "It would be wise to follow the ramifications
of personal contact radiating from every known
case of infantile paralysis so far as possible." And
this work was supported by the contribution of
$50,000 from a well-known foundation to be ex-
pended under a specialist, who opened his office in
Brooklyn on the 17th of July, and with a force of
physicians and nurses undertook to follow the cases
of persons who had come into contact with this
disease. If control of contacts was good practice
on July 17, it would have been even better practice
on June 15.
Infantile paralysis is a disease in which contact
infection is the only known means of transmission.
In support of this, Flexner" says: "The virus en-
ters the body, as a rule, by way of the mucous
membrane of the nose and throat, and is readily
distributed by coughing, sneezing, kissing, and by
means of fingers and articles contaminated with
these secretions. * * * The fact has been de-
termined that the noses and throats of healthy
persons who have been in intimate contact with
cases of infantile paralysis may become contami-
nated with the virus, and that such contaminated
persons, without feeling ill themselves, may convey
the infection to other persons, chiefly children, who
develop the disease. * * * Protection to the
public can best be secured through the discovery
and isolation of those ill with the disease and the
sanitary control of those persons who have been
associated with the sick."
The Medical Record of July 8 stated : "A more
plausible theory than that of the biting of the fly
is that the disease is spread in the same way as
influenza or common colds, for it is known that the
pathogenic agent is contained in the nasal secre-
tions of the sick."
The Journal of the American Medical Associa-
tion, in its issue of July 8, states editorially regard-
ing the epidemic in California in 1913: "In prac-
tically every instance infection could be explained
on the theory that epidemic poliomyelitis is trans-
mitted by contact from acute cases or carriers.
* * * All become potential agents for the dis-
semination of the virus, as do also healthy persons
who have been in intimate contact with those who
are ill. The prevention of such dissemination is the
actual prevention of the disease."
Neufeld12 says: "The infected virus exists not
only in the patients having the disease, but also in
acute cases for at least six months after, as well as
in healthy persons in the surroundings of the sick."
The quotations are sufficient to make it clear that
the best knowledge regarding infantile paralysis is
that transmission commonly occurs by contact, con-
sequently the epidemiologist in taking steps for the
prevention of this disease must look upon the con-
trol of all persons coming in contact with the cases
of this disease, not as an incidental measure, but
as the most important measure which can be ap-
plied for the suppression of such epidemics. The
delay in applying this measure for the suppression
of the New York City epidemic is an instance of
the character of the control of epidemics so com-
monly applied in American municipalities. True
preparedness would have made it possible to apply
the right remedy at the earliest monient when the
outbreak was recognized.
The warfare against infectious diseases requires
a preparedness all its own. It is necessary to main-
tain an emergency form of organization just as a
fire department is organized. There must be not
only a perfect alarm system, but a force capable of
quick and intelligent action in the location where
the conflagration starts. The ordinary type of
bureau of infectious diseases cannot answer this
purpose. It demands a special bureau of epidemi-
ology, with a man at its head who has specialized
in that science, and with a consulting board, making
available to him, instantly and regularly, the best
consulting service. Such an organization might
well be included within the regular department of
health; but so connected with the various special
departments, such as the diagnostic laboratory,
statistician, research laboratories, sanitary inspec-
tion service, disinfection service, etc., that all of
these departments can be instantly swung into line,
not aimlessly, but as instruments in the hands of
the epidemiologist. In his book on typhoid fever,
Whipple says: "To control an epidemic and keep
it within bounds demands prompt and energetic
measures. A community afflicted with an epidemic
is sometimes almost panic stricken. Correspondents
fill the public press with theories, and many foolish
things may be said and done. What is needed is a
strong central authority that for a time can exer-
cise almost autocratic power, and a government and
a public opinion that will uphold such authority and
provide all necessary resources." Like the fire de-
partment, a real, strong bureau of epidemiology
might seem to be inactive between epidemics, but
when one estimates the cost to the community of
such conflagrations of disease as occur, it will ap-
pear that like the fire department, communities are
justified in keeping mobilized constantly an ade-
quate force, properly informed and equipped, and
capable of acting intelligently and with a strong
hand to instantly suppress a conflagration of dis-
ease.
True preparedness means that steps be taken now
for the epidemics that are to occur in the future.
Steps should be taken now for the grippe epidemic
that is to occur next January. Steps should be
taken now to prevent the scarlet fever epidemic that
is due next spring, also the measles, whooping cough
and other spring outbreaks.
It is certain that the regular seasonal epidemics
L\S2
MEDICAL RECOKD.
[Aug. 12, 1916
will yield to a campaign of preparedness. Public
education alone can be made to do wonders in the
reduction of mortality and morbidity in these sea-
sonal outbreaks. For the occasional and irregular
outbreaks preparedness also can give the com-
munity a far better service than it has ever re-
ceived in the past. The immediate application at
the beginning of an outbreak of the very best
measures for the suppression of the epidemic would
result from an adequate study of each of the infec-
tious diseases causing these irregular outbreaks
and a comprehensive plan of action readymade for
immediate application when emergency calls.
Where communities are not big enough to main-
tain a department of epidemiology of the first class,
such service should be established for the district or
county. Certainly each state should have a first-
class department of epidemiology, fully equipped to
suppress epidemics that occur within the State.
Above all, the United States Public Health Service
should have a national department of epidemiology
so thoroughly competent that it can act in inter-
state outbreaks, and, when called upon, in local out-
breaks.
It is looking ahead considerably to assume that
communities are yet ready to accept public health
service of this kind. It will probably be necessary
for each large municipality to have several severe
epidemics of its own to arouse the civic conscious-
ness. New York City should take the lead in such
preparedness. In this particular instance the suf-
fering which has occurred can be made of actual
benefit to the city if it results in immediate steps
for a stronger form of organization and adequate
preparedness for the prevention of the epidemics
of infectious diseases which experience has shown
are certain to threaten the city in the future.
REFERENCES.
1. Blyth: Lecture on Sanitary Law, 1893.
2. Chapin: Sources and Modes of Infection, 1910.
3. Doty: Prevention of Infectious Diseases, 1911.
4. Wassermann: Seuchenbekampfung im Krieere,
1915.
5. Rosenau : Preventive Medicine and Hygiene, 1913.
6. Kirchner: Z.eitschrift fur aerzliche Fortbildunq.
Vol. XI, 1914.
7. Kiefer: Journal of American Medical Ass'n Dec.
7, 1912.
8. Neufeld: Seuchenentstchung und Seuchenbe-
kampfung, Berlin, 1914.
9. Hune: Der Einfluss gesunder Keimtriiger, etc.,
Deutsche mUitara rztl. Zeitschrift, Vol. 42, 1913,
10. MacNutt: Manual for Health Officers, 1915.
11. Flexner: Journal of American Medical Ass'n.
July 22, 1916.
12. Neufeld: Spinal-Kinderlahmung; Monograph
1914.
30 Chuhch Street.
VACCINES IN ACUTE INFECTION.
By ELLIS BONIME, M.D.,
NEW ^ ORK
ADJ. PROFESSOR Mill NOTHERAPY DIVISION OF SURGICAL DEPART-
MENT, NEW voliK POLYCLINIC MEDICAL SCHOOL AND
HOSPITAL.
It is not the purpose of this paper to enlarge upon
the method of using vaccines in acute disease, but
rather to bring out five important points which are
essential to make the use of vaccines in acute infec-
tions successful.
It is well known that the failure of vaccine has
been reported most frequently in acute infections
and if we can find a way to better success in these
cases, we shall come nearer to saving life than in
any other form of disease coming under the thera-
peusis of vaccine.
Acute infection counts within its radius the most
desperate conditions; and because of failure we have
acquired a fear of the use of vaccines, — a fear
largely brought about by the idea that vaccines add
to the toxins already present in the body. I do not
wish to go into the theories of vaccine therapy in
this paper so as to avoid befogging the importance
of the points I wish to bring out. I shall not go into
a detailed explanation why the above fear is ground-
less and the reason for it entirely without founda-
tion. I shall merely state that vaccines are not tox-
ins; that they merely stimulate at the point of in-
oculation the formation of antibodies specific to the
vaccine and therefore to the disease.
The five important points that I wish to bring out
in this paper are as follows: (1) A correct etiolog-
ical, bacteriological diagnosis; (2) the correct time
of administration of the vaccine; (3) the determina-
tion of correct intervals between inoculations; (,4)
the prevention of the growth of the causative or-
ganism, or the growth of new organisms beyond the
reach of the antibodies; (5) the proper preparation
of vaccines from growths of the causative organism.
1. A correct etiological bacteriological diagnosis.
— In discussing the correct etiological, bacteriolog-
ical diagnosis, we must bear in mind that a virulent
bacteria will very often grow much more rapidly on
artificial culture media than virulent ones, and if
both are put on the same culture medium will de-
stroy the virulent bacteria. Thus it can easily be
seen how a vaccine may be made from an unrelated
organism. The failure to get results in the use of
immunotherapy has often been brought about by
the use of just such a vaccine. The taking of a
smear from the point of infection, inoculating cul-
ture tubes, and sending them to a laboratory with a
request to make a vaccine, without first determining
the causative organism, will bring about many fail-
ures without vaccine as a therapeutic agent being at
fault. I have seen containers filled with vaccine,
ready for shipment to a physician, labeled "so many
million organisms per cubic centimeter, containing
a small micrococcus, a bacillus unidentified, and Sta-
phylococcus albus." This vaccine may or may not
have contained the causative organism, and not only
is the presence of the causative organism in doubt,
but its quantity unknown, a fact which prevents
even approximate dosage.
To illustrate this point, I shall relate the follow-
ing case:
Case I. — Miss W. H., aged 28. Operated on by
suprapubic cystotomy for severe hemorrhage into the
bladder from tuberculous ulcerations in the bladder wall.
Three or four days later a severe chill occurred, fol-
lowed by temperature rise to 104° or 105°, and for 93
days this daily temperature rise continued, with remis-
sions to below normal. The patient's condition at this
time became very grave. She was greatly emaciated.
About the ninetieth day, tubercle bacilli were found
in her urine and for the first time the tuberculous origin
of the trouble was discovered. This discovery was re-
sponsible for my being called in on the case by the at-
tending physician, who knew my work with tuberculin.
The question of vaccine had not been considered up to
this time. As previously stated, acute infection had
now lasted for ninety-three days, and when I examined
her, I found her in a most desperate condition, sufferinc
from what appeared to me to be a streptococcus septi-
cemia. All urine came from the suprapubic incision,
but was not recognizable as urine; it was a thick,
creamy discharge having microscopically the appear-
ance of pure pus which on analysis showed urinary ele-
ments. A microscopical examination showed numerous
tubercle bacilli with a short-chain small streptococcus
predominating, with an admixture of other organisms
Aug. 12, 1916]
MEDICAL RECORD.
283
such as staphylococcus, and a small micrococcus, the
identification of which we did not deem worth while at
the time. Suitable culture media were at once inocu-
lated and the making of a vaccine of the streptococcus
was ordered. Meantime a stock streptococcus from a
similar condition was at once injected in order not to
lose valuable time waiting for the autogenous vaccine to
be made. The laboratory report, both a day and two
days later came back that no streptococcus grew in the
media. For a few days fresh inoculations were made
with the same result. Finally, on the third or fourth
inoculation, we were able to isolate the streptococcus.
The reports always came back that there grew either a
small micrococcus unidentified, a staphylococcus, or the
colon bacillus; and in each case I rejected the growth
for a vaccine, as I was convinced from the pus appear-
ance in the smear that the streptococcus was the causa-
tive organism. The stock vaccine proved efficient; we
not only had the patient's temperature normal within
48 hours after the first inoculation, but after three more
inoculations, during a period of two weeks, the patient
was out of bed. Pure urine appeared from the supra-
pubic wound with only a microscopic trace of pus. At
this writing the patient is still coming to the office for
tuberculin treatment, which was instituted ten days
after the first inoculation of vaccine; the suprapubic
wound is closed ; the urine which began to come through
the normal channel shortly after the pus disappeared, is
free from tubercle bacilli ; the bladder is under normal
control, micturition occurring only four or five times a
day and once at night; her weight, which was ninety
pounds at the beginning of treatment, is now 116, and
she has for the last two weeks resumed her former occu-
pation of general housework.
2. The correct time of administration of the vac-
cine.— In discussing the time of day for a vaccine
inoculation in acute infection, we must bear in mind
that time is a great factor in this class of patients.
We cannot indiscriminately give an approximate
dose of vaccine, especially if we are forced to use a
stock vaccine pending the manufacture of an autog-
enous one, and then wait four or five days for an
effect before a repetition of the dose. We must so
gauge our inoculation, that in 24 hours we may be
able to judge whether our inoculation was sufficient
to effect a beneficial influence on the patient's con-
dition.
In studying a temperature curve, in acute infec-
tion, we find that during 24 hours there is an ascent
of temperature continuing for several hours, a
period during which the highest temperature is
maintained, and then a long interval during which
the curve descends, reaching its lowest level at nor-
mal, or even below normal. The period of ascent is
the period of resistance, during which time the de-
fensive mechanism of the patient is exercised to its
maximum. At the height of the curve the patient
holds his resistance until the moment of exhaustion,
when the temperature begins to fall. During the
falling of the temperature there is a multiplication
of the bacterial elements, replacing those destroyed
during the defense and perhaps even accumulating
to a larger extent than they were present before. It is
during this period of lack of defensive power on the
part of the individual, plus the lowered temperature
which is favorable to the growth of bacteria, that
we can extend any aid by artificial means. The es-
tablishment of an antibody factory in the subcu-
taneous connective tissue, away from the point of
infection, will prevent the reinforcement of the
enemy and will turn the tide of battle in favor of
the patient. It is therefore clear that a vaccine in-
oculation should be given during the descent of the
curve ; at the same time we must allow the maximum
time for the accumulation of a sufficient amount of
artificially stimulated antibodies to produce a posi-
tive effect. And so it is best to choose an hour or
two after the high point of temperature for the day
has been reached. This will allow sufficient time for
the vaccine to become active before the lower tem-
perature of the day has been reached; in other
words, the time of the least resistance; and if the
dose was sufficient, this effect will be shown by the
high point of the day following not reaching as
great a height as on the day previous. If the height
of the day is 104° and is reached about 4 P. M., the
proper time for inoculation would be approximately
6 P. M., and the efficacy of this dose should be mani-
fested by the temperature at 4 P. M. the following
day reaching only between 102° and 103'. How-
ever, if no temperature change occurs in twenty-
four hours, then the dose given was not sufficient
and a reinoculation can be practised in the same
relation to the height of the temperature as previ-
ously.
Thus it is clear that by gauging inoculations at
the correct time with relation to the height of the
temperature curve, we can judge the effect of treat-
ment within twenty-four hours and reinoculations
will be practised without the loss of precious time.
At these reinoculations, either the dose can be in-
creased, or the discharge further examined for a
possible error in the stock vaccine used; or one can
become convinced that an antogenous vaccine is nec-
cessary without unnecessary delay.
To illustrate this the following case may prove
of interest:
Case II. — Mrs. M. R., aged 66, had suffered from
diabetes and chronic interstitial nephritis for many
years, but managed to keep in fairly comfortable health
by being under the care of physicians at all times. She
infected her great toe in cutting a corn; the infection
spread rapidly over the entire leg with swelling doubling
its size, temperature rose to 104° and the surface of the
entire limb looked almost like an erysipelas. Both from
the appearance of the leg (erysipelas) and the septic
temperature I concluded that it must be a streptococcus
infection and used as stock an erysipelas strain from a
former patient. The temperature reached its height at
about 9 P. m., and when I arrived between 10 and 11
P. M. to give the first inoculation, I found the patient in
her fifth day of the disease, with the last two days in a
very critical condition, having been constantly in a mut-
tering delirium. The pulse was very poor and the urine
showed signs of acute nephritis.
A dose of 20 mil. of the vaccine was administered, but
the temperature at 9 P. M. the following day reached
104.5°. At 11 p. m. 40 mil. of the streptococcus was
given, a smear from the serum taken from a bleb over
the ankle showed a few short chains of streptococci ;
cultures were made from this, and a vaccine ordered,
but was cancelled two days later, as the temperature in
twenty-four hours after the second inoculation had
reached only 102.5°, with the patient out of delirium,
and expressing a desire for food. The swelling mark-
edly diminished, the redness almost entirely disappear-
ing except for four or five patches about the size of a
silver dollar remaining over both sides of the ankle, two
or three over the anterior surface of the tibia, and one
just over the knee. Two days later a fluctuation ap-
peared under these red spots; under local anesthesia
punctures were made and a seropurulent discharge
evacuated from each area. Cultures produced no growths
from this discharge. Forty-eight hours after the last
inoculation the temperature came to normal and re-
mained normal until the sixth day after this inocula-
tion, when the temperature again rose to 101 " at 4 P. M.
At 7 P. M. a third inoculation was given, using 50 mil.
of streptococcus as the dose, and the next day the tem-
perature was normal, the discharge from the punctured
incisions stopped, and in another two days healing of all
these areas occurred. After inoculation of 50 mil. of
streptococcus on the fifth day after the last the patient
was pronounced cured.
Four years after this occurrence I had occasion to see
this patient at the home of one of her married daughters,
whom I was called to see in consultation; she told me
that whereas previous to this blood poisoning she had
had attacks of facial erysipelas nearly every year for
several years, the erysipelas had never returned since.
3. The determination of correct intervals between
inoculation. — Incidentally, the last quoted case illus-
284
MEDICAL RECORD.
[Aug. 12, 1916
trates this point as well. After an effective dose, it
is better to wait for the tendency to the recurrence
of the temperature in order to determine the in-
terval than it is to readminister vaccine by guessing
at the intervals; it is more scientific, it will prove
the value of vaccine by eliminating the conviction
that a spontaneous cure has occurred, and will pre-
vent the possibility of a negative phase by cumula-
tive effect. Once the temperature has again shown
a tendency to rise, the interval can be determined
for future inoculations as one day before the ex-
pected return of rise in temperature. The fear is
groundless that the return of temperature might
bring back the severe condition where vaccine may
not again prove efficacious; as when once vaccine is
effective in a given condition, it will subsequently
be even more efficacious in the same condition.
4. The prevention of the growth of the causative
organism, or the growth of neiv organisms beyond
the reach of the antibodies. — As the form of
therapy with which we are concerned is an immuno-
therapy, our defense against the invading organism
can be successful only so long as the invading or-
ganism can be reached through the circulation. But
if the infection brings about a profuse serous ac-
cumulation such as occurs in peritonitis, or in
pleuritic effusions, the antibodies, when carried into
the effusions, are so diluted that but few organisms
can be reached; on the other hand, these serous
effusions form such fine culture media for the
growth of the bacteria that, were we to permit it,
this growth could far outstrip any defensive prod-
ucts the circulation might throw into this effusion
to counteract it.
Having come to realize that our enemy is beyond
our reach, we must adopt other methods in combina-
tion with our immunotherapy to counteract this pos-
sible invasion from his stronghold. That can be
done by aspiration, by catharsis, by filling cavities
with substances that will resist bacterial growth
after the serous effusion has been removed. In the
pleural cavity this is particularly effective by using
olive oil to replace the aspirated serous discharge.
The olive oil in the pleural cavity will not only fill
the hollow when the expansion of the lung fails, but
it will also act as a lubricant between the roughened
parietal and visceral pleura. A host of other
methods exist both to get rid of, when already pres-
ent, and to prevent serous effusions, methods which
the scope of this paper does not embrace.
Again, bearing in mind that an infection may be
beyond the reach of antibodies, the failure of im-
munotherapy in cerebral infections may be ac-
counted for. We know that the cerebral cavities are
beyond the reach of the antibodies, and unless we
use antitoxic substances injected directly into the
cerebrospinal circulation, immunology must prove
a failure here.
5. The proper preparation of vaccines from
growths of the causative organism. — In dealing
with autogenous vaccines, it must be borne in mind
that slipshod methods may creep into a bacterio-
logical laboratory as well as into any business in-
stitution. I know of instances where standardrza-
tion is done by comparison of the opacity of the
resultant suspension of bacteria in the normal saline
with other opaque fluids, supposed to be equivalent
to certain bacterial counts. Unless great care is ex-
ercised in the making of vaccines, autolysis of the
bacteria may occur, making the vaccine innocuous.
Again, it may not be amiss to mention that the
improper treatment of the infected culture tube may
play an important part in producing an inactive
vaccine. For instance, if an infected culture tube
is exposed to cold or allowed to lie around for any
length of time, although we may get the microor-
ganism to grow again when placed in an incubator
at proper temperature, it may have become so at-
tenuated that it will no longer stimulate antibody
formation; or else its stimulation may become so
feeble that it will have very little value as a vaccine.
In conclusion I would like to call attention to the
fact that many elements enter into the use of the
artifically induced immune response as a thera-
peutic agent besides those I have mentioned. And
if the points I have brought out in this paper are
not found as important as I wish to make them, at
least let this writing serve as a warning against the
disregard of vaccine in acute infections before a
thorough analysis is made and the cause of failure
discovered elsewhere than in the vaccine itself.
24 East Forty-eighth Street.
THE HISTORY OF CONDENSED MILK, WITH A
NOTE ON ITS THERAPEUTICAL USES.
Br PAUL BARTHOLOW. M.D..
NEW YORK.
The history of condensed milk emerges bit by bit
from beneath the records of kindred industries, as,
for example, the refining of sugar and the evapora-
tion of fluids and substances liable to decomposition.
It deals with important subjects in physics and
chemistry which have been stowed away from sight
and have therefore been unduly neglected. It is al-
most essential in understanding the uses of con-
densed milk that we should know something of the
principles upon which it is made, yet this knowledge
has hitherto ended at the "curtain" or peroration of
the lecturer or manufacturer when introducing con-
densed milk as a food for children and babies. The
mere mechanics of the subject should preserve us
from a view so superficial.
Some of the contributions to this science do not
demand much notice. The dissertation of Braun,
and the brief history of Hosford in the Milch. Zev-
tung several decades ago, come to nothing, or next
to nothing, for they describe methods of manufac-
ture that have long since gone to pieces. Mohan,
indeed, has given us something more in a brief ref-
erence to the patents of Newton and of Green, but
it is not clear whether he has read the original speci-
fications or not. For, as to Green's patent, it can-
not be stretched to cover any method related to the
manufacture of condensed milk.
The invention of the process really originated
with Howard, whose vacuum pan recalls some names
illustrious in science and trade. It was invented,
wrote Maumene in his "Fabrication du sucre," t. i.,
3, in 1816. The account of the apparatus was given
by Howard's friend, Thomas Thomson, in the Annals
of Philosophy, 1816, Vol. 8, p. 209, which was trans-
lated and published in the Annates de chimie et de
physique, 1816, p. 373. "In the ordinary way of
boiling sugar, the temperature is so high that a
considerable portion of the sugar is converted into
treacle. Mr. Howard's vessels are globular, and of
copper, and connected with an air pump, which is
wrought during the whole time the boiling goes on.
The consequence is that a vacuum is formed within
the boilers. This enables the boiling to take place
at a temperature so low that there is no risk of de-
stroying any of the sugar. The vacuum is such as
to support a column of mercury from one to four
inches in height. There is a thermometer attached
Aug. 12, 1916]
MEDICAL RECORD.
285
to each boiler, and likewise a mercurial gage to
give the degree of rarefaction." (From A Short
Sketch of Mr. Howard's New Process of Refining
Sugar). Manufacturers of sugar and of condensed
milk have made full use of this invention. The
vacuum pan described in Thomson's memoir is virtu-
ally the same as the globular and cylindrical ap-
paratus in use to-day. According to Foster (Treat-
ise on Evaporation) "the vacuum pan is quite as
old, even older than the multiple apparatus . . .
it has the same unpractical globular form, low and
confined evaporation space, small heating surface."
These passages describe the vacuum pan used in
refining sugar and in condensing milk; they show
that the two industries are inseparably connected.
Even the multiple system of Wellner-Jelinek by
which large surfaces of milk or sugar are exposed to
evaporation, is used by some manufacturers, in
making evaporated milk, which in this context must
not be confounded with condensed milk. It is cer-
tainly important that Howard's vacuum pan has
given such an impulse to the manufacture of con-
densed milk.
What must be regarded as the most valuable fea-
ture of Howard's system is generally found in the
manufacture to-day. In nearly all factories the
vacuum pans are worked upon the general principle
of Howard's. The air is kept, by the working of
an air pump, at such a state of rarefaction that the
milk boils at a temperature too low to cause brown-
ing, and the other changes incident to exposure to
a temperature of 100° C. By carefully regulating
the supply of heat to the pan, and of cold water to
the condenser the progress of the operation being
watched through a glass plate in the roof of the
chamber, the condensation is carried on at a rapid
but uniform rate until completed. The milk after
sugar is added is raised to such a temperature that
it may begin to boil immediately when brought into
the rarefied atmosphere of the vacuum pan.
Richmond in his "Dairy Chemistry" refers to the
multiple evaporation system, without, however, tell-
ing us where it is employed. A vacuum pan with
a fairly large vapor space is used by the best manu-
facturers in America. The heat is carefully regu-
lated, as well as the cold water to the condenser,
and the milk is boiled at an even, rapid rate until
concentration is sufficient, a point easily told by an
experienced operator. The pans have a large heat-
ing surface, fitted with coils, as in the Wellner-
Jelinek system. There is a high vapor space and
low boiling level, unlike many pans in which the
steam coils occupy most of the space, leaving little
or no room for the charge. In a really good and
modern pan the full charge is only 0.1 to 0.12 meters
above the top row of tubes, which are of copper.
These tubes are placed in 2, 3, or 4 rows, according
to the size of the pan, and heated separately with
steam. A high vapor space in the pan is indis-
pensable to the manufacture of a good brand of con-
densed milk, since it allows the dispersion of gases
from the mass of boiling milk. Such a system, how-
ever, is in my experience not often seen, the proof
being the low standard of condensed in the constitu-
ents of the original milk. According to Tibbies,
these variations in the composition of condensed
milk are so great that it is essential that some
standard should be fixed. Now, a medium quality
of cow's milk would contain before condensation 3.3
per cent, of fat, and condensed to one-third its bulk
10 per cent, of fat. Such milk should also contain
8.5 per cent, of solids-not-fat before evaporation,
and the condensed substance at least 25 per cent, of
solids-not-fat. It has therefore been an established
custom of the British Government to stipulate that
it should contain not less than 10 per cent, of fat,
and 25 per cent, of solids-not-fat. The Board of
Agriculture made the following regulation under
Section 4 of the Food and Drugs Act 1899.
"That any condensed milk (other than that labeled
'Skimmed Milk' in conformity with provisions of
Section 2, Food and Drugs Act, 1899) in which the
amount of milk-fat is less than 10 per cent., or the
amount of solids-not-fat is less than 25 per cent,
shall be deemed to be so deficient in some of the nor-
mal constituents of milk as to raise a presumption
until the contrary is proved, that it is not genuine."
This English rule is a good one, and should be
followed.
It is now more than fifty years since Gail Bor-
den first manufactured condensed milk on a com-
mercial scale. In 1856 he received a patent for a
"process for concentrating sweet milk by evapora-
tion in vacuo, having no sugar or other foreign
matter mixed with it." Readers of advertisements
naturally conclude that he invented condensed milk;
at least that is the impression these advertisements
make until corrected. But there is no doubt in the
minds of those who have studied the history of con-
densed milk in detail that it was a Frenchman who
first thought of it, and an Englishman, named New-
ton, who perfected it. The Frenchman was Appert,
who in 1809 published his "L'art de conserver
toutes les substances animales et vegetales." This
little book, which is now extremely rare, was dedi-
cated to Gay-Lussac. At the time Gay-Lussac was
a Member of the Board of Arts and Manufactures.
His opinion of Appert's method is of particular in-
terest. "The Board of Arts and Manufactures," he
wrote, "has reported to me the examination it has
made of your process for the preservation of fruits,
vegetables, meat, soup, milk, etc., and from that
report no doubt can be entertained of the success of
such a process. As the preservation of animal and
vegetable substances may be of the utmost utility
in sea voyages, in hospitals and domestic economy,
I deem your discovery worthy of an especial mark
of the good will of the government."
Appert tells us how he condensed milk, "reducing
it to two-thirds of its original volume." He sweet-
ened it with sugar, though sugar, he says, is "hurt-
ful to the patient." Evidently he disliked sugar.
Indeed, his opinion on its use for preserving milk
might have been written at the present day. I quote
it at length. "A second inconvenience is this, that
a large quantity (of sugar) is required to preserve
a small quantity of milk; and hence the use of it is
not only very costly, but even in many cases per-
nicious."
It is clear that the original idea in condensing
milk was to preserve it, and its appropriate uses
are equally distinct. Preserved or condensed milk
was intended for armies, fleets, and hospitals, and
not at all for children or babies. An English trans-
lation of Appert's work was published in London in
1811. Englishmen followed Appert in his process,
and a patent for evaporating milk in a vacuum pan,
it is stated vaguely by Mohan, was granted to Green
in 1813. I have been unable to find this patent in
the Specifications of British Patents. But there is
a patent that was granted to Green in 1850 for the
"preservation of substances liable to decomposition
and destructive agencies." (Eng. Pat. 13,420.)
There is no doubt, however, that the process of
286
MEDICAL RECORD.
[Aug. 12, 1916
condensing milk in vacuo was fully developed in
1835 in the patent granted to Newton. (Eng. Pat.
6787, 11 March.) As the words of the specification
tell the story of the original condensed milk, it is
worth while to repeat them. (Specifications of Brit-
ish Patents 1830-1835.) "A method for preparing
animal milk and bringing it into such a state as
shall allow of its being preserved for any length of
time with its nutritive properties and capable of
being transported to any climate for domestic or
medicinal use."
"Taking the milk in a fresh state, as drawn from
the animal, having first strained it, if necessary, to
get rid of any dirt or other improper matter which
may have accidentally fallen into the pail or other
vessel while milking, I introduce into the milk a
small quantity of pulverized loaf sugar, say, from
fiftieth to one hundredth part in weight of the whole
quantity of the milk, which quantity may, however,
be greater, dependent upon the desired sweetness of
the preparation when completed. On the sugar be-
coming perfectly dissolved I subject the milk to a
tolerably rapid evaporation, either by blowing
through the milk warm or cold air by means of a
suitable apparatus of any convenient form such, for
instance, as those at present in use for evaporating
syrups, or by means of external heat in connection
with a vacuum above the surface. . . . Warmth
will best be obtained from hot water or from steam,
or heated air. ... By evaporating the aqueous
particles of the milk in this way, its nutritive or
essential parts may be concentrated, and its sub-
stance reduced to the consistency of cream, honey,
or soft paste, or even into dry cakes or powder, and
may in the latter states be exposed to the air for
a length of time without being impaired, the sugar
tending to preserve it. By dissolving the milk so
prepared in a proportionate quantity of warm or
cold water the original milk is reproduced, with all
its properties, original flavor and salutary quali-
ties."
These early methods of making condensed milk
proved most expensive undertakings. Though the
quality of the product was good, even superior, the
quantity was clearly not great enough for the needs
of fleets, armies, and hospitals. It is therefore no
small achievement of Gail Borden to have manufac-
tured condensed milk on a scale meeting commercial
conditions and requirements. I am inclined to think
that the article he produced in 1857 was of better
quality than the present brands. In 1857 a com-
mittee of the New York Academy of Medicine pub-
lished a report on condensed milk after a visit to
Gail Borden's laboratory. The details are not com-
plete, but enough is said to make a not unpleasant
picture. In the following words we get the im-
pression of a primitive process, but one which is
not tainted by modern arts. "The milk, immedi-
ately after leaving the cow, was strained into an or-
dinary milk can, then placed in a cold water b?.th
until it was entirely deprived of its animal heat.
It was then heated to a temperature of 175° Fahr.
The milk is now passed through a second strainer,
and without delay removed to a vacuum pan, where
water is evaporated. This pan consists of a large
metallic vessel supplied with a jacket for the re-
ception of steam, by means of which heat is ap-
plied." It is not stated whether sugar was added.
The uses of this condensed milk are appropriately
noted. It "imparts a delicious flavor to coffee, and
whenever used in the various departments of th"
culinary art has given entire satisfaction." At the
end of the report the committee publishes letters
from the stewards of steamship companies praising
the milk as an article of food on long voyages.
The indications for the use of condensed milk are
plain. It is both a food and medicine: a medicine
for invalids, the sick in hospitals; a food for sol-
diers, sailors, and travelers. Its chief fault is the
seductive sweetness that makes such an appeal to
children. Again, the saturation of low-graded milk
in sugar is a source of profit to manufacturers. At
present the conditions of trade are such as to make
the original uses of condensed milk more significant
than ever. The food crises in Europe has reached
such an acute stage as to necessitate the constant
production of condensed milk for the armies and
adult civil population.
BIBLIOGRAPHY.
1. Maumane: Fabrication du Sucre.
2. Wing: Milk and Its Products.
3. Tibbies: Foods.
4. Willoughby: Milk: Its Production and Uses.
5. Braun : Ueber kondensierte Milch.
6. Hosford: Milch-Zeitung 1877-8.
7. Mohan: Joum. Soc. Chem. Ind., 1915.
8. Crato: Kondensierte Milch aus mager Milch.
Veroffentl. aus d. Gebiete d. Militar Sanitatswesen,
Bd. 55.
9. Richmond : Dairy Chemistry.
10. Carrick: The Menace of Skimmed Condensed
Milks.
411 East Forty-first Street.
THE PROBABLE FUTURE EVOLUTION OF
INSURANCE MEDICINE.
By H. E. MACDONALD, M.D.,
LOS ANGELES. CAL.
LECTURER ON LIFE INSURANCE EXAMINATION, COLLEGE OF PHY-
SICIANS AND SURGEONS.
Life insurance is now doing a wonderful work but
its present field of operation is greatly restricted;
whether necessarily so is subject to argument but
that it should be enlarged, if possible, is not a mat-
ter for dispute, because even a casual observation
discloses the fact that as the business is now con-
ducted the life insurance agent is laboring under
an almost impossible condition — those who are able
to secure life insurance do not urgently need it
while those who need it most cannot get it. Let
us see if the present unsatisfactory condition is
necessary and, if not, how it may be remedied.
The average duration of life does not change rap-
idly from generation to generation. It is true the
potential longevity of man now is only a fraction
of what it was in antediluvian times and actuaries
tell us it is now being shortened in each genera-
tion. It doubtless will continue to fall so long as
doctors rely on the augmentation of immunity to
prevent disease, (see "Physiology and Pathology of
Senescence," So. Cal. Practitioner, May, 1911), but
by using the statistics compiled in recent genera-
tions it is possible to quite accurately estimate the
average duration of life in this generation. There-
fore it is safe to insure the inhabitants of a country
basing the price charged upon mortality tables; it
is also safe in the same way to insure all the in-
habitants of a state, even of a healthful county. It
is not safe, however, to insure those who volun-
tarily apply for insurance because it was found
early in the history of insurance that those who are
anxious about their health are prone to apply for
insurance while those in good health do not seek it.
This character of human nature is a thorn in the
Aug. 12, 1916J
MEDICAL RECORD.
287
side of the insurance business. With the discovery
of this trait in men there appeared two new factors
in the insurance scheme — the agent to solicit the
healthy, and the medical examiner to keep out the
diseased.
But the entrance of the doctor into the insurance
business marked the beginning of the end of insur-
ance as it is now conducted. The plan of life in-
surance based on mortality tables of average lives
has no place for the medical examiners. Ignorance
of physical condition is required for life insurance
to be ideal, and just as knowledge of the health of
applicants comes in, the pure insurance feature will
go out of life insurance, for common honesty will
demand that the cost of insurance will depend on
the individual risk if this risk be known and, to
carry the thought to its ultimate conclusion, if
death could be accurately anticipated life insurance
would be a crime.
This of course would not affect the legitimacy of
accident insurance, and accident insurance, if we
cling to mortality tables while using medical exam-
iners, is certain to be the insurance of the future.
If we exclude present infection in an applicant by
scientific test and demonstrate, by examination, a
normal nervous system, a perfect heart, soft ar-
teries, good lungs, healthy kidneys, and a digestive
system in good working order, then it is not life
insurance he needs so much as accident insurance
for almost any illness he may contract will be acci-
dental.
I might say, in passing, that accident insurance
of the future will cover infection, because contract-
ing an infection is generally as accidental as a lick
on the head. The present line drawn by accident
companies between sickness and accidental injury
is a purely imaginary line. For instance, they ad-
mit that ptomaine poisoning is an accident, but
claim autointoxication is a disease. The fact is
autointoxication, so-called, is often caused by
putrefactive germs in the intestinal canal. It fol-
lows the only difference between this form of auto-
intoxication and ptomaine poisoning, as recognized
by accident companies, lies in this : in ptomaine
poisoning the germs make the ptomaine outside the
body while in autointoxication the ptomaine is made
inside the body, a distinction too fine to be drawn.
Accident insurance in the future will cover infec-
tions and a premium will be charged commensurate
with the risk involved. This will eliminate the dis-
satisfaction now prevalent and it will demand a
thorough examination by accident companies.
To get back to life insurance, the ideal insurance
is state insurance where everybody, sick and well,
is compelled to carry a certain amount of insurance,
the premiums charged being the premiums of our
life companies to-day. At the present time this is
impractical. But is life insurance as conducted to-
day a dishonest business? No, it is not dishonest
but illogical. The managers and actuaries probably
honestly believe they are running the business on
the foundation of the average expectation of life as
shown by mortality tables. But some men by ac-
tual measurement are as old at 30 as others at 60.
(See "How Old is Ann?" So. Cal. Practitioner, Sep-
tember, 1916.) The fact is life insurance is run on
the firm foundation of medical science and the abil-
ity of examiners to measure the expectation of in-
dividual lives. If this be true there is no logical
reason why insurance should not be issued to sick
and well alike. The mortality in typhoid fever,
lor instance, is just as uniform as is the mor-
tality experienced by the various insurance com-
panies.
We, the medical examiners, are willing to assume
the responsibility of making prognosis in all cases
and will promise to place the actual mortality as
near (if not nearer) the expected as we do at the
present time. Now we are asked simply "Is this a
good risk?" Then we will be able to say how good
or how bad.
If the insurance business continues to be con-
ducted by private corporations there is bound to
come a time when life insurance premiums will be
made according to the risk involved. This means
competition in prices. It also means examinations
or appraisements and price-making before insurance
is sold. It will also require thoroughly scientific
diagnostic and prognostic methods. At first thought
it may appear that this would be a very expensive
method of conducting the insurance business but I
believe it will be almost free from expense.
Suppose an insurance company decide to conduct
their business in this way. They will hold their ex-
amination in prognosis after the graduation of a
class in a medical college. Those who pass will be
appointed examiners whose duty it will be to exam-
ine insurance prospects for a small fee or nothing.
In doing this they will immediately have a practice,
unremunerative it is true, but it will grow into a
paying practice which will be along the line of pre-
ventive medicine, which will be the medicine of the
future and which will be ushered in immediately by
this plan of making life-insurance examinations.
That the procedure may threaten to undermine
the whole structure of medical ethics will not stop
it and there will probably be a way to avoid this
catastrophe. Who knows that competition in prices
in the insurance business may not ultimately be the
life of the insurance business as it now is of every
other business?
But whether they insure substandards or not the
company that adopts the plan of examining pros-
pects and suspects free of charge is going to get
the lion's share of the insurance business. It will
put new life in life insurance and will take the
drudgery out of the present agency methods.
Bakek-Detwiler Building.
Alcoholism a Symptom.— W. A. White states that a
normal man does not become an inebriate. This goes
counter to the accepted belief that an alcoholic has
simply been overcome by a habit-forming drug. Take
away his drink and he will never become normal. In-
efficiency to face the world leads him to resort to liquor,
and when he is deprived of the latter he still remains
inefficient. Some men also have periodic psychoses
which may be ushered in by a drinking spell and cease
to want drink when the psychosis has ceased. Ineffi-
ciency is accompanied with a desire to escape the sense
of reality, which may lead a man to shut himself up
and drink to stupor. From the author's viewpoint
alcohol in such cases is never a stimulant and differs
from a mere habit-forming drug which call for use in
ever increasing amounts. — Interstate Medical Journal.
Treatment of Human Rabies. — Geiger reports thirty-
three cases of rabies in man occurring in a recent epi-
demic in California. Nine people had begun or finished
the Pasteur treatment, but according to the canons of
treatment in only three of the nine is failure to be
charged. Short incubation period showed extreme
virulence, and twelve patients had been bitten about
the face. The average duration of illness was three
days. In but six cases had the bites been cauterized.
There were two cases of pseudo-rabies, one simulated
and the other hysterical, which are not included. The
dog accused remained healthy. No sedative was of any
avail, and this is true of quinine. This is an old
remedy recently revived. — California State Journal of
Medicine.
288
MEDICAL RECORD.
[Aug. 12, 1916
Medical Record.
A Weekly Journal of Medicine and Surgery.
THOMAS L. STEDMAN, A.M., M.D., Editor.
PUBLISHERS
WM. WOOD &. CO., 51 FIFTH AVENUE.
See fourth page following reading matter for Rates of Subscription
and Information for Contributors and Subscribers.
New York, August 12, 1916.
CHEMOTHERAPY OF TUBERCULOSIS.
The many failures in the field of serotherapy dur-
ing the past quarter of a century, beginning with
Koch's discouraging fiasco in 1890, and the large
measure of success obtained with salvarsan and
similar products in the treatment of syphilis, not
to mention quinine in malaria and ipecac in amebic
dysentery, have turned the attention of experi-
menters and clinicians to the possibilities of chemo-
therapy in the conquest of disease. As ever, tuber-
culosis is the touchstone in all those attempts, and
this for many reasons: it is the most common of
all mortal diseases, so that material for study and
experiment is never lacking; its germ is known, so
that experiments in vitro as well as by animal in-
oculation are easily carried out; its course, once it
has reached the second stage, is so almost invari-
ably progressive that its arrest under any method
of treatment would seem fairly attributable to the
measures thus carried out; and finally the fame to
be accorded one who discovers a real cure of the
disease is so great as to tempt many to put forth
their best endeavors to obtain it.
One of the latest of these experimental studies
has been made by Gensaburo Koga of Tokyo who
makes a preliminary experimental and clinical re-
port in the Journal of Experimental Medicine for
August, 1916. He used a compound of copper and
potassium ferrocyanide treated in a special way so
as to prevent the formation of free hydrogen cya-
nide. In the animal experiments, in which over 150
guinea-pigs were used, the preparation exerted a de-
cided action upon the tuberculous lesions. A single
injection was without any appreciable effect, but
after repeated injections a decided regressive
change was observed in the lesions and the number
of bacilli decreased until they were finally no longer
to be found on microscopical examination. That the
tissues were not absolutely sterile, however, was
shown by the fact that injection of emulsion of the
same into the peritoneal cavity of guinea-pigs was
followed in some instances by the development of
tuberculosis.
Trials of the copper cyanide in the treatment of
human tuberculosis were made in a number of
cases, reports of eleven of which are given in some
detail. The author's conclusions, which seem to be
justified by the reports, are "that the preparation
greatly improves or apparently cures pulmonary
and surgical tuberculosis in the first and second
stages, and that it seems also to produce beneficial
effects upon the disease in the third stage. The
duration of those beneficial efforts is still to be es-
tablished by more numerous trials and many years
of observation." In the same journal is a report
by Morisuke Otani of eighteen cases treated with
Koga's preparation, in a number of which very fa-
vorable results were obtained, though in some abso-
lute failure was noted.
We have thought it worth while to comment upon
these experiments, in spite of the fact that Koga
does not give directions for the preparation of the
drug, apparently therefore intending to keep it
secret, because they present a strong argument in
support of the value of chemotherapy in tubercu-
losis and, by analogy, in other infectious diseases.
The trustworthiness of the reports and the repute
of the authors may be accepted on the authority of
the journal which publishes the papers. It is not
to be supposed, however, that there is only one
preparation that is sufficiently parasitotropic and
not too organotropic to be efficacious in the treat-
ment of tuberculosis and other bacterial diseases;
indeed we have considerable evidence to support
Barton L. Wright's claim that succinimide of mer-
cury has this property and that tuberculosis and
many other infections may be controlled by intra-
muscular injections of this drug. Its efficacy has
apparently been proved in various diseases by a
number of observers and it possesses the great ad-
vantage of being an open remedy, always to be had,
and available by any one of ordinary competence.
Kago's and Otani's reports are of great value as
affording additional testimony regarding the effi-
cacy of chemotherapy in bacterial infections, and
the experience of Wright and others would appear
to justify further trials with succinimide of mer-
cury along this line of therapeutic endeavor.
THE DEVELOPMENT OF PHYSICAL RESERVE
FORCE.
Whatever other significance there may be in pres-
ent-day military movements in the direction of
preparedness, it indicates a physical renaissance
that must redound to the good of the race gen-
erally and to its stability particularly. Physical
improvement, as such, even if separated from a
mental improvement of the race, is of great benefit.
Physical development the result of healthy indul-
gences can go a long way to overcome the unhealthy
tendencies, the sedentary life, and the vices of
present-day civilization — to such an extent the fore-
runners of physical and mental decay. Perhaps the
enormous increase in the mentally deficient is actu-
ally the result of these tendencies, and not merely
relative, as is so often claimed. In any event, even
the training of these defectives must be essentially
a physical one. First, they must be taught the
muscular power and the muscular coordination be-
fore they are prepared for much mental training.
"A crooked mind in a crooked body" is as true as it
ever was. The oft-repeated charge that a great
mind and a great body do not go hand in hand is
not true. The college athlete with a poor record in
Aug. 12, 1916]
MEDICAL RECORD.
289
his mental work is a poor student only because all
his attention, all his time, and all his energies are
directed to the athletic pursuits to the neglect of
the mental. There should, of course, be maintained
a proper balance here, as everywhere. In the build-
ing up of the body it is not the barbaric sport that
is demanded, or the highly competitive, but rather
the rational sport aimed at the development of defi-
nite muscle groups and the general increase of their
resisting power or reserve force. The barbaric and
the highly competitive sports are signs of physical
decadence, in which the decadent, being themselves
unable to get personal benefit from physical exer-
cise, demand this from others to stimulate their
failing powers.
The importance of increasing the muscular power
and the muscular reserve is at once apparent when
it is realized that the muscles are really the internal
organs of respiration, wherein the interchange of
blood necessities takes place. The increase of mus-
cular power increases the extent of this respiratory
membrane. The tendency toward physical training,
as well as its specialized form, military training,
does not aim so much at the increase of the actual
physical power as at the increase of the reserve
power. The former, no matter how small, is usu-
ally sufficient to mainttain ordinary bodily needs.
But the ordinary muscular force is wholly inade-
quate to sustain any unusual demands of the
body, whether from disease or otherwise, and
against which the body must be prepared. The laity
speak of the increase of reserve force as a "hard-
ening" process. Under this conception it is believed
that any hardship or discomfort increases the body
reserve, and that the more suffering and hardship
the better. The more comfort and ease under which
one lives, the less reserve force there is developed —
because not needed — and the "softer" they become.
Hardening is exercise of the wholesome kind against
resistance. It must, however, be done with an eye
on the actual powers of the body, from the stand-
point of endurance. The amount of fatigue must
never rise beyond a point where the fatigue products
can be easily absorbed and the body recuperate.
Otherwise, whatever increase of power there is will
be actual, and needed to drive a less easily running
human engine. There may be increased muscular
power, but it will be bound — "muscle bound" to the
actual needs of the body.
To be rational, the hardening process, or the re-
serve building, must be periodic and ever increas-
ing. The body must be immunized, so to say,
against a certain amount of fatigue toxin before
it attempts to incur more of it. The belief that the
body can be placed indiscriminately in positions of
discomfort and hardship which will of necessity be
the means of improving it is fallacious. For a
body that is already on the ragged edge this sort of
immunization may be fatal. In actual immuniza-
tion methods, contraindications especially include
the ill, the weak, and the sensitive. The injection of
bacterial products often produces a negative phase
that is too much for them. In muscle building, this
same negative phase must be reckoned with, other-
wise there will be exhaustion and collapse.
The advantage of building up a reserve force is
well illustrated in cardiac conditions. A break in
compensation is really a lowering of the reserve
force, no matter how large is the actual force gen-
erated to drive the blood against increased resist-
ance. A reserve force of varying height is neces-
sary to prepare the heart against any emergency
demands made upon it. In the normal heart, the
reserve force is always many times that of the
actual force. And while this same condition is of
prime importance in the muscles generally, and
should be developed either by systematic physical
training, by "hardening," or by military training,
it should be encouraged only under proper guidance.
Each individual must have prescribed for him the
proper kind and the proper amount of physical exer-
cise, else there will be a great many who will suffer
from the general application of a good principle,
that should have been applied specially.
THE TOO-READY WRITER AND THE HIGH
COST OF PAPER.
Those who are in possession of the facts have for
years been deploring the extravagance of the Amer-
ican people with their resources, and nowhere is this
national failing more strikingly emphasized than
in the paper industry. Whole forests are laid waste
to feed a paper mill which, when it has exhausted
one region, moves on to another, leaving behind it
a scene of ruin. If all the old paper and rags were
hoarded by the housekeepers for sale the result
would be a decrease in the price of paper and a
resultant double increase in the family finances,
from both buying and selling. Already magazines
are feeling the high cost of paper; some have in-
creased their subscription rates, others are con-
templating this step. Some English medical peri-
odicals are economizing by issuing a limited quan-
tity of their annual indices and supplying them
only to subscribers who write and ask for them.
George Eliot speaks somewhere of the too-ready
writer. He has a facile pen and delights to exer-
cise it. Undeterred by the superficiality of his
knowledge of a given subject he plunges boldly in,
eking out his remarks by glittering generalities
whenever he feels himself at a loss for real material.
The more he writes on a subject, the more clearly
he reveals the tenuity of his information to the
experts in that particular branch, and with it all
he manages to impress some with his versatility.
We are all familiar with the physician who goes
around laden with reprints which he forces upon
acquaintances. He is the same gentleman who per-
sists in discussing every paper presented in the
medical meeting whether he has anything to say
germane to the subject or not. On examining his
productions for a year we find as a rule little origin-
al work and that little first published in a leading
periodical and then reprinted with slight revision
in many smaller ones. One interesting case is
dragged in ad libitum et ad nauseam to illustrate
points in many papers and his references are near-
ly always confined to himself.
In view of the destruction of the forests to feed
the paper mills, in view of the possibility of war
with its privations, and for the snke of a lcng suffer-
290
MEDICAL RECORD.
[Aug. 12, 1916
ing public, will not the medical writer who has
nothing to say, say it? The English publication
Nature, which has been forced to reduce its size,
in its issue of March 23d, hits the nail on the head
when it begs its contributors to "confine themselves
to essentials, points of prime importance, in order
that our record of scientific works and events may
still be as extensive as possible, though it must
necessarily be less detailed." There is food for
thought in this request. American medical writ-
ers would do well to avoid historical summaries, re-
hashes of text-book material, and unnecessary detail
in the report of cases even though we have no Royal
Commission on Paper scrutinizing our use of that
necessity.
Fainting Attacks in Children.
This complaint attacks both sexes, but girls some-
what oftener than boys. Occasionally the fainting
spells date from quite early life, but usually they
do not appear until about the fifth year or later
and are commonest after the beginning of the
school age. In general features the attacks are
very similar in all cases. The child is observed
to "go white" ;_ he may fall down but does not lose
consciousness entirely, although in some cases he
is dazed, or even only semi-conscious. Occasionally
retching or even vomiting occurs, but in no case is
urine voided involuntarily. The attack lasts for
a period varying from a few minutes up to half an
hour or even longer, and passes off gradually.
Sometimes it is followed by a headache. The
commonest time for the attacks to occur appears
to be in the morning, often before breakfast, or
while the child is getting ready for school. Many
of the children are nervous and dyspeptic, but in
a considerable number the general health is quite
good and the appearance of the child is flourishing.
The preceding statements are taken from an article
by R. Hutchison in the British Journal of Children's
Diseases for June. Despite the large number of
patients with histories of fainting spells, the author
saw but one attack himself. In his summary he
neglects to state that the attacks are frequently
repeated through a sort of cycle. The distinctiou
from petit mal is readily made. In the cases nar-
rated there is no mention of family history. The
author is wholly unable to account for these seiz-
ures, and can only accuse the sympathetic. With
one possible exception the heart's action was nor-
mal. The attacks disappear under improved diet
and roborant measures. The literature of this sub-
pect is extremely limited, but this is true enough
of syncope in general. Since fainting seizures of-
ten represent epileptic equivalents, a further study
of these cases might repay the trouble.
I
Venereal Disease in the Austrian Army.
It always happens that in a great war venereal dis-
eases flourish. As the present European war is the
biggest war ever known, so it is to be expected that
venereal diseases should be rampant. That such is
the case is stated in a paper contributed to the Mili-
tary Surgeon, July, 1916, by E. Kilbourne Tullidge,
formerly Captain-Surgeon in the Austrian Army.
He points out that the statistics of the French, Ger-
man, and Austro-Hungarian armies show that the
number of troops both in the home zone and on the
front are acquiring venereal diseases with results
that far out-distance the records of any previous
wars. Of the three important venereal diseases
commonly met with, syphilis is the most frequently
manifest among the soldiers, about 33 per cent, of
whom are married men. Emphasis is laid upon the
fact that prophylaxis is the one feature that stands
out in caring for syphilis, and that all things should
be eliminated that increase the lure of extramatri-
monial sexual intercourse, not only during a sol-
dier's active service but also at home in the com-
munities and large cities. The writer insists that
the whole subject of venereal disease not only in war
time but in times of peace should be regarded and
managed strictly from a hygienic-medical stand-
point without regard for esthetic considerations.
The day of prudery in fighting this disease is past,
and the matter must be considered entirely from
the common-sense standpoint of public health and
safety.
Jfetnfi of tip Hwk,
Poliomyelitis Epidemic. — With a total of 5,519
cases and 1,251 deaths to August 9, the epidemic of
poliomyelitis in New York City still causes con-
siderable concern. In the State outside of New
York City, 630 cases had been reported to August
5 with 57 deaths. The disease has also made in-
roads into the adjoining States, and on August 4,
the State Health Board of Pennsylvania ordered a
quarantine against children under sixteen years en-
tering the State from New York and New Jersey.
Many of the towns of New York State and of New
Jersey and Connecticut had already adopted more
or less stringent quarantine regulations against
children from New York City, and efforts have been
generally made to prevent the traveling of children
from one place to another.
The laboratory workers invited by Health Com-
missioner Emerson to study the epidemic and dis-
cuss possible measures for its control, met at the
College of Physicians and Surgeons on August 3
and 4. Dr. Simon Flexner of the Rockefeller Insti-
tute was elected to preside, and two committees
were appointed. The first, which is to study lab-
oratory methods, is made up of Dr. Ludwig Hek-
toen, Dr. Hans Zinsser, Dr. Richard M. Pearce, Dr.
J. W. Jobling, Dr. G. W. McCoy, and Dr. Theobald
Smith; and the second, which is to study methods
of prevention, of Dr. Victor C. Vaughan, Dr. M. J.
Rosenau, Dr. William M. Park, Dr. Francis W.
Peabody, Dr. John Howland, Dr. Augustus Wads-
worth, and Dr. Charles C. Bass. At the close of the
meetings a report was made to the Health Commis-
sioner, of which the following is a part:
"The weight of opinion favors the view that in-
fantile paralysis is mainly spread through personal
contact, and measures have been directed chiefly
from this point of view. Cognizance, however, has
been given to additional methods of transmission,
among which is the bite of insects. For sanitary
purposes it is proper to consider that this disease
is transmissible directly from the sick to susceptible
persons, or indirectly from the sick through car-
riers. ... In seeking to abate the epidemic, stress
must be especially laid upon two things as is now
being done: (1) The early recognition and notifica-
tion of the disease, and (2) the immediate isola-
tion of patients and cases of suspicious illness. Fur-
thermore, on account of incomplete knowledge con-
cerning the disease, measures known to be effective
in checking the spread of other infections should be
Aug. 12, 1916J
MEDICAL RECORD.
293
portion are possessed of an immunity against any
ordinary dosage from these specific infections. And,
further, the race is a debtor to our profession to
the extent of absolute prophylactic measures in two
of these diseases.
Because of many etiological factors that tend to
show kinship in these affections, a possible rela-
tionship between their separate organisms, it would
seem rational to attempt to bring about a partial
immunity against infantile paralysis, by the use of
an allied antitoxin. I suggest, therefore, the use of
the antitetanic serum as a prophylactic measure;
say about 500 c.c. every week for three weeks or
more, to all children known to have been definitely
exposed. It may be that we would render unpalatable
the nerve cells for that combination which is the
peculiar terror in this disease. If we fail — we have
at least tried, and done no harm.
Hardee Johnston, M.D.
Birmingham, Ala.
OUR LONDON LETTER.
(From our Regular Correspondent.)
NEW CHELSEA HOSPITAL COLLEGE OF SURGEONS'
MUSEUM — NATIONAL COUNCIL — CALCUTTA HOS-
PITAL SCHOOL OBITUARY.
London, July 15, 1916.
The Queen opened the new Chelsea Hospital for
Women on Tuesday. It is a red-brick structure of
Georgian design and located within a few minutes'
walk of the old hospital, close to St. Luke's Church.
On one side of the way the houses have been re-
cently demolished and the new hospital will form
an important part of one of the many improvements
which have gradually transformed the locality be-
yond recognition during the last forty years. Her
Majesty had, as usual, a hearty reception from large
crowds of people as she drove by and was received
at the hospital by the Bishop of London, the Mar-
chioness of Londonderry, the Countess of Ilchester,
the chairman, the honorary treasurer, the senior
surgeon, and a guard of honor of Chelsea pension-
ers in their old-fashioned scarlet coats. A bouquet
was presented by the ladies' committee and Her
Majesty proceeded to the board room, where the
rector, the mayor and mayoress, and various offi-
cials were presented. The ceremony of inaugura-
tion took place in the out-patient department, where
a great gathering of friends were assembled. The
address of welcome having been read, the Bishop
of London offered prayer and the choir sang a
hymn which was composed by Sir Arthur Sullivan
for the foundation ceremony of the old hospital
thirty-six years ago. The Queen then formally de-
clared the new building open, afterward making a
tour of inspection of the wards, one of which is
named after her, "Queen Mary Ward." At the old
building excellent work was done for many years,
but in course of time its accommodation was too re-
stricted. The new effort was made possible by the
gift by Earl Cadogan of the site, valued at £22,000,
the promise of £10,000 from the Lunz trustees, and
the release of a mortgage of £4,000 by the chair-
man, Mr. Dyer Edwardes, a dinner which realized
£8,000, and a matinee £2,000. A sum of £30,000 is
still required to set the establishment on a firm
footing. The building is constructed according to
the latest scientific ideas. On the walls the dis-
temper used in the Lariboisiere of Paris has been
employed, which is said to last for eight to ten
years. This is the first time of using it in England.
The building of a new nurses' home must now be
undertaken.
Professor Keith announces in the report of the
Museum of the Royal College of Surgeons, of which
he is the conservator, that at present it is closed
except for those engaged in research. Donations
to the collection have been nearly as many as during
peace. The working staff has been reduced to three
men. Last year the college undertook at the re-
quest of the Director-General A. M. S. the collec-
tion and preservation of specimens illustrating mili-
tary surgery as met with in the present war. Over
800 specimens judiciously selected have, accord-
ingly, been added to the War Office collection,
classified by Dr. Colin Mackenzie. Last month mem-
bers of the U. S. Army and Navy medical services
visited the museum and examined the collection and
the means of preservation employed. Dr. Cabot of
Harvard also visited the museum with twenty-five
medical men about to serve under him in Prance.
Prof. J. M. Thomson has presented the collection
of his father, Allen Thomson, to the museum. Pro-
fessor Parsons has presented a series of clavicles
and Professor Symington preparations showing how
far the arrangement of the convolutionary pattern
of a brain can be reduced from a study of endo-
cranial casts.
At the first annual meeting of the National Coun-
cil for Combating Venereal Diseases on June 23, Sir
T. Barlow reviewed the work of the provisional
executive committee. The council had been for-
tunate in the support accorded to it in all directions
and meeting no opposition worth mentioning. Dr.
Frederick Taylor, chairman of the medical commit-
tee, remarked that although the subject had been
obscured by the closing of some special wards, as
soon as certain promised facilities were afforded by
the provision of treatment centers, the whole pro-
fession would rise to the occasion. Lord Syden-
ham was elected president and said that he had
urged the election rather of a medical man, but had
been overruled by those who preferred a layman
with what was called an "open mind." The com-
mission was indebted to the medical members, par-
ticularly to Dr. Mott, for much original matter in
the report, which appeared at an opportune mo-
ment when it was most important to remove every
preventable cause of racial deterioration. More-
over, all experience warned us of the danger
of an outbreak of venereal disease at the close of
a war. Some of the recommendations of the com-
mission must await legislative action, but he hoped
would not be forgotten, especially the suppression
of quack advertisements and the modification in
some degree of the marriage law. The council
would remind the government of the necessity for
the provision of centers at which diagnosis and
treatment would be facilitated, and he gratefully
acknowledged the presentation by the Grocers' Com-
pany of a syphilis ward at the London Hospital,
which was the more commendable inasmuch as it
could make no sentimental appeal. The council
should also arouse and maintain the interest of the
people and act as a general center of enlighten-
ment, a task requiring no little influence with hos-
pital committees and municipal authorities. Sir
Rickman Godlee, chairman of the military commit-
tee, gave an account of the propaganda among the
troops ; there had been 1000 delivered to some
800,000 men in the various commands. Sir M.
Morris paid a tribute to Lord Sydenham's chair-
manship and said the report was likely to have a
294
MI DICAL RECORD.
[Aug. 12, 1916
more practical result than the report of almost any
other Royal Commission.
The Calcutta School of Tropical Medicine bids
fair to be a success. It includes a laboratory and
a hospital; the latter, it is hoped, will be ready
within a year, and the new eye hospital of the
Bengal Government is to be erected opposite. Sir
Leonard Rogers, I. M.S., is the first director of the
institution, which owes its existence to so great an
extent to his labors. To commemorate his services
a committee has been formed in Calcutta to pro-
vide and place a bust or portrait of him in the
school.
Dr. William Anderton of Ormskirk died on June
12 at 69. He held several medical appointments
in the town and was chairman of the local Bee-
keepers' Association and had been appointed to act
as judge at the coming show at Manchester.
Dr. William Alexander of Bournemouth died very
suddenly of angina pectoris just as he had closed
a hard day's work. He was 53 years old; took
M.B., C.M.^ Aberdeen in 1887. Owing to ill health
he went to South Africa, but returned at the open-
ing of the Boer War and settled at Bournemouth,
where he practised for the last 16 years.
Boston Medical and Surgical Journal.
July 27, 1916.
1. Hemoptysis as a Symptom. Frederick T. Lord.
2. Common Sense ami Consumption. John B. Hawes, 2d.
3. Sprains and Sprain-fractures of the Wrist Joint. A. C.
Burnham.
4. A Study of Peptic Ulcer from the Diagnostic Point of
View. Roscoe H. Philbrick.
,ri The First Case in which Abdominal Surgery was Sug-
gested for the Relief of Epilepsy. Hale Powers and
Frank H. Lahey.
6. Prolapsus Ani in Adults. T. Chittenden Hill.
7. Scientific Research in Chronic Medicine from the Physio-
logical Point of View.
1. Hemoptysis as a Symptom. — Frederick T. Lord
has reviewed 549 clinical cases of hemoptysis and 307
instances of hemoptysis with autopsy taken from the
records of the Massachusetts General Hospital. He
states that judging from these cases it may be taken
as a clinical rule, subject only to rare exceptions, that
hemoptysis out of a clear sky, or when cough and
scanty expectoration alone cloud, it is due to pulmonary
tuberculosis. The rule seems to hold as well in those
cases in which the hemoptysis occurs during a mild
acute respiratory infection after exertion, moderate in-
jury, or without any apparent cause. Exertion of itself
cannot be regarded as an adequate cause of hemoptysis,
but it may lead to bleeding earlier than would otherwise
occur in a patient with tuberculosis owing to the added
strain on the walls of blood vessels already weakened
by disease. Initial hemoptysis, even though the only
symptom, without subsequent manifestations of pul-
monary disease and the maintenance of full health un-
til life is terminated by some other cause, is to be re-
garded as of probably tuberculous origin. Of the vari-
ous causes of hemoptysis in the probable order of their
frequency pulmonary tuberculosis undoubtedly occupies
the first place. It occurs in about (50 per cent, of all
cases at some time in their course. It is represented
among the 307 autopsy cases above referred to by only
27 cases, owing to the usual exclusion of patients in
the active stage of the disease from the wards of the
hospital. Chronic passive congestion probably occupies
second place, but heads the list of the autopsy series
with 105 cases. Then follow lobar (not broncho-)
pneumonia, with 100 cases, pulmonary infarction with
48 cases, nontuberculous pulmonary suppuration with
14 cases, aortic aneurysm with 7 cases, new growths
of the lung with 5 cases, and ulceration of the trachea
and bronchi due to syphilis in one case. These records
are of further interest in a negative sense because of
their failure to confirm the still too prevalent belief
that vicarious menstruation is an adequate cause of
hemoptysis, no example of which was found in the
autopsy series. Hemoptysis in the course of disturb-
ances of the nervous system, in patients with the so-
called "arthritis diathesis," and in those with high
blood pressure, is likely to find its true explanation in
one of the above mentioned groups. With reference to
the influence of hemoptysis on the course and termina-
tion of the tuberculous cases the writer finds that for
the most part the bleeding is intercurrent and without
any appreciable influence upon the course of the under-
lying disease, but in certain cases the hemoptysis is a
direct cause of the fatal termination; this was the case
in five instances in this series. The danger of the re-
tention of infected blood and consequent spread of the
tuberculous process is constantly to be borne in mind in
the treatment of hemoptysis due to tuberculosis, and it
seems highly undesirable to use morphia as a routine
as is so generally the custom in these cases.
2. Common Sense and Consumption. — John B. Hawes,
2nd, thinks that pulmonary tuberculosis is often
wrongly diagnosed, and as a result many nontuber-
culous patients are sent to sanatoria and health resorts,
where they run a grave risk of "catching" tuberculosis.
He insists that the physician must always remember
that he is dealing with a human being, and not merely
a set of lungs normal or abnormal. While the diagnosis
may justly be made on signs in the lungs alone, or on
constitutional signs alone, in the vast majority of cases
there is a combination of both. It is usually the care-
ful study of the patient's history, his habits, surround-
ing occupation, and the constitutional signs and symp-
toms that he presents which is of paramount import-
ance and which is most often neglected. In doubtful
cases, it is possible and often wise to institute proper
treatment without definitely stamping the patient as
tuberculous. Above all things it should be remembered
that from the patient's point of view, it is better to be
"safe and sorry," better to undergo a few weeks or
months of treatment and to gain physically by so doing,
than to linger along in false security until the chances
of cure are gone.
5. The First Case in which Abdominal Surgery was
Suggested for the Relief of Epilepsy. — Hale Powers
and Frank H. Lahey report a typical case of epilepsy
operated on on September 17, 1914, a colectomy having
been performed by Dr. Lahey. They believe that this
operation undoubtedly assisted in the cure of this
patient, though perhaps the patient would have been
relieved had he been willing to submit to the regime
upon which he was finally placed and which has pro-
duced equally good results in other cases. The reason
for the resort to surgery and to the medical treatment
outlined is based on the belief that in so-called idio-
pathic epilepsy the essential lesion is not in the nervous
system but is dependent on gastric and intestinal stasis.
The medical treatment consists in a diet excluding fried
food, fresh white bread, pastry, beans, milk, except in
moderate quantities only with meals, and uncooked
fruit, except oranges, figs and dates. The diet list
bears directions to the patient to chew thoroughly, eat
slowly, never hurry after eating, and never to eat too
much. The medication consists in bromides, thymol,
and sodium bicarbonate when there is flatulency or
abdominal pain. The author urges conservatism in
the employment of colectomy in epilepsy and believes
it should be reserved for cases in which rational non-
operative treatment, with painstaking attention to de-
Aug. 12, 1916]
MEDICAL RECORD.
295
tail, dheeted toward the relief of the intestinal con-
dition, has failed, and for cases in which, because of
mental enfeeblement or for other reasons, the co-
operation of the patient in the treatment cannot be
secured.
6. Prolapsus Ani in Adults. — T. Chittenden Hill de-
scribes an operation for this condition which he has
used with entiie satisfaction for twelve years. The
proceduie is a modification of that of Mr. Goodsall of
London. Local anesthesia is produced by infiltrating
the structures with novocaine all around the anus to a
level well above the internal sphincter, caution being
exercised not to infiltrate within the muscular wall of
the rectum, as this renders it difficult to estimate how
much should be removed at the operation. The pro-
lapsed fold of the right side is slightly elevated with
a couple of hemostats and an incision made with scis-
sors at the muco-cutaneous juncture about a quarter
of an inch deep. While making moderate traction in
a downward direction, the three curved needles, which
have been previously threaded on a linen ligature a
yard long, are passed in at the line of incision and
brought out at the upper part of the prolapse in the
following manner: The middle needle is first passed in
the center, and the other two needles are inserted on
either side of the middle one, thus dividing the fold
into four equal portions. The four loops are now
identified, the needles cut off, and each loop in turn
tied very tightly. In this way the entire fold is com-
pletely strangulated, and as the ligatures are not inter-
locked, there is no occlusion of the anal canal. The
operation is completed by excising a goodly portion of
the mucous membrane below the ligatures, care being
taken to leave enough so that they will not slip off.
When the prolapse is bilateral the same procedure is
cai ried out on the other side. The advantages of this
operation are that it can be painlessly performed un-
der local anesthesia, that it is short, that there is
absence of hemorrhage, that the end results are always
satisfactory, and that this method of applying the liga-
tures brings about a more normal repair than any other
operation.
The New York Medical Journal.
July 29. 1916.
1. Medical Women, in History and in Present Day Practice.
Mary Sutton Macy.
2. Anaphylactic Food Reactions in Skin Diseases, with
Special Reference to Eczema. Albert Strickler.
'!. Rertexions on Predisposing Factors in Infantile Paraly-
sis. Max Talmey.
4. Early Pulmonary Tuberculosis. The Signs and Symp-
toms. Robert Abrahams.
'■. Urinary Toxemia. Willard H. Kinney.
6. Tuberculous Infection and Tuberculous Immunity. Al-
bert C. Geyser.
7. Early Syphilis Its Clinical and Microscopical Diagnosis.
Oscar L. Levin.
5. Six Months* Work in Anesthesia. From the Second
Surgical Division. New York Hospital, 1915, with a
Report of Endotracheal Cases to Date. Alma Vedin.
9. Bursitis Subacromialis. Treatment of the Acute Form.
Heinrich F. Wolf.
10. Unilocular Cyst of the Kidney. Maximilian Schulman.
11. Laboratory Facts in Poliomyelitis: Observed in the
Willard Parker Hospital. S. R Klein.
2. Anaphylactic Food Reactions in Skin Diseases. —
Albeit Strickler has studied 46 cases with eczema,
a great majority of them being kept under observa-
tion for some weeks. Their plan had been, whenever
possib'e, to withhold local treatment entirely to see
what benefit, if any, diet exerted on the course of the
eruption, as to both subjective and objective phenomena.
From a study of the table presented it is shown that
50 per cent, of the patients were in a greater or lesser
degree benefited by the changed diet, as shown by the
anaphylactic food tests. In 26 per cent, the food tests
were entirely negative, and in the remainder the cor-
rection of the diet, as shown by the food tests, did not
have any bearing on the disease. In addition to the
li) cases of eczema, 10 patients with urticaria, 18 suf-
fering with acne vulgaris, and 3 with acne rosacea,
were studied. From these observations the conclusion
is warranted that anaphylactic food tests are of value
in the etiological diagnosis and in the treatment of
various diseases of the skin. These reactions find their
greatest value in eczema, where the development of a
strong positive reaction holds out great hope for an
improvement or cure in the skin condition, and in some
instances an amelioration of the associated gastro-
intestinal disorder by exclusion of the incriminated
articles of food. In chronic urticaria, acne vulgaris,
and psoriasis the results of these tests are disappoint-
ing, inasmuch as the information secured from the
cutaneous tests has not as a rule led to therapeutic
success. A very weak reaction obtained by the endermic
injections is not of convincing value, although it is
advisable to correct the diet according to the findings.
In chronic eczema the anaphylactic food tests offer
hopes for the patient so far as the possibility of rapid
improvement or cure is concerned and also with regard
to conferring immunity against future attacks by the
employment of prophylactic measures. It will no longer
be necessary to starve the patient with eczema.
5. Urinary Toxemia. — Willard H. Kinney suggests
that before making a diagnosis or prognosis in a case
of suspected urinary toxemia the following: questions be
considered: 1. What pathological condition underlies
the clinical picture? 2. Is the condition restricted to
the kidneys, or is any other system involved? 3. What
is the functional capacity of the kidney; is it permanent
or temporary and subject to change? 4. Is the con-
dition amenable to treatment? Clinical or functional
studies alone are inadequate from the standpoint of
prognosis. A perfectly normal urine may be excreted
by a congenitally deficient kidney. Postoperative renal
infection is more frequent thai was formerly believed.
Miller and Cabot have fou::d the phthalein output
usually diminished, especial y after laparotomy and
operations for cancer. Generally speaking, the diminu-
tion is proportionate to the amount of ether used and
the length of the operation. Shock decreases the elimi-
nation of phthalein, while postoperative albuminuria is
not in proportion to the phthalein reduction. In sum-
marizing the treatment of urinary toxemia the author
states that success depends upon one factor — elimina-
tion. He recommends calomel and high colonic irriga-
tions. Hypodermoclysis and intravenous saline trans-
fusion are indicated in certain cases. Diaphoresis is
best accomplished by the dry hot pack, preceded by
some cold acidulated drink and the application of an
ice cap to the head. For the dry, furred tongue nitro-
glycerine, 1/100 of a grain every three hours, seems
to be the best drug. Sparteine has taken the place of
digitalis both as a diuretic and a heart stimulant.
When hiccoughing occurs the administration of sodium
bicarbonate or Hoffman's anodyne seems to be of use.
In some instances there is a condition of apathy, with
slight muttering delirium, and when these symptoms
manifest themselves it is well to get the patient out of
bed and into a wheeled chair. When drainage has been
instituted careful watching for obstruction is impera-
tive. It sometimes becomes necessary to perform
bilateral decapsulation of the kidneys in order to re-
store renal function. In concluding the writer empha-
sized the following points: Prophylactic care before
operation, careful clinical study corroborated by func-
tional tests of the renal output, comparative studies
of toxic retention in the blood as well as in the urine,
careful selection of the anesthetic and speed in operat-
ing, close attention to maintenance of drainage when
indicated, and to the renal output after operation.
296
MiiDICAL RECORD.
[Aug. 12, 1916
8. Six Months' Work in Anesthesia. — Alma Vedin
makes this report from the Second Surgical Division of
the New York Hospital. The cases comprise general
and gynecological surgery, as well as a small percentage
of tonsils and adenoids. The routine method employed
has been ether by the drop method, preceded by nitrous
oxide in adults and ethyl chloride for young children.
In head and neck cases, endotracheal or pharyngeal in-
sufflation has been used, and in minor cases nitrous
oxide and oxygen, or ethyl chloride. Chloroform has
seldom been employed. In 656 cases in which careful
records have been kept there has been no conscious
vomiting in 334, or 50.91 per cent; 210, or 32.01 per
cent., had slight vomiting, whereas 112, or 17.07 per
cent., had prolonged vomiting. Seventy-seven suffered
from headache and 269 from varying degrees of thirst.
Forty-five complained of cough; 13 of these were
■coughing before operation. It is generally thought that
without a preliminary hypodermic of morphine and
atropine the patient will suffer much with mucus, but
this was found not to be the case. The postoperative
pneumonias have been studied by Dr. Frederick Ban-
croft, who says that ether is the safest anesthetic, and
its administration by the open drop method the safest
and most practical method for the general hospital
clinic. During the year 1915 there have been 15 cases
■of pneumonia among 1413 operations, or 1.06 per cent.
Of these 46.6 per cent, proved fatal. One of the great-
est factors in the etiology of postoperative pneumonias
is the operative nightgown. The endotracheal method
was used in 115 cases, and is considered as being
■especially indicated for operations in which it is incon-
venient for the surgeon and the anesthetist to occupy
the same field, as in thoracic surgery, brain surgery,
and operations about the neck. It is particularly useful
in thyroidectomies. Pharyngeal insufflation, while it
may be satisfactory in the majority of cases, is not
always absolutely smooth, as the catheters may become
clogged with mucus and blood if the operation is in the
mouth.
9. Bursitis Subacromialis. Treatment of the Acute
Form. — Heinrich F. Wolf expresses the opinion that
there exists an acute form of bursitis subacromialis,
and that it is produced by various etiological factors
analogous to those of acute articular rheumatism. A
treatment which seldom fails consists of wet dressings
kept on day and night, changed every twelve hours,
high doses of aspirin, 50 to 60 grains daily, and very
gentle massage.
Journal of the American Medical Association.
July 29, 1916.
1 . The Care of Children's Teeth : The Most Neglected
Feature of Pediatric Medicine. Thomas C. McCleave.
2. The Prognosis in Infantile Paralysis. Walter •',. Stern.
3. The Necessity of Revising the Nomenclature of the
Anatomy of the Rrain. William Fuller.
4. Perforated Ulcers of the Stomach and Duodenum. Ray-
mond p. Sullivan.
:.. Pseudo-Appendicitis. F. Gregory Connell.
Plastic and Reconstructive Surgery. John Staige Davis
7 Conjugal Paresis: Report of a Case. H. H. Drvsdale.
8. A Bacteriologic Study of the Causes of Some Stillbirths:
Preliminary Report. Joseph B. IV I *e<
'J. Treatment of Amebic Dysentary. John Pelham Bates.
10. Discission of Crystalline Lens. Edward Jackson.
11. Preliminary Capsulotomy in Immature Cataract. Will-
iam Evans Bruner.
12 Retinal Detachment in Hydrophthalmla. Arnold Knapp.
13. A Case of Cerebrospinal Syphilis Associated with Pneu-
mococcic Meningitis. E. M. Hammes.
1. The Care of Children's Teeth: The Most Neg-
lected Feature of Pediatric Medicine. — Thomas C. Mc-
Cleave. (See Medical Record, June 17, page lilt;.)
2. The Prognosis in Infantile Paralysis. — Walter G.
Stern states that the death rate of epidemic infantile
paralysis is as high as that of any of the most serious
diseases of childhood. While a few perfect complete
cures are authentically reported, the vast majority of
patients make only a partial recovery of muscle power,
with a more or less imperfect functional result. Spon-
taneous cure unassisted by treatment is at its maximum
in from three to six months. Careful treatment —
physiologic rest, graded massage, stimulating electric
applications, resistance exercises, muscle training, etc. —
improves greatly the chances for partial recovery and
lengthens indefinitely the period in which such recovery
can take place. Misuse, overwork, overstimulation,
overexertion, contractures, and deformities are particu-
larly harmful and detract from the power of recovery
and often destroy what little muscle power has been
gained. The prognosis for recovery in a given case
depends on many factors, most of which represent un-
knowns, and only one being under the direct control of
the physician. These are: 1. The amount of actual
permanent destruction of the ganglion cells of the an-
terior horns, or of the brain. 2. The amount of nerve
cell congestion and edema, and neuritis. 3. The regen-
erative and reconstructive powers of the nervous system.
4. The amount of muscle degeneration and overstretch-
ing (loss of tone). 5. The presence of bone and joint
deformities. 6. The curative effect of proper treat-
ment. The prognosis should always be guarded, con-
servative, and truthful, lest the parents, expecting too
much, should in their disappointment throw away all
rightful gain in strength, power, and function, while
seeking the chimera of a perfect cure. With proper
treatment, followed by braces, orthopedic operations,
and the like, almost every patient with infantile
paralysis should, so to speak, "be put on his feet" and
acquire independent and useful function of the afflicted
member.
3. The Necessity of Revising the Nomenclature of
the Anatomy of the Brain. — William Fuller makes a
plea for simplicity in the study of anatomy as in other
branches of science. The use of generalizations and
the elimination of numerous proper names would be a
great help to the student. Structure and its supposed
function should be considered together in giving a name
to any part of the body, so that one reading the history
of medicine might be able to compare the progress of
one age with that of another. When found necessary
names could be changed to conform with the under-
standing without much confusion by writing the old
names in parenthesis. The change could gradually be
made in this way with but slight embarrassment. The
essayist cites two of the many absurdities of the present
nomenclature. The cingulum (girdle) properly named
should be called the superior internal logitudinal com-
missure, one of the four great longitudinal commissures
associating the memories with the frontal lobe of the
brain. This large tract arises in front from the olfac-
tory and marginal convolutions, passes backward over
the corpus callosum, then downward and forward, and
terminates in the hippocampal lobe. A different name
is applied to each of the three different parts of its
course. As nearly all parts of the brain encircle the
bundles of the internal capsule in the same manner, why
select this particular girdle as the cingulum, when they
could all be represented together in a single generaliza-
tion? Again, there are the "forceps major" and "forceps
minor"; the writer has dissected many brains and has
failed to find them. Multiplicity of names could be
avoided and simplicity attained by the adoption of a
systematic generalization of the parts of the central
nervous system in connection with that of the whole
body. When the attempt is made to associate the
knowledge acquired of the anatomy and functions of
the nervous system with psychology or psychiatry we
are in the presence of technical words and phrases of
uncertain significance, and the situation might be
Aug. 12, 1916]
MEDICAL RECORD.
297
greatly cleared up if the science of mind can be reduced
to a, few basic principles easily understood, and from
which all the phenomena relating to mind are evolved
as the result of reflex action.
I. Perforated Ulcers of the Stomach and Duodenum.
— Raymond P. Sullivan. (See Medical Record, July 1,
.1916, page 38.)
5. Pseudo-Appendicitis. — F. Gregory Connell. (See
Medical Record, July 1, 1916, page 39.)
6. Plastic and Reconstructive Surgery. — John Staige
Davis. (See Medical Record, July 1, 1916, page 38.)
8. A Bacteriologic Study of the Causes of Some Still-
births: Preliminary Report. — Joseph B. De Lee reports
.a case of a child of a healthy mother born with a tem-
perature of 101° Pahr., which within a few hours rose
to 103°. The child died of streptococcus septicemia,
the mother showing no signs of infection. Later a phy-
sician's wife came under his observation who, after
-a mild pharyngitis, developed albuminuria and eclamp-
sia. Artificial delivery was performed. Out of the
child's nostrils pure pus exudated in which the pneumo-
coccus was found. He reports additional cases that
indicate that the child can become ill independently of
its mother, and may even die, the mother being only
indirectly affected, or not diseased at all. The writer
thinks that this discovery opens up an immense field
for study and that we may find that the cause of many
<;ases of so-called "habitual abortion" and repeated pre-
mature labor after viability and before term, and that
we may come on new problems of immunity, focal in-
fections, nephritis during pregnancy, eclampsia, puer-
peral sepsis, blood-borne transmissions, and new as-
pects of the transmutations of bacteria.
10. Discission of Crystalline Lens. — Edward Jack-
son calls attention to the great variations that occur
in the behavior of the eye following this operation,
which he illustrates by extracts from a series of case
histories. He concludes that for monolateral cataract
up to middle life, discission is to be considered as a
proper procedure; and in many cases the patient will
prefer it to extraction. The first discission should make
only a short opening in the capsule; but may well
penetrate to the center of the nucleus, so that disinte-
gration of the nucleus may begin as soon as possible.
The amount of swelling from a given interference will
be proportioned to the size of the opening in the cap-
sule, and the absence of previous change in the lens
substance. Severe reactions and surgical shock are
provoked by the presence of large masses of lens sub-
stance in the anterior chamber. Possible hemorrhage,
from making puncture through the vascular limbus,
causes no danger to offset the greater safety from
infection secured by this point of entrance.
The Lancet.
July 8. 1916.
1. Hunterian Lecture on the Development of the Structures
Associated with the Roof of the Primitive Mouth. J.
Ernest Frazer.
■2. An Investigation into Some of the Effects of the State of
Nutrition of the Mother During Pregnancy and Labor
on the Conditions of the Child at Birth and for First
Few Days of Life. G. F. Darwall Smith.
:3. Report on the Casualties from the Jutland Coast Action
Received at Royal Naval Hospital, South Queensferry.
W. M. Ash and C. P. G. Wakeley.
4. Some of the Uses and Abuses of Massage. E. Bellis
Clayton.
5. An Experience of Galyl at Royal Naval Hospital. Chat-
ham. Sheldon F. Dudlev.
■ 6. Two Cases of Penetrating Wounds of the Abdomen In-
volving the Inferior Vena Cava. D. C. Taylor.
"7. On the Use of Tuberculin in General Practice. J. Linton
Bogle.
S. The Use of Ammonia in the Chlorination of Water. Jo-
seph Race.
2. An Investigation into Some of the Effects of the
State of Nutrition of the Mother During Pregnancy
and Labor on the Condition of the Child at Birth and
for the First Few Days of Life.— G. F. Darwall Smith
has investigated 6,162 cases obtained from the lying-in
hospitals of London and Dublin. He concludes that his
statistics do not absolutely prove anything, but they
suggest that a state of bad nutrition of the mother at
the time of labor due to insufficient food greatly in-
creases the percentage of dead births and of premature
births; it slightly decreases the average weight of the
full fim3 baby at birth; definitely increases the post
natal infantile mortality; has little if any effect during
the first eight or ten days of the progress of babies
who live during that time, and possibly increases the
death rate of babies during the first three or four days
of life. A state of good nutrition of the mother at the
time of labor, on the other hand, considerably increases
the average weight of the full-time baby at birth and
increases the percentage of mothers who are able to
suckle during the first eight or ten days of the puer-
perium quite apart from any effect from the use of
ample diet during this time. The figures also suggest
that on the whole a state of average nutrition of the
mother is the most favorable condition.
5. An Experience of Galyl at Royal Naval Hospital,
Chatham. — Sheldon F. Dudley relates his experience
with galyl, which he has substituted for neosalvarsan
in the treatment of syphilis, having given about 1.500
injections. Taking the results as a whole, he finds that
neosalvarsan seems to have slightly more power in
producing a negative Wassermann than galyl. Clini-
cally galyl seems to be almost as valuable as neo-
salvarsan, ordinary chancres and ulcerative lesions
generally clearing up within ten days, but it must be
confessed a few cases a month or so after injection
still have the remains of a rash, and more rarely an
unhealed sore, an event which in the writer's experience
was exceptional with neosalvarsan. Still it can exhibit
the same dramatic cures as the older drug. This fact,
points to arsenic as the important element in these
drugs. The dose 0.4 gm. galyl contains just one-half
as much arsenic as 0.9 gm. of neosalvarsan, which
probably accounts for the slightly less therapeutic effect
and lesser toxicity of galyl. It would seem that though
excellent results have been obtained with neosalvarsan
and mercury with a month's interval between the intra-
venous injections, this interval is unnecessarily long
in the case of galyl. As the dose recommended has
only half the arsenic content of neosalvarsan, the inter-
val could be halved without any more likelihood of the
occurrence of cumulative arsenical poisoning, and if
this were done galyl would probably be as good an agent
for the cure of syphilis as neosalvarsan.
7. The Use of Tuberculin in General Practice. —
J. Linton Bogle reviews the general principles of tuber-
culin administration and calls attention to certain errors
that are to be avoided. It is necssary to remember in
passing from one dilution to another the strength is
ten times greater, so that in changing from a smaller
injection of greater strength the increases should be
small. Again, dilutions newly made are stronger than
old dilutions, and the extractive toxin tuberculin dilu-
tions are less stable than those made from the ground
bacillary bodies, such as T. R. It is desirable to make
fresh dilutions every two or three weeks in the former
case, and every four or six weeks in the latter. A
nervous patient, tending to high temperatures or
hemorrhage, requires smaller doses and of a slowly
acting preparation, such as B. E., and hence the course
will be lengthened. Although experts, with their knowl-
edge and wide experience, may be able to use tuber-
culin in most cases of tuberculosis with benefit and
without injury, there are cases in which the general
practitioner would do well to avoid the use of this
remedy. In mixed infections, catarrhal or bronchial;
298
MEDICAL RECORD.
[Aug. 12, 1916
in tuberculosis complicated by disease of the heart or
kidneys; in rapidly advancing or extensive disease; in
cases of high fever and quick pulse; in anemia asso-
ciated with little power of resistance; in those in whom
there is a strong hemorrhagic tendency, and in cases
of infantile tuberculosis, tuberculin as a rule does no
good. It is only in conjunction with rational general
treatment that the striking results of this special treat-
ment are manifest.
The British Medical Journal.
July S, 1916.
1. The Care of the Pregnant Woman. Archibald Donald.
2. Tuberculins and Vaccines : From the General Practition-
er's Point of View. E. Havling Coleman.
3. The Transfusion of Whole Blood : A Suggestion for its
More Frequent Employment in War Surgery. L.
Bruce Robertson.
4. A Simple Technique for Intravenous Injections in Infants.
Ann Martin.
.".. Acute General Hemorrhagic Peritonitis. Arthur J. Ny-
ulasy.
6. A Case of Pneumococcic Conjunctivitis. J. Cropper.
1. The Care of the Pregnant Woman. — Archibald
Donald expresses the opinion that the supervision of
all pregnant women would mean a great deal of un-
necessary trouble, as in the majority of cases in which
danger threatens during pregnancy the patient will
voluntarily apply for help. His experience leads him
to believe that even if supervision were greatly in-
creased the results in the saving of infant life would
be comparatively small. There are several much more
important causes of fetal death than the diseases of
pregnancy, and these would not be dealt with in a
scheme of supervision during pregnancy. Under these
the writer mentions particularly abortion and stillbirths
caused during delivery. Furthermore, it must always
be borne in mind that sterility, either absolute or rela-
tive, has a most important effect on the birth rate.
If any improvement is to take place as regards still-
births, it ought to be on the lines of the further de-
velopment of those institutions which already exi^t.
While the writer believes that the cooperation of the
medical officers of health and the health authorities
generally with the medical profession is most important,
much more good would be done at much less cost if the
cities were to subsidize maternity hospitals instead of
creating a new system. If found advisable, smaller
centers might be established under the hospital control
in various parts of the town. The greatest stress
should be laid on education. The pregnant woman
should be taught how to take care of herself and warned
of certain dangers that may arise. Midwives and
medical students should receive a more thorough train-
ing. More facilities should be given for the medical
practitioner to have postgraduate instruction. The
study of the pathological problems connected with abor-
tion and stillbirth should be stimulated by the provision
of well-equipped clinical laboratories in connection with
maternity hospitals. The solution of the matter is not
in statistics and notification, but in education and re-
search.
2. Tuberculins and Vaccines. — E. Hayling Coleman,
writing from the general practitioner's point of view,
says that in making a decision whether or not to use
a vaccine, cases may roughly be divided into four
groups: 1. Those in which a vaccine is usually suc-
cessful and much more likely to succeed than other
remedies. 2. Those in which ordinary remedies have
o tar failed and we know that a vaccine may cure,
though not so frequently as in the first group. 3.
Cases of serious disease, in which the use of a vaccine
can do no harm, and may decidedly increase the
patient's chance of recovery. 4. Cases in which, though
vaccines often fail, yet other remedies do so almost
invariably. Among the conditions belonging to the
first group are recurring boils and carbuncles, chronic
nasal and post-nasal catarrh when due to the pneumo-
coccus, chronic tracheitis of old people, cystitis due to
infection of the bladder by B. coli and chronic gleet;
in all of these autogenous vaccines rarely fail. Under
group 4 the writer discusses rheumatoid arthritis, and
says that the most promising cases are those due to
septic absorption from the pus about the teeth in
pyorrhea. The vaccine should be prepared from this
pus. His experience with this class of cases has not
been very hopeful, and he feels inclined to believe that
the difficulty is due to the dense tissues and poor vas-
cular supply of the parts which are affected in this
disease. In chronic suppuration of the middle ear he
has also found the vaccines to fail. In discussing the
use of tuberculins the essayist brings up the matter of
mixed infections and says that most failures of tuber-
culin are due to this not being recognized. He has had
some of his best results by combining Dr. Curie's nascent
iodine tieatment with B. E. He believes the iodine
acts on the adventitious infection, and the B. E. then
has a fair chance with its own bacillus. He has also
seen good results from the use of a vaccine made from
the adventitious organism along with tuberculin. An-
other point which is emphasized is that in treating a
patient with tuberculin the sputum becomes less in-
fective, the tubercle bacilli often completely vanishing,
even though from the symptoms and physical signs it is
evident that the disease still has a strong hold. This
is of great value in preventing the spread of infection.
Some fear giving tuberculin in cases with hemoptosis,
but the writer has never known harm to follow pro-
vided the tuberculin is properly employed.
5. Acute General Hemorrhagic Peritonitis. — Arthur J.
Nyulasy reports three cases of this condition which
have come under his observation, two of them resulting
from criminal abortion and coming to autopsy. One
of these presented a striking lividity of the skin, in-
volving the whole body. The third case, which is de-
scribed in detail, is remarkable because of the absence
of serious symptoms. This is accounted for partly by
a preliminary diarrhea, and partly by the large quan-
tity of blood which escaped from the engorged peri-
toneal vessels. The conditions found at the operation
suggest that acute infective inflammation of the peri-
toneum is not per se nearly so serious as appears to be
commonly supposed, and that, providing the focal factor
and any free toxic fluid be removed from the abdomen,
and that there is no paralytic ileus, the patient may
recover with comparative ease from a most extensive
acute infection of the peritoneum.
I
Acute Mammary Carcinoma. — Learmonth gives the
large number of synonyms in use for this affection. In
1911 Schumann collected notes of forty-five cases from
literature. Of 579 cases of cancer of the breast in the
Johns Hopkins material, eight were of this nature.
Rodman personally has seen seven cases. Leitch en-
countered two cases in five years' pathological work in
London, and also saw four cases in Glasgow and one in
Dundee. But one five-year recovery is on record (Blood-
good's case). As is well known the affection simulates
a fulminating mastitis, and early in its cours™ differen-
tial diagnosis is impossible. The disease occurs espe-
cially during pregnancy and lactation. The exact num-
ber of cases of these types is not stated. It is possible
that certain cases of cancer of the nursing breast
belong here (two are mentioned by the Mayos). Leitch
found in his cases that medullary cancer predominated.
Owing to the frequency of erroneous diagnosis, the out-
look for this type of cancer is highly pessimistic. — The
Canadian Medical Association Journal.
Aug. 12, 1916]
MKDICAL RECORD.
299
Snauranrf 4H?i»trinr.
Typhoid Vaccination for Policyholders. — The
following is from a letter to the policyholders of the
Southland Life Insurance Company of Dallas, Tex.,
by Dr. W. A. Boyce, associate medical director:
"It is not our purpose to prescribe what rules should
be followed regarding the prevention of typhoid.
This is fully covered by the bulletins of the various
health departments and the federal authorities. We
do wish to call attention to the fact, however, that,
supplementing the precautions as advised by the
health authorities, it is most desirable that every-
one be immunized against this disease by being vac-
cinated with antityphoid vaccine. That antityphoid
vaccination is successful in almost absolutely pre-
venting the disease and, in any event, lessening the
severity of it, has been clearly demonstrated in the
tests of the vaccination made at San Antonio in
1911 upon enlisted men in the U. S. Army as well
as in the French Army and the British Army in
India, and other places. As antityphoid vaccina-
tion has met with such success, the Southland Life
Insurance Co. offers to all of its policyholders the
advantage of this vaccination free of charge. Our
physicians will be on duty for this purpose from 2
to 4 p. m. each business day except Saturdays. We
will endeavor to handle all cases as expeditiously
as possible, but to avoid unnecessary delay it is
requested that those desiring to take advantage of
this offer notify this company in advance, so that
proper arrangements may be made. Assignments
will be made in the order of application for treat-
ment."
The Obligation of the Medical Examiner. — Dr.
Henry Wireman Cook, in a paper with this title,
read before the Section on Life Insurance, State
Medical Association of Texas, said that the obliga-
tions of the work of life insurance examining might
be divided for study under three general heads':
(1) Moral obligation; (2) Business obligation; (3)
Professional obligation. With regard to moral obli-
gation the confidence implied in an appointment as
examiner should not only guarantee the best pro-
fessional service, but should bring loyalty, interest,
and cooperation. The medical report should be ab-
solutely unbiased by the importunities of the agent,
the demands or threats of the applicant, or the
appeal of the prospective widow or orphans.
An for the business obligation, in insurance un-
derwriting, promptness is a most vital factor. A
delay by the examiner of twenty-four hours in com-
pleting an examination may cost the agent several
hundreds of dollars, which he has earned by weeks
of hard work. All the ordinary business demands
must be observed in insurance work: Courtesy,
tact, promptness, rapidity, and accuracy on the part
of the examiner are of equal importance to scientific
requirements.
The scientific obligation is the part of the service
that is most clearly recognized and understood, and
yet it is frequently covered in a careless and in-
different manner. The work of a general prac-
titioner, owing to the insistent demands upon his
time, is apt to become superficial and hurried. In
insurance work the one examination is final, and on
its representation must be risked a liability for
thousands of dollars. Careless methods which may
be corrected in practice are disastrous in insurance
work. The examination must be approached in an
orderly manner, and each detail given systematic
attention.
The personal history of the applicant is a very
important factor. The difference in attitude of a
patient and an applicant cannot be too strongly
emphasized. The patient is fluent in the description
of his symptoms, his indiscretions in habits, his
previous illnesses. The admission of such impair-
ments must often be drawn from an unwilling ap-
plicant by patient and skillful questioning. This,
of course, is particularly true of an impaired ap-
plicant who is attempting to obtain standard insur-
ance, and in such a case a correct history is vital.
A true history of alcoholic excess or venereal dis-
ease is naturally extremely difficult to obtain, as
few men hesitate to misstate these answers. In the
physical examination proper, a physician has an
opportunity to use to the utmost his skill and knowl-
edge.
The applicant will not submit to such an ex-
amination as we can give a patient. The work
must be done quickly, and a judgment based on a
single interview. It is therefore particularly im-
portant that the examination should be made sys-
tematically, carefully and thoroughly. There may
be no second opportunity to correct mistakes and
omissions. The general condition of the applicant
must be carefully noted. An impaired risk fre-
quently "looks" impaired without any definite lesion
being discoverable. General tendencies should be
borne in mind: for example look especially for signs
of tuberculosis in young light weights, where there
is history of indigestion, recent change of climate ;
look for thickened arteries, high blood pressure,
casts and albumin in men over 45, in the obese, in
high livers, in applicants with short family history
and with several cases of apoplexy, heart disease,
or Bright's disease in the immediate family.
No part of the physical examination furnishes
less satisfactory data in proportion to its impor-
tance than the urinalysis. The average physician
fails in this work because of the neglect of a few
simple requirements. There must be a strong
bright light, a dark background, clean test tubes,
properly prepared reagents, and a little care and
time. The Ulrich modification of the heat and acid
test is recommended for this purpose. — Texas State
Journal of Medicine.
Dilatation of Heart Following a Cold Bath. —
Where an insured holding an accident policy in-
demnifying him against bodily injuries which, in-
dependently of all other causes, are effected solely
and exclusively by external, violent, and accidental
means, suffers an injury due to the dilatation of the
heart, following the voluntary taking of a cold-wa-
ter bath, it is held in New Amsterdam Casualty Co.
v. Johnson, L.R.A., 1916, B. 1018, that the injury
will not be considered as the result of an accident,
where, under the circumstances attending the dila-
tation, there is no evidence that anything occurred
which the insured had not planned or anticipated,
excepting, of course, the dilatation and its conse-
quences.
False Statements in an Insurance Application. —
Where the secretary of an insurance order knew
of the falsity of statements as to physical health
contained in a member's application, and the medi-
cal examiner must have discovered their falsity,
yet the insurer, for over two years having con-
tinued the membership and accepted the prem-
iums, was held, by the Colorado Supreme Court,
to be estopped in an action on the certificate to
set up the falsity of the statements in the appli-
cation.— McRory v. Independent Order of Puritans
(Colo.) 154, Pacific 92.
300
Ml DICAL RECORD.
[Aug. 12, 1916
Hay-fever, Its Prevention and Cure. By W. C.
Hollopeter, A.M., M.D., LL.D., Attending Physician
St. Joseph's Hospital; Pediatrician to the Philadel-
phia General Hospital; Professor Pediatrics, Emeri-
tus, Medico-Chirurgical College; ex-President of the
Association of American Teachers of the Diseases
of Children; ex-Chairman of the Section on Diseases
of Children, American Medical Association ; Member
of American Academy of Medicine, etc. Price, $1.25
net. New York and London: Funk & Wagnalls
Company, 1916.
After careful perusal of this work, it is found that the
neurotic element is still considered to play a large part
in the causation of hay fever, and that a keen men-
tality in the victim likewise seems to be a happy co-
efficient. Dr. Hollopeter may therefore have high hopes
that between sneezes and the carrying out of his many-
sided and detailed treatment, the patient may have the
opportunity to read about the numerous theories of
hay-fever to be found in this volume of 347 pages.
Judged from the medical standpoint the book shows
the work of years, for it is practically a compilation
of each and every theory and mode of treatment that
has ever been advanced for hay-fever. The majority of
theories and treatments are stated in the words of
the originators, which means an enormous amount of
quotes in the text; but this rather adds to the value
of the book. While the author's own theory and mode of
treatment cover but a small portion of the text, they
are so definitely stated that one cannot fail to com-
prehend them. The bibliography, extending from the
years 1565 to 1916 and covering forty pages, is another
valuable contribution to hay-fever literature. The book
is beautifully printed, but somewhat loosely bound. The
cover is a work of art being of a soothing, dark green
color, and having gold golden rod as a decoration. If
the psychic element plays such a strong role in the
production of hay-fever, was it not a daring stroke to
put this beautiful, but dangerous weed where it must
meet the eyes of the suffering victim?
When one has finished the book there is a realization
that it is well-written, well-compiled. The author's
treatment includes local — upon which he lays great
stress — systemic, and hygienic measures. He adheres
strictly to medicines in his local treatment and has
nothing to do with the pollen or bacterial vaccines, or
autoserums. However, a feeling of disappointment
creeps over one that after all Dr. Hollopeter's book
brings out the fact, perhaps unconsciously, that there is
no cohesion in the various treatments of the different
theorists, each one working out his ideas irrespective
of the theories of other workers in the field. Will there
ever come a physician who will be broad enough to give
a thoughtful combined treatment to the same patient,
both pollen and bacterial vaccine, and at the same time
investigate his intestinal, nasal, and nervous conditions?
The intestinal theorist will have none of the vaccines,
the laboratory man refuses the medicinal or surgical
aids, and the internist relies solely on his drugs. It
it not to be wondered at that each stickler for his pet
theory can hope to cure only a certain proportion of
hay-fever victims.
Handbook of Massage for Beginners. By L. L. Des-
PARD, Member and Examiner, Incorporated Society of
Trained Masseuses. Price, $2.00. New York: Oxford
University Press, American Branch, 1916.
Despard's book is a very satisfactory one. The war and
the consequent rapid pressing into service of those pre-
viously untrained in massage has been the immediate
cause for the publication of the book. It is frankly a
shortened and simplified edition of his text-book, and is
intended for those who have time or opportunity for
only a short course of training. All the study of anat-
omy included in the text-book is omitted. The various
movements and manipulations of massage are well de-
scribed and excellently illustrated. The immediate and
indirect effects of massage are explained and the values
of their effects to the general economy. After presenting
the subject from a general standpoint, Despard gives
the special treatment indicated in various special condi-
tions. The manipulations and exercises are properly
balanced, and reasons for choice of movements and their
order are given, so that the student has continual em-
phasis laid in the condition which he is attempting to
improve. The last forty pages are given to an exposi-
tion of medical electricity. This is very clear and goes
into enough detail in regard to electricity, so that the
student should handle the apparatus with intelligence.
Strength of current and length of treatment to be given
for various conditions are stated.
Hysteria and Accident Compensation. Nature of
Hysteria and the Lesson of the Post-litigation Re-
sults. By Francis X. Dercum, M.D., Ph.D., Pro-
fessor of Nervous and Mental Diseases, Jefferson
Medical College, Philadelphia; Consulting Neurologist
to the Philadelphia General Hospital ; President of
the Philadelphia Psychiatric Society; ex-President of
the American Neurological Association and of the
Philadelphia Neurological Society; Foreign Corre-
sponding Member of the Neurological Society of
Paris, and of the Neurological and Psychiatric Society
of Vienna; Member of the Royal Medical Society of
Budapest, etc. Philadelphia: The George T. Bisel
Company, 1916.
In the light of the present interest in workingmen's
compensation, Dr. Dercum's extremely interesting book
is of especial value. Dr. Dercum is in position to have
first-hand knowledge of the "litigation hysteria" of
which he writes. He holds that the hysterical person is.
"born, not made," that injury and fright are not respon-
sible for the hysterical condition for which compensa-
tion is sought, since these conditions do not arise and
persist unless there is the possibility of obtaining com-
pensation. He says that "fright hysteria is of imme-
diate onset, its symptoms supervene at once at the time
the fright is experienced, and as a rule it is of short
duration and usually rapidly subsides. . . . Very
frequently the history of the hysteria of litigation is
that of a slow and gradual development," really devel-
oping under the hands of the lawyer and medical experts
who are called in to determine that he should have
compensation. Dr. Dercum says that the final proof of
the fact that litigation is the determining factor is the
rapidity with which recovery without treatment takes
place after settlement is finally made. His conclusion is
sound: "To deny compensation would seem to be the
only way in which the question can be solved. If it be
not possible to recover for litigation hysteria, litigation
hysteria will have no existence. To deny compensation
has already been advocated in Germany, and in France
one of the courts, in a given case, declared that the
plaintiff was suffering not from the accident alleged but
from an erroneous opinion which he had formed as to
the rights to which he was entitled, and ruled that he
could not recover."
Year-Book of Pharmacy. Comprising Abstracts of
Papers Relating to Pharmacy, Materia Medica, and
Chemistry, Contributed to British and Foreign Jour-
nals from July 1, 1914, to June 30, 1915, with the
Transactions of the British Pharmaceutical Confer-
ence at Its Fifty-second Annual Meeting, Held in
London, July 14, 1915. Editor of the Abstracts, J.
O. Braithwaite. Compiler of the New Remedies
Section, Thos. Stephenson, F.R.S.E. Editor of the
Transactions, Reginald R. Bennett, B.Sc, F.I.C.
London: J. & A. Churchill, 1915.
The index of this work contains about 2,500 titles,
including subjects and proper names. All the British
Pharmacopoeia revisions are comprised in a special
section. Of the 400 pages of actual text about one-half
are devoted to excerpts on chemistry and over one-
fourth to pharmacy. The section on New Remedies
and New Uses of Old Remedies is very brief. Under
the heading "Notes and Formula:" we find many non-
proprietary cosmetics. American special literature is
well represented, while abstracts from German litera-
Precis de Medecine Operatoire. Par A. Broca, Pro-
fesseur d'Operations et Appareils a la Faculte de
Medecine de Paris. Avec 510 figures dans le texte.
Prix, 9 francs. Paris: Masson et Cie., Editeurs,
1916.
This work is of a very old type, comprising solely the
technique of ligation of vessels, amputations, and dis-
articulations. The number of pages is less than 300,
and all the illustrations are in the text. It is virtually
an atlas, and one, moreover, of pocket size and flexible
covers. It seems singular that the preface contains
no reference whatever to the present war or to mili-
tary surgery. One must, however, read between the
lines that, despite the absence of any authorization
from the government, such a work would be extremely
timely for thousands of physicians at the front, who
are operating without special training. If an author-
ized work of this type is not already in use in the
army, we venture the prediction that the latter will be
made official. Its excellence is quite beyond criticism.
Aug. 12, 1916J
M1D1CAL RECORD.
301
£>0ri?tij Imports.
ASSOCIATION OF AMERICAN PHYSICIANS.
Thirty-first Annual Meeting, Held in Washington, May
9, 10 and 11, 1916.
The President, Dr. Sewall of Denver, in the Chair.
(Concluded from page 264.)
Thursday, May 11 — Third Day.
The Effects of Exposure to Cold upon Experimental
Infection in the Respiratory Tract. — Drs. James Alex-
ander Miller and Willis Noble made this contribu-
tion. They stated that a widespread medical belief
was that exposure to cold was an important factor in
the incidence of many diseases. Since the development
of modern bacteriology the importance of this factor
had gradually diminished and at the present time there
was considerable difference of opinion as to whether
such exposure played any part whatever in the causa-
tion of disease. Experimental evidence was conflicting
and as a great many of the animal experiments had
been conducted with pneumococcus with which there
had been considerable difficulty in producing experi-
mental disease with regularity in animals, the results
were not conclusive. The present experiments were
carried out with rabbits inoculated with Bacillus bovi-
septicus, which was an organism which caused the well
known laboratory disease in rabbits commonly desig-
nated as "snuffles." It was selected for experiment be-
cause these conditions produced in rabbits were so simi-
lar to those caused by some of the respiratory infections
in man, particularly pneumococcus, and because of the
relative difficulty of producing pneumococcus pneu-
monia in rabbits. The experimental animals were kept
in a warm temperature for periods of time varying
from twenty-four hours to a week and were then inocu-
lated by spraying the nose and throat with virulent
cultures of the "snuffles" bacillus. They were then
immediately chilled by exposing them to outside
weather, the temperature of which was 45° F. and
lower. The experiments were carried out in the winter
of 1914 and 1915 and another series in the winter of
1915 and 1916. The totals for both series showed that
of 37 experimental animals 15, or 40.5 per cent., reacted
to the infection, while of an equal number of controls,
nine, or 24.3 per cent., reacted. The striking difference
between the two groups in the first year's experiments
led very strongly to the belief that the exposure must be
an important contributing factor. The second year's
series, although a much smaller number, distinctly
modified the strength of this opinion, as an equal num-
ber of experimental and control rabbits reacted to in-
fection in this series. Taking both series together, how-
ever, the conclusion seemed justified that exposure to
cold after previous subjection to warm temperatures
rendered rabbits somewhat more liable to infection with
the Bacillus bovisepticus.
On the Expectorant Action of Ammonium Chloride. —
Dr. Warren Coleman of New York presented this
paper. He said that experiments had been made on
the action of ammonium chloride on dogs, but there
were a number of factors influencing results which
could not be properly controlled in animal experiments
with reference to the expectorant action of drugs, so
he determined to try the effects of this drug on human
beings. His subjects were a house physician, a nurse
in training, four other physicians and himself. With
the first subject he began with 0.02 mg. and in-
creased the amount up to 0.05 mg. In a second subject
he went up to 0.06 mg. He himself took the drug in
one-half grain doses every two hours, the last dose
between seven and eight o'clock at night, and he found
that the next morning the taste of the drug would
appear. This had a two-fold significance. It identified
the form in which the ammonium nitrogen was present
and its relation to the conversion of ammonium chloride
in the liver. It seemed that the ammonium chloride left
the body in the form that it entered. It also had the
effect of relieving the soreness and dryness of the
respiratory tract. As to its action a plausible explana-
tion was that it carried water with it and thus softened
the mucous and that a softening action was due to the
salt also, and that with a softening of the mucous
membrane the normal mechanism of secretion came into
play.
Dr. Abraham Jacobi of New York said that as a
matter of history he would like to take the liberty of
telling them that when he had lectured before the stu-
dents of the College of Physicians and Surgeons, not
fifty years ago, but some time ago, he told them that
ammonium chloride was an inert drug, that it did not
have as stimulating an action as the carbonate. In
Germany physicians used to give as a placebo, when
they were unable to make a diagnosis, a prescription
calling for two drams of ammonium chloride and two
drams of licorice. He used ammonium carbonate in
chronic bronchitis with viscid secretion and found it
would do something toward liquifying the secretions.
Dr. Samuel J. Meltzer of New York said he be-
lieved they had two kinds of expectorants. One kind
increased the secretions and the other was the cause of
irritation, and one prescribed one kind or the other
according to the action desired. What Dr. Jacobi said
with reference to ammonium carbonate must have been
a slip. Ammonium carbonate does not have the action
he had attributed to it. It should be remembered that
drugs did not always act directly, that they sometimes
had a catalytic action. They underwent changes,
entered the circulation and in that way produced a
local effect. The experimental study of medicine was
absolutely necessary and the only good evidence was
that of man himself. These personal experiments were
practical, but one must have the faculty of observation
and of analysis.
Dr. Max Einhorn of New York said he was de-
lighted to hear Dr. Coleman say that he had tried
this drug on human beings to see what effect it pro-
duced. That was the right way to proceed. Trying
it on himself was better than trying it on anyone else.
In his experience in the treatment of gastric condi-
tions he had found ammonium chloride of great benefit.
Dr. Coleman in closing the discussion said that in
reply to Dr. Erlanger's question as to whether the
ammonium chloride appeared to be in the sputum or the
saliva, they were planning experiments in which they
would furnish specimens of the saliva and of the
sputum and investigate the matter. As for himself he
never got the taste of the ammonium chloride from the
saliva, but only in the sputum from the bronchial tubes.
As to the stage of the disease when the drug was
effective, he found that it gave relief when there was
dryness with irritation and a non-productive cough.
As to whether the effect of the drug was brought about
by a central or a peripheral action, he believed its
action depended upon its elimination by the bronchial
mucous membrane, but did not believe it had any action
upon nerve centers.
Coagulation Time in Lobar Pneumonia, with Statistics
and Experimental Study of the Coagulation Process. —
Drs. J. M. Anders and George H. Meeker of Philadel-
phia presented this communication. They stated that
undoubtedly microorganisms did have an influence upon
the coagulation time of blood but their true significance
was undecided. It had been said that acute infections
tended to retard the process of coagulation. They
made their tests on blood taken from the lobes of the
ears and the finger tips both before and after the
crisis in pneumonia. The blood was taken one and two
hours after meals. They found that the coagulation
time was somewhat shortened, on a mean average, of
about two minutes. The hypothesis was suggested that
the pneumococcus circulation in the blood might lib-
erate thrombokiiiase from the walls and that this gained
access to the circulation. There was no laboratory evi-
dence that could be accepted as proof of this. Dr.
Anders said that he believed that the percentage of
leucocytes circulating in the blood might be the cause
of the somewhat shortened coagulation time of the blood
in this disease. It was possible that prothrombin was
liberated more rapidly and had an effect upon the
coagulation time. This theory lacked support, since
it had not been shown that there was an increase in
the calcium salts in the blood in pneumonia. Dr.
Meeker had made quantitative study of the amount of
calcium salts in the blood of pneumonia patients and
found that the amount of calcium in the blood of these
patients was practically the same as that in leutic
infection. They concluded that the coagulation time
of the blood was shortened in lobar pneumonia; that
the influence of pneumonia on the coagulation time,
though trivial, was constant and that from their ex-
periments in regard to the calcium content of the
blood in pneumonia the influence of the calcium salts
must be quite considerable.
Dr. Samuel J. Meltzer of New York said he wished
to mention that in experimental pneumonia there was
a difference in the amount of calcium in the blood in
the virulent and the non-virulent forms of the disease.
302
MEDICAL RECORD.
[Aug. 12, 1916
In the non-virulent form there was not much calcium.
Dr. Rufus I. Cole of New York called attention to
some observation published by Dochez in which he
showed that there was much increase in fibrogen in the
blood in pneumonia and yet the coagulation time was
delayed. Where there was a large amount of calcium
in the blood we could not have this phenomenon.
Dr. Max Einhorn of New York asked Dr. Anders if
he had watched the amount of sodium chloride retained
in the blood and the elimination through the kidneys.
The sodium chloride retention might have some effect
on the coagulation time of the blood.
Dr. Anders said that since seeing these experiments
he felt that in the case of pneumonia they encountered
a paradox, it seemed that the coagulation time was
shortened, yet they knew that after death the large
vessels were occupied by large thrombi and this would
indicate that post mortem the coagulation went on
slowly.
A Study of the Action of Certain Diuretics in Chronic
Nephritis. — Dr. Henry A. Christian of Boston said
that on this occasion they would report on the action
of theocin. He said that a considerable number of
drugs considered to be active diuretics had been shown
to shorten the life of animals with severe nephritis
and that as a consequence our faith in active diuretic
drugs was decreasing'. He described the experiments
that he had made by means of a series of charts. The
first four of these charts showed the effect of theocin on
active nephritis as regarded the sodium chloride excre-
tion, and nitrogen urea, and diuresis. He concluded
that as a rule theocin produced a marked diuresis in in-
verse ratio to the degree of renal function. Often when
there was an active diuresis there was a decrease in
renal function, probably indicating fatigue and sug-
gesting that it was better to give a diuretic inter-
mittently rather than continuously. Another point that
was brought out was that one might have an active
output of urine but no increased output of nitro-
genous substances. So that it was a question how much
the drug affected the patient where there was no
uremia. In uremia which had a definite relation to the
retention of nitrogenous substances it was a question
how much effect diuresis had towards detoxifying the
patient. In some patients there was no diuresis and no
increased output of nitrogenous substances; in these
there was a decreased renal function and in these cases
the drug was probably really harmful. Basing their
opinion on their observation of acute and chronic
nephritis and cardiorenal diseases as influenced by
diuretic drugs the indications were that one should
exercise great caution in the use of diuretic drugs.
Dr. William S. Thayer of Baltimore said he con-
sidered this quite an important piece of work and one
quite in accord with his clinical experience. In cardio-
renal disease where the heart begins to fail diuretic
might be indicated, but in chronic renal disease the ad-
ministration of diuretic was a dangerous and serious
procedure.
Dr. James M. Anders of Philadelphia said that this
paper had a very practical bearing. On cases of kid-
ney impermeability with more or less cardiac involve-
ment, one should make the phthalein test for renal
function and if one found a degree of renal function
of less than 30 per cent, in two hours one should avoid
the employment of a laxative containing members of
the purin group. To promote the elimination of poisons
in such cases as Dr. Christian had described large
draughts of water might be used. He felt sure that
water employed in this manner often changed the scales
in the direction of improvement.
Dr. Christian in closing the discussion said that as
to the phthalein (est as an indicator of the degree of
kidney function we shou'd distinguish between the out-
put due to chronic passive congestion and that due to
renal insufficiency. In passive congestion one might use
a diuretic and digitalis and a low nhtlnloin output was
no contraindication if one used the diuretic combined
with digitalis. As to water a large intake of water
shortened the life of animals with very acute nephritis;
this subject had been studied verv little and what was
obviouslv needed was a study of the effect of water on
the renal function.
Toxic Effect of Urea on Normal Individuals. — Dr. A.
W. Hewlett. Drs. Gilbert and Wichett of Ann Arbor,
Mich., contributed this paper in which they recorded
their observations with reference to the effects of the
administration of urea on animals. They found that to
get effects they had to introduce large amounts of urea
very much beyond the amount that was present in clin-
ical uremia. Doses of 100 grains every few hours
were given until the urea in the blood rose to the level
of that in the blood of ui emic patients. There was like-
wise a rise in the Ambard coefficient to nearly double
what it was before the administration of the urea.
When there was 75 per cent, urea nitrogen per 100 c.c.
of blood the symptoms began to show themselves by
headache, dizziness, prostration, drowsiness. They had
what was known as the asthenic type of uremia. There
was no vomiting, the appetite was good and there was
no rise in blood pressure. There was a tremendous
output of uiea in the urine, but in 24 hours the larger
part of the urea that had been administered was out
of the body. From these observations it seemed that
urea might be a cause of asthenic symptoms.
Dr. Warren Coleman of New Vork cited a case
which seemed to indicate that to some extent urea might
be a factor in the production of uremia, but said that
there were other cases in which it could not enter as a
factor.
Experimental Endocarditis, Its Production with Strep-
tococcus Viridans of Low Virulence. — Drs. H. K. Det-
weiller and W. L. Robinson or Toronto made this
piesentation by invitation. They stated that the
cultures of streptococcus viridans obtained from the
blood from cases of chronic endocarditis reported a
year ago had been inoculated into a series of rabbits
and endocarditis was produced in a number of cases.
The inoculations were, all intravenous and consisted of
enormous quantities of the organisms suspended in
saline. The autopsy findings led them to believe that
this organism had a special affinity for the heart,
and especially for the heart valves. Evidence was
forthcoming to show that the streptococcus viridans
obtained from the normal mouth was equally productive
of heart lesions, and any grade of endocarditis might
be produced by any one organism, depending upon the
amount injected, the number of injections, and the
length of time between the first inoculation and the
death of the animal.
Blood Sugar Estimations as a Test of Carbohydrate
Tolerance. — Dr. Louis Hamman of Baltimore read this
paper. He stated that frequent examinations of the
blood and urine after the administration of glucose
to fasting persons revealed four types of reaction.
The normal reaction was a rapid rise in the blood sugar
to a level not exceeding 0.15 per cent. From this point
it again rapidly declined, the whole reaction being
over in less than two hours. In the diabetic the blood
sugar rose more slowly but reached a higher point,
0.2 per cent, and over. The high point was maintained
for some time, and the decline occurred gradually, the
whole reaction lasting three hours and longer. If the
blood sugar rose above 0.175 per cent, sugar appeared
in the urine. The third type of reaction was the renal
reaction. This occurred in a sma'l number of persons,
in whom, although the blood sugar curve was in all
other respects like the normal reaction, still sugar ap-
peared in the urine. In severe cases of diabetes this
same low thread shape was often found. In the fourth
reaction, the nephritic, the blood sugar rose to a high
level, often exceeding 0.2 per cent., and the blood sugar
curve resembled the diabetic reaction: however, no
sugar or only a trace of sugar appeared in the urine.
The writer concluded that the blood sugar reaction
after the administration of glucose and relation to
glycosuria gave valuable clinical data in diabetes and in
other conditions.
The Vital Capacitv of the Lung and Its Relation to
Dyspnea in Heart Disease. — Drs. Francis W. Peabi'hy
and A. Wentworth of Boston read this paper in
which they showed that the production of dyspnea in
patients with heart disease depended in part, at least,
on inabi'ity to increase the minute volume of nir
breathed to as great extent as the normal person. This
was due to a decrease in the vital capacity which limited
the depth of breathing. The tendency of a patient to
become dyspneic on exertion varied closelv with the de-
gree of the decrease in vital capacity. The determina-
tion of the vital capacity gave an indication of the
amount of exercise which would produce dyspnea, and
was a guide to the severity of the functional disability
cf the case.
Gns-rohydrorrhea in Cirrhosis of the Liver Accompa-
nied by Pvloric Stenosis — Dr. Max Einhorn read this
parer The term "gastrohydrorrhea," he said, signi-
fied the flow of a watery fluid from the stomach con-
taining neither hydroch'oric acid nor rennet or pepsin
ferments. Such a flow to the amount of one to one and
a half quarts a day was encountered in a patient suffer-
Aug. 12, 1916]
MEDICAL RECORD.
303
ing from cirrhosis of the liver accompanied by a pyloric
stenosis. No ascites had developed. At autopsy a
typical cirrhotic liver and a pyloric tumor (cancerous)
were found. The gastrohydrorrhea was explained by a
transudation process relieving the venous congestion in
the stomach and was akin to an accumulation of ascitic
fluid from the intestines in cirrhosis of the liver without
pyloric obstruction.
The Immunizing Effect on Swine of Desiccated Sensi-
tized Hog-Cholera Virus. — Drs. C. W. Duval and M. J.
Couret of New Orleans state that the method hitherto
used of preparing a sensitized virus for hog-cholera
had been expensive, involving the sacrifice of two ani-
mals. They had devised a method by which the virus
can be prepared with a smaller quantity of blood and
which is equally effective. They gave one-fourth to
one mg. as a first dose and repeated it three weeks
later by a dose of five to ten mg. This conferred
immunity for at least ten months. Some of the animals
immunized with this virus had withstood large doses
of virulent virus at the end of ten months.
Action of Opium Alkaloids and Their Combinations on
the Vomiting Center.— Dr. David L. Macht of Baltimore
related his experience with the opium alkaloids. He
said that the opium alkaloids, morphine, codeine,
papaverine, etc., might be divided into two groups.
Morphine produced vomiting when administered in
small doses and the others did not, so morphine was in
a class by itself and the others formed a second group.
He had tried administering these drugs in various ways,
subcutaneously, intramuscularly, intravenously and
the only one that produced vomiting was morphine. If
apomorphine was given after morphine no vomiting
was produced because the apomorphine paralyzed the
vomiting center. The remarkable phenomenon in con-
nection with the administration of combinations of
these drugs was that they did not produce vomiting.
On the average a combined dose of morphine and one
of the others of 0.5 of a grain did not produce vomit-
ing, but a dose of 0.3 of morphine did produce vomit-
ing. They had found that 5 mg. or 1/12 grain of
morphine produced vomiting in some instances whereas
as much as 20 mg. of pantopon could be given with-
out any nausea. The writer offered an explanation of
the difference in the action of morphine and the other
alkaloids of opium based on the fact that they were
members of different chemical groups.
The Role of the Liver in Acute Pylocythenia. — Dr.
Paul D. Lamson of Baltimore, Md., presented this con-
tribution. He recorded his experiments by which he
had tried to find the course of the increase of red blood
cells in polycythenia. They produced experimental poly-
cythenia in animals by huge doses of epinephrin and
then by removing various organs tried to find which
one was responsible for the increase of the red cells.
There were two theories to account for the increased
red cells. One was that they were tucked somewhere
in the body and the other that the increase was a re-
sult of the division of cells. No signs of new cell
formation had been found. After excluding all the
other organs as the possible source of the increased red
cells he had tied off the circulation of the liver and
found that the liver was the organ responsible for the
increase of red cells in polycythenia. Thus far they
were unab'e to give an explanation of the process by
which this increase was brought about.
NEW YORK ACADEMY OF MEDICINE.
Stated Meeting— Held May 4, 1916.
The President, Dr. Walter B. James, in the Chair.
An Explanation of Some Disorders Supposed to Have an
Emotional Origin. — Dr. Walter B. Cannon, George
Higginson Professor of Physiology, Harvard Medical
School, Boston, Mass., delivered this address, in which
he said that during the past four or five years many
of the researches of the Harvard Physiological Labora-
tory had been concerned with the bodily changes which
accompanied strong emotions, such as fear and rage.
These were fundamental experiences in man and the
lower animals, so much so that their expression con-
stituted a sort of common language. The studies which
had been carried on had revealed interesting relations
batween these emotions and certain glands of internal
secretion, and had suggested also a way in which emo-
tional excitement might occasion pathological states.
When a cat became infuriated, the pupils were dilated
and the hair was erect from the neck to the end of
the tail. But besides these surface manifestations
there were internal changes; for example, the heart
beat rapidly and the activities of the stomach and in-
testines were stopped. Both the internal and the ex-
ternal changes were due to the passage of nerve im-
pulses to viscera along the neurones of the sympathetic
division of the autonomic system. The relation of the
fibres connecting the central nervous system with these
neurones was such as to provide for diffuse action on
all the viscera that were innervated by this division.
The adrenal glands were supplied with nerves from the
sympathetic division; and also the secretion of the
adrenal medulla affected all structures innervated by
the sympathetic division precisely as if they were being
stimulated by its impulses. They had found that the
adrenal glands secreted adrenin in times of great ex-
citement, that there was an increased liberation of
sugar from the liver so that glycosuria might result,
that there was an abolition or prompt lessening of
muscular fatigue, and that there was a very much more
rapid clotting of blood. It was known also that adrenin
caused a redistribution of blood in the body so that it
was sent away from the alimentary canal whose ac-
tivities were inhibited, to the heart, the lungs, the
central nervous system and active skeletal muscles. It
was known, also, that adrenin caused dilation of the
bronchioles and it was known that it increased the
number of red blood corpuscles per cubic millimeter —
an increase which Lamson had shown occurred also
to a marked degree in cases of emotional excitement.
These changes, as true of man as of the lower animals
in times of great emotional stress, were significant
when the conditions which would give rise to the emo-
tions were considered. Fear was associated with the
instinct to flee; rage with the instinct to fight. These
were the emotions and instincts underlying the struggle
for existence. They were also the emotions and in-
stincts into which all other instincts might be readily
turned when they were thwarted. The internal changes
were all directed towards increasing the efficacy of
the organism for physical struggle. The increased
blood sugar provided a source of muscular energy. The
altered distribution of blood and the increased number
of red blood corpuscles arranged for carrying an abund-
ance of oxygen to the active structures. The dilated
bronchioles allowed ready ventilation of the lungs when
oxygen was greatly needed and carbon dioxide was
being produced in large amounts. The provision for
lessening muscular fatigue was directly useful in
muscles likely to be employed in continued action. The
rapid coagulation of blood tended to preserve that
precious fluid in case of injury to blood vessels. The
organism in which these changes most promptly oc-
curred had the greatest reinforcement of its abilities
and was most likely to be favored in physical struggle.
These arrangements for reinforcement accounted for
the great power and endurance which were exhibited
in times of intense excitement. Other glands than the
adrenal were not so readily studied because of the
difficulty of recognizing their secretions. It had long
been known, however, that physiological activity was
accompanied by the presence of an electrical difference
which might be observed by connecting an active part
with an inactive part of the body through a sensitive
galvanometer. Justification of this method of studying
glands could be obtained by applying it to the sub-
maxillary gland. It had been found that the electrical
change began before the external secretion appeared,
disappeared as secretion stopped, and was not related
either to flow of fluid in the ducts or a change of blood
flow in the capillaries. Since the only feature that
could not be abolished without abolishing the electrical
change was secretion, the electrical effect was a true
indicator of a secretory process. When this method,
therefore, was applied to the thyroid gland, the posi-
tive testimony of the galvanometer was evidence of
thyroid secretion. The electrical method showed that
the thyroid gland was subject to impulses from a part
of the sympathetic division of the autonomic system,
i.e. the cervical sympathetic. The secretion came
promptly — after a latent period from 5 to 7 seconds.
The vagus nerve was without control, and pilocarpine,
as a stimulator of vagus endings, was likewise without
control. The influence of the sympathetic was not due
to anemia, for shutting off the blood supply had no
such effect as was produced by sympathetic stimulation.
Control by the sympathetic implied that adrenin might
be effective in stimulating the thyroid. This, in fact,
was the case, for a marked electrical chanee was pro-
duced when adrenalin (0.1 c.c. of 1:100,000) was in-
304
MEDICAL RECORD.
[Aug. 12, 1916
jected intravenously into a cat. Furthermore, the
action current of the thyroid appeared if the nerves to
the adrenal gland were stimulated, an effect which did
not occur if the adrenal glands had been previously
removed and which was delayed if the return of blood
from the abdominal cavity was delayed until the blood
was again allowed to flow. Thus a hormone relation
between the adrenal and the thyroid was clearly demon-
strated. This electrical evidence, which was obtained
in cooperation with Dr. J. McKeen, Cattell, had been
confirmed by the observations of Dr. Robert L. Levy.
He had found that both stimulation of the cervical
sympathetic trunk and injection of stimulating doses
of adrenalin greatly augmented the effects of small
doses of adrenalin in raising blood pressure. This in-
crease of efficacy of adrenalin was not produced if the
thyroid glands had previously been removed. The
proof that the thyroid responded rapidly to sympa-
thetic stimulation and that it was effective in com-
bination with adrenal secretion showed that there was
another bodily change to be added to those already
mentioned as occurring in times of great emotional ex-
citement. In the course of this work two questions had
arisen. First, why were organs which were disturbed
in times of emotional stress not disturbed at other
times? It seemed probably that they were protected
from interference by a high neurone threshold inter-
posed between the central nervous system and the
visceral cells. Consequently only when great excita-
tion was present in the central nervous system was
this threshold crossed and the changes in the viscera
brought to pass. The second question was, why, in
certain pathological cases, was there apparently fre-
quent or continuous disturbance of these same viscera?
It seemed possible that this might be due to a wearing
down of the high threshold here or there from frequent
or great emotional experiences. Thus the situation
would be like a break in a dike, and only a slight dis-
turbance in the central nervous system might then be
needed to result in a pouring through of impulses at
the low point and consequently a fairly frequent or
continuous disturbance in the viscus innervated by this
region. Thus dyspepsia, tachycardia and probably per-
sistent glycosuria, reported as having an emotional
origin, might be accounted for. To test the effect of
continuous stimulation the phrenic nerve was fused
with a peripheral portion of the cut cervical sympa-
thetic. This operation, done with the aid of Dr. C. A. L.
Binger, resulted in some animals in tachycardia, in-
creased excitability, loose movements of the bowels,
exophthalmus on the operated side (in one case) and,
as Dr. Reginald Fitz showed, in great increase of meta-
bolism (in one case an increase of 130 per cent.).
These phenomena had disappeared on removal of the
thyroid gland on the operated side. The adrenal glands
in two animals that had died of the disease had been
greatly enlarged. The changes thus produced re-
sembled in many respects the symptoms of exophthal-
mic goitre and supported the view that this disease
might be primarily due to overactivity of that part of
the nervous system disturbed in emotional excitement, —
possibly, as suggested above, a local stimulation in the
cervical region. Two vicious circles might be opera-
tive: one through the nervous system due to increased
excitability from increased thyroid secretion and re-
sulting thus in increased nervous stimulation of the
gland; the other through the blood stream due to in-
creased adrenal activity from overaction of the thyroid
and stimulating the thyroid in turn in the manner
indicated above. The evidence previously presented
showed that besides any routine function, the adrenal
gland had an emergency function brought out in times
of great excitement. It was not unreasonable to sup-
pose that the thyroid gland likewise had an emergency
function evoked in critical times, which would s
to increase the speed of metabolism when the rapidity
of bodily processes might be of the utmost importance,
and besides that augmenting the efficiency of the
ad renin which would be secreted simultaneously.
Dr. Hr.M'Y Rutgers Marshall opened the discus-
sion by invitation. Tie said that he was led to his
view as to the result of reading Charles Darwin's "The
Expression of the Emotions in Man and the Animals,"
In which he conclusively showed thai the activities com-
monly called the expression of the emotions wire in-
stinctive activities that had been inherited because of
their racial value. This point was very effectively cor-
roborated by Dr. Cannon's experiments. This was the
view commonly hold and as such deserved some study
For it was not at all clear on the face of it. how in-
stinctive reactions, which always arose automatically,
and immediately, upon the receipt of a definite stimulus
could be caused by emotional states. Now, William
James held, on the contrary, that the instinctive re-
actions caused the emotions, which were what Lloyd
Morgan had aptly called "back strokes," which were
resultant from the automatic instinctive reactions
which we called expressions. To put the matter in the
vivid language which Mr. James used, we did not flee
because we were afraid, but we were afraid because
we fled. We did not strike because we were angry, but
we were angry because we struck. In other words, he
held that the emotions of fear and anger, for instance,
were after results of the purely automatic instinctive
activities involved, directly or indirectly, with the run-
ning away, or with the striking of the enemy. In his
more mature view the speaker said he had come to
hold that the causal relation was not involved at all
between the mental and the physical. All that the
evidence pointed to was the existence of a strict one
to one corresponding between the two. This was an
important point, and Dr. Cannon's experiments seemed
to corroborate it. Some of the results of such a view,
both physiological and psychological, he had attempted
to point out in an article published in the April num-
ber of Mind, in connection with the study of retentive-
ness, and of Bergson's and Freud's theories of dreams.
Under such a view it would be seen that they no longer
held that there existed a causal relation between the
emotion and its expression ; that they were no more
warranted in saying with Professor James that they
were afraid because they fled, that in saying with the
common man, that they fled because they were afraid.
All that one was warranted in saying was that the
specific form of the instinctive reaction necessarily in-
volved the equally specific form of the emotion, and
vice versa. To put this in another way, what might be
called an instinctive action was a relatively immediate
reaction to a selective definite stimulus, and was based
wholly, or in large part at least, upon inheritance.
Man displayed a countless variety of such instinctive
actions, varying greatly in complexity. The extreme
limit in one direction was the simple reflexes, and the
so-called emotional expressions were examples in the
direction of complexity. Corresponding with the more
complex instinct-actions changes were noted in the con-
sciousness which might be called instinct-feelings.
These differed as the instinct-actions differed. One felt
such an instinctive feeling when quite automatically he
rushed forward, and again when he jumped back sud-
denly to escape an automobile. And the instinctive
feelings in the two cases were as distinctly different
as the instinct actions were distinctly different. Now
most of our instinct-actions recurred but seldom in
anything like a definite form. Certain of them, how-
ever, did recur frequently, and were relatively constant
in form. In such cases one came to recognize them
and describe them as Darwin, and as Dr. Cannon had
done. In like manner the corresponding instinct-feel-
ings recurred for the most part, infrequently in any
thing like a definite form; but some of them did, and
these were recognized and given names. In the speak-
er's view it was the instinct-feelings of this latter
type that were what we called the emotions. Thus it
would be seen that this general conception taught us
that a definite type of behavior necessarily involved
a definite attitude of mind, and rice versa; and that
each change of an individual's behavior necessarily
involved a corresponding change of the individual's
mental attitude ; and vice versa. As nations were merely
aggregations of individuals, this meant that definite
changes of national attitude of mind must necessarily
go with changes of national habits of action; a fact
which, in the speaker's view, we were overlooking at the
present moment. Perhaps this distinction might appear
of little importance, but to him it seemed very im-
portant indeed. For, under the view which he had de-
fended the emotions, as types of mental states, could
not be looked upon as causally related with what we
called their expressions; but merely as symptomatic ac-
companiments of these instinctive activities. It made
all the difference in the world which position we took.
For if we treated our mental states as causally related
with physical states, the physician was tempted to step
outside the real sphere of his work. While if we
treated our mental states as symptoms of physical
states, the mental states he employed merely and prop-
erly as aids to the discovery of such physical con-
ditions as the physician was called upon to deal with.
The speaker said he was especially interested in the
Aug. 12, .1916]
MEDICAL RECORD.
305
impressive evidence furnished by Dr. Cannon of the
marvellously intricate coordination of minor systemic
parts necessary to the very existence of the high organ-
isms; evidence that had been accumulated in large
measure in the last decades, and which led us to aban-
don the study of the physical organism as though it
were a quasi atomic collection of separate organs;
leading us rather to study it as was now being done,
as a whole system of enormous complexity, in which
each organic path had its place as a minor system. The
biologist was thus coming daily to look upon problems
relating to organization as of greater and greater im-
portance, as was indicated, for instance, in the last book
from the pen of the eminent English physiologist, Hal-
dane. And correspondingly in the realm of conscious-
ness psychologists had discarded psychological atomism
and were treating the mind as an immensely complex
system of psychic systems. This fact that the physi-
logical and mental structure and functioning were to
be considered as single wholes was surely often over-
looked on the physiological side, for instance, by those
pedagogues who urged intensive specialization in any
particular field to the abandonment of broad culture.
They forgot that this specialization tended to involve a
loss of such balance of judgment as was required if
real advance in thought was to be made. It had led in
the scientific world to a great amount of pleading
which passed without protest. The physician could be
said to have escaped altogether the dangers involved in
the forgetfulness of the fact that each part of the
body was essentially related to the system as a whole.
It was certainly overlooked if a surgeon operated where
these was no urgent need, and where there was at the
same time no little hope of a readjustment of function-
ing, by natural processes, which would leave the sys-
tem intact and newly balanced. He seemed to observe
this same forgetfulness when he heard his friends say,
"My doctor tells me this drug will make me sleep, and
has no after effects," or "My doctor says the medicine
may help me and cannot in any event do me any harm."
No one who was impressed with the import of the facts
brought to their attention by Dr. Cannon could be
guilty of such thinking, and he had dared make these
critical remarks because he felt that they could not
possibly apply to these present, except as they might
urge them to take note of these things in the guid-
ance of their pupils.
Dr. Charles L. Dana said that he was not a physi-
ologist and he could not criticize but only accept Prof.
Cannon's data. He accepted also as most reasonable
the theory of the mechanism of defense which had
been described. The speaker said that he subscribed to
the laboratory work and the deductions presented by
Dr. Cannon, and he did so in spite of a very critical
attitude which he had begun to feel towards labora-
tories in general. They were doing splendid and con-
structive work, but they were also enslaving and in a
way enfeebling the clinician; and they were sending
out occasionally misleading and incomplete announce-
ments. The laboratory often needed a humanizing in-
fluence, and should be more dominated by clinical spirit.
He said that he had one practical suggestion to make
bearing on Prof. Cannon's observations. There were
emotional states which came on acutely, but lasted very
intensely for weeks and months. These were cases of
acute mania, or hypomania, in which the patient was
joyously exhilarated, alert, talkative, had violent bursts
of anger and was intensely active physically and men-
tally under the pressure of the emotional state, which
some morning suddenly left him, or a contrary state of
agitating depression occurred. These emotional states
might be like those brought on by shock. The question
whether they were brought on or kept up by periodical
explosions of pluriglandular activity would be worth
examining. We knew that in hyperthyroidism there
was often a distinct excess of emotional tone.
Dr. Harlow Brooks spoke from the standpoint of
the internist, and said there were two points that should
be thus considered. First, how could they explain the
influence of the emotions in the development of or-
ganic disease. In the clinical study of hypertension, of
angina pectoris, and allied conditions, there was no
clinician but realized the influence of the emotions in
the development of organic disease. In the clinical
study of hypertension, of angina pectoris, and allied
conditions, there was no clinician but realized the in-
fluence of the emotions in the etiology of the disease
In bronchial asthma, and in fact, the whole range of
cardiac renal and vascular disease, they recognized
this. This was one side of the question which touched
the clinician. Secondly, there was another field which
was more potent so far as clinicians were concerned,
and that was in the treatment of disease. All recog-
nized how much the emotions had to do with the
patient's convalescence. Also the important condition
of ''lack" of over emotion in the care of certain condi-
tions such as cardiac and renal diseases. He wished
they could carry away with them the idea that it
would be of great help to them if they would study
more how the emotions controlled disease, how discipline
and rest helped them to actually cure disease. By con-
trolling the emotions, the habits, etc., they might be
able to actually cure many of these conditions. He
thought that they had been given this evening the ex-
planation of many of the problems confronting them
in every day practice.
Dr. Walter Timme said that he believed that emo-
tional complexes had as reactions, disturbances of the
normal state in the three nervous levels, the psychic,
the sensori-motor and the vegetative. It was the vege-
tative that had engaged them at the present moment.
As this vegetative level combined both the sympathetic
and the extended vagus systems, and as these were
interactive, it was hardly possible to consider one with-
out the other. Emotions, such as anger, stimulated
the sympathetic, but such emotions as depression,
chagrin, or worry, stimulated the vagus and produced
physiological changes which were constantly seen,
notably, visceroptosis. One possible objection to Dr.
Cannon's conclusions regarding the effect of the in-
creased adrenalin in the adrenal veins of an animal
that had been frightened, was that these same veins
also depleted the adrenal cortex as well as the medulla.
The adrenal cortex in human beings comprised almost
nine-tenths of the gland, while the medulla which pro-
duced the adrenalin was only one-tenth. In animals
the cortex was notably smaller proportionately than in
human beings, and in acerebrate humans and idiots
the cortex was almost entirely absent. It was note-
worthy that with such absence the individual had much
less inhibition of his emotional discharges in anger and
fright. It might therefore be presumed that the cortex
secretes a substance which was possibly antagonistic to
adrenalin, and whose activity must be taken into
account in such experiments as Dr. Cannon had de-
scribed. An interesting problem was propounded in
considering the mutual relations of adrenalin and the
sympathetic system, namely, that they were mutually
stimulating; that was, adrenalin irritated the sympa-
thetic system, which in turn stimulated the adrenal
gland to a future production of adrenalin. This newly
formed adrenalin again effected the sympathetic with
the secondary effect upon the andrenals, and so on, ad
infinitum. And yet this was not so in fact, for it
seemed that the adrenalin was immune to sympathetic
stimulation produced by adrenalin. As for the inter-
relation of thyroid and adrenalin, he thought it had
fairly well been proven that thyroid acted as a sen-
sitizer to adrenalin just as it did to cocaine, enhancing
its effects. In conclusion, he said their thanks were
due Dr. Cannon for his elaborate work in establishing
upon a firm basis what heretofore had depended upon
empiricism. He had helped to transfer the entire
system of internal glandular activity from the realm
of the art of medicine to the realm of the science of
medicine.
Dr. John Rogers remarked that none could doubt
an emotional cause for many diseases, nor the physical
effects of emotion. Excitement had often caused him
while hunting to forget all sense of fatigue. Dr. Can-
non had shown how emotion caused an increase in the
circulation of adrenalin, or of the secretion, from the
adrenalin gland; also, that an increased activity on
the part of the adrenal caused an increase in the ac-
tivity of the thyroid. This was directly applicable
to the clinical phenomena observed in Graves' disease.
Here emotion or physical fatigue intensified the symp-
toms of over-activity of the thyroid. The adrenal
gland was a very important part of the chromaffin or
sympathetic nervous system. A few years ago no one
had heard of the autonomic system; now it appeared
that these two groups of nerves, or the sympathetic
and autonomic, supplied every important organ in the
body. They seemed to convey to each organ opposing
influences. The autonomic fibers in the main appeared
to convey secretory and motor impulses which some
recently published experiments showed were activated
by the products of several endocrine glands. This acti-
vation could apparently be inhibited by an extract of
the whole adrenal gland or by adrenalin. This sug-
306
MEDICAL RECORD.
[Aug. 12, 1916
gested that normally there was a perfect balance be-
tween the adrenal or chiomaffin, sympathetic system
and the autonomous with their activating endocrine
glands. When this balance was disturbed there arose
the manifestations of disease. The adrenal was sup-
posed to be supplied by the vagus which should have a
secretory influence. Stimulation of the vagus stimu-
lated the secretory activity of all the endocime glands,
including the adrenal, but the adrenal activated the
sympathetic and so tended to inhibit the activity of the
other endocrine structures. When this balance was
disturbed there ought to arise the manifestation of
disease, as above stated, and which now passed under
the name of sympatheticotonic or vagotonic. Dr. Timme
had hinted that adrenal was not the normal product of
the entire living adrenal gland. If this suspicion
proved true and adrenalin was some day lound only
in the stable part of some complex labile substance, it
might then be possible to demonstrate the mechanism
of the complicated diseases of which exophthalmic
goitre was an example.
Dr. Samuel J. Meltzer said that he wished to as-
sure Dr. Dana that Dr. Cannon had a very efficient
clinician and physician associated with his laboratory in
the person of Dr. Cannon himself. It had been most
instructive and enjoyable to hear such closely packed
facts as weie contained in Dr. Cannon's address, all
being the result of his own observations. He offered
facts and when he offered theories they were a tight
fit with his facts. Dr. Cannon's experiments pointed
to the effect of the adrenals on the emotions of fear
and hatred, but there was a further field for experi-
ment in the discovery of the source of the softer emo-
tions, such as the love of mothers for their children,
for music, and for beauty. Perhaps those responsible
for the fighting in Europe had very large adrenals.
Dr. Cannon's animal used in experimenting on the
harsher emotions was a cat. It was to be hoped that
his choice of his next animal for experimentation
further along these lines would rest on a pigeon, for
instance, when he would perhaps find the controlling
factor of the softer and desirable passions.
Dr. Thomas Darlington said that the presentation
of facts gathered in laboratory experimentation was
frequently so complicated by technical details as to
cloud the main issue, and he felt that everyone shared
his appreciation of the simple and lucid manner in
which Dr. Cannon had clothed his address. It had
been said at another meeting at the Academy that the
greatest accomplishment of the laboratory was in
aiding the practitioner to benefit and cure his patients,
and it was certain that such experiments as Dr. Can-
non's could be verified by any practitioner who realized
that the first step toward a cure of disease was to
relieve tr"> mind of th^ patient of fear. As Oliver
Wendell Holmes had said:
".Ah! sad and sick the suffering ones who miss
The touch and presence of a man like this,
Whose thrilling magnetism and cheerful laugh
Add to the remedies their better half,
And reinforce the courage and the will
And give sure virtue to the doubtful pill."
£>tate HHrftiral ICtrntsutij fSoar&H.
STATE BOARD EXAMINATION QUESTIONS.
The University of the State of New York.
May, 1916.
(Concluded from page 222.)
obstetrics and gynecology.
1. Give the etiology of hemorrhage appearing ex-
ternally after the birth of the child.
2. Describe the management of the third stage of
labor in normal delivery.
3. What is placenta proevia? Give its varieties and
its management.
4. What is concealed accidental hemorrhage? Give
its etiology and its diagnosis.
5. Describe methods of examination of the female
organs of generation.
6. What is the recognized normal position of the
uterus? By what means is it retained in this position?
7. Describe the separation of the placenta.
8. What is erosion of the cervix? Give its etiology
and its management.
9. Wnat hygienic care should be observed at the pe-
riod of jjuuescence.'
10. Wliat is accouchement force? When is it indi-
eated ?
11. Describe uterine polypi. Give their origin and
their histologic composition.
1Z. What are the causes o-f venereal warts? Give
treatment.
pathology.
1. Describe ophthalmia neonatorum.
2. What portion of the uterus is the most common
initial site of malignancy?
3. Give the technic of making a red blood count.
4. Give the pathology of erysipelas.
5. Give briefly the urinary findings, both chemical
and microscopical, in chronic parenchymatous ne-
phritis.
6. What changes take place in an inflamed part,
causing redness and swelling?
bacteriology.
7. Describe in detail how you would examine spinal
fluid for meningococci, morphologically and culturally.
8. How would you determine whether or not a sore
throat is caused by the diphtheria bacillus? Give de-
tails of procedure.
9. Describe a method of staining tubercle bacilli.
How could you isolate the bacilli from chest fluid?
10. What is a typhoid cairier? How can it be ascer-
tained bacteriologically that an individual is a typhoid
carrier?
11. What is meant by active immunization? Give an
example in which this principle is applied to the pro-
phylactic immunization of man.
12. What is the principle underlying Pasteur's method
of treatment of an individual who has been bitten by a
mad dog?
diagnosis.
1. What are the symptoms of intracranial hemor-
rhage (apoplexy)?
2. Differentiate a syphilitic mucous patch from an
aphthous ulcer of the buccal mucosa.
3. Describe the physical signs produced by pulmonary
tuberculosis in its incipient stages.
4. Differentiate between aortic stenosis and mitral in-
sufficiency.
6. Describe the renal conditions resulting from ar-
teriosclerosis and give their symptoms.
6. Describe the symptoms and the clinical course of
alcoholic cirrhosis of the liver.
7. Give the symptoms produced by deflections of the
nasal septum.
8. In what disease conditions is there an increase in
the number of leucocytes in the blood (hyperleucocy-
tosis) ? Mention three common disease conditions in
which the number of leucocytes is stationary or less-
ened Ueucopenia).
9. What symptoms indicate a perforation of the bowel
in the course of typhoid fever?
10. What are the symptoms of myxedema and of what
is it sismificant?
11. Mention two conditions in which wrist drop is an
important symptom.
12. Describe the physical signs present in lobar pneu-
monia and the modifications to be noted in the different
stages of the disease.
ANSWERS.
obstetrics and gynecology.
1. Postpartum hemorrhage. Causes: Anything in-
terfering with the firm contraction of the uterus after
the expulsion of the child; retained placenta, or mem-
brane, or clots: weakness of the uterine muscle; rapid
labor; delayed labor; poorly developed uterine muscle;
inflammation or disease of uterus; lacerations; imper-
fect separation of the placenta; mismanagement of the
third stage of labor.
2. In the third stage of labor the physician should
seize the fundus of the uterus through the abdominal
vail and knead and rub it until it contracts vigorously;
then he should press it down in the direction of the axis
of the pelvic inlet. This should last for about a quarter
of an hour after the child is born. The placenta, after
it is expressed, should be carefully taken by the physi-
cian so as to be sure that it is all expelled; at the same
time care must be taken that no particle of membrane
remains behind. Fluid extract of ergot may be admin-
istered.
Aug. 12, 1916]
MEDICAL RECORD.
307
3. Placenia prxvia is the condition in which the pla-
centa is attached in the lower uterine segment and may
be near or over (partially or completely) the internal
os. Varieties: (1) Central, when the placenta com-
pletely covers the os. (2) Partial, when the placenta
overlaps the os. (3) Marginal or lateral, when the pla-
centa reaches the margin of the os but does not overlap
it. Treatment at term: (1) Introduce one or two fin-
gers within the os (the hand being in the vagina) and
dissect the placenta from the uterine wall for about
three inches from the os uteri in all directions, pushing
it to one side if necessary. (2) Rupture the mem-
branes, and if there is an unfavorable presentation, turn
the child and make the breech engage in the os; or, if
the head presents, the forceps may be used, if speedy
delivery is necessary. Stop the hemorrhage by a tam-
pon; this must be tight and thorough. Accouchement
force is indicated; this consists of dilatation of cervix,
version and immediate extraction of the child.
4. Concealed hemorrhage is one form of hemorrhage
in premature detachment of the placenta. The blood
dissects its way between the placenta and membranes,
but does not escape externally (or only very slightly).
Cause: Separation at center of placenta, the edges still
being adherent; detachment of placenta at upper mar-
gin only; plugging of parturient canal and thus
hemorrhage from any cause cannot escape. Symptoms
are pallor, syncope, thirst, rapid and weak pulse; the
uterus is soft and enlarged.
5. The patient should be free from corsets and con-
stricting bands; the bladder and rectum should be
empty. External palpation: The patient should be
in the lithotomy position, on a suitable table or bed.
The examiner stands on one side, and palpates the
lower abdomen to determine any enlargement of the
uterus. Inspection will show the presence of parasites,
discharges, caruncle, chancre, condylomata, and lacera-
tions. Vaginal touch: The examiner separates the
labia with the thumb and finger of one hand; and two
fingers of the other hand well lubricated are introduced
into the vagina. Pressure is made on the perineum
until the posterior fornix is reached, when the palmar
surfaces are turned forward and the size, position, and
condition of the cervix are determined. Then with the
palmar surface of the external hand gentle pressure is
made on the abdomen and the two hands are approxi-
mated. A digital vaginal examination will show: (1)
The condition of the perineum, whether torn or not;
(2) the size, shape, dilatability, temperature, discharges
(if any) of the vagina; (3) the presence of cystocele,
rectocele, prolapsed uterus, or other abnormal condi-
tions of vagina; (4) position, shape, size, consistence of
cervix, with presence of absence of erosions, lacera-
tions (5) condition, shape, size, location, and mobility
of uterus; (6) sometimes presence of abnormalities in
tubes, and ovaries, and uterus (such as tumors, in-
flammations, etc.) Rectal examinations : In virgins and
in some cases of extreme retroversion one finger is in-
troduced into the rectum and with the other hand on
the abdomen a more satisfactory bi-manual examina-
tion can be made. Instrumental examination: in the
lithotomy position, by the use of a bi-valve, a tubular
or Ferguson speculum, the condition of the cervix can
be inspected. This is best accomplished in some cases
by use of the Sims position and the Sims speculum. At
the same time in rare and selected cases by steadying
the anterior lip of the cervix with a bullet forceps the
uterine sound may be passed to determine the size and
position of the uterus.
6. The recognized normal position of the uterus is
one of slight anteflexion, with its long axis at right
angles to the long axis of the vagina. The anterior
surface of its body rests on the bladder, and the cervix
points backward toward the coccyx. The uterus is not
fixed, but moves freely within certain limits. It is
held in place by ligaments.
7. Separation of the placenta from the uterine at-
tachment is due to the retraction and contraction of the
uterus which brings about a disproportion between the
placenta and its site: the attachments between the two
are torn through. In the intervals between the con-
tractions a moderate hemorrhage takes place behind
the placenta, and this is a factor in bringing about the
separation.
8. Erosion of the cervix is a condition in which the
vaginal portion of the cervix uteri has on its surface a
mucous patch consisting of a layer of cnlumna"- <>rji-
thelium and newlv formed glands; these replace
squamous stratified epithelium. The condition was
formerly described as an ulcer but a true ulcer is
characterized by loss of tissue, and there is no loss of
tissue in an erosion. The causes are unknown; erosions
are found in virgins, nulliparous, and parous women.
Treatment consists in cleanliness, mild astringent
douches, cauterization of the cervix, general improve-
ment of the health and surroundings of the patient; in
severe cases Emmett's operation, and amputation of the
cervix have been recommended.
9. Hygiene of puberty: "The period of puberty should
be taken as extending not only over the few months
required for the establishment of menstruation, but
as including the time necessary for full physical de-
velopment. During this time the energy of the girl is
taxed by the rapidity of sexual development, by the
great liability to circulatory disturbances, by the phys-
ical and mental strain of education, and by the con-
ventionalities of society. The necessity, therefore, for
great care is apparent. Nutritious and simple diet,
frequent rest, moderate amusements, and adequate ex-
ercise are essential, Study, especially during menstru-
ation, should never be pressed to the point of fatigue.
Inasmuch as passional life now begins, and the whole
nervous organization is therefore subject to new im-
pulses and requirements, books and associates should
be selected carefully, and whatever may unduly excite
the emotions should be excluded. Errors committed
now may have grave consequences, such as malnutri-
tion, psychoses, sterility, menstrual and other functional
disorders, and may make the woman a hopeless invalid.
One of the most serious errors is premature marriage."
— (Dudley's Gynecology.)
10. Accouchement force: "By this term is under-
stood the forcible dilatation of the intact or partially
dilated cervix, followed by version and extraction of
the child. Indications: In this country the most usual
indication for accouchement force is threatened or
actual eclampsia. Occasionally it becomes necessary in
concealed or accidental hemorrhage, and also in the
rare cases of acute edema of the lungs, or broken car-
diac compensation complicating pregnancy, as well as
in certain cases of placenta prasvia." — (Williams' 06-
stetrics.)
11. Uterine polypi are pedunculated tumors attached
to the uterine mucous membrane. Mucous polypi "grow
most frequently from the cervix. According to some
authorities they occur only as a result of inflammatory
changes, being a mere local hypertrophy and hyper-
plasia. These polpi vary from a pea to a hen's egg in
size. They are made up of the elements of the mucosa
and are very vascular, usually of a cherry-red color.
Often more than one are found. They are covered with
columnar epithelium ; when growing near the os ex-
ternum, they may be partly or, sometimes, entirely
covered with stratified squamous epithelium. They are
made up of spaces lined with columnar or cubical epi-
thelium, lying in a delicate connective tissue stroma,
rich in capillaries; often blood is found diffused among
the fibrils. In some cases, where the spaces are some-
what distended, the lining epi'helium may be consider-
ably flattened. They contain thick or thin mucus. As
these polypi grow and descend they dilate the cervix.
Sometimes those growing in the body do not tend to
work their way down through the cervix. They some-
times tend to recur; in some cases there is a malignant
tendency. Sometimes these growths may have a cover-
ing of stratified squamous epithelium, through growing
from the cervical mucosa." — (Webster's Diseases of
Women.)
12. Venereal Warts. Causes: Gonorrhea, syphilis,
irritating discharges, want of cleanliness, and (some-
times) the congestion and leucorrhea of pregnancy.
Treatment: Excision of wart by curved scissors, fol-
lowed by cauterization : application of calomel and sal-
icylic acid; douches: cleanliness; tonics; and removal
of the cause, if possible.
PATHOLOGY.
1. Ophthalmia neonatorum is an infectious, purulent
inflammation of the conjunctiva in the newborn, due to
the gonococcus or other pyogenic germ ; produced by
contact of the eye with the vaginal secretion of the
mother during labor, or infected fingers, or instru-
ments, etc.
The treatment is (1) Prophylactic. — Whenever there
is the possibility of infection, or in every case, wash the
eyelids of the newborn child with clean warm water,
and droo on the cornea of each eve one drop of a 1 or 2
ner cent, solution of nitrate of silver, immediately after
birth. (2) Remedial. — Wash the eyes carefully every
half-hour with a saturated solution of boric acid; pus
308
MEDICAL RECORD.
[Aug. 12, 1916
must not be allowed to accumulate. Two drops of a 2
per cent, solution of nitrate of sliver must also be
dropped on to the cornea every night and morning. The
eyes must be covered with a light, cold, wet compress.
The patient must be isolated, and all cloths and com-
presses used must be burned.
"The disease, if untreated, declines spontaneously,
and the discharge almost ceases in about six weeks, the
palbebral conjunctiva being left thick, relaxed, and
more or less granular. Cicatricial changes identical
with but less severe than those resulting from chronic
granular lids, and analogous to those which occur in
stricture of the urethra, sometimes follow; considerable
permanent thickening of the ocular conjunctiva may
also occur. There is a great risk to the cornea in this
disease, partly from strangulation of the vessels, partly
from the local influence of the discharge. If within the
first two or three days the cornea becomes hazy and
dull, like that of a dead fish, there is great risk that
total or extensive sloughing will occur. In many of the
milder cases ulcers form a little below the center and
rapidly cause perforation. In other cases clear, deep
ulcers form close to the edge of the cornea. There is
less risk of ulceration of the cornea in the purulent
ophthalmia of infants than in that of adults." — (Nettle-
ship's Diseases of the Eye.)
2. The cervix is the most common site of malignancy
of the uterus.
3. To make a red blood count: "The finger is cleansed
and punctured. As soon as the blood is flowing freely
a red-blood pipette is brought into contact with the drop,
suction made, and the blood drawn up to the mark O.B.
In the case of an extremely anemic patient draw it up
to the mark 1. If the mark is slightly over-reached,
touch the point of the pipette against the towel till the
column is brought back to the 0.5 mark. When the
blood is drawn to the proper mark, and that on the out-
side of the tube wiped off (being careful not to touch
the point), the pipette is immediately plunged into the
diluting solution and suction made as soon as it is below
the surface. This is drawn up until the mark 101 is
reached. The pipette, held in the horizontal position, is
tapped rapidly with the fingers in order to mix thor-
oughly the blood. Next blow out the diluting fluid and
place a medium-sized drop of the diluted blood upon th©
small glass cylinder in the counting-chamber. The next
step is the careful adjustment of the cover-slip over the
drop of diluted blood. The drop should now nearly
cover the central glass slide; there should be no air
bubbles in it; it should not overrun the gutter. If the
slide be held up to the light on a level with the eyes,
a play of colored rainbow rings may be seen. This in-
dicates that the technique has been correct. A few min-
utes should elapse before counting to allow the corpus-
cles to settle. The counting-chamber is exactly one-
tenth of a millimeter deep. The ruled square used for
counting reds is a square millimeter divided into 400
small squares, so that each small square is 1/400 square
millimeter. Use the low dry lens, with most of the light
shut off. It is well to adopt the rule of beginning with
the lower right square and counting upward. Every
fifth square above and to the left is subdivided by an
extra line to facilitate the counting. The corpuscles
lying. on the upper and left lines are counted; those on
the lower and right are not. Continue this upward
course till five squares are counted, then take the next
square to the left and go down five, then the next to the
left and go up again five squares, and so on till the
number of corpuscles in 200 small squares is counted.
This sum is divided by 200, thus giving the number in
each small square. To calculate the number of corpus-
cles per cubic millimeter, multiply by 100, because the
blood has been diluted 100 times; then by 400, because
each small square is one four-hundredths of a square
millimeter; then by 10, as the square millimeter is only
one-tenth of a millimeter deep. This gives the number
of corpuscles in a cubic millimeter. In short, with a
dilution of 1 :100 the number of corpuscles in each small
square is multiplied by 400,000. If the dilution has
been 1:200, multiply by 800,000." (Arneill's Clinical
Diagnosis.)
4. Pathology of erysipelas: "Sections of the affected
skin reveal an infiltration with granular leucocytes and
serum, often including many micrococci, and involving
the subcutaneous cellular tissue and to a variable depth
the fat. The leucocytes are most numerous in the capil-
laries and lymph-spaces of the outer zone, where the
disease is advancing; they are also numerous around
the hair follicles and sweat glands. Pus is formed in
the worst cases. The edema is most pronounced in
loose cellular tissue, as beneath the eyelids and the pre-
puce. Abscesses and infarction are occasionally found
in the lungs, spleen, and kidneys." (French's Practice
of Medicine.)
5. In chronic parenchymatous nephritis: "The quan-
tity of urine is diminished, it is cloudy from urates; the
specific gravity may be high in the early but is low in
the later stages. Albumin is abundant, sometimes more
so than in any other disease. The heavy sediment con-
tains large numbers of nearly all the varieties of tube
casts, hyaline, epithelial, granular, and fatty. The lat-
ter are especially characteristic. Occasional red corpus-
cles, many leucocytes, and numbers of degenerated
epithelial cells are also found. The amount of urea is
decreased." (Butler's Diagnostics of Internal Medi-
cine.)
6. The redness is due to the hyperemia which is pres-
ent in inflammation, the hyperemia being caused by the
dilated vessels of the part.
The stvelling is caused by the excess of blood present
in the part, by the leucocytes brought to the part, by the
exudate within the tissues, and by the newly-made tissue
cells.
BACTERIOLOGY.
7. To examine spinal fluid for meningocci: The fluid
should be received in a sterile container, and then cen-
trifuged. The sediment is stained with Gram's stain;
the diplococcus intracellularis meningitidis is a diplo-
coccus, very small, with no capsule, non-motile, non-
flagellate, Gram-negative, but staining by ordinary
methods. A culture must be made very promptly; it
grows at body temperature, on Loeffler's blood-serum
mixture or glucose ascitic agar neutral to phenolphtha-
lein. Transfers must be made frequently as the diplo-
coccus is readily killed by heat, drying, sunlight, or
disinfectants.
8. A sterile swab is rubbed over any visible mem-
brane on the tonsils or throat and is then immediately
passed over the surface of the serum in a culture tube.
The tube of culture, thus inoculated, is placed in an in-
cubator at 37° C. for about twelve hours, when it is
ready for examination. A sterile platinum wire is in-
serted into the culture tube, and a number of colonies
of a whitish color are removed by it and placed on a
clean cover slip and smeared over its surface. The
smear is allowed to dry, is passed two or three times
through a flame to fix the bacteria, and is then covered
for about five or six minutes with a Loeffler's methy-
lene-blue solution. The cover slip is then rinsed in
clean water, dried, and mounted. The bacilli of diph-
theria appears as short thick rods with rounded ends;
irregular forms are characteristic of this bacillus, and
the staining will appear pronounced in some parts of
the bacilli and deficient in other parts. Methods of
culture: The bacillus of diphtheria grows upon all the
ordinary culture media, and can be readily obtained
in pure culture. Loeffler's blood serum, particularly
with the addition of a little glucose, is an admirable
medium for the rapid growth of this bacillus. The
medium should be alkaline and not less than 20° C.
The characteristics of the bacillus of diphtheria: The
bacilli are from 2 to 6 mikrons in length and from 0.2
to 1.0 mikron in breadth; are slightly curved, and often
have clubbed and rounded ends; occur either singly or
in pairs, or in irregular groups, but do not form chains;
they have no flagella, are nonmotile, and aerobic; they
are noted for their pleomorphism; they do not stain
uniformly, but stain well by Gram's method and very
beautifully with Loeffler's alkaline-methylene blue.
9. To demonstrate the existence of tubercle bacilli in
the sputum: The sputum must be recent, free from
particles of food or other foreign matter; select a
cheesy-looking nodule and smear it on a slide, making
the smear as thin as possible. Then cover it with some
carbolfuchsin, and let it steam over a small flame for
about two minutes, care being taken that it does not
boil. Wash it thoroughly in water and then decolorize
by immersing it in a solution of any dilute mineral acid
for about a minute. Then make a contrast stain with
solution of Loeffler's methylene blue for about a minute;
wash it again and examine with oil immersion lens.
The tubercle bacilli will appear as thin red rods, while
all other bacteria will appear blue.
The chest fluid should be treated with antiformin,
which kills most bacteria but not the tubercle bacilli;
it is then centrifuged, and from the sediment the
tubercle bacilli may be cultivated on blood serum. On
account of the difficulty of obtaining material free from
other bacteria (which grow more rapidly than the
Aug. 12, 1916]
MEDICAL RECORD.
309
tubercle bacilli), it is often necessary to inoculate
guinea pigs subcutaneously with the sediment, and then
obtain cultures from these animals as soon as the
tuberculous infection has developed.
10. A typhoid carrier is a person who is not suffering
from the disease, but whose excreta contain the typhoid
bacilli and who, therefore, is capable of giving the dis-
ease to others. The finding of the typhoid bacilli in the
feces (and urine) of such a person is proof of his being
a typhoid carrier.
11. Immunity, or the power to resist invasion by
microorganisms with the subsequent development of dis-
ease, is active when the cells or tissues of the invaded
individual bring about this immunity, either by de-
stroying the bacteria or by neutralizing their poisonous
products. Such an immunity may be acquired in sev-
eral ways; one is by inoculation, another is by vaccina-
tion; this latter is used as a prophylactic measure
against smallpox.
12. The principle underlying Pasteur's treatment for
rabies: "It consists of an active immunization with
virus, attenuated by drying, administered during the
long incubation period in doses of progressively in-
creased virulence. By the repeated passage of street
virus through rabbits, Pasteur obtained a virus of
maximum and approximately constant virulence which
he designated as virus fixe. He then ascertained that
such virus fixe could be gradually attenuated by drying
over caustic potash at a temperature of about 25° C,
the degree of attenuation varying directly with the time
of drying. Thus, while fresh virus fixe regularly
caused death in rabbits after six to seven days, the in-
cubation time following the inoculation of dried virus
grew longer and longer as the time of drying was in-
creased, until finally virus dried for eight days was no
longer regularly infectious and that dried for twelve to
fourteen days had completely lost its virulence. The
method of active immunization which Pasteur used con-
sisted in injecting, subcutaneously, virus of progres-
sively increasing virul«nce, beginning with that derived
from cords dried for thirteen days and gradually ad-
vancing to a strong virus. Thus the patient was immu-
nized to a potent virus several weeks before the incuba-
tion time of his own infection had elapsed." (Hiss and
Zinsser's Bacteriology .)
DIAGNOSIS.
1. Symptoms of intracranial hemorrhage (apoplexy) :
There may be prodromal symptoms such as vertigo,
pain in the head, or impairment of memory; but as a
rule the attack is sudden with vertigo and unconscious-
ness; there may be retention or incontinence of urine,
the urine has a high specific gravity and may contain
albumin; hemiplegia generally ensues; the tongue pro-
trudes toward the affected side; asphasia (either motor
or sensory) may be present; the face is flushed, breath-
ing is stertorous ; the body temperature is first sub-
normal and then elevated; the pulse is slow and full; in
severe cases the pulse becomes weak, and the respira-
tions become of the Cheyne-Stokes type; the reflexes
are abolished.
2. Apthous ulcers are sharply defined, extremely sen-
sitive, and evanescent in character.
Mucous patches are rounded or oval, fiat, slightly ele-
vated or depressed, grayish or pinkish in color, and
slightly painful.
3. The early manifestations of pulmonary tuberculo-
sis are: (1) Physical signs: Deficient chest expansion,
the phthisical chest, slight dullness or impaired reson-
ance over one apex, fine moist rales at end of inspira-
tion, expiration prolonged or high pitched, breathing
interrupted. (2) Symptoms: General weakness, lassi-
tude, dyspnea on exertion, pallor, anorexia, loss of
weight, slight fever, and night sweats, hemoptysis.
4. In aortic stenosis, there is a systolic murmur
heard loudest at the base of the heart, and transmitted
into the carotid arteries; the pulse is characteristic,
being small and slow. In mitral irisufficiency, there is
a systolic murmur heard loudest near the apex and
transmitted to the left axilla and sometimes to the
angle of the left scapula; there is frequently an ac-
centuated second pulmonic sound; the pulse shows noth-
ing that is characteristic.
5. The renal conditions resulting from arteriosclero-
sis are those found in chronic interstitial nephritis.
The symptoms are: Increased arterial tension, enlarge-
ment of the left ventricle and then of entire heart,
accentuated second aortic sound, retinitis, choked disc,
anorexia, nausea, vomiting, diarrhea, uremia, dyspnea,
dry and itching skin; the urine is increased in quan-
tity, and has a low specific gravity, albumin is either
absent or present in very small quantity; a few hyaline
casts may be present.
6. Alcoholic cirrhosis of the liver. "Obstruction of
the portal circulation first causes congestion and
catarrh of the stomach, hence the initial symptoms are
anorexia, fetor of the breath, fullness and distress
after eating, eructations, nausea, vomiting of mucus,
flatulence, and constipation. For months, and even
years, these phenomena may be the only evidence
of the disease. As the pressure in the portal system
increases, the collateral vessels enlarge, and as a result
the superficial abdominal veins become prominent and
hemorrhoids develop. Engorgement of the portal sys-
tem also leads to ascites and swelling of the feet, to
enlargement of the spleen, and not infrequently to
copious hemorrhages from the stomach or bowel. The
size of the liver varies; it may be increased or dimin-
ished. There is a gradual loss of flesh and strength.
The skin is muddy in appearance, but conspicuous jaun-
dice is not common and occurs only as a complication,
nervous symptoms — delirium, stupor, convulsions, and
coma — occasionally appear toward the end of the dis-
ease. They are probably due to the retention of poisons
that the liver is unable to convert or to eliminate. The
majority of cases terminate fatally in from three to five
years, or in from one to two years after the compen-
satory circulation fails. Death results from exhaus-
tion, hemorrhage, pulmonary edema, intercurrent dis-
ease, or toxemia." — (Stevens' Practice of Medicine.)
7. Deflections of the nasal septum may cause: Ob-
struction to inspiration; catarrh of the nasopharynx;
hypertrophy of middle or inferior turbinated bone on
the non-obstructed side; atrophy of turbinated bone on
the obstructed side; interference with hearing; mouth-
lireathing.
8. The leucocytes are increased in : Inflammatory dis-
eases, abscesses, certain infectious diseases (such as
erysipelas, pneumonia, meningitis, diphtheria), lym-
phatic leukemia, splenomedullary leukemia.
Leucopenia is found in: Pernicious anemia, typhoid,
and miliary tuberculosis.
9. Intestinal perforation in typhoid fever: Sometimes
there is severe, sudden pain localized in the abdomen,
and sometimes there is little or no pain. Marked
tympanites, great weakness, collapse, anxious look,
small, rapid pulse, and difficult breathing are present.
The legs are apt to be drawn up, and nausea and vomit-
ing may ensue. Hepatic and splenic dulness disappear,
and leucocytosis may be present.
10. Symptoms of myxedema: The body becomes
swollen and edematous, but does not pit on pressure;
the skin is dry and rough; the hair is brittle, and tends
to fall out; wrinkles are obliterated, and the face
assumes a stolid expression; the muscles become flabby;
movement, mental processes, and speech become slow;
the temperature of the body is subnormal.
The condition is significant of lack of thyroid secre-
tion.
11. Wrist-drop is an important symptom in:
Paralysis of the musculo-spiral nerve due to lead
poisoning or multiple neuritis.
12. Physical signs of lobar pneumonia: "Inspection
reveals during the first stage deficient movement of the
affected side, due to pain. The apex-beat is normal in
situation, and the interspaces do not bulge. In the
second stage the healthy side rises normally, the af-
fected side lagging behind. If both lower lobes are
impervious to air, the diaphragm cannot descend and
the epigastrium does not project during inspiration,
the breathing being conducted by the upper part of the
chest (superior costal respiration). Palpation during
the first stage shows the vocal fremitus to be more
distinct than normal, especially over the diseased por-
tions. In the second stage, the vocal fremitus is .mark-
edly exaggerated, except in those rare instances of oc-
clusion of the bronchi by secretion. The cardiac
impulse is felt in the normal position. Percussion — In
the first stage, the percussion note is slightlv impaired
at times, having a hollow or tympanitic quality. In the
second stage there is dullness over the affected parts,
with an increased sense of resistance. Over unaf-
fected adjoining areas the resonance is increased
(Skoda's resonance). Auscultation. — In the first stage
there is heard over the affected part a feeble vesicular
murmur, associated with the true vesicular or crepitant
(crackling) rale, hea'-d at the end of inspiration only.
Tn the second stage there is harsh, high-pitched, bron-
chial respiration, at times resembling a to-and-fro
metallic sound, except in those rare instances in which
310
MEDICAL RECORD.
[Aug. 12, 1916
the bronchi are more or less filled with secretion.
Bronchophony, or distinctly transmitted voice, is pres-
ent and at times pectoriloquy, or distinct transmission
of articulated sounds, may be heard. In the third
stage, the breathing changes from bronchial to bron-
chovesicular and the crepitant rale (crepitatio redux)
returns. As resolution proceeds, the breath sounds are
associated with large and small moist and bubbling
rales." — (Hughes' Practice of Medicine.)
BULLETIN OF APPROACHING EXAMINATION'S
NAME AND ADDRESS OK PLACE AND DATE OF
STATE SECRETARY NEXT E \ A MINATION f
Alabama* W. H. Sanders, Montgomery . . Montgomery . ..
Arizona* J. W. Thomas, Phoenix Phoenix
Arkansas T. J. Stout. Brinkley Little Rock , , . Nov. 11
California C. B. Pink ham, Sacramento . Los Angeles Oct. 3
Colorado David A. Strickler, Empire
Building, Denver Denver Oct. 3
Connecticut* Chas. A. Tuttle, New Haven. . . New Haven .... Nov. 14
Delaware J. II. Wilson, Dover Dover Dec. 12
Dist. of CoTba. . E. P.Copeland, Washington Washington.. . Oct. 10
Florida* E. W. Warren, Palatka Palatka Dec. 5
Georgia C-T. Nolan, Marietta Atlanta Oct. 10
Idaho* Charles A. Dettman, Burke Oct. 4
Illinois C.t*. Drake, Springfield Chicago ...
Indiana W. T. Gott, Crawfordsville Indianapolis , .Jan. 9
Iowa G. H. Sumner, Des Moines Iowa City
Kansas EL A. Dykes, Lebanon Lebanon Oct. 10
Kentucky J. N. McCormack, Bowling
Green Louisville
Louisiana E. L. Leckert, New Orleans New ( Orleans. . . Nov. 30
Maine F. W. Searle, Portland Portland . . Nov. 14
Maryland. J. McP. Scott, Hagerstown Baltimore .Dec. 12
Massachusetts*.. W. P. Bowers, State House, Bos-
ton Boston Sept. 12
Michigan B. D. Hanson, 205 Whitney
Buildins, Detroit Lansing Oct. 10
Minnesota. T. McDavitt. St. Paul Minneapolis Oct. 3
Mississippi J. D. Gilleylen. Jackson Jackson Oct. 21
Missouri J. A. B. Adcock, Jefferson City... Kansas CitA, . Sept. is
Montana* Wm. C. Riddell, Helena Helena Oct. 3
Nebraska H. B. Cummins, Seward Lincoln
Nevada S. L. Lee, Carson City Carson City.. . Nov. 6
N. Hampshire. . Walter T. Crosby, Manchester . Concord Dec, is
New Jersey A. Mac Mister, Trenton ..... .Trenton Oct. 17
New Mexico .... W. E. Kaser, East Las Vegas . . . . Santa Fe
New York....)
New York H. H. Horner, Univ. of State of Mbany . ... Sept. 19
New York, Albany 3yn . . . |
.Buffalo J
N. Carolina H. A. Rovster. Raleigh Raleigh
N. Dakota G. M. Williamson, Grand Forks. .Grand Forks. ...Ian. 1
Ohio Geo. H. Matson, Columbus Columbus Dec.
Oklahoma R. V. Smith. Tulsa Oklahoma City.Oct. 10
Oregon B. E. Miller, Portland Portland Jan. 2
Philadelphia. '
Pennsylvania ... X. C. Schaeffer, Harrisburg.
■ Pittsburgh
Rhode Island.. . .G. T. Swarts, Proviil ...Providence. . ..Oct. 5
S. Carolina H. E. Boozer, Columbia Columbia Nov. 14
S. Dakota P. B. Jenkins, Waubay .Deadwood
Memphis )
Tennessee \. B. DeLoaeh, Memphis - Nashville
Knoxville J
Texas M.P. McElhannon, Beltoo San Antonio. . .
Utah G. F. Harding, Salt 1 akeCity Sail LakeCity..
Vermont W.Scott Nay, Underbill Burlingl >n Feb. 13
Virginia I.N. Barney, Fredericksburg . .Richmond. . . .Dec. 12
Washington* . C. N. Suttner, Walla Walla Spokane Jan. 2
W. Virginia . . . .S. L. Jepson, Charleston Clarksburg: . Nov.
Wisconsin J. M. Dodd, Ashland Madison . Jan. 9
Wyoming H. E. McColIum, Laramie . Laramie
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Original Arttrfra.
DOGMATIC PHYSIOLOGY.
By J. ALLEN GILBERT, Ph.D., M.D.,
PORTLAND, ORE.
The average physician has but little interest in
psychology. He knows comparatively little in re-
gard to it and gives it comparatively little impor-
tance among the various branches of science. In
fact he is loath to accord it any existence at all as
a separate science and classifies it for convenience
as a branch of physiology. For him mind is but a
product of brain, sensation a modification of the
brain cell, consciousness a mere effervescence from
nerve matter and thought in general a side issue
having reference only to the brain that gave it
birth. The ultimate fact is functioning matter.
Psychic data are but shadows of the real thing.
The atom is his God and force his mainspring.
With these two fundamental realities he spins off
with infinite satisfaction the whole series of phy-
sical and psychological phenomena, always with-
holding from psychology a standing in any way
equivalent to that of the objective sciences. He
rides over contradictions in his statements with a
complacency which is admirable for its audacity.
Materialistic in his tenets he is nevertheless ultra-
idealistic in his actions and in his demands upon
the actions of others. Though he may not adhere
to any definite rule of action he always demands it
of the other man. In his daily life he belies the
tenets which he defends so vigorously on theoretical
grounds. Psychological inquiry is reserved as a
sort of mental gymnasium, but the real work of life
is to be found in the more tangible phenomena of
physics and chemistry, which he looks upon as
stable and abiding. The laws of perception do not
bother or worry him in that he knows but little of
them.
In a sense one feels prompted to apologize for
bringing up anew a subject which has been so thor-
oughly discussed in years gone by, and yet after
years of work in a psychological atmosphere it
makes one shudder to observe the boldness with
which physiology asserts herself in medical circles.
Has psychology no relation to metabolism and gen-
eral therapeutics? Is the physical organism a mech-
anism with no kinship to the higher emotional
aspects of man's nature? Is there nothing of man
but the chemical process known as physiology?
Whatever answer we may give to such questions it
is evident in medical circles that physiology has
usurped the throne and hands down its dicta with a
positiveness which is far less critical in its funda-
mental tenets than the old-time dogmatic theology.
Not all physicians boycott the psychic. However,
the average physician's training is confined to deal-
ings with the material side of man and in the ab-
sence of supplementary interest in psychology he
sees only the physical and rules out as irrelevant all
phenomena that can not be subjected to his pet
atomic theory. He begins his studies in the dis-
secting room. Here he finds what are to him funda-
mental facts in the shape of nerve, muscle, and bone.
They are what is left of a former physiological
mechanism worn out and yet sufficiently intact to
suggest the modus operandi ante mortem. He be-
gins where psychology leaves off, and failing to find
the higher emotions, he naturally assumes their
effervescent nature and subsequently wastes but
little time upon them. Working backwards his
whole aim is to learn how the machine ran down.
Physiological processes are no longer apparent ex-
cept in the foul odor which fills the room. The
process of decay attracts his attention, but he little
realizes that here the same chemical forces are at
work as those he later encounters in the test tube
or in the blood coursing through the arteries of a
vivified organism. Later study of the physiological
processes which account for the metabolism of the
body gradually leads him up to and prepares him for
the climax of organic chemistry, viz., the process
of reproduction. Clinging to the criterion of visible
change for his recognition of reality the higher
emotions escape his attention because of the all-
absorbing attractiveness of the changes he can trace
and put his finger upon. Like the child who quickly
differentiates the moving light from the confusion
of stimuli which fill his limited mental horizon he
fastens his faith upon that which moves. Very
quickly his system of thought is hinged upon the
motion of things and nothing so thoroughly enlists
his admiration as that form of motion which is
manifest in reflex or automatic processes as if in
them were to be found a spontaneity of activity
most nearly akin to motion as such. He is finally
satisfied with explaining all reality upon the basis
of the atom in motion.
On the accouchement bed, later in his experience,
he delivers the new-born child as a mere bundle of
reflexes into which he at times literally breathes
the breath of life. It never becomes more to him
than a bundle of reflexes which automatically de-
velops a machine of infinite intricacy, wears out,
and suffers dissolution. He spends his last futile
efforts upon the post-mortem investigation, trying
to discover why the machine ran down and with the
tabulation of a pathological finding upon the death
certificate dismisses the whole affair from his mind,
with possibly no acquaintance whatever with the
true man whose inner life was a sealed chapter to
him.
Psychological phenomena persistently intrude
themselves upon his attention and in the majority
of instances they are with equal persistence pushed
aside as irrelevant. They merely serve to help him
locate the difficulty with the machinery. Of their
312
MEDICAL RECORD.
[Aug. 19, 1916
true significance he has but little conception. Medi-
cal terms are not made to fit them. They destroy
the harmony of his theories. He identifies them
with hysteria, which, to the average physician, is a
sort of psychological dumping ground for all
phenomena which disorder his materialistic postu-
lates. They are uncanny, mystical and superfluous
so far as his interpretation of the mechanism of the
universe is concerned. Except for an occasional
plea of hysteria or insanity he has no need of them.
They are in his way. With an authoritative wave
of the hand he dismisses them as mere products
of the brain and proceeds with his physiological
investigations.
This attitude toward psychic phenomena continu-
ally compels him to confront contradictions and diffi-
culties which he is unable to explain. Physiology
answers his queries with a dogmatism character-
istic of the so-called objective sciences. Without
investigation the objective thing with its corre-
sponding function is posited and accepted as the
fundamental fact, little realizing the difficulties to
be encountered in accounting for the intangible
facts of consciousness which are as obstinate as any
that science has to deal with. Whether he will or
not he must face certain conceptions which daily
experiences thrust upon him.
In the following paragraphs it is desired to dis-
cuss briefly a few of the problems which continu-
ally drive the materialistic physician into contradic-
tions and to which physiology has no answer except
by way of a dogmatism without ground or ex-
planation.
Is Mind an Entity? — The answer that one gets
to this question in medical circles is often amusing.
Physiology answers with a derisive grin. Loyalty
to what she conceives to be scientific methods urges
the necessity of subjecting all reality to the various
methods at the disposal of the so-called objective
sciences. One does not advance very far, however,
on such a postulate until he finds himself in a hope-
less tangle of contradictions. But contradictions
seem to have no effect upon the mental equilibrium
of those materialistically inclined. The usual mode
of escape is simply to deny any existence to mind
as such, referring all phenomena to a physiological
process or to a mechanical result of atoms in mo-
tion. The explanation contains more difficulties
than the thing to be explained.
In the light of modern progress it would be folly
to emphasize the value of laboratory research be-
cause it is universally recognized. Everybody real-
izes its importance, but to hope that all phenomena
may eventually be subjected to the methods of phy-
sics is to reverse utterly the true order of things.
Physiology and biology fail altogether to explain
the difficulties which a physician faces daily: and
when one forces psychology into the realm of physics
it is inconsistent and unscientific to demand that she
shall assert and defend herself in terms of a science
entirely foreign to her true nature in their funda-
mental tenets. Men have always demanded proof
that they exist, whereas the fundamental principle
of psychology — in fact of all thought — must be ac-
cepted without proof or question. To question its
existence is in fact one of the best proofs of the
incorrectness of the tenet which affirms its non-
existence. Absolute doubt leaves no ground for
proof.
He who attempts either to define or to explain
himself will continually find himself falling back
upon the unexplained in his explanation. He must
accept himself to start with. This is the only point
upon which psychology dogmatizes, if dogmatism it
be to accept your own existence without question.
The physiologist by way of contrast posits the uni-
verse in space and then proceeds to try to get
himself out of it, little realizing that through per-
ception he has been instrumental in delineating
external stimuli into an objective spread-out world
capable of interpretation in terms of motion. He
balks at the conception of a continuum of self as a
basis for experience simply because, so far as he
can observe, there seem to be breaks in conscious-
ness. For him, that only persists which gives contin-
uous objective evidence of its existence. He must be
able to check it up and keep account of it. So far
as personal experience is concerned, it matters but
little whether there are breaks in the continuity
(as the physicist views that term) so long as the
experiences of the past are linked to or unified with
those of the present. Experience knows no gaps.
Because there are so-called gaps in consciousness is
no argument against the continuity or identity of
self. He who picks up his past and identifies it
as his experience is but realizing his own identity.
He identifies himself, as it were, by the persistence
of a given perception group. He thus becomes a
unit in the great social scheme upon which civiliza-
tion itself is dependent. Other men learn to know
him as an individual — not merely as an individual
animal organism with certain anatomical and phy-
siological attributes or functions, but as a subject
taking his position in a certain social scheme where
morals, esthetics, ideals, and relation in general hold
sway. But what will physiology do with an ideal?
How can it classify an ambition? How will it evolve
a conscience or a noble determination? Where is
the beauty of a landscape except in that unity of
consciousness which asserts its own identity? Let
a man lose that identity of self and he is imme-
diately and justly dealt with as a mere physio-
logical mechanism until such time as he can "give an
account of himself" again. When he does he again
becomes a vital force in society politic. We may
trace out the infinite complexity of nerve ramifica-
tions as an explanation of psychic content and yet
the personal equation slaps back at us with a re-
siliency which upsets all our calculations. We find
ourselves face to face with a psychological resist-
ance which refuses to be explained away by any
lengthy disquisitions on "matter in motion." The
self-assertiveness of the individual is a phenomenon
which fails to find its raison d'etre in a concatena-
tion of atoms and molecules, while sociologically the
psychological unit is an indispensable entity. Out
of that unity of self-consciousness springs the long
list of ideals upon which man builds his social
structure. From that unitary entity known as self
we build all our more general conceptions of the
universe which lead us back in our thought to a
unitary basis for all reality. While such mental
gymnastics in search of a Kantian "Ding an sich"
may not prove of practical value, yet it verifies the
persisting entity upon which all such speculations
depend. All men reason backward to some such
all-embracing entity. The religious enthusiast calls
it God and endows it with all his anthropomorphic
emotions ; philosophy, perhaps more staid in voicing
its creed, resorts to the impersonal by choice of a
more general abstract term such as the "absolute" ;
science with her breadth of differentiating classifica-
tion calls it "nature" ; physics sees in it pure "force,"
while psychology interprets in terms of her own
Aug. 19, 1916]
MEDICAL RECORD.
313
vernacular and calls it "mind." It makes but little
difference what you call it. All such names lead
to a common source, viz.: the self-conscious entity
which we know ourselves to be. It is the unit to
which all experience has reference and on which all
scientific knowledge rests. Physiology herself, as a
science, is impossible without it.
The Necessity for Unity. — Science is but a
classification of accumulated data and every sci-
ence requires its fundamental unit. If it has none
it creates one upon a hypothetical basis. It must
have one. In most cases it is a borrowed conception.
The only real unit is to be found in psychology and
from the unity of consciousness other sciences build
up or posit a unit purely hypothetical in nature.
The physical sciences have struggled for years to
obtain an absolute unit upon which to base their
deductions and inductions. The only thing they
have is a manufactured product based upon the
unity of consciousness. Instead of reducing the
multiplicity of separate elements to be dealt with
in physiology the laboratory has only multiplied
their number. The farther chemistry goes the more
so-called units she is compelled to add to her list
of elements. The fact is that objective science has
no real unit. The atom of physics is purely and
simply a 'transference of self into a foreign sci-
ence. The same is true of the unit of mathematics.
The mere process of counting begins with the posit-
ing of self as the unit from which we start. Addi-
tion and subtraction are but a duplication of the
unity we conceive and know ourself to be. Not only
do we duplicate our unity in things but all relations
of things can have meaning only as they are re-
ferred to this unit for consideration, comparison
and classification. Any individual object is one only
as we give it a separate existence — a selfhood as it
were — analogous to our own. Unless we do this
the external world has no unit. Division and sub-
division finally drive us to the indivisible and thus
by a leap into the dark we posit the indivisible atom
which is in reality only a hypothetical unit based
by analogy on the unity of self. Ignoring all per-
ception the physiologist posits the atom as the real
abiding unit, and through interaction of atoms he
evolves the physical organism and consciousness
with all its complexity. The unity of conscious-
ness from which the atom as a basic unit got its
birth is relegated to an unimportant position as a
mere product of the interaction of atoms. Nothing
could be more completely reversed than such a con-
ception. The reality of self is sacrificed to a mere
abstraction which is based upon the very reality of
the self whose existence is denied. As investiga-
tion proceeded the atom became insufficient to ex-
plain all phenomena and the daring scientist took
another leap into the dark and fastened his faith
upon the ion of which we are told there are thou-
sands in one atom. It would have been safer
to posit millions of them instead of thousands.
How long will it be before the imagination becomes
dissatisfied with the ion and makes another leap
into the dark? No unit is divisible. Back again
we go to the I that is always I — the only real
unitary entity of experience.
Science is dependent upon a unit as the basis of
classification and is impossible and inconceivable
except as it refers to a unitary basis which makes
classification possible. Classification is not explana-
tion, but it does at least force one back to an ad-
mission of the underlying unity of personality which
makes classification possible. So, eventually every
ultra-scientific medico, it matters not how material-
istic he may be, must pay his respects to a psycho-
logical principle and at least admit the validity and
reality of his own unitary perceptive conscious-
ness.
The Atom. — This mighty mite has dominated the
medical mind with a relentless hand. It is the phy-
sician's Frankenstein creation. Built from his own
deductions it has turned upon him and dominates
all his researches. He has built it up and endowed
it with his own perceptions till at the present time
it well-nigh controls medical postulates. Having
posited the atom as the source of the objective world
and endowed it with all the possibilities of physio-
logical processes he finds no difficulties in building
up a harmonious universe explicable in terms of
physiology or atoms in motion. Nothing could be
more contradictory. In the first place the atom
is only hypothetical and in the second place motion
can have no significance except as it refers to some
unitary entity capable of throwing things in rela-
tion one to the other. Relation means nothing when
divested of its conscious content. Any quality or
any phenomenon the physiologist finds hard to har-
monize in the world about him he ascribes to the in-
herent nature of the atom itself. Thus all difficul-
ties are swept away by merely assuming their solu-
tion in the inherent nature of the atom. Naturally
one is able to draw out anything he puts in. More
and more inexplicable phenomena have been packed
into this indivisible and yet elastic hypothetical unit
until it has finally burst, releasing thousands of ions
which now stand at the horizon of man's imagina-
tion. Such a process gives breathing space to the
imagination for a time, but one fails to see wherein
any advantage has been gained by shifting the
finality one step farther back. To back-water is
always embarrassing and since the atom is but a
hypothetical basis of explanation it would seem ad-
visable to fortify ourselves against any possibility
of attack by positing an ultimate unit sufficiently
flexible or absorptive to embrace any possibility
that might arise. The atom is but the outward
demonstration of the effort of the human mind to
settle upon some unit as a starting point in ex-
planation. Physics has no other way of reaching
unity except by dividing and redividing till a
thing (?) is reached which is so small that you
can not make two out of it — a purely spatial con-
ception.
Explanation. — Explanation is, strictly speaking,
only relative. It begins and ends in the unex-
plained. Certain axioms of thought have to be ac-
cepted without explanation and the final explication
of any phenomenon has within it the original in-
explicable postulate. We accept many things as self-
evident merely because they are of daily occurrence,
but when we stop to explain even the simplest of
them we find it wholly as difficult as to explain the
universe itself. Physicians hold up their hands in
horror at anything like dogmatism and yet no class
of scientists is more dogmatic than they. They
are sticklers for explanation and yet thrust upon
you certain postulates which you are expected to
accept. To question their validity brands you as
unscientific. What can be more dogmatic than the
positing of an atom as the basis of all physics and
physiology when all admit that experience is the
source of all scientific knowledge. Physiology
merely dogmatizes on the fundamentals and ex-
pects us to admire her as she juggles the various
facts of experience in an attempt at explanation.
No one ever saw an atom or handled one. Meta-
physics is decried by the physiologist as sophistry
314
MEDICAL RECORD.
[Aug. 19, 1916
and yet what could be more metaphysical than this
fundamental atom? The real unit of thought
which makes theory possible is ignored and reality
is bestowed upon a thing that is theoretical and
metaphysical through and through. Physiological
changes are undoubtedly chemical in nature and
where processes are seen to work out to a definite
end or desired result we immediately recognize a
systematic organization of forces and tend to per-
sonify the process, as it were, and forget the real
underlying fact of experience. After all, psychol-
ogy, with all her self-confidence, is but a process. The
chemical and mechanical changes which take place
in a physical organism represent the true activity
and are called physiology when worked up into a
system of chemical changes to a certain end. Hence
physiology as a science is teleological in nature and
is scarcely fitted to dogmatize upon the results of
chemical changes or upon the nature of the ele-
mental agencies at work in the process.
Scientific explanation is but accurate classifica-
tion. Certain qualities are grouped according to
their similarity. When we chance upon an element
simple in nature and at the same time persistent in
its uniformity of action we say we have an original
element. On the basis of these we then proceed to
"explain." Such explanation can be nothing but a
narration of perceptions regarding the activity of
so-called things and physiology's only method of
noting activity is in terms of motion. Hence, by a
reverse process, physiology argues that all phenom-
ena are but matter in motion — a conception thor-
oughly saturated with contradictions.
One must dogmatize on the knowledge of self.
Every theory of knowledge has in it that element
of dogmatism which asserts knowledge of self with-
out explanation or question. Through perception a
so-called knowledge of things other than self is
attained. Not that the perceptive process is a thing
tacked onto the mind as such, but in the knowledge
of self mind and things fuse with an intimacy
which defies ultimate analysis. To the average
physician such a conception has no meaning. By
a biochemical activity of the cortical centers of the
brain, mind is evolved by him; and even after it is
thus produced it is denied any reality other than
a non-abiding effervescence from brain commotion.
Dogmatism? Not only dogmatism but a complete
reversal of the path along which science has ad-
vanced. The very brain itself is dependent upon
perception for its proper position or classification
in the scientific world. As a thing belonging to the
so-called objective world it must submit to certain
categories of mind before it can assume its posi-
tion as head of a nervous system in a general
classification of histological structures. No — ex-
planation must begin with the grounds of explana-
tion. Knowledge is axiomatic.
Relation of Mind and Body. — Nowhere are the
physiologist's difficulties more pronounced than in
his attempts to explain the relation of mind and
body. In one breath he denies that mind is an
entity at all and in the next speaks of the effect of
mind on body. Physiology always offers something
tangible, but in mind the physiologist finds nothing
to put his finger upon and hence he gives it no
reality.
On principles of physics and physiology by what
right does he call mind a product, for a product
must still have the physical properties or qualities
of matter and contain within it the constituent ele-
ments which produced it. At times to extricate
themselves from such a dilemma they assert bodily
that "mind is the cortex," regardless of the con-
tradictions involved. After the smoke of such an
argument has cleared away one's self always comes
back with a vividness all the more striking because
of the acuteness of self-consciousness engendered b
the psychic resistance involved in such a struggle.
One becomes all the more convinced of one's own
reality and in the same relative degree suspects
that possibly the difficulty lies in one's own concep-
tion of the nature of body rather than in the nature
of mind. Physiology catches herself dogmatizing
in regard to things of which she knows nothing and
to extricate herself always falls back inconsistently
on experience which is essentially psychological in
nature.
Things are not the dead inert masses we are
sometimes prone to consider them. They have an
activity of their own and an individuality revealed
by their own spontaneous activity. Under existing
conditions there is an interdependence between
mind and things which defies analysis. Neither ex-
ists without the other — in fact both dip back into
the same throbbing sea of activity which we call
reality. Take from so-called things all the ele-
ments having a conscious content and there is noth-
ing left but an abstraction. The fact that ex-
ternal stimuli are built up into things by a con-
scious process does not make them any less real but
only adds to them the qualities and attributes
which make them spatial objects to be dealt with in
terms of physics. This conception does not reduce
things to subjective realities but merely does away
with all antagonism between so-called mind and
matter which in fact blend with an intimacy which
defies analysis. To explain the relation of mind and
body is then the same problem as to explain our re-
lation to each other or to explain the relation of
things one to the other. Neither is the product <
the other. Thus it is folly to waste time denying
existence to either one or the other. Both must be
accepted, but the nature of the two for scientific
classification must depend upon the grounds of
knowledge of the two. Matter, as physics depicts it,
is devoid of any characteristics which make knowl-
edge possible, whereas psychology presents a basis
of knowledge which is accepted by all men whether
civilized or savage. No two men will agree as to
the nature of matter but all men agree to the funda-
mental knowledge of self, which is the sine qua non
of all scientific thought. Thus all men find com-
mon ground in the acceptance of the facts of con-
sciousness. To prove that that which is known as
the external world also reacts in terms of conscious-
ness would be difficult, if not impossible, but it
leaves us at least with the conviction that those
activities known as things in some way carry on an
existence comparable to our own.
Structure and. Function. — "Structure" and "func-
tion" are terms with but little ultimate difference
in meaning and are used for convenience to define
different aspects of the same thing. In one sense
a discussion of such terms is the same old query
as to "which is first, the hen or the egg?" and yet
physicians dwell upon structure as the essential ele-
ment while function, as they see it, is but a play of
forces secondary to and dependent upon the under-
lying anatomical basis called structure. It is read-
ily admitted that if you remove structure (assum-
ing that to be possible) there would be no function,
but it is equally true that if you take function from
structure (assuming that also to be possible — which
Aug. 19, 1916]
MEDICAL RECORD.
315
it is not) there is no structure left. Both supposi-
tions are impossible. Any entity without its active
principle is an abstraction — such suppositions are
not only ridiculous but impossible. Structure and
function are literally synonymous. To function is
the very essence of existence and structure is but
the visible evidence of function rather than the
basis of it.
Within the kidney of the living animal are taking
place certain chemical and mechanical changes
which result in the formation of urine. The kidney
which has ceased to secrete urine is nevertheless
functioning with exactly the same chemical strin-
gency as before cessation of the flow of urine. The
tender vine rotting on the rubbish heap, torn from
its roots, is as active and cogent as it was with all
the possibilities of a fruitful harvest ahead of it.
Its activities have simply changed direction, due to
a change in surrounding circumstances. To speak
of living and dead material is but figurative. The
changes going on in a mammary gland have their
exact equivalent in the granite crumbling on the
hillside. The gland literally becomes milk. By a
truly chemical process there is a changing combina-
tion of the elements of the cell by which it breaks
clown and the resultant of the chemical forces at
play is milk. The gland has literally given up itself
to make milk. Here, then, the processes of secre-
tion and decomposition become identical. The only
difference lies in the psychological interpretation.
Teleology has crept in. It is as truly the function
of iron to secrete rust as it is the function of the
mammary gland to secrete milk or of the kidney to
secrete urine. Is an oxygen atom dead in water and
alive in blood, inert in iron and active in the plant?
The activity of iron in forming rust is as spon-
taneous as that of the mammary gland in secreting
milk. The only difference lies in the psychology of
the affair. To ascribe life to one form of reality
and deny it to another is but to change words with-
out a distinction. Actual transformation of the
mineral into the vegetable and animal goes on daily
before our eyes and vice versa. A boundary line is
absolutely impossible. Chemistry knows no "dead."
To place a structural atom back of the atomical
function which we experience is but a meta-
physical substructure for function to rest upon,
whereas function was the reality with which we be-
gan and which alone we know. Here is where the
dogmatism of physiology becomes most manifest.
Structure is postulated and function is tacked
onto it.
The Possibility of Psychotherapy. — Here the diffi-
culties of physiology become even more manifest.
Our answer as to whether psychotherapy is possible
must depend entirely upon what significance we
grant to psychic processes. If mind is to be looked
upon as matter, or as matter in motion, or as a
product of matter, then the possibility of interaction
is not denied by any one, for all admit the action
of one particle of matter upon another. If we find
it impossible to identify mind and body, the only
alternative left to him who clings to the material-
istic hypothesis is to look upon consciousness and all
psychic phenomena as a sort of hybrid effervescence
from brain tissue incapable of organizing itself
sufficiently to react upon the brain which gave it
birth. There is still another escape left to the
materialist and he frequently avails himself of it,
viz., to deny the existence of consciousness in toto,
which is simply intellectual suicide. This would
preclude the possibility of any discussion whatever.
To assume the possibility of psychotherapy at all
forces upon us the admission that mind must have
or be an entity in some sense comparable to the
reality we call matter, else action and reaction
would be impossible. It is immaterial what names
we apply to the various aspects of reality so long
as we admit the reality of anything which we in-
troduce into our scheme of action and reaction. If
we hold that mind is but a product of matter, we
are forced either to the conclusion that mind as
such a product has no activity of its own and
hence can not affect matter; or else we must admit
that the material product (mind) is a handiwork
of another part of matter. This, however, is im-
possible according to physics. If consciousness is
a function of matter, the product or result of that
function according to physical laws must be a phy-
sical product ; which is again contrary to the ultra-
materialistic idea of consciousness. If mind is mat-
ter then mind should, yes must be an object of
perception, for matter is by nature an object of ex-
perience. Hence one part of matter perceives
another part of matter which again is contrary
to physics, though in reality it is not far froni the
truth.
One could cite an indefinite number of contra-
dictions in the physiological postulate, but all are
based upon the fundamental error in refusing to
admit our own existence as the starting point of
all scientific attainment. Matter must be in-
terpreted in terms of consciousness and conscious-
ness of self must be accepted without question and
without explanation. Accepting consciousness as
our starting point, all reality must be interpreted
as in some sense conforming to the rules govern-
ing conscious life; and this postulate is easy of ac-
ceptance when we vivify all nature into one huge
acting and interacting maelstrom of reality.
From the standpoint of physiology the product
of cerebration would still be a physical entity, but
no physiologist looks upon the product of cerebra-
tion as still physical or as even having the qualities
of matter. He assumes the brain as ultimate mate-
rial abiding fact and consciousness is looked upon
as secondary, non-material, and evanescent with no
abiding essence to give it the right of existence
as such. He refuses to give it any further signifi-
cance or causative efficacy though he repeatedly
escapes his own inability to explain the facts which
confront him by ascribing them to the effects of
mind on body. The fundamental error lies in the
assumption of a structure preceding function,
whereas structure and function are synonymous
from the standpoint of explanation. Action and in-
teraction are identical except in the psychological
or teleological interpretation we put upon them.
In the same way mind and matter are but terms
to designate certain activities in certain conditions
and their relation only calls for explanation in de-
termining the nature of the phenomena encountered
in experience. The kernel of the dispute lies in the
nature of so-called matter rather than in the nature
of mind which every man knows by direct experi-
ence. The average physician assumes accurate,
definite knowledge of the objective world and feels
called upon to account for the existence of con-
sciousness after accepting matter as an assumed
fact, whereas consciousness is the basis of explana-
tion and objective things call for explanation.
This tenet does not deny reality to objective
things nor does it preclude the possibility of faith-
ful adherence to scientific methods. It is only an
316
MEDICAL RFXORD.
[Aug. 19, 1916
appeal for the recognition and classification of any
fact whatever its nature may be, and if there is
any fact known to science it is the primal fact of
consciousness. Either that existence of a mental
process must be denied in toto or else we must admit
the mutual interaction of so-called "matter" and so-
called "mind." A discussion of the nature of mind
does not come under the present discussion.
Sanity and Insanity. — Pray tell, what can sanity
or insanity mean in the light of physiology or
physics? Nature slips no cogs. She knows no
freaks. A freak is a freak only from the stand-
point of classification, and classification is psycho-
logical and not physiological. Exceptions arise from
faulty or inadequate classification. The very essence
of sanity is self-consistency and if all phenomena,
mind included, are but a mechanical outcome of
atoms in motion, then consistency must follow. No
mere mechanism is crazy. As the astronomer peers
into the sky and discovers the comet with its un-
usual action, he does not presume to assert that it
is crazy merely because he can not properly classify
it or explain its actions. The general balance of the
heavenly forces compels him to accept a universal
concert of action and the comet only emphasizes
his limitations in knowledge. On the same grounds
physiology notes the chemical changes and, in con-
sistency with the laws it observes, every datum
should merely be accepted and classified. Judged
by the laws of physiology no act could be called
insane. As an act it merely calls for classifica-
tion. Its consistency with what goes on about
it is a fact to be accepted on the basis of the
fixed postulates of physiology. Once having dog-
matized on the mechanical nature of the process
underlying all phenomena, physiology surrenders
her right to judge any act as regards its fitness,
adaptability, or teleological significance. The fact
carries its own qualifications with it, viz., its ex-
istence. It is a unit in a mechanical process, the
chain of which would be broken and meaningless
without it.
Insanity carries more with it than the mere fact
that the anomalous has presented itself. There is
in it the element of consistency with self. Any act
must be judged sane or insane not with reference
to the community or general laws governing the
actions of men, but with reference to the man him-
self. Any act which takes its place in a series of
logical and self-consistent acts must be looked upon
as sane. This necessarily infers a unitary basis or
ground of action, and a diagnosis of insanity as-
sumes the entity and reality of mind as a basis for
consistency. A disconnected isolated fact can
neither be sane nor insane. It must have refer-
ence to a unitary continuum of consciousness.
What, I repeat, can insanity mean in the light of
mere cerebration? To adjudge an act insane on
grounds of physiology merely convicts us of inade-
quate classification. Popular methods adjudge a
man insane who does not act as other men do,
whereas the true diagnosis of insanity rests, not
upon a comparison with the general consensus of
opinion, but upon the consistency or inconsistency
of one's own acts with reference to each other.
Man has within himself his own conviction of in-
sanity or the means of defending his sanity in the
absence or presence of self-consistency. One thing
would seem self-evident, viz., sanity, to mean any-
thing at all, must refer to mind and not to body.
It must be diagnosed by means of the psychic mani-
festations of the subject. Mind has no histology
and no anatomy and therefore no pathology as that
term is generally used. That insanity has corre-
lated with it a pathological nervous condition proba-
bly no one will deny. Every psychic act has its
counterpart in the nervous system. However, to
mistake a morbid anatomy or an abnormal physio-
logical process for insanity is to confound con-
sciousness with nervous activity and a neuron with
sensation. A diseased brain is not a crazy idea, nor
an insane man. At present but little is known of
the morbid brain anatomy accompanying insanity,
and at best it is known post mortem; but should
even the most astounding morbid anatomy be pres-
ent we must still appeal not to physiological proc-
esses but to the individual before pronouncing in-
sanity or sanity. Could we know thoroughly the
pathology and histology of the brain we could with
certainty describe the mental condition of the pa-
tient and yet for a diagnosis of sanity or insanity an
appeal must be made to the man. The diagnosis of
sanity or insanity must rest upon the psychological
examination of the man in question.
Ethics. — Every physician has his system of eth-
ics. He may not be willing to live by it himself
but he is sure to demand a certain rule of life from
other men. It is difficult, however, to find any place
for ethics in a system of philosophy where the
entity of mind is denied and where all phenomena
are but chemical change. This, however, is another
of the physiologist's contradictions which apparently
does not affect his devotion to his pet philosophy.
Theoretically he makes ethics impossible but in
practice his theoretical speculations are submerged
beneath a stringent demand for what ought to be.
In his calculations and deductions of laws psychic
life has been looked upon as a by-product and
hence is not incorporated in the laws he has de-
duced. If a law of universal application is to be
established, then the fact that men ought to do so
and so must have equal force with the fact that men
do do so and so.
One hesitates to break in on the apparent har-
mony of the forces of nature by the expression of a
wish that anything might be otherwise than it is, to
say nothing of suggesting that certain things ought
to have been different from what they are. The
accuracy with which sets of experiments work out
to a definite end can not fail to attract the attention
of even the most ignorant observer. We notice the
systematic consistency of the activities going on be-
fore us. Soon we find ourselves deducing a series
of laws expressing that harmony of concerted
action, but in our admiration for the accuracy of
the workings of nature we forget that we have de-
duced the laws and, overawed by the universal ap-
plication of the laws we have deduced, we reverse
the true order of things and come to look upon these
laws as governing the activity of things, whereas
they merely express activity and never govern it in
any sense. The act is the thing in question, and the
law is but a convenient formula by which we keep
track of the activity of things. Physiology as such
knows nothing of laws. The chemist may go into
ecstacy as he watches the transformation of sub-
stances one into another and yet the different ele-
ments entering into the combinations are but act-
ing their individual parts subject to surrounding
conditions. That an oxygen atom should respond
in different ways under different stimuli from with-
out is quite natural and yet its individual action
is always that peculiar to an oxygen atom if such
a statement may not seem tautological and ridicu-
Aug. 19, 1916]
MEDICAL RECORD.
317
lous. Any variation in what previously seemed to
be unwavering persistent consistency of activity
merely calls for readjustment of laws to fit the new
fact or act if such it proves to be.
Hence human conduct introduces an uncertainty
not because we have entered a realm whose phe-
nomena are lawless but because our present laws
are too narrow to include it. This uncertainty is
due to the intrusion of an element omitted in our
formulation of laws and unknown in the physical
realm, viz., the personal equation. It cannot be
counted upon with any degree of accuracy. While
the activity of things, if analyzed thoroughly, is
manifestly spontaneous in character and in its es-
sentials does not differ from that sort of activity
known as human conduct, yet in the latter concep-
tion we find a conception not to be found in the
realm of physiology. It is the principle "I ought —
you ought." It is incompatible with the atmosphere
of the physiological laboratory. Misconduct is
never considered as a possibility in the crucible or
test tube. If human conduct is but the result of the
interaction of atoms of the brain, why do we insist
upon misconduct within the cerebral mass boiling
and bubbling within the cranial crucible? No one
rests satisfied with the fact that a man has done
so and so. He is praised or blamed. He did what
he "ought" to have done, or he "ought" not to have
done what he did. No one seems willing to sit by
and wait to see what a man will do. He is exhorted
to do this or not to do that in accordance with the
principle of "ought."
If man admits that moral obligation is a fact
and not a fallacy, then our laws must be so revised
as to admit this disturbing element or else the con-
ception of human conduct and the principle of
"ought" must be reduced to terms in harmony with
the facts already included within the law. Either
human conduct must be reduced to a physiological
process stateable in terms of the atomic theory or
else the action of things must be looked upon as in
some way in harmony with the acts we classify as
human conduct and to which we attach praise or
blame. Either human conduct, courts, law, justice
and rights in general are a farce or things must be
given an interpretation which is broader than the
present physical view will permit. The difficulty
lies in a faulty conception of things. Men perceive
the relation of things, and conduct as such is based
upon this characteristic. Individual initiative is a
characteristic of all activity whether it be in a post
or in a man, and the only thing which differentiates
human conduct is the power to see things in their
relation one to another and evolve from their rela-
tion a rule of action.
Nowhere is the conflict of theories more trouble-
some and at the same time more manifest than in
the medical mind. To the great majority of phy-
sicians the mind is a product of brain and sensa-
tion, is but a modification of cortical centers, and
yet no class of men is so firm in its demands for a
professional ethics, even though they may not ad-
here to any such code of laws. The Code of Ethics
issued by the American Medical Association is their
court of appeal, and no document could be more
thoroughly saturated with the conception of
"ought" and "ought not" than this guide to the
physician's conduct. Are these precepts advising
the cortex what to do? No class of men guards
their professional rights with more jealous care
than do these very adherents to the automatism of
psychic action. In one breath they will refer all
moral action to changes in brain substance, and
in the next complain of the "injustice" or rascality
of some fellow physician. They tell us that a cer-
tain member of the medical fraternity "ought" to
be expelled from full fellowship with the elect be-
cause he did what he "ought" not to have done.
To be sure, if there is no such thing as rights or
justice, then the man of straw is easily knocked
down; but here again no class of men is more in-
sistent on its rights than these same advocates of
the absolute dependence of consciousness on modi-
fications of brain tissue. It is useless to waste
time trying to prove that personal rights are to
be admitted. Physicians not only admit it but are
persistent and at times bitterly insistent upon the
maintenance of their professional rights, dignity,
and honor. They deem themselves consistent in it
also. But, what can be meant by rights, dignity,
and honor, in terms of cerebration or physiological
metabolism? By what corollary to the general law
of equality of the physical elements does a brain
cell don the garb of selective rights and honor and
pose as superior to any other cell within the body?
What can be meant by development, better, higher,
lower, inferior, superior, et cetera, in the realm of
physiology? Such terms refer to an "ideal" which
can scarcely be identified with the cortex. The
ideal is based upon principle and there is no place
for principle in the atomic theory. The law of
tooth and claw is universal except where the ideal
leaves its imprint and duty holds sway.
Either we must admit that our present physical
laws are too narrow to include all data or else we
must hold that all psychic life is a phantasma-
gorical farce made up of delusions, illusions, and
hallucinations. The latter conclusion gives relaxa-
tion and peace of mind for a time, but at once
there looms up before us out of the universal farce
at least one fact that the farce we are enacting is
real, and then the whole mental wrestle begins over
again. The delusion and hallucination at least
demand some consideration as entitled to reality.
It has merely been an attempt to argue ourselves
out of existence. Nor will we be satisfied with
imaginings, phantasms, and farces. If all is farce,
the consciousness of that farce still stands out as a
surviving fact to belie our assumption that all is
farce.
What is the elaborate Code of Ethics issued by
the American Medical Association as a guide to all
its members? Is it a code of predictions as to
what the cortex is going to do? Is it even a list
of things the cortex "ought" to do? Is it an at-
tempt to invade the nervous system with the prin-
ciple of duty? Or is it an appeal to a self-con-
scious personality, not only capable of initiating
activity but of guarding and granting personal
rights based upon the "ideal"? One thing is cer-
tain, the Code of Ethics as issued by the American
Medical Association is not a dissertation on physics
or physiology. It is an appeal not to the cortex
but to the man.
However vigorously physicians may attack the
entity of mind and the reality of morals, they sel-
dom if ever act out their own speculations. There
is a standard of morals among deterministic phy-
sicians just as cogent and binding as among any
other classes of men. Though we may by mental
gymnastics rob ourselves of personal rights, yet
when the mental tension required in the process re-
laxes, our own conviction of obligation to an ideal
slaps back at us with a vividness which leaves no
318
MEDICAL RECORD.
[Aug. 19, 1916
doubt as to its reality. Our joys and our sorrows
face us with a stubbornness born of action. We quit
our cogitations and proceed as before, sacrificing our
rights here and demanding them there, censuring
to the right and praising to the left with an inward
conviction that certain things "ought" and others
"ought not" to be.
The Code of Ethics then is an embodiment of
the principle of rights. It is an ensemble of prin-
ciples. Ideals are held up, self-respect is urged,
others must be considered and selfsacrificed to
their welfare. Strange reactions these to emerge
from a physiological laboratory! Men must learn
to be men. He who lacks seZ/-respect can not be
reached by a code of ethics and it is useless to
enact laws unless the general esprit-de-corps of the
profession is able to find itself reflected in them.
Hence, the prerequisite of ethics would be self,
not illusory, imaginary, and farcical, but real and
abiding. What can physiology do with a code of
ethics? Rules and men must both embody prin-
ciple, and physiology as such has neither man nor
principle. In order that we may respect others
and their rights we must realize a self-respect
which makes us subservient to principle, i. e. to the
ideal, and ideals have reference only to personal-
ity.
SOME RECENT MEDICAL OBSERVATIONS IN
THE EUROPEAN WAR ZONE.
By J. A. NYDEGGER, M.D.,
SURGEON, UNITED STATES PUBLIC HEALTH SERVICE.
After a sojourn and travel of some months' dura-
tion in the area of European war activities one
should not be lacking in some impressions. A few
of these impressions — confined to the field of medi-
cine, I will endeavor to recite briefly. Reaching
England May the first, and armed with letters
of introduction to the heads of various European
Red Cross Associations, no difficulty and but little
delay was experienced in obtaining invitations to
visit such military hospitals and similar institutions
as was desired, although the great number of these
available made it quite impossible always to select
the most interesting ones. This early experience,
coupled with the fact that during the greater part
of the time I was busily engaged in the pursuit
of other professional investigations, made it neces-
sary to select certain types of hospitals for study,
if one wished to see a variety of cases, to note the
methods of treatment, and view the classes of hos-
pital buildings and their equipment. First-aid and
Field hospitals I did not have the opportunity of
inspecting, but receiving hospitals, distributing hos-
pitals, general, convalescent, and special hospitals
were made freely accessible in the countries of Eng-
land, Ireland, Scotland and France.
The first and perhaps most striking impressions
one had, on visiting the wards of one of the large
general hospitals, was the preponderatingly large
number of wounded being cared for as compared to
the number seen suffering solely from diseases
strictly medical in nature.
Thus, in some of the hospitals visited fully 90 per
cent, of all officers and men were being treated for
disabilities of a surgical nature. Judging from the
extent of my observations in this respect, as also
from the numerous conversations had with medical
officers, one would be justified in placing the general
average of the wounded admitted to hospitals at 90
per cent, or above, and the medical cases at 10 pei
cent, or less. This low admission average of medical
cases bears witness in the highest degree to the
efficiency of the army sanitarians, in maintaining
the soldiers' environment, whether in field, bar-
racks, or trenches, in a high sanitary condition, and
thereby maintaining the incidence of communicable
diseases at the lowest possible figure. In fact, this
is one of the marvels of this great war, where we
realize for almost the first time in history that medi-
cal science has outwitted disease, that the former
order of things has been reversed, and that more
lives are being destroyed by bullets than by disease.
The types of wounds one saw in hospitals, of
course, varied much. Wounds caused by shrapnel
greatly predominated. Following these, and per-
haps next in frequency, came those caused by ma-
chine guns, grenades, infantry rifle, and larger pro-
jectiles. Shrapnel wounds and compound fractures
were seen most. Bayonet wounds are generally
fatal, terminating promptly in death, so that I can-
not recall having seen a single wound of this na-
ture.
The parts of the body most frequently wounded
are the arms, head, neck, and lower extremities, al-
though shrapnel wounds of all parts of the body
are seen.
I saw one soldier who had 157 wounds caused by
shrapnel, and these were all over his body. He had
lost one foot and a part of a leg, had a permanently
stiffened and contracted arm from lacerated and
torn muscles and nerve destruction, still he was
anxious to get out of the hospital and again serve
his country. I was told of another soldier who had
received over 300 shrapnel wounds and had recov-
ered. The most helpless lot of wounded one sees are
perhaps those with injuries of the spine and cord,
with loss of control of both bowel and bladder, and
frequently paralysis of extremities.
For these cases radical treatment so far holds out
but little hope, and apparently little was being done
beyond keeping them as clean as possible and at-
tempting to make them comfortabe. The resort to
the use of hand grenades has resulted in the injury
and destruction of many eyes. Many eyes have also
been destroyed by shrapnel.
I was much impressed with the general results
obtained in hospital treatment. The mortality has
been low. When one has survived his wound until
he reaches a hospital his chances of ultimate recov-
ery, thanks to the skilled treatment and nursing re-
ceived, are good. I had the opportunity of inspect-
ing the records of a number of the hospitals visited.
In one large general hospital with 1300 beds, with
an admission of 11,000 cases since the beginning of
the war, the mortality was seven-tenths of 1 per
cent, from all causes. Another smaller hospital,
with some 450 admissions since opening, gave a still
lower mortality rate. The death rate in hospitals
should be even lower in the future because of the
fact that tetanus, which existed among the wounded
last fall and winter and caused numerous deaths,
has been reduced to a minimum by the timely ad-
ministration of antitoxin a short time after the
wound is received.
Typhoid fever and dysentery, the scourge of for-
mer armies, so far are almost unknown in the West.
The protection afforded the troops in the field by
the timely administration of the prophylactic vac-
cine, on the one hand, and the results so far achieved
on the other by sanitation are simply marvelous.
Rules are rigid; a soldier drinking unsterilized
water is courtmartialed and punished severely. It
Aug. 19, 1916J
MEDICAL RECORD.
319
has been demonstrated that men can live in trenches
for a prolonged period and still maintain good health
if but due regard is paid to the warding off of dis-
eases. So far, also, cholera and typhus fever have
not reached the western area of the war, although
showing a decided increase in parts of eastern Ger-
many, Austro-Hungary, and Russia, in spite of all
that is being done to prevent their spread. When
the time comes, as it doubtless will, when it will be
necessary to move large bodies of troops quickly
from the east to the west, or vice versa, without
first having undergone proper quarantine and with-
out the customary disinfection of clothing and indi-
viduals, and these troops occupy trenches and camps
hastily vacated by the opposing army and left in
unclean and unsanitary condition, then will come
the grave danger of introducing these diseases
among the hitherto healthy soldiers; and this fear
on the part of sanitarians was more than once com-
municated to me while traveling in the war zone.
The occurrence of such a condition could only tend
to increase greatly the danger of the ultimate in-
troduction of these diseases into the United States.
One method of treatment noted, "the open-air
treatment of the wounded," was especially inter-
esting. At Cambridge, England, an asbestos-board
pavilion hospital, with wards enclosed only on three
sides, with openings protected by louvres for free
circulation of air, was erected early in the war.
On the south side the wards had been left en-
tirely open to sun and air, except ordinary sun-
blinds hanging from the top; at first the building
was designed for a limited number of beds, but the
success of the open-air treatment was soon so pro-
nounced that the building was extended to a ca-
pacity of over 1200 beds. The hospital is open at
every point to the sun and air, the two most power-
ful allies the surgeon can have in dealing with
wounds in war. The wounded are transported there
frequently direct from the trenches in northern
France. The wounds in many instances are septic,
having been soiled with earth and mud, and the or-
ganisms are those that flourish most in these sur-
roundings. Therefore they have the peculiar char-
acteristics that they can grow only in the absence
of air. These organisms are not those with which
the surgeon has usually to deal. It was very soon
found that to cover such wounds up deeply and
treat them in closed hospitals was fatal to the pa-
tient.
A surgeon related to me some of his experiences
in handling this class of wounds near the front in
the early days of the war. The stench in the wards
after a few days was awful. In despair the un-
fortunate men were removed, for the sake of the
others, to tents outside, as they thought, to die. In
forty-eight hours the wounds had ceased to smell,
the surfaces looked cleaner, and, except in a few
cases where the organisms were too virulent, the
patients recovered. It was thus found that the ad-
mission of fresh air to the wounds caused these
bacteria to perish rapidly and from a state of ap-
palling sepsis the wound was reduced to one of com-
parative cleanliness, to .the great benefit of the pa-
tient. I was shown wounds of this nature which,
when admitted to the hospital a short time pre-
viously, were septic but had cleaned up in a mar-
velously short time and were in a healthy condition.
The patients in this hospital also presented a
freshness and vigor in their convalescence which
are generally absent among those who have been for
some time in an ordinary hospital. The pallor and
weakness usually noticeable in a man recovering
from a serious wound or illness were more or less
absent. The conception of the open-air treatment
of disease is not a recent one. The idea has of late
years been elaborated and practically applied in the
adoption of open-air hospitals or sanatoriums for
the treatment of tuberculosis, and now the well-
thought-out design, equipment, and nursing which
distinguish the Cambridge hospital, and its adap-
tion for the treatment of the wounded, are distinct
advances in the same direction.
The devastating effects of the constant bursting
of huge shells over men in the trenches, even when
no actual injury is caused by the flying projectiles,
is one of the many unexpected results of modern
warfare. Although not actually hit, some of those
so exposed suffer for a varying length of time from
loss of memory, from eye trouble, ranging from
blindness to dimness of vision; loss of sense of taste
and smell, impaired hearing, and physical upsets.
Some never recover but go on into a marked state
of mental decline. Various terms have been ap-
plied to this condition, such as "battle shock," "nerve
shock," "mental shock," and "wounds of conscious-
ness." Scores of men, both in the ranks and among
the officers, while apparently fit to the outward eye,
nevertheless suffer in a marked degree from this
condition, which perhaps can best be described as
"nerve fatigue," as a result of the wear and tear of
a war of high explosives. The effects of severe shell
fire are very complicated; but it may be said simply
that they tend to show themselves in a dazed state
which may, on the one hand, be developed with com-
plete unconsciousness or, on the other, lightened till
a condition comparable to neurasthenia is observed.
The individual, having passed into this state of
lessened control, responds easily to small stimuli ;
is emotional, at one moment at the height of mental
exhilaration and the next in the depths of despair.
At night insomnia troubles him, and such sleep as
he gets is full of visions of past experiences on the
battlefield. The quality of the individual's nerve
fibers and nerve cells counts for much when sub-
jected to such strains, and the weaker give way
first. The part that heredity plays in these cases
is well exemplified. Fully 80 per cent., I was in-
formed, of all of these patients have a neurotic fam-
ily history. Special hospitals are provided for their
care, with quiet, rest, comortable and cheerful home-
like surroundings, with the use of electricity, mas-
sage, and dieting, and in a few instances psycho-
therapy.
The effects on the troops of gases when released
in large amounts have revealed another demoraliz-
ing and destructive agent which the medical officers
have to contend with in the present war. Being
heavier than air, the gas tends to settle in the
trenches and overcomes and kills those who are un-
fortunate enough to inhale it in sufficient quantity.
A favorite way is to discharge it when the direction
of the wind is favorable and allow it to be dissemi-
nated among the opposing forces in that way.
Chlorine gas is the active principle of this gaseous
compound and is very destructive to life. Many are
killed outright, while others are rendered uncon-
scious, some to succumb later. The irritation caused
by the inhaled gas sets up an intense inflammation
of the bronchopulmonary tract, and one is literally
drowned in his own secretions. Some of those who
survive the first serious effects of the gas are left
with a chronic inflammation of the respiratory tract.
Those who have fortunately inhaled air but slightly
320
MEDICAL RECORD.
[Aug. 19, 1916
mixed with gas soon recover. I had the opportunity
of seeing a limited number of these cases. Protect-
ive masks against the gas are now used by the
troops.
One still saw in the hospitals soldiers suffering
from the results of last winter's exposure in the
trenches, such as frost-bitten feet. Conservatism in
the treatment of these cases has been the rule, and
every bit of the extremity that is possible is saved.
Another winter should see far less of such injuries
to deal with. The trenches of to-day are places of
comparative comfort and luxury as compared to
those of last winter. They are now roofed over in
many instances, with concrete floors or shelves to
stand on, and are drained and properly policed.
The z-ray apparatus plays a valuable part in the
military hospital of to-day. Even the field hospitals
are equipped with portaDle outfits. No military hos-
pital would be considered complete in equipment
without such an apparatus. The large hospitals are
supplied with elaborate machines, and they have
proved invaluable in the armamentarium of the sur-
geon in fracture work and in the locating of bullets
and fragments of shells. The surgeon in war could
not work without it.
I was able to visit a considerable number of hos-
pitals of all classes in the United Kingdom and
France, and on the whole I found them thoroughly
equipped, some luxuriously so, to furnish every aid
and comfort to the wounded and sick. Many of the
private improvised hospitals are models of perfec-
tion in all departments. One of the best of this
class in England is that of Mr. Mortimer Singer, an
American by birth at Steventon, near Oxford.
The present war, with the use of high explosive
shells, producing frightful wounds, with great de-
struction of bone tissue, has developed numerous
mechanical appliances for the treatment of these
injuries. Of these perhaps the two first used are
the Balkan splint, for leg wounds requiring exten-
sion and suspension, and the hip-brace splint, for
wounds of the upper arm. The former consists of a
firm wood frame about 3 feet broard and 6 feet high,
extending centrally over the length of the bed. The
limb is ingeniously suspended by means of a metal
splint, cords, pulleys, and weights, fhis splint first
came into use during the Balkan War, hence its
name. It has since been improved upon and is
now extensively used.
The hip-brace splint is supported from the hips
by metal uprighls connected with a covered metallic
belt. The upright braces are attached at the top to
a metal splint strapped to support the upper arm in
a horizontal or inclined and flexed position. This
splint is also much in use.
A survey of the hospitals visited showed them on
the whole to be well supplied with competent doctors
and nurses. In fact, some of the hospitals visited
had a surplus of both.
The high explosive type of shells now used, caus-
ing extensive shatter of bones, with great destruc-
tion of soft tissues, will furnish abundant bone and
nerve surgery in the countries involved in war for
the next ten years, and thousands of the wounded
and incapacitated will continue as wards of their
respective nations for the remainder of their lives.
The Present Status of the Argyll-Robertson Pupil.—
Max W. Jacobs concludes that there is at present no
reason to doubt the close relationship between lues and
the Arjryll-Robertson pupil, although the latter has
been seen now and then in non-luetic alcoholics, due,
perhaps, to a gliosis. — Journal Missouri State Ass'n.
BONIME'S MODIFICATION OF KOCH'S
TREATMENT OF TUBERCULOSIS.
BY RICHARD COLE NEWTON. M.D..
MONTCLAIR, NEW JERSEY.
LATE PRESIDENT STATE BOARD OF HEALTH OF NEW JERSEY ; CON-
SULTING PHYSICIAN TO THE MOUNTAINSIDE HOSPITAL.
Perhaps nothing can be more gratifying to our
sense of justice than the reflection that at last the
epoch-making labors of Robert Koch, in demonstrat-
ing the pathology of tuberculosis and in providing
a remedy against it, seem to be about to receive their
due mead of appreciation. His gigantic intellect
unraveled the fundamental problems concerning this
disease which had baffled countless investigators
since the beginning of history. The treatment that
he devised to overcome it is, we believe, the most
efficient yet brought forward, and will presumably
never be superseded by anything more efficacious,
it can be modified with advantage, as many tubercu-
lin therapeutists have shown, but if the true nature
of the disease is now known and the action of tuber-
culin upon it is rightly explained, it does not seem
probable that Koch's ideas will ever be entirely
superseded. Practically all writers now agree with
him that the crux of the successful treatment of
tuberculosis lies in its timeliness, and that the only
logical method of handling this great problem is the
nearest possible approach to the preventive method.
If, by any possibility, we can prevent the spread of
the contagion, our efforts, hitherto so inadequate,
to banish the great white plague from the earth,
may at last be crowned with success. Can any words
demonstrate more clearly the great mental grasp of
Professor Koch than the following with which he
closes his exhortation to treat tuberculosis in its
earliest recognizable stage, "only then will the new
method have become a genuine blessing for suffering
mankind, when it will have come to pass that all
cases of tuberculosis are taken early under treat-
ment and the occurrence prevented of advanced, ne-
glected cases which, up to the present, have formed
the inexhaustible source of ever-recurring infec-
tion."
If then, the greatest intellect which has up to this
time turned its best efforts toward the conquest of
tuberculosis, understood so well a generation ago
the pathology and therapeutics of this disease, why
is it that today so much uncertainty and doubt is
felt throughout the medical profession regarding
Koch's method of treatment? The strange, almost
romantic history of tuberculin therapeusis is known
of all ; yet the rationale of the subject and the tech-
nique of the treatment are still almost unknown to
the profession at large. For this unfortunate state
of affairs there would seem to be several reasons.
First and foremost, the great body of medical opin-
ion has not rebounded from the almost unspeakable
disgust and disappointment which followed the uni-
versal outburst of enthusiasm caused by the an-
nouncement that Koch had prepared a certain
remedy for tuberculosis. Almost in an instant the
whole world, lay and professional, gentle and simple,
learned and ignorant, had jumped to the joyful eon-
elusion that the "great white plague" had been con-
quered at last, and that a disease hitherto considered
hereditary and incurable was to be banished from
the earth forever. The older members of the pro-
fession well remember the disappointment, deep,
bitter and lasting, which followed the announce-
ment that the new agent had failed and that no
permanent good, but rather evil, had resulted from
Aug. 19, 1916]
MEDICAL RECORD.
321
its use. The reason underlying this untoward re-
sult was simply that neither Koch himself nor his
associates really understood the extreme potency of
the remedy which he had advocated. He had let the
genie out of the bottle and was unable to harness
him. Nor could anyone explain then exactly how
this new agent was to accomplish its purpose, nor
how much harm might be done by improper dosage.
Although Koch recommended what were then
esteemed small doses to be given by hypodermic in-
jection, the doses were in reality too large and the
intervals between them were too short. He used 1
mgm. of the dried tuberculin in solution as the
first injection, followed in a day or two by an in-
jection of 5 mgm., and this was followed in
two days more by 10 mgm. The dose seems
then to have been raised to 12.5 mgm. and so con-
tinued until the patient felt much better or worse.
It is easy to understand with our present knowledge
why this course of treatment disappointed its ad-
vocates; but unless we give due weight to the in-
tensity of the "tuberculin delirium," it is hard to
realize the extent of the reaction in the minds of
the profession against this form of treatment. No
doubt two or three centuries earlier the use of
tuberculin would have been forbidden by law. Yet
such a prohibition would have been practically super-
fluous, for only a few of Koch's devoted followers
retained their faith in tuberculin. Gotsch, Spengler,
and probably a few others, who had been associated
with Koch, continued to use it, while the body of
the profession almost unanimously followed the
great Virchow in utterly condemning it. Virchow
frightened the medical men of that day by as-
serting that tuberculin "mobilized" the more or less
quiescent bacilli in the system of a consumptive and
drove them to the uttermost parts of the body to
carry on their work of destruction.
The advanced lesions found in the cadavers of
those dead of tuberculosis were said to have been
increased if not caused by tuberculin, in much the
same way as two hundred or more years before, the
lesions of chronic malaria were asserted to have
been caused by the use of quinine. Nor in all the
succeeding years have certain members of every
community ceased to malign the salts of the cin-
chona bark; so it is not likely that with an ap-
parently good case made out against tuberculin by
Virchow and other savants we shall cease to be told
of its dangers by the prejudiced and the ignorant
for many years to come. One medical friend of
the writer's, who claims to have been using tuber-
culin for twelve years, and another who has used it
more or less for eight years, are dissatisfied with
it, and unite in asserting that they have little or no
confidence in the Bonime method of treatment,
although neither of them appears to have used it
properly. These men remind one of the gentlemen
cited by Pottenger, who deprecated the administra-
tion of tuberculin, one or more of whom had not
taken the temperature of their patients either be-
fore or after the injections of tuberculin, and at
least one other who never examined the chests of
his patients, and did not seem to know whether they
had tuberculosis or not. It goes without saying that
whatever the merits of any plan of treatment may
be, only those who have mastered its technique are
entitled to pass judgment upon it, and it is naturally
a great drawback to the successful administration
of tuberculin at the present time that so few men are
competent to handle so powerful and so insidious a
remedy. Probably no one who has not enjoyed at
least six months thorough clinical and didactic teach-
ing on the subject, and who is not in addition a
practised and reliable physical diagnostician, should
attempt to use tuberculin by the Bonime or any
other method.
However, to return to the history of the present
revival of Professor Koch's treatment, we observe
that it was finally pointed out that the lesions
found in the bodies of those dead of tuberculosis
were much the same whether tuberculin had been
administered as a remedy or not. And as time went
on it was ascertained that of all the patients treated
with tuberculin in Koch's clinic, quite a fair pro-
portion had recovered their health, so that the
disease in their cases at least had been arrested and
the fearsome remedy had done them no permanent
harm. Some of these patients are living to-day. As
intimated before, Spengler, Gotsch and other savants
who had worked with Koch, never lost their faith in
tuberculin. After using graduated doses for ten
years, Gotsch, at Koch's suggestion, published his
results which showed that his cases had done bet-
ter than could have been expected without the use
of tuberculin. Some of the best minds in the pro-
fession then began to realize that the remedy had
been condemned too hastily. In America Dr. Tru-
deau is said never to have lost his faith in the ulti-
mate triumph of this form of medication. Gradu-
ally step by step the value of a judicious use of
tuberculin has been wringing a more or less re-
luctant assent from the profession, and the end is
not yet.
Neither so far does there seem to be any revival
of the "tuberculin delirium" of Koch's time, and this
is as it should be, for, as Dr. Baas delights to
remind us in his History of Medicine, nothing in
medical progress that meets with instant and up-
roarious approbation turns out to be of permanent
value. And while human nature remains as it is,
and always has been, it is far better that there
should be sufficient opposition to the introduction of
such a remedy as tuberculin to force its advocates
to be very sure of their ground. If each step of the
advance be stubbornly contested false, extravagant
and misleading claims will be checked in their in-
cipiency and the true status of the new agent will
be the sooner and the more firmly established.
Just now tuberculin is not one of the medical
fashions in America, and for reasons to be given
later we hope that it never will be so fashionable
that any one except a real expert will ever consent
to use it. Its injudicious use, even in Koch's hands,
was unavoidable thirty years ago when it was so
little understood. Now, however, its onward march
is steady and its advocates are ready to give reasons
for their faith and to show their cases.
In America Pottenger has worked with tuberculin
twenty-five years. He says that between two of his
comparatively recent visits to Germany, a period of
three or four years I believe, he observed that the
percentum of the tuberculosis sanatoria using tuber-
culin treatment had risen from twenty-five to about
seventy-five. Ritter was converted from an op-
ponent to a strong advocate of this treatment by his
experience in his own institution, where he began
(probably in desperation) to treat the most un-
promising cases such as had been excluded from the
public (insurance) sanatorium or had already under-
gone an unsuccessful course of non-tuberculin treat-
ment.
Dr. Bennett says (in The Practitioner for Jan.,
1913) that when he began treating tuberculosis with
322
MEDICAL RECORD.
[Aug. 19, 1916
tuberculin he could not banish from his mind the
fear of the injury which the remedy might do the
patients, and continues, "The first few weeks did
nothing to remove this feeling, but as soon as I
abandoned all attempt to hurry matters and was
content to make the treatment reactionless, the feel-
ing of opposition died away and I now feel quite con-
vinced that tuberculin is of the very highest value
in the treatment of the disease." This able practi-
tioner had used tuberculin in fear and trembling for
some years until the light broke upon him that he
should no longer try to abort or drive out a constitu-
tional disease in a few days. In other words that
he should not try to force nature's hand, but should
humbly study and carefully follow her methods and
she would do her part by gradually but surely heal-
ing the sufferer from a disease which had been gen-
erally regarded as hopeless. The Journal of Vaccine
Therapy for September, 1913, after summarizing a
series of cases, says editorially : "No ill effects were
traceable to the tuberculin. The chief danger in the
administration is, we think, an impatience on the
part of the immunisator," who has ever to contend
with the obsession, so common in the lay and often
in the professional mind, that the larger the dose
the greater the benefit. Our editor goes on to re-
mark that one would not endeavor to raise a pa-
tient's toleration to strychnine to a thousand times
the initial dose, and yet tuberculin is to a non-im-
munized tuberculous patient a more powerful drug
than strychnine.
Tuberculin, while it is innocuous to a non-tubercu-
lous person, will, by dissolving the capsules of the
tubercle bacilli, already present in the body of a
tuberculous subject, set free certain toxiri^. These
must be neutralized by the appropriate antibodies
or they will do serious harm. These antibodies are
secreted by the body cells under the stimulus of the
toxic action of the bacilli. However, only a limited
number of antibodies can be produced at once, and
if the dose of tuberculin is too large, even very
slightly so, too much toxin is liberated and harm is
done. As Professor Park puts it, "we have the
paradoxical condition that the (bodily) mechanism
associated with protection is also the mechanism of
intoxication when over-developed or over-active," or,
as other writers {e.g. Riviere, Morland, Rosenau and
others) put it, the hypersusceptibility is necessary
for the production of immunity, and these two op-
posing states are interactive and mutually depend-
ent.
Hence, our guiding principle in tuberculosis
therapy is to stimulate sufficiently, if possible, but
never to overstimulate the hypersensitive body-
cells. If our stimulus is insufficient, we shall pro-
duce a state of allergy without accomplishing our
object. This we may also do by too soon intermit-
ting the treatment. We are treading on dangerous
ground and must always be guided by the motto that
haste makes waste. The action of tuberculin in-
jected into the tuberculous body may illustrate the
whole process of the disease. The consumptive pa-
tient is constantly producing antituberculin to com-
bat his autoinoculation, as has been shown by the
complement deviation test by Bordet and Gengou. So
long as his body cells can keep up this supply of de-
fensive agents the disease does not gain appreciably.
Sometimes the bacilli are entirely routed and the
patient regains his health. Often, however, these
invading bacilli are driven into retirement and may
not reappear for years. In childhood glandular
and joint lesions are frequently arrested, and in
adults pulmonary lesions are also frequently, but not
generally, recovered from. This shows how long and
how hard nature fights to subdue and expel the in-
vader, and how beneficial a little help at the right
moment may be. The sooner we can give the help
the more chance there is that nature, properly re-
inforced, will conquer. Babies having practically no
antibodies are extremely susceptible to the deadly
action of the bacilli. If, however, we can even partly
tuberculize them before they succumb to the inva-
sion it seems probable that they will produce suffi-
cient antibodies to free their system from tubercu-
losis for the rest of their lives. An intercurrent in-
fection, like measles, seems to completely banish
hyper-susceptibility just as an overwhelming auto-
intoxication may do, so in a way that we do not
comprehend our- principal line of defense may be
completely thrown down and acute general miliary
tuberculosis may supervene. These conditions, so
crudely sketched, seem to me to indicate, not alone
the necessity, but the eminent advantage of using
tuberculin in a proper manner. Just so long as the
body cells are able to react to tuberculin, just so
long more antibodies will be thrown out and the pa-
tient's general condition will be improved and some
advanced cases will be cured. In like manner we
see an occasional recovery in a patient who has been
treated by the ordinary methods, apparently with-
out avail, and who has been sent home to die, when
far advanced in the third stage of consumption.
In this patient the bodily forces have finally over-
come the invader by the production of a state of
complete immunity. So with tuberculin we may, and
frequently do, in apparently hopeless cases, pro-
duce at last a state of complete immunity to the
poison of the bacillus. It would, however, be unrea-
sonable to expect to produce such a state in a
majority of third stage cases.
Now, how shall we administer this remedy? With-
out taking the time to discuss the various tuber-
lins and their method of administration, let us take
up the consideration of what promises to be a feas-
ible and efficient method in all cases. I refer to a
method devised by Dr. Ellis Bonime of the Poly-
clinic Medical School and Hospital, and practised by
him for a number of years. In cases that show
unmistakable symptoms of any form of tuberculosis
and in some doubtful cases no diagnostic doses of
tuberculin are necessary. But in many cases a
diagnosis must 'be made and is impossible with-
out the subcutaneous use of tuberculin. The von
Pirquet test, which is so easy to apply, is not of
much value after the first year of life. Although
if it be negative when properly applied and re-
peated once, there is a strong probability that the
patient is not tuberculous.
The only positive test is the subcutaneous injec-
tion of the proper dilution of 0. T. Starting in
cases of suspected pulmonary tuberculosis with .10
cc. of No. iv dilution, and taking the temperature
every two hours in the twelve hours succeeding the
injection, if there be no reaction in 48 hours .50
cc. of No. iv is given; if no reaction follows this,
give .10 cc. No. iij; if this has no reaction .50 cc
of No. iij. Then .10 cc. No. ii; then .50 cc No.
ii. and finally .10 cc of No. i. If, after these five
injections, given every 48 hours, no reaction oc-
curs, the patient is non-tuberculous. In giving the
injections a sharp, perfectly clean needle should be
used. The needle should be passed in parallel to the
skin into a spot on the outer aspect of the upper
arm that has been previously painted with iodine.
Aug. 19, 1916J
MEDICAL RECORD.
323
No covering of any sort is needed over the site of
the injection, although some practitioners prefer to
paint the spot with collodion. The so-called
"Record" syringe, imported from Germany, is the
proper one to use, although there are fairly good
syringes of American manufacture.
The determination after dosage is the next step
in the procedure. Dr. Bonime has not used logar-
ithms or involved mathematical formulae to regulate
his doses. He leaves nothing to chance. He declines
to treat a case where he cannot have reliable tem-
perature records. The increase of his dosage is in
arithmetical progression, not in geometrical progres-
sion, which was formerly largely used and was un-
questionably very harmful. He repeats each increase
once. He dilutes the tuberculin with V2 of 1 per
cent, phenol in sterile normal salt solution. He uses
preferably Koch's old tuberculin made into six or
more dilutions, each one a decimal of its predeces-
sor. This formula has been recommended by Park
and Williams and others, and is not new. The selec-
tion of the appropriate dilution to each case calls
for the best judgment and clinical experience. Dr.
Bonime protests vigorously against routine and rule
of thumb methods. Only an experienced clinician
and tuberculin therapist is competent to select the
appropriate dilutions for each case, as it comes
along. A mistake here may vitiate and render
abortive the entire course of treatment. In a gen-
eral way experience has demonstrated that closed
glandular tuberculosis should be started on No. iii
(dilution 1-1,000), but open or postoperative cases
should be started on No. iv (dilution 1-10,000) be-
cause of their increased susceptibility. Closed pul-
monary cases should be started on No. iv, whereas
open pulmonary cases should begin on No. v
(1-100,000) or No. vi ( 1-1,000,000). But there will
prove to be many exceptions. Each case must be
individualized and its needs and limitations carefully
determined, as e.g. colored people and Italians are
more susceptible than others and should be started
on the dilution next higher than that used for most
Caucasians. We should never forget that we are in-
stituting a course of treatment of a hydra-headed
and treacherous disease which may pervert every
one of the bodily functions and attack every one
of the bodily organs.
As explained above, our main hope, in fact, in
tuberculin treatment, our only hope of success, is so
to marshall and direct the forces of the patient's own
body that they will repel the invader and shake off
the insidious and slowly developing infection, which
may have maintained itself alive, albeit inactive, in
the tissues for months and years, stealthily awaiting
the time when the bodily defenses shall be relaxed
so that the invading forces may begin their ruthless
march of destruction.
Having begun the administration of the selected
dilution of O. T., Dr. Bonime increases his initial
dose with the utmost caution, using at first .10 c.c.of
the selected dilution. He increases this by .02 c.c.
after a three or four-day interval. The next hypo-
dermic injection will be another increase of .02 c.c,
making .14 c.c. The next increase will be by .04 c.c,
which will be repeated once. Then .06 c.c. also to be
repeated once. The injections are made twice a week
in the late afternoon or evening, and the increased
dose should precede the four-day interval, as the
larger interval lessens the probability of a reaction.
Reactions must be avoided at any cost, and the
immunizator should never .forget that he may undo
weeks of good work by a little carelessness. Thus
he should be especially particular about the needles
and syringes used, and in the observation of strict
antisepsis in making the injections.
The general scheme of treatment is as follows,
beginning, let us say, on Monday at 8 P. M. Sup-
pose the case to be one of "closed" pulmonary tu-
berculosis.
We give on
Mon 10 c.c. No. iv) T .„
_, -, o „ „ xt • t Increase .02 c.c.
Thurs 12 c.c No. iv]
Mon 14 c.c. No. iv) T n.
Thurs 18 cc No. iv[ Increase .04 cc
M°n g cc. No. iv Increase 06cc
Thurs 28 c.c. No. iv)
M°n 34 cc. No. iv ) Increage og c c>
Thurs 42 c.c. No. iv]
Mo" 50 c.c. No. iv » Increase 10 cc
Thurs 60 c.c. No. iv)
M°n ™cx- No. iv) Increase .12 c.c
Thurs 82 c.c. No. ivj
Mon 94 c.c. No. iv
Thurs 10 cc. No. iij
Etc., etc.
A reaction is indicated by a rise of temperature
of one or more degrees Fahrenheit (occurring dur-
ing the second twelve hours, after the injection),
above the usual temperature of the patient as shown
by the recorded temperatures for that hour of the
day. It has been found, so seriously in earnest are
all consumptive patients to get the upper hand of
their disease, that they or their friends can be re-
lied upon to take and record their temperatures as
often as may be required. Naturally, rectal tem-
peratures are to be insisted upon. Even school
children can be excused to go to the toilet every
two hours to take their temperatures.
Most of the cases in Dr. Bonime's clinic are am-
bulatory and home talent must be depended upon
to keep the temperature records. It is rather sur-
prising to note how well most of these patients
learn to do this. Sutherland says in the British
Medical Journal for Sept. 16, 1911, that "it has been
demonstrated that eighty percentum of the early
cases of tuberculosis can be treated at their own
homes without interference with their occupation."
We have no space to discuss here the economic ad-
vantage of this proposition. Generally speaking of
course, the help of competent nurses or young physi-
cians for follow-up work would be very great.
Dr. Bonime requires four hour temperatures
daily while his patients are undergoing his treat-
ment; and on the days succeeding the injections of
tuberculin he has the temperature taken every two
hours. This is done for the purpose of detecting a
reaction. Should one occur, the treatment must be
suspended for a week and not resumed until after
every symptom of constitutional reaction has sub-
sided. Then the injection of tuberculin should be
that of the third previous dose. To illustrate; if on
a Tuesday a reaction shall follow the injection of
the preceding Monday which was, we will say, .50
c.c of No. iv dilution, no injection is given until
the Monday following the dose that caused the re-
action, then the dose would be .34 c.c. No. iv solu-
tion. No reaction will probably follow. Then the
gradual cautious approach to a saturating dose will
be resumed and the increase of .02 c.c. of the solu-
tion will be adopted (each increase to be repeated
once) so that on the next Thursday .36 c.c. not .42
(as in the original schedule) will be given. Then on
Monday following .36 c.c, etc, so that it will be
324
MEDICAL RECORD.
[Aug. 19, 1916
three and one-half weeks before a dose as large as
the dose that caused the reaction will be again
reached. Fortunately the reactions that do occur
in this method of treatment are so small, the high
temperature sometimes lasting only a half hour,
that they do little harm and are frequently, if not
generally, unaccompanied by any perceptible symp-
toms except the temperature increase. Hence the
necessity for the two-hour thermometric observa-
tions during the second twelve hours after the
tuberculin injections.
When the patient has been safely conducted
through the various dilutions and has reached that
stage of immunization that he will not react to 0.1
c.c. pure 0. T. This is to be followed in a week by
.20 c.c. pure 0. T. then if there be no reaction Dr.
Bonime switches him onto bacillary emulsion
(B. E.). This he considers imperative in joint
cases and highly desirable in all cases of tubercular
infection. Because the B. E. will immunize the pa-
tient against certain products of the infection
which are more or less refractory to the action of
O. T. The same decimal dilutions are made of
B. E. but for the patients having passed safely
through the injections of O. T. only dilution No. i,
of B. E. is used. When using B. E. the intervals
should be doubled, since it takes longer for the neu-
tralization of the larger percentum of toxin con-
tained in the B. E. than in the 0. T.
Beginning with dilution No. i of B. E. it
is customary to increase by tenths of a c.c.
given weekly through this dilution. When 0.1
c.c. pure B. E. has been reached without reaction,
the intervals are extended to three months. If the
patient can take, without reaction 0.1 c.c. pure O. T.
four times in a year, he is presumably immune from
infection with the T. B. although under certain cir-
cumstances as e.g. an attack of measles, this im-
munity may be broken down and the state of hyper-
susceptibility may recur and another course of
tuberculin treatment may be necessary to restore
the patient's immunity. Beginning, usually with
No. i O. T. and continuing as before.
A course of Dr. Bonime's treatment may last
from four to eighteen months, but the average
duration of a sanatorium course of treatment lead-
ing to a complete arrest of a tuberculous process is
two and one-half years, and of these arrested cases,
at least 30 per cent, relapse and die of tuberculo-
losis.* Whereas, it is agreed by practically all of
the authorities of the present time that all cases
having had a thorough course of tuberculin are
more resistant to tuberculous infection than those
who have not been so treated. I am not aware of
the existence of any statistics covering the above
mentioned point, although it is to be hoped that
some will soon be available.
It is hardly necessary to observe that ambulatory
patients who have been able to maintain themselves
and their families and have kept away from the
enervating influences of a sanatorium are in a far
better fix to maintain their improved condition and
their place in the world than if they should return
from sanatorium conditions and again try their
luck in the unfavorable surroundings where they
developed their original tuberculosis.
This paper is already too long and no space is
left to speak of joint and grandular tuberculosis,
and the treatment of mixed infections. For the
*The annual report for 1915 of the Rhode Island
State Sanatorium for Tuberculosis gives the death rat,'
of their discharged cases for the past ten years at 57
per cent, of 2142 patients. This is the entire number
which it has been possible to trace.
minutia? of the therapeusis of these phases of
tuberculosis the reader is referred to Dr. Bonime's
forthcoming book and to a paper by Dr. Sidney
Twinch of Newark, read in the orthopedic section
of the recent Congress of American Physicians and
Surgeons, giving a series of forty-five or fifty joint
cases, some of whom had resisted the routine
treatment for years and all of whom have been
cured or greatly benefited by the Bonime treatment.
If Dr. Pottenger can report an improvement in
his results of from 20 to 25 per cent, more cures
of tuberculosis under tuberculin treatment than
where the dietetic-hygienic treatment alone was
employed, and if certain tuberculin clinics in Eng-
land and Germany can report 100 per cent, of
cures in the early stages of tuberculosis by the ju-
dicious use of tuberculin, we believe that we shall
see still better results in all cases of tuberculosis
by the simpler, safer and more exact method of
treatment taught us by Dr. Bonime.
As Dr. E. Mariette {Brit. Med. Journal, Sept.
16, 1911) strongly puts it "The results claimed by
German writers, which are confirmed and en-
dorsed by those who have used their methods in
this country, ought to be sufficient to convince
every practitioner in charge of an uncomplicated
case of phthisis, that if he withholds from his pa-
tient the benefits of a thorough course of tubercu-
lin he is almost as guilty of culpable negligence as
he would be in performing an operation without
due antiseptic precautions."
42 Church Street.
THE RELATION OF TUBERCULOSIS OF THE
BRONCHIAL GLANDS TO THE DIAGNOSIS
OF TUBERCULOSIS OF THE LUNGS.*
By MARY E. LAPHAM, M.D.,
HIGHLANDS CAMP SANATORIUM, HIGHLANDS, N. C
Tuberculosis of the bronchial glands may cause
tuberculosis of the lungs in three ways: by repre-
senting the primary focus of infection whence sup-
plies of tubercle bacilli may be transported to the
lungs at any time; by direct extensions of tubercu-
lous processes from the glands surrounding the root
of the lung ; by pressure upon the trachea and bron-
chi which induces such secondary pathological
changes in the lungs as to favor the development of
tuberculous processes^
From this point of view, the diagnosis of tuber-
culosis of the lungs may begin with that of the
bronchial glands and we should never say that there
is no danger from tuberculosis until we have proven
that there are no tuberculous processes in the bron-
chial glands. After we are confident that there are
no physical signs in the lungs suggesting tubercu-
losis we must remember that it is equally important
to determine whether there are any tuberculous
processes in the bronchial glands or not and if there
are, then the problem is how to estimate their effect
upon the lungs when we have no physical signs to
guide us.
There are two reasons for not finding tuberculosis
of the lungs when it already exists: there are no
physical signs or we find pathological conditions
which are common to non-tuberculous diseases of the
lungs, and because these conditions are of such long
duration we take it for granted that they cannot be
tuberculous.
*Read at the meeting of the National Society for the
Study and Prevention of Tuberculosis, Washington,
May' 12. 1916.
Aug. 19, 1916]
MEDICAL RECORD.
325
When tuberculous processes extend from the
hilum into the lung, it may not be possible to detect
them by a physical examination and there is no
analogy between the diagnosis of the apex or the
pleura or other peripheral parts of the lungs and
these creeping, thread-like peribronchial infiltra-
tions which give no sign of their presence. It is
possible to say with more or less accuracy that the
upper part of the lung is involved to such or such
an extent by depending upon physical signs, but
this is not true of the infiltrations extending from
the hilum into the lung because the tissues are
not impacted, there is not the infiltration en bloc,
the physiological function of the larger bronchi is
not altered, there is the same content of air, the
intima is not roughened, the breath sounds are not
changed and there is no dullness, so that we have
nothing to inform us of the first act of the tragedy
being played in the lungs. A theoretical considera-
tion of the pathology of these peribronchial exten-
sions shows us when to expect their revelation by
physical signs and when not.
Enlarged tuberculous glands surrounding the root
of the lung threaten its integrity in two ways:
first by pressure upon and interference with the
return circulation of blood and lymph from the
lungs; second, by direct extensions by contiguity
because these glands lie so close to the lung that as
Osier has said it is sometimes very difficult to say
where the lung tissues end and the glands begin.
Kraemer has compared the effects of the pressure
exerted by these enlarged glands upon the return
circulation from the lungs with those caused by en-
larged cervical and inguinal glands and suggests
that just as they cause edema and dilatation of the
veins of the face, neck, external genitalia, and lower
extremities, so the enlarged glands at the hilum
cause stasis and edema of the drainage territories
adjacent to them.
Remembering that the network of vessels sur-
rounding the alveoli would cover 150 square meters
of surface if spread out on the floor, and that all
their immense content must be returned through
the relatively narrow portals of the hilum, it is
quite possible that a slight amount of pressure at
the hilum might produce a disproportionate amount
of obstruction which would congest the nearest
areas of drainage which in the right lung would
be the upper part of the lower lobe, the middle
lobe, and the lower part of the upper. This edema-
tous condition might easily cause effusions into the
interlobar fissures with subsequent plastic absorp-
tion and scar formations. Edematous infiltrations
of the tissues surrounding the hilum would be more
apt to cause dullness and altered breath sounds if
there were not such an excess of large air pas-
sages over smaller that the air content was pre-
served over that lost. The exaggeiation of the
breath sounds into something like bronchophony
may be caused by the pressure imparting a better
carrying quality to the walls of the bronchi and
this and d'Espine's sign of increased transmission
of the whispered voice are often the only and most
reliable physical signs obtained from tuberculous
processes in the bronchial glands. The pressure up-
on the bronchial circulation, the tendency to suffu-
sion, to slowing of the currents, to subsidence of
their contents, and to a backward wash out of the
bronchial glands favor the gradual extension of
tuberculous processes through the sheaths of the
larger bronchi and on point by point to the smaller
ones. Leaving the regions surrounding the hilum
and tracing these peribronchial infiltrations on
their way through the lung, we find that there are
no physical manifestations of their presence until
they reach air passages which are not sufficiently
rigid to resist their pressure ; up to this point they
have not affected the interior of the bronchi, but
have remained purely interstitial and inert; there
is no attack and no defense; like foreign bodies
they are fibrosed as fast as deposited and no harm
is done because there is no toxemia, no absorption,
and no liberation of toxins. These fibrosed pro-
cesses are more like lichens stretching along the
limbs of trees than disease producers. Coming to
the smaller and softer air-passages with no carti-
lages to keep them open, they collapse, the air can-
not enter so freely, the breath sounds are weak-
ened, and the lobules are not filled sufficiently to
expand them promptly anad vigorously; insuffici-
ent breath sounds and insufficient expansion of
the alveoli are the characteristic consequences of
pressure upon the smaller air-passages. There is
no reason for altered breath sounds, for harsh or
granular breathing or for any of the signs of dis-
integration; nor is there any dullness, for the air
content of the larger bronchi is preserved. It may
even be that instead of dullness there is an increase
of resonance suggesting emphysema. Even in the
long, thin, flat chest with little or no motion in the
intercostal spaces; even when the lung is so tied
down that the chest rises and falls as a whole en
cuirasse, we may find to our surprise that not only
is there no dullness but actual hyperresonance in
some regions. Resonance characteristic of an ex-
cess of air, of emphysematous conditions. It is
possible that the walls of the larger bronchi are
rigid with their infiltrations and so do not expel
their air as they should and that the retained air
more than compensates for the loss in the terminal
lobules. It is possible that we have a bronchitic
emphysema which is comparable to the alveolar
form and produces the same lack of collapse and
expansion with the same insufficient exchange of
air and suppressed breath sounds. As one by one
the terminal areas are choked off, the leaves or the
breathing spaces of the bronchial tree are obliterat-
ed, they collapse, form atelectatic areas, and the
lung is tied down. Thus one lobule after another
disappears until finally the branches chiefly remain
and the breath cannot get much beyond the bron-
chi. This is fibroid phthisis par excellence without
breaking down, without disintegration, without ab-
sorption of toxins. As the rigidity of the bronchial
walls increases they cannot stretch and follow the
expanding chest wall so that the thorax is drawn
in eventually and there is dimpling over the hilum
and in the second and third intercostal spaces near
the sternum. But all these evident manifestations
come too late; what we need is detection as these
infiltrations begin to creep from the hilum along
the main bronchi through the paravertebral re-
gion on up to the apex, or through the subpleural
spaces out to the axilla, or downwards towards the
base. When the lobules in the apex collapse we
can discover it; when half an inch or more of
normal lung substance in the cortex covers up the
deeper extensions, how can we detect them by phy-
sical signs? The pathology of these peribronchial
extensions teaches us not to depend upon physical
signs because we cannot obtain them ; not to ex-
pect the signs of pneumonic infiltrations because
the tissues are not infiltrated compactly; not to
look for disintegration because there is no break-
326
MEDICAL RECORD.
[Aug. 19, 1916
ing down; not to rely upon harsh or granular
breathing or rales of any kind, but rather to seek
for indications of gradual obliteration of the
breathing spaces in the terminal lobules. Apply-
ing the ear directly to the skin we notice that, as
we feel the chest wall pulled out against it, we
cannot hear the accustomed response of the enter-
ing air; instead of the rush of the air through the
air-passages and the prompt and uniform unfolding
of the alveoli, we hear little or nothing; it is rather
as if some stupor robbed us of our keenness of
perception; as if our senses were dulled; as if a
veil were drawn across between us and the lung;
all is dulled, blurred, obscured, suppressed, just as
the nature of the pathological processes would lead
us to expect.
The pressure from enlarged tuberculous glands
surrounding the trachea and bronchi produces
different effects upon the lungs from those
caused by the glands at the hilum. When these
glands enlarge and press upon the walls of the
trachea and bronchi, circular constriction does not
so much follow as a flattening or lateral thrusting
in which narrows the lumen aand causes tracheo-
bronchial stenosis. In the beginning this stenosis
does not obstruct the entrance of air because in-
spiration distends the air passages as the chest
wall is pulled out and the stenosis is relieved; the
entrance of air is also furthered by the weight of
the atmosphere pressing down upon the column of
air reaching from the upper air passages to the
alveoli and forcing it down upon the retreating
alveolar walls. As the chest wall falls back the
lumen of the air passages is compressed, the ste-
nosis returns, and now the column of air driven up-
ward by the collapse of the lung meets the stenosis
and the weight of the atmosphere is against its
escape. Delayed and difficult expiration results
with retention of air distal to the stenosis; as the
bronchial glands enlarge and the pressure in-
creases, the difficulty of getting rid of the accumu-
lated air becomes greater until finally expiratory
dyspnea results ; gradually the intra bronchial and
intra-alveolar pressure from the retained air in-
creases and the essential features of asthma ap-
pear with more air entering the lung during in-
spiration than can be easily expelled by expiration,
and attacks of expiratory, asthmatic dyspnea de-
velop; with increasing accumulation of air and rise
of intra-alveolar pressure, emphysema follows ; if
the backward thrust of the air against the stenosis
is sufficiently great to force the wall of the bron-
chus out, there is bronchiectasis and expectoration
of profuse, purulent sputum which as a rule does
not contain tubercle bacilli; if the entering force of
the column of air is not sufficient to distend the
smaller air passages, they collapse and form areas
of atelectasis; these atelectatic areas are especially
apt to form in the lobules and to constitute the
acinous-lobular type of infiltration. Irritation at
the point of pressure and interference with the
bronchial circulation cause hyperemia, inflamma-
tion of the mucosa, exudations, and chronic bron-
chitis which may persist for years. The congestion
of the vessels in the bronchial walls may cause
rupture with hemoptysis and hemorrhages occur-
ring at intervals and persisting for years. The
irritation of the bronchi establishes a tendency to
catching colds and repeated attacks of bronchitis.
A cough may persist for years annoying and parox-
ysmal or so insignificant as to escape notice; dry
and hard when due to pressure on the vagus, wet
and easy when due to catarrhal conditions. As a
consequence of tracheo-bronchial stenosis there are
secondarily induced in the lungs diseased condi-
tions similar to those of bilateral, chronic, diffuse
bronchitis, asthma, emphysema, bronchiectasis, and
atelectasis, together with hemoptysis and hemor-
rhages. In these cases of tuberculosis of the
lungs secondary to tuberculosis processes in the
bronchial glands, we cannot depend upon physical
examinations of the lungs for sufficiently reliable
information to positively exclude the presence of
danger. Before we can conscientiously give the
verdict, no tuberculosis of the lungs because there
are no physical signs, we may be forced to seek the
aid of tuberculin and the Roentgen ray.
The tuberculosis of bronchial glands is closely
associated with the diagnosis of those cases of in-
cipient tuberculosis which cannot be revealed by
physical signs.
The child has a cough, or does not gain in weight,
or is not strong. The adult is not quite up to par —
does not feel just right; has an innate conviction
that something is wrong; cannot say just what it
is — but he is worried and anxious about himself:
There is not enough vigor, or he does not sleep
well or is very nervous. How many of these cases
are dismissed with the comforting assurance that
nothing is wrong? That the child is all right and
the man tired or neurasthenic? Take a little vaca-
tion or go out in the country for a few days and
you will be all right. There is absolutely nothing
to worry about — there is nothing in the lungs.
In these cases with clinical suggestions of tu-
berculosis which cannot be confirmed by physical
findings in the lungs, before assuring the parent or
patient that there can be no tuberculosis because
nothing can be found in the lungs, we should re-
member that it is very possible that we are dealing
with tuberculosis of the bronchial glands which
may some day cause tuberculosis of the lungs and
that to discover pulmonary tuberculosis effectually
in its very incipiency we may have to begin with
that in the bronchial glands.
A NEW METHOD OF EXTIRPATION OF THE
LACRYMAL SAC WITHOUT RE-
SULTANT SCAR.
By J. A. KEARNEY, M.D.
NEW YORK.
LECTURER ON OPHTHALMOLOGY, NEW YORK POLYCLINIC MEDICAL
l"OL AND HOSPITAL.
No visible facial scar may be assured the patient
who submits to the operation for the removal of the
lacrymal sac by way of the slit canaliculi.
Most ophthalmic operators have experienced great
difficulty in obtaining the patient's consent when a
suggestion to remove the sac through a facial in-
cision with a certain scar remaining of uncertain
dimensions, but little or no resistance is offered by
them to the operation promising as good result with-
out a scar. Especially is this the case with women.
Where there has existed for a time an annoying
chronic dacryocystitis of either the catarrhal type,
with regurgitation of mucoid secretion into the con-
junctival cul-de-sac, or the recurrent phlegmonous
type, the extirpation of the lacrymal sac bee im s im-
perative, and the patient is confronted with the
choice of operation.
It is possible to do this operation with a local
anesthetic injected into the skin about the sac, but
Aug. 19, 1916J
MEDICAL RECORD.
327
it is much more satisfactory to administer complete
anethesia, preferably ether.
The conjunctival cul-le-sac is flushed with a
saturated boric acid solution after the contents of
the lacrymal sac are milked into it. Bowman's Num-
ber 1 probe is passed through each canaliculus as far
as the bony wall; this dilatation allows the engage-
ment of the tip of a Weber's knife, which is passed
down the upper canaliculus, making the usual Bow-
man slit, then down the lower one in the same way.
There usually remains a bridge of tissue between the
distal ends of the incisions. This is severed with a
curved bistoury. The anterior lacrymal crest is
then located and the internal canthal ligament is
divided at its insertion here.
The diseased sac and the surrounding granu-
lomatous tissue and the bone beneath, when found
carious, are then broken up by the appropriate cur-
ettes and scraped out through the original incision.
The walls of the canaliculi are scraped also. The
Instruments used :
canaliculus knife ; 3,
curettes.
1, Bowman's No. 1 probe ;
curved bistoury; 4, 5, '".
2, Webber's
special sac
cavity is then cleansed with a swab saturated in bi-
chloride of mercury solution (1 to 500). A thick
pad of cotton wrung out of saturated boric acid
solution is placed over the operated area and a head
bandage is applied firmly over it so as to produce
pressure sufficient to keep the walls opposed and
prevent swelling.
The after-treatment consists of cleansing of the
conjunctival cul-de-sac and the renewal of the band-
age daily for three or four days.
The advantages of this operation are: (1) There
is no scar remaining on the face; (2) there is less
difficulty in obtaining consent to operate when no
facial scar is assured; (3) there is much less hemo-
rrhage during the operation; (4) there is no pos-
sible return of the condition, because the mucous
lining is ablated from the puncta to the upper por-
tion of the nasal duct.
Conclusions as to results: (1) Cessation of all
sac secretion immediately after operation; (2) epi-
phora diminishes gradually and finally ceases.
Case I. — A. C, an Italian boy aged nine years com-
plaining of severe pain over the lacrymal sac area on
the right side. Eye was closed, the tissues in this re-
gion were deep red and swollen to the size of a small
walnut. There was no sign of pointing; epiphora was
only slight. August 20, 1913 ether was administered.
Dr. W. H. Long of Philadelphia, assisted. Bandage
applied for four successive days. There was a grad-
ual reduction of the redness and swelling. At the end
of three weeks there was no discoloration of skin or
epiphora.
Case II. — A brother of Case No. 1, aged eleven years,
suffering pain over the right lacrymal sac; this region
was red, slightly swollen, and a fistulous opening ex-
isted in its lower portion. Epiphora not annoying.
There was a history of a few previous attacks. August
20, 1913, ether was given. Dr. W. H. Long assisted.
Bone was found carious. Fistulous opening was scraped
and bandage applied. At the end of four weeks there
was no redness and with difficulty the previous site of
the fistula could be found. There was no epiphora.
Case III. — J. McD., aged ten, a son of Irish parents,
complaining of tears overflowing and at times a thick
secretion filling the left eye. The skin was elevated
over the lacrymal sac area (mucocele) and pressure
here expressed a mucoid secretion through the puncta
filling the conjunctival cul-de-sac. August 29, 1913
ether was given. Dr. W. H. Long assisted. Bone was
found carious; bandage applied for four successive
days. There was no reaction observable at any time
after the operation. At the end of four weeks the
epiphora was lessened considerably. At the end of
eight weeks the epiphora was only slight occasionally
outdoors and none at all indoors.
Case IV. — T. G., a son of Irish parents, aged ten,
complaining of pain over the lacrymal sac area of the
right eye. A recurrent phlegmonous attack of dacryo-
cystitis. No complaint of epiphora. August V, 1913
ether was given. Dr. W. H. Long assisted. The bone
was found carious. Bandage kept on for five days.
At the end of five weeks there was no epiphora, no
pain, and no discoloration of skin.
Case V. — Mrs. A. L., an Italian woman, aged thirty-
two, consulted me because the tears overflowed and the
conjunctival cul-de-sac of the left eye filled occasion-
ally with a thick viscid secretion. There was no muco-
cele, but pressure over the sac area caused a mucoid
secretion to fill the cul-de-sac. She gave a history of
probing and treatments for the past three years. May
14, 1914, ether was given. Dr. B. L. Gordon of Philar
deiphia, assisted. Bone was found carious. Bandage
applied and renewed daily for five days. One month
after the operation, no secretion and epiphora lessened.
At the end of four months there was no epiphora in-
doors and only occasionally outdoors.
Case VI. — Miss L. R., a Jewish woman aged thirty,
consulted me because of a thick secretion filling the left
cul-de-sac and epiphora. The secretion blurred her
vision occasionally and she begged for relief. She gave
a history of this condition lasting about five years, dur-
ing which time the lacrymal passages were probed and
medicated. June 16, 1914, ether was given. Dr. B. L.
Gordon assisted. Bone was found carious and ban-
dage applied. There was no reaction observable after
the operation at any time. At the end of eight weeks
there was no secretion and no epiphora.
Case VII. — Miss A. B., aged twenty-five, a daughter
of Irish parents, complaining of a thick secretion in
her right eye and overflowing of tears so annoying that
it interfered with her work. Skin was distended over
the sac (mucocele) and when pressed the glairy fluid
filled the cul-de-sac. August 16, 1914, ether was given.
Dr. Austin O'Malley of Philadelphia, assisted. No
carious bone found. Bandage applied. Next day there
was no reaction. Bandage removed in three days. Eye
looked well. Went back to work the fourth day after
the operation. The epiphora lessened a great deal at
the end of the first week. At the end of three months
the tears did not seem to bother her much indoors and
only slightly outdoors. At the end of six months
there was no epiphora at anv time.
Case VIIL— Mrs. B. B., aged thirty-five, a Jewish
woman, suffering from a recurrent attack of pleg-
monous dacryocystitis on the right side. Had had three
or four previous attacks and wanted relief. Ether
given September 18, 1914. Dr. B. L. Gordon assisted.
Carious bone found. Bandage applied. Redness and
328
MEDICAL RECORD.
[Aug. 19, 1916
swelling gradually disappeared. She had no annoying
epiphora at any time. One month after the operation
she was entirely well.
Case IX. — An Italian woman presented herself for
treatment in my service in the eye dispensary in the
Polyclinic Hospital, New York, with the tissues red
and swollen over the right sac area, complaining of
great pain. There was some epiphora. She gave a
previous history of thick secretion in her eye and
probings and treatments of the lacrymai sac. August
26, 1915, cocaine injected into the skin surrounding the
sac. Dr. T. A. Northcott assisted. Bone found carious.
Bandage applied. Case observed every other day. The
discoloration disappeared at the end of one month. The
tears were still annoying. At the end of four months
there was no epiphora.
Case X. — A German woman, aged forty-five, applied
for treatment, in the eye dispensary of the Polyclinic
Hospital, New York, in my service, with an annoying
glairy secretion in the left cul-de-sac and epiphora also.
She had been probed and medicated for five or six
years previous without results. September 25, 1915,
cocaine injected into the skin about the sac. Dr. P. A.
Cavanaugh assisted. Bone found to be carious. Bandage
applied. The bandage loosened during the night. The
next day over the field of operation the tissues were
swollen and the wound gaped. Bandage reapplied.
Swelling disappeared slowly. The healing took place
from the bottom of the wound. Opening cleansed daily
and at the end of two months the walls of the wound
were adhered. Bandage applied daily during this time.
At the end of three months there was no sac secretion
and the epiphora lessened a great deal. At the end of
four months the epiphora was present only in the wind.
Case XI. — An Italian woman, aged forty-five years,
applied for treatment in my service at the eye dis-
pensary in the Polyclinic Hospital, New York, com-
plaining of epiphora and occasionally a filling of the
light conjunctival cul-de-sac with the regurgitated
viscid secretion of a chronic catarrhal sac. No muco-
cele or active inflammatory process. The lacrymai pas-
sages had been probed and medicated for the past five
or six years with no results. October 20, 1915, cocaine
injected in the skin around the sac. Dr. J. E. Burns as-
sisted. Bone found carious. Bandage applied. After
three months there was no secretion or epiphora.
Case XII. — An Englishwoman, aged thirty-six, who
complained of pain over the left sac area with epi-
phora and secretion applied for treatment in my ser-
vice at the eye dispensary in the Polyclinic Hospital,
New York. Her eye was closed from the swelling in
this region. Skin tense. She had been treated for at-
tacks of this character for the past six or seven years
with probes and medication. December 15, 1915, ether
given. Dr. L. B. Nicholson assisted. The sac was
a mass of frog spawn-like granulation tissue. Bone
carious. Bandage applied. The area appeared normal
in one week. The end of a month epiphora less than
originally. After three months there was no epiphora.
Case XIII. — Englishwoman, employed in the laundry
of the Polyclinic Hospital, had been probed and medi-
cated for the past two or three years. She had an
attack of a recurring phlegmonous kind. Skin swollen,
red and tense over the right sac extending to lid and
closing the eye. She applied for treatment in my ser-
vice at the eye dispensary in the Polyclinic Hospital.
December 17, 1915, cocaine injected into the skin. Dr.
W. A. Ryan assisted. The corium above the sac
was greatly thickened and contained a few pus cavities
that were broken down and curetted from within. A
great deal of roe-like granulation tissue was scraped
away. The bone was carious. Bandage applied. No
redness of skin at the end of one month. At the end
of three months tissues quiet and some epiphora, but
much less than originally. After four months epiphora
not annoying indoors and only slightly in the wind.
Case XIV. — B. R., an American boy, aged eleven
yea^s. An attempt at removal of the right lacrymai
sac through an incision in the skin was made about one
year before by another surgeon. There was a broad
scar remaining and the mucoid secretion regurgitated
into the conjunctival cul-de-sac at intervals. On pres-
sure over the sac area a great deal of thick viscid
secretion filled the conjunctival cul-de-sac. He applied
for treatment in my service at the eye dispensary in
the Polyclinic Hospital, New York. March 22, 191C>
ether was given. Dr. A. L. Bass assisted. Bone found
carious. Bandage applied. At the end of four weeks
there was no epiphora and the boy was well.
17 East THIRTT-EIGHTH S
THE CONTROL OF THE NEXT EPIDEMIC OF
INFANTILE PARALYSIS.
By F. ROBBINS. M.D.,
NEW YORK.
Since the first extensive epidemic of infantile
paralysis in the United States (132 cases, Ver-
mont) in 1894, and especially since the severe
New York City epidemic of 1907, with approxi-
mately 2,500 cases, the control of this disease has
become an urgent municipal problem. Nearly
9,000 cases were registered in the United States in
1910. The total figure for the current New York
epidemic to date (August 15, 1916) exceeds 6,000
cases.
The great lesson taught by the last epidemic is
the interpretation of anterior poliomyelitis as a
contagious disease which spreads from one human
being to another. Prophylaxis accordingly as-
sumes greater importance in the control of future
epidemics than ever before, and preparedness is
now in order against the next invasion of the
ultramicroscopic pathogenic agent. While the
significance of the passive human carrier is be-
ginning to be appreciated, the defensive measures
in use fail to do justice to this source of con-
tamination. As in practically all epidemic dis-
eases, the actual original focus of infection and
the starting point for all later cases of the dis-
ease must be sought in an infected human being.
Patients in future will be strictly isolated and a
better knowledge of the biological properties of
the pathogenic agent will furnish a more reliable
basis for the hygienic measures to be adopted in
the community. The spread of poliomyelitis, in
future epidemics, will be checked in a similar
way as is now in use for infectious diseases, such
as scarlet fever and diphtheria. Measures will
be instituted for the removal and disinfection of
the patient's secretions (from the respiratory no
less than from the digestive tract), and for the
purification of the sick room after his recovery.
Healthy children in a stricken family will be re-
garded as potential germ carriers, and excluded
not only from schools, libraries, and places of
amusement, but also from street cars and other
public conveyances. Visitors, children or adults
will not be allowed in the homes of patients hav-
ing the disease. The greatest difficulty will be en-
countered in restricting the social relations of
adult members of infected families who, like
children, may be passive germ carriers, although
this fact is often disputed for commercial rea-
sons. In this connection it will be found that the
poliomyelitis germ is not ubiquitous, that is to say,
it does not occur irregularly, in healthy indi-
viduals, but the bacilli carriers always come from
infected surroundings.
The infection is now generally conceded to take
place essentially through the invasion of the naso-
pharynx in which the virus of the disease has
been known to persist for years. By means of ex-
perimental inoculation of nasal mucus into mon-
keys, it has been conclusively established that
the infectious virus remains viable in the nasal
passages for at least six months, in patients who
have recovered from the disease, or in healthy
persons from their surroundings. Typical polio-
myelitis was transferred to healthy monkeys, by
Osgood and Lucas, through the filtrate of the
nasopharyngeal mucosa of two monkeys which
had died, in the absence of anv other demonstrable
Aug. 19, 1916]
MEDICAL RECORD.
329
infection, six weeks and five and a half months
respectively, after the acute stage of poliomye-
litis. Such observations illustrate the persist-
ence of viable infectious poliomyelitis virus in the
monkey's nasopharyngeal mucosa for weeks and
months after the end of the acute paralytic stage
and for a much longer time than its survival in
the central nervous system. The fact cannot be
overemphasized that the virus of this disease may
exist for a very long time in an efficient condi-
tion, in the mucosa of the nasopharynx. On the
basis of this assumption each cured case repre-
sents for a long time a serious source of danger to
the community.
When the same conclusions are reached by a
process of reasoning from different premises, the
chances of the accuracy of these deductions are
greatly augmented. With special reference to the
poliomyelitis problem the importance of the naso-
pharynx as the entrance avenue of this infection
and the urgent necessity of prophylaxis by naso-
pharyngeal hygiene have been pointed out for
years by representative otorhinologists and pub-
lic health experts in the persons of Dr. William
Sohier Bryant and Dr. Charles E. North, whose
teachings and recommendations, had they been
generally understood and heeded, would in all hu-
man probability have checked the spread of the
current epidemic, as they will presumably serve
for the control of the next. The bacteriological
laboratory can only provide the key and fit it into
the recalcitrant lock of disease; the key must be
turned, the door thrown open, and the light let in
by the experienced clinician, the learned special-
ist, and the rare expert in preventive medicine.
The localization of the infectious virus in the
nasopharynx fortunately renders it accessible to
judicious intervention. No purposeful efforts
have been made so far to control the infection
which emanates from the nasal secretion, and it
is perhaps too early in the century to anticipate
the banishment of the pocket handkerchief at the
appearance of the disease. The day will come
when the customary cotton rag is replaced by
the cheap and clean Japanese paper napkin, which
is burned after it has been used. People will
realize that for a long time after the patient's re-
covery his pocket handkerchief continues to rep-
resent a possible source of infection. Infants and
children are helpless against the rubbing of
strange handkerchiefs over their perspiring or
grimy faces. The public roller towel of the past
was innocuous as compared to the family pocket
handkerchief. Bitter experience will drive home
the lesson that neglected noses, mouths, and
throats, are largely if not exclusively responsible
for the ultimate crippling of the unfortunate vic-
tims of disease and ignorance.
The possible involvement of the hypophysis or
pituitary body, by way of nasopharyngeal infec-
tion, in infantile paralysis (W. S. Bryant) opens
up an entirely new vista and the existence of a
pharyngeal hypophysis, an outpost of the cerebral
hypophysis, adds to the force of the argument.
Not only has the hypophysis been credited with a
protective influence, in the sense of regulating the
resistance of the body against disease, but the
functional activity of all organs is influenced by
the posterior portion of the cerebral hypophysis
through the intermediary of the subsidiary centers
located in the bulb and spinal cord. The posterior
pituitary body is the chief center of the spinal sys-
tem (Sajous). Before the outbreak of the next
epidemic of anterior poliomyelitis, pathologists
will have examined under the microscope the
changes of the cerebral hypophysis of children
who have succumbed to the disease. Reports will
be available showing if the pharyngeal hypophy-
sis, which is usually present, has undergone the
compensatory hypertrophy sometimes noted in
cases of organic pituitary disease, or if it presents
inflammatory .changes indicative of a local infec-
tion. The existence of close physiological and
pathological relations between the nasopharynx
and the hypophysis was pointed out by Citelli in
1912. Stimulation of the accessible pharyngeal
hypophysis, with the object of furthering the func-
tion of the cerebral hypophysis through local ap-
plication of radium, would seem to be at least
worthy of a trial.
In diphtheria, a disease likewise contracted by
nasopharyngeal infection, the changes of the
cerebral hypophysis have been investigated and
the cellular exhaustion which exists in these cases
has been referred to the augmented compensatory
activity of the hypophysis, as the result of the
missing function of the medullary substance of
the suprarenals (Abramow). The hypotonia of
the vascular system in diphtheria is explained by
Creutzfeldt and Koch as the result of degenerative
changes of the intermediate lobe of the hypophy-
sis, the part which secretes the blood-pressure
raising substances. The clinical administration
of pituitrin in diphtheria is followed by a distinct
rise in blood pressure and combined pituitrin
adrenalin treatment was recommended by Creutz-
feldt and Koch as the most rational method of cor-
recting the circulatory disturbance in diphtheria.
The beneficial effects of adrenalin have been
known for years, but although the interrelation of
the endocrinic system is a part of contemporane-
ous knowledge, a more liberal application of the
endocrinic principle is left to coming clinicians.
The phenomena following upon the administration
of pituitary substance are known to resemble
those elicited by adrenal preparations. Unfortu-
nately, no observations are available concerning
the effect of hypophysis extract in cases of infan-
tile paralysis, although many are claimed to have
been benefited by adrenalin, and although it has
been shown that the points of attack of adrenalin
are sensitized by the simultaneous action of
doses of hypophysis extract almost inert in them-
selves. The cooperation of these two substances
causes a disproportionately stronger vascular con-
traction and the blood-pressure raising effect of
adrenalin is also remarkably increased by the ad-
dition of small amounts of hypophysis extract.
The rise of blood pressure is sustained much
longer by pituitary substance than by adrenalin,
and according to Sajous the temperature and the
muscular tone are also apparently sustained for a
longer time by the active principle of the hypo-
physis. A great practical advantage, as compared
to adrenalin, especially in children having anterior
poliomyelitis, consists in its simple administration
by the mouth, without loss or impairment of
therapeutic efficiency.
Serotherapy of anterior poliomyelitis has been
recommended by Netter, in France, since 1910, on
the basis of favorable clinical experience with the
application to this disease of an efficient medica-
tion in cerebrospinal meningitis. The intraspinal
injection of blood serum derived from patients
330
MEDICAL RECORD.
[Aug. 19, 1916
who have had infantile paralysis aims at bring-
ing the virulent invaders of the nervous centers
in contact with a fluid containing antibodies capa-
ble of neutralizing their pathogenic effects. It is
not surprising that on etiological and other
grounds the treatment of poliomyelitis with intra-
spinal injections of blood serum from convales-
cents has given rise to much controversy and ad-
verse criticism. The method is now being tried in
some hospitals in a limited number of cases, but
it is too early to foretell the results of this tenta-
tive therapy.
In view of the appalling cost of a poliomyelitis
epidemic — aside from the municipal expenses di-
rectly incidental to its prevalence, it is also neces-
sary to count the financial encumberment of indi-
viduals, families, and ultimately the State itself,
by the more or less crippled survivors — the ques-
tion arises if the future will not see the wisdom
of entrusting the welfare of the community to a
competent guardian of the public health, who in
his person unites the variegated but inert knowl-
edge of bacteriologists, neurologists, practitioners,
commissioners, etc., and whose competence in
dealing with an incipient local epidemic is based
on a thorough knowledge of the laws of universal
epidemiologv.
BIBLIOGRAPHY.
Osgood and Lucas: "Transmission Experiments With
the Virus of Poliomyelitis," Jour. Am. Med. Assoc, Vol.
LVI, I, 1911, p. 495; Ibid., Vol. LX, II, 1913, p. 1611.
Bryant, W. S. : "Epidemic Poliomyelitis," New York
Med. Jour.. Vol. XCII, 1910, p. 1215.
Bryant, W. S.: "The Involution of the Nasopharynx
and Its Clinical Importance," Am. Jour, of the Med.
Sciences, Vol. CXLVIII, 1914, p. 61.
North, Ch. E.: "An Investigation of Recent Out-
breaks of Typhoid Fever, etc.," Medical Record, Vol.
LXXIX, 1911, p. 517.
North, Ch. E.: "Sanitation in Rural Communities,"
Phil. Am. Acad. Pol. and Soc. Sci., 1911, p. 129.
Citelli: "Ueber die Physiopathologischen Beziehun-
gen Zwischen dem Hypophysen System, etc.," Zeit-
schrift f. Laryngol. Rhino!.. Vol. V, 1912, p. 514.
Sajous: "The Internal Secretions and the Principles
of Medicine," Sixth Edition, Phila., 1914.
Abramow: "Ueber Veranderungen in der Hypophysis
Cerebri bei Experimenteller Diphtherie," Centralblatt
fur Allgem. Pathol.. Vol. XXV, 1914, p. 414.
Creutzfeldt and Koch: "Ueber Veranderungen in der
Hypophvsis Cerebri bei Diphtherie," Virchovo's
Archiv., Vol. CCXIII, 1913, p. 123.
Netter, A.: "Serotherapie de la Poliomyelite Anteri-
eure," Hull, de VAcad. de Med.. Vol., LXXI, 1914, p. 525.
Wtter, A.: Bull, ef Mem. v' .!/.</. des Hop. de
Paris, 1916. XL., p. 299.
41 West Fortt-fifth Street.
EPIDEMIC POLIOMYELITIS.
PRELIMINARY REPORT ON 33 CASES.
By HERMAN K SHEFFIELD, M.D.,
NF.W YORK.
All but one of the cases were observed by me
through the kindness of colleagues in the boroughs
of Kings, Richmond, Queens, Manhattan, and the
Bronx, and in Perth Amhoy, N. J. Three of the
patients were from 1 to 2 years old; fifteen from 2
to 3 years; nine from 5 to 6 years, and six from 8
to 10 years old. Twenty-two were hoys and eleven
girls. All of them were apparently in good health
previous to the attack and well developed mentally
as well as physically. The onset was very sudden
in twenty-nine of the cases, while four of them
showed signs of general malaise for from five to ten
days. The history of infection could not be traced
with any degree of certainty. In all but four of
the cases poliomyelitis prevailed in the immediate
neighborhood. In one case, a physician's child, there
was a history of the father having taken his child
in his automobile while attending to two cases of
infantile paralysis. The presumption is also that
while leaving his child in the car in front of the
patient's house, it must have come in contact with
some infected children of the neighborhood. In the
cases of two children of Manhattan there was the
presumption that the father in one case, an uncle
in the other, both insurance collectors in the in-
fected districts of Brooklyn, have conveyed the dis-
ease to the victims. One patient of Long Island had
not come in contact with any child for six weeks
previous to being stricken with the disease. Here
also it was assumed that an adult carried the in-
fection.
In nine cases one or more extremities were in-
volved; in twelve cases the disease was limited to
the muscles of the neck, throat, and palate, and
in the remaining twelve the muscles of the chest,
spine (patients were unable to turn around), and
abdomen were affected. Nine children died, six
of them within from 24 to 48 hours after the onset.
The other children have greatly improved, whether
fully or not it is too early to tell. The majority
of cases began with headache and sore throat, the
tonsils presenting either simple congestion or also
small grayish white deposits. It was often asso-
ciated with difficult, though not painful, degluti-
tion. In the twelve cases in which the throat mus-
cles were involved there was distinct hoarseness,
the voice in speaking often resembling that observed
after intubation. Associated with these symptoms
was usually also regurgitation of fluids through
the nose in drinking, so that the entire clinical
picture fully agreed with that of postdiphtheritic
paralysis ; indeed, so much so that on five occasions
the family physicians deemed it imperative to ad-
minister diphtheria antitoxin, in one instance as
much as 18,000 units. In practically all the cases
there was distinct drowsiness. The children, how-
ever, when aroused were perfectly conscious and
able to respond to questions intelligently. Twitch-
ing of the muscles was very common even in the
absence of high fever. In three cases convulsions
of short duration occurred during the onset. The
temperatures ranged between 100° and 104 F., most
commonly about 102 : F., while the puke rate was
invariably high, between 120 and 180 per minute,
even in the absence of fever. Careful testing of
the reflexes showed exaggeration in twelve cases,
diminution in fourteen, and abolition in seven, the
last being in the cases in which paralysis of the
extremities predominated. In three children there
was partial implication of the sphincters, in one
of the anus, and two of the bladder, herein not
being included the several cases of anuria of from
twelve to thirty-six hours' duration. Muscular pain
was pronounced some time during the course of
the disease, most commonly at the onset, and I
believe it was the pain which was responsible for
the apparent presence of the Brudzinski and Kernig
signs. Although the child was able to hold the
head erect and to bend it backward, there was con-
siderable difficulty or even inability to bring the
chin down upon the sternum! The gastrointestinal
tract was but little affected, about half of the cases
gave a history of occasional vomiting, and the great
majority of the children refused to eat on account
of the difficulty in swallowing. On the other hand.
some children _ maintained a very healthy appetite
Aug. 19, 1916]
MEDICAL RECORD.
331
for food, in fact, better than during good health,
so much so that their parents cast some doubt upon
the correctness of our diagnosis. In three cases
slight facial paralysis was manifested and persisted
after partial disappearance of the other symptoms.
Evidently the symptomatology of the disease dur-
ing the present epidemic does not materially differ
from that observed on previous occasions. In all
epidemics certain groups of symptoms, depending
upon the seat of the lesion, seem to predominate,
and in the beginning tend to obscure somewhat the
diagnosis; but with an epidemic prevailing, there
should be no difficulty in arriving at correct con-
clusions. In this epidemic, as in previous ones,* we
occasionally meet with atypical cases, as, for ex-
ample, facial paralysis with crossed paralysis of the
extremities, but these cases can readily be differ-
entiated from encephalitis by the absence of
spasticity and athetosis in the former and the fact
that in poliomyelitis the spinal fluid shows an in-
crease in albumin and globulin, a fair reduction
of Fehling's, and a cellular increase, usually of
mononuclears. This test, by the way, is of ines-
timable importance in all doubtful cases, when the
question arises between poliomyelitis, rheumatic
affection, acute scurvy, hip-joint disease, or in-
juries, and the like. Diphtheria can readily be dis-
tinguished from poliomyelitis involving the throat
by the presence of Klebs-Loeffler bacilli in the
former, and by the other clinical symptoms asso-
ciated with diphtheria.
Exempting the six cases that succumbed to the
attacks before any therapeutic measures had been
employed ( indeed two of them died during my con-
sultation with the family physicians), I believe the
results of the treatment presently to be outlined
compare favorably with those of all other methods
of treatment in vogue, including the injection of
serum and adrenalin.
The treatment consists of cupping (six to ten
cups on each side of the spinal column) ; hot 1 101
to 105 : F.) mustard baths every four to six hours;
sodium or ammonium salicylate (one or two grains
for every year of the child's age, every two to six
hours), and strychnine (small doses) internally; oc-
casionally lumbar puncture, especially where twitch-
ing or rigidity is pronounced, and camphorated oil
hypodermically, whenever respiratory difficulty
presents itself. Immobilization of the paralyzed
limbs, and light massage and passive motion are
resorted to immediately, irrespective of acuteness
of symptoms.
il'T West Eighty-seventh Street.
THE RICE DIET;
HOW TO PREPARE AND EAT IT.
By H. S. BARTHOLOMEW, M.D.,
NEW YORK.
PHYSICIAN TO THE CLINIC AT ROOSEVELT HOSPITAL FOR DISEASES
OF THE STOMACH AND INTESTINES.
It is not the intent of the writer of this brief arti-
cle to enter into the subject of diet or to extol the
merits and uses of the so-called "rice diet," but to
emphasize the importance of impressing upon the
patient strict observance of details in the prepara-
tion and consumption of the rice if good results are
to be obtained from the same. To tell the patient
he must go on a rice diet for a stated length of
time will not suffice; he must be impressed with the
*Atypical Poliomyelitis, Medical Record, March 23,
1012. "
importance of the details laid down regarding it,
otherwise it will fail of its purpose.
The so-called rice diet consists of rice, butter,
bread, water and salt. Absolutely nothing else is
allowed in the way of food or drink. This is to be
eaten three times a day at the regular meal time —
enough may be taken to satisfy the hunger. It
must be eaten very slowly, thoroughly masticated,
and at least one half-hour should be consumed at
each meal.
The rice is to be freshly prepared each time and
eaten while hot, not allowed to stand and become
cold and soggy. It must be eaten with a fork —
not a spoon. Butter is the only other article of
food to be eaten upon the rice and bread — no cream,
milk, or sugar is allowed. Salt may be used to
season to taste.
Ordinary white wheat bread, at least one day
old; freely spread with butter is the only other food
to be eaten with the rice. One or two ordinary slices
may be taken at each meal.
Water not too cold may be taken with the meals
in moderation — nothing else in the way of drink.
The water must not be drunk or taken into the
mouth during mastication, as it will interfere with
the action of the saliva upon the rice and bread. It
must be drunk while the mouth is empty. Between
meals water should be drunk very freely; the min-
eral and spring waters may be taken.
Butter must be used rather freely both upon the
rice and bread, at least one-fourth of a pound being
taken daily.
Preparation : Place two quarts of water in a ket-
tle or pot of twice or three times this capacity to
avoid boiling over, add one-fourth teaspoonful of
salt and allow to boil vigorously, sprinkle in slowly
five tablespoonfuls of white rice* previously rinsed
in cold water, this being the average amount for one
person — more or less may be used. Allow to boil
vigorously without stirring or covering the pot for
thirty minutes (by the clock), drain in a cullender
and set on the back of a hot stove for a few minutes
to dry — not too long as it will become hard and
tough. Serve on a hot plate, add a piece of butter
the size of a small hen's egg and mix with two
forks, lifting the rice from the bottom of the plate
each time until the butter is all melted, coating each
grain of rice. Salt to taste and eat at once with a
fork.
Patients taking the rice diet who are inclined to
constipation must see that daily evacuations of the
bowels are obtained. Morning aperients taken on
rising give the best results. Carlsbad salts (the
artificial being equally as good as the imported ) ,
one to two teaspoonfuls dissolved in a glass full of
hot water and drunk the first thing on rising in
the morning are excellent, especially in the robust
and fleshy. To vaoid the unpleasant effects experi-
enced by some, such as nausea, a good plan is to
rise on awaking in the morning, take the aperient
and return to bed for a short time.
By adhering strictly to the above details in the
preparation and consumption, the rice diet patients
will be impressed with its importance; they will not
tire of it ; proper digestion is insured and results
will be most gratifying to both physician and
patient.
207 West Fifty-sixth Street.
*Of late the brown or natural whole rice is being ad-
vocated by many physicians owing to the fact that the
vitamine is found in its outer covering or husk. It may
be used in the rice diet.
332
MEDICAL RECORD.
[Aug. 19, 1916
Medical Record.
A Weekly Journal of Medicine and Surgery.
THOMAS L. STEDMAN, A.M., M.D., Editor.
PUBLISHERS
WM. WOOD & CO., 51 FIFTH AVENUE.
See fourth page following reading matter for Rates of Subscription
and Information for Contributors and Subscribers.
New York, August 19, 1916.
THE STANDARDIZATION OF CLINICAL
METHODS.
It has long been the dream of all workers in clin-
ical pathology that some day there will exist a
standardization in the methods used in the clinical
laboratories so that reports, often couched in iden-
tical phraseology, might mean the same thing.
Many workers, especially those in charge of the
clinical laboratories of large hospitals, have ex-
pressed themselves vigorously toward the same end.
The subject is brought again to mind by the almost
simultaneous appearance of two small manuals of
laboratory methods.1 Both are good, but an exam-
ination of their content? will show certain differ-
ences that are far from being merely academic.
They are naturally restricted to the presentation of
the single method which has seemed best or most
convenient to the author and for the most part ara
free of discussion of the significance of findings.
The differences in the methods offered are often
trivial but sometimes vital, so that an adherent of
one book could hardly duplicate the results of an
adherent of the other unless the different substances
examined for were present in unmistakable quanti-
ties.
McJunkin, for instance, recommends the addition
of kieselguhr to the urine in order to clear it be-
fore testing for albumin, ignoring the fact that this
will absorb a certain amount of the albumin pres-
ent. He is also an enthusiastic user of the Mc-
Junkin polychrome stain, which is quite natural.
Hill advises that the blood-acid mixture in the use
of the Sahli hemoglobinometer be allowed to stand
one minute before diluting, while McJunkin does
not mention time at all, and both fail to speak of
the importance of the direction of the source of
light in the use of the Tallqvist scale. So it would
be possible to point out several places where the two
authors differ in quite essential details as to method.
If one were to go further and include in such a
comparative study others of the numerous manuals
on the market the result would be exceedingly con-
fusing to any except a trained clinical pathologist.
'"A Manual of Practical Laboratory Diagnosis." By
Lewis Webb Hill, M.D., Graduate Assistant. Children's
Hospital, Boston. W. M. Leonard, Boston. 1916.
"Hospital Laboratory Methods," for Students. Techni-
cians and Clinicians. By Frank A. .McJunkin. A.M.
M.D., Professor of Patholojry, Marquette University
School of Medicine, Milwaukee, Wis. Price $1.25 net
Philadelphia. P. Blakiston's Son & Co. 1916.
So much for the state of things as it exists at the
present time. The advantages of a manual of stand-
ard methods would be many and, for the most part,
obvious. Much of the laboratory work that is re-
ported from hospital wards is done by the interne
staff, which is composed of men who have had but
little training and who apply various methods in
what is only too often a casual fashion. A stand-
ardization of methods would at least introduce a
uniformity of technique and reporting vocabulary
and would help tremendously in enabling one to
compare the reports from different institutions. If
the reader is not convinced of the necessity of such
a manual let him offer a specimen of sediment from
a urine containing an increased number of leuco-
cytes to a number of internes and ask them whether
there is pus present. His conviction will be assured
if he asks them to examine it daily for several days.
The replies will vary to such an extent that it will
be difficult to believe that all the men were examin-
ing the same specimen. Such a manual would have,
of course, no place in the teaching at the medical
school except that such and such a method would
be noted as "the standard method" and the reasons
given therefore. Each professor would teach as he
saw fit and, in the hospitals also, special methods
would be introduced as necessary or desirable.
No single man is capable of devising such a man-
ual. It should be taken up by some national society
or by a congress of the hospital clinical pathologists.
It should include but one method for each test and
should describe the technique in minute detail so
that there could be no possibility of misunderstand-
ing it. It should also prescribe the terms in which
reports are to be worded. It should be as extensive
or as limited in its scope as the circumstances at
the time seemed to warrant, and above all it should
be subject to fairly frequent revision so as to in-
clude improvements and changes as they might oc-
cur. The resulting manual would in many ways
compare to the Pharmacopeia as an accepted stand-
ard, and the delegates should pledge themselves to
the observance of its directions, each in his own
institution. It would be a large job — there is no
doubt about that — and the first edition would be
long in preparing. Revisions would not demand so
much time and the work would be distinctly worth
while. That the accomplishment of this work would
demand a considerable self-sacrifice on the part of
the delegates as to both time and beliefs in favorite
methods should only stimulate them to increased
efforts to produce a creditable result. The Medical
Record hopes that the matter will be considered in
the near future by some influential society and
thereafter pushed through to a successful conclu-
sion.
CONTRIBUTIONS TO NEGRO PSYCHOLOGY.
We in America have here a psychological problem
peculiarly our own. It is a matter of grave respon-
sibility in whatever aspect it is presented to con-
sideration. The psychopathologist is awaking to
the importance of our negro population in his field
of interest whether in practice or in scientific in-
vestigation.
Psychopathology is only one side of psychology,
Aug. 19, 1916]
MEDICAL RECORD.
333
one mode of its application, and both stand in the
service of society. Therefore Ferguson's* recently
published report of his experimental study of the
negro must arouse a practical medical and sociologi-
cal interest because of the close relation and inter-
dependence between mental capacity and social and
individual health and efficiency. Ferguson summar-
izes the conclusions that have been drawn in the
past concerning the mental and cerebral conditions
of the American negro, some based on experimental
studies, others not. There is wide difference of
opinion in regard to the mental capacity of the negro
as compared with that of the white, taking into ac-
count variously the size of the head, its contour, and
the extent of convolution in the brain. Earlier
studies were not very accurate, and the conclusions
were untrustworthy. Later more accurate mental
tests were made. Experiments of this sort, the Eb-
binghaus completion test, the Columbia maze test,
and others, were utilized by Ferguson to determine
if possible the mental difference between the negro
and the white, as well as between the pure negro and
the mulatto.
The general results arrived at through experi-
ments carefully made seem to prove a somewhat
greater mental capacity in the white race and also
in the mixed race compared with the pure negro.
Valuable, however, as this study is, and the author
does not claim for it more than a beginning of in-
vestigation into this difficult subject, psychopath-
ology seeks a great deal more. The author of the
monograph touches upon the further psychic fac-
tors, and without a due consideration of them there
is the danger that always attaches to these static
psychological tests, that of forgetting the broader
psychic setting which keeps before us the inten-
sively and extensively human character of the
problem.
Some studies sent out from the Government Hos-
pital for the Insane in Washington present the same
racial differences from another point of view, and
suggest, besides the social value in understanding
the situation, the equally valuable contribution of
negro psychology to the understanding and control
of mental symptoms. This, of course, lays stress
upon the genetic attitude toward the question, and
that informs this valuable scientific study of Fer-
guson with fresh vitality. A genetic approach is es-
sentially an interpretative one. It throws an illumi-
nation upon the differences which must exist in the
physical cerebral capacity as well as the differences
in psychical development, the over-emphasis in the
American negro upon certain levels which we have
come to know as infantile, either racial or indi-
vidual. Moreover, interpreting them, it offers the
broader basis for educational adjustment which Fer-
guson suggests. It makes us also more patient with
this alien race. Dr. Evarts {Psychoanalytic Review,
Vol. I, pp. 389-394) reminds us not only of their re-
cent savage origin but of the unexampled position
into which they were thrust, suddenly dropped into
a civilization ages beyond them, to which, however,
they were compelled to adapt themselves, with even
*"The Psychology of the Negro," by George Oscar
Ferguson, Jr., Archives of Philosophy, No. 36, April,
L916.
the support of servile dependence early removed
from them. Their adjustments have not come about
by natural evolution. No wonder, then, that certain
psychological reactions seem unaccountably in ad-
vance of cerebral development and that also an in-
fantile or primitive psychical nature is uppermost.
They have of necessity and with commendable suc-
cess adopted much from their environment. Geneti-
cally, however, their development has not kept pace.
Then comes also the admixture of white blood and,
as Ferguson reports, the superiority of the partially
white to the pure negro, which testifies to the her-
editary development of brain capacity.
These two sides of the study, on the conscious and
on the unconscious level, we might say, manifest in
different ways the same attempt and partial success
toward the adaptation required of this race placed
in this anomalous situation. The latter study is es-
sentially pathological, but as such is no less valuable
in its contribution to an appreciation of the situa-
tion and most effective means in the accomplish-
ment of this peculiar problem of adjustment. These
psychoanalytic studies reveal the failure in adjust-
ments and the compensations adopted, but as such
they throw much light upon the fundamental ele-
ments of just such failure and mode of compensa-
tion in the psychoses and psychoneuroses of white
patients of a higher grade of culture, but who, we
must remember, are products of the same origins
and whose unconscious inheritance therefore differs
only in its greater accumulation and in the greater
remoteness of the primitive elements.
THE APERIOSTEAL STUMP AND ITS CARE.
Under this title H. H. M. Lyle (Annals of Surgery,
June, 1916) makes some very interesting and prac-
tical suggestions. To obtain a useful stump three
cardinal points must be observed: (1) Correct treat-
ment of the bone; (2) correct treatment of the soft
parts; and (3) prevention of stump atrophy. All
amputations of the lower extremity should yield
stumps capable of directly supporting the whole
weight of the body. There are four methods of
treating the bone: the osteoplastic, tendinoplastic,
periosteal, and aperiosteal. Lyle says that the
osteoplastic is the ideal method but requires ideal
conditions; the tendinoplastic is of limited useful-
ness; the periosteal, although employed by the ma-
jority of surgeons in this country, is inferior to the
other methods and should be abandoned ; while the
aperiosteal, in the advent of complications in heal-
ing, is the only one likely to furnish a useful end-
bearing stump. He considers it the simplest, most
universally applicable, and most practical.
After directing attention to the fact that when
one examines standard artificial limbs for thigh am-
putations one will see that the stump socket is de-
signed to avoid direct pressure on the end of the
stump and to transfer as much weight as possible
to the pelvic girdle, Lyle refers to a paper read at
the meeting of the American Medical Association
two years ago in which he called attention to the
notoriously bad results obtained in amputation
through the shaft of the femur and strongly advo-
cated the employment of the aperiosteal method
334
MEDICAL RECORD.
[Aug. 19, 1916
where the osteoplastic could not be used. In a series
of 47 femur cases from all parts of the country
which he had occasion to examine he found but two
true end-bearing stumps. In the majority of these
cases he felt that the fault did not lie with the
technique of the operator, but with the method of
bone treatment and the after-care of the stump. The
aperiosteal method aims to produce a painless sup-
porting stump capable of early functional use. The
technique of the bone section is as follows: Bone
and periosteum are divided together, then a small
cuff of periosteum 0.5 cm. in depth is removed and
the marrow cavity is spooned out for a like distance.
The cuff should not be dissected up as a preliminary
step to bone section. In the removal of the cuff of
periosteum no periosteal shreds should be allowed
to remain; for such shreds, retaining their primi-
tive osteogenetic function, are capable of producing
painful bony spicules which would interfere with
the early functional use of the stump. More than
1 cm. of periosteum and marrow should never be
removed because of the possibility of resulting bone
necrosis.
In spite of correct technique in the amputation
itself the stump may become atrophied and useless
if not quickly used as a real support. Lyle spe-
cifically states that this is the special feature of the
aperiosteal method that he wishes to emphasize.
His plan of after-treatment is as follows: "The pa-
tient is put to bed with the leg elevated. As soon
as the wound is healed begin Hirsch's medico-
mechanical treatment. Massage the stump twice
daily, and after each treatment rub in a 2 per cent,
solution of salicylic acid in olive oil. At night
bathe in a warm sodium carbonate solution. Pro-
tect the stump with lamb's wool. Place a box at
the foot of the bed and have the patient press the
stump against it for from five to ten minutes three
times p day, then four times a day, and finally every
hour.
After each treatment energetically flex and extend
the hip and knee. Now begin standing exercises.
Rest the stump on a bran-bag or a cane-seated chair,
at first placing the weight evenly on both legs ; later
place all the weight on the stump. At the end of
two weeks the patient should be able to wear a peg-
leg, later a permanent prosthetic appliance which
directly receives the weight through the end of the
stump."
Lyle believes that no surgeon should under-
take an amputation by the aperiosteal or any
other method unless he is willing to carry out the
after-treatment which aims to provide a painless
end-bearing stump. He also believes that an early
functional use of the stump is the best method of
preventing atrophy, although this is in direct oppo-
sition to the usually accepted teachings.
It" Lyle's conclusions are generally approved by
those who have had a similar opportunity to study
conditions here and at the base hospitals abroad, it
will mean a revolution in the technique of amputa-
tions of the lower extremity and in the manufac-
ture of prosthetic apparatus designed to receive
stumps formed in accordance with the principles
which he has laid down.
RADIUM IN THE TREATMENT OF EXOPH-
THALMIC GOITER.
Among the ever increasing number of morbid
states in which radium is used externally or inter-
nally with more or less success, exophthalmic goiter
deserves mention. Dr. W. B. Aikins of Toronto
chose this as the subject of his presidential address
at the meeting of the Ontario Medical Association,
June 2, 1916, in which he pointed out that clinical
experience showed that many cases did not re-
spond satisfactorily to other methods of treatment,
and that in many of these refractory cases he had
found the employment of radium to be of decided
benefit.
Abbe of New York was the first to use radium
successfully in the treatment of exophthalmic goi-
ter, and his favorable experience with this remedy
had been repeatedly confirmed by other writers. The
experiments of Victor Horsley and Finzi showed
that the most constant changes after the application
of radium affected the blood and lymph vessels.
Aikins' own clinical experience showed that when
applied over the thyroid the more penetrating ra-
dium rays diminished the vascularity and reduced
the secretion of the gland.
Dawson Turner, who has had very favorable re-
sults, thinks that radium has two definite advan-
tages as compared with the a"-rays, namely, (1)
The possibility of giving definite doses; (2) The
fact that it can be applied without noise or excite-
ment while the patient remains quietly in bed. Aikins
reports at some length a number of cases of
exophthalmic goiter in the treatment of which he
had employed radium with excellent results.
The concluding portion of Aikins* presidential ad-
dress is devoted to a brief consideration of the psy-
chological aspect of the condition, and its signifi-
cance in relation to treatment. But while he allows
that in relief of those nervous symptoms, which
form a prominent feature of exophthalmic goiter,
psychotherapy plays an important role, he is of the
opinion that physicians who have not had much ex-
perience of neurotic and neurasthenic people, and
consequently do not understand them and have no
sympathy with them, should refrain from under-
taking medical treatment of this kind in which the
psychic element is such an important feature.
ALCOHOLISM IN SWITZERLAND.
Switzerland, so far as we know, has never acquired
the reputation of an alcohol-ridden land. We do
not hear much about Swiss pauperism, crime, and
insanity, nor of Swiss plans for fighting the drink
evil. Nevertheless, at a meeting of the Zurich
Medical Society last spring (C<>r>expondenz-Blatt
;iir Schweizer Aerzte, June 24) Dr. Meyer frankly
asserted that Switzerland does not really deserve its
good reputation as a moderation country. There
is at present an alcohol monopoly in Switzerland
which it is proposed to extend to the activities of
household stills which have hitherto been exempt.
A beer tax is also regarded as a future certainty.
so that the consumption of spirits is not only bound
to increase, but the government will evidently profit
Aug. 19, 1916]
MEDICAL RECORD.
335
in a twofold manner by such increase. Meyer does
not state how the domestic output is to be incor-
porated into the State monopoly.
In this connection certain facts are of interest.
In all the Swiss towns there are numerous little
"joints" which depend entirely for their existence
on the amount of spirits which they can sell before
the men go to work in the morning. These places
open at an early hour, and the quantity of spirits
sold during this period is said to be immense. In
rural districts brandy is served at table and is
drunk not only by the women, but, so the author
states, by the children as well. The peasant sells
some of his home-made brandy, but reserves much
for home consumption. The amount of alcohol sold
by the State represents an expenditure per capita
per annum of six francs, or about twenty-four
francs per adult man. It is estimated that, if the
home-made brandy consumption is included, this
rate will be about doubled, or nearly fifty francs
worth of alcohol for each grown man. The physi-
cian often sees cases of alcohol abuse and the best
way of reaching the evil seems to be to restrict
the home production in the interest of public health.
It is certainly significant that while the great fight-
ing countries are striving to cut down the manufac-
ture and consumption of alcoholics, an isolated neu-
tral country shows no disposition to follow this lead
and even leans in the opposite direction.
Antityphus Sanitation in Mexico.
For those who know the condition of anarchy that
prevails in many parts of Mexico, though naturally
much less in evidence in the capital city, it will
come as a mild surprise to learn of the systematic
and scientific efforts being made for the control of
the form of typhus which prevails in that country.
From the Boletin del Consejo Superior de Salu-
bridad for March we learn that there is a special
service for combating typhus in Mexico City and
outside municipalities in which the disease occurs
in endemic form. The medical inspectors pay
visits to all public places in the municipalities — pris-
ons, churches, shops, theaters, etc. — in addition to
domiciliary visits undertaken principally to pro-
nounce upon their sanitary condition. Typhus vic-
tims are interned and their premises fumigated.
When the infection shows no falling off, as in cer-
tain quarters inhabited by the very poor, a second
visitation is made. During the month many ob-
jects, chiefly pieces of bedding, were destroyed by
fire — in the words of the report there was a total
of 3,547 incinerations. Special efforts were di-
rected to make the street cars safe for travelers,
over 15,000 notably dirty people being turned back
from the ears during the month. The number of
theaters visited was forty-six, of which all but six
were pronounced clean. Of the whole number
thirty-eight had been disinfected. The number of
dirty patrons turned back was 4,111. Overcrowding
was prevented by discontinuing the sale of tickets.
The number of churches visited was eighty-two, and
it was necessary to turn back 773 filthy subjects,
1,022 who had brought food with them, 141 sick peo-
ple, and 154 beggars. Barbers apply parasiticides
after hair cuts and shaves. Over 800 subjects were
freed from lice. Despite the vigor of the campaign
nearly 2,000 new cases of typhus appeared during
the statistical month.
A Murphy Button in a Strange Situation.
At a meeting of the Societe des Chirurgiens de
Paris, Le Bee {Revue de Chirurgie, February,
1916) showed a soldier who had a scrotal tumor
with fistula. This tumor proved to be a Murphy
button. The patient had no hernia and the inguinal
rings were normal. Le Bee's explanation of the
matter is that some surgeon had done a castration
and for cosmetic reasons had wished to put some-
thing in the scrotum to take the place of the ablated
testicle; and that he had taken for this purpose the
first thing that came to hand. However, the button,
often invaluable in its proper field, was intended by
its originator to cut its way out and it had begun
to run true to form in this instance.
Sferoa of tbr Week
Poliomyelitis Epidemic Continues. — The total
number of poliomyelitis cases in this city to August
17 was 6,658 and the total number of deaths 1,497.
In the remainder of the State, up to the same date,
957 cases had occurred. The prevalence of the
disease in the city as compared to other years is
shown by the following figures prepared by the
Health Department: In 1913, 310 cases; in 1914,
129 cases; in 1915, 92 cases; in 1916, up to August
5, 4,856 cases, and to August 12, 6,140 cases. In
New Jersey also the disease continued to spread
during the week, the total number of cases reported
to August 12 being 1,461. In Pennsylvania 296
cases had been reported to the same date, 161 of
them in Phialdelphia. The question of opening the
New York City public schools on September 11 was
discussed at a conference with the Health Commis-
sioner recently, and as a result the Board of Edu-
cation passed a resolution authorizing the president
of the board to act upon any recommendation made
by the Health Department. President Wilson re-
cently signed an act appropriating $85,000 for use
of the Public Health Service in preventing the
spread of this disease, and $50,000 in addition to
provide for the appointment of more assistant sur-
geons.
Clinics for Poliomyelitis. — Because of the suc-
cess of the special poliomyelitis lecture clinics con-
ducted recently under the auspices of the Depart-
ment of Health and in response to numerous re-
quests that they be repeated, a new course of clinics
has been arranged through the cooperation of the
attending physicians at the various hospitals where
these cases are treated. Attendance at the clinics
will be strictly limited, and physicians desiring to
attend should apply in advance to the respective
hospitals for cards of admission. Groups will be
formed in the order of application. When the group
is complete the applicant will be referred to the
clinic held in the following week. Clinics will be
held at Bellevue Hospital, Pavilion 32, every Mon-
day at 4 P. M.; at Lebanon Hospital, every Tuesday
at three thirty; at Willard Parker Hospital every
Wednesday at four; at the Babies' Hospital every
Thursday at four; at Mt. Sinai Hospital every
Friday at four, and at the Kingston Avenue Hos-
pital every Friday at four. The clinics will con-
tinue for the next five or six weeks.
Health of the Canal Zone.— The chief health
officer of the Canal Zone reports that no cases of
yellow fever, smallpox, or plague originated on or
were brought to the isthmus during the month of
June, 1916. In fact, the last case of smallpox on
336
MEDICAL RECORD.
[Aug. 19, 1916
the isthmus occurred in a passenger from a steamer
arriving at Cristobal on February 3, 1915; the last
case of smallpox contracted on the isthmus was in
1907. The last case of yellow fever contracted on
the isthmus occurred in November, 1905, while the
last case of bubonic plague contracted there dates
back to August, 1905. During the month of June
the health of the employees at the canal remained
good, the total admissions to hospitals and quarters
being 756, a rate of 287.99, as compared with 285.45
for the preceding month, and 369.87 for the cor-
responding month of last year. The total number
of deaths from all causes among employees was 20,
of which 17 were due to disease, giving a death rate
of 6.48, which is higher than that for the same
month of 1915. There were no cases of typhoid
fever during the month. A census of the Canal
Zone completed shows a total population of 31,048,
including employees, non-employees, and military
garrisons, within the Zone limits. The population
of Panama City is now 60,778 and of Colon 24,693 ;
during the month of June the death rate in the
former was 30.01 and in the latter 24.30 per 1,000.
Army Medical Corps Examinations. — The Sur-
geon General of the United States Army announces
that preliminary examinations for appointment of
first lieutenants in the Army Medical Corps will be
held on September 5, 1916, at points to be here-
after designated. Full information concerning
these examinations can be procured upon applica-
tion to the "Surgeon General, United States Army,
Washington, D. C." The essential requirements
are that the applicant shall be a citizen of the
United States, between 22 and 32 years of age, a
graduate of a recognized medical school, and of
good moral character and habits, and shall have had
at least one year's hospital training as an interne,
after graduation. The examinations will be held
simultaneously throughout the country at points
where boards can be convened. Due consideration
will be given to localities from which applications
are received, in order to lessen traveling expenses
as much as possible. In order to perfect all neces-
sary arrangements for the examinations, applica-
tions should be forwarded at once to the Adjutant
General of the Army. There are at present over
two hundred vacancies in the Medical Corps of the
Army.
Extra Milk Depots. — In response to the appeal
of mothers in the Williamsburg and Brownsville
districts of New York, Nathan Straus has prom-
ised to continue the maintenance of the emergency
milk depots which were established in these dis-
tricts early in the summer. The original purpose
was to supply milk for the children of the locked-
out garment workers, and this necessity having
largely passed the closing of the depots was an-
nounced. The announcement, however, brought
forth such urgent requests for the continuance of
the charity that it was decided to keep the depots
open for the present, and if the demand warrants it
to make them permanent.
Exchanging Surgeons. — Drs. Hugo Zieschank
and Otto Glantz, two German army surgeons, sailed
from Xew York last week for Holland, en route for
Germany, having been sent from Australia to be ex-
changed for two British surgeons now prisoners in
Germany.
Death of Aged Indian.— Chief Givan-Ha-Dav
(Falling Snow), 104 years old, and said to have
been the oldest Iroquois Indian, died in a hospital
in Toledo, Ohio, on August 12. The chief had gone
to Toledo a few days before to take part in a play
given by the Boy Scouts, and succumbed to the in-
firmities of old age.
American Chemical Society. — A meeting of this
society will be held in New York, in conjunction
with the second national exposition of chemical
industries, on September 25 to 30, 1916. Sessions
will be held at Columbia University and at the Col-
lege of Physicians and Surgeons, New York, as well
as at the Grand Central Palace and at Rumford Hall
in the Chemists' Club Building. A detailed pro-
gram will be issued shortly by the secretary of the
society.
Personals. — Dr. Albert Warren Ferris, formerly
medical expert and director for the Commissions
for the Reservation of Saratoga Springs, has gone
into practice in that city. No physician is any
longer connected with the State control of the
springs and bath houses.
Dr. Charlton Wallace of New York announces
his removal to 11 East Forty-eighth Street.
Dr. Isham G. Harris, formerly medical superin-
tendent of the Mohansic State Hospital, Yorktown.
N. Y., has been appointed superintendent of the
Brooklyn State Hospital, succeeding Dr. Elbert
Somers, who resigned on August 1.
Gen. William C. Gorgas, U.S.A., head of the Yel-
low Fever Commission of the International Health
Board of the Rockefeller Foundation, arrived at
Bogata, Colombia, from Panama, on August 9. Gen-
eral Gorgas will consult with the Colombian gov-
ernment on sanitary conditions of ports in that
country.
Glanders Diminishing. — The Department of
Health of New York City reports that the success
of the administrative measures for the control of
glanders among horses during the past year is
shown by the decrease in the number of cases ob-
served. These measures embrace the sanitary con-
trol of all stables in the city, the closing of public
horse troughs, the making of specific tests on all
horses exposed to infection and the destruction of
all animals reacting, the supervision of horse-shoe-
ing establishments, and the distribution of circu-
lars containing information on the disease, among
horse owners, stable keepers, etc. During the first
quarter of 1914, 229 cases of glanders were re-
ported, of 1915, 232 cases, and of 1916, 127 cases;
during the second quarter of 1914, 313 cases, of
1915, 161 cases, and of 1916, 82 cases; during the
third quarter of 1914, 227 cases, and of 1915, 145
cases; and during the last quarter of 1914, 384
cases, and of 1915, 166 cases. It will be noted that
the reduction has been steadily progressive.
Obituary Notes. — Dr. Edwin Bassett Tefft of
New Rochelle, N. Y., a graduate of the University
of Buffalo, medical department, in 1864, a mem-
ber of the American Medical Association, the Med-
ical Society of the State of New York, the West-
chester County .Medical Society, and the New
Rochelle Medical Society, and consulting physician
to the New Rochelle Hospital, died at his home,
after a long illness, on August 6, aged 72 years.
Dr. George S. Crawford of Clifty, Ind., a grad-
uate of the Medical College of Indiana, Indianapo-
lis, in 1874, and a member of the Indiana State
Medical Association and the Decatur County Medi-
cal Society, died at his home on July 26, after a
long illness.
Dr. Michael Kelly of Fall River, Mass., a grad-
uate of Bellevue Hospital Medical College, New
York, in 1885, and a member of the Massachusetts
Aug. 19, 1916]
MEDICAL RECORD.
337
Medical Society and the Medical Society of Bristol
County, died at his home, after a long illness, on
July 28, aged 61 years.
Dr. James Hudson Wheeler of Pittsfield, Mass.,
a graduate of the Detroit Homeopathic Medical Col-
lege, Detroit, Mich., in 1873, died, after a long ill-
ness, on July 25, aged 69 years.
Dr. Joshua S. Wood of Irvinton, Ga., a graduate
of the Atlanta Medical College, Atlanta, Ga., in
1877, died at his home, after a long illness, on July
20, aged 72 years.
Dr. Andrew P. Wilson of Los Angeles, Cal., a
graduate of the University of Southern California,
College of Medicine, Los Angeles, in 1902, and a
member of the American Medical Association, the
Medical Society of the State of California and the
Los Angeles County Medical Society, died suddenly
on July 20, aged 50 years.
Dr. William F. Fairbanks of Kansas City, Kan.,
a graduate of the Western Reserve University,
School of Medicine, Cleveland, in 1886, and a mem-
ber of the Kansas Medical Society and the Wyan-
dotte County Medical Society, died at his home on
July 22, aged 56 years.
Dr. Louis Hornby Fraser of Presque Isle, Me.,
a graduate of the College of Physicians and Sur-
geons, Boston, in 1910, and a member of the Maine
Medical Association and the Aroostook County Med-
ical Society, died suddenly on July 23, aged 43
years.
Dr. Alvah C. Lewis of Salt Lake City, Utah, a
graduate of Columbia University, College of Physi-
cians and Surgeons, New York, in 1877, and a mem-
ber of the Utah State Medical Association and the
Salt Lake County Medical Society, died in San
Diego, Cal., on July 12.
(Obituary.
JOHN BENJAMIN MURPHY, M.Sc, M.D., LL.D.
CHICAGO.
Dr. John B. Murphy of Chicago, professor of the
principles and practice of surgery in Northwestern
University, died suddenly, from heart disease, at
his summer home on Mackinac Island, Mich., on
August 11. Dr. Murphy had been in poor health
as a result of overwork during the winter, but was
not thought to be dangerously ill; his condition was
considered to be partly the result of his having been
poisoned at the banquet given to Archbishop
Mundelein at the University Club, Chicago, last
winter.
Dr. Murphy was born in Appleton, Wis., on De-
cember 21, 1857, and was educated in the public
grammar and high schools, afterward entering Rush
Medicai College, Chicago, from which he was grad-
uated in 1879. After three years of general practice
he went to Germany for study, and on his return he
entered the field of clinical surgery in which he
achieved great distinction, and to which he had
contributed largely. In 1902 he was awarded the
Laetare medal by Notre Dame University, a medal
given each year to a Catholic layman who has done
conspicuous service to humanity, science, art, or
religion, and his work was recognized also by the
University of Illinois which bestowed the degree of
LL.D. on him in 1905, by the Catholic University of
America, which gave him the same degree in 1915,
and by the University of Sheffield, England, which
in 1908 honored him with the degree of M.Sc. In
addition to his work in the Northwestern University
Medical School, Dr. Murphy was professor of clin-
ical surgery in the Chicago Postgraduate Medical
School, advisory surgeon of the Cook County Hos-
pital and the Alexian Brothers' Hospital, chief sur-
geon at Mercy Hospital, and attending surgeon at
the West Side Hospital. He was a member of the
American Medical Association, of which he was
president in 1911, the Illinois State Medical So-
ciety, the Cook County Medical Society, the Ameri-
can Association of Obstetricians and Gynecologists,
the American Surgical Association, the Southern
Surgical and Gynecological Association, the Western
Surgical Association, the Chicago Orthopedic So-
ciety, the Chicago Surgical Society, the American
College of Surgeons, and the Mississippi Valley
Medical Association, an honorary member of the
Royal College of Surgeons of England, and a life
member of the Deutsche Gesellschaft fur Chirurgie,
and of the Societe de Chirurgie of Paris.
Dr. Murphy, besides being gifted with an excep-
tional technical skill, was a man of striking original-
ity, and he enriched medicine with many useful in-
ventions; two of the most noted of these were the
well-known "button" for intestinal anastomosis, and
artificial pneumothorax, by the injection of nitrogen
into the pleural cavity, for the compression and
"splinting" of the tuberculous lung.
A SUGGESTION IN THE PREVENTION OF
INFANTILE PARALYSIS.
To the Editor of the Medical Record:
Sir: — It seems well proven that infantile paralysis
is an infectious and communicable disease, due to a
specific virus which exists constantly in the central
nervous organs and upon the mucous membrane
of the nose, throat, and intestines in persons suffer-
ing from it. The virus enters the body by way of
the nose and throat and is known to leave it in the
secretions of these organs, and is distributed by
sneezing and coughing and by articles contaminated
with these secretions. In the interior of the body
it is probably destroyed in a few days but persists
in the mucous membrane of the nose and throat
several weeks; it disappears from the nose and
throat in humans, in most cases in four weeks,
though it has been known to persist for a number
of months. The virus has been found in the nasal
secretions of healthy persons, who come in contact
with the sick — therefore both the healthy carrier
and the chronic carrier have to be reckoned with.
The fact that the virus has never been demon-
strated in the blood of the sick discredits the idea
that it can be spread by blood-sucking or biting in-
sects. A period of six weeks is considered right
for the length of quarantine. In the light of the
brilliant work lately done on this disease by many
eminent men, it is conspicuous that if the nasal
secretions can be kept free from contamination with
the harmful virus, then the spread will stop. This
virus must contain an organism specific to the dis-
ease, though never yet definitely brought to light.
Isolating the cases early and care with the hands
and secretions, together with quarantine sufficiently
long, are our best weapons of defense. This is being
done, but there will continue to be cases that escape
notice. One may ask, can we render the mucous
membrane resistant by the use of an antiseptic in
the nose and throat that will destroy the virus
or so lower its virulence that it cannot take hold?
338
MEDICAL RECORD.
[Aug. 19, 1916
An antiseptic possessing the power to destroy the
virus and in no way injurious to the Schneiderian
membrane should be given a trial. The one that
seems most to possess this bactericidal power, and
at the same time is nonirritating to the nasal mu-
cous membrane, is a solution of colloidal silver. It
clears the nasal mucosa of the persistent influenza
bacillus better than anything I ever used. If every
mother in infected districts would put into each
nostril of her children twice a day one medicine
dropper full of 10 per cent, colloidal silver solution
for a period of six weeks, no harm would come
from it but to the children's clothes — and who knows
what good. The results might be brilliant, and this
is here offered as a suggestion probably worthy of
trial. John W. Winston, M.D.
Thiktv-thikd Street and Colonial Avenue,
Norfolk, Va.
A PREVENTIVE AND CURE FOR POLIOMYE-
LITIS.
To the Editor of the Medical Record:
Sir: — Last year I immunized a monkey with
milk of magnesia (MgO,H,) against poliomyelitis
by injecting the following into the peritoneal cav-
ity and spine: Milk of magnesia 0.5 c.c, secretions
from nose and throat 0.5 c.c, add sterilized distilled
water 5 c.c; this thins it enough to pass needle.
Waiting ten or fifteen days after inoculation, no
symptoms developed. The secretions from the nose
and throat in poliomyelitis are acid. The blood and
spinal fluid are subalkaline. The point of entrance
lies in the nose and throat and the virus thence
passes to the intestine. Now MgO.H, increases
alkalinity and when the virus comes in contact with
it decomposition or neutralization is the result. As
a preventive I have given milk of magnesia to over
150 children since July 3 living in infected districts
and not one has contracted the disease. As the
virus enters the nose and throat passing to the in-
testine, it can readily be seen how efficacious
MgO,H, is. Milk of magnesia is slowly soluble
and mixes thoroughly with the virus, besides re-
maining in the mouth and intestine much longer
than some more soluble hydroxide. Dosage: Chil-
dren, 1 to 2 years, 15 to 20 drops; 3 to 4 years, V2
teaspoonful; 5 to 7 years, 1 teaspoonful; children
older than 7 years, 1 to 2 teaspoonfuls, in water
every four hours.
As a cure I would suggest a serum published by
me in the International Clinics, Vol. IV, 24th Series,
under "Treatment of Lobar Pneumonia." This
scrum can be used for any infectious disease. It
produces active immunization by inducing leuco-
cytosis and increasing the antibodies or defensive
enzymes. It is prepared as follows: Dried horse
serum from 500 c.c. of fluid serum; sodium car-
bonate (anhydrous), 1.62 grams; sterilized dis-
tilled water, 500 c.c. Dissolve the dried horse
serum in water, then add the anhydrous Xu.CO,.
Dose: 30 c.c. to 100 c.c. introduced into the general
circulation, either intravenously or hypodermically.
This dosage for adults. Children in proportion to
weight. Intraspinally 5 c.c. to 15 c.c, first with-
drawing this quantity or a larger amount of spinal
fluid. Often mi:- dose cures a case of poliomyelitis.
Leucocytosis and immunity take place and the
subalkalinity is overcome. When the spinal fluid is
normally alkaline the enzymes there are activated.
The horse serum and Xa Co bring about this result.
Chas. F. d'Artois-Francis. M.D.
951 St M irks .v. enue,
"kl.Y.V N. V.
OUR LONDON LETTER.
(From Our Regular Correspondent.)
NERVE INJURIES IN WAR — NERVE SHOCK — FUNC-
TIONAL PARALYSIS — MODERN TESTING TORN
NERVES HARVEIAN SOCIETY'S CLINICAL MEET-
ING.
London, July 22, 1916.
Major C. F. Bailey, R. A. M. C, has contributed
a paper on Nerve Injuries in War Time to the
Brighton Medico-Chirurgical Society. He opened
with a warning against jumping at a conclusion,
and emphasized the importance of careful search
for sensory defects, particularly loss of epicritic
sensibility, and then mentioned the fallacies that
may arise and the difficulties experienced with for-
eigners, maligners, and patients of little intelli-
gence. He considered condenser-testing of great
value as superseding faradic and galvanic muscle-
testing. To obtain extreme accuracy he tested
doubtful muscles against normal ones on the oppo-
site side. He referred also to the difficulty experi-
enced in preventing the powerful currents necessary
to cause contraction of damaged muscles, from over-
flowing and so setting up contraction in the op-
ponents of the damaged ones, for that would be in-
jurious instead of beneficial. At the Eastern Gen-
eral Hospital cases which had been operated on
proved the accuracy of the diagnosis obtained by the
condensors. Accounts of various cases of injured
nerves v/ere given, including hypoglossal, spinal ac-
cessory, third and fourth cervical, posterior thoracic,
ulnar, median, musculo-spinal, sciatic, etc.
Major A. H. Buck, R. A. M. C, president, dis-
cussed cases of nerve-shock and asked whether in
those in which the nerve is constricted, but not di-
vided, paralysis is shown by complete reaction of
degeneration and further if the trunk of the nerve
is ruptured in its course does it recover function
without operation?
Captain Gervis referred to the extreme accuracy
of modern methods of testing and asked how the
difference in skin resistance is allowed for. Lieut.-
Col. Jowers asked abou the condition of nerves
supposed to be functionally paralyzed.
Dr. E. R. Hunt reported a case of local anes-
thesia immediately following extraction of a tooth
(lower molar), due, it may be presumed, to injury
of the mental branch of the inferior dental nerve.
Major Bailey ( replying) said cicatricial constric-
tion might produce complete reaction of degenera-
tion. If this were complete, or even of high degree,
it indicated exploration; if the nerve was found to
be torn across, the ends might be so close that re-
covery was possible, though not probable and so was
a negligible consideration. The difference of skin
resistance was met by interposing such a large con-
stant resistance that the variation in the skin could
be neglected.
At the Harveian Society's clinical meeting the
following cases were shown: (1) Septic papilloma-
tosis of lower extremity, producing great over-
overgrowth; (2) soft sore which had lasted thir-
teen years and led to extraordinarily extensive scar-
ring; (3) intrathoracic tumor in a young woman,
x-rays revealed a shadow behind the upper part of
the sternum and the microscopical examination sup-
ported the view that it was lymphadenomatous; (4)
multiple osteomata developing in an adult (male) ;
(5) a man who had been operated on for tempero-
sphenoidal abscess; (6) a patient with stone in
ureter; an ar-ray was shown with an opaque bougie
Aug. 19, 1916]
MEDICAL RECORD.
339
in the ureter alongside the stone; (7) woman with
enlarged liver (jaundiced) ; (8) photograph of pa-
tient who survived three days after an electrical
burn caused by a current of 11,000 volts which had
destroyed three of this patient's limbs.
Mr. J. E. R. McDonagh, in his Hunterian Lec-
tures (R. C. S.), mentioned some points as to the
use of intramine and ventured to prophesy that this
drug is going to play a very important part in the
treatment of syphilis, and not only so, but in all
chronic infections, since it has already been shown
to be of considerable value in tuberculosis and in
chronic gonorrhea. He even thinks it probable that
it may find a place in the treatment of malignant
disease.
'ffrogrraa of iJfadtral &rienre.
Boston Medical and Surgical Journal.
August 3, 1916.
1. Results Obtained in the Treatment of Diabetes Mellitus.
May 1, 1915 — May 1, 1916. Elliott P. Joslin.
2. Definition and Detection of Acidosis in Diabetes Melli-
tus. Albert A. Hornor.
3. Observations on the Blood Sugar in Diabetes Mellitus.
Orville F. Rogers, Jr.
4. Tests of Renal Function from the Standpoint of the
General Practitioner. Francis W. Peabody.
5. Eye Changes in Renal Diseases — Their Diagnostic and
Prognostic Value. Peter Hunter Thompson.
6. The Physiological Point of View and Autopsies. Francis
J. McCrudden.
1. Results Obtained in the Treatment of Diabetes
Mellitus. — Elliott P. Joslin refers to two former commu-
nications on this subject in which there was a note of
hopefulness unusual in an article on diabetes and pre-
sents the present communication because it seems to
show that these new hopes and explanations of avoid-
able causes of death were justified. Speaking roughly,
he says that the average duration of life of 408 of his
fatal cases has been five years, and that of 490 of his
living cases has already reached six years. During
the year ending May 1, 1915, 211 cases of diabetes came
under his observation and of this number 15 per cent,
died; during the subsequent year 314 cases were seen and
11.7 per cent, of these have died. A conservative esti-
mate would place the decrease in mortality over the
previous year at 20 per cent. These figures become
still more encouraging when the writer adds the study
of thirty-seven fatal cases seen this last year which
show that death might have been deferred in about
one-half of these if the methods of treatment now in
general use had been adopted. A comparison is also
made of the duration of fatal cases of diabetes in
Massachusetts for 1915, compared with the author's
total fatal cases. This shows that the greatest dif-
ference in mortality between the statistics of the State
and those of the writer lies in the early decades of life.
A further startling difference lies in the number of
cases in each group who succumbed during the first
year to the disease. In the writer's series of 490 cases
of diabetes, 94 per cent, have already passed the first
year of the disease, the danger zone of the diabetic. In
a study of the causes of death in 408 cases of the
author's series it was found that two out of every
three died of coma, that 87 per cent, of all those who
succumbed during the first year of the disease died of
coma, and that this was the case in 100 per cent, of
fatal cases in children. Therefore, if the mortality of
diabetes is to be reduced, our energies should be di-
rected first toward the avoidance of coma, because the
treatment of coma is so unsatisfactory; and, second,
particular attention should be exercised in the man-
agement of cases of diabetes in the first year following
the detection of the disease. Furthermore, all cases
should be persistently followed up, and the good effects
of treatment should not be allowed to lapse by indif-
ference or neglect.
2. Definition and Detection of Acidosis in Diabetes
Mellitus. — Albert A. Hornor observes that it is easy to
note the drowsiness, exaggerated respiration, and dry
skin, so characteristic of the diabetic about to die in
coma. So seldom does the patient recover and so
temporary are the few recoveries recorded that it is
manifestly necessary for us to recognize precomatose
conditions if we would save the diabetic patient. The
author discusses the demonstrable differences between
the metabolism of a comatose diabetic and the meta-
bolism of a healthy individual, and says in conclusion
tht the acidosis of diabetes mellitus, aside from its
clinical picture of exaggerated respiration, drowsiness,
and rapid pulse, may be defined as a condition in which
the carbon dioxide tension in the blood, and conse-
quently, in the alveolar air is reduced; the acetone
bodies in the urine and blood are increased and asso-
ciated with this is a rise in the excretion of ammonia;
glycosuria is marked, and, saving exceptional cases,
toward the end of prolonged coma, the carbohydrate
balance is markedly negative. All these factors are
important in determining the degree of acidosis, and,
where time and facilities permit, should be ascertained.
The detection of glycosuria, the demonstration of a
positive ferric chloride reaction, and the determination
of a diminution in the alveolar carbon dioxide tension,
are the procedures suitable for beside use. The carbo-
hydrate balance is also a valuable indication and one
surely to be determined, but, unfortunately, it must
always furnish information, in part, at least, a day
late.
3. Observations on the Blood Sugar in Diabetes Mel-
litus.— Orville F. Rogers, Jr., aims to present some con-
clusions as to the value or necessity of determining the
blood sugar in treating diabetics, either from a prog-
nostic or a therapeutic standpoint. He states that dia-
betics have a higher blood sugar when they are excreting
sugar in the urine than they do when the urine is
rendered sugar-free. The threshold of sugar excretion
varies in different diabetics and apparently in the same
individual at different times. Sometimes the blood
sugar returns to normal under treatment, and this is
generally in the milder cases, though there are some
exceptions to the rule. A persistently elevated blood
sugar may be an indication of the greater severity of
the disease or it may occur in apparently mild cases,
but generally associated in the latter instances with
some renal impairment. By keeping the carbohydrate
intake well below the limit of tolerance, as shown by
the appearance of glycosuria, it has been found that
the blood sugar will almost, if not quite, sink to normal,
and their experience leads to the belief that efficient
treatment can be carried out in most instances, using
the urinary sugar alone as the therapeutic guide.
There are a certain number of severe cases with marked
acidosis or nephritis in which the true picture of the
condition is much illuminated by direct blood exami-
nation, both for sugar and alkali reserve.
6. The Physiological Point of View and Autopsies. —
Francis H. McCrudden states that at the Robert B.
Brigham Hospital they are demonstrating to physi-
cians, students, patients, and others, the usefulness of
the physiological point of view of the problem of treat-
ment in chronic disease, and it is evident that the
patients appreciate its usefulness. From the large pro-
portion of cases of death in which permission foe
autopsy is obtained, it has become evident that their
ideas are spreading to the relatives of the patients.
Since the hospital opened on April 1, 1916, complete
autopsies have been carried out in 70 per cent, of all
340
MEDICAL RECORD.
[Aug. 19, 1916
those dying. No other American hospital has attained
results that at all approach these. While many factors
may have contributed to this unusually high percentage
of autopsies, in the last analysis success depends upon
the degree to which the relatives can be made to ap-
preciate what has been done to help the deceased and
the extent to which they can be made to understand
that in giving permission for a post mortem examina-
tion they may be contributing something toward help-
ing other patients. The figures presented bring out
another point, namely, that the emphasis laid on the
physiological point of view need not lead to any neglect
of pathological anatomy, since in this hospital the
direct result has been an increase in the possibilities
for pathological-anatomical studies.
New York Medical Journal.
August :., 1916.
Dexter D.
1. Shoes. Physiological and Therapeutic.
Ashley.
2. Herpes Corneae "Febrilis." Samuel Theobald.
3. The Management of the Complications of Pregnancy.
John A. McGlinn.
4. Syphilis and Tuberculosis in the Same Lung. Robert A.
Keilty.
5. Removal of an Interstitial Fibromyoma. John A.
Sheehey.
6. The Nephritic Toxemia of Pregnancy. Arnold H. May.
7. The Pathogenesis of Psoriasis. Abner H. Cook.
8. Medical Women (Conclusion). Mary Sutton Macy.
9. Some Orthopedic Principles in Pediatric Practice. Samuel
W. Boorstein.
10. Some Eye Symptoms of Diagnostic Value. John L.
Decker.
1. Shoes, Physiological and Therapeutic. — Dexter D.
Ashley emphasizes the fact that we should not try to
combine all the qualities in a single shoe to meet all
conditions, occupations, and positions in life. He says
that in prescribing shoes the doctor's path will be
smoother if he can modify the shoes commonly worn
by the patient or, if these are impossible, direct him to
select a fairly good trade shoe to be modified. Seldom
is the custom shoe perfect or exactly as designed, and
the patient will expect much more from a "made-to-
order" shoe in the way of immediate relief of symptoms.
Comparing the outline of the foot with the shoe of
civilized man, ordinary shoes would appear as a mon-
strosity to us were it not that long association with
these forms has dulled our perceptions. The physiolog-
ical shoe for approximately normal strong feet should
conform to the foot outline without undue restraint.
The sole should be strong, elastic, straight to the floor
line, with sufficient curve to prevent stubbing. It
should be broad enough to carry the vamp, and may
have a pointed or rounded toe. The center of the sole
should correspond with the center of the foot. The
welt should be wide enough to protect the vamp. The
insole should be of flexible leather, and should be flat
or very slightly convex in the anterior part behind the
anterior metatarsal arch. The shank should be rather
narrow, yielding, and elastic, tending to the outer side.
The heel should be as wide as the individual's heel in a
snug counter and % to 1 inch high for adults. It should
be built straight down from the rand and set well
forward, centering under the os calcis. Since most of
us have become accustomed to unnatural positions of
the feet, to place them at once in an approximately
physiological position would arouse pain and discom-
fort by bringing into action unused muscles, ligaments,
and weight-bearing facets. The writer points out in
detail the defects of ordinary shoes. ai.d shows skia-
graphs of feet taken through the shoes which illustrate
the mechanical disadvantages of faulty construction.
2. Herpes Cornea "Febrilis.'- — Samuel Theobald
writes with special reference to the etiology of this
condition. He thinks that the qualifying term "febrilis"
is not well chosen; for though herpes labialis and, per-
haps more general, facial herpes not infrequently occur
as an accompaniment of "colds," attended by fever, this
is, according to his observation, not true of corneal
herpes. He says further that the severe pain which
some describe is not, in his experience, a usual symptom
of this condition. He feels that the primary lesion
which gives rise to simple herpetic keratitis, and which
explains the corneal hyperesthesia, is situated in the
ciliary ganglion, and shows why he thinks this view
is tenable. In the treatment of herpetic keratitis the
local remedies which he has found most useful are
holocaine and atropine; frequently one, sometimes both,
of these are supplemented by instillations of dionin.
The rapid subsidence of the keratitis is seldom observed
and the patient should be prepared for a somewhat
tedious recovery.
3. Management of the Complications of Pregnancy.
— John A. McGlinn discusses a number of complications
of pregnancy with which he has had personal experi-
ence. In two instances in which pregnancy occurred in
a retrodisplaced uterus the uterus became incarcerated.
In both of these instances, it being impossible to replace
the uterus manually, the abdomen was opened and the
uterus freed from incarceration by internal manipula-
tion. One of these patients miscarried, the other was
delivered at term of a living child. In cases of this
kind the author is opposed to both abortion and the
rupture of the membranes unless laparotomy is posi-
tively contraindicated. He warns against attributing
a right-sided abdominal pain to appendicitis in every
case, since the infection of the right urinary tract is a
more frequent cause of this pain than appendicitis. In
discussing such complications as appendicitis, intestinal
obstruction, and fibroid tumors of the uterus, one point
which has impressed the writer is the frequency of
postoperative abortion. Finally he protests against the
tendency on the part of reputable physicians and sur-
geons to terminate early pregnancy because vomiting
is aggravated, and says that as a matter of fact very
few cases of toxenia of early pregrancy call for the
termination of gestation. The majority of such cases
are not toxic at all, and the condition is cured under
proper treatment.
6. The Nephritic Toxemia of Pregnancy. — Arnold H.
May points out that the growing uterus, variously
weighted, depending on the development of the child,
by pressing on the renal excretory apparatus, is a factor
in the etiology of the nephritic toxemia of pregnancy,
and advocates as a prophylactic measure in cases in
which there is a predisposition to this condition, and as
an adjuvant factor in the treatment where the disease
already exists, the use of a special bed. This bed con-
sists of a headpiece and a footpiece separated by an
area of about 2 feet, each part having a separate spring
and mattress. Between these parts the bed is open,
except for an adjustable sling made either of rubber or
cloth, preferably the former. The rubber sheet is suffi-
ciently long so that it can be depressed to various de-
grees to accommodate the abdomen. The patient as-
sumes the recumbent position with the face down. By
this means a great degree of comfort may be assured
the patient and pressure is withdrawn from the kidney.
7. The Pathogenesis of Psoriasis. — Abner H. Cook
reports ten cases in which the skin condition was un-
questionably psoriasis, all of whom were treated with
emetine hydrochloride, and three recoveries resulted;
these three patients had pyorrhea alveolaris with En-
dameba buccalis. One case of pyorrhea failed to re-
spond to the three courses of emetine, and there was no
improvement in his psoriasis. One patient had a semi-
nal vesiculitis, and after eradicating the disease with
autogenous vaccine and other appropriate measures the
psoriasis cleared up. Fistula in ano, discharging pus,
Aug. 19, 1916J
MEDICAL RECORD.
341
was found in one case; after operation the fistula healed
and a complete recovery from psoriasis resulted. The
removal of infected tonsils was followed by the dis-
appearance of the psoriasis in one case. Syphilis was
the only infection found in one case, and iodides and
mercury had no effect upon the psoriasis. Two pa-
tients having psoriasis but no other disease or infec-
tion were dismissed without relief. The cases of re-
covery from psoriasis, after the removal or cure of
other infections, strongly suggest that these infections
caused the disease. Further, on account of the char-
acter of the infections it is suggested that the organ-
isms most likely causing psoriasis were the staphylo-
cocci and streptococci.
8. Medical Women in History and Present-Day Prac-
tice.— Mary Sutton Macy concludes a serial article on
this subject, which she summarizes as follows: "What
have women accomplished in medicine since they be-
gan its practice?" (1) They have made a large pro-
portion of permanent contributions to medical science,
especially if we take into consideration the fact that
historically they have always been in a minority in the
profession; and (2) repeatedly crowded back and even
out of the profession by the aggressiveness and num-
bers of their medical brethren, they have as repeatedly
— and let us hope at last permanently — proved their
ability to compete on equal terms with a fair degree of
success and at least an average proportion of scientific
achievement of the first rank. They have done this in
spite of a most obstinate spirit of opposition on the part
of their medical brethren; in spite of the seemingly
insurmountable obstacles placed in their path by dogged
masculine determination. Their courage has been
dauntless, each attack more determined than those
preceding and actuated by the keenest sense of justice
and of fair play.
Journal of the American Medical Association.
August 5, 1916.
1. Adenomyoma of the Rectovaginal Septum. Thomas S.
Cullen.
2. Peter Parker, the Founder of Modern Medical Missions :
A Unique Collection of Paintings. C. J. Bartlett.
3. Thyroid Extract in the Treatment of Malignant Uveitis.
James Bordley, Jr.
4. Effects of Heat on the Eye. William E. Shahan.
5. Orthopedic Surgery in War Time. Robert B. Osgood.
6. A PI in of Treatment in Infantile Paralysis. Robert W.
Lovett.
7. Specific Treatment of Infantile Paralysis : Preliminary
Note. Abraham Sophian.
8. Focal Infection in Relation to Certain Dermatoses. M. L.
Ravitch.
9. The Diet of Children After Infancy. J. H. Mason Knox.
L. Adenomyoma of the Rectovaginal Septum. — Thom-
as S. Cullen. (See Medical Record, June 17.)
2. Peter Parker, the Founder of Modern Medical
Missions. — C. J. Bartlett says that the laying of the cor-
ner stone of the hospital for the Yale Medical School
in Changsha, China, which occurred some few months
ago, makes this a fitting time to recall that this work
is the natural outgrowth of that begun by another Yale
man eighty years ago. His name was Peter Parker,
and to him belongs the distinction of being the founder
of modern medical missions. The writer reviews the
biography of this remarkable man, picturing him as a
student in both the divinity school and medical school
at Yale and describing both his medical and missionary
work in China. His great work began with the open-
ing of the Ophthalmic Hospital in Canton in November,
1835, as a missionary hospital. This institution was
forced to extend its scope so as to include general
surgical cases. A number of unusual cases occurring
in the early history of the hospital are reported. Of
special interest in this connection is a collection of be-
tween eighty and ninety oil paintings illustrating surgi-
cal conditions as Dr. Parker found them in Chira.
When the first commissioner to China reached there in
1844 he appointed Dr. Parker as secretary to the lega-
tion, and from that time he added onerous diplomatic
undertakings to his missionary and medical work. This
biography is of particular interest because of the em-
phasis that it places on Dr. Parker's greatest accom-
plishment. He was a missionary in the strict sense of
the word, and a diplomat of no mean order, but his chief
contribution to the spread of civilization was as a medi-
cal man in founding medical missions. This article is
of further interest in setting forth those qualities of
mind and heart which should form the ideal of one who
would choose this field as a life work.
3. Effects of Heat on the Eye.— William E. Shahan
describes his experiments on animals made to determine
the physiologic limit of heat tolerance for stated lengths
of time and the thermaphor which he used in making
the experiments. It is evident from these experiments
that the substantia propria has no sharply defined limit
of physiological tolerance to heat, but that the effects
on it vary increasingly with increase in the intensity of
the heat applied. It would appear, however, that 130°
F. (54.4 C.) is as high as it is safe to go without
producing gross permanent changes. There seems to
be excellent theoretical reasons for believing that the
cornea will stand more heat than certain invading or-
ganisms, such as the pneumococcus of ulcus serpens
that have a relatively low thermal death point. Experi-
ments in ulcus serpens indicate that any temperature
up to 130° F. applied directly to the ulcus serpens for
ten minutes has no beneficial effect whatever. It is
probably even harmful. The writer believes, however,
that before heat is discarded as useless in these condi-
tions it is necessary to investigate another method of
using it, namely, that of applying higher degrees for
shorter lengths of time. An investigation of this kind
is now under way.
6. A Plan of Treatment in Infantile Paralysis. —
Robert W. Lovett presents a plea for a definite uniform
plan for the treatment of infantile paralysis in all of its
stages, for a direct attack on the disease based on its
pathology, and for persistency and precision in that
therapeutic attack, with special care as to the avoid-
ance of fattgue from over-exercise and over-treatment.
It is the belief of the author that nowhere in orthopedic
surgery does the difference between the best and in-
different treatment have more effect on the ultimate re-
sult than in this disease. During the first stage of the
disease the essayist emphasizes the importance of quiet
and advises that the feet be kept at right angles to the
legs to avoid the most common deformity, dropped foot.
Toward the end of this period, which may be assumed
to have ended when tenderness has disappeared, im-
mersion in a warm salt bath is desirable. During the
second stage, which may be assumed to begin with the
disappearance of tenderness and to last for two years
or more, the problem is to restore the maximum func-
tion to the affected muscle and to study most carefully
the measures most likely to accomplish this end. With
the acute stage over it is on the whole desirable to get
the oatient on his feet, i.e. to institute ambulatory treat-
ment. In the writer's opinion muscle training is the
measure of greatest value at this stage, being one of
the most powerful factors in determining ultimate mus-
cular function. It should always be borne in mind
that fatigue and overtreatment by massage and exer-
cise are detrimental factors of the highest importance
too ]Utle attended to. During the third or stationary
stage, the requirements of the preceding stage as to
care of the muscles still exist but are less urgent. Even
in this stage muscle training may accomplish much.
342
MEDICAL RECORD.
[Aug. 19, 1916
The dominant requirements of this stage are operative,
and are, first, the correction of the deformity, and, sec-
ond, operations to improve function and secure sta-
bility. Finally the author discusses the various opera-
tions that have been employed for the improvement of
function.
8. Focal Infection in Relation to Certain Dermatoses.
— M. L. Ravitch reports ten cases of skin disease in
which the etiology was obscure and which were re-
sistant to treatment, and in which the discovery and
removal of a focal infection resulted in a disappearance
of the dermatosis. He states that he might have cited
many more cases. In commenting on these cases, he
says that not al' systemic and skin derangements are
due to focal infection. A great many obscure diseases
may be traced to faulty internal secretion, which offer
a great field for the clearing up the etiology of obscure
diseases; but, again, faulty internal secretions may be
due to focal infection. All these things teach one to
be on his guard and to make thorough examination in
doubtful cases. The skin should be considered not as
surface only, but as a cutaneous organ, as capable of
infection from within as any other organ.
9. The Diet of Children After Infancy. — J. H. Mason
Knox. (See Medical Record, June 24, page 1164.)
The Lancet.
July 15, 1916.
1. An Inquiry into the Natural History of Septic Wounds.
(A Report in Three Sections to the Medical Research
Committee.) Kenneth Goadby,
2. Digitalis in Aortic Incompetence. Seymour Taylor.
3. Abdominal Pregnancy, Probably Primary. Frederick J.
McCann.
4. Indications and Contraindications in the Pneumothorax
Treatment of Pulmonary Tubercle. Clive Riviere.
5. A Case of Oblique Hemianopia from Wound of Optic
Chiasma. Purves Stewart and A. D. Griffith.
6. Early Ether Analgesia. D. P. D. Wilkic.
1. An Inquiry into the Natural History of Septic
Wounds. — Kenneth Goadby has made a study of the bac-
teriological flora of wounds from the moment of ad-
mission to the hospital, and subsequently through the
various stages of the illness, correlating the bacteri-
ological knowledge with the clinical symptoms, surgical
treatment, and sequela?. The condition of the blood was
also studied in relation to the degree and variety of
sepsis, and particular attention given to the benefit or
otherwise of the use of bacterial vaccines. As the
inquiry progressed other problems related to the per-
sistence of unhealed wounds with sinus formation, and
the appearance of general disturbance with secondary
attacks of fever and inflammation, often associated
with trivial surgical interference with the wound, de-
manded special attention. The inquiry is divided into
three main lines of research, necessitating the division
of the report into three sections, namely, (1) Sinuses
and sinus formation; (2) Vaccine therapy and wound
infection; ('■',) (k'neral tissue reactions in wound infec-
tion. In the first section of the report the author con-
cludes that there is a preponderance in infected wounds
of certain classes of anaerobic bacteria — namely, organ-
isms referable to the groups: 1. B. cedematis maligni;
(2) /.'. ■perfringens (Veillon) ; and (3) /.'. hibler; that
there is a small incidence of /.'. tetani, at present only
in cases of clinical tetanus; that wounded tissues, es-
pecially sequestra, contain anaerobic bacteria months
after the original injury, even when the external wound
has healed; that infection of the wounded and par-
tially healed tissues with anaerobic bacilli predisposes
to sinus formation; that persistent infection of the
wounded tissues is the chief, if not the essential, factor
of the "flares" occurring after operations upon sinuses;
that the use of appropriate vaccine therapy is an im-
portant and urgent concomitant of surgical treatment
in the prevention of "flares" after secondary operation,
and in the prevention of sinus formation and second-
ary hemorrhage; that the biological activity (digestive
activity) of anaerobic bacilli is more important than the
specific infectivity. As a result of his investigations into
sinus cases generally the author suggests as a routine
treatment of chronic sinuses resulting from gunshot
and other projectile wounds that the case be treated
as though anaerobes were present. An autogenous vac-
cine, preferably a sensitized one, should be made from
the organisms in the sinus; streptococci and the coli
or proteus group must be included when present. Such
cases should not be operated upon until efficient im-
munization (three weeks at least) has been carried
out. From the results recorded in this report it would
appear that the anaerobic bacteria, even if present in
the sinus, may be disregarded, provided precautions are
taken to immunize the patient before operation and to
provide an efficiently drained wound. All chronic
sinuses which alternately heal and break down should
be treated by vaccine therapy before subsequent sur-
gical procedure is adopted.
2. Digitalis in Aortic Incompetence. — Seymour Tay-
lor records further experiences confirmatory of opinions
that he has previously expressed as to the effect of
digitalis in aortic incompetence. He states that as he
lives longer and sees more cases, and registers the
results of treatment, or the failures and successes of
prognosis, he becomes more impressed with the value of
clinical experience as against theories of the labora-
tory or the seductive whisperings of a physiological
instrument. The writer has for many years recorded
the life histories of patients who have suffered from
aortic regurgitation, recorded their longevity, their
mode of death whether lingering or sudden, and com-
pared a series of cases treated with digitalis, and an-
other series of cases in which the drug has no place
in the defense. He finds that sudden death in the
cases treated with digitalis is by no means uncommon.
If in addition to aortic insufficiency the patient has
also mitral regurgitation, then digitalis is a useful
remedy. The chief object of this present communica-
tion is to put on record some additions to the number
pf cases having aortic regurgitation who have survived
to old age and to whom digitalis has never been jriven,
though he has had them under his care for ten to
fifteen years. In cases having attacks of dyspnea and
requiring medication he has treated successfully by
small doses of trinitrin (gr. 1/200), and a very dimin-
ished dietary, usually about a third of the daily
amount, with one day's fasting each week.
4. Indications and Contraindications in the Pneumo-
thorax Treatment of Pulmonary Tubercle. — Clive Ri-
viere states that pneumothorax treatment should be
borne in mind as soon as ulcerative processes appear
in the lungs and where life is threatened, but it must
not be postponed until life is in danger, for it is mostly
then too late. The high function of pneumothorax
therapy is to restore the lost cases to health; but the
bad outlook must be recognized in good time if pneu-
mothorax treatment is to succeed. A phthisis case
may be to the initiated "lost." so far as ordinary
methods of treatment are of avail, long before the end
is in sight. It is at this stage, and even before, that
the suitability of pneumothorax must be decided upon
if a clear other lung, absence of widespread adhesions,
and a reexpansible lung are to be with any likelihood
attained. On the other hand, it must be admitted that
the advanced, apparently unilateral, hilus tuberculosis
cases are seldom met too late for this treatment, and it
is remarkable how often the pleura remains sufficiently
unadherent to allow the production of an efficient pneu-
Aug. 19, 1916]
MEDICAL RECORD.
343
mothorax over disease extending even from apex to
base. The writer mentions the following contraindica-
tions to pneumothorax, bilateral involvement, advanced
emphysema, asthma, disability of the circulatory or-
gans and kidneys, intestinal tuberculosis, and diabetes.
Dyspnea in itself he does not consider a contraindica-
tion; neither does he consider laryngeal tuberculosis a
contraindication unless very advanced. Pneumothorax
may be an emergency operation for bleeding otherwise
uncontrollable and likely to prove fatal, or it may be
undertaken for some cases of recurrent hemoptysis.
6. Early Ether Analgesia. — D. P. D. Wilkie recom-
mends a method of producing ether analgesia for minor
operations for which a local anesthesia is unsuitable
and where the aparatus for administering nitrous oxide
and ethyl chloride are not available. His method of
producing brief analgesia is, after having made all
preparations for the operation, to place a Shimmelbusch
mask over the patient's face and to pour 3 drachms
of ether over the mask and bring a folded towel over
the face and mask and keep it closely applied. It will
be found that in from thirty to fifty seconds, provided
the patient breathes deeply and regularly, the stage of
analgesia has set in and will last from fifty seconds
to three minutes, the usual duration being slightly less
than two minutes. The writer finds this method suit-
able for such minor operations as incision and scraping
of multiple abscesses of the neck, removal of septic in-
growing toe-nails, circumcision, cutting of projecting
portions of two phalynges with bone forceps, etc. The
patient is usually able to walk out of the operating
room and feels no unpleasant after effects.
British Medical Journal.
July 15, 1916.
1. Some of the Principles and Problems Related to the
Treatment of Gunshot Fractures. Hey Groves.
2. A Reconsideration of the Principles and Methods of
Hugh Owen Thomas. 1. Some Reflections on Thomas's
Splints. (To be continued.) J. Linn Thomas.
3. An Extension Splint for Fractures of the Humerus. Don-
ald Hingston.
4. A Method of Treatment of Shell Shock. E. T. C. Mil-
ligan.
5. Gunshot Wound of Spinal Cord and Trachea : Recovery.
G. W. Thompson and G. W. Stanley.
6. Eusol and Other Methods of Wound Treatment. C. W.
Duggan.
7. The Danger of Iodine Solutions for Sterilizing the Skin in
Abdominal Operations. A. Ernest Maylard.
8. Extraction of Intracranial Foreign Bodies. Sidney
Matthews.
1. Some of the Principles and Problems Related to
the Treatment of Gunshot Fractures. — Hey Groves
writes from his experience in the Queen Alexandria
Military Hospital, where he was also entrusted with
the founding and administration of a central splint fac-
tory which has brought him in contact with a great
number of medical officers and the various conditions
under which military surgery has to be undertaken.
In his opinion the plan of having a factory where frac-
ture apparatus can be made on the premises of the
hospital is a simple, efficacious, and economical plan
which should be adopted by all large military hospitals;
it encourages the trying of new ideas, and the treat-
ment of severe gunshot wounds under modern condi-
tions presents new problems that require solution. It
has been well said that every severe case of gunshot
wound complicated by fracture presents two stages.
In the first there is a wound complicated by a fracture,
and in the second there is a fracture complicated by a
wound. At no stage can either be neglected, yet the in-
fected wound claims first attention, and that until it
has been restored to a healthy and healing condition.
From the earliest possible moment, and until bone
union is firm, the limb must be immobilized and placed
in such a position that the wound can be frequently
dressed without moving it or without changing the
relative position of the bone fragments. Having se-
cured immobilization, the main points in the treatment
of the wound are that within forty-eight hours every
wound, except the clean through-and-through bullet
wound, should be disinfected by excision and the re-
moval of foreign bodies. At a period of a week or ten
days after the injury disinfection of wounds seems
hopeless and a selective method must be adopted, leav-
ing those alone in which infection is quiescent and
opening up those only in which it is active. It is easy
to state this principle but a matter of some difficulty
to carry it out correctly. There is no doubt that a
ragged shell wound with a retained missile must be
opened up early and freely, and, equally, that clean
perforating wounds should be left alone, but there is
a large class intermediate between these which gives
trouble and anxiety. The only safe rule to follow would
seem to be to open up all cases in which there is any
doubt. An irregular temperature, local tenderness, a
rising leucocyte count, and an infection by the strepto-
coccus, B. pyocyaneus, coliform or gas-producing bac-
teria, are all facts which require immediate operation.
In cases in which it is not possible to open up deep
pockets and in which if a tube only is left a trouble-
some sinus results, whereas gauze packing is painful
and difficult, a special plugging instrument has been
found very helpful. This device was invented years
ago for packing the uterus, and consists of a metal
tube and a stylet terminating in a Y-shaped fork. The
tube is inserted at the bottom of the cavity to be packed
and the ribbon gauze is pushed in by the stylet. The
writer expresses no opinion as to the relative advan-
tages of various antiseptics, as his experience has
consisted largely in the treatment of cases ten days
after injury, at which time mechanical drainage and
lavage must be the all-important elements of treatment
by which the tissues can disinfect themselves.
4. A Method of Treatment of Shell Shock. — E. T.
C. Milligan describes a well-known treatment of hys-
teria which has been used successfully in the treatment
of shell shock. This consists in the administration of
chloroform slowly, in a quiet room and apart from
other patients, and when a suitable degree of anesthesia
is induced in suggestion carried out by the anesthetist.
In all types of cases suggestion is continued until the
patient has fully recovered consciousness. When quite
rational the man is assured of his cure, promised a
rest, given morphine, and allowed to enjoy a much-
needed sleep. The aftertreatment consist of prolonged
rest and change of surroundings. Cases of loss of
memory, loss of speech, loss of hearing, hysterical at-
titudes of the limbs, and loss of function have been
successfully treated in this way.
La Presse Medicale.
July 20, 1916.
Application of Pachon's Method to the Study of the
Cardiopulmonary Circulation. — Colleville quotes Naegeli
as stating that tuberculosis appears at puberty in 96
per cent, of individuals. The hardships of the present
war may increase the number of cases of active tubercu-
losis to a "shuddering" extent. We must be prepared
to recognize incipient and quiescent cases, and recently
it has been stated that Pachon's oscillometer and
Schick's cutireaction are likely to form the best rou-
tine methods for this purpose, the former being espe-
cially calculated to reveal the lowered blood tension of
the tuberculous. The author appears to have devoted
himself chiefly to the question of recovery from tubercu-
losis in the troops. Oscillographs reveal nerve depres-
sion, and the influence of the innervation upon the cir-
344
MEDICAL RECORD.
I Aug. 19, 1916
culation is of the greatest significance for the tubercu-
lous. In the nontuberculous with nervous depression
it is impossible to increase the respiratory capacity, and
they rebel against all exercise. If either a physical or
psychical stimulant favorably modifies this state of
adynamia it is at once shown in the oscillograph, which
first shows overactivity and then assumes the normal.
The same law is in evidence in the nervous tuberculous
subject. Bearing in mind that respiratory capacity de-
pends in part on the elasticity of the lungs as well as
on the intrapulmonary circulation, these two factors
must be studied in common. In lungs which retain their
elasticity respiratory gymnastics are in order; in others
we must use an excito-cardiac medication, such as ca-
chets of sweetened camphor. A tuberculous subject is
not fatally deprived of power of ventilating his chest.
It is to be hoped that oscillographs may be made to
afford a basis for a classification of tuberculous sub-
jects.
Forearm Prosthesis. — Ducroquet discusses this subject
extensively in connection with amputations of the fore-
arm. There should be three so-called points of fixation
in the latter, viz., the point of support for the appa-
ratus, which is the lower part of the arm; the point of
counter-ascension, the upper part of the forearm, and
the elbow joint. In other words, we have the forearm
prosthesis, which covers and protects the stump; an
armlet for the upper arm, and a hinge mechanism con-
necting the two, with perhaps a sling over the shoulder.
This apparatus is, of course, old and simple, and serves
but as a base for special prosthesis. For the mechanic
an artificial hand is, of course, out of the question. The
object of prosthesis at present is to invent apparatus
to enable him to work at his trade. The simple hook
may be used by various kinds of laborers, but each
man must have more than one kind of apparatus. The
gardener uses a special ring which plays in a sort of
stirrup, also a spade holder. The vinedresser needs a
pruning hook to immobilize branches which have to be
cut or sawed away. The chauffeur can employ a so-
called "bell" as a substitute for his closed hand on the
lever of his machine, the bell being held in a fork. A
single apparatus is in use for holding saws and ham-
mers. A complete set of apparatus has been devised
for brushmakers. On the other hand, the commercial
traveler requires no technical prosthesis but a specially
articulated hand with considerable prehensile ability.
Many inventors appear to be occupied in perfecting spe-
cial forms of prosthesis.
Le Bulletin Medical.
July 21, 1916.
Elie Metchnikoff. — Roux, long the chief assistant of
the deceased scientist, gives some reminiscences con-
cerning the latter which are not contained in the nu-
merous necrologies. Three minutes before the end came
Metchnikoff was conversing with Roux and others.
By advice of Widal, his physician, he had taken to his
bed three days before. Death occurred from syncope
due to a slight change of position. The entire period
of treatment was seven months. In May, 1915, when
he had attained his seventieth birthday, the officers of
the Pasteur Institute held a celebration in his honor.
Roux, who was unable to be present, addressed a letter
to his colleague in which the hitter's great services to
science and humanity were reviewed. His seventy
years were pronounced a short term for the work ac-
complished by him, which was sufficient to have made
several men eminent. After the reading aloud of this
letter Metchnikoff conversed familiarly with his col-
leagues on the subject of longevity. He spoke of hav-
ing reached the end of his career. The statistics of the
Italian Bodio furnished the proof that the Psalmist's
estimate was in the main correct. He was fortunate
in having attained it, for longevity was hereditary and
none of his immediate relatives had reached such an
age. He spoke of Lister, who died at eighty-five, his
father at eighty-three, and his paternal grandfather at
ninety-three. That he was alone among his own rela-
tives to reach seventy he ascribed to the carrying out of
his own theories of combating autointoxication. He
mentioned especially Welch's bacillus as an implacable
enemy of mankind, not only to the wounded in the pres-
ent war but to all in times of peace as well, as an in-
testinal denizen. He had used the lactic acid bacillus
for some eighteen years as part of his food regimen.
The science of longevity is in its infancy and we are as
yet ignorant as to why the aged die at so great a rate
from pneumonia and malignant growths. What we
seek at present is not great longevity in the individual
but how to cause all men to reach the age of seventy.
As for cancer, he believed firmly in its exogenous origin.
He would like to see two plans of prevention carried
out in the elderly, to wit, sterilization of all food and
absolute cleanliness of the skin. As another preventive
factor against premature senility he advocated a suita-
ble mental state, freedom from pessimism and from fear
of death and disease. In this connection he quoted Tol-
stoi, who in speaking through certain characters ap-
peared to regard the prospect of death as sufficient to
destroy all ambition and endeavor. The desire to live
may vary inversely with the age, but the cessation of
this desire should be natural only in those who have
reached advanced years and with it a satiety of life.
In the future the old man may succeed better in re-
taining the full possession of his faculties and with it
the desire to live. The great war is mentioned in this
connection, as if it had produced conditions which mili-
tated for the time against progress in the science of
macrobiotics, but the interruption will only be tempo-
rary. The great scientist's body was cremated and his
ashes will rest in the Pasteur Institute in a large urn
of red marble.
Death Following a Sting by a Wasp. — Recently death
occurred to an engine room artificer of Portsmouth,
England, who had been stung by a wasp while sleeping
on board his ship. The swelling of his neck was so
great that he had to be sent to the Haslar Hospital,
where he died on the following day. At the inquest
Surgeon Caldwell Smith ascribed death to bacterial in-
fection caused by the wasp's sting. The deceased was
a healthy man, hence the virulence of the infection must
have been extreme. A verdict of accidental death was
rendered. — The Medical Times.
The Corroborative Diagnosis of Mastoiditis by Means
of the X-Ray. — Harold Hays says that the diagnosis of
mastoiditis, as a rule, can be made readily from both
the subjective and objective findings. Such further
data as those obsei-ved by the .r-ray are not neces-
sary. Yet we are inclined to make use of every aid
to confirm our diagnosis, particularly in those doubt-
ful cases in which the question arises as to the ad-
visability of operation. The majority of the cases of
mastoiditis are operated on without the corroborative
evidence of the x-ray picture. In those cases which do
not respond to treatment, and where certain complica-
tions are set up, such as sinus thrombosis and epidural
abscess, the .r-ray findings will frequently determine
the condition of the underlying bone before extensive
destruction has taken place. Proper .r-ray pictures of
the mastoid are of decided value in determining the
necessity for immediate operation. — New York Medical
Journal.
Aug. 19, 1916]
MEDICAL RECORD.
345
Candy Medication. By Bernard Fantus, M.D., Pro-
fessor of Pharmacology and Therapeutics, College of
Medicine, University of Illinois, Chicago. Price, $1.00.
St. Louis: C. V. Mosely Company, 1915.
Dr. Fantus' little book on candy medication belongs
primarily to the prescription pharmacist and the coun-
try practitioner who must dispense his own drugs, for it
gives in detail the method of preparation by which a
number of drugs may be given in candy form. How-
ever, the introduction of the book and the method to the
pharmacist will depend largely on the physician and
especially the pediatrist. Up to this time the most
palatable doses have been prepared by the large drug
houses. This new method of prescription preparation
which Dr. Fantus presents should prove useful for the
ill-controlled adult patient as well as for children be-
between 3 and 10, as Dr. Fantus suggests. He gives
formulas for fifty-seven medications, but on looking
through the list one finds rather a large number which
would be infrequently used for children. No doubt other
drugs will be added to the list in the near future. It
would seem a definite mistake to give hexamethylenamine
in the form of candy tablets. This drug irritates the
kidneys unless given with the sufficient amount of fluid.
If a patient is given tablets, there is no assurance that
the necessary amount of water will be taken, and, more-
over, hexamethylenamine is entirely tasteless in the
proper amount of water.
The After-Treatment of Operations: A Manual for
Practitioners and House Surgeons. By P. Lock-
hart-Mummery, F.R.C.S., Eng., B.A., M.B., B.C.
Cantab. Senior Surgeon, St. Mark's Hospital for Can-
cer, Fistula, and other Diseases of the Rectum, The
Queen's Hospital for Children, London, and Honorary
Surgeon to King Edward VII Hospital for Offi-
cers; Special Consulting Surgeon to City of London
Military Hospital and Fulham Military Hospital ;
Jacksonian Prizeman, and Late Hunterian Professor,
Royal College of Surgeons. Fourth Edition. Price,
$2.25 net. New York: William Wood & Co., 1916.
This book, which has already reached its fourth edition,
is one that should be of much value to at least three
classes of readers — nurses, members of house staffs, and
general practitioners, particularly those in the country
who are often called upon to operate when no expert
surgeon is available or who must look after the patient
after the operation itself has been done by a consulting
surgeon. We may also say that there are compara-
tively few surgeons, with the possible exception of those
connected with an active metropolitan hospital service,
who will not find many valuable suggestions in this
little book; for the text is written by an experienced
surgeon of world-wide reputation and embodies, to a
large extent, the methods he has himself found most
efficacious. The book has been brought up to date in
many ways. As evidence of this we find a short but
remarkably meaty chapter on the treatment of gunshot
wounds, while the chapter on surgical shock has been
rewritten and the influence of Crile's recent teachings is
very manifest.
Books of this sort are needed; for we thoroughly
agree with the author in the statement that it has be-
come too common to think that the operation is every-
thing and that the after treatment is merely a matter of
course. On the contrary, while, as he says, the opera-
tion is the most showy part of the treatment, many a
case is saved or lost through skillful and careful or care-
less work on the part of the doctor or nurse after the
operation itself has apparently been successfully done.
This is one of the books with a mission; and the nurse,
interne, or practitioner who is familiar with its teach-
ings will save many patients who might otherwise be
lost and will certainly make a host of others more com-
fortable during their convalescence.
Therapeutic By-Ways: Being a collection of therapeu-
tic measures not to be found in the text books. Col-
lected from all sources. Condensed and arranged.
By Dr. E. P. Anshutz. Price, $1.00. Philadelphia:
Boericke & Tafet, 1916.
Even though we have not the faith in the doctrine of
similars and in the efficacy of high potencies, we may
read much of interest in Anshutz's "Therapeutic By-
Ways." He has had patience for years to gather from
the men and books which passed his way, and much
from past superstitions has gone into his little book.
His one very sensible comment on experimental phar-
macology is the following: ". . . for why may not
the infinitesimal do that which the crude and the pal-
pable may not do? Does man, in this day, still hold to
the belief that because he cannot see a thing it does not
exist? If he does he kicks over the best in modern
science and makes his senses the arbiters of science."
Tonsils and Adenoids: Treatment and Cure. From
the Standpoint of the Physician and Laryngologist.
No Preference to that of the Surgeon and Laryngecto-
mist. By Richard B. Faulkner, M.D. (Columbia
University). Price, $1.00. Pittsburgh, Pa.: The
Blanchard Company.
The Tonsil and Its Uses, Vocal, Mechanic and
Physiologic. By Richard R. Faulkner, M.D.
(Columbia University). "The tonsil is an organ that
must be respected." — Lermoyez. "You have no right
to destroy it." — Von Levinstein. "It is absolutely
necessary in the modulation of the singing voice in
crescendo and diminuendo." — Lamperti. "It is the
sound-post in the mechanism of speech and song." —
The Author. Price, $1.00. Pittsburgh, Pa.: The
Blanchard Company.
These two books are so closely related that it seems
suitable to notice them together. The pamphlet on ton-
sils and adenoids is one of brief statements and refer-
ences to the author's larger book. The "Note" on the
first page reads: "The figures in the body of the text
refer to pages in my book on 'The Tonsils and the
Voice.' The reader is advised, in every instance, to
refer to the page indicated and read what is there set
forth," and ninety-two page references are given in
twenty-three pages! The book has, however, some ex-
cellent advice as to the treatment of diseased tonsils,
and Dr. Faulkner's association with those to whom the
voice is of such vital importance gives his opinion
weight.
The author seems given to superlatives, and such
statements as "Pain anywhere not associated with in-
creased temperature must be looked upon as reflex," can
scarcely be accepted. What about the more than occa-
sional gangrenous appendix where there is no rise of
temperature for several hours after the beginning of
pain? And the headache of hypophyseal tumor is cer-
tainly not reflex according to his use of the word.
One-third of "The Tonsil and Its Uses" is taken up
with quotations from medical and musical people. One
of the author's deductions is that "persons who have
large tonsils are generally healthy." Such a statement
needs indisputable statistics to back it. However, when
all is said, Dr. Faulkner is working in the right direc-
tion— toward the intelligent medical treatment of dis-
eased tonsils as against indiscriminate tonsillectomy
and tonsillotomy.
Manual of Vital Function Testing Methods and
Their Interpretation. By Wilfred M. Barton,
M.D. Associate Professor of Medicine, Georgetown
University, Attending Physician to Georgetown Uni-
versity Hospital. Price, $1.50 net. Boston: Richard
G. Badger, 1916.
The author has collected from the literature the meth-
ods for testing the functional capacity of the liver,
kidney, pancreas, heart and the ductless glands and
has thereby rendered a great service to the many who
lack the time and energy to search them out inde-
pendently. While in several instances the methods are
described with insufficient detail, nevertheless the refer-
ences are given and those unfamiliar with chemical
methods can find the technique in full in the original
sources. The book is a welcome one and should find a
wide circle of readers. The discussion of the value of
the various tests described is, as a rule, brief and well-
considered and the author has not allowed his enthusi-
asm to warp his judgment.
The Medical Clinics of Chicago. May, 1916. Vol-
ume I — No. 6. Published Bi-monthly. Price, $8 per
year. Philadelphia and London: W. B. Saunders
Company.
This number closes the first volume of the Medical
Clinics, and a comparison with the first number shows
a very definite improvement during the year. The
number of cases discussed in a single issue has de-
creased, and there is more thorough discussion of the
conditions presented. In this issue there are presented
about eighteen cases from ten clinics. There are very
interesting discussions of the Allen treatment of dia-
betes and of rickets, although in the latter the blood
changes which may appear in the course of the disease
are not adequately pictured. There is appended a very
complete index for the volume.
346
MEDICAL RECORD.
[Aug. 19, 1916
J§>0ri?ty Shorts.
COLLEGE OF PHYSICIANS OF PHILADELPHIA.
Stated Meeting, Wednesday, June 7, 191(5.
The President, Dr. Richard H. Harte, in the Chair.
Glucose Formation from Protein in Diabetes. — Dr. N.
W. Janney of New York in this communication empha-
sized the importance of the exact knowledge of the
maximum extent of glucose formation from protein in
diabetes for the clear understanding of the glycosuric
process and its dietary treatment. Various criticisms
he said could be offered to previous experiments to this
end which had been made upon human diabetics and
depancreatinized dogs. A critical study of phlorrhizin
diabetes had led to the conclusion that glucose forma-
tion from protein in this condition represented essen-
tially the same process as that occurring in the human
glycosuric subject. Therefore a technique had been
developed permitting of quantitative determination of
the amount of glucose arising from protein fed to ani-
mals made completely diabetic with phlorrhizin. The
results so obtained were applicable to the problems pre-
sented by diabetes mellitus. It could thus be actually
demonstrated experimentally that 58 per cent, of glu-
cose as a maximum could originate from the body pro-
teins of man. This corresponded to the urinary glucose
(nitrogen ratio 3.4:1), which was of diagnostic value.
If the glucose excreted by fasting diabetics should show
this relation to the nitrogen, the severest form of dia-
betes was present. The more nearly and the more
quickly the G:N ratio approached 0:1 on fasting, the
more favorable the diagnosis. In these experiments, he
observed, it had also been shown that practically all the
sugar, and no more, excreted by fasting completely dia-
betic animals arose from protein. It was therefore
evident that glucose formation from fat in diabetics
was inconsiderable. By use of the new method of ex-
perimentation a series of pure isolated proteins had
been found to yield large amounts of sugar in metab-
olism varying from 48 to 80 per cent., according to
the protein examined. Contrary to existing opinions,
the animal or vegetable origin of proteins was found
to bear no relationship to their ability to produce glu-
cose in the animal organism. Variations in the amounts
of sugar arising from individual proteins were essen-
tially due to the differing amounts of glucose yielding
amino-acids entering into the make-up of the protein,
although certain alimentary factors influencing diges-
tion also played a role.
In another investigation glucose formation from va-
rious meats had been similarly studied. Beef, rabbit,
fish (halibut), chicken, and eggs were found to give
rise in the diabetic organism also to considerable
amounts of glucose, 36 to 48 per cent., calculated for
water-free solid material. It could likewise be ascer-
tained that from bread 61 per cent, of sugar was
formed in the diabetic's body. Von Noorden's food
tables for diabetics were regarded by Dr. Janney as
very inadequate, since they did not take into considera-
tion the large amounts of sugar arising in metabolism
from protein. The new data alluded to rendered it pos-
sible, however, to compare the combined amounts of
carbohydrate present in and arising within the glyco-
suric organism from various protein foods to that of
bread. An accurate diet table for diabetics could thus
be calculated in which was represented the actual rela-
tive adaptability to the diabetic dietary of protein foods
as compared with bread. It was estimated that ap-
proximately 250 to 350 parts of the usual varieties of
cooked meats were found to be equivalent, from the
standpoint of sugar production, to 100 parts of bread.
Eggs were said to present a decided advantage over
other forms of protein food, 525 to 600 parts of eggs,
whether boiled, raw, or fried, being equivalent to 100
parts of bread. Regarding the glucose production from
proprietary protein foods, contrary to the prevailing
opinion, the effect of the high protein content of such
products was to cause so much sugar production in
metabolism that in nearly all cases these gluten and
albuminous preparations were more harmful to the dia-
betic than equal amounts of wheat bread. Since in-
creased glycosuria resulted from ingestion of carbo-
hydrates, proteins, and fats (the latter by indirect ac-
tion), the author said it was now quite evident that the
only way to rest the glycolytic function was to prac-
tically abstain from all food whatsoever. The rationale
of the Allen fasting treatment for diabetics was there-
fore emphasized by these researches. In view cf the
extent of sugar formation from protein, it was also
clear that the classical "strict" diet for diabetics should
no longer be ordered. A mixed diet containing mod-
erate amounts of protein and fat and low amounts of
carbohydrates was said to be more palatable and to
present no greater disadvantages than the high protein
and high fat diet. The results of chiefly scientific im-
portance obtained in the series of investigations men-
tioned, Dr. Janney said, had been described in articles
which had appeared elsewhere; the detailed results ref-
erable to the diabetic dietary were in course of pub-
lication.
Dr. James E. Talley of Philadelphia expressed his
gratification at having a scientific demonstration of the
fact that the protein of egg was better borne than
other proteins. From experience with patients with
poor tolerance for some time after their starvation
cure some practitioners had come empirically to such
conclusion. He regarded as troublesome problems with
these patients satisfying calory needs, the appetite, and
the family apprehensions.
Dr. George M. Piersol expressed his interest in hav-
ing more scientific data concerning the rationale of the
Allen treatment, which all agreed had in the last year
proven to be the most successful means of combatting
diabetes. Since this rationale had always been a mat-
ter of conjecture and some controversy, all explanatory
evidence was of great value.
Dr. Janney, in closing, cautioned that the results
given be not taken too positively. They were to be con-
sidered, if possible the most reliable known at the pres-
ent time, still merely as a general guide in the protein
feeding of diabetics. To accept that a certain protein
should be entirely discarded for another owing to a
difference of a few grams in sugar formation was as-
suming an unwarranted position, owing to the various
digestive and other factors involved. When, however,
the glucogenetic capacity of one food was strikingly
less than that of another — for example, eggs as com-
pared with meats, or meat as compared with commer-
cial preparations high in protein — then it was that the
practical utility of this new data became most im-
portant.
The Physical Cultural Effect of Preparedness. — Colo-
nel William H. Arthur, Medical Corps, U. S. A., presi-
dent of the Army Medical School, presented a paper
under this title.
Individualism and Decadence. — Dr. Robert T. Morris
of New York under this caption took up the question
of struggle, beginning with the struggle of inorganic
elements for place in the periodic table. Struggle oc-
curred, he said, not only between the cells of an indi-
vidual but between individuals in a family, between
families in a town, between towns in a State, and be-
tween States in a great organization of States, and that
conflict would continue, as it belonged to the laws of
evolution. As civilization advanced the periods of
peace between large groups of civilized people would be
of longer duration, but the warfare and struggle when
they did come would be more terrible. He stated that
at the present time almost all the Aryan nation groups
were declining, but that the progressing Slavic groups
were bound, according to the laws of nature, to attack
the rest of us at some time in the not very distant
future; further, that a nation like Japan, which had
formerly been content with esoteric philosophy, would
struggle for dominion over the world whenever such a
nation developed exoterically. Mass action of the peo-
ple in a nation of the future would be accomplished
through the agency of patriotism. Patriotism, he ob-
served, was a nasty little prejudice given to man by
nature, apparently for the purpose of keeping him in
herd form in nations, which prejudice was flatly op-
posed to the beautiful ideal of the brotherhood of man.
He believed that there was need for military training
in America, provided the people had a sentimental wish
to retain their identity as a nation; if not, they might
continue in the development of that individualism which
led to early decline, rendering them more vulnerable to
the attack of a predatory nation, which predatory na-
tions were developing on all sides. The United States
of America might be regarded at present as a big.
helpless, fat. juicy rabbit waiting to be taken, and the
people as too fat to fight. In considering the elements
of many nations now included in the people of America
it was to bo noted that these different elements were
being hybridized; crosses were being made between spe-
cies, which did not give large possibilities for mass ac-
tion. Plant and animal breeders claimed that specific
Aug. 19, 1916]
MEDICAL RECORD.
347
hybrids, or crosses between species, did not make dur-
able types. The strongest nations were those belonging
to crosses between varieties and not species. In this
country, the author said, the people were not crossing
species freely. With the introduction of various con-
flicting elements there was not quite the freedom of
which the people of this country had boasted, but a
more or less discreet autocracy instead of such concrete
autocracy as might belong to a responsible king. The
politician exercised a discreet autocracy in every town,
hamlet, and State, and there was not the freedom which
had been claimed. Furthermore, the people of this
country were developing that most valuable and, at the
same time, most dangerous trait known as individual-
ism. In the regard for the individual rather than for
the State there was occurring that rapid fall in birth
rate which belonged to older countries. The birth rate
he regarded as a sort of gage which indicated what was
in the boiler of a country. Military training was of
advantage in that it allowed young men to feel that by
mass unit action- they were working for each other and
for the State. Military training gave them intelli-
gently the idea of mass action, which would hook out
the hyphen between this and the older countries. Inci-
dentally it taught them deference to authority and self-
control in the interest of personal physical health.
Prof. William A. Stecher, Director of Physical Edu-
cation in the Public Schools of Philadelphia, felt that
in the discussion of military training sight was being
lost of the fact that the elements of training upon which
most weight was placed were not those of which most
people were thinking when speaking of military train-
ing. A study of the training given to the youth in
European nations would show that real "military"
training did not begin until the young man entered the
army at nineteen or twenty years of age. As soon,
however, as the boy — and the girl — entered school, pre-
military training began in the form of sufficient and
effective physical training. He felt that the recent
movement for preparedness had made people realize
that which teachers had always known, that physical
training had also a mental and a moral end. That
which was being asked for under the term "military
training" really should be termed "more effective phys-
ical training." He would agree not only that every
young man should serve his country, but that his train-
ing for good citizenship should begin as soon as he
entered school. Specific military training in the ele-
mentary schools he regarded as entirely out of place,
because he made a distinct cleavage between premilitary
work and military work. He advocated military train-
ing and believed that the medical profession could help
very materially in securing in the public schools the
type of training fitted for the growing youth. Could
boards of education be told by the medical profession
that a few minutes of physical training per day would
never make a healthy boy or girl, but that they should
have from an hour to an hour and a half of physical
training per day, in the open air if possible, the country
would have young men at nineteen years of age physic-
ally fit to join the army.
Dr. A. C. Abbott referred to his impressions upon
reading "The First Hundred Thousand," the story of
a Scottish regiment recruited from men in all walks
of life, consisting in the beginning of an ignorant, het-
erogeneous mob, but after a few months of training
becoming a coordinated, well-disciplined, self-reliant
fighting machine which gave good account of itself at
the opportune time. An advantage equally important,
the result of team work in a trained company of men,
was the acquisition of ability to take and act upon
orders without losing self-respect and learning thereby
how to give orders. He would urge the reading of Mr.
Maxim's "America Unprepared," which book showed
modern warfare to be a matter largely of machinery.
In Dr. Abbott's opinion modern warfare had become a
new science, demanding special training. He advocated
preparedness. He believed in compulsory military serv-
ice and that the real preparedness should be as full an
education in the construction and w-orkings of the mod-
ern machinery of warfare as was possible to be given.
Dr. James M. Anders felt that physicians should take
advantage of every opportunity of pointing out the
health value, if nothing more, of training in the camps
of the country. He agreed with Professor Stecher that
the physical training in the public schools should be
carried at least to the level of competent and satis-
factory industrial work. Were this done, beyond doubt
better material would be furnished for the making of
soldiers. He agreed also with the statement of ex-
President Roosevelt that military preparedness implied
industrial and economic preparedness, and referred to
the testimony of Col. E. F. Glenn before the Senate
committee to the effect that military drill should begin
in the public schools at the age of twelve and should
be given for twenty minutes daily for every school day
of every year up to the age of sixteen years. Colonel
Glenn would not put a gun into their hands during this
period, and would not have them called out until they
reached the age of eighteen. This, it seemed to Dr.
Anders, would be a feasible plan, although not in ac-
cord with the views expressed by Professor Stecher,
which would make for better preparedness. He em-
phasized the point that efforts at preparedness should
commence as early as possible in life, whether con-
sidered from the health, industrial, economic, or mili-
tary standpoint.
Dr. James Tyson called attention to a line of train-
ing apparently too elementary for consideration but
which was important — that involved in the ordinary
physical acts of walking, sitting, and standing. In this
respect girls and boys were too often left to chance, and
grew up under conditions favoring deterioration of the
anatomy and physiology of the body.
Dr. Morris, in closing, said that military training
allowed young people to think in terms of the State in-
stead of in terms of the individual.
NEW YORK ACADEMY OF MEDICINE.
joint meeting of the sections on obstetrics and
pediatrics.
Held March 28, 1916.
Dr. George W. Kosmak in the Chair.
Dr. Kosmak, at the request of Dr. Haynes, the chair-
man of the Section on Pediatrics, pointed out briefly the
reasons why such a joint meeting of the Section on
Obstetrics and the Section on Pediatrics should prove
of interest and advantage to the members of both
sections and to the general practitioner. He stated that
the trend of modern medicine had been toward spe-
cialism, and that although this development had un-
doubtedly contributed to the advance of medicine and
aided in its transformation from an art to a science, it
was essential to remember that the various apparently
isolated organic systems of the body were more or less
closely interrelated and interdependent. Therefore the
practitioner in the special branches of medicine was
subject to the same necessity for coordinating his work
with that of the immediately related subjects. This
was of peculiar significance in the question which was
brought up for discussion this evening, namely, "The
Care of the Newborn Infant from the Obstetric and
Pediatric Standpoints." The obstetrician unfortunately
had concerned himself more with the care of the mother
than with that of the infant and usually had dismissed
the latter from his mind unless some startling abnor-
mality occurred. The pediatrist was necessarily inter-
ested in the baby as such and only too often was called
in to care for a child with errors of growth and nutri-
tion that might have been corrected or perhaps avoided
earlier in its life. The subject of prenatal development
was receiving increased attention by research workers,
but unfortunately the practitioner of medicine was un-
acquainted with their observations and their practical
application to the human subject had not been exten-
sively made. In the lower animals several investigators
had shown the effects of injurious substances on the
development of the embryo and within the past year
Werber had succeeded in producing deformities of the
most varied type, such as cyclopia, ear defects, hydro-
cephalus, and alterations in the circulatory apparatus
by exposing the fertilized eggs of one of the teleost
fishes to oxybutyric acid and to acetone. These experi-
ments led one to believe that possibly various toxic
products in pregnant women resulting from altered
metabolism might account for departures from normal
fetuses at birth or even for defects that manifested
themselves in individuals later in life. Such imaginings
brought one into the field where it was difficult to dis-
tinguish between fact and fancy, but they should lead
to further experiments on higher animals and to more
detailed observation on the human subject. It was in
such fields as these that the obstetrician and the
pediatrician must extend their attention, for by corre-
lated work it would be possible to contribute something
more definite than the fanciful theories referred to
348
MEDICAL RECORD.
[Aug. 19, 1916
which would in time make for the betterment of the
race. Dr. Kosmak said he hoped that this meeting and
similar ones would tend to bring these two specialties
closer together and by their united work bring the sub-
jects to be discussed more prominently before the gen-
eral practitioner.
Correlation of the Pediatrist and Obstetrician. — Dr.
Roger H. Dennett presented this paper in which he
stated that in no other branch of medicine was there a
specialty which called for both surgical technique and
the peculiar mental attitude of the internist. These
two specialties had been combined in a mediocre sort
of a way, but no single individual had ever achieved
eminence in both. Ever since specialism had developed
it had been the custom for the obstetrician to take care
of the newborn baby from birth until the second, third,
or fourth week of life. The pediatrician had been the
consultant only, called in when things went extremely
wrong. Dr. Dennett said there was not in New York
City, to his knowledge, a public lying-in service, large
or small, or a private obstetrical institution, in which
newborn babies were visited each day by a pediatrician,
just as the mother was cared for by an expert. There
could be no question but that the study of congenital
disease was one of the most neglected, and at the same
time most needed, phases of medicine. Here was the
first reason why the pediatrician should have the care
of infants from birth. A second reason was that the
mortality could in all probability be enormously reduced
if proper attention were given to these diseases. Finally,
infant morbidity and its peculiarly distiessing accom-
paniments might be lessened during the first year by
preventing many cases of malnutrition and gastro-
intestinal disturbances. The Bureau of Child Hygiene
of the New York Department of Health was now making
an investigation of the subject of the early mortality
from congenital diseases and had shown that 40.3 per
cent, of all the deaths under a year were due to con-
genital diseases, whereas the deaths from respiratory
or diarrheal diseases were little more than one-half that
number, 23 per cent. The Health Department further
stated that 70 per cent, of all deaths due to congenital
causes might be classed as preventable, and that 48
per cent, of these deaths occurred in the first ten days
of life. When it came to the subject of morbidity,
statistics were less available, but it was probably the
general opinion of pediatricians that at least 50 to 75
per cent, of all their difficult feeding cases could have
been averted had the pediatrician had the opportunity
of supervising the infants' fare from birth. Though
there might be some question as to the advisability of
the obstetrician turning over all his infants at birth to
the pediatrician, there could be no question but that
both the infant mortality and morbidity might be
lowered by doing so when the infant was two weeks
of age. That was, whenever the obstetrician discharged
the mother he might recommend that a pediatrician be
consulted who should give the infant a thorough
physical examination and also give dietetic and hygienic
advice for future use. The follow-up work which the
Babies' Welfare Association was now doing was a step
in the right direction so far as public institutions were
concerned. This organization had cared for four thou-
sand cases last year, and this year the numbers were
growing as the work was becoming better known. In
the opinion of the essayist the proper correlation of the
pediatrician and the obstetrician might be brought
about in the following ways: (1) By giving as much
careful attention to the appointment of the pediatric
staff of the lying-in hospitals as was given to the ap-
pointment of the obstetrical staff. (2) The pediatrician
once having been appointed should make his daily
rounds and study and observe his cases from a clinical,
laboratory, and pathological standpoint, as he was now
doing in his own children's and babies' wards. (3) The
obstetrician should educate the laity to expect his
duties to end, so far as the infant was concerned, after
it had been washed and dressed, with the possible ex-
ception of the rare of the cord. (4) If the obstetrician
cared for the infant as well as for the mother up to the
time that the mother's convalescence was completed,
he should recommend that the infant be then put in the
care of a pediatrician.
On the Need and Value of Systematic Prenatal Care.
— Dr. RALPH Waldo Lobenstine read this paper in
which he said that to be of real value prenatal care
must be systematic, intelligent, and untiring. The whole
scheme of prenatal care must begin with intelligent
understanding and cooperation on the part of tne ex-
pectant mother. In order to accomplish the best results
not only must the women of the community be aroused
but the doctors themselves. There had been a failure
to recognize the fact that prenatal care would prevent
the development of, or at least lessen the frequency of,
many of the serious complications of pregnancy, would
prevent many unnecessary maternal deaths, would pre-
pare the mother for labor, lessen invalidism, and exert
a deep influence on the welfare of the infant. It was
truthfully claimed that 90 per cent, of American women
were absolutely without proper prenatal care. Of all
the progressive countries the United States was the
most backward in this regard. The finest skill at the
time of delivery might not and frequently did not save
the life of the child, or even that of the mother, when
prenatal care had been insufficient or entirely wanting.
Health statistics were particularly difficult to deal with
in this country because of the incomplete registration
area and because even in this area birth records and
still-birth records were very incomplete. We had prac-
tically no record of the large number of abortions,
spontaneous and induced, that occurred annually. Bacon
of Chicago, however, in a careful statistical study, esti-
mated that annually approximately 80,000 infants lost
their lives at the time of birth or during the first two
weeks post partum as the result of injury at the time
of birth. If to this number were added those that died
i?i ute.ro prior to the onset of labor, there was probably
an annual loss to the country of 150,000 infants. To
this number must be added the great number of early
miscarriages, which, when spontaneous, were more or
less dependent on the same causative factors as were
to be found in the case of the non-traumatic still-births
and subnormal infants. According to the Children's
Bureau in Washington among all babies dying under
one month of age nearly three-quarters died of causes
operative before birth. In the larger proportion of
cases these causes were malformation, congenital de-
bility, premature birth, and injuries at birth. The
causes of death in the newborn during the first four
weeks of life appeared then to be due not to diseases
successfully attacking a previously healthy child, but
to physiological unfitness in the newly born to maintain
an independent existence. Actual death was one thing,
but we had another problem in the child that lived for a
while or for many years, immature in body and mind,
or actually deformed. These abnormal or subnormal
beings were thus partly because of causes over which
we had more or less control, and partly because of
factors arising in the course of pregnancy over which
we might at times be almost powerless. The more
common antenatal causes of death were syphilis, alco-
hol, renal and cardiac disease, sexual excess, deficiency
in food supply of the mother, subnormal state of the
father, as well as of the mother, at the time of con-
ception, and bad physical environment during preg-
nancy. The less tangible antenatal factors were
gonorrhea, the heavy use of tobacco, opiates, and the
complex toxemias of pregnancy. The essayist consid-
ered these factors more in detail and expressed the be-
lief that even the so-called low grade toxemias of preg-
nancy were often responsible for conditions of mal-
nutrition, acidosis, and hemorrhagic disease and had
received far too little attention. Syphilis and gonorrhea
together were responsible for over 50 per cent, of spon-
taneous abortions and premature interruptions of preg-
nancy, and in addition for the high infant mortality
during the early weeks of life. The evil effects of over-
fatigue had commonly been disregarded. Freedom from
anxiety, particularly during the last six weeks of preg-
nancy, not only assisted the parturient herself but
reacted in a most gratifying manner upon the offspring.
The ultimate blame for this high mortality in both
mother and child was to be explained by the ignorance
or indifference on the part of a large section of the
community, in matters concerning parturition; poverty
with its perplexing problems; insufficient obstetrical
training of the physician; the midwife question, and
lack of prenatal care. The remedy lay in publicity
without exaggeration, general improvement of social
conditions, and in the gradual elimination of the mid-
wife. They should work with this end in view, but in
the meantime, an adequate practical plan should be
developed in order to offer these poor patients safer
medical attention, greater hospital facilities, and more
adequate home nursing. National legislation would ac-
complish much and an ever closer cooperation between
milk stations, prenatal clinics, social workers, doctors,
and midwives would gradually nlaee the latter in their
proper sphere, namely, that of trained obstetrical at-
tendants. The status of the doctor called for serious
Aug. 19, 1916]
MEDICAL RECORD.
349
consideration. The disheartening conditions to be found
among doctors practising obstetrics in this class of the
community were due to circumstances brought about
partly by faulty training and partly by sociological con-
ditions. If in many instances the doctor was no better
than the midwife it was not primarily the doctor's
fault, unless he was guilty of criminal negligence. It
was a singular fact that so much time was devoted in
our medical schools and hospitals to general surgery
and so little to practical obstetrics, when the latter
would be needed in a far greater degree. It was also
strange that so few of our fine general hospitals were
willing to receive confinement cases. They seemed to
regard obstetrical cases as more or less of a nuisance,
and did not appreciate the importance to the community
of the proper care of these patients. Every woman
should find it possible to obtain regular, systematic,
prenatal care during the greater part of her pregnancy
and should be urged to seek this guidance and to seek
it early in pregnancy. The best solution of the ques-
tion of the care of maternity cases in their homes might
prove to be some form of industrial insurance, such as
was being carried out, for example, at the present time
by the Metropolitan Life Insurance Company.
Accidents and Diseases of the Early Weeks. — Dr.
L. E. LaFetra read this paper in which he said that
injury of the infant was the result of prolonged labor,
especially dry labor, difficult forceps extraction, abnor-
mal presentations, and difficult extraction of the after-
coming head. Injury also resulted from compression
of the umbilical cord, particularly when the cord was
tight around the neck. Forceps were less a cause of
injury than failure to use them early in case of difficult
labor. The essayist then discussed injuries under three
groups, those affecting the head, the neck, and the
extremities. In discussing injuries of the head, he
pointed out that cephalhematoma might be distinguished
from fracture by its limitation to the separate cranial
bones and by the fact that the floor of the swelling was
on the same level with the rest of the skull. Fracture
of the cranial bones was not frequent, was practically
always depressed, and was frequently accompanied by
signs of intracranial hemorrhage. The elevation of the
depressed bone could be accomplished most success-
fully by the strong hook devised by Dr. Kosmak. The
serious injuries to the head were those which resulted
in intracranial hemorrhage either meningeal or cerebral.
The loss of the sucking reflex was the most important
sign of serious brain lesion. Absence of pulsation in
the fontanelle was commonly present. Localization of
the site of the hemorrhage was often not possible, but
when it could be localized immediate operation was
indicated. The commonest result after recovery from
brain hemorrhage was spastic paralysis of one side of
the body or of both extremities. When more than two
extremities were involved there was always mental im-
pairment. In discussing injuries to the neck, Dr.
La Fetra said that ruptures of the cords of the brachial
plexus occurred when pressure or traction was put upon
the neck with the head rotated. This resulted in
brachial paralysis with flaccid shoulder and inverted
hand hanging limp at the side. Dr. Alfred Taylor had
secured good results from operating on some of these
bad cases. The essayist then called attention to the
congenital defects to which the newborn infant was
subject, such as congenital heart disease, congenita!
hypertrophic stenosis of the pylorus, spina bifida, cleft
palate and hare lip, club foot, chondrodystrophy and
Mongolism. Constitutional disease was shown specially
by syphilis, but also by sclerema and general debility.
Among the acquired diseases the most important in the
early days of life were the acute infections, including
gonococcus, opththalmia, and vaginitis, the former of
which would be entirely prevented if physicians were as
careful about instilling nitrate of silver as all midwifes
were required by law to be on penalty of losing their
licenses. Erysipelas was not frequent, but was
peculiarly fatal in young babies. Tetanus was
formidable, but less so since the antitoxin was used
intraspinously. Sepsis in infants might be caused by a
great variety of germs; the infant might be born septic
or might become infected through aspiration of infected
liquor amnii. The umbilical cord was the most fre-
quent port of entry for sepsis, and next in frequency
was the skin. Sepsis in the newborn occurred in many
forms; some cases ran their course without symptoms
or with only a little fever; others showed signs of sup-
purative pylephlebitis, acute gastrointestinal disease,
or of pneumonia, especially bronchopneumonia. Other
patients showed the symptoms of meningitis, and still
others were cases of hemorrhagic disease with or with-
out a combination of the meningeal, pulmonary, or
intestinal symptoms. Occasionally sepsis affected the
joints, bones, or the tissues near the joints. In the
treatment of sepsis prophylactic measures were the
best. The most promising treatment was either trans-
fusion or the injection of normal blood or serum. In
order to better emphasize the clinical significance of
some of the injuries and diseases already mentioned,
Dr. LaFetra discussed more fully certain symptoms,
namely, cyanosis, convulsions, hemorrhage, and vomit-
ing. He stated that convulsions and cyanosis occurred
in many of the same conditions. They might arise
from intracranial hemorrhage, due to birth injuries or
to sepsis, it being difficult to separate the two causes,
but in the cases due to sepsis the symptoms came on
several days or weeks after birth instead of at once.
Both hemorrhagic disease and hemophilia were now
treated by the injection of human blood or blood serum,
obtained from some member of the patient's family,
or if this was not available, diphtheria antitoxin had
been very satisfactorily used in many cases. The use
of the whole blood was more convenient and could be
employed with less loss of time, according to the sug-
gestion of Dr. Oscar M. Schloss, who used from 10 to
30 c.c. every four to eight hours as long as the
hemorrhage continued. He had not had any bad
results. Dr. LaFetra said he had had excellent results
in several cases at Bellevue Hospital, not only of
hemorrhagic disease but of general debility and sepsis,
with the use of blood or blood serum. The modern
treatment of hemorrhages when due to syphilis was the
injection of salvarsan or neosalvarsan intravenously
together with the use of inunctions of mercury com-
bined with the injection of blood or blood serum. Many
a life was now saved by these procedures which for-
merly would surely have been lost. In considering the
significance of vomiting, the writer said that occasional
vomiting was met with in all infants whether they were
nursed or bottle fed, but there was a type of vomiting
which was persistent and not controlled by any simple
measure. He then described the projectile vomiting
characteristic of pyloric stenosis, and stated that the
important signs in the diagnosis of this condition were
projectile vomiting without evidences of indigestion,
visible peristalsis, and palpable pylorus. In addition
to these symptoms, obstinate constipation and the find-
ing of food remains in the stomach several hours after
feeding were important. The x--ray after the bismuth
meal might show the stenosis beautifully. Since at the
onset it was impossible to distinguish between hyper-
trophy combined with spasm of the pylorus and spasm
alone, the aim of conservative treatment must be to
prevent all irritation of the pyloric end of the stomach
by food remains or acid products of gastric digestion.
In addition to dietetic measures, treatment should be
directed to removing acid mucus, to rendering the pylo-
rus less sensitive, and to relaxing whatever spasm was
present. Dr. La Fetra said his personal experience
with pyloric stenosis comprised eighteen cases. These
could be divided into two groups: First, those in whicH
the spasm was the prominent feature, and, second,
those that had spasm and hypertrophy in which the
hypertrophy either was or became the most prominent
feature. Of the cases with spasm alone, or spasm with
some hypertrophy, there were ten; all of these except
one recovered without operation. In two of these cases
operation was advised by other consultants because of
the marked peristaltic waves, and the hard spool repre-
senting the pylorus. Five years had elapsed with one
of these patients and four with the other, and the chil-
dren were in perfect health. The patient that died had
severe spasm with marked peristaltic waves, but no
tumor and necropsy showed a normal pylorus. Of the
cases in which the hypertrophy was the prominent fea-
ture, seven were operated upon and six died; the other
patient died while the surgeon was deciding whether
the case needed operation. In the writer's opinion oper-
ation was absolutely indicated as offering the only hope
of recovery in all cases in which hypertrophy was the
prominent feature. The most important indications for
operation were progressive loss in weight together with
the absence of food residue in the stools. The after
care of operated cases was extremely important, careful
feeding, extreme quiet and the employment of the Mur-
phy Drip being of extreme importance.
Observations on Conditions in the Newborn, with
Special Reference to the Comparative Value in Methods
of Treating the Umbilical Stump. — Dr. John O. Polak
of Brooklyn read this paper. He said that to be ac-
350
MEDICAL RECORD.
I Aug. 19, 1916
cepted as satisfactory any method of treating the navel
cord must show improved morbidity records on the fol-
lowing points: (1) The temperature of the child during
the desiccation period; (2) the degree of icterus and
the time of its disappearance; (3) the day on which the
slough separates; (4) the condition of the stump after
separation; (5) the frequency with which hernia fol-
lowed, and, finally, the influence which the particular
method had upon the body weight of the fetus. At the
Long Island College Hospital, during the past five years
he and his associates, Dr. Beck and Dr. Hefter, had
given four methods a trial and had kept careful records
of their results. In their first series they cut the cord
at a distance of seven or eight centimeters from the
umbilicus, tied it near its distal end and then turned
the cord over and tied it a second time, proximal to the
first ligature, with the ends of the one placed at the
distal end. The loop of the cord thus made, after being
wrapped in gauze soaked in alcohol, was laid over the
left side of the infant's abdomen, and a bellyband sewed
on. Later they had employed the single ligature of the
cord. After stripping the cord of Wharton's jelly, a
ligature of narrow tape was applied at a distance of two
and one-half centimeters from the navel. The sterile
dressing was applied as in the first series. Later they
had employed a method suggested by Dr. Dickinson
which consisted in clamping the cord at birth and wrap-
ping it in sterile gauze until the obstetrician had cared
for the mother. Then donning fresh gloves the operator
made an incision through the amniotic covering at the
skin margin. The vessels were then isolated and ligated
with iodized catgut. The cord was then cut away
distal to the ligature, the vessels allowed to retract, and
the skin margin closed with sutures. A sterile dressing
completed the operation, after which the binder was
sewn on. This method was ideal as a surgical proced-
ure, but opened up too many possibilities to trust to an
interne for its performance. Since last June Dr. Polak
said they had modified this method in the following way:
The cord was clamped at birth, and with forceps at-
tached and wrapped in sterile gauze, the child was put
aside while the mother was cared for. Then with sterile
gloved hands the cord was stripped of its jelly, and a
fine nosed Kelly clamp was placed on the cord at the
amniotic junction, after first being assured of the ab-
sence of any navel cord hernia. This clamp compressed
the cord, expressed the Wharton's jelly from the area to
be ligated and gently crushed the vessels. When the
forceps were removed an iodized catgut ligature was
firmly tied in the crease thus made and the cord cut
away with a knife just distal to the ligated vessels. The
sterile dressing and binder were applied as in the previ-
ous methods. This dressing was not disturbed until it
became soiled, when it was replaced by a similar one.
Dr. Polak said the comparative table presented com-
prised data with reference to 176 cases treated by this
new method and 125 treated by the old one. These data
showed that the latter method gave as good results as
that of Dr. Dickinson. In 176 cases the cord dropped
off between the third and fifth day, there was no slough-
ing mass, or excessive granulations; as compared with
21 cases in the series of 125 by the old method, infection
had been absent, icterus markedly diminished, and the
regain of the birth weight had been uniformly more
rapid than when a large mass of navel string had been
allowed to slough. Theoretically there should be fewer
hernia as the umbilical opening was not kept patent by
a mass of granulating tissue. Since the mouth was an-
other avenue of infection and the epithelium the in-
fant's sole protection against infection we should guard
against its injury by the over-diligent nurse who at-
tempted to cleanse the mouth of mucus with a gauze
covered finger. The primary inspired mucus might be
gotten rid of by inversion of the child, and stroking of
the thorax and neck from the abdomen toward the head,
or by aspiration with a catheter. For nearly two years
they had discarded the practice of washing the baby's
mouth before and after nursing, depending wholly upon
a sterile nipple to safeguard both mother and child
from infection. As a result of this there had been a
marked diminution in the occurrence of thrush. In
speaking of hemophilia, Dr. Polak said that they had
found that the daily examination of the infant's stools
by their resident had enabled them to find the first signs
of blood, and they felt that not a few babies' lives had
been saved by this daily inspection. With the first ap-
pearance of blood whole blood from the mother was
given subcutaneously into the child, preferably in the
region of the back. In severe cases of hemorrhage they
had found that a combination of mother's blood, subcu-
taneously, in 10 c.c. doses, three or four times daily, with
transfusion of the infant, injecting the blood through the
anterior fontanel into the longitudinal sinus had been
life-saving.
Care and Feeding During the First Month. — Dr.
Godfrey R. Pisek presented this paper. He said that
it would be conceded that the first month in the infant's
life was the most important from the standpoint of car«
and feeding. It was shown by the latest available
statistics for the first month of life in- Greater New
York, that for the first eleven weeks of 1916 the deaths
under one month numbered 1,199, against deaths under
one year of 2,787; in other words almost 50 per cent, of
the deaths occurred in the first month of life. This high
mortality could only be lowered by active measures of
correction and prevention. Although the attitude of
pediatricians had changed considerable during the past
five years in the artificial feeding of infants, there was
a unanimity of opinion that breast milk was the infant's
birthright which it should not be denied. Infants were
still removed from the breast by physician or nurse for
insufficient reasons, despite the fact that 85 per cent, of
all infantile deaths were those artificially fed. The mod-
ern mother was usually not ignorant of the advantages
of breast feeding and was usually eager to cooperate in
preserving the supply. By the addition of one or at most
two bottles a day the supply could be kept up and at the
the same time allow a period of freedom for the mother.
Dr. Pisek said his private case book showed that 30 per
cent, of the babies received their mother's milk onlyj
48.8 per cent, were on the bottle and breast, and 22.5 per
cent, were receiving the bottle exclusively. While these
figures might vary somewhat in different localities, they
showed that breast feeding was on the increase among
those who had been accused of shirking their responsi-
bilities. It was a mistake to remove the baby from the
breast because milk had not appeared in forty-eight or
seventy-two hours after birth, or because there was some
vomiting after birth, or because of one hasty or inac-
curate examination of the milk, or because the mother
or attendants "think the breast milk does not agree."
Every effort should be made to enable the infant to have
the breast alone or at least part breast feeding during
the first month of life, for, while the infant might appear
to do well for a week or ten days on a formula, its re-
sistance then broke down and its digestion became sadly
disturbed and was difficult to correct. Complete empty-
ing of the breasts was the best way of securing a good
supply of milk. If artificial milk must be supplied it
should not be in the form of rich top milk mixtures, but
rather a weak formula, low in fats and proteins,
although high in sugar. Only after it was certain that
the infant had adapted itself to cow's milk should the
strength be increased in the other elements. The
healthy new-born infant could be trained to take the
breast at four-hour intervals, but this was not the
natural interval, the three-hour interval being prefer-
able. In order to determine in questionable cases just
how much milk the infant was receiving, it should be
weighed before and after nursing throughout one whole
day at least. The :r-ray had shown conclusively that
babies could take an amount of milk far in excess of
their rated gastric capacity because the milk tended to
pass at once into the duodenum. Mixed feeding should
not be introduced during the first month if it could be
avoided since greater resistance was obtained after a
month or two on the breast alone. More than one or
two bottles a day were likely to diminish rather than to
increase the milk supply, because the breasts would not
be thoroughly emptied. If it had been satisfactorily de-
termined that the secretion was constantly deficient,
then a bottle feeding should follow each nursing period.
If circumstances demanded artificial feeding during the
first month of life the physician must recognize the im-
portance of the problem, since one mistake at this pre-
carious period might endanger the life of the infant.
The new born infant should not be given such an amount,
of food as would produce a gain in weight; the caloric
requirements were not to be fulfilled until the end of the
second week. Boiling the milk during these first weeks
was often necessary in order to prevent the formation
of tough curds. All were agreed that the cleanest and
most wholesome milk obtainable was the suitable milk
for infant feeding. The treatment of such milk would
depend upon the necessity of preserving it. or it? modi-
fication by a degree of heat which would so alter its
properties as to meet the demands of the individual
infant. The amount of food allowed would depend on
the period selected and should be calculated on a twenty-
four hour basis. A baby during its first week would
Aug. 19, 1916]
MEDICAL RECORD.
351
take ten to twelve ounces daily; in its second and third
week from twelve to sixteen ounces; and when a month
old twenty ounces. Proprietary foods were often seem-
ingly successful, particularly when of the carbohydrate
variety, because of the large amount of dextrimaltose
which they contained, or because of their colloidal action
on milk, but it should be remembered that giving an
infant some sort of food that would be retained and
cause a gain in weight was not necessarily good infant
feeding. The food must contain enough protein and
mineral matter to repair waste and produce new tissue,
and enough fats and carbohydrates to supply energy.
At no time was it as necessary to inculcate regularity
of habits and to abide by the laws of hygiene as in the
first month of the baby's life. The obstetrician and the
pediatrician must join hands, for on them devolved in a
large measure the responsibility of reducing the mor-
tality of the new born.
Remarks on the Occurrence of Syphilis in the Mother.
— Dr. J. R. LosEE read this paper in which he referred
to the many theories on the transmission of syphilis
from the parents to the offspring, but said that for the
present it was necessary to reason from the history and
the clinical findings. There was no definite means by
which a parent subject to latent syphilis could be assured
that all his children would be born free from any mani-
festations of the disease. The theory that the spermatic
fluid affected the ovum which went on to the develop-
ment of a fetus, which in turn affected the mother
seemed hardly possible. The maternal theory according
to which the mother was infected primarily and the
fetus secondarily was quite probable and very easy to
explain. As most of the still-births from syphilis took
place in the latter months of pregnancy, it was fair to
assume that the fetus was infected from the mother
through the placenta, but whether the placenta could
transmit spirochetes without showing pathological evi-
dence of it was an unanswered question. A considera-
tion of the effect of syphilis on the offspring included
both the transmission of the infection in its active form,
or the transmission of the latent form of the disease.
Comparatively few infants born of syphilitic parents
went through life without at some time presenting
symptoms of the disease. Maternal syphilis had always
been considered to play a considerable part in the eti-
ology of abortions, macerated fetuses, premature births,
and still births, but it was fair to assume that the same
etiological factors were present which had been said to
cause abortions in nonspecific women. Intrauterine
death of the fetus from the sixth month to term had
long been known to be due in most instances to syphilis,
and 35 to 40 per cent, of still-born children were due to
syphilis. In the past year, of twenty-seven women who
were delivered of macerated fetuses at the Lying-in
Hospital, nine gave a positive Wassermann reaction.
Syphilis had been held responsible many times for the
intrapartum death of the infant, but the mechanical
conditions which sometimes occurred during delivery
and which caused asphyxia would have to be excluded
before syphilis could be regarded as the sole etiological
factor. Boardman said that two-thirds of all syphilitic
children were born about the eighth month; at the
Lying-in Hospital in a series of 106 mothers with posi-
tive Wassermann reactions, there were thirty-one living
babies delivered at term; this might appear a rather
large proportion of syphilitic children to reach term, but
some of the mothers had received antiluetic treatment
during the last three months of gestation. Onlv about
28 per cent, of the children born syphilitic survived the
first year. The Wassermann reaction was valuable in
making a diagnosis in doubtful cases, and a four plus
reaction meant but one thing. There had been many
negative reactions in infants whose syphilitic mothers
had received considerable treatment. The spirochetes
might be sufficient in number and virulence to produce
symptoms in the infant and at the same time not pro-
duce enough anti-bodies in the blood serum of the
mother to give a positive Wassermann reaction. Judg-
ing from the Wassermann reaction, syphilis had little or
no part in the etiology of fetal anomalies. At the
Lying-in Hospital, during the past two years the sera
of 2,049 patients were examined, and sixty-four, or 3.05
per cent, gave a positive Wassermann reaction. This
gave one a fair conception of the extent of the disease
among women at the child-bearing age in the lower east
side of the city. The result of the antiluetic treatment
of pregnant women, estimated by the number of children
born with or without symptoms, depended on the amount
of treatment the patient received during pregnancy.
It was believed that salvarsan could be given in moder-
ate doses at intervals of a few days, without danger to
the fetus and without inciting premature labor, but
large doses were dangerous. There was considerable
difference of opinion as to whether salvarsan given in-
travenously to the mother was transmitted to the fetus.
Of ten cases treated during pregnancy, five received
arsenic and mercury from the second month to term;
three gave birth to living babies without symptoms and
with a negative Wassermann reaction; one who was in
the active secondary stage throughout her pregnancy
was delivered of a living baby without symptoms, but
with a positive Wassermann, and one was delivered of a
macerated fetus at seven months. Of the five cases
which received treatment from the seventh month to
term, five living babies were delivered and three gave
positive Wassermann reactions.
Dr. Henry Koplik said that in a large metropoli-
tan city like New York it was astonishing how little
was done for the new-born infant in the maternity hos-
pitals, especially in view of the vast sums of money
that had been put into these institutions and the fact
that no facility had been omitted that would contribute
to the care of the mother; yet very secondary care was
given the infant. He had seen a considerable number of
infants in one small room tucked against the side of the
wall in structures something like waste baskets. He
had also seen ten or twelve babies cared for by a single
nurse who was expected to care for all the wants of all
these infants. Fully 30 per cent, of the infants below
three months of age died during the first month of life,
so that it was highly important to give attention to the
infants in these hospitals. There was little excuse for
sepsis in a modern hospital, yet Dr. Koplik said he
would blush to tell how many cases of sepis he had seen
in these institutions. Again there was little excuse for
artificial feeding in a modern hospital. It was painful
to see the large number of babies on the bottle. It
seemed that if the mother was unable to nurse her baby
mother's milk could be obtained from other sources. In
many hospitals they still relied upon primitive methods
in dealing with hemorrhage and melena. On finding the
first traces of blood the first thing to do was not merely
to stop the bleeding but to place the child in such a con-
dition of resistance that he might be able to combat
other troubles. In addition to more room and better
facilities for the care of the new-born in our hospitals,
the staffs of maternity hospitals should have special
physicians to take charge of the new born and to give
these babies the benefits of modern progress in pedia-
trics. A great deal had been said with reference to
prenatal care, but Dr. Koplik said that, in his opinion,
not much could be done in this direction unless they
could obtain the cooperation of the fathers as well as
that of the mothers. The father must appreciate the
necessity of these things and more could be done by
getting the cooperation of the whole family than by
simply trying to care for the mother and the unborn
infant alone.
Dr. Edwin B. Cragin said that as obstetrician he
would acknowledge that they were under great obliga-
tions to the pediatrist, but he would also like to call at-
tention to the fact that if it were not for the skill of the
obstetrician the pediatrist would not have so many
babies to care for, so that it seemed to him that the
pediatrist was also under great obligations to the obstet-
rician. To judge from the first paper it would seem
that the obstetrician was unfit to care for the baby
during the first month, but if the obstetrician had eyes
and ears and was a keen observer, if he watched the
woman carefully through her pregnancy, if he had the
opportunity of studying from fifteen to eighteen hundred
babies a year, and was any sort of a man, he must learn
quite a little about the care and feeding of the new-born
infant. If Dr. Koplik had made the rounds of these
maternity hospitals he would have found that the babies
were given due consideration and he would have found
that even the "waste baskets" on the walls had their
advantages, since they could be taken off the walls when
the beds were to be made or could be separated to avoid
infection of one baby from another. The properly
trained obstetrician should not be regarded as an incom-
petent care-taker of a baby during the first month.
Many women, much to their regret, could not nurse their
babies. At the Sloane Maternity they could not get
breast milk enough. Whether because of the nervous
strain and high tension of modern life, or whatever the
cause, the fact remained that fewer mothers were able
to nurse their babies than ten years ago. Breast milk
was difficult to buy and what could be bought was
usually taken for private patients.
352
MEDICAL RECORD.
[Aug. 19, 1916
Dr. Polak spoke of having dispensed with the habit
of swabbing babies' mouths. For a number of years
they had not allowed the nurses to swab the babies'
mouths either in the delivery room or before or after
nursing. Less than a month ago the head nurse com-
plained that they were having more cases of thrush than
they ought to have and they were now allowing the
nurse to cleanse the mouths of the babies with sterile
cotton and boric solution once a day at the time of the
bath. This was simply an instance of one of the prac-
tices which we discard and then go back to later on.
The duty of the obstetrical hospital today was to get
the mothers early and surround them with every possi-
ble care. A Wassermann test should be made in the
case of every patient early in the course of pregnancy
both for the welfare of the mother and for that of the
baby. Moreover it was of great interest to the hospital
because a baby apparently healthy at birth might be
sent out of the hospital and then given to a foster
mother and give that foster mother syphilis; hence the
making of a Wassermann test was extremely important.
Having followed the woman during her pregnancy, and
having seen her safely through the puerperium, it was
then their duty to put the mother and baby in touch
with the proper welfare agency or pediatrician, so that
proper care might be insured after the baby left the in-
stitution.
MisreUanii.
The Medical Record is pleased to receive all new
publications which may be sent to it, and an acknowledg-
ment will promptly be made of their receipt under this
heading; but this is with the distinct understanding that
it is under no obligation to notice or review any publica-
tion received by it which in the judgment of its editor will
not be of interest to its readers.
Obstetrics, Normal and Operative. By George
Peaslee Shears, B.S., M.D. Published by J. B. Lip-
pincott Company, Philadelphia and London. Illus-
trated. Price, $6.00.
Burdett's Hospitals and Charities, 1916. The
year book of philanthropy and hospital annual. By
Sir Henry Burdett, K.C.B., K.C.V.O., twenty-seventh
year. Published by the Scientific Press, Ltd., 28 and
21) Southampton St., Strand, W. C. Price $2.00.
Text-Book of Physics and Chemistry for Nurses.
By A. R. Bliss, Jr., Ph.G., Ph.C, A.M., Phm.D.,
MD., and A. H. Olive, A.B., A.M., PhC, Phm.D.
Published by J. B. Lippincott Co., Philadelphia and
London 49 illustrations. 239 pages. Price, $1.50 net.
Surgical and Gynaecological Nursing. By Ed-
ward Mason Parker, M.D., F.A.C.S., and Scott Dud-
ley Breckinridge, M.D., F.A.C.S. Published bv J. B.
Lippincott Co., Philadelphia and London, with 134 illus-
trations in text, 425 pages. Price, $2.50 net.
.Metropolitan Water and Sewerage Board. Fif-
teenth annual report for the year 1915. Published by
Wright & Potter Printing Co., State Printers, 32 Derne
St., Boston, 1916. Public Document No. 57. 224 pages.
Hospital Laboratory Methods for Students,
Technicians and Clinicians. By Frank A. McJun-
kin, A.M., M.D. Published by P. Blakiston's Son &
Co., 1012 Walnut St., Philadelphia. One colored plate
and ninety-three illustrations in text. 139 pages. Price,
$1-25 net.
Catarrhal and Suppurative Diseases of the Ac-
cessory Sinuses of the Nose. Bv Ross Hall Skil-
lern, M.D. Published by J. B. Lippincott Co., Phila-
delphia and London. Second edition, thoroughly re-
vised, with 287 illustrations. 417 pages.
The Clinics of John B. Murphy, M.D. , at Mercy
Hospital, Chicago. Edited by J. G. Skillern, Jr.,
M.D., of Philadelphia. Published bi-monthly by W. b!
Saunders Co., Philadelphia and London. June, 1916.
Vol. 5, No. 3. Illustrated. 549 pages. Price, $8.00
per year; foreign, 35 shillings.
Sti dies prom Rockefeller Institute for Medicax
Research. Reprints Vol. XXI II. Published by the
Rockefeller Institute for Medical Research. New York
1916. Illustrated. 506 pages.
Skin Cancer. By Henry II IIa/.en, A.B., M.D. Pub-
lished by C. V. Mosby Co., St. Louis, 1916. Ninety-
seven text illustrations and one colored frontispiece
251 pages. Price, $4.00
Tm. Dream Problem. By Dr. A. Maeder, Zurich.
Published by Nervous and Mental Disease Publishing
Company, New York. Price, 80 cents.
The New York State Hospital Commission, in
conjunction with the State Charities Aid Associa-
tion, has recently established a mental clinic in the
out-patient department of the Williamsburg Hos-
pital, Brooklyn, under the charge of Dr. E. M.
Somers, superintendent of the Long Island State
Hospital, and Dr. W. A. Macy, superintendent of
the Kings Park State Hospital. There are now
three mental clinics in Brooklyn, the others being
at the Long Island College Hospital and the Long
Island State Hospital, and at all of these free advice
and treatment with respect to incipient mental con-
ditions are given with the hope of preventing com-
plete mental breakdown in the patients coming to
the clinic. After care among the insane is also a
feature at these clinics and social workers are em-
ployed.
Infantile Scurvy and Pasteurized Milk. — In the
discussion of a paper by Dr. Funk on "Vitamines,
a New Factor in Nutrition," at the Academy of
Medicine, Dr. L. Emmett Holt expressed the opin-
ion that infantile scurvy was undoubtedly on the
increase in this city and that the increase was due
to the exclusive use of pasteurized milk in the
artificial feeding of infants. That this conclusion
is probably correct is indicated by the interesting
clinical observation reported by Dr. Alfred Hess
at the same meeting. Hess found that a mild
grade of scurvy developed in a group of infants
artificially fed on pasteurized milk and barley
water, while a control group, to whose diet orange
juice was added, but who otherwise received the
same milk modifications as the first group, re-
mained entirely free from scurvy.
Among the infants in the first group the scorbutic
symptoms promptly disappeared on the administra-
tion of orange juice.
Most of the cases of infantile scurvy now being
encountered are of a milk type; so mild, in fact,
that many of them escape recognition even at the
hands of experienced physicians. On the other
hand, the dangers of milk-borne disease are real,
and constantly carry with them a grave menace
to life through tuberculosis, typhoid fever, septic
sore throat and other infectious diseases. In con-
trast to this we have a mild grade of scurvy which
can readily be prevented or cured by the addition
of a little orange juice to the diet. Furthermore,
a safe raw milk (guaranteed or certified) is avail-
able for those cases in which pasteurized milk
even with the addition of ample antiscorbutics
does not meet the requirements. Such cases must
be extremely rare.
Instructions have been given by the Depart-
ment of Health to the physicians and nurses in
charge of its milk stations and of the baby wel-
fare work in the homes to be on the alert for any
of the early signs of scurvy and to insist upon the
use of orange juice or other suitable antiscorbu-
tics when babies are exclusively bottle-fed on
pasteurized milk. While the Department of Health
has no intention, therefore, of altering its policy
with regard to pasteurization, physicians may
rest assured that it likewise does not contemplate
or look with favor upon any administration of
milk control in any community which eliminates
the privilege of securing a safe high-grade raw
milk for those whose lives may depend upon its
use. — Weekly Bulletin of the New York City De-
partment of Health.
Medical Record
A Weekly Journal of Medicine and Surgery
Vol. 90, No. 9.
Whole No. 2390.
New York, August 26, 1916.
$5.00 Per Annum.
Single Copies, 15c.
©rigutal Artirka.
SEBORRHOIC DERMATITIS.
By WILLIAM P. CUNNINGHAM, A.M., M.D.,
NEW YORK.
ATTENDING DERMATOLOGIST TO THE MISERICORDIA HOSPITAL.
In my student days we had a ridiculous bit of
doggerel which ran about like this : "All I know
is Syphilis and Eczema ; and I can't tell which from
which; except by the fact that Eczema itches and
Syphilis does not itch." In our boastful contempt
for the science of dermatology we would chant
this shameful confession of puerile immaturity
and stupid self-sufficiency. We didn't give a straw
for dermatology and we gloried in our ignorance.
What enthusiast for humanity would waste any of
his valuable time in pursuit of such an ignoble
object as the relief of itching? There were many
loftier ambitions in medicine than that! There
were the grave diseases that threatened life to be
mastered ; there was the magnificent art of surgery
beckoning to our mounting souls! Fudge for pim-
ples and pruritus ! With a steadfastness worthy
of our high ideals we clung to our haughty aloof-
ness and graduated in disdainful darkness on the
whole distasteful topic. This most of us retained
in our day of early dreaming of the dazzling of the
world ; and in that later day of disillusionment
when during the grind of an active practice we
discovered the need but lacked the time to repair
our blunder. We soon found that the big things
were in the hands of a few men, that the common
run of human ills were ours to alleviate. We many
times found acne staring us in the face. We were
many times embarrassed by our inability to relieve
the itch of a patient whose esteem meant much to
us. We realized too late that there is an imposing
number of complaints disturbing the pride and
comfort of the patient that must be attended to
as zealously as the graver abnormalities that
jeopardize existence. Where itch "hath murdered
sleep" the application is obvious. But even the de-
mands of vanity have frequently a substantial
basis of economic importance. Socially girls with
acne are badly handicapped. They may be over-
looked in the matrimonial quest. They are not
sought after in business. They often lose excel-
lent opportunities for material and professional ad-
vancement. Men, too, with their reputed contempt
for the lighter conceits of life are sometimes seri-
ously hampered by the presence of disfiguring erup-
tions. Aside from their unsightliness, they are
needlessly mistaken for contagious conditions and
their victims are cruelly avoided. It is superfluous
to state that itching dermatoses do not enhance the
winning ways of business or social intimates. The
person who is given to scratching is looked upon
with disapproval and distrust. Such a person will
soon face the alternative of quitting the practice
or quitting his job. Driven by the double incen-
tive of seeking relief and saving his occupation
he will demand instant results at the hands of the
doctor. And if the doctor is one of those high-
minded scientists with a contemptuous disregard
for the little things of life he will find himself
facing the alternative of losing a profitable patient
or condescending to investigate what he had here-
tofore despised. In short, he is jolted into his
senses by the discovery that, to the patient, this
persistent irritation is one of the big things of life :
that it is just as essential to his health and happi-
ness to cure him as it is to operate for appendi-
citis on an enlarged thyroid. The present ill is
the biggest ill to the exasperated sufferer and he
will not hesitate to assert that he would sooner
have a serious condition and be done with it than
be an object of suspicion and dislike. Opportuni-
ties are seldom vouchsafed the busy practitioner
to retrieve his deficiences, and it is almost certain
that unless he happens to hit upon the proper treat-
ment by a lucky chance, he will be chagrined by
the defection of his patient into other and prob-
ably no worthier hands.
The blame for this costly lack of practical knowl-
edge rests squarely upon the shoulders of the fac-
ulties of our medical colleges. Students on grad-
uating have some acquaintance with the eye, ear,
throat, nose, rectum and generative apparatus, and
are capable of delivering at least a glancing blow
at the diseases appertaining thereto. But in the
matter of the skin their ignorance is proportionate
to the apathy of their instructors. Both are the
victims of an error of mental refraction whereby
the perception of relative values is badly obscured.
And yet this defectively equipped practitioner, un-
less all his time is taken with the demands of his
business (when it is obvious he will not feel his
lack), may with a little attention learn many use-
ful lessons as it were on the wing, which will serve
him profitably on occasion. Familiarity with cer-
tain common forms of skin disease is readily ac-
quired and cannot fail to prove a valuable asset.
For example, the subject of this paper if properly
grasped, will furnish the means of deciphering
many otherwise inexplicable conditions.
Seborrhoic dermatitis is frequent. It occurs at
all ages. It has well-marked characteristics which
are usually in evidence. It has no mysterious in-
ternal causation. Its origin is local. It begins upon
the scalp. Thence it descends by the scattering of
the scales to contiguous and even remote locali-
ties. The chief distinguishing feature of a typical
case is a greasy scaliness. There is a dermatitis
accompanied by an increased flow of the natural
cutaneous lubricant — the sebum. This partly dries
and thus forms scales or crusts that are unctuous
354
MEDICAL RECORD.
[Aug. 26, 1916
to the touch. At times the dermatitis predomi-
nates and the drying is more complete and the
scales are finer and crisper. Beginning as it al-
ways does upon the scalp it first produces an annoy-
ing oiliness which resists stubbornly all our efforts
at control. Soon the hair begins to fall. Later
there is an alteration in the exudation and it loses
its pronounced greasy character and forms a fine
bran-like scale popularly known as dandruff. And
still the hair continues to fall. This is the threat-
ening condition for which assistance is oftenest
sought. The grease may be combated finally by
persistent washings, and the dandruff may be
zealously brushed away, but the thinning of the
hair excites the gravest apprehension among men as
well as women, and they frantically demand its in-
hibition. This is not prompted solely by vanity
but by the dread of the effect of the signs of age
upon business opportunities. It is usually main-
tained that with the advent of maturity depart the
vim and push of youth. It is a curious commentary
upon the sinuosity of human intellection that the
very men who entertain that opinion would be
shocked at its application to themselves. In pass-
ing it may not be amiss to reflect that the weak-
ness that we contemn under the name of vanity
may be in reality only another phase of that strug-
gle for existence, and for the supremacy of the
fittest that is so relentless among us. The woman
paints her face to extort observation and admira-
tion. She seeks the glances of the male. Behind
this is more than the childish desire for approval.
She is following the world-old impulse of her sex
to attract a mate and protector. We concede that
she is mistaken in her method, but there is no
gainsaying the motive.
The cause of the falling hair is the situation of
the disease in the sebaceous glands and the hair
follicles. The sebaceous glands open in the neck
of the follicles and the hair is destroyed by the in-
flammatory action and by the alteration in the
quantity and consistency of the sebum. It is
swamped or choked accordingly as the exudate is
profuse and oily or scanty and dry. The follicle
is wrecked by the disturbance within it. The
struggle is to a finish and the follicle does not
"come back." The thinning of the hair is most
pronounced upon the vertex, but may be pretty
even all over the scalp, especially in women. Some
itching is usually associated with the disease; occa-
sionally a great deal. This is the reason for the
evocation of that ridiculous hybrid known as
"seborrhoic eczema." It may be as well to lay the
monster here as elsewhere. There is no such en-
tity as "seborrhoic eczema." Admitting or denying
the oneness of eczema with dermatitis there is no
question that the disease we are considering is a
plain unequivocal dermatitis with a hypersecretion
of sebum. It lacks vesiculation and this distin-
guishes it from that other variety of dermatitis
that we designate "eczema." From the scalp the
process may extend upon the forehead, behind the
ears into the eyebrows and over the face. In these
various situations its appearance may be typical,
namely, that of reddened patches covered with
greasy scales or an intertriginous character may
be acquired behind the ears or a dry scaly charac-
ter upon the cheeks. The skin about the angles of
the nose and mouth may present a patchy look with
a yellowish tinge and a slight furfuraceous scaling.
There is no vesicular oozing. There is very little
infiltration. Itching may be moderate. It is rarely
troublesome. Circles and loops of various sizes are
sometimes noted. Again, in an acute exacerbation
the whole countenance may be involved in one red
and scaling mask. But there is always the element
of greasiness and the absence of vesiculation and
thickening. Corroboration may be found in the
scalp. Extension may take place to the neck either
in patches or by continuity.
On the body the disease is set up by the scales
that drop from the scalp, or are carried down by the
hands or the drawing of the undershirt over the
head. It has a predilection for the sternum axillse,
umbilicus, groins, and interscapular region. In ex-
tensive cases it may be almost universal except
for the palms and soles. These two localities are
never affected. The disease upon the body may be
exactly like that upon the head, or owing to the
friction of the clothing and opposing surfaces and
the retained heat of the covered skin it may present
decided variations. Usually the patches are a yel-
lowish red. Often the yellow is only suggested, not
actually discernible; a distinction that the French
express by the word "nuance." The patches are
round, oval, or irregular, but always with a well-
defined margin. Scaliness is usual and variable.
On the parts exposed to pressure, such as the axilla,
the scales may be removed by maceration, on other
parts they may be removed by the friction of the
clothing; and then we have only the reddened
patches clearly outlined, slightly thickened if at all,
but free from evidences of vesiculation. Some of
the aberrant cases assume fantastic forms, circi-
nate, gyrate, and geographical. If upon examining
a patient you find reddish or yellowish lesions in the
indicated situations, whether scaly or bare, large
or small, and you also find a pityriasis capitis, with
or without a thinning thatch, it is reasonably cer-
tain that you have to do with seborrhoic derma-
titis. "Reasonably certain" is an etymological in-
coherence because certainty is certainty and there
are no degrees thereof. But this mode of expression
will be condoned when it is explained that it is em-
ployed to convey the idea that convincing as clinical
appearances may be there is yet an element of un-
certainty in the diagnosis. Unfortunately some
phenomena of seborrhoic dermatitis so closely sim-
ulate some phenomena of psoriasis that the distinc-
tion is often a matter of opinion. These are called
border line cases both by the men who believe in
their identity and by those who do not. There are
authorities who maintain that psoriasis is a dry
form of seborrhoic dermatitis and that seborrhoic
dermatitis is a greasy form of psoriasis. Others
assert that a true psoriasis develops upon the
lesions of the simulating malady. A real patholog-
ical transmutation has occurred. There are still
others and probably the large majority who stoutly
insist that the two are entirely distinct even when
apparently identical. There have been cases where
the doubt has been resolved only by the recurrence
of psoriasis in an utterly unmistakable form. The
prognosis is entirely different in the two diseases
and it is imperative, aside from the academic in-
terest, to get the diagnosis right. You can assure
the victim of seborrhoic dermatitis that his dis-
ease is curable. To the psoriatic, you can hold out
no such hope. Psoriasis will recur with certainty
at the change of the seasons, and at periods of
mental depression and physical unfitness. The best
that can be looked for is the repulse of the attack
within a reasonable time after its appearance and
the restriction of it to regions that can be con-
Aug. 26, 1916]
MEDICAL RECORD.
355
cealed. This may be accomplished by arsenic
chrysarobin and ammoniated mercury, aided and
abetted by a proper modification of diet. Not only
in the interest of the patient but in the interest
of the physician the distinction between these two
conflicting conditions should be clearly drawn be-
cause it would be humiliating in the extreme to
make a prediction quickly proven to be erroneous.
The obstinacy of psoriasis, its persistent recur-
rences, and its selection of sites avoided by sebor-
rheic dermatitis will definitely establish the dis-
tinction. Psoriasis favors the extensor surfaces of
the limbs. The elbows and knees are rarely exempt.
The eruption may be scanty and the individual
lesions no larger than pin heads, yet these four
locations are nearly always involved. It is a diag-
nostic point of the greatest significance and should
be steadily borne in mind. With a sealing eruption
so situated psoriasis may be proclaimed and de-
fended with the utmost confidence. On the trunk it
is apparently distributed without much choice of
locality. It is somewhat rarer in the areas favored
by seborrhoic dermatitis, namely, the groins
axilla? and umbilicus. It is very rare upon the face.
But we should not overlook its occasional appear-
ance in these unusual situations, especially when it
involves a great deal of the cutaneous surface. As
a general proposition it may be avouched that
seborrhoic dermatitis is thicker in the middle line
of the chest and back and thins out towards the
flanks. Psoriasis reverses this order of progres-
sion. It is thicker on the flanks and thins out
towards the middle line. This peculiar distribu-
tion of seborrhoic dermatitis is accounted for by
the method of its communication from the head to
the trunk. The scales naturally fall more in the
middle line. The contrary course on the part of
psoriasis admits of no explanation whatsoever.
The character of the scale is offered as a differen-
tial point between the two diseases. That of pso-
riasis is dry and pearly. That of seborrhoic der-
matitis is greasy. Even in the so-called seborrhea
sicca the scale on being rubbed between the fingers
reveals its oily composition. In the border line
cases recently mentioned the drying of the scale
may have been so complete as to defeat this means
of comparison. Another method of demonstrating
the significance of the scale is to scratch it with
the finger nail. If it peels off without revealing
a bleeding point it is not psoriasis. If it does re-
veal a bleeding point it is psoriasis. The one ele-
ment of uncertainty in this proceeding is the cir-
cumstance that any scaly lesion will bleed if you
scratch it hard enough. And unconsciously in our
effort to sustain our preconception, we will cheat
by a little extra pressure. So this means of dif-
ferentiation is not to be too confidently relied upon.
On the scalp the two conditions are especially liable
to be confounded because unless the seborrhoic
feature is strongly emphasized, the findings are
remarkably alike. The hair if thick conceals the
conformation of the psoriasis patches, so that
nothing but a more or less dense scaliness is dis-
cernible. In seborrhoic dermatitis, however, there
will sooner or later be noticeable thinning of the
hair. This does not occur in psoriasis. Itching is
present in seborrhoic dermatitis and is rather un-
usual in psoriasis. Considering that the eruption
of psoriasis upon the scalp is frequently the thicker
and denser of the two, it is curious that itching is
absent and that the hair does not fall. The expla-
nation of the hair loss in seborrhoic dermatitis lies
undoubtedly in the relation between the seborrhoic
gland and the neck of the hair follicle. The gland
opens into the neck of the follicle. Involved in the
inflammatory process at its very root the hair is
choked to death. The pressure of the denser
psoriasis patch should, in the very nature of things,
be heavier and if that factor alone were sufficient
to destroy the hair, baldness would be a constant
consequence. A simile might be found in the heavy
mantle of snow that does no damage to the under-
lying vegetation and the cloudless frost that pene-
trates to the heart of the struggling root and nips
its life out. It is true that seborrhoic dermatitis
is observable at every period of life, but it is nat-
urally commoner after the fuller development of
the sebaceous glands at puberty. Many cases oc-
cur in children. It has been seen in a most aggra-
vated form in a child three weeks old; its head en-
tirely bald and a well-defined crusted eruption at
the nape of the neck, under the nose, on the chin,
behind the ears, in the axillae, in the groins on the
scrotum, and covering the buttocks and back of the
legs clear down to the heels. Another case was
observed in a child of seven, where the scalp was
covered with a heavy crust of the color of sulphur.
The eyebrows and ears were slightly affected. A
diagnosis of "regular eczema" was sought to be
established because owing to the activity of the
dermatitis there was a little oozing. An inspection
of the body, however, revealed a typical seborrhoic
dermatitis. It has been shown that much of the
infantile eczema is of this character, especially
when it involves the umbilical and genital regions.
The differentiation has sometimes to be made be-
tween this condition and orbicular eczema. Orbicu-
lar eczema is a circular or oval patch, arising ab-
ruptly from the surrounding skin, presenting when
frequent many of the features of vesicular eczema,
but clearly of so distinct an individuality that its
proper classification has yet to be determined.
When chronic these patches become scaly and then
the resemblance to seborrhoic dermatitis is quite
marked. The distinction rests upon the minor de-
gree of infiltration and itching and the contempo-
raneous involvement of the scalp, in the seborrhoic
manifestation. Sometimes it rests upon the reputa-
tion of the eminent man who makes it.
Ringworm of the face or body has been confused
with the circinate eruption of seborrhoic dermatitis.
Ringworm shows more pronounced central clearing
with a decidedly elevated edge, studded with vesicles
and pustules. It would be rare indeed for sebor-
rhoic dermatitis to be limited to a single lesion
whereas that is the rule in ringworm. Where multi-
ple ringworm invades the face or body of an adult
the confusion may be troublesome for a time. Close
scrutiny will relieve it. Ringworm of the crotch,
absurdly designated "eczema marginatum," is oc-
casionally a source of perplexity because it occupies
one of the classical situations of seborrhoic derma-
titis. A sharply defined and distinctly elevated
border, with central clearing or at any rate central
paling, indicates the disassociation. A scraping ex-
amined under the microscope will be conclusive.
Pityriasis rosea has been paradiagnosed sebor-
rhoic dermatitis and vice versa. Parenthetically it
may be explained that a "paradiagnosis" is a nearly
correct incorrect diagnosis. Etymologically con-
structed on the order of "paraphrase," "parallel,"
"paraclete," and "paratyphoid," it suggests some-
thing resembling something else. It is a diagnosis
that just misses its aim. It is a "para" or "near"
356
MEDICAL RECORD.
[Aug. 26, 1916
diagnosis. It bids fair to be a handy word saving
the frequent employment of a phrase.
To come back to pityriasis rosea; if its peculiari-
ties are distinctly recalled, a correct opinion can
always be pronounced. The outline of typical
pityriasis rosea would roughly conform to that of
a bay leaf. Its tint is pinkish or pale red with a
hint of yellow. The surface is slightly scaly. It
has been compared to cigarette paper because of
the delicate crinkling it displays. A peculiarity
often noticed is the curling up of the epidermis into
a little cuff between the pinkish periphery and the
fawn-colored central portion. You may support
your diagnosis against any amount of adverse argu-
ment if you discover that sufficing sign. Even in
cases that have been badly treated and in which the
original color and outline have become obscured,
you may by diligent search be able to find the little
cuff and establish the diagnosis. Frankly, pityriasis
rosea is a trivial affection, noteworthy only because
of its euphonious title, its persistence under mis-
directed treatment and the doubt it creates in the
mind of the apprehensive patient. The treatment
for seborrheic dermatitis will not touch it so it is
important to make the differentiation.
Intertrigo is a dermatosis that appears in locali-
ties favored by seborrhoic dermatitis ; the axillae, the
groins, the mammary folds, and the retroauricular
cleft. Circumscribed, inflammation thus confined
is immediately attributed to the friction of the
parts and the case is regarded as etiologically dis-
posed of. Aside from the fact that in undoubted
intertrigo something more is involved than mere
heat and friction (else intertrigo would be uni-
versal) ; it is curious that it is frequently counter-
feited by seborrhoic dermatitis. Much of the ac-
cepted infantile eczema about the genitals is sebor-
rhoic. In tissues folded on themselves maceration
is certain to complicate any eruption. Hence the
two conditions bear a strong likeness to each other.
But in the seborrhoic condition will be found out-
lying spots where there is no overlapping adjust-
ment, and these establish the correct diagnosis.
The ordinary, commonplace "eczemas" offer evi-
dence of present or preceding vesiculation and in-
filtration, and pruritus is obtrusive as a rule. "By
these signs ye shall know them." But one variety
of "eczema" — the erythematous — wherein vesicula-
tion is so slight that it is entirely hypodermic, and
discernible only to the marvelous vision of the ex-
pert dermatologist, may be and in point of fact fre-
quently is mistaken for seborrhoic dermatitis, or
vice versa. This confusion is commoner on the face
than on the trunk and limbs, for on the face the
scales of seborrhoic dermatitis are apt to be drier
and less unctuous owing to the action of the air and
frequent ablutions. It is also disposed in patches
unless it happens to be very extensive.
It favors the eyebrows, the angles of the nose
and mouth, and the retroauricular space. It is al-
ways associated with pityriasis capitis. Lupus
erythematosus is frequently overlooked under the
impression that we have to do with seborrhoic der-
matitis. At a certain stage of the graver con-
dition the resemblance is striking. One of the older
titles of lupus erythematosus based on its alleged
etiology, was seborrhea congestiva. If the older
pathologists believed that one led to the other the
distinction must oftentimes be extremely difficult.
The lupus give the evidence of deeper invasion, its
scales are .-canty and very adherent, and — a sign that
settles the question beyond all peradventure — there
is atrophy demonstrable here and there throughout
the lesion. Lupus erythematosus is regarded to-day
by many acute observers as a tuberculide. That is
a disease produced by the toxins of the bacilli and
not by the bacilli themselves. Its prognosis is vastly
different from that of seborrhoic dermatitis. Be
especially circumspect in expressing an opinion
about lesions on the scalp and on the helix and in
the concha of the ear. Both diseases affect these
regions. Make a careful search for atrophic areas
before coming to a conclusion.
The causation of seborrhoic dermatitis is sub
judice. There are those who believe they know
and those who admit they do not. Sabouraud offers
his microbacillus. Unna offers his morococcus.
Others postulate a nervous origin. Stelwagon lays
stress upon constitutional causes as predisposing,
but declares that the essential pathogenic factor
must be considered parasitic. In point of fact,
nothing is settled upon the question of etiology. The
parasitic origin is supported by the fact that the
eruption is scaly, begins on the scalp, has a tendency
to take the circinate form and is controlled by para-
siticides.
Transmission by autoinoculation lends additional
plausibility to this view. But even the most earnest
advocates thereof qualify their opinion by urging
attention to systemic conditions on the ground that
vulnerability to the parasite is increased by lowered
vitality from any cause whatsoever.
Before leaving this topic it may not be unfruitful
to repeat the declaration of Sebouraud that acne
and acne rosacea are consequences of seborrhea
and that they will never be cured until the latter is
controlled. This is introduced for what it is worth.
Seborrhoic dermatitis is quite amenable to treat-
ment except upon the scalp, where it is difficult to
make effective applications on account of the hair.
On the body ointments of sulphur, resorcin or am-
moniated mercury, singly or in combination, are
usually successful. Our results upon the body are
in sharp contrast to those upon the scalp. This is
the more regrettable because it is the ravages in
the later situation that are costly and disfiguring.
On the non-hairy surface the lesions may be hidden
unless the face is involved. And even in the latter
contingency prompt response to treatment may be
anticipated. But upon the scalp the disease presents
two exasperating features. It destroys the hair
and stubbornly resists the efforts made to cure it.
The destruction of the hair is disconcerting to. both
man and woman, for reasons that are perfectly
obvious. The woman foresees the loss of her attrac-
tiveness ; the man foresees the aspersion of waning
efficiency. The former has methods of concealing
the depletion; the latter rears his glistening pate
in impotent despair. He is the subject of stupid
raillery upon the traditional but undoubtedly apoch-
ryphal fondness of baldheaded men for advanced
positions at spectacular theatrical performances.
What association there can possibly be between wan-
ing hair and waxing sensuality has never been ex-
plained. It is probably nothing but a wicked in-
vention of the professional humorist. These con-
siderations are weighty enough to stimulate the
doctor to earnest cooperation with the apprenhensive
patient for the preservation of his locks. What are
the best means of accomplishing this laudable pur-
pose? As the mill will never grind again with the
water that has passed, so the scalp will never bloom
again with the hair that has departed. Once it has
fallen out, under the blight of seborrhea, we may
Aug. 26, 1916]
MEDICAL RECORD.
357
bid it a fond farewell. Much may be done, however,
to stay the devastation and tenderly nurture that
which is left. On the scalp lotions are preferable
to salves, because of the aversion to greasy heads in
most civilized assemblages. It is fair to admit that
the results leave much to be desired. Factors re-
sponsible for this are the complicity of accumulat-
ing years in the attenuating process; and the dis-
inclination of the average patient to make an uphill
fight in the face of trivial encouragement. But
persistence will win here as in any other field of
human endeavor, if it is intelligently guided. Lo-
tions should be applied with a medicine dropper
directly to the scalp and rubbed in gently but stead-
ily for about fifteen minutes. Energetic action will
precipitate the falling of those hairs already
loosened by the disease. Washing the head should
be restricted to the demands of decency. It should
not be undertaken under the delusion of assisting
the cure, for water is decidedly objectionable, unless
properly medicated. On these rare occasions a good
brand of tar soap should be used. The lotion most
in vogue is composed of resorcin 10 per cent, in
alcohol and water. Glycerin may be added if the
hair is dry. The proportions of alcohol and water
may be varied to suit individual requirements. If
the resorcin proves unsatisfactory bichloride of mer-
cury may be substituted in the same menstruum.
One grain to the ounce will be a fair average
strength. If another essay is demanded a 1 per
cent, solution of lysol is helpful. It has the disad-
vantage of being malodorous. This may be miti-
gated by oil of bergamot. If lysol prove offensive
or inefficacious betanaphthol 2 per cent, in alcohol
and water is worth a reasonable trial. Some cases
will not yield to lotions and in order to stay the
falling hair recourse must be had to the ointment
of ammoniated mercury 5 per cent. It will not be
prudent to exceed that proportion. It is to be ap-
plied only at night, and the hair may be wiped off
with a towel in the morning.
The changes may be rung on the remedies, and
sulphur may be cautiously combined. But this sums
up the profitable procedures in any case of sebor-
rhea. In these days of bold experimentation the
.r-ray was certain to be turned upon the scalp for
the relief of thia alarming denudation. It may be
affirmed in all fairness that it offers no better pros-
pects than the chemical applications; if it is used
with discretion and restraint. If pushed beyond
the bounds of prudence it will cause a complete
alopecia, which may or may not be permanent, and
which may be followed perhaps after a lapse of sev-
eral years by all the disfigurement and hazard of
an z-ray burn. It is "better to bear those ills we
have than fly to others that we know not of."
616 Madison Avenue.
Preeclamptic Toxemia. — J. O. Arnold states that this
condition should be treated as promptly and actively as
eclampsia itself; that morphine in sufficient quantity
is the safest and most effective agent for temporarily
controlling convulsions; that vivisection, early and
freely, is the quickest and best means for securing
elimination and reducing blood pressure; that the high
degree of acidosis in eclampsia calls for alkali-salt
solution to replace the toxic blood withdrawn; that in
practically all cases, after controlling the convulsions,
the second step in treatment is to empty the uterus.
By preeclampsia the author means impending eclamp-
sia, the case seen at the time of the first convulsion. —
Therapeutic Gazette.
IS INFANT MORTALITY AN INDEX TO
SOCIAL WELFARE? SCANDINA-
VIA'S REPLY.
Br KATE C. MEAD, M.D.,
MIDDLETOWN, CONN.
Sir Arthur Newsholme, the eminent English sta-
tistician, says that infant mortality is the most
sensitive index we possess of social welfare. And
then he adds: "If babies were well born and well
cared for, their mortality would be negligible. The
infant death-rate measures the intelligence, health,
and right living of fathers and mothers, the stand-
ards of morality and sanitation of communities and
governments, the efficiency of physicians, nurses,
health officers, and educators." — Bulletin of the
Chicago School of Sanitary Instruction.
This quotation, though of recent date, applies not
only to the unenlightened families of the twentieth
century, but to the most highly educated classes of
past ages. Being well-born and well-cared-for are
relative terms, and if we to-day who are well-born
can use our brains and our funds in caring for the
ignorant the time may come when all babies will
have as good a chance to live as seems to fall to the
lot of the babies of the educated classes at present.1
Two hundred years ago the babies even of the nobil-
ity in Europe were seldom well-born or well-cared
for. Queen Anne of England who died in 1714
at the age of sixty-nine, bore fourteen children,
only one of whom lived more than a few hours or
weeks, and the one survivor, upon whom the fate
of the nation seemed to hang, died before he was
eleven years old. That the early deaths of these royal
infants was an index of the lack of general intelli-
gence of that age is shown in the general debased
state of morals and religion. The recorded con-
versation at social functions ran upon preserving
the English Constitution, but not at all on saving
the constitution of babies, although one-sixth of all
English infants died of sepsis, and half of the rest
died of what we now class as preventable diseases.
This high mortality was common to all enlightened
countries even fifty years ago, but gradually it has
been lowered until now, in the United States, only
15 per cent, of the babies die in their first year, a
decrease which seems commendable when we find
that, though we are eighteenth in a list of the in-
fant mortality of different countries, Italy has a
rate of 16 per cent., Germany 19, Austria 22 and
Russia 26. But why should we be content before
we have reduced our death rate to that of Sweden
in the first rank, with its infant mortality of only
7% per cent.?
This question leads us to look into our municipal
housekeeping, where, as Sherman H. Kingsley has
shown, the weakest spot is continually marked by
the presence of the little white hearse, the most
sensitive index to the enlightenment of any com-
munity being its infant mortality. Or, as Holt has
pointed out, it is not the unfit, but the unfortunate;
baby that dies, and this baby who was born in the
midst of poverty or unenlightenment dies or grows
up sickly in its home, or perishes sooner in a found-
ling asylum. These early deaths in any case, then,
are the index to our poor economies in municipal
housekeeping.
That the death rate of infants in foundling asy-
lums is enormous may be seen from statistics quoted
by Dr. Philip Van Ingen, who finds that the rate
in New York State's foundling homes is 422 to the
thousand, while the death rate of the babies in the
358
MEDICAL RECORD.
[Aug. 26, 1916
slums of New York City is hardly more than one-
fifth of that number. That the deaths in these
foundling homes are mostly unnecessary is seen by
comparison with the death rate of foundlings in
Sweden, which is only 4 per cent., but we shall see
that there are good reasons for this difference.
Sweden has not only hospitals for sick babies, but
small boarding homes for well babies, and large
asylums for mothers with their babies. By such
methods New York City has cut down its infant
deaths 17 per cent, in the past five years, that is, by
boarding 44 per cent, of its foundling babies in
small homes where each individual may have a
mother's attention, under the supervision of doc-
tors and nurses. For caring for marasmic babies
the foster mothers receive $15 a month, and for
healthy babies $10. In this way, Dr. Josephine
Baker tells me, the infant mortality was cut in half,
at an expense to the public treasury of 69 cents a
day; whereas the foundling asylums were formerly
allowed from $1 to $2.29 cents a day for each in-
fant, graft not eliminated, and funerals to be paid
for.2 In Stockholm, however, the cost of running
the homes for mothers and babies is very much
less than in New York, the amount spent for food
for each mother, per diem, being only 14 cents, and,
as the mothers nurse their own babies and help do
the work of the home while learning the principles
of infant hygiene, there is little need for doctors
and nurses.
That sick children may have to be cared for in
large institutions rather than in boarding homes,
no one will deny. Therefore hospitals for tubercu-
lar babies and for syphilitics must be maintained in
every country until these diseases are wiped out.
We have perhaps not realized the necessity for the
isolation of syphilitics as well as the tubercular, but
recent statistics as to the number of syphilitic
women in our institutions are startling. It is stated
that of the pregnant women awaiting confinement
at Bellevue, 25 per cent, gave positive Wassermann
reactions. Dr. Jessie Fisher finds 22 per cent, posi-
tive reactions among the patients, men and women,
at the Connecticut Hospital for the Insane. Dr.
Edith R. Spalding finds 44 per cent, of the women
syphilitic at the Massachusetts Reformatory for
Women. Dr. Louise Mcllroy of Glasgow finds 49
per cent, of positive Wassermanns in her out-patient
clinic. But notwithstanding these figures, and the
fact that every civilized country has realized that
patients with tuberculosis and syphilis should be
segregated, there must have been carelessness in
the matter even in Germany and America to account
for a part, at least, of their excessive infant mor-
tality. In Sweden and Norway, on the other hand,
where the May Flower Society has been active for
many years in segregating only the tubercular chil-
dren, under the care of deaconnesses and doctors,
the infant mortality has been reduced 50 per cent,
at one-half the cost of such institutions in our
country.
Not only has New York City discovered that
Scandinavia has chosen the better way, both finan-
cial and sociological, to conserve the babies, but
other American cities are trying the same plans.
Boston, for instance, has recently proved that visit-
ing nurses and milk stations afford a very inex-
pensive means of lowering the death rate of babies,
which was 134 to 1,000 births in 1910, as compared
with 99.5 in 1914, a decrease of 25 per cent., with
an average of 1,132 babies saved every year. In
Boston, moreover, where 20,000 babies are born in
a year, fully one-half need assistance, and nearly
2,000 die.
If, as Prof. Irving Fisher has shown, a baby's life
is valued at $1,700, this saving to Boston in dollars
and cents pays an enormous interest on the salary
of its nurses and the up-keep of its milk stations,
but the money, however, is as nothing in comparison
with the unlimited value to the public of the educa-
tional teachings of these nurses in the homes of the
badly-born and unenlightened. Boston now has
third place in the list of first-class cities in the
United States in respect to its infant mortality,
while Philadelphia is sixth, and in the summer of
1914 Boston lost only 99.5 babies in the 1,000, while
New York lost 117.
If, then, Boston's infant mortality has been re-
duced so much by visiting nurses, there is reason to
suppose that it can be further reduced by a radical
change in the institutional care of infants, as well
as by new methods of caring for the poor in the
maternity hospitals, and by a better control of mid-
wives. If this is true of Boston, it is as true of all
our cities. One of our best obstetricians has said
that there are only a few good lying-in hospitals in
the United States. Another teaches his students that
every pregnant woman is in a pathological condi-
tion, and should be treated in a surgical hospital.
There is evident truth in each of these statements,
but without new hospitals, and even with midwives,
Scandinavia has far excelled us in the saving of
infants.
It is probable that the average intelligence of
Scandinavian midwives is far superior to that of
most of our midwives, who come mainly from the
countries of eastern and southern Europe, where
their training has been far inferior to the hospital
training of the Scandinavians. It is said that 40
per cent, of the children among our foreign popula-
tion are born under the care of midwives, whose
only qualifications are that they can read and write
in their own language, and that they have seen six
confinement cases. In England, and France, and
Germany, where for military reasons a failing birth
rate and increasing infant mortality mean national
disaster,3 midwives are being carefully trained and
supervised, for in these countries women have for
centuries been considered the natural obstetricians.
By this method alone they have lowered their mor-
tality one-third, and if we in the United States
should thus deal with our midwife problem, and by
so doing lower our infant mortality one-third, we
should take third rank instead of fifteenth, and if,
in addition, we should give premiums to mothers
who nursed their babies for two months before re-
turning to work, as Germany has done, we might
further reduce our infant mortality by one-half, and
thus take our place beside Sweden in the first rank
of baby-savers for, naturally, proper homing of
little children would be a part of these other
reforms.'
While paying attention to reducing our infant
mortality, we should also inquire into the causes of
the premature births and of the deaths of the babies
who die before they have more than gasped a few
times. It has been found at the Sloane Maternity
Hospital that 58 per cent, of the deaths at term
are from congenital weakness and atelectasis, 3 per
cent, die from injuries during labor, and 4 per cent,
are caused by congenital syphilis, besides another
4% per cent, born dead probably because of syphilis.
This last disease claims its toil in Scandinavia as
well as in America, but with the exception of tuber-
Aug. 26, 1916]
MEDICAL RECORD.
359
culosis, alcoholism, and syphilis, there is nothing in
Scandinavia to cause cell deterioration in both par-
ents and offspring, or to lessen their homogeneity as
a nation and their hardiness as a race. In America
we have to combat ignorance, neglect, and concealed
poverty. Koplik has found that 60 per cent, of our
deaths in earliest infancy are due to these three
causes, which do not exist to any extent in Scandi-
navia, where, by means of governmental supervi-
sion of the people and intelligent methods of pre-
venting extreme poverty and neglect, there is less
congenital debility, and owing to almost universal
breast-feeding fewer cases of digestive disturbances
and a much higher average of intelligence. This
fact is brought out clearly in the death lists of
Scandinavian infants in a Connecticut town where
only one baby dies in a year from a population of
nearly a thousand Swedes. The Scandinavian in-
fant, therefore, starts with fewer handicaps, and
even if its mother gives it away or deserts it later,
its digestion has not been impaired by early artifi-
cial feeding. When the Swedish government takes
care of infants in large or small homes, it continues
to feed them on a diet containing at least a little
breast milk, and houses them with other perfectly
healthy babies, among whom there is little danger
of mixed infections. Hence Sweden's 4 per cent,
institutional mortality puts to shame our institu-
tional mortality of 40 to 75 per cent.
Moreover, if our unintelligent mothers were not
allowed to return to their homes from the maternity
hospitals until they had lived for at least two months
with their babies in convalescent homes where they
could iearn how to care for themselves and their
babies properly, as is done in a great number of
cases in Scandinavia, we should not only lower our
infant mortality markedly, but also improve the
health of the mothers, and prevent many subsequent
gynecological operations. In Stockholm alone, for
instance, a city of 350,000 inhabitants, there are
between fifteen and twenty coordinated institutions
for the care of mothers with their babies under
government inspection. In Connecticut, on the
other hand, with its population of 1,500,000, there
are in all eight county homes for orphans or degen-
erate children over four years old, small orphanages
in the three or four largest cities, two or three small
homes for unmarried mothers, a Children's Aid
Society, which cares for comparatively few babies
in boarding homes, and an inadequate institution
for feeble-minded children, none of these institu-
tions being coordinated with the lying-in hospitals.
Doubtless one State is like another in these respects,
homes and asylums being under government in-
spectors, who make perennial visits, and report
everything as in "a satisfactory condition." Recent
graft disclosures in New York, however, throw some
light on the high cost of maintaining such institu-
tions. Where it is possible for a physician, not a
specialist, to obtain from a New England legislature
a grant of money for removing the tonsils and ade-
noids from every child in an institution for orphans,
it would seem possible for many other abuses to be
found. Humanitarian motives, doubtless, were the
reasons for founding our institutions "for poor,
decayed, and impotent persons," but such institu-
tions should be sufficiently modern, and under so
enlightened a board of managers that the inmates,
young or old, should be fitted in them for life and
not for death. In one of our most progressive
States, for example, the infant mortality under one
year of age was 37 per cent., until the largest cities
of that State took the matter in hand. Then, by
more careful housing and inspection of homes, to-
gether with the cooperation of visiting nurses and
milk stations, they cut this rate down to 10 per cent,
in their most crowded districts.
But even now the infant mortality in New Eng-
land is not as low as the average low figure of Nor-
way and Sweden. Perhaps to understand the rea-
sons why this is so we might go more into detail
as to the baby-saving methods employed in Scandi-
navia, beginning with the personal work of Profes-
sor Medin, in Stockholm, who revolutionized the
teaching of pediatrics in the University Medical
School. His foundation was laid upon the precept
that no milk was like mother's milk, and as his
Swedish mothers were strong they were able to
nurse their babies provided they had good food and
were not overworked. Then he believed in isolating
all sick babies with their mothers, and allowing no
children to visit any foundling asylum, because of
the danger of infection. He does not believe that
tuberculosis of the bovine type is ever the cause of
human tuberculosis in babies5, and he says that he
has never seen a case of tubercular infection not of
human origin. Before Professor Medin retired
from his University work, at the age of sixty-five,
he was instrumental in building the Sachs Hospital
for Sick Babies. Here his theories for the nourish-
ment and treatment of sick infants from all parts
of Sweden are put into practice. The hospital has
room for fifty-four babies, four wet-nurses, a resi-
dent physician, and the other personnel of such an
institution. It is built on a bluff above the fjord,
in a most beautiful location, isolated from all other
buildings. A mother may live in the hospital with
her baby if necessary, or she may visit it during
the day to nurse it, according to its needs. The
milk of the wet-nurses is squeezed into bowls and
kept on ice until needed for some formula. No
goat's milk, albumin milk, nor pasteurized milk is
used in the formulae, but cow's milk may be modi-
fied with buttermilk, flour, sugar, and human milk,
these formulae being represented graphically, in
blocks of color, on a chart at the foot of each bed.
There are four wards, each containing eight cribs ;
there are also eight single rooms provided with
double doors and double windows, in order to assure
freedom from noise and a constant temperature for
premature babies. There is one head-nurse who
prepares all the formula? with the aid of servants,
two ward nurses, and fourteen pupil nurses who
spend three months at this hospital as part of their
general training.
When we consider that in a hospital for infants
too ill to remain in any other institution there can
be maintained a mortality of only 4 per cent., we
are not surprised that in the foundling hospitals
the mortality is only 3 per cent, among 300 well in-
fants under two years of age. This is perhaps the
more remarkable to us from the fact that these hos-
pitals are not built on a new model, the wards being
dormitories where twenty-four babies sleep, or six-
teen babies and eight mothers; and yet there is no
"congenital debility," and there are no epidemics of
measles or other contagious disease, to disturb the
routine of the institution. The entire expense of
running these homes is 70 cents per capita a
day, including the cost of food, at 14 cents, and at-
tendance. Much of the work of the institution is
clone, naturally, by the mothers who nurse their own
babies; whatever extra milk they may have being
bottled for other babies, provided the mother is free
360
MEDICAL RECORD.
[Aug. 26, 1916
from syphilis. After these babies are weaned the
mother of any child may relinquish it to the insti-
tution by making a cash payment of $200. If a
child is adopted into a family the institution has
the supervision of it until it is seventeen years old.
If it is not adopted it is sent to one of the many
boarding homes throughout the country, where from
twenty-five to fifty live under healthy conditions,
learning, as they grow up, all kinds of housework
and market-gardening. In these homes each child
costs the institution 50 cents a day. If they live
with foster-parents the institution, or the govern-
ment, pays $30 a year for their keep. It would seem
that the Scandinavians had reached the lowest pos-
sible figure for the welfare of the foundlings as well
as the lowest possible mortality, the death rate in
the country "homes" averaging 2.8 per cent., while
the death rate in the cities is 7.46 per cent.
If one visits these homes for children one finds
them plump and happy. They are satisfied with a
simple diet of, for example, cereal and milk for
breakfast, fish soup or meat stew with bread and
butter, fruit or a simple dessert for dinner, and
rice cooked with prunes for supper. They sleep in
one dormitory without an open window, but with
doors open into the matron's or deaconness' room.
In Norway many of the children in these institu-
tions are from homes where one or both of the par-
ents have tuberculosis. In a home of this type in
Bergen, on a hillside above the fjord, there were
thirty-five boys and girls between eight months and
eleven years of age, six being from one family, the
mother of whom was dying of phthisis. The mor-
tality of such children is 8 per cent, but they are
sent to hospitals or sanitariums as soon as they be-
gin to show signs of any disease.
It might be asked if these statistics of the infant
mortality in Scandinavia were carefully computed,
or if the deaths at birth, or the still-births had been
registered. This question has been answered by
Professor Johannessen" of Christiania who has
shown that while it cannot be proved that every il-
legitimate birth is recorded, it is probable that very
few escape the vigilance of the authorities, so that
while the deaths among the illegitimate are twice as
high as among the legitimate, even this figure is
less than half the corresponding rate in Berlin. In
Norway, as everywhere, the death rate among the
well-to-do is much lower than among the poor, rising
to 9 per cent, among the poor, 12 per cent, among
the very poor, and 19 per cent, among the illegiti-
mate. That there are a great many unmarried
mothers in Scandinavia can not be doubted, for
they are found in every country where there is a
standing army of underpaid and underworked men.
The condition is so ordinary that in one of the larg-
est art-museums in Norway there is an enormous
painting entitled, "A young mother kills her illegiti-
mate baby in a cow shed." The museum paid a
large price for the picture, critics hung it in a
prominent place, and crowds of visitors gaze at it
as a work of art, without apparent horror or svm-
pathy.'
Moat of the illegitimate babies are born in the
maternity hospitals, many of which are modern and
thoroughly practical. The patients enter the hos-
pital in labor, are bathed in shower baths, exam-
ined, put to bed in the delivery room, and delivered
by midwives or by obstetricians. After a few hours'
rest they are taken into a ward, and the following
day the baby is baptized in the presence of its
father, if possible; it receives its father's name, and
frequently a wedding follows this simple ceremony,
the mother going to his home after two weeks.
If, however, the father can not be induced to marry
the mother of his child it is baptized with his name,
and the mother takes it to one of the many conval-
escent homes for a few months, where she partly
supports herself by working as laundress, or by
sewing. The government allows only about $10 a
year for the support of the woman, the rest she
must earn.
In a country like that where mothers nurse
their babies, milk stations are not so necessary as
diet kitchens and school dinners, such as are pro-
vided in all the cities of Scandinavia; for it is rec-
ognized that if a mother is to nurse her baby she
must have nourishing food, and if a child is to grow
strong and robust it must have a well-proportioned
diet. In the villages, on the other hand, the prob-
lems are more serious. The government, while re-
ceiving little revenue from many of its isolated com-
munities, is obliged to provide doctors and midwives
for the inhabitants, as well as schools and churches,
and employment for women whereby they may earn
money during the long winters. In northern Sweden
there is one State-paid midwife to every 6,046 per-
sons. Her salary is 300 kronor a year (about $84),
plus two kronor for each new baby. In the more
populated places in the south of Sweden there is one
midwife to every 3,274 persons, at twice the salary.
In Norway the doctors and midwives in the country
undergo great hardships during the long winters,
for the distances between farms or settlements are
great, and travel by water or around the mountains
is slow and cold. Were it not for the hardiness of
the inhabitants of the seashore and dark valleys
the mortality would be very great, for it is difficult
to obtain medical help in emergencies. But where
human beings are aggregated together for warmth,
like sheep, in closely shut cottages, tuberculosis
thrives. Hence the need for the philanthropic May
Flower Society, and its intelligent care of the pre-
tubercular cases, as well as of those who have the
disease.
In speaking of Scandinavia one is apt to overlook
the little country of Denmark, once the most power-
ful nation of the group. Until recently this country
has treated its problems after the manner of Ger-
many, and its infant mortality from cholera infan-
tum has been high. Professor Hirschsprung of the
University in Copenhagen, was however famous as a
teacher and writer on pediatrics. He reduced the
infant mortality 50 per cent, during his working
years, but he could not obtain the low figures of
Sweden because his government was not awake to
its responsibility in the matter, and the farmers
preferred to export all of their dairy products, while
the mothers were obliged to work hard on the farm
and eat poor rations. Where mother's milk and
cow's milk were lacking, and where cholera infantum
was endemic, the difficulties in saving the babies
were great. A tea made from blueberries, and a
soup made by boiling bread in beer, could not reme-
dy an original loss of digestive function in a child.
Hence the wonder is that Denmark's infant mor-
tality was as low as 15 per cent, when that of Ger-
many was 19 per cent. Now, however, Copenhagen
has a great new hospital with an up-to-date pavilion
for children, as well as pavilions for all the other
departments of a university hospital and medical
school. Under Professor Bloch the students are
obliged to take a course in pediatrics, and to work
out percentage and caloric formula?. The city has
Aug. 26, 1916]
MEDICAL RECORD.
361
its milk-stations, ,and its cottage homes for foun-
dlings, so that one easily understands why its infant
mortality has now dropped to 10 per cent.
There are several inferences to be drawn from the
preceding brief accounts of the factors concerned in
lowering the infant mortality in Scandinavia, one
being the evident superiority of the institutions in
those northern countries over many of the American
institutions. When one visits the hospitals or clin-
ics in the large cities one is impressed with the
greatness of their surgeons and doctors, and with
the team work of the faculties as a whole. Many of
these men have international reputations, among
whom we might mention Rovsing and Hirschsprung,
of Denmark, Johannessen and Strumm, of Chris-
tiania, John Berg and Oskar Medin, of Stockholm,
each of whom gives, or has given, his best hours to
the university or hospital, and to the public what
remained of strength and enthusiasm. Evidently,
then, a paternal government and a high rate of tax-
ation, by means of which the rich are compelled to
care for the poor, have been succesful in improving
the health of the Scandinavian people. It is, more-
over, evident that neither the size of the hospital
nor the number of beds in a ward, nor midwives, nor
maternity hospitals, nor pasteurized milk, have been
the cause of the low infant mortality; but the les-
sons for Americans are essentially the following.
We must have intelligent, healthy mothers with
breast milk for their babies. We must train our
midwives to care for the poor in their homes. We
need better teaching in pediatrics and obstetrics in
our medical schools. And we should build more
sanitary small homes for our foundling infants, or
see that those who are boarded in families are cared
for properly. When we shall have achieved these
reforms we shall find our economic conditions im-
proved, and with lessened expense we shall have a
much lower infant mortality.
Besides these lessons for the saving of infants,
Scandinavia teaches one the necessity of more ra-
tional methods of administering charity as well as
laws. Where a government supervises the build-
ing of homes for workmen it prescribes the rate of
interest which may be taken from the rent of such
homes, and keeps the prices of dwellings within the
reach of the laborers. The parks and the water-
fronts of the Scandinavian cities are kept clean and
attractive for the good of the people as a whole.
Doctors and hospitals are provided for the poor, as
well as school teachers and priests. Women of the
higher classes are appointed inspectors of the poorer
districts, and these inspectors are in reality friendly
visitors who give advice and alms when they find it
necessary. Deaconesses, many of whom are trained
nurses, go about among the poor, caring for the sick
and infirm as they do in this country, but their
charges for nursing are within the means of all but
the poorest, for there are State pensions waiting for
them in their old age, and comfortable homes pro-
vided by the government. Their nursing is more of
a mission than a means of livelihood. Moreover, the
public schools are possibly the greatest part of this
entire system, for there not only is the mind of
each child developed to its particular capacity, but
from its teeth to its feet the child is cared for; its
physical needs are satisfied by food which it learns
how to prepare, and its body trained by gymnastics.
Children study harder, play better, obey more
promptly, and eat much more simple food than
American children. For these reasons the health
of school children is more uniform than it is here,
and their death rate is half that in the United
States.
It must be admitted that there is a great deal of
insanity in Scandinavia, and a deplorable amount of
tuberculosis, but, apparently, neither the infant
birth-rate nor the mortality is influenced by these
diseases, for the men and women in general are
healthy, and their out-of-door life keeps them
strong. And yet, ten years ago the infant mor-
tality was double what it now is, although the adults
were seemingly as robust then as now. The net re-
sult, therefore, of this survey of the causes of a
low infant mortality in Scandinavia points once
again to the quotation with which this article was
begun, and which, in two words, means "health edu-
cation."
REFERENCES.
1. Dr. Rowland G. Freeman says he believes that the
mortality of well-cared-for babies is scarcely more than
one-half of one per cent. Not one baby in one hundred
and twenty consecutive cases in his private practice
died during the first year. Moreover, he finds that a
group of children from intelligent parents grow heavier
and taller than similar groups of institutional children
who are well cared for but not well born. (Am. Jour.
of Diseases of Children, November, 1914.)
2. This fact is brought out by Prof. K. Stolte, of
Berlin, who believes that the treatment of a baby must
be individualized and that someone must act as its
mother, playing with it and sometimes even nursing
it before its time if it seems hungry. This is surely a
scientific heresy, although emanating from a German.
(Jahrbuch fiir Kinderhcilkun.de, Berlin, 1914.)
3. In 1914, in England and Wales the number of
births was 23,000 less than the average of the five
preceding years. In Berlin there were 3,500 fewer
births in 1914 than in 1913, and 1,600 more infant
deaths. In fact, in 1914 Germany's infant death rate
was higher than that of any other country of Europe
except Russia. These facts are given by Dr. Alice
Hamilton in the Survey, January, 1916.
4. It has been found in Germany, that during August
only forty-two breast-fed babies die, as against 260
bottle-fed babies. Miss Lathrop of the Children's
Bureau recently verified these figures by an investiga-
tion at Johnstown, Pa., and found that among the
poorer working people who did not nurse their babies
the infant mortality was five times greater than among
the well-to-do who nursed their babies.
5. Other excellent authorities estimate that 25 per
cent, of all tuberculous children under five years old
suffer from infection of bovine origin; and that bovine
tuberculosis causes from 6 to 10 per cent, of the deaths
from tuberculosis in children of this age. (McCleve,
T. C, Cal. State Medical Journal, January, 1914.)
6. See articles by Prof. Dr. Alex. Johannessen, Chris-
tiania, 1902 and 1908: D^deligheden i Norge af B'/>rn
under 1 Aar. Also, De Forskiellige D0dsaarsagers
Indflydelse paa Spaedbarnsd^deligheden i Norge.
7. In Norway, Johannessen states, the greatest death
rate is at birth; 223 in 10,000 dying from congenital
debility. Of the remaining deaths digestive diseases
head the list, causing three times as many deaths
among city babies as among those in the country. If
convulsions and teething, as causes of death on the
certificates, are counted among digestive disorders, the
rate of deaths is raised to 3.4 per cent, in Christiania,
as against 2.4 per cent, in the country. The number of
cases of digestive diseases drops one-half after the
first year, while contagious diseases double. Pneu-
monia is third on the list of causes of deaths, infectious
diseases fourth, and tuberculosis fifth.
Carcinoma of the Colon; Its Early Recognition and
Removal. — Rowlands states that in complete obstruction
one of the following steps should be adopted: 1. Colos-
tomy above the obstruction and well away from it. 2.
Short-circuiting, such as ileocolostomy. 3. Resection
with drainage after Paul's method. If the obstruction
is incomplete the bowel must be emptied and the patient
carefully dieted for a week before the operation of resec-
tion is attempted. — Guy's Hospital Gazette.
362
MEDICAL RECORD.
[Aug. 26, 1916
THE PHYSICIAN AND PSYCHOTHERAPY
By SMITH ELY JELL1FFE. .Ml), Ph.D.,
NEW YORK.
Dr. X :
Dear Sir — The fact that you are one of the trans-
lators of has led me to address this letter to you.
My husband suffered a complete nervous collapse in
July, 1909. He was pronounced a victim of neurasthenia
by local physicians, which opinion was confirmed later
by Dr. Y of B Hospital for the Insane.
The patient took medicine under direction of Dr.
Y for two years. Rest and change of scene have
greatly improved but have failed to cure. He is pos-
sessed by worry, indecision, nervousness, etc. I desire
to find a physician who uses psychoanalysis in the
treatment of nerves. Our local physicians seem either
afraid or ignorant of that method, and I have failed
utterly in gaining any help in looking up the proper
person to consult. My means are limited, but neverthe-
less I am prepared to make great sacrifices for sake of
treatment.
Will you recommend someone that uses this treat-
ment? Our need is very great, and that is my only
excuse for asking this favor from a stranger.
Thanking you in advance for the courtesy of a reply,
I am,
Yours truly,
Mrs. A.
"Is there no balm in Gilead? Why, then, is not
the health of the daughter of my people recov-
ered?"
The culture wrested from the centuries which have
intervened since this cry went up from an ancient
prophet of mankind has brought us much of advan-
tage. Science has put into our hands countless tools
by which we can further comfort and health. We
should be masters of the art and practice of com-
plete health. And still the cry is heard. "The wise
men are ashamed, they are dismayed and taken. . . .
They have healed the hurt of the daughter of my
people slightly, saying, Peace, peace; when there
is no peace."
It is not the stirring of sentiment to bring back
this ancient outcry against the failure of those
in high places to minister to the profoundest hu-
man needs. Our physicians occupy to-day this ex-
alted station, and still an incessant and increasing
call for help falls vainly upon our ears. It is not
desire and purpose to help that are wanting. It
is, nevertheless, lack of sympathy in the truest sense
of the word, sympathy which is understanding. The
physician has compassion in that the sufferings are
too often likewise his own, but the deeper under-
standing which could bring relief is somehow not
his. Perhaps a little research will reveal some of
the causes for this darkening of our understanding,
and therefore our failure just where the need is most
pressing.
What is the reality of this human cry in its mod-
ern form? No prophet stands upon the mountain
top to voice the burden of a suffering people. The
complaint, however, is no less insistent. Its force
is the noiseless current, often, of the soul weighted
by its own inner conflict or of the helpless witness
of such an unspoken conflict in a cherished relative
or friend. To one of the many who have tried to
understand this fundamental situation as the cause
of the most grievous and widespread ills of mod-
ern life there come repeatedly such letters as that
which stimulated this short paper.
A wife writes for advice in choosing medical as-
sistance for her husband. He has been a nervous
wreck for a number of years. He has seen twenty
doctors and more. Medicine was prescribed for him
for two years, the result of which the letter does
not mention. It however goes on to say that "rest,
change of scene have greatly improved but have
failed to cure. He is possessed by the worry, inde-
cision, etc., of nervousness." The same familiar
story. The profound burden of these words falls
only upon those who have borne it themselves, or
upon those whose vision has been directed by psy-
choanalysis and clarified by the courage of self-
analysis to penetrate beneath the surface of the con-
scious life into the immeasurable territory of the
unconscious, where the deeper life of man is hid-
den, and where the mighty racial forces which have
made civilization, and those that would hinder it
for the sake of primary individual freedom, strive
in titanic conflict. The stifled cry, checked by the
impulses we call pride, humility, self-distrust, re-
gard for our fellow men, reveals only in partial
glimpses the existing struggle.
The letter here referred to represents the condi-
tion of many. The world about us is full of this
sort of resigned, hopeless struggle, or of determined
but futile efforts to rid oneself of such unsocial,
unproductive forms of behavior, or again of those
who have found a false refuge even more useless and
vain and pitiable. The entire strength of science,
of new thought, and of the thousand and one cults,
lies in the fact that the regular profession is too
busy with things material to interest itself in the
mental or spiritual life of the multitudes.
Is it not high time that we awaken to the meaning
of such phenomena? That we look about us to see
if there is any way by which we can understand
their intrinsic, their actual meaning, in order to
find and utilize the remedy? Physicians have not
been wholly idle nor indifferent. Yet ignorance
and lack of understanding have led to an appar-
ent indifference, to a condition of mental slothful-
ness and moral cowardice which was expressed very
recently by one physician, who said, half humor-
ously, wholly seriously: "Oh, I never have anything
to do with neurotics. I send them out at once."
Others have manifested the helplessness that para-
lyzes even sincere effort to relieve suffering, and
have prescribed rest, travel, amusement, aimless oc-
cupation, all the accessories of therapy which fail
because they ignorantly condemn a patient to palli-
ative measures which only perhaps condemn the
sufferer to a little further attempt to repress an
irrepressible conflict, while in reality the secret
struggle accompanies him on his journeys, thrusts
itself upon all this occupation, stalks like an unwel-
come, ghostly guest at every festive scene, making a
mockery of the measures prescribed by the physician
or urged by solicitous friends. Too often, also,
enormous expense is incurred, and prolonged in the
fruitless efforts of escape, and the very hopelessness
of cure is even notoriously capitalized. The intense
reality of the individual struggle recognizes all too
clearly the ineffectualness of such means. They pal-
liate the "hurt" and cover it "slightly," but such
measures have too long cried "Peace, peace, when
there is no peace."
There is one, and only one, way to remedy this
state of affairs. That way is to set to work to
understand why men and women and children are
suffering from nervous and mental disturbances and
the tremendous significance of these maladies in
regard to their cause and as to what must be done
about it.
This, it will be said, is what physicians have
tried to do. But they have not succeeded in the
unraveling of the psychoneurosis of which all hu-
Aug. 26, 1916]
MEDICAL RECORD.
363
manity has a trace. Freud, however, through careful
experimental work, and with a sublime courage, dis-
covered a method of penetrating the deeper and
vaster portion of a man's life than that with which
we are accustomed to reckon, a territory hardly sus-
pected, and surely not understood. There lie all the
forces of the past which have made the race and
the individual, and these forces are still active, still
striving for mastery the one over the other. The
recognition of this is more revolutionary than ap-
pears at first thought. The comprehension of the
fact demands further profound consideration of the
widely diverse character of these forces and their
antagonism and incompatibility. This necessitates
a knowledge and understanding of biological evolu-
tion and of anthropology in order to know the in-
stinctive forces in their intrinsic nature and the
gradually advancing modes of expression through
spiritualization or sublimation of the same. Only
thus can we realize why they are factors to-day in
the normal outflow of energy, or for the blocking
of that energy which causes maladaptation to social
requirements and the concealed internal struggle,
which breaks forth to consciousness in the disguise
of all sorts of painful or unproductive symbolic
symptoms.
The courageous investigations of Freud and his
followers into this darkened portion of man's na-
ture disclosed this immeasurable stream of energy
or libido, a force that cannot be abated, only di-
verted, dammed, and introverted through the inertia
which is a psychological feature of infantile and
primitive feeling, which produces and fosters the
overwhelming desire to return to infantile and prim-
itive conditions and modes of reaction which reality
sternly forbids. Hence the strong repression of this
antisocial attitude and those lawless individual ten-
dencies which mark it; hence, also, the failure of
repression, the yielding to the infantile pull which
occasions the conflict, or the complete yielding which
shuts the individual away into a thoroughly un-
social world of his own.
Is it the self-knowledge which this theory of
psychoanalysis involves which makes it so difficult
of acceptance? For, of course, it precludes a dis-
tinction in kind between the mental life of the sick
and the well. Only a difference of degree of adjust-
ment to reality and of freedom from infantile do-
minion exists. Therefore, our acceptance of the
theory demands an acknowledgment of inacceptable
impulses existing within each one of us in all their
primitive and infantile egotistic force. It demands,
also, that we search out and understand these im-
pulses, and see whether they master us or are our
servants. They court disguise, so that this involves
a thoughtful psychological attitude and unwearied
searching into all the history of mankind in order
to discover his modes of expression and the means
of disguise universally employed; to discover, also,
the mistakes into which the infantile mode of
thought and action have led man away from the
pathway of achievement and advance, as well as
his victory over the inertia and self-seeking which
has brought the race onward.
All this is necessary equipment with which to
approach the problem of individual mental and nerv-
ous disease. For the individual repeats the history
of the race. A knowledge of one acquaints us with
the real nature of the other, and gives the only
means of intelligently and effectively handling the
complex entanglements into which the fundamental
struggle of impulses, rendered keener and more in-
sistent by the increasing demands for repression
which follow advancing culture, has plunged vast
numbers of our population.
It may be said that other means than psycho-
analysis are just as good. Let us grant this, and
use those means, if they exist. If there are other
methods of thought and of therapy which have the
courage and the indefatigable industry to penetrate
the unconscious realm, the harboring place of all
the mysteries and terrors of mankind, and to recog-
nize this unconsciousness as the heritage of every
one, the physician, as well as the patient before
him, by all means let us use them.
These possibilities determine the opportunity and
the responsibility of the physician toward psycho-
analysis. It is the most effective tool yet fashioned
with which to discover the psychic needs of man-
kind and to meet them. Therefore, we cannot pass
it by in indifference or fear. It is in its use that it
may be rightly valued, as well as perfected where
it is incomplete. It grants much to those who em-
ploy it carefully and conscientiously in knowledge,
understanding, genuine sympathy, and one's own
increasing self-control and effectiveness. Its de-
mands are even greater. It lays upon the physician
the responsibility of reaching the distraught mind
in its suffering and incapacity for life, of restoring
such a mind by patient, unremitting effort, a slow
process when dealing with the delicate intricacies
of the human psyche, to a new confidence in itself
in independence and freedom from infantile forces.
It makes him the conductor of the new-born soul
into a freedom which is racially productive and
creative. He must bear in mind that he works
hand in hand with the patient, who learns the first
principles of independence by sharing in the labor
of the analysis. Together they have discovered the
undiminished energy, the immortal libido, and
learned to free it from its bonds. Their last and
greatest task is then to direct this libido into pro-
gressive, constructive paths, to set it flowing free,
satisfied, and in harmony with any demands reality
may make upon it, because pouring outward. In-
troversion brought no satisfaction. The libido finds
at last what it sought there in vain. It expresses
now its true nature, in which alone it can really
live, for to it belongs "the glory to go on and to
be."
Psychoanalysis, however far it may in itself need
completion and perfection, opens up limitless possi-
bilities and opportunities, because it deals with
human life as it sweeps back into the past, as it
extends in breadth and intensity into the future,
and because it considers it not merely as a whole,
but in relation to individual complexities and indi-
vidual relationships and adjustments to the whole,
and to individual share in the racial task. Beware,
then, lest we pass by on the other side. Let not our
"wise men be ashamed, dismayed and taken," and
cry "Peace, peace, when there is no peace."
64 West Fifty-sixth Street.
Obstetrical Anesthesia and Analgesia. — Frisbie con-
cludes that in scopolamine, morphine, or narcotics we
have a valuable method of relieving a very painful
stage of labor if used with necessary care; that the
dosage advocated by most authorities is higher than is
needed to secure a sufficient degree of analgesia (most
mothers do not demand complete relief from pain) ; that
its safety and value may be greatly increased by com-
binations with other anesthetics such as nitrous oxide
during the secondary stage or chloroform and ether in
the perineal stage. — New Mexico Medical Journal.
364
MEDICAL RECORD.
[Aug. 26, 1916
MEDICINE AS PRACTISED BY THE CHINESE
By WILLIAM W. CADBURY, M.D.,
CANTON, CHINA.
PHYSICIAN TO THE CANTON CHRISTIAN COLLEGE.
Since the opening of the Canton Hospital in 1838,
the advance of Western medicine in China has been
gradual but continuous. Of recent years the medi-
cal profession of the United States has shown
considerable interest in the hospitals and medical
schools established by missionaries, and this in-
terest has been greatly intensified by the recent
announcements of the China Medical Board of the
Rockefeller Foundation that it is their intention
to assist and carry on the institutions already es-
tablished at Peking and Shanghai. It is the pur-
pose of the Board to make the schools equal to or
even better than any now existing in the United
States.
In view of this greater interest of the medical
profession of our country, there is doubtless more
or less speculation as to what is the status of
Chinese Medicine as it has existed and still exists
among the people of this vast Empire. The notes
here submitted are partly the result of personal
observation in the city of Canton, and partly of
conversations with a Chinese doctor of the old
style. I have also referred largely to the articles
noted below under references.
Medicine in China may be considered under two
divisions — the purely superstitious, which depends
on charms and magic and is largely fostered by the
Taoist priests, and the art of medicine as practised
by the Chinese doctor. These two phases of treat-
ment of the sick are closely interwoven with one
another so that it is sometimes impossible to draw
the line between them.
Let us first consider the superstitious practices
and beliefs. In the city of Canton may be found
temples dedicated to the "Spirit of Medicine," or
healing. The ignorant people, especially women,
believe that the deity presiding in these temples
can restore health upon the payment of small sums
of money to the priest and the performance of
certain rites.
Chinese medicine like philosophy rests on a
dualistic basis. At the bottom of all the laws of
the universe are two principles, the "yang" and the
"yin." They are generally represented by a circle
divided into two parts, each of which is a comma
shaped object resembling a serpent. One is white
and the other black, or one is green and the other
red. The circle represents the great absolute and
the two divisions within it the "yang" and the
"yin." Again the "yang" or male element or force
is represented by straight lines, and the "yin" or
female element by broken lines. Thus the panta-
gram was devised by a Chinese Emperor about the
year 2900 B. C. This is made up of combinations
of straight and broken lines surrounding the circle
and its two divisions, making a perfect emblem of
the balancing of the forces of the universe. Over
many a doorway in China this sign is displayed to
warn off evil spirits. The principle of duality
typified by the "yang" and "yin" is more compre-
hensive than "male" and "female." They stand for
positive and negative, the sun and the moon,
light and dark, acid and base, heaven and earth,
and they correspond to Ohrmuzd and Ahriman of
the Zoroastrians, Osiris and Nis of the Egyptians,
the even and the odd of Pythagoras.
The universe with its dual forces is a Macrocosm.
Man is the Microcosm. Thus we read that as
heaven has its orders of stars, and earth its cur-
rents of water, so man has his pulse. As earth has
its water courses, called lakes, springs, etc., so man
has his courses in the pulse — the three "yang" and
the three "yin."
The priests explain these forces of the universe
by personifications in the form of evil spirits or
devils, and the people are kept in constant fear of
these demons of the air which they believe are con-
stantly bent on bringing disease or death. Hence
the many superstitious practices resorted to for
deceiving or warding off the evil spirits. The
priests recite incantations, paper money is burned,
and the pantagram is hung over the doorway. The
demons are especially fond of marring beautiful
children, hence the parents invent disgusting names
for their offspring in the hope of misleading these
tormentors. Boys are especially liable to injury at
the devils' hands. Hence a guest never inquires
into the sex of a new-born child, and a boy is often
dressed as a girl and called by a female name.
The Chinese physician is quite a different in-
dividual from the Taoist priest, although magic
and astrology are inextricably bound in with his
theories of the human organism.
The first authority on medicine in China was the
Emperor Chen Long, who lived about 2737 B. C,
and made a classification of some hundred medicin-
al plants. A later emperor wrote up medical sci-
ence so far as it had progressed in 2637 B. C. In
the earlier ages there was some progress in
anatomy, but for the last one thousand years at
least, there has been practically no advance. The
profound respect for the dead has interfered with
dissecting and the performing of autopsies. Again
there is no cooperation between doctors and no
medical organization. The so-called Imperial Acad-
emy of Medicine at Peking has no jurisdiction over
physicians in other parts of the country. It is
composed of the physicians to the Emperor. They
give instruction to the younger members in the
medical classics. Generally speaking the practice
of medicine is unlicensed. Most doctors receive
their library from a father or relative who also
imparts the secret remedies on which his reputa-
tion was established. During his apprenticeship
the young doctor diligently studies the classical
books and practices palpation of the pulse. The
doctor is called upon only for more serious mala-
dies. For the simpler complaints home remedies
and the formulas of old women are used. In times
of war the Chinese soldiers attend to their own
wounds. Advertisement is quite ethical and the of-
fice of a doctor may be recognized by the tablets
displayed about the entrance, on which the skill of
the physician is testified to in high sounding
phrases. These testimonials are usually signed and
presented to the doctor by grateful patients. The
name of the doctor is of great importance, thus
one hears of Dr. "Root-of-Strength," Dr. "Rhu-
barb" and Dr. "Salts of Hartshorne."
As one would suspect from the absence of dis-
section and the experimental methods, the Chinese
conception of physiology and anatomy is fanciful
to the extreme. The body is said to be divided into
three parts: (1) the upper or head; (2) the
middle or chest; and (3) the lower part or ab-
domen, and lower extremities. Life depends on
the equilibrium of the "yang" and the "yin." It
is but one manifestation of the universal life. The
Aug. 26, 1916]
MEDICAL RECORD.
365
body is the microcosm, the universe the macro-
cosm. The "yang" is the warm principle, actively
flowing. The "yin" is the moist principle passive-
ly flowing. As the whole order of the universe re-
sults from the perfect equilibrium of these two
forces, so the health of man depends upon their
equilibrium in the body. If the "yang" or active
principle predominates there is excitation; if the
"yin" or passive principle predominates, there is
depression of the organism. The action of these
two forces manifests itself through eleven organs :
the heart, liver, lungs, spleen, left kidney, large
and small intestines, stomach, gall-bladder, urinary
bladder, and right kidney. The lungs are divided
into four large and two small lobes. The larynx
passes directly into the heart, which is the organ
of thought, together with the spleen. The liver
has seven distinct divisions. The gall-bladder is
the seat of courage. The urine passes directly
from the small intestines into the urinary bladder
through the ileo-cecal valve. The brain and spinal
marrow produce the semen which passes directly
into the testicles. There are said to be three hun-
dred and sixty-five bones in the body.
Functionally the viscera are divided into two
groups known as the six viscera in which the
"yang" resides, and the five viscera in which the
"yin" resides. The first group is composed of the
gall-bladder, stomach, small intestine, large intes-
tine, bladder, and left kidney, with its three heat
centers the three lumbar sympathetic ganglia. The
five viscera are the heart, liver, lungs, spleen, and
right kidney. The diaphragm is placed beneath the
heart and lungs, and covers over the intestines,
spine, and stomach. It is an impervious membrane
and covers over the foul gases, not allowing them
to rise into the heart and lungs. The stomach,
spleen and small intestines are the digestive or-
gans. They prepare the blood which is received
by the heart and set in motion by the lungs. The
liver and gall bladder filter out the various hu-
mours. The lungs expel the foul gases. The kid-
neys filter the blood, while coarser material is
evacuated by the large intestines. The "yang"
which is of subtle nature has a constant tendency
to rise. The "yin" which occupies the brain and
vertebral column as well as the five viscera tends
to descend.
Each of the organs has a canal whereby it com-
municates with other organs. Thus the liver, kid-
ney, and spleen are connected with the heart by
special vessels and the vas deferens arises from
the kidney. Some of these communicating chan-
nels end in the hands and some in the feet. One
of the vessels in the little finger is used to deter-
mine the nature of infantile diseases. Six of these
vessels carry the "yang" and six carry the "yin."
These two forces are disseminated through the
whole organism by means of the gases and the
blood. The former act upon the latter as the wind
upon the sea. The interaction of these two as they
circulate in the vessels produces the pulse. The
blood makes a complete circulation of the body
about fifty times in twenty-four hours. In these
fifty revolutions the blood passes twenty-five times
through the male channels or those of the active
principle and twenty-five times through the female
channels or those of the negative principle. The
blood is said to return to its starting place once in
every half hour, instead of once in twenty-five sec-
onds, according to modern physiologists, having
traversed a course of some fiftv-four meters.
Element
Color
Taste
Earth
Yellow
Sweet
Wood
Green
Sour
Fire
Red
Bitter
Metal
White
Sharp
Water
Black
Salt
Each organ is related to an element: fire rules
the heart, metal the lungs, etc. There is likewise
a close relationship to the planets, to season, color,
and taste. This interrelationship is well illustrat-
ed by the following table: —
ORGAN 1 LA. NET
Stomach Saturn
Liver Jupiter
Heart Mars
Lungs Venus
Kidney Mercury
Auscultation and percussion are wholly un-
known as diagnostic aids to the Chinese physician.
Entire reliance is placed on palpation of the pulse
and the general facies of the patient in making
the diagnosis. The taking of the pulse is almost
like a solemn rite.
The pulse may be palpated at eleven different
points, as follows: — Radial, cubital, temporal, pos-
terior auricular, pedal, posterior tibial, external
plantar, precordial, and in three places over the
aorta. Usually, however, the physician is satis-
fied with the palpation of the pulse of the right and
left wrist. With the right hand he feels the left
pulse and with the left hand the right pulse. He
applies three fingers, — the ring, middle, and index
finger over the pulse and the thumb underneath the
wrist. Then he palpates the pulse with each finger
successively. Under the ring finger the pulses of
the right hand reveals the condition of the lung,
middle of chest, and large intestines, while in the
left hand the ring finger determines the state of
the heart and the small intestines. The pulse under
the middle finger corresponds on the right to the
condition of the stomach and spleen, on the left to
the state of the liver and the gall-bladder. The in-
dex-finger placed over the pulse of the right radial
shows the condition of the bladder and the lower
portion of the body, over the left radial it reveals
the state of the kidneys and ureters. For each of
these six pulses the physician must practise weak,
moderate, and strong pressure, to determine wheth-
er the pulse be superficial, moderate, or deep. This
must be done during nine complete inspirations.
If the pulse be rapid the "yang" principle is pre-
dominant, if slow, the "yin" is predominant. There
are twenty-four main varieties of pulse. The
Chinese physician must be trained to palpate the
pulse so skilfully that by this single means the
nature of diseases and even the months of gestation
in a pregnant woman may be determined. Ten or
more minutes must be spent in the palpation of
the pulses.
Sometimes a Chinese physician will consider
other factors. For example, it is said that by ex-
amination of the tongue thirty-six symptoms may
be diagnosed according as the tongue is white,
yellow, blue, red, or black, and depending on the
extent of the coating. From the general appear-
ance of the face and nose the state of the lungs
may be discovered. Examination of the eyes, or-
bits, and eyebrows shows the condition of the liver.
The cheeks and tongue vary with the state of the
heart, the end of the nose with the stomach. The
ears suggest the conditions of the kidneys; the
mouth and lips the state of the spleen and stomach.
The color and figure of the patient also count in a
diagnosis.
Diseases are spoken of as internal and external.
External cases are those apparent on the surface,
such as all skin affectations, tumors growing on
the surface and of late all surgery has been classi-
fied as the practice of external diseases. Internal
diseases include all fevers and diseases of the heart,
366
MEDICAL RECORD.
[Aug. 26, 1916
lungs, and abdominal organs. More specifically
diseases are classified under nine heads as follows:
(1) Affections of the great blood-vessels, including
smallpox; (2) diseases of the lesser blood-vessels;
(3) fevers; (4) female complaints ; (5) cutaneous
diseases; (6) conditions requiring acupuncture;
(7) diseases of the throat, mouth, and teeth; (8)
disease of the bones; (9) affections of the eye.
Diseases are said to be produced by internal and
external agents. Among the external diseases are
(1) wind, which causes headache or apoplexy, diz-
ziness, chapping of face, diseases of the eye, ear
nose, tongue, teeth, etc.; (2) Cold may cause cough,
cholera, heart pains, rheumatism, and abdominal
pains; (3) heat causes chills and diarrhea; from
dampness comes constipation, distention of abdo-
men, watery diarrhea, gonorrhea, nausea, pain in
kidneys, jaundice, anasarca, pain in small intes-
tines, and pain in the feet: (5) from dryness come
thirst and constipation; (6) Fire causes pain in
the sides, diabetes, etc. The diseases of internal
origin are classified as disorders of the gases,
blood, sputum, and depressed spirits.
The treatment of disease by the Chinese doctor
consists chiefly in the administration of drugs.
Surgery has been an unknown art. Recently two
charitable institutions have been established in
Canton for the treatment of the sick according to
native methods of practice. At one of these so-
called hospitals I was informed that bullets were
removed by placing a kind of plaster at the wound
of entrance. The ingredients of the plaster have
a remarkable magnetic power over the imbedded
bullet and gradually draw it out through the same
opening by which it entered. My informant had
never seen this line of treatment actually carried
out, however.
Perhaps in no line does the native practitioner
show his ignorance more than in the treatment of
fractures. No attempt is made to reduce the
parts. A special clay is placed in a wooden bowl.
The heads of several chickens are cut off, while
incantations are repeated and the blood is allowed
to flow on the clay in the bowl. Blood and clay
are now mixed together and applied to the frac-
tured extremity. Bandages are used to bind on
thin strips of bamboo. When the last turn of the
bandage is being wound on, the blood of another
chicken is poured on.
The only real operation performed by the Chinese
is the castration of eunuch, and castration as a
penalty for adultery. With one sweep of a sharp
knife the genital organs are completely removed
on a level with the skin of the pubis. A metal
plug is inserted in the urethral opening and a cloth
rung out of cold water is applied to the bleeding
surface and firmly bound on. The patient is al-
lowed to drink no water for three days when the
dressing is removed, the plug withdrawn and the
patient allowed to urinate.
Coming now to the real field of the Chinese doc-
tor we find that the number and variety of reme-
dies recommended in the Chinese Materia Medica
can only be compared to our own National Phar-
macopeia. The great Materia Medica compiled in
the 16th century is composed of 52 books and con-
tains 1892 remedies. Kipling's verse applies to
the Chinese as to the British people for whom he
wrote it: —
"Alexanders and Marigold,
Eyebright. Orris, and Elecampane,
Basil, Rocket, Valerian, Rue,
(Almost singing themselves they run)
Vervain, Dittany, Call-me-to-you,
Cowslip, Melilot, Rose of the Sun,
Anything green that grew out of the mould,
Was an excellent herb to our fathers of old."
The drugs and other medicaments are weighed
out according to a decimal system as follows: —
1 tael or leung equals 40.00 gm.
1 tsin " 4.00 gm.
1 fan .4 gm.
1 lei .04 gm.
1 ho " .004 gm.
Often a prescription is given because of the re-
semblance of the drug to the organ affected. Thus
for renal diseases, haricot or kidney beans are
given. Minerals are administered as salts. Plants
are used in the form of roots, stems, leaves, flow-
ers, and dried fruits. The bones of a tiger are
frequently ground up and given to a debilitated
person. The grasshopper is dried and used as a
medicine and the shells of the cicada are collected
from the bark of trees and mixed with other in-
gredients. Tinctures and extracts are prepared
from rice wine. Pills are often made with a thick
shell of parafine which is broken off and the con-
tents chewed up. Various forms of plasters and
blisters may be applied to the skin. The actual
cautery is often used as a revulsive.
Among the pills the best are the "Wai Shaang
Uen" or life preserving pills costing about a dol-
lar apiece. They are composed of Manchurian gin-
seng, deer's horns, and other drugs. Among other
common remedies may be named dried, powdered
rattlesnake skins, the bile of the ox and dog for
jaundice, dried shrimps, etc. Quicksilver is often
poured into gun-shot wounds in order to dissolve
the bullet. In some drug shops two signs are hung
at the entrance ; on one are written the names of
venereal diseases, on the other such diseases as
hemorrhoids, wounds, ulcers, etc. The patient ex-
plains in which class his disease belongs and is
promptly given the appropriate remedy. Among
the most used drugs are some that are found in
the western pharmacopias, viz., ginseng, rhubarb,
sulphur, pomegranate root, aconite, opium, arsenic,
and mercury.
Diseases of the liver and eyes, which are sympa-
thetic organs, are cured by giving pork's liver.
In Kwangtung Province human blood is considered
an excellent remedy and at executions people may
be seen collecting the blood in little vials. It is
then cooked and eaten. A genuine prescription
written by a physician to be used as a laxative was
composed of Rumex hydrolepathium, Quercus glau-
ca, Sodium sulphate, and Magnolia hypoleuca. The
parts from these plants are boiled with the sodium
sulphate and the "tea" is drunk by the patient.
A remedy which I have not infrequently seen
applied to a patient in extremis is as follows: —
A rooster is killed and the body is cut in half,
longitudinally, and the bleeding half is quickly
applied to the skin of the patient's1 abdomen. If
there is any possibility of cure this is supposed
to be infallable.
The use of the acupuncture needle seems to be
seldom resorted to in the neighborhood of Canton.
The theory on which it is based is that if one
punctures the blood-vessels connecting different
organs the disease will be aborted. Three hundred
and eighty-eight points suitable for acupuncture
are described. There is a mannikin at Peking
pierced with holes at all the points suitable for
Aug. 26, 1916]
MEDICAL RECORD.
367
acupuncture. Paper is pasted over it and students
learn to find the proper holes through the paper. The
needles vary from 1% to 28 cm. in length and are
made of gold, silver, or steel. During the opera-
tion the patient coughs and the errant humours
are directed back into their normal courses.
Such in brief is medicine as it is practised by
the Chinese doctor of to-day. One is reminded of
the old humoural theory of Europe in the Middle
Ages. But modern education in China has brought
a new light to the people and in all the large cities
and many of the small ones, Western medicine is
slowly but surely winning its way.
REFERENCES.
1. Andrews, J. A.: Medical Record, 1882, Vol. 22,
p. 52.
2. Arnold, W. F.: Southern Practitioner, Nashville,
1895, 17, p. 323.
3. Cadbury, W. W.: China Medical Journal, 1914,
Vol. 28, p. 375.
4. Cohn, I. E.: Medical Record, 1892, Vol. 42, p. 477.
5. Culin, S.: American Journal Pharmacy, Phila.,
1887, 59, p. 593.
6. Gregory, J. J.: Medical Record, 1893, Vol. 44,
p. 165.
7. Hodvedt, I. M. J.: North Western Lancet, Min-
neap., 1901, Vol. 21, p. 101.
8. Kerr, J. G. : Cincinnati Lancet-Clinic, 1893, n. s.
31, p. 660.
9. Krause, Berl. klin. Wochensch, 1903, Vol. 40, pp.
18, 39, 68. Abstracted Brit. Med. Jour., 1904, p. 960.
10. Regnault, Jules: Medecine et Pharmacie chez les
Chinois et chez les Annamites. A. Challamei, Paris.
11. Simon, G. E.: Rev. d'anthrop., Paris, 1885, 2s.,
VIII, p. 620.
12. Thwing, E. P.: Medical Neivs, 1890, 57, p. 210.
13. "Viator": Medical News, 1883, Vol. 43, p. 216.
THE TREATMENT OF PARALYSIS AGITANS
AND ARTHRITIS DEFORMANS BY THE
CONTINUOUS BATH.
By SAUL DANZER, M.D.,
BROOKLYN, NEW YORK.
ASSISTANT ATTENDING PHYSICIAN TO THE SEA VIEW HOSPITAL ;
CLINICAL ASSISTANT IN NEUROLOGY AT THE VANDERBILT
CLINIC (COLUMBIA UNIVERSITY); ASSISTANT IN IN-
TERNAL MEDICINE AT THE GERMAN HOSPITAL
DISPENSARY.
The treatment of the chronic diseases, arthritis
deformans and paralysis agitans, extends over a
long period of time and is very unsatisfactory if
one wishes to treat the complaints of these patients.
Since arthritis deformans occurs not infrequently
in young and middle aged people, the need of im-
proving them and relieving their symptoms, if it
is not possible to cure them, becomes very apparent.
It is with this purpose in view that we began to
work up this problem under the direction of Prof.
Simon Baruch, who advised the use of the continu-
ous bath (which is really a hammock bath in a tub
of continuously running water) for these cases.
We began with a temperature of 95 deg. Fahr.,
which, because of its proximity to the temperature
of the body surface, might exert a sedative effect.
The next question that arose was the duration
of these baths. In order to get positive informa-
tion on this matter, we had to subject patients to
these baths for varying lengths of time. The
minimum exposure was 25 minutes and the maxi-
mum was 17 hours, so that patients treated for
the longer period ate and slept in the baths. The
longer baths seemed preferable from the theoreti-
cal standpoint, because if any effect was to be pro-
duced on these patients, the dosage of the baths
would have to be generous.
From the practical viewpoint, however, we came
to different conclusions. First, because patients
tried to avoid urination and defecation in the tubs
( although they knew the running water would
carry off the excreta). Secondly, because of the
strain resulting from the maintenance of the body
in the one position, which produced fatigue and
gave them generalized pains and aches. It can
easily be seen that both of these were bad for our
patients.
We found by experience that the ideal method
was frequent treatments of shorter duration. Be-
cause of the large number of cases that had to be
treated at the hospital, we fixed the duration at
two hours, to be given daily. After the baths the
patients would receive light general massage and
alcohol rubs for their systemic tonic effect.
We then had to find out for how long a period
bath treatment should extend. Accordingly we gave
them every day for three to four weeks and watched
for results. We thus noticed that the patients would
feel very comfortable during this time. If they were
given for longer time (as five or six weeks) they
would feel tired and weak after the baths and
would not improve much, and might even complain
of pains, insomnia, etc. Thus we realized that we
had reached the limit, so we decided to leave the
patients out of the baths on each seventh day of
the week and limit the total number to thirty, which
series might again be renewed after an interval
of one month. By this regime we obtained very
favorable results.
Upon further experience we learned that cases
of arthritis deformans and paralysis agitans could
not very well be treated in the same room at the
same time; for while the nervous cases complained
of the high temperature of the room and wanted
the windows opened, the arthritics preferred the
windows closed because they felt cold. Likewise,
the Parkinsonian patient said that he preferred
water colder than 95 deg. and the patient with the
joint affection wanted the temperature raised.
Accordingly we grouped the nervous cases to-
gether and treated them at one time with the room
well ventilated and the water at 92 deg. Fahr.; the
joint cases were treated together in a warmer room
and the bath was given at 98 deg. Thus we ob-
tained marked improvement in both types of cases.
Results of Treatment — General Condition. — In
order to observe these cases carefully, tempera-
ture, pulse, respiration, and blood pressure (sys-
tolic and diastolic) were taken a half hour before
the baths and every half hour while in the baths,
also a half hour after the patient came out of the
bath. In general, we found that during the first
half hour in the bath there was a slight fall in blood
pressure, a slight increase in pulse rate and in the
frequency of respiration, which soon dropped to
normal. Urine examination and blood counts were
taken with no remarkable results.
A fact worth mentioning is that when the patient
was left in the tub too long (past the physiological
dose) the pulse, respiration, and blood pressure
rose, and in cases of paralysis agitans the muscular
rigidity increased. Fatigue and discomfort rather
than any direct effect of the bath itself may ac-
count for these symptoms.
Arthritis Deformans: Pain. — It was remarkable
to see how quickly patients felt relieved when placed
in the tub; even the most advanced cases showed
improvement. Out of all of these cases at the
Montefiore Home and Hospital, in only one case
368
MEDICAL RECORD.
Aug. 26, 1916
can we say definitely that no improvement resulted
and this case was one complicated with optic atro-
phy and blindness in which treatment had to be
suspended because of the general irritability. In
many, benefit was noticed after the second or third
bath.
Patients who for years had to take aspirin or
some other form of salicylic acid to quiet their
pains and give them rest, could now get along quite
comfortably with no medication at all. This was
already a gain, because we were dealing with the
most advanced and desperate cases of the disease.
Some patients were relieved only while in the bath,
while in others the improvement was more lasting.
Joint Motion and Muscular Rigidity. — These were
also favorably influenced and very early in the treat-
ment we noticed that the patients began to move
joints that were comparatively stiff before. This
was due both to the relief from pain, as previously
described, and also because of the muscular relaxa-
tion produced by the warm water. A remarkable
case that was seen was in a man suffering from
arthritis deformans for about twelve years and who
had not walked for the past three years. When I
first saw him he was suffering from an acute ex-
acerbation of a chronic nephritis. He was- given
the routine treatment and after three baths pain
was relieved and he began to move some of his
joints. After ten baths he walked without the
help of a cane, a feat which he had not accomplished
within three years. Because of the benefit received
this patient asked to have his course of baths pro-
longed. Accordingly he received them for two
weeks more during which time he steadily im-
proved, but because of other patients waiting to
receive treatments more baths had to be denied him.
Paralysis Agitans. — In this condition, as is well
known, the patients complain of parasthesias I es-
pecially burning sensations) along the back, mus-
cular tremor, and rigidity. Parenthetically, I wish
to say that our routine medication for these cases
was hyoscine, which in some instances had to be
given thrice daily in order to obtain relief. When
the bath treatment was begun, all forms of medica-
tion were stopped and patients who for years would
crave for their hyoscine could do without it very
well.
The parasthesias were the first to yield. As a
rule the greatest relief would be obtained while in
the water with a return of some pain afterwards,
while in others complete improvement resulted for
the time being. Muscular rigidity was also les-
sened, thereby giving more motion to the joints.
The tremor was also diminished while in the water.
In si. me cases we noticed that after improving
for a few days the patients became worse again,
namely, their tremors increased and their rigidity
returned. Upon further investigation we found
that this occurrence was parallel with states of con
stipation, hence wi tried to pay special attention to
the bowels at this time and noticed that things
cleared up again. Accordingly we began to pre-
SCribe light cathartics and enemas every night, with
very satisfactory results.
of the Uathx.~\Xe must now
ask ourselves how do these baths art'.' What is the
mechanism of these baths on the disease condil ions?
In order to answer this we must analyze the symp-
toms and get at their cause.
Let us consider first arthritis deformans. The
pain in this disease may be due to the following:
1 l Painful skin areas corresponding to the joints
affected with arthritis. Because of this, irritation
of the skin would produce reflex muscular spasms,
thereby approximating the joint surfaces, which of
course aggravated the pain, thus producing a vi-
cious cycle. (2) A neuritic involvement, as in
peripheral neuritis, since there is evidence that ar-
thritis deformans is the result of a metabolic or
toxic process.
The painful skin surfaces are relieved because
of the soothing effect of the tepid water (98°).
To understand this thoroughly, I would refer to Pro-
fessor Baruch's Hydrotherapeutic Law. The effect
of any hydriatic procedure is in direct proportion
to the difference between temperature of the water
and that of the skin. When the water is of a tem-
perature above or below that of the skin, it is stim-
ulating. As the temperature approaches that of
the body surface, the effect is a sedative one. Or-
dinarily the skin temperature is 92° and the skin
over an inflamed joint is a little warmer than over
the adjacent areas; hence temperature slightly
higher than 92' (95° — 98°) are most sedative in
arthritis deformans.
As pain and hyperirritability of the skin are les-
sened, the reflex muscular rigidity and resulting
joint pain are diminished. The pain due to the
coexisting peripheral neuritis is relieved because
of the eliminative effect of the warm bath on the
skin. Also because of the soothing effect as just
described.
In Parkinson's disease the pain and reflex mus-
cular spasms and tremors are in a great measure
the result of an influx of stimuli coming in through
the nerve fibrils of the skin. Evidence of this fact
is given by the increase of all these symptoms when
a cold stream of air passes over these patients or
when the atmosphere of the room is too warm. An-
other form of peripheral irritation tending to ex-
aggerate all these symptoms is constipation. So
marked was this that one could actually use mus-
cular rigidity as an index to the condition of the
patient's bowels. Now, if the skin forms the portal
of entry for the irritated influences and since water
at the temperature given soothes, we can readily
see how the continuous bath acts on the diseases
in question.
Conclusion. — The continuous bath does not cure
paralysis agitans or arthritis deformans, nor does
it change the pathological process in the least. It
does, however, offer great relief to these patients
and improves their symptoms subjectively and ob-
jectively. It is far superior to the salicylates for
arthritis deformans or hyoscine for paralysis agi-
tans, and certainly has none of the objectionable
features belonging to the prolonged use of those
drugs.
As a palliative measure the continuous bath in
our opinion is to be highly recommended.
\\ENCE.
Herpes of the Cornea in Influenza. — C. W. Walker re-
ports this cas.>: Physician, aged thirty-four, after hav-
ing treated many patients with influenza, fell a victin"
to the disease and developed a herpes on the right side
of the face. About two weeks later a foreign body
lodged in his risrht eye, and despite its extraction the
traumatic conjunctivitis became much worse, and a few
days afterward the cornea was seen to tie ha7y. From
the very first the eye had been refractory to I
and the effected cornea soon showed ulceration; the
ulcers, however, now resp ded quickly to the proper
treatment, leaving excentric opacities with vision intact.
— The Ophthalmic Record.
Aug. 26, 1916]
MEDICAL RECORD.
369
PROCTITIS.
By CHARLES J. DRUECK. M.D.,
Proctitis or inflammation of the rectum is quite
commonly met with in general practice, and re-
quires careful diagnosis and prompt treatment.
Several different varieties are distinguished, al-
though the symptoms in general are much the same
in all and the case frequently terminates in fistula.
Proctitis is divided into acute and chronic varie-
ties, each of which has several forms, according
to etiology or development. Thus the acute con-
sists of the catarrhal, dysenteric, diphtheritic, and
gonorrheal ; the chronic, of the catarrhal, syph-
ilitic, tuberculous, papillomatous, and stenosing.
The catarrhal acute form of proctitis is due to
intestinal disturbances and occurs chiefly in chil-
dren, although occasionally it is found in adults.
Usually the mucous membrane alone is involved,
being congested, even tumified at times, and the
epithelial layer may be shed off during the engorge-
ment. In dysenteric proctitis the whole colon is
frequently involved, especially in the tropical
variety. The rectum, like any other mucous mem-
brane, is liable to the invasion of diphtheria, but
infection is rare. Gonorrheal proctitis is com-
monly found in women on account of the close prox-
imity of the vulva and rectum, and is usually the
result of unclean] iness, sodomy, or abscess of
Bartholin's gland that has ruptured into the rec-
tum.
Chronic catarrhal proctitis may result from re-
peated attacks of the acute form or may begin as
a deeper and a chronic inflammation. Constant re-
infection and irritation, together with a sluggish
venous flow, tend to prolong any inflammation in
the rectum. In aggravated cases, the surface is
granular with multiple ulcerating points. Hyper-
trophy of the glands occurs, causing papillomatous
growths which project into the lumen of the rectum
(papillomatous proctitis). When the inflammation
extends deeper than the mucous membrane and in-
volves the areolar and muscular tissues around the
rectum, a constriction results later, from the con-
traction, and we have a stenosing proctitis.
In adults, proctitis may result from fecal impac-
tion in the rectal pouch, exposure to colds as sitting
on a cold or wet seat, foreign bodies in the rectum,
hard substances in the fecal mass, as fish bones,
pins, hulls of cereals; injury from the tip of the
syringe, strong purgatives, or arsenic, bichloride
of mercury, irritating suppositories, the extension
of inflammation or colitis, or the irritating dis-
charges from the bowel above. Esmarch reports
a case of proctitis as a symptom of gout, the rectal
inflammation alternating with other symptoms.
Proctitis may also result as an extension of in-
flammation from hemorrhoids, prolapse, or eczema
about the anus. Both acute and chronic proctitis
may result from inflammation of neighboring or-
gans, as the bladder, prostate, vagina, or uterus.
The symptoms vary with the severity of the at-
tack and the duration of the trouble. The chronic
forms are less painful and tender than the acute.
A sensation of weight, heat, or fullness appears in
the rectum and may amount to actual pain, which
in severe cases may involve the uterus, bladder,
and sacral region, and even radiate down the
thighs. With this tenesmus, a constant and inef-
fectual desire to empty the bowel occurs, and this
continual straining frequently produces a prolapse
of the mucous membrane, especially in children.
Irritation of the trigonum vesicae causes frequent
micturition or sometimes retention. By this time
the engorged membrane is bleeding, perhaps with
a mere streaking of the passage or occasionally
considerable discharge of clear blood. Kelsey re-
ports a case in which this loss of blood was the first
symptom that attracted the patient's attention. A
case of proctitis with hemorrhage without any of
the antecedent symptoms is rare. Later mucous
and pus are voided. Examination at this stage re-
veals ulceration to some extent. It may be very
superficial and limited to one or two small points
or have many foci, some of which may be quite
deep and involve the whole thickness of the mucous
membrane or even perforate the bowel. When
ulceration occurs above the peritoneal fold it re-
sults in peritonitis, and when below that line in
abscess and fistula. A chronic proctitis may in this
way cause a stricture.
In all forms of proctitis the anus is red and
painful, the sphincter and levator ani muscles are
irritable and spasmodic, and associated with the
local symptoms there is always more or less con-
stitutional disturbance. In chronic proctitis, the
symptoms are less marked, diarrhea alternates with
constipation, and the discharge occurs only with
defecation. The inflammation may be limited to
only a small part of the rectum or may be more
diffuse and involve all of the organ.
The symptoms of dysenteric proctitis are similar
to those of the chronic catarrhal form except that
more of the bowel is involved and the systemic in-
fluence is more marked. When the diphtheritic
variety is found other members of the patient's
family should be cautioned about using the same
closet. The gonorrheal form has its characteristic
free, creamy white discharge issuing from the anus,
the rectum becomes hot and swollen, and the pain
is burning and intermittent. The anus chafes and
the sphincter is spasmodic in its action. This form
of proctitis is usually of short duration and can
easily be differentiated on account of the disease
in the vulva or urethra and by finding the gono-
cocci in the pus. It may, however, if untreated, de-
generate into a chronic proctitis. The discharge is
freer and contains more pus than any other form
of proctitis. It must be remembered, though, that
gonorrheal proctitis is rare; Gosselin saw only one
case in three years.
The following case in my own practice some time
ago gives a vivid picture of this form of trouble:
Patient referred to me by Dr. Watts and first seen
by him, suffered from gonorrheal infection of the whole
genital tract. Abscesses had developed in Bartholin's
glands and rupturing into the rectum had produced
labiorectal fistula on either side of the vagina, from
which there was considerable discharge. The examina-
tion revealed sinuses into the rectum above the external
sphincter. Rectal examination showed on inspection a
free discharge from the vagina and also from the rec-
tum when the patient was requested to bear down, al-
though the sphincter which was spasmodically con-
tracted, would ordinarily retain the discharge. The anus
was quite inflamed. Digital examination showed the
rectum was tender and disclosed an abrupt stricture
about two and one-half inches above the anus. This
stricture was at nearly the lower level of the internal
sphincter muscle and was annular in shape and dia-
phragm in form, that is, a thin, membranous septum.
No marked induration was felt at any point, but as the
finger was withdrawn it was covered with blood and
pus and a few shreds of mucous membrane. The spec-
ular examination was especially instructive. The active
inflammation began immediately above the external
sphincter and appeared localized below the stricture.
The whole mucous membrane had a honeycombed ap-
370
MEDICAL RECORD.
[Aug. 26, 1916
pearance and was covered with white fibrous shreds
resembling the "tripper-faden" of urethritis, only much
larger. They were easily removed, but left the mucous
membrane inflamed and bleeding. As the rectum was
dilated the stricture could be seen to stretch and tear.
The trouble appeared to be localized within the lower
two inches of the rectum.
Proctitis is not very serious, as a rule, unless
the cause cannot be found and removed. When the
cause is removed the case heals kindly unless com-
plicated by ulceration, abscess, or fistula. Some-
times a perirectal lymphangitis or phlebitis may
protract the case or cause a fatal termination.
Acute proctitis will pass off in ten days or so, leav-
ing no appreciable permanent alteration in the
bowel, except in those cases in which ulceration or
gangrene has occurred. Chronic proctitis is liable
to continue indefinitely unless the cause can be re-
moved. The mucous membrane is thickened and in-
durated and loses its sensibility more or less, so
that a large bolus of feces may collect without
stimulating the rectum to expulsion. Stricture of
the rectum generally has some chronic proctitis
associated with it; below the stricture the mucous
membrane is congested and covered with pus or
mucous, while above the stricture ulceration occurs.
A thorough examination of a case of proctitis is
important and a digital examination should be
made in every patient presenting a chronic diar-
rhea, because many of the causes given above as
predisposing to or exciting proctitis may be
promptly determined. When the patient is placed
in the knee-chest position, the proctoscope is well
oiled and introduced, and as the obturator is with-
drawn the air rushes in and dilates the bowel;
then by turning the proctoscope from side to side
and gradually withdrawing it the whole surface of
the rectum may be carefully and thoroughly ex-
plored.
The treatment of proctitis varies considerably
with the exciting cause and, therefore, before in-
stituting any treatment a thorough examination
must be made. The parts being irritated and in-
flamed, the examination is very painful unless an
anesthetic, general or local, is administered. In
many instances where for various reasons chloro-
form should not be given at the time of the exam-
ination, the patient may be relieved of most, if not
all, of the pain by the application of a 2 per cent,
solution of cocaine. A general anesthetic has much
in its favor, because when the patient is asleep the
sphincter may be thoroughly dilated, thus reliev-
ing the tenesmus and greatly facilitating subsequent
examination or treatment. At the same time, any
local trouble or cause of the proctitis may be re-
moved, thereby accomplishing two things at one
sitting.
Acute cases require absolute rest in bed, because
when the patient is up and about his duties the de-
pendent position of the vessels, together with the
thinness of their walls and the associated conges-
tion and inflammation, produce a venous stasis
which seriously impedes or prevents regenerative
changes.
The diet should be plain and of such a variety
as will insure soft or semisolid evacuations. It is
also advisable to maintain a largely absorbable
dietary that the bowels may move infrequently,
thus sparing local movements of the parts. Twice
each day the bowel should be douched with two
quarts of cleansing solution as hot as can be borne.
To begin with, a temperature of 105° F. may
be used and the temperature raised each day. Plain
boiled water with the addition of a handful of salt
has given me the best results. I have devised a
douche tip of my own to be used in these cases,
because I have found it impossible to obtain a free
return flow with any I have found, and unless the
exit is large the fluid will pass up into the colon
and carry the infection up with it, instead of wash-
ing it out. By practical experience I find that
douching in this manner washes out a large amount
of infectious material, such as secretions, fecal ac-
cumulations, and hordes of microorganisms; dis-
solves mucous and pus, flushing them out as
shreds; contracts the vascular structures, thereby
stimulating circulation, relieving the local conges-
tion, and depleting the tissues.
Following the douche, about two drams of
astringent antiseptics or other medicinal mixtures
is injected and the patient is instructed to retain it.
Silver nitrate, hydrastis, glycerole of tannin, or
acetate of lead in various combinations and
strengths, according to the case, are the most relia-
ble drugs. If the pain and tenesmus are not re-
duced, laudanum and starch water may be injected
every two or three hours until the patient is re-
lieved; from twenty to sixty minims may be needed
in this way.
Hot fomentations applied over the hypogastrium
give much relief when the inflammation extends
over a large area and when there is general, diffuse
pain and tenderness. In mild cases limited to the
lower end of the rectum, the applications of cold
to the anus and perineum or the injection of cold
water into the rectum relieves the congestion
promptly.
When the proctitis is due to thread worms injec-
tions of lime water or salt water and the adminis-
tration of santonin internally will be enough.
Gonorrheal proctitis, like its counterpart in the
urethra, is especially intractable. Silver nitrate
solutions 1-3,000 should be used to douche the rec-
tum, but the same conditions must be observed as
are mentioned above. The strength is to be grad-
ually increased as a tolerance is established until
a 3-1,000 solution is used. Following the douche
the whole mucous membrane is swabbed with
balsam of copaiba or a suppository containing
balsam of copaiba and iodoform, each 5 grains, may
be inserted.
The chronic forms of proctitis are somewhat dif-
ferent. The douching should be instituted in these
just the same as in the acute cases because of its
alterative effect. The excessive secretion is con-
trolled with applications of alum, zinc, or silver, or
any of these combined in a suppository with iodo-
form, or one minim of oil of turpentine.
When ulceration, periproctitis, or any other com-
plication exists it requires its own treatment, which
for obvious reasons cannot be entered into in this
paper. Syphilitic cases are associated usually with
strictures which may require surgical treatment,
although I have seen astonishing changes occur
under general internal medication. Tuberculous
proctitis is usually secondary to disease higher up
and is accompanied with so much ulceration, to-
gether with the general systemic infection, that
treatment is unsatisfactory. The treatment of
proctitis due to cancer is surgical, of course, and
cannot be considered here.
Proctitis in either the acute or chronic form is
always a serious matter, deserving of the physi-
cian's most careful attention because the inflamma-
tion itself may debilitate, and especially because
Aug. 26, 1916]
MEDICAL RECORD.
371
complications which may invalid ihe patient are
prone to occur. Each case is a law unto itself, and
this article cannot go into the details that may per-
plex the attendant, but simply tries to give the
reader a clear clinical picture in general and to lay
down the main lines of treatment.
43S East Forty-sixth Street
A CASE OF LACERATION OF THE LIVER.
Br C. A. WAYLAND, M.D.,
AND
R T. WAYLAND, M.D..
S \N JOSE, CAL.
The liver, in consequence of its anatomical situa-
tion, size, and firm attachment, becomes subject to
injury when direct violence occurs against the upper
right abdominal quadrant and the lower part of the
thorax. Its lack of elasticity and its consistency
further predispose to the tearing of this organ at
the time of injury. As compared with injuries of
other abdominal viscera, we find that one observer
collected 3G5 cases, of which 189 concerned the liver
and 176 represented the combined injuries of the
pancreas, kidneys, and spleen. Out of the 189 cases
involving the liver, 120 were located in the right
lobe. Most cases are due to direct violence caused
by a blow, fall, or the end of a rib penetrating its
structure. A few cases, however, are predisp
by certain diseases, e.g. syphilis, tuberculosis, amy-
loid degeneration, hypertrophic cirrhosis, tumors,
and malarial fever. Males are injured more fre-
quently than females, and painters, carpenters, and
railroad employees are the usual victims.
According to another writer, out of 543 cases col-
lected 80 per cent, died if not operated upon, while
the mortality following operation was from 40 to 50
per cent. A number of factors may enter into the
ultimate outcome of the case. For example, a small
tear through the peritoneal coat of the liver may
result only in the formation of a hematoma, while
on the other hand a deep laceration severing bile
ducts and large vessels will cause a severe hemor-
rhage which will rapidly prove fatal. The admix-
ture of bile and blood at the time of the injury prob-
ably prevents rapid coagulation. The severity
of associated injuries to other organs will, of course,
alter the ultimate outcome of the case. An inter-
esting fact noted is the rapid recovery from gun
shot wounds of this organ produced by the modern
bullet, while stab wounds are more apt to prove
fatal.
The following represents a very striking and in-
structive case that came under our care
Mrs. M. V., age 34, married. In good health previous
to accident. On the afternoon of February 18, at 4
P.M., patient was thrown from a wagon on which was a
large barrel of oil. She struck on hard ground and the
edge of the barrel fell on the upper part, of her abdomen.
In some way she received a severe blow to the head,
which was evident from the symptoms she had of con-
cussion. Immediately following the accident she walked
to an automobile and rode about half a mile. Owing to
the gradual development of unfavorable symptoms we
were not summoned until 6 p.m., and by this time she
was in shock and the abdomen revealed signs of some
intraabdominal calamity, producing hemorrhage which
called for immediate operation. She was hurriedly
taken to a hospital.
Rallying slowly to a state of semi-consciousness, the
patient became restless and thirsty. She vomited
(vomitus containing dark blood), yawned, and had air
hunger. Her mind was not clear. She complained of
severe pain located in the left upper abdominal quad-
rant, which was continuous, sharp, and cutting in char-
acter. It did not radiate. Marked dyspnea was present.
Examination showed a fairly well developed female
adult. Showed evidence of collapse. Skin was a peculiar
greenish white color and very cold and clammy. Both
pupils dilated. The left reacted sluggishly to stimuli.
There was ptosis of the left eyelid. Mucous membranes
were blanched and anemic. The tongue cold, dry, and
white in color. On protruding it deviated to the left
side. Lips drawn to the same side. The lungs were
clear and resonant throughout. Respiration labored,
rapid, jerky, and limited on the left side.. Heart action
rapid. Sounds weak. No murmurs heard. The
abdomen was distended. Board-like rigidity of the
upper left quadrant; marked tenderness in the epigas-
trium. No masses were felt. Slight dullness present in
both flanks; more marked in the left. Liver dullness
not noticeably increased. Neither kidneys nor spleen
palpable. The left arm and hand were completely
paralyzed, but sensation was maintained. Her pulse
rapidly became weaker until it could no longer be felt.
Operation. — Preparation consisted of a dry shave of
the entire abdomen and the application of the tincture
of iodine. Only a small amount of ether was needed,
owing to the collapsed condition of the patient. An in-
travenous of normal salt solution and adrenalin chloride
was started. A left rectus incision was ma-ie through
the abdominal wall, extending from the costal angle to
the supra public region. The abdominal cavity was
found full of blood, and a hurried examination revealed
a laceration of the left lobe of the liver. It was about
five inches in length, situate at the lower anterior mar-
gin and extending up between the right and left lobes.
Associated with the laceration was a gapping of the
fissure between the two portions of the liver. Blood
was rapidly oozing from the tear. Gauze was packed
into the rent while the blood was evacuated from the
peritoneal cavity and the other abdominal viscera ex-
amined, but no other serious injury was found present.
The edges of the gapping wound were approximated
with No. 2 catgut mattress sutures. Due to the close
proximity of the suspensory ligament, a few sutures
passed through it and thus not only aided in holding up
the liver but also lessened the danger of the sutures to
cut the hepatic tissue. Owing to the fact that the
sutures at the upper angle of the laceration would not
hold, an iodoform gauze pack was put in this area. A
small drain of iodoform gauze was inserted down to the
line of sutures, and both drains were brought out at the
upper angle of the wound. The peritoneum was sewed
with catgut, and through and through silk-worm gut
sutures were used in order to rapidly close the abdomen.
Dressings applied.
The intravenous of salt solution and adrenalin
chloride was continued throughout the operation, a
total of one quart of salt solution and one drahm of
adrenalin chloride being given. Her pulse gradually
became palpable under this stimulation. The patient
was returned to bed in a very critical condition.
Following the operation the foot of the bed was ele-
vated; the extremities were bandaged, external heat
was applied, and enteroclysis of salt solution started.
Camphorated oil, strychnine sulphate, and morphine
sulphate were used as indicated. Her pulse remained
irregular, weak, and at times could not be palpated.
Twelve hours following the operation six ounces of
blood taken from her brother was given intravenously.
(The indirect method with sodium citrate as an anti-
coagulant was used.) No ill effects were noted by us
use, while on the other hand she gradually regained
strength. Immediately her pulse became regular and
of fair volume. In twenty-four hours bile-stained
drainage appeared upon the dressings and this necessi-
tated frequent changing. This bile-stained drainage
continued for about three weeks, and then gradually
disappeared as the wound healed. The gauze drains
were slowly pulled out until the seventh day, when they
were removed entirely. On the second day after the
operation she manifested evidence of a low grade peri-
tonitis by vomiting, slight rise in temperature, and
tympanites. This subsided two days later. Jaundice
did not appear throughout convalescence. On the
twenty-third day following the operation the patient
had a convulsion, which started on the left side of the
body and then became general. This was followed by a
period of unconsciousness which lasted for about twenty
minutes, and then she became apparently the same as
before the convulsion, except that she had a complete
motor palsy of the left side. This remained for two
days and then gradually began to improve, until at the
present time she has complete power of her left leg and
372
MEDICAL RECORD.
[Aug. 26, 1916
nearly the entire use of the left arm and hand. Con-
valescence was slow but uninterrupted, except for the
one convulsion mentioned. The wound healed by first
intention except at the point where the drains came out,
and here granulations gradually filled in the opening.
Six weeks following the accident the patient was able
to leave the hospital in very good condition. At the
present writing she has resumed her usual household
duties.
The following points suggest themselves upon a
study of this case
1. The necessity of seeing a case early and recog-
nizing an internal hemorrhage.
2. Early laparatomy if hemorrhage is present,
even though the patient is in shock.
3. Make a free median abdominal incision, using
plenty of room to work.
4. Control bleeding by sutures, packing, or cau-
terizing.
5. Drain the site of the laceration in the liver.
6. Drain the peritoneal cavity.
7. Treat the hemorrhagic shock by replacing the
lost fluid into the circulation and stimulating.
14n North Third Street.
UNIVERSAL IMMUNIZATION.
Kv HERMAN B. BARUI H M.D.,
NEW VOKK.
For several years I have given much thought to
the subject of immunization. On June 10, 1910, I
proposed to Dr. Simon Flexner, of the Rockefeller
Institute, to make some experiments at my own ex-
pense on injections of a serum from the blood of an
equine case having a temperature of 106° Fahr.,
into another case with the intention of producing a
premature crisis. Dr. Flexner kindly replied, Oc-
tober 20, 1910: "I do not doubt that there is a cer-
tain amount of toxin present in the blood of pa-
tients suffering from pneumonia. ... It is impos-
sible, however, for me to take up any special work
in this connection since we are engaged in other
problems."
On the same subject, I wrote to Dr. Henry Smith
Williams on December 30, 1914, the following:
"Lobar pneumonia stands as a monumental rebuke
to the medical profession. Nature so plainly points
the way to its cure, and yet we poor blunderers
stand impotently by and it claims thousands of vic-
tims annually."
Accordingly, I engaged with the consent of the
Health Department, the services of Dr. A. Silk-
man, Veterinarian of the Department, to elaborate
such a serum from a horse suffering from acute lo-
bar pneumonia. This work has progressed most
satisfactorily to date and will be made the subject
of a later communication.
Under date of August 10, 1916, 1 wrote Health
Commissioner Dr. Haven Emerson, to furnish me
with fluid drawn from the spinal cavity of a polio-
myelitis patient for similar experiments at my own
expense on the same horse. This 1 have not yet
been able to undertake.
It has lung been known that an attack of certain
infectious febrile diseases protects the individual
against a subsequent attack. More recently the
theory of persistent antibodies has been accepted as
the cause of such immunity. The nature of such
antibodies is not at all well established, but prob-
ably they exist in the blood as hormone secretins,
which have been determined to be in the nature of
enzymes. As. for instance, in a patient having once
been attacked by scarlet fever; if the disease is suc-
cessfully combated by the system, it is because the
system has reacted to the toxins of the disease and
produced an antitoxin or antibody which has been
generated under the influence of the hormone secre-
tins which occur in the blood at the time of the at-
tack and are probably produced by the red blood
cells and in turn react on the blood cells themselves
and cause an increase in the secretion of the anti-
bodies or antitoxins, and when these become great
enough in number or strength, the patient is en-
abled to overcome the toxin or poison produced by
the specific organism causing the infection, and the
patient recovers.
In the case of scarlatina, this immunity is per-
manent or practically so, and there is theoretically
always circulating in the blood of a patient recover-
ing from scarlatina, an unknown quantity of hor-
mone secretins which are probably in the nature of
a ferment. Whenever the toxins of scarlet fever
or the streptococcus gain access to the system of
such a patient, this toxin immediately reacts on the
hormone secretins which, acting as ferments, cause
an immediate increase in the antibodies which pro-
tect against scarlet fever and cause the toxins of
scarlatina to be overcome and the patient is not at-
tacked by the disease a second time.
Believing that the theory will hold good for all
diseases one attack of which protects against sub-
sequent attacks, under date of December 16, 1915,
I wrote in instructions to Dr. Silkman, who was
then engaged in elaboration of the pneumonia serum
under my direction, as follows: "As soon as the
above work on the pneumonia serum is completed, it
is proposed immediately to conduct experiments with
a view to obtain a vaccine or immunization against
scarlet fever, measles and other diseases in which
one attack prevents against future attacks. The pa-
tient having once suffered from scarlet fever, is sel-
dom, if ever, subject to a second attack. Therefore,
a permanent antitoxin is circulating in the blood of
such patient and produces immunity. It is my
theory that even small doses of the serum of such a
patient injected into an infant or child, would pro-
duce permanent immunity. If not, monkeys of the
larger type could be exposed to scarlatina or measles,
or injected with the proper streptococci, or other in-
fectious material, and a vaccine or serum worked
out in this way."
So far, I have not been able to complete the lat-
ter work, but working along these lines we have ob-
tained a serum which has been successful in a mod-
erate number of cases in equine pneumonia. In this
case, the hormone secretins are fugitive, being rap-
idly eliminated from the patient's system, and for
this reason an attack of pneumonia does not confer
immunity. This idea occurs to me as being especial-
ly interesting at this time with the unfortunate
prevalence of anterior poliomyelitis in New York
City and adjacent territory.
As a matter of practical moment, I believe that,
if the blood of an adult be drawn under proper
aseptic precautions and the serum isolated, an in-
jection of from one to six ounces of such serum ac-
cording to the age of the patient will produce an
immunity in a child if the subject from whom the
blood is drawn has suffered from this disease. I
believe it will be possible largely to prevent the oc-
currence of scarlet fever, measles, typhoid fever,
smallpox, typhus fever, and all diseases an attack
of which produces an immunity of greater or lesser
extent for the future.
The above theory may serve to explain in a way
Aug 26, 1916J
MEDICAL RECORD.
373
the results which Dr. Abraham Zingher of the Wil-
lard Parker Hospital has had in the use of serum
obtained from normal adults in combating polio-
myelitis in its early stages.
There is reason to believe that, if children are
injected with the serum drawn and prepared from
the blood of their parents or other individuals at an
early age if the donors have suffered from scarlet
fever, measles, or any of the immunizing diseases,
such offspring will be rendered immune to these dis-
eases and that eventually it will be possible to breed
a race of humans who will be progressively immune
to all of the acute infectious diseases. The longevity
of the race will then be vastly increased because of
the large number of permanent disabilities that are
produced by the so-called "diseases of childhood,"
and the above thought contains a suggestion which.
carried out, will produce results of great perma-
nent service to future generations as well as to the
present.
It may be that experiments will prove that the
hormone secretins are found in the red blood cells
or in the coagulum rather than in the serum, but
a carefully conducted series of animal experimenta-
tions would readily prove whether the serum alone
or a combination of a saline extract of the coagu-
lum would be necessary to produce the desired re-
sult.
The terrible results of the present epidemic and
the large number of cripples which it will undoubt-
edly leave in its wake, in addition to the death toll
of 20 per cent, should make it well worth while to
attack this problem when the present excitement
has subsided, so that the future may not see the
anguish and suffering which the present affliction
has brought to all of us who are parents and have
the responsibility of such cases upon us.
71 East Fifty-second Street.
A FATAL CASE OF POLIOMYELITIS IN AN
ADULT.
BY J. GARDNER SMITH, M.D.,
NEW YORK.
The following account of a fatal case of poliomye-
litis in an adult may be of interest. An apparently
healthy young man of twenty, whose home was in
the best environment in upper Manhattan, worked
in a large, airy architect's office in Brooklyn. Sat-
urday noon, July 29, he ate lunch downtown, car-
ried his dress suit case and a small tent to a New
Jersey town; pitched some hay in the afternoon,
ate a hearty dinner, pitched his tent and slept on
the ground that night. He was awakened by the
great explosion, walked a mile and back to the tent,
where he slept the balance of the night. On Sun-
day he complained of headache and sore muscles,
but returned to New York that night, ate heartily,
took a bath, retired, and slept fairly well. Monday
morning he vomited and complained of severe head-
ache. He was seen in the evening by Dr. Clyde K.
Miller. The patient at that time complained of
headache and stiffness of neck and muscles, but had
no fever; he was given a laxative. Tuesday morn-
ing the patient could not wind his watch and paraly-
sis of the arms progressed. Wednesday morning
he could not raise his arms from the bed; could
rotate arms and forearms slightly; chest mus-
cles paralyzed. Reflexes of lower extremities exag-
gerated ; Koenig and Babinski tests positive. After
consultation with the Health Department and Re-
search Laboratory I made a personal call upon Dr.
S. J. Meltzer. We followed Dr. Meltzer's sugges-
tions. At 5 P. M., 10 c.c. of clear spinal fluid with-
drawn and 2 c.c. of adrenalin injected; 10 p. m.,
20 c.c. of fluid withdrawn and 3 c.c. of adrenalin in-
jected. Thursday, 1 A. M., 5 c.c. withdrawn and 2
c.c. of adrenalin injected; 5 A. M., 10 c.c. withdrawn
and 3 c.c. adrenalin injected; 10 A. M., 4 c.c. with-
drawn and 2 c.c. adrenalin injected. The last in-
jection was given at 2 P. m., 4 c.c. withdrawn and
2 c.c. adrenalin injected.
The patient also received urotropin 5 grains every
four hours and oxygen under pressure was admin-
istered with Dr. Meltzer's apparatus ( obtained from
Tiemann & Co.) .
Thursday, 10 a. m., there was a distinct improve-
ment; the patient could flex his arms across the
body and could use his thoracic muscles ; but he
had difficulty with the muscles of the neck, throat,
and tongue, and some ocular palsy was present.
About 1 p. M. paralysis above the waist increased.
He became irrational, and at intervals was deeply
cyanotic. He died at 7.40 p. m.
This very bad case seemed to be fatal from the
start; it presented a mixture of the encephalitic and
bulbospinal types. The paralysis spread rapidly.
Death occurred probably from paralysis of the re-
spiratory and vasomotor centers. The adrenalin
treatment was begun very late and very little hope
could be entertained regarding its effect. Never-
theless, after the fourth injection an unmistakable
improvement in the spinal paralysis took place.
Regarding the question whether adrenalin could
accomplish a cure, Meltzer says ( Medical Record,
July 22, p. 160) that on account of the comparative-
ly low mortality of infantile paralysis it could not
be answered for some time to come. "However."
he says, "there is one form of evidence which is of
actual value and that is when an improvement is
observed which has to be ascribed to the treat-
ment." It seems to me that the present case offers
such evidence. *
The questions unsolved are, where and when did
the man contract the disease? What was its incu-
bation? Where is the danger? Two nurses and
mother and father were in close attendance. Dr.
Miller attended the patient ten or twelve times and
I visited him five times. We are all well at this
date, August 21. The problems to solve are: First,
what is the germ causing this disease? Second,
how, by whom or in what way is the germ carried?
Every suggestion by layman or physician should be
reported and recorded. Every one who has had the
disease should come forward and offer a little blood
to help some one else.
Until the germ is isolated an exact serum can-
not be made. Every facility for study with animals
ought to be encouraged. Until the exact cause and
method of contagion has been discovered we must
resort to all known methods of quarantine and pre-
vention and do many things which may later prove
superfluous.
21 West 122d Street.
The Value of Deep Percussion in the Diagnosis of
Subacute Intraabdominal Disease. — Neuhof refers to
this procedure for the elicitation of localized tenderness,
and states that it has been of great value in the diagno-
sis of subacute and subsiding intraabdominal affections,
especially in the examination of obese individuals and
of those who do not sufficiently relax their abdominal
wall for satisfactory palpation. The method is free
from danger and should therefore be made part of the
routine physical examination in subacute and subsiding
intraabdominal affections. — Archives of Diagnosis.
!74
MEDICAL RECORD.
[Aug. 26, 1916
Medical Record.
A Weekly Journal of Medicine and Surgery.
THOMAS L. STEDMAN, A.M., M.D., Editor.
PUBLISHERS
WK. WOOD & CO., 51 FIFTH AVENUE.
■ urth page following reading matter for Rates of Subscription
and I: itors and Subscribers.
New York, August 26, 1916.
FUNCTIONAL PSYCHIC DISTURBANCES IN
THE LIGHT OF WAR.
Psychiatrical problems receive their share of en-
lightenment from the vast laboratory the war has
thrown open to medical science. Neuropathology
and psychopathology are the subjects of much atten-
tion and discussion. Thus it comes to pass that
modern theories in regard to the relation of psychic
trauma and psychopathic predisposition are being
distinctly advanced.
The observations made by Dr. Lewellys F. Barker
in his presidential address delivered before the
American Neurological A on in May, 1916,
printed in full in the J ' Mt ntal
ase for July, and in abstract in the Medical
ORD of July 29, are confirmed by reports from
the front, a number of which are published in ab-
stract in th( of Neurology and Psychiatry
for May, 1916. There is an agreement of opinion
that a distinction can assuredly be made between the
psychotic or the psychoneurotic disturbance arising
as the result of battle shock and that which is
complicated by a psychopathic tendency, which
only awaits, in order to • become active, such
extreme conditions and such excessive and un-
toward demands for adaptation as the exigencies of
war present. Sudden and violent abnormalities in
reaction are inevitable. Their occurrence, however,
"h no way denies the nee to be attached to
the unci mental life in the production of
mental disturbances. It does not argue for the cur-
rent inflexible conception of pathological causes
which attributes such phi i o the im-
mediate traumatic agent.
rthy that these disturbances of men-
tal equilibrium, inevitably induced and violent
though they may be in character, are easily amen-
able to a wise therapy. The factor of chief sig-
nificance in the consideration of the genetic theory
of the functional neuroses and psychoses is the
appearance and perhi <tence of accompany-
ing mental phenomena which seem to be aroused by
the immediate traumatic outbreak and to follow in
its train. Testimony poil rally in this direc-
tion, that it is with the man who furnishes the fruit-
ful soil, neuropathic or psychopathic, in whom these
sequelae are observed. The precipitating cause ap-
plies the spark to the unconscious material. The
actual emotional importance of the immediate
trauma manifests itself in the terrifying nature of
the dreams of actual war experience. These, how-
ever, are transient phenomena. There are blended
with these dreams, Dr. Bruce reports, quoting from
the Lancet, "episodes utterly alien to the war" and
events "in the patient's past history, the revivified
emotions associated with which the war incidents
have served to awaken, by stirring up similar emo-
tions." One might expect some experience of hor-
ror to usurp consciousness and even to build up a
permanent delusional s\ stem, which does happen at
times unless an interpretative therapy comes to the
rescue. Nevertheless, the deep-laid emotional ex-
periences and sentiments which make up the person-
ality, chiefly through the unconscious, by their self-
assertion in the face of such crises, witness to the
measure of their importance and reality.
The psychotherapy of the battlefields and hos-
pitals is permeated with the modern comprehensive
viewpoint and conditions there are met in the spirit
which takes into account the whole psychical history,
recognizes the remote contributing causes and be-
lieves in the value of the interpretative attitude
toward the patient himself and in his psychic re-
education. It is striking to note in passing how fre-
quently hypnosis is condemned as inadequate or
actually deleterious. It is also of interest to ob-
serve how the demands of reality operate under war
conditions to bring the patient back to his normal
state, particularly in the acute transient conditions
without the psychopathic background. This serves
as an intensified illustration of the fundamental
principle of psychoanalytic therapy. It is a radical
application of the "reality principle" as the royal
road to psychic health, a reality specially urgent
and particularly effective amid the necessities of
war.
Much of interest and much of value is thus af-
forded in the knowledge of mental disturbances, in
the borderland cases as in the distinctively neuro-
tic or pronounced psychotic conditions, and much
is being added to the effectiveness of psychotherapy
along these lines.
ERYSIPELAS TREATED WITH DIPHTHERIA
SERUM
ABOUT two years ago Pollak recommended ordinary
diphtheria antitoxin in the treatment of erysipelas
and one year later Roller, a Swiss, briefly reported
a case of his own in which he followed successfully
the plan of Pollak. In the Correspondenz Blatt fiir
Sehweizer Aertze for July 8, Roller reports his
second case. The patient was an old woman who
was subject to attacks of facial erysipelas which
had hitherto yielded to ichthyol applications. In
the present attack ichthyol had been of no avail.
After nearly all of the face and scalp had become
involved, and the patient presented a high morn-
ing temperature, :»000 units of diphtheria anti-
toxin were injected. A remarkable decrease in
swelling was vra .pparent and subjectively
the patient was much better. By the end of twenty-
four hours the swelling seemed to have disappeared,
but as areas of tenderness remained in the scalp,
1000 more units of antitoxin were given. She was
now objectively well, although probably by reason
Aug. 26, 191C.1
MEDICAL RECORD.
375
of her age her general condition was somewhat
grave, she being extremely weak, with insomnia
and night sweats. At the end of five days she was
discharged cured.
In comparing his two cases Roller finds several
points of parallelism which show that the serum
acts directly upon the cause of the disease. These
refer to the sudden arrest and regression of the
local process and a critical defervescence accom-
panied by profuse sweating. The second pat
seemed doomed. Taken by themselves these two
cases prove nothing, but taken in conjunction with
Pollak's results they tend to corroborate the latter.
The author apparently uses colloidal silver in the
routine treatment of erysipelas and used it perfunc-
torily in the reported cases, but had never seen any
constant improvement follow its use when given
alone. It is possible, however, that the combination
of serum and silver is superior to serum alone, and
he would use both in severe cases or in the presence
of special indications. He has seen cases in which
a surprising improvement followed at once upon
an intravenous injection of silver.
Roller's contribution is of great interest at the
present time because ichthyol has practically dis-
appeared from the market as a result of the war.
The price of the very small reserve is prohibitive
for the treatment of a malady like erysipelas, the
importer's price being quoted at $16 a pound, and
with the profit of the distributor and dispenser
added the consumer might have to pay as much as
2 or 3 cents a grain. In hospital practice the nor-
mally high price of the drug has made it necessary
to use cheaper applications when practicable, and
in consequence it has never been possible to deter-
mine to what extent ichthyol is really a life-saving
remedy. But deprived of it altogether public and
private patients alike should be expected to suffer
somewhat, and the serum treatment might to a
certain extent offset the loss.
ARTIFICIAL PURIFICATION OF OYSTERS.
An interesting series of experiments carried out by
the Public Health Service ( Public Health Reports,
July 14, 1916) point to the economic possibilities of
rendering oysters safe for human consumption.
When it is considered that because of the abundant
sources of food supply shell fish thrive very well in
bays and estuaries polluted by sewage, it can be
seen what prolific sources of infection they can be.
Urban typhoid epidemics have often been traced to
this source. And while the artificial purification of
the oyster does not do away with the esthetic ob-
jections to eating an animal fattened in sewage it
does eliminate the disease factor. The Rhode
Island Fish Commission has placed the conditional
limit of colon bacillus infection at 10 colon bacilli
to the cubic centimeter. The usual infection with
colon bacilli is many hundred per cubic centimeter.
It has long been known that there is a tendency
to the self-purification of oysters when transferred
to pure water. The self-purification is complete
within from a few hours to two days. The modus
operandi is evident when one realizes that the
passage of water through the oyster is very large
and very rapid. As much as 20 to 50 gallons of
water pass through in a day. The passage of food
particles through the intestinal tract is quite as
rapid. In France basins of filtered water have long
been used to effect this purification, but the cost of
this process compared with the sale price of the
oyster renders the method quite impracticable. And
indeed, if it is fairly clean, unfiltered sea water is
better for purification purposes because the food
particles in unfiltered water stimulate passage
through the intestinal tract and help to carry
through and to discharge the contained colon bacilli.
Instead of filtered water, therefore, the usual
methods of the chemical purification of water were
utilized in these experiments to render the oysters
free from colon infection. In carrying out these
experiments oysters were inoculated with both free
cultures of colon bacilli and attached colon bacilli;
i.e. with the bacilli in finely divided agar suspen-
sion. The water was then disinfected with 10 per
cent, calcium hypochlorite solution. A considerable
purification of the oysters contained therein oc-
curred within six hours, and a remarkable purifica-
tion within twenty-four hours. The results were
below the conditional amount permitted by the
Rhode Island Fish commission, although the amount
of the artificial infection was much greater than
it would be in natural infections in polluted
oyster beds. Usually two closes of hypochlorite were
given, the second after six hours in order to reach
such infection still within the oyster and
net discharged because of the possible closure of
the shell during the first period, and because of the
rapid decomposition of the hypochlorite. This
treatment was found not to have a bad effect upon
the flavor of the oyster or upon its well-being. In
the case of an element of food so widely used any
method that will insure the safety of the consumer
while preserving the flavor of the oyster is deserv-
ing of consideration.
The Function of the Thyroid.
Opinions with regard to the chief function of the
thyroid differ considerably. Some believe that it
governs metabolism, others that it is a vital anti-
septic, and yet others that it is concerned with
growth alone. In the Medical Press for June 7,
1916, Dr. Jos. Geike Cobb endeavors to answer these
questions and gives a few facts and some theories
dealing with the function of this gland. Firstly,
then, the thyroid gland possesses the peculiar prop-
erty— peculiar in the sense that it is not shared, so
far as is known, by the other endocrine glands — of
being able to store its secretion. This is proven by
the fact that in cases where the gland has atrophied
or been removed, its secretion can be replaced by
artificial ingestion. As Dale says, we quite natu-
rally turn to the colloid as being the stored up secre-
tion, and, indeed, are justified in doing so, as there
is evidence to show that this substance arises in
droplets in the epithelial cells lining the vesicles.
Again, this secretion contains a relatively large per-
centage of iodine, and on this fact, or partly on
this fact, has arisen the theory that the thyroid
has a phagocytic or antitoxic action. In fact, there
are a tangle of theories concerning the action of
the thyroid, some of which seem to give grounds
for belief that its action is in a certain direction.
373
MKDICAL RECORD.
Aug. 26. 1916
However, it is definitely known concerning the thy-
roid that a train of symptoms follows its deficiency
or absence, whether produced experimentally on
arising spontaneously, and that these symptoms will
yield to thyroid feeding. Thyroid is, therefore, con-
cerned with the growth of bone, with the develop-
ment of the body, and with a normal circulation.
Further, in the adult, there is now no doubt that
absence or diminution of the secretion produces, or
helps to produce, a condition of secondary anemia.
Whether this argues any direct connection with the
hematopoietic system it is at present impossible
to say. That the thyroid is a direct circulatory
stimulant there is no doubt; for the slow pulse,
cold extremities, sluggish circulation, and deficient
action of the sweat glands in submyxedema are
very well recognized. The interaction of the thy-
roid with the other ductless glands will probably
show that the relation between the thyroid and some
of the other endocrine glands, notably the spleen,
is a close one.
Volhynia Fever.
At a session of the Berlin Medical Society last
February (Berliner klinische Wochenschrift, March
20) a new fever was described by His, Jungmann,
and others. It has been studied in the German
armies on the Eastern front, and bears consider-
able resemblance to malaria. The febrile crisis comes
on suddenly and lasts one day, but from four to
six days elapse before a second crisis. The pains
are severe, especially in the lower limbs, and the
shins may be very tender to pressure. The patient
feels most wretched. The Polish physicians have
looked on the ailment as a form of malaria or of
relapsing fever, according to circumstances, but the
Germans regard it as a third disease to be known as
febris volhynica. The cyclical course suggests a
protozoan cause, probably carried by an insect, and
its incidence — mass infection in hospital patients —
suggests that the latter is the louse. A study of
the blood by Topfer with dark illumination has
shown the presence of a motile spirochete, but a
short bacillus with clumping tendencies may have to
be excluded as a cause. Jungmann has recognized
the presence of organisms which resemble diplo-
bacilli, and are constant in the blood of fever cases.
These are in a high degree motile, and show con-
siderable variety in form. No attempts at cultures
were made, but by injecting the warm fresh blood
into the tissues of guinea pigs febrile paroxysms
were set up. The suffering caused by the disease
is intense, and apparently the pains in the legs and
back are as bad as those of any other infection. No
mortality or permanent disability has been noted.
The disease appeal's to vanish spontaneously in time.
Tenderness of the shins persists longer than any
other symptom. Russian prisoners knew of the
disease but had no name for it. Their physicians
prescribed quinine with benefit, but the Germans
found the remedy inert.
A General Indication for the Use of
Thiosinamine.
PATIENCE and persistence in the use of a remedy
along the line of a definite general indication often
yields striking clinical results. Thus Dr. Gonzales
Castro reports in h'l Sinln Mt diva for June 24 that
for four years he has been steadily employing
thiosinamine and believes that it is especially indi-
cated in imperfect or defective resolution in wound
healing and inflammation. In one case an old man
with some prostatic hypertrophy had developed
gonorrhea five months previously and had eventually
sought relief for complete retention. The stenosis
was evidently due in part to abuse of injections of
nitrate of silver, which had produced several wide
strictures. While it was possible to empty and
treat the bladder and secure some improvement by
progressive dilatation, the author nevertheless
made use of thiosinamine by subcutaneous injec-
tion. The rapidity in improvement could not have
been accounted for by dilatation only, for within a
brief interval the author passed gradually from a
No. 8 to No. 24 and the patient's recovery was ap-
parently complete after treatment for thirteen days
only. Another case was one of traumatism of an
eye which resulted in a large corneal ulcer and
hypopyon. The cornea was opened and the pus
evacuated. The development of a large leucoma
was almost certain, but the author instilled into the
conjunctiva a mixture of cocaine and thiosinamine
and the result was a perfect recovery, not a trace of
corneal opacity having developed. These succcesses
are not isolated, but represent only a small part of
a series of favorable results from this remedy in
the author's experience.
Nruia of % Wtek.
Poliomyelitis Situation. — The hoped-for de-
crease in the new cases of poliomyelitis in New
York has not yet been apparent, 7,446 cases in all
having been reported up to August 23, with 1,731
deaths. In Brooklyn and Richmond the epidemic
appears to be "burning itself out," however, and
in Manhattan there was a slight drop in the num-
ber of new cases for a few days. In the city as
a whole 912 new cases were reported in the week
ending July 29, 1,117 in that ending August 5,
1,151 in that ending August 12, and 912 again in
that ending August 19. It is feared that with the
close of vacations numbers of susceptible chil-
dren not before exposed may return to the city,
and that the epidemic may have a temporary flare-
up. The date of reopening the schools in the
city has not been definitely determined, but is
probable that they will open as usual on Septem-
ber 11. At Princeton University, however, it has
been decided to defer the opening to October 10.
In the State outside of New York City 1,239
cases were reported up to August 20, with 150
deaths.
For the purpose of securing an additional sup-
ply of immune serum a citizens' committee has
been formed; this committee will endeavor to get
in touch with the 700 or more persons here known
to have recovered from poliomyelitis and will ask
that they give blood. A fund of $2,000 has been
raised to defray the expenses of the work.
The Committee on After-Care of Infantile
Paralysis has selected the visiting nurses of the
Henry Street Settlement to follow up all paralyzed
patients in Manhattan and the Bronx, each patient
being reported to the Settlement as soon as re-
leased from quarantine by the Department of
Health.
Conference on Poliomyelitis. — The conference of
State health officers and representatives of the
Public Health Service held in Washington on
August 17 and 18, adopted a report containing a
Aug. 26, 19161
MEDICAL RECORD.
377
set of rules intended to check the interstate
spread of the disease. As a first step, the report
states, the situation should be put in the hands of
the Public Health Service. The service should
then undertake an investigation of the infected
area, should make notification of the removal of
persons under 16 years of age from an infected
area to another State, and should issue permits for
travel based on inspection by agents of the service,
not on the certificates of private physicians. The
report disapproved of quarantine by one State
against another, or by one community against an-
other in the same State; it was thought that the
Public Health Service could perform all the duties
of notification and certification required in inter-
state relations in case of unusual prevalence of
poliomyelitis, and that State Health authorities
should perform like services between communi-
ties in the same State. The report recommends,
further, that all cases of poliomyelitis be reported
immediately to the local and the State health au-
thorities, and by the latter to the Public Health
Service; that all persons 16 years of age or under
moving from an infected area be kept under medi-
cal observation for at least two weeks ; that the
period of isolation of a case of poliomyelitis be not
less than six weeks from the date of onset; that
persons suffering from the disease and their at-
tendants should be rigidly isolated in a properly
screened room, all bodily excretions to be disin-
fected at the bedside, it being understood that re-
moval of a patient to a hospital is greatly to be
preferred to isolation at home; that in case of
death from poliomyelitis the funeral should be
strictly private; that wherever the disease is un-
usually prevalent assemblages of children in pub-
lic places should be prohibited, and that schools
should not be open without thorough medical su-
pervision ; that because of the existence of un-
known carriers of the virus, measures should be
taken to prevent contamination by human excre-
tions, to suppress the fly nuisance, and to do away
with the common drinking cup; and that a general
educational campaign for cleanliness and sanita-
tion, with particular instruction concerning per-
sonal hygiene, especially of the mouth and nose.
be carried out. The report states that the epi-
demic prevalence at this time in certain States in-
dicates a likelihood of epidemic prevalence next
year in States not now affected, and it is, there-
fore, believed that the measures recommended
should be continued in operation at least until such
time as the incidence of the disease has subsided
to or below its usual level.
Gift to Dental School. — Columbia University has
recently received from Mr. James N. Jarvie a gift
of $100,000 for the new dental school to be con-
nected with the university, for which an endow-
ment of $1,000,000 is being sought. It is now ex-
pected that the school will open in September in a
temporary building near the College of Physicians
and Surgeons.
Painless and Shockless Childbirth. — In the ar-
ticle with this title by Dr. Kapp in the Medical
Record of August 5, in one of the case reports the
dose of heroine given was said to have been gr. J L» ;
it should have been, as stated elsewhere in the ar-
ticle, gr. 1 12.
Quinine in Poliomyelitis. — Dr. N. McL. Whit-
taker of Brooklyn recommends an intramuscular in-
jection of 10 to 20 grains of quinine and urea hydro-
chloride, followed by 3 or 4 grains of quinine per os
every hour or so until the patient has received 4^
grains or until evidences of quinine poisoning ap-
pear. He also recommends quinine in 2 to 5 grain
doses every night as a prophylactic.
American Chemical Society. — At the meeting of
the American Chemical Society to be held in New
York on September 25 to 30, there will be conducted
a symposium on occupational diseases, presided over
by Prof. Charles Baskerville of the College of the
City of New York. Among the subjects to be con-
sidered are the chemical trades, prophylaxis in
chemical industry, diseases incidental to work in
aniline and other coal-tar products, cedar lumber,
mines, and explosives. The discussion will be par-
ticipated in by a number of the leading authorities
of the country.
Public Health Service. — As recently announced,
Congress has made an appropriation for thirty-
three additional assistant surgeons in the United
States Public Health Service, and examinations will
shortly be held in various cities for the convenience
of candidates. Information as to these examinations
may be obtained from the Surgeon General, United
States Public Health Service, Washington. The
tenure of office in these positions is permanent, and
successful candidates will receive commissions im-
mediately. After four years' service, assistant
surgeons are entitled to examination for promotion
to the grade of passed assistant surgeon, and in
turn to the grade of surgeon. Assistant surgeons
receive $2,000; passed assistant surgeons, $2,400;
surgeons, $3,000; senior surgeons, $3,500, and
assistant surgeon generals, $4,000 a year, and all
grades receive longevity pay, 10 per cent, in addi-
tion to the regular salary for every five years up to
40 per cent, after twenty years' service.
Red Cross Preparedness. — As a result of its
campaign the membership of the American Red
Cross increased, during the six months ending July
31, 1916, from about 27,000. which represented the
growth of the society for the past ten years, to
about 210,000. During the same period the num-
ber of Red Cross chapters increased from 110 to
199. While up to six months ago practically noth-
ing had been done towards organizing volunteer aid
lor the sick and wounded of our army and navy.
since that time the necessary staffs for twenty-five
base hospitals for 500 beds each for the army have
been enrolled ; several naval base hospitals of about
half the size are under preparation : funds for the
purchase of equipment of sixteen of the twenty-five
army base hospitals, amounting to $25,000 each,
have been subscribed, and the purchase of this
equipment has been begun, the material being stored
so as to be ready for immediate use in case of need.
Old Hospital Wrecked. — A dispatch from Paris
states that the Civil Hospital of Rheims, formerly
the Abbey of the Church of St. Remy, which was re-
cently destroyed by German artillery fire, was one
of the finest edifices in the city. Although the build-
ing was almost entirely reconstructed in the eigh-
teenth century, there remained in one portion a
part of a primitive cloister, a perfectly preserved
and magnificent specimen of the twelfth century.
The linen room had contained a beautiful collection
of tapestries, but these were recently removed to
the museum in Paris.
Good Health of the Guard.— The report for the
week of August 12 of the health of the men on the
Texas border shows that the sick rate among the
National Guard was only 1.21, while among the
regulars it was 2.38.
378
MEDICAL RECORD.
[Aug. 26, 1916
Opportunity for the Study of Poliomyelitis. —
There is at the present time a position open for a
graduate physician in the poliomyelitis ward at
Bellevue Hospital, New York, where he will receive
board and lodging in the hospital during the period
of his service, which would be a six months' term,
which could be supplemented by a further period of
six months if desired. Application should be made
to the superintendent of the hospital, Dr. George
D. O'Hanlon. Preference would be given to appli-
cants having previous hospital experience, but the
latter is not necessary.
Opportunities in Civil Service. — The New York
State Civil Service Commission calls attention to
the opportunities offered to qualified physicians for
appointment to positions in the medical service in
State hospitals, prisons, and charitable institutions.
Although the salaries offered seem to afford ade-
quate compensation, the number passing the ex-
aminations has not been sufficient to meet the needs _
of the service. For instance, at a recent examina-
tion for prison physician, salary $2,000, the number
of applicants was small and no one passed the ex-
amination successfully; an examination held at the
same time for assistant prison physician, salary
$1,500, produced only two eligibles. On examina-
tion for assistant physician in the State Hospital
held on January 22, 191G, produced eighteen eligi-
bles, but the list was practically exhausted by July
1. In the opinion of the commission the State Hos-
pital Service really offers a career, as there is a
regular line of promotion for the medical staff from
assistant physician to superintendent.
Philadelphia General Hospital. — Dr. Richard C.
Norris has resigned as visiting obstetrician to the
hospital, and has been appointed consulting obstetri-
cian. Dr. Edward A. Schumann has been made
visiting obstetrician.
Red Cross Shipments. — The American Red Cross
announces that from April 1 to July 1, 1916, 217
shipments consisting of 32,605 packages and having
a total value of $1,002,021.87 were shipped to the
Allied Powers, and that during the same period of
48 shipments, consisting of 6,667 packages and hav-
ing a total value of $310,732.36 were shipped to the
Central Powers. In addition, 34 cases of tetanus
antitoxin, of a value of $131,986, were sent to Vi-
enna, and 34 cases valued at $229,595.60 to Berlin;
for these the American Red Cross was reimbursed
by the Austrian and German Red Cross respectively.
Smaller shipments, having a total value of $17,-
949.12, were also made to other countries, so that
during this period the total value of the supplies
shipped was $1,330,703.35. The total value of the
supplies on hand en July 1 was $79. 047.63.
Since October last, when the American Red Cross,
owing to lack of funds, withdrew the hospital units
it had established and maintained for more than a
year in Europe, it has been endeavoring to obtain
permission from Great Britain to send hospital
supplies to the Central Powers. Great Britain now
suggests, however, that the Red Cross reestablish
the hospital units and promises to permit the pas-
sage of hospital supplies to these hospitals, and,
in accordance with this suggestion, application has
been made to the ( enl ral Powers, through the State
Department, for permission for the reestablishment
by the American Red Cross of one or two
units of six doctors and eight nurses each, in i
of the countries. Germany, on the other hand, has
recently announced that free passage of Red Cross
supplies to other countries will no longer be allowed,
and that German naval forces will receive orders to
take such articles for their own use when they come
within their reach.
American Association for Study and Prevention
of Infant Mortality. — The seventh annual meet-
ing of this society will be held in Milwaukee on
October 19 to 21, 1916. The subjects to be dis-
cussed include governmental activities in relation
to infant welfare, care available for mothers and
babies in rural communities, standards for infant
welfare, nursing, morbidity, and mortality in in-
fancy from measles and pertussis, public school
education for the prevention of infant mortality,
and vital and school statistics. Dr. S. McC. Hamill
of Philadelphia is president of the association, and
Dr. William C. Woodward of Washington presi-
dent-elect for 1917. Programs and further in-
formation may be obtained from the executive sec-
retary of the association, 1211 Cathedral Street,
Baltimore, Md.
Medical Society of the Missouri Valley. — Under
the presidency of Dr. John P. Lord, the annual
meeting of this society will be held at the Hotel
Fontenelle, Omaha, Neb., on September 21 and 22,
1916. Particulars may be obtained from the sec-
retary, Dr. Charles Wood Fassett, St. Joseph, Mo.
Obituary Notes. — Dr. John Alva McCorkle of
Brooklyn, N. Y., professor of medicine in the Long
Island College Hospital, died at the hospital on
August 15, aged 69 years. Dr. McCorkle was gradu-
ated from the University of Michigan, Department
of Medicine and Surgery, Ann Arbor, in 1873, and
a year later became associated with the chemical
department of the Long Island College Hospital.
In 1880 he was made professor of materia medica
at the school, and in 1886 professor of medicine.
For the past twelve years he had served as president
of the College Hospital, and was also visiting phys-
ician to the hospital, consulting physician to the
Kings County Hospital, the Norwegian Deaconess
Hospital, the Jewish Hospital, and St. John's Hospi-
tal, and physician to the Long Island State Hospital.
He was a member of the American Medical Asso-
ciation, the New York State and Kings County
Medical societies, the Brooklyn Pathological Society,
and the Academy of Medicine.
Dr. Adam J. BLESSING of Albany, N. Y., a grad-
uate of the Albany Medical College in 1886, and a
member of the Medical Society of the State of New
York and the Albany County Medical Society, died
at his summer home in Sacandaga, N. Y., on
August 6, aged 52 years.
Dr. WAJLDEMAR Dorfman of New York, a grad-
uate of the University of Berne, Switzerland, in
1882, died recently at his home.
Dr. Henry Cooledge Frost of Buffalo, N. Y.. a
gi-aduate of the Cleveland University of Medicine
and Surgery, Cleveland, Ohio, in 1874. surgeon to
the Homeopathic Hospital, and consulting surgeon
to the County Hospital, died in Montreal, from heat
prostration, on July 22, aged 56 years.
Dr. Georgk WARREN Brown of Winsted, Conn., a
graduate of the Eclectic Medical of Maine, Lewis-
ton, in 1883, died at his home, after a short illni
on August 2, aged 65 years.
Dr. James H. Lackey of Nashville, Tenn., a grad-
uate of the Cincinnati College of Medicine and Sur-
gery, Cincinnati, Ohio, in 1874, and a member of
the Tennessee State Medical Association and the
Nashville Academy of Medicine, died suddenly at
his home, from neuralgia of the heart, on July 26,
aged 68 years.
Aug. 26, 1916]
MEDICAL RECORD.
379
THE TREATMENT OF POLIOMYELITIS.
To the Editor of the Medical Record:
Sir : — From recent observations and study of cer-
tain phases and aspects of the present epidemic of
poliomyelitis I cannot resist the impulse of again
calling the attention of the medical profession to
the treatment of acute cases of poliomyelitis with
a combination of quinine, phenacetin, antipyrine,
and caffeine citrate in medicinal doses (as sug-
gested in my previous communication in the New
York Medical Journal of July 22 last), being fully
confident that with this treatment, especially in the
preparalytic stage, we are able to arrest the prog-
ress of the disease within twenty-four to forty-
eight hours, and thus check or abort the advent of
paralysis in perhaps 90 per cent, of cases. I am
making this apparently bold statement with full
appreciation of the danger of humiliation, in the
event of an unprejudiced disproval of my state-
ments, yet I do so fearlessly and without hesita-
tion, being fully convinced of the efficacy and
merit of the treatment.
The following prescription may serve to illus-
trate the dosage, vehicles, and mode of administra-
tion:
K Quinine sulphate,
Phenacetin.
Antipyrin, of each 20 grains.
Caffeine citrate, 4 grains.
Syr. yerba santa,
Syr. tolu,
Distilled water, of each equal parts to make
4 oz.
M. Sig. : One teaspoonful every two hours for
children of about one to two years of age; in severe
cases and somewhat older children, every hour till
temperature, pain, muscular stiffness, and hyper-
esthesia disappear, then every two or three hours
at the discretion of the physician. In children of
from three to five years of age, the same prescrip-
tion, but in doses about one-third larger. In chil-
dren above that age, the doses may be modified at
the discretion of the physician, but on no occasion
will it be necessary to give more than 1\\ grains of
each of the first three drugs, and not more than
V± grain of caffeine per dose.
In case, however, some paralysis or muscular
weakness should begin to manifest itself, which
may happen, but very rarely, the administration of
iodide of potassium with very small doses of Fow-
ler's solution, in addition to the foregoing medi-
cines, will soon effect a complete cure (provided
the case is not of long standing). For instance, in
the case of a two-year-old child:
J} Potassium iodide, U dram.
Solution of pot. arsenite, 15 drops.
Comp. syrup of sarsaparilla.
Distilled water, of each 2 oz.
M. Sig.: A teaspoonful every three hours, the
physician exercising his judgment as to older and
younger children as the case may be.
I desire further to make a few remarks, and to
submit certain prominent points and features in
connection with the etiology and pathology of the
present epidemic.
On close analysis of the various reports of the
Health Department, as well as from my personal
daily investigations and diligent study of every-
thing that may be associated with the epidemic, I
find very little, if any, proof or even fair evidence
as to the existence of any relationship between the
etiology of poliomyelitis and sanitary or hygienic
conditions and surroundings. Nor are there any
palpable data or strong enough indications as to the
communicability or contagiousness of this affection.
As a matter of fact, cases of poliomyelitis are found
under all conditions and surroundings, irrespective
of sanitary or hygienic standards. I have person-
ally inspected houses and families where infantile
paralysis had occurred and which I found in almost
ideal sanitary and hygienic conditions; while on the
other hand, I have visited dozens of houses with
the most deplorable sanitary conditions with chil-
dren actually bathing, as it were, in foul decompos-
ing garbage and refuse in which not a single case
of poliomyelitis has made its appearance.
Another noteworthy fact is to be found in the
relative rarity of more than one case of the disease
occurring in the same family or the same house.
Children are developing the disease while appar-
ently far removed from, and in no way in contact,
direct or indirect, with any supposed source of in-
fection. On the other hand, children coming in
direct contact with patients seldom contract the
disease.
A physician friend of mine who is an interne in
one of the institutions with a large number of
poliomyelitis cases (about 350) told me that they
are keeping nonpoliomyelitic and healthy children
together, and feeding them together, and have never
noticed any evidence of contagion.
While far from depreciating the excellent and
highly important precautions as to cleanliness, sani-
tation, and general hygiene, which are absolutely
necessary for the prevention of all infectious and
communicable diseases, and which it is the duty of
every one of us to enforce to the best of our ability,
I fail to see enough reason for extraordinary isola-
tion and quarantine in this particular case.
In the face of the foregoing facts and phenomena
it appears that the real factors which may be re-
sponsible as etiological agents in the present epi-
demic, are to be looked for in other directions, and
in my opinion are to be found in some special at-
mospheric conditions, as temperature, humidity, at-
mospheric pressure, etc., which conditions are well
known to be highly influential in predisposing to
many pathological changes and organic lesions en-
tirely independently of outside infections. Hence,
why is it not possible that some special atmospheric
conditions may set up, in susceptible individuals, a
certain inflammatory process in the spinal cord?
B. SCHEINKMAN, M.D.
152 Canal Street, Nhw York.
OUR LONDON LETTER.
(From Our Regular Correspondent.)
DYSENTERY — CASES FROM THE FRONT — NATURE AND
DISTRIBUTION — SINGLE AND MULTIPLE INFECTIONS
COMPARISON OF MILITARY HOSPITAL TO POST-
OFFICE — LAMBLIA INTESTINALIS.
London, July 29, 1916.
Drs. A. M. Kennedy and D. Rosewarne in the
course of investigating cases of dysentery invalided
home from Gallipoli found that the condition seemed
to be due to infection by Lamblia intestinalis ; in
12 cases they readily found this parasite. The per-
sistence of the infection is a point illustrated by
their cases. Previous observers have recorded a
chronic dysenteric condition resisting all ordinary
380
MEDICAL RECORD.
Aug. 26, 1916
treatment. Wenyon had three patients who main-
tained the infection for years. Some had repeated
attacks accompanied by mucous diarrhea, but one
of them showed no symptoms of intestinal trouble.
The pathogenicity of the lamblia is not yet ad-
mitted as beyond question, so that a series of cases
like these are of interest and may contribute to a
decision of this point. The writers record their
cases without making any dogmatic statement.
They do not attempt to decide whether there had
been a primary amebic dysentery on which a sec-
ondary infection had been planted. That is a ques-
tion which may well interest bacteriologists who
have the opportunity of investigating it. No posi-
tive agglutination was obtained with any of these
patients' sera or with known dysenteric bacilli. If
the organism be pathogenic, then how to deal with
carriers becomes an important question. That they
are not uncommon appears from the numbers found
in the series under consideration — 12 out of 136
consecutive cases of so-called dysentery — approxi-
mately 9 per cent.
The nature and distribution of the parasites in
1,305 dysenteric cases has been reported to the
Lancet by Dr. Fantham, who took an active share
in examining some 3,800 stools from soldiers in the
hospitals of the western command. Most of the
patients were convalescing. The parasites were
mostly protozoa and Blastocystis enterocolia. Com-
bined infections in 446 positive cases are stoipd.
In single infections there were 325 cases; in dcrjfele
infections 79; in triple 33; quadruple 7; quintuple
2. Besides these, 499 examinations were made by
Dr. Fantham of 14 special cases in the military hos-
pital. All were parasitised and examined daily
while in hospital. Most of them were specially ex-
amined for lamblia then for entameba. Double,
triple, and other multiple infections were found in
some of the stools: thus one patient showed when
first seen Girardia intestinalis and Antameba coli.
Soon spirochetes (eurygryata and blastocystis) ap-
peared in his feces and later E. histolica. The pe-
riodicity of these cases was different. The lam-
blia decreased, disappeared for 13 days, then re-
appeared in sparse numbers; the spirochetes acted
similarly in a shorter period. Tetramitus was also
een in this patient. Multiple infection was. how-
ever, rather rare. There are not so many parasites
in a formed stool as in a diarrheic one. Relapses of
lambliasis are met writh. Some workers say the
organism is harmless and give no treatment for it;
and patients infected with it have been discharged
from hospital as they had not dysenteric bacilli also,
but they may carry the infective cysts of the para-
site wherever they go and the danger of their set-
ting up diarrhea is obvious. It is now commonly
believed that amebic dysentery may be carried into
a healthy district by an infected person who has
ymptoms that trouble him, and the manner of
preventing this is a problem demanding investiga-
tion.
he Royal Society of Medicine .Major Tate
McKenzie compared a great military hospital to
a general postoffiee in which the patients were
sorted out as first, second, and third class matte? .
The first was rapidly distributed to the Red Cross
hospitals, but after treatment returned; the second
had to stay a time at a convalescent hospital. Many
of these found their way back to the front. For the
third it was more difficult to provide either in hos-
pital or homes. Early in the war they were sent
from on< depot to another. Hut later the
general arranged a series of command-depots to
which were sent all cases for which there was a
reasonable hope of cure within six months. The
object was to return to the front those fit and to sort
out and arrange for the others employment for
which they were capable.
PrngrraH of ffteoual i>mnre.
Boston .Medical and Surgical Journal.
August in. 1916
1. Tin- Diagnosis and Management of Vasomotor Disturb-
ances of the Upper Air Passages J. !.. Goodale.
2. Asthma in Children, 11. Its Relation to Anaphylaxis. Fritz
B. Talbot
.') Preparation of Veg tabli i I Pi foi Anaphylai
Tests R, P. Wodeno
t Normal Reaction of the Skin to Stroking. Edward A. Trai
.".. Protein Extracts in States of Hypersensitization. Hi
M. Bakei veland Floyd.
ti. Hay-Fever: Its Treatment with Autogenous Vaccines and
Pollen Extract. Leon s. Medalia.
7. Embolic Pneumonia Following the Mastoid Operation.
■ Seorge 1. Ri shards.
1. The Diagnosis and Management of Vasomotor
Disturbances of the Upper Air Passages. — J. L. Goodale
calls attention to the fact that in a large proportion of
vasomotor diseases of the upper air passages the dis-
turbances are dependent upon the entrance of a foreign
proteid into the system. The method of entrance may
be through the contact of the proteid in question witli
mucous membranes of the respiratory or gastrointesti-
nal tract by inhalation or ingestion respectively. For-
eign proteids may perhaps also develop in or upon these
mucous membranes through autolysis of pathogenic or
saprophytic bacteria. The application of the skin test
to these conditions is of diagnostic value when em-
ployed with a recognition of the phylogenetic re-
lationships of animals and plants, as determined by
sero-biology. Proteid material for testing should be
prepared both from the keratin and sera of domestic
animals, from the pollen of the cheif causes of hay-
fever, and from the various articles of food which
enter commonly into the diet. Bacterial proteids de-
rived from the various invaders of the respiratory
tract should be available either in solution or in solu-
ble form. When the skin reactions to the various
classes of pollen proteids have been determined, the
management of cases will depend largely upon the
relative preponderance of the local reactions in rela-
tion to the clinical history. If the case is found to be
seasonal, as in hay-fever, immunization treatment by
injection of pollen extracts is likely to be of service
but will probi have to be repeated annually. I !"
the cause is perennial and is due to inhalation of for-
eign proteids, it is wiser to avoid the cause than to
seek to effect a cure by immunization. If the dis-
ing proteid enters into the ordinary articles of
diet, a tolerance may be gradually established by feed-
ing the substance in ; ively increasing
These investigations confirm the present method-
treating disturbances of bacterial origin, and empha-
size the importance of draining regions which can re-
tain the products of bacterial activity. Vaccine ther-
apy in anaphylactic cases should be more accurately
guided than in ordinary individuals. The writer con-
cludes that we possess in the intelligent application of
the skin test a very definite aid in the diagnosis and
ni management of cases of vasomotor dis-
turbances of the upper air passages.
2. Asthma in Children. 11. Its Relation to Ana-
phylaxis.— Fritz B. Talbot has followed Eorty-five eases
of asthma in childhood over a period of several year-
ami has studied twenty-three of these cases carefully;
of these, eighteen had eczema at some time or other.
Aug. 26, 1916 J
MEDICAL RECORD.
381
This is a higher proportion than "was found by Berk-
hard. A family history of asthma, hay-fever, rose cold,
eczema, or idiosyncrasy to some food was present in
nineteen out of the twenty-three cases, while in the
remaining four cases there were no notes in the family
history on these points. In nineteen of the twenty-
three cases there was a positive skin test to fresh egg
albumen. Of the forty-five cases there were thirteen
in which the skin test gave no clue to the etiological
cause of the asthma. In one case thirty-eight tests
were made before positive information was obtained;
this illustrates the difficulty of finding the cause of
asthma. It was found that one individual was apt to
react to more than one form of protein. The essayist
concludes that a definite etiological connection may be
established between most cases of asthma and some
foreign protein by the skin test. Information given
by the skin test is of inestimable value in outlining the
treatment of the case, and with the use of this infor-
mation marked improvement or cure often follows.
Experience has shown that when a positive skin test
is obtained for a food and the food is then removed
from the diet, the general condition of the patient
almost invariably improves, and in many instances a
cure results. It is still too early to say whether all
of the positive reactions are of equal clinical impor-
tance, but experience seems to show that the severity
of the symptoms is not always indicated by the size
and character of the reaction.
4. Normal Reaction of the Skin to Stroking. — Ed-
ward A. Tracy describes what he believes is a normal
reaction of the skin to a mechanical irritant because
of the fact that it was observed in 1,165 out of 1,236
individuals examined. As there were known disease
conditions present in the remaining cases, it strength-
ens the deduction that this reaction is normal. The
phenomenon is that when the skin of a normal qui-
escent subject is stroked by a wooden instrument (a
tongue depressor or a match) it reacts by a deepening
of the skin tint, generally brief in duration, appearing
where the stroke was made or in its immediate vicinity,
and then, after a period of about fifteen seconds, by a
longer lasting whitish color, showing itself in the loca-
tion where the stroke was made. The writer gives his
reasons for believing that this phenomenon is caused
by a double nerve mechanism, one for vasodilation
(autonomic) and one for vasoconstriction (sympa-
thetic), together with at least two hormones in the
blood stream, the hormone X (Eppinger and Hess'
"autonomyn") activating the vasodilator mechanism,
the other hormone, adrenalin (or analogue inciters of
sympathetic nerve endings), activating the vasocon-
striction nerve mechanism. The examination of a pa-
tient should include this test for the following reason:
If the vasodilatation component alone is present we know
that the hormone X, or analogues, is in excess in the
blood, or that the hormone adrenalin (or pituitrin witli
analogous action) is in insufficient amount to activate
the sympathetic nerve endings in the blood vessels
tested. If the vasoconstriction component alone be
present we know that the hormone adrenalin (or ana-
logue i is present in excess in the blood, or the hormone
X, or analogues, is present in insufficient quantity to
activate the autonomic fibrils in the blood vessels.
5. Protein Extracts in States of Hypersensitization.
— Horace M. Baker and Cleaveland Floyd point out the
defects in the methods at present in use of preparing
protein extracts and find the following method equally
applicable to both food and bacterial preparations. The
material to be used is secured in large quantities and
suspended in normal salt solution and 0.5 per cent,
phenol added. A bacterial suspension is autolyzed at a
temperature of 48 C. for twenty-four to seventy-two
hours, depending upon the organism. The suspension,
immediately following the period of autolyzation, is
quickly evaporated to dryness by a constant tempera-
ture of 40" C, thus favoring the reduction of the pro-
tein to a soluble form. To carry out this step the sus-
pension is placed in a flat-bottom glass dish over a
water bath, with an air current from an electric fan
directed over the suspension. The flame under the
water is protected by a shield to prevent variations of
temperature. By this simple device the temperature
remains constant and the quick evaporation to dryness
is obtained. For testing purposes the powdered ex-
tract is ground up with glycerine in the proportion of
10 nig. of the powder to 1 c.c. of glycerine. One or
two drops of this preparation are used for the test,
which is carried out in a way similar to the von Pir-
quet tuberculin test.
New York Medical Journal.
August 12, 1916.
i The Story of Dementia Prsecox. Francis X Dercum.
:'. Congenital .Syphilis. Fred Wise.
8. Our American Voice ami Articulation. Charles 1'revost
Grayson.
4. Vincent's Bacillus in the Cervix. Guthrie McConnell.
■ Health Insurance from the Viewpoint of the Physician. A.
C. Burnham.
6. Modern Methods of Transfusion, 1 Miller Kahn.
7. Hereditary Chorea ('larenee King.
8 Gonorrhea and Its Complications. A. Hyman.
1. The Story of Dementia Praecox. — Francis X. Der-
cum says that briefly put the story of dementia praecox
begins with an impaired germ plasm. It deals with an
organism defective and deviate in its development, a
quality which involves the nervous system as well as
other structures. In the course of its development the
organism becomes toxic through a metabolic break-
down as a result of the mere strain of living. The
cortex, already feeble and with diminished resistance,
becomes a prey alike to exhaustion and intoxication,
and the subsequent course is one of deterioration, the
final chapter of which is dementia. Under circum-
stances like these it is not surprising that the clinical
picture should vary greatly. This accounts for the
tendency to separate out of the great mass of cases
special forms, as is illustrated in the eighth edition of
Kraepelin's Psychiatric, in which no less than eight
forms are differentiated. The writer ventures the pre-
diction that the original classification into the hebe-
phrenic, catatonic, and paranoid forms as presented
in Kraepelin's original generalizations, modified, it
may be, by subdivisions, is the one that will survive.
He believes also that Kraepelin has gone too far in
embracing, under the generalization of dementia prae-
cox, the hallucinatory paranoid states of the adult.
Purposes of study and clinical distinction are best
served by limiting the conception of dementia praecox
to the endogenous deteriorations of adolescence. For
the adult form the term hallucinatory paranoia is much
preferable. The writer further believes that Kraepelin
is wrong in separating so widely the lucid paranoia of
the adults, i.e. the paranoia simplex of Ziehan, the
paranoia chronica of Siemerling, the Verrilcktheit of
Westphal and Sander, the delires systematizes des
•■< gemeres of Magnan from the o;her paranoid forms.
In concluding he objects to the word schizophrenia,
which Bleuler has devised and proposed as a substitute
for the name dementia praecox, as not distinctive, and
expresses the hope that it will not survive.
3. Our American Voice and Articulation. — Charles
Prevost Grayson feels sure that no amount or depth of
patriotism can anesthetize our ears that they will find
anything musical in the voice of the average Amer-
ican, male or female, particularly female. He thinks
382
MEDICAL RECORD.
[Aug. 26, 1916
that those who are self-appointed custodians of the
larynx and its vocal function, and of every nerve and
muscle that plays a part in aTticulation, should assume
a responsibility in correcting this national defect. They
should all unite in saying that vocal instruction should
be introduced and made an essential part of the curri-
culum of every school, public or private; that every
child should be taught not only how to use his voice
correctly but that he should be marked as rigidly for
his proficiency or his lack as he is for any other of his
studies. This instruction should be continued through
high school, college, and university, and should include
distinct enunciation as well as correct pronunciation.
He urges that it is a part of the duty of each individual
laryngologist to help bring about this innovation. It
is but a commonplace to say that nothing so promotes
the health and functional vigor of the larynx as culti-
vation of either the speaking or the singing voice. In
all probability there is scarcely a day that each laryn-
gologist does not warn one or more of his patients of
the injury they are inflicting on their throats by some
more or less glaring misuse of the voice. How much
better would it be to render such warning entirely un-
necessary by beginning the prophylaxis of the laryn-
geal trouble and the conservation of the human voice
before harm has been done and bad vocal habits have
been formed ?
5. Health Insurance from the Viewpoint of the Phy-
sician.— A. C. Burnham discusses the more salient
abuses occurring in the administration of the benefits
of health insurance, and suggests solutions for a few
of the problems that may arise. He believes that the
systematic care of the industrial population on a large
scale can be accomplished only by means of State con-
trol through a department modeled somewhat along
the lines of the medical department of the United
States Army, having hospitals, full-time medical offi-
cers, nurses, and other necessary medical employees.
He outlines the plan as follows: The State would be
divided into districts, and a medical unit having full
care of the insured would be assigned to each district,
the insured being directed for treatment to the head-
quarters of the unit having charge of the territory in
which he lives. Specialists would be in attendance at
certain hours and on call when required. Regular at-
tendance upon the patients would be assured, the physi-
cian being sent from the medical center upon request.
The clerical work would be done at the various centers
by lay employees. ■ If in such a system the salaries
were made large enough, permanency of position was
assured, and opportunity for advancement permitted,
many physicians would be eager to choose just such a
career. This system would, as a rule, assure quicker
convalescence and more scientific treatment for the in-
jured, pleasanter and more satisfactory work for the
physician, and cheaper and better results for the State.
Finally the author urges that if we are to have health
insurance, and if we are to hope to benefit by the mis-
takes of others, this subject should be kept before the
profession and thoroughly discussed before the Health
Insurance act is passed — not afterward.
7. Hereditary Chorea. — Clarence Kii :r describes the
principal features of this condition and calls attention
to an observation made by H. O. Waters, who was one
of the firsl men in this country to write upon this
subject, which seems to have escaped the notice of
other writers. This authority recorded that in one of
his patients the movements ceased temporarily under
the influence of all kinds of instrumental music except
that from a common jewsharp. The writer refers to a
case coming under his observation and previously re-
ported in which the soft tones of a church organ had a
remarkably quieting effect which lasted about an hour.
He now reports another case in which the music of a
violin had a quieting effect upon the patient, so much
so that it became a regular practice for a fellow pa-
tient to play a few strains of music before he at-
tempted to eat his meals. It was not uncommon for
him to throw himself from bed or nearly so unless
soothed by music. The questions arise wThether in some
of these patients there may not be an idiosyncrasy by
which pathological stimulation of the nerve tracts lead-
ing to involuntary twitchings of the muscle fibers is
interrupted or held back by psychic means for a time,
or the inhibitory action of the sympathetic stimulated
in the same way that intense fear or anger deadens
pain. These cases suggest the possibility that music
may be made a more valuable therapeutic measure
than has been supposed, possibly ranking with, or even
higher than, suggestion or hypnotism.
8. Gonorrhea and Its Complications. — A. Hyman re-
ports a series of twenty-five cases of gonorrhea and
its complications treated with the vaccine of Nicolle
and Blaizot. During the period of vaccine treatment
local therapy was withheld. Seven of the cases were
definitely cured by the vaccine. Cases of uncompli-
cated acute or chronic urethritis were not influenced by
the treatment. Cases of epididymitis were only slightly
improved. Cases of chronic prostatitis showed the
highest percentage of cures. Rather marked improve-
ment followed the treatment in a few cases of gonor-
rheal rheumatism. From this experience it may be
concluded that the atoxic gonococcus vaccine, although
occasionally followed by a brilliant result, is most in-
constant in its effects. It cannot be relied upon for a
satisfactory result in any given case. The results in
some of the cases justify further experimentation with
the vaccine of Nicolle and Blaizot.
Journal of the American Medical Association.
August 12, 191C.
1. The Nervous System as Influenced by High Altitudes.
George A. Moleen.
2. Complications and Sequt-l:c of the operation for Inguinal
Hernia ; an Analysis of One Thousand and Five Hun-
dred Cases at the Massachusetts General Hospital.
Lincoln Davis.
3. The Prevention of the Obstruction of Gas Following
Operations on the Colon. A. J. Ochsner.
4. The Superiority of tin- Right Side Anus in the Handling of
Partial and Complete Obstruction of the Lower Colon
and Sigmoid in the Cases Unsuited for Radical Opera-
tion. John Young Brown.
5. Lipectomy and Umbilical Hernia. Walter Lathrop.
6. The Action of Vai i i R< medies on the ?:xeised
Uterus of the Guinea-Pig. J. D. Pitcher, W. it. Dellzell,
and G. E. Burman.
7. Operative Treatment for Threatened Gangrene of tie Foot,
with Special Reference to Reversal of the Circulation.
J. Shelton Horsley.
S. Tuberculosis of tie Cervical Lymphatics: A Study of
Six Hundred ami Eighty-Seven C: ses. Charles N.
Dowd.
9. Osteoclasis and Osteomy. Wallace Blanehard.
10. Lues Maligna- Willi Report of Two Cases. Perry A Bly.
11. Intraspinal Injection of Magnesium Sulphate in Delirium
Tremens. Edward A Leonard, Jr.
1. Trie Nervous System As Influenced by High Alti-
tudes.— George A. Moleen refers to the general belief
that "nervousness" is a result of living at high altitudes
which has been accepted by the public, and in no little
part by the profession, without inquiry as to the reason
for the manifestations commonly grouped under the
term "nervousness." An investigation of this sub-
ject shows that neurasthenia does not occur more fre-
quently at high altitudes than at lower ones, because
the general standard of living is better than in the more
congested centers of population; the confined artificially
lighted indoor workers are less common; there is a
greater average of bright, cloudless days, and lastly,
there is a greater intensity or actinism of the light.
It is the class of patients who are able to live with
more comfort at the lower altitudes and who manifest
Aug. 26, 1916]
MEDICAL RECORD.
383
irritable neurotic disorders repeatedly on going to
higher elevations that prompted this investigation as
a result of which it may be concluded that the demand
for oxygen carrying elements of the blood increases
directly with the altitude. In normal individuals this
requirement is met through an increase in the red blood
corpuscles and hemoglobin in from three to five weeks.
This is normal acclimatization. This power of adapta-
tion is diminished or wanting in certain individuals and
results in oxygen want or anemia. As a result of di-
minished or limited oxygen supply, the increased excita-
bility or irritability of the nerve structures may be ex-
plained. If by therapeutic or other means the blood-
forming mechanism can be stimulated into activity, in-
dividuals should find no more difficulty in living tranquil
lives in the high altitudes than at the sea-levels.
2. Complications and Sequela? of the Operation for
Inguinal Hernia. — Lincoln Davis presents an analysis
of 1500 consecutive cases of inguinal hernia operated
upon at the Massachusetts General Hospital from Octo-
ber, 1908, to December, 1914. In the 1500 cases there
was a total of 1,756 operations, counting double hernia
as two operations. In the male cases, numbering 1,388,
the Bassini technique was employed 834 times, the
Ferguson 764, and Halsted 15, with 24 cases of varying
and miscellaneous technique. In 88 cases the hernia
was direct; in others indirect. No cases of strangulated
hernia were included. In 10 cases the hernia was of
enormous size. In 69 cases the hernia was compli-
cated by undescended testicle. There were 9 cases in
which the bladder was contained within the sac. The
appendix was found within the sac eight times, and re-
moved in the course of the operations 46 times. There
were 7 cases of sliding hernia. There was hydrocele
present in 40 cases, marked varicocele in 26 cases. In 50
cases there had been a previous operation for hernia
with recurrence. The anesthesia was general in 1,319
cases. Non-fatal postoperative complications of more
or less severity developed in 438 cases, or 28 per cent.;
some of these were trivial. In many cases the com-
plications were multiple. Among the complications
were sepsis in 178 cases; hematoma in 112 cases; affec-
tions of the respiratory tract in 138, and many miscel-
laneous complications, as otitis media, cholangeitis,
persistent hiccough, phlebitis, acidosis, pyelitis, and
mental symptoms. In summing up the writer states
that the results of operation are on the whole good.
The operation has a definite though low mortality
rate (in this series 0.53 per cent.) and should not be
undertaken on the old and infirm without good reason.
Postoperative cough, hematoma, and sepsis are impor-
tant factors in the incidence of recurrence, but the lat-
ter seems to play a lesser role than is generally assigned
to it. A strikingly large number of patients anatomic-
ally cured complain of pain, probably due to nerve trau-
matism. General anesthesia is still best in the routine
cases. Spinal anesthesia, on account of its greater dan-
ger and serious sequela?, should have little place in
this operation. Local anesthesia has a wide applica-
tion in cases in which inhalation anesthesia is contra-
indicated, but carries a slightly greater risk of sepsis.
3. The Prevention of Obstruction of the Passage of
Gas. — A. J. Ochsner. (See Medical Record, July 8,
1916, page 82.)
4. The Superiority of the Right Side Anus. — John
Young Brown. (See Medical Record, July 8, 1916,
page 82.)
5. Lipectomy and Umbilical Hernia. — Walter La-
throp. (See Medical Record, July 8, 1916, page 86.)
6. The Action of Various "Female" Remedies on the
Excised Uterus of the Guinea-Pig. — J. D. Pitcher, W.
R. Delzell and G. E. Burman make a report on their
investigations of this subject undertaken at the sug-
gestion of the Therapeutic Research Committee of the
American Medical Association. They have found that
when the contractions of the uterus were altered the
tendency was always toward a reduction in the ampli-
tude of the excursions; in no instance did a drug appre-
ciably increase the excursions. The following drugs
lessened the amplitude of the excursions: Aletris fari-
nosa, Pulsatilla pratensis, Ichthyomethia piscipula,
Scrophularia nodosa; somewhat less active were Vale-
riana officinalis and Cypripedium pubescens; the drugs
possessing very weak action were Dioscorea villosa, Sen-
ecio aureus and Scutellaria lateriflora. A large number
of drugs were found to be entirely inactive; among
these were Viburnum prunifolium, Viburnum opulus,
Mitchella repens, Castanea dentata, Chamxlirium lu-
teum, Passiflora incarnata, Cnicus benedictns, Silybum
marianum and Leonurus cardiaca. The work shows that
the domestic use of teas made from these drugs for
any supposed action on the uterus is quite irrational,
for water either extracts but a very small part of any
of the active principles of the drugs, or, in the majority
of them, none at all. These investigators conclude
that not only are the drugs in this list unimportant,
but that they are practically worthless. Their use is
harmful as well as futile, since it tends to perpetuate
therapeutic fallacies.
7. Operative Treatment for Threatened Gangrene
of the Foot. — J. Shelton Horsley. (See Medical
Record, July 1, 1916, page 35.)
8. Tuberculosis of the Cervical Lymphatics: A
Study of Six Hundred and Eighty-seven Cases. —
Charles N. Dowd. (See Medical Record, June 17, 1916,
page 1112.)
11. Intraspinal Injections of Magnesium Sulphate
in Delirium Tremens. — Edward A. Leonard makes this
preliminary study based on his experiences with 12
cases in which lumbar puncture was performed, the
amounts of cerebrospinal fluid removed varying from
10 to 40 c.c. Alter removal of the cerebrospinal fluid
a cubic centimeter for every 25 pounds of body weight
of a 25 per cent, solution of magnesium sulphate, at a
temperature from 95 to 100: F., was introduced through
the lumbar puncture needle into the canal. There were
ten recoveries and two deaths in the series.
There is a rapid subsidence of the delirium and rest-
lessness, and a restoration to normal within twenty-
four hours, following this treatment; it is certainly
of value in view of the little good sedatives do and the
high mortality among these cases.
The Lancet.
July 22, 1916.
1. An Inquiry Into the Cardiac Disabilities of Soldiers on
Active Service. John Parklinson.
2. An Enteric-like Fever in the Anglo-Egyptian Sudan. Albert
J. Chalmers and Norman Macdonald.
3. The Gangrene of War: Gaseous Cellulitis or Emphyse-
matous Gangrene. Alfred J. Hull.
4. Cardiac Symptoms Following Dvsenterv among Soldiers
E. B. Gunson.
5. The Radical Treatment of Gastric Ulcer. Joseph Cunning,
fi. The Treatment of Hemorrhoids by Interstitial Injection
T. Bird.
7. An Unusual Case of Albuminuria. O. Leyton.
1. An Inquiry into the Cardiac Disability of Soldiers
on Active Service. — John Parklinson records the results
of an inquiry into the various conditions which lead
men on active service to report sick with symptoms
suggesting heart disease. It is based on 90 unselected
cases passing through a casualty clearing station in
France. Among these 90 cases valvular disease was
present in 28. In 16 cases there was a history of acute
rheumatism; in 18 the chief symptom was shortness
of breath; in 8 it was pain; all cases with pain had also
384
MEDICAL RECORD.
[Aug. 26, 1916
shortness of breath. Palpitation was an additional
symptom in one-half the cases. The symptoms were
provoked by doubling and marching, and in 25 cases
they had been present before enlistment. There were
in this series 40 cases of so-called "soldier's heart,"
which the writer considers more in detail, and in com-
menting on these he states that among soldiers in
training and on active service are found a number who
report sick for cardiac symptoms on exertion, but show
none of the physical signs indicative of heart disease.
These men are the subjects of a cardiac disability
which is unmasked by the exertion required of a sol-
dier. It is not a specific variety of heart disease, and
needs no specific name. In about one-half the cases
in this series the disability had been present to some
extent in civil life, and was, therefore, not the result
of military service. This relative cardiac inefficiency
may be a sequel of acute rheumatism, dysentery, influ-
enza, or other infection; the result of myocardial
changes due to age, especially in soldiers over forty;
it may be associated with nervous disorder, particu-
larly where palpitation is a prominent symptom; it
may be due to a heart endowed with limited efficiency,
the individual having always been "short-winded." A
simple exertion test, such as climbing 25 or 50 steps,
reproduces the symptoms in these patients, and so
furnishes valuable information on the functional effi-
ciency of the heart. Some degree of myocardial dis-
ease is present in a number of cases to which the his-
tory of infection bears witness. The absence of abnor-
mal physical signs in the heart of a soldier should not
prevent his discharge from the army if, under training
or on active service, he shows breathlessness and pre-
cordial pain whenever he undergoes exertion well borne
by his fellows. In this series was one man of forty
with a to-and-fro murmur at the aortic area, who had
served 16 months with no symptoms whatever of aortic
incompetence, the defect having been discovered at
a chance examination.
2. An Enteric-like Fever in the Anglo-Egyptian Su-
dan.— Albert J. Chalmers and Norman Macdonald state
that, in addition to the usual varieties of enteric fever,
last year they came across a number of cases of an
enteric-like fever which was not caused by the ordinary
organisms, as shown by blood cultures, fecal cultures,
and agglutination tests. They have isolated an organ-
ism from these cases, the cultural and biochemical reac-
tions of which indicate that it belongs to the Typhoid-
Colon group. This organism the authors have named
the B. khartonmensis. They find that it can be differ-
entiated from the more important members of the Colon
Subgroup, and that it belongs to the Entericus Sub-
group, which can be easily distinguished from the
Typhoid-Colon Subgroups. They also show that it can
be differentiated from other members of this subgroup.
They therefore conclude that it is a distinct species,
and describe it in detail. It failed to agglutinate with
a colon specific serum of high titre, but it showed group
reactions with high titre paratyphoid A and B specific
sera. It is, therefere, related not merely to the Colon
Subgroup, but to the Paratyphoid-Gaertner Subgroup,
and the writers consider it, and possibly the whole
Entericus Subgroup, to be connecting links between the
two collections of organisms.
5. The Radical Treatment of Gastric Ulcer. — Joseph
Cunning states that gastrojejunostomy has fallen into
disrepute because it frequently fails to relieve the
symptoms, because it is sometimes performed upon
pre-operative diagnosis of ulcer, when the real cause
of the symptoms lies elsewhere, and because it may
add to the patient's former troubles bilious vomiting
or jejunal ulcer. His experience teaches that all gas-
tric ulcers can be excised except those that are adher-
ent to important structures in the neighborhood, and
that gastrojejunostomy is useless for these. When
the ulcer is adherent to important structures, the stom-
ach can be detached from the base of the ulcer, the
opening closed, and the base of the ulcer, after being
scraped, and being now excluded from the stomach,
will give no further trouble.
6. The Treatment of Hemorrhoids by Interstitial
Injection. — T. Bird writes of this method of treatment
of hemorrhoids, not because it is new, but because he
thinks it does not receive the attention it deserves. It
was used in this country by Hoyt some thirty years
ago, and consists of equal parts of hazeline and dis-
tilled water, to which is added 10 per cent, of pure
carbolic acid; the whole of the acid is not dissolved
unless warmed. The bottle must be shaken, when the
solution becomes turbid, and it is then ready for use.
As much as 15 minims may be given at one sitting,
though it is customary to begin with 3 minims. It
usually requires eight or nine injections, at intervals
of two days, to effect a cure. When this method is
used, recurrences are very rare. Some cases in old
people are better treated in this way than by cautery
or incision.
British Medical Journal.
July 22, 1916.
1. On Industrial Diseases Prevailing among Iron and Steel
Workers in Middlesbrough. J. Watkin Edwards.
2. Head Injuries in War. Augustus W. Addinsell.
3. Notes on the Treatment of Hernia Cerebri. S. Smith.
4. Treatment of Fractured Mandible Accompanying Gunshot
Wounds. H. P. Pickerill.
5. The Treatment of Chlorine Gas Poisoning by Venesection.
A. Stuart Hebblethwaite.
fl. Death After Xitrous Oxide-Oxygen and Local Anesthesia.
W. J. McCardie.
1. Industrial Diseases Prevailing among Iron and
Steel Workers in Middlesbrough. — J. Watkin Edwards
quotes from the Supplement to the Sixty-fifth Annual
Report of the Registrar General the statement that in
the iron and steel industry the mortality at every
stage of life is above the standard for "Occupied and
Retired Males." At every stage of life the death rate
exceeds the average for metal workers generally, being
18 per cent, above the standard. This led the author
to investigate conditions at Middlesbrough, where the
manufacture of iron and steel is the chief industry.
He finds that the death rate here for males between
the ages of twenty-five and sixty-five is 40 per cent,
higher than that of females. The diseases which caused
the most deaths were organic heart disease, pulmonary
tuberculosis, bronchitis, and pneumonia, the latter caus-
ing by far the largest number of deaths. The adverse
influences which seem to be at work causing these dis-
eases are: Working at high temperatures; long hours
of work; fatigue; insufficient rest, sleep, and recreation;
working at night; careless exposure to cold and wet;
intemperance; inhalation of dust; inhalation of poison-
ous gases, such as CO; trauma. The death rate from
pneumonia is between two and three times higher in
Middlesbrough than in the country generally, and men
engaged in the iron and steel industry are much more
liable to it than others. In the majority of cases the
disease seems to be conveyed by autoinfection, a con-
dition of lowered resistance due to one or more of the
above-mentioned causes furnishing the state of ill
health favorable to the growth of the organism. As
prophylactic measures special attention should be given
to oral sepsis, enlarged and unhealthy tonsils and ad-
enoids, indigestion, and constipation. In a general
way. whi>re work entails great effort and the full natu-
ral workday of 240 foot-tons is much exceeded, an
eight-hour day should be the maximum demanded.
Aug. 26, 1916]
MEDICAL RECORD.
385
2. Head Injuries in War. — Augustus W. Addinsell
states that they have been told that "practically al-
ways" depressed fracture of the inner table is accom-
panied by "a cone-shaped pulping of the underlying
brain which acts as an immediate source of irritation
to the surrounding brain, and therefore that an ap-
parently wounded dura should be opened." He objects
to this statement on the ground that the pulping of
the brain tissue cannot be recognized before the dura
is opened and that there is no evidence that softened
brain tissue is a source of irritation or is beyond re-
covery. Therefore, in those cases in which he has re-
moved pieces of depressed bone and foreign bodies and
the dura has been intact he has not opened it. His
experience has embraced thirty-seven cases. The plan
usually adopted is to allow the patient complete rest
for three or four days, unless the symptoms very ur-
gently call for immediate interference. These cases •
show in general that a wound of the skull, however
slight, should not be regarded too lightly. They also
seem to show that when definite focal symptoms arise
while the case is under careful observation they should
be dealt with promptly if they be within the reach of
legitimate surgery. In defense of his waiting policy
the author states that all of the patients who have
developed epileptiform seizures and paralysis while
they have been in the hospital, and upon whom he has
operated for depressed fragments of bone, have either
recovered from their symptoms or improved, and in
none have the symptoms returned prior to their trans-
ference to England. He rarely uses a drain inside the
skull unless the wound of the brain is so deep as to
give rise to grave risk of the destroyed and infected
brain matter finding its way into the ventricles. An-
other practical point emphasized is in the matter of
incision of the scalp. It is advisable nearly always to
turn down a flap for the purpose of examining for bone
injuries, which in a number of cases have been found
to occur at some distance from the wound of entrance
in the scalp, due to shell or schrapnel having pierced the
scalp in an oblique direction.
3. Notes on the Treatment of Hernia Cerebri.- —
S. Smith records his experience at a base hospital
where between six and seven hundred cases of gunshot
wound of the head have passed through his hands.
One of their most difficult problems was the prevention
of, or, if that was impossible, the treatment of, hernia
cerebri. As a means of diminishing the cerebral ex-
posure they have found suture of the edges of the scalp
wound after excision of the edges of the original wound
only possible in a very small proportion of their cases.
As an antiseptic lotion they have found a mixture con-
sisting of equal parts of carbolic lotion (1 in 20), hy-
drogen peroxide (10 vols.), and water especially valu-
able. In cases in which hernia cerebri occurs, whether
following operation or where no operation has been
performed, the systematic use of lumbar puncture has
proved of the utmost value. If after the first puncture
the hernia shows no signs of decreasing and compres-
sion symptoms do not decrease, the tapping is repeated
on alternate days until the pressure, as shown by the
manometer readings, is brought down to within reason-
able limits. The author describes his method of per-
forming the lumbar puncture under general anesthesia,
and emphasizes the importance of the sitting posture
as a valuable auxiliary in the treatment of these cases.
5. The Treatment of Chlorine Gas Poisoning by
Venesection. — A. Stuart Hebblethwaite gives a detailed
account of thirty cases of chlorine gas poisoning upon
whom venesection was performed and who lived. He
states that venesection is not required for all cases.
Two types of cases, which he calls the "cyanotic" and
the "cardiac failures," require no bleeding. In order
to be successful early venesection is necessary. It is
performed by direct incision into the median cephalic
or median basilic vein, the amount of blood extracted
ranging from 15 to 25 c.c, depending upon the patient.
The results in practice were relief of the cyanosis, re-
lief of congestion in the lungs, relief of acute head-
ache, and promotion of sleep. The theory upon which
the treatment is based is that (a) the resistance of the
heart is lowered in ratio to the amount of blood with-
drawn and (b) the resulting abstraction of fluid from
tissues to make up for the loss — and it is not unreason-
able to suggest that this abstraction takes place from a
place where fluid is in excess — that is, in the water-
logged lungs. This again would lead to a lessened re-
sistance through the pulmonary system.
Journal de Medecine de Paris.
July. 1916.
Paludism and Quinine. — Job and Hirtzmann, after
some laboratory research in a military hospital, con-
clude that the action of quinine upon the hematozoon
is constant even amid variations. When the condition
is a paludism of first onset without gametes in the
blood — i.e. when the first manifestations of the disease
date back only eight or ten days — an intensive quinine
treatment maintained for three or four weeks will steri-
lize the body so that there will be no recurrence. After
the gametes have appeared in the blood, quinine medi-
cation will suppress the anemia and in a general way
the other manifestations of chronic paludism; but it
must be kept up until the disappearance of spleno-
megaly and until the blood count is normal, as shown
by repeated examinations. The authors have never
seen the so-called quinine-resisting hematozoa. If there
is any reason to believe that the drug is not absorbed
in the intestine it may be given by hypodermic. Dur-
ing the first two days 1.5 grams are given in six doses,
one every two hours. The dose is then reduced to 1
gram for the next four days. The patient has thus re-
ceived 7 grams during one week. During the second
week the patient takes a gram for five consecutive
days, and during the third week the same dose for four
consecutive days, then for three days, and so until
cured. The results of giving quinine as a preventive
are lacking in precision. At least half a gram daily
should be used and the results may still be in doubt.
Probably 1 gram given on two consecutive days each in
one week will give better success.
Le Bulletin Medical.
■Inly 28, 1916.
A Certain Method of Differentiating Diphtheria Ba-
cilli from Its Congeners. — Martin and Loiseau refer to
cultivation of the diphtheria bacilli in Veillon tubes,
in which the organisms proliferate throughout the me-
dium. It was long ago noted that the Klebs-Loeffler
bacillus is anaerobic, while the microorganisms asso-
ciated with it and resembling it are aerobic and flourish
at the surface of the medium. The latter is classed as
a peptonated, saccharated gelose. Two hundred and
fifty cubic centimeters of minced veal are macerated
in 500 c.c. of water and mixed with an equal portion of
Martin peptone. To each liter of this mixture are
added 8 grams gelose, 15 grams glucose, and 2 grams
potassium nitrate. After solution add the white of
one egg. Then heat at 115° C. for one hour and filter.
Divide among sterile test tubes of the height of 10
or 12 cm. Sterilize again by heating at 100° C. for
half an hour on three consecutive days. Begin with a
pure culture. With a glass hook take a bit of colony
386
MEDICAL RECORD.
[Aug. 26, 1916
and place it in a tube containing 10 c.c. sterile bouillon.
A little of this dilution should be slid down the side of
the Veillon tube and the latter then shaken to scatter
the microorganisms. The gelose in the tube should
now be melted by boiling, then cooling rapidly to
50° F. Now add with a pipette 1 cm. of the bouillon
dilution of bacilli to the length of the tube and mix
carefully. Cool the tube and place it in the incubator.
Often after fifteen hours we shall find colonies scat-
tered uniformly throughout the tube without any pre-
dominance in the field of asrobiosis. The so-called Hoff-
man bacillus, on the other hand, while it behaves in the
same manner in nonsweetened media, is quickly dif-
ferentiated from the true diphtheria bacillus in the
Veillon tube, in which in from twenty-four to thirty-
six hours it may be seen in the uppermost centimeter
of the tube, close to the surface. After some days
standing colonies are seen growing luxuriantly on the
surface of the medium, while the diphtheria bacillus
remains unchanged beneath the surface. The term
Hoffman's bacillus is synonymous with the pseudo-
diphtheritic bacillus of writers.
Metastases Which Follow the Treatment of Tumors
with Roentgen Rays and Radium. — Kirmisson contrib-
uted an article on this subject in the Bulletin for July
12, and following is the discussion: Bazy mentioned a
case of lymphadenoma in the parotid region (diagnosis
by biopsy). As it was deemed inoperable, a radium
tube was inserted. This was six years ago, and the pa-
tient is now alive and well. Ten years ago a radiologist
treated his wife for cancer of the cervix with x-rays,
within and without. She, too, is living and well to-day.
The case was a postoperative recurrence. Schwartz
saw prompt improvement follow the use of radium on
a ganglionary malignant tumor, but a fatal metastasis
suddenly appeared at the base of the skull. He also
cites a case of local recurrence after radium treatment
and a pelvic recurrence of cancer of the uterus which
was doing splendidly under radium treatment. But
these cases are exceptional. Routier saw a remarkable
cure of a lymphosarcoma of the tonsil under radium;
on the other hand, a cancer three times removed seemed
to relapse with unusual rapidity under radium treat-
ment. Gaucher stated that even superficial cancers
sometimes recur after radium and x-ray treatment.
As is well known, both resources are at times able to
cause cancer de novo. To offset such cases, Beclerc,
whose experience is immense, has cured with radio-
therapy a number of deep-seated, inoperable intraab-
dominal tumors. Thus in a case of a large metastasis
to the spleen from a testicular tumor, with advanced
cachexia, seven days' use of the tubes caused a rapid
disappearance of the splenic growth with a gain of
24 kg. That was five years ago, and the patient is
now fighting at the front!
La Presse Medicate.
July J7. 1916
Remote Results of Pleuro-Pulmonary Projectile
Wounds. — Denechau sums up his experience as fol-
lows: There is a definite syndrome common in these
results. In about one-half the victims an active life
is possible — even a return to the ranks. The condition
is amenable to treatment by respiratory gymnastics,
but remote complications may supervene. These in-
clude pulmonary tuberculosis; while simple pleurisy
may pursue a severe course with empyema, abscess,
gangrene. Projectiles which remain in the thorax con-
stitute a source of danger of infection, and should, if
possible, be removed. The author has studied fifty
cases. At first at least forty, or 80 per cent., seemed
to have recovered in all respects. Examination, how-
ever, revealed the presence not only of functional but
structural anomalies. The former comprised pain and
dyspnea. Pain was constant at the site of the wounds,
spontaneous but increased by cough, rapid exertion,
yawning, etc. In sixteen out of forty dyspnea was se-
vere enough to interfere with an active existence. In
a number of cases the injury had evidently been re-
sponsible for tracheobronchial adenopathy. The .r-ray
also showed evidences in the wound track in nearly
every case examined. In nineteen of the material the
bullet was still in the thorax and in fourteen of these
seemed to be well tolerated. In three a small cavity
formed, which in one instance suppurated at recurring
intervals. A fistula eventually formed. In this pa-
tient the ball was extracted and no more pus formed.
In six other cases the ball was also extracted, but no
details are given. In the entire series of seven cases
there was no improvement followed in the functional
anomalies.
Improved Tracheotomy in the Adults. — Luc believes
that he has simplified the technique and cut short the
duration of this operation. He is at present at the Val
de Grace, where tracheotomy is often required in sol-
diers with laryngeal stenosis. Local anesthesia is al-
ways employed. The patient's throat is made promi-
nent by placing a cushion under his shoulders, with
head extended and supported by an aid. If, as often
happens, the patient is in dyspnea, the latter elevates
the head at each paroxysm. The operator should be
at the left of the patient while giving the anesthetic
(novocain-adrenalin). Five minutes are allowed for
diffusion. The incision is begun at the upper border
of the cricoid cartilage and its entire length is 5 cm.
Retractors are then applied and the cartilage denuded,
while the trachea is similarly exposed under the use of
a grooved director. A special narrow retractor is now
applied over the first ring of the trachea in the lower
angle of the wound and pulled downward, fully
exposing the passage. The bistoury is now plunged
into the tracheal wall, the back of the instrument being
against the retractor, and the rings are successively
divided from below upward. The tracheotomy tube is
now inserted and the small retractor withdrawn. A
few clamps bring the lips of the wound together and
hold them in apposition.
Excessive Fertility. — A correspondent calls attention
to a remarkable case of fertility in an Italian woman
of 40, residing not far from Pompeii. Up to date she
had borne 56 children. She had given birth once to
sextuplets and at least twice to quadruplets, while
triplets had been born on a number of occasions. While
some of these children had been born alive the mother
had been unable to raise any of them with a single ex-
ception, that of the first born daughter. The ages at
death and causes of death are not mentioned. The sur-
viving child had been placed by the mother in a con-
vent.— Correspondenz-Blatt fiir Schweizer Aerzte.
Dialysates. — The principle of Burger of obtaining
active principles of fresh plants by dialysis, which has
recently attracted notice, is only a reintroduction of the
principle of Golaz, who was the first to claim that
dialysates are superior to extracts. Preparations made
by Golaz's procedure have been in the market since
J696, and have been continuously in use, according to
a letter from a correspondent who likes especially a
dialysate of valerian which can often replace bromides,
the cost of which is now excessive. Other dialysates
may prove useful as substitutes for high priced drugs.
The writer also likes the dialysates of digitalis and
strophanthus. — Correspondent - Blatt fiir Schweizer
Aerzte.
Aug. 26, 1916]
MEDICAL RECORD.
387
Monk SpmrntB.
The Treatment of Infantile Paralysis. By Robert
W. Lovett, M.D., Boston, John B. and Buckminster
Brown Professor of Orthopedic Surgery, Harvard
Medical School; Surgeon to the Children's Hospital,
Boston ; Surgeon-in-Chief to the Massachusetts Hos-
pital School, Canton; Consulting Orthopedic Surgeon
to the Boston Dispensary; Member of the American
Orthopedic Association; Corresponding Member of
the Royal Society of Physicians, Budapest; Korre-
spondierendes Mitglied der Deutschen Gesellschaft
fur Orthopadische Chirurgie, Socio della Societa Itali-
ana di Ortopedia. With 113 illustrations. Phila-
delphia: P. Blakiston's Son & Co., 1916.
Coming from the pen of so distinguished a surgeon who
has devoted many years to the therapeutic as well as
the surgical treatment of infantile paralysis this book
needs but little comment except to recommend it heartily
to the members of the medical profession who are desir-
ous of the most approved up-to-date methods of combat-
ing the sinister results of this dread disease. Dr.
Lovett himself says that since the great prevalence of
infantile paralysis in America from 1907, our advance
in knowledge of the affection and its treatment, espe-
cially on the therapeutic side, has been so rapid that
it has not had time to find its way into the text-books,
but exists almost wholly in the fugitive periodical
literature. The book is a small one, containing but
161 pages. However, not a word is lost, as the explana-
tions are remarkably clear and concise, almost ele-
mental in their directness. To add to the clearness of
text, the illustrations are clean-cut and well-produced.
The author dwells at length on the subject of muscle
training, because, as he says, all experienced surgeons
are to-day agreed that the operative treatment of this
disease should not be undertaken until at least two
years after the onset, and during this time, when the
most rapid progress is to be made, the treatment needs
to be a non-operative one of which muscle training is
the most important therapeutic measure. The text is
divided into the treatment of the acute, convalescent,
and chronic phases, operative treatment, muscle train-
ing, and the spring balance muscle test.
Surgery in War. By Alfred Hull, F.R.C.S., Major
Royal Army Medical Corps, Surgeon British Expedi-
tionary Force; Late Lecturer on Surgical Pathology,
Royal Army Medical Corps, Millbank; and Surgeon,
Queen Alexander Military Hospital. With a Preface
by Sir Alfred Keogh, K.C.B., M.D.. Hon. Physician
to H. M. the King; Director General Army Medical
Service. With 26 Plates and 55 Text Figures.
Price, $4.00. Philadelphia, Pa.: Blakiston's Son &
Co., 1916.
The surgical practice of the present war is in many
respects novel; that is to say, the manner in which
wounds should be treated has been, to some extent, re-
vised as a result of the teaching of the present cam-
paign. This is due partly to the character of the
wounds brought about by modern implements and en-
gines of destruction and partly to the unprecedented
conditions under which war is being waged. Mr. Hull's
book is the summary and conclusions of the surgical
experiences of an able surgeon of the present campaign
from its commencement up to the time when the book
was written. The most interesting portion of the work
is that which deals with the methods of treating sepsis.
Sir Almroth Wright's work on the bacteriological side
together with recent surgical developments have prob-
ably revolutionized measures of treating sepsis, al-
though it must be borne in mind that by no means the
last word has been said on the subject. The book by
Hull, as well as being interesting in a high degree, is
valuable in the existing state of affairs in this country.
Manual of Operative Surgery. By John Fairbairn
Binnie, A.M., CM. (Aberdeen), F.A.C.S. Surgeon
to the Christian Church, the German and the Gen-
eral Hospitals, Kansas City, Mo.; Fellow of the
American Surgical Association; Menibre de Societe
Internationale de Chirurgie and of the Western
Surgical Association. Seventh edition, revised and
enlarged. Price, $7.50 net. Philadelphia: P.
Blakiston's Son & Co., 1916.
Most books on operative surgery are written with one
eye to the needs of the student and the other to those
of the practising surgeon, the result often being a com-
bination of elementary and advanced material satis-
factory to neither. Binnie not only makes no bid for
textbook honors, but specifically disclaims catering to
undergraduate requirements. His book, therefore, is some-
what unique; for it is especially devoted to the unusual
and difficult phases of the subject rather than to the typ-
ical and more or less commonplace. This does not mean
that what might be called the normal surgery of the ap-
pendix, gallbladder, etc., has been neglected, but that
more space has been devoted to the problem of dealing
with complications which may be found or which may
wise during the course of operation than is usual in other
operative surgeries. In addition, much space has been
given to such subjects as the surgery of the pituitary
body, spleen, pancreas, heart, blood-vessels, and other
organs and structures where surgery steps in compar-
atively rarely, or where there has been marked pro-
gress in surgical technique in recent years.
Some rather surprising omissions may be noted.
Cushing's work in pituitary surgery is barely men-
tioned and his method of operating is not described,
although dishing has been sufficiently prominent in
this field to warrant rather full reference to his work.
In discussing the treatment of hydrocephalus I. S.
Haynes' method of draining the cisterna magna cer-
tainly not only deserves mention, but detailed descrip-
tion and comment. In the section of blood transfusion
it is surprising to find no reference to the Lewisohn-
Weil citrate method. Much more successful clinical
surgery of the heart has been done than the book seems
to indicate. In the section on cervical tumors there is
no mention of tumors of the carotid body, although
Callison and McKenty reported one case and analyzed
the reports of fifty-nine others from the literature in
December, 1913, while we have noted reports of several
others since then. While agreeing that section of the
vagus "is not necessarily fatal," its danger should be
emphasized rather than minimized, as was emphasized
editorially in the Medical Record for January 3 and
10, 1914. The value of the article on cervical rib would
be much enhanced by utilization of the material con-
tained in Henderson's report of thirty-one cases ob-
served at the Mayo Clinic. While Fuller's method of
seminal vesiculotomy is described and discussed, Binnie
fails to mention that of Squier which represents a dis-
tinct advance in the surgery of precision.
Among minor criticisms we would note that iodoform
in the form of powder, emulsion, or as iodoform-im-
pregnated gauze is continuously and obtrusively recom-
mended. Because of the danger of iodoform poisoning,
if for no other reason, we feel that the indiscriminate
use of iodoform gauze as a drainage material should
be condemned. Finally we note that there are a great
many typographical errors both in the text and in the
otherwise excellent index.
American Public Health Protection. By Henry
Bixby Hemenway, A.M., M.D., author of the Legal
Principles of Public Health Administration, etc.
Price, $1.25. Indianapolis: The Bobbs-Merril Com-
pany, 1916.
This book has been written with the object of arousing
the public to a sense of their selfish interest in efficient
public health administration. With the view of thus
arousing these instincts of self-preservation the work is
dedicated to the Women of America as "the power be-
hind the throne." Dr. Hemenway appears to have writ-
ten a forcible little work which should aid in achiev-
ing his object.
The Sex Complex. A Study of the Relationships of
the Internal Secretions to the Female Charac-
teristics and Functions in Health and Disease.
By W. Blair Bell, B.S.. M.D., London, Examiner in
Gynecology and Obstetrics to the University of Bel-
fast, and to the Royal College of Surgeons, England;
Hunterian Professor of Royal College of Surgeons,
England; Gynecological Surgeon to the Royal In-
firmary, Liverpool, etc., etc. Price. $4.00. New-
York: William Wood & Company, 1916.
This new and important work on endocrinology should
be read by all progressive physicians. The first section
is devoted to the results on the female genitals and con-
stitution of extirpation of the various endocrinic glands.
This is necessarily based for the most part on animal
experiment. The second section deals chiefly with hu-
man physiology and pathology — the results upon the
uterus, ovaries, and secondary sexual characteristics of
derangement of endocrinic functioning, the phenomena
of puberty and the menopause, hermaphrodism, etc.
While most of these facts in Part II are well known
they are summed up and correlated in a logical and con-
cise manner.
388
MEDICAL RECORD.
[Aug. 26, 1916
Diagnostic Methods, Chemical, Bacteriological and
Microscopical. A Textbook for Students and Prac-
titioners. By Ralph W. Webster, M.D., Ph.D.,
Assistant Professor of Pharmacological Therapeutics
and Instructor in Medicine in Rush Medical College,
University of Chicago; Director of Chicago Labora-
tory, Clinical and Analytical. Fifth edition. Price,
$4.50 net. Philadelphia: P. Blakiston's Son & Co.,
1916.
This work first appeared in 1907 and the appearance
at this time of the fifth edition is one of the best testi-
monials to the value of the book. The frequency with
which the editions have appeared have enabled the
author to keep up with the times in the presentation
of the numerous new methods which are appearing in
such rapid succession. A large number of the newer
methods have been added to this edition and the num-
ber of references has been generously augmented so
that it is some twenty pages larger than the previous
edition. It is also rather more attractively bound than
the fourth edition was. The discussion is treated con-
servatively, but it is chiefly as a book of methods that
the work is valuable. It can be unreservedly recom-
mended.
Cambridge Public Health Series. Under the Editor-
ship of G. S. Graham-Smith, M.D., and J. E. Purvis,
M.A. Post-Mortem Methods. By J. Martin
Beattie, M.A., M.D., Professor of Bacteriology, Uni-
versity of Liverpool. Formerly Joseph Hunter Pro-
fessor of Pathology, University of Sheffield. Price,
$3.25. Cambridge: The University Press; New
York: C. P. Putnam's Sons, 1915.
The present volume is the most recent addition to the
excellent series of monographs on subjects relating to
public health published by the Syndics of the Cambridge
University Press. About one-half of the book is de-
voted to the general technique of autopsies and con-
tains nothing strikingly different from what is said in
most works on the subject. The second half is of
especial interest, however, for it consists of a series
of chapters on the diseases of the various systems and
organs of the body, and on the more important diseases.
Under syphilis or leukemia, for example, will be found
enumerated all the evidences of those diseases that may
be found after death, and in a similar way the other
commoner conditions are discussed, as well as many
tropical disorders. There are also useful sections on the
bacteriological methods to be employed, on the recogni-
tion of cases of poisoning, and also on making autopsies
on animals. The book is one that will be found useful
by anyone engaged in post-mortem work, and con-
tains a great amount of information in a very com-
pact form.
A Manual of Surgical Anesthesia. By H. Bellamy
Gardner, M.R.C.S., L.R.C.P. London. Honorary
Anesthetist to the King George Hospital; Formerly
Anesthetist and Instructor in Anesthetics at Char-
ing Cross Hospital; Anesthetist to St. Mark's Hos-
pital for Fistula, The National Orthopedic Hospital
and the Male Lock Hospital ; Assistant Anesthetist
to the Royal Dental Hospital of London. Second
Edition. Octavo of 220 pages, with 8 plates and
36 illustrations. Price, $2.25. New York: William
Wood and Company, 1916.
In this book the subject of general anesthesia is taken
up thoroughly and cardinal principles are strongly em-
phasized, both in connection with anesthesia in gen-
eral and as applied to the administration of the various
individual anesthetics, anesthetic mixtures, and se-
quences. Chapters are also included on spinal and in-
tratracheal anesthesia, ether infusion, and anociassoci-
ation. The result is a very useful manual for the
student or recent graduate who is about to begin his
hospital interneship, or for the practitioner who has
not had the benefit of such a training in administering
anesthetics as is obtained by members of a hospital
house staff. While this book is written with the idea
of instructing in all the principles pertaining to the
art of inducing safe general anesthesia, and while
all pains have been taken to warn the practitioner of
the pitfalls that are to be avoided if one is to bring
the patient through the anesthesia successfully, the
author recognizes the fact that no amount of book
knowledge alone will make a successful anesthetist —
that a man must have a certain amount of experience
under direct, competent supervision. One who is thor-
oughly conversant with the teachings herein contained
will be well equipped to profit by the practical clinical
instruction that every doctor should receive before at-
tempting to administer a general anesthetic on his own
responsibility.
The Basis of Symptoms. The Principles of Clinical
Pathology. By Dr. Rudolph Krehl, Professor and
Director of the Medical Clinic in Heidelberg. Author-
ized Translation from the Seventh German Edition
by Arthur Frederic Beifeld, Ph.B., M.D., Instruc-
tor in Medicine, Northwestern University Medical
School, Chicago. With -an Introduction by A. W.
Hewlett, M.D., Professor of Internal Medicine, Uni-
versity of Michigan, Ann Arbor. Third American
Edition. Price, $5. Philadelphia and London: J. B.
Lippincott Company, 1916.
Readers who are familiar with the earlier editions of
Krehl's classical work will find in the present trans-
lation of the latest German issue many important
changes. In the first place, the new title more truly
represents the scope of the book than the old, which
now appears as a subtitle. There is much new material
on such subjects as the disorders of heart action, es-
pecially in relation to rythm, on nephritis, the func-
tional tests of the kidney and the significance of the
non-protein nitrogen, on gastric secretion and motility,
on the diseases of metabolism and the glands of internal
secretion, and on questions of infection and resistance,
etc. What is of especial importance is that the trans-
lator has added much material, incorporating the work
of American investigators, which has not been suf-
ficiently recognized in the German text. The editorial
notes so introduced are numerous and add greatly to
the value of the book, which is unique in the field
covered and should certainly be read by every student
of medicine.
Studies in Surgical Pathological Physiology From
the Laboratory of Surgical Research, New York
University. Volume I, 1915.
This volume, edited by Dr. John William Draper, is
composed of reprints of twenty-seven articles on various
topics by certain physicians and surgeons connected
with the New York University, together with an an-
nouncement regarding courses in research work in sur-
gical pathological physiology that are offered in that
University. A short "Foreword" is contributed by Dr.
William J. Mayo, in which he remarks that the growing
practice of republishing in one volume the results of
investigations of a group of men studying different
aspects of the same subject is most helpful ; and, re-
ferring to this volume in particular, he says that the
contents should be familiar to every surgeon, since its
subject matter is representative not only of the surgery
of to-day, but of to-morrow. Upon reading this volume
we must say that Dr. Mayo has expressed our own
sentiments most happily.
There are so many topics discussed that it is mani-
festly impossible to enumerate them here. Some papers
detail studies upon the alimentary and neural canals;
others discuss the Abderhalden reaction in its various
aspects, particularly in its relation to surgical diag-
nosis; shock comes in for its share of attention; there
are a number of papers on renal and ureteral condi-
tions; and many others on topics too numerous to
mention individually. The ensemble is the result of
much hard and infinitely painstaking work by the
authors: and we hone that the University authorities
will continue to publish such volumes in the interest of
the wider dissemination of accurate knowledge along
these or similar lines.
The Clinics of John B. Murphy, M.D., at Mercy Hos-
pital, Chicago, Vol. V, No. 2, April, 1916. Octavo
of 176 pages with 33 illustrations. Published bi-
monthly. Price per year, paper, $8; cloth. $12. Phila-
delphia and London: W. B. Saunders Company, 1916.
The initial article in this number of the Clinics is a
talk on the surgery of the tendons and tendon sheaths.
Among the topics illustrated by clinical cases are: Wry
neck; cervical rib, with a collective review on the
surgery of cervical rib; hemorrhagic dural cyst: phleg-
mon of conus medullaris, with diagnostic discussion
by Dr. Mix; musculospiral paralysis treated by tendon
transference, and various other paralytic cases treated
in this way or by tendon lengthening and fascial di-
vision; perforating ulcer of the heel; traumatic syno-
vitis of the shoulder: and a number of others in addition
to the usual crop of bone and joint cases. From the
standpoint of the average subscriber we should say
that this number deserves as strong commendation as
the previous issue deserved criticism.
Aug. 26, 1916]
MEDICAL RECORD.
389
g'Drifta Sfrjrorta.
MEDICAL SOCIETY OF THE COUNTY OF NEW
YORK.
Stated Meeting, Held April 24, 1916.
The President, Dr. Frederic E. Sondern, in the
Chair.
Resolutions upon the Death of Dr. Wisner R. Townsend.
— Dr. Alexander Lambert read these resolutions.
Resolutions upon the Death of Dr. Charles H. Richard-
son.— Dr. John Van Doren Young read these resolu-
tions.
Delegates to the Medical Society of the State of New
York. — Dr. J. Milton Mabbott was appointed to fill
the vacancy caused by the death of Dr. Charles H.
Richardson. Dr. Samuel J. Lopetsky was appointed
to till the vacancy caused by the resignation of Dr.
Floyd M. Crandall.
The scientific session was devoted to a symposium on
gastric and duodenal service as studied at the Mount
Sinai Hospital.
Experimental Studies of Etiology of Gastric and
Duodenal Ulcer. — Dr. Herbert L. Celler and Dr.
William Thalheimer presented this communication,
which was read by Dr. Thalheimer. Many attempts
had been made to produce chronic ulcers experimentally
in animals, but without success. Rosenow in a recent
report stated that he had recovered streptococcus from
96 per cent, of excised gastric ulcers, and had produced
acute and chronic ulcers in 60 per cent, of the animals
injected intravenously with the streptococci. These
streptococci were non-hemolytic and corresponded to
the Streptococcus viridans or mitis type. As a result
of these investigations Rosenow came to the conclu-
sion that non-hemolytic streptococci were the cause of
gastric ulcers in man, but that these organisms reached
the stomach by a hematogenous route. They used the
same technique as Rosenow, a description of which was
furnished by him. Recently isolated cultures were used
for animal inoculation as recommended by Rosenow.
They examined eight ulcers removed at operation, and
the consistency of the results obtained warranted this
report. All of the ulcers were of the chronic indurated
type. From six ulcers they recovered non-hemolytic
streptococci — streptococci were seen in cultures from
the seventh, but could not be isolated — and from the
eighth no streptococci were recovered. Yeast was re-
covered from four ulcers. These resembled sac-
charomyces. They studied an additional specimen of
peptic ulcer which occurred at a gastroenterostomy
stoma of a case operated upon two years previously,
in which a pyloric exclusion and gastroenterostomy
were performed for duodenal ulcer. Streptococci were
also recovered from this peptic ulcer. They did not find
organisms in the depth of the ulcers, as reported by
Rosenow, but only on the surface. Streptococci and
yeast were the common findings, but other types oc-
curred as well. As a result of their studies it was
impossible to decide definitely whether or not the gas-
tric lesions produced by the injection of streptococci
were to be considered ulcers. The superficiality of the
rabbit lesions following the injection by the intra-
venous route, as well as the entire absence of inflam-
matory reaction in the deeper gastric tissues, inclined
them to believe that these defects were certainly not
analogous to the chronic ulcer seen in the human
stomach. The promptness of healing in the embolic
lesions in the cats tended to strengthen this conclusion.
It had been demonstrated by Bolton, Wilensky, Geist,
and others that defects produced mechanically in the
gastric mucosa and muscularis of cats healed in two
to four weeks. In the defects produced in the rabbits
by injection of streptococci into a branch of the gastric
artery, these organisms were found in great numbers
in the tissues about the lesions. By analogy it might
be assumed, even in the absence of microscopic proof,
that streptococci were also present at some time in the
lesions in the cats. The embolic lesions in the stomach
of the cats in their series healed spontaneously within
approximately the same length of time as those me-
chanically produced. It was evident, therefore, that in
these instances the injected streptococci failed to retard
the process of healing. The constant presence of non-
hemolytic streptococci in human gastric ulcers might
be adduced as an argument in favor of the role played
bv this organism as the cause of the ulceration or its
chronicity. If streptococci could be demonstrated in
considerable numbers in the depth of human gastric
ulcer this conception would gain a firmer basis. Gastro-
jejunal ulcer might readily be considered as due pri-
marily to purely mechanical factors. Streptococci were
recovered culturally from emulsified pieces of tissue.
Although the histological picture was identical with
that of the other ulcers in the series the most careful
search failtd to show the presence of streptococci on
the surface of the lesion or in the tissues about it. One
must consiaer the possibility that in this case the strep-
tococci were directly deposited upon a preexisting me-
chanical aefect and were not the essential causative
factor in the formation of the ulcer. The nature of
both the experimental gastric and cardiac lesions indi-
cated that the streptococci recovered from the ulcers
were of a low grade of pathogenicity. In addition to
the streptococcus other organisms were invariably re-
covered from the inoculated tubes. No attempt was
made to identify these strains culturally. The same
types were usually identified microscopically in sec-
tions, proving that the isolated organisms other than
streptococci were not accidental contaminations. Fur-
thermore, these bacteria were quite as numerous in the
sections as streptococci, and penetrated to the same
depth in the ulcer. The types most frequently encoun-
tered were yeast and a thick Gram positive bacillus.
Some of the isolated strains of yeast proved pathogenic
for rabbits on intravenous inoculation. Their data were
insufficient to warrant an expression of opinion as to
the sigificance of these organisms. In conclusion they
stated that it must be assumed that some cause was
operative in certain cases of gastric ulcer and prevented
the healing of defects in the gastric mucosa and was
inoperable in others. Even though non-hemolytic strep-
tococci were present practically in all gastric ulcers,
they could not convince themselves that these organisms
had been proven as yet to be the factor which either
initiated the ulceration or prevented healing. Never-
theless, the constant presence of streptococci in this
type of lesion was a suggestive fact, and further ex-
periments to determine their significance were being
undertaken.
Consideration of Causes of Recurrent Symptoms After
Operation for Gastric and Duodenal Ulcer. — Dr. Abra-
ham 0. Wilensky read this paper. He said the surgi-
cal treatment of ulcer of the stomach or duodenum did
not terminate with the completion of the healing of the
abdominal wound and the discharge of the patient from
the hospital. It should be followed by a long period of
careful after-treatment directed toward the correction
of those accompanying disturbances in the functions of
the stomach which were always initiated by the ulcera-
tive process. Such treatment was properly in the do-
main of the general practitioner from whom such pa-
tients were usually referred for operation, or in that of
the expert medical man devoting himself to the cnre_ of
these disorders of the stomach or duodenum. During
this postoperative period symptoms frequently arose
referable in a general way to the original seat of
trouble, at times at variance with those complained of
before operation, at other times mimicking those ante-
operative symptoms in some of their aspects, and often
again reproducing the original symptom complex. In
order to point out the causes productive of these post-
operative symptoms, they had made a careful study of
all the patients operated upon for gastric and duodenal
ulcer and had correlated the complaints of these pa-
tients with anatomic and pathologic facts made evident
at secondary operations, and had attempted to show
the physiological relationships between the resultant
postoperative symptoms and the causative objective
findings. When these patients were discharged from
the hospital the subjective symptoms had been alleviated
and the gnawing pain and distressing nausea and vom-
iting had disappeared; the patients then believed that a
cure had been accomplished, and excesses were imme-
diately committed, and enormous quantities of food
taken." What happened then gave them, perhaps, the
largest group of cases. The most common symptom
was vomiting: if not corrected pain, pyrosis, and gase-
ous eructations appeared. Ulcer of the stomach or
duodenum was almost always associated with changes
in the quality and relative quantities of the ingredients
of the gastric juice, and this disturbed condition of the
normal secretorv function gave rise to svmptoms that
nnpeared immediately or very shortly after oneration.
The great majority of these svmptoms orginated in in-
discretions in diet. The usual symptoms were pyrosis
and belching. Secondary svmptoms due to a reflex
interference with the motility of the large intestine
led commonly to various degrees of constipation and
390
MEDICAL RECORD.
[Aug. 26, 1916
in a few cases to diarrhea. There were some patients
who began to complain even before their discharge, and
the symptoms described were exactly the same as
were present before the operation. Secondary opera-
tions might be done, and it would be impossible to find
traces of any open ulcerations or of the scars of any
healed ulcers, or in fact any other intraabdominal
lesion amenable to surgical treatment. It might be as-
sumed, therefore, that these patients had never had any
lesion in the stomach and that the original operation
had been unnecessary.
Cases were also found in which pain was experienced
for a short time following operation, due to a want of
accurate apposition in the suture line of the gastro-
enterostomy or remaining after the excision of the
ulcer-bearing area. True peptic ulcerations appeared
in the line of the stomach or a short distance there-
from in the jejunum in about 2 per cent, of those pa-
tients who had a recurrence of their symptoms, and
the clinical picture was very characteristic. A repro-
duction of the original symptom complex occurred in a
short time after the operation and the patient believed
that the old ulcer had reappeared. Progression might
be vejy rapid and perforation with its consequent peri-
tonitis might quickly arise. Secondly, the symptoms
continued much as before the operation. Most of the
cases of gastrojejunal ulcer belonged to this group.
Thirdly, the symptoms developed slowly and a tumor
formed in the upper abdomen. Operation revealed a
fairly large jejunal ulcer which had undergone sub-
acute perforation and had become surrounded by a
large mass of indurated and adherent intestine and
omentum. Fourthly, such a tumor developed suppura-
tion within it and the abscess ruptured into an ad-
herent hollow viscus. In other patients the period of
good health extended over a much longer period than
was indicated in the previous groups, the symptoms
beginning insidiously and increasing slowly. Vomiting
soon appeared and became prominent and disturbances
were found in the mechanics of the stomach. In some
patients there seemed to be a natural predeliction
toward the formation of postoperative intraabdominal
adhesions. As regards the recurrence of the ulcerations
or the formation of new ulcerations, one might say
very little for they were as little enlightened in this
respect as in the etiolog} of the original ulcer.
Limits of Operability in Carcinoma of the Stomach. —
Dr. Richard Lewisohn read this paper. He said that
the question of surgical interference in cases of cancer
of the stomach was still very much under discussion.
Though this subject had been widely debated for over
thirty years, opinions as to the advisability of surgical
interference in these cases still differed very widely.
On the one hand they found many of their colleagues
who claimed that every case in which a diagnosis of
cancer of the stomach had been established ought to be
operated upon ; on the other hand, they often heard the
opinion expressed, and mainly from their medical con-
freres, that once the diagnosis of cancer of the stomach
was established an operation would be useless, because
at the very best such an operation might prolong life
for a few months only. There could be no doubt that
their present operative results were far from being
perfect. Their operative statistics could be improved
materially if these cases were turned over to the sur-
geon at a much earlier date than had been the custom
before. The physician hesitated to subject his patient
to an operation unless he had established the diagnosis
beyond a doubt. This brought up the question : "What
established the diagnosis of cancer?" It should be
stated most emphatically that all the clinicai findings
varied very materially in the different cases, and if
they waited until all their clinical data pointed abso-
lutely toward cancer of the stomach, the time for the
possibility of a permanent surgical cure of this disease
had usually been passed. At Mount Sinai Hospital
during the last three years, 134 cases of cancer of the
stomach came under observation. A detailed investiga-
tion of the different clinical factors which led them to
establish the diagnosis proved that in many of the
cases only a small percentage of the so-called cardinal
symptoms were present. Lactic acid, which was often
considered as one of the cardinal symptoms, was absent
in 30 per cent, of the cases, whereas free hydrochloric
acid was present in about 40 per cent. Frequent and
persistent vomiting was often found in pyloric tumors,
whereas carcinomatous growths of the lesser curvature
rarely caused vomiting. Many a case of gastric car-
cinoma had been treated medically for an unduly long
time because of the erroneous argument that a diag-
nosis could not be established in the absence of vomit-
ing. The absence of blood in the stools, blood in the
vomitus, palpable mass, etc., did not by any means ex-
clude the presence of gastric carcinoma. Youth did not
exclude the presence of gastric carcinoma for 13 per
cent, of their patients were under 40 years of age and
one was only 25 years of age. Even the .r-ray had
failed them in some cases which were proven to be
stomach cancers on the operating table. They had no
diagnostic symptom which made the diagnosis an abso-
lute certainty and, in order to give to the greatest num-
ber of patients the benefit of a possible radical cure,
they had to risk an occasional unnecessary exploratory
laparotomy. However, their experience had shown
that such an exploration with a negative result was
very rare. Even in cases which clinically gave the
suspicion only of cancer of the stomach, the operative
findings usually showed that the growth was much
more extensive than they had assumed from their clini-
cal studies of the case. What advice should they give
to patients who came to them with large palpable
tumors? Their experience caused them to believe that
cases of large carcinomas of the stomach could be
divided into four groups. (1) If a large tumor of the
stomach was causing pyloric stenosis, the indication for
operation was clear. If a radical operation was possi-
ble, such a tumor should be removed, otherwise a gas-
troenterostomy. (2) An attempt at operative interfer-
ence ought to be made if the general cachexia was not
too far advanced. Localized metastatic involvement
was no contraindication; such glands could be easily
removed with the tumor en masse. In a great many
cases the patients with large tumors were very good
operative risks. In the majority of the cases the re-
moval of the tumor was technically very easy. (3)
These were cases with large movable tumors and
metastasis which made a radical cure impossible. A
removal of the tumor would prolong the life of the
patient and make his existence much more comfortable.
(4) Fixed tumors of the stomach with extensive metas-
tasis. These were really the only inoperable cases. The
current idea that when a large tumor was palpable the
case must surely be inoperable on account of extensive
metastasis was certainly not in accordance with their
observations. Among the 134 cases which were ad-
mitted in the last three years, 22 were considered as
having inoperable tumors and the patients were sent
home. In 28 cases only a palliative operation was possi-
ble, and in 51 cases nothing but an exploratory opera-
tion was performed. Resection of the tumor was possi-
ble in 33 cases. They did not consider that the size of
the tumor alone was a contraindication if the general
condition of the patient, metastasis in the liver or in the
cul-de-sac and other considerations did not stamp the
case as obviously inoperable. Although very many of
these cases made an uneventful recovery, the number
of radical cures was very small, between 5 and 10 per
cent. Being aware, however, of the fact that operative
interference was the only possible means of a cure and
that without operation these patients had no chance of
recovery, they should not be too conservative in their
operative indications. For the present the knife of the
surgeon offered the only possibility of a radical cure.
Recurrent Ulcer of the Stomach and Gastric Jejunal
Ulcer.— Dr. Albert A. Berg described the method em-
ployed by him in doing a gastroenterostomy plus pyloric
exclusion. He was very optimistic regarding the results
recently obtained.
Dr. Leopold O. Stieglitz said, that he wished that
the internist who saw many cases of ulcer of the
stomach or duodenum could share Dr. Berg's optimistic
views as to the ultimate result of the operative treat-
ment of this condition. The internist might be more
ready and willing to submit their cases to the surgeon
if the permanent results obtained were as satisfactory
as those obtained by the surgeon in the treatment of
appendicitis or gall stone disease; in the latter cases
the internist could feel confident, that the surgeon would
achieve an actual cure by the removal of the "causa
peccans" of the patient's illness. But in operating for
ulcer of the stomach the surgeon did not change the
underlying morbid condition, that originally led to the
formation of an ulcer — an ulcer was not a disease in
itself, but rather a complication of a morbid gastric
condition — and gastroenterostomy did not permanently
affect this underlying morbid condition, nor change the
factors that originally caused the ulcer to form. It
was very much like treating an ulcer of the leg without
paying any attention to the varicose veins that were
the real cause of the ulcer formation. The cause of
Aug. 26, 1916]
MEDICAL RECORD.
391
failure in many of the operated cases might be ascer-
tained by a careful study of the individual case. Thus
in a case of ulcer of the pyloric region with total anacid-
ity in which very profuse hemorrhages had led to
operative interference a gastroenterostomy had been
done with occlusion of the antrum. Within a week
another profuse hemorrhage had occurred; some nine
months later another one and two years thereafter
another almost fatal hemorrhage. Now the .r-ray had
shown that in achyllia gastrica the pylorus was not
tightly closed, and there was reason to assume that
some of the peptic ulcers of the pyloric region were
caused by the regurgitation of pancreatic secretion
through the patent pylorus into the anacid stomach,
where self-digestion took place. If that was the case
it was easy to understand why in the case in question
the hemorrhages had recurred, as there was nothing
to interfere with the continued regurgitation of pan-
creatic secretion into the antrum of the stomach. He
also reported another interesting case with enormous
hyperacidity in which the operation had not given
permanent relief. He stated, however, that the results
achieved by medical treatment — as far as the question
of permanent cure was concerned — were about as dis-
heartening as those by surgical methods. They could
not promise the patient that any medical or surgical
methods would effect a permanent cure. But these
cases certainly offered a splendid field for further study
and investigation.
Dr. Seymour Basch said that the field of gastric
ulcer was very broad and few had any conception of
the problems attending the solution of the questions
arising; all surgical and clinical investigations were
of great value, but it was well to check both the surgeon
and the internist. Only recently the experimental work
of Kosenow had taken the world by storm. His inves-
tigations, however, could not be substantiated. The
results obtained in experiments on animals were not
the same as those obtained in the human being. In
animals the incidences in their lives were vastly differ-
ent from those in the human being. The first consid-
eration must be paid to the public. How frequently did
not the people state that in these cases of gastric or
duodenal ulcer operation was the last resort. Again,
frequently the internist was convinced that a patient
should be operated upon, but yet the patient would put
the time of operation off so long that the operation
would fail to do him any good ; then, too, the operation
would jeopardize the life of the patient at this late
period. Surgeons were often at fault because they
lacked a unanimity of opinion as to the treatment.
The internists were at sea because they were not able
to interpret the findings and state what the end re-
sults might be. The patients lost confidence. Dr.
Basch believed, however, that these cases could be bet-
ter clarified if they were studied in a broad and proper
way. It was better for the patient if he was in a hos-
pital where he could receive the benefits of the labora-
tory, the avray, and better clinical observation. The
worse cases were those who were without the hospitals.
If they could adopt in private practice the methods
employed in the hospital they would without doubt get
better results. One of the best means for dividing the
surgical from the medical cases was the rr-ray. This
would show the uncomplicated cases that would be bet-
ter treated by the internist; it would also point out the
cases in which certain complications had occurred and
where medical means would not avail. With regard
to some of the causes of recurrences in the late cases,
they had not been as yet sufficiently, studied out, but
it was well known that certain concomitant conditions
were often overlooked. Some frequently did not make
a diagnosis of ulcer, and yet ulcer was present. One
late cause was the gradual closing of the gastroenteros-
tomy opening and another the making of an opening
too high up. A frequent cause of failure was that the
surgeon did not turn the patient over to the internist
for treatment after operation. Again the internist
was often very careless in the after-treatment. There
were two points in the treatment that Dr. Basch wished
to emphasize, the importance of rest and protection.
If one gave us improper diet there could be no rest
for the ulcerous area. In many cases of chronic ulcer
wonderful results were obtained from the use of the
duodenal tube, which gave both rest and protection to
the area involved.
Dr. Edward A. Aronson said that the papers and
the discussion they had listened to led them to the old
battleground, the medical treatment versus the surgical
treatment for the cure of gastric and duodenal ulcer.
It was hardly fair to make a comparison for the follow-
ing reasons : The internist could never be positive about
his diagnosis because there was no absolute diagnostic
sign ot the presence of an ulcer. The surgeon some-
times erred also for an ulcer might be present or ab-
sent, and they could only accept his word as to its
presence when he opened and inspected the stomach
itself. The personal equation of the surgeon counted
for much in that one surgeon would consider an in-
duration another would pass by and regard the con-
trary. They based their estimate on surgical statistics,
but this was wrong, because no two surgeons operated
exactly alike. The economic conditions of their pa-
tients also played a big role. The bread-winner of the
family wanted a quicker road to complete recovery, and
they could expect this sooner from surgery than any
medical means. This accounted in a way for the selec-
tion of cases for medical and surgical treatment. The
former class included patients whose financial condi-
tion was so much better than the latter. Dr. Aronson
6aid he had been in the fortunate position of being able
to see a very large amount of postoperative material
which was directed to his clinic at the Mount Sinai
Hospital Dispensary from the surgical divisions of the
hospital and to study the results of both medical and
surgical treatment of ulcer. When the patient was re-
turned to the physician uncured, that was, still com-
plaining of symptoms referable to his stomach after
surgical treatment, he believed it was his first duty to
endeavor to determine whether any complication of the
operation was present, whether the symptoms were
due to indiscretions in both choice and quantity of food,
whether they were purely nervous, or whether the
original disease was still causing the symptoms. Con-
sideration of the complications of the operation con-
stituted a most important factor because the frequency
of these complications resulting from surgical tech-
nique depended upon the experience of the surgeon. It
was needless to state that unfortunately not every sur-
geon could perform a properly functionating gastro-
enterostomy, and it was also gratifying to say that as
a result of improved technique many of the former
frequent bad surgical results were rapidly disappear-
ing. Retention of food or the presence of a large
amount of gastric secretion in the stomach was an im-
portant factor in preventing the normal healing of an
ulcer, and the object of gastroenterostomy was partly
to facilitate the emptying of the stomach and to pre-
vent any retention of food or undue increase in the nor-
mal intragastric pressure by excessive peristalsis. The
majority of cases cured by gastroenterostomy were
those in* which there had never been any difficulty what-
ever in the emptying of the stomach. At the present
time the late end results of surgical treatment, that
was, gastroenterostomy plus pyloric exclusion for ulcer,
were being studied, some of the patients having been
operated upon almost three years ago. In the majority
of those patients who complained of symptoms referable
to the stomach, it had been found that they were due to
a retention of either food or gastric secretion depend-
ent upon lack of muscular tone, that was, a diminished
peristole of the stomach. The latter was determined
by a rather novel method in the hands of two investi-
gators at the hospital who would shortly publish their
results. There was but little doubt that this so-called
atony had a direct bearing on the prolongation of the
symptoms.
Dr. P. B. TuRCK said that the negative findings were
of value not only in eliminating all but the essential
factors in a problem, but especially in correcting a
false conclusion which might otherwise become estab-
lished. These experiments of Celler and Thalheimer
indicated that ulcer was not produced by streptococci.
They also showed that in no case of ulcer in man could
streptococci be found in the deeper tissue. It was
shown long since by Holman, Nauwerck, and others that
any erosion or ulcer in the stomach would show bac-
terial forms on its surface, including, of course, the
streptococcus: but such findings had no significance-
no causal relationship to ulcer. Dr. Turck's experi-
ments, published in 190f!. showed that bacterial injec-
tions did not produce ulcers in animals. Only by the
feeding of intestinal bacteria could peptic ulcer be re-
produced iust as it was found in the human stomach.
As regards the surgery of ulcer, he personally consid-
ered perforation and cicatricial stenosis as the only
indications. Senn, ten years ago, and Bland Sutton
to-day gave weight of opinion against routine opera-
tion. This was in line with recent conclusion of Kutt-
ner, Faulhaber, von Redwitz, Boyd, E. von Herezel
392
MEDICAL RECORD.
[Aug. 26, 1916
Pester, and Zweig. The reason of surgical failure was
explained by the observations of Hamburger and Leach.
Rational treatment would consider the whole ulcer
status rather than merely the local lesion of ulcer itsell
and an outline of this therapy was to be published very
shortly.
Dr. .Mark I. Knapp said he would confine his re-
marks only to the question of the etiology of ulcer.
They had heard the analogy of gastric and duodenal
ulcer to ulcer of the leg, as caused by varicose veins.
This comparison was excellent. In the leg they had the
bursting of a distended vessel, which resulted in an
ulcer, because of the inability of the constantly irri-
tated surface to heal. If then, they were to have in the
stomach similar conditions, they could understand the
formation of ulcers here. If they should have varicose
veins in the stomach, they would have the first condi-
tions necessary to ulcer formation. Had they such
varicose veins in the stomach? Why, yes; varicose
veins in the stomach were quite frequent. Did such
dilated, varicose veins in the stomach ever rupture?
Again, yes. He reminded them of the condition known
as hemorrhagic erosions of the stomach. The hemor-
rhages did issue from the dilated and distended vessels,
which burst open. Again, Dr. Thalheimer told them
of yeast being found in the ulcers and also streptococci.
If, now, such burst vessels were prevented from heal-
ing by the constant irritating presence of microorgan-
isms and yeasts, they got the open, non-healing wound
of ulcer. Dr. Thalheimer spoke of the presence of
yeasts. He reminded them of his article on "Organ-
acidia Gastrica," published in the Medical Record,
September 6, 1902. It was there he described for the
first time organacidia gastrica, and made three sub-
divisions, one of which he named "zymosia gastrica,"
which meant yeast fermentation in the stomach. It was
in this disease, where they found not plain yeast cells —
these did no harm — but the growing, budding, sporu-
lating yeasts and microorganisms, which were of grave
consequence. It was the presence of these which kept
the exposed, torn vessel from healing and developed the
ulcer. And now the question was, how did they get
the distention and thinning of the vessels? Here they
had to think of the vessels as they ran through the
muscularis. If there was a great spastic contraction of
the muscularis, the return circulation would, for the
time being, be impeded or, perhaps, stopped altogether.
If such contraction again and again recurred, the result
would, of necessity, be an attenuation and finally a rup-
turing of the distended vessel, the same as in' hemor-
rhoids. Therefore, for the production of an ulcer they
must have repeated spastic contractions of the mus-
cularis with consequent distention and attenuation of
the choked-off vessel, the final rupturing of such dis-
tended vessel, and, in addition thereto, there must be
chronically present in the stomach irritating material,
which irritated the wounded surface of the torn vessel
and, not only, prevented it from healing, but caused
the attendant inflammatory changes around the
wounded vessel, the identity of which was finally ef-
faced by the inflammatory exudate and infiltrate" sur-
rounding it. Therefore, prolonged irritation caused
within the stomach, if continued for long time, the
chronic spastic contractions of the muscularis which
would ultimately lead to the developing of ulcer. The
continued chronic irritation of the stomach proceeded
from the pathological presence within the stomach of
the volatile, acrid, irritating organic acids, mentioned
and described by him in the article above mentioned.
The presence of these acids must not be assumed, but
proved by the tests which he had given and which were
so easily and rapidly performed.
Stated Meeting, Held May 22, 1916.
The President, Dr. Frederic E. Sondern, in the
Chair.
Modern Methods in Municipal Milk Control. — Dr.
Charles E. North presented this communication,
which was illustrated with lantern slides. He said
there were four objects of municipal milk control which
must be the aim of the public health officers in under-
t!»King municipal control work and were as follows-
(1) To insure the food value of milk as an article of
food. This referred to those physical and chemical
characteristics which identified it as milk, including
standards for its chemical components, such as butter
fat. total solids, solids not fat. and salts. (2) To in-
sure so far as possible the safety of milk. This re-
ferred to the prevention of milk infections, and the pre-
vention of the transmission of disease by milk. Spe-
cifically, it related to the bacteria of infectious diseases
transmissible by milk, and to bacteria which could not
be well recognized as specific, but which damaged the
milk itself or by toxic products damaged the milk con-
sumer, especially infants. (3) The promotion of de-
cency as a characteristic of milk. The value of decency
in food products deserved special consideration for its
own sake, entirely apart from questions of safety. This
subject related especially to the sanitary care which
had been exercised to protect milk from contamination
and pollutions so that it was clean and pure. (4) The
provision for an abundant supply at the lowest price
consistent with the characteristics above mentioned.
The value of milk as a food made it desirable that it
should be made available to all consumers at a mod-
erate cost. Regulations which increased the cost so
that it became a hardship to the consumer decreased the
use of milk, and caused injury to persons who would
benefit from its wider use. The methods used in the
past in municipal milk control were chemical analysis,
dairy inspection, veterinary inspection of cattle and
tuberculin testing, medical inspection of employees, cer-
tified milk, and bacterial testing. The modern methods
of milk control were considered under the following
headings:
1. Grades ayid Standards for Milk. — The purpose of
grading was to attach proper labels to milks of differ-
ent sanitary character. It was recognized that there
were an unlimited number of degrees of excellence,
from the highest to the lowest. For practical purposes,
in large cities arbitrary lines could be drawn between
three degrees of excellence. The highest grade of milk,
carrying a "Grade A" label, should be milk satisfac-
torily clean, which was entirely safe, and which could
be sold at a reasonable price, although such price must
be necessarily higher than the price of any other grade.
The primary object of this grade should be to place be-
fore the public a milk satisfactory for infant feeding.
The second grade milk should correspond to the bulk
of the market milk in sanitary character, and be sold at
the regular market price, and while not so clean, yet
entirely safe, and suitable for drinking purposes, espe-
cially by persons who were not so sensitive to the re-
quirements of decency in milk which was to be used
for drinking purposes. The third grade milk should be
milk unfit for drinking purposes, but which still had
some value for manufacturing purposes. In small cities
two grades might be sufficient: "A" and "B." The
lines of division should not be drawn until a careful
survey of local conditions had been made, and the de-
grees of excellence on which these lines were based
would necessarily differ in different communities.
2. Pasteurization and the Place It Should Occupy. —
Pasteurization had come to occupy a place of first im-
portance in furnishing a guarantee of safety to milk.
No other measure yet discovered was able to give a
life insurance to milk, or to protect milk consumers
against infectious bacteria. The alleged objections to
pasteurization as causing changes in the food value of
milk were not substantiated by extensive medical ob-
servation. While there was some evidence that the
feeding of pasteurized milk in infants might, in some
cases, tend toward the development of rickets or scurvy,
yet the feeding of orange juice so easily offset any such
tendencv that this objection could not be permitted to
offset the enormous advantages to be gained by pas-
teurization. The, infectious diseases caused by raw
milk, even of the best character, justified the pasteur-
ization of all milk, including such raw milk as cer-
tified. Pasteurization could lie easily controlled by
public health authorities by the use of recording in-
struments and bacterial testing.
3. Tuberculin Testing, and the Place It Should Oc-
cupy. — Tuberculin testing of dairy cows had been em-
phasized unduly by many municipalities as a measure
of primary imnortance in safeguarding municipal milk
supplies. In the first place, tuberculin testing was pro-
tection only against bovine tuberculosis, and was not a
protection against any other infectious disease trans-
missible by milk. In the next place, it was not a com-
plete protection against bovine tuberculosis even in the
hands of the best dairymen and veterinarians. Expe-
rience had repeatedlv shown the presence of tuber-
culosis in dairy herds and in certified dairies which
were under the supervision of medical milk commis-
sions. Tuberculin testing had a place, but only a small
place, in municipal milk control. The pasteurization of
Aug. 26, 1916]
MEDICAL RECORD.
393
milk entirely destroyed the tubercle bacilli, and the
adoption of pasteurization made tuberculin testing un-
necessary as a protection against bovine tuberculosis.
Such testing then became primarily an economic meas-
ure, which it was desirable to use for the protection
of dairy herds and of the dairy industry. In most
large cities at best but a small portion of the milk
supply could be obtained from tuberculin tested cows.
The complete control of bovine tuberculosis by this
test in most dairy districts would mean the loss of from
30 per cent, to 50 per cent, of dairy cows, a milk famine,
and an enormous increase in the price of milk, without
corresponding benefits to the milk consumer.
4. Veterinary Inspection of Cattle. — Dairy cattle
should be free from obvious disease. Common decency
demanded this. Cattle diseases that could be detected
by the physical examination of a competent veterina-
rian should be eliminated. To accomplish this it was
necessary to establish regulations requiring periodic
physical examination of dairy cows.
5. Medical Inspection of Dairy Employees. — Dairy
employees should also be free from obvious disease.
Regular medical examinations to determine this in-
volved an expense hardly justified where the milk was
to be pasteurized. The only safeguard in this matter
upon which the public could depend was the reporting
of cases of infectious diseases by the dairymen. This
was not worth much, but was all that it seemed feasi-
ble to request at present.
6. Bacterial and Chemical Testing, and Its Function.
— The milk testing laboratory must necessarily make a
sufficient number of chemical tests to determine
whether milk was being adulterated, or watered, or
skimmed, or altered in any way dishonestly. Prosecu-
tions based on these tests were almost universally prac-
ticed by municipal, state, and federal authorities, and
should continue as a fundamental part of the municipal
milk control. The bacteriological laboratory had a
much larger function to perform. The close parallel
between the numbers of bacteria in milk and its sani-
tary character made the bacterial test the surest and
most valuable means of detecting faults in milk sanita-
tion. When milk was clean and fresh the numbers of
bacteria were certain to be very low. When it was
dirty or stale, the numbers would be very high. It was
always certain that milk containing large numbers of
bacteria was either dirty or stale, or both. In the grad-
ing of milk the lines drawn between the different grades
should be based on difference in sanitary character.
This meant differences in contamination with dirt, and
in staleness due either to age or lack of refrigeration.
Consequently the most important element in milk grad-
ing should be the bacterial standard for each grade.
In well conducted laboratories the variations between
consecutive tests of the same milk was so small that
only a few such tests were necessary to give a correct
index of the sanitary character of the milk. Five con-
secutive tests showed plainly the sanitary grade in
which a milk belonged. The laboratory testing of milk
was no longer a matter of mystery or great expense,
but could be put on an efficiency and business basis
which made possible a large volume of testing at com-
paratively nominal expense to municipalities. Labora-
tories capable of testing 100 samples of milk daily
could be installed for $200. Laboratory workers capa-
ble of plating and counting from 50 to 100 samples
daily could be secured in many places from $10 to $12
a week salary. Thus every municipality could have
its own bacteriological laboratory, and even small
towns and villages could be possessed of these facili-
ties. Milk dealers, even those having comparatively
small businesses, could afford to conduct regular labo-
ratory tests for bacteria. Another new and most im-
portant function of the bacterial laboratory was that
it should act as a guide to dairy inspection. By proper
distribution of bacterial tests over the supplies of the
milk dealers distributing1 milk in a municipality, the
health department could soon ascertain what dealers
were bringing clean and fresh milk, and what dealers
were bringing dirtv and stale milk into the citv. The
bacteriological laboratory also quickly furnished in-
formation as to the efficiency of pasteurization. The
tabulation of these reports concerning the character
of raw milk and pasteurized milk, for the first time in
the historv of milk control, laid a correct foundation
for inteHigent dairy inspection. The assembling of
bacterial tests on the desk of an officer in control of
dairv milk supply made it possible for him to direct
the force of dairy inspectors toward those places which
were most in need of such inspection.
7. Dairy Inspection, and the Place It Should Occupy.
— Dairy inspection had for years been made prominent
as a means of milk control. There had been a tendency
toward the development of dairy inspection as such
in many municipalities to an extent that had over-
balanced other methods of milk control, and actually
interfered with progress in the right direction. In
some municipalities the money and time devoted to the
work had not been reflected in a corresponding involve-
ment in the character of the milk supply. Dairy in-
spection without bacterial testing was aimless. With-
out the bacterial test, the dairy inspector went to his
work blindfolded. Without a knowledge of the results
of the bacterial tests of milk from a given dairy dis-
trict the dairy inspector devoted his time, in many
cases, to dairies which needed no inspection and, in
many instances, devoted too little time to dairies which
were the real sources of polluted milk. The product
itself was the object of primary importance to the pro-
ducer, the consumer, and the health officer. Dairy in-
spection alone did not lay its emphasis on the product,
but on the environment of the product. The place to
lay the emphasis in municipal milk control was on the
product itself. The first step toward this was the grad-
ing of the milk and the establishment of milk stand-
ards. This grading should be based primarily on the
sanitary character of the product, and not on the dairy
score or the inspection of the dairy. The next step in
transforming the product was the establishment of a
system of laboratory testing of milk for bacteria. Such
tests could be made in very large volume at very small
cost. By voluminous bacterial testing of this sort the
health officer could be abundantly supplied with con-
stant information as to the sanitary character of all
sources of the municipal milk supply. By these same
tests he could also keep constantly informed regarding
the efficiency of pasteurization. Armed with this in-
formation, properly tabulated, and in the hands of a
central office, the force of dairy inspectors could then
be controlled so that its activities, instead of being aim-
less, vacillating, or uncertain, became concentrated on
worst portions of the milk supply as indicated by the
laboratory test. The force of milk and dairy inspectors
became virtually a flying squadron, directed toward the
places where they would do the most good. This meant
most intimate coordination between the bacterial and
chemical laboratory work and dairy inspection.
Prof. W. H. Conn of Wesleyan University said that
the first work on bacteria had been done in his labo-
ratory twenty-nine years ago and since then a great
many changes had taken place. The dairy industry
had "been revolutionized and many early ideas regard-
ing the bacteria had been changed, as well as modified,
until now many of their early beliefs of the early days
were gone. During that time the significance of bac-
teria had steadily grown; the bacterial content of the
milk had gradually impressed itself upon us until to-
day the greater significance of the organisms was
greater than ever before. Many attempts had been
made to control the milk problem. He said he was sure
that the medical profession to-day more fully realize
the dangers that are associated with milk than ever
before. A great many attempts had been made to get
control of the milk industry. Dairy inspection alone
did not insure the safety of the product. In 1889 he
first made the suggestion to the dairymen in neighbor-
ing cities that the dairy inspection would some day be
adopted by the municipality, and he was looked at with
great amazement. Professor Conn said he wished to
say a few words concerning the attempts that had been
made to control the problem. Of all these the be=t had
been the system of graded milk and a change that is de-
veloping with great rapidity at the present time. New
York City was its home; it started in this city, and
the influence it exerted extended elsewhere. This
graded milk furnished a safe milk for the masses, and
this was the key to the whole thing. This grading of
the milk unites the producer, the dealer, and the con-
sumer in one common interest. Emphasis was laid
upon the four following points in connection with the
bacterial standard of milk: (1) Clean, fresh milk from
healthy cows would always give a low bacterial count.
(2) The high bacterial count would always come from
either dirty milk, stale milk, warm milk, or milk from
diseased cows. (3) It was perfectly possibly to fur-
nish even New York with a milk of low bacterial count.
(4) Taking all things together the bacterial count of
milk gives more information concerning the nature of
the milk or its wholesomeness than any one fact. The
main point he wished to emphasize was that the grad-
394
MEDICAL RECORD.
[Aug. 26, 1916
ing of the milk supply which was spreading from New
York to other cities should be by new administrative
methods. The administration of the milk industry in
our communities had developed in the past years under
different conditions. In earlier years they had aimed at
finding men who were delinquent in producing and
selling milk illegally, so that they might be taken to
court and possibly fined. It was hoped that from such
stimulus the dealers would produce a product of milk
that was of a proper grade. Now the attempt should
be to determine the grade of a dealer's whole supply.
New administrative measures were now needed. The
grading of milk involved bacteria testing, dairy inspec-
tion, and especially the coordination of the two in order
to prevent conflicts, to prevent waste of effort, and to
pick out delinquent dairies and diseased cows.
Dr. Haven Emerson, Commissioner of Health, New
York City, called attention to the policy of the Depart-
ment of Health in considering matters pertaining to
the milk supply and the work that had been done and
was being done in connection with the various milk
commissions in educating the people with respect to
clean milk. The New York County Medical Milk Com-
mission, the New York Milk Committee, and the Na-
tional Commission on Milk Standards had been im-
pressed with the importance not only of local munici-
pal but State control of the milk supply. There should
be a closer cooperation between the local and rural
health officers of different localities responsible for the
care of the communities, so that it would not be neces-
sary to send inspectors from cities into the country to
inspect the conditions of milk production. Dr. Emer-
son referred to the outbreak of typhoid fever in Bay
Ridge, where there occurred about one hundred cases
infected by milk contaminated by a typhoid carrier who
had also been responsible for a number of cases that
had recently occurred in a village in New Jersey. This
carrier infected the water supply of the dairy. The
value of country milk inspections lay in its educational
effect. The inspectors should be graded according to
the educational work they do. It was interesting to
note that the attention of the consumer was being di-
rected to other factors in connection with the milk sup-
ply beside the "cream line." The people were now buy-
ing milk according to the grade and not according to
the "cream line." They recognized safety as of greater
importance. The suggestion had been made that the
city should not use certified milk or other raw milks,
but he believed, contrary to what had been stated, that
there would always be a proper demand for a high
grade raw milk. It should be possible always to pro-
duce raw milk that was safe enough to be marketable.
Dr. William H. Park said that he believed that
probably Dr. North was better known in the work on
the milk problem than any one else and had done much
to simplify the problems confronting them; for in-
stance, he had emphasized over and over again that it
was not necessary to have certain kinds of floors in
the barns. If the milk was clean and had been pas-
teurized it would be all that was necessary for the ordi-
nary milk supply. With what had been said regarding
raw milk he said he could not agree. It should be re-
membered that the barns of to-day were supervised
by men of intelligence; they were also owned by them.
The bacterial count was purely quantitative and not
qualitative. With regard to the safety of certified
milk, it was impossible for them to say that somebody
would not make a mistake. None of them, however,
had been able to trace any disease resulting from the
use of certified milk since 1902. Therefore, he thought
it best to agree with Dr. Emerson that certified milk
was a reasonably safe supply. He did not think it was
quite fair for anyone to state that the New York City
and the New York State and National Committees were
responsible for the introduction of the graded milk.
Dr. North had a great deal to do with the forming of
the committee. The results of the work which had
ead throughout the country were of great value. In
the City of New York itself most of the good that re-
sulted must have the credit given to Dr. Lederle and
Dr. Biggs.
Dr. I.insly R. WILLIAMS said that although the
present bacteriological examination of milk was emi-
nently desirable, yet it was not feasible except in the
larger cities, that pasteurization was of the greatest
importance and that in the rural sections certified milk
did not always mean that it was produced under ideal
conditions. Dr. Williams urged physicians who were
nding patients to rural New York for the summer or
who, themselves, practiced in other parts of the State.
to write to the State Health Department any complaint
they might have of any local milk supply in New York
State.
Some Recent War Experiences in the Hospitals of
France. — Dr. Clarence A. McWilliams told of his expe-
riences in France, where he was sent by the French
Hospital to take charge. His talk was illustrated with
terior of the hospitals, the trenches, the system of
transporting the wounded, the wounded men, etc.
lantern slides showing both the interior as well as ex-
§»tatr Iflp&tral ICirrnaing (Boards.
STATE BOARD EXAMINATION QUESTIONS.
Ohio State Board of Medical Examiners.
June 6, 7, 8, and 9, 1916.
ANATOMY.
1. Name the subdivisions of the abdominal cavity.
2. Give a description of the knee joint.
3. Name the carpal bones.
4. Describe the prostate gland.
5. What is the length of the intestine and its divi-
sions?
PHYSIOLOGY.
1. Describe the functions of visceral muscle.
2. What is the nature of the nerve impulse? Discuss
nerve fatigue.
3. What are the advantages of a mixed diet? How
does a purely protein diet affect metabolism?
4. What is the mode of secretion and discharge of
the bile?
5. Give histology of blood plates.
6. Discuss intravascular coagulation. What patho-
logical conditions of the vessels favor its development?
7. Locate the cardio-accelerator center. How is the
heart rate affected through the vagus nerve?
8. Describe Cheyne-Stokes respiration. With what
pathological states is it usually associated?
9. Describe effects of removal of parathyroid tissue.
10. What is the origin, distribution, and function of
the third nerve?
CHEMISTRY.
1. Give the chemical formula for mercurous chloride,
mercuric chloride, and mercurous nitrate. Give one
characteristic of each.
2. State the difference between a physiological and
chemical antidote for poison, and give an example of
each.
3. What is organic chemistry? State the general
properties of organic compounds.
4. Differentiate between fermentation and putrefac-
tion.
5. What is methyl alcohol? Give formula, proper-
ties, and uses.
MATERIA MEDICA AND THERAPEUTICS.
1. Name the three principal serums. Give mode of
administration and indication for use of each.
2. Name the different preparations of digitalis and
aconite. Give dose and cumulative action of each.
3. Cocaine hydrochloride — its physiological action
and principal uses. Give symptoms and treatment of
an habitue.
4. For what purposes are diuretics employed. Name
the principal ones. How are they usually classified?
5. Give the physiological action, use. and dose of
salicylate of sodium.
6. Potassium salts — name the principal ones and give
dose and use of each.
7. Name three external antiseptic remedies, (iive
indications, and state how each may be used.
8. Nux vomica — its therapeutic uses, important prep-
arations— dose of each.
9. Give the indications for internal use of corrosive
sublimate; state dose.
10. Give the therapeutic uses and state the dose of
opium and its alkaloids.
DIAGNOSIS.
1. (Jive symptomatology of incipient pulmonary tuber-
culosis.
2. Give etiology and physical signs of myocarditis.
8. Describe difference in symptomatology of acute
dilatation of heart and hypertrophy of heart.
4. How can the functional competency of each kidney
be demonstrated?
Aug. 26, 1916]
MEDICAL RECORD.
395
5. Give differential diagnosis: ulcer of stomach,
ulcer of duodenum, and cholecystitis.
6. Give early signs of hyperthyroidism.
7. Differentiate enlarged gall bladder and ptosed
right kidney.
8. Describe physical signs of effusion in acute
pleuritis.
9. What is the most important sign of leukemia?
10. What are the early signs of acute poliomyelitis?
PATHOLOGY.
1. What is the blood picture in myelogenous leu-
kemia; give source of abnormal cells found.
2. What is a hemorrhagic infarct; what would be
the course of such a condition — for example, in the
kidney?
3. Describe tubercle formation, and the various path-
ological results in pulmonary tuberculosis.
4. Give method of preparing a vaccine for furuncu-
losis.
5. Describe your precautions in treating a case of
diphtheria: (a) for the physician; (6) for the pa-
tient's family; (c) for the general community.
ANSWERS.
ANATOMY.
1. The abdominal cavity is divided into the abdomen
proper and the pelvis.
2. The knee joint is a ginglymus, and is formed by
the condyles of the femur, the head of the tibia, and
the patella. "The external ligaments: the anterior
or lig amentum patellse is the continuation of the ten-
don of the triceps extensor. Above it occupies the apex
and rough marking on the lower and posterior surface
of the patella; below it is attached to the lower part of
the tubercle of the tibia. There is a bursa between the
upper part of the tubercle and the ligament. The poste-
rior ligament (lig amentum posticum Winsloivii) , broad
and thin, covers the back of the joint. It consists of a
central and two lateral parts. The lateral parts spring
above from the femur above the condyles and are at-
tached below to the head of the tibia. The central part
is derived from an expansion of the semi-membranosus
tendon, and passes from the inner tuberosity of the
tibia to the inner side of the upper part of the outer
condyle of the femur. The internal lateral ligament,
broad and fiat, is attached above to the inner condyle
of the femur; below, to the margin of the inner tuber-
osity, to the internal fibrocartilage, and to the inner sur-
face of the shaft of the tibia for 1% inches. The long
external lateral ligament, a rounded cord, is attached
above to the external condyle of the femur, and below
to the external part of the head of the fibula, dividing
the biceps tendon into two parts, a bursa inteivening.
The sliort external lateral ligament, very indistinct, lies
parallel and behind the preceding, attached above to the
outer condyle of the femur, and below to the styloid
process of the fibula. The capsular ligament, thin, fills
up the intervals between the special ligaments; it is at-
tached to the margins of the articular surfaces of the
bones, and blends with the fascia lata of the thigh :
above it receives expansions from the vasti (lateral
patellar ligaments).
"The Internal Ligaments: The anterior or exter-
nal crucial ligament is attached to the depression in
front of the spine of the tibia and to the external semi-
lunar fibrocartilage; it passes upwards, backwards,
and outwards to the posterior part of the inner side of
the external condyle of the femur. The posterior or in-
ternal crucial ligament is attached to a depression be-
hind the spine of the tibia, to the popliteal notch, and
the posterior border of external semilunar fibrocarti-
lage, this latter slip being sometimes called the ligament
of Wrisberg ; it passes upwards, forwards, and inwards,
the posterior fibers attached by side of oblique curve of
inner condyle, the anterior ones to the fore part of inter-
condylar fossa and to the anterior part of the outer
surface of the inner condyle. The semilunar cartilages
are thicker at the circumferences than at the central
margins and serve to deepen the cavities for the head
of the femur. The internal semilunar cartilage is oval
in shape, the anteroposterior diameter being the longer.
Its anterior extremity is attached to the tibia in front
of the anterior crucial ligament, and the posterior ex-
tremity in front of the posterior crucial ligament. The
external semilunar cartilage is nearly circular; its an-
terior extremity is attached to the tibia in front of the
spine, the posterior extremity to the back of the spine."
(Aids to Anatomy.)
3. The carpal bones, from radial to ulnar side, are
(in the first row) scaphoid, semilunar, cuneiform, and
pisiform; (in the second row) trapezium, trapezoid,
os magnum, and unciform.
4. The prostate gland is about the size and shape of
a horse-chestnut, and surrounds the neck of the blad-
der and first part of the urethra in the male. It is sur-
rounded by a dense capsule, and consists of three lobes
(two lateral and one middle) ; it is pierced by the
ejaculatory ducts and by the urethra. Its base is at-
tached to the base of the bladder, and its apex is in
relation with the posterior layer of the triangular liga-
ment and the compressor urethra muscle. The pos-
terior surface is in relation with the rectum and is
about an inch and a half from the anus.
5. The small intestine is about twenty-one feet in
length, the duodenum being about ten inches, the
jejunum about eight feet, and the ileum about twelve
feet. The large intestine is about five or six feet in
length, the cecum being about two and a half inches,
the ascending colon about five inches, the transverse
colon about twenty inches, the descending colon about
eight and a half inches, the sigmoid colon about seven
teen inches, the rectum about five inches, and the anal
canal about one and a half inches. All these measure-
ments are liable to variation, particularly those of the
large intestine.
PHYSIOLOGY
1. The function of visceral muscle. "In a general
way is may be said that the visceral muscle determines
and regulates the passage through the viscus or organ
of the material contained within it.' The food in the
stomach and intestines is subjected to a churning proc-
ess by the muscles, in consequence of which the digest-
ive fluids are more thoroughly incorporated and their
characteristic action increased. At the same time the
food is carried through the canal, the absorption of
the nutritive material promoted, and the indigestible
residue removed from the body. The blood is delivered
in larger or smaller volumes according to the needs
of the tissues through a relaxation or contraction of
the muscle fibers of the blood-vessels. The urine is
forced through the ureters and from the bladder by the
contraction of their respective muscles." (Brubaker's
Textbook of Physiology.) During labor the uterus ex-
pels the fetus, followed by the placenta and membranes.
2. The nature of the nerve impulse. "As to the
nature of the nerve impulse but little is known. It has
been supposed to partake of the nature of a molecular
disturbance, a combination of physical and chemical
processes attended by the liberation of energy, which
propagates itself from molecule to molecule. The
passage of the nerve impulse is accompanied by changes
of electric tension, the extent of which is an indication
of the intensity of the molecular disturbance. Judging
from the deflections of the galvanometer needle it is
probable that when the nerve impulse makes its appear-
ance at any given point it is at first feeble, but soon
reaches a maximum development, after which it speedily
declines and disappears. It may. therefore, be graphi-
cally represented as a wave-like movement with a defi-
nite length and time duration. Under strictly physio-
logical conditions the nerve impulse passes in one
direction only; in efferent nerves from the center to the
periphery, in afferent nerves from the periphery to the
center. Experimentally, however, it can be demon-
strated that when a nerve impulse is aroused in the
course of a nerve by an adequate stimulus it travels
equally well in both directions from the point of stimula-
tion. When once started, the impulse is confined to the
single fiber and does not diffuse itself to the fibers ad-
jacent to it in the same nerve trunk." (Brubaker's
Textbook of Physiology.)
Nerve Fatigue. "Inasmuch as nerves are parts of
living cells, the seat of nutritive changes, it might be
supposed that the passage of nerve impulses would be
attended by the disruption of energy-holding com-
pounds, the production of waste-products, the liberation
of heat, and in time by the phenomena of fatigue.
Though it is probable that changes of this character
occur, yet no reliable experimental data have been ob-
tained which afford a clue as to the nature or extent
of any such changes. Stimulation of motor nerves with
the induced electric current for hours appears to be
without influence either on the intensity of the nerve
impulse or the rate of its conduction." (Brubaker's
Textbook of Physiology.)
3. Mixed Diet. "The chemical composition of the
tissues, taken in connection with their metabolism dur-
ing starvation, implies that no one article of food is
396
MEDICAL RECORD.
[Aug. 26, 1916
sufficient for tissue repair and heat production; but
that all classes of food — in other words, a mixed diet —
are essential to the maintenance of a normal nutrition.
Experimental investigation has also conclusively estab-
lished this fact. Moreover, the amounts of nitrogen and
carbon eliminated daily, and the ratio existing between
them, indicate the amounts of proteid, fat, and car-
bohydrate which are required to cover the loss." (Bru-
baker's Textbook of Physiology.)
Metabolism on a purely protein diet. "Notwithstand-
ing the chemical composition of the proteins and the
possibility of their giving rise to both fat and carbo-
hydrate during their metabolism, it has been found
extremely difficult to maintain the normal nutrition for
any length of time on a pure proteid or fat-free diet.
This, however, has been accomplished with dogs. It
was found, however, that, in order to maintain the equi-
librium, it was necessary to increase the proteins from
two to three times the usual amount. Thus a dog
weighing 30 to 35 kilograms required from 1500 to
1800 grams of flesh daily in order to get the requisite
amount of carbon to prevent consumption of its own
adipose tissue. Under similar circumstances, a human
being weighing 70 kilograms would require more than
2000 grams of lean beef — an amount which, from the
nature of the digestive apparatus, it would be practi-
cally impossible to digest and assimilate for any length
of time. Even the slight habitual excess beyond the
amount normally required is imperfectly assimilated
and gives rise to the production of nitrogen-holding
compounds which, on account of the difficulty with
which they are eliminated by the kidneys, accumulate
within the body and develop the gouty diathesis, with
all its protean manifestations." (Brubaker's Textbook
of Physiology.)
4. Mode of secretion and discharge of bile. "Al-
though the liver presents some physiological peculiar-
ities there is no reason to believe that the condi-
tions of secretion therein are different from those
in any other secretory organ, or that any other struct-
ure than the cell is engaged in this process. As shown
by chemical analysis, the bile consists of compounds,
some of which, like the bile salts, are formed in the
liver cells, out of material furnished by the blood by
a true act of secretion, while others, such as cholesterin
and lecithin, principles of waste, are merely excreted
from the blood to be finally eliminated from the body.
The bile is thus a compound of both secretory and ex-
cretory principles. The flow of bile from the liver is
continuous, but subject to considerable variation dur-
ing the twenty-four hours. The introduction of food
into the stomach at once causes a slight increase in the
flow, but it is not until about two hours later that the
amount discharged reaches its maximum. After this
period it gradually decreases up to the eighth hour, but
never entirely ceases. During the intervals of diges-
tion, though a small quantity passes into the intestine,
the main portion is diverted into the gall bladder, be-
cause of the closure of the common bile duct by the
sphincter muscle near its termination, where it is re-
tained until required for digestive purposes. When
acidulated food passes over the surface of the duo-
denum, there is an increase in the secretion, or at least
the discharge of bile, and as this takes place after the
nerves distributed to the liver are divided, the assump-
tion is that an agent, possibly secretin, is developed in
the duodenal mucous membrane, which, absorbed into
the blood, is ultimately distributed to the liver cells
and by which they are excited to activity. At the
same time there is excited, through reflex action, a
contraction of the muscle walls of the gall bladder and
ducts, a relaxation of the sphincter, and a gush of bile
into the intestine, the discharge continuing intermit-
tently until digestion ceases and the intestine is emptied
of its contents." (Brubaker's Textbook of Physiology.)
5. The blood platerlets are small granular or homo-
geneous discs, about 1.5 to 3.5 /" in diameter. The
edges are rounded and well defined ; they have no
nucleus; they have been estimated at about 250,000
to 300,000 to the cubic millimeter of blood.
6. Intravascular coagulation. "So long as the rela-
tions of the blood and the vascular apparatus remain
physiological, no coagulation occurs in the vessels. The
reasons assigned for this are: (1) the absence of
thrombo-kinase in sufficient amounts; (2) the presence
of an antithrombin. On either assumption the reaction
between prothrombin and calcium with the formation
of thrombin does not take place. If the vessels are in-
jured as they are when ligated or torn or in any way
impaired, coagulation promptly takes place with the
subsequent occlusion of the vessel. As to whether the
injured tissues or the blood cells now generate an agent,
thrombo-kinase, which activates the prothrombin and
calcium, or whether they generate an agent thrombo-
plastin, which neutralizes an antithrombin, is a sub-
ject of discussion." (Brubaker's Textbook of Physi-
ology.)
7. The cardio-accelerator center is in the medulla.
The vagus nerve is the inhibitory nerve of the heart; it
slows the heart. Section of one vagus produces slight
acceleration of the heart. A more marked effect occurs
when both vagi are divided. The inhibitory action of
the vagus is continuous.
8. Cheyne-Stokes respiration "is a condition in which
the respirations gradually increase in volume and rapid-
ity until they reach a climax, when they gradually sub-
side, and finally cease for from ten to forty seconds,
when the same cycle begins again. It may occur in
tuberculous meningitis, cerebral hemorrhages, em-
bolism, thrombosis, aneurysm of basilar artery, uremia,
heart disease, etc." (Hughes' Practice of Medicine.)
9. Removal of the parathyroids is followed by twitch-
ing and spasms of the voluntary muscles, paralysis of
the legs, increased frequency of respiration, and death.
10. The third cranial nerve (motor oculi) arises from
the inner side of the crus cerebri, in front of the pons,
and from the floor of the aqueduct of Sylvius. It enters
the cavernous sinus and then passes forward to enter
the orbit through the sphenoidal fissure. While in the
sphenoidal fissure it divides into two branches. It is
the motor nerve for the following five muscles of the
eyeball, and is distributed to these muscles: the
superior rectus, levator palpebral superioris, internal
rectus, inferior rectus, and inferior oblique muscles.
CHEMISTRY
1. Mercurous chloride, Hg;CL, insoluble in water.
Mercuric chloride, HgCl=, soluble in water.
Mercurous nitrate, Hg:(NOj):, is efflorescent.
2. Physiological antidotes act as such by combating
one or more of the physiological actions of the poison,
such as opium for belladonna.
Chemical antidotes act as such by uniting chemically
with the poison and thus converting it into a harmless
or insoluble compound, such as magnesium sulphate for
lead poisoning.
3. Organic chemistry is the chemistry of the carbon
compounds.
General properties of organic compounds: They may
be solids, liquids, or gases; if solid, may be crystalline
or amorphous ; they may be volatile or non-volatile, and
they are very liable to undergo change when acted upon
by heat or reagents. The more complex they are, the
more readily they undergo change.
4. Fermentation is a form of decomposition of or-
ganic matter containing only carbon, hydrogen, and
oxygen.
Putrefaction is a form of decomposition of organic
matter which contains nitrogen in addition to carbon,
hydrogen, and oxygen.
5. Methyl alcohol is the hydroxyl of methyl, CH3OH.
It is a colorless liquid having an ethereal and alcoholic
odor and a sharp, burning taste. It burns with a pale
flame, giving less heat than that of ethyl alcohol. It
mixes readily with water, alcohol and ether, and is a
solvent for sulphur, phosphorus, potash, soda, and resin-
ous substances.
MATERIA MEDICA AND THERAPEUTICS
1. Ant idiphth critic serum should be given to patients
suffering from diphtheria, or even suspected to be suf-
fering from that disease. It is given subcutaneously.
Antimeningococcic serum is injected into the spinal
canal after the withdrawal of about 30 cc. of cerebro-
spinal fluid. It is administered to patients suffering
from cerebrospinal meningitis.
Antistreptococcic senim is given in various diseases
due to streptococcus infection (erysipelas, puerperal
fever, septicemia, ulcerative endocarditis). It is given
subcutaneously.
2. DIGITALIS. Fluidextract, njj ; extract, gr. i-v; in-
fusion, 5ij ; tincture, ttjjxv.
Symptoms of cumulative effect of digitalis: Weak,
dicrotic pulse, perspiration, nausea, vomiting, lowered
reflexes, lowered body temperature, vertigo, muscular
tremors, lassitude, delirium, stupor.
Aconite. Fluidextract. tlEJ ; tincture, TP£x.
Symptoms of aconite poisoyiing usually manifest
themselves within a few minutes; sometimes are de-
layed for an hour. There is numbness and tingling.
Aug. 26, 1916J
MEDICAL RECORD.
397
first of the mouth and fauces, later becoming general.
There is a sense of dryness and of constriction in the
throat. Persistent vomiting usually occurs, but is ab-
sent in some cases. There is diminished sensibility, with
numbness, great muscular feebleness, giddiness, loss of
speech, irregularity and failure of the heart's action.
Death may result from shock if a large dose of the
alkaloid be taken, but more usually it is by syncope.
3. COCAINE HYDROCHLORIDE. Physiological action:
Local anesthetic (externally) ; internally it is a muscu-
lar, cerebral, circulatory, and respiratory stimulant,
also a mydriatic. Its principal uses are : As a local
anesthetic; also in paralysis agitans, chorea, and alco-
holic tremors.
The chief symptoms of an habitue, are: — "Emotional
excitement, physical unrest, mental impairment, moral
turpitude, hallucinations, mild epileptiform attacks,
dilatation of the pupils, a rapid and feeble pulse, severe
gastric disturbance, wasting and anemia. Treatment:
The drug should be withdrawn rapidly but not sud-
denly. Treatment in a sanatorium is always advisable.
Stimulants like strychnine are often useful. Hygienic
and dietetic measures calculated to improve general nu-
trition are indicated." (Stevens' Materia Medica.)
4. Diuretics are used: To dilute the urine, to increase
the flow of the urine, to remove liquids from the body
(as in dropsy), to remove toxic substances from the
body, and to stimulate atonic kidneys.
Diuretics are classified, as (1) Those that act as such
by increasing the arterial pressure, digitalis, squills, and
strophanthus are examples; (2) those that act by dilat-
ing the renal vessels, such as caffeine; (3) those that
act as stimulants to the renal epithelium, such as caf-
feine, theobromine, scoparius, calomel; and (4) various
salines which act by increasing the water in the blood,
such as several of the salts of lithium and of potassium.
5. Sodium Salicylate. Dose, 15 grains. Physiologi-
cal action: — Antiseptic; irritant; strongly cholagogue;
antipyretic; diaphoretic; diuretic (markedly increasing
the excretion of uric acid). In exceptional instances
skin eruptions are caused, and in some individuals a
train of symptoms analogous to those of cinchonism,
and designated as salicylism, results from the use of
salicylic preparations.
Uses: — Externally, as antiseptic and stimulating ap-
plications and for the checking of abnormal perspira-
tion ; also in parasitic and other skin diseases. Inter-
nally, rheumatic fever (in which it seems to act as a
specific); gout; migraine; sciatica; diabetes; chole-
lithiasis. (Wilcox's Materia Medica.)
6. Potassium salts: Carbonate, gr. xv; bicarbonate,
gr. xxx ; acetate, gr. xxx; citrate, gr. xv; sulphate, gr.
xxx ; bitartrate, gr. xxx; nitrate, gr. vij ; chlorate, gr.
iv; permanganate, gr. j ; iodide, gr. vij ; bromide, gr. xv;
cyanide, gr. 1/5.
The carbonate and bicarbonate are used for itching
and for skin diseases; the latter is also used for dys-
pepsia, rheumatism, gout, jaundice, and gall stones.
The acetate and citrate are used for gout, rheumatism,
in dropsy, renal diseases, cardiac diseases, and in gen-
eral as diuretics. The sulphate and bitartrate are used
as cathartics, the latter also as a diuretic. The nitrate
is used (by inhalations of its fumes) in asthma. The
chlorate is used for inflammatory conditions of mouth
and throat. The permanganate is used for wounds,
sores, ulcers, erysipelas, and as a douche in gonorrhea,
gleet, etc.; also as an antidote to morphine poisoning.
The bromide is used in epilepsy, insomnia, neuralgia,
migraine, delirium tremens, convulsions, nymphomania.
The iodide is used in syphilis, asthma, chronic rheu-
matism. The cyanide is used to relieve vomiting, gas-
trointestinal pain, and cough.
7. Three external antiseptics: — For rooms and furni-
ture, sulphur dioxide, generated by burning three
pounds of sulphur for each 1000 cubic feet of space; for
hands of surgeon, mercuric chloride, in solution of
1:1000; for glassware, dry heat at about 150° C, con-
tinued for an hour.
8. Nux Vomica. Preparations and Doses Extract-
urn nucis vomica?, gr. \i ; fluidextractum nucis vomicae,
Trpj ; tinctura nucis vomica?, Tljx; strychnine, gr. 1/64;
strychinEe sulphas, gr. 1/64; strychinae nitras, gr. 1/64.
Therapeutic indications: As a general tonic or bitter;
in indigestion, cardiac depression, impaired peristalsis,
pneumonia, phthisis, amenorrhea, dysmenorrhea, im-
potence, some forms of paralysis, chorea, epilepsy, neu-
ralgia, alcoholism, and urinary incontinence.
9. Corrosive sublimate is used internally in the treat-
ment of diohtheria, syphilis, and as a tonic. Dose, gr.
1/100 to 1/20.
10. Opium. Therapeutic uses: As an anodyne, a
hemostatic, in inflammations, as an expectorant, in
diarrhea, in alcoholism, manias and diabetes, as an
antispasmodic, in insomnia, and as a diaphoretic.
Dose: Of powdered opium, gr. j; morphine, gr. 1/5;
morphine sulphate, acetate, and hydrochloride, each gr.
\i ; codeine, gr. % ; codeine sulphate and phosphate,
each, gr. %.
diagnosis
1. The early manifestations of pulmonary tubercu-
losis are: (1) Physical signs: Deficient chest expansion,
the phthisical chest, slight dullness or impaired reson-
ance over one apex, fine moist rales at end of inspira-
tion, expiration prolonged or high pitched, breathing
interrupted. (2) Symptoms: General weakness, lassi-
tude, dyspnea on exertion, pallor, anorexia, loss of
weight, slight fever, and night sweats, hemoptysis.
2. "Acute myocarditis may be incident to rheumatism,
pneumonia, septicemia, tuberculosis, typhoid fever, etc.,
and accompanies acute pericarditis and acute endo-
carditis. Subjective symptoms are generally absent,
but the condition may be suspected when the heart be-
gins to dilate rapidly, when the pulse becomes ex-
tremely rapid, thready, and irregular, or when the tem-
perature suddenly rises. A systolic murmur may be
heard at the apex."
"Chronic myocarditis results from sclerosis of the
coronary arteries, but may follow acute myocarditis.
The symptoms appear insidiously, and include dyspnea,
palpitation, weak, rapid, and irregular pulse, anginoid
pains, maniacal attacks, vomiting, etc. The area of
dullness is increased. The pulmonary second sound
may be accentuated if the right heart is hypertrophied,
and a murmur may be heard at the apex." (Pocket
Cyclopedia of Medicine and Surgery.)
3. In cardiac hypertrophy "the symptoms depend
upon the amount of hypertrophy. If only sufficient to
compensate for valvular defects or other circulatory
disturbances there will be no symptoms. When the
enlargement is disproportionate to the obstruction, it
is manifested by increased and forcible cardiac action,
precordial discomfort, headache, dizziness, ringing in
the ears, flushes or flashes of light, dyspnea on exertion,
congestion of the face and eyes, dry cough, epistaxis,
and restless nights, with more or less jerking of the
limbs. The arteries become full and the pulse is firm
and bounding. The carotids and superficial arteries
pulsate markedly, the patient frequently complaining
of throbbing sensations. A sphygmographic tracing
shows the line of ascent vertical and abrupt, but the
apex is rounded, and the line of descent is oblique, un-
less there is more or less insufficiency of the valves."
In cardiac dilatation "the manifestations are refer-
able to the enfeebled circulation and include feeble
pulse, headache aggravated by the upright position, at-
tacks of syncope, cough, dyspnea, jaundice, dyspepsia,
constipation, scanty, often albuminous urine, mental
dullness, vertigo, often relieved by a copious epistaxis,
and finally dropsy beginning in the lower extremities.
The condition terminates in death by exhaustion."
(Hughes' Practice of Medicine.)
4. The functional activity of each kidney may be "de-
termined by the intramuscular injection of 1 cc. of a 5
per cent, acqueous solution of methylene blue; the col-
lection of the urine (from each kidney) after the lapse
of one-half hour, one hour, and hourly thereafter; and
noting the time of the appearance of a bluish tint to
the urine, the time of maximum coloration, and the
time of disappearance of the coloring. Normally a
slight tint may be observed in the first specimen, cer-
tainly at the end of one hour. The maximum coloration
occurs at the end of three or four hours, and the urine
is free of coloring at the end of thirty-six to forty-
eight or sixty hours. Delay of beginning excretion
beyond one hour, and of maximum coloration beyond
the fourth hour, and continuation of excretion, as may
occur for five or six days, is indicative of deficient func-
tional activity." (Kelly's Practice of Medicine.)
5. Gastric ulcer is generally caused by injury or bac-
teria, is most apt to occur between the ages of twenty
and forty-five. After eating there is pain localized in
the stomach, vomiting occurs soon after eating, hema-
temsis is common, there is localized tenderness over the
stomach, and examination of the gastric contents shows
an excess of free HC1.
In duodenal ulcer the pain is apt to be more to the
right, and to occur at an interval of two or three hours
after meals; the hemorrhages will be intestinal, and
the blood will be passed by way of the bowels, and not
398
MEDICAL RECORD.
[Aug. 26, 1916
vomited. In many cases the symptoms are identical
with those of gastric ulcer.
Cholecystitis: The pain is further to the right, and
with tenderness and muscular rigidity, is referred to
the region of the gall bladder; there are rise of tem-
perature, increased pulse rate, leucocytosis, and vom-
iting.
6. Hyperthyroidism is exophthalmic goiter; the cardi-
nal symptoms are tachycardia, exophthalmos, goiter,
and tremor.
7. In enlarged gall bladder pain is located in the
region of the liver and may radiate to the right shoul-
der; there may be jaundice.
In ptosis of the right kidney the kidney may be pal-
pated and often replaced; the pain radiates down the
ureter; chill, nausea and vomiting maybe noticed; blood
may be found in the urine; when the kidney is replaced
all the symptoms cease.
8. Physical signs of effusion in acute plcuritis: There
is fullness or bulging of the affected side, with oblitera-
tion of the intercostal spaces and displacement of the
cardiac impulse; over the effusion there is little or no
vocal fremitus, while above the effusion it is exag-
gerated; over the effusion the percussion note is dull,
above the effusion it is tympanitic; the fluid changes
its level with different positions of the body; on ausculta-
tion there will be heard a feeble vesicular murmur;
vocal resonance is diminished or absent over the fluid
and increased above the effusion.
9. The most important sign of leucemia is a persistent
increase in the total number of leucocytes.
10. Early signs of acute poliomyelitis: Fever;
malaise; chilliness; tonsilitis, coryza, diarrhea; convul-
sions; profuse sweating; rigidity of head, neck and
limbs; pain in neck and back. There may be no early
signs.
PATHOLOGY
1. In myelogenous leucemia the white cells are
enormously increased, the red cells are decreased; the
chief feature of the blood is the large number of
myelocytes which it contains; the eosinophiles are also
increased; so, too, are the basophiles or mast cells;
the polymorphonuclears are absolutely increased, but
relatively diminished as the myelocytes increase; the
lymphocytes are not very numerous. The myelocytes
are derived from the bone marrow.
2. A hemorrhage infarct is an infarct where the ob-
structed area is full of blood. Sooner or later the
infarct becomes decolorized, owing to diffusion of the
dissolved hemoglobin; the involved tissues degenerate
and become absorbed; and scar tissue, more or less
pigmented, may remain at the site of the lesion. In-
farction is always accompanied by necrosis and fatty
degeneration. Hemorrhagic infarct occurs but rarely
in the kidney.
3. Tubercle formation. — "Miliary tubercles are tiny
grayish nodules, and each consists of a collection of
cells. The bacillus is brought to the tissues by a blood
vessel. The bacilli set up changes in the tunica intima
and the connective tissue around the vessel, which re-
sult in the formation of a collection of cells which are
bigger than leucocytes. They are derived from connect-
ive-tissue cells and endothelial cells. One or more of
these in each tubercle increase in size or coalesce to form
a giant cell. The giant cell forms the center of the
tubercle; it has many nuclei arranged around its periph-
ery, and contains bacilli. Around it are arranged lay-
ers of epithelioid cells. Beyond these are collected
many leucocytes, which merge through granulation
tissue into the normal structures. The structure is not
bo typical in all cases, as giant cells may be absent.
No blood vessels are present in tubercles, and the sur-
rounding vessels are narrowed or obliterated by en-
darteritis."
Results. — "(1) Caseatioti is a result of progressive
action of the bacilli. Two factors contribute to this:
(1) The destructive action of the bacillus; (2) the de-
fective blood supply from endarteritis. The center of
each tubercle softens and becomes yellow or caseous.
Neighboring tubercles after caseating coalesce, and a
tuberculous abscess is formed and in its walls further
miliary tubercles are found. (2) Retrogressive changes.
— The resistance of the tissues is considerable, and if
circumstances are favorable the bacilli are destroyed or
their growth inhibited and retrogressive changes occur.
The tubercle may be converted into fibrous tissue, and
only a cicatrix remains; or the caseous matter may be-
come encapsuled, and perhaps resume activity at some
later date, if the capsule is ruptured by some injury.
Sometimes calcification occurs. (3) Diffttsion is a
marked feature. This may be (1) local, by direct ex-
tension; (2) to distant viscera, by minute emboli; (3)
acute general tuberculosis may occur in any case. Tu-
bercles are scattered throughout the body, and the dis-
ease is fatal in a few weeks." — (Aids to Surgery.)
4. Method of preparing vaccine. — "(1) The causal
organism (in this case the Staphylococcus pyogenes) is
obtained from the seat of the lesion and isolated in
pure culture at 37° C. on a suitable medium such as
agar. (2) The culture growth is emulsified in about
5 c.c. of a 0.9 to 1.0 sodium chloride solution. (3) The
bacterial emulsion is transferred to a water bath or
incubator, and kept at 60Q C. for from thirty to sixty
minutes. (4) The number of bacteria in the emulsion
is estimated. (5) The vaccine is diluted with normal
saline solution until each cubic centimeter contains an
appropriate number of organisms for the dose, e.g. 10
millions, 100 millions, 1,000 millions, etc. (6) The
sterility of the emulsion is proved and a small amount
of antiseptic, e.g. phenol 0.5 per cent, or tricresol 0.25
per cent., is added, and the vaccine is filled into sterile
bulbs for use. In practice the bulb is opened, the con-
tents are filled into a sterile syringe, preferably all
glass, and the vaccine is injected subcutaneously under
strict aseptic precautions." — (Bruce's Materia Medica
and Therapeutics.)
5. The physician should wear a gown while with the
patient, should inspect the patient's eyes, nose, and
throat through a pane of glass so that the patient may
not cough in his face, and should carefully wash his
hands in an antiseptic solution before leaving. The
patient should be isolated, and the nose, throat, and
mouth should be washed with an antiseptic solution;
diphtheria antitoxin should be administered as early as
possible. The family should be kept away from the
patient, and all infected articles should be soaked in a
solution of corrosive sublimate or carbolic acid. The
community is protected by the above procedure; but, in
addition, the disease should be reported to the proper
health authorities, other children from the family should
not be allowed to go to school or church or other public
places, strict quarantine must be observed, and there
must be a thorough disinfection at the close of the case.
(To be concluded.)
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©rtstnal Arttrkfi.
A CLASSIFICATION OF THE EPILEPSIES.
By ELIAS C. FISCHBEIN, M.D.,
SONTEA, N. T.
CRAIG COLONY FOR EPILEPTICS.
Nomina si neseis, perit cognitio rerum (Coke).
If you do not know their names, the knowledge of
things is lost.
There is pressing need for a new classification of
the epilepsies. The nomenclature of these disease
conditions has suffered from the fact that names
have been applied by various authors with no adher-
ence to any unity of scheme: "Quot homines, tot
nomina" — is almost applicable to this state of affairs,
that there are nearly as many names as men to do
the naming. The great majority of sypmptom com-
plexes found in this multiphase disease have had ap-
pended to them the noun "epilepsy," presumably for
the sake of clearness. Unfortunately the result has
been confusion. We have psychic epilepsy, tetanoid
epilepsy, matutinal epilepsy, Gelineau's epilepsy,
masked epilepsy, hysteroid epilepsy, etc., a state of
affairs which has led to a great deal of bother and
annoyance in memorizing. Each one of these has
had to be remembered separately and every person
interested in the study of these conditions (in order
to assist his memory) has had to make a provisional
working classification of his own, the latter, however,
not necessarily coinciding with that of any of his
contemporaries. Hence the confusion.
Epileptic attacks have been assigned as belonging
to one of three groups: Grand Mai, Petit Mai, and
Psychic. The difference in the implied meaning be-
tween the first and second is that "grand" refers to
the matter of importance over "petit." This is true
in a very limited sense only so far as the impression
made upon the onlooker of a fit; but this is not so
in reality. Many observers have advanced the opin-
ion that, insofar as relates to actual injury to the
brain, more damage is done by the sensory and
psychic accessions. It is admitted, however, that
such sensory and psychic seizures do not appear as
severe. It was first pointed out by Esquirol,* for in-
stance, that "transient epileptic vertigo is more dam-
aging to the intellect than the far more violent and
formidable grand mal seizures." From this stand-
point the terms "grand" and "petit" are misnomers
and should be abandoned.
These two names (grand and petit mal) also
carry with them the sense of severe and less severe.
One can appreciate the inconsistency of applying
nomenclative designations which include within
themselves a sense of apparent prognostic value, to
disease conditions in which the prognosis is very
uncertain, to say the least.
*Traite des Maladies Mentales, tome 1, p. 288.
Epilepsy, so-called, is a polyphase disease consist-
ing of a multitude of syndrome complexes which
have been found to be very nearly related one to
another. In the following pages these syndromes
have been grouped in classified form, the object be-
ing to fashion a classification which might follow
proper scientific observance and at the same time
possess such flexibility as to allow later of tenta-
tive and inductive growth.
At the present time it would be futile to attempt
to classify these symptom complexes from an etio-
logical, a pathological, or an anatomico-pathological
standpoint. Our stock of information along the
above lines is as yet comparatively meager, and
even this is fragmentary and (apparently) uncor-
rected.
The classification here presented is constructed
upon clinico-symptomatological lines, the object be-
ing as far as possible to define each group sharply,
to give it a name that will refer to characteristics
which are constant and peculiar to that group, so
that the name will be not only designatory in a con-
ventional sense but also descriptively correct. An
endeavor has been made to correlate these names
so that each one may suggest its antithesis.
It seemed to the writer that in the formation of
a working classification of these diseases, it would
be well to use terms which, notwithstanding that
they are in Latin, might be easily understood by
those not especially versed in languages other than
their own ; recalled with little difficulty in that they
have more or less relationship with the nomencla-
ture used up to the present time, and, memorized
more easily in that the classification of terms is, so
far as it was possible to make it, dichotomous.
In the following schema each term is first given
in Latin form, placed in its group or class and
marked as follows: A Roman numeral designates
the group; a Roman capital designates the class,
and Arabic numerals designate subclasses. The
latter are further divided into subheadings marked
by either Roman or Greek letter, as the case might
be. Following the classified list of epileptic syn-
dromes is an explanation of each item under its
proper designative letter or number. Certain of
the terms and their place in the classification will
here be explained, while at the same time the Eng-
lish translation and common synonyms will be
given in parentheses. Other terms, the meaning
of which is self-evident, will only be mentioned.
In order that there may be no misunderstanding
as to the exact meaning of terms, more or less
lengthy notes have been appended. The enumera-
tion of symptoms is as brief, however, as is com-
patible with a clear understanding of the term. It
might be added that in the explanations I have al-
lowed myself a certain amount of latitude, this be-
ing justified by the interest shown of late in these
matters.
400
MEDICAL RECORD.
[Sept. 2, 1916
I. PAROXYSMI* MOTORII.
A. Paroxysmi Motorii Majori.
1. Paroxysmi Motorii Majori Vulgaris,
a. Paroxysmi Seriates.
6. Status Epilepticus (paroxysmi continui ma-
jori).
c. Paroxysmi Innocentii.
d. Paroxysmi Alcoholici.
a. Paroxysmi inter Bibenda.
P. Paroxysmi in Alcoholophilia.
7. Dipsomania Aequivalens.
e. Paroxysmus Procursivus.
/. Paroxysmi Assymetrici.
a. Paroxysmus Unilateralis.
p. Paroxysmus Hemiplegicus.
7. Hemiplegia Transitoria.
2. Paroxysmus Motorius Major Pin us.
3. Paroxysmi Motorii Majori Eccentriei.
a. Paroxysmi Infantum.
a. Paroxysmus Infantum Eccentricus.
p. Paroxysmus Infantum Verus.
7. Spasmophilia.
6. Paroxysmi Parturientium.
c. Paroxysmi Uraemici.
d. Paroxysmus Tetanoideus.
B. Paroxysmi Motorii Minori.
1. Paroxysmus Motorius Minor Purus.
2. Paroxysmus Minor Moto
3. Myoclonus.
a. Myoclonus intermittens.
6. Myoclonus partialis continuus (Kojewnikoff).
c. Myoclonus progressivus.
4. Pseudo-myoclonns.
5. Tetanilla.
6. Paroxysmus Nutans.
7. Paroxysmus Rotatorius.
8. Paroxysmus Partialis Jacksonii.
II. PAROXYSMI SENSORIALES.
A. Paroxysmus Sensorialis Puri s.
B. Paroxysmus Sensorio-Motorialis.
C. Vertigo.
1. Vertigo Sensorialis.
a. Vertigo subjectiva (gyrosa).
6. Vertigo objectiva.
2. Vertigo Psycliica.
D. Hemicrania.
1. Hm • Simplex.
2. Hemicrania Ophthalmia
3. Hemicrania Mquival
E. Aura sine Convulsione.
F. Paroxysmus Thalamic! rs.
G. Paroxysmus Vasovagosus.
H. Narcolepsia.
1. Narcolepsia Vera.
2. Narcolepsia Hysterica.
a. Status Catatepticus.
6. Catalcpsia Hysterica.
3. Paroxysmus So7nnolentu.<.
III. ACCESSIONES MENTIS MANIFEST.^.
^4. Accessio Mentis Minor.
1. Acc< i to Mentis Minor Agitata.
2. Accessio Mentis Minor Stuporosa.
3. Accessio Mentis Minor Migrans.
/;. Accessio Mentis Major.
C. Accessio Hysteroidea post convulsione.
D. ai.terationis Mentis.
1. Depravatio Mentis Epileptica.
a. Depravr.tio epileptica rapida.
6. Depravatio epileptica tarda.
c. Depravatio epileptica intermittens.
d. Depravatio epil ilminans.
2. Dementia Epileptica Vera.
IV. ACCESSIONES MENTIS LARVAT7E.
A. Poriomwm {automatisma wmbulatoria)
1. Somniatio Morbosa.
2. C' pU .'■.
a. Conscientia duplex migrans.
b. Tersonalitas di versa.
3. Somnamhvhifio.
4. Pavor Nocturia's.
/:. Status Affectus.
Y. HABITUDO MENTALIS KPILEPTICA.
*I have made free use of the noun "paroxysm" in
that it expresses the meaning of a sudden recurrence
of symptoms and at the same time does not necessarily
imply a convulsion. It is best translated by the word
I. MOTOR CONVULSIONS.
A. Major Motor Convulsions.
1. Common major motor seizures,
a. Serial Seizures.
6. Status Epilepticus.
(Continuous major paroxysms)
c Innocuous Convulsions.
a. Convulsions while Drinking ("rum fits").
p. Epilepsy in a Drinker.
7. Dipsomania as an Equivalent.
e. Procursive Seizures.
/. Assymetric Seizures.
a. Unilateral Convulsion.
P. Convulsion followed by Hemiplegia.
7. Transitory Hemiplegia.
2. Pure Major Motor Convulsion.
3. Reflex Major Motor Convulsions,
a. Infantile convulsions.
a. Reflex infantile convulsions.
P. True (epileptic) infantile convulsions.
7. Spasmophilia.
6. Eclamptic Convulsions.
c. Uremic Convulsions.
d. Tetanoid Convulsions.
B. Minor Motor Convulsions.
1. Pure Minor Motor S< izurt .
2. Minor Motor-sensory Seizure.
3. Myoclonus.
a. Intermittent myoclonus.
6. Localized and continuous myoclonus.
c. Progressive myoclonus.
4. Pseudo-myoclonus.
5. Tetany.
6. Nodding Spasm.
7. Rotary Spa
8. Jacksonian Convulsion.
II. SENSORY SEIZURES.
A. Pure Sensory Seizure.
B. Sensory-Motor Seizure.
C. Vertigo.
1. Sensory Vertigo.
a. Subjective vertigo.
b. Objective vertigo.
2. Psychic Vertigo.
D. Hemicrania.
1. Simple Hemicrania.
2. Ophthalmic Hemicrania.
3. Hemicrania as an Equivalent.
E. The Aura Without a Convulsion.
F. Thalamic Seizure.
G. Vaso-vagal Attack.
H. Narcolepsy.
1. True Narcolepsy (Gelineau's).
2. Hysterical Narcolepsy.
a. Status Catatepticus (in an epileptic).
b. Hysterical catalepsy (in a non-epileptic).
3. Somnolent Attack (a minor sensory seizure).
III. FRANK MENTAL ACCESSIONS.
A. Minor Mental Accession.
1. Minor Mental Accession with Excitement.
2. Minor Mental Accession with Stupor.
3. Minor Mental Accession with Wandering.
B. Major Mental Accession ("epileptic mania").
C. Hysteroid Convulsion following an epileptic.
D. Mental Changes.
1. /, '/. ,i!nl Deterioration.
a. Rapid.
6. Slow.
C. Intermittent.
d. Fulminant.
2. Epileptic Dementia.
IV. MASKED MENTAL ACCESSIONS.
.4. Poriomania (ambulatory automatism)
1. /'
■J. Dual i ■
a. Dual consciousness, with wandering.
6. Diverse personality.
3. Somnambulism.
4. Paror (night terrors).
B. Status Affectus (psychogenic epilepsy).
V. EPILEPTIC CHARACTER,
"seizure." Sauvages prefers this term. He refers to
epilepsy as "Morbus clonicus universalis chronicus et
periodicus. cum sensuura feratione in paroxysmo et ante
actorum oblivione."
Sept. 2, 1916]
MEDICAL RECORD.
401
EXPLANATION OF SCHEMA.
I. Paroxysmi Motorii (motor seizures) in which
the most striking symptom is violent contraction,
or series of contractions, of muscles.
A. Paroxysmus Motorius Major (major motor
seizure).
1. Paroxysmus Motorius Major Vulgaris (ordi-
nary major motor seizure). This is the common
major motor seizure, the one which of all other at-
tacks, occurs most frequently. This type may al-
ternate with other forms of seizure in the same in-
dividual. Usually any given major motor seizure
in an individual is an exact replica of the seizure
preceding it. It must be remembered that there
may be differences in onset and general character-
istic in various persons, therefore a composite pic-
ture of the common major motor seizure will here
be very briefly outlined :
Aura; initial cry; loss of consciousness; fall;
tonic spasm; deviation of eyes and face; flexion of
head toward one or other shoulder; cyanosis and en-
gorgement of face; insensitiveness of conjunctiva?;
cessation of breathing for several seconds; clonic
spasm, stertorous breathing, biting of tongue;
frothy, blood-stained saliva on lips; initial con-
traction with, later, wide dilatation of pupils, non-
reactive to light; involuntary passage of urine,
more rarely, of feces; post-convlusive coma and
later, headache; transient weakness of one or more
limbs, rarely paralyses; mental confusion for a
variable length of time.
There are variations of this syndrome depending
on special manifestations of symptom grouping be-
fore, after or during the seizure. The most com-
mon aside from the above will now be briefly dis-
cussed.
a. Paroxysmi Seriales (serial seizures). This
term needs no explanation nor does the condition
require elaboration as it is a very common occur-
rence.
b. Status Epilepticus (Paroxysmi Continui Ma-
jori ; continuing major motor seizures). The old
name is retained because usage has made it repre-
sent a typical picture. The more descriptive term
"Paroxysmi Continui Majori," is, however, here
suggested.
c. Paroxysmi Innocentii (innocuous convulsions).
This term is here introduced, not because there is
any difference in character between these and com-
mon major motor seizures, but in order to focus
attention on the fact that a certain small percent-
age of epileptics have their attacks without ap-
parent subsequent mental deterioriation. These in-
dividuals, however, do show a certain modicum of
degenerative psychic abnormality. As to whether
the latter is causative or resultant with regard to
the epilepsy is an open question. In this class are
included people who rank intellectually high (Na-
poleon, Caesar, Mahomed, Ann Lee, etc.).
d. Paroxysmi Alcoholici (alcoholic epilepsy; alco-
holic seizures). The use of the term alcoholic epi-
lepsy has resulted in a great deal of confusion. It
actually includes three types of seizures associated
with alcoholic indulgence and the promiscuous appli-
cation of the term to all three is the cause of much
ambiguity. The three types are:
a. Paroxysmi inter bibenda (convulsions while
drinking; "rum fits"). Attacks occurring onhj when
the patient resorts to drinking. Seizures disappear
during abstinence, and there is usually no mental
deterioration. This type is in close relation with
delirium tremens and approaches a psychotic con-
dition on an alcoholic basis.
(S. Paroxysmi in Alcoholophilia (convulsions oc-
curring in a person exhibiting alcohol-desire). In
other words, epilepsy occurring in a drinker. At-
tacks do occur during periods of abstinence; the
case shows a progressive course, periodic moods,
irritability, etc. — i.e. the epileptic character. This
type represents a pure epilepsy occurring in an alco-
holic.
y. Dipsomania aequivalens (epileptic dipsomania).
A rather rare condition in which the drinking de-
bauches are really epileptic equivalents.
e. Paroxysmus Procursivus ("epilepsia cursiva" of
Bootius; procursive epilepsy). This form exhibits
peculiarity in that the epileptic will, immediately be-
fore the fit, run forward 20 or 30 feet or he may
run around in a circle and then fall in the seizure.
Otherwise this type is exactly similar to the com-
mon major motor attack. It is mentioned here only
that it may represent the entire group of major
motor seizures which approach in type the common
form with the exception of one or several abnormal
characteristics. I will only mention a few of these :
Paroxysmus retropulsivus (with running backward
before the seizure), P. gyratorius (rolling on the
ground), P. uncinatus (aura of sight, smell,
etc.), P. analepticus (gastric aura rising to head),
etc.
f. Paroxysmi Assymetrici (assymetric seizures).
The term "hemiplegic epilepsy" has been applied to
various conditions. There are three distinct types,
and the fact that the same term is used for all three
has of necessity resulted in ambiguity. A convul-
sion which has unilateral distribution is called hemi-
plegic epilepsy (Bravais) ; as seen in the schema
it is here termed "paroxysmus unilateralis."
There is another form of so-called hemiplegic
epilepsy in which, following a convulsion, there is
permanent paralysis of one side. This form is here
termed "paroxysmus hemiplegicus."
A third type is that in which an individual with
the Habitudo Mentalis Epileptica (epileptic men-
tal make-up), has episodic occurrences of hemi-
plegia with or without the concurrence of convul-
sions, and in whom the hemiplegia later disappears.
This form is also usually referred to as hemiplegic
epilepsy. In this classification the type is called
"Hemiplegia transitoria." Although this is not a
paroxysm in the full sense of the word, it is here
interpolated on account of its confusion with other
types of assymetric epileptic attacks. (Vide "Som-
niatio Morbosa," group IV.)
One more type must be mentioned only to be ex-
cluded from this group, and that is Paroxysmus
Partialis Jacksonii, which is often referred to as
hemiplegic epilepsy, an absolute misnomer. (See
B, 6.)
2. Paroxysmus Motorius Major Purus (pure ma-
jor motor seizure; conscious epilepsy). A major
motor seizure in which the sensorium is, wholly or
in part, free from involvement. There is retention
of consciousness in whole or in part. L. Pierce
Clark has reported three cases and quotes Lemoine,
Radcliffe, Tamburini, and several others who have
reported this type of attack. In the Craig Colony
for Epileptics there are at present two patients
who show pure major motor attacks of modified
form. The occurrence of this type is rare, but it
serves as an excellent illustration of involvement
of musculature only and exemption of the sen-
sorium.
402
MEDICAL RECORD.
[Sept. 2, 1916
3. Paroxysmi Motorii Majori Eccentrici (reflex
major motor seizures).
a. Paroxysmi Infantum (.convulsions of infants;
eclampsia infantum; infantile convulsions). In-
fantile convulsions may be of two distinct types.
<x. Paroxysmus Infantum Eccentricus (reflex in-
fantile convulsion). The infant may be of normal
physical and mental make-up, but there may occur
temporary reflex disturbance of the very sensitive
nervous organism. Such disturbance may be caused
by gastrointestinal disorder, fevers which involve
the brain and its matrices, diarrhea resulting from
dentition or worms, etc. On the other hand, one
may see a
p. Paroxymus Infantum verus (true infantile
convulsion). Occurring in an infant which is really
an epileptic, and in which the paroxysm is only one
of many which have occurred before or will occur
later.
Aside from these two types we must take into
consideration the type which, though not epileptic,
is still affected with a certain nueropathic consti-
tutional instability. This is manifested by hyper-
excitabiiity of the peripheral nervous system, re-
sulting in tendency to tonic and clonic spasms
(chorea, laryngismus stridulus, tetany, apnea, car-
popedal contractions, etc.). To this condition has
been given the name "Spasmophilia" or the spas-
mophilic diathesis. Phenomena coming under the
group of spasmophilias should be distinguished
from true epileptic paroxysms, as they have not
been proven to be strictly epileptic in nature.
b. Paroxysmi Parturientium (puerperal convul-
sions; eclampsia gravidarum). Common major mo-
tor seizures upon a uremic basis.
c. Paroxysmi Ursemici (uremic convulsions). At
times these attacks cannot be distinguished symp-
tomatically from the common major motor seizures.
They occur in nephritis with its concomitant symp-
toms. There is usually no intial cry. The onset is
sudden. Convulsions may occur every hour or two
and there is deep coma between attacks. Follow-
ing such seizure or series of attacks there may be
coma persisting for several days or weeks. There
may be amaurosis without visible retinal lesion and
there may be development of mono- or diplegia.
d. Paroxysmus Tetanoideus (tetanoid epilepsy).
A type of major motor seizure in which there is
tonic contraction only, of muscles. The individual
may lose consciousness and fall, going immediately
into tonic contraction and then recovering. Some-
times the epileptic does not fall, but goes into a
tonic spasm for several moments and then relaxes,
recovered. A severe type of this condition which
is comparatively rare has been described by Pritch-
ard.
B. Paroxsmi Motorii Minori (minor motor seiz-
ures i, as distinguished from the severer type men-
tioned under Class A. These types are often found
associated with other forms of epileptic accessions
in the same individual.
1. Paroxysmus Motorius Minor Purus (pure
minor motor seizure; "jerks"; "starts"), character-
ized by twitching and jerking of muscles in groups
without loss of consciousness. Of common occur-
rence in frank epileptics. Often seen immediately
before a major motor seizure.
2. Paroxysmus Minor Motorio-sensorialis 'minor
motor-sensory seizure, in which the motor phenom-
ena predominate. In general the individual may be
said to become suddenly semi-rigid, eyes stare, pu-
pils dilate slightly, one or other limb is flexed or ex-
tended, respiration is difficult for a moment, and
then recovery. He may have an aura before the at-
tack and there may be semi-stupor with purposeless
and automatic acts following. The paroxysm itself
usually lasts not more than several seconds.
3. Myoclonus (paramyoclonus multiplex of Fried-
reich ; choreic tics ; multiple tics ; myoclonus spinalis
multiplex; myokymia). This term, which is in com-
mon use, meets our needs. It so happens that myo-
clonus and its modified forms is one of the few
syndromes properly cognomenated. Briefly the dis-
tinguishing features of this affection are lightning-
like contractions of groups of muscles. The con-
tractions may involve only one gro.up of muscles or
the whole body. Consciousness is not lost. They
may occur as epiphenomena to major or minor seiz-
ures, or as an uncombined symptom complex. These
contractions may also involve one group of muscles,
later extending to the whole body musculature and,
in certain instances, terminate in a major motor
seizure. The following terms are already in
use and should be adhered to: (a) Myoclonus in-
termittens, (b) myoclonus partialis continuus (Ko-
jewnikoff's epilepsy), and (c) myoclonus progres-
siva (syndrome of Unverricht and Lundborg). The
names are descriptively correct and self-explana-
tory.
4. Pseudo myoclonus. Single or multiple myo-
spasmias on a hysteric or choreic basis. The name
has also been applied to the sudden localized mus-
cular contractions seen immediately before major
motor seizures, but these must be regarded as part
of the aura.
5. Tetanilla (tetany) is mentioned here only as a
reminder that it occurs in relation with epilepsy
and often requires diagnostic consideration. The
three important clinical types are (a) Tetanilla
gravidarum, (b) T. rhachitica, (c) T. thyreopriva.
6. Paroxysmus nutans (nodding spasm; salaam
convulsion). A peculiar bobbing of the head for-
ward. It is found most frequently in children. Of-
ten the child, while sitting at table, will have a
seizure of this type and strike the table chin first.
This form of minor motor seizure was first de-
scribed by Sir Charles Clark.
7. Paroxysmus Rotatorius (Dervish spinning;
"whirling Dervish"). A type of minor motor seiz-
ure in which the individual (usually a child), does
not fall but spins about on one or othe other foot
for from several seconds to several minutes. In
this form consciousness is not entirely lost but
considerably obtunded. This name should not be
confused with Paroxysmus gyratorius (see I, A,
i.e. P. procursivus) ; in the gyratory paroxysm,
which is a major motor type, the individual after
falling to the ground, rolls about, over and over
until the tonic state reaches its height.
8. Paroxysmus Partialis .lacksonii (Jacksonian
epilepsy; hemiplegic epilepsy; cortical epilepsy;
symptomatic epilepsy). The chief characteristic of
this form of convulsion is its localization to a cer-
tain set of muscles. This localization of the fit
does not change. It must be remembered that a
symptomatic convulsion is not necessarily a Jack-
sonian seizure. In a general way paroxysmus par-
tialis Jacksonii is a type of localized convulsion lim-
ited either to one side of the body or to one set of
muscles ; consciousness is not lost. The convulsions
are due to reflex causes, i.e. cerebral abscess, hem-
orrhage, cicatrix, or tumor. It is also seen in rela-
tion with uremia, paralytic dementia, and alcoholic
excess. At times the convulsion begins as the usual
Sept. 2, 1916J
MEDICAL RECORD.
403
focal one, but spreads so as to involve other muscles
and ends with a typical major motor seizure. There
has of late years been a tendency to do away with
eponyms in medical literature. While in perfect
accord with this trend, the writer feels that the
work of Hughlings Jackson in the field of epilepsy
has been of such value that his name should be
associated with the form he first described.
Up to this point we have been discussing myo-
spasmias, i.e. those incidents in the epilepsies which
are chracterized by spasmodic muscular contrac-
tions. We now come to several groups in which
convulsions do not play a prominent role. The fol-
lowing series of syndromes are divided into sensory
and mental (psychic) accessions.
II. Paroxysmi Sensoriales (sensory seizures).
Those paroxysms which involve the sensorium
wholly or in part, but which are sudden in onset
and of short duration, with either unconsciousness
or the cognition of pain, vertigo, ideas, sensations,
reminiscences, etc., on the part of the individual.
A. Paroxysmus Sensorials Purus (pure sen-
sory seizure; "faints"; "loss"). The individual be-
comes suddenly pale, his eyes stare, and the seizure
is over. This type may occur alone or in the form
of an aura (see Aura sine convulsione, II. E.).
The characteristic of this form is a periodic, tran-
sitory disturbance of consciousness.
B. Paroxysmus Sensorio-motorialis (sensori-
motor attack). In this a pure sensory seizure is
accompanied by slight muscular spasms and con-
tractions. A common form.
C. Vertigo (circumgyratio; giddiness; dizzi-
ness). A rather frequent episode in epilepsy char-
acterized by a sense of instability of either the sub-
ject himself, or by apparent lack of stability of ob-
jects about him. Due to disturbance of either epi-
critic or protopathie sensibility on the one hand,
or to disturbance of associative subconscious im-
pulses on the other. Disease or disturbed function
of the labyrinth, eyes, skin, stomach, muscles, ten-
dons, and joints may result in erroneous mental
conception as to position in space. There are two
main types.
1. Vertigo Sensorialis (sensorial vertigo). This
may be either subjective (vertigo gyrosa), or ob-
jective, and is the result of confusion of function
on the part of the associative paths upon which the
individual normally depends to recognize his posi-
tion in space.
a. Vertigo subjectiva (gyrosa). The individual
feels himself falling, floating or spinning around.
b. Vertigo objectiva. In which the surrounding
objects appear to move.
2. Vertigo Psychica (psychic vertigo). A sensa-
tion of disturbance of equilibrium brought on by
agitating thoughts, memory pictures, and emotions.
These disturbing thoughts, emotions, and memories
cause the same confusion in mental association as
was mentioned in connection with sensory vertigo.
D. Hemicrania (megrim; migraine; cephalalgia;
neuralgia cerebralis). This type of nervous dis-
turbance occurs either in relation to a seizure, as
an equivalent or unaccompanied by attacks. The
headache, although termed "hemicrania," never oc-
curs as exactly confined to one side; but it is usually
felt as more severe on one side than on the other.
Migraine resembles epilepsy in several ways. Both
are hereditary. Both are periodic in point of occur-
rence. Both may show an aura. Migraine may be
replaced by a psychic equivalent, like any epileptic
attack. Both migraine and epileptic seizures are
followed by somnolence. Epilepsy may exist syn-
chronously with migraine in the same individual.
Epileptic seizures may be replaced by attacks of
migraine and vice versa. Three well-marked types
exist.
1. Hemicrania Simplex (simple migraine). At-
tacks are periodic and followed by somnolence.
They usually persist during the life of the indi-
vidual.
2. Hemicrania Ophthalmica (ophthalmic mi-
graine). In this form the migraine is associated
with visual disturbances, spectral, and objective,
i.e. hemianopsia, scintillating scotoma, amaurosis,
ocular palsies, etc.
3. Hemicrania Mquivalens (h. occurring as an
equivalent). This may be the only symptom for
years, later to be replaced by true epileptic attacks.
( In such cases to be regarded as a larvate form ) .
E. Aura sine Convulsione (aura without a con-
vulsion). This form of occurrence should be re-
garded as a pure minor sensory attack. The sub-
jective symptomatology of the various aurse is ex-
tremely diverse, but for the sake of explicitness
several common types will be referred to.
1. The analeptic aura: a sensation or "feeling"
which subjectively seems to start in the region of
the stomach and ascends rapidly to the head.
2. The "familiarity" type: in which the individ-
ual has the mental impression of being in sur-
roundings or of going through a mental conception,
that seems to have been experienced at some previ-
ous time.
3. The "strangeness" type: a certain subcon-
scious complex is allowed to come to the surface
and produces an impression of strangeness and in-
congruity with the surroundings.
4. The "visual" type: flashes of light and color,
especially blue, violet, and red. Reminiscences of
scenes, animals, pictures, etc. There are many
other forms; special sense aurse, auditory, olfactory,
gustatory, etc. Any of the above should be re-
garded as sensory seizures when not accompanied
by convulsions.
F. Paroxysmus Thalamicus (sensory epilepsy;
thalamic epilepsy). A minor sensory episode in
which there are delusions of sight, hearing, or
smell and in which there are also hallucinations.
Usually occurs as an equivalent to seizures. This
type is thought to be due to organic involvement
of the thalami.
G. Paroxysmus Vasovagosus (vagal attack; vaso-
vagal attack). First described by Sir William
Gowers. Consists of sudden and periodic attacks
of headache and dyspnea followed by somnolence;
sudden waking from this sleep with a sense of suffo-
cation, wild beating of the heart, and rigor. This
in turn is followed by flushing and a feeling of
warmth; the attack is over. There may be ab-
sence of the period of somnolence. This condition
is existent upon an epileptic basis.
H. Narcolepsia i narcolepsy). A disease con-
dition characterized by recurring somnolence.
Thought to be due to disturbance of the hormone
secretion of the anterior hypophyseal lobe. This
condition was first scientifically described by
Gelineau and later by Friedman. Five conditions
are to be taken into consideration:
1. Narcolepsia Vera (true narcolepsy; Gelineau's
epilepsy). This form is of very rare occurrence,
but epileptic in nature. A sudden onset of appar-
ently true sleep lasting about five to ten minues, oc-
curing at any time of day and showing periodicity
404
MEDICAL RECORD.
[Sept. 2, 1916
in matter of recurrence. Net followed by head-
ache.
2. Narcolepsia Hysterica (hysteroid narcolepsy).
This form may occur in epileptics in the form of
Status Catalepticus, or in non-epileptics in the form
of trance. Therefore we have
a. Status Catalepticus i catalepsy, stupor vigilans,
catochus, etc.). A hysterical form of narcolepsy
observed in epileptics. Hysteroid in nature and
probably not dependent upon the condition causing
the epilepsy. In this occurrence there is a sudden
suspension of the action of the senses and of con-
sciousness with great muscular plasticity, the limbs
and trunk preserving the different positions given
to them. A rather rare condition.
b. Catalepsia hysterica (trance; ectasis). A con-
dition which is purely hysterical and not in relation
with epilepsy. Consists of sleep episodes which
last for days and weeks. Interpolated here for dif-
ferentiation.
3. Paroxysmus Somnolentus (sleep attack). A
true minor sensory seizure in which the only
marked symptom is somnolence. This type occurs
in epileptics with comparative frequency and should
be sharply distinguished from narcolepsy, which is
a rare condition.
We will now take into consideration the mental
accessions. These may be either frank (manifest)
or masked (larvate).
III. Accessiones Mentis* Manifesto (frank
mental accessions).
A. ACCESSIO Mentis Minor (minor mental ac-
cession; intellectual Petit Mai). This form is one
of the epiphenomena to seizures. It may occur be-
fore or after a seizure; it may also occur as an
equivalent. There are three types :
1. Accessio Mentis Minor Agitata (excited minor
mental accession ; mental disturbance) . There may
be a sensory aura consisting of one of the uncinate
group (smell, hallucinations of sight or hearing,
unusual brightness of objects, etc.). There may be
me vertigo. The individual becomes despondent,
is aware of difficulty in collecting his thoughts
; nd of fixing his attention. Volition is lost and
there are certain uncontrollable impulses, which
may cause him to commit any form of violence,
theft, homicide, suicide, arson, etc. Sometimes
ecstatic visions or sounds are experienced in this
e (cenesthesis).
This attack is of comparatively short duration,
eral minutes to an hour or so. It may culminate
•n some act of violence following which the epi-
leptic recovers with practically total amnesia for
all the incidents which had occurred.
2. Accessio Mentis Minor Stuporosa i stuporous
minor mental accession; "mental confusion").
This form presents a stuporous condition, some-
times even amounting to a lethargy ; pupils slight-
dilated, lack of orientation and insight, verbi-
geration of set phrases, and purposeless automatic
movements. This picture of epileptic mental con-
tusion is very common following seizures or as an
equivalent to them.
:;- Accei Is Minor Migrans (wandering
minor mental accession). This form may occur as
an equivalent to a seizure or, more oft
an attack. The individual wanders about aimli
and it' molested resists to the point of viol,
'Sometimes the epileptic will have this type of ac-
idered psychologically, sensory and motor phe-
nomena are also mental processes. The designatory
i mental" is here used in a conventional sense
cession during the night, in which case he will rise
from bed and wander away, barefoot and unclothed.
His wanderings end only when the period of som-
nolence, which forms the terminal stage Of this
condition, claims him. He will often be found on
the street or in the fields, as the case may be,
while in this somnolent state.
B. Accessio Mentis Major (major mental ac-
cession; epileptic mania; extreme mental disturb-
ance; epilepsia furiosa). This form may be pre-
or post-paroxysmal; it may also occur as an equiva-
lent. The onset is usually sudden in which respect
it resembles a major motor seizure. There are
cases, however, in which the onset is preceded by
extreme headache or vertigo with vomiting; there
may be slight spastic movements of limbs or mus-
cles of the face. Emotionally one sees either de-
pression or some excitement, and often irritability.
Within an hour or perhaps a few hours there is an
explosion into a full blown mania. The epileptic
may cry, yell, or bite and tear at his bedclothes.
In some cases he talks or shouts incessantly, unin-
telligible jargon or stereotyped phrases. Some epi-
leptics show evidences of hallucinations of sight or
hearing which cause fear and dread. Mental epi-
sodes of this kind are very often followed by rapid
and profound mental deterioration. Following the
accession there is usually stupor and after recovery,
total amnesia.
While discussing this subject attention might be
drawn to a condition not at all uncommon and
which we can for convenience term "Mania transi-
toria liberorum," i.e. transitory mania of children.
Maudsley has remarked that, "In children, as well
as in adults, brief attacks of violent mania, a genu-
ine mania transitoria, may precede, or follow, or
take the place of an epileptic fit; in the latter case
being a masked epilepsy. Children of three or four
years of age are sometimes seized with attacks of
violent shrieking, desperate stubbornness, or furi-
ous rage, when they bite, tear, kick, and do all the
destruction they can ; these seizures, which are a
sort of vicarious epilepsy, come on periodically and
may either pass in the course of a few months into
regular epilepsy or may alternate with it."
I put this type of epileptic episode under the
heading of major mental accessions in order that
it may be more easily remembered. It might, with
reason, however, be put with the Affect form. Oc-
curring, as it does, in young children and of ap-
parently psychogenetic origin, the consideration of
this type brings us into the domain of "Mutterleib-
trieb" recently expounded by L. Pierce Clark in
his paper on Affect Epilepsy. ■
C. Accessio Hysteroidea Post Convul^ione
(hysteroid attack following an epileptic convul-
sion). Usually occurs after minor motor seizures.
The result of an unstable condition of the psyche,
such as is found in pure hysteria, combined with in-
activity of the higher centers as the result of the
effect of epileptic seizures: the lower center: are
thereby released from higher inhibitory control, and
the result is a convulsive enisode closely resembling
a major or minor motor attack.
D. Alteuationks Men is m ntal change
1. Depravatio Mentis Ep otica -epileptic men-
While one need not accept in toto the promul-
gated by the Freudian disciples with regard to
relationship between sexuality and these forms, still
one is forced to wonder whether there are not certain
grounds for belief that there is some connection be-
tween sexuality and epilepsy. 1 might here cite the
well-known o accredited to Hippocrates —
qv ffuvouatav i'r/7.: |Atxpav EictXi^tav.
Sept. 2, 1916J
MEDICAL RECORD.
405
tal deterioration). A retrograde change in the
associative, attentive, and perceptive faculties, the
result of the effects of epileptic accessions (motor,
sensory, or psychic) upon the intellect (see Habi-
tude mentalis epileptica). Depending upon the
course of deterioration, four types exist:
a. Depravatio Epileptica Rapida (rapid mental
deterioration), in which there is appreciable fail-
ing of intellect in the course of from several months
to a year.
b. Depravatio Epileptic Tarda (slow epileptic
mental deterioration), in which the course of de-
terioration is prolonged over a length of time ex-
tending from one year to several years. This type
usually shows gradual merging into dementia epi-
leptica. This form of deterioration is the most
common and is marked by one special feature, i.e.
failure in the perceptive faculty. The sphere of
perception shows unsettlement in one or more of
three different ways: retardation and difficulty of
perception, breaks in perception, and falsifying of
perception.
a. Retardation and difficult of perception : re-
sults in restriction of thought association and
therefore poverty, narrowing and slowness of idea-
tion; prolonged reaction time. This in turn leads
to stereoptypy, perseveration, and circumstantial-
ity.
[J. Breaks in perception : lead to twilight states,
fugues, absences, etc.
f. Falsifying of perception: leads to impulsive-
ness, delusions and hallucinations.
c. Depravatio Epileptica Intermittens (intermit-
tent epileptic deterioration), in which there is a cer-
tain amount of mental failure for a length of time
followed by standstill as regards deterioration.
Later there is a continuation of mental failure.
(/. Depravatio Epileptica Fulminans (fulminant
epileptic deterioration). A rare type. Within the
short period of three or four days, more or less, the
individual's mental condition changes from perhaps
fair intelligence to that of low grade dementia.
This phenomenon may be comitial to seizures or
may occur aside from attacks.
2. Dementia Epileptica Vera (true epileptic de-
mentia). This form must be distinguished from
paralytic and senile dementia, from dementia prse-
cox, idiocy, imbecility, and the epiphenomena to
seizures. The affection is slow and progressive.
It is seen in a comparatively large number of epi-
leptics, especially so in those in whom the onset of
the disease occurs late in life. Judgment and rea-
son are lost wholly or in part. Attention becomes
poor and memory is weakened. Orientation is
poor in all respects. Mental confusion is more or
less constant ; delusions are common. There may
be changes in the voice as to modulation, inflection,
clearness of articulation and pitch. These voice
changes in the form of "plateau speech" collective-
ly form a syndrome often found in those showing
epileptic affectivity. The dementia is multiform as
to symptoms and there are different types which as-
sume special character depending on the course
(slow, rapid, or intermittent), or on the accom-
panying complications (paralyses, contractu!'-,
pseudo-paralyses, etc.
IV. Accessiones Mentis Larva t.-e < masked men-
tal accessions; "psychic epilepsy"; masked epilep-
A. Poriomania (ambulatory automatism).
1. Somniatio Morbosa (disease dream; dream
state; twilight state; "absence"; Dammerzustand;
"fugue"; crepuscular state). This type of mental
accession occurs as an equivalent to seizures in the
frank forms of epilepsy or, more commonly, as a
periodically recurring mental episode in the larvate
forms. The condition is polyphase in its manifes-
tations. The "dream state" may recur in exact
duplicature or vary as to character of events in the
same individual. The condition comes on suddenly
and ends suddenly with either return to the usual
condition or with somnolence and headache. Many
citations might here be given of these conditions,
but as I am endeavoring to make these explana-
tions of terms as briefly definitive as possible, two
tvpes only will be briefly mentioned (taken from
A. V. Goss) :
a. Partial Aphasia coming on suddenly after
nervous strain. Unconsciousness for an hour or
two. Existence for ten days with partial loss of
memory for past events and persons ; sudden recov-
ery with complete restoration of memory for every-
thing, but complete amnesia for occurrences during
the ten days.
b. A condition allied to somnambulism as well as
to "Hemiplegia transitoria." The patient falls
asleep and in ten to twenty seconds he awakens to
find himself paralyzed in one or more limbs. A
few seconds later the paralysis passes off, the epi-
sode is over.
It must be remembered that the above two epi-
sodes are not typical of dream states, as each indi-
vidual experiences heterologous arrangement of
mental concepts and events peculiar to himself.
2. Conscienta Duplex (double personality; dual
consciousness; dissociated personality). There are
at least two well-defined types :
a. Conscienta Duplex Migrans (dual conscious-
ness with wandering). The type of occurrence in
which the individual will, without external mani-
festation of mental aberration, wander away from
his home and town, spend days, weeks or months
in a new environment. He conducts himself either
peaceably or not as the case may be. Later he re-
turns to his original personality with total amnesia
for the entire period just gone through.
b. Personalitas Diversa ( diverse personality ;
heterogeneous personality). An individual, let us
call him "A," suddenly changes his state of con-
scious being to that of an individual having an en-
tirely different mental make-up. From a person,
let us say, of studious, serious, introspective char-
acter, there is evolved a personality shallow-
minded, bright, cheerful, and care-free. We will
call this latter "B." The last personality may ob-
trude itself on the first at periodic intervals, with-
out warning and at any untimely moment. These
invasions on one personality by another are there-
fore seen to partake of the character of an epileptic
attack. This form of accession may occur in a
frank epileptic as an equivalent to a seizure. Usu-
ally it is a larvated accession in an individual who
shows no other marked symptoms of epilepsy, but
who may later show up as a masked type. Cases
are on record in which there have been obtrusions
of two or even three personalities upon the so-called
normal one. One more point should be noted in
the discussion of this type; that while these episodes
occur in persons who are neuropathically tainted and
who may later develop epilepsy, still they may oc-
cur in people who are not. epileptics.
Under the heading of disease dream (somniatio
morbosa) the following two conditions must also
be considered :
3. Somnambulatio (somnambulism; sleep-walk-
406
MEDICAL RECORD.
[Sept. 2, 1916
ing). A periodically recurring and temporary sus-
pension of volition and consciousness, usually ac-
companied by automatic acts. A morbid disease
entity en the borderline between epilepsy and hys-
teria. "Dr. Darwin was, I believe, the first to
advance the idea that somnambulism is nearly re-
lated to epilepsy; incubus he also regards as related
to both somnambulism and epilepsy." (Pritchard
in his "Diseases of the Nervous System.")
4. Pavor Nocturnus (night-terror). Commonly
seen in children. In a case of this kind the child
awakes two or three hours after falling asleep. It
screams in terror and is apparently unable to rec-
ognize anyone; during this period the child may
get up from bed and run about in a frenzy of fear
as though trying to escape from something which
was frightening it. This form is rather serious
in import, as it indicates an unstable nervous con-
stitution and may be the forerunner of a subse-
quent epilepsy.
B. Status Afpectus i psychogenic epilepsy; af-
fect epilepsy; emotional epilepsy; masked epilepsy).
One often finds a mixture of the classic form of
or motor seizure with psychoneurotic episodes.
I -e latter may be found in a frank epileptic as
equivalents. When, however, they occur in an in-
dividual who does not have epileptic seizures, these
odes combined with a peculiar constitutionally
neuropsychopathic mental make-up form the condi-
tion which has been termed the "affect" or psychic
form of epilepsy by Bratz and Leubuscher.
Without somatic reason, and in individuals who
are really hereditary neuropathic and psychopathic
degenerates and who, we have reason to believe,
are highly reactionary to environmental psychic
stimuli, occur periodic attacks of dizziness, "faint-
ing spells," temporary losses of consciousness, audi-
and visual hallucinations, maniacal seizures.
isions and suicidal attemps. There also occur
disorientations which last variable lengths of time.
Often one sees attacks simulating those of true epi-
leptic type, somewhat less severe perhaps, and usu-
ally brought on by external excitation or insult.
There is no, or very little, deterioration in these
cases. They do not go into status and very rarely
do they have series of seizures; when they do, how-
r, the number of convulsions is small. They do
not as a rule injure themselves in attacks, and
death in a seizure doe> not occur.
V. HABITUDO MENTALIS EPILEPTICA -epileptic-
mental make-up; epileptic character). A peculiar
mental state, the result of exogenous stress upon
a mind ontogenetically and phylogenetically
mal. There are found perversions of emotion,
judgment and memory, also certain contraventions
normal conduct as the result of egocentrii
relig nd disordered moral criteria. In order
that these inversions may be better remembered I
will here put them down in classified form.
1. Emoti - -Shows marked instability,
irritability, and hypersensitiveness.
a. Instability — leading to lack of inhibition; ca-
prii in moods with changes that are in-
stantani despondencj with
'. itli docility, taciturnit; and
loquaciousness, defiance and obsequii etc.
Hysteri mi be a i omplicating factor.
b. Irritability leading to sudden, p ? and
impulsive t. of rage and violence, or to
esses in venery or alcoholism.
c. Hypersens -leading to optimism, af-
fection. ' red Li ion and jealousy.
2. Judgment. — As a class epileptics show one
form of judgment almost exclusively (.and that in
modified form), namely, esthetic judgment. This
form is characterized by appeal to the emotional
side of consciousness and cannot be defined in terms
that might be apprehended by the intellect. This,
as opposed to scientific esthetics in which the ideal
or standard may be described, analyzed and defined
in terms of its factors. An epileptic of everyday
type who shows a little deterioration only, forms
opinions by "feeling," i.e. emotion. As regards his
conceptive determinations, there is not necessarily
any inference or ideal standard, of either excellence
or deficiency. Therefore, decisions made by him are
often erroneous. This accounts for his poor ability
to adapt himself to his environment, either topo-
graphical or social.
3. Memory. — Primary identification I involving
the senses) is fairly good as a rule. Secondary
identification (involving reminiscences, images, men-
tal concepts, etc.j is usually quite poor. Amnesias
and paramnesias are of frequent occurrence. An-
other peculiarity of epileptics is, that matters of
general information are easily forgotten, but those
things which relate to personal affairs and inter-
ests are well retained, i.e. ipsocentric memory
sphere.
4. Egocentricity. — One finds two marked factors:
a. Unsociality — as evinced by quarrelsomeness
uncontrollable temper, moroseness, obstinacy, arro-
gance, conceit and boasting.
b. Self-consciousness — of high degree, as shown
by egocentric narrowing of the sphere of interest
and thought, magnification of his own importance,
self-assuredness; also a combination of the "know-
it-all" attitude with, at the same time, self-depre-
ciation.
5. Religiosity. — Bible-reading and piety which is
often hypocritical; religiousness in contrast to de-
praved ethical standards in the same individual.
6. Moral Sphere. — Stigmatized by various degrees
of fabrication, subterfuge, truculence, malice, cop-
rolalia and sexual perversions, as opposed to piety
and beneficence in the same person.
One often hears the statement, in referring to
a patient's seizures, "He has grand mal attacks."
The presumption is that by this remark is meant,
that the individual in question is having major
motor attacks. A glance at the classification shows
that there are sixteen different kinds of major
seizures. Such a remark is therefore seen to lack
preciscness. The classification also takes into con-
sideration ten minor motor types, fourteen sensory
types, seven manifest psychic, and seven larvate
psychic incidents. These fifty-four types represent
the mosl imporl ins of epileptic episodes.
There are modifications of many of these, but any
such modification can easily be put in its pri
in the schema.
BIBLIOGRAPHY .
a, R. Osgood: "Duplex Pei oi ility," Journ. of
X, rr. and Met Vol. XVIII, p.
Aschaffenberg, Gustav: Ueber Epilepsie und epilep-
toide Zustande in Kindesalter, Arch,, f. Kinderheilk.,
. ,
Wilson. S. A. Kinnier: "The Temporosphenoidal
Forms of Idiopathic Epilepsy." Lancet, Vol. I, 1914. >.
651.
Waterman. George A.: "The Relationship Between
Epilepsy and i tton Mr, I. mi, I S trg. -limn,..
Vol. CbXX. p. 337.
Yawger, X. S.: "Alcoholism and Epilepsy." Am.
Journ. of thi t, Vol. CXLVII, 1914, p. 735.
Alfiewsky: Sur rAnatomie pathologique de l'Epilen-
sie de Kojewnikoff, Rmie Neurologique, 1914, p. 522.
Sept. 2, 1916J
MEDICAL RECORD.
407
Miinzer, Arthur: Beobachtungen uber die psychischen
Anomalien der Epileptiker, Berlin klin. Wochenschr.,
1913, Nr. 38, S. 39.
Price, G. E.: "Affect Epilepsy," Journ. of Nerv. and
Ment. Disease, Vol. XL, 1913, p. 880.
Shanahan, William T. : "Myoclonus Epilepsy," with
a report of two additional cases, idem, 1907, August.
•Browning, William: "The Epileptic Interval," idem,
Vol. VIII, June, IS'.):;.
Mosher, J. M.: "Mental Epilepsy," idem, 1893, p.
398.
Pellessier, F. : "Myoclonus," Rev. Neurologique, 1912,
1 sem., p. 53.
Seglas, J. (Bicetre) : Crises de petit mal epileptique
avec aura paramnesique : illusion de fausse reconnais-
sance, idem, January 15, 1907.
Gowers, Sir William: "Diseases of the Nervous Sys-
tem," Vol. II, 1898.
Gowers, Sir William: "Vagal and Vasovagal At-
tacks," Lancet, June 8, 1907.
Liveing, Edw. : "On Megrim and Sick-Headache,"
London.
Wilder, Burt G. : "Some Misapprehensions as to the
Simplified Nomenclature of Anatomy," Science, April
21, 1899.
i
THE CLINICAL MANIFESTATIONS OF ANI-
MAL PROTEIN POISONING.
By ROBERT CURTIS BROWN. M.D..
MILWAUKEE, WIS.
We might divide all the diseases to which mankind
is subject, as Herbert Spencer does his philosophy,
into the known and the unknown.
Of the known diseases the principal ones are
those due to infection. Of these the causes are well
understood, and a suitable prophylaxis may be pro-
vided. It is of those diseases of obscure origin, of
which many causes have been suggested, but none
accepted that I am going to speak.
Much has been written about the cause of gout,
but there is only one thing in regard to gout of
which we are certain, and that is, if we give a
gouty person an excess of protein food the nitrogen
excretion does not rise abruptly and fall abruptly,
as in a normal person, but it rises slowly and falls
slowly, that is, the metabolism is delayed.
I have found by experience on myself and others
that certain gouty manifestations such as head-
ache, neuralgia, myalgia, arthritis and certain skin
and mucus membrane manifestations can be
brought on by eating meat, meat soup, eggs, and
cheese.
Typical gout is but an episode in the life of a
gouty person; indeed, a man may suffer all his life
from gouty manifestations and never have an at-
tack of true gout. As the gouty manifestations are
much more important than gout itself, and as the
word gout gives no idea of its etiology, I am going
to call these manifestations those of protein poison-
ing. I will illustrate my meaning by the following
animal experiment. Horsely and Schiff have shown
that if the thyroids of sheep or goats are removed
they, being herbivorous animals, are not affected,
but if thyroidectomy is performed on dogs they will
die. If they are fed on bread and milk or boiled
meat, they will live for some time, but if they are
fed on roasted meat or meat juice death in convul-
sions ensues. It seems only logical to assume that
the meat contains a poison. Complete thyroidec-
tomy in the human being is fatal to life. I wish,
therefore, to advance the following hypotheses :
The animal 'protein of our food contains a poison,
for which the human body has certain defensivt
agents, which neutralize it and render it harmless.
If the protein is given in excess, or is given to an
individual who is especially susceptible by having
been born into a gouty family, certain manifesta-
tions are produced.
In this way the whole question of metabolism
may be ignored. When we come to consider the
various manifestations of protein poisoning it will
be found that most of the diseases not due to infec-
tion, namely those in the unknown class, are due to
this poison. Although I use the name protein
poisoning for lack of a better, it must be borne in
mind that the extract of the meat contains more of
the poison than the boiled meat and that the poison
is probably an extractive of animal protein. My
contention is that animal protein contains a soluble
poison. From my own experience and that of others
in whom manifestations can be produced in a very
short time by eating an excess of animal protein,
I believe that the poison is directly absorbed and is
not a product of intestinal digestion as believed by
Combe of Lausanne or a product of metabolism as
clamed by Haig of London.
The poison not alone affects every tissue in the
body, but can also affect the function of an organ,
as, for example, it can cause periodic polyuria,
which is a frequent symptom of protein poisoning.
As I seem at first to state dogmatically that cer-
tain affections are caused by animal protein, I will
explain that in a study of a very large number of
cases, over two hundred, I found these manifesta-
tions'so closely associated with manifestations that
can be proved to be due to animal protein in the
diet that it seems only logical to assume that they
are due to the same cause. In the second place these
affections occur only in patients who have a history
of other protein poisoning manifestations and in
whose family manifestations of protein poisoning
are common. In the third place these affections can
be very much relieved or cured entirely by the with-
drawal from the diet of animal protein.
That the ductless glands should often be affected
is not strange, for they are, probably, the chief
agents in neutralizing the poison. They are liable
to hypertrophy from increased exertion, and if they
are "called upon for a great excess of secretion, the
body itself may suffer from the effects of that over-
Mvretion. Simple goiter, exophthalmic goiter, and
the diseases due to hypertrophy and oversecretion
of the pituitary body are thus explained. Over-
secretion of the adrenals may lead to arterioscler-
osis and its results. I have found goiter and ex-
ophthalmic goiter very common among those having
other manifestations of protein poisoning. The
simple hypertrophy of the gland in young women
at puberity occurs frequently in gouty families and
is some times associated with menorrhagia. The
simple goiter of pregnancy is probably explained by
the increased work the gland is called upon to per-
form. Exophthalmic goiter occurs frequently, and
less evident signs of hyperthyroidism are very com-
mon in patients having other signs of protein
poisoning, such as purpura, hay fever, nasal
turgescence bronchial asthma, migraine, gouty
pains, and the various skin lesions.
Headache is probably the most frequent symp-
tom of protein poisoning; it may take the form of
migraine of neuralgia or pain in the insertions of
the muscles. Headache that is not due to eyestrain
or sinus trouble is usually due to protein poisoning.
There are various neuralgias, myalgias, and pains
in the joints which can be experimentally produced
in a susceptible subject by taking an excessive
amount of animal protein. By a susceptible sub-
ject, I mean one who has either consumed a large
408
MEDICAL RECORD.
fSept. 2, 191G
amount of animal protein during his own life and
so become susceptible, or who has inherited (and
this is most always the case) the susceptibility from
his ancestors who were also subject to protein
poison manifestations.
Periodic turgescence of the nasal mucous mem-
brane is a very common manifestation of protein
poisoning; this can also be experimentally pro-
duced in a susceptible subject by taking an ex-
cessive amount of animal protein. This affection
is very important, for it often leads to secondary
infection of the sinuses and is the primary cause
of sinus trouble. It is often treated by cauteriza-
tion and removal of the turbinates, the primary
cause being overlooked. These patients are sub-
ject to hay fever. Hay fever is itself a manifesta-
tion of protein poisoning, and occurs only in fami-
lies with a gouty history, and sufferers from hay
fever usually have other manifestations, as for ex-
ample migraine, purpura, bronchial asthma, or
gouty pains. Periodic sore throats which may be-
come chronic, bronchial asthma, and chronic bron-
chitis are also manifestations of protein poisoning.
Susceptible patients are very liable to frequent
coryzas. Follicular tonsillitis is very common in
patients having protein manifestations; this of
course is an infection, yet it is quite probable that,
as the germs are always present on the tonsil, the
poison eliminated causes an irritation which is fol-
lowed by secondary infection.
In the digestive tract the most common affection
that I have noticed is hyperacidity. Almost all
sufferers from protein poison have digestive
troubles of which hyperacidity and its accompany-
ing constipation are very frequent. In one case
of very obstinate cankers of the mouth of over a
year's duration, I found that the cankers disap-
peared in a very short time with the withdrawal
from the diet of all animal protein. This made me
think of ulcers in other parts of the digestive tract.
.Much to my surprise I found that all my patients
who had ulcer of the stomach or ulcer of the
duodenum had other symptoms of protein poison-
ing and had also gouty family histories. The irri-
tation caused by the elimination of the poison is
likely the primary cause of ulcei the stom-
ach. Another common manifestation is periodic
intestinal colic. This is often mistaken, especially
in children, in whom this manifestation is quite
frequent, for appendicitis. Periodic diarrhea with-
out apparent cause is common, this is a condition
that is much influenced by atmospheric conditions.
Some patients suffer from mornin.tr diarrhea which
seems to act as a safety valve for their other mani-
festations. Mucous colitis is another manifestation.
In the secretions of mucous colitis eosinophils are
found, as in the secretions of bronchial asthma.
Rosinophilia in the blood and in the secretions
is a characteristic symptom of protein-poisoning
manifestations, especially of the skin and mucous
membranes.
There are many protein poisoning manifestations
in the skin, such as urticaria, angioneurotic lema,
eczema, ichthyosis, and psoriasis. Urticaria fre-
quently follows an ■ ' protein in
and certain individuals seem especially su ceptible
to special ]>■ uch as fish, white of egg, etc.
Angioneurol a often occurs in connection
with other protein poisoning manifestations. The
sydrome that IV Osier speaks of is an ex-
ample. Eczema occurs both in the old and young.
The children of gouty parents often have eczema
which can be cured by the withdrawal of animal
protein from the diet.
Ichthyosis is often seen in several members of a
family and is hereditary. I have a family in which,
besides the ichthyosis that three members have, one
has arthritis deformans, two others have periodic
attacks of intestinal colic, and one has a goiter. It
is well known that the thyroid extract has consid-
erable effect on ichthyosis. Schamburg has shown
the effect of the withdrawal of protein from the diet
on psoriasis. Acne is an example of a skin affec-
tion, when the infection is secondary to the irrita-
tion caused by the elimination of the protein poison.
Acne is found almost entirely in gouty families and
in connection with it one can also find other evi-
dences of protein poisoning. In my own case I
found that the acne which I had always had on my
back would disappear entirely on my abstaining
from animal protein. In a case of exophthalmic
goiter which I have treated recently, the patient
had a decided gouty history and his face was cov-
ered with pimples. Upon withdrawing the protein
and giving a suitable eliminative treatment his
symptoms of hyperthyroidism as well as his acne
disappeared very quickly.
Periodic outbreaks of purpuric spots in women
are far more common than are generally supposed
and will often be found if looked for. They are in
my experience found only in families whose mem-
bers present other evidences of protein poisoning
and are, I believe, an evidence itself of protein
poisoning. Hemorrhage from the mucous mem-
branes is a very common manifestation of protein
poisoning, for example, nosebleed and menorrhagia.
Pupura hemorrhagica is a syndrome in which sev-
eral manifestations of protein poisoning are com-
bined, such as intestinal colic, hemorrhage from
mucous membranes, hemorrhage into the skin, and
sometimes fever. I have one very interesting case
of pupura hasmorrhagica of the intermittent type.
The patient is subject to gouty pains and headache,
and is a sufferer from hay fever. One brother has
gout, another bronchial asthma, her daughter
suffers from nasal turgescence. has a goiter and
is afflicted with acne. This patient has also with
her purpuric attacks, bleeding from the bladder and
rectum, renal and abdominal colic, and nasal
turgescence, and the attacks are often followed by
furunculosis.
In the joints we may have gouty pains, inflam-
mation, or chronic conditions such as Heberden's
nodes and arthritis deformans. In the muscles are
the various myalgias, lumbago, stiff neck, etc. In
the nerves, supraorbital neuralgia is very common,
also sciatica and other forms of neuritis. These
can be said to be due to protein poisoning only when
there are other manifestations such as nasal
turgescence, asthma, enlargement of the thyroid;
but if careful examination is made this will almost
ahva.v s be found to lie the case.
In making a diagnosis of protein poisoning the
family history is of extreme importance, for •
haps the mo I importanl and most interesting char
acteristic of protein poisoning is the inherited s
ceptibility. I can show among my case . fo ir and
five generations of inherited susceptibility. For in-
nce, in one family there were five generations
of purpura i all in females l several of the children
in the fifth generation had goiters, and one had
an exophthalmic goiter; many in this family were
subjecl to migraine and various sorts of gouty pains
in muscles, nerves, and joints.
Sept. 2, 19] 6 J
MEDICAL RECORD.
409
The multiplicity of the manifestations in the
same individual is characteristic. A patient will
have Heberden's nodes in the fingers, will be sub-
ject to periodic turgescence of the nasal mucous
membrane, have purpuric spots, hyperacidity, and
be subject to neuritis. Another patient will have
a slight enlargement of the thyroid, have attacks
of bronchial asthma, migraine and mucous colitis.
besides various myalgias.
The variability of the symptoms in parent and
child is characteristic. A father may have gouty
pains and chronic bronchitis with a tendency to
asthma, and one child have very bad acne, another
bronchial asthma, and another a goiter, all the chil-
dren having other manifestations in addition. The
grandchildren will, when young, be subject to aci-
dosis with symptoms in either the respiratory or
digestive tract as well as in the skin.
The periodicity of the attacks is characteristic,
as for example migraine, bronchial asthma, periodic
nasal turgescence and sore throat.
The cessation of one set of symptoms with the
onset of another is most peculiar. A man will have
a violent urticaria which will stop with the onset
of asthma. When the asthma stops the urticaria
will commence again. A patient having been oper-
ated on for floating flidney which was really renal
colic will be cured of her hyperacidity also, but will
be troubled with nasal turgescence after being
treated for so-called sinus trouble, that will stop
and she will suffer from bronchial asthma, that will
get better, and then she will have lumbago and in-
tercostal neuralgia which she and perhaps her phy
sician calls pleurisy. I have such a case that was
treated by fourteen different physicians before I
made a diagnosis of protein poisoning. She was a
very heavy meat eater. She had been treated for
tuberculosis, floating kidney, sinus trouble, pleurisy,
etc.
Atmospheric conditions and climate have consid-
erable influence on the manifestations of protein
poisoning. Damp weather will often bring on an
attack of migraine, bronchial asthma, pains in the
joints, nerves, or muscles, or an attack of mucous
colitis. Some of the conditions are wonderfully
improved by a change of climate, for example
asthma or chronic bronchitis.
The eosinophilis are often much increased in cer-
tain lesions of the skin and mucous membrane in
poisoning by animal portein, for example urticaria
and bronchial asthma. In mucous colitis and bron-
chial asthma the eosinophilis are found in excess
in the secretions. Acetone is often present during
attacks and is present in excess in a subject even
when free from attacks.
The acidosis in children is really a protein poison-
ing, and it may show itself in a great variety of
symptoms. In children considerable fever is often
present when the respiratory mucous membrane or
the mucous membrane of the digestive tract is in-
volved. Sore throats and intestinal colic are very
common. The intestinal colic is often mistaken
for appendicitis.
I have one patient who has had three major
operations for severe abdominal pain which we
know now was due to protein poisoning, her kid-
ney was found normal, her gall-bladder also, and
at another time her appendix was removed though
normal. She had other gouty manifestations, she
was of a gouty family; she had a high percentage
of eosinophiles during attacks and acetone in the
urine.
In some cases the condition is mistaken for tuber-
culosis. I will cite a few cases in my practice.
Case I. — About six years ago I examined a young
woman who had a cough, some rales, and a persistent
evening rise of temperature. There was an old tuber-
culous lesion at one apex, and signs of an old pleurisy.
At the time I examined the blood every day for a week
and found that the percentage of eosinophiles was con-
stantly very high, over fifteen per cent., which I thought
a. the time might be due to an intestinal parasite. I
made a diagnosis of active tuberculosis and the woman
passed several years in various sanitoriums. There
never was much sputum, and no bacilli were ever found.
Although the .r-ray showed the old lesions, no one was
ever able to locate the active lesion, the only symptom
of which was the persistent slight temperature. Re-
cently I was called to see her and found her suffering
from an active nasal turgescence, there was acetone ir.
the urine, and eosinophiles were again increased. T
then remembered that I had once treated her for goiter.
Then it all flashed upon me that she had been suffering
all the time with protein poisoning. She had a well
marked gouty family history.
Case II. — My assistant at the Children's Free Hos-
pital dispensary wished me to look at a case in which
he had made a provisional diagnosis of acute miliary
tuberculosis. I noticed on examination that the breath-
ing was labored and that the child had a goiter. There
were rales all over the chest. The mother and three
other children, who were present, had goiters, the
mother had gouty fingers and eczema on her hands, one
child had an active urticaria. The mother said she fed
the children principally on meat, meat soup, and eggs.
The patient was suffering from bronchitis with asthma,
and was a victim of protein poison.
We have found on reconsidering our diagnosis
at the South Side Dispensary for Tuberculosis that
there are probably dozens of children in whom we
have made a diagnosis of tuberculosis, because they
had a persistant temperature who really had protein
poisoning. This is a typical history of a boy in
which a diagnosis of tuberculosis had been made
on account of occasional rales and a persistant tem-
perature; he is robust and seems perfectly well
now.
Case III. — Edward P., age eight years, had eczema
when an infant, the eczema will appear now at times;
he gives a history of attacks of shortness of breath.
The present attack has lasted eight weeks, he is now
suffering from polyuria, and has a persistent rise in
temperature. The' mother of the patient has gouty
pains in he arms, especially in damp weather, she has
acid dyspepsia and frequent outbreaks of ache on her
back. 'She is troubled with a planter wart. Her
father had rheumatism and asthma. One sister has
gouty pains and frequent headaches and suffers from
hay fever.
I have pointed out how animal protein poisoning
may resemble tuberculosis. It also in some cases
produces symptoms that resemble typhoid fever or
meningitis.
Case IV. — I have a ease now under observation in
which a diagnosis of typhoid was at first made. There
has been a continued' fever with daily remissions for
over six weeks. Repeated blood examinations fail to
reveal the typhoid bacillus or give a Widal reaction.
Eosinophiles" could be found in the blood, as is not the
case in typhoid. Acetone was present in excess at first,
but with the withdrawal of all animal protein and the
sriving of sodium bicarbonate that has disappeared.
The patient looks perfectly well and feels so, except that
has a fover which looks as if it would continue for
some time.
Case V. — We have a case at the Milwaukee Children's
Hospital of a boy eight years of age. He h<*d convul-
sions and a temperature of 105 deg. on entrance with
the head symptoms of meningitis. His breath had a
fruity odor and acetone was in excess in his urine. Re-
red lumbar puncture showed only a clean fluid and
his reflexes were normal. There was a considerable
leucocytosis. After about six weeks of fever he com-
pletely recovered.
I believe many a case of bilious fever is due to
410
MEDICAL RECORD.
LSept. 2, 10 LG
protein poisoning and many a case of recovery from
meningitis is really a recovery from protein
poisoning.
There are often nervous symptoms connected
with protein poisoning. Periodic fits of nervous
depression or the blues are very common. One also
meets with real neurasthenia which will clear up re-
markably with a proper regulation of the diet and
eliminative treatment.
I have by no means exhausted the number of pro-
tein poisoning manifestations. Probably the whole
of the lithemic diathesis of Bouchard should be in-
cluded as nephritis, the uremias and eclampsias
arteriosclerosis, gallstones, renal colic, etc.
Diabetes is very common in the family history
of protein poison manifestation. Indeed, as pointed
out by many authors, there is a distinct relation
between gout and diabetes.
It is possible that the defensive and metabolic-
agents are so occupied with the protein poison that
there comes a time when their ability properly to
metabolize the carbohydrates fails.
It is quite possible that protein poisoning has to
do with the formation of tumors. I have found
fibroids in women and enlarged prostates in men
very common, and one can always find in those con-
ditions other manifestations of protein poisoning.
The most interesting condition I have noticed is
the history of warts. Of course warts are very com-
mon, but those afflicted with plantar warts consult a
physician on account of the discomfort.
I have yet to find a case of plantar warts in which
there was not some other manifestation of protein
poisoning. This leads one to think of carcinoma.
According to the French school, carcinoma is
usually if not always found in gouty families. A
line of research with the idea of protein poisoning
being a factor in the cause of cancer should cer-
tainly be instituted. Of the cases of cancer of my
knowledge, all had some manifestation of protein
poisoning.
Although the diagnosis is very easy when the
manifestations are borne in mind there is probably
no diagnosis so often overlooked. Turbinates are
removed, good teeth extracted, and abdominal opera-
tions performed when the trouble is simply a mani-
festation of protein poisoning. I could quote dozens
of such cases. If a careful questioning of the
patient shows he is subject to hay fever, headache,
or neuritis one's suspicions should be aroused. An-
other patient may have a goiter, purpuric spots, be
subject to nosebleed, polyuria, etc.
Another may have acne, warts, hyperacidity, and
be subject to muscular rheumatism. Another may
have bronchial asthma, periodic asthma, periodic in-
testinal or renal colic. In all these cases a careful
examination of the family history will confirm the
diagnosis.
The most important cases are those in which a
differentia! diagnosis must be made between protein
poisoning and tuberculosis, typhoid fever, and men-
ingitis, but usually a diagnosis can be made by the
presence of acetone and eosinophilia and the absence
of the cardinal symptoms of the more serious dis-
the manifestations are so variou onsid-
eration of the treatment in detail is out of the ques-
tion, tint certainly no treatment is of much avail
without the withdrawal from the diet of meat, n
'. eggs, and cheese for a time at least.
That considerable improvement in protein poison-
ing follows the withdrawal of the carbohydrate
probably due to the fact that the defensive and
metabolic agents are thereby given more opportun-
ity to dispose of the real offending agent which is
the protein.
An eliminative treatment of Carlsbad salts in
the morning and acetyl salicylate three times a day
is indicated. Bicarbonate of soda and an addition
to the diet of plenty of fruit are useful therapeutic
measures. I have found in certain cases, especially
in neuritis, good results from injections of cacody-
late of soda.
The proper administration of the animal extracts
is especially useful in purpura, in hemorrhage, and
in affections of the ductless glands; also in affec-
tions of the respiratory mucous membrane and in
other protein poisoning manifestations. Atmos-
pheric conditions (which influence the elimination
through the skin and respiratory mucous mem-
brane) have such a strong influence that a change
of climate is sometimes of great benefit.
On the whole the treatment is very satisfactory
and it is surprising to see how many patients, who
have all the sources of focal infection removed with-
out benefit, except the temporary relief due to post-
operative starvation, become free from their com-
plaints when animal protein is withdrawn and suit-
able eliminative treatment advised.
It is unnecessary for me to quote further from
the large number of cases I have collected, for I
am sure any physician will find dozens of cases in
his own practice which will support my contention
chat animal protein is the cause of almost all dis-
ease not due to infection and that these diseases
are merely manifestations of damage done to the
various tissues of the body through the inability
of the natural defenses of the body, of which the
ductless glands are among the principal ones, to
neutralize ai.d render harmless a poison which is
in animal protein.
1240 V* - Building
SOME CLINICAL ASPECTS OF RADIUM
THERAPY."
}-:> WALTER B. CHASE, M D.. F.AJ -
BROOKLYN. NEW YORK.
SURGEON BETHANY DEACONESSES HOSPITAL. CONSULTING GYNE-
COLOGIST LONG IS! AND COLLEGE HOSPITAL, CONSULTING
SURGEON RADIUM SANATORIUM, NEW YORK CITY.
For many years my practice has been, and still is,
to operate on all operable large malignant growths,
but want of confidence in the ability of myself and
more skillful operators to prevent frequent recur-
rence, has convinced me that operative surgery has
about reached the limits of effectiveness, and that
perforce we must look to some other supplemental
remedy. For ten years it has been my custom to
make use of postoperative prophylactic radiation.
As preliminary, reference is made to a few fun-
damental propositions:
1 In its ineipeney cancer is always a single
1 lesion. (2) Every case of cancer has a devel-
opmental period, when early cure is possible, save
lor anatomical reasons, or coincidental disease. (3)
1 ure of cancer depends upon removal or destruction
of all malignant cells. (4) There are three principal
features in the practical application of radium, viz.,
the amount of radium used, the time of its appli-
cation, and the tissue resistance of the individual
patient. This gives emphasis, that the law of
*Read before the Medical Association of the Greater
City of New York. June 5, 1916, at St. George, Staten
Island. . .1
Sept. 2, 1916]
MEDICAL RECORD.
■in
radium therapy must be studied in every individual
case. (5) The resisting powers of normal struc-
tures is much greater than that of tumor growths,
and affords a conservative margin of safety, a most
important clinical factor. (6) It should also be
remembered the younger the patient the more grave
the malignancy and vice versa.
The results of radium treatment are palliative and
curative. The palliative influence of radium is
fourfold: (1) analgesic; (2) inhibition or arrest of
malignant or benign growths in varying degrees and
for varying periods of time; (3) its property of
diminishing or destroying offensive odors in local
ulceration, malignant or non-malignant; (4) its ef-
ficacy as a hemostatic in uterine hemorrhage. In
these several applications of its therapeutic influ-
ence are opened fields of knowledge little known and
'ess appreciated, often offering a boon to the dis-
couraged— the only barrier against utter hopeless-
ness.
Postoperative Prophylactic Radiation. — When
operative surgery with its unnumbered victories in
the cure of cancer, with its perfected technique,
guided by the tact and skill of the accomplished
operator, does its best in the hope this will effect
a cure, the period of suspense and anxiety remains
until three to eight years have passed if the patient
survives so long. This anxious solicitude arises
from fear that areas of malignant cells, of unknown
and unknowable location, have not been removed
by the scalpel, and may remain as a menace of re-
newed lawless proliferation, the essential and path-
ognomonic feature of malignancy. It is this persist-
ency of recurrence which leads an increasing num-
ber of operators to resort to postoperative radiation.
This has been my practice for ten or twelve years
until I have come to believe the last prohibitive and
possibly curative step has not been taken until
radium has been used. Briefly, but in no exhaustive
way, I shall quote from authorities who resort to
radiation in postoperative cases. It is here that
surgery and radium find ample opportunity of reci-
procity, without infringing on the rights of either,
a procedure wh'ch offers ample encouragement for
general adoption.
Miller' says prophylactic raying after operation
is now fairly well established on a rational basis.
In six utterly hopeless cases, from a surgical stand-
point, of recurrent carcinoma, following hyster-
ectomy, four yielded to radium treatment, but final
results cannot yet be known. Two other cases were
only temporarily benefited. One point in favor of
radium which should not be overlooked in the final
analysis is that the present statistics will be based
on material that had passed beyond surgical relief
before radium is used.
Nahmmacher deduces that operable tumors must
"be operated upon unless the operation is refused,
and the operation must be followed by prophylactic
radium treatment. Inoperable tumors must be
rayed immediately.
Foveau de Courmelles3 states that radium and
.x-ray should not be regarded as antagonistic to
surgery, but as accessory means. All operations for
•cancer should be followed by prophylactic radium.
Schmitz' says that radium therapy is indicated
'(1) In inoperable cancers of the uterus, vulva, and
vagina; (2) in operable cases where operation is
refused or is otherwise impossible. The results of
radium therapy in the London Radium Institute,
presided over by men of worldwide reputation
(.Teeves, Brunton, Ramsey, French, Tate, Pierce,
Pinch, and others), are worthy of particular notice;
more so as it is the rule of this institute to use
radium only in inoperable cases, with a few ex-
ceptions. In this annual report they say: "During
the year 1914 the number of patients was 841.
There were no selected cases, and radium was never
used but in inoperable ea . i eepting those who
refused operation, or where radium was used as a
last resort. Since the opening of the institute in
1911, numerous patients who have undergone opera-
tions' for malignant diseases have received post-
operative prophylactic radiation. It would be ex-
dingly difficult, if not impossible, to make any
statement as to the precise value of radium treat-
ment in preventing or minimizing the danger of re-
currence, but as the majority of these cases have
suffered from severe and extensive and rapid pro-
gressive malignant disease, and the operators had
expressed grave doubts as to the possibility of re-
maining free from the disease for more than a few
months, the relatively slight proportion of recur-
rences so far recorded (19 per cent, does much to
justify routine postoperative radiation. It should
prove of special service in those malignant growths
in which it is found impossible to operate well be-
yond the appreciable area of the disease."
If since August, 1911, the time this Institute was
opened, such results have followed in cases regarded
as almost hopeless, the operator who carries his ef-
fort to the extreme limit of surgical possibility, can
feel one other opportunity remains of palliation, if
not of cure, sufficient to keep the fire of hope burn-
ing in the most unfortunate of mortals. What oper-
ator for the most favorable cases of malignant
growths can produce reliable statistics so favorable
— only 19 per cent, of recurrences — in cases almost
hopeless, for a similar period of time? It should
require no argument to establish the efficacy of
radium thus applied. It is of supreme importance
that postoperative radiation be applied soon, when
granulations are well established, and that one
should not wait for recurrence, when the chances of
control are greatly minimized. When it is remem-
bered that the traumatism of operation is a potent
factor in rekindling the fires of malignancy, precious
time will not be lost in waiting for such develop-
ments.
It is encouraging to note the surgical world is
awakening to the value of and necessity for post-
operative prophylactic radiation. This is evidenced
by a growing desire among operators in this country
for its early application. It is already appreciated
and used in the great European centers. It is par-
ticularly gratifying it is being used for such a pur-
pose in the great clinic at Rochester, Minn. These
facts give impetus to the prospect that such a pro-
cedure may in the near future become an established
routine surgical necessity. The period of time in-
tervening between radical operation for cancer and
postoperative prophylactic radiation— often months
or years — is a serious barrier to the best re-
sults radium offers. At this time a patient under
my care who was operated on two years since by a
surgeon of distinguished ability, dosages of 600
mgm. of radium offers faint hope of benefit.
A common procedure — that of taking a section of
cancer growth for diagnosis, independent of prepa-
ration for immediate laboratory diagnosis at the
time of operation, is a step fraught with grave risk
to the patient, by stimulating, as just referred to
a more rapid development. Make your Wassermann,
differentiate rational and physical signs, but rather
412
MEDICAL RECORD.
[Sept. 2, 1916
trust to clinical diagnosis than risk such a pro-
cedure. Exceptions to this rule are found in making
sections for deep-seated growths, the diagnosis of
which could not otherwise be formulated. The time,
the period of its use, are matters which demand ex-
perience obtained only by close observation and sea-
soned judgment.
Preoperative radiation has a place in cancer ther-
apy. In cases where the surgeon is in doubt as re-
gards removal of large growths, on account of tume-
faction and pronounced fixation, it is found the
gamma rays will promote absorption of effusion,
often non-malignant, by its decongestive influence,
diminishing infiltration, and glandular enlargement,
whereby mobility is increased, and the size of the
tumor and its relations determined.
Schmitz' says, "In fact, an inoperable uterine can-
cer may be made operable within about three or four
weeks by the use of 3000 or 4000 mgm. hours of
radium. The objective changes are restoration to
its former shape and disappearance of the infiltra-
tion of the perimetrium and recurrence of former
mobility — while the subjective changes are a cessa-
tion of hemorrhage and cachexia, and improvement
in the general condition of the patient." It re-
quires no prescience to appreciate how greatly im-
proved the chances of the patient are — say, in mam-
mary cancer — when operation is preceded by ab-
sorption or destruction of structures, which were
barriers to accurate dissection and primary union.
It may, and often does, determine the great question
whether to operate or otherwise.
The following cases illustrate the value of radium
in relieving pain and arresting hemorrhage:
Case I.' — H. W. C, male, age 56, came under my
care January, 1914, suffering from inoperable cancer
of the throat and tongue. He was weak, mildly
cachectic, suffering nagging pains which yielded to
radium treatment, amounting in all to 700 mgm.
hours up to June 30. At this time the pain was so
abated all opiates were discontinued, and he was free
from pain up to Aug. 30, the time of his death.
Case II. — Mrs. W., age 44, married, multipara, a pa-
tient of Dr. Stevens, of this city. Seen October 30.
1915, suffering from cervical cancer, with metastasis,
too late for radical operation. Two thermocauterv op-
erations were done during the continuation of the ill-
ness to lessen the areas of carcinomatous growth on the
ix and vagina, with marked benefit. After the sec-
ond thermocautery operation both hemorrhage and odor
were corrected by the occasional use of radium. Dur-
ing the earlier three months of treatment, radium was
applied at intervals aggregating 700 mgm. hours. Dur-
ihe las! three months and up to the time of her
death, no anodynes were required.
Case III."— Mrs. K., of Jersey City, multipara, aged
32, first seen September 1, 19] I. \dvanced inoperable
carcinoma of entire uterus, suffering hemorrb
cachexia, and great exhaustion, taking opiates. Com-
'■ing September, mil, rad twice a
week. In less than a month pain was almos
orrhage controlled, appetite and strength much in-
ed. From this time on until three weeks liefore
her death in January, 1915, she was almost without
pain. The potency of radium as a hemostatii
an analgesic was well illustrated in this case.
\se IV.' — Mrs. L„ aged 70, widow, mothe
me under my care February, 1911,
r of the cauliflower variety. Sin was
k, cachectic, with a prospect of living' six or eight
months. She had three thermocauterv op< each
'.veil by the use of radium; after "the secoi
tion almost complete healing took place. Recurrence
followed and radium was again used with partial h<
'"!-'■ She ed free from hemorrhage and pun
though m declining health until January, I ime
of her death. It is quite safe to affirm that th
of comfortable existence were afforded to her by 'ther-
mocauterv operations and radium.
V.- Mrs. \.. age i 57. Menopause aboul n
years previous. Some eight months past, afti
striking on upper portion of sacrum with contusion of
the abdominal wall over the right ovary, her physician
feared malignancy. Her health failed and ordinary ac-
tivities were almost suspended on account of localized
pain in the lower right segment of the pelvic cavity;
the right ovary was painful and tender, and there was
pain in the region of distribution of the sacral nerve,
attended with occasional loss of blood. Four applica-
tions of radium were made in August, 1915, in vagina
and crossfire from lower abdominal wall. Pain abated,
the uterine hemorrhage was arrested, and she recovered
average health.
A physician of this city reported to me recently
an advanced case of cancer of the stomach and pan-
creas in a woman aged seventy, where pain was only
mitigated by opiates. Immediately following an in-
travenous injection of 100 micrograms of radium
salt, there was complete relief of pain up to the time
of her death, six weeks later. This case, with
others, gives confidence in the belief that this newer
method will prove valuable. If radium possessed
only the single property of palliation it would justify
the enormous expense incident to its production.
It is stated as a general procedure that uterine
cancer, cervical or corporeal, without metastasis
should be removed by panhysterectomy, except when
coincident conditions make it impracticable.
Uterine Hemorrhage. — Perhaps no field of radium
therapy at the present moment is attracting so much
attention as its influence in uterine hemorrhage,
of diverse pathogenesis. This applicability em-
braces the hemorrhage due to uterine fibroma,
chronic polypoid endometritis, hemorrhagia me-
tropathica (with slight findings), in the bleeding
of young girls, and to degenerative and vascular
changes at the menopause. Kelley* recommends
thorough dilatation and curettage with applications
of radium made to the uterine cavity. These re-
sults may be augumented by cross-fire of radium in
the vagina, rectum, and over the abdominal wall.
Very serious bleeding occurs in uteri so small as to
make intrauterine application of radium impracti-
cable or impossible. Here radium cross-fire affords
opportunity for ample gamma-ray influence.
Three months since a woman of forty-eight — at
the menopause — was suffering from metrorrhagia
due to diffuse uterine fibroma. The size of the
uterus, which was symmetrically enlarged, was that
of two and one-half months' pregnancy. Intra-
uterine use of radium in a single dose of 800 mgm.
hours was administered. The uterus diminished 25
to 30 per cent, in size, and the hemorrhage was to a
large degree controlled so that she may not require
further treatment.
Case VI. — Mrs. M., aged 61, weight 235 pounds, ap-
parently in robust health. Passed the menopause eight
years since. For five years has (lowed occasionally fol-
lowing unusual exercise. First seen September 15,
1915, with her physician and another consultant. There
was an edematous condition of the cervix and uterine
body and portions of the vagina; depth of the uterine
cavity three inches. Suspicious of corporeal ma-
;ncy. curettage for diagnostic purposes was ad-
vised and declined. Between September 15 and October
13. three hundred and fifty-two mgm. hours of radium
applied with cross-tire at intervals. Xo recurrence
of hemorrhage until December IS, when it became pro-
Curettage was done and radium applied to the
ne cavity for live hours. Three times radium was
used up to March 2 for slight hemorrhage. On May 5,
over two months from last use, a more active hemor-
rhage appeared and 800 mgm. hours of radium were
applied in the uterine cavity, since which date there
has been no hemorrhage; health good and she goes
about as usual. While recovery is not anticipated,
there is reason to hope her life may be considerably pro-
longed. Her age. the low type of malignancy, her sus-
ceptibility to radium, as already demonstrated, combine
to strengthen the possibility.
Sept. 2, 1,16:
MEDICAL RECORD.
413
Case VII." — Mrs. J. M., aged 30. Compiled from the
official reports of my work during July, August, and
September, 1915, at the Norwegian Hospital, in the
service of Drs. Delatour, Skelton, and Graham. This
patient has serious metrorrhagia; she is very pale,
complains of weakness, headache, and backache. Ad-
mitted to Norwegian Hospital July 20, 1915. History
shows she has been bleeding for one year and four
months, the flow being practically constant. On admis-
sion she was markedly exsanguinated, heart sounds
weak, respiration 25, pulse 80 to 90, hemoglobin 40 per
cent. Pelvic examination revealed a moderately pro-
lapsed uterus and first-degree retroversion. Diagnosis
polypoid endometritis. July 21 to 24, serious uterine
hemorrhage, so marked as to require vaginal packing
to control it. July 25 packing removed, and Dr. Chase
introduced 25 mgms. of radium into the uterine canal,
which was removed after thirty-three minutes. July
26, considerable bloody discharge. July 31, enough dis-
charge to cause spotting. August 1 and 2, no bleeding.
August 22, slight discharge. August 23, bleeding-
stopped. August 24, discharged, to return for observa-
tion by request. General condition improved, hemo-
globin 70 per cent. The patient began to feel better
and increased in strength from the very date she was
given radium. Up to October 7 she had not returned.
The extreme weakness of this patient forbade any
heroic measures, and even curettage (much more
hysterectomy) was contraindicated. At the time
the radium was used she passed into a condition of
syncope, and the extreme weakness forbade any
effort at cervical dilatation. Recent inquiry early
in May gives the belief that the woman is in com-
fortable health and is employed as a janitress.
Case VIII. — Official report of radium treatment at
the Methodist Hospital, service of Drs. Spence and
Graham. Mrs. E. S., aged 47, multipara. Complains of
bleeding from vagina; health has always been excellent.
Menstrual history shows she was regular until June,
1914; duration of flow five to six days; no dysmenor-
rhea. Did not menstruate from June, 1914, until
March, 1915; was not pregnant. This period was one
of normal duration. Did not menstruate again until
September, 1915, and continued to flow until October 30.
Began latter part of September with scant bloody dis-
charge, which later became profuse, with no mem-
branes. Since she came to the hospital she has had
very little bleeding, but she bled some November 5. The
next day radium treatment was applied by Dr. Chase,
and she has had no bleeding since. The cervix was
found to be apparently normal but the uterus was very
small, about the size of an English walnut. Radium
was used but once and then by cross-fire in the vagina.
Information received June last confirms the belief she
is in fairly good health.
Case IX. — Bone Carcinoma. — Miss L., of Buffalo, aged
20, was seen by me April, 1915. She had been an invalid
for seven years from involvement of the left hip and
later the left ilium. Her first physician regarded the
case as rheumatism, and treated it accordingly. Later
another physician diagnosticated it tuberculous, and she
wore plaster casts at the hip without relief. At this
juncture an .r-ray picture was taken showing enlarge-
ment of the upper portion of the femur and ilium. A por-
tion of bone was removed from the great troachanter
and the laboratory diagnosis established the presence of
carcinoma. She entered my service at Bethany Deacon-
ess Hospital in this city May 30, 1915, and remained
until July. During this period radium was applied
twenty-five times at varying intervals, amounting in
the aggregate to 2650 mgm. hours. Once it was buried
behind the trochanter ma:or and once over the ilium
above Poupart's ligament for a period of twelve hours.
Her health was improved and she returned to her home.
There has. been some fluctuation in her condition
since that period, but under date of May 30, 1916,
she reports herself very greatly improved. Is able to
go down stairs, sit in hammock, and quite satisfied to
remain as well as she is. This patient should have more
radium.
Case X.1" — Sarcoma. — Mr. H., aged 52, came under
my care at Trinity Hospital December, 1914, for radium
treatment, after removal by Dr. Campbell of a melanotic
sarcoma the size of a hickory nut at middle third dorsal
aspect of right arm, which refused to heal. Radium
was applied three times, healing promptly followed, and
at this date there is no recurrence.
Briefly I refer to two other cases of sarcoma oc-
curring in the joint experience of Dr. Bissell and
myself in St. Vincent's Hospital two years since.
One patient, C. V.,' in whom hip and thigh
were extensively involved from violent traumatism,
became so much worse that death seemed imminent,
but recovered after three applications of radium
buried in the thigh, so as to resume laborious work
for a year or eighteen months. This case has
attracted much notice from various sources, and is
mentioned by Coley in his article on Sarcoma of
Long Bones in the Annals of Surgery, 1914. He
has suffered relapse — has drifted about to different
hospitals. At present he is recovering from a
radium burn, but apparently will be able to resume
work when healed. The other case," one of recur-
rent sarcoma over the scapula, healed promptly.
The patient removed West, and has not been heard
from since.
Epithelioma is more easily mastered than most
forms of cancer, particularly the basal cell variety.
If the ulcer occurs near or after middle life, par-
ticularly if it is of the cutaneous variety, and not of
too long standing, or not consisting of old and well
differentiated cells occurring on mucous surfaces,
they are more refractory, but with wise manage-
ment cases are recoverable. The use of needles con-
taining radium plunged into the tumor, whether in
the throat, tongue, or tonsils, and in many external
large growths, has brought about improvement.
This form of using radium is only in its infancy,
but promises advantages over other methods, in
properly selected cases, and we are constantly dem-
onstrating its utility in the Radium Sanatorium of
New York City.
Mammary epithelioma,' if seen and attacked be-
fore metastasis, yields results often satisfactory. I
reported such a case in a woman aged 80 having
cancer of the right breast, who was altogether re-
lieved in 1914, and remained in perfect health since.
I have experienced great satisfaction in observing
recently the results of radium in large cutaenous
epitheliomata of the face disappearing under one,
two, or three treatments. During the past year a
physician of this city was treated by me for epitheli-
oma of the hand. Healing was complete after three
applications. Another case, an Italian fish monger,
had epithelioma of the face, so offensive that patrons
refused to deal with him. It disappeared entirely
after three radiations. A physician of this city' suf-
fered from pronounced hyperkeratosis of the hand
due to ar-ray burns, a tumor the size of a chestnut
forming between the second and middle fingers on
the dorsal aspect. There was no healing after opera-
tion, but recovery followed almost without scar after
three applications of radium. This case illustrates,
paradoxical though it may appear, what is amply
confirmed by authoritative observation, that .r-ray
cancer is curable by radium. Tousey" gives personal
experience to the usefulness of radium in combat-
ing hyperkeratosis resulting from .r-ray exposure.
The field of radium therapy is so broad that only
points can be considered here and there. My ex-
perience in treating inoperable cancer of the rec-
tum is not altogether discouraging, particularly if
it is seen early, and is of the annular variety. When
radium does not effect a temporary cure, it often
inhibits growth and diminishes pain. About two
years since,7 a woman, aged 50, came under my care
after operation for carcinomatous degeneration of
a rectal polypus. Six applications of radium of fifty
to one hundred mgms. each were made within a
414
MEDICAL RF'.CORD.
[Sept. 2, 1916
month. The growth was two and one-half inches
from the anus and involved three-fourths of the
circumference of the gut and was of the annular
variety. She remains in good health. Last August
another similar case, not yet reported, appeared in
a woman 45, who, at the time, was suffering from
what was feared to be malignant ulceration of the
stomach; she was confined to her bed and greatly
exhausted. Radium was used as in the former case.
Amelioration of the general condition followed and
with it relief of the gastric symptoms. At the end
of a month the growth had disappeared and with it
other coexisting troubles. Recently she is in good
health.
Another inoperable case of rectal cancer* was re-
lieved and life prolonged which is worthy of men-
tion.
The possibility of intravenous injections of ra-
dium salt and the use of radium water holding in
solution radium salt, or emanation, in chronic rheu-
matoid arthritis, arthritis deformans, chronic rheu-
matism, arterio-sclerosis with high blood pressure,
with or without renal or hepatic complication, and
neuritis with faulty metabolism and inadequate ex-
cretion, might occupy this whole evening. Perhaps
in the whole field of radium therapy the results are
nowhere more surprising and startling than in this
class of cases. Coincident with the use of radium
in this manner are evidenced an increase in red
blood corpuscles and hemoglobin, and augmentation
of nervous and muscular vigor, in many cases wholly
outside of ordinary experience. Few unprejudiced
observers can reach any other conclusions. Evi-
dence is not wanting" that it is possible to reduce
the blood pressure not only temporarily but in a
proportion of cases permanently.
It may be noted"' that a practical field for the use
of radium is found in tuberculous glands in which
the cosmetic results are most satisfactory. The
same results are frequently seen in goiter."
The demand for larger practical knowledg of
radium and its uses, forces itself on our considera-
tion, as the subject expands in breadth and interest.
Among the multiple questions propounded, not yet
elucidated, is the problem how to apply radium so
as to secure the maximum of good results. Up to
this time the matter of screening without large
and cumbersome covers has been an embarrassment
in securing ideal results. Apparently this prob-
lem is now receiving a satisfactory solution in the
Radium Sanatorium in New York City. Here we
use hollow needles, holding smaller or larger quan-
tities of radium effectively screened which can be
plunged directly into benign and malignant growths,
large or small. Particularly is this applicable in
applying radium to the tongue, tonsils, and pharynx.
owing to difficulty experienced in keening the ap-
plicators in proper position. In larg ■ growths,
needles of varying length can be introduced at reg-
ular distances and varying depths, so as to main-
tain an effective cross-fire, not only, but to reach
large areas at greater depths thereby affording ade-
quate gamma radiation.
n massive quanti radium are applied
externally for deep penetration of the liver, spleen,
pancreas, and other intraperitoneal viscera, this
method has an effectiveness hitherto impossible.
In the present state of our knowledge the outlook
for the mastery of cancer by one method has not
been realized. The surgeon with his scalpel, the
of radium and x-ray, the application of cold
i rid heat, and the destruction of tissue by chemical
agents are all curative in their own .sphere, but
leave more to be desired than has been accomplished.
I have in this paper shown how one or more of
these agents could follow each other with advantage
and effectively, but until hearty co-operation and
reciprocity are established, the highest ideals now
possible in the treatment of cancer will lack ac-
complishment. For such co-operation my appeal is
made to this body of influential and distinguished
members, and to the entire medical profession, until
such time as research work, ably and persistently
carried forward, reveals a positive antidote.
REFERENCES
1. Miller, C. Jeff: Surgery, Gynecology and 06-
sti ti ics, April, 1916.
2. Nahmmacher: Strahlen Therapie, Vol. IV.
3. Foveau de Courmelles: Journal de Physique
Therap., Vol. II.
4. Senmitz: "Radium and Mesothorium in Uterine
Cancer," Surgery, Gynecology and Obstetrics, January,
1915.
5. Chase: "Report of the London Radium Institute,
1914," L. I. Medical Journal, June, 1915.
6. Chase: N. Y. Medical Journal, January 9, 1915.
7. Chase: American Journal of Obstetrics, January,
1915.
8. Kelly: Journal, of the American Medical Associa-
tion, August 22, 1914.
9. Chase: L. I. Medical Journal, December, 1915.
10. Chase: L. I. Medical Journal, June, 1915.
11. Tousey: N. Y. Medical Journal, July 8, 1916.
12. Field: Medical Record, January 22, 1916.
9S6 Park Place.
ECLAMPSIA, A PREVENTABLE DISEASE.*
i:v J( IHN W. WINSTON. M D.,
NORFOLK, VA.
In order for this to be a preventable disease there
must be hearty cooperation between physician and
patient. It is the duty of a pregnant woman to her-
self, as soon as she becomes pregnant, to present
herself to her physician for a thorough examina-
tion; and it is the duty of the obstetrician to his
patient to make himself thoroughly acquainted with
her physical condition.
The time has passed when a woman, because of
modesty, should take for granted that she can man-
age her own affairs when pregnant, until the time
for labor, and the obstetrician is grossly unfair
who consoles his patient with the idea that every-
thing will go along smoothly without first knowing
her physical condition.
The physician who does good obstetrics to-day
must have recourse to the blood-pressure test, as it
ranks ahead of uranalysis, and it is on this point,
which is often neglected, that I wish mostly to
dwell.
Von Basch, in 1881, was the first to use the
sphygmomanometer for the clinical study of blood
pressure. Flint, in 1886; Delafield, in 1891; Sten-
gel, in 1899.
The first reports of observations on human blood
pressure were made in 1903, by Richard C. Cabot,
and a more detailed report in 1904. Janeway first
contributed to the literature of the subject in 1906.
The October, 1915, number of the Johns Hopkins
Hospital Bulletin contains an up-to-date contribu-
tion to the subject by Janeway.
With the stethoscope over the brachial artery, the
pressure is increased around the arm until all sound
stops, when it is gradually reduced until a sharp
tap is first heard, which marks approximately the
*Read before the Norfolk County Medical Society,
April 24. 1916.
Sept. 2. 1916J
MEDICAL RECORD.
415
systolic pressure. The pressure is still further low-
ered until all sound disappears, when it is again
gradually raised to the point where the first tap is
audible, and this marks approximately the diastolic
pressure. The difference between the two is called
the pulse pressure.
Diastolic pressure is more constant than systolic,
and, as it measures the peripheral resistance, it
would seem to be a more accurate index of either
high or low tension.
In high arterial tension, a large pulse pressure
occurs which seems to be compensatory, while a low
pulse pressure is the sign of a failing heart. A
pulse pressure below 30 mm. is low, and one above
50 mm. is high.
It is important then to know all three pressures
in a beginning pregnancy. As the distance between
the systolic and diastolic widens as the pressure
goes up, it would seem safer to trust to the systolic
in pregnancy until more observations are made with
the diastolic.
The systolic pressure ascertained by palpation is
from 5 to 10 mm. lower than that by auscultation,
and this is the method most used to find it, and the
one referred to in this paper.
Early toxemia is indicated by a rise in blood
pressure, and any departure from a normal metab-
olism is shown, and shown before any physical sign
or any noticeable change in the urine.
Blood pressure should be taken from the first, in
the pregnant woman, so as to know the pressure
normal to the individual and to be able to watch any
change.
As soon as pregnancy is established the urine
should be examined and the blood pressure taken,
and continued every two weeks until the last month
and a half, and then at least once a week. A record
should be kept, and signs of danger should shorten
the intervals of examination.
John C. Hirst, in a report of 100 cases, found the
average systolic pressure 118 mm. up to 7% months,
after which there was normally a rise of 8 or 10
points. According to H. C. Baily, individual read-
ings vary to the extent of 30 mm. without having
any significance. Blood pressure during labor, in
normal cases, averages a rise to 140 and 150 mm.
John C. Hirst says that a high and constantly
rising blood pressure always precedes albuminuria
and all the constitutional signs of an impending
eclamptic attack.
Baily says that convulsions may occur and the
blood pressure be no higher than 155 mm. Hirst
says that 192 mm. is the highest blood pressure he
ever saw without eclampsia, and that the highest in
eclampsia was 320 mm. Both Hirst and Baily say
that blood pressure in the early toxemias (persist-
ent vomiting) is often low.
As far as it is possible to lay down any definite
rule, we may say that a pressure below 125 mm.
can be disregarded ; a pressure from 125 to 150 mm.
needs careful watching and moderate treatment ; a
pressure of 150 mm. which was at the beginning
100 mm. is more serious than one that was 130
mm. at the start. A pressure above 150 mm. needs,
usually, active eliminative treatment, and if it per-
sists in climbing higher it will, in all probability, re-
quire the induction of premature labor.
F. C. Irving reports that the blood pressure in
5,000 cases ranged from 80 to 225 mm.: 400 of this
series were never below 100 mm. or above 130 mm.
F. S. Newell found from 100 to 130 mm. a normal
range in his cases. Haussling puts the average
from 100 mm. to 135 mm. Irving says a lower
pressure than 100 mm. occurred in 9 per cent, of
his cases, and that it has little significance, but is
an individual peculiarity. All of the cases he
classes as toxemia had, at some time, both albumin
and elevated blood pressure, and he applies the term
toxemia to those cases having at some time both
manifestations, with the addition of one or more of
the following signs or symptoms : Headache, dis-
turbance of vision, persistent vomiting, epigastric
pain, antepartum bleeding, and edema.
The specific gravity of the urine varies with the
intake of water, but, if studied, is of the utmost
importance, a persistently low reading in a pregnant
woman being a dangerous sign. Irving found albu-
minuria and toxemia most frequently in women
under 20, and high pressure in them a more serious
sign than later in life. In elderly women, a high
pressure was more common, with seemingly less
importance as an evidence of toxemia. Between 20
and 30, he found that elevated blood pressure and
toxemia were least common, making this decade the
safest for child-bearing.
Albuminuria occurs oftener than elevated press-
ure, but is at times of no significance. Whenever
albumin is found the urine should be centrifuged,
and examined under the microscope to determine the
cause.
Irving also finds elevated blood pressure is often
the first sign of toxemia. The majority of his pa-
tients showed albumin and high blood pressure at
the same time. Elevated blood pressure preceded
albuminuria in 50 of his cases, accompanied it in
113 cases, and followed it in 24 cases. One patient
in 32 with a blood pressure of 130 to 140 mm.
had toxemia, and one in 11 with pressure 140 to 150
mm. had it. Between 150 and 160 mm. the fre-
quency of toxemia suddenly rose to more than one
in three; while one-half of all between 160 and 180
mm. had toxemia, all above 180 mm. had toxemia.
The abrupt rise in albuminuria and toxemia above
150 mm. shows that the danger point lies near here.
A rising blood-pressure curve is a better copy of
the toxemia tracing than the albuminuria line, and
it is fair to say that elevated pressure is more com-
monly an index of toxemia than albuminuria, and
is apt to be an earlier sign. Newell emphasizes the
fact that a rapid rise from a low level is more
dangerous than a high stationary pressure.
Irving, in his report of 5,000 cases, found 64
patients suffering from toxemia, but only three who
faithfully followed directions had eclampsia. All
patients showing albuminuria, or a blood pressure
above 130, were at once put on a meat-free diet, with
restricted salt and increased amount of fluid, and
was directed to take large doses of magnesium sul-
phate and return to the clinic in a few days. Should
evidences of toxemia develop, the woman is admit-
ted to hospital and put to bed, and the same treat-
ment is more vigorously carried out. Should she
fail to improve, and the condition grow worse, labor
should be terminated.
The eliminative treatment was successful in 29
cases, and in 11 labor was induced. Nine patients
out of 4,472, the number actually delivered in Irv-
ing's series, developed eclampsia, which is one in
497. Five were in primipara? and four in multi-
para?.
Six of the nine did not report at the clinic for one
month before onset of seizures, and two of these
died. Three eclampsia cases in all died. Only one'
had convulsions with a pressure less than 160 mm.:;
416
MEDICAL RECORD.
LSept. 2, 1916
her highest point was 140 mm., and the last reading
of this patient was only 110 mm. This case again
shows that a rising pressure from a low level, even
though it does not pass the arbitrary danger point,
may be a sign of impending danger. Eight had
both albumin and increased pressure.
Irving's statistics show that only one of every
1,591 pregnant women died with eclampsia.
The death reports of the city of Norfolk show
that in the last five years we have had 46 deaths
from eclampsia, while 7,159 births are all that have
been reported. It is claimed that one-third more
births occur than are reported, the discrepancy be-
ing the fault of midwives, mostly, and some careless
physicians. This would run our birth rate to 10,000,
while the deaths from eclampsia would be the same
(46).
As reports stand, we are credited with one death
from eclampsia in every 156 births, and this is ap-
proximately about ten times as much as it should
be. If we are given credit for the full number of
births that actually do occur, then we have one
death from eclampsia in every 218 cases, which is
seven times as high as hospital cases show. In this
city there are a large number of midwives; here I
think lies the cause of this high death rate, as they
pay no attention to anything except tying the cord,
and filth. The physician is called only in time to
sign the death certificate. These figures show that
it' they in any way benefit mankind they also kill
a lot of women. It is plain, also, that it is every
physician's privilege, as well as his duty, to report
•every birth.
Reports of two cases in my practice in last six
months in which premature labor was induced are
as follows:
Case I. — Mrs. C, age 28 — one child, boy, twelve years
abortion three years before, due to patient using
dirty catheter, causing violent infection and rupture
>f right tube with local peritonitis. Abdominal section
was performed by the author, removing right tube and
ovary, also appendix which was involved by exudate,
and free drainage was instituted. The incomplete
iimrtion was completed and the uterus was packed
with iodine gauze.
The early part of the pregnancy was accompanied
by some pain and dragging in the lower abdomen and
nausea with vomiting for several months. A sister
died in an eclamptic attack. Her blood pressure up to
7% months was 125 to 130 mm., and a urine entirely
free from albumin and casts. At this time the ankles
began to swell and the patient had slight headache,
with slight trace of albumin in the urine, the blood
pressure was 140 mm. Diet, forced fluid, and salts
with patient in bed, caused improvement, but in the
course of two weeks the symptoms returned and per-
sisted in spite of eliminative treatment, and the pres-
sure ran up. I had seen this patient nearly dead once
and did not propose to take another chance, so I dilated
the cervix by the Harris method six different times.
once under ether and three times with chloroform. The
patient delivered herself three days after the first
dilatation was started. The time between dilatal
was about six hours, and chloroform was substituted
tor ether, as we could not yet her to sleep with the
first. Delivery at home of patient
This woman did not have a single vaginal douch.
and there was not a trace of infection. The child
was born 20 days ahead of time, with no harm to
either mother or child. Eclampsia might not have
occurred, but no harm was done, and it is better to
be on the safe side.
A woman who has the degenerative cl
eclampsia, even though she escape the ns.
is not a well woman for a long time, if ever the
same.
Case II.— Mrs. M.. age 35— two child nd 10.
No other history. Early pregnancy was accompanied
by only slight nausea. The woman took everything
her so-called friends suggested to bring about an abor-
tion. Everything progressed normally, however, up to
nearly the ninth month, when suddenly she became
edematous and the blood pressure, in spite of elimina-
tive treatment, climbed rapidly to 170. There was no
albuminuria, but the specific gravity of the urine
dropped to 1008 and the twenty-four-hour amount was
small.
The patient was taken to hospital and the cervix was
dilated every three hours by the Harris method, five
times in all, the first three times without an anesthetic
and last two with ether. Patient delivered herself
twenty-four hours after beginning induction; morphine
Vs gr. with hyosine 1/200 gr. was given six hours be-
fore delivery. The child was born with the cord
around its neck, which was slipped over the head. The
baby very much cyanosed and refused to breathe for
thirty minutes. Artificial respiration and breathing
into and out of lungs through gauze finally started the
breathing. No vaginal douches were used and an intra-
uterine swab on the third day, because of high tem-
perature, proved the track to be absolutely sterile both
by smear and culture.
This woman was delivered 30 days before time,
but made an uneventful recovery, and the child is
perfectly normal.
BIBLIOGRAPHY.
Billings, Frank: Practical Medicine Series, Vol. I.
Year Book, 1916.
Hirst, John C: New York Medical Journal, June 11,
1910.
Bailey, H. C: Surgery, Gynecology a?id Obstetrics,
Vol. V, p. 985.
Newell, F. S.: Journal A. M. A., January 30, 1915,
p. 393.
Haussling: Journal Med. Soc, New Jersey, 1912, Vol.
iX, p. 242.
Irving, F. C: Journal A. M. A., March 25, 1916, Vol.
LXVI, No. 13.
PELLAGRA: ITS ETIOLOGY AND TREAT-
MENT *
By J. F. YARBROUGH. M.D..
COLUMBIA. AI.A.
On April 10. 1916, the writer published in the
Southern Medical Journal an article on Pellagra, in
which the etiology and treatment of the disease were
discussed at length. In this paper I said: "Pella-
gra is an autointoxication, the result of a carbo-
hydrate diet in which there is practically no protein.
This carbohydrate or alcoholic material, when taken
into the stomach, is quickly converted by the normal
heat of the body into what distillers call 'sour
mash.' The production of this 'sour mash' three
times daily, for weeks and months, finally so crip-
ples the metabolic activity as to permit this fer-
mented material to be taken into the circulation
without the necessary chemical changes. As a re-
sult, the victim's metabolic function is practically
destroyed by eating alcohol, and the result is the
varied and complex symptoms we call pellagra."
After a more thorough study, and an intimate hos-
pital acquaintance with the disease, and after many
clinical experiments conducted in the hospital, I am
thoroughly convinced that the correct etiology of
the disease has been discovered.
The symptoms of pellagra are so familiar that it
is unnecessary to enumerate them here; however,
it might be well to call your attention to the fact
that cases occur in which no dermatitis appears,
and they may be easily overlooked, and the direst
-equences follow.
The treatment of pellagra may be considered un-
Read by invitation before the State Medical Associa-
tion at Mobile. Ala.. April 19, 1916.
Sept. 2, 1916]
MKDICAL RECORD.
417
der two heads — dietetic and medicinal. Too much
stress cannot be placed upon the necessity of imme-
diately eliminating all carbohydrate or alcoholic ma-
terial from the diet. I wish to insist with all the
earnestness at my command that the carbohydrates
must be eliminated if recovery is to be expected.
All treatment will prove futile so long as small
quantities are allowed. I do not believe pellagra
will ever be successfully treated by the general prac-
titioner, because the diet cannot be controlled in the
home. Contrary to the opinion of physicians in
whom great confidence may be placed, diet alone is
not sufficient to bring relief to these sufferers. A
mild case of recent origin may be relieved in this
way, but many of our patients would have gone
promptly to their rewards if the diet had been the
only means employed. The Gibraltar on which we
mainly rely is dilute nitric acid, twenty to thirty
drops in a glass of water, one hour before meals,
or as nearly on an empty stomach as possible. Dr.
Goldberger, in the Journal of the American Medical
Association, February 12, 1916, throws out this
challenge: "Hereafter, the clinician who would at-
tribute therapeutic value to any drug or other rem-
edy in the treatment of pellagra, should be prepared
to show, what has not heretofore been done, that
the curative effect claimed cannot be attributed to
the diet."
I accept the challenge, and submit the following
evidence :
Case I. — Mr. S. J., white, age 47, height six feet,
weight one hundred and twelve pounds. Admitted Sep-
tember 15, 1915, exhibiting the following symptoms:
Oral cavity typically pellagrous; ulcers covered inner
surface of lips and under the tongue, fissures in the cor-
ners of the mouth, salivation. Characteristic dermatitis
on the dorsal surface of the hands, forearms, face and
neck. Severe burning of the hands, feet, and stomach.
Profuse diarrhea, stool by count every forty minutes;
diarrhea of more or less severity had persisted for the
past three years. Arthritis of both ankles: at intervals,
alarming dyspnea, and insomnia. Systolic pressure 180.
Patient very weak, and could talk but little with great
effort. Profoundly anemic — not a trace of pink shown
anywhere. This man. not from choice but from neces-
sity, had been living for the past six months on protein,
raw eggs and sweet milk, as an ulcerated mouth would
not tolerate solid food. On entering the hospital he was
given two raw eggs and eight ounces of sweet milk
every three hours, and at midnight, simply continuing
his former diet. Medicinally he was given thirty drops
of dilute nitric acid in a glass of water three times daily,
on as nearly an empty stomach as possible. After the
third day his stools were never more than two in twenty-
four hours so long as he remained in the hospital. By
the end of the first week, uicers and salivation had dis-
appeared. At this time the tips of his ears, nose, lips,
and nails were distinctly pink, — the anemia disappeared
as if by magic. He was dismissed at the end of the
fifth week, seemingly well, having gained thirty-two
pounds. Ninety days from the date of his dismissal
he weighed one hundred and seventy-five pounds, and
is now doing hard work in the field every day.
Case II. — Mrs. G. L., white, age 27, height five feet
two inches, weight ninety pounds. Admitted December
1, 1915. Physical examination showed oral cavity typ-
ically pellagrous. Characteristic dermatitis on dorsal
surface of the hands, forearms, and face. Constipation,
insomnia, melancholia, and profound anemia. This pa-
tient was in the hands of a competent physician, who,
seeing tne result of Dr. Goldberger's experiment with
the convicts of Mississippi, placed this patient on a
strictly protein diet, and she remained thereon until
her life was despaired of. On entering the hospital the
diet was continued, and the acid given, with the result
within one week her ears, nose, lips and nails were dis-
tinctly pink. She was dismissed seemingly well De-
cember 25, having gained fifteen pounds, anemia gone —
in fact exhibiting every symptom of health.
Case III. — Miss M. R. , white, age eighteen, height
five feet, weight ninety pounds. When taken ill in the
Fall of 1913, she weighed one hundred and sixty pounds.
This patient, during January and February, 1916, was
treated in one of the best hospitals in the South, in a
distant State. She remained there on diet treatment
until her condition was regarded as hopeless, and sent
home to die. On entering the hospital March 18, 1916,
she presented the following symptoms: Characteristic
dermatitis on hands, forearms, face, and dorsal surface
of feet and lower limbs; oral cavity pellagrous, with
ulcerations. Diarrhea, frequent fetid stools. Profound
melancholia. Systolic pressure 90, very anemic, with
a pulse of 40, almost moribund. She was put on the
diet of raw eggs, milk, and orange juice. Thirty drops
of dilute nitric acid in a glass of water was adminis-
tered three times daily, and at midnight. Since the sec-
ond day, her stools have not been more than two in
twenty-four hours. At the end of the first week her
mental condition had wonderfully improved, with nails,
ears, nose, and lips showing pink. She is now in the
hospital gaining more than half a pound every day.
Case IV. — Mrs. J. T. , white, age thirty, presented
herself for treatment December 15, 1915, exhibiting the
following symptoms. Oral cavity pellagrous. Charac-
teristic dermatitis on dorsal surface of hands and fore-
arms. Diarrhea; nervous and irritable; very weak and
anemic. This being an intelligent woman and living
only a block from me, it was considered an ideal case
on which to test the diet treatment. December 15, 1915,
she was put on a strictly protein diet — milk, butter,
eggs, beef, peas, bean bread, and vegetables. April 12,
1916, she presented the following symptoms: Oral cav-
ity improved, tongue still had slick glazed appearance;
constipation, no gain in weight, nervous symptoms im-
proved; still weak and anemic.
Diet certainly did not relieve these patients, nor
do I believe any quantity of the richest proteins the
earth affords will alone produce such results as we
have obtained in Cases I, II, and III. If time al-
lowed, we could produce a great mass of additional
evidence in support of our contention.
Of the more than one hundred cases treated in
the hospital it has never required more than four
weeks to seemingly relieve our uncomplicated cases.
They regain their flesh, the anemia disappears, and
they return to their several vocations. Dr. Deeks
had a similar experience in the treatment of pel-
lagra while in charge of the Ancon Hospital, in the
Canal Zone.
If Dr. Goldberger's theory is correct, diet could
not have been responsible for the rapid recovery of
these patients, because he says in the article re-
ferred to : "Such observation as I have been able
to make strongly suggest that the real recovery,
from an uncomplicated attack may not take place
until after a minimum of about three or four months
of full feeding of fresh animal proteins and le-
gumes." Dr. Goldberger here admits that it re-
quires a minimum of three to four months to obtain
definite results from the diet treatment. If by the
addition of nitric acid we obtain the same results
in one-fourth of the time, it seems clear that this
drug is a valuable adjunct in the treatment of the
disease.
The following is abstracted from the article re-
ferred to in the Southern Medical Journal: "Prob-
ably the most important reason why this drug
should be employed is the fact that the blood is
found to be acid. The hemoglobin of an acid blood
carries but little oxygen, hence the acute progressive
anemia that quickly follows an attack of pellagra.
The administration of nitric acid renders the blood
quickly and positively alkaline. At once it assumes
its normal function of carrying oxygen, and the
anemia disappears as if by magic."
To prevent the possible conveyance of an errone-
ous impression, it might be well to explain what is
meant by an acid blood. We all know that a great
departure from its normal alkalinity would prove
quickly fatal. However, there are conditions in
which the blood very nearly, if not quite, reaches a
418
MEDICAL RECORD.
LSept. 2, 1916
faint acidity. And I refer to this condition when
speaking of an acid blood. Dr. George W. Crile
recognized this condition in an article entitled, "The
Kinetic Drive," recently published in the Journal of
the American Medical Association, in which he
says: "Oxygen is supplied by the lungs. If the
blood be acid, oxygen cannot be carried by the
hemoglobin. Energy transformation depends, there-
fore, on the maintenance of the alkalinity of the
blood."
In an editorial article in the same journal, on
"Alveolar Air and Acidosis," the condition of the
blood I have tried to describe as found in pellagra
is recognized, for the writer says: "Finally, how-
ever, the reserve supply of bases in the tissue is ex-
hausted, and the increased acidity of the blood stim-
ulates the respiratory center, causing increased
aeration and a decrease in the carbon dioxide ten-
sion of the blood. The chief variations depend
largely on the consumption of carbohydrate, which
raises the amount. By virtue of the strong auto-
matic regulation of the blood reaction, and the in-
creased aeration of the blood resulting from the
respiratory stimulation, the increased amount of
non-volatile acid in the blood tends, therefore, to
decrease the amount of carbon dioxide in the blood,
and hence in the alveolar air. This is the condition
called acidosis, and it is characterized clinically by
air hunger, or dyspnea, stupor, delirium, vomiting,
convulsions, and finally coma." The writer here
describes the exact symptoms we find in many fatal
cases. He also says that the consumption of the
carbohydrates increases the acidity of the blood.
This is the proposition for which we are now con-
tending, and have contended for a long time.
Blood, deprived of its normal supply of oxygen,
must of necessity deteriorate rapidly, and with it
all of the normal functions of the body, particularly
that of digestion. Alkalinity restored, the intake of
oxygen quickly restores the sick and dying cor-
puscles. They spring into new life, giving tone and
vigor to the entire body. Metabolic activity is
regained, and the anemia rapidly disappears.
I frankly admit that I do not understand by what
process nitric acid transforms an acid into an alka-
line blood. One of America's foremost biological
chemists is now bending his efforts to solve the
problem. However ignorant we may be of how this
transformation is accomplished, it does not alter
the fact that it is done. The departure of the blood
from its normal alkalinity in this disease is, I be-
lieve, the most important discovery made in the
study of pellagra, because I am thoroughly con-
vinced the carbohydrate diathesis referred to in
my former article is the common parent of a num-
ber of allied disorders: Pellagra, muscular and ar-
ticular rheumatism (other than gonorrheal or spe-
cific), nephritis, neuritis, cystitis, vaginitis (other
than gonorrheal), leucorrhea, acne, eczema, and all
allied conditions, are, I believe, the result of a car-
bohydrate diet. Nitric acid, together with proper
food, is the golden key that opens wide the door to
health and happiness.
Causes and Treatment of Perthes's Disease. — 1 c.
b'idner ur^es that osteochondritis deformans juveniles
i:: really a mild infection of hematogenous origi
tie neck of the femur at the epiphyseal line: that the
:al treatment to hasten recovery and limit destruc-
tion is the clearing out of this focus, and that mechan-
ical treatment, which precludes weight-bearing- should
be faithfully carried out until the normal structure of
the tissues of the head and neck of the femur has
completely restored, in order that deformi'y may lie
avoided. American Journal of Orthopedic Surgery
THE WASSERMANN REACTION IN TWO
HUNDRED AND FIFTY-ONE TUBERCU-
LOUS DISPENSARY CASES.
By W. l:,VY JONES. A.B., M.D..
SEATTLE. WASH.
These were unselected cases coming to the public
tuberculosis clinic of the city of Seattle with a
ready-made diagnosis of tuberculosis. Seventy-
three gave a positive reaction and one hundred and
seventy-eight a negative one. The percentages by
sexes were approximately the same in both the
positive and negative reactions; i.e. 70 per cent,
male and 30 per cent, female. The degree of the
reaction in either sex is shown in the following
table, -f - -+- denoting complete inhibition of hemo-
lysis.
+ ++ +++
Male . . .A 17 12 24
Female 4 3 13
Total 21 15 37
This gives 14 per cent, of all cases a + + + re-
action, 20 per cent, a -f- -r or stronger, and 29 per
cent, a + or stronger.
The cases were divided into two classes; 189
coming from the public sanatorium where a Was-
sermann is a part of the routine examination, and
the other 02 from the outpatient department where
blood was taken to clarify the diagnosis. Among
these 62 ; 30 were proven non-tuberculous, and of
this 30; 19 or 7.6 per cent, of the total 251 were
not tuberculous, but frank syphilitics masking as
tuberculous. If these non-tuberculous and the in-
complete cases from the outpatient department
are eliminated and only the 189 routine cases
counted; the figures drop to 11 per cent. +-^ +
positive, 17 per cent. -| — h or stronger, and 25 per
cent, -f or stronger.
Two cases showed a hilus involvement only ; a
characteristic sign of pulmonary syphilis; but
both of these had bacilli in the sputum as well as
a positive Wassermann. Two of the positives were
diagnosed tuberculosis on the physical findings
and general symptoms, in spite of repeated neg-
ative sputum examinations, and one was treated as
presumptive tuberculosis though the presence of
this disease could not be substantiated even by
physical findings. This 1 per cent, of the total gave
more than a suggestion of lung syphilis or medi-
astinitis.
Ages varied from a sixteen-year-old girl giving
a sfhgle + reaction who had signs of congenital
lues, to a man of seventy with a -f- -f- blood and ab-
solutely no symptomatic signs. The average age
was 33 years.
Old scars, nerve signs, and symptoms, and the
like were strangely absent, or could be directly
attributed to the tuberculosis. Palpable post-
cervical and epitrochlear glands, our most constant
sign of syphilis, were almost invariably present in
both positives and negatives, probably due to the
emaciation, as all cases gave a history of loss in
weight.
Occupations told nothing more than the occupa-
tions of a like number in the general charity dis-
pensary.
Histories were absolutely worthless, as the wo-
men denied everything with vigor, and the men
fearful of being refused treatment, admitted
chancres in only a few cases. Those admitting a
Sept. 2, I916J
MEDICAL RECORD.
41&
probable infection were most often the weakly pos-
itive or negative reactions. One point in the family
history might be considered, in that most of the
positive married females were living separated
from their husbands. Family difficulties had an
amazing frequency among the positive married
men also. This leaves a question as to what rela-
tion domestic discord and syphilis have to each
other.
By nationality 66 per cent, of the negatives were
American born and 44 per cent, foreign. The pos-
itives gave practically the same figures, and no
one nationality showed a preponderance towards
either positive or negative.
All blood examinations were made in the city
bacteriological laboratory and after the original
Wassermann technique. The cases were taken from
the files of the tuberculosis division of the city
health department, and due credit is given to the
officials in that department for permission to con-
sult the records and assistance in compiling these
statistics.
No attempt is made at the present time to give
the reason for such a high percentage of positives,
nor to determine whether the weaker reactions
were due to syphilis, or as some claim to the tuber-
culosis.
1105 Cobb Building.
iHritfnilrr.ai 5fatrs.
.Malpractice, Insufficient Evidence of. — Action was
brought for malpractice by injuring the neck of the
plaintiff's femur by negligently manipulating her leg,
causing it to be shortened about two inches and to turn
outward. The plaintiff had been suffering from chronic
sciatica for about three months, during which time she
had only been visited twice by a doctor to administer a
necessary narcotic. The plaintiff was called in to op-
erate, which he did by manipulating the leg and flexing
the joints in order to break up the adhesions at the hip
and knee joints and along the sciatic nerve. All the
physicians who testified in the case stated that the con-
dition of the plaintiff's leg was the result of a tubercu-
lar condition of the upper end of the femur, which de-
stroyed a portion of the bone, permitting the muscles of
the leg and hip to shorten the leg to the extent that the
bone was destroyed by the tuberculosis. There was no
evidence that the operation was not the proper one, or
of any negligence in the way in which it was performed,
so that, unless the doctrine of res ipsa loquitur could be
applied, there was no evidence of negligence to go to
the jury. Even the medical expert for the plaintiff
testified that if there had been a fracture at the neck of
the femur at the time of the operation it would have
been evidencd by an immediate shortening of the leg
and eversion of the foot, but that the latter would also
have resulted from a breaking up of the adhesions, and
that the rotation of the foot outward alone after the
operation did not indicate a fracture any more than a
reduction of the adhesions. There was no evidence of
an immediate shortening of the leg; so that upon the
only theory advanced by the plaintiff that could have
indicated a fracture in the operation, the evidence sus-
tained but one of the two necessary elements. The doc-
trine of res ipsa loquitur has no place in a case like
this. The court quoted from Ewing vs. Goode (C. C),
78 Fed. 442, where Judge Taft said : "A physician is
not a warrantor of cures. If the maxim res ipsa lo-
quitur were applicable to a case like this, and a failure
to cure were held to be evidence, however slight, of neg-
ligence on the part of the physician or surgeon causing
the bad result, few would be courageous enough to prac-
tise the healing art; for they would have to assume
financial liabilitv for nearlv all the 'ills that flesh is
heir to.' "
The defendant was employed for one trip only to
perform the operation. The plaintiff lived at a distance
of ten miles away. An agreement was made as to what
his fee should be in case other visits were necessary, and
he told the plaintiff and her husband to notify him if he
should be needed. He was never called subsequently.
It was held that his services were concluded by assent
when the operation was performed, and the case did not
come within the rule that a doctor may not, after ac-
cepting an employment, abandon a patient without rea-
sonable opportunity to procure another physician. —
Miller vs. Blackburn, Kentucky Court of Appeals, 185
S. W. 864.
Compensation for Services — Failure to Take Blood
Test. — in an action by a surgeon to recover for profes-
sional services it appeared that the patient was suffer-
ing from exophthalmic goiter, and upon consulting t.ie
plaintiff was advised by him to go to certain specialists
for treatment. Not desiring to do so, the patient and
her husband requested the plaintiff to perform the
necessary operation. The patient was thereupon sent
to the hospital, and in a day or two the operation was
undertaken. It progressed until about half the goiter
had been removed, when the patient died. The de-
fendant, over objection, was allowed to introduce evi-
dence that no blood test was taken prior to the opera-
tion, and that such a test was usual to determine the
oxygen-carrying power of the blood, which if below a
given point renders an operation of this kind extra-
hazardous. On appeal this was held an error, as there
was no evidence that the blood of the patient was below
the required oxygen test, nor was theie any attempt to.
show that the failure to take the blood test contributed
to any extent to the patient's death. Before a charge
of negligence can be sustained against a physician or
surgeon there must be some evidence that the failure
to use proper skill, either in the thing done or in the
thing left undone, was the proximate cause of injury
to the patient. In other words, there must be some
connection between the act and the result complained
of. Here there was none. It did not appear that it
was the custom in that locality to take blood tests. A
physician or surgeon does not guarantee to cure his
patient, or that his treatment will be successful. And
the plaintiff's remark, after he had urged her to go to*
the specialists and she had refused, "Well, if you are-
willing to take a chance with me I will take a chance-
with you," did not show that the plaintiff agreed to de-
mand compensation only in the event of a successful
operation. Judgment for the defendant was reversed.
— Harvey vs. Richardson, Washington Supreme Court,
157 Pac. 674.
Privileged Communications. — The Washington statute
prohibits a physician from testifying without the pa-
tient's consent to any information acquired in attend-
ing such patient which was necessary to enable him to
treat such patient. In an action for personal injuries
it appeared that the plaintiff's physician visited him,
expecting to prescribe. The defendant asked him on
the witness stand whether the plaintiff was up and
dressed; whether he was moving about; whether he
was staggering, walking in a hesitating manner, reel-
ing, or showing any signs of nausea or dizziness. The
defendant attempted to justify the questions because
the plaintiff had previously related that he took from'
this doctor a draught of medicine which put him to
sleep. It was held that this did not justify the admis-
sion of the physician's testimony, as "what the plaintiff
said was not an attempt to describe the doctor's treat-
ment or theory of the disease or to quote the doctor
while shutting his mouth. — Wesseler vs. Great Northern
R. Co.. Washington Supreme Court, 157 Pac. 461.
Proof of Value of Services Rendered. — Action was-
brought by a physician upon an account rendered by
him as a licensed physician, and also upon an account
assigned to him which covered services as a pathologist
rendered by the assignor. The defendant had verbally
agreed to pay the claims of both the physician and the
pathologist for services to her son when "in the State of
California. It was held that the agreement was not
void under the statute of frauds, though not in writing.
There was no dispute about the services having been
rendered by the physician, that he charged the plaintiff
S300 therefor, that the services were worth that sum.
that he was paid on his individual account S125. lovin-r
a balance unpaid of S175. For this he was held en-
titled to recover. But there was no proof of the value
of the services rendered by the pathologist. In the
absence of an express agreement, one who brinsrs to
such a service as was rendered by him due care and
skill can recover the reasonable and customary price
therefor, but such reasonable and customary fee must
be shown by competent evidence. Proof of the price
charged without any proof of the value of the service
performed was not sufficient, ?nd did not meet the test.
— Johnson vs. Jones, Ind. Apr- Hate Court, 112 N. E. 830.
420 MEDICAL RECORD
Medical Record.
A Weekly Journal of Medicine and Surgery.
[Sept. 2, 1916
THOMAS L. STEDMAN, A.M., M.D., Editor.
PUBLISHERS
WM. WOOD & CO., 51 FIFTH AVENUE.
See fourth page following reading matter for Rates of Subscription
and Information for Contributors and Subscribers.
New York, September 2, 1916.
TWO LITTLE-KNOWN FACTS ABOUT
MORPHINE.
Every practising physician passes through two
phases in his daily dealings with certain drugs,
especially those remedies known as specifics and
those which act upon some particular symptom, as
morphine does upon pain. The first phase is the
gradual increase of faith in the medicine in question
until he comes to accept it as practically infallible.
And then sooner or later come unaccountable in-
stances of failure and his divine confidence is rudely
shaken.
This is true of morphine. This powerful drug is
duly hedged about with restrictions in the mind of
the young practitioner so that he hesitates to use
it except it be absolutely necessary. But now and
then it becomes a dernier ressort and after a num-
ber of experiences of its speedy and effective anal-
gesic action he comes to hold it in reserve as the
ace of trumps. Among the cases which now and
then require opium are the worst ones of migraine.
Theoretically, of course, we do not use opium in
migraine and practically, thanks to the anilin de-
rivatives, it is indeed rarely necessary. Once in a
while, however, it is necessary to resort to this
drug, and very rarely it is not effectual. It is
probably a conservative statement that every phy-
sician who has practised more than ten years has
met wiih cases of migraine which did not yield to
morphine.
Now as to the explanation. Adler' says that
these cases are neurotic and the migraine is en-
tirely psychic in origin. The affliction ministers to
the neurotic's desire to dominate his environment
by making all his family and friends anxious to
wait on him and he does not readily yield this ad-
vantage. If this is the true analysis of such a
migraine we can readily see why drugs, even mor-
phine, are ineffectual. The only way to handle the
situation is to educate the neurotic to perceive that
he undergoes his suffering merely to subjugate oth-
ers and that these are far more effectual and socially
useful ways of maximating his ego-consciousness
(as Ad'.er puts it) than by making overy one around
him miserable.
So much for a psychical aspect of morphine. A
physiological peculiarity connected with the drug
"'The Neurotic Constitution," bv A. Adler, New
Moffat. Yard and Co., 1916.
has been recently reported by Drs. McGuire and
Lichtenstein,2 who have observed approximately 12,-
000 cases of drug addiction in the Tombs prison
during the past twelve years. They claim that many
of the women opium habitues present a wonderful
growth of hair. Not only is it long, but thick and
oily. It is common, say these physicians, to see
female addicts with hair reaching to the ground.
They explain this as being a purely nutritive pro-
cess; opium and its derivatives stimulate the numer-
ous sweat glands distributed to the scalp and the
roots of the hair, increase the moisture of the scalp,
and thus cause a growth of hair.
CARBON MONOXIDE POISONING.
Carbon monoxide gas is the most frequent cause
of poisoning as noted in the cases brought to our
hospitals, and yet its action and, in consequence, the
treatment of the poisoned patient, have been sub-
ject to a great number of misconceptions which
have doubtless resulted in the loss of a good many
lives. These facts are well brought out in an article
by Yandell Henderson in the Journal of the Ameri-
can Medical Association. August 19, 1916. It is a
very general belief that the compound formed by
the union of carbon monoxide and hemoglobin is
such a stable one that it is useless to attempt to
break it up by the usual therapeutic means. As a
result of this belief it has been the accepted mode
of treatment to bleed the patient in order to remove
the toxic compound from the circulation and to re-
place the blood thus removed by saline solution or
the blood from a healthy person.
Henderson details experiments which show that
carbon monoxide-hemoglobin is not the stable com-
pound that it has been thought to be, but that the
carbon monoxide may be displaced by subjecting
the blood to a large mass of good air or air enriched
by oxygen. Furthermore, he found that persons
who had been poisoned with illuminating gas (the
poisonous constituent being carbon monoxide)
when removed to an atmosphere of fresh air, puri-
fied their blood of the toxic gas within half an hour
at most. "Practically all of the carbon monoxide is
thus eliminated, and the hemoglobin fully restored
in three or four hours." He emphasize-- the con-
clusion that phlebotomy is therefore an illogical and
possibly dangerous procedure, especially as it is al-
most always performed more than an hour after the
patient is removed from the influence of the gas.
His observations also explain why it is generally so
difficult satisfactorily to demonstrate the presence
of carbon monoxide-hemoglobin in the blood ob-
tained by such phlebotomy. According to this au-
thor the symptoms are due to the effect upon the
central nervous system of the deprivation of oxy-
hemoglobin during the period when the poisonous
gas was present. The harmlessness of temporary
"gasing" was demonstrated in the Pike's Peak ex-
pedition of which the author was a member. The
carbon monoxide method for the estimation of blood
volume was used, and although the members of the
party repeatedly inhaled sufficient of this gas to
'"The Drug Habit," by Frank A. McGuire, and
Perry M. Lichenstein, Medical Record. July 29. 1916
Sept. 2, 1916J
MEDICAL RECORD.
421
combine with about 20 per cent, of their hemoglobin,
no ill effects were manifest.
The treatment then is quite simple. Henderson
says: "Thus it appears that about all that can be
done in cases of carbon monoxide poisoning is to
administer artificial respiration when the patient's
own breathing has failed or is feeble, to administer
oxygen for half an hour (longer is useless), to keep
them warm if their temperature has fallen, to sup-
ply water to the system, preferably by a Murphy
drip, and otherwise to give them good nursing and
such symptomatic treatment as may be called for."
He also suggests that the coma may be allied to
that found in acidosis and that the intravenous ad-
ministration of sodium bicarbonate may be of value.
Thus it seems that the prognosis is fixed at the
moment the patient is removed from the influence
of the gas and that the best results are to be ob-
tained, as in so many other pathological conditions,
by abstaining from too active interference.
ATRIOVENTRICULAR DISSOCIATION.
Atrioventricular dissociation is by no means the
same as the Stokes-Adams syndrome, although in
the majority of cases the latter belongs to the
former, or, in other words, such dissociation is the
principal cause of the syndrome. Dissociation often
occurs in the absence of the nervous crisis held to
characterize heart-block. Again, while the pulse in
dissociation may be as low as 30 to 40, this condi-
tion must not be confused with bradycardia. Rou-
tier (review in La Riforma Medica, July 10) recog-
nizes three degrees of atrioventricular dissociation,
viz., (1) Simple blocking from arrest of the stimu-
lus of contraction in the auricle ; the response of the
ventricular contraction is then wanting. (2) Com-
plete dissociation, in which auricle and ventricle act
independently of each other, from separate stimuli.
(3) Incomplete dissociation which is simple blocking
with the addition of occasional autonomous con-
tractions of the ventricle. Dissociation may be due
to some anomaly of conduction or to some disturb-
ance of excitability. The principal cause under the
former head is organic disease involving the bundle
of His. This state of affairs, being progressive,
tends to cause complete dissociation. In the second
place certain poisons exert a selective action on the
bundle of His (muscarine, physostigmine, digitalin,
aconitine). Asphyia suspends the function of the
same structures. Finally the fibers of His are ren-
dered refractory by too rapid and frequent stimu-
lation of the auricle, and we see arrhythmia develop
as in auricular flutter and tachysystole. Under the
head of disorders of excitability come hyperexcita-
bility of the autonomous centers, of the ventricle, as
in the case of atropine poisoning, and an opposed
state of autonomous slowing of .the ventricle. In
certain cases the ventricle remains refractory to
this over-stimulation.' Other disorders of excita-
bility are seen in the failure of extrasystole of
auricular origin, and also in the compensatory re-
pose of the ventricle after an extrasystole. Routier
does not recognize dissociation of purely vagus ori-
gin, but vagal hypertonia may act in connection
with other factors in causing complete dissociation.
We are still in ignorance of the part played in
dissociation by the sympathetic fibers — the plexuses
of which are scattered throughout the myocardium
and about the coronary arteries. Holding the view
that adrenalin acts selectively upon these fibers
Routier has been able to demonstrate an action by
them upon the phenomenon of dissociation. An
acceleration is due to the action of adrenalin on the
terminals of the coronary plexuses, but the block
can be overcome only by an action of the sympa-
thetic fibers in His's bundles, which can respond
only when enough muscle remains for a contraction
wave. Routier is satisfied that a purely muscular
lesion of the His bundle cannot lead to dissociation
and that the latter is in the main of nervous
pathology.
LATE OPERATIONS FOLLOV/ING MEDICAL
TREATMENT IN GUNSHOT WOUNDS OF
THE ABDOMEN.
After a careful study of the results obtained with
and without operation in penetrating wounds of the
abdomen, referred to in the Medical Record of
March 11, 1916, Quenu made out a strong case for
early operation and apparently showed that when
the projectile actually entered the abdominal cavity
it was very probable that the individual who sur-
vived under medical treatment would come to op-
eration sooner or later because of complications of
one sort or another. In another communication on
this subject to the Societe de Chirurgie of Paris
(Revue de Chirurgie, February, 1916), Quenu says,
that, as a result of further study, he has become
still more convinced of the correctness of his earlier
conclusions.
In connection with this contention that in med-
ically treated cases with recovery operation may be
only deferred, a case reported by A. Chalier (Le
Progres Medical, July 5, 1916) in which a rifle bul-
let had to be removed after having been encysted in
the omentum for 18 months is of considerable in-
terest, particularly as Chalier states that somewhat
similar cases have been reported by Walther,
Goullioud, and Quenu. In Chalier's case there had
been vomiting and marked meteorism for the first
two days after receipt of the injury but these sub-
sided under the influence of rest and proper diet.
No operation was done during the three and one-
half months the patient was in the hospital. On
various occasions since then he had had colicky
pains and symptoms of subtotal obstruction and he
entered Chalier's service complaining of these symp-
toms, pains in the lower extremities, and difficulty
in walking. Radioscopic examination showed that
the projectile was fixed in the abdominal cavity a
little in front and to the right of the promontory
of the sacrum, not embedded in the bone. Upon
operation the bullet was found encysted in the
omentum, which latter was strongly adherent to
the posterior parietal peritoneum. The cystic
pouch, containing the bullet and a quantity of red-
dish fluid, was resected and convalescence was un-
eventful. Chalier considers it strange that the bul-
let had been tolerated for 18 months without grave
consequences ; yet as he says, fusion of the omentum
422
MEDICAL RECORD.
[Sept. 2, 1916
to the posterior abdominal wall gave rise to inter-
mittent mechanical troubles which might have been
so suddenly increased at any time as to have re-
quired emergency operation.
The Tobacco Habits of Schoolchildren.
An illuminating glimpse into the possible diver-
sions of our boys and girls while away from sight
at school is afforded by a recent report'' which con-
tains the results of an investigation by Drs. Stiles
and Richards of the Public Health Service. To be
sure the children in question were largely drawn
from a rather low stratum of society, but in the
present democratic arrangement of our public
schools the girl from a refined surrounding is so apt
to rub elbows with the hooligan from Goat Alley
that the fear is rather that she will absorb the
mannerisms of the gutter from him than that he
will improve by her example. Drs. Stiles and Rich-
ards examined 2,215 pupils, ranging in age from 4
to 20 years. They were divided into two groups,
those who had toilet facilities in the house being
known as the sewerage, or for short the "S" group,
and those who had an outside privy only, the "P"
group, this grouping being considered roughly in-
dicative of the cultural level obtaining in the house-
hold. It was found that no girls chewed or smoked
tobacco. About one-half of 1 per cent, in the S
group dipped snuff and slightly less than that in the
P group. Only one boy in the 1,043 examined took
snuff and it was not ascertained whether or not his
home had plumbing. About iy2 per cent, of the
boys in the S group chewed and 3 per cent, in the
P group, but 6.5 per cent, of the S group smoked,
while only 5 per cent, of the P group indulged them-
selves thus. The tender age of some of these dev-
otees of nicotine is surprising. Thus there were
three boys of 11 years who chewed, two of 10 years,
two of 9 years, and one of only 8 years. There were
six 10-year-old boys who smoked, three 9-year-old
ones, one of 8, and one of 6 years! Moreover, two
boys had begun the habit at 6 years and one at the
age of 3. This last prodigy will probably shatter
the retro-barn-door record of all of us, no matter
how precocious. There was one 12-year-old girl
who dipped snuff, one 11-year-old one, and a boy and
a girl of 9 who indulged. One girl had begun this
habit at the age of 4 and two at the age of 3. Of
course, the inception of habits such as the above at
the early age quoted can only mean gross neglect of
parental duties, but the fact remains that if the
conditions found in the city studied may be consid-
ered as at all typical the profession must change its
attitude in regard to the tobacco habit and not
arbitrarily rule out any age as too young in con-
sidering the possibility of its influence in a given
case.
Points of Attack of Tuberculosis.
In the nation-wide battle against tuberculosis any
information from authentic sources about this
plague is of value, therefore we welcome an article,
contributed by Dr. George M. Kober to a recent
Public Health Report, dealing with the routes by
which the bacillus may enter the body. Infection by
inhalation is the most frequent method, according
to Kober. The germs may be propelled into the
atmosphere by talking, coughing, or sneezing. The
* "Tobacco and Snuff. Theii I by White School
Children in the City of X." by C. W. Stiles and I). X.
Richards, M.D.
dangerous zone about a patient with tuberculosis
extends 3 feet in every direction, Fliigge says. The
next most frequent way is to take them in through
the digestive tract. Eating utensils may be the
media of transmission ; milk and meat are frequent-
ly infected. Analyses of a number of samples of
milk from dairies in Washington, D. C., showed that
6.72 per cent, of them harbor germs. This, of course,
brings up the question of bovine and human tuber-
cle bacilli. It has recently been said that the former
may be changed into the latter by a prolonged resi-
dence in the human body. Among the things which
Kober indicts are allowing babies to creep on a dirty
floor, long skirts, and insanitary dwellings. Apr<
of the latter he quotes the famous "lung blocks' of
Biggs of New York and Flick of Philadelphia-
Flies are also a frequent source of infection, to add
another argument to the scores against this in-
sect. Dust is a favorite habitat of the germ — in
the United States and Germany just twice as much
of the disease has been found among workmen whose
trades were dusty in nature, although in this case
the dust acts chiefly as an irritant, thus preparing
the soil for growth of the bacillus. On the other hand,
damp soils and houses predispose to tuberculosis.
Kober also calls attention to the amazing preva-
lence of the germ. Thus recent autopsies by Ham-
burger and Monti in Vienna have shown that 95
per cent, of children actually have the germ in their
systems by the time they are twelve or thirteen.
According to Nagels 97 per cent, of all people have
foci of tuberculosis at one time or another in their
lives. City dwellers should remember that the
greater the park space in their communities the less
will be the tuberculosis, and they should encourage
the city fathers to increase these breathing spaces
rather than diminish them. It is gratifying to note
that the death rate has dropped from 326 per 100,-
000 in 1880 to 147.6 in 1913. Dr. Kober optimisti-
cally believes that we are on the way to stamp out
the disease altogether.
The Elastometer.
Our methods for recognizing the degree of edema
have heretofore been crude. Changes in the body
weight have been utilized to some extent, especially
in connection with degrees not palpable to the
finger. Roughly speaking a gain in weight in the
absence of nutritive factors may imply a condition
of waterlogging. Widal claimed that a gain of over
15 pounds meant a state of edema. In ordinary pal-
pation the milder degrees cannot be perceived, and
Schade's elastometer therefore is regarded as an
improvement in the diagnosis of edema. According
to an article by Schwartz in La Riforma Mcdica for
July 10, this consists of a disk which when sunk into
the skin and subcutaneous tissue registers the
changes in elasticity by means of a lever acting on a
recording cylinder. Several similar disks are used
in the vicinity of the first and other readings ob-
tained. The first disk is weighted, while the con-
trol disks are not. If normal elasticity is present
the skin when compressed returns quickly to the
normal, as shown in the curve registered on the
cylinder; but if the disk is weighted the curve is
replaced by a horizontal line and when the weight
is removed there is a perpendicular fall. In edema-
tous tissues with loss of elasticity the curve ascends
after the use of the weight, but more slowly ; when
the weight is removed the curve descends, but not as
in normal tissues is its original base.
Sept. 2, 1916]
MEDICAL RECORD.
423
2fauia uf th» Week
Poliomyelitis on the Decline. — A considerable
reduction in the number of cases of poliomyelitis
in all the boroughs of New York City has been evi-
dent during the last few days, and it is believed
that the worst of the epidemic is over. The total
number of cases up to August 29 was 7,908, with
1,889 deaths. For the week ending August 26, 753
cases were reported in all boroughs, as compared
•with 912 during the week ending August 19, and
1,151 in that ending August 12. The decrease has
been especially noticeable in Brooklyn, where the
epidemic started. Outside of New York City there
were reported in the State up to August 26, 1,802
■cases with 199 deaths. The State Department of
Health now has sixteen diagnosticians and sixteen
sanitary supervisors in the field, and is sending
specially employed consultants for inspection and
visitation to seventeen hospitals scattered through-
out the State. In New Jersey 2,241 cases were re-
ported up to August 26. The date of opening the
public schools in New York has not yet been deter-
mined, and the question of deferring the opening of
Columbia University is under consideration.
City Death Rate.— The New York City Depart-
ment of Health points out that in spite of the
severe epidemic of infantile paralysis this summer
the death rate of the city for the first thirty-four
weeks of the year was but very slightly in excess of
that for the same period of last year, the respective
figures being 14.57 and 14.53 per 1,000 of popu-
lation. This increase represents only four deaths
per 100,000. In every age group except that of
children under five > ears of age there was a de-
crease in the death rate, proving that the general
sanitary condition of the city is better this year
than last.
Dr. Louis Livingston Seaman, president of the
British War Relief Association, sailed from New
York on August 26 for London. He will supervise
the work of the association in England, France, and
Belgium.
Dr. Murphy's Estate. — It is reported that the
estate left by the late Dr. J. B. Murphy of Chicago
will total 1,125,000, of which $1,000,000 is in real
estate.
Death of an Old Indian. — Ayoushakatsagom, a
veteran Cayuse Indian, died at Pendleton, Ore., on
August 23, at the reputed age of 120 years. His
memory went back to events which occurred during
the war of 1812.
Plattsburg Medical Camp. — Three sessions of
the Medico-Military Instruction Camp at Platts-
burg, N. Y., will be held this summer, each last-
ing two weeks. The first began on August 10, the
second, on August 24, and the third will open on
September 8. The course for each session covers
military surgery in the field. Lieutenant-Colonel
Henry Page and Major P. W. Huntington are the
officers in charge.
The Sanest Fourth. — For the fourteenth year
the Journal of the American Medical Association
has collected and published statistics of the acci-
dents occurring in the United States as a result of
the Fourth of July celebration. The report shows
most strikingly the good effects of the campaign for
a safe and sane fourth which has been carried on
for some years. In 1903. the year in which the
first collection of statistics was made, 466 deaths
were reported as due to fireworks; in 1916 only 30
deaths were so reported. In the former year the
injuries numbered 4,449, and in 1908 the number
rose to 5,623, while in 1916 the total casualties
were only 850. The deaths due to lockjaw declined
from 406 in 1903 to none in 1916, and not one case
of blinding was reported.
Five Babies in Seven Months. — Mrs. Julius
Cojenski of Greenwich, Conn., is reported to have
established a record in having given birth to trip-
lets and seven months later to twins. None of the
children have survived. Although only twenty-
seven years old, the woman is said to have been the
mother of thirteen children, of whom only five are
living.
Association of Railway Surgeons. — The twenty-
sixth annual session of the New York and New Eng-
land Association of Railway Surgeons will be held
at the Hotel McAlpin, New York, on Wednesday,
October 18, 1916. A very interesting and attrac-
tive programme has been arranged. Dr. William S.
Bainbridge will deliver the address in Surgery,
taking for his subject the Cancer Problem. Rail-
way surgeons, attorneys, and officials, and all mem-
bers of the medical profession are cordially invited
to attend. Dr. D. H. Lake of Kingston, Pa., is
the president of the association, and Dr. George
Chaffee of Little Meadows, Pa., is the correspond-
ing secretary.
American Association for Clinical Research. —
The eighth annual meeting of this association will
be held at the Hotel Majestic, New York, on Sep-
tember 28 to 30, 1916, under the presidency of Dr.
Daniel E. S. Coleman, New York. An interesting
programme has been prepared, and clinics will be
held daily at the Flower and Metropolitan Hospitals.
Further details may be obtained on application to
the permanent secretary, Dr. James Krauss, 419
Boylston Street, Boston, Mass.
Caledonia County (Vt.) Medical Society. — At
the annual meeting of the society held at St. Albans
on August 11, the following officers were elected:
President, Dr. Frank E. Farmer, St. Johnsbury;
Vice-President, Dr. David E. Brown, Lyndonville;
Secretary-Treasurer, Dr. Hugh H. Miltimore, St.
Johnsbury.
Gifts to Hospitals. — St. Mary's Hospital. Phila-
delphia, has received from Mr. George Nevii a gift
of $5,000 for the endowment of a free bed.
By the will of the late Mr. Hall Engles of Phila-
delphia the following bequests are made to institu-
tions in that city: To the Pennsylvania Hospital,
the Protestant Episcopal Hospital, the Presbyterian
Hospital, the Polyclinic Hospital, the Jefferson Hos-
pital, and the Samaritan Hospital, $10,000 each; to
the Philadelphia Home for Incurables, the Jewish
Hospital Association, and the Medico-Chirurgical
Hospital, $5,000 each.
Convention of Colored Nurses. — The ninth an-
nual convention of the National Association of Col-
ored Nurses was held in New York on August 15 to
17, with 160 delegates in attendance.
Study of Malaria. — The International Health
Board of the Rockefeller Foundation has announced
that it is conducting two sets of experiments to
determine how effectively malaria may be controlled
in a temperate climate under conditions prevailing
in typical farming communities of the Southern
States. The first of these experiments, to test the
practicability of malaria control by detecting car-
riers and freeing them of the parasites, is being
carried on at Bolivar, Miss., under the direction of
the Mississippi Board of Health. The second set
is being conducted in Arkansas in cooperation with
424
MEDICAL RECORD.
[Sept. 2, 1916
the United States Public Health Service, and has
for its object the testing of the practicability of
malaria control by a combination of relief meas-
ures. In neither case will the experiments include
the extermination of mosquitos by major drainage
operations.
Hospital Ship to Moros. — With the cooperation
of the Philippine Government, the Rockefeller
Foundation is preparing to send a hospital ship to
the Sulu Archipelago for the treatment of the Moros
and members of allied tribes, many of whom have
been found to be suffering from skin diseases,
malaria, hookworm, dysentery, and other ills. In
Mindanao and Jolo, it is said, the Moros have been
reached to some extent by the dispensaries, but the
great bulk of the population still stands in need of
medical service. The ship, which is now being
equipped, will be sent out for a five years' cruise.
Red Cross Unit Sails. — Consisting of ten sur-
geons and twelve nurses in charge of Dr. Daniel
Fiske Jones of Boston, the third Harvard Red Cross
unit sailed from New York on August 17 for Liver-
pool. The party will be sent direct to the British
Expeditionary Base Hospital No. 22 on the French
front, and will relieve the first and second units,
whose terms of service have expired.
Obituary Notes. — Dr. Ezra Bradway Sharp of
Camden, N. J., a graduate of the University of
Maryland, School of Medicine, Baltimore, in 1888,
died at his home on August 24, aged 55 years.
Dr. Wilbur Lee Pepper of Philadelphia, a grad-
uate of the Jefferson Medical College, Philadelphia,
in 1892, and a member of the American Medical
Association, the Medical Society of the State of
Pennsylvania, and the Philadelphia County Medical
Society, died at Reheboth Beach, Del., on August 18,
aged 46 years.
Dr. Andrew L. Van Patten of Los Angeles,
Cal., a graduate of the Hahnemann Medical College
and Hospital, Chicago, 111., in 1876, died at his
home, after several months' illness, on August 3,
aged 71 years.
Dr. John M. Eager of the American Sanitary
Office, Naples. Italy, died at his station on August
17, aged 52 years. Dr. Eager was graduated from
the College of Physicians and Surgeons. New York,
in 1888. and was appointed to (he United States
Public Health Service, in which, at the time of his
death, he held the rank of surgeon, in 1892. He
was a member of the American Medical Association.
Dr. Carl V. Cole of Lake City, Minn., a grad-
uate of the University of Minnesota, College of
Homeopathic Medicine and Surgery. Minneapolis,
in 1904, was killed in an automobile accident on
August 7, aged 39 years.
Dr. Ozias WlLLARD Peck of Oneonta, N. Y.. a
graduate of the Yale University School of Medicine,
New Haven, in 1857, consulting physician to the
Aurelia ()sl>orne Fox Memorial Hospital, Oneonta,
a surgeon in the United States Army during the
Civil War, health officer of Oneonta for twenty-six
years, and a member of the New York State and
Otsego County Medical societies, died at his hi
on August 4, aged 81 years.
Dr. JOHN M. Crawford of Cincinnati, Ohio, a
graduate of the Pulte Medical College, Cincinnati.
in 1879, consul general to Russia during President
Harrison's administration, and a former president
of the Western Academy of Medicine, died at his
home on August 13, aged 72 years.
Dr. HARRTf D. Barnitz of San Antonio. Tex., a
graduate of the Georgtown University School of
Medicine, Washington, in 1880, former president of
the Board of Health of San Antonio, and a member
of the State Medical Association of Texas and the
Bexar County Medical Society, died at his home,
after a short illness, on August 6, aged 63 years.
Dr. Ulysses G. Grigsby of Perry, Iowa, a grad-
uate of the Eclectic Medical College, Cincinnati,
Ohio, in 1896, died as the result of injuries received
in an automobile accident, on July 27, aged 48 years.
Dr. Horace W. Coombs of Cave City, Ky., a grad-
uate of the Eclectic Medical College, Cincinnati,
Ohio, in 1870, died at his home, after a long illness,
from cancer of the stomach, on August 3, aged 69
years.
Dr. Frank Hammett Holt, superintendent of
the Michael Reese Hospital, Chicago, since 1915, a
graduate of the Harvard University Medical School
in 1899, a member of the American Medical Asso-
ciation, the Illinois State Medical Society, the Chi-
cago Medical Society, and the Massachusetts Med-
ical Society, and formerly superintendent of the'
Boston City Hospital, died at his home after a short
illness, on August 3, aged 47 years.
Dr. Lyman Beecher Shehan of Superior, Wis.,
a graduate of the Medical School of Maine, Portland,
in 1884, died at his home, after a long illness, on
July 28, aged 61 years.
Dr. James D. Weaver of Eatonton, Ga., a grad-
uate of the College of Physicians and Surgeons,
Baltimore, in 1882, and a member of the Medical
Association of Georgia and the Putnam County
Medical Society, died at his home as the result of
injuries received in an automobile accident, on Au-
gust 5.
Dr. Kenneth D. Wise of Los Angeles, Cal., a
graduate of Jefferson Medical College, Philadelphia,
in 1865, died at his home after a lingering illness,
on July 31.
Dr. Clinton De Witt Van Dyck of New York, a
graduate of the Albany Medical College, Albany,
N. Y., in 1879, a member of the New York State and
County Medical societies, and for twenty-six years a
medical supervisor of the Metropolitan Life Insur-
ance Company, died suddenly from apoplexy, at At-
lantic City, X. J., on August 10, aged 61 years.
Dr. Edward Kerschner of Hagerstown, Md., a
graduate of the New York University Medical Col-
lege, New York, in 1861, and since that time a
member of the medical service of the United States
Navy, serving through the Civil War and retiring
a few years ago with the rank of Medical Inspector,
emeritus professor of naval, military, and state
hygiene in the New York Post-Graduate Medical
School, New York, died at his home, after a brief
illness, on August 20, aged 77 years.
Dr. Thomas Powell of Los Angeles, Cal., a grad-
uate of the New York Medical College, New York,
in 1858, and a member of the American Public
Health Association, and the American Association
for the Study and Prevention of Infant Mortality,
died at his home, suddenly, on August 18, aged 78
years.
Dr. William Jefferson Rowe of Buford, Ga., a
graduate of the Medical College of Georgia, Au-
pusta, in 1887. died, suddenly, at the home of his
daughter in Flowery Branch, Ga., on August 12,
aged 60 year-.
Dr. WOOSTER BEACH of Westchester, N. Y., a
graduate of the College of Physicians and Surgeons,
New Y'ork, in 1854, and a founder and first presi-
dent of the Medico-Legal Society of New York, died
at his home on August 6, aged 83 years.
Sept. 2, 1916]
MEDICAL RECORD.
425
ADRENALIN IN POLIOMYELITIS.
To the Editor of the Medical Record:
Sir: — During the course of an epidemic of a dis-
ease the therapeusis of which is still unsettled, it
would appear wise to report cases upon which the
newer procedures were tried, that the apparent re-
sults of such procedures may stimulate or discour-
age further application.
The following three consecutive cases of infantile
paralysis were seen in consultation. The treatment
consisted of adrenalin administered intraspinally,
after the withdrawal of cerebrospinal fluid and in
one case by the use of immune serum in addition.
Case I. — Boy, 6 years (bulbar type) ; ill three days.
temp. 105°, glands enlarged at angle of jaws; supposed
to be suffering from nasopharyngitis. The symptoms
were vomiting, inability to swallow, irregular respira-
tion, involuntary evacuation of urine and feces. The
child was in coma, there was retraction of head, the
occiput resting upon spine, the sclera only showing;
respiration of the Biot type, Macewen, Brudzinski and
Kernig signs present. Knee jerks absent, temp. 105°,
pulse 120, respiration varying from 1 to 30 per minute,
condition growing constantly worse. Spinal puncture
performed and 70 c.c. clear fluid withdrawn, 6 c.c.
1:1000 adrenalin administered by gravity, convulsive
twitching followed procedure for several hours. Six
hours later condition was no worse than when punc-
ture was done; a second puncture was made, and was
a dry tap, although repeated attempts were made to
withdraw fluid ; no adrenalin was administered at this
time. The condition continued to improve. After 12
hours there was a short period of consciousness; the
child was able to swallow teaspoonful doses of water ;
respiration was less irregular. Eighteen hours after
the withdrawal of fluid and administration of adrenalin
the child was conscious, rigidity was almost absent, he
swallowed well, respiration was regular, temp. 99°, and
except for weakness of all muscles the boy was appar-
ently not very ill. Three weeks after onset he was
entirely normal except for slight weakness in the lower
extremities, which is growing less daily, and which
does not interfere with walking.
Case II. — Boy, 4% years (bulbar type) ; symptoms
similar to those in Case I except that respiration was
not so seriously affected. An intraspinal adrenalin in-
jection was given 48 hours after onset of acute symp-
toms, and repeated four times. Immune serum was
once administered intraspinally. Recovery from severe
symptoms required 4 days. Two weeks later the boy
was entirely normal except for slight weakness of the
external recti muscles of both eyes.
Case III. — Boy, 2V2 years (spinal type) ; paresthesia
marked; ill 5 days with irregular temperature and
symptoms. There was slight rigidity of the neck;
Brudzinski and Kernig signs present, knee jerks ab-
sent. Paralysis of all extremities and muscles of chest;
involuntary evacuation of urine and feces. Temp. 103°,
pulse 130, respiration regular but difficult. Spinai
puncture was performed 24 hours after acute symptoms
appeared — 60 c.c. clear fluid withdrawn, and adrenalin
administered as above; this was repeated once. Tem-
perature normal after 72 hours. Fourteen days after
the first puncture there was complete restoration of the
upper and left lower extremities, with partial restora-
tion of the muscular activity of the right lower ex-
tremity.
The foregoing cases are briefly reported, not as
showing results of treatment, bjut to place on rec-
ord the experience with a procedure which is ap-
parently harmless and full of promise. The only
untoward result of this therapeutic measure was a
rather severe urticaria appearing within twenty-
four hours in Cases I and III.
In contrast with the results in the foregoing cases
are five cases of this disease seen prior to them in
which no intraspinal injections were given. Two
died of respiratory paralysis. One had a spastic
paraplegia of both lower extremities after six
weeks. One has a flaccid paralysis of both lower
extremities after eight weeks. One has made a
complete recovery. It would appear that the ideal
treatment in the light of present knowledge and
experience consists of: (1) Early puncture and
withdrawal of cerebrospinal fluid; (2) Administra-
tion of adrenalin intraspinally; (3) Followed im-
mediately with the introduction of immune serum
or, in its absence, normal serum.
Sidney V. Haas, M.D.
666 West End Avenue.
New York.
OUR LONDON LETTER.
(From Our Regular Correspondent.)
HEART DISEASE IN THE EXPEDITIONARY FORCE IN
FRANCE — VALVULAR CASES — DR. PARKINSON'S
SUMMARY OF FORTY CASES OF DISORDERED ACTION
OF THE HEART — "HEART STRAIN" AND "SOLDIER'S
HEART."
London, August 5, 1916.
Dr. John Parkinson, temporary captain R. A.
M. C, attached to the military hospital for heart
cases, and the cardiac department of the London
Hospital, has recorded the result of his inquiry into
the conditions leading men on active service to re-
port sick, with symptoms suggestive of heart dis-
ease. He based his inquiry on 90 cases passing
through the casualty clearing station with the Ex-
peditionary Force in France. Every patient sent
to his wards from a field ambulance with a diag-
nosis of heart disease, from March, 1915, to Janu-
ary, 1916, is included in the inquiry without either
selection or rejection, so that the series is consecu-
tive. But the number seen gives no indication of
the frequency of the cases or their proportion to
the total sick. Absence of special means of inves-
tigation and the brief period of observation — usu-
ally 2 or 3 days — were disadvantages in the in-
quiry, but there was an advantage in that the men
were seen very shortly after reporting sick. A
detailed history of each patient was first obtained ;
notes on infections, recent or remote, followed by
a statement of his capability of exertion at school
and at work. The effects of training and cam-
paigning were next noted and then the immediate
cause for reporting sick. About an hour would be
required to secure a satisfactory history, for the
most part in the patient's own words, without lead-
ing questions. His general condition and tempera-
ment were first noted ; then the position of the apex
beat in the recumbent position, which served as
some guide to the size of the heart; for its func-
tional efficiency a fixed amount of exertion served
as a test. In the 90 cases there were 22 in which
other diseases were present. Of these 2 had acute
and 3 chronic nephritis, 1 acute and 1 chronic
bronchitis; one had enlarged thyroid and tachy-
cardia; one had goiter without symptoms of thy-
roidism though complaining of a choking sensation
when marching; three were for disordered heart
action on account of syncope and 3 others for an
unusual degree of sinus arrhythmia ; the 7 others
were considered examples of tuberculosis (pul-
monary), arteriosclerosis, chronic alcoholism, im-
maturity, debility, epistaxis and lymphatic leu-
kemia.
Among the 90 cases there was valvular disease
in 28; 8 of these had mitral incompetence, 4 mitral
stenosis, 8 aortic incompetence, 1 aortic stenosis, 2
acquired pulmonary stenosis (with rheumatic his-
tory, thrill over pulmonary area), 1 had aortic and
426
MEDICAL RECORD.
LSept. 2. 1916
mitral incompetence and there were 2 patients with
doubtful mitral stenosis. A case of thoracic aneu-
rysm and one of dextrocardia are for convenience
included in this series of 28.
In 16 cases there was a history of acute rheuma-
tism; in 18 the chief symptom was shortness of
breatvi; in 8 it was pain, but these had dyspnea as
well. There was palpitation in half the cases; of
8 patients, 6 having aortic incompetence, com-
plained of giddiness or faint feelings. Syncope
had occurred in 1 case of aortic incompetence and
in 1 of pulmonary stenosis. Great exhaustion on
the march, with weakness of the legs on exertion,
was complained of, in many cases before enlist-
ment. A man of 40 had a two-and-fro (bellows)
murmur without displacement of apex beat, and
had served 16 months, including 6 at trench work;
he had no symptoms and the incompetence was dis-
covered at a chance examination.
The so-called soldiers' heart was present in 40
■cases. These were men complaining of heart symp-
toms, especially breathlessness and precordial pain
but in whom physical signs could not be found. In
the army service they are classified as D. A. H.
(disordered action of heart) ; in general medical
literature they are often referred to as "soldier's
heart." They are also at times spoken of as "ir-
ritable heart" and "heart strain," but the terms
have little to recommend them. Captain Dr. Park-
inson gives a careful summary of 40 cases, from
which important conclusions can be deduced. Thus
among soldiers in training or on active service a
number come on the sick list for cardiac symptoms
on exertion, but who have no physical signs of heart
disease. They are the subjects of a cardiac dis-
ability which is manifested on the exertion required
of a soldier, but this is not a specific disease and
requires no such name as "soldiers' heart"; in fact
it had in about half the cases been perceived be-
fore enlistment. The inefficiency may be a sequel
of acute rheumatism, influenza or some other in-
fection; so it may be due to myocardial changes
due to age, especially in soldiers of 40 or more; or
again to functional nervous disorder; or to limited
cardiac efficiency, the patient having always been
■"short-winded" — maybe from an unrecognized in-
fection in earlier years or defective physical train-
ing. A simple exertion test, as climbing a few
steps, reproduces the symptoms and so gives infor-
mation on the efficiency of the heart's function.
Some degree of myocardial disease is present in
numerous cases as seen in the persistence of the
disability and the reaction to simple exertion tests.
From this Dr. Parkinson concludes that the absence
of abnormal physical signs in the heart of a soldier
should not prevent his discharge from the army if.
under training or on active service, he shows
"breathlessness and precordial pain whenever he un-
dergoes exertion which is well borne by his fellows.
Gonorrhea in Women. — F. McCann states that when
a man becomes infected with the gonococcus lie soon
becomes aware of its presence. A woman, accustomed
to having a leucorrheal discharge of varying se\
and various premenstrual and menstrual pains, may
never be aware of the acute stage of a gonoa
infection. Moreover, a woman infected by a man with
chronic gonorrhea usually has a subacute infection.
Salpingitis, although occurring some weeks or even
months after infection, may be met with quite early
in the disease and cause symptoms suggesting an acute
peritonitis. — Practitioner.
•Prnamui nf iflrMral Srmtrr.
Boston Medical and Surgical Journal.
August 17. 1»16.
1. Tubercular Infection in Infancy and Childhood. Vander-
poei Adriai
-. 1 I End of the Humerus. W. E. Ladd.
3. Tii i ib rculosis Disp Their
Relation to th< i ractising Physician. John S. Hitch-
. ■.
\ rears Work of .i Local Tuberculosis Hospital. Albert
C ', tchell.
. i . n on ;is i.i the I revention of Infantile Paralysis.
Stewart Whittemore.
• i i n nological Examination in Cancer of
the Breast Jul.:: W bane.
7. Auricular Standstill: An Unusual Effect of Digitalis on
the Heart, wil ti Reference to 1 ardio
gram. i nil 1 1. While.
2. Fractures of the Lower End of the Humerus.— W.
E. Ladd presents a study of 45 cases from the Chil-
dren's Hospital in which the records are complete, the
skiagrams satisfactory, and end results have been se-
cured. In general, the method of treatment followed
had been reduction by manipulation only and im-
mobilization in the position of acute flexion. In a
small number open operation has been resorted to, or
a special variation in the position of immobilization,
as indicated by the direction of the displacement of the
fragments. For restoration of function, massage and
passive motion have not been employed, but active
motion has been relied upon entirely. There were 25
cases of supracondylar fracture which gave a total of
84 per cent, perfect results, with a probability that,
92 per cent, of the cases will be eventually perfect.
All of these cases in which there was slight displace-
ment or no displacement gave perfect results. For dis-
placements which are irreducible operative reduction is
practiced immediately after the injury before swellnig
has taken place or a few days later when the swelling
has had time to subside. In general the practice pur-
sued was that of Ashurst and Treves and his colleagues.
After a careful study of the work of Neuhof and
Wolf, the author states that he does not believe that
their conclusions are correctly drawn, nor that their
results justify the adoption of early passive motion
and massage as valuable treatment. The results of
operative treatment in a few selected cases in their
series to some extent justifies Its employment. It is
found that from three widely separated clinics, cases
treated upon general lines of similarity have yielded
approximately 90 per cent, of perfect results, and hence
one is justified in saying that a fracture of the Iowet
end of the humerus in a child treated properly should
result in a perfect arm in nine cases out of ten and
a useful arm in practically every case.
5. A Suggestion as to (he Prevention of Infantile
Paralysis. — W. Stewart Whittemore refers to the work
of Hektoen and Rappaport, which shows that kaolin
is effective in removing bacteria from the nose and
throat. His personal experience with the use of this
agent in the treatment of infections of the nose and
throat during the past year has been very gratifying
and he suggests that it may possibly be effective in pre-
venting the infection of children and adults with in-
fantile paralysis. Powdered kaolin should be inflated
into the nose and throat every two hours during the
day. He says that only by the use of kaolin in a large
number of cases in which there has been exposure to
possible infection with poliomyelitis can it be deter-
mined whether it is of value or not.
fi. Preoperative Roentgenological Examination in
Cancer of the Breast. — Jchn W. Lane points out that
early recurrences and early postoperative deaths in
cancer of the breast are often due to the performance
• if an efficient operation upon badly selected and already
hopeless cases and that such occurrences bring the
Sept. 2, 1916]
MEDICAL RECORD.
427
operation into disrepute. During the past year he has
made it his custom to subject every case of cancer or
suspected cancer of the breast to a very complete
roentgenological examination. It has been possible by
this means to demonstrate metastases in the medias-
tinum, in the femur, pelvis, spine, and humerus; but
not as yet has he been able to demonstrate to his com-
plete satisfaction a pleural dissemination. These cases
were prevented from going to the operating table and
were not subjected to needless surgery. The writer
advocates a thorough roentgenological examination as a
routine preoperative procedure in all cases of suspected
cancer of the breast.
7. Auricular Standstill: An Unusual Effect of Digi-
talis, with Especial Reference !o the Electrocardiogram.
— Paul D. White reviews the usual ways in which
digitalis may affect the human heart and electrocardio-
gram and calls attention to another effect which he has
not seen described. That is the removal by digitalis
of all evidence of auricular activity from the electro-
cardiogram and from the jugular pulse tracing. There
is no evidence that the auricle is contracting at all.
Against the possibility of an isoelectric P in Lead II is
the absence of P in Leads I and III also, and the
absence of a in the jugular pulse. Auricular fibrillation
may be excluded by the entire absence of fibrillation,
oscillations of the galvanometric string, and the per-
fectly regular ventricular rate. The atrioventricular
node is probably giving rise to ventricular complexes,
because their shape is that of normal complexes of
supraventricular origin and they occur regularly. No
deflections appear, suggesting that the atrioventricular
node is also giving rise to auricular activity. In other
words, there appears to be auricular standstill. Three
cases have been found at the Massachusetts General
Hospital in which this digitalis effect has been seen.
All three showed definite evidence of auricular action
in electrocardiogram and jugular pulse tracings after
the effect of the digitalis intoxication had worn off; in
all three the A-V conduction showed some delay during
the recovery from the digitalis. In none of the three
at the time of the disappearance of auricular activity
was there any evidence of auricular fibrillation, ven-
tricular escape, or complete atrioventricular rhythm.
New York Medical Journal.
August 19, 1916.
1. The Treatment of Acute Poliomyelitis. S. J Meltzer
'1. Autotherapy and Poliomyelitis. Charles H. Duncan
3. The Control of Epidemics. Jacob n Manning.
4. An Evaluation of Paraphrenia. (To be concluded.) Ed-
ward A. Strecker.
5. A Study of Drug Action. Thomas J. Ma:
6. American Medicine of the Eighteenth Centurv Geo
Wythe Cook.
7. Radiotherapy in Chronic Arthritis. Ernest Zueblin.
S. Toluol. Leverett Dale Bristol.
9. Abnormal Labor. Solomon Wiener.
2. Autotherapy in Poliomyelitis. — Charles H. Duncan
advises a trial of autotherapy in the treatment of
poliomyelitis based on a personal experience with
twelve cases in which this method of treatment seemed
to influence the prognosis favorably. His suggestion is
to withdraw a considerable amount of spinal fluid and
inject a small portion of it into the muscles of the
back. Autotherapy has proved effective in cerebro-
spinal meningitis and other toxic neuritides, and it is
logical to conclude that it may be applicable to polio-
myelitis. The writer also suggests that tests be made
in treating tetanus and other toxic neuritides by the
autotherapeutic method.
3. The Control of Epidemics. — Jacolyn Manning dis-
cusses the problem "What should be done in invasions
like the present one of infantile paralysis?" and sug-
gests that a competent pathologist and diagnostician
should investigate the cause of death and the contribu-
tory cause of death in every case, and state these on
the death certificate during the period of the plague.
Where there is the slightest doubt of the cause of
death a postmortem examination should be made of the
central nervous system, brain, midbrain, and spinal
cord, since this is the only way of determining with
accuracy whether or not any person has been a victim,
of poliomyelitis. The list of diseases terminating in
sudden death which may simulate poliomyelitis is quite
extensive, including, in very young infants, gastro-
enteritis, bronchopneumonia, measles, and diphtheria;
in adults, ptomaine poisoning, lockjaw, cerebral apo-
plexy, and heat stroke. A missed diagnosis and faulty
death certificate in a fatal case of epidemic polio-
myelitis endangers the community more than a frank
case of paralysis. A point of value in handling an epi-
demic which kills by the thousands and cripples when
it does not kill would be the interdiction of all public
funerals in any city duringvthe progress of an epidemic.
There were 188 deaths of children under 5 years of
age from diarrheal disease reported for the week end-
ing August 5, 191G, in New York City. It would be in-
teresting and might prove instructive to hold post-
mortem examinations for one week, with microscopic
examinations in all fatal cases in which the death cer-
tificate stated gastroenteritis to be the cause of death.
5. A Study of Drug Action. — Thomas J. Mays states
that sound is a force like heat, light, and electricity,
and possesses the fundamental physical properties of
motion, action, and reaction with which other physical
forces are endowed and is amenable to the same thera-
peutic laws which obtain among the substances that he
has considered in previous papers on drug action. In
other words, he considers music a force, the elective
action of which is confined to the field of the human
emotions, and that it exerts a stimulant as well as a
depressant action. He points out how these properties
may be made available in the field of therapeutics..
Generally speaking, the stimulant action of music lies
within the bounds of the various major keys, which may
be said to move in harmony with the various bodily
forces; its depressant action, while not having an in-
tense antagonism to the normal movement of the bodily
forces, nevertheless sets up a sufficient interference
with the latter to occasion a state of mental despond-
ency. Major music is a tonic to the emotions which
may be compared to a stimulant dose of strychnine or
quinine, while minor music depresses emotional ac-
tivity in a manner comparable to bromide or a sleep-
ing potion. The apparent objections to this theory are-
discussed and the opinion expressed that music as an
agent in the treatment of consumption has probably a
t ronger claim on the scientific attention of the medical
profession than many of the remedies that are in use
at the present time. Keeping in mind the undercurrent
of tribulation and oppression that is nearly always-
present in the minds of those suffering from consump-
tion, it would seem probable that by far the larger num-
ber of cases would receive benefit from various forms
of major music.
7. Radiotherapy in Chrcnic Arthritis. — Ernest Zueb-
l.n reports a number of cases in which the ordinary
antirheumatic remedies did not produce the desired
therapeutic effects and in which radioactive substances,
such as mesothorium, locally applied to the diseased
joints produced a remarkable change in the subjective
and objective symptoms of acute and chronic deforming
arthritis. Not only is pain relieved by the local appli-
cation of the radiating energy, but also the infiltration
of the articular and periarticular structures becomes
less noticeable, and a reduction of the synovial fluid
and a gain in the active and passive motility are no-
428
MEDICAL RECORD.
LSept. 2, 1916
ticed. The danger of ankylosis resulting from the im-
mobility of the joints engendered by the pain can and
should be overcome by radioactive treatment whenever
the ordinary internal medication proves unsatisfactory.
Between radium, mesothorium, and magnesium sulphate
there seems to exist a physical similarity which ap
pears to be one of quantity rather than quality, and
which may help to explain the similar therapeutic re-
sults obtained by the latter, though the rapid and more
lasting effect must be expected from the more radio-
active and fresh preparations.
8. Toluol. — Leverett Dale Bristol discusses the value
of heat and various chemicals in the sterilization of
vaccines made from nonsporogenous Gram negative
bacteria, and emphasizes the fact that if enzymes and
toxins are to retain their full strength to stimulate the
formation of antienzymes and antitoxins the heat must
be used very carefully or not at all in killing bacteria
for vaccines. He suggests the following method of
sterilizing vaccines by toluol: When a sufficient growth
of a pure culture of bacteria has taken place upon the
slant surface of plain agar medium, the toluol is run
into the tube so that the entire surface of the medium
containing the bacteria is covered. As a rule most of
the Gram negative nonsporogenous bacteria will be
killed in twenty-four hours. The toluol is then poured
off to be used on other cultures, and the agar slants
containing the killed cultures are replaced in the in-
cubator for a short time to complete the evaporation
of the toluol. Subcultures are then made to control the
sterility of the vaccines, after which sterile salt solu-
tion is added and the dead culture carefully scraped
off the medium into suspension in salt solution. If the
toluol has not had too long an influence the bacteria
retain their size, shape, and staining qualities.
Journal of the American Medical Association.
Aui I 116.
1. The Teaching of Dermatology. Howard Morrow.
2. Some i ibservations on the Teaching of Surgery. John
Allan Wyeth.
::. Hospital Internship. J. M
4. Tl Diseases: The Status of Surgical. Samuel
Robinson.
5. The Use of Chloroform in the First Stages of Labor.
dore Hill.
C. The Influence of Diet on the Developn i 1th of
the Teeth. Jay I. Durand.
A Plea for the Prevention of Deformities in the Healing
rker.
S. Sheet Rubber Superior to Gauze Sponges in Abdominal
Operations. John W. K
9. I.. ondylitis Willis C. Campbell.
10. The Value of the Wasserm
i Falls and Josiah .1
11. A study of an Epidemic of Fourteen C
with Cui
nication. Benjamin F. S
12. Carbon Monoxide Poisoning. Yandell Hen
\ the Serum Tr<
fantile Paralysis). Simon Plexner.
1. The Teaching of Dermatology. — Howard Morrow
comments on the tendency in a number of medical
schools to place dermatology in the elective group of
the curriculum and in others the tendency to decrease
the number of required hours, thus conforming too
closely to the minimum amount of time allotted by
the schedule of the Association of Medical
Colleges, namely, forty-five hours. He says that i
student intends to become a general practitioner, to
confine his interest to special branches, or to enter
public health work, a course in dermatology and
syphilography extending over at least siNty hours is
absolutely essential. It is certainly unwise to graduate
a student who cannot differentiate syphilitic lesions
from those of a similar type, and wh recognize
the mild form of variola and other exanthems. Gen-
eral practitioners should be able to recognize and
ordinary impetigo and typii I hing
of dermatology, lantern slides, colored photographs
microscopy, and clinical demonstrations should be util-
ized. The advantage of having a serologic department
connected with the department of dermatology cannot
be overestimated. Modern investigation and research
in dermatology indicate that there are many derma-
toses associated with internal pathological conditions.
This fact emphasizes the importance of treating pa-
tients with obscure cutaneous eruptions in a hospital
where they can be studied from all phases by many-
physicians and observed by advanced students. By this
method, cases in which the etiology cannot be ascer-
tained will have the advantage of study by the derma-
tologist, pathologist, chemist, and the physician doing
internal medicine, and in this collaboration rests the
future in the study and development and teaching of
dermatology.
2. Some Observations on the Teaching of Surgery. —
John Allan Wyeth. (See Medical Record, June 17,
1916, page 1112.1
4. Thoracic Diseases.— Samuel Robinson. (See Med-
ical Record, July 1, 1916, page 32.)
5. The Use of Chloroform in the First Stages of Labor.
— Isadore Hill. (See Medical Record, July 8, 1916,
page 85.)
6. The Influence of Diet in the Development and
Health of the Teeth. — Jay I. Durand. (See Medical
Record, June 24, 1916, page 1163.)
7. A Plea for the Prevention of Deformities in the
Healing of Burns. — Charles A. Parker recommends a
treatment for burns of the so-called third degree and
holds that however extensive such burns may be, so
long as they are compatible with life, healing may and
should be obtained without deformity and with good
function. The treatment consists in the application of
movable plaster casts in the early stages of healing,
before contractures occur, over the proper dressing of
the burn. The elbow, wrist, and fingers should be kept
extended. The hip and knee should be extended with
the foot at right angles to the axis of the limb, and the
toes extended. For burns of the axillary region the
arm should be maintained in an abducted position. In
burns of the front and sides of the neck the chin must
be kept high. The cast can be removed daily, the
wounds dressed, and the cast immediately replaced
during the whole process of healing. In dressing the
wound after all sloughs have separated, ribbons of
adhesive plaster are applied directly on the wound and
extending some distance beyond the margins for at-
tachment to the normal skin. The ribbons are usually
placed at the margins of the burned area first and then
laid on in parallel strips slightly overlapping each
other until the whole region is covered. The adhesive
plaster is changed two or three times a week, or when-
ever it becomes loosened from the healthy skin. Owing
to its permeability it furnishes an ideal condition for
healing and is much more efficient than a scab over
large areas. Over the adhesive plaster a dressing of
dry gauze is placed, which is usually changed daily.
The changing of both the adhesive plaster and the
gauze is painless.
8. Sheet Rubber Superior to Gauze Sponges in Ab-
dominal Operations. — John W. Keefe. (See Ml
RECORD, July 8, 1916, page 86.)
9. Localized Osteospondylitis. — Willis C. Campbell
reports four cases in which certain local changes were-
found in the vertebra which appeared to be analogous
to nonarticular osteoarthritis and for which he has em-
yed the term osteospondylitis. This process, of
which he finds no accurate description in the literature,
is decidedly local and seems to be an affection of one
intervertebral disk. The roentgenogram shows crescent-
shaped lamellae of bone which are thrown from the
Sept. 2, 1916J
MEDICAL RECORD.
429
body of one vertebra to its adjacent fellow and may
completely encapsulate the disk, producing solid ex-
ternal fixation of two vertebra? or only a part of the
circumference may be involved. In some, the bony
ridge may be incomplete and connected by only one
extremity to the vertebral body, and at times there
may be no apparent union of either extremity to the
bodies. Similar anomalies may be seen in other spinal
affections, especially spondylitis deformans, but always
multiple and often involving the entire spine. In all
four of the cases reported the affection was in the
lumbar region. The etiology is probably the same as
in monoarticular osteoarthritis. Three of the cases were
relieved by simple orthopedic procedures, as no focal
infections could be found. These cases are reported
because the differential diagnosis of spinal lesions by
the roentgenogram is very meagerly considered in the
literature, few text-books mentioning local manifesta-
tions aside from those due to traumatism or tubercu-
losis.
10. The Value of the Wassermann Test in Pregnancy.
— Frederick Howard Falls and Josiah J. Moore. (See
Medical Record, June 17, 1916, page 1114.)
11. A Study of an Epidemic of Fourteen Cases of
Trichinosis with Cures by Serum Therapy. — Benjamin
F. Salzer makes this preliminary communication, based
on a study of 14 cases of trichinosis, in which the
patients were admitted to the wards of St. Joseph's
Hospital, Far Rockaway, N. Y. In the course of these
studies he has confirmed the following findings of others:
1. The Kernig reaction was present in all the cases.
2. Edema of the face occurred in all the cases. 3.
Edema of the lower extremities occurred in six cases.
4. The reflexes in the lower extremities were abolished
in all the cases and are still absent now (six months
having elapsed since the cases first came under observa-
tion). 5. Trichina? were found in the blood in nine
cases of the fourteen. 6. Trichina? were readily found
in the cerebrospinal fluid in eight of the fourteen cases.
In addition to these observations he has found that the
diazo reaction was in direct proportion to the degree
of eosinophilia. The leucocytosis diminished as the
eosinophilia increased. The blood coagulation time
is markedly prolonged in trichinosis. In one case of
trichinosis in a child three years of age trichinae were
still found in the cerebrospinal fluid three months after
the clinical recovery. Trichina? were not found in the
urine in any case. They were not found in the uterus
but were abundantly present in the placenta. They were
present in large numbers in the milk of a nursing
woman and were found in the piece of mammary gland
excised. In two cases the duodenal tube was passed
under control of the fluoroscope; in one of these,
trichina? were abundantly found. This patient was
now suffering from cholecystitis. The feces were clay
colored throughout the disease in every case; this was
probably clue to the reduction of bilirubin by living
trichina?. Trichina? were present in the stools of all
the cases throughout the disease and in three cases
in which studies were carried on after recovery. The
author relates a number of observations made on
animals and states that the use of serum from human
patients who recovered removed the eosinophilia per-
sisting after recovery in man or animals within forty-
eight hours. The injection of normal serum had no
therapeutic value in trichinosis in man or animals; the
same is true of salvarsanized serum and salt solution.
In animals the injection of convalescent serum gives
an almost complete prophylactic result. In two cases
of trichinosis in the very active stage of the disease
the use of immune serum proved to be of remarkable
curative value. In twenty-four rabbits suffering from
the disease, experimentally produced, the immune
serum had a curative effect within twenty-four hours.
13. A Note on the Serum Treatment of Poliomyelitis.
— Simon Flexner reviews the experiments on monkeys
which have formed the basis for the serum treatment
of poliomyelitis, refers to Netter's results with the
serum treatment in a series of 35 cases of the disease,
and says the serum injections are usually given sub-
durally as early after the appearance and recognition
of the symptoms of poliomyelitis as possible. The dose
of the serum must be sterile, not necessarily activated,
and should be determined by the age of the patient
and the amount of serum available. Probably doses
ranging from 5 to 20 c.c. will be suitable, the injec-
tions to be repeated several times at twenty-four hour
intervals, according to clinical conditions and indica-
tions. Since the immune substances have been found
to persist in the blood for many years, it is probable
that persons who have passed through an attack of
poliomyelitis many years earlier may be utilized as
sources of the serum; reasoning from analogy it would
probably be advantageous to prefer persons whose at-
tack was less remote, so as to insure as high concen-
tration of the immune bodies as possible. The condi-
tions surrounding the injection of the serum into the
meninges are identical with those observed in the
analogous case of epidemic meningitis. The effects of
the immune serum should be sought in the prevention
or minimization of the paralysis when employed in the
preparalytic stages, and the arrest of its extension
when used in progressing paralytic conditions.
The Lancet.
July 29, 1916.
!. Observations on Fifty Laparotomies Performed for (Gun-
shot Wounds of the Abdomen. G. H. Stevenson and
C. Mackenzie.
2. On the Advantages of Using a Broth Containing a Trypsin
in Making Blood Cultures. S. R. Douglas and 1j
< '<<] 'Ill'l-I >k
3. Treatment of Carriers of Amebic Dysentery. Note on
the Use of the Double Iodide of Emetine and Bismuth.
H. H. Dale.
1 A Note on the Necessity for Prolonged Treatment in
Cases of Infantile Paralysis. Francis Hernaman-
Johnson.
'■ Six Cases of Wounds of the Buttock with Perforation of
the Intestine. R. B. Blair.
6. A Serious Defect in Some of the Registered Hospitals
for the Insane. Henry Rayner.
1. Observations on Fifty Laparotomies Performed
for Gunshot Wounds of the Abdomen. — G. H. Stevenson
and C. Mackenzie present a synopsis of these 50 cases,
of which 17 recovered and 33 died. The cause of death
in the fatal cases was as follows: general peritonitis,
10 cases; hemorrhage and shock, 19; lung conditions,
2 cases, and secondary hemorrhage from the kidney
in one case and sloughing of the gut in one case. Since
the beginning of the war the opinion with reference to
the expectant treatment of abdominal wounds has
undergone a change and completely altered the outlook
in such cases. Patients are operated on as quickly as
possible. It is wrong to wait, no matter how bad the
patient may appear, as so often in such cases hemor-
rhage and infection are progressing. Even though no
pulse can be felt, an operation is not thereby contra-
indicated, as it gives the last possible chance of re-
covery. Many of the patients in this series were oper-
ated on within five or six hours of their being wounded,
though many others did not reach the hospital for
twelve to twenty-four hours. Regarding the question
of whether a man will stand an operation or not, they
took the view that, if intraperitoneal perforation of
the gut is present he will almost certainly die if not
operated upon, and that it is right to give him the
chance, even though it be only one in a thousand. The
technique used in these operations differs little from
430
MEDICAL RECORD.
LSept. 2, 1916
that in the similar operations of civil practice, end to
end anastomosis being the usual method when resec-
tion is necessary, except when several feet of the gut
have to be removed, when the lateral anastomosis is
employed, as this is undoubtedly stronger. Where
suture is possible, suture in the transverse axis is pref-
erable to the longitudinal in lesions of the small in-
testine. The writers have found pituitrin a most valu-
able drug in the after-treatment of abdominal cases.
In a recent article it is stated that it is not so usual
in gunshot wounds of the bowel for the gut to be com-
pletely divided; in the present series this is a com-
paratively common occurrence.
2. On the Advantage of Csing Brcth Containing
Trypsin in Making Blocd Cultures. — S. U. Douglas and
L. Colebrook have confirmed the findings of Wright and
his fellow workers, which showed that when, by mix-
ture with trypsin, the antitryptic power of the blood
is neutralized, the blood loses its power of clotting and
also its bactericidal properties. They state that these
are precisely the changes which it is desirable to bring
about when attempting to cultivate pathogenic micro-
organisms from the circulating blood. A series of blood
cultures performed in duplicate with trypsin broth and
simple broth has shewn that the employment of trypsin
in that procedure is clearly advantageous, the or-
ganisms having been in some cases recovered only in
the trypsin tubes, while in other cases they were re-
covered earlier and more frequently in these than in the
control tubes. It is probable that this method favor.
the cultivation of any microbe that may be present in
the blood, and not especially one parti i i ism or
group of organisms, as is the case with bile media;
staphylococci, streptococci, paratyphoid 1 acilli, and an-
thrax bacilli, were readily isolated from blood by the
use of trypsin broth. In order to be sure of neutraliz-
ing the antitryptic power of the inoculated blood it is
recommended to employ broth containing not less than
5 per cent, of trypsin solution (compound solution of
trypsin, Allen and Hanbury's) and to add not more
than 1 c.C. of blood to each 5 c.C. tube of such broth.
When blood has to be sent by post to a laboratory,
undiluted trypsin solution may be added to the speci-
men of blood immediately on its withdrawal from the
vein, in the proportion of 1 of trypsin to 4 of blood.
3. Treatment of Carriers of Amebic Dysentery. — H.
H. Dale states that the problem in the treatment of
entamebiasis in England during the past year has been
that of freeing the chronic "carriers" from their in-
fection. While experience in Egypt has led to the con-
clusion that a full course of 10 or 12 grains of emetine
hydrochloride, given hypodermically, will practically
always eradicate the infection, experience has shown
that there is a not inconsiderable proportion of cases
in which such a course of emetine treatment has led
only to a temporary absence of cysts from the feces.
Ten cases regarded as hopeless when treated by this
method have been given a course of treatment with
double iodide of emetine and bismuth with the result
that six of these patients have shown six weeks' absence
of cysts with daily examinations. Thirty to 36 g]
of the double iodide of emetine and bismuth, equivalent
to about 10 to 12 grains of emetine hydrochloride, has
tarded as a full course, and the daily dose has
varied from 2 to 1 grains, given in capsules. The
lency of vomiting under this treatment is in no
way een .parable to that seen with the ipecacuanha
treatment, and there is no need to adopt the prec
tionary measures to avoid vomiting which the latter
treatment entails.
4. A Note on the Necessitj for Prolonged Treatment in
Cases of Infantile Paralysis.— Francis II.- aman-John-
son believes that much of our treatment of the weak-
ness and deformity which may result from an attack
of infantile paralysis fails owing to lack of proper
following-up. He reports an illustrative case that
showed no improvement for over two years and then
under careful orthopedic treatment and supervision a
very marked improvement ensued. He states that the
therapeutic lessons which have been learned in connec-
tion with infantile paralysis are of special interest be-
cause they are equally applicable in dealing with war
injuries to nerves and muscles. The following three
lessons should always be kept in mind: 1. A muscle
which is chronically overstretched cannot recover. It
must be relaxed by means of a suitable splint. This
principle was insisted on by Robert Jones many years
ago, and its importance cannot be over-emphasized.
2. When such a muscle responds moderately well to
faradism — or, in more modern terms, to the small or
medium capacities of the Lewis Jones instrument — its
recovery will be greatly hastened (and in some cases
even determined) by daily rhythmical electrical stimula-
tion. The relaxed position must, however, be main-
tained throughout. 3. Exercise, whether voluntary or
electrically provoked, must never be carried to the
point of fatigue. The contraction of a muscle should
be not less vigorous — with the same stimulus — at the
end of a sitting than at its commencement. It is bet-
ter that recovery should be delayed by over-caution
than that it should be made impossible by excess of zeal.
British Medical Journal.
July 29, r
I. Two Hundred Consecutive Hysterectomies t"i Fibroids
Attended with Recovery. John Bland-Sutton.
.' Some Notes on Trem h Fever. T. Stretthill Wright.
3. Pathogenicity of Giardia (Lamblia) Intestinalis to Men
and to Experimental Animals. H. B. Fantham
Annie Porter.
I. Bacillary Dysentery i Sliisa i Contracted in England. P
L. Sutherland.
5 ini the Curve of the Epidemic. (Supplementary Xote.)
John Brownlee.
G. On the Importance of Technical I '.tails in the Preparation
oi a Transport Blood-Agar for the Cultivation ol th
Meningococcus. Dorothy Jordan I .lie
. The Duration of Bilharziosis in South Africa. V '• Caws-
ton.
1. Two Hundred Consecutive Hysterectomies for Fi-
broids Attended with Recovery. — John Bland-Sutton has
removed the uterus for fibroids in more than 2000
women. In the Middli sex Hospital, in 1892, three
women had the utetus removed for troublesome fibroids;
two died in consequence of the operation. In 1912,
there were seventy-one abdominal hysterectomies per-
formed in the hospital and all recovered, showing a
great improvement in twenty years. (If the last 200
cases of hysterectomy for this disease that the writer
has performed in this hospital all recovered. Among
these 200 hysterectomies 188 were subtotal. During1
the period covered by these 200 cases hysterectomy I
been performed in the writer's ward .imyoraa,
fibrosis uteri, cancer, septic infection, and for ova
fibroids three times, and also four abdominal myec-
tomies. All the patients recovered. These results have
been obtained with a minimum use of antiseptics.
Women with uterine fibroids who show signs of diabetes,
.ophthalmic goitre, cardiac disease, arterial sclerosis,
and albuminuria are rarely submitted to operation.
Ai'ter describing the different va tetie of fibroids the
author ventures the following aphorisms: There are
two things disquieting in diagnosis: 1. To distinguish
between solid ovarian tumors and large subserous
fibroids. 2. And between tubal swelling and uterine
fibroids. Three foolish things are: 3. To give opin-
ions on pelvic swellings without making a vaginal ex-
amination. 4. Or on hypogastric swellings without
passing a catheter. 5. To remove fibroids without ex-
Sept. 2, 1916]
MEDICAL RECORD.
431
amining the woman's urine for sugar until she is coma-
tose two or three days after the operation. Four things
useful to know: 6. When a barren woman between
and 45 has retention of urine, it is almost certain that
she has a fibroid in her womb. 7. A fibroid that sud-
denly becomes painful during pregnancy is probably in
a state of red degeneration. The clinical signs simulate
tubal pregnancy, axial rotation of an ovarian tumor,
and acute infection of the appendix. 8. Errors in the
differential diagnosis of fibroids and pregnancy are
usually made before the beating of the fetal heart is
audible. 9. A cancerous mass in the pelvic colon, in
contact with the uterus, imitates the signs of a sub-
serous fibroid. Four things that are wise: 10. When in
doubt whether a big uterus in a young woman contains
a child or a fibroid, wait for a month and re-examine
the patient. 11. To remember that ovarian tumors give
much trouble to pregnant and lying-in women, but
fibroids are more deadly, for they are liable to become
septic. 12. After the removal of a fibroid in the pro-
creative period of life a woman is more liable to grow
more fibroids than to conceive successfully. 13. To
remember that uterine bleeding after the menopause, in
a barren woman with a fibroid, often signifies the ex-
istence of cancer within the uterus.
2. Some Notes on Trench Fever.— T. Strethill Wright
relates that among a large number of cases that came
to them from the front there were thirty cases of a new
type. They were characterized by a peculiar temper-
ature chart, which showed a series of "spikes" occur-
ring at more or less regular intervals, and separated
by afebrile periods. The onset was generally sudden,
the majority of the cases showing an initial period of
pyrexia of two to three days, severe headache, and
pain in the legs and small of the back. The pain so
far as could be determined was invariably muscular.
During the febrile paroxysms the other symptoms
were always worse. The fever was accompanied by
loss of appetite and coated tongue. Sweating was a
common accompaniment of the sharp falls in tempera-
ture. The only other common symptoms was a tend-
ency to constipation. Attempts to discover an organ-
ism to which the infection may be attributed have not
as yet been rewarded with success. The examinations
of the blood, feces, and urine, in a large number of
cases were all negative as to evidence of typhoid or
paratyphoid infection. The evidence shows that these
were not atypical cases of enteric, but genuine cases
of trench fever, and it may be definitely stated that
the disease has every appearance of being a distinct
clinical entity.
3. The Pathogenicity of Giardia (Lamblia) Intesti-
nalis to Men and to Experimental Animals. — H. B. Fan-
tham and Annie Porter present their personal evi-
dence based on their observations of pure cases of lamb-
liasis in man and of some experiments with human
Lamblia on animals. They state that in both human
and animal lambliasis stools, as well as at post-mortem
examinations, erosion, and distortion of the intestinal
epithelial cells occurred, owing to direct suctorial action
of the flagellate Lamblia. Giardia (Lamblia) intes-
tinalis is pathogenic to man, and is capable of produc-
ing diarrhea, which may be persistent or recurrent.
The virulence of the parasite varies, and lambliasis
occurs in tropical and non-tropical countries. The
Lamblia cysts can remain infective for some time.
Lambliasis occurs in rodents, especially rates and mice,
and can be of human origin. Lambliasis may also be
produced in cats. It is possible for such animals to
serve as reservoirs of lambliasis, and by contaminating
the food of man by their excrement to propagate
lambliasis. Sufficient atttention has not been given to
this method of infection in the trenches in the fighting
area.
7. The Duration of Bilharziosis in South Africa. — F.
G. Cawston says that, judging from the number of
men who were infected with bilharziosis during the
South African war and the number of these who are
still receiving compensation from the army authorities,
a study of the duration of the South African form of
this infection is of great importance. He finds that
the vast majority of persons in Natal who suffered
from the affection some twenty or thirty years ago have
by this time entirely grown out of the symptoms, and
in a large number of these microscopic examination of
the urine shows no evidence of the past infection. On
these grounds a life insurance company can be recom-
mended to accept an otherwise suitable applicant at the
usual rates, provided the urine has shown no sign of
blood or mucus for otie year and has not contained any
of the eggs for six months, so far as can be judged
from occasional microscopic examinations. A number
of those, however, who contracted the disease twenty
or thirty years ago have suffered continually from its
symptoms ever since, though they may not have been
sufficiently severe to require continuous medical treat-
ment. Several cases in which the disease has persisted
are cited which lead to the conclusion that even if some
of the remedies employed are effective in destroying
the parasites in the blood stream and in diminishing
the hematuria, the escape of the spine-pointed eggs
which continues is too frequently associated with bacil-
luria and damage to the bladder wall to enable one to
pronounce such a case as cured, even though it is ex-
ceptional to hear of cases which have died or whose lives
have been shortened by bilharziosis.
La Presse Medicale.
I I 24, 1916.
Differential Diagnosis Between Pulmonary Tuberculo-
sis and Chronic Affections of the Nasal Fossae. — Rist
discusses protracted cough and other symptoms of in-
tranasal origin which simulate tuberculosis of the lungs
despite inability to find the bacillus and perfectly cleat-
s-ray shadows. These patients may or may not pre-
sent stethoscopic alterations in the thorax. It is not
enough to tell them they are not tuberculous; some ex-
planation must be found for the cough. The cardio-
vascular apparatus and kidneys should be examined.
Mitral stenosis has simulated phthisis, by reason of
associated cough and hemoptysis. Another condition
which sometimes simulates tuberculosis is gastroptosis
with gastric atony. These subjects emaciate and often
cough after meals. The old rule holds good that when-
ever you cannot make a diagnosis, suspect tuberculosis.
To exclude this gastric affection an .T-ray following a
bismuth meal is sufficient. Abortive Graves's disease
is a thjrd affection which can simulate consumption,
especially if the thyroid and eyeball are not prominent.
However, negative sputum and .v-ray finds readily ex-
clude tuberculosis. But there are numerous suspects
which have none of the preceding affections, especially
among the troops. By the way, it is singular that in
the routine examination for suspected tuberculosis, the
nasal passages are seldom included. This is a great
error when we consider the number and variety of
lesions which are of common occurrence in the latter,
and the symptoms to which they give rise, including
cough and hemoptysis. It is true that subjects with
narrow fossa?, spurs, etc., soon learn to adapt them-
selves to the disturbed respiration. The author, how-
ever, knows of a rhinologist who was believed to be in
consumption who had nothing worse than chronic
purulent rhinitis. Patients of this class take cold
432
MEDICAL RECORD.
[Sept. 2, 1916
frequently, and every morning must clear the upper
respiratory tract of tenacious, often bloody mucopus
which is often present in large quantities. Every
Spring their conditions seem aggravated and they be-
lieve themselves affected with some serious intra-
thoracic infection. Other patients have atrophic
rhinitis and rejoice in dry, clear passages. They
"never need handkerchiefs." Yet these subjects are
mouth breathers, because one or both nostrils is ob-
structed. All such subjects may often be recognized at
a glance by the large, thin, curved nose, sometimes
deflected to one side, which suggests unerringly con-
genital narrowness of the nasal passages. The contour
of the nostrils also readily indicates the same condition.
A thick root of the nose suggests hypertrophy of the
middle turbinals. When these subjects speak the voice
also betrays them (rhinolalia of a special type).
As is well known subjects with chronic rhinitis are
also hoarse. The cough may be dry or moist, and
aside from sputum which is merely streaked with
blood, we may see at times free blood from rupture of
varicosities in the throat. Some of these patients also
suffer with bronchitis with slight temperature rise
which, of course, points all the more to phthisis — even
to the stage of softening. How is this pseudotubercu-
losis produced? We have plainly to do with a nasal
insufficiency with "false passage" (mouth breathing).
As is well known certain authors now contend that
mouth breathing by causing slight flatness at the apices
from lack of inflation is the most puissant cause of
clinical pseudotuberculosis in its initial stage. Lemoine
holds this view in moderation, while Kronig pushes it to
extremes in speaking of a sclerosing atelectasis. The
author describes at great length his views of spreading
infection from some focus in the nose, which slowly
involves some of the sinuses, cause polypi, tonsillitis,
the "closed follicles" of the pharynx (which are mis-
takenly cauterized by lhinologists), chronic catarrhal
laryngitis, etc. In other words, a spreading infection
is fastened upon a noninfectious condition — which is
simply one of malformation. The original nasal insuf-
ficiency is of course greatly aggravated. A bronchitis
represents a downward extension of the process. As
a matter of fact but little bronchitis is primary. True
primary bronchitis is simply essential asthma. To
combat the entire chronic infection we must begin at the
parent spot — the septal spur, hypertrophied turbinate,
the chronic sinusitis. The result will often be surpris-
ing. The "tuberculous" subject is suddenly cured.
La Presse Medicale.
August 3, 1916.
Glycuronuria and Its Variations. — Gautier refers to
the study of Roger and Chiray of the presence of gly-
curonic acid in the urine. As a product of the hepatic
cell, it was investigated in connection with diabetes,
hepatic circhosis and retention icterus; also in pneu-
monia and cancer. The author has gone over the
ground, and his results tend to confirm the claims of
Roger. The test used by Grimbert and Bermier is
preferred to that employed by Roger. The urine is
ted mercuric acetate and the filtrate heated with
naphthoresorcin and chlorhydric acid. After cooling
it is shaken up with an equal volume of ether. If the
result is positive a blue violet color appears. If the
result is negative there is either no color change or one
of yellowish brown. According to Roger, the human
urine always contains a little glycurnic acid. Its per-
centage varies with the diet. It is relatively large in
meat eaters and small in those on a vegetable or milk
regimen, and after fasting. Ingestion of a little cam-
phor will in such cases cause the percentage to rise.
In hepatic insufficiency the acid disappears wholly fiom
the urine when the prognosis is fatal, and is a good
measure of hepatic efficiency, the amount dwindling
with the degree of insufficiency. If there is some doubt
as to the result, Roger uses an alimentary reinforce-
ment in giving 1 gram of camphor. If the resu
then negative, the liver is hopelessly compromised. The
author has tested 200 subjects, including the sound and
diseased. Camphor will not increase the amount pres-
ent in the urine of the healthy (the tested subject must
be on a standard diet). Given to those with hepatic
disease variable results follow. In diabetes the result
is always negative. In hepatic circhose it may at first
promote the elimination of the acid, but not in the ad-
vanced case. Roger found the maximum per cent, of
acid in a case of acute lysol poisoning. On the next day
no acid appeared in the urine, but this default lasted
but a short time. This overproduction of acid in the
presence of camphor and lysol suggests that an anti-
toxic activity is involved, either by combination or
elimination. In absence of acid in the urine of dial-* I
the sugar seems to be in no w-ise concerned. In
Laennec's circhosis of the liver the acid which nearly
vanishes in the presence of ascites increases in per
cent, after tapping. In cardiac liver results were in-
consistent, but the presence or absence of the acid has
a marked prognostic value. In cancer of the liver sup-
pression of acid in the urine means an early death, ac-
cording to Roger, who indeed here includes cancer in
all localities. The author's results are quite opposed to
this teaching. In conclusion he expresses the opinion
that the research into glycuronuria will yield most
valuable results in diagnosis and prognosis.
La Bulletin Medical.
Aliriust 5. 1916.
Virilism and Inversion of Sexual Characters. — Blanc-
ard considers this subject from the special viewpoint of
the activities of the interstitial tissues of the genera-
tive glands. By virilism he refers of course to acquired
made characteristics in the female. Hippocrates relates
two cases of virilistic transformation in women named
Phoetusa and Namyxia. Ambroise Pare described cer-
tain degenerate women whom he termed hommasses
(viragos) who, in losing their feminine somatic char-
acteristics, assumed those of men, becoming also robust
and bold. He ascribed these changes to suppression of
the menses. Apert was the first to advance a scien-
tific explanation of acquired virilism, viz.: the presence
of lesions of the suprarenal glands. It was not until
later that changes in the sexual glands were held to
be responsible, although these changes were alleged to
be secondary to those in the suprarenals. Tuffier's
celebrated case of suprarenal virilism reported in 1914
left no doubt as to the nature of at least one form of
virilism. The author, who is a zoologist, states that
analogous behavior is seen in certain birds. As far
back as John Hunter attention was attracted to the
assumption by elderly female birds of male plumage.
Hunter regarded the phenomenon as teratological. The
Germans have described such behavior under the term
virilescence. The pheasant seems especially disposed to
this affection, the transformation, however, being in-
complete. The altered hens do not cease to lay. The
theory advanced of ovarian origin seems to have little
formation in fact. This virilescence has been noted in
at least twenty-six species of bird belonging to four
orders. All barnyard fowls seem to be included. Mam-
mals are also subject to virilistic change, but the sub-
ject has received but scant attention. As in birds the
changes are restricted to the tegumentary structures.
Sept. 2, 1916]
MEDICAL RECORD.
433
Martvwxa Miliums.
THE FUTURE OF INSURANCE MEDICINE.
In the issue of the Medical Record for August 12
there is a brief but very interesting article by H. E.
MacDonald on the probable future evolution of in-
surance medicine. He shows very clearly that those
who need the insurance most, those who are physi-
cally under par, are the very ones who find insur-
ance hardest to get. The perfectly well find it easy
to obtain but do not need it so much and often do
not want it at all. He goes on to predict that in
the future the insurance companies will accept all
or nearly all risks and will base the rates in the in-
dividual case upon the prognosis offered by the ex-
amining physician. He continues: "Suppose an
insurance company decide to conduct their business
in this way. They will hold their examination in
prognosis after the graduation of a class in a medi-
cal college. Those who pass will be appointed ex-
aminers whose duty it will be to examine insurance
prospects for a small fee or nothing (italics ours).
In doing this they will immediately have a practice,
unremunerative it is true, but it will grow into a
paying practice which will be along the line of pre-
ventive medicine, which will be the medicine of the
future and which will be ushered in immediately by
this plan of making life-insurance examinations."
It is in this part of his article that we wish to
register our objection to Dr. MacDonald's plan.
One of the faulty points of the insurance scheme as
it is carried out at the present time is the inade-
quate fee which is paid, in certain sections and by
certain companies, for examinations. There is
nothing more true than the old saying that we get
what we pay for and no more. The examination is
only too often conducted in a hasty and inadequate
manner so that it is the belief of many men in in-
surance medicine that they would do as well with-
out physicians as with them. An experienced man,
a good judge of his fellow men, and a keen observer
would be able probably to pass the applicants at a
glance with as good results as are obtained by the
young doctor who does two or three hundred exam-
inations a month at a dollar a head and in the in-
terval attempts to build up his practice so that he
may be able to quit the insurance business which
he considers pot-boiling and of a deadly monotony.
It is very generally admitted that accurate progno-
sis requires much more experience and keen obser-
vation than does the average diagnosis and yet it is
proposed that this service be carried on by very re-
cent graduates "for a small fee or nothing." The
lure held out that "it will grow into a paying prac-
tice" is liable to prove a disappointment to those who
try it. Most applicants who are already ill will have
their own physicians and the young examiner will
find that what little income he may be able to ob-
tain will be eaten up in carfares while getting about
to do his free examinations. It is a notorious fact
that of all men, physicians do the greatest amount
of work for nothing and, in consequence, their good
nature is abused to a shameful degree. Let us reg-
ister an earnest protest against any movement
which aims to increase the amount of free work
which is to be contributed by our ill-treated profes-
sion. We are happy to give of our time and labor
to benefit our fellow man so far as we are able, but
in return for that the least which we can expect is
a living wage and such consideration as will enable
us to maintain our self-respect.
Diseases of the Lungs, Liver, Pancreas, and
Kidneys in Relation to Obesity. — Dr. F. Parkes
Webber, in a paper read before the Assurance Medi-
cal Society in London, concerning diseases in rela-
tion to obesity, said that emphysema of the lungs
with progressive dilatation of the right side of the
heart and other results might be at first masked
by obesity. Of great importance was the ausculta-
tion of the infrascapular regions for the more or less
permanent crepitation which showed the presence
of chronic catarrh or chronic edema of the base
of one or both lungs. Pulmonary tuberculosis was,
of course, generally associated with underweight
rather than overweight, but there were exceptions,
and old quiescent or obsolete pulmonary tuberculosis
might, partly as a result of methods of treatment,
occasionally be associated with a plethoric type of
corpulence. It was a well-known trusim to say that
the detection of cholelithiasis or nephrolithiasis
might be rendered more difficult by the presence of
obesity. Cholelithiasis was acknowledged to be re-
latively frequent among fat persons, rather more
so in women than in men. Obesity might sometimes
draw the examiner's attention away, and so in a
sense, mask the presence of chronic nephritis,
especially contracted granular kidneys, notably so
if the urine only intermittently contained albumin,
and even then in mere traces. Examination of the
centrifuge sediment of the urine for tube-casts
might be of some use, but it must be remembered
that one or two hyaline or even granular casts
might occasionally be found in the urine of prac-
tically healthy persons by the help of the centri-
fugal machine. Estimation of the brachial systolic
blood-pressure might likewise aid in the diagnosis.
Occasionally an ophthalmoscopic examination in
such cases might reveal the presence of unsuspected
retinal changes. In regard to the pancreas, one
might remember that the subjects of acute hemor-
rhagic pancreatitis were not rarely corpulent indi-
viduals, or individuals who had been addicted to
alcohol.
The Personal History. — Dr. W. A. Boyce says
the personal history is very important, and a local
examiner should never disregard a history of pre-
vious sickness. An applicant might say he had
been treated by a physician in the adjoining town
for "biliousness," when many times it was for
syphilis, appendicitis, gallstones, or some other
disease that would have quite an influence on
his mortality. Inquiry should be made, and date,
duration, and name and address of the attending
physician should be given ; also the abdomen should
be palpated and other examinations made and de-
tails given of the findings. — Texas State Journal.
"Accidental Means." — In an action on an acci-
dent policy, it appeared that the plaintiff attended
a football game on a cool day when the ground
was damp, and contracted a cold, resulting in lum-
bago. After medical treatment and the debility
resulting from a purgative, and while lying in bed,
he had a paper brought, reached for it, and raised it
suddenly above his head, when his strong blood
pressure caused a rupture of the retina, destroying
the sight of one eye. It was held he could not re-
cover on a policy insuring him against bodily in-
jury through "accidental means," since, while the
result was not foreseen, the cause producing the
result was not accidental, but an ordinary natural
movement, executed as intended. — Stone v. Fidel-
ity & Casualty Co. of New York, Tennessee Su-
preme Court, 182 S. W. 252.
434
MEDICAL RECORD.
[Sept. 2, 1916
Honk Steuteuis-
Cleft Palate and Hair Lip. By Sir W. Arbuthnot
Lane, Bart., M.S., F.R.C.S., Senior Surgeon to Guy s
Hospital, and Emeritus Surgeon to the Hospital for
Sick Children, Great Ormond Street. Third Edition,
102 pages, with 58 illustrations and diagrams. Price,
$4.00. London: Adlard & Son. Chicago: Chicago
Medical Book Company. 1910.
Lane's own contribution to this work takes up about
60 pages, of which about half is devoted to a statement
of his views regarding the factors that influence the
growth of the nasopharynx and of the mouth and of the
bones that surround those cavities. He then propounds
the following questions regarding cleft palate: "What
is the best age for operation? (2) What is the best
method of performing the operation? (3) How and
when can any complication such as harelip be met to
the greatest advantage?" From Lane's answers to these
questions we learn that the best time for operation
upon cleft palate is the day of birth or as soon after
that as possible; that the best method of performing
the operation is Lane's method, which is briefly de-
scribed and is illustrated by a number of rather occult
diagrams and which is to be performed with instru-
ments devised by Lane "to replace the clumsy instru-
ments originally in use;" and that if, besides a cleft
of the hard and soft palate, the lip is defective on one
or both sides, two courses are open to the operator —
if the closure of the cleft in the lip does not interfere
with the free passage of air through the nose the clefts
in the lip and palate may be closed simultaoneously, but
if the cleft in the lip is very extensive and if its closure
will interfere with the free passage of air through the
nares the lip and hard palate may be closed in the first
instance, the cleft in the soft palate being dealt with
later.
Mr. Cortlandt MacMahon contributes 10 pages on
Speech Training, and Mr. W. Warwick James, 30 pages
on Dental Treatment of Cleft Palate.
The Clinics of John B. Murphy, at Mercy Hospital,
Chicago. Vol. V, Number I. Octavo of 194 pages,
with 32 illustrations. Published bi-monthiy. Price
per year, cloth, $12.00; paper, $8.00. Philadelphia
and London : W. B. Saunders Company. 1916.
In this number of the Clinics we find about one-fourth
of the book devoted to six clinical cases that are of in-
terest to the general surgeon ; while the other three-
fourths is made up of the seemingly inevitable and un-
ending bone and joint material. This might well be
called an orthopedic number; for it is of comparatively
little interest to those not specializing in bone and joint
work. From the ordinary subscriber's point of view
we should say that this is about the poorest number of
the Clinics that has yet appeared.
Lateral Curvature of the Spine and Round Shoul-
ders. By Robert W. Lovett, M.D., Boston, John B.
and Buckmeister Brown Professor of Orthopedic
Surgery, Harvard Medical School; Surgeon to the
Children's Hospital, Boston; Surgeon-in-Chief to the
Massachusetts Hospital School, Camden ; Consulting
Orthopedic Surgeon to the Boston Dispensary; Member
of the American Orthopedic Association; Correspond-
ing Member of the Royal Society of Physicians, Buda-
pest; Korrespondierendes mitglied der Deutschen
Gesellschaft fur Orthopadische Chirurgie, Socio della
Societa Italians di Qrtopedia. Third edition, revised
and enlarged; with 180 illustrations. Price, $1.75.
Philadelphia: P. Blakiston's Son & Co. 1
The third edition of Dr. Lovett's Lateral Curvature of
the Spine contains an interesting added chapter on the
History of Scoliosis. The chapter on treatment has
been expanded and changed where Dr. Lovett's experi-
ence has given indication. The book is an excellent one
and a new edition will be welcomed.
\ Manual of Practical Nursery. Prepared for the
Washington University Training School for Nurses
in the Barnes and St. Louis Children's Hospitals.
Edited by HELEN LILLIAN BRIDGE, B S., R.N., Assist-
ant Superintendent and Instructor of Nurses. Wash-
ington University Training School for Nurses, St.
Louis. Price. $1.00. St. Louis: C. V. Mosby Com-
pany. 1916.
Miss Bridge's manual should be very helpful to nurses
in training. It is not a ti such in-
formation as the nurse must have during her actual
time on the ward. R< for various treatments
•are given and ich group a note stating the length
of treatment or any special warning which may be nec-
essary. Routines on surgical, gynecological and ob-
stetrical sources are given, typhoid routine, routine for
admission of patients.
There is an inset leaf between each two pages, so
that variations can be noted and the book adapted to
the use of every training school. The book will help a
nurse as a constant check until the details of her work
have become part of herself.
Venereal Diseases, a Manual for Students and
Practitioners. By James R. Hayden, M.D., F.A.C.S.,
Professor of Urology at the College of Physicians
and Surgeons, Columbia University, New York;
Visiting Genito-Urinary Surgeon to Bellevue Hos-
pital; Consulting Genito-Urinary Surgeon to St.
Joseph's Hospital, Yonkers, New York. Fourth
edition, thoroughly revised. Illustrated with 133 en-
gravings. Philadelphia and New York: Lea and
Febiger. 1916.
The author presents his fourth edition in more attrac-
tive garb by arranging his text in chapter form, by
additional illustrations and by bringing the treatment
of syphilis up to date. Condensed as it must be for
students' use, the treatment of gonorrhea, urethral
stricture, and syphilis are clearly and carefully written.
Among other praiseworthy features is the advice to
use the inunction method of mercurial administration
in the treatment of syphilis. In view of the fact that
this book is primarily intended for senior medical stu-
dents and that the teachings in this period of a medical
career are most lasting, the author wisely avoids
theories, debatable therapeutic procedures, and in gen-
eral holds his course to "the middle of the road."
Diagnose und Therapie der Gonorrhoe beim Manne.
Von Sanitatsrat Dr. S. Jessner, Konigsberg i. Pr.
Zweite verbesserte Auflage. Preis 3.50 Mk. Wiirz-
burg: Verlag von Curt Kabitzsch. 1916.
Whoever enjoys the recitation of facts couched in beau-
tiful language should read this book. As a scientific
treatise on a common disease, much is lacking. The
author arranges his second edition in the orthodox man-
ner, beginning with the anatomy of the region and
ending with the treatment of gonorrheal sequela?. In
the course of these chapters the reviewer encounters
some untenable positions and unforgiviible omissions.
For example, he objects to urethral dilatations with
modern dilators because their use requires much prac-
tice and much time is consumed in administering the
treatment, the instruments are costly and are expensive
additions to the physician's armamentarium, and be-
cause he can accomplish the same results with simpler
methods. Sic transit Oberlander. The operation for
rapid relief and cure of acute gonorrheal epididymitis
as developed by an American surgeon is not mentioned,
although it is universally accepted by urologists as the
most modern and most conservative treatment. The
book is not typically Teutonic in thoroughness, nor does
it bear the marks of a labor of love. Likewise, it is
devoid of illustrations.
The Principles and Practice of Perimetry. By
Luther C. Peter, A.M., M.D., F.A.C.S. Associate
Professor of Ophthalmology, Philadelphia Polyclinic
and College for Graduates in Medicine; Ophthal-
mologist to the Rush Hospital for Consumption and
Allied Diseases. Illustrated with 119 Engravings
Price, $2.50. Philadelphia and New York: Lea &
Febiger, 1916.
The subject of perimetry is one that should enlist the
very careful consideration of every practitioner of
ophthalmology. The information obtained by the in-
telligenl and thorough study of fields of vision is of
very great importance as a means of diagnosis and of
prognosis. The author of this work has presented the
subject in a very attractive and practical manner.
Part I is devoted to a description of the normal field
of vision and the various factors that influence its ex-
tent. Part II describes the methods employed in
perimetry. Part III is concerned with the anatomy
and physiojogy of the visual tract. Part IV treats of
the changes in form of the fields for form and colors
due to disease. Part V is devoted to a description of
the fields of vision as thev are affected by special dis-
eased conditions. Part VI describes the changes in the
fields of vision due to "functional" nervous disease. An
appendix treats briefly on anomalies of the fields, due
to loss of parallelism in visual axes and of the defect
due to the presence of foreign bodies. A bibliography
and index follow. The work is well adapted to the
of the student.
Sept. 2, 1916]
MEDICAL RECORD.
V,r,
AMERICAN PEDIATRIC SOCIETY.
Twentieth Annual Meeting, Held in Washington, I). C,
May 8, 9, and 10, 1916.
( Special Report to the Medical Record. )
The President, Dr. Rowland G. Freeman, New York
City, in the Chair.
Presidential Address. — Dr. Rowland Godfrey Free-
man of New York said there was an agent of won-
derful power and value to the pediatrician, the use and
action of which was little appreciated, namely, fresh
air. By fresh air as a therapeutic agent he meant
moving and cool out-of-door air. This stimulated the
appetite, induced quiet sleep, brought color to the
cheeks, and increased the resistance of the organism
to infection. The claim that fresh, cool air raised ma-
terially the blood pressure had not been confirmed by
subsequent investigations, and they seemed to be driven
to the position that the favorable action of fresh air on
the organism was due to the absence of the deteriorat-
ing effects of closed rooms. In the fresh air the body
had the advantage of normal conditions. The idea that
air which had been breathed by other people was un-
healthy probably arose from the unpleasant odor of
closed and crowded rooms, and from symptoms elicited
by extremes of this sort. The symptoms produced by
closed places were depression, headache, thirst and
difficult breathing and the elements producing these
symptoms were supposed to be a diminution of the
oxygen and an increase in the carbon dioxide, with the
possible appearance in such an atmosphere of a really
poisonous product from the expired air. Experiments,
however, for the most part discredited this theory. The
amount of oxygen in crowded, closed rooms was not
depleted to a danger point, nor is the amount of carbon
dioxide increased to such a point. Efforts to find a
poisonous element in such air had been made from time
to time with negative results. In 1883, Hermans of the
Hygienic Institute in Amsterdam, concluded that the
discomfort of crowded places was due to the inability
of the body to cool itself in a hot, moist atmosphere.
These symptoms then were due to stagnant, hot, moist
air surrounding the body, and would be accentuated in
people wearing heavy, impervious clothing that pre-
vented access of moving air to the skin. It was evi-
dent then that they should wear as little clothing as was
consistent with comfort. The result of these elaborate
experiments was in brief that fresh air was good, not
because it supplied oxygen, not because it was over-
loaded by carbon dioxide, not because it contained no
poisonous element, but because it allowed the body to
exist under such circumstances that it could control its
moisture and temperature. They had to combat the
traditional fear of drafts and the habit of many people
of living in close, hot rooms. The cold air of winter
was much more stimulating and produced better results
in children than the mild air of spring and autumn.
The best results from fresh air were obtained by keep-
ing the children out of doors day and night. Out-of-
door sleeping porches enclosed on three sides and
roofed, but open to the south, furnished the best fresh
air at night, while in the day time balconies and rooms
without heat and windows wide open supply the air they
needed. They should see that the children were not
sealed in heavy, impervious covering so that the skin
was unable to rid itself of the heat and the moisture.
In all the acute infectious diseases Dr. Freeman be-
lieved that there was now a general acceptance of the
advantage of fresh air, excepting perhaps, in measles
and scarlet fever. In tuberculosis and pneumonia there
was no question of its advantage. It would seem that
some explanation was due as to why, if all these state-
ments were true, children were still housed and many
adults had a panic if a breath of cold air struck the
back of their necks or their bald heads, while children
who were brought up without fear of cold enjoy it
wherever it struck. It was sincerely to be hoped that
many of the coming generation might be brought up
under different ideas and might be less dependent on
hot, offensive, stagnant air for the supposed comforts
of life.
Recent Progress in Our Knowledge of the Physio-
logical Action of Atmospheric Conditions. — Dr. Fred-
erick S. Lee of New York (by invitation) said that
recent experiments in the physiological laboratory of
the Columbia School of Medicine had changed their ideas
concerning the physiological action of atmospheric condi-
tions. It had long been the custom to ascribe to chemical
components of the atmosphere the bad effects of living
in air that had already been breathed by human beings.
They now knew that, except under very extraordinary
circumstances, the harmfulness of respired air was
not due to its chemical components. The harmfulness
of living in confined air was found in certain physical
rather than chemical features — the air was too warm,
too moist, and too still; and if it had not these physical
features it was not harmful. By way of a general
summary it might be stated that when an existing
external temperature was fairly comfortable to the indi-
vidual an elevation of it, especially when such elevation
was accompanied by an increase of humidity, was dele-
terious. This went to demonstrate that a moderately
dry and cool air in motion constituted the most physio-
logically helpful aerial envelope of the body. In these
days they heard much of "fresh" air and its merits.
They had fresh air funds, fresh air schools, and fresh
air babies. All were commendable, but while giving
to their funds, opening their schools, and putting their
babies out of doors, let them closely understand what
constituted fresh air. The freshness of so-called "fresh"
air laid, not in more oxygen, less carbon dioxide, less
organic matter of respiratory origin, and the hypo-
thetical presence of a hypothetically stimulating ozone,
but rather in a low temperature, a low humidity, and
motion.
Some Studies on the Mode of Infection in Pyelitis in
Infancy. — Dr. Richard M. Smith of Boston presented
this paper. He said there had been two antagonistic
theories to explain the mode of infection of the kidney
in pyelitis of infancy; one maintained that that infec-
tion took place through the urethra, bladder and ure-
ters; the other that the infection came by means of the
blood and lymphatics. The disease was much more
common in the female than in the male, the proportion
being nearly 3 to 1. The organism most frequently
causing the disease was the colon bacillus. Directly
against the ascending theory of infection were the facts
that colon bacilli had never been shown to pass up the
normal unobstructed ureter and that the colon and
tubercle bacilli had been introduced repeatedly into the
bladder, and in the presence of a normal mucous mem-
brane and were excreted without causing damage of
any kind. Ascending infections occurred only in the
presence of obstruction to the outflow of urine and
would not occur if the sphincter of the ureter was nor-
mal. The theory of infection of the kidney by the blood
and lymphatics rested upon much surer ground. Dr.
Smith said that he had made seventy-one cultures from
the vagina, vulva and urethra of forty infants and
young children. One infant six hours old and all over
eighteen hours, except one child who was six days old,
showed growth from the vaginal culture. All the vulvar
and urethral cultures were positive. The first organ-
isms to appear were streptococci and staphylococci, and
then the small bacilli, not colon. Colon bacilli were
found in vaginal cultures of infants as early as the
fifth day. Dr. Smith said that his findings were in
accord with those of Scmidgall, who found the vagina
of new-born sterile ten out of thirteen times and by
the second day a profuse growth of cocci. The colon was
isolated twelve times out of twenty-one in new-borns
after the second day. It was also shown that the vaginal
secretions did not kill off the pathogenic organisms. A
possible source of infection with colon bacilli or other
bacteria was certainly present in the vulva, urethra
and vagina, and a slight trauma might easily accom-
plish the entrance of organisms into the lymphatic
vessels and blood, and thus to the kidney. The source
of infection in pyelitis, in the majority of instances,
males and females together, was the gastrointestinal
tract. Some infections might arise from infection in
the skin, teeth or tonsils and in some local septic
processes.
Diet and Growth in Infantile Scurvy. — Dr. Alfred
F. Hess of New York City read this paper, in which
he reported the results of observations on infants fed
on pasteurized milk -alone. He said there had been con-
siderable difference of opinion as to whether pasteurized
milk could induce the scorbutic condition. In its report
in 1912 the Commission on Milk Standards stated that
pasteurization did not destroy the chemical constit-
uents of milk and that it was not altered by exposure
to heat under 145° F. for thirty minutes. In order to
test the validity of this statement he had made a test
among a certain number of inmates of an infant's
436
MI.DICAL RECORD.
[Sept. 2, 1916
home, where all the babies were fed on Grade A pasteur-
ized milk which had been heated to 145° F. for thirty
minutes. The babies had been receiving orange juice
in addition. This was discontinued. No other change
was made in the diet. Almost all the babies %vho did
not receive orange juice developed a more or less
marked form of scurvy, whereas those who continued
to receive orange juice remained entirely free from
this disorder. The results of this investigation were
questioned by some who were loathe to believe that
pasteurized milk could in any way lead to scurvy and
hence the observations were continued during the fol-
lowing year. The results were the same, so that the
writer felt safe in saying that a diet of pasteurized
milk led to the production of scurvy in infants unless
some antiscorbutic food was also given. The scurvy met
with in infants fed on pasteurized milk was as a rule
not of the florid type met with in infants fed for months
on proprietary food, but might rather be described as
latent or rudimentary. There was a gradually increas-
ing pallor, failure to gain in weight, the development of
some petechial hemorrhages, and, in the more marked
instances subperiosteal hemorrhages. It seemed prob-
able that this type of the disorder was far more com-
mon than was generally recognized by physicians and
that there were many infants suffering from slight
nutritional disturbances which might be attributed to
this cause. It was not to be inferred from these con-
clusions that the use of pasteurized milk was fraught
with danger, but merely that it was an incomplete
diet for babies and must be given with antiscorbutic
food. There were also secondary factors contributing
to the development of scurvy, such as the individual
variation depending upon hereditary characteristics,
that was up on the amount of antiscorbutic material
which the infant brought with it when it came into the
world. Secondary food factors also seemed to play
a part. Malt preparations seemingly predisposed to
scurvy, and it seemed that there was an intimate rela-
tionship between the development of scurvy and the
amount of carbohydrate in the diet. The sovereign cure
for scurvy was orange juice, which was efficacious even
when boiled for ten minutes. Boiled potato might
be used in infant feeding when orange juice could
not be readily obtained. One tablespoonful of mashed
potato to one pint of water might be used instead of the
usual cereal decoction. In connection with this study
observations were carried out to ascertain the effect
of infantile scurvy on growth. It was found that
although the infants continued to gain in most in-
stances for a few weeks following the discontinuance
of orange juice, they soon reached a stationary plane
and for months were unable to rise above this level,
but increased in weight promptly when the antiscor-
butic food was again added to their diet. It was also
found that scurvy had a direct effect upon the growth
in length. Lack of growth, however, did not always
play an essential part in the constitution of scurvy.
Orange juice was found to be a corrective for the lack
of growth as well as for the failure to gain in weight
in this series of cases. There was no reason why orange
juice might not be given to an infant at the age of one
month and there were many arguments in favor of
giving it at this early period.
Dr. L. Emmett Holt of New York said that for
several years he had held the view that pasteurized
milk was responsible for a number of cases of scurvy,
and during the past year this view had been confirmed.
While they all recognized the advantages of pasteurized
milk, it would be a mistake to approve of the commer-
cial pasteurization of all milk. On the other hand, they
all knew of instances in which the milk was inadequately
certified and physicians did not wish to be responsible
for such conditions. As Dr. Hess had pointed out,
scurvy was caused by many other things, there were
additional factors and hereditary predispositions to be
taken into account. There were comparatively few
cases caused by pasteurized milk alone. Still, he
thought it would be advisable that they should band
together to counteract the present tendency to pasteur-
ize all milk. Ten or twelve years ago nearly all the cases
of scurvy came from the continued use of proprietary
foods while to-day it comes from pasteurized or boiled
milk. The point to be emphasized was that if they used
pasteurized milk an antiscorbutic must be used early
and continuously.
Dr. Samuel S. Adams said he had always been op-
posed to commercial pasteurized milk, but 'he did not
necessarily object to pasteurization in the home. The
reason he was so much opposed to commercial pasteur-
ized milk was because the milk was so often contam-
inated before it was pasteurized. He said he had seen
four cases of scurvy .vithin the last week in the city
of Washington which were due to pasteurized milk.
Dr. A. D. Blackader of Montreal said he wished to
emphasize the importance of pasteurized milk as a
cause of scurvy. He said he had seen two instances in
infants brought to him because of obscure symptoms,
partly nervous and associated with lack of growth,
but with no classical symptoms of scurvy. There was
a rapid disappearance of all the symptoms following
the addition of orange juice to the diet of these infants.
When he saw these cases he thought he had observed
something new, but Dr. Hess had anticipated him in
describing this subacute type of scurvy due to a defi-
ciency of vitamines.
Dr. Henry L. K. Shaw of Albany, N. Y., said he
wished to defend pasteuried milk, as his experience
with epidemics of milk borne sore throats led him to
believe the danger of raw milk much greater in this
direction than the danger of developing scurvy. They
had had seventeen epidemics of septic sore throat in
New York State directly traceable to milk and in one
of these there were seventy cases. There had also been
some fatalities. The danger of septic sore throat was,
in his opinion, greater than the danger of tuberculosis
from raw milk. On the other hand, scurvy was not a
fatal disease and could easily be prevented or cured, so
that he thought the weight of evidence was in favor of
pasteurized milk.
Dr. Percival J. Eaton of Pittsburgh, Pa., said that
commercially pasteurized milk was not really a per'
fectly pasteurized milk. It was pasteurized with over-
heated steam at a pressure of fifteen pounds and that
process produced a sterilized milk. One got better re-
sults with a certified milk pasteurized at home.
Dr. SAMUEL McC. Hamill of Philadelphia said he
was not opposed to the pasteurization of miik; in the
cities this was necessary. There was, however, a
tendency to favor the pasteurization of all milk so that
one would be unable to get raw milk. This would be a
mistake and it was time to take some action. The
medical profession was largely to blame for this atti-
tude of health officers and dairymen. But in any action
that this society took in this matter it should state
very definitely what pasteurization of milk meant. Dr.
Hamill said he believed in the pasteurization of milk,
and while it was not always done satisfactorily at the
present time it was done better than formerly.
Dr. Henry L. Coit of Newark, N. J., asked Dr. Hess
regarding the condition and vitality of the children
upon whom he had based his deductions; he said he
would like to know something of their heredity and en-
vironment. He also thought the tendency to pasteur-
ize all milk was a most disquieting thing to medical
men. In instructing mothers as the their borne modi-
fication of milk he said he had abandoned the use of
the word pasteurize. He had found that the word "re-
fine" had a hypnotic effect on the women so he in-
structed them how to "refine" certified milk.
Dr. Henry Heiman of Now York City said we should
have laws to govern the commercial pasteurization of
milk. One could not always be sure whether a child
was getting pasteurized or sterilized milk. Frequently
the mother in heating the milk at the time of feeding
raised it to too high a temperature. One could give
five drops of orange juice, or pineapple juice, to an in-
fant at the age of one month. Simply giving the fruit
juice would furnish the missing link.
Dr. Maynard Ladd of Boston said he had seen a half
dozen cases of scurvy produced apparently on raw milk
and was not able to account for it at first, but found on
investigation that the milk was overheated at the time
of feeding, so that the children were getting practi-
cally pasteurized milk.
Dr. Alfred F. Hess, in closing the discussion, said
the conclusion to be drawn from the paper was not
that pasteurized milk had not an advantage over raw
milk, but only that pasteurized milk was not a com-
plete food for an infant, and that it was necessary in
addition to give orange juice, or potato water, or some
other antiscorbutic. The commercial potato flour would
not do. Dr. Herman asked why the boiling did not
destroy the vitamines of the orange juice and did de-
stroy those of the milk? That may be explained by the
fact that the change that a substance underwent in
boiling was dependent upon the medium in which it
was boiled. The vitamines might stand boiling in water
but not in fats, such as milk. As to the condition of
the children and their environment, the environment
Sept. 2, 1916]
MEDICAL RECORD.
437
was of the best and the children were normal and had
been under observation for a long lime, most of them
from birth.
Sarcoma of the Kidney Treated by X-Ray. — Dr.
Alfred Friedlandeb of Cincinnati said that it was
generally accepted as axiomatical that the only hope
in cases of sarcoma of the kidney in childhood laid in
early nephrectomy, but even with this procedure the
mortality was very high on account of the likelihood of
metastases, even in those cases in which the operation
was well borne. This patient was four years of age
and was admitted to the Cincinnati General Hospital on
October 20, 11)15. The history was one of increasing
languor and lassitude, with loss of appetite and anemia.
Except for the condition of the abdomen, the physical
findings were not of moment. The entire left abdomen
was filled by a tumor extending from the costal margin
in the nipple line to 3 cm. above the umbilicus. It was
hard, distinctly nodular, apparently not tender to
touch, and could be moved forward by pressure from
behind. Urinalysis on admission showed distinct
microscopic hematuria. The blood showed a secondary
anemia. Fluoroscopic examination with the colon
partly filled with gas showed a sharply defined dark
shadow in the region normally occupied by the kidney.
X-ray plates of the lungs for the characteristic meta-
static sarcomatous shadows were negative. The x-ray
treatments were given because of the apparent hope-
lessness of the case. After the seventh treatment it
was noticed that the tumor had decreased very mark-
edly in size. Later the child had an attack of in-
fluenza, then one of measles which was followed by
death. The autopsy revealed a sarcoma of the left
kidney with small metastases in boah lungs and in
the liveif.
Transient Abdominal Tumor in a Child of Five Years,
with Redundant Colon. — Dr. George N. Acker and Dr.
Edgar P. Copeland of Washington, D. C, reported
this case. Dr. Copeland said that in December, 1914,
a year before his first examination, the child became
suddenly ill in the night, with extreme nausea, severe
vomiting, and the appearance of a rounded tumor in
the hypogastrium, simulating a distended bladder. The
tumor was elastic, but not specially tender to the touch.
The physician made a diagnosis of intussusception, but
a few hours later he was surprised to find that the
tumor had entirely disappeared, and the patient made
a good recovery. Since this initial attack, others had
occurred at varying intervals, seldom less than three
weeks, and on several occasions as long as six weeks,
apart. The tumor had invariably appeared first over
the region of the bladder, moved about the abdomen
spontaneously, and finally disappeared. Its appear-
ance was always associated with nausea and vomiting,
and its disappearance with a pronounced paroxysm of
abdominal pain. When Dr. Copeland first saw the pa-
tient he found him in bed on his back with the thighs
partially flexed. The attack then was several hours'
old, and there was still some nausea. Presenting in
the hypogastrium was a smooth, rounded tumor about
the size of an orange, elastic but not tender, and dull
on percussion. It strongly suggested a distended blad-
der. There was a well-pronounced beading of the ribs.
The pulse was rapid, but regular. The temperature
was normal. The leucocyte count was 11,500. The
von Pirquet and Wassermann tests were negative. Un-
der restricted feeding and large enemata slowly ad-
ministered the mass spontaneously disappeared.
The clinical history, in the light of the x-ray find-
ings, would seem to justify the assumption that the
phantom tumor was the result of a temporary kink-
ing of the redundant colon or sigmoid incident to its
displacement to the right, which was followed by either
fecal or gaseous distention in the loop. When the loop
filled itself to a certain point, it swung gradually to the
left and automatically unkinked itself with a disap-
pearance of the tumor mass.
Report of a Case of Influenza in an Infant with Two
Unusual Complications — Purpura and Subcutaneous
Emphysema. — Dr. Henry T. Machell of Toronto,
Canada, reported this case. The baby when seen in
consultation was 6% months old and had always been
well and healthy. The child was taken ill with grippe
on March 28 and was seen by Dr. More on April 6.
There was then a well-developed lobar pneumonia of the
right base. The temperature was 104° Fahr., pulse
140, and respirations 60. There were purpuric rashes
over parts of the body, the face, particularly the chin,
the shoulders, arms, chest, legs, and feet. The petechias
varied in size from a mere dot to one patch on the left
shoulder the size of a ten-cent piece. Another patch on
the left cheek was slightly smaller. These large spots
had a punched-out feeling to the palpating finger as
though they had previously contained fluid. The skin
was unbroken. The mother stated that this rash had
been present from the first appearance of the illness.
On April 13 there was noted a slight swelling at the
sides of the neck, under the chin, and down over the
upper part of the chest. This swelling continued to
increase until two days later, when he was again called
to see the child. The swelling around the neck, cheeks,
and chest had increased to such an extent that the chin
was crowded upward and the head forced backward.
It was tense, tympanitic, and crackling under the fin-
gers. It was symmetrical in size and obviously em-
physematous. He said that this was the first time he
had seen purpura or emphysema as a complication or
sequel to influenza either in his own practice or in con-
sultation. The emphysema gradually improved and
within five days from the time he had last seen the
patient it had almost entirely disappeared. On April
19 the child had an extra severe coughing spell, when
the emphysema suddenly became more marked, his
breathing became embarrassed, and he died within
twenty-four hours. An autopsy was not allowed. Pur-
pura as a complication of influenza was rare. Em-
physema had been mentioned as occurring occasionally
in pertussis, bronchitis, etc., but he had not seen it
mentioned in connection with influenza.
A Brief Report of Sixty Blood Examinations in In-
fancy with a Review of the Recent Literature of the
Blood in Infants. — Dr. M. H. McClanahan and Dr.
A. A. Johnson of Omaha presented this report, which
Dr. McClanahan read. He stated that while the study
had required a great deal of work the results were
very briefly stated, that was that his observations were
practically in accord with those already published in
the literature. He reviewed the literature and com-
pared his findings with those of other investigators.
The Creatin and Creatinin Content of the Blood in
Children. — Dr. Borden Veeder and Meredith Johnson
of St. Louis presented this communication, which was
read by Dr. Veeder. After citing the results of the esti-
mation of the creatin and creatinin content of the
blood by Folin and Denis, Myers and Fine, and Meyers
and Lough, he stated that very few such observations
had been made on children. In children the non-pro-
tein content of the blood did not vary in any marked
degree from that of the adult. Tileston and Comfort
made determinations on 51 children with a variety of
clinical conditions. Normal children gave values of 20
to 34 mg. per 100 c.c. of blood. In normal infants the
non-protein nitrogen content had been found to vary
between 23 and 44 mg. per 100 c.c. by Schultz and Pet-
tibone. The method used in the study presented were
those of Folin and Denis for the non-protein nitrogen
and of Folin for the creatin and creatinin. Determina-
tions were made on 70 children. The blood was taken
early in the morning before the children had had their
breakfast. The cases were grouped into normals, scar-
let fever at the time of exanthem when there was an
elevation of temperature, afebrile scarlet fever in the
first week, and a number of examinations made in the
third week of canvalescence when the urinary findings
were negative. In addition a number of miscellaneous
cases were investigated. The creatinin figure for nor-
mal children varied from .58 to 3.44 per 100 c.c. In
10 children the figures were under 2 mg. and in two
above. The febrile scarlet fever cases varied between
1.08 and 3.82 mg., but with one-half above 2 mg. and
nine under 1 mg. The highest figure in the early
febrile case was 3.78. There was no specific retention
in any of their cases, although as a whole the figure
for the creatinin content of the blood in children was
somewhat higher than for adults. A comparison of
the creatinin content with the non-protein nitrogen
showed that as a general rule both the non-protein
nitrogen and creatinin were within the same general
limits as had been found for normal adults, and as
Tileston found for the non-protein nitrogen in chil-
dren, although the average figures for both were a little
higher in children. In six cases of nephritis which they
studied the retention figures were not high and but one
case was fatal. This was not a uremic case. The non-
protein nitrogen was not increased in two cases and the
creatinin was normal in three. In one case with a low
protein figure the creatinin was high and in two the
opposite condition held. As the nephritis in a given
case improved the amount of retention decreased. A
number of cases of scarlet fever were followed from
438
MEDICAL RECORD.
[Sept. 2, 1916
the stage of the acute exanthem until desquamation
was completed and tests were made weekly for five
weeks. None of these cases developed a typical post-
scarlatinal nephritis in the third or fourth week. After
the acute febrile period was over there was usually a
slight fall in the non-protein nitrogen and creatinin,
although in the second week a few showed a slight in-
crease. There was no apparent relationship between
the amount of creatin and creatinin. Dr. Veeder said
they had found much less creatin in the blood of chil-
dren than Folin reported having found in adults. Folin
found about 10 mg. per 100 c.c. and they had found in
children rarely over 5 mg. per 100 c.c. This was in-
teresting in view of the fact that creatin was found in
the normal urine of children and was not present in
the urine of adults. They had been unable to find any
specific relationship between the amount of creatin and
creatinin, or any relationship between the amount of
creatin and the clinical condition. There was no fixed
relation between the total non-protein nitrogen and the
cieatinin-creatin content. Dr. Veeder also reported ob-
servations on a child starved for other purposes and a
few experiments as to the effect of copious water drink-
ing and a fixed diet, and also of the effects of a fixed
creatin-free diet. The child during the period of starva-
tion showed a slight increase in all three substances
during the period of starvation. The results of the ex-
periments in diet and water drinking were negative.
The Hospital Care of Premature Infants. — Dr. L. E.
La Fetra of New York presented this paper, which he
stated was a resume of his personal experience in the
observation and treatment of these cases. During the
past two years they had admitted to the premature
ward of Bellevue Hospital 278 premature infants. Of
these 13 were still in the ward and 265 had been dis-
charged. The mortality among these infants was very
high, but most of it occurred during the first few days
after admission to the hospital. The records of the
last 200 cases showed that 30 were saved and dis-
charged as cured that was, strong enough so that their
mothers could care for them successfully. Of the 170
that died, 90 died on the first day and 118 within the
first three days. It was most unusual that a baby
weighing less than 2% pounds was saved. The great-
est number of infants admitted to the premature wards
had a history of utero-gestation of seven and seven and
one-half months. Aside from the small size and weight
of these infants they were extremely feeble muscularly,
and this feebleness extended to the muscles involved
in the acts of sucking and swallowing. In many in-
stances this latter weakness was the underlying cause
of fatal inanition. The symptoms manifested by these
babies were subnormal temperature, imperfectly de-
veloped skin, so that the premature infant radiated
more heat proportionately than the normal infant.
Again, the heat regulating centers seemed not to be in
satisfactory operation, so that the baby was very sus-
ceptible to the heat changes of its environment. These
babies also show a tendency to cyanosis and are ex-
tremely susceptible to all sorts of infection. Absorp-
tion from the gastrointestinal tract of deleterious sub-
stances, whether as the result of fermentative processes
in the intestines or of germ infection might cause pro-
found and even fatal disturbances in a very short time.
General sepsis might arise from this source or might
come from the umbilical wound, or from an abrasion
of the skin. In the general management of these chil-
dren the aim was to reproduce in as far as possible
the conditions of intra-uterine life. The baby should
be kept in an even temperature approximating that of
the body and should be shielded from all sorts of ex-
ternal shocks whether thermal or mechanical. The skin
should be protected from all chance of contagion and
injury and the eyes should be protected from light.
Dr. Le Fetra said he was not in favor of using in-
cubators. The plan of setting apart a small room as
an incubator room was far more satisfactory. Here
the baby did not undergo any chilling when the clothes
were changed. Probably the most satisfactory in-
cubator was that devised by Dr. Edwin B. Cragin and
described in the Journal of the American Medico! As-
sociation for September 12, 1914. At Bellevue they
were using the sunny corner of a ward facing south,
which had a capacity of ten beds and a cubic air space
of 1,000 cubic feet per infant. After much experience
they had found that babies did besl when kept in a
temperature of 76 F. to SO F. with a humidity of
60 to 70 per cent. In their ward the moisture was ob-
tained by keeping a large pan of water simmering on
an electric stove. Premature babies should be handled
only when necessary to change the gauze diaper. The
clothing should be the simplest possible. Babies weigh-
ing less than four pounds should be wrapped in cotton
until the temperature remained constantly at normal,
and the weight had risen to four or four and one-half
pounds. In general, the most satisfactory method of
feeding these babies was to use the Breck feeder, since
this had the advantage of teaching the baby to suck.
In some cases the baby could not swallow satisfactorily,
and then one had to resort to gavage. The food most
suitable and that requiring the least digestive effort
was breast milk. The milk was to be expressed from
the breast two or three times a day and a requisite
amount mixed with whey or barley water or granum as
a diluent and then fed to the baby through the Breck
feeder. At Bellevnue they used one-half breast milk
and one-half whey at first, one ounce being given every
one and one-half to two and one-half hours, depending
upon the size of the baby and its stomach capacity. If
it was impossible to obtain breast milk, the following
might be substituted: cow's milk, 6 per cent.; top milk,
five ounces; whey, 10 ounces, and five ounces of Im-
perial granum, to make a 20-ounce mixture. To this
was added milk sugar or dextri-maltose, one-half to
one and one-half ounces. The number of calories re-
quired by the premature baby was much higher than
for babies at full term; it was necessary to increase
the calories to one and one-quarter to one and one-half
times the ordinary requirements. An important ap-
paratus in the premature room was the oxygen tank,
which should be kept coupled up and ready for use in
case of cyanotic attacks. As to prognosis, weight was
the best criterion they had, but one must not despair
of even the smallest babies. If a baby survive for a
week it had a better chance of living, since the fact of
its having survived that long augured a good constitu-
tion.
Dr. B. S. Veeder of St. Louis said that in St. Louis
they were using a small room in St. Louis for the care
of premature infants. The room was heated from a
closet, the temperature kept at 80°, or somewhat above,
and the children were practically not dressed at all.
They were feeding more than 125 calories, usually
about is., calories.
Dr. J. P. Sedgewick said Dr. Le Fetra had spoke of
feeding the babies every hour and a half or two hours.
It was possible to have the premature babies do well
on four-hour feedings. They gave them more than
the capacity of the stomach would indicate. The calo-
ries usually ran from 120 to 150. They started with
10 or 15 c.c, usually five times daily, or 75 c.c. a day,
and increased this amount as rapidly as the infant
could take it, but had no regular rule of putting so
much into a child at such and such a time.
Dr. B. Raymond Hoobler described an improvised
incubator that could he made in a home, by means of
a clothes basket and barrel hoops, covered with
klankets and heated with electric light bulbs, black cloth
being used to keep the light from the eyes.
Further Experience with Homogenized Olive Oil
Mixtures. — Dr. AlAYNARD Ladd of Boston read this
paper. He called attention to the fact that in a paper
read before the American Pediatric Society, in June,
1915, he had described the homogenizing machine of
M. Gaulin of Paris for purposes of modifying milk for
difficult feeding cases, especially those showing intoler-
ance for fat. It was possible by this process of homo-
genization to improve the emulsion of a modification of
cow's milk so that it would be even finer than that of
breast milk without altering in any way the chemical
properties of the milk. There was reason to believe a
milk so treated might be better digested and assimi-
lated. Still more interesting was t'.ie possibility of sub-
stituting some other fat than the fat of cow's mi!k in
cases of malnutrition, in which it was often difficult to
make a child gain normally in weight without precipi-
tating sooner or later a digestive crisis. It appeared
reasonable in certain cases in which the child responded
to breast milk containing two to three times as much
fat as cows' milk to question whether there was an in-
tolerance to fat or whether there was something in the
cows' milk fat that was not present in breast milk.
The principal differences in the fats of cows' milk and
human milk were in the size of the fat globules and
the proportion of volatile fatty acids. Olive oil was
almost wholly olein and palmatin and free from vola-
tile fatty acids, which formed a large proportion of
the cows' milk fat. This fact had led him to suggest
the use of olive oil in order to obtain the fat per-
centages in modified milk mixtures and so to eliminate
Sept. 2, 1916]
MEDICAL RECORD.
439
the volatile fatty acids, and also to secure an emulsion
as fine or finer than that of human milk. The milk
sugar and protein were to be obtained from skimmed
milk as usual; and additional carbohydrates, in the
form of dextrin-maltose and starch, were prescribed
according to the usual indications. Dr. Maynard said
he had applied this method of feeding to 37 cases, in-
cluding practically all the cases of difficult feeding
that he had opportunity to study. In this series of 37
cases, whose average gain on previous feedings was
five ounces per month, for a period of 6.3 months, on
the homogenized olive oil substituted for the fat of
cows' milk the average gain per month was 18.15
ounces. The average period of the homogenized oil
feeding was 4.7 months, a sufficient time to determine
its permanent effects. The improvement in the babies'
general condition had been as striking as that of their
gain in weight. Vomiting and sour regurgitation, when
present as symptoms, were quickly relieved. The child
improved in strength, in the quality of its fat, and in
the development of its functions. The appetite im-
proved rapidly and the stools soon became normal in
appearance, if the sugars were intelligently prescribed.
(By this he referred to proper proportions of dextrin
and maltose.) Barley water was used in nearly every
case. In some cases the mixture was heated to 212°
F.; in others given unheated. Lime water was usually
given in amounts of 5 to 10 per cent, of the total mix-
ture, but not as a matter of routine. The percentage
of olive oil was almost invariably started at 1.5, and
did not exceed 3.50 per cent. The total carbohydrate
was usually started at about 5 per cent and never
exceeded 7 per cent. The protein was started at 1.50
per cent, and seldom exceeded 2 per cent. In his opinion
hunger was the safest guide as to the child's tolerance
to the amount of fat it was taking.
Dr. Ladd also described his experience with olive oil
mixtures in infectious diarrheas due to indigestion and
fermentation. The general scheme of treatment was
as follows: After the initial period of catharsis and
starvation, a fat free lactic acid milk, diluted two-
thirds and one-half, was given. If the infecting organ-
isms proved to be of the Flexner or Shiga type dex-
trin-maltose was added up to 4 or 5 per cent., and some-
times barley water. If the gas bacillus was present no
carbohydrates were added. After a period of several
days, when the acute febrile disturbance showed dis-
tinct signs of subsiding, olive oil was homogenized
with the lactic acid milk in percentages of 1.00, 1.50,
and, if well tolerated, 2,00, thus adding considerably to
the caloric value of the food. The results briefly sum-
marized were as follows: There were 19 cases of in-
fectious diarrheas on the service of Dr. Wyman at the
Floating Hospital, 15 of Flexner bacillus type, one of
gas bacillus, and three undetermined. Four cases died,
giving a mortality of 22 per cent., about the same as
in the other service. Of the 15 cases that lived, eight
were in the hospital on an average of 21 days each,
and lost over their entrance weight 15 ounces. Seven
were in the hospital on an average of 14 days each, and
gained an average of 10.7 ounces over their entrance
weight. Whether this showing was better or worse
than the other services they had no statistics to show.
In the writer's opinion, however, based on this limited
series of cases, olive oil homogenized could be given
safely after the severe acute febrile stage had passed
and in the period of convalescence, and was more ef-
fective in making up the loss of weight than the fat of
cows' milk. A study on fat metabolism of infants fed
on homogenized milk was carried out on the Boston
Floating Hospital during the season of 1915 by Dr.
C. H. Laws of the University of Michigan, the results
of which were decidedly significant and justified the be-
lief that homogenized milk mixtures and the substitu-
tion of cows' milk fat offered an additional and valuable
resource in infant feeding in cases of difficult digestion
with malnutrition.
A Method of Preparing Synthetic Milk for Studies of
Infant Metabolism. — Dr. HENRY I. BOWDITCH and
Alfred W. Bosworth of Boston presented this com-
munication, in which they stated that in connection with
their studies concerning infant feeding it became neces-
sary for them to have control of all the factors entering
into the composition of the food used, and as only
liquid food could be used it soon became evident that a
synthetic food from pure materials offered the only
solution to the problem. The method by which they
obtained this consisted of four steps: (1) The prepara-
tion of the isolated food material for use in the syn-
thetic milk. (2) The recombining of these materials
to give a mixture of Jhe desired composition. (3) The
emulsification or homogenization of the fat and any
of the solid or insoluble constituents entering into the
composition of the food. (4) Pasteurization or steril-
ization of the food after it had been made. The sub-
stances used were pure water, pure fat, pure sugar,
pure protein, pure salts of various kinds, and the pro-
tein-free milk of Osborne and Mendel. In some cases
they had used sugars of the purest commercial grade,
while in others they had used recrystallized lactose.
The purest commercial olive oil was used and butter
fat prepared according to the method of Osborne and
Mendel. Thus far they had used only one protein —
casein — and had made use of chis substance in three
forms, calcium caseinate and sodium caseinate of com-
merce, and pure casein prepared according to their
method already published. Osborne and Mendel had
shown that a pure synthetic food of pure materials con-
tained no vitamines. But these substances were pres-
ent in a preparation made by them and called protein-
free milk. When the continued use of a synthetized
milk was required for more than a few days it was
always wise to add some of this protein-free milk in
order to get the benefit of the vitamines carried in it.
All these synthetic milks had been made up on the per-
centage basis. The sugar was dissolved in one-half the
volume of distilled water required for the complete
mixture and the salts added to this sugar solution.
The protein was dissolved or suspended in the other half
of the water. If larosen or nutrose were used they
were rubbed to a fine paste with a small portion of the
water, the remainder of the water added, and then the
whole warmed to effect complete solution. If pure
casein or paracasein was used they might be suspended
in the water and homogenized with the fat or they
might be dissolved by the addition of alkali, one-half of
a cubic centimeter or normal alkali or its equivalent
being used to each gram of protein. The two and one-
half volumes were now united, the fat melted and added
and the whole homogenized. For this purpose the Man-
ton-Gaulin homogenizing machine was used, which was
of special design, built for laboratory use. The writer
described the machine and the method of cleansing it
before use and of passing the mixture through under
successively higher pressures until it was thoroughly
homogenized, when it presented the appearance of milk.
It was then transferred to glass fruit jars and steril-
ized, lightening jars with glass tops being the best for
this purpose. If the food was to be kept for any num-
ber of days it should be reheated and then stored in a
cold place.
(To be continued.)
Notes on Ureteritis. — Harry Kraus refers to the rela-
tively small literature of this not uncommon condition.
This is due to its great infrequency as an irolated af-
fection. In pregnancy the natural results of compres-
sion are circulatory disturbance and edema. Here we
sometimes see secondary infection of an ascending,
probably lymphatic origin. As a rule, however, uret-
eritis appears to be descending in type and due to
disease of the renal parenchyma or kidney pelvis. Clin-
ically the descending form manifests itself at the lower
segment. Only in tuberculosis is the entire canal in-
volved. Ureteritis from a foreign body is a local
phenomenon, which, by causing dilation or sacculation,
may be recognized by the :r-ray after injection of a
contrast fluid. — The Urologic and Cutaneous Review.
Thymol from Horsemint. — The recently issued Bulle-
tin 372 of the United States Department of Agricul-
ture deals with this subject. Thymol has been an im-
port, and since the present war the supply has been re-
duced to almost a tenth of the normal. It is obtainable
from our native wild horsemint, and the government ex-
perts have learned that under cultivation an acre of im-
proved mint will yield twenty pounds of oil from first
plantings, which amount then increases to an annual
yield of thirty pounds with a utilizable content of 70
per cent. As thymol is worth at present about $2 per
pound, an acre of horsemint will not yield above S40
per annum gross. The cost of production, which in-
cludes rents, taxes, fertilizer, growing, harvesting, use
of distilling plant, etc., will make the cost of production
somewhere about one-half this amount. While this im-
plies a profit of 100 per cent, the margin is not great
enough for a safe investment in an untried industry.
Other oil-bearing plants could be grown with the mint,
with but little increase in expense, and this seems to
be the recommendation of the government. — Southern
Practitioner.
440
MEDICAL RECORD.
[Sept. 2, 1916
IfltHrrUamj.
Luminous Insects and Enzyme Action. — The de-
pendence of photogenesis in fireflies, phosphorescent
animals, fungi, bacteria, etc., upon enzyme action
has been shown abundantly in the past few years.
In 1913 Dubois showed that the mechanism of light
production in beetles is bound up in the action of an
oxidizing zymase upon an organic protein product
in the presence of water. He terms this protein
luciferin. It is contained in the form of granules
in the photogenic organ while the oxidizing zymase,
which he terms luciferose, is dissolved in the blood.
When the latter passes the luminous organs the
action of luciferose on luciferin gives rise to light.
This reaction can be obtained in vitro, using in-
stead of the zymase a chemical oxidizing agent.
The luminosity of meat, dead wood, deal leaves,
etc., is due to peculiar bacteria, and oxidation is
likewise involved here. A hypothetical substance,
photogen, is believed to be actuated by light waves
in the presence of oxygen. The above jottings are
found in an article by Dr. Walter G. Smith in the
Dublin Medical Journal, June 1. 1916.
History of Diphtheria in Australia. — The
records in Victoria began in 1871. From 1871 to
1892 the death rate per million inhabitants varied
from 275 to 922, the average being about 521. In
1893 it was but 155 and in 1894, 190. These low
figures antedated the use of antitoxin. From 1895
there was a drop until in 1906 the low mark of 47
was reached. The drop was not steady, however,
for in 1897 and 1898 it shot up to 270 and 209 re-
spectively. Since 1906 the rate has risen; in 1911
and 1912 it was 181 and 185 respectively. In 1914
it was down to 148. Two factors must play a role
in these irregularities. First, a recurring exhaus-
tion of epidemic influences; second, the thorough-
ness or reverse with which the health office is ad-
ministered. In New South Wales the available re-
cords began in 1875. From that period to 1895,
when antitoxin was first used the annual death rate
per million inhabitants varied from 277 to 768.
In 1894 the figure was 378. From 1895 to 1900 it
fell steadily to 65. This is the lowest mark
reached. Since 1901 the rate has shown great
variation. The highest mark was 178 in 1913. In
1902 it was 131. In 1903-1906 inclusive it remained
below 100. From 1909 to date (save in 1913) it
ranged from 117 to 139. Membranous croup is
counted throughout as diphtheria. — The Medical
Journal of Australia.
"Germano-Medical Sacerdotalism. — W. C. Hos-
sack, Port Health Officer, Calcutta, confesses that
he is not a bacteriologist, but thinks the bystander
can see some things not realized by the man on the
inside. Given sufficient identification marks im-
mutability of bacteria may seem to be proven. Yet
some sudden cosmic change like the arrival of the
monsoon will upset all the specific characteristics.
Thus an "inulin nonfermenter" suddenly becomes
an "inulin fermenter." There is a similar liability
in regard to anaphylaxis, phagocytosis, immunity
reactions, hemolysis, agglutination, etc. The
Noguchi test seems to have invalidated the Wasser-
mann test, for the latter is positive for several dis-
eases, and in over a third of the cases of the latter
there seems room for a difference of opinion. In
other words, it is about 82 per cent, only efficient.
What the author deplores is the ceaseless piling up
of mere varieties by bacteriologists, which has made
their study a dreary chaos, that is leading nowhere.
He blames the Germans for this state of affairs
because the real progress in bacteriology must be
credited to Germans like Koch and Ehrlich and
therefore one must not attack the high priests of
that science. The only way out is to let other men
than bacteriologists pass judgment on what is really
valid and stable. If there is mutation its limits
must be fixed by something less elusive than per-
centage fermentations. More stress should be laid
on the actual germ recoverable from an infectious
case. Chemists, physicists, and other scientists
should pass on all matters which involve their re-
spective subjects. — Indian Medical Gazette.
The Medical Record is pleased to receive all new
publications which may be sent to it. and an acknowledg-
ment will promptly be made of their receipt under this
heading; but this is with the distinct understanding that
it is under no obligation to notice or review any publica-
tion received by it which in the judgment of its editor will
not be of interest to its readers.
A Manual of Surgical Anatomy. By Lewis
Beesly, F.R.C.S., and T. B. Johnston, M.B., Ch.B.
557 pages. Illustrated. Published by William Wood &
Co., New York, 1916. Price, $3.75 net.
Aids to Bacteriology. Third edition. By C. C.
Moor, M.A. (Cantab.), F.I.C., and William Partridge,
F.I.C. 276 pages. Published by William Wood & Com-
pany, New York, 1916. Price, $1.25 net.
A Manual of Practical Laboratory Diagnosis. By
Lewis Webb Hill, M.D. 179 pages, interleaved, illus-
trated. Published by W. M. Leonard, Boston, 1916.
Colon Hygiene, Comprising New and Important
Facts Concerning the Physiology of the Colon and an
Account of Practical and Successful Methods of Com-
bating Intestinal Inactivity and Toxemia. By J. H.
Kellogg, M.D., LL.D. 462 pages. Illustrated. Pub-
lished by Good Health Publishing Co., Battle Creek,
Mich., 1916. Price, $2.
Diagnosis and Treatment of Surgical Diseases
of the Spinal Cord and Its Membranes. By
Charles A. Elsberg, M.D., F.A.C.S. Published by W.
B. Saunders Company, 1916, Philadelphia and London.
158 illustrations, three of them in colors. 330 pages.
Price $5.00 net, cloth.
The Expectant Mother. By Samuel Wyllis
Bandler, M.D.. Professor of Gynecology in the New
York Post-Graduate Medical School and Hospital. Pub-
lished by W. B. Saunders Company, Philadelphia and
London. 213 pages, with 14 illustrations. Price $1.25
net, cloth.
The National Formulary. By American Phar-
maceutical Association. Prepared by the Commit-
tee on National Formulary of the American Pharma-
ceutical Association. Published by the American Phar-
maceutical Association, 1916, Fourth Edition, Official
from September 1, 1916. 394 pages.
Studies in Immunization Against Tuberculosis.
By Karl von Ruck, M.D., and Silvio von Ruck,
M.D. Published by Paul B. Hoeber, New York, 1916.
439 pages.
Nervous Disorders of Women. The Modern Psycho-
logical Conception of Their Causes. Effects, and Ra-
tional Treatment. Bv Dr. Bernard Hollander.
Published by E. P. Dutton & Co., New York, 1916. 215
pages. Price $1.25 net.
Treatment of Infantile Paralysis. By Robert
W. I.ovett, M.D. Published by P. Blakiston's Son
& Co., 1012 Walnut St., Philadelphia. Illustrated.
1G3 pages.
The Primary Lung Focus of Tuberculosis in
Children. By Dr. Anthon Ghon, Professor of Patho-
logical Anatomy at the German University in Prague.
English Edition. Authorized Translation by D. Barty
King, M.A., M.D. Published by Paul B. Hoeber, New
York, 1916. Illustrated. 172 pages. Price $3.75.
Abnormal Children (Nervous, Mischievous, Pre-
cocious, and Backward). A book for parents, teach-
ers, and medical officers of schools. By Bernard
Hollander, M.D. Published bv E. P. Dutton & Co.,
New York, 1916. Illustrated. 224 pages. Price $1.25
net.
Medical Record
A Weekly Journal of Medicine and Surgery
Vol. 90, No. II.
Whole No. 2392.
New York, September 9, 1916.
$5.00 Per Annum.
Single Copies, 15c.
GDngutal ArttrkH.
THE CLINICAL POSSIBILITIES OF THE
PHARYNGEAL PITUITARY.
AN ACCOUNT OF THE CLINICAL RELATION OF THE
NASOPHARYNX TO THE HYPOPHYSIS-SYSTEM.
By W. SOHIER BRYANT, A.M., M.D.,
NEW YORK.
The intention of this paper is to show (1) that the
hypophysis-system may be affected clinically
through that portion of the system lying in the
nasopharynx, the pharyngeal pituitary, and (2)
that the results of clinical treatments of the pharyn-
geal pituitary are similar to those obtained, in like
conditions, by hypophysis-medication.
To illustrate these points I will discuss (1)
adenotomy in its relation to the pharyngeal pitui-
ary and the hypophysis-system, and (2) certain
postnasal treatments which influence the hypo-
physis-system by way of the phaiyngeal pituitary.
The Pharyngeal Pituitary. — To make this discus-
sion clearer it may be well to include a brief outline
of our knowledge of this organ :
The pharyngeal pituitary is a part of the hypo-
physis-system. It represents the lowermost ex-
tremity of Rathke's pouch, the hypophsial pedicle
of the embryo, which, failing to emigrate through
the cranium, has not disappeared through retro-
gression, but has become organized, in man, into a
true glandular body in the pharynx. The phyloge-
netic history of the hypophysis-system shows that
in the lowest vertebrates, the glandular lobe — itself
a portion of the primitive pharynx — is in open com-
munication with the pharynx; this communication
is usually lost in the ascending scale, by the chon-
drification of the base of the skull, but remnants of
hypophysisis-tissue remain along the route trav-
eled by the embryonic hypophysis from the ectoder-,
mic Anlage to the brain. In mammals several hypo-
physis-remnants or accessory hypophses, have been
found in rabbits and cats (Arai) and in dogs. In
man the accessory hypophysial tissue takes the form
of the hypophysis of the pharynx. Consequently, in
contrast to the cerebral hypophysis which lies in-
accessible in the sella turcica, protected by the
sphenoid bone, this accessory hypophysis-tissue lies
exposed at the pharyngeal angle,1 the most unpro-
tected spot in the pharynx. It is located underlying
Luschka's tonsil, and it may be found anywhere
within the extreme boundaries — the mucous mem-
brane in the middle line, the posterior margin of
the vomer, and the base of the sphenoid.
The pharyngeal hypophysis is known to be pres-
ent in the fetus and in individuals of all ages up to
seventy-six years. In a fetus of 18 mm. it meas-
ured 1U mm. in length (Erdheim) ; in the adult, its
average length appears to be about 5 mm. The
shortest length given in the literature is 1J2 mm.
(fetus); the longest, 7 mm.; the least width, *4
mm. ; the greatest, 3 mm. ; the least thickness, 1/5
mm.; the greatest, 1% mm. These measurements
are given here regardless of age. The size of the
pharyngeal pituitary has been urged against the
possibility of its functional importance. When,
however, we consider the average dimensions of the
cerebral pituitary (15 mm. in the transverse direc-
tion, 8 mm. in the anteroposterior, and 6 mm. in the
vertical), in relation to its vital importance in the
general economy, it is seen that the size of the ac-
cessory pituitary can be no argument against its
activity.
According to Citelli, numerous capillaries and
small veins are found both within and around the
pharyngeal hypophsis ; these vessels anastomose
with the veins of the pharyngeal mucosa and the
submucous tissue as well as with the veins of the
periosteum of the lower sphenoid surface and the
bone.
Histologically, the pharyngeal pituitary resembles
the glandular portion of the cerebral pituitary, but
it probably remains more embryonic in structure.
The literature emphasizes its histologic variability.
My own sections showed strong chromophile ele-
ments, with a general structure closely resembling
the adrenal.
The function of the pharyngeal pituitary is prob-
ably auxiliary to that of the cerebral pituitary.
Citelli has found indirect circulatory connections be-
tween the pharyngeal hypophysis and the cerebral
hypophysis, through a venous plexus in the sphenoid
body. There is also probably some nervous connec-
tion between them, and it is possible that there may
be mutual secretory and stimulative activity be-
tween them. In cases of atrophy of the cerebral
hypophysis, the pharyngeal hypophysis, very signifi-
cantly, is sometimes found to be in a state of hyper-
secretion. The fact that the pharyngeal pituitary is
regularly present in man, although very inconstant
and often absent in animals, leads Pende to suggest
that this gland may possess a high functional im-
portance, perhaps a function of its own, which is
different from that of the greater portion of the
glandular lobe of the cerebral pituitary. My own
theory of the physiological significance of the
pharyngeal pituitary is partly explained by its loca-
tion, which brings it into physiological, as well as
anatomical, relations with the lymphoid tissue of
Waldeyer's ring. It lies in the median line in close
association with Luschka's tonsil, a portion of the
defense mechanism of the ring. The pharyngeal
pituitary is the representative of the cerebral pit-
uitary located, like the lymphoid tissue, in the most
vulnerable part of the body, because the exposure
of this portion needed the strongest defense mech-
anism the body is capable of, which is the pituitary-
system.
442
MFDICAL RECORD.
[Sept. 9, 1916
The Relation of Adenotomy to the Pharyngeal and
the Cerebral Hypophyses. — The importance of the
pharyngeal pituitary lies in the fact that this ex-
ternal portion of the glandular hypophysis may have
its functional mechanism interfered with by the in-
Fig. 1. — This and the following figures shcra sections of the
pharyngeal pituitary of an individual 40 years of age; gen-
eral paresis death from bronchial pneumonia. Stained with
hematoxylin-eosin. Figure 1 is a section of the anterior por-
tion of tiie pharyngeal pituitary, showing it situated in midst
of the mucoperiosteum. near the superior end of the choanal
septum. A group of poorly staining, <>r clear cells, is seen.
fections of the upper air tract, especially of the
rhinopiiarynx and the pharyngeal angle. Citellr be-
lieves that the pharyngeal hypophysis is in func-
tional contact not only with its surroundings, the
pharyngeal mucosa and the adenoid vegetations, but
also with the cerebral hypophysis. Accordingly, the
common inflammations of the pharyngeal mucosa
exert an injurious effect upon the functional and the
anatomical development of the pharyngeal hypo-
physis and indirectly upon the cerebral hypophysis.
In chronic hypertrophy of the pharyngeal tonsil
("adenoids"), the pharyngeal hypophysis is like-
wise hypertrophied, as would be most natural con-
sidering its relations with the pharyngeal tonsil as
component parts of the defense mechanism. Fur-
thermore, if the pharyngeal hypophysis is affected,
the cerebral hypophysis is also involved; the bearers
of "adenoids" have been known to present a hyper-
plastic condition of the cerebral pituitary with hy-
persecretion. Other chronic affections of the naso-
pharynx which must of necessity involve the pharyn-
geal pituitary result in pathological changes of the
cerebral pituitary. Citelli's' findings justify the as-
sumption that part of the associated disturbances
with adenoid vegetations represent toxic phenomena
in consequence of impaired hypophysial function.
Consequently, it is of great importance that in
adenotomy at least one means is afforded of reliev-
ing the hypophysis-system of infections incident to
its location, and of stimulating it to normal func-
tioning. The clinical relation of adenotomy to the
hypophysis-system is revealed in cases of "ade-
noids" : adenotomy, an operation which impinges
upon the periphery of the hypophysis-system, re-
lieves the pharyngeal pituitary, together with the
lymphoid tissue, as is shown by the reaction of the
hypophysis-system in form of more rapid growth
and improved nutrition after this operation. (It
seems hardly necessary to state that the pituitary-
system is known to be of essentia
the normal course of the processes of growth (see
Cushing.') Furthermore, adenotomy relieves a
psychic symptom-complex pathognomonic for hypo-
physial lesions, which is associated with "adenoids"
and affections of the nasal passages; this complex
comprises loss of memory, partial or complete;
aprosexia, mental and emotional sluggishness, and
morbid drowsiness and somnolence. The frequent
remarkable psychic change after adenotomy is a
matter of common knowledge. It is interesting
that Citellr states that this symptom-complex can
be removed through operative or local treatment of
the primary disease, alone; or it can also be removed
through general hypophysial treatment without lo-
cal measures; a certain and permanent recovery is
ensured through the combination of these two meth-
ods of treatment.
Postnasal Treatments and the Hypophysis-sys-
tem.— The statements recorded above are all dis-
cussed at greater or lesser length in the literature.
The writer has now an entirely new statement to
make regarding the clinical significance of the
pharyngeal pituitary, and will attempt to place a
large variety of postnasal treatments on the same
level with adenotomy in regard to the hypophysis-
system.
The treatment of the post-rhinopharynx is well
known and widely used, and its effects are recog-
nized iis very important in all infections of this
region and their complications. There is great va-
riety of technique used in treating this region;
many eminent physicians treat it in routine manner
and have done so for a long time. I have a special
treatment of the postnasal region, the technique
and impirical indications of which were suggested
by Dr. E. D. Spear; the treatment consists of an ap-
plication of irritating fluids — usually ammonia
ferric sulphate or hydrogen peroxide — by means of
a cotton carrier through the nose, to the vault of
the pharynx in the median line from the base of the
vomer backwards. For nearlv thirtv vears I have
Fig. 2. — Oblique seel the posterior portion of the
pharyngeal pituitary, showing its position in the mucoperios-
teum oi the vomer close to the sphenoid; it is overlaid by
the anterioi uschka's tonsil and a great quantity
of mucous glands. Chromophile or deeply staining cells ap-
in the pharyngeal pituitary.
been using this stimulation empirically in (1) hyper-
trophic conditions of the lymphoid tissue and the
mucous membrane of the rhinopharynx with hyper-
trophic ear conditions, instead of adenotomy; (2)
in conditions of the mucous membrane where hyper-
Sept. 9, 1916]
MEDICAL RECORD.
443
trophy and atrophy in various -combinations are
associated with atrophic middle-ear catarrh; (3)
in atrophic conditions of the rhinopharynx associ-
ated with hypotrophic conditions of the middle ear;
(4) in otosclerosis; (5) in tonsillitis; (6) in cases
of articular synovitis.
s
*$&> . ,
4. ••'.«'',
.V 'if- *
■ ■*. •
-
Fig. 3. — Section of the anterior portion of the phary
pituitary more highly magnified. Composed chiefly of
cells.
peared (in some sections that I had made of the
nasopharynx), which I located as being precisely in
the region I had stimulated. This glandular body
was the pharyngeal pituitary ("discovered" by
Erdheim in 1904). Subsequent investigation re-
vealed it as an integral part of the hypophysis-sys-
tem, so placed as to be clinically accessible.
After making this discovery of the suggestive lo-
cation of the pharyngeal pituitary in regard to post-
nasal stimulations, I compared what is known of
adenotomy and its effects on the hypophysis-system
with the fact that the results of postnasal stimula-
tions are those associated with the activities of the
hypophysis-system ; that is, blood tension, pulse rate,
and circulation are affected almost immediately and
infection is reduced. I then compared the results of
stimulating the pharyngeal pituitary with the re-
sults of hypophysis-medication in like pathological
conditions, and found that clinical treatment of the
pharyngeal pituitary by means of chemical stimula-
tion and the introduction of hypophysis-substance
into the system are remarkably similar in their re-
sults in arthritis, otosclerosis, osteomalacia, etc.
Compare, for instance, both the general and the
local effects of the chemical stimulation of the
pharyngeal pituitary as given above, with those ob-
tained by Whitbeck: "Rheumatic Arthritis Treated
by the Extract of Pituitary Body.'"' In his series
of cases the regulation of the blood pressure, from
high to normal and from low to normal, is strikingly
similar to that obtained by chemical stimulations of
the pharyngeal pituitary; likewise, the results in
the regulation of pulse and circulation are similar,
ngeal
clear
The effects of these applications are immediate:
after one application there occurs (1) an equaliza ,
tion of the circulation, shown by improved color of
the face; a red face loses color and a pale one be-
comes rosy; (2) the blood tension is likewise equal-
ized; when abnormally low, an increase of tension
occurs, whereas, when abnormally high, a reduction
generally follows; similarly (3) the pulse is brought
from either extreme closer to the normal. Repeated
applications are followed by a consciousness of
euphoria — an objective general physical improve-
ment. A tonic effect is characteristic. The most
striking of these general effects is the regulation of
the blood pressure, so that it tends always to ap-
proach the normal.
The local effect, in catarrhal ear troubles and in
otosclerosis, is an improvement of the hearing; in
articular synovitis there is an immediate noticeable
relief of pain; fluid in the joints is got rid of, and
motion is restored. In the case referred to in my
article, "Acute Articular Synovitis of Cryptic Naso-
pharyngeal Origin,"5 pain was relieved after the
first postnasal application, motion was gradually re-
stored and fluid disappeared completely in eleven
treatments.
I had made use of these empirical stimulations
for a good many years before I had any understand-
ing of their relation to the pituitary-system. The
beginning of my enlightenment as to the real cause
of the remarkable results from this form of treat-
ment came when an unknown glandular body ap-
Pig. 4. — Section ol the anterior portion of the pharyngeal
pituitary showing a structure resembling that of the supra-
renal gland.
as are also the local results of relref from pain and
alleviation of joint symptoms. Compare also Ma .
in whose three cases of gonorrheal arthritis, all in-
flammation had disappeared and motion had returned
after ten days' use of pituitary medication.
444
MEDICAL RECORD.
LSept. 9, 1916
Borchardt* advises the use of hypophysis-extracts in
infectious diseases with a lowered blood pressure and
in rachitis. Denker' and Citelli'" connect otosclerosis
with hypophysis dysfunction, and Denker looks for
good results from hypophysis-medication. Koch"
has treated osteomalacia successfully by hypophysis-
medication; severe pains which were not relieved by
narcotics or by antirheumatic remedies were imme-
diately relieved even by a few cubic centimeters of
hypophysis-extract, with an especial improvement of
the subjective conditions. Likewise, Klotz," Elfer,"
and Weiss" have used pituitary-medication success-
fully in rachitis or osteomalacia, and there is men-
tion in the literature of its successful use in Still's
disease. It is also not without interest in regard to
the regulation of the pulse noted above, that Hew-
lett' makes the statement that pituitary extract is
the only drug which will convert the abnormal pulse
form so frequently seen in fever into a relatively
norma! pulse form.
As an example (under somewhat different tech-
nique) of the effects of stimulation of the pharyn-
geal pituitary in toxic conditions, the following is
striking and illustrative. At the request of an-
other physician I examined the throat and nose of
a patient of his, a young woman of twenty-four,
who had never menstruated, and who was subject to
occasional "crying spells," but who was otherwise
apparently normal. When I saw her she had been
prostrated for some time, had a temperature run-
ning to 101%°, and showed a slight swelling and
irritation of the adenoid. All signs were negative.
As tonsil and nasal treatment did not relieve the
lymphoid hypertrophy, I used forcible application
in the "adenoid region" of iodine and glycerine,
which caused bleeding and considerable discomfort,
soon followed by a rise of temperature to a steady
temperature of 104°. The case was then diagnosed
as typhoid fever, which ran its course and pro-
ceeded to convalescence. In this case there was
probably a slight chronic hypopituitarism associ-
ated with ovarian dysfunction ; there was, never-
theless, a sufficiently active pituitary function to
respond in form of temperature to stimulation of
the pituitary-system. The explanation is that the
pituitary-system had been so depressed with toxins
that it was too sluggish to react until stimulated.
Conclusio7is. — It seems possible to say, on the
foregoing evidence, that intervention in the region
of the nasopharynx whether it takes the form of
(1) adenotomy (or of scraping, slitting, finger-
manipulation or forcible application to the adenoid),
or (2) of chemical application through the nose to
the region of the pharyngeal tonsil, affects the
hypophysis-system through the pharyngeal pitui-
tary. After adenotomy and chemical stimulation
of the pharyngeal tonsil, the results in (1) rapid
growth and improved nutrition, (2) in relief from
aprosexia and morbid somnolence, etc., (3) in tree-
ing the system of infection and local relief of pain,
(4) in the regulation of blood pressure, of pulse, of
circulation, and of temperature, all speak for them-
selves as to the involvement of the cerebral pit-
uitary in the renewed activity of the pharyngeal
pituitary. Consequently, it is possible in depressed
states of the pituitary-system to supply pituitary
activity in either of two ways— the first," by clinical
treatment of the .pharyngeal pituitary through in-
tervention in the nasopharynx ; the second, by sup-
plying pituitary substance to the system. It is very
likely possible to combine advantageously the clin-
ical and the therapeutic modes of treatment.
If adenotomy and postnasal treatments are in ef-
fect, as we assume, stimulations of the pharyn-
geal pituitary, by which the pituitary-system is in-
fluenced, then, on account of the interrelation of the
pituitary, the thyroid, the adrenals, etc., adenotomy
and postnasal treatments must influence in some
degree the entire glandular system, a fact which in
itself is another explanation of the relief after
postnasal intervention.
It goes without saying that while for many years
physicians have unwittingly been activating the
pharyngeal pituitary and the hypophysis-system by
treatment of the nasopharynx, any idea that there
might be clinical possibilities offered by the location
of an outlying portion of the hypophysis-system in
the pharynx, has barely been considered. It is of
extreme importance to the oto-laryngologist that
this gland be investigated and some definite idea of
its clinical possibilities be gained. Doubtless, in
certain cases, the stimulation of the hypophysis-
system through the pharyngeal pituitary might be
impossible, as the literature states that it is some-
times atrophied, or composed of Malphigian cells
or of pavement epithelia ; on the other hand, in cer-
tain abnormal cases where an open craniopharyn-
geal canal persists, which, according to Citelli, are
less rare than was formerly thought, postnasal in-
tervention would be quite literally a stimulation of
the hypophysis in situ. In the great majority of
cases, however, as the writer's experience has
shown, it is possible to assume a normal pharyn-
geal pituitary, with functionating elements, which
respond to clinical treatment. That this outpost of
the pituitary-system lying in the pharynx is of
clinical importance in the treatment of certain dis-
eases, i? without doubt. And, of necessity, to the
oto-laryngologist must belong the responsibility of
opening up this new field of clinical work.
REFERENCES.
1. Bryant. W. S.: "The Involution of the Naso-
pharvnx and Its Clinical Importance," Amer. Jotirn. of
Med.' Sciences, July, 1914, Vol. CXLVIII, No. 1, p. 61.
2. Citelli, S. : "L'ipofisi faringea nella primi e seconda
infanzia. Sui rapporti colla mucosa faringea coll'
ipofisi centrale." Societa Italiana di Larvngol. Otol. e
Rinol., Rome, April, 1910. Internat, Centralbltt. f.
Laryngol., Vol. XXVII, 1911, p. 37; Anatomischer An-
zeiger, Vol. XXXVIII, 1911, p. 242.
Citelli and Basile: "Confirma sperimentale dei rap-
porti fisio-patologici tra faringe nasale e ipofisi,"
Rii-ista Italiana di Neuropatologia, Vol. VIII, 1915, p.
385.
Basile, C: "Histologische und funktionelle Veran-
derungen der centralen Hypophyse des Menschen in
einem Falle von Lymphosarkom des Nasenrachens,"
Zeitschrift f. Laryngol. Rhinol, etc., Vol. VII, 1915, p.
659.
3. Citelli, S : "Sur les rapports physio-pathologiques
entre le systeme hypophysaire et les lesions du larynx
et les lesions de lonpue duree du pharynx nasal et du
sinus sphenoidal," Rivista Italiana di Neuropathologia,
Vol. IV, 1911-12, pp. 4S0 and 529; Zeitschrift f. Laryn-
gol, Vol. V, 1913, p. 513.
4. Cushing: "The Pituitary Body and Its Disorders,"
Philadelphia and London, 1912.
5. Bryant, W. S.: "Acute Articular Synovitis of
Cryptic Nasopharvngeal Origin," Jorum, of the Amer.
Med. Assn., July 10, 1915, Vol. I. XV. pp. 163-4.
6. Whitbeck, B. H.: ••Rheumatic Arthritis Treated by
the Extract of Pituitarv Bodv." Amer. Journ. of Orthop.
Surgery, Vol. XII. 1915, p. 484.
7. Macv, M.: "Pituitarv Gland in Gonorrheal Ar-
thritis," Medical Record, June 19, 1915, p. 1024.
8. Borchardt, L. : "Lehrbuch der Organotherapie,"
Janregg und Bayer, 1914. p. 246.
9. Denker: "Zur Pathogenese und Therapie der
Otosklerose," Ref. Zeitschrift i. Ohrenheilkunde, Vol.
I. XXII. 1915. p. 63; Deutsche med. Wckschrft., Xo. 19,
l'.'l 4. p. 939.
Sept. 9, 1916]
MEDICAL RECORD.
445
10. Citelli: "Contribution a la connaissance de l'otos-
clerose," Archives Internat, de Laryng. d'Otot. de
RhinoL, Vol. XXXVI, 1913, p. 681.
11. Koch, C: Medizin, Kliniks, Vol. VIII, 1912, p.
1022.
12. Klotz: Munchener mcd. Wchschrft., No. 21, 1912,
p. 1145.
13. Elfer: Dtsch. Archiv. f. Klin. Med., Vol. C, 1913,
p. 289.
14. Weiss, K.: Therapeut. Monatshefte, H. 7, 1913, p.
490.
15. Hewlett, A. W. : "Effects of Pituitary Substances
on Fever Pulse," Michigan State Med. Soc. JrL, Vol.
XIV, 1915, No. 4; JrL Am. Med. Assn., No. 16, 1915,
p. 1360.
Literature of the Pharyngeal Pituitary.
Arai, A.: "Der Inhalt des Canalis craniopharyngeus,"
Anatomische Hefte, Vol. XXXIII, No. 100, 1907, p. 411.
Arena, C: "Contribute alia conoscenza della cosi-
detta 'Ipofisea Faringea' nell' uomo," Archiv. Ital. Ana-
tomia-Embryologoa, Vol. X, 1912, p. 383.
Arena, C. : "Ulteriore contribute alio stato presente
della questione sull' ipofise faringea nell' uomo." Archiv.
Ital. di Laringologia, Vol. XXX, 1910, p. 89.
Citelli: "Sul significato e sulla evoluzione della ipofisi
faringea nell' uomo," Anatomischer Anzeigcr, Vol. XLI,
1912, p. 321.
Citelli : "Sur la frequence relative du canal cranio-
pharyngien chez les enfants et les jeunes gens et sur
l'importance de ce fait pour una therie," Annales des
Maladies de V Oreille, da Larynx, du. Nez. et. du.
Pharynx, T. XXXIX, No. 4, 1913, p. 338.
Civalleri, A.: "Sul' esistenza di un ipofisi faringea
nell' uomo adulto," Internat. Monatsschrift f. Anat. u.
Physiol, Vol. XXVI, 1909, p. 20.
Christeller: "Die Rachendach-Hypophyse des Men-
schen unter normalen und pathologischen Verhaltuis-
sen," Virchow's Archiv., Vol. CCXVII, 1914, p. 185.
Erdheim : "Ueber Hypophysengang gesehwiilste und
Hirn cholestome," Sotzungsberichte der Kaiserl. Akad.
d. Wiss., Vienna, Abt. III., Vol. CXIII, 1904, p. 537.
Goetsch, E.: "The Pituitary Body (Critical Review),"
Quarterly JrL of Med., Vol. VII, 1913-14, p. 173.
Haberfeld, W.: "Die Rachendach-Hypophyse andere
Hypophysengangreste und deren Bedeutung f. die
Pathologie," Zeigler's Beitrage zur Pathol. Anatomic u.
zur allg. Path.. Vol. XLVI, 1909, p. 133.
Pende, N.: "Die Hypophysis pharyngea, ihre Struktur
und ihre pathologische Bedeutung," Zeigler's Beitr, zur
Pathol, Anat. u. allg. Pathol, Vol. XLIX, 1910, p. 437.
Poppi, A.: "L'ipofisi cerebrale, faringea, e la glandola
pineale in patologia," Monograph, Bologna, 1911; In-
ternat. Ctlbltt, f. Laryngol., Rhinol, etc., Vol. XXVIII,
1912, p. 56; Archiv. f. Ohrentwilkunde, Vol. 90, 1913, p.
222.
Sotti and Sarteschi: "Sur un cas d'agenesie du
systeme hypophysaire accessoire avec hypophyse cere-
brale integre et gigantisme acromegalique avec infan-
tilisme sexuel," Archiv. Ital. de Biol., T. LVII, 1912, p.
22; Archiv. p. le Scienze Med., Vol. XXXV, 1911, p. 188.
Stendell, W. : "Die Hypophysis Cerebri (Rachendach-
Hypophyse — Review)," V. Opel, Lehrbuch der ver-
gleichen den Anatomie, etc., Jena, 1914, p. 122.
Testut, L. : "Hypophyse Pharyngee," Traite d' An-
atomie Humaine. Vol. IV, p. 957, 1912.
Tourneux, J. P.: "Pedicule hypophysaire et hypophyse
pharyngee chez l'homme et chez le chien," Journ. de
V Anatomie. No. 3, 1912, p. 233.
Note: Two very different theories of "adenoids" in
relation to the hypophysis-system may be found in the
writings of Citelli and' Poppi — W. S. B.
19 West Fifty-fourth Street.
Congenital Obliteration of the Bile Ducts.— T. B.
Holmes thinks that atresia of the bile ducts is not so
extremely rare as is commonly believed ; hence every
medical man should bear in mind the possibility of
its occurrence. It appears to be, in the majority of
cases, a developmental anomaly, and in 16 per cent of
cases thus far reported the anatomical relations sug-
gested the possibility of surgical relief — an artificial
passage to the duodenum, or this absent, a temporary
fistula. The actual number of cases of operative cure
or relief in comparison with the total number of cases
recorded seems to be about 3 or 4 per cent. — American
Journal of Diseases of Children.
HEREDOSYPHILITIC DENTAL STIGMATA.
Br JOHN BBTHUNE STEIN, M.D.,
NEW YORK.
PROFESSOR OF PHYSIOLOGY AND DISEASES OF THE MOUTH, NEW
YORK COLLEGE OF DENTISTRY.
IT has long been known that stigmatism of the
teeth may be caused by heredosyphilis.
Syphilitic hypoplasia (misnamed erosion and atro-
phy) of the teeth, is apparently caused not direct-
ly by the Treponema pallidum in the tissues of the
embryo, fetus, or young child but indirectly by the
severe disturbance in the metabolism of the young
organism brought about by the syphilitic infection ;
the extent of the hypoplasia depending upon the
seriousness of the disturbance which in turn is de-
termined by the amount and duration of the infec-
tion. The syphilitic infection may be so great and
the disturbance in metabolism so severe that the
cells of the embryo, fetus, or young child are un-
able to resist it and instead of stigmata being pro-
duced, death results.
Syphilitic hypoplasia of the teeth is a subject of
great diagnostic and economic importance, but of
late has seemed to slumber in "no man's land," in-
teresting apparently neither dentist nor physician.
It is to be remembered that heredosyphilis is
essentially the same as self-acquired syphilis, it is
syphilis acquired in utero from the syphilitic moth-
er. Syphilis "ab ovo" has not been discovered al-
though the Treponema pallidum has been found in
the ovocyte.
The study of syphilitic hypoplasia of the teeth
presupposes some knowledge not only of the de-
velopment of the teeth (especially the time when
the formation of dentine begins and the height
which the so-called dentine cap should normally
reach at various periods of the teeth's develop-
ment), but also of the time of their eruption.
It is also to be remembered that a tooth is formed
partly of epithelium (ectodermic in origin) — the
enamel; and partly of connective tissue (mesoder-
mic in origin) — the pulp, dentine, and cementum.
The first traces of the teeth (Fig. 1*) are seen in
the second month of embryonic life when a groove —
the dentinal or enamel groove develops along the in-
ner edge of the embryonic jaw. From the floor of
this grove an epithelial lamina or ridge — dentinal
ridge, enamel ledge, dental shelf (Zahnleiste)
forms, constituting the anlage of the enamel organs.
The dentinal ridge or enamel ledge develops solid
protuberances — dentinal bulbs or enamel germs at
points where the temporary (deciduous or milk)
teeth will later appear; each point corresponding
to a temporary tooth. The dentinal bulbs or enamel
germs are somewhat knoblike; later, their bases
spread and flatten until finally the underlying con-
nective tissue — dentinal papillse projecting up into
them make them cup-shaped, each enamel germ
grows deeper into the underlying connective tissue,
but remains connected by a thick epithelial cord
(neck) with the dentinal ridge on the inner (lin-
gual) side of the enamel germs.
The enamel germs become the enamel organs,
which remain connected by thin epithelial cords
(so-called necks) with the dentinal ridge and have
the double function of determining the shape of
the crowns of the several teeth, and producing the
enamel for them.
*I am indebted to Dr. Francis Ovary for the drawings
in Figs. 1 to 6. Figs. 2-3 were drawn from sections
made in the Histology Laboratory of the New York Col-
lege of Dentistry.
446
MEDICAL RECORD.
[Sept. 9, 1916
An Enamel Organ consists of the following layers
of cells, viz., (1) An inner layer of hexagonal cylin-
drical cells — enamel cells, also called ameloblasts,
adamantoblasts, (2) A stratum intermedium, of
more or less round cells, (3) A stellate reticulum,
or an enamel pulp, of stellate cells, (4) An outer
layer of flat cells. See Figures 1-2-3.
The dentinal papillse growing vertically soon be-
come surrounded on all sides by the cap-like enamel
organs, and at the periphery of the papillse there
develops a layer of columnar cells (odontoblasts)
of mesodermic origin which form the dentin, by a
process thought to be analogous to that observed
in the formation of bone, by the osteoblasts. After
the formation of a considerable amount of dentine
by the odontoblasts, the enamel cells grow in length,
and finally from or by them (by the process of
amelification) the enamel prisms are formed.
While these processes are taking place a con-
e-year molars, 6th month of intrauterine life; in-
cisors, 1st month after birth; canines or cuspids,
3d and 4th month after birth; biscuspids, 6th month
after birth; 2d or 12th year molars, 3rd year after
birth; 3d molars or wisdom teeth, 12th year after
birth.
At birth no permanent teeth have begun to calci-
fy except the first molars.
Figure 4 shows the time of the inception of cal-
cification ( dentinification) of the teeth.
If the morbid influence of syphilis does not affect
the tooth during its development, it erupts com-
plete in form and structure. Syphilitic stigmata
upon the teeth can be produced only during the de-
velopment of the teeth and are the result of some
interruption in the process of calcification. Sus-
pended or improperly performed calcification pro-
duces irreparable stigmata, which may be seen on
any part of the tooth from its morsal surface to
DENTINAL BULB OR
ENAMEL GERM \ DENTINAL GROOVE
DENTINAL GROOVE \ 7
A.x L B
DENTINAL RlDCiE OR
ENAMEL LEDQE
TUNICA PROPRIA
^MESODERM)
/TUNICA PROPRIA
EPITHELIUM OF EMBRYONIC JAW (Mesoderm)
TUNICA PROP!
(MESODERM!
NECK OF ENAMEL OR6fl
OR EPITHELIAL CORD
OUTER LAYER OF ENAMEL QRCiflN
STELLATE RETICULUM
STRATUM INTERMEDIUM
INNER LATER OF ENAMEL CELLS
TUNICA PROPRIA
(M.ESODERM1
DENTINAL GROOVE
C
DENTINAL RIDGE OR
ENAMEL LEDG.E
DFNTINAL PAPILLA,
TUNICA PROPRIA
(MESODERM)
OE.NTINAL RipqE OR ENAMEL LED6.E
AL GROOVE
DENTINAL RIDGE. OR
ENAMEL LEDQE
NTINIAL SACS
V^' ■ ■ TUNICA PROPRIA (V\E.S0DERM>
NECK OF ENftMEL ORGAN
OR EPITHELIAL CORD
DENTINAL PAPILLA
DEVELOPING, BONE
ODONTOBLASTS
OSTEOBLASTS
r o ya/rr
Fig. I .— D ; the earlier periods in the development ot the tooth.
nective tissue covering — Dental Sac, which is rich
in cellular and fibrous elements forms around each
developing tooth. The cementum is thought to be
produced from the cells in this dental sac.
The dentine always begins to form at the sum-
mits of dentinal papilla- so that dentine caps (Figs
2 and 3) arc formed before amelification ta
place; later on. however, dentinification and ameli-
fication proceed synchronously. The process of den-
tinification which is remarkably regular proceeds
from the summit of the dentinal papillae and grad-
ually forms the crown, neck and the root of the
tooth.
Dentinification takes place much earlier than is
generally supposed. According to Magitol and
Legros the dentin, caps of the teeth begin to form
approximately as follows: —
Deciduous teeth: Incisors and cuspids. 17th
week of intrauterine life; 1st and 2nd molars, 18th
week of intrauterine life. Permanent teeth: 1
its gingival margin depending upon the time when
the syphilitic infection is sufficient to produce them.
If the disturbance caused by the syphilitic infec-
tion is sufficiently active at the time when dentini-
fication is about to begin the hypoplasia will be
upon the morsal surface of the tooth, but if the
syphilis is active later on, the stigma may show
itself at a higher level upon the facial, lingual and
mesial surfaces of the tooth, upon that part of the
tooth which is them undergoing development. Thus
it is possible to tell from the stigmata on the teeth
the time when some vicious disturbing influence
attacked the embryo, fetus, or new-born child.
The apparent relationship already referred to be-
tween the degree of syphilitic infection and the de-
gree of syphilitic hypoplasia of the teeth is indi-
cated by the fact that the hypoplasia of the dentine,
and the enamel, may be slight, or extending through
various degrees, very marked. The dentine may be
covered with but poorly differentiated enamel or
Sept. 9, 1916]
MEDICAL RECORD.
447
no enamel; or the tooth may not be formed at all,
the cells of the tooth germ having been destroyed.
Syphilitic hypoplasia of the deciduous teeth rare-
ly occurs, because the beginning of dentinification
for these teeth takes place, as we have said, from
syphilis will be seen upon them. But, because at
this time only about half the crowns of the incisor
teeth have undergone dentinification, the stigmata
will, after their eruption be evident on them, at the
same level, viz., about half way up, on the crowns
Fig. 2. — A longitudinal section of the left upper deciduous
first molar from a human fetus of about four and a half
months, showing the early formation of the dentin cap. (Leitz,
oc. III. obj. 1.) 1. Dentin cap; 2. outer layer of enamel or-
gan; 3. epithelium; 4. epithelial debris: ."». tunica propria;
6. dentinal ridge ; 7- dental sac : 8. stellate reticulum.
about the seventeenth to the eighteenth week of
intrauterine life, and if the fetus is infected with
syphilis at this time it usually dies. Syphilis is a
potent abortionist ; but it is possible when the
syphilitic mother is given antisyphilitic treatment
that the life of the fetus may be saved.
The first molar, incisor, and cuspid teeth of the
second dentition are the ones which show frequent-
ly the evidences of heredosyphilis, (Figs. 5-6) be-
cause the first molars are beginning to undergo den-
tinification during the last months of fetal life and
the incisors and cuspids during the first three or
four months after birth. (Fig. 4) It is at this
time that the syphilitic process is most intense,
frequently causing the death of the fetus or child.
Suppose the syphilitic infection, theretofore not
sufficiently active to interfere with the process of
calcification, is most intense at the fourth month
after birth; (Fig. 5) calcification of the deciduous
teeth having already taken place no evidence of
Fig. 3. — Higher magnification of the contents of the circle
in Fig. 2. Notice that the enamel has not begun to form.
(Leitz. oc. IV. obj. 5.) 1. Dental sac ; 2. outer layer of enamel
organ ; 3. stratum intermedium ; 4. dentin cap ; 5. inner layer
of enamel organ; ii. odontoblasts. .. dentinal papilla; S. pa-
late reticulum.
of all the eight incisor teeth. Dentinification for
the cuspid teeth is beginning at this same period,
consequently only the summit of these four teeth
will be affected. The first and second bicuspids
will not be affected at this time as dentinification
has not yet begun. But the first molar teeth at
the fourth month after birth have considerable
dentine (half or two-thirds) formed for the crowns
of their teeth, consequently the lesions will appear
about half or two-thirds the way up, on the crowns
of those teeth.
The second and third molar teeth cannot be af-
fected as dentinification does not occur until some
years later.
The stigmata of developmental syphilitic hypo-
plasia are usually found upon the same group of
teeth at about the same level on their crowns.
Some general morbid influence produces the hy-
Fig. 4. — The time of tl I inn of calcification I dentinification ) of the teeth.
448
MEDICAL RECORD.
Sept. 9, 1916
poplasia for a local cause would produce a more or
less local result, e. g. an osteoperiostitis of the left
half of the mandible might interfere with the de-
velopment of the teeth on that side but not upon the
other side nor with teeth of the maxilla?.
the first to describe this extraordinary dental L-tig-
ma and explain its pathological significance. This
form of ■ syphilitic dental hypoplasia, which was
the first recognized, is characterized in its most
typical form by a marked crescentic indentation of
i ' A s mi-diagrammal i Qtation of a system-
>l hypoplasia of several sorts of upper and lower teeth
(incisors, cuspid and molars). The general systemic dis-
turbance which must have caused these stigmata occurred
about the fourth month after birth. (The third molars have
not been inserted in the drawings.)
A local cause cannot produce, but a disturbance
in metabolism occasioned by the severe general sys-
temic syphilitic infection of the embryo, fetus,
or young child could produce: (1) Multiple and
disseminated stigmata of the teeth in both maxilla?
and mandible. (2) Symmetrical stigmata here and
there upon homologous teeth. (3) Systematized
stigmata at the same level on different sorts of
teeth.
The most characteristic stigmata of the teeth in
heredosyphflis are: (li Hutchinson's teeth; (2)
Hypoplasia of the morsal surface of the incisor
teeth, other than Hutchinson's teeth; (3) Hypo-
plasia of the morsal surface of the cuspid teeth ;
(4) Hypoplasia of the facial, lingual, and mesial
surfaces of the teeth in the form of pits, furrows
repress tatioi
poplasia of several sorts of upper and lower teeth
is, and molars). The general sysl
which must have caused these stigmata commenced
h week of lntra-uterlne life and continued
up to about the fourth month after birth. (The third molars
Ijeen omit:
and honeycombed teeth; (5) Symmetrical hypo-
plasia of the four first molars; (6) A systematized
hypoplasia of several sorts of upper and lower teeth,
i. g. incisors, cuspids and molars.
Hutchinson's Teeth. — Jonathan Hutchinson was
Fig. 7. — Typical Hutchinson teeth. (Fournier.)
the morsal surfaces of the two upper median in-
cisor teeth (Fig. 7). The term Hutchinson's teeth
has been misapplied to any other tooth having a
similar depression upon its morsal surface. This
form of hypoplasia has also been seen in heredo-
syphilitics upon the four inferior incisor teeth and
even upon cuspid teeth.
According to Hutchinson this term is to be ap-
plied to the superior central incisor teeth of the
second dentition presenting a semilunar depression
on their morsal surfaces, the teeth being screw-
driver shaped ( wider at their neck and narrowing
towards their morsal surfaces) and converging
obliquely, i Figs. 7 and 8.)
This lesion when typical has such an individuality
that no other dental lesion can be confused with it.
It can be recognized at a glance. It is impossible
to misunderstand it, although it varies in charac-
ter with the age of the heredosyphilitic. When the
tooth erupts the characteristic semilunar indenta-
tion upon its morsal surface does not exist. The
place where the future crescent is to form is filled
in with hypoplasic tooth structure, either in the
form of acuminate buds, points, or spicules form-
ing a sort of fine denticulation, or in the form of
a more or less homogeneous lobular mass. This
hypoplasic dentine, which is not covered with en-
amel, is non-resistant, friable, and rapidly crumbles
and wears away so that after a few years it en-
tirely disappears and in its place we have the cres-
centic notch.
During adolescence the morsal surfaces of Hut-
chinson's teeth change and at maturity lose their
Fig. S. — Typical Hutchinson teeth in a patient twenty-two
years of age. H( re the crescents have nearly disappeared, but
the beveling on the facial surface of the teeth is still evident.
Notice the pits on these teeth, especially the upper left central
incisor. The cause of this patient's condition, facial paralysis,
was first recognized through these two upper central incisors.
His blood afforded a positive Wassermann t\ V Health
Dept. ) reaction, and examination of his eyes revealed a
heredosyphilitic choroiditis.
characteristic appearance. The arcs on these mor-
sal surfaces gradually diminish; at 20 to 22 years
(Fig. 8) they are noticeably effaced, and at about
the twenty-fifth year the characteristic crescents
disappear entirely and the morsal surfaces become
Sept. 9, 1916]
MEDICAL RECORD.
449
rectilinear. But at the twenty-fifth year an im-
portant characteristic of the lesion, the beveling
of the inferior facial surfaces of the teeth, still
persists; for the crescents of Hutchinson involve
not onlv the morsal surface of the teeth but also
faces of the incisor teeth the following are the
most frequent types : (1) Flattened; (2) Saw-like;
(3) Stunted. . .
In the flattened type the summit of the tooth is
flattened on its facial and lingual surfaces, resem-
Ftg. 9. — An early stage of Hutchinson's teeth, showing the
crescents before hypoplasic tooth structure lias been worn
away. Patient 14 years of age. Mal-coaptatioh of the teeth.
the facial surface in that the beveling extends from
above downwards, slanting from the facial to the
lingual surface of the teeth, and so involving more
of their facial surface. These bevels which crown
the crescentic notches are the last of the stigmata
to be effaced through usage of the teeth and they
are the last vestige of Hutchinson's teeth, disap-
pearing at about the thirtieth year. The teeth then
are shorter and have lost all their diagnostic sig-
nificance.
The so-called "crescentic notch of Hutchinson"
may also be seen upon the following permanent
teeth: (1) The lateral superior incisors ; (2) All the
lower incisors; (3) Very exceptionally upon the
cuspids.
Legros, Hutchinson, Moon, and Fournier report
having seen Hutchinson's crescent upon one upper
central incisor tooth, the other being perfectly
normal.
The superior incisor teeth, especially the central
incisors may have the screw-driver shape, but
neither converge nor have they crescentic notches
upon their morsal surfaces. This lesion is at times
so slight that it is liable to be overlooked. Such
teeth have not been conclusively shown to be of
heredosyphilitic origin.
Hutchinson's triad, viz., Hutchinson's teeth, in-
Fig. 10. — Teeth of heredosyphilitic (?). eleven years of
age. Hypoplasic flattening of the morsal surfaces of the
upper central incisors, hypoplasia of cuspids, amorphism of
teeth. Absence of upper right lateral incisor. Patient had a
hypoplasia of the morsal surfaces of the first molars, more or
less general venous ectasia, general infantilism, a high and
contracted dental arch, general adenopathy, and had under-
gone two operations for adenoids. Wassermann negative
(N. Y. Health Dept.).
terstitial keratitis, and otitis media, are pathogno-
monic of heredosyphilis.
Hypoplasia of the Morsal Surfaces of the Incisor
Teeth other than Hutchinson's Teeth. — Among the
numerous forms of hypoplasia of the morsal sur-
Fig. 11. — This case shows pits on the teeth, saw teeth,
hypoplasia of morsal surfaces of the upper lateral and all the
lower incisors and upper left cuspid, and microdontism and
amorphism of teeth. The patient was thirteen years of age,
and but 4 ft. 1 in. in height, showing all the signs of general
infantilism, and a persistence of the deciduous upper second
molars, hypoplasia of the two upper and loss of the two lower
first molars, and delayed dentition of three second molars, a
heredosyphilitic choroiditis, and a positive Wassermann (by
N. Y. Health Dept.) reaction.
bling somewhat a tooth which had the summit of
its crown compressed on its four sides in a vise
(Fig. 10). This hypoplasic surface appears yellow,
gray, or even black at some points and is irregular,
uneven, and roughened with more or less vertical
furrows. I have seen cases where this stigma ex-
tended on the crown of the tooth to the height of
3 mm. from the morsal surface. It is evident that
this portion of the teeth is friable and easily falls
to pieces. Fournier compares it to "a sheet of
heavy paper."
The "saw-like teeth" (Figs. 11-13) have morsal
surfaces which are irregular and rugged as if
fine vertical incisions or little grooves had been
filed on them.
The teeth with "stunted" morsal surfaces have
circular grooves about 2 or 3 mm. from their sum-
mits, from which emerge amorphous yellowish caps.
Sometimes these caps appear like small teeth placed
upon larger ones ; at other times the caps have small
buds upon their summit giving the caps the appear-
ance of a clove, "stunted" teeth with such caps are
sometimes called "clove teeth."
Hypoplasia of the Morsal Surface of the Cuspid
Teeth. — Syphilitic hypoplasia of the cuspid teeth
occurs nearer the morsal than gingival margin of
these teeth. A circular constriction is evident near
their morsal surface, th" hypoplasia portion ap-
FftClftL MtSlAL UNGUAL
Fig. 12. — Typical syphilitic stigmata in the form of trans-
versely arranged furrows and pits on the facial, mesial, and
lingual surfaces of incisors.
pearing somewhat like a teat upon the end of the
tooth.
Hypoplasia of the Facial, Lingual, and Mesial
Surfaces of the Teeth in the Form of Pits and Fur-
rows, and Honey-combed Teeth. — The pits in the
450
MEDICAL RECORD.
[Sept. 9, 1916
teeth vary in size, they may be very small like the
depression made in soft wax with the point of a pin
or they may be large, deep and similar to a depres-
sion made in soft wax with the head of a match.
The surface of these pits is irregular and in young
Pre. 13 Se< leg ;nd of Fig. 1 5
teeth is white, but later becomes gray, brown or
even black. These pits varying in depth, may be
very superficial with a slight covering of enamel,
or may extend a considerable distance into the
dentine (Figs. 8-11). They involve by prefer-
ence the incisors, especially the central superior
incisors. They vary in number and where several
exist they are usually disseminated without order,
but at times they are arranged in a horizontal line
and more rarely in two superimposed horizontal
lines separated from each other by one or two
millimeters.
Stigmata in the form of furrows are more com-
mon than pits upon the crowns of teeth. The tooth
appears as if it had been scratched transversely
and the scratch, furrow, or sulcus encircles the
tooth horizontally.
The furrow may be so superficial that it is likely
to escape notice and resembles a line on a sheet of
paper made by the pressure of one's finger nail.
This lesion, which is not very evident, gives one the
impression that it is a transverse line, not a groove,
crossing ih. The existence of the groove,
however, is proved by scratching the crown of the
tooth with the finger nail. Sometimes the groove
Oiaj lie a quarter to one-half a millimeter deep with
little or no enamel covering. This form of lesion
later becomes gray or black and so more striking
and evident.
Instead of the stigma taking the form of a sin-
gle groove traversing the circumference of the tooth
horizontally, there may be two, three or more of
them (Fig. 12). The multiple grooves which are
superimposed horizontally on the crowns of the
teeth are located nearer the morsal surface than
gingival margin of the tooth. The grooves are sep-
arated by bands of enamel which form light ridges
between them. Such teeth have been called by the
French "dents en etage, dents en escalier, or dents
en gradin." We might call them "graded" or "in-
termittently affected teeth." The grooves, alternat-
ing with the ridges, indicate alternating periods
of exacerbations and remissions of the disease.
The morsal surface of such teeth where the first
grade or step of the hypoplasia appears is usually
thin, rough, irregular, brownish in color and with-
out any enamel covering. It rapidly falls to pieces
and disappears so that in adolescence or in young
Figs. 13, 14, and 15 are taken from casts showing the
teeth of a heredosyphilitic, thirteen years of age, whose
father, mother, sister, and two brothers were also syphi-
litic, all giving a positive Wassermann (by otto l.owy.
Newark, X .1. i reaction excepting the youngest brother
(two months of age). An examination of his blood was
not made becaus.- the Treponema pallidum was found by
me under the dark field microscope in the exudate taken from
(lie mucous patches about his mouth. This case shows de-
layed dentition, hypoplasia of three of the first molars (the
left upper first molar not having erupted), persistence of all
the deciduous molars in the mandible and the second de-
ciduous molars in the maxilla, a saw tooth, microdontism,
amorphism of teeth. Hutchinson's crescents on the upper lat-
eral incisors, and ma on of th teeth.
adult life the tooth is deprived of its morsal sur-
face and the shortened crown of the tooth appears
as if this morsal surface had been cut off trans-
versely.
Stigmata in the form of furrows usually appear
on the incisor teeth but they may appear upon the
cuspids or first molars.
Sometimes a third, a half, or three-fourths of the
crown of the tooth is hypoplasic, so that its surface
is uneven, rough and at times anfractuous, and
appears grayish yellow, even grayish black. Four-
nier calls such a lesion "erosion en nappe." Tomes
calls the teeth "honey -combed teeth."
Symmetrical Hypoplasia of the Four Permanent
First Molar Tet th. The morsal surface of the four
permanent first molar teeth is completely changed
(Fig. (', ) . In infancy and adolescence two-thirds
or three-quarters of each tooth nearer its
morsal surface is hypoplasic. diminished in all
its diameters, eaten away, and marked off
Sept. 9, 1916]
MEDICAL RECORD.
451
from the rest of the tooth by a circular constric-
tion; so that there appears to be a small stump-like
tooth, a stump of undeveloped dentine, emerging
from the remaining apparently normal crown. This
surface is extremely irregular with rough, conical,
pointed eminences which are at times markedly an-
fractuous, has fissures which are more or less deep,
and penetrate even the dentine, and has a yellow,
brown, dirty gray, or black appearance. This hy-
poplasic stump partially covered with enamel is
gradually worn away and crumbles to pieces so that
it finally disappears and with the crown of the tooth
thus shortened, the morsal surface becomes flat,
yellow in color and surrounded by a zone of white
enamel. This symmetrical hypoplasia of the morsal
surfaces of the four permanent first molar teeth is
of the greatest importance in the diagnosis of here-
dosyphilis.
Later on caries attacks the central portion of the
morsal surface of these teeth, frequently destroy-
ing them. Thus, the heredosyphilitic may have
either a hypoplasia of the crowns of his first molar
teeth or caries at the center of the remainder of
the crowns of three or four of his molar teeth, or
a loss of some or all of his first molar teeth through
caries, or a combination of these conditions.
The hypoplasia of the morsal surfaces of these
first molar teeth, which must have begun at some
time after the beginning of the sixth month of
intrauterine life, proves that the fetus has been at-
tacked by some disease at this time, and syphilis
appears to be this disease.
I quote from "Diseases of the Mouth" (F. Zins-
ser— J. B. Stein) : "On the facial surfaces of all
the upper and lower incisor and cuspid teeth are
several furrows and cuplike erosions, and all their
morsal surfaces are notched in several places. All
the first molars are missing except the lower right
one, in which there is a central caries, apparently
following a developmental hypoplasia of the morsal
surface. The cuspid and bicuspid teeth show on
their surfaces slight erosions and transverse fur-
rows. This is the result of a condition existing
before birth and continuing to the end of the first
part of the second year of life. The history of this
case is very instructive."
"The patient, a boy of twelve years of age, had
been treated a year and a half for a parenchymatous
keratitis. The diagnosis of syphilis was not made,
and antisyphilitic treatment was not energetically
applied because the keratitis did not react well to
mercury. The Wassermann reaction was negative,
there were no other symptoms of heredosyphilis,
and the condition of the teeth was attributed by me
(Zinsser) at that time to rhachitis. A year later
the boy returned with a severe syphilitic perfora-
tion of the hard palate and a positive Wassermann
reaction. If the hypoplasia of the lower right first
molar had been recognized as a sign of heredo-
syphilis and energetic antisyphilitic treatment re-
sorted to, the patient would have been spared the
severe disfigurement."
A Systematized Hypoplasia of Several Sorts of
Upper and Lower Teeth. — This form of hypoplasia
affects several sorts of teeth ; the teeth of one sort
at one level and those of another sort at another
level. The hypoplasia is multiple, being as a rule
found on (1) All the incisor teeth (superior and
inferior). (2) All the cuspids (superior and in-
ferior. (3) All the first molars (superior and in-
ferior). It does not seem to affect the bicuspids
or second and third molar teeth.
Dental infantilism. — Delayed dentition, micro-
dentism and persistence of the deciduous teeth may
serve as a stigma of heredosyphilis. Microdentism
of all teeth is rare, but a number of teeth — mostly
the superior and inferior incisors — and occasional-
ly single teeth exhibit this condition (Figs. 13, 14,
and 15).
The so-called persistence of the deciduous teeth,
i. e., their non-replacement by the permanent teeth
occurs more frequently than is generally supposed
(Fig. 14-15) — in one-third of the cases of heredo-
syphilis, according to one observer (Chompret).
Few physicians or dentists have recognized this
condition in heredosyphilis. It is a very important
diagnostic sign. The deciduous teeth which remain
in the mouth for a longer time than is usual are in
order of frequency, the following: — (1) the second
molars; (2) the first molars; (3) the cuspids;
(4) the incisors.
The persistence of the deciduous tooth appears to
be due to the absence or arrested development in
the tooth which should displace it.
Absence of Certain Teeth, etc. — The absence of
certain teeth is a stigma which occurs in heredo-
syphilis implying a non-formation or complete ar-
rest in development of the dentinal germ or folli-
cle.
Abnormalities in the position of teeth and
amorphism of the teeth (Fig. 13) (teeth with
crowns somewhat resembling sharks teeth, piano-
keys, pebbles, squares, twisted teeth, pegged-shaped
teeth, etc) are frequently attributed to heredo-
syphilis and less frequently, the following condi-
tions, viz., (1) Vulnerability of the teeth and
marked liability of the teeth to caries resulting in
premature edentation. (2) Malcoaptation of the
teeth, or, as Fournier called it "the absence of the
sign of the artichoke" (Fig. 13). (3) Asymmetry
of the superior maxillary bones. Prognathism and
deformities of the lip and palate. (4) The presence
of supernumerary teeth.
Some forms of hypoplasia of the teeth are cer-
tainly syphilitic, and some may be attributed to
syphilis but there are forms of hypoplasia of the
teeth which are certainly not caused by syphilis.
Non-syphilitic hypoplasia of the teeth has been
seen in animals (the bull and very frequently the
dog).
Fournier found that of 480 cases of heredosyphi-
lis examined by him approximately 43 per cent dis-
played hypoplasia of the teeth as marked stigmata
of the disease.
Many patients with hypoplastic teeth have been
seen by me whose blood has given a negative Was-
sermann reaction. This does not disprove the syph-
ilitic nature of the hypoplasia because the syphilis-
may have been cured or arrested. Some of our
patients with hypoplasia of the teeth whose blood
gave at first either a negative or a weak positive
Wassermann reaction gave later a distinct positive
Wassermann reaction. The luetin reaction of No-
guchi, which he and others claim is valuable in de-
tecting heredosyphilis, may be useful in confirming
the diagnosis of syphilis in eases where dental stig-
mata exist.
Hypoplasia may affect the teeth at hazard and
without method, depending upon some local acci-
dent or affection, and apparently has no significance
or its significance is at present unknown. But the
hypoplasia which I have described either affects
symmetrically certain sorts of teeth (the first mo-
lars or incisors especially, the two upper central
452
MKDICAL RECORD.
[Sept. 9, 1916
incisors) or affects several sorts of upper and lower
teeth, e. g., the incisors, cuspids, and first molars,
in a more or less systematized way.
There must be some general morbid cause for
these conditions. Morbid conditions other than
syphilis, can produce hypoplasia of the teeth, but
the hypoplasia thus produced is not the same as
that caused by syphilis, and vice versa. Of all
diseases, syphilis is the most frequent cause of hy-
poplasia of the teeth (.80 per cent of the cases ac-
cording to Fournier). Heredosyphilis is essential-
ly a dystrophic disease and exercises its noxious
influence especially during intrauterine life and
the first months after birth, at a time when dentini-
fication is beginning or progressing.
What diseases are met with in intrauterine and
the first months of extrauterine life which would
profoundly affect the cells of the entire organism
and the cells of the dentinal germs in particular?
Rachitis rarely occurs during the first six months
of life; usually in the second year. To-day variola
is seldom met with. Scarletina, measles, diphtheria
and typhoid fever are rarely observed during the
first year of life. Acute rheumatic fever seldom oc-
curs before the fifth year; and can it be said that a
disturbance in metabolism occasioned by gastro-
enteritis could cause hypoplasia of the morsal sur-
faces of the first molar teeth?
Has an authentic case been recorded either of a
symmetrical hypoplasia of the crowns of the four
molars, or of Hutchinson's teeth, or of a systema-
tized hypoplasia of several sorts of teeth, upper and
lower, which was caused by any disease other than
syphilis?
Heredosyphilis appears to be the only cause of
these three forms of hypoplasia of the teeth, and
until some better proof is forthcoming must be re-
garded as the definite cause.
The diagnostic significance of syphilitic dental
stigmata is of great importance:
1. In detecting heredosyphilis; because the stig-
mata are at times the only evidences of this disease.
2. In tracing, in a patient with these stigmata,
the possible syphilitic origin of some condition the
cause of which was unknown and was not suspected
of being syphilitic.
3. In tracing back the existence of syphilis, as,
for example, in diagnosing the condition of a wom-
an (the mother of a child when she has no mani-
festations and gives no history of the disease), an
examination of her children's teeth may prove her
to have had syphilis; and so in diagnosing a young-
er child's condition (an epileptic for example) the
examination of an older brother's or sister's teeth
may alone reveal or lead to a discovery of the di-
seased syphilitic condition through which the young-
er had passed.
4. In life insurance examinations.
5. In the effective administration of the efforts
of all interested in dental, oral, social, moral, and
mental hygiene.
East Twenty-third Street.
The Speech in Athetosis. — W. B. Swift relates a case
of athetosis which shows in the vocal mechanism as a
constant intertwining change of mouth positions, so
that all sounds art' immediately varied into other forms
of vowels and other sounds of consonants; their inter-
relations are extremely varied. In brief, athetoid speech
is a constant variation in vowel form and consonant
sound, clear only when correctly struck during the
constantly changing contractions or when, during rare
moments of relaxation, the sounds are hit before con-
tractions occur. — Review of Neurology and Psychiatry.
PRIMARY CARCINOMA OF THE LUNGS
Bt ERNEST SCOTT, M.D.,
PROFESSOR OF PATHOLOGT, OHIO STATE UNIVERSITY,
AND
JONATHAN FORMAN. MP.
COLUMBUS, OHIO.
(FROM THE DEPARTMENT OF PATHOLOGY OF THE OHIO STATE-
UNIVERSITY. I
Increased interest in primary carcinoma of the
lung in recent years has furnished statistics which
indicate that this condition is more frequent than
is usually stated. Reinhardt, in 545 cases of car-
cinoma, found five which were primary in the lung.
Passler recorded 16 cases in 1000 cases of car-
cinoma. In the course of 16,047 autopsies in one of
the large hospitals of Petrograd during the last ten
years, primary carcinoma of the lungs is reported
by Laurinovich as having been found sixty-one
times, or 0.38 per cent. In the laboratory of
pathology at the Ohio State University, three pri-
mary pulmonary carcinomata were chanced upon,
while 302 carcinoma were being collected.
A summation of the more recent statistics made
by Weller, in 1913, gave an incidence of 0.3 per
cent in 11,093 autopsies. In the same year, von
Wiczkowski compiled the reports of 126 cases in
58,497 autopsies.
In 1912, Adler published his excellent monograph,
in which he gave the reports of 374 collected cases
of primary pulmonary carcinoma. In 1913, Weller
Fig.
1. — Tde type of cells seen in the more undifferentiated
areas of cases I. II, and III.
published a collection of the primary carcinoma
of the larger bronchi. His series contained nineteen
cases not mentioned by Adler, including his own
case. In 1912, there were seventeen other cases re-
ported, one each by Apert and Rouillard, Gilchrist,
Pfister, and Edlavitch, together with 13 cases by
Kolszewski. In 1913, von Wiczkowski added six
cases, Lombardo and Argaud, Crespin, and Legroux
two cases. In 1914, Leclerc and Michel reported a
case, and Edlavitch added his second case. In 1915,
the paper of Laurinovich, based upon sixty-one
cases, appeared, and in 1916 Herrman and Mayer
report a single case.
There are not doubt many other cases which have
been reported but are buried in papers bearing upon
some other phase of work. As examples of this,
there is the brief report of a case by Ash, in a dis-
cussion of the pathology of mistaken diagnosis in
the Consumptive Hospital, and also the case de-
scribed by Howard and Schultz in their monograph
on the biology of tumor cells.
In lower animals, primary tumors of the lung are
rather frequent. Tyszer. who first called attention
Sept. 9, 1916J
MEDICAL RECORD.
453
to the frequency of neoplasmata of the lungs in
mice, found fifty-two lung tumors in seventy mice,
which had developed eighty-three spontaneous
tumors, or 62 per cent, of the total. Slye quotes
Sticker that, in 1026 cancers in horses, cattle, dogs,
sheep, cats and pigs, 3 per cent, were primary in
the lungs. In her own series of 6000 autopsies upon
mice, Miss Slye found that 1 per cent, of the series
presented primary malignant tumors of the lungs.
This paper is a study of four specimens of primary
carcinoma of the lung, which are in the Museum of
Pathology at the Ohio State University.
Case VI, however, is of the dermoid type, and
presents a different picture. In this case, the lung
is small and firmly bound in with adhesions. A
mass measuring 5x6 cm. in cross section occu-
pies the upper lobe, and attaches itself to the
ascending and transverse portion of the arch of
the aorta involving the bronchial lymph nodes in
its growth. The bronchi are completely filled and
obliterated by the new growth.
Histological examination shows a tumor com-
posed of squamous epithelial cells, which present
intercellular bridges and a concentric arrangement
Case
Age, Sex. Lung
Occupa- I In-
tion I volved
I
Clinical Symptoms
II. 2129.
Male. 60. | R.
Broker.
.Mai.-. 4S.' R.
Salesman
III. 2574. Male. 60.
Manufac-
turer.
IV. 256S.
Male. 50.
Chemist
in smelt-
ing works
"Bulla che" in right .lust for last year. Attacks of violent cough-
ing during last IS months. Distinct shortness of breath for 6
months. Slight irregular fever. Areas of consolidation in right
lung. Marked cachexia.
Began with attacks of violent coughing and sharp pain in right
chest. Treated in sanitorium for tuberculosis. Pleurai cavity
tapped and then rib resected both with negative results. Evi-
dences of consolidation in right lung. Marked orthopnea. At
the end swallowing became nearly impossible. Patient Inst :.l)
pounds in all.
Two years previously patient .aught in a belt and suffered severe
contusion to right chest wall. From this time on. a dry hacking
cough developed. During the last few months, slight dyspnea
and a slight, irregular fever B. C. (.shortly before death) 1.">,OOI)
leucocytes with So per cent polymorphonuclears.
Began as a "bronchitiB"with a constant dull pain in the left chest.
Followed by cough paroxysmal and very severe in character.
Slight, irregular increase in temperature. Towards the end
swallowing became somewhat difficult.
Mil. ..-purulent and rath- Diagnosis: Tuberculosis,
er abundant. Xeg. to Autopsy by Dr. Scott.
tuberculosis.
Mue. .-purulent. Xega- Diagnosis: Tuberculosis,
tive upon repeated . \- Autopsy by Dr. Scott.
atnination for tubercle
bacilli.
Small in amount.
Abundant and muco-
purulent. 15 examina-
tions negative for tu-
berculosis.
Seen by many physicians
who made a diagnosis
of tuberculosis. Last
one diagnosed a cancer
of lung. Autopsy by
Dr. Barnes.
Diagnosis: Tuberculosis.
Autopsy by Dr. Scott.
The important features of the clinical notes are
given in the accompanying table. It is interesting
to note that, based upon a slight increase in tempera-
ture, the presence of a cough, evidence of consolida-
tion in the lung and the loss of flesh, each case was
mistaken for one of pulmonary tuberculosis in an
advanced stage.
Complete autopsies were held in each instance, and
no new growths were found other than in the lung.
There is a striking similarity in Cases I, II and
III. The new growth in each instance begins in the
large bronchus at the root of the lung, and extends
along it into the substance of the lung. In each case,
the growth consists of a yellowish mass in which
remnants of bronchi may be seen. In Case I, the
upper lobe is chiefly involved. In Case II, the tumor
occupies the middle lobe and the upper portion of
the lower lob, while in Case III the lower lobe is in-
volved exclusively. In all three cases, the bronchial
lymph nodes have been invaded and overgrown by
the neoplasm. The growth has extended into the
pericardium in Cases I and II. In Case II, there is
also a distinct invasion of the esophagus producing
stricture. In each lung there is a thickening of the
pleura, which is especially marked over the por-
tion of the lung involved by the tumor.
The histological pictures presented by the first
three specimens is also very similar, varying with
the portion of lung examined. Sections taken from
the roots of the lungs, and including the wall of
the larger bronchi, show masses of large cells
which are definitely epithelial in type. Sections of
the esophagus at the constriction in Case II show
that this stricture is due to an invasion by the
tumor cells rather than to a primary growth. Sec-
tions taken from the main mass of the tumors
present cells which have lost their distinctly
epithelial character and have become small in size
and irregular in shape, and appear when taken by
themselves not unlike those from certain sarcomas.
They, however, resemble somewhat the cells seen
in the basal layer of normal bronchial epithelium.
with keratinized centers. Karyokinesis is abun-
dant throughout the tumor. In certain areas, espe-
cially from those in the outer border of the cell
masses, ten or more mitotic figures may be seen
in almost every field presented in the use of a 16
mm. objective.
It is of further interest to note in Case IV that
a branch of the tenth nerve is markedly infiltrated
with cancer cells. This patient had suffered con-
stantly from pain in this region. The need of
more investigation into the relationship between
pain in carcinoma and the invasion of the nerves
has recently been emphasized. As regards this
feature of primary carcinoma of the lungs, Kretsch-
mer noted the involvement of the left vagus,
and Passler reported extension into the "larger
nerves."
In lower animals metastasis outside of the lung
substance is not common. In her series of mice,
Miss Slye reported four cases of metastasis in
pulmonary carcinoma. In Adler's series of 374
human cases, metastasis is mentioned 280 times.
In none of the four cases here reported do nodules
appear, which do not have continuity with the pri-
mary tumor.
In two of these cases (III and IV), mitosis is a
conspicuous part of the histological picture. Hen-
rici in his case mentioned the presence of cell divi-
sion. Howard and Schultz noted the mitotic figures
in their case. Miss Slye noted that she had never
seen a lung tumor in which the mitotic nuclei were
not difficult to find. In relation to the etiology, it is
interesting to note that there is only a moderate
amount of anthracosis in each of these cases. Pig-
mentation, therefore, would not appear to play an
important etiological role here.
In Case IV, the patient had been subjected for
years to the influence of heavy tobacco and strong
chemical vapors. This exposure might easily be
considered as an exciting factor, the more espe-
cially when the epidermoid character of the tumor
is considered.
454
MHDICAL RECORD.
[Sept. 9, 1916
Grosser injuries have long been considered as
causative factors in the production of carcinoma.
Adler, in his series of lung carcinoma, found that
in only six of the 374 cases was traumatism in the
ordinary larger sense recorded. So as an im-
portant etiologic factor this can be eliminated.
Gross injury is recorded in only one of this series.
In Case III, it is noted that the contusion was done
to the right side of the chest, and that the cancer
developed in the left lung, thus making an etiologi-
cal relationship quite improbable.
As to the probable origin in each instance, it
is to be noted that there is a distinct invasive
growth within the lumen of the bronchus. In two
Cases (III and IV), the growth in the upper por-
tion of the bronchus extends for a considerable
distance unaccompanied by any peribronchial
growth whatever. Further in each case, there is
direct continuity of the growth in the lumen with
that in the lung substance.
In Cases I, II and III, it is difficult to determine
the exact histogensis from the microscopical evi-
dence alone. This is not at all remarkable when
the continuity and embryological identity of the
bronchial and alveolar epithelium is taken into con-
sideration. Cuboidal and rather high colummar
types of cells may arise from either of these loca-
tions.
In these cases the tendency to undergo a more
complete differentiation exhibits itself in the
growth within the bronchus. Here quite high
columnar cells may be seen. As the tumor cells
are followed out into the lung substance, they lose
their differentiation. First, they come to resemble
cells of the fusiform type seen in the normal bron-
chial epithelium. Then they pass over into a type
of small irregular cells which are not unlike those
of a basal layer of the mucosa. In some areas all
differentiation is lost, and the cell presents itself
as a small round cell with scant cytoplasm and a
small deeply staining nucleus. These cells so
closely simulate the cell type seen in undifferen-
tiated lapidly growing sarcomata that a mistaken
diagnosis might easily be made had not sections
Deen taken from the bronchus.
seen such as Miss Slye and others have noted in
mouse cancers. There are considered by her as
probably of alveolar origin. In all of this series
the air sacs are invaded and filled by tumor cells,
presenting much the same picture as that described
on of keratinized whorls in
IV.
Alveolar epithelium may, it is true, be trans-
formed into a columnar type, but in no instance do
any of these cells present an apparent attempt to
resemble the large flat cells of normal alveolar
epithelium. There is not a papillary formation
Fig. 3. — The intercellular bridges developed by the cells of
the carcinoma in case IV.
by Henrici in his case, where the tumor cells were
using the alveolar wall for their stroma.
While these data are not convincing evidence as
to the bronchial origin, it is very suggestive of
such an origin, especially when the gross features
of the specimens are taken into account. Mitotic
nuclei were not difficult to find.
As to Case IV, the evidence is somewhat cleared.
As Henrici observes, "it is a far cry from simple
aveolar epithelium to a structure composed of
stratified squamous cells, having inter-cellular
bridges, forming types of epithelial pearls, and in
some instances keratin." Several observers have
noted metaplastic change to a squamous type of
epithelium on the part of the bronchial mucosa in
the absence of tumor formation. Haythorn re-
ported this observation in three cases of pnei*j
monia. He considers these metaplastic cells as
newly formed from the growing layer in an at-
tempt at repair. In Case IV, there is a distinct
history of prolonged irritation to the bronchial
mucosa and the epithelium of the bronchi, where
it is not involved in the new growth, presents many
areas of metaplasia to a distinctly flattened type of
cell, so that this case would seem to bear out Hay-
thorn's conception. These facts, together with the
gross features of this case, make a bronchial origin
quite probable.
Conclusions. — 1. The fact that Adler was able to
collect only 374 authentic cases of primary car-
cinoma of the lung from the literature up to 1912,
and that at least 120 cases have been reported since,
makes it apparent that the condition is much more
frequent than the earlier statistics would indicate.
2. A study of these cases tends to confirm the
idea that the majority of the so-called primary
carcinoma of the lungs are probably in reality of
bronchial origin.
3. A casual histological examination may lead to
a diagnosis of sarcoma in certain cases of car-
cinomata of the lungs.
Acknowledgement is due for the clinical notes on
Cases I, II and IV to Doctors Horton, Edmiston
and Deem, in whose practice these cases respec-
tively occured. We are also obligated to Dr. Robert
L. Barnes for the presentation to the Museum of
the specimen in Case III. together with the clini-
cal notes and for permission to report the case.
REFERENCES.
1. Adler: Primary Malignant Growths of the Lungs
and Bronchi. New York, 1912.
2. Ash: The Pathology of the Mistaken Diagnoses
Sept. 9, 1916J
MEDICAL RECORD.
455
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3. Apert et Rouillard: An Epithelioma of the Lung.
Bull, et mem. Soc. anat. de Par., 1912. Vol. LXXXVII,
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4. Argaud: Crespin, et Legroux. 1913. Metaplasia
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20. Passler: On Primary Carcinoma of the Lung.
Virchows Archiv., Vol. CXLV, p. 191.
21. Pfister, Karl: A Dissertation of a Case of Heter-
otype, Mixed Cancer of the Lung. Miinchen, 1912.
22. Reinhardt: Primary Cancers of the Lung. Arch,
der Heilk. Vol. XIX, 1878, p. 369.
23. Roubier et Bachelard : Cancer at the Hilum of
the Right Lung. Lyon mid. 1914. Vol. 122, p. 695.
24. Svle, Holmes and Wells: Tumors of the Lung in
Mice. Jour. Med. Res., Vol. n. s. XXV, p. 417.
25. Tyzzer, E. E. : A Series of Spontaneous Tumors
in Mice, etc. Fifth Report of the Cancer Commission
of the Harvard University, 1909, p. 153.
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Commission of the Harvard University, 1907, p. 71.
26. Von Wicskowski: Primary Lung Cancers. 1913.
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27. Weller: Primary Carcinoma of the Larger
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Policlinico. Vol. XIX. sez. med. p. 167, 1912.
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Lung. Trudi. i. Protok Imp. Kavkazk. med. Obsh.
Tiflis. 1911-2 Vol. XLVIII, p. 27.
32. Gallard et Donzelot: Cancer and Tuberculosis of
the Lung. Bull, et mem. d. hop. de Par. Vol. XXXIII,
p. 89, 1912.
33. Graus: Cancer of the Lung, Limousin id.
Limoges. Vol. XXXVI, p. 4, 1912.
34. Polvanski: Three Cases of Cancer of the Lungs,
Therap. Obozr. Odessa. Vol. VI, p. 561, 1913.
35. Schmidt: A Paper on Carcinoma of the Lung,
Correspondenzblatt d. Ver. deutsch. Artzte, Reichen-
berg. 1914. Vol. XXVII, p. 1.
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izinische Zeitschrift, St. Petersburg, 1913; Vol.
XXXVIII, p. 291.
710 North Park Street.
GASTRO-ENTEROLOGY AND SURGERY.
By J. C. JOHNSON. M.D.,
ATLANTA, GA.
Ordinarily the matter which I wish to discuss
would not be entitled to a place in a program de-
voted to purely scientific subjects. But I think
that it is as vital as any before the profession and
that it deserves special mention at this time.
I refer to the increasing tendency, on the part
of some, to magnify the importance of surgery and
to minimize the importance of internal medicine
in the treatment of gastrointestinal diseases. Quite
a number of our leading surgeons have expressed
the opinion that more than 90 per cent of gastro-
intestinal diseases are primarily surgical, while
others, with the same meaning, say that primary
disease of the alimentary tract is very rare. These
expressions have been much quoted, and, the opin-
ions have become convictions in the minds of many.
These opinions are based, of course, upon opera-
tions or examinations which revealed some condi-
tion associated with indigestion supposed to be
without the reach of internal medicine. It appears
that no account has been taken of the majority of
patients with gastrointestinal diseases who never
apply to a surgeon for treatment, and in whom,
presumably, the per cent of surgical cases is rela-
tively small. It is reasonable to suppose that those
who have subscribed to this doctrine have consid-
ered all the facts involved. Yet, in the light of
modern science it is hardly credible that any one
can hold views so radical, and, as we believe, so
erroneous. It should be remembered that some of
these clinicians and writers are accepted as au-
thority in departments of medicine other than those
which they so ably represent, and that they speak
the last word to a large audience in the wide field
of medical practice — that they also have the strong-
er voice in shaping the policy of under-graduate
schools, wherein to a greater extent they direct the
thought and inspire the emulation of the students.
This departure from our faith in elementary medi-
cine is more significant since we find general prac-
titioners joining in the movement. The possible
evil of it is clear. Not all of us, even veterans in
practice, are prepared to follow safely in the foot-
steps of some of those who move along the highest
vantage ground. Especially is it impossible for an
undergraduate to discriminate between what is
established, and what remains in doubt, and to se-
lect from the mass before him the essentials he
should know. Naturally he learns what is most
impressed upon him. And he is impressed more
by the objective demonstration of a theory than
by the subjective analysis of a fact.
If it is true that primary disease of the alimen-
tary tract is rare, it is also true that much of the
medical curriculum is useless. If it is true that
more than 90 per cent of gastrointestinal diseases
are surgical, the articles of our faith should be re-
vised, and the principles of our practice should be
amended. If it is not true that primary disease of
the alimentary tract is rare, or that 90 per cent of
gastrointestinal diseases are primarily surgical, the
profession should not allow this fallacy to stand in
the way of progress.
By whom shall these questions be answered, and
by what shall the correctness oF these answers be
*Read at the annual meeting of the American Gas-
tro-Enterological Association in Washington, May 10,
1916.
456
MEDICAL RECORD.
[Sept. 9, 1916
judged? Law has its standards, so have art, litera-
ture, and other departments of science. What has
medicine? Nothing agreed upon but basic princi-
ples of organic life. Only by these, therefore, can
an impartial decision be rendered in any case.
Opinions may differ, and methods may change,
but the laws of organic life do not change. By
these laws we have denned the pathology of di-
seases and have constructed a system of therapeu-
tics. By them have our research efforts been di-
rected and controlled. By them has medicine been
elevated from the plane of simple mechanics to the
dignity of a more comprehensive science. And
they cannot be set aside by any art, however bril-
liant. I have honestly tried to find some reasonable
basis for the contentions of those who are inclined
to overlook these facts. But I can see nothing be-
yond the effect of overzeal on the one hand — of
bias and indifference on the other. I confess that
I do not know what constitutes a surgical disease.
I have heard of infectious disease caused by some
infection, of traumatic diseases caused by trauma-
tism. By the same token I can only infer that a
surgical disease is one caused by some surgeon.
Otherwise, the question remains — whence these di-
seases? Do they spring like Minerva, full fledged
from the head of Jove? Or do they come by way
of vital processes, like other diseases — waiting
their turn of development and their place in the
order of physical change?
The eye of the professional world is riveted upon
the alimentary tract and its accessories. There is
an insistent cry, especially by surgeons, for the
early recognition of diseases common to these parts
— which amounts to asking the internist to distin-
guish by conditions, the pre-existence of which they
deny, the character of something the occurrence
of which they say is improbable. In other words,
the internist is to exercise his skill by watchful
waiting, thus automatically opposing the very end
which he is expected to hold most conspicuously in
view. Despite these contradictions, many are join-
ing in a feverish search for objective symptoms
upon which to base a diagnosis. There is not so
much thought about what has happened, or about
what is happening to give expression to these symp-
toms. The art of finding out is becoming of more
concern than the knowledge of what is found, and
what is found is considered of more importance
than what produced it.
I do not believe that substantial progress in med-
icine and surgery is favored by a policy which does
not embody every essential principle of medical sci-
ence, or that any practice, however successful in
some particulars, can continue intelligently which
does not harmonize every factor related to it. Cer-
tainly the future of preventive medicine is not en-
couraged by depreciation of one department by an-
other.
The newer knowledge of digestion has come hard-
ly less from the laboratory and from the clinical
experience of the internist than from the operating
room. The internist, therefore, may speak with
equal authority of those phenomena most intimate-
ly connected with diseases of the digestive system.
The channels of our education are too wide and too
poorly guarded for us to encourage or condone a
weakness within our own system. For this reason
it cannot he agreed, even by the assent of silence,
that the greatest number of gastrointestinal di-
seases are either primarily or secondarily surgical.
On the contrary, it must be insisted that just the
opposite is true. I believe that a brief review of
fundamental facts must convince the most doubtful
of this. Disease is not an entity — as every well
informed physician knows, but a part and product
of perverted physiological action. This perversion
must start somehow, somewhere and there must be
a definite cause for it. Let us find an example in
a disease usually classed as surgical. From the
standpoint of many surgeons intestinal stasis may
be due either to adhesions, atony or kink of the
colon. Granting this, and for the time being over-
looking the more frequent causes such as errors
in diet, abnormal secretion, malnutrition — what is
the origin of the atony, adhesions and kinks, and
how do they come about?
Something precedes everything. Gallstones do
not exist already in the blood and do not precipi-
tate by gravity. Adhesions do not form or reform
from mere contact or coincidence. The colon does
not kink spontaneously and atony does not develop
over night. Gallstones, kinks, and adhesions are
neither diseases within themselves nor the primary
causes of disease. They are the results thereof.
There is no disease which consists of mechanical
insufficiency or obstruction alone, or which can be
defined by a single circumstance, or limited in its
relation to one event. One condition in disease may
favor production of another. But the question is
what favors production of the first and how and
why. This we can only explain by looking from a
given effect through a known pathological process
to the initial action or a primary cause.
The primary cause of disease is either overwork,
underwork, injury, or infection of a part, or of the
whole body, as the case may be. Regardless of the
cause, the requirements for development are the
same. The primary forces engaged in the devlop-
ment are the same. The order of development may
vary, and the forces may have different direction,
but in essentials of pathology diseases are closely
akin — all being the product of perverted metabo-
lism. And when we speak of metabolism we must
claim a limitation which does not exist, if we do
not in the same connection speak of digestion with
its primary importance and possibilities as a causa-
tive factor in disease. It is another thing to speak
of secondary conditions which jeopardize health or
threaten life and the only relief promised is by the
knife. But this discrimination has not been made.
They say that more than 90 per cent, of gastro-
intestinal diseases are surgical. They do not say.
as it should be said, that no disease is surgical by
legitimate birth, but some acquire a surgical na-
ture, while others have it thrust upon them.
Please let it be remembered that we are not
discussing what surgery can do, nor even when it
should be done — though the latter especially is a
question worthy of debate. Surgery has done won-
ders and promises to do more. And I would not, if
I could subtract from the glory of its achevements.
Yet the genius of a work consists not in the char-
acter or measure of transformation, but in what
remains untouched in the accomplishment of the
desired result. We believe that some operations
have been performed with disadvantage to the
patients. On the other hand, surgery is needed
in many cases where it is neglected. There are
many gall bladders which should be emptied and
released and many kinks which should be straight-
ened. Many appendices languish in the iliac vale,
unwept, unhonored and unsung, which should have
gone the way of their renowned compatriots.
Sept. 9, 1916]
MEDICAL RECORD.
457
The point is, where can the internist and the
surgeon meet, and upon what can they agree. I
think the answer is very simple. Unless we are
willing to repudiate the laws of biologic and physio-
logical entities upon which such stress is laid by
undergraduate medical schools, we must acknowl-
edge their validity and potency in practice. Cor-
rect interpretation of these laws allows no diverg-
ence of opinion as to their relation in disease as
well as in health. According to the laws, if ap-
pendicitis can be the primary cause of gastritis,
gastritis can be the primary cause of appendicitis.
If perverted metabolism can induce myasthenia
cardise, it can by the same factors lead to myas-
thenia gastrica, atony, or kink of the colon, and
by the same laws and the same factors does pri-
mary disorder of digestion result in perverted
metabolism.
The same chemicovital and physical forces which
preserve a balance of salts in the plasma and sub-
stance of the cells, can, when not controlled, become
the morbid action anticipating the production of
cholelithiasis, or other changes of form or state
which we are pleased to call surgical. These are
truths which should be emphasized, for they are
master keys to many problems which separate us
in our ideas and in our efforts.
701 Hurt Building.
THE INADEQUACY OF PRIVATELY-FEED
MEDICINE.*
Br INEZ C. PHILBRICK, A.M., MD,
LINCOLN, NEB.
The history of medical progress records a growing
sense of professional inadequacy on the part of pro-
fession and laity, and of effort directed toward its
correction. Necessarily, in prescientific days,
progress was slow. Early acceptance of disease and
health as imposed from without by malevolent or
beneficent agencies precluded any general develop-
ment of a sense of personal or professional respon-
sibility for the futilities of the healing art. Nor
did empiricism, with its medley of truth and error,
offer either incentive or opportunity for the search
for new facts. Isolated discoveries of vast moment
attested that most valuable attribute of the human
mind — scepticism — which in every age has led in-
vestigation.
Scientific medicine beginning, in any adequate
sense, with the work* of Virchow and Pasteur, in
the middle of the last century, a time of intense
general scientific ferment, has developed synchron-
ously with vastly increased transportation facilities,
opening new lands to settlement; the organization
of industry on the factory basis, with its outgrowth
of occupational disease and accident, and, as a part
of the speeding-up policy of competitive industry,
its demand for increased efficiency of workers ; a
change from a rural to an urban environment for
nearly one-half of the population; an appalling in-
crease in poverty; and, along with this the growth
of the social conscience, which is democracy, de-
manding for the individual not only the right to
live, but the right to health.
Tremendous demands have been put upon medi-
cine. Its adequacy has been tested to the utmost,
and found wanting, as attest the various supple-
mentary health agencies to-day in operation, or
*Read at a meeting of the Nebraska State Medical
Society, May 24, 1916.
projected. That medical inadequacy has been more
from the art side than from the scientific, from
the practical more than from the theoretical, that
there has been more of knowledge than of applica-
tion of that knowledge to human needs, must be
ascribed to conditions governing medical practice
rather than to any unusual inertia of the medical
mind.
Two years ago, in a paper read before this so-
ciety, I discussed in detail and at length the in-
herent inadequacy of privately-feed medicine, the
determining principle in this inadequacy being
competition. It has seemed to me of value to con-
sider at this time the various supplementary health
agencies already in operation or planned, to de-
termine if they be free from or exhibit the evils
and weaknesses characterizing privately-feed medi-
cine, and, if they utilize those methods imposed by
modern conditions.
The past few decades have revolutionized knowl-
edge of the causation of disease and of means neces-
sary to its cure. To-day are demanded as routine
procedures diagnostic methods which require much
time, expensive equipment, accuracy of technical
knowledge, delicacy of manipulation, trained inter-
pretation. Present demand is for a highly organ-
ized system of medical practice, with minute special-
ization, limitation of function and cooperation.
Contrariwise, present practice is still in theory on
the ameba plan, presupposing the ability of any
part of the medical mass, equally with any other,
to procure, assimilate, and make contact with the
environment. No physician to-day can acquire,
assimilate, and apply to the prevention, diagnosis,
and cure of disease any considerable part of medi-
cal knowledge. Nor can he command facilities for
efficient work.
The other day, in cleaning my attic, I was strik-
ingly reminded of the enforced changes in my prac-
tice in two decades; and I am certain my experi-
ence has not been exceptional. Unopened vials of
tropasolin, congo red, methyl violet, Canada balsam;
a number of Levis' perforated metal splints;
Thoma-Zeiss hemacytometer and von Fleischl
hemaglobinometer; silver chloride dry cell and acid
cell galvanic batteries, etc., recalled the days when
I, not from choice, but of necessity, to eke out
income, in my inadept way, stained and mounted
specimens, treated fractures, counted red and
white blood cells, and estimated hemoglobin other
than by the Talquist paper, and had not relegated
the use of the electric current to the electrothera-
peutist, who alone can develop and bring to bear its
therapeutic virtues. My office table, as I am sure
does that of most general practitioners, bears wit-
ness to the abandonment of the attempt to more
than keep abreast in a general way of medical
progress. Two general medical weeklies replace a
former half dozen more special journals. And in
these, many of the articles are so technical as to
make the reading of only conclusions the part of
wisdom.
Efforts to remedy professional inadequacy have
proceeded along two lines — improvement of service
and more effective application of service. Impelled
to self-preservation from the assaults of Christian
Science, faith healing, osteopathy, chiropractic
(these star witnesses to medical inadequacy), and
with, doubtless, in less degree, an altruistic motive,
the profession has adopted increasingly higher
standards of medical education, preparatory and
technical. Medical schools are diminishing in num-
458
MEDICAL RECORD.
[Sept. 9, 1916
ber and gaining in quality, as is true of medical
graduates. We may safely trust that effort along
this line has gained sufficient momentum to carry
it over to the standard set by the Committee on
Medical Education of the A.M.A. — State medical
education — with State schools providing that ade-
quate equipment impossible to privately endowed
schools; more largely free from the temptation to
sacrifice standards to numbers; with salaried, full
time professorships.
Of supplementary health agencies instituted for
the more effective application of medical knowledge
must be considered first that one having as its ob-
ject the prevention of disease — the Public Health
Service, national and local, including medical school
inspection. Instituted in response to the recogni-
tion of control as the essential factor in prevention
of disease, its effort was first directed toward con-
trol of the individual, through compulsory examina-
tion, isolation, and enforced treatment, as by vac-
cination; and later, toward control of environment,
through drainage of soil, destruction of parasites,
factory inspection, building regulations, etc. To-
day we already see the beginnings of effort toward
control of heredity.
Established chiefly for the protection of trade
interests, and the better-to-do classes, from the
ravages of epidemic disease, the Public Health
Service has grown increasingly altruistic, and of
vastly greater social significance. In so far as it
has been adequately supported, and free from par-
tisan political alignment, allowing of freedom of
action unrestricted by expedient subservience to in-
dividual persons or interests, its workings have been
eminently satisfactory. Already it has achieved
results of incalculable value. When, with the gen-
eral institution of non-partisan government, it shall
be brought under the operation of civil service, the
minor weaknesses which it has exhibited will dis-
appear. To-day, no one desirous of medical progress
would advocate its limitation, but rather the ex-
tension of its field and the enlargement of its
activities. The Public Health Service, supported
by taxation, of general application, its staff under
governmental control is, in so far as it goes, State
medicine.
Of supplementary health agencies next come vari-
ous forms of health insurance, necessitated by the
economic inability of at least half the population
to avail itself of medical examination and care. All
of these, whether they be private (as through lodges,
fraternal orders, etc.), supported by dues, and ap-
plying only to members; or contractual, between
State and private organizations, applying to certain
economic classes, State supported, but in part
privately administered, as in England; or as pro-
posed in the health insurance measures outlined
by the committee of the American Association for
Labor legislation, such measures to come before the
coming legislatures of New York, New Jersey, and
Massachusetts, support is to be divided between
workers, employers, and State, and the details of
organization and administration left to the medical
profession, all of these exhibit certain weaknesses
in common — class legislation, friction between
privately employed and State employed physicians,
increased administrative cost, through multiplica-
tion of boards and officials, and lack of specializa-
tion, censorship, and control of medical service.
Per capita contract or contract by visit (as opera-
tive in lodges, etc.), gives, of necessity, cheap, in-
efficient, and dishonest service. Unlimited choice of
physicians, as in France, has led to inconceivable
abuses. Limited choice, as in England, has given
rise to similar evils in lesser number. Under all
these forms of health insurance the physician is
employed as an individual rather than, as would
be the case under State medicine, as a salaried
member of a specialized staff, working in constant
association and cooperation with fellow members,
with time rotation in service, his work censored,
and his relation to the public impersonal. While
the present English panel system, the nearest
approach to State medicine, has already accom-
plished much for profession and public, already lead-
ing members of the British profession are calling
for its complete socialization.
The recent introduction of health inspection into
many large industrial establishments employing
thousands of men, the service performed by
physicians salaried by employers, has proven the
inability of privately-feed medicine to reach a large
part of the industrial population until it is more or
less incapacitated by disease. Such inspection is
instituted primarily in the interests of employers,
with the object of increasing efficiency and profits;
and often works extreme hardship to the physically
defective worker, through loss of employment, or
transfer from better to that which is less well paid.
Of plans for bringing the best medical service
within reach of persons of moderate means, that of
most recent and general interest is proposed by a
no less distinguished member of the profession than
Dr. Richard Cabot of Boston, in the columns of a
popular magazine — that of the voluntary or insti-
tutional lay group, in control of hospital facilities,
and employing a salaried staff of medical specialists.
This plan Dr. Cabot frankly admits to be a buffer
against the shock of the coming of State medicine
until such time as government shall be by the quali-
fied rather than the unscrupulous. In his distrust
of State medicine Doctor Cabot seems to me unfair
to the relatively creditable record of governmental
administration of public utilities, the postal service,
public education, as well as the Public Health Serv-
ice. Indisputably, in the buying of medical serv-
ice, as in commercial buying, the group can bargain
more advantageously than can the individual, and
the larger the group, the more advantageously.
However, this group plan will not insure the best
medical service. It is not the opinion of one special-
ist member of the group, but the consensus of
specialist opinion that is desirable. To assemble
voluntary groups sufficiently large to affect any con-
siderable portion of the community, and possessed
of sufficient funds for physicians' salaries and hos-
pital maintenance, with any promise of permanence
of membership lay or medical, and with the inevi-
table prospect of friction between various groups,
seems to me to offer insuperable difficulties. The
logical outcome of Doctor Cabot's plan is the com-
munity group, working through the community
group of hospitals — general, contagious diseases,
maternity — which is the only group combining
permanence, control of adequate funds, authority
and representation of the interests of all the people
of the community.
Further convincing proof of the inadequacy of
privately-feed medicine along all lines is found in
the conditions for effective service demanded by
specialists in various fields. In general, all em-
phasize the need of early diagnosis and of con-
tinuity of treatment — these being impossible un-
der the present system with its private fee and lack
Sept. 9, 1916]
MEDICAL RECORD.
459
of control. It is now possible for the patient,
whether from financial inability or inertia, to post-
pone examination by a physician until alarmed by
symptoms of disease. And after he has presented
himself for examination, and treatment is insti-
tuted, he is advised by well-nigh every acquaintance
whom he meets, to seek another medical advisor;
and if possessed of any income worth while, at every
turn he encounters, ready to snatch him, a hungry
horde of medical vampires, made vampires by the
conditions under which they work.
In a recent symposium on tuberculosis, before
an Eastern State medical society, it was the con-
sensus of opinion that adequate handling of the
tuberculosis problem called, specifically, for notifica-
tion and intitutional treatment — dispensaries with
visiting nurses for ambulatory cases; sanatoria
for incipient bed cases; hospitals for advanced
cases ; and, in general, for improvement of indus-
trial conditions, eradication of poverty, money and
more money, and authority. What system of prac-
tice save State medicine can measure up to these
requirements?
Dr. William F. Snow, general secretary of the
American Social Hygiene Association, who pre-
sumably voices advanced opinion as to the preven-
tion, diagnosis, and cure of venereal disease, names
as essential conditions for its eradication: notifica-
tion ; provision of public health laboratories for free
bacteriological and serological examinations; am-
ple facilities at public expense for clinical diagnosis
and advice; free treatment of ambulatory cases,
hospital care for advanced cases ; the following-up
of such cases by social service workers ; compulsory
examinations generally of large bodies of men, as in
schools and industrial establishments, and wherever
food is handled. As necessary accessory measures
are named: public education; provision of ample
public facilities for wholesome recreation; reorgani-
zation of industry ; elimination of alcoholic drinks.
What part, may I ask, has privately-feed medicine
in such a program?
As regards cancer, hope of discovery of causation
and consequent prevention rests in the research of
salaried specialists. Here early diagnosis is above
all imperative. Its accepted treatment — surgery —
with the surgeon's fee, the cost of hospital care, the
expense of subsequent a:-ray or radium treatment,
cannot be obtained, except through charity or at
public expense, by many of its victims, and imposes
a grievous burden upon the families of all its vic-
tims save the very wealthy. Indisputably, dread
of the expense of treatment is in part responsible
for delay in seekng medical advice. The diagnosis
and cure of no other disease more imperatively calls
for State medicine.
Recently, Dr. G. E. de Schweinitz, the dis-
tinguished ophthalmologist, in a plea for the con-
servation of vision and prevention of blindness,
called attention to the need of effort along legal,
institutional, social, and industrial, as well as pro-
fessional lines. He demanded for the individual
case of ophthalmia neonatorum notification and hos-
pital treatment, and called attention to the fact
that only two hospitals in Philadelphia admit such
cases. For trachoma he demanded quarantine; for
glaucoma, education of the public as to symptoms,
and correlation of social work in treatment ; for
myopes, classification and training for appropriate
employment. I am sure you will grant this to be
a program for State medicine. Already, under the
working of medical school inspection, certain
municipalities have assumed responsibility for re-
moval of diseased tonsils and adenoids, and the
correction of errors of refraction.
Dr. William Palmer Lucas, physician in chief in
the department of pediatrics in the University of
California, in outlining an ideal child welfare serv-
ice for the community, calls for cooperation between
department of pediatrics, hospital, laboratory, medi-
cal school inspection service, and board of health,
holding that only through unification of all these
agencies can the problems of child welfare be solved.
Such unification is possible only under State medi-
cine.
Consider that triad of disease — heart, kidney, and
vascular — the menace of our middle age, the Neme-
sis of our high-geared civilization. Leading
authorities name as necessary for their limitation
— early diagnosis, medical and social supervision,
and appropriate employment. As steps in the pre-
vention of organic heart disease (with application
to kidney and vascular disease as well) are de-
manded: medical school inspection for early detec-
tion of defects; a special vocational training for
those showing defects; control of infections; pub-
lic education as to causation and prevention of such
defects ; compulsory examinations at intervals after
leaving school; and I myself would add — the bar-
ring from school and college curricula of strenuous
and competitive athletics— basketball, football,
track athletics.
There has been recently brought to professional
attention by a leading member of the New York
profession, whose name I do not at this moment of
writing recall, the valuable therapeutic asset which
this country possesses in its mineral springs, espe-
cially those at Saratoga; and the necessity, judg-
ing by European experience, of State ownership and
control, if they are to be developed and operated in
the interests of the public health.
Let me but refer to the inadequacy of privately-
feed medicine in the field of orthopedics, with its re-
quirement of minutely specialized knowledge, costly
and extensive equipment, and prolonged institu-
tional care; in the treatment of neuroses, where in-
stitutional treatment is imperatively demanded, the
same free of cost, or at a cost below that possible
in a private sanatorium; in the treatment of im-
aginations of disease, which have filled the Chris-
tion Science churches, and the waiting rooms of
practitioners of medicine on a bath house basis.
Let me instance the absurdity of conceding to the
Public Health Service control of acute epidemic
disease through quarantine, and then relinquishing
its treatment to the general profession. And I
might continue indefinitely.
In view of all this, I am not liable to the charge
of proposing a Utopia when I affirm the coming of
State medicine, nay, that it has all but arrived. If
I may venture an opinion as to the manner of its
coming it is that it will be through utilization of
the appropriate organization already existant — the
Public Health Service, through the natural evolu-
tion of this service, which at present has been
worked only upon the surface, and is capable of vast
expansion.
Doubtless the chief obstacle to the coming of
State medicine will be the privately-feed medical
profession. A change in the professional attitude
is demanded. The medical monopoly, forced to
choose between economic advantage and the public
good, and as between public and profession, assum-
ing the attitude, "my profession, right or wrong,"
460
MEDICAL RECORD.
[Sept. 9, 1916
must go, and that speedily. Medicine exists for the
public, and not the public for medicine. It will be
the part of professional wisdom to accept the
change from within before such time as it shall
be imposed from without.
1033 H Street.
ALKALOIDAL ADJUVANTS IN GENERAL
ANESTHESIA.
BY RAYMOND C. COBURN. M.A., Mil,
NEW YORK.
The oscillation of the pendulum in human affairs
is quite well shown in the development of general
anesthesia. The first attempts, followed by more or
less success, according to authentic writers, to at-
tain loss of sensation for surgical procedure, were
by substances derived from the vegetable kingdom.
Then came the discovery of the inhalation anes-
thetics, and the exclusive use, practically, of these
agents, for this purpose, for the next half of a cen-
tury. In our own day the pendulum is swinging
back to the vegetable kingdom for either the sole
or adjuvant agents in the production of approved
anesthesia.
The patient who realizes that an operation is
impending is more or less apprehensive of the pro-
cedure, discomfort, suffering, and result. This pre-
operative fear is highly productive of shock, and it
is here that the primal "anesthetizing draughts,"
now displaced by the refined and more certain and
quicker acting alkaloidal solutions hypodermatically
administered, prove their usefulness. Under the in-
fluence of morphine the nerve and cerebral centers
are tranquilized, and a neutral psychic state in-
duced, that is, fear is banished. With preliminary
morphine, the induction of anesthesia is smoother
and more rapid, consequently there is less struggl-
ing. All observers agree that patients who have
struggled during induction do badly in anesthesia
and are very prone to suffer from shock and cardiac
weakness. Gatch has shown that this struggling
produces excessive cardiac strain. In addition, be-
ing a narcotizing agent itself, morphine lessens the
amount required of the principal anesthetic.
In the administration of morphine preliminary to
the chief anesthetic, either atropine or scopolamine,
or both, should be combined with the morphine.
When morphine is used without scopolamine the
dose should be 1/6 grain to the average adult, and
if nitrous oxide is to be the chief anesthetic 1/150
grain of atropine should always be combined with
this amount of morphine. In robust males this
medication may properly be increased to Vi grain
morphine and 1 100 grain atropine. If ether is to
be the principal anesthetic it is not so essential that
atropine be combined with the morphine, although
I consider it is always preferable to do so. When
scopolamine is used 1/6 grain morphine and 1 200
grain scopolamine is the preferred dose for the
average adult, and this medication should be given
one hour prior to the time of operation; whereas if
morphine and atropine alone are used the time of
administration is preferably one-half hour before
the operation. When scopolamine is combined with
morphine the tranquilizing effect, especially upon
the higher brain centers is quite pronounced, and
the pulse rate and respiration are both thereby de-
cidedly lessened in frequency.
Combining either atropine or scopolamine, or
both, with the preliminary morphine overcomes one
of the objections that has been urged against such
use of this narcotic, namely, that it interferes with
the utilization of the pupil as a guide to the depth
of anesthesia. With the use of either of these com-
binations the size of the pupil is a more reliable
guide to the depth of anesthesia than when no pre-
liminary medication is used, for while the pupil
does not begin to dilate till a slighter deeper anes-
thesia is attained, yet when the pupil is dilated it
is more surely indicative of a deep anesthesia, as
this medication tends to prevent reflex dilatation
under light anesthesia. Besides, the upper lid re-
flex is a much more reliable sign of the depth of
anesthesia than is the size of the pupil, or its re-
action to light, either with or without preliminary
medication.
It is properly held by those who have raised
objections to this preliminary alkaloidal medication
that it should be employed only by those versed in
its use. But, indeed, no anesthetic, or system of
anesthetization, is safe enough to be placed in the
hands of the unskilled and untrained. This is not
the age for a skilled profession to decry anything
that is of benefit simply because its use requires
training and experience.
There is decidedly less postoperative nausea and
vomiting when the preliminary alkaloidal medication
is used. This is probably due to the fact that this
medication, plus the amount of the principal anes-
thetic that is then necessary to produce the required
depth of anesthesia is less toxic than is the larger
amount of the principal anesthetic when used alone
to produce the same depth of anesthesia. This
disposes of the objection that it is not advisable to
introduce into the system several such toxic agents
at one time, for in actual practice there is less toxi-
cation manifested when there is a proper combina-
tion of these synergistic agents than when only a
single narcotic is used.
It is not contended that this preliminary medica-
tion should be indiscriminately used in all cases,
but rather that in all cases in which it is used there
should be discrimination. The disintoxicating or-
gans of the young are not as fully developed as are
most of the other organs; and in the aged the disin-
toxicating organs have a subnormal activity, so, in
the extremes of life, if used at all, the dose of the
preliminary alkaloids must be smaller accordingly
than the usual medication for these ages. Patients
who are very ill, especially those suffering from
the various toxemias and toxications, and who,
therefore, require smaller amounts of narcotics to
produce a given effect, should be given only small
doses of the preliminary alkaloids. Most of the
so-called idiosyncrasies against morphine are found
in the last mentioned class, more particularly the
chronic, and are, therefore, not true idiosyncrasies.
In such patients the eliminating and disintoxicating
organs are constantly overworked, and consequently
cannot adequately respond to the sudden increase in
toxic substances thrown upon the system. Such
patients do not tolerate ether any better than mor-
phine, as these substances are so toxic to them that
they act in the nature of "the last straw."
Of even greater importance than the preliminary
time of the operation to prevent centripetal impres-
medication is the use of alkaloidal adjuvants at the
sions passing from the field of operation. Crile's
exhaustive researches show that unless the opera-
tive field is blocked off from the central nervous
system through local anesthesia, noxious impulses
pass continually from the traumatized area to the
I nain, even though the patient is surgically anes-
thetized ; that the anesthetized patient is not as a
cadaver merely because there is no visible response
Sept. 9, 1916]
MEDICAL RECORD.
461
to traumatism; but that from the traumatized area
impulses pass to the brain and produce injury just
as certainly (.but not to as great a degree) as though
the patient were completely conscious ; that the
brain "feels every thrust of the knife and traction
on the viscera, even though the patient be pro-
foundly sleeping." As soon as the profession thor-
oughly grasps the full significance of these teach-
ings a new spirit will pervade surgery, and the time
is not far distant when lack of gentleness will be
considered as unscientific as lack of asepsis.
The technique, briefly summarized, is infiltrating
the skin and each of the subsequent layers in the
line of incision, with a one-fourth per cent, solution
of novocain, and in certain cases the deeper layers,
but away from the incision with a one-sixth per
cent, solution of quinine-urea hydrochloride.
Objection is raised at once that this procedure
consumes too much time, but this objection, like
most of objections to new methods, is more theo-
retical than practical. My own experience has been
that the surgeons using the nerve-blocking tech-
nique consume less time to the average than those
not using it. As this seems strange I venture an
explanation. Those using this method are strongly
imbued with the idea that they must work gently,
otherwise there would be no need of using this tech-
nique, therefore they do no unnecessary surgery.
If the getting-in process is delayed it is only slight-
ly so, and the getting-out procedure is more than
correspondingly accelerated, for the no-injury idea
is so predominant. "Get-in" and "get-out," with
emphasis on the latter, are not bad ideas in ab-
dominal surgery, from the viewpoint at least of the
anesthetist.
Nitrous oxide is the general anesthetic par ex-
cellence to use in conjunction with these alkaloidal
adjuvants. The resulting anesthesia is so light
that whenever the surgeon passes beyond the
blocked area changes in the patient's respiration im-
mediately warn him of his transgression, so that
he may either cease his traumatizing, or extend his
local anesthesia. This system of anesthetization
enforces gentleness. When the technique is per-
fect there is rarely need of any adjuvant ether
whatever. Even in such procedure as the removal of
the gall-bladder, which otherwise requires the deep-
est type of general anesthesia, I have been able to
dispense with ether entirely; the operation is prac-
tically shockless, the patient's vitality is conserved,
his resistance is left unimpaired, and his ultimate
recovery is thereby rendered more certain.
Ep.ettox Hall, Eighty-sixth Street and Broadway.
Administration of Narcotics to Relieve Pain and Cure
Drug Habit. — In a prosecution under the Texas statute
making it unlawful to prescribe a narcotic drug for an
habitual user thereof, it appeared that the person to
whom morphine was administered had been a morphine
fiend, and had become emaciated and was confined to
her bed. The defendant, as physician, administered the
morphine for two purposes: First, to relieve her of her
present suffering; and, second, to cure her of the habit.
The evidence of the woman showed that he succeeded in
both. The Texas Court of Criminal Appeals held that
the statute does not prohibit the prescribing of the drug
when necessary to alleviate pain or cure the drug habit.
It was held to be error to exclude the defendant's evi-
dence that he gradually reduced the size of the dose, and
finally ceased it altogether ; that being material to show
that the drug was prescribed in an effort to cure the
habit. It was also error, there being evidence that the
drug was prescribed to alleviate pain, to refuse to charge
that if the drug was administered in an effort to relieve
pain the defendant physician was not guilty. — Fyke v.
State (Tex.) 184 S. W. 197.
Basis for Hypothetical Question. — In an action for
personal injuries error was claimed in not sustaining
an objection to hypothetical questions asked a medical
witness, Dr. Piatt. This witness had heard all the
testimony in the case, including the testimony of
plaintiff, and of his attending physician, Dr. Comstock,
as to his condition. He was asked his opinion as to the
permanency of the injuries to plaintiff's jaw, basing
it upon the testimony of plaintiff as to his condition,
and the testimony of his attending physician as to what
he found and what he did, excluding any opinion he had
expressed. The objection was that the question "does
not give the elements, and is too broad as it does not
give in detail the facts, but leaves to the witness to
eliminate that which his own judgment may induce him
to eliminate." Other questions of like tenor were asked,
objected to on the same ground, and permitted to be
answered. The answer of the witness was that in his
opinion the injury was permanent.
The appeal court did not think that the questions
were fairly open to the objections made. It is of course
true that it must be made plain to the jury as well as
to the expert what facts he bases his opinion on, and
he must not be left to decide between conflicting facts,
but must assume as true the facts stated in the question
or those found in the testimony he is asked to base his
opinion upon. But this witness had heard plaintiff
testify, not only as to the condition of his jaw, but as to
the history of the case, and the history and habits of
the plaintiff. He was asked to give an opinion based
upon this testimony, and the testimony of the attending
physician as to what he found. It appeared from the
cross-examination of the witness that the past history
of the patient and his habits were elements necessary to
be considered in giving an opinion as to the permanency
of the condition of his jaw, and the witness understood
that these elements were included in the hypothetical
questions asked. The claim was that these elements
were not included in the questions and not shown by the
testimony, and therefore that the expert must have
based his opinion in part on knowledge acquired outside
of the court room and not disclosed to the jury. If this
had been the case, the testimony should have been
stricken out, but the record did not bear out the claim
as to the facts. The past history of the patient, as well
as his past life and habits, was quite fully disclosed by
his own testimony and the testimony of Dr. Comstock,
and the exnert was asked to assume this testimony to be
true and to take it into consideration in giving his
answer. The court did not think that the expert
"usurped the functions of the jury," or that there was
any error in the rulings made in regard to his testi-
mony. Nor was there anything in the claim that the
testimony of the doctor showed that he was not com-
petent to testify. — Johnson v. Quinn, Minnesota Supreme
Court, 153 N. W. 267.
Hypothetical Questions. — The general rule is that a
hypothetical question should include a full statement
of all material facts, if they are uncontradicted, or
such facts as the interrogating party may reasonably
deem established by the testimony of his witnesses, but
should not assume facts not warranted by the evidence.
If opposing counsel is of opinion that material facts
are not included in a hypothetical question he may in-
corporate these facts in questions asked on cross-exami-
nation, and may also frame questions involving a con-
sideration of facts which he contends are established
by his evidence. The exact form of the question and
the extent of the examination are under the control of
the trial judge, whose duty it is to see that the ex-
amination is properly conducted. — Albert vs. Philadel-
phia Rapid Transit Co. (Pa.), 97 Atl. 680.
Medical Evidence as to Damages. — In an action for
personal injuries where there was evidence that prior
to the accident the plaintiff had enjoyed good health,
that immediately thereafter she was removed to a hos-
pital in an unconscious condition and was confined to
bed six or eight weeks and was absent from her em-
ployment for some months, and frequently since the
time of the accident was subject to convulsions, it was •
held that the testimony of physicians, who made their
examination more than two years after the accident,
as to her condition is not to be stricken out on the
ground that the connection between the accident and
the plaintiff's present condition was not shown. — Albert
vs. Philadelphia Rapid Transit Co., Pennsylvania Su-
preme Court, 97 Atl. 680.
462
MEDICAL RECORD.
[Sept. 9, 1916
Medical Record.
A Weekly Journal of Medicine and Surgery.
THOMAS L. STEDMAN, A.M., M.D., Editor.
PUBLISHERS
WM. WOOD & CO., 51 FIFTH AVENUE.
See fourth page following reading matter for Rates of Subscription
and Information for Contributors and Subscribers.
New York, September 9, 19 16.
THE MORBIDITY OF DRUG INTOXICATIONS.
The success in the present reduction of disease,
and the increase of the span of life from an average
of nearly 12 years in the Dark Ages to the present
average of 50 years, through achievements in pre-
ventive medicine, have been mainly the result of
a reduction in the infectious disease incidence. In
a great measure, this is due to the fact that the
attack on the infectious disease element is an
extrinsic one which places but a slight burden
of moderation on the individual, the measures
necessary in this sort of preventive work even
helping to increase the personal and the esthetic
conveniences of every one. But because there is
required an intrinsic endeavor to render it effective,
preventive medicine has had little appreciable effect
upon the incidence of the degenerative diseases
which appear in persons in the prime of life — be-
tween 40 and 60 years of age. It is estimated
that the annual death rate from the degenerative
diseases, exemplified in kidney, heart, and blood-
vessel diseases has increased over 100 per cent
within the last 20 years. These figures bear mute
testimony to the increasing desire of the seden-
tary for artificial stimulation and of the overstren-
uous for artificial sedation.
The resistance of the body is reduced by such
things as alcohol, tobacco, narcotics, occupational
poisons, and syphilis. While alcohol leads the list
of drug intoxicants in being the most prolific cause
of the degenerative conditions, both of the body
and of the central nervous system, it rarely oper-
ates alone, being usually accompanied by dissipa-
tion of other kinds, and the "strenuous life" and
syphilis often add their effects.
Moreover, quite apart from the increased use of
strong alcoholic beverages, there has been an enor-
mous increase in the manufacture and consumption
of patent medicines. The public is persistently
dosing itself with drugs of various kinds and of
various actions. Some are stimulants, some seda-
tives, and some combinations of both, and the tak-
ing of them is often a fad or a pure habit, the con-
sumers not knowing really why they take these
medicines. To be sure, many of these patent medi-
cines are purely alcoholic, and the effect is that of
alcohol. With all of them the body is put to the
trouble of eliminating highly irritating substances
which have the tendency to reduce the vitalitv of
the eliminating organs, as well as often positively
injuring them. It is through such injury that the
general fibroid changes are often set in motion.
The expenditure for these unproductive and highly
injurious products has been estimated to be over
$150,000,000 a year. The increase in the population
of this country has been nowhere in proportion to
the increase in the consumption of drugs. While
the population has increased about 100 per cent
in the last twenty years, the increase in the use
of these products has been over 750 per cent.' All
drugs, no matter what their proper value is, are
potentially harmful. They are not intended for
consumption at random, but only under expert guid-
ance. All the untoward and poisonous effects of
these drugs are met with in the consumers. There
are the effects on the heart, blood-vessels, kidneys,
muscles, nervous system, etc. Because the body
often establishes a tolerance to these poisons, an in-
creasing amount must be used to get the original
effect, and so the habit is formed.
What the remedy for this great evil may be is a
secret still in the laps of the gods. Prohibition noto-
riously does not prohibit, except to a limited degree,
and the various antinarcotic laws, including the
defective and vexatious Harrison law, merely make
it more difficult and more costly for drug victims
to get their favorite narcotic or stimulant. As for
patent medicines, the enforced publication of their
formula? and their percentage of alcohol has little
or no deterrent effect. Nevertheless, the curbing
of the alcohol and drug-intoxication habit is one
of the most important considerations in the problem
of increasing the stamina of the people, of reduc-
ing the death rate, and of increasing the span of
life. Perhaps the research foundation recently es-
tablished in Hartford may succeed in throwing some
light on this dark subject.
PHYSIOLOGY AND PSYCHOLOGY, AND THEIR
EUPHORISTIC HARMONY.
Progress in knowledge depends upon pressing for-
ward toward an unachieved goal. Attainment of
the end would defeat advance in its very initial im-
pulse. Therefore the elusiveness of the goal toward
which psychology turns and its refusal to yield
clear knowledge of the intimate relation of mind
and body afford emphatic proof of the importance
of the effort directed thither. What is demanded,
what must be accomplished in the search is this.
Our pragmatic knowledge must be increased and
our power of control enlarged. We must continual-
ly widen the horizon and shift our viewpoint toward
an ever better adjustment of mind and body so that
the former has a more complete and harmonious
mechanism at its disposal and so that the latter is
not turned aside to the service of mental caprice and
unbalance. Every sincere effort, then, from either
side of the problem, to throw light upon this ob-
scurity is just so much practical service rendered
to the theory and the practice of life in its possibili-
ties.
George Van Ness Dearborn, in an article on
'Martin I. Wilhert, Reprint No. 227, Public Health
Reports.
Sept. 9, 1916]
MEDICAL RECORD.
463
"Movement, Cenesthesia, and the Mind" (Psycho-
logical Review for May, 1916), throws a hearty
"euphoristic" interest into the problem in his study
of the flood of "animus" which pours into the cor-
tical "gray" from the environment which our own
physical bodies afford in themselves or as trans-
mitters of external stimuli. Earlier studies of his,
particularly "Certain Further Factors in the Phy-
siology of Euphoria" (Psychological Review, May,
1914), discuss more fully certain divisions of phy-
siological activity which furnish a constant and im-
portant stream of influences which must affect
psychological well-being. These are chiefly the
nutritional area so greatly extended by the pres-
ence and function of the intestinal villi for absorb-
ing and storing the lipoid and perhaps protein sub-
stances conducive to the euphoria of the nervous
system, also the great cinesthetic system of sensa-
tions, and by no means of least importance the
epicritic sensibility of the skin area. The later
study bases itself upon these and other organic
contributing factors, but concerns itself chiefly
with the universal movement continually present in
the body in which all parts of the organism have
their part and likewise with "cenesthesia" or the
sum of influence which the afferent nerves continu-
ally transmit to the gray matter.
All of this is of an importance not to be set
aside. It must be and is the basis of accurate
laboratory research in order to determine with in-
creasing accuracy and knowledge how the organic
processes can influence our psychic euphoria, and
therefore our capacity, and to know what the definite
relationships are which make psychology and physi-
ology mutually dependent. Yet just here the author
is hampered still by the psychophysical attitude of
which he himself complains. The reason is not far
to seek. The relations of mind and body are
reversed. There is too much about "behavior's
nuerility," "skeleton of mind," and the like,
from the point of view that makes the mind
the product of this cenethesia of all the vast con-
tributing area of bodily tissues comprised in our
organic make-up. The reactionary influence of a
complex organism upon the mind that controls and
utilizes it is quite another thing from the "raising
a good quality of mind" from such influences.
Headed in the right direction, phylogenetically,
from the mind to its potentially perfected im-
plement, the body, then it is possible to enter into
the depths of practical discovery. Then the uncon-
scious or "subconscious" is freer for investigation
even through the study of this organic cenesthesia
and movement. The autonomic thus becomes but a
division of the vaster unconscious, but perhaps the
relation is even closer than that the author con-
ceives between the higher nervous action and the
autonomic "subconscious" of the nervous system on
the one hand, and the conscious and unconscious
mind on the other, the master, director, and artisan,
too, of the organism. Ideational euphoria, he be-
lieves, lies beyond physiological euphoria, but that
it arises from cortical associations reflects again
the reversed point of view. Mental readjustments
effected through purely mental therapy, which takes
into account the individual psychical determinants,
the sum of which may well form a psychic cenes-
thesia, prove themselves so effectual in dissolving
physical dysphoria that we must conclude that the
author has laid the emphasis on the wrong side.
There is such rich suggestion, however, in Dear-
born's discussions of the contributing physiological
factors in the close relationship of what psycho-
analysts have styled "libido areas" and psychic
states that his work is stimulating to follow. He
has pushed onward into the unknown and cast out
some very definite charting lines for steady scien-
tific advance.
THE DETOXICATING ACTION OF SLEEP.
While this title may at first suggest something
new in physiology, it only connotes the old view
that sleep is due very largely to the accumulation
of waste products and persists until these have been
taken up by the circulation. It is a corollary, there-
fore, that in loss of sleep the body becomes in a
measure intoxicated. In animals deprived of sleep
death occurs at the end of three or four days with
a gradual lowering of temperature and reduction
of erythrocytes to 2,000,000. Under the combina-
tion of excessive muscular labor and injection of
meat extractives an animal succumbs in from thirty
to forty hours. The injections made at the conclu-
sion of the labor precipitate a condition of extreme
lassitude. According to certain authorities sleep is
not even a function per se but the result of fatigue
toxins. Upon the view that the thyroid gland pre-
sides over disintoxication the claim is made that in
hypothyroidism there is always a tendency to
drowsiness. From a similar viewpoint the power
of alcohol to produce drowsiness and deep sleep has
been ascribed to an overstimulation of the thyroid;
for while alcohol in small doses increases the activ-
ity of the gland the reverse becomes true when large
quantities are taken.
The toxic or antitoxic nature of sleep is thus dis-
cussed in a brief article by De Castro in the Revista
de Medicina y Cirugia de la Habana for July 25.
It is indeed evident that some of the older views of
sleep have not made good. We do not know whether
or not sleep is dependent on a particular state of the
cerebral circulation, for it apparently occurs with
anemia, hyperemia, or the ordinary status. Drowsi-
ness after a full meal is still held to be due to a
derivation of blood from the brain and it has been
shown that when one drops asleep there is a sud-
den lowering of blood pressure. But no theory of
sleep can be devised on this basis which can begin
to account for all its phenomena. A good night's
rest from which a subject awakes refreshed and
active, appears to show that all fatigue toxins have
been expelled from the cells. But it is evident that
such a slumber can have little in common with the
somnolence which follows a gluttonous meal during
which toxins accumulate and from which the sub-
ject wakes unrefreshed and with most wretched sub-
jective sensations. Any sleep apparently normal
which fails to refresh could not have been true
slumber of the detoxicating type.
The neurasthenic, regarded usually as poisoned
by his cell products, may be a sound sleeper in ap-
pearance but has no corresponding advantage over
464
MEDICAL RECORD.
[Sept. 9, 1916
a neurasthenic with insomnia, and at no time of
day does he feel so devitalized as upon waking.
Conversely the active man who can do with little
sleep must have superior facilities for detoxication,
or perhaps for some unknown reason he is more im-
mune than others to fatigue poisoning. The fact,
however, that many individuals who lead sedentary
lives are able to obtain prolonged and refreshing
sleep seems to show that sleep cannot be regarded
merely as a measure of fatigue poisoning. To ac-
count for such cases we have to invoke the agency
of habit and the adaptability of mankind to meth-
ods of living.
REVACCINATION AGAINST TYPHOID AND
PARATYPHOID FEVERS.
Paratyphoid fever is said to be extremely frequent
in the various armies in Europe. There has been
no severe epidemic of typhoid since the commence-
ment of the war, but from almost the very outset
of hostilities, there has been a somewhat wide prev-
alence of paratyphoid fever. In the Medical Press,
August 2, 1916, F. Widal and I. Gourmont
point cut that on account of the extensive preva-
lence of this disease Landouzy, as far back as De-
cember, 1914, indicated the practice of vaccination
as the sole effective prophylactic procedure that
could be adopted to fight successfully against this
malady and called for a comparative study of the
method of successive vaccination against typhoid
and paratoyphoid fever respectively, and of that of
double vaccination carried out by the injection of a
mixture of the typhoid and antityphoid bacilli.
In August of last year such tests were made by-
one of the writers, who concluded that the final
choice should be that of a triple vaccine, consisting
of a number of typhoid bacilli equal to that con-
tained in the simple antityphoid injection, and a
double number of each of the paratyphoid bacilli,
A and B. This observer has reported experiments
of which the results furnished cogent proof of the
powerfully immunizing action of such vaccines when
heated; and he has also shown that this vaccine
had the effect of making the several specific anti-
bodies of each of those microbes appear in the
blood of the vaccinated individual and has demon-
strated the harmlessness of his procedure. Widal
and Gourmont state that they have revaccinated
with the triple vaccine about 4,000 persons who
had previously been immunized with the simple
antityphoid vaccine. Furthermore, they always
used the triple vaccine even in the persons who had
had typhoid, for the reason that they believed
that even in such cases it could not be other than
advantageous to profit by the supplementary anti-
typhoid vaccination for the purpose of reinforcing
the degree of immunity against the typhoid infec-
tion itself. In summarizing their results they as-
sert that the triple vaccine suffices for all the re-
quirements of both antiparatyphoid and antityphoid
revaccination.
As paratyphoid prevails to a considerable extent
among our troops on the Mexican border, it might
not be amiss to test the value of the triple vaccine
there.
The Poliomyelitis Panic.
A meeting of the town board of Oyster Bay, L. I.,
held on Monday of last week, was taken possession
of by a number of indignant citizens who passed
a resolution regarding the poliomyelitis situation,
setting forth "That it is the sense of this committee
that the credulity of the public has been preyed
upon sufficiently long in the neighborhood; that the
business interests are sufficiently paralyzed; that
frenzy and terror have been sufficiently propagated ;
that it is high time for a return to common sense,
the discharge of the medical maniacs, the resump-
tion or local business, the recall and restoring to
confidence of our easily scared summer residents,
and the application of common horse sense to the so-
called epidemic with which we as well as other com-
munities have been afflicted." This is a little strong
in spots, but it is only what was to be expected as
a natural reaction against the quarantine hysteria
that is raging epidemically in this neighborhood.
When a town stations men at every point at which a
ferocious child may possibly enter, even though it
wants only to pass through, and drives back the in-
vader practically at pistol point unless it is armed
with a certificate from a board of health — and in
certain places even then, that community has
plainly lost its head. When, furthermore, the
healthy child, admitted on the strength of the official
certificate, is immediately quarantined and forbid-
den to leave its home for twenty days, the commun-
ity so ordaining is devoid of reason. Although
poliomyelitis has not been proved to be spread by
direct contagion, and possibily never will be, it
nevertheless is for the present a justifiable pre-
caution to isolate the sick; but to war upon the
well, to forbid children in evident health, riding in
an automobile, to pass through the town at a speed
of ten or more miles an hour, and even to expell
children known to be in perfect health from a town
in which they have been passing the entire sum-
mer because in the winter they live in New York
City, betrays a degree of hysterical panic and
craven fear that, were it not a fact, would be be-
yond belief. A Sicilian peasant mob in time of
cholera could hardly do worse, but theirs would be
the sin of the mindless while the suburban health
officer is supposed to know better.
Ktma of t& Wstk.
Poliomyelitis Receding Rapidly. — The last days
of August witnessed a sharp decline in the number
of cases of poliomyelitis in New York City, and
for the week ending September 2, 477 cases only
were reported. The total number of cases to Sep-
tember 6, was 8,330, of which 2,047 were fatal.
The passing of the epidemic was clearly indicated
by the fact that the Willard Parker Hospital, which
had at one time nearly 1,100 patients suffering
from the disease, on September 4 harbored only
950. On the same date there were in all the
hospitals in the city 3,784 patients under treat-
ment. Dr. Charles E. Banks of the United States
Public Health Service, in charge of the quarantine
regulations in reference to infantile paralysis in
New York, has protested against what he calls the
inconsistent quarantine polity inaugurated by local
health authorities in towns near New York City,
especially in Westchester and Nassau Counties.
He has suggested that there should be some State
board which could regulate the action taken by
Sept. 9, 1916]
MEDICAL RECORD.
465
local authorities in small villages, so that a uniform
and sensible method of guarding against the spread
of disease could be promoted without interference
with the business of a community. It really is
time that some official notice should be taken of the
inane action of many so-called health officials. Sep-
tember 25 has been definitely decided upon as the
date for the reopening of the public schools in
New York City, provided, of course, that no flare-
up of the epidemic occurs before that time.
The after-care of children discharged from the
hospitals as cured has been considered by the De-
partment of Health, and it has been arranged that
in each case a formal notice of the approaching dis-
charge of a child shall be sent to the parents, set-
ting forth the child's condition, and urging that the
family physician be consulted or that the nearest
orthopedic dispensary (a list of these dispensaries
being inclosed) be visited. The facts in each case
are sent also to the director of the committee on
after-care, Dr. Donald E. Baxter. In this way,
it is hoped, many permanent disabilities may be
avoided. The Department of Charities of the city
has estimated that $100,000 will be needed for the
care of those convalescent from poliomyelitis up
to January 1 and more after that date. The De-
partment of Health has already received over $26,-
000 in voluntary subscriptions for the purchase of
braces and other appliances.
Changes in Red Cross. — The active executive
management of the American Red Cross at National
Headquarters in Washington, passed on Septem-
ber 1 to Mr. Eliot Wadsworth of Boston, who has
been elected to succeed Major General Arthur Mur-
ray, U. S. A., resigned. Gen. Murray has devoted
himself to the constructive upbuilding of the Red
Cross for the better part of a year. Mr. Wads-
worth has already had considerable experience in
war relief matters, having served as a member of
the Rockefeller Foundation War Relief Commis-
sion in 1915, as a member of the Poland Relief
Commission, and later as director general of the
International Commission for the Relief of Poland.
Dental Hygiene at Columbia. — The New York
School of Dental Hygiene has become allied with
the new Columbia University School of Dentistry
and the College of Physicians and Surgeons. The
school will open on September 27, classes being
held in the Vanderbilt Clinic.
Street Accidents. — The National Highways Pro-
tective Society reports that during the month of
August 48 persons, of whom 25 were children,
were killed on the streets of New York by vehicles.
In the State outside of New York City during the
same time 54 persons were killed by automobiles,
trolleys, and wagons while in New Jersey 26 per-
sons were killed in the same way. In New York
State 8 persons were killed at railroad grade cross-
ings, as compared with 17 during the same month
of last year.
Inquiry Into Garbage Disposal. — Dr. Linsly R.
Williams, Deputy Commissioner of the State De-
partment of Health, has been appointed by Gov.
Whitman to conduct an investigation into the pro-
posed building of a garbage disposal plant for
New York City on Staten Island. The taking of
testimony was begun at Borough Hall, St. George,
Staten Island, on August 28, and some thirty ex-
perts will be examined. The building of the plant
has been bitterly opposed by some of the residents
of Richmond Borough.
Tuberculosis Test Town. — The National Asso-
ciation for the Study and Prevention of Tuber-
culosis is sending representatives through New
York and Massachusetts in search of a town of
about 100,000 population, in which studies may
be made of the new theories for the control and
elimination of tuberculosis. The officers of the
association desire to find for the test a town which
has some industries, since tuberculosis is a poor
man's disease, one not too far removed from in-
dustrial centers, and one with but few commuters.
It is planned to expend about $150,000 in the ex-
periment.
Paratyphoid in Camp. — An outbreak of para-
typhoid is reported in the camps of the New York
division of the National Guard in Texas.
Study of Infant Mortality. — The seventh annual
meeting of the American Association for Study and
Prevention of Infant Mortality will be held in Mil-
waukee on October 19 to 21, 1916. The preliminary
program includes a discussion of measles and
pertussis, a symposium on governmental activities
and vital and social statistics in regard to infant
welfare, and discussion of public school education
for the prevention of infant mortality and of nurs-
ing and social work in rural communities. Full par-
ticulars may be obtained from the executive secre-
tary of the association, 1211 Cathedral Street,
Baltimore, Md.
German Hospital Red Cross Unit. — The complete
equipment of an American Red Cross base hospital
unit with a staff from the German Hospital, New
York, has been made possible by a gift of $25,000
from Mr. Fritz Achelis of this city. The unit is
now being organized by the Military Relief Depart-
ment of the Red Cross. Dr. Frederick Kammerer,
who recently returned from active service with the
German Army, has been made director.
Civil Service Examination. — The United States
Civil Service Commission announces an open com-
petitive examination for both men and women, for
the purpose of filling a vacancy in the position of
medical interne in St. Elizabeth's Hospital, form-
erly the Government Hospital for the Insane, Wash-
ington, D. C. The position carries a salary of
$900 a year and maintenance. The examination is
open to graduates of reputable medical colleges or
students in their senior year. Candidates must be
unmarried, and twenty years or over on the date
of examination, and must not have graduated pre-
vious to the year 1914 unless they have been con-
tinuously engaged in hospital, laboratory, or re-
search work along the lines of neurology or psychi-
atry since graduation. Application blanks may be
obtained from the United States Civil Service Com-
mission, Washington, D. C.
Removals. — Dr. Frederic E. Sondern announces
his removal to 20 West 55th Street.
Dr. Charlton Wallace has removed to 11 East 48th
Street.
Obituary Notes. — Dr. Warren Fisher Gay of
Boston, Mass., a graduate of the Medical School of
Harvard University in 1893, and a member of the
American Medical Association, the Massachusetts
Medical Society, and the Suffolk District Medical
Society, died suddenly at his home, on August 26,
aged 50 years.
Dr. William H. B. Pratt of Brooklyn, a gradu-
ate of the College of Physicians and Surgeons, New
York, in 1867, consulting physician and a member
of the Board of Managers of the Methodist Episco-
pal Hospital, Brooklyn, consulting physician at the
Home for Dependent Children and the Home for
466
MEDICAL RFXORD.
[Sept. 9, 1916
Aged Men, and a member of the American Medical
Association, the Medical Society of the State of
New York, and the Kings County Medical Society,
died at his home, on August 27, aged 74 years.
Dr. Ernest Watson Cushing of Boston, emeritus
professor of abdominal surgery and gynecology at
Tufts College Medical School, Boston, a graduate of
the College of Physicians and Surgeons, New York,
in 1871, and a member of the American Medical
Association, the Massachussetts Medical Society,
the Suffolk County Medical Society, the American
Gynecological Society, and the American College of
Surgeons, died at the Cushing Hospital, of which
he was the head, on August 27, aged 69 years.
Dr. Howard Fellows Morse, formerly of Lynn,
Mass., a graduate of the University of Vermont,
College of Medicine, Burlington, in 1904, died sud-
denly, at his home in Center Harbor, N. H., on
August 15.
Dr. George Whitehouse Ryan of Boston, a
graduate of the Tufts College Medical School, Bos-
ton, in 1899, died at the Commonwealth Hospital,
after a short illness, on August 15, aged 44 years.
Dr. Hugh L. McLaurin of Dallas, Tex., a grad-
uate of the Medical Department of the Tulane Uni-
versity of Louisiana, New Orleans, in 1884, and a
member of the American Medical Association, the
State Medical Association of Texas, and the Dallas
County Medical Society, died at his home suddenly,
on August 11, aged 54 years.
Dr. Edward E. Flagg of Moreland, Okla., a mem-
ber of the American Medical Association, the Okla-
homa State Medical Association, and the Woodward
County Medical Society, was instantly killed in an
automobile accident, on August 18, aged 42 years.
Dr. Augustus Assenheimer of New York, a
graduate of the New York University Medical Col-
lege in 1868, and a member of the New York Acad-
emy of Medicine and the New York State and Coun-
ty Medical Societies, died at his summer home in
Far Rockaway, N. Y., on August 24, aged 67 years.
Dr. John Wesley Ward of Pennington, N. J., a
graduate of the University of Pennsylvania, De-
partment of Medicine, Philadelphia, in 1866, and for
many years medical director of the New Jersey
State Hospital at Trenton, died at his home on Au-
gust 25, aged 76 years.
Dr. John A. Fritchey of Harrisburg, Pa., a
graduate of the University of Pennsylvania, De-
partment of Medicine, Philadelphia in 1879, and
three times mayor of Harrisburg, died at the Pres-
byterian Hospital, Philadelphia, after a long illness,
on August 25, aged 58 years.
Dr. William F. Waldron of Brooklyn, N. Y., a
graduate of the New York University Medical Col-
lege in 1893, died at his home on August 24, aged
44 years.
Dr. Edgar T. Sprattling of Atlana, Ga., a grad-
uate of the College of Physicians and Surgeons,
Baltimroe, in 1891, a member of the Medical Asso-
ciation of Georgia and the Fulton County Medical
Society, and a captain in the Fifth Regiment of the
National Guard of Georgia, died suddenly on Au-
gust 25.
Dr. John Bart Webster of Philadelphia, a grad-
uate of the Medico-Chirurgical College, Philadel-
phia, in 1887, and a member of the New York State
Medical Society, the Medical Society of the State
of Pennsylvania, the Philadelphia County Medical
Society, and the American Medical Association, died
at his home, from heat exhaustion, on August 9.
©bttuary.
WILBUR B. MARPLE, M.D.
Dr. Wilbur Boileau Marple of New York, surgeon
to the New York Eye and Ear Infirmary, died sud-
denly, of apoplexy, while playing golf at his sum-
mer home, Kennebunkport, Me., on August 30, aged
60 years. Dr. Marple was graduated from Amherst
College in 1877, and from the Starling Medical Col-
lege, Columbus, Ohio, in 1881, since which time he
had practised in this city. In addition to his work
at the New York Eye and Ear Infirmary with which
he had been connected for many years, he served as
consulting surgeon in ophthalmology to the Work-
house and Babies' Hospital. He was also a member
of the American Medical Association, the New York
State and County Medical Societies, the American
College of Surgeons, the American Academy of
Ophthalmology and Oto-Laryngology, the American
Ophthalmological Society, the New York Ophthal-
mological Society, the New York Academy of Medi-
cine, the American Therapeutic Association, the
New York Clinical Society, and the Hospital Grad-
uates' Club.
DOCTORS,
PREPAREDNESS
RED CROSS.
AND THE
Sir Frederick Treves is one of the most distin-
guished of British surgeons, and has had a large
experience of military service in the Boer war and
the present great conflict. He has recently written
an interesting article in the London Times, in which
he states clearly the logical and proper relation be-
tween the Sanitary Service of the army and the
Red Cross. He says :
"However efficient an army medical service may
be, the help of the Red Cross organization is — and
ever will be — a necessity. All those who are fami-
liar with the operations of the Army Medical De-
partment in the present war will admit that its
work has been beyond praise, and will own, indeed,
that it could scarcely be surpassed.
"No army medical service can be maintained in
time of peace upon a war footing. There is evolved
in such times an elaborate scheme for expansion in
war; but one prominent and inevitable feature of
that scheme is the enrollment of a vast body of
personnel from the civil population in the form of
doctors, nurses, orderlies, motor drivers, clerks,
cooks, dispensers and the like. In such work a
civilian society can act with greater ease and
promptness than can a huge organization like the
War Office, and thus it is that in the supply of per-
sonnel the Red Cross societies have undoubtedly
rendered sterling service. In the furnishing of
medical and surgical comforts also the Red Cross
societies are untrammelled by those very necessary
forms and procedures which must be observed by
a government body dealing with public funds.
"In the matter of personnel, the Red Cross Socie-
ties provide a vent for that ardent sympathy which
the people of this country feel for the wounded sol-
dier, and, at the same time, make the bounteous
eagerness to be of service which has been so glorious
a feature in this unexampled campaign. In this
eagerness to be kind, to do something for the
wounded and the sick, the men and women of Brit-
ain, and of Britain beyond the seas, will not be de-
Sept. 9, 1916]
MEDICAL RECORD.
467
nied. They insist upon taking their share in the
work of mercy ; they demand the right to assist ;
they decline to sit still with listless hands. This re-
solve ot the generous folk of the Empire is the foun-
dation of all Red Cross work, and it has expressed
itself in a way of which the country of Florence
Nightingale may well be proud."
The same opinion has been reached by the mili-
tary and Red Cross authorities in the United States.
Congress enacted and the President proclaimed some
years ago that the American Red Cross was the one
agent which should render aid to its land and naval
forces in time of war, and that the personnel en-
gaged in this work should constitute a part of the
sanitary forces. Even the sphere of activity of this
volunteer aid was specified by the President. The
service at the front was forbidden to it, being the
special and appropriate domain of the medical serv-
ice of the military establishment. This pronounce-
ment of rude and practical common sense should
have power to dispel the romantic dream-picture in
which the beautiful young Red Cross nurse (not
registered) is seated on the battlefield with the head
of the stricken warrior on her lap.
The allotted sphere of volunteer assistance is
specified to be at the base of military operations,
along the line of communications, on hospital ships,
and at hospitals in the home country.
As the military base may be in a foreign coun-
try, and if not will be always, we hope, on our
borders, the Red Cross in its enrollments of per-
sonnel classifies them as follows, according to the
locality at which their services will be available:
Class A. Willing to serve anywhere, at home or
abroad.
Class B. Willing to serve anywhere within the
limits of the home country.
Class C. Willing to serve at place of residence
only.
Although the War Department as long ago as in
1912 had prescribed in orders the units which the
Red Cross should organize and their sphere of
action, and had provided for the registration of
these units in the Surgeon General's Office, nothing
further was done at that time. This inactivity was
due in part to the fact that our people were not at
that time interested in questions of preparedness,
and in part to the fact that the Red Cross was or-
ganized and administered along exclusively civilian
lines and without reference to its charter obliga-
tions to assist the military forces in war and "con-
stitute a part of the sanitary service thereof."
But when the world-conflict aroused us from our
dream of a peace that would be perpetual because
we so willed it, the Red Cross awoke also to its re-
sponsibilities, and reorganized its administrative
machinery so as to meet them. All of its external
activities were divided into two great departments
of Civilian Relief and Military Relief, each under
a director general. At the same time, ex-President
Taft was selected to be the administrative head of
the society. He presides over an Executive Com-
mittee of unusual distinction and virility. Its mem-
bership includes the Secretary of the Interior, the
Surgeons General of the Army and Navy, and three
other men and one woman of national reputation.
A colonel of the medical corps, U. S. Army, was se-
lected to be at the head of the new Department of
Military Relief. Congress recognized the far-reach-
inch importance of this reorganization by authoriz-
ing in the National Defense Act the detail of five
regular medical officers for duty with this depart-
ment. Its director at once placed his department at
the disposition of the Surgeons General of the Army
and Navy, and proceeded to carry out their wishes
and instructions as to the direction and scope of
its activities. The Navy to be efficient has to be
always on a war footing, and the battle fleet is but
little capable of expansion by volunteer units. Its
needs in the way of volunteer medical assistance in
war will therefore he small and easily met. With
the Army, however, the case is far different.
The Army is like a spear of which the regular
establishment is the small iron head, sharpened and
ready for use, while behind it is the great militia,
which is the shaft which must be shaped and fitted
to the head when war comes. No nation maintains
a sanitary establishment any larger than is actually
necessary to care for the regular army in time of
peace, and no provision of additional officers is made
to meet the needs of expansion. In our Army even
this modest requirement has not heretofore been
met, and the medical establishment has had to call
in additional aid to do its work, even in time of
peace, although for the line of the Army a decided
surplus of officers has been maintained. Now this
medical spear head of trained officers is nearly all
required for the service of the front, where spe-
cial military training is necessary, and only enough
will be left for the second zone, the line of com-
munications and base, and the third zone, the home
country, to fill the more important administrative
positions. The strictly professional work of these
zones must be done by the medical volunteers from
civil life, and fortunately for the professional work-
ers in these two zones preliminary military train-
ing is not essential as it is in the zone of the front.
The supreme importance of the base hospitals
is appreciated when it is remembered that in
the scheme for the rescue and care of the
wounded the base hospital is the first real
hospital that the wounded man encounters in
his journey to the rear. The so-called field hospi-
tals and evacuation hospitals of the zone of the
front are in fact not hospitals at all, but mere
shelters for the wounded, where they are put under
cover and fed and their wounds are dressed while
they are waiting to be transported to the base,
They have no trained nurses or comfortable beds
with mattresses and sheets, or any real comforts.
Not until he arrives at the base hospital does the
soldier find a bed where broken bones can lie in
comfort, or the grateful ministrations of a Red
Cross nurse, or the quiet and order of a fixed hos-
pital. Here also the wounded, except a few emer-
gency cases, will find the surgical staff on whose
skill will depend their lives or future usefulness in
life. Thus it is clear why the base hospital looms
largest among the Red Cross organizations, and
why the organization of these was the first task
given by General Gorgas to the Director General
of Military Relief.
It is evident that here is the crucial point in
the care of the wounded, and their interest can be
best served by transporting here en bloc the trained
and skillful staffs of our best hospitals. This is
what the Red Cross has now undertaken to do for
the medical service of the Army, and twenty-five
of these base hospital units are now organized or
in process of organization in the best hospitals of
our country. It should be clearly understood that
though organized by the Red Cross they will not
be administered by it. As soon as they are called
into service by the War Department or the Navy
468.
MEDICAL RECORD.
[Sept. 9, 1916
Department, they "will constitute a part of the
sanitary service thereof," in the language of the
President's proclamation, and come absolutely and
entirely under military authority, and they will be
transported by the military authority from their
mother hospital to the military base. The nurses
will still wear, as a sort of vestigial organ, the
red cross on their caps, but the medical staff will
wear the uniform of the Officers' Reserve Corps, U.
S. A., the commission of which they will have had
from the time of their muster-in as a Red Cross
unit.
Another Red Cross unit of great practical value
is the field column, which is in fact a sick transfer
company, which will bring the sick and wounded
from the evacuation hospitals in the zone of the
front back to the base hospitals. The field column
will use for this transportation motor ambulances
or hospital trains or boats, or all three.
In the zone of the home country are yet other
units, called general hospitals, which will be or-
ganized in the larger civil hospitals or at army
posts for the reception of the overflow and the con-
valescents from the base hospitals. The plans for
the expansion of these will be prepared, and the
personnel enrolled as far as practicable in advance
of the time when they will be needed. There are
still other Military Relief activities of the Red
Cross, which space does not permit to be described.
The Red Cross, in addition to the organization
of units, has undertaken in conjunction with five
great national medical societies an enrollment of
the profession, so as to acquire a record of the
capabilities and special accomplishments of the
medical profession of the United States. By an
arrangement with the National Association of
Nurses, it has enrolled and holds ready for service
over 7000 nurses, the cream of the nursing pro-
fession of this country. Non-professional person-
nel is also being enrolled for service in war, such
as stenographers, clerks, chauffeurs, cooks and hos-
pital a+tendants.
The Red Cross Chapter in any city is the local
organization, whose duty it is to finance the mili-
tary relief activities of the community, supervise
the enrollment of the non-professional personnel,
and give such other assistance as may be needed.
As the Red Cross is the accepted agency for medi-
cal preparedness, it is clearly the first step of every
medical man to "join now," and promote in every
way the growth and success of this great national
institution.
Jefferson R. Kean,
Colonel. Medical Corps, U. S. A., Director General
of Military Relief, American Red Cro
OUR LONDON LETTER.
(From Our Regular Correspondent.)
TREATMENT OF CONVALESCENT SOLDIERS BY PHYSICAL
MEANS — EARLY DIAGNOSIS — SYPHILIS — DIA-
THERMY— HIGH-FREQUENCY CURRENTS — WHIRL-
POOL AND OTHER BATHS — HOT SAND — ACTIVE CON-
GESTION.
London, August 11,
MAJOR Tate MCKENZIE, R. A. M. C, has brought
before the Surgical Section of the Royal Society of
Medicine the treatment of convalescent soldiers by
physical means; he compared a great military hos-
pital to a general post office, in which the sick and
wounded were sorted into first, second, and third
class matter — the first being rapily distributed to
Red Cross and other military hospitals, where treat-
ment, operative or general, soon enabled them to re-
turn to the line. The second class had further to
stay at a convalescent institution commanded by an
officer of the R. A. M. C, where they could obtain
treatment by physical means, including regulated
exercise; many of this class found their way back
to the front. The third class presented more diffi-
culty, as they were so chronic as to be referred from
depot to depot. For some months now such cases
have been sent to special depots, each under a com-
petent officer for purposes of discipline but with a
medical officer attached. It is hoped that men fit
for light duties may be able to release stronger offi-
cers for active service and may also allow the dis-
discharge of men from whom no further satisfac-
tory work can be expected. Each special depot is
for the accommodation of 2,000 or 4,000 men.
The physical therapeutics under consideration in-
clude electricity, hydrotherapy, massage, exercises,
training, and marching. The three forms of cur-
rent were employed. The committee of the Royal
Society of Medicine on balneology assisted in con-
verting an ordinary hut into a good hydrothera-
peutic establishment. The pool bath at 94 5 Fahr.
would hold twelve men sitting up to their necks in
that water, in which they usually remained an hour.
This was the routine for patients suffering from
shock and disordered cardiac action. A whirlpool
bath was used for limbs with painful scars or frost-
bitten; the temperature of this was 110" F. and
the water was kept violently agitated ; compressed
air introduced into the stream provided a bubbling
effervescent envelope for the painful limb, which
in about 20 minutes was found to be flushed and re-
mained so for hours. It was an excellent prepara-
tion for massage, which sometimes could not be
borne without it. It could be followed by passive
manipulation and the numerous exercises of mus-
cles and joints designed to re-educate them and
restore the general physical training.
Lieut.-Col. R. J. Morris remarked that more than
a century ago Professor Ling elaborated physical
exercises as a definite system of treatment. These
exercises he claimed as active or passive again or
reduplicated. In these last the work was partially
done by the patient, but another person provided re-
sistance. Since November over 76 per cent, of men
in his depot had returned to service after physical
treatment — massage, gymnastics without apparatus,
but by experienced masseurs; also with apparatus,
as bicycle, rowing, dumbbells, graduated weights,
galvanic and faradic currents, and other means.
When his patients could bear more strenuous exer-
cises he passed them on to the army gymnastic staff
at Aldershot.
Dr. Bezley Thorne extolled mineralized baths
for cardiac rheumatic cases. He had had trench
rheumatism cases put on their feet by these which
had resisted salicylates and other remedies. In-
stead of drying after a bath he let patients dry
gradually in their blankets. Long emersions should
not be given when irritable heart and muscular
tremor were present.
Dr. Fortescue Fox thought the preceding reports
opportune and valuable. Whirlpool baths were a
new feature so nothing dogmatic would be said
about them. At high temperatures they assisted
immobilized limbs.
Colonel Rodd said the important point was early
diagnosis. At the Ramsgate Canadian institution
a special board attended to this and in six weeks
Sept. 9, 1916]
MEDICAL RECORD.
469
quite a number of myopathic and neurasthenic cases
were found to have tertiary syphilis ; when treat-
ment for this was applied many of the patients were
soon back in the firing line.
Dr. Cumberbatch said too little attention had been
given to electrical methods, diathermy, and high-
frequency currents. Injuries to nerve trunks would
need attention for eighteen months or more before
the return of some degree of power and the best
treatment was by baths supplied with the rhythm-
ically varying, sinusoidal current. His results with
this were uniformly good.
Major Turrell said diathermy was of great value.
The whirlpool and other baths affected the surface
only, but in diathermy the current went directly
through the tissues intervening between the two
electrodes and could be made to bear on every part
of the body. It had been efficacious for relief of
acute pain and for frost-bite, was quite safe and
warmed the tissues — a good preliminary to mas-
sage, it cleared up joint effusions and phlebitis and
liberated fibrous adhesions.
Dr. W. Gordon had great faith in hot sand for
some forms of injury, more than radiant heat or
light in some cases.
Dr. Ackerley had been treating by physical means
for more than twenty years, the aim being to over-
come defects of circulation by producing active con-
gestion in the part. Pain was sometimes the only
obstacle to movement and must be met in the best
way. Active movements could not be borne at first.
The Jiriy meeting of the new Dermatological So-
ciety was devoted to the exhibition of cases. Dr. D.
Vinrace showed one of diffuse cellulitis following
syphilis, contracted four years ago by a man of
forty. He had had four doses of salvarsan and
fancied himself cured. Last December he consulted
Dr. Vinrace for a diffuse cellulitis in his neck, for
which he had taken neosalvarsan and later galyl.
The swelling subsided very slowly. Both mercury
and iodide of potassium were administered.
Dr. Vinrace also showed a case of leukoplakia in a
man. He, too, was about forty. A similar case was
shown by Dr. Vinrace some weeks ago. It came on
gradually and subsided slowly. The patient had
had gonorrhea but not syphilis. He was a very
nervous man and a great smoker. Dr. Eddowes, in
the chair, thought the tests for syphilis should all
be applied as the man might be suffering from a
condition left by that disease. Leucoplakia used
to be called the "smoker's patch," and that smoking
aggravated it he had no doubt.
Dr. Eddowes then showed a case of urticaria pig-
mentosa, macular form, in a girl of twelve. It
contrasted forcibly with a case lately shown by
Dr. Samuels. The president repeated an opinion
he has often expressed to the effect that rich, hot,
fatty food was a cause of urticaria. The mother
declared that fat made the girl bilious and gave her
heartburn.
The Nonoperative Treatment of the Accessory Si-
nuses.— Lewis A. Coffin has abandoned the idea of cur-
ing diseases of the sinuses, either by operative or other
measures, and is satisfied to produce an arrest under
constant treatment. By means of a special apparatus
for suction, with or without the addition of cannulas,
he exhausts as far as practicable the air in the sinuses,
beginning with low pressure with resulting escape of
mucus, and thereupon forces into the cavities under a
pressure up to ten or fifteen pounds air medicated with
nebulized oil, iodine and the Bulgarian bacillus. He also
gives a course of autogenic vaccine treatment. In two
chronic cases he appears to have produced relative re-
covery.— Virginia Medical Semi-Monthly.
OUR LETTER FROM ALASKA.
( From Our Special Correspondent. )
FEAST TO THE DEAD CHILDBIRTH — NAMING THE
BABY — PUBERTY — MARRIAGE AMONG THE ESKIMO.
St. Michael, Alaska, April 30, 1916.
Some of the Eskimo thoughts are very beautiful, as
for example "The Feast to the Dead," and some
of their acts are strange and very unnatural even
in comparison with those of the lower animal. A
good example of the latter is the care of their chil-
dren.
There is usually in each village a squaw who
claims to be versed in matters of midwifei-y, and
she attends the mothers in confinement. The most
capable midwife in this connection is the one who
does the least work and who interferes with Nature
the least. It used to be customary for primipara?
to be considered unclean, and as such they were put
off by themselves until the child was born, food
being handed to them through a crack, but never a
word spoken. This custom is passing away with
the Eskimo of the lower Yukon. The newborn babe
may or may not be wanted. Formerly it was the
custom to kill many of the female babies, as they
were considered food consumers and in return pro-
duced nothing. If it is decided to kill the female
baby it is taken out on the tundra or far out on the
ice, the mouth filled with snow and left there to
freeze to death. It was the custom to kill these
females at any time up to the age of five years if
it was decided that the child was a burden. This
custom fortunately seems to be passing away, and
certainly is not tolerated where there are civil
authorities.
The baby is named. If born in a village the child
is given the name of the last person who died there.
In doing this they believe that the spirit of the dead
person leaves the grave and enters the child. It
now behooves the relatives of the dead person to
contribute to the support of the infant as will be
spoken of in describing the "Feast to the Dead."
The Eskimo believes that spirits or shades ("ta-
gunuhak" as he calls them) preside over every-
thing, and believing this he makes every attempt to
avoid offending them as the shade would bring
disease upon him, make him have bad luck with the
seal, tomcod, white whales, etc. For the same rea-
son the native never punishes a child after it is
named until the child is large enough to care for
itself. At this time the spirit of the dead ceases to
act as a protectorate, so in slapping a child about
the age of twelve they will not offend the shade. If
the baby is born in camp it is named for the first
object the mother sees after its birth, as for ex-
ample, a tree, mountain, etc.
Apparently the Eskimo care very little for their
young. They are filthy, poorly clothed, and without
a diaper. They are transported in the hood of their
mother's parka, and it is a common sight to see the
child's nose bleeding from striking its head against
the neck of the mother. The mother usually nurses
the child until it is about three or four years of age,
and one will sometimes see a mother nursing both
a baby and a two-year-old child. They nurse their
young until the young can eat raw tomcod or dried
salmon fish and sop seal oil with their fingers. The
babe of an Eskimo squaw is not kept as clean as a
Malamute will keep her pup. Another example to
show how little they care for their young. A mid-
wife will sometimes see a baby that she would like
to have, if so, will put it under her parka and carry
it away, regardless of how it is to be fed. Anteso-
470
MEDICAL RECORD.
[Sept. 9, 1916
luck, "Cyndrock Mary, the Reindeer Queen," was
the midwife for a squaw at St. Michael and took
quite a fancy to the baby. The following day she
wrapped it up and packed the baby sixty miles by
dog team to Unalakleet, with the weather below
zero, and raised the child. This is permissible with
the native.
When a girl reaches the age of puberty she is
considered unclean, and must remain in a corner of
the house for forty days. She must have a hood
on, hair streaming over her face, and face turned
toward the wall. In some places she is kept only
four days in this position and then behind a grass
mat. The native speaks of her as being "agulinga-
gak," meaning "has become a woman." Should a
man come close enough to her during this time to
be touched, he is supposed to become visible to all
the animals, so that when he goes hunting he will
have no luck as the animals will see him. At the
end of the period in which she remains in seclusion
the girl takes a bath and puts on entirely new gar-
ments. She is now ready to become a wife. If no
suitors approach her in a reasonable time the father
gathers together much food and has a festival (com-
ing out party of better society) to announce that his
daughter is ready for marriage.
When the Eskimo sees a girl that he desires to
marry he tells his father, who in turn has an inter-
view with the girl's father. If the match is ap-
proved of, the young man puts on the very finest
clothing that he can get and goes to call. He also
takes the finest suit of clothing he can get for the
girl, and she dresses up in it. Then they are man
and wife according to the native belief. If there
are no children in one of either of the parents'
families the newly married couple goes to live with
that family. Child betrothals are common and take
place in one of two ways. The mother of the girl,
regardless of the age, may take a boy to live in her
home to become the girl's husband when they grow
up, or a girl may leave her home and be adopted by
a boy's mother for this purpose. There is evidence
to show that two native men of different villages
sometimes become bond-fellows, and when one goes
to the other's village he is given the privilege of his
bond-fellow's bed and wife. The children of these
kind of families call one another "katknun."
Annually the "Ihlugi," or "Feast to the Dead," is
held. This is soon after the Bladder Festival and
before salmon fishing begins. It is for the purpose
of offering clothing, food, and water to the spirits
of those who have died within the year. The day
before the festival the nearest male relative of the
dead to be honored goes to the grave and plants a
stake bearing the family totem. If the deceased
was a man this is a kyak paddle; if a woman, a
wooden dish. This is to call the spirit to the grave
where it waits until called to the Kashim, or Coun-
cil House. No work is permitted in the village dur-
ing this festival, and the use of any sharp instru-
ment is strictly prohibited for fear of injuring the
spirit, as the spirit would bring evil upon the vil-
lage. Persons who are to honor their dead take an
oil lamp to the Kashim at mid-day, light it and place
it upon a stake in front of the seat where the de-
ceased was accustomed to sit. This is to furnish
light for the shade and is kept burning until the
festival is over. The villagers now gather in the
Kashim, the relatives bringing food as far as the
door, where it is left. An old man seated in the
middle of the floor, and beside the main lamp, begins
a rhythmical beating on a drum as an accompani-
ment to his song. This is usually the Medicine
Man. The villagers join in as a chorus, but to the
white man's ears there is no music to this. The
music is to call the spirit, and when it arrives the
relatives go to the door and procure a bit of each
kind of food they brought. Returning, they throw
this upon the middle of the floor and pour water
upon it, washing the food through the cracks. In
this way the spirit is believed to receive the benefit
of the food. The remaining portion of the food is
then brought in and distributed to the guests, and
with loud stamping upon the floor, shouting, and
singing, the spirit is driven from the building not
to return until the next "Feast to the Dead." The
native is afraid to die if he leaves no one to repre-
sent him at these festivities, as he feels that his
shade would suffer from destitution.
•pmgrfBfi nf iftpfttral ^»rirnrp.
Boston Medical and Surgical Journal.
August 24, 1916.
1. Hygiene of the Mind. Benjamin P. Croft.
2. Mental Preparedness. James J. Putnam.
3. The Meaning of the Mental Hvgiene Movement. William
A White.
4. The Menace of Mental Deficiency from the Standpoint of
Heredity. Henry H. Goddard.
5. The Functions of Social Service in State Hospitals. Han-
nah Curtis.
1. Hygiene of the Mind. — Benjamin P. Croft dis-
cusses the hygiene of the mind more particularly as it
applies to the physician, though his suggestions are
equally valuable to others. He says he has wondered
many times of late whether as practitioners of med-
icine we are not in danger of forgetting the real sig-
nificance of the influence of our minds upon the suc-
cessful conduct of our work, and the better preservation
of our physical bodies and those committed to our care.
In our constant efforts to cure diseases either by drugs
or surgery or both we are prone to forget how im-
portant the influence of a proper control of the emo-
tions is. History teaches that the loss of emotional
control has in some instances resulted in death, and
there are on record many instances of the effect of
emotion on the various physiological functions. There
seems to be no question as to the need of regular sys-
tematic mental and physical diversion from one's usual
occupation. In discussing this proposition the essayist
considers what benefits may be derived from outdoor
occupations, such as golf, agriculture, geology, etc.,
and from the relaxation of literature. He thinks that
the mental relaxation and stimulation of friendship is
one of the benefits we are losing out of our busy modern
lives. Above all, he emphasizes the importance of
attaining and keeping an attitude of mental optimism.
This mental habit should be cultivated early in life; but
it is never too late to begin.
2. Mental Preparedness. — James J. Putnam states
that the European war — its causes, its emotional his-
tory, its probable results, the obligations of America
with reference to international affairs — relates very
naturally to mental preparedness. The question there-
fore arises as to how we shall make our children and
ourselves mentally more stable and to what end we
should seek mental stability. The principles chiefly
significant are that the human race, as a whole, un-
doubtedly does move toward a type which we can repre-
sent to ourselves ideally, though only ideally. This is
the goal of ideal perfection. The evidence is strong
that an influence is actually at work that indicates the
existence of such a goal and points the way toward it.
This influence is opposed by the tendency to reversion,
and the problem of helping our children resolves itself
Sept. 9, 1916]
MEDICAL RECORD.
471
into how we can best neutralize this tendency. The
author discusses how this may be done through a proper
direction of the elemental passions, through a recog-
nition that the same forces are immanent and vital in
the child that have brought mankind to where it is and
that will carry it still farther. If the child is to pro-
gress toward the goal of social companionship and
usefulness, three things must be properly directed,
egoism, love, and imagination. If the European war
has taught us anything it is that highly organized
social efficiency is indispensable for the ultimate suc-
cess of civilization and the attainment of human ideals.
3. The Meaning of the Mental Hygiene Movement. —
William A. White points out that in primitive com-
munities many courses of action were tolerated which
would not be endured in a civilized community; that in
a civilized community one cannot do anything that he
may happen to choose without crossing the path of
some one else. The group of people who are called in-
sane are those who exhibit a type of conduct that can-
not be tolerated in the community in which they live.
The characteristic of this type of conduct is social in-
efficiency. There are many different kinds of socially
inefficient conduct, as for instance the pauper, the crim-
inal, the neurotic. They all have one characteristic in
common; they cannot adjust themselves to their social
environment. A proper environment means a great
many things and can only be obtained in an institution
where the problems regarding these different types of
people should be worked out, and they should be worked
at until solutions have been reached which are suf-
ficiently valid, sufficiently correct, sufficiently definite
and far-reaching, to be backed up by the community
and formulated in some sort of statute. The institution
conducted on scientific principles aims to provide an
environment in which these people who cannot adjust
themselves to the community can find their best personal
expression, and an environment in which they can pay
back what they are getting from the community. The
writer thinks we shall never entirely solve the problem
of the mentally defective, but we can perhaps make
the distance which separates the man at the top of
the ladder and the man at the bottom a little bit
shorter, by concerted and really tremendous effort.
4. The Menace of Mental Deficiency from the Stand-
point of Heredity. — Henry H. Goddard emphasizes the
fact that the essence and importance of the menace of
mental deficiency lie in the rapid propagation of the
feeble-minded compared with other classes in the com-
munity. Formerly when all stocks were equally prolific
and the mentally deficient were more exposed to elimi-
native accidents, natural process served better to main-
tain the balance. Now the feeble-minded are more pro-
tected by society from disaster, and the steadily de-
clining fertility of the superior stocks tends to destroy
this advantage. Optimists believe that the situation
will yet right itself; but there seems, nevertheless, oc-
casion for very genuine and serious concern, unless ad-
ditional measures are taken to correct the disturbance
of evolutionary process created by modern protective
measures, which favor the survival of the unfit, and by
modern practice which limits artificially the number of
fit who survive. Broadly speaking corrective meas-
ures may be of two kinds — those which tend to restrain
the inferior, and those which tend to increase the
superior stocks. Dr. Goddard emphasizes the former,
but calls distinct attention also to the latter.
New York Medical Journal.
August 26, 1916.
1. The Substitute Feeding of Infants. J. P. Crozier Griffith.
2. The Physiological and Toxic Actions of Formaldehyde.
Samuel E. Earp.
3. Fever, a Part of the Syndrome of Toxemia. Francis M.
Pottenger.
4. Typhoid Fever. I. L. Xascher.
5. The General Practitioner. J. V. O'Connor.
6. An Evaluation of Paraphrenia. (Concluded.) Edward
A. Strecker.
7. Chronic Suppurative Otitis Media. Hugh B. Blackwell.
s. Orthopedics of the Hand. Lawrence G. Hanley.
9. Frostbite in the Hand Resembling Raynaud's Disease.
X. S. Tawger.
1" The Value of Iodine in Gonorrhea. M. Abramovitz.
2. The Physiological and Toxic Action of Formalde-
hyde.— Samuel E. Earp discusses the physiological ac-
tion of formaldehyde, and reports three cases of poison-
ing from formalin. Two of these were accidental and
one was due to an attempt at suicide. All recovered,
though the first patient was moribund and there was ap-
parently no possibility of recovery. The treatment con-
sisted of the administration of a quart of milk by the
stomach tube after the stomach had been washed by di-
luted aromatic spirits of ammonia, which is supposed to
be the only antidote for formaldehyde. Milk of magne-
sia was also given. As a stimulant sulphate of strych-
nine was administered according to the requirements of
the case. These cases are reported to call attention to
the danger of this agent which is used commercially
with hardly a thought of its being harmful.
3. Fever, a Part of the Syndrome of Toxemia. — Fran-
cis M. Pottenger recalls that in attempting to classify
the symptoms of tuberculosis he has suggested that
those belonging to the toxic group were, for the most
part, an expression of general discharge through the
sympathetic nervous system and that they were caused
by the action of toxins upon the central nervous cells.
In this manner he has accounted for the rapid heart ac-
tion, lack of appetite, coated tongue, deficient secretion
on the part of the stomach and other glands of the in-
testinal tract, particularly the liver and pancreas, and
for the deficiency in motility on the part of the stomach
and intestinal tract. He accounted for the symptoms of
malaise, lack of endurance, and nervous irritability as
part of the same picture. Further study has led him to
believe that fever, too, belongs to this same group, and
instead of being considered an entity should be consid-
ered as one of the sjTnptoms of toxemia. His theory
briefly put is that fever is due to the action of the tox-
ins on the nervous system. It arises largely from con-
striction of the superficial vessels interfering with heat
dissipation. Its production is a part of general sympa-
thetic stimulation. The collapse which results from ex-
cessive toxic action is due to a vasodilation, a temporary
or permanent vasomotor paralysis, and is accompanied
by perspiration, rapid dissipation of heat, and subnor-
mal temperature. This theory would also account for
the fever which follows various depressive emotional
states.
4. Typhoid Fever. — I. L. Xascher reports two un-
usual cases of typhoid fever. The first was irregular in
its onset and course, the symptoms in the first place be-
ing rather indicative of a lobar pneumonia. The subsi-
dence of the symptoms referable to the chest and the
persistence of diarrhea toward the end of a week led to
the suspicion of typhoid fever. Although text-books say
there is no eruption after the fourteenth day. in this
case the typical typhoid spots appeared in the third
week. Delirium occurred on the twentieth day and for
several days thereafter. The severe typhoid state began
at this time and lasted for about a week after. The sec-
ond case, a daughter of the first patient, aged thirteen
years and weighing 130 pounds, had the disease, which
ran a fairly typical course for about a month when she
developed signs of pulmonary involvement, although
there had been no chill, cough, pain, expectoration, or
any of the usual symptoms of pneumonia. From this
time until the patient died, some eight weeks later,
there was no relationship between temperature, pulse.
472
MKDICAL RECORD.
[Sept. 9, 1916
and respiration, there being frequently a marked rise or
fall in temperature, pulse, or respiration, without any
apparent cause. There was a persistence during the en-
tire time of four groups of symptoms — gastric, intesti-
nal, pulmonary, and cerebral. There was a frequent ab-
sence of correspondence between symptoms and physical
findings. There was an improvement in the tempera-
ture, pulse, and respiration toward the end. There
seemed to be two and perhaps three distinct infections
— typhoid, pneumonia, and septic. During the course of
her illness the patient vomited pus, and pus came from
the rectum and vagina. Autopsy revealed a unique con-
dition. There was a pus reservoir lying between the
transverse colon and the diaphragm; perforation of the
diaphragm upward into the pleural cavity; no patholog-
ical condition in the lungs, except adhesion of the lower
lobe of the left lung to the diaphragm; there were wide-
spread adhesions and necrotic areas in various organs
and tissues, and the second and third lumbar vertebrae
were denuded. There was absence of perforation of the
vegina or of any other assignable cause for the presence
of pus in the vagina. The liver was enormously en-
larged, weighing five and three-quarters pounds. Both
kidneys were also enlarged.
7. Chronic Suppurative Otitis Media. — Hugh B. Black-
well reports sixteen cases in which he has performed the
following operation: He makes the usual postaural in-
cision, as in the Stacke operation. The soft parts ante-
rior to this incision are elevated and retracted forward;
the cortex is removed with a gouge and the subcortical
cells with curettes until the antrum is opened; the pos-
terior bony canal wall is lowered and the antrum wi-
dened to its fullest possible extent. When the short
process of the incus becomes visible, the external attic
wall is removed by placing the back of the curette ex-
ternal to and in front of the incus and curetting from
within outward. The bony canal wall is still further
lowered until the facial ridge is reached, leaving only an
epitympanic ring in its superior portion, with a width
of about one-sixteenth of an inch. In four instances I
have removed this ring in the superior and outer quad-
rant of the circle, leaving the membrana typmani and
ossicles intact. The granulations, polypi, and choleste-
atoma lying in the external and internal attic are re-
moved by curetting internal or external to the incudal
body, care being observed not to destroy the suspensory
ligament of the malleus or its external lateral ligament.
In curetting near the incus great care must be taken not
to disturb the ligament which binds the extremity of its
short process to the bone below and just in front of the
external semicircular canal. The drum and ossicles are
of course not removed, but left in situ. An L-shaped
metal flap is cut, as in a radical operation, the cartilage
removed, and the flap sutured to the temporal fascia.
The mastoid wound and attic region are packed snugly,
thereby furnishing support to the flap, and the posterior
wound is sutured. The author does not present this op-
eration as one that would entirely replace the radical
procedure, but is convinced that when a proper selection
of cases is made it will yield even better functional re-
sults as well as a dry ear.
Journal of the American Medical Association.
:•;. 1918.
1. Congenital Deformation and Defunctlonallzatlon of the
and Colon. Joseph 1 1 nan.
2. Indications for Choi ithrie.
?,. Fat Embolism in i ind Preven-
-i. The Evolution Deformans Coxae Juve-
nalis All" 1 1 >ergj.
5. Elective Localization of Bacteria in Diseases of the Nerv-
ous System. Edwan "\\
tl. Poll' with Some Obsi on Thin \
Archibald l. Hayne and Francis P. Cepel
7- Municipal Control of Infantile Paralysis. Abraham
Sophian.
S. Gastrointestinal Findings in Acne Vulgaris. Especially
Fluoroscopic. Lloyd W. Ketron and John H. King.
1. Congenital Deformation and Defunctionalization
of the Caudal Ileum and Colon.— Joseph Rilus Eastman.
(See Medical Record, July 8, 1916, page 80.)
2. Indications for Cholecystectomy. — Donald Guthrie.
(See Medical Record, July 8, 1916, page 86.)
3. Fat Embolism in Bone Surgery- — Edwin W. Ryer-
son relates several cases of fat embolism that have
occurred in his experience which lead him to believe
that this is a much more frequent and serious danger
in bone and joint surgery than he had supposed. He
reviews the various methods that have been proposed
for the treatment of fat embolism, and states that these
are apparently not on a well-defined basis and cannot
be considered as having any curative value in cases in
which a large quantity of fat has been forced rapidly
into the lungs. It seems likely that a complete stasis
of the circulation during and a short time after the
operative procedures would probably prevent or at
least reduce the transportation of the fat through the
venous channels. The tourniquet can be left in place
as long as half an hour, and can then be gradually
loosened. Animal experiments show that fractures and
contusions of the bones cause much more embolism than
does the performance of a typical Albee bone trans-
plant to the spine. The use of the chisel and mallet is
far more dangerous than the motor saw. The experi-
ments also showed that when a tourniquet was ap-
plied the fatty embolism from all kinds of traumatism
to the bones was markedly decreased. The tourniquet
should be made a matter of routine in bone surgery.
4. The Evolution of Osteochondritis Deformans Coxa?
Juvenalis. — Albert H. Freiberg calls attention to a de-
formity of the femur occurring in children which in
its later stages bears much resemblance to that seen in
so-called arthritis deformans of the adult. The most
striking difference, however, is seen in the absence of
new bone formations, or osteophytes, in those portions
of the joint peripheral to its bearing surface. In its
symptoms also the disease of early life differs from
that of the adult, being in the former of much milder
character and often of such insidious course as to es-
cape detection until the terminal deformity has been
discovered. It seems quite evident to-day that these
juvenile cases have in their earlier stages, and in for-
mer years, constituted largely the class of cases which
were formerly regarded as mild hip tuberculosis. Here
may be found the explanation of the remarkably com-
plete restoration of function in cases of hip disease
which were formerly brought forward from time to
time as evidence of the efficiency of this or that method
of treatment. A roentgenological study of these cases
identifies them with the disease accurately described by
Perthes. The writer believes it is logical to assume,
as an etiological basis for osteochondritis deformans
juvenalis, a chronic infectious process of probably sec-
ondary character, just as is done in explaining other
deforming joint dseases of later life.
5. Effective Localization of Bacteria in Diseases of
the Nervous System.— Edward C. Rosenow. — (See Med-
ical Record, July 1, 1916, page 31.)
6. Poliomyelitis, with Some Observations on Thirty
Cases. — Archibald L. Hoyne and Frances P. Cepelka
state that the cases in this series were, with a few ex-
ceptions, of a mild type and there were no fatalities.
Two of the cases were of the encephalic variety, all the
others being spinal. Eighty-six and two-thirds of the
patients were under five years of age. There were
fourteen boys and sixteen girls. Practically all the
children were fair-haired, there being but one really
dark-complexioned child in the series. Where the pa-
Sept. 9, 1916]
MEDICAL RECORD.
473
tient was received early, following lumbar puncture,
from 0.5 to 1 c.c. of 1:1000 epinephrin chlorid solution
was given intraspinally. This was repeated every four
to six hours, provided the pulse rate did not exceed 160.
In no case was the dose repeated more than three
times. Some patients showed marked improvement in
from one-half to one hour following the injection. Such
marked improvement was seldom permanent, but grad-
ual improvement in some instances seemed to be more .
rapid. The authors draw the following conclusions:
(1) There is still some unknown agency responsible for
the transmission of poliomyelitis. Not every case is
acquired through direct contact or by means of a hu-
man carrier. (2) A leukopenia is not characteristic
of poliomyelitis, since a leukocytosis was present in al-
most every case observed by us. (3) In order to con-
trol an epidemic or an impending epidemic, isolation
by means of compulsory hospitalization will give the
best results. (4) An isolation period of three weeks
from the date of attack is probably sufficient.
7. Municipal Control of Infantile Paralysis. — Abra-
ham Sophian, who was special Commissioner of Health
for Bridgeport, Conn., in charge of prophylactic meas-
ures against infantile paralysis, gives the result of this
experience. He says that, following the outbreak of
the epidemic in New York, cases immediately occurred
in neighboring cities that had close business relations
with New York and in some of these cities the epi-
demics were very large. The relatively larger number
in other cities as compared with Bridgeport indicates
that active preventive measures are important. The
preventive campaign as planned and carried out in
Bridgeport may be classified as follows: (1) Quaran-
tine of the sick and healthy contacts. Quarantine of
the sick should be rigid and, until we learn more about
the disease, should cover the probable period of the
epidemic, about eight weeks. (2) Exclusion of prob-
able carriers from New York and adjoining cities in
which the disease was epidemic. (3) Establishment of
a special central hospital to which was enforced com-
pulsory removal of all patients with infantile paralysis.
(4) Organization of a special medical "poliomyelitis di-
agnosis squad." (5) Repeated circularization of the
physicians, calling attention to abortive cases and the
preparalytic stage of the disease. (6) Mobilization and
enlargement of all the sanitary forces covering the
street-cleaning department, garbage department, po-
lice and fire departments, regular sanitary inspectors,
and the staff of nurses.
8. Gastrointestinal Findings in Acne Vulgaris, Espe-
cially Fluoroscopic. — Lloyd W. Ketron and John H. King
present an analysis of thirty cases of acne vulgaris
which were subjected to a fluoroscopic examination of
the gastrointestinal tract; the patients also received
test meals, and analysis of the gastric contents was
made. It was found that 93 per cent, showed gastric
abnormalities and 70 per cent, showed intestinal ab-
normalities. The most common gastric findings were
hyperacidity, 48.1 per cent.; retention, 36.6 per cent.;
atony, 33.3 per cent., and ptosis, 40 per cent. The most
common intestinal findings were cecal stasis, 46.6 per
cent.; ptosis of the colon, 36.6 per cent., and right
lower quadrant adhesions, 23.3 per cent. Clinically,
62.3 per cent, of the cases gave evidence of gastric dis-
turbances and 40 per cent, of them were constipated.
None of the cases examined gave entirely normal gas-
trointestinal findings, and 60 per cent, of the cases
showed abnormalities which were of such a nature as
to permit gastric and intestinal stasis, followed by
toxic absorption. The conclusion seems evident that
while there are a number of predisposing factors to
this disease, one of the most important is gastrointes-
tinal derangements.
The Lancet.
.1 u,gu3l
1916.
1. Observations on the Development of the Regulation of
Temperature and Its Clinical Significance. M. S. Pem-
2. An Address on the Tuberculous Soldier Delivered at the
Annual Meeting ot the National Association for Pre-
vention of Tuberculosis on July 26th. William Osier.
3 Serum Reactions "t :."" I'nselected Cases of "Enteric"
with tli. ' Ixford Standard Agglutinable Cultures.
Ernest Glynn and E. Cronin Lowe.
4. Acute Intestinal Obstruction. George F. Aldous.
5. Immobility after Joint Injury. John Collie.
6. Extraction of Bullet from Middle Mediastinum. L. E.
Barrington-Ward.
7. Cessation of Tachycardia on the Outbreak of Spontaneous
Perspiration. Thomas Oliver.
3. An Address on the Tuberculous Soldier. — William
Osier states that the Allied armies in the west have
been singularly free from camp diseases; the common
civilian diseases, however, have had their innings, and
have played relatively the more important role. The
soldier takes with him into camp two great enemies —
the tubercle bacillus and the pneumococcus. The pro-
portion of tuberculous individuals is much less than
among civilians. In 1915, 2770 cases of tuberculosis
were dealt with by the Chelsea Boards, but it cannot be
said just what proportion this bears to the enlisted
force. An inquiry shows that in 13 sanatoriums out
of 160 cases 90 were regarded as due to the war; in
five other places most or very many out of 84 were
attributed to this cause. Of the 2770 cases considered
in 1915 only 1641 were granted pensions. The ques-
tion arises as to what becomes of the remainder. Re-
viewing the whole situation Osier offers the following
suggestions: (1) A more searching examination should
be made of all recruits. Doubtful cases should be re-
ferred to the tuberculosis expert of the district. Men
unfit to be worked up to the soldier standard become
simply material for pension claims. (2) Army ex-
perts should decide upon the doubtful cases before
their discharge. Provision should be made for their
study. There are plenty of tuberculosis experts in
khaki whose knowledge should be used to put these
cases in their proper category. (3) A national organi-
zation should look after the welfare of the tuberculous
soldier. A roll and record should be kept, and every
case supervised with the greatest care. The National
Association should undertake this work in cooperation
with the Society for the After-care of Soldiers. A
small central committee of these two bodies could or-
ganize committees in each county and bring official
pressure to bear on authorities to furnish the proper
hospital accommodation.
4. Acute Intestinal Obstruction. — George F. Aldous
presents notes on ten cases of acute intestinal ob-
struction, in some of which the causes are common and
in some rare. In dealing with these cases he empha-
sizes the importance, first of early operation, and, sec-
ondly, of one or more enterotomies to reduce toxemia.
He admits that it is occasionally difficult to make a
diagnosis but is sure that it is safer to open the ab-
domen when acute symptoms are present than to wait.
6. Extraction of Bullet from Middle Mediastinum. —
L. E. Barrington-Ward recounts the case of a soldier
sent back to England six weeks after having received
a wound of the chest, which had healed. The man ap-
peared to be healthy when at rest. Exercise gave him
sharp pains over the precordia and breathlessness. A
radiogram showed a bullet apparently lying in the peri-
cardium near the left border of the heart just above
the diaphragm. On screening, movements of the bullet
due to cardiac and respiratory excursions were well
seen. At operation an incision was made in the mid-
line of the sternum from the level of the fifth costal
cartilage downward to the sixth costal cartilage, and
then along the sixth costal cartilage outward. The
474
MEDICAL RECORD.
[Sept. 9, 1916
sixth costal cartilage was removed. The left lung
and pleura were pushed aside; it was thus found that
through this incision it was possible to palpate thor-
oughly the heart and explore the pericardium. At a
depth of about 4 inches from the surface the bullet
was found adherent to the pericardium and also to
the pleura and the lung. It lay surrounded by a few
beads of pus with its long axis applied to the peri-
cardium, apex forward. The bullet was extracted, the
pericardium closed with fine catgut, the muscles
brought together, a small rubber tube inserted super-
ficially, and the skin wound closed with Michel's clips.
Among the points of interest in this case were the
comparative freedom with which the heart and peri-
cardium could be examined without embarrassment
under inhalation anesthesia and the possibility of sepa-
rating the pleura off the pericardium without any
recognizable collapse of the lung taking place.
British Medical Journal.
August 5. 1916.
1. Notes on Military Orthopedics. VI. Disabilities of the
Knee Joint. Robert Jones.
2. Further Observations on the Treatment of Gangrene by
Intravenous Injection of Hypochlorus Acid (Eusol).
John Fraser and H. J. Bates.
3. Convalescent Paratyphoid and Dysenteric Cases Consid-
ered from the Preventive Standpoint. I. Walker Hull.
D. C. Adam, and R. E. Savage.
4. Treatment of Scabies by Sulphur Vapor. John Bruce and
Stanley Hodgson.
5 The Economical Use of Solutions of Costly Alkaloids for
Ophthalmic Purposes. N. Bishop Harman.
1. Disabilities of the Knee Joint. — Robert Jones gives
a broad classification of these derangements and dis-
abilities, with their diagnostic signs, and indicates ap-
propriate lines of treatment. He points out that there
are three common conditions which are not always as
clearly distinguished by practitioners as they might be.
They are: (1) Simple sprain of the lateral ligament,
usually the internal; (2) slipping of the semilunar
cartilage, and (3) nipping of the infrapatellar pad of
fat. All of these injuries are associated with effusion
of fluid into the joint, and in all the patient complains
of more or less recurring disability after the lesion.
Simple sprain of the internal lateral ligament is
marked by a special tender spot over the attachment
of the ligament and nowhere else. A joint which has
been the seat of a definite injury will generally fill up
with synovial fluid when first used. Therefore the ap-
plication of a pressure bandage should never be omit-
ted. If the knee is carefully brought into use by grad-
uated exercises each succeeding day there should be
less effusion. If the effusion does not become less the
patient is using the knee too much. The author's ex-
perience of operations on the internal semilunar carti-
lage covers some 2,000 cases, on the basis of which he
states that the knee should never be opened except
under the most scrupulous aseptic conditions, and never
in a hospital where there are a large number of septic
cases. The procedure which he prefers is to place the
leg so that it hangs over a table at right angles to the
thigh. The knee is wrapped in sterile gauze soaked in
biniodide solution. The incision is made through the
gauze. A second clean knife should be used for the
deeper dissections. The incision is made over the an-
terior end of the cartilage, nearly but not quite paral-
lel to the upper edge of the tibia. Great care should be
taken never to allow the incision to extend far enough
to the inner side to cut any fibers of the internal lat-
eral ligament, since this is a fault that leads to weak-
ness of the knee lasting for months or years, and is
still frequently met with in cases which have been
operated on by the old, large J -shaped incision. In re-
moving the whole cartilage great care should be taken
that no tags of cartilage are left projecting from the
attachment to the coronary ligament, as these fre-
quently give rise to continued symptoms, due to nipping
or adhesions. No movement of the knee must be al-
lowed after the incision has been made, as this may
favor the entrance of air. It is not until the stitching
is complete and pads placed over wound that the knee
is straightened. If the operation is performed with a
tourniquet around the thigh no vessels need be tied,
and if elastic pressure is applied before the tourniquet
is removed there need be no fear of bleeding into the
joint. A knee cage is presented which is useful in pro-
tecting thickened retropatellar pads of fat, and em-
phasis is placed on the importance of providing for the
restoration of the quadriceps muscle, which is wasted
and weakened in all these injuries to the knee.
3. Convalescent Paratyphoid and Dysenteric Cases
Considered from the Preventive Standpoint. — I. Walker
Hall, D. C. Adam, and R. E. Savage have reported
their findings in a large number of typhoidal and dys-
enteric convalescents examined during the last eight
months, the investigations in each case consisting of the
estimation of the agglutination content of the blood,
the microscopical examination of the stools, and. cul-
tural isolation from the urine and feces. The cases
grouped themselves into three batches. The first ex-
tended from September to December, 1915, and con-
tained some acute and subacute infections. There were
297 cases in this group, convalescent from four to
twelve weeks, and bacilli were present in the excreta
in 3.7 per cent. The second group covered the period
from December, 1015, to February, 1916, and comprised
cases of early convalescence. There were 156 of these
and bacilli were found in the excreta in 1.3 per cent.
The cases comprising the third group came in from
February to May. There were 217 cases, all appar-
ently fit for work again, and bacilli were not present
in the excreta of any of these. The above groups were
all paratyphoid convalescents. There were 605 dysen-
teric convalescents examined, and bacilli were found in
the excreta of 1.1 per cent. In the paratyphoid cases
E. histolytica was present in 10.06 per cent.; in the
dysenteric convalescents, in 6.68 per cent. The fact is
brought out that in convalescents from dysentery, ty-
phoids, paratyphoids, and probably other conditions,
there is protozoal infection to an equal extent. The
average time required for the disappearance of E. his-
tolytica from the feces was 22.9 days, but one case has
yielded positive findings for 125 days already. It was
found that the date of disappearance of the bacilli
from the excreta of typhoid and paratyphoid conva-
lescents varied from eight to fifteen weeks from the
time of the onset of the attack, and in the dysentery
convalescents the time of disappearance of the bacilli
varied from eleven to fourteen weeks from the time of
onset of the disease.
4. Treatment of Scabies by Sulphur Vapor. — John
Bruce and Stanley Hodgson say that in the treatment
of a considerable number of cases of scabies the ordi-
nary treatment by sulphur ointment is slow. For the
past twelve months they have given sulphur dioxide
gas a trial and have found that it meets their re-
quirements. The treatment is given in a cabinet con-
structed along the lines of a home Turkish bath. The
seat provided for the patient consists of three narrow
cross-bars placed 30 inches above the level of the floor.
This enables the fumes to reach all portions of the
buttocks and nates. The patient is first well scrubbed
and then placed in the cabinet and allowed to remain
for fifty minutes. The writers have treated over 200
cases and have had about 2 per cent, returns, and in
these instances they think some article of clothing es-
caped disinfection.
Sept. 9, 1916]
MEDICAL RECORD.
475
5. The Economical Use of Solutions of Costly Alka-
loids for Ophthalmic Purposes. — N. Bishop Harman rec-
ommends the following as an "ophthalmic solvent" for
cocaine, etc., since it is more satisfactory in the pres-
ervation of solutions than others in common use:
Distilled water 1 pint
Methyl salicylate 2 grains
Oil of gaultheria 2 minims
Tincture of iodine 2 minims
The mixture is well shaken, poured into a stoppered
bottle, and left for forty-eight hours, when it is ready
for use. As watery solutions are wasteful and unsatis-
factory, the solution may be thickened with gum arabic
until the solution is so viscid that it will cling in a fair
round drop on a small lacrymal probe. It has been
found that cocaine, atropine, and homatropine are
equally effective in this gummy solution, and the econ-
omy of their use is noteworthy.
Le Progres Medical.
July 20. 1916.
Sulphohydrargyric Medication. — Loeper, Bergeron,
and Vahram refer to the great number of so-called
rheumatic ailments among the soldiers, at least one-
eighth of all who are invalided from active service
being of that type. But while exposure, cold, damp-
ness, fatigue, and trauma may be responsible and may
play some part in the genesis of these affections, infec-
tions and anomalies of metabolism are even more at
fault. It must not be forgotten that these causes of
rheumatism act upon a syphilitic soil. In a special re-
search the authors have found forty-one cases of rheu-
matism in the causation of which syphilis played a pre-
dominating role. This material represents about one-
third of all the doubtful cases. The diagnosis of syph-
ilis was based on positive work, coexistent lesions of
syphilis, history, and the success of antiluetic meas-
ures. Certain cases of frankly syphilitic and tabetic
arthropathy are not included in this series. Of this
series twenty-five cases were in the tertiary stage,
early or late. Syphilis appeared as an arthralgia four
times, as polyarticular arthritis eight times, as "white
swelling" four times, as hydarthrosis five times. Ar-
thritis sicia was present in eleven patients and deform-
ing rheumatism in ten. Two patients were probably
heredosyphilitics, and twenty others denied infection.
When syphilis is thus completely masked by rheuma-
toid lesions, a combined plan of treatment appears in-
dicated. The authors obtained two complete cures with
neosalvarsan alone and six others with injections of
biniodide of mercury. Still others yielded to ordinary
mercurial treatment by mouth. Finally there were
cases refractory both to salvarsan and mercury. Since
colloidal sulphur is now being widely tested on ordi-
nary rheumatism, the authors made use of a colloidal
association of mercury and sulphur. No combination
of any sort results. In twenty cases thus treated sev-
enteen showed improvement. There were five complete
recoveries. The manifestations following the injections
were slight and sufficiently like those following the in-
jection of sulphur alone. We have, in fact, a new form
of "mixed treatment" for these hybrid cases.
Le Progres Medical.
August 'j, 1916.
Cancer of the Stomach; Metastasis to Cerebellum; Ter-
minal Meningitis. — De Portunet and Cade sum up their
remarkable ease as follows: The patient was but 31
years old when he appeared with cancer of the stomach.
Instead of the rapid evolution of the growth which is
usually anticipated at such an age, its course had been
extremely torpid and its actual onset was probably sev-
eral years earlier than the earliest symptoms. Through-
out the patient's disease he remained in good health
until near the end. The nervous phenomena which an-
nounced the metastasis were extremely complex and
conflicting. The course was rapid and suggestive of
meningitis, although fever was absent; it also sug-
gested generalization of a meningoencephalitic process.
Cytological examination of the cerebrospinal fluid
showed a slight opacity and increaise of tension. The
cell content was rich, comprising polynuclears, lympho-
cytes, endothelia, and especially large cells regarded as
coming from a neoplasm. Autopsy showed cancer on
the posterior aspect of the stomach, submucous infil-
tration, extension to pancreas, lymphatic generaliza-
tion, a secondary nodule seated superficially in the in-
ferior portion of the left lobe of the cerebellum. In the
same locality there was purulent meningitis. The gas-
tric neoplasm was of the extreme scirrhous type. The
patient, a soldier, had been interned for a supposed
tumor on the anterior aspect of the stomach. It was
readily palpable, hard, and irregular in shape. Patient
vomited continuously, and his general condition was
bad. Examination failed to reveal thoracic anomalies,
ascites, melena, etc. Aside from the tumor there was a
gland paquet in the supraclavicular region. He had
complained of his stomach for the past five or six
years; nevertheless he had kept up with his duties until
the time of transfer to the hospital. A diagnosis was
made of the malignant growth of the stomach, inopera-
ble. A few days after his internment nervous mani-
festations supervened, all the extremities becoming
paralyzed and contractured. A comatose state next set
in. Death occurred even before a clinical diagnosis
could be made, although study of the punctate led to the
opinion of a neoplastic meningoencephalitis independ-
ent of autopsy finds.
Systemic Disturbances from Pyorrhea Alveolaris. —
B. P. Rivers, Jr., intimates that gastric ulcer and ap-
pendicitis as well as postoperative pneumonia may some-
times be traceable to Rigg's disease. Aside from these
local infections a general run down state may have the
same cause and disappear after thorough cleansing of
the teeth. The symptoms presented by a single patient,
a woman of forty, comprised the following: loss of
appetite, bad taste in the mouth, excessive flow of
saliva, pain in the stomach after eating, burning sen-
sation in the empty stomach, morning nausea. Every
afternoon she felt feverish, languid and tired. There
were frequent attacks of constipation and diarrhea and
much flatulence. There had been loss of weight. The
mental state was poor, melancholic. The mouth was in
a very bad shape because bleeding gums prevented the
use of the tooth brush. She had recurrent attacks of
tonsillitis. Blood tinged pus could be squeezed from
the gums. The woman could not do her work as school
teacher and believed herself about to die in a short
time. Cases like this are not uncommon. — Kentucky
Medical Journal.
The Energy Index of the Circulatory System. — Barach
states that changes in the activity of the circulatory
system are accomplished by the adjustment of three fac-
tors, maximum pressure, minimum pressure, and pulse
rate. Since these are measurable factors a calculation
based on the triad should indicate the total energy ex-
penditure of the circulatory system. The product of
such a calculation based upon this triad should indi-
cate the total energy expenditure of the circulatory
system. The product of such a calculation, which I
term the energy index, under normal conditions repre-
sents a kinetic force per minute equal to not over 20,000
mm. Hg. pressure. — American Journal of the Medical
Sciences.
476
MEDICAL RECORD.
[Sept. 9, 1916
Hunk 2Utiirtu0.
The Intestinal Putrefactions: Clinical Studies of
Enterocolitis. By Charles Fremer Reckham,
M.D. Price, $2.00. Providence, R. I.: Snow & Farn-
ham Company, 1916.
The intestinal putrefactions have been greatly in evi-
dence during recent years and their study has been
elaborate and painstaking. A good deal has been
learned on the subject and perhaps a good deal has been
conjectured. However, that intestinal putrefaction is
responsible for many conditions of ill health cannot be
denied and therefore it is well that physicians and sur-
geons should be acquainted with the best means of
fighting it. Dr. Fremer has written a practical book,
which contains a considerable amount of valuable in-
formation, a book which should prove useful for refer-
ence.
Plague. Its Cause and the Manner of Its Exten-
tion — Its Menace — Its Control and Suppression —
Its Diagnosis and Treatment. By Thomas Wright
Jackson, M.D., Member American Red Cross Sani-
tary Commission to Serbia, 1915; Lately Captain and
Assistant Surgeon, U. S. Volunteers; Lately Lec-
turer on Tropical Diseases, Jefferson Medical College;
Member Manila Medical Society and Philippine Isl-
ands Medical Association, etc. With bacteriological
observations by Dr. Otto Schobl, Bureau of Science,
Manila. Illustrated. Price, $2.00. Philadelphia:
J. B. Lippincott Co., 1916.
The author of this work writes with authority since for
two years he was in charge of all plague suppressive
measures in Manila. The book in as far as it is a per-
sonal one is of great value and extreme interest and
contains such an amount of odd facts in connection with
the rat problem as to give it a status as a faunal au-
thority. The author lives strictly up to his title, so that
the pathology and symptomatology are practically ex-
cluded. The work should doubtless be classed under
the head of sanitation and should prove to be most
valuable to all who have to do with public health
matters.
Blood Pressure — Its Clinical Applications. By
George William Norris, A.B., M.D. Assistant Pro-
fessor of Medicine in the University of Pennsylva-
nia; Visiting Physician to the Pennsylvania Hospi-
tal; Assistant Visiting Physician to the University
Hospital ; Fellow of the College of Physicians of
Philadelphia; Member of the Association of Ameri-
can Physicians, etc. Second edition, revised and en-
larged. Illustrated with 102 engravings and one col-
ored plate. Price, $3. Philadelphia and New York:
Lea & Febiger, 1916.
Dr. Norris' work on blood pressure is the second edi-
tion in less than two years. On October 24, 1914, the
first edition was reviewed in these columns and the one
just issued has been thoroughly revised, and contains
several notable additions. In fact, the somewhat
voluminous literature on the subject has been sifted
and the author has incorporated the salient features
in his present work. Books dealing with blood pressure
are welcome as they all add something to our incom-
plete knowledge of the matter for the significance of
the variations in blood pressure is not altogether un-
derstood as yet. There is a certain amount of con-
fusion between cause and effect. However, works like
the one before us, written concisely and clearly, will
serve to elucidate the obscure points or, at any rate,
will present all that is known concerning blood pressure
in easily intelligent language. The chapter dealing
with blood pressure in arteriosclerosis is, perhaps, espe-
cially worthy of attention. The work is well got up
and adequately illustrated and may be recommended as
likely to be of practical use to the busy practitioner.
The Johns Hopkins Hospital Reports. Volume:
XVII. Batlimore: The Johns Hopkins Press. 1916.
This volume comprises eight monographs, each of
which merits a separate notice. The most compendious
of these is the Statistical Experience Data of the Hos-
pital from its inception in 1892 to 1911 by the well-
known statistician Hoffman. There are 72 classifica-
tions of figures. Nearly 44,000 patients have been ad-
mitted, of whom nearly 10,000 were colored. Winter-
nitz in a paper on primary cancer of the liver reports
five cases from the hospital records. There appears
to be over 150 cases on record, yet the disease is ex-
tremely rare in extensive autopsy material. Cancer of
the bile ducts is included, and constitutes over one-
fourth of the total. Two articles deal with thrombosis
—'•Free Thrombi and Ball Thrombi of the Heart," by
J. H. Hewitt, and "Venous Thrombosis During Myo-
cardial Insufficiency," by Sladen and Winternitz. Two
further articles, largely experimental, deal with leu-
cemia — "Benzol as a Leucotoxin," by L. Selling, and
"Leukemia in the Fowl," by H. C. Schmeisser. The
two remaining papers are valuable anatomical contri-
butions— "The Origin and Development of the Lym-
phatic System," by Florence R. Sabin, and "The Nuclei
Tuberis Laterals and the So-called Ganglion Opticum
Basale," by E. F. Malone. The volume is richly illus-
trated; aside from numerous text figures, charts, etc.,
there are twenty-three special plates, comprising nu-
merous colored and halftone figures.
A Treatise on Blood Pressure in Ocular Work with
Special Reference to Factors of Interest to Re-
fractionists. By Eugene G. Wiseman. Illustrated
with 19 engravings. Rochester, N. Y.: John P.
Smith Printing Co., 1916.
The author of this book does not appear to be a physi-
cian and his book is frankly written to enlarge the
usefulness of the optometrist. He expects to be criti-
cized bitterly for his effort, although it does not appear
by whom; since if he is not a graduate physician there
can hardly be any medical censorship. The book con-
siders in succession the general subject of blood
pressure determination, the relation of ocular to gen-
eral pathology, and the use of blood pressure tests in
optometry. The latter section is quite original in con-
ception and execution. Incidentally a table of 100 cases
of retinitis and retinal hemorrhage in nephritics is
given with blood pressure finds. The author has gone
extensively into the classical literature of ophthalmol-
ogy and general medicine.
The Endocrine Organs. An Introduction to the Study
of the Internal Secretions. By Sir Edward A.
Schafer, LL.D., D.Sc, M.D., F".R.C. Professor of
Physiology in the University of Edinburgh. Price,
$2.50. London and New York : Longmans, Green &
Company, 1916.
This book is founded upon the Lane medical lectures
delivered by Sir Edward Schafer at Stanford Univer-
sity, California, in the summer of 1913. These lec-
tures have been revised and published with several
appropriate illustrations. The aim of the work is to
supply a concise account of our present knowledge of
the internal secretions for the benefit of students and
practitioners who may be desirous of obtaining more
information regarding them than is afforded by the
ordinary textbooks of physiology, but have not the
time nor opportunity to peruse extensive monographs
or consult original articles. The Edinburgh professor
has well succeeded in this aim. No one is better fitted
to speak authoritatively on the internal secretions than
he, and his little work will prove immensely useful to
both students and practitioners.
Diseases of the Eye. A Handbook of Ophthalmic
Practice for Students and Practitioners. By George
G. de Schweinitz, M.D., LL.D. (University of Penn-
sylvania). Professor of Ophthalmology in the Uni-
versity of Pennsylvania ; Ophthalmic Surgeon to the
University Hospital; Consulting Ophthalmic Surgeon
to the Philadelphia Polyclinic Hospital, the Philadel-
phia General Hospital, the Orthopedic Hospital, and
the Infirmary for Nervous Diseases. Eighth Edi-
tion. Philadelphia and London: W. M. Saunders
Company, 1916.
DE Schweinitz's Diseases of the Eye had become a
household word with members of the medical profes-
sion, and its editions have been so numerous that there
is little left to say concerning the work. In this, the
eighth edition, chapters have been revised in accord-
ance with the latest developments in ophthalmology and
the treatment thereof during the past three years. The
metric equivalent of the doses of the remedies and the
strengths of the solutions has been substituted for the
old mode of measuring. Several new subjects are dealt
with for the first time, including Clifford Walker's
method of testing the visceral field; anaphylactic kera-
titis; family cerebral degeneration with macular
changes; the ocular symptoms of diseases of the pitui-
tary body. A portion of the chapter on iritis has been
rewritten and additions and alterations are numerous
throughout the book. A number of new illustrations
have also been inserted.
Sept. 9, 1916] MEDICAL RKCORD
477
AMERICAN PEDIATRIC SOCIETY.
(Special Report to the Medical Record.)
(Concluded from page 439.)
Tuesday, May '.) — Second Day.
The President, Dr. Rowland G. Freeman of New
York, in the Chair.
Report of Committee on Vaginitis. — Dr. J. C. Git-
tings, Dr. Samuel McC. Hamill and Dr. C. A. Fife
presented this report which was the result of an in-
vestigation which had been in progress several years.
It included a summary of the replies to a questionaire
sent to a large number of hospitals and homes for chil-
dren, and formed the basis of a set of recommendations
which were submitted for the approval of the society.
After a thorough discussion of the subject the Society
unanimously adopted the following resolutions which
were to be embodied in a letter to health officers: (1)
That cities be required to provide adequate hospital and
dispensary facilities for the care and treatment of chil-
dren having vaginitis. (2) That matrons be placed in
charge of girl's toilet rooms in public schools. (3)
That toilet seats embodying the principle of the U-
shape be used in all schools and that the toilets be of
proper height for different ages. (4) That city and
state laboratories be empowered and equipped to make
bacteriological examinations for physicians when pa-
tients cannot afford to pay a private laboratory fee.
(5) That educational literature on the subject of
vaginitis be prepared and distributed to mothers
through the medium of physicians, hospitals, dispen-
saries, health centers, municipal and visiting nurses.
That asylums for children and day nurseries be licensed,
and that the license be not granted unless: First, the
institution has adequate facilities for the recognition of
gonococcus vaginitis; and second, that the institution
exclude children having this disease if they could not be
properly isolated.
It was further recommended that the American
Pediatric Society address a letter to hospitals which
should contain the following recommendation: (1)
That separate wards be maintained for the treatment
of children with vaginitis who were also suffering from
other diseases. (2) That microscopic examinations of
smears be made before admission to the general wards
of the hospital. In securing smears extreme care should
be taken to observe rigid antiseptic precautions. (3)
That observation wards be provided. (4) That indi-
vidual utensils be provided. (5) That single service
diapers be used, at least for girls, or that diapers be
• sterilized in an autoclave at 15 pounds pressure for five
minutes. (6) That nurses be required to make daily
inspection of the vulva of each child at the time of
bathing, and report immediately the slightest sugges-
tion of a discharge. Other recommendations governing
the detail of hospital routine and the prolonged observa-
tion of cases were adopted.
Certain Phases of the Vulvovaginitis Problem. —
Dr. B. K. Rachford spoke on this subject, emphasizing
and enlarging upon the points brought out in the recom-
mendations and discussing specially the attitude of the
laity toward this form of infection. He said that at
present the very name "vaginitis" struck terror to the
average individual and carried with it a stigma of dis-
grace that was to be deplored. He urged that efforts
be made to lead the laity to a recognition of the fact
that vaginitis in the child and in the adult were dif-
ferent. A proper attitude in respect to this form of
infection would be an important step towards its pre-
vention and elimination.
Provocative and Prophylactic Vaccination in the
Vaginitis of Infants. — Dr. Alfred F. Hess of New
York read this paper. He said that in the institution
with which he was connected their efforts were directed
toward preventing the admission of infected infants, in
attempting in many different ways to avoid the spread
of the infection, in diagnosing the cases at the very
earliest possible moment, and, finally, in resorting to
every means to effect a cure. There was no doubt that
vaginitis might be due to other organisms than the gono-
coccus. Tests had been carried out by Dr. Edwin Lang-
rock that showed that pus cells might be found in the
smears taken from infants during the first 48 hours of
life and that these must not be regarded as pathological
but as a probable reaction of the external tissues to the
inevitable invasion of bacteria. They had found that
the fundamental cause of vaginitis must be considered
to be the latent carrier, some healthy infant who har-
bored the gonococcus. During the past five years au-
topsies had been performed on four infants who had
vaginitis while in the institution. They all showed the
same pathological condition. Macroscqpically the vagina
appeared negative, as did the body of the uterus and
appendages. The only abnormal condition was redness
of the tip of the cervix, so that we must regard the aver-
age gonococcus infection as a cervitis rather than a
vaginitis. The degree of vaginitis in children who ap-
plied for admission to the institution was about 50 per
cent., indicating that the disease was not particularly
associated with child-caring institutions. In order to
overcome the danger of the latent carrier they had,
during the past year, administered three injections of
gonococcus vaccine to infants soon after they were ad-
mitted to the institution. The object of these injections
was provocative, to see if they would bring to light a
latent infection. The dosage was entirely empirical.
At the present time they were giving 100, 200 and 400
millions. Usually two injections were sufficient to bring
about a reaction. During the past year these provo-
cative injections had led to the discovery of eight new
cases during the first week or two after their admission
to the institution. The vaccine was found to be valu-
able, not only for diagnostic measures, but to a certain
extent for prophylaxis. It had been used in about 100
infants and by it they had been able to change the en-
tire nature of the vaginitis in their institution and as
a result they had a nonclinical type of the disease.
There was not only an acquired susceptibility to gono-
coccus infection, but also a natural susceptibility and a
well defined natural immunity. This immunity was rare
and in many instances not absolute.
Some Early Symptoms Suggestive of Protein Sen-
sitization in Infancy. — Dr. B. Raymond Hoobler of
Detroit presented this communication. After referring
to the work of Dr. Talbot in respect to the action of
foreign proteins in causing asthma and that of Dr.
Schloss in respect to their relation to eczema and gas-
trointestinal disturbances, said that he had made ob-
servations and had collected considerable data concern-
ing the early symptoms of protein sensitization in in-
fancy. He also reported on the symptoms that were
observed in guinea pigs sensitized to foreign proteins.
In these the first symptom of protein sensitization was
peripheral irritation; the reward was characterized by
convulsions, and the animal either died in this stage, or
immediately following a convulsion. When this second
stage was not reached the animals usually made a com-
plete recovery. These symptoms were quite similar to
those seen in a human being sensitized to a foreign
protein ; this sensitization was characterized by the ap-
pearance of a rash, urticarial or erythematous, vomit-
ing, great muscular weakness, and in rare instances
soeedy death. Patients having this condition might be
classed in three groups according to the intensity of the
symptoms, whether mild, moderate, or severe. The de-
gree of intensity of the symptoms depended upon the
quantitv and frequency with which the foreign m-otein
was injected. There may also be a family predisposi-
tion to some form of sensitization in the father, mother,
or grandparents to the protein of egg, milk, oatmeal,
fish, or some other food. It was important to know
whether one was dealing with a patient with such a
hereditary tendencv. The skin manifestations which
apeared first might be the form of the mildest ery-
thema, or an intense urticaria, or there might be single
wheals like an insect bite, or again it might be of the
miliary type, the class of eruptions formerly classified
as intestinal rashes. There might also be vasomotor
disturbances, as sneezing snuffles, or dry cough, as in
infants who had many colds and never showed any
pathological lesion ; these were frequently showing the
first symptoms of anaphylaxis. Other symptoms were
asthmatic attacks which appeared and then disappeared
as suddenly as they had come, recurrent attacks of
acute indigestion, fretfulness, irritability, and sleep-
ness. Fortunately all these symptoms did not usually
appear in one child. Sometimes one and sometimes
another of these symptoms would be premonitory. At
times the symptoms persisted throughout life and some-
times they disappeared later in life. Certain nutritional
disorders of a biological character might be of this
nature. Many of these symptoms were symptoms of
other diseases, but when one got this group of symp-
toms and they recurred from time to time they should
478
MEDICAL RECORD.
[Sept. 9, 1916
be suggestive of anaphylaxis and it was important to
have this condition recognized early.
Dr. Oscar M. Schloss of New York said that it was
only rational if they assumed that the acute explosive
attacks were of anaphylactic origin to believe that there
were milder types which bore a definite relation to them
but were not so marked. Many of the milder dis-
turbances might suggest sensitization to a food protein,
yet there was no definite evidence that such was the
case. Many more experiments would have to be made
before one could make definite statements on this phase
of the subject. The question of heredity in connection
with protein sensitization was of great interest. In the
majority of cases reported and in those he had seen the
parents or others in the family had shown some allied
condition. Usually the treatment of desensitization
which he had described gave good results.
Dr. Fritz B. Talbot of Boston said it should be re-
membered, in discussing this problem, that the condition
of anaphylaxis which gave symptoms was a relatively
rare one. In looking over hospital records he had found
that there were relatively few cases of asthma, but a
considerable number of skin cases that might be due to
anaphylactic action. He had been able to find few cases
of erythema due to anaphylaxis, but he believed that all
urticarias were due to some form of anaphylaxis.
Miliary rashes he was unable to connect with any
anaphylactic phenomena. Rough skin might be due to
anaphylaxis; it had seemed to have such a connection in
one case and also with deficiency of thyroid secretion.
Some of these cases gave a definite skin test, but they
did not always get well when one took out the food that
gave the skin reaction. The respiratory symptoms,
common colds and snuffles, Dr. Talbot said, he would
put down to adenoids. Other symptoms which were
mentioned in connection with the respiratory system
he would diagnose as bronchitis or croup. Some symp-
toms of indigestion were of anaphylactic origin, but he
thought this was one of the last things in connection
with anaphylaxis that they would be able to prove.
Several of his patients had volunteered the information
that when they took a protein to which they were sen-
sitized they had the sensation that it stayed in the
throats, and some said that it gave them a shivering
sensation.
Calcium Metabolism in a Case of Hemophilia. —
Dr. D. Cowie and C. H. Laws of Ann Arbor presented
this report. They stated that the subject upon whom
the observations were made was a hemophiliac and gave
a family history of bleeding. They found that by ad-
ministering large doses of calcium the calcium content
of the blood could be raised but as soon as the calcium
was discontinued it immediately dropped. The con-
clusions they drew from this work were that in this
hemophiliac the calcium content of the blood was below
normal : that by feeding calcium the amount of calcium
in the blood could be increased appreciably, and that
during this time the coagulation time was lengthened.
The Calcium Content of the Blood in Rachitis and Tet-
any.—I Ms. John Howland and McKim W. Marriott
presented the results of this investigation. They re-
viewed the theories that had been advanced in respect
to rickets and calcium metabolism, and said that there
had been no studies made to show whether calcium was
present in sufficient amounts in the blood of rachitic
patients. They had advised a method by which they
could determine the amount of calcium in one-half c.c.
of blood serum, and had determined the calcium content
in the blood of 11 cases of rickets and a number of
rols. They had found in the greatest number of
instances a value between 10 and 11 mg. per 100 c.c.
of blood serum. In those having rickets there was in
some instances a reduction of calcium, but they never
found less than 9 mg.. and often ten or nearly 11, so
they thought that they could say that rickets did not
depend upon an insufficiency of calcium, but primarily
or some condition in the bone. It had also seemed
e calcium disturbance was related to the onset
tetany. They therefore determined the amount of
i urn in the blood of seven infants with tetany by
means of accurate technique and all showed a marked
action in the calcium content of the blood. They
found that in general the figures ran between 6 and 7
mg. of calcium per 100 c.c. of serum, though in one
instance it was as low as 5 mg. They also' made the
determination in two children with no active symptoms
of tetany, but who gave an electric reaction, and in one
of these there was a moderate reduction of the calcium
and in the other none. When the child lost the evi-
dences df tetanus the calcium content of the serum be-
came normal. The findings in children with convul-
sions were almost the same as in dogs that developed
tetany after thyroidectomy, in that the calcium content
was somewhere between five and seven mg. per 100 c.c.
of serum. It seemed that the parathyroid exerted a
distinct effect on the calcium in the blood.
Dr. L. Emmett Holt said the findings of Dr. How-
land were very well borne out by the effect of magne-
sium sulphate administered hypodermically in tetany.
He had given calcium chloride by the mouth in large
doses, but the results were slow in manifesting them-
selves. During the last two years he had been admin-
istering magnesium sulphate hypodermically and the re-
sults manifested themselves in from fifteen to twenty
minutes. One did not need to repeat this oftener than
once in twenty-four hours. One should use the anhy-
drous salt which was twice as strong as Epsom salts.
Early Morning Toxic Vomiting in Children. — Dr.
Thomas S. Southworth of New York read this paper
in which he directed attention to the vomiting of chil-
dren which not infrequently occurred in the early morn-
ing either before or soon after the first feeding. This
he believed was of toxic origin since the vomitus after
the long night period contained no food residue unless a
morning feeding had been given. It was sharply dis-
tinguished from the vomiting of undigested and fer-
menting food from failure of gastric digestion, which
usually occurred later in the day. The cases, one of
which was related as typical, had neither the charac-
teristic histories nor clinical symptoms and course of
recurrent vomiting, which was another toxic type. In
the recurrent type the toxemia was probably of gradual
and cumulative evolution, brought to a head by con-
stipation or some unusual factor. Elimination was slow
and vomiting prolonged. Fever was not constant. In
the type under consideration with early morning vomit-
ing fever was a usual accompaniment, often rising
sharply, and there was an acute putrefactive process
in the intestine with absorption and attempted re-
elimination by the gastric mucous membrane. It was
assumed that this toxic material accumulated in the
stomach during the hours of slumber when reflexes were
more or less deadened and asserted its presence in
vomiting after awakening. Purgation resulted in foul
stools often containing mucus. After the stomach was
emptied by one or two acts of emesis at short intervals
there was not the same tendency to recur which ob-
tained in the recurrent type. The extreme caution in
the resumption of feeding often displayed after attacks
of recurrent vomiting frequently led to under-nutrition
in children whose attacks occurred at rather short in-
tervals. A slightly greater care was demanded in the
acute toxic type of intestinal origin, especially in the
summer months because of the intestinal condition, but
with care and reasonable feeding might be promptly
inaugurated. The author believed early morning vomit-
ing without food residue from the previous day to be a
sign of value as indicating an acute toxemia arising
in the intestinal tract.
Dr. T. DeWitt Sherman asked Dr. Southworth if
he had had gastric analyses made of the vomited
material at any time and whether it showed achylia of
hyperchlorhydria and whether there might be a neurotic
element involved.
Dr. Fritz B. Talbot asked Dr. Southworth if he had
tested for acetone in the early morning urine. He said
he had quite a number of instances of this kind and
invariably found acetone.
Dr. Isaac Abt of Chicago said that the vomiting
might be the effect of something outside the gastroin-
testinal tract. The chronic alcoholic vomited because
he had a nasal pharyngitis. It was possible that a
pharyngitis might have had something to do with the
production of the vomiting in several of these cases.
Dr. Southworth said he had made no such examina-
tions and it was probable that some of these children
might have had hyperchlorhydria. If there was a defin-
ite odor of acetone an examination of the urine was
made. As to Dr. Abt's question, if he had seen these
cases there would have been no question in his mind
that they were as stated. A child coughed a great deal
because of the presence of mucus in the pharynx, but
the type of case referred to had no cough which could
have been the cause of the early morning vomiting.
A Study of the Etiology of Chorea.— Drs. John
Lovett Morse and Cleavki \m> Floyd of Boston pre-
sented this communication which was read by Dr.
Morse. He said this study was undertaken primarily to
determine, if possible, the parts which syphilis and
bacterial infection played in the etiology of chorea. A
Sept. 9, 1916J
MEDICAL RECORD.
479
review of the literature seemed to show that there was
very little evidence in favor of the syphilitic origin of
chorea and mucn against it. In their investigation of
26 cases of chorea tnere was nothing whatever in the
history of 21, or 81 per cent., of these cases to suggest
syphilis. In the others there was a history of miscar-
riages. The blood of three of the children in whose
families there was a history of miscarriages gave a
negative Wassermann test. None of the children
showed any of the stigmata of syphilis. Of the 25
children in this series, 21, or 84 per cent., gave a posi-
tive skin reaction to tuberculin, yet it would be absurd
to assume that tuberculosis was the cause of chorea in
these 21 children. The conclusion, therefore, seemed
justifiable that syphilis seldom, if ever, played an active
part in the etiology of chorea. This series of cases con-
firmed the general belief as to the frequency of the
association of chorea with rheumatism and endocarditis.
Seven, or 37 per cent., had had rheumatism in the past
or in connection with the chorea; six of them had acute
endocarditis, and six chronic valvular lesions, a total of
12, or 46 per cent. The tonsils were normal in but 11
cases, or 42 per cent., and had been removed on account
of disease in four others. The teeth were normal in
but seven of these patients; pyorrhea was present in
two, and definite pus pockets were found in three others
when the teeth were extracted. A review of the litera-
ture showed that the results thus far obtained from
blood cultures were inconsistent and inconclusive. Dr.
Morse said that during the past year he and his asso-
ciate had made a study of these 26 cases of chorea in
the acute stage of the disease with a view to determin-
ing the presence of an infecting agent in the blood
stream and cerebrospinal fluid, the frequency with
which it could be obtained, and its cultural characteris-
tics. In every instance the cultures as well as the
smears from the cerebrospinal fluid were negative.
Blood cultures were negative in all but five instances.
In one case a small bacillus, diphtheroid in type, ap-
peared. This was a Gram negative organism and was
not pathogenic for rabbits. Diplococci were found in
one case, but no organisms were cultivated. In both
of these instances the tonsils were enlarged and the
teeth carious. In another case positive blood cultures
were obtained after ten days of incubation and this
patient had endocarditis and had had several attacks
of rheumatism. Autopsy in this case showed a general
septicemia and cultures from the heart's blood and the
knee joints gave a good growth of streptococci. The
fact that the organism taken from this patient caused
lesions in the brain and meninges of rabbits similar to
those found in the brain and meninges of this patient at
autopsy suggested that it was also the cause of the
chorea in this child. The absence of organisms in these
cases might be explained by the fact that most of them
were mild or only moderately severe in type. It might
also be possible that the failure to detect the organisms
more often in the blood or spinal fluid might have been
due to the fact that they were only tempo-
rarily present in the blood stream and tended to locate
themselves in the meninges, endocardium, or joints.
< While there was much that pointed to a microorgan-
ism or group of microorganisms as the cause of chorea
the bacterial origin of chorea was not as yet proven.
The Effect of Subcutaneous Injections of Magnesium
Sulphate in Chorea. — Dr. Henry Heiman of New York,
presented a brief report on several cases of chorea
treated by subcutaneous injections of magnesium sul-
phate. He said the effect of this agent seemed to be
entirely negative and that they could not hope to give
any relief in chorea by the administration of magnesium
sulphate subcutaneouslv.
The Prognosis and Treatment of Banti's Disease in
Children. — Dr. Edwin E. Graham of Philadelphia read
this paper. He stated that the juvenile form of this
disease tended to run a more acute course than the
adult form. If not treated or if treated only medicinal-
ly it was almost invariably fatal. Under sure-ical
treatment the prognosis was rather more favorable than
otherwise, the outlook depending upon the duration of
the disease at the time the spleen was removed. If done
early splenectomy was attended with slight mortality,
and in uncomplicated eases a cure might be expected;
but when the disease was complicated by other affec-
tions of chronic infectious nature, the value of the
operation was questionable. Splenectomy was even
more advantageous in children than in adults. After
the removal of the spleen in most cases the blood picture
more or less approached normal, but in a few cases it
might vary greatly, so that five years might elapse be-
fore the count became normal. When Banti's syndrome
was well established the prognosis was most unfavor-
able even though splenectomy was performed. If an
abundance of iron was supplied to the system after the
removal of the spleen wmch was the organ in which
metabolism took place, polycythemia would take place in
many cases, and an increase in red cells was always
noted at varying intervals after operation ; therefore in
splenic anemia iron was undoubtedly indicated both
theoretically and practically. Splenectomy was both
useless and dangerous in cases in which the hemoglobin
was below 30 per cent., and the red cells below 2,000,000.
The operation should as a rule be attempted only when
there was no edema, no parenchymatous nephritis, and
no serious degenerative change in the liver, and while
the patient was still able to go about. In severe casee
blood transfusion done shortly before the operation
seemed to increase the ability of the child to with-
stand the shock of the operation. Dr. Graham re-
ported in detail a case of splenectomy in a child nine
years of age in which recovery ensued.
Dr. Henry Koplik said he thought there might be
some question whether all the cases reported as Banti's
disease were really such. He cited an instance of a
patient who as a boy had jaundice and an enlarged
spleen. Operation was refused. The boy had grown to
manhood and was now an engineer. He was now in
apparently good health though he still had an enlarged
spleen and liver.
Wednesday, May 10 — Third Day.
Familial Icterus in the New Born. — Dr. Isaac Abt.
of Chicago made this contribution. He stated that
familial icterus had nothing in common with Buhl's or
Winckel's disease. There was no evidence to prove that
it was a septic process. It was not present at birth, in
none of the cases reported was there a history of birth
injury, and it did not seem to be due to the toxemia of
pregnancy. One might say that the children were in
a sense defective and very soon after birth became in-
capacitated to carry on extrauterine life. The disease
usually began on the second day of life and rapidly in-
creased in severity. The symptoms were those de-
scribed by Pfannenstiel, namely, catarrhal condition of
the mucous membrane, sometimes with bloody discharge,
frequent catarrhal stools, bile pigment in the urine, and
meningeal irritation. The disease occurred in succes-
sive pregnancies. Occasionally several normal children
would be born and then several would die in a few days
after birth as the result of grave and progressive
icterus. The disease bore no relation to syphilis and
had nothing in common with family jaundice. Isolated
instances of this condition had been reported from time
to time, but the writer had encountered examples of
familial icterus in the new born in two families. The
first occurred in an Italian family in which there was
nothing in the history of the parents or grandparents
in any way connected with the condition in this infant.
The mother had borne five children, two of whom were
living and three dead. The two eldest children had al-
ways been well; the third baby seemed strong and
robust at birth, developed jaundice on the second day
and died on' the third day. The history of the fourth
and of the fifth, the case he had observed, was the
same. The second case occurred in a Russian family.
The mother. 23 years of age, had borne six children.
The first child had chronic nephritis and was 11 years
of age. The second child was living and well. The
third pregnancy resulted in miscarriage. The fourth
child became jaundiced on the second day, was seized
with convulsions, had freauent stools, became worse,
and died on the third day. The fifth child gave a simi!ir
history. The sixth child became jaundiced on the sec-
ond dav, its condition grave on the third dav, but on the
fifth day an improvement was noted, the jaundice
gradually disappeared, and the baby was now a year old
and well.
Dr. WILDER TlLESTON of New Haven called attention
to the fact that in these cases there was a yellow icterus
staining of the base of the brain which was never seen
in jaundice and which might be correlated with the
nervous symptoms.
Dr. T. DeWitt Sherman of Buffalo said that poisons
had been mentioned as a cause of jaundice and the
auestion had occurred to him whether jaundice and al-
lied conditions might be due to the poison of chloroform
administered to the mother at the time of labor, since
they knew that chloroform produced hyaline and fatty
degeneration and this effect was concentrated on the
liver.
480
MEDICAL RECORD.
LSept. 9, 1916
Measles, Pertussis, and Pneumonia. — Drs. . P. J.
EATON and E. B. Woods of Pittsburgh reported a group
of cases which appeared simultaneously in one family
chiefly because it showed the peculiar mix-up of infec-
tious disease that might be possible. Two children in
a family were about half way through whooping cough
when a third child came down with measles, then
whooping cough, followed, by a chest deformity, which
gradually disappeared. One of the two children hav-
nig whooping cough contracted measles, which was fol-
lowed by pneumonia, while the other did not; the latter
child was watched very closely. The measles cases
were treated by cool, fresh air and vaccines. Di . Eaton
stated that it was his custom to administer vaccines to
children who were exposed to measles.
Scarlet Fever and Measles Occurring Simultaneously.
— Dr. D. J. Milton Miller of Atlantic City presented
this paper. He said he reported these cases not be-
cause of their great rarity but because they were in-
teresting. There was an impression that if a child was
suffering with one infectious disease he was immune to
others, but this was a mistake. Patients suffering with
one infectious disease seemed to be more susceptible to
other infections. This seemed to be especially true of
measles, pertussis, and scarlet fever. It was quite usual
when one of these diseases occurred to have it followed
at short intervals by another or they might be concur-
rent from the outset. In scarlet fever and measles
the diagnosis was very difficult. The case presented
had the usual symptoms of measles. On the tenth day
a characteristic scarlatinal desquamation was observed,
and a complicating otitis media followed. Three sisters
of the patient contracted measles but not scarlet fever.
One of these children who was not isolated did not
contract scarlet fever. One of the sisters who never
came in contact with the patient contracted measles.
Dr. Matthias Nicoll of New York emphasized the
fact that the character of the desquamation in scarlet
fever was not always typical. He had seen sheet des-
quamation in measles, though it was rare.
Dr. Miller said he felt convinced that his first case
was one of scarlet fever, as the peculiar eruption at
the finger nails was present and he had never seen
this in any other disease than scarlet fever; his diag-
nosis rested to a great extent on that.
Observations on Measles. — Dr. Charles Herrman
of New York presented this communication. He stated
that the deaths reported as due to measles gave an
inadequate idea of the real number caused by this dis-
ease. A large number died from complicating broncho-
pneumonia, especially between the ages of one and
two years. This was suggested by the parallelism be-
tween the curve of morbidity from measles and the
curve of mortality from bronchopneumonia between one
and two years of age. In a series of 300 secondary
cases of measles which he had observed, the fever ap-
peared on the tenth or eleventh day from the time of
infection in 56 per cent.; catarrhal manifestations on
the eleventh or twelfth day in 60 per cent.; the ton-
sillar spots on the ninth "to the thirteenth day; the
Koplik spots on the eleventh or twelfth day in 54 per
cent.; the eruption on the twelfth to the fourteenth day
in 67 per cent. In 7.2 per cent, the catarrh was present
on or before the tenth day; the Koplik spots in 12.8,
and the tonsillar spots in 34 per cent. In 4 per cnt.
of the cases in which the tonsillar spots were present
as early as the sf/enth day and in a few cases the ton-
sillar spots were present in patients who did not show
the Koplik spots. The presence of the tonsillar spots
would be found valuable in schools, hospitals, and
asylums, in detecting and isolating the patients early.
Infants under two months of age were absolutely im-
mune. At eight months this immunity had gradually
disappeared. This gradual disappearance was shown
by a longer period of incubation. In infants between
five and eieht months the disease was usually milder.
This was also shown by the fact that onlv 11 per cent,
of these lost weight, whereas of those between eight
months and two years 76 ner cent, showed such a loss.
The immunity was probably conveyed through the pla-
cental circulation; onlv those infants whose mothers
had the disease seemed to acquire it. Infants between
three and five months who had come into intimate con-
tact with measles and did not contract it. sometimes
were not infected when exposed later in life.
Dr. Henry KOPLIK said that five days before the ap-
pearance of the eruption in measles a febrile move-
ment and the Koplik phenomenon might be observed.
There was absolutely no other reaction "during this time
except the slight fever.
Dr. S. McC. Hamill of Philadelphia asked Dr. Herr-
man if he implied that it would be a good thing to
expose children under five months of age to measles.
Dr. Herrman, in closing, said he had not said that
it would be a good thing to expose children under five
months of age to measles because one could not be ab-
solutely sure that they would not contract the disease.
He would not like to put himself on record as advising
exposure of a child to an infectious disease. What he
had brought out in his paper would explain why chil-
dren from five to eight months of age had the disease
in a mild form.
The Energy Metabolism of a Cretin. — Dr. Fritz B.
Talbot of Boston presented this study. He said that
a typical cretin, three years and 8 months of age, was
studied in the respiratory chamber devised by Benedict
in the Laboratory of the Carnegie Institute at Wash-
ington. They found his basal metabolism per kilo body
weight was 40% calories per square meter body sur-
face, 898 calories per 24 hours (Lissauer). In the
absence of normal data in children of the same age,
this metabolism was compared with that of a normal
eight months' baby and a normal ten months' baby.
It was found that the metabolism of the cretin was de-
cidedly lower than that of the two normal babies. Un-
fortunately results after treatment with thyroid had
not been sufficiently accurate to use. These results
were consistent with those of Magnus Levy and the
more recent work of Dubois in Lusk's Laboratory. The
practical application of these findings was that the
cretin required less food than children with sufficient
thyroid activity and after treatment with thyroid ex-
tract would require more food than before treatment.
The Bacteriology of the Urine in Healthy Children
and Those Suffering from Extraurinary Infection. —
Dr. Henry F. Helmholtz of Chicago reviewed the
various theories as to the mode of infection in pyelitis
in children and said he thought a study of the bac-
teriology of the normal urine and urethra might
throw some light on this problem. With this ob-
ject in view he had examined catheterized specimens
taken from thirty infants and from thirty-one girls
over two years of age. The urine was collected by a
very careful technique. It was found that in 119 spe-
cimens taken from 61 different individuals, 61 were
sterile, and 58 contained bacteria. Of those from 24
normal infants 13 were sterile and 11 contained bac-
teria. In specimens from girls over two years of age
35 were sterile and 27 contained organisms. The num-
ber of bacteria found in the first series was consider-
ably larger than in the second. This might be ex-
plained by the fact that in the older children one could
cleanse the urethral orifice much easier and could in-
troduce the catheter directly into the urethra. The
bacterial flora was practically the same in both series,
Gram positive staphylocpeci and pseudodiphtheroid or-
ganisms predominating; the former were present in
practically every case in which any organisms were
found. The writer concluded that it might be assumed
on the evidence given that organisms of the colon
group were not normal inhabitants of the female
urethra and that in extra-urinary infections occurring
in the first two years of life the colon bacilli were fre-
quently found in the urethra, that was in about one-
third of the cases. In girls over two years of age the
urethra was almost free from organisms and entirely
free from organisms of the colon group.
Oxycephaly in Two Brothers. — Dr. W. W. Butter-
worth of New Orleans reviewed the literature of this
subject and said the classical symptoms of oxycephaly
were exophthalmos, pain, and some disturbance of
vision. It was a rare occurrence to find this condi-
tion in two brothers with a history of a similar con-
dition in the grandfather. These children were not
mentally deficient. The condition had been variously
attributed to ossification of the sutures, defective bone
development, and a hydrocephalic condition in infancy.
The x-ray pictures showed a mottling of the inner
plate of the cranium and .r-ray pictures of the other
bones showed that enlargement of the condyles of the
large bones was not unusual and that there was some
enlargement of the bones of the face.
Meningitis in the New Born and in Infants under
Three Months of Age. — Dr. Henry Koplik of New
York presented this communication. He said that men-
ingitis in the new born might be secondary to general
sepsis or it might occur as a primary infection. The
symptomatology in the primary condition was very ob-
scure. The signs by which meningitis was recognized
in older children were not applicable to these babies.
Sept. 9, 1916J
MEDICAL RECORD.
481
There was no rigidity, no bulging, no Babinski, and
no condition of muscle clonus, so that it was not to be
wondered at that the diagnosis was difficult to make.
He had sought for some characteristic symptoms. He
had found that the convulsions might be simple or there
might be only slight twitchings of the extremities.
Again, there might be only one convulsion with very
high fever 105" F. or over, and then this might remit
or subside. After the disease had lasted for a week
or ten days the temperature came to a lower level and
might run along at about 100° F. or slightly above.
Bulging of the fontanel was not present; in some cases
there seemed to be a depression. Macevven's sign was
very difficult to determine in new born babies. Some
gave the signs of fluid in the head and some did not.
It was only later in the disease after a week or ten
days that one could get the signs of fluctuation, and
the increase in the quantity of fluid could be detected
by the bulging and by the tympanitic note over the
temple. The trauma incident to difficult labors made
the diagnosis more difficult in some instances. In some
infants the disease was very severe and in some the
symptoms were so mild that even the mother did not
notice them until the child was two and one-half to
three months old. The results of lumbar puncture in
these cases was very interesting. In a series of twelve
cases the streptococcus was isolated four times, the
pneumococcus three times and the meningococcus three
times; two were secondary cases. One case showed
very distinctly that the meningitis was secondary to
arthritis. In the secondary cases the streptococcus
was found i,. the blood. The other case which he had
observed began with a pyelitis and later developed a
colimeningitis as a secondary infection. The fate of
these babies was disheartening; they were all fatal
sooner or later. Only one out of the twelve was still
alive and that one had a marked hydrocephalus. New-
born babies did not bear lumbar puncture well. In
discussing the modes by which infection might take
place, Dr. Koplik suggested that during resuscitation
by the suction method infection might be conveyed if
the attendant was a meningitis carrier, and it might
also be the result of trauma or of putting the fingers
in the infant's mouth.
The Use of Salt Solution by the Bowel in Infants
and Children. — Dr. Edwin E. Graham of Philadelphia
presented this paper in which he said that his ex-
perience with the Murphy method of injecting saline
solution by slow proctoclysis in certain conditions in
children had led him to believe that it was of much
more value to the pediatrist than most of them were
aware of. In the acute infectious diseases toxemia
might be greatly influenced by the employment of the
Murphy drip. It was also of value in uremia and
suppression of urine and generally speaking for toxemia
from any cause, whether it was autointoxication, min-
eral poisoning, or septicemia. If nephritis with edema
was present the administration of salt solution by this
method was unwise, although in a few such cases it
had apparently been employed with success. Dr.
Graham said he had been greatly impressed by the re-
sults of the Murphy drip in profuse diarrhea due to
intestinal infection. In employing this method there
were several points to be observed: The catheter must
be introduced 4 or 5 inches into the bowel; there
must be a good return flow, and the water must be
kept at a temperature of about 110° P. The water
should have a drop of about 12 inches. It was a good
plan to allow it to flow for an hour and then allow
the patient a rest of one hour. If slight edema made
its appearance the treatment was to be discontinued.
The solution should be carefully prepared; to say a
teaspoon of sodium chloride to a pint of water was
exceedingly inaccurate.
A Case of Disseminated Sclerosis. — Drs. George N.
Acker and Josepf S. Wall reported this case. Dr.
Acker stated that the patient was a colored child 4%
years of aee. who came to the out-patient department
of the Children's Hospital on March 2, 1916, com-
plaining of "nervousness " The family history was
negative. The child's trouble had come on gradually
and she had grown progressively worse. The chief
symptoms presented were shaking of the body, nystag-
mus, exaggeration of all the reflexes, rapidity of pulse,
but not enlargement of the heart. Ten davs later her
symptoms were aggravated and her mental condition
se»~>ed dulled. The drinking test pave rise to a typical
vo''+;onal tremor. There were marked elbow and wrist
ierk<= and ankle clonus was present in both extremities.
The heat and cold sense were apparently normal except
in the right thigh where there was some dissociation of
the senses. The writers were of the opinion that the
case fell into the category of disseminated sclerosis.
Dr. Joseph S. Wall of Washington reported on the
present condition of the child which, he said, was, on
the whole, changed but little from that recorded in the
paper.
The Danger to Hospital Efficiency from Diphtheria
Carriers.— Drs. Samuel S. Adams and Frank Leech
of Washington, D. C, made this contribution. They
emphasized the point that there must be team work on
the part of all connected with the hospital from the
highest authority to the humblest employee. Among the
numerous details that were requisite for the proper
administration of a hospital it was important that every
hospital have a well-trained medical superintendent who
should have exclusive control over all matters con-
nected with the hospital. The members of the medical
staff should be medical men who had been promoted
from dispensary work. Provision should be made for
follow-up work not only for the hospital but for the
out-patient department. Efficiency experts should be
engaged from time to time to check up the work and
criticise the same, from the president of the Board of
Directors to the orderly. The writers then described
a diphtheria epidemic in the hospital with which they
were connected which had greatly hampered the work
of the hospital for a number of weeks. The occur-
rence of two cases of diphtheria led to a culture of
every individual in the house with the result that 51
positive cultures were found out of a total of 100,
including employees, nurses, and internes. The hos-
pital wards were closed for a period of three weeks to
the reception of new patients. At present they had
reduced the number of positive cultures to seventeen.
A search for the source of infection seemed to point
to a nurse in the baby ward who had suffered from
sore throat. There were twelve babies in this ward
and eight gave positive cultures. To prevent the oc-
currence of such outbreaks they felt convinced that
all institutions for the care of sick children should be
provided with a suitable detention ward for the de-
tention of all new admissions. Cases when admitted
should have nose and throat cultures taken and be
placed in the detention ward for five days. If it was
impossible for financial reasons to provide a deten-
tion ward, cubicles should be provided in each ward
and proper nursing technique carried out to prevent the
dissemination of minor contagions. Illness in internes
and nurses should be immediately attended to. Visitors
to ward patients should be restricted to adults only,
and such visitors admitted as infrequently as possible.
Tests of the virulence of diphtheria carriers should
be made, thus relieving ourselves at once of a large
number of cases which it would be otherwise neces-
sarv to isolate.
The Schick Reaction in Infants.— Drs. Henry L. K.
Shaw and William E. Youland of Albany presented
this communication. They stated that there was no
question of the accuracy of this test in detecting; the
individual susceptibility and immunity to diphtheria.
A review of the results of the Schick test as reported
by various observers in cases under one year of age.
snowed a variation of from 0 to 40 per cent., and
from one to two years of age the variation was from
15 to 65 per cent. The writers had made an investi-
gation among ninety-five infants under two years of
age in two infants' institutions and two hospitals in
Albany. In making the tests they used the standard
diphtheria toxin diluted so that 1 c.c. contained one-
fifth the M. I. D. and 0.1 c.c. of this diluent was used
in making the test. The procedure of Park and Zin-
gher of heating one-half of the diluted toxin at 70° C.
for three minutes was used for the purpose of con-
trol. The reactions were read daily and the final in-
terpretation made on the fourth day. In practically
no case did a typical pseudo reaction occur. In some
cases the reaction did not appear until the third day,
though it appeared more frequenfv on the second day.
In 66 children under one year of age they found 47
per cent, positive, while of 29 children between one
and two years of age 58.6 per cent, were nositive.
These results were remarkably similar to those of
Park and Zingher. From their exnerience with this
grouD of cases it would seem that when virulent diph-
theria bacilli were found in infants having no anti-
toxin in their tissues, a careful examination for diph-
theritic rh^;tis shou'd be made, as thev hid five cases
in which, without such examination, it would have been
overlooked.
482
MEDICAL RECORD.
[Sept. 9, 1916
STATE BOARD OF EXAMINATION QUESTIONS.
Ohio State Board of Medical Examiners.
June 6, 7, 8 and 9, 1916.
(Concluded from page 398.)
PRACTICE.
1. Describe the symptom complex of uremia; tell
how you might suspect it to be impending in a given
case, and what treatment you would employ in an
effort to avert it.
2. In what diseases should one be on the lookout for
acute endocarditis, and how would you recognize its
occurrence?
3. Give symptoms of cancer of the liver involving the
neighborhood of the hepatic duct.
4. Given a case of a man of sixty-five of alcoholic
history, with edematous ankles, dyspnea, and cough
with occasional bloody expectoration, albuminuria, and
blood pressure of 150 (sys.) ; what would be your pre-
sumptive diagnosis?
(6) Trace the prognosis of the case from the primary
condition.
5. In an instance of alleged hematemesis, give other
possible sources of the blood, and tell how you would
recognize the origin in a given case.
6. Describe your treatment of a case of pulmonary
tuberculosis, moderately advanced, involving chiefly
one side, with a temperature of 101° Fahrenheit, and
subject to occasional hemorrhage.
7. Give symptoms and treatment of a case of in-
fluenzal pneumonia.
8. Give symptoms of acute myelitis, differentiating
it from multiple neuritis.
9. Mention some indications of cerebral syphilis.
How would you make a positive diagnosis? Briefly
outline the treatment.
10. How would you treat a case of acute articular
rheumatism?
DERMATOLOGY, SYPHILOLOGY, AND DISEASES OF EYE, EAR,
NOSE, AND THROAT.
1. Describe psoriasis. Give treatment.
2. Of what disease is the occurrence of pruritus ani
a frequent sign?
3. Upon what evidence would you base a belief that
a patient is cured of gonorrhea"?
4. Describe signs and symptoms of congenital syph-
ilis.
5. Outline an approved treatment of syphilis.
6. What are the dangers of acute suppurative in-
flammation of the middle ear?
7. Describe trachoma. Give treatment.
8. Describe tuberculous laryngitis.
9. Give treatment of acute suppurative inflammation
of frontal sinus.
10. Give treatment of nasal polypi.
OBSTETRICS.
1. When would you be justified in inducing prema-
ture labor?
2. How would you diagnose the existence of preg-
nancy?
3. What are the symptoms of fetal death?
4. State the indications and contraindications for the
use of the curette and describe the technique of this
operation.
Name the stages of labor and describe the man-
agement of the third stage in detail.
SURGERY.
1. Shock: (a) Cause; i l> 1 Symptoms; (c) Outline
t reatment.
2. Acute Suppurative Appendicitis, (a) Diagnosis:
(1) Subjective and objective symptoms; (2) Dlfferen-
between this and similar abdominal disorders;
Preliminary treatment. (6) Operation: (1) Sur-
gical technique; (2) After treatment; (3) Prognosis.
' "lies' Fracture: (a) Diagnosis; (6) Pathology;
(c) Treatment.
4. Hip-Joint Disease: (a) 1'iagnosis; (/») Treat-
ment— surgical, mechanical: (c) Prognosis.
nshot Wounds: (a) Give rule regarding prob-
ing; (6) Give rule regarding immediate operation; (c)
In a gunshot wound of the knee what would be your
course of pursuance?
ANSWERS.
PRACTICE.
1. Symptoms of uremia. — Headache, insomnia, con-
vulsions, vomiting, delirium, dyspnea, amaurosis, and
coma. Uremia may be suspected from the presence of
nephritis, a urinous odor of the breath, scanty urine,
and increased arterial tension.
The patient should be put to bed; croton oil (1 minim)
may be administered; vensection and dry cupping over
the kidneys may be tried; diaphoretics are useful.
2. Endocarditis is apt to occur during or following
rheumatism and scarlet fever. The signs and symptoms
may be negative; but there is generally some alteration
in the character of the heart sounds, and dilatation of
the heart may be present; the pulse rate is often in-
creased. The sounds heard depend upon the valve af-
fected, and since the mitral valve is the one most com-
monly involved there is apt to be a systolic murmur
heard best at the apex and transmitted to the left axilla.
3. Symptoms of cancer of liver. — Pain, tenderness,
and a sense of weight in the hepatic region; emaciation
and weakness; cachexia; jaundice, vomiting, and fever.
4. The case is one of cardiac decompensation, follow-
ing endocarditis (which may have been due to rheuma-
tism, scarlet fever, or some other infection). The
prognosis of endocarditis is good so long as compensa-
tion is maintained ; but is unfavorable when compensa-
tion is ruptured.
5. In a case of alleged hematemesis other possible
sources of the blood are: The blood may have been
swallowed (as in epistaxis, after tonsillectomy, pul-
monary hemorrhage). The main question is to dif-
ferentiate between hematemesis and hemoptysis:
Hematemesis.
Hemoptysis.
1. Previous history of gas-
tric, hepatic, or splenic
disease.
2. Blood is vomited.
3. Blood is dark colored
and not frothy.
4. Blood may be mixed
with food.
5. Giddiness or faintness
usually precedes vomit-
ing.
6. Nausea and weight in
epigastrium.
7. Often followed by mel-
ena (black, tarry
stools).
1. Previous history of pul-
monary troubles.
2. Blood is coughed up.
3. Blood is frothy and
bright red.
4. Blood may be mixed
with sputa.
5. Sensation of tickling in
the throat usually pre-
cedes.
6. Dyspnea and pains in
the chest.
7. Is not usually succeed-
ed by melena.
I Hughes' Practice of Medicine.)
6. Treatment of pulmonary tuberculosis : — "By day
the consumptive should be, short of actual fatigue,
as much as possible in the open, and at night the win-
dows should be widely open top and bottom. Where
there is fever he must keep to bed; but when possible
the bed should be outside, and where that is not pos-
sible the windows must remain open in presence of
fever or any other acute symptom. In ordinary cir-
cumstances he should sleep alone. A stuffy bedroom
with several people in it means rapid deterioration for
the patient, and infection for the rest. Sanatorium
treatment is not yet possible for all, nor, except in in-
cipient cases, and in the rich, can it be continued long
enough for cure; but it reduces the disease to a quiescent
stage, and trains the patient in the habits he must
afterwards continue. Sea voyages undoubtedly do good
in many cases of early phthisis, the comparative steril-
ity of the air contributing to the result; but no con-
sumptive who is not a good sailor should be sent on
such a voyage, nor any one who is unable to travel in
comparative comfort, or who must travel alone. In the
later stages sea voyages are contraindicated. If
change of climate is decided upon, the place selected
should be sunny, and should give facilities for the open-
air life. Either a dry cold climate may be chosen or a
warm one, according to circumstances. In the earlier
stages cold dry air is best. High altitudes are, how-
ever, unsuitable for those with a tendency to hemopty-
sis. Adjuvants to the open-air treatment are exercise
and dietetic t real meat. The consumptive should wear
wool or flannel next the skin, but should not be over-
loaded with heavy clothes. Tepid baths, followed by
brisk rubbing, are of benefit, and much good is done
by carefully graduated exercise, which promotes a regu-
lated auto-inoculation. The food must be nourishing
Sept. 9, 1916]
MEDICAL RECORD.
483
and varied, and ample in quantity, systematic over-
feeding, indeed, being advocated by many. Everything
must be done to combat the very common anorexia and
dyspepsia.
Medicinal Treatment is (a) General. — Creosote or
guaiacol, cod-liver oil, and tonics, such as the hypophos-
phites and arsenic, are the principal remedies, (b)
Symptomatic. — The following symptoms call for special
treatment: — (1) The cough. — As this is a persistent
and constant feature of the disease, avoid rushing at
once to cough mixtures. A common exciting cause of
the nightly cough is the changing from a warm room
to a cold bedroom; or again, tickling of the fauces by
the uvula. A useful combination is that of morphine,
spirits of chloroform, and dilute hydrocyanic acid. For
laryngeal and bronchial irritation, inhalations of tinc-
ture of benzoin or creosote are of much value. (2)
The night-sweats. — Picrotoxin, aromatic sulphuric acid,
atropine, and oxide of zinc are the favorite remedies.
Atropine gr. 1 100 to 1/80 in pill at night, is the most
reliable. (3) The dian-h-ea is usually best controlled
by mineral astringents, in combination with opium.
(4) Fever should be treated by rest, fresh air, quinine,
and cold sponging, or, if need be, the cold bath. Anti-
pyrin, etc., may be occasionally used. Hemoptysis de-
mands rest in bed, quiet, light food given cold, ice to
suck, injections of morphine and atropine or inhalation
of nitrite of amyl." (Wheeler and Jack's Handbook
of Medicine.)
7. Lobar pneumonia. "The first stage is character-
ized by sudden onset with chill, a sharp pain in the
side, rise of temperature, a short and sharp cough,
rusty-colored, viscid sputum, and dyspnea. There may
be headache, insomnia, scanty urine with diminution
of urea, chlorides, phosphates, and sulphates, insomnia,
and herpetic vesicles on the face, and there is always an
increase in the number of leucocytes in the blood.
Physical examination will reveal diminished expansion,
impairment of the normal percussion note, feeble or
suppressed respiratory murmur, moist or dry rales,
crepitation, and sometimes a pleural friction sound.
In the second stage the dyspnea is more marked; the
face is more or less livid in color; the temperature is
high (104°-105° P.) ; and the pulse increases in rate
(110-120), its tension and fullness lessening with the
progress of the disease, and growing feeble and inter-
mittent. Headache, delirium, and various other nerv-
ous symptoms may be present. Expansion is dimin-
ished and vocal fremitus is exaggerated upon the af-
fected side. There is dullness with increased resistance
over the consolidated lung, and auscultation detects
bronchophony or bronchial breathing over this same
area.
The third stage is ushered in by a sudden drop of tem-
perature on or about the fifth or ninth day, followed
by a natural sleep, free sweating, and relief from suf-
fering. In this stage the subcrepitant rale (rale re-
dux) is heard in the midst of the bronchial breathing,
together with numerous moist rales. Dullness may per-
sist for some time, but usually by the twelfth or four-
teenth day the lung has returned to its normal state."
Treatment : "Consists in rest in bed, milk diet, and
the administration of fractional doses of calomel fol-
lowed by a saline in the early stage. The nervous
symptoms and temperature may be controlled by apply-
ing ice-bags or compresses wrung out of cold water
(60°-70° F.) to the chest or by the use of the warm
or cold wet-pack. The heart and pulse should be sus-
tained by the administration of alcohol, strychnine (gr.
1/60-1/20), atropine, caffeine, strophanthus, and nitro-
glycerin. Digitalis may also be employed. Inhala-
tions of oxygen afford temporary relief when the
dysonea and cyanosis are extreme. In young, vigorous,
and plethoric adults, with hyperpyrexia and a high-ten-
sion pulse, bleeding may be beneficial in the first 48
hours. Convalescence should be guarded, and tonics,
stimulants, etc.. will be found very "seful in this period
of the disease." (Pocket Cyclopedia.)
8. Acute myelitis is generally of rapid onset, the feet
and legs become heavy and numb, twitching and con-
vulsions may occur, the flexors are more affected than
the extensors, walking is difficult, paraplegia develops.
there is usually some fever, there may be girdle sensa-
tion at the level of the lesions, anesthesia of bladder
and rectum are common, the reflexes will be absent if
the lesion extends completely across the cord, priapism
is common.
In multiple neuritis the onset is slower, the sphincters
are rarely involved, the sensory disturbances are more
severe, the extensors are more involved than the flex-
ors, atrophy of the affected muscles rapidly supervenes,
the mental condition is frequently affected.
9. Indications of cerebral syphilis: Headache, usually
worse at night; insomnia; vertigo; hemiplegia, and
aphasia; tendency to improvement and relapse; there
may be paralysis or unconsciousness, optic neuritis. The
diagnosis is made by a Wassermann reaction, which
must be positive.
Treatment consists of inunctions of mercury (either
the ointment or the oleate) or intramuscular injection
of a mercurial salt; potassium iodide, either alone
or in combination with mercury; sulphur baths are
said to aid the elimination of the mercury from the
system. Small doses of salvarsan have been recom-
mended by some.
10. "The treatment of acute articular rheumatism
consists in rest of the parts, and the patient should lie
between blankets. The joints should be enveloped in
soft wool or flannel. Restricted diet is essential. Frac-
tional doses of calomel (gr. % every hour for 6 hours)
should be administered, followed by a saline purgative.
Salicylic acid or its derivatives may be given in full
doses, and diuretics are especially indicated. Hyper-
pyrexia may be controlled by phenacetine (gr. 5.). Dur-
ing the convalescence, tonics are of decided advantage.
Locally, lead-water and laudanum or belladonna lini-
ment may be used. The diet should be carefully regu-
lated." (Pocket Cyclopedia.)
DERMATOLOGY, SYPHILOLOGY, AND DISEASES OF EYE, EAR,
NOSE, AND THROAT.
1. Psoriasis "is a common chronic inflammatory dis-
ease of the skin, characterized by variously sized lesions,
having red bases, covered with white scales resembling
mother-of-pearl. It affects by preference the extensor
surface of the body. The lesions are infiltrated, ele-
vated, clearly defined, covered with white, shining,
easily detachable scales which, upon removal, reveal a
red, punctate, bleeding surface. The eruption is ab-
solutely dry, and itching is usually absent."
"The treatment consists of the internal administra-
tion of arsenic, cod-liver oil, oil of copaiba, or potas-
sium iodide, and the use of local applications. The
scales should be removed by soap and water, alkaline
baths, or oily substances. Ointments containing sali-
cylic acid (3 per cent, to 10 per cent.), tar (5 1 to 3 1
of ointment), ichthyol (5 1 to g 1). chrysarobin (gr.
20 or 30 to J 1), ammoniated mercury (gr. 15 or 20 to
3 1), etc., are very beneficial, and should be used after
the scales have been removed." (Pocket Cyclopedia.)
2. Pruritus ani is a frequent sign of hemorrhoids,
diabetes mellitus, thread-worms, and fissure of the anus.
3. A patient may be considered cured of gonorrhea
in the continued absence of discharge, gonococci, and
shreds.
4. Signs and symptoms of congenital syphilis. — Im-
peded breathing, snuffles, necrosis of nasal bones, ery-
thematous rash on buttocks, general atrophy with a
wizened "old man" appearance, fissures of lips and
angles of mouth, mucous patches in the mouth, condy-
lomata, hemorrhages under the skin, onychia, enlarge-
ment of spleen, prominent forehead, Hutchinson teeth,
interstitial keratitis, periostitis, and gummata of the
internal organs.
5. Treatment of syphilis. — Intravenous or intramus-
cular injection of Salvarsan in dose of 0.5 gram, to be
repeated twice at intervals of a fortnight. Intramuscu-
lar injection of calomel or administration of mercury
with chalk by mouth. Iodide of sodium or potassium
must also be administered during the second year. This
may be combined with the mercury by the administration
of the protiodide of mercury. Sometimes mercury mav
be given by inunction. The patient must have his teeth
attended to, use a mild antiseptic mouth-wash, and
should give up alcohol and tobacco. Calomel or iodo-
form may be used as a d'isting powder for the chancre.
6. The dangers of acute suppurative inflammation of
the middle ear are: Chronic purulent otitis media, per-
foration of ear drum, boils of external auditory meatus,
ankylosis or necrosis of ossicles, mastoiditis, facial pa-
ralysis, meningitis, thrombosis of lateral sinus, abscess
of brain or cerebellum.
7. Trachoma is an inflammatory condition of the con-
junctiva, accompanied by hypertrophv, granule forma-
tion, and subsequent cicatricial changes.
Etiology. — It is caused by contagion from another eye,
being transferred bv means of the secretion.
Treatment "consists in an attempt to reduce the in-
flammatory svmptoms and secretion, and to check and
remove hypertrophy of the conjunctiva, thus shortening
484
MEDICAL RECORD.
[Sept. 9, 1916
the duration and diminishing the liability to conjunc-
tival cicatrization and to sequelae. This is accomplshed
either by the use of certain irritating applications or
by mechanical (surgical) means.
Irritating application*.— Sulphate of copper in the
form of a crystal or pencil is the favorite local applica-
tion. Nitrate of silver (1 or 2 per cent, solution),
gylcerole of tannin (5 to 25 per cent.), and the alum
stick are also employed. _
Mechanical (surgical) treatment includes expression,
grattage, excision, curetting, electrolysis, :r-rays, and
galvanocautery." (May's Diseases of the Eye.)
8. Tuberculous laryngitis is generally secondary to
pulmonary tuberculosis. The mucosa of the larynx is
swollen, and small tubercles may be found on the vocal
cords The tuberculous masses caseate and ulcerate;
the pharynx, epiglottis, and trachea may become in-
volved by extension. The signs and symptoms are those
of the primary tuberculosis, with the addition of hoarse-
ness, dyspnea, and dysphagia.
9 Acute suppurative inflammation of the frontal
sinus is treated by opening the sinus by an incision
along the inner part of the eyebrow, and then by tre-
phining and curetting the wall of the cavity; the
infundibulum is enlarged, and a drainage tube inserted
for a few days; the cavity is then washed out daily,
through the nose, till all discharge has ceased.
10 Nasal polypi, if mucous, are to be removed by a
wire snare; if they recur, the bone should be curetted;
if there is much bleeding, the nasal cavity is to be
packed with gauze for twenty-four hours. In case of
fibrous polvpi these must be scraped away; but treat-
ment is only possible in the early stage.
OBSTETRICS.
1 Conditions that justify the induction of premature
labor: (1) Certain pelvic deformities; (2) placenta
prarvia; (3) pernicious anemia; (4) toxemia of preg-
nancy; (5) habitual death of a fetus toward the end of
pregnancy; (b) hydatidiform mole; (7) habitually large
fetal heau. ,
2. Positive signs "I pregnancy: (1) Hearing the
fetal heart sound; (2) active movement of the fetus;
(3) ballottement; (4) outlining the fetus m whole or
part by palpation; and (5) the umbilical or funic souffle.
Doubtful signs of pregnancy: (1) Progressive enlarge-
ment of the uterus; (2) Hegar's sign; (3) Braxton
Hick's sign; (4) uterine murmur; (5) cessation of
menstruation; (6) changes in the breasts; (7) discolo-
ration of the vagina and cervix; (8) pigmentation anl
striae; (9) morning sickness. Subjective signs of preg-
nancy, in the order of their appearance, are: Cessa-
tion of menstruation, morning sickness, increased fre-
quency of urination, active fetal movemets. Object n,
signs of pregnancy, in the order of their appearance,
are: Softening of the cervix, changes in the mammary
glands, discoloration of the vulva and vagina, pulsation
in the vaginal vault, Hegar's sign, active fetal move-
ments, ballottement, palpation of the fetus, intermittent
uterine contractions, hearing the fetal heartbeat, rate of
growth of the uterine tumor.
3. Symptoms of death of the fetus during the later
months of pregnancy are: Cessation of the signs of
pregnancy, the abdomen and uterus are both diminished
in size, the fetal heart sounds and movements cease,
there is no pulsation in the cord, the mother's breasts
become flaccid and occasionally secrete milk. If the
fetus has been dead for some time crepitus of its cranial
bones may be elicited.
4. Curettage is indicated: (1) For removal of pla-
cental debris (2) in hemorrhagic endometritis, (3) in
some forms of dysmenorrhea (membranous), i li for
diagnostic purposes, (5) in some cases of puerperal
sepsis, (6) sometimes to check hemorrhage, due to fib-
roids. Contraindications : (1) The least suspicion of
even the possibility of pregnancy; (2) menstruation;
(3) acute endometritis; (4( malignant disease of the
uterus or vagina ; (4) i Ivic inflammation.
Technique. — All antiseptic and aseptic precautions
are necessary, the patient should be in the dorsal posi-
tion, the vagina is to be disinfected, and the cervical
canal dilated; a speculum is introduced into the vagina
and the cervix is drawn down with volsella; the uterine
cavity is irrigated with creolin or lysol; a curette is
inserted to the fundus and moved down to the internal
os; the operator should begin at one cornu and go in
the same direction all around till he reaches the starting
point, and if necessary repeat till no more spontry or
hyperplastic tissue appears; the fundus should be
fcraped separately by moving the curette along it from
side to side; in going toward the fundus no scraping
should be done, and care must be taken not to perforate
the uterus; should this happen no fluid must be in-
jected; otherwise the uterus and vagina are again irri-
tated, and one or more strips of iodoform gauze are in-
serted into the cavity to act either as a hemostatic
plug or as a drain, which is diminished with two days'
interval and withdrawn on the sixth day. A hemostatic
tampon should be placed in the vagina and withdrawn
the following day. If any fever arises, the tampon
is at once removed and the vagina douched with anti-
septic fluid every three hours. If not, the vagina is
only swabbed with the same every day, and packed
loosely with iodoform gauze. After the final removal
of the gauze the antiseptic douche is given twice a day
until there is no more discharge. The patient should
remain in bed for a week.
5. Labor is divided into three stages: The first stage
begins with the commencement of labor, and ends with
the complete dilatation of the os uteri. The second
stage begins with the complete dilatation of the os uteri,
and ends with the birth of the child. The third stage
immediately follows the second, and ends with the ex-
pulsion of the placenta and the beginning contraction of
the uterus.
In the third stage of labor the physician should seize
the fundus of the uterus through the abdominal wall
and knead and rub it until it contracts vigorously; then
he should press it down in the direction of the axis of
the pelvic inlet. This should last for about a quarter
of an hour after the child is born. The placenta, after
it is expressed, should be carefully taken by the physi-
cian so as to be sure that it is all expelled; at the same
time care must be taken that no particle of membrane
remains behind. Fluidextract of ergot may be admin-
istered. The dangers are: hemorrhage; retained pla-
centa or clots or pieces of the membranes and sepsis.
SURGERY.
1. Shock is the name given to a sudden and general
depression of the vital powers; due to some strong
stimulation (such as injury or emotion), acting on the
vital centers in the medulla and producing vasomotor
paralysis. Shock is primary when the symptoms ap-
pear promptly ; it is secondary when the symptoms
don't appear for several hours (often observed after
railway accidents, intoxication, etc.)
Symptoms of shock. — The blood pressure is lowered
considerably; the pulse is very compressible, rapid,
short, and often difficult to count; the respirations are
quick, sighing, and irregular; the skin is cold, clammy,
and pale; perspiration may be profuse, but other secre-
tions are diminished; body temperature is subnormal;
muscles are relaxed; and reflexes are diminished.
Treatment. — Place the patient in the recumbent posi-
tion, with the head low, apply warmth to the body,
administer a stimulant, and give a hot saline infusion;
morphine, hypodermically, may be necessary for the
relief of pain. Adrenalin solution is administered into
the arterial system.
In surgical operations shock may be largely prevented
by reassuring nervous patients, keeping the patient
warm, the avoidance of the excessive catharsis, and
semi-starvation that often prevails before operation, the
administration of strychnine and atropine before opera-
tion, the avoidance of delay and undue handling of
parts during the oneration, prompt checking of hem-
orrhage, and by using the utmost gentleness.
2 Acute suppurative appendicitis begins suddenly
".ith pain about the umbilicus or right iliac fossa, vom-
iting, constipation, and slitrht fever. There is some ten-
derness at or about McBurney's point, a spot at the
junction of the outer and middle thirds of a line join-
imr the umbilicus and anterior superior iliac spine, and
rigidity of the right rectus muscle.
A well-marked swelling is usually present, and the
pulse steadily increases in frequency. There is also a
steadily-increasing leucocytosis. A persistently high
temperature, or a subnormal temperature with an in-
creasing pulse-rate, are strong indications as to the
presence of pus. Three terminations may occur: l.The
attack may subside, leaving the pus shut up. 2. The
abscess may point and discharge itself into the bowel
or on the surface, or it may track upward along or
behind the colon, and form a subphrenic abscess. 3 The
localized abscess may burst and cause general periton-
itis. The rectum should always be examined, as a col-
lection of pus may be felt in Douglas's pouch. — (From
Aids to Surgery.)
Diagnosis. — This is made by the sudden and severe
Sept. 9, 1916J
MEDICAL RECORD.
485
abdominal pain, unilateral rigidity of lower part of
abdominal wall, tenderness over McHurney's point, with
nausea, vomiting, fever, and leucoeytosis.
In distended gall-bladder. — The pain is more severe
and sudden, and is in the region of the liver; it radi-
ates to the right scapula and toward the umbilicus;
chills and sweats are common; also vomiting, and some-
times symptoms of collapse and jaundice; all the symp-
toms come on more suddenly. In gallstone colic. — The
pain is excruciating and is in the region of the liver;
it radiates to the right scapula and toward the um-
bilicus chills and sweats are common also vomiting, and
sometimes symptoms of collapse and jaundice; calculi
may be iound in the feces. In ulcer of the pylorus, the
pain is in the epigastric region, may radiate to the left
shoulder, and is increased by taking food (usually about
one to three hours after a meal) ; vomiting may occur
from one to four hours after eating; hemorrhage may
be present; the acidity of the gastric contents is above
normal, owing to excess of free hydrochloric acid. In
renal colic. — The pain is in the region of the affected
kidney; it radiates down the thigh; there are intense
rigors, retraction of the testicle may be present, also his-
tory of previous attacks or of calculi ; the urine may be
scanty, suppressed, or bloody. In acute peritonitis. —
Both thighs aie flexed, pain and tenderness are more
general and are increased by movement, vomiting is
frequent, the abdomen in general is distended and is
tense and tympanitic.
Salpingitis is diagnosed by: A dragging sensation in
the neignborhood of the affected tube; colicky pain,
which is increased on exertion or even on standing ; ab-
dominal tenderness; menstrual disorders, as amenor-
rhea, metrorrhagia, dysmenorrhea, menorrhagia; dys-
pareunia ; there may be septic symptoms and perito-
nitis; sterility generally ensues. On examination there
will be found a fulness in Douglas's pouch and one or
both lateral fornices; in these latter will be felt either
the tubes, distorted and possibly adherent, or a sausage-
shaped tumor, which is very painful; the uterus is retro-
verted or retroflexed, and may be bound down by ad-
hesions; there may be an intermittent expulsion of pus
accompanied and preceded by a burning pelvic pain.
In ovaritis the pain is not localized, but spreads to the
vagina and rectum; it is usually worse just before the
menstrual period, which sometimes affords relief; on
vaginal examination the ovary is found to be tender.
Treatment. — "Where pus is present or suspected, the
abdomen should be opened over the swelling, and in most
cases it will be found that there are adhesions to the
anterior abdominal wall, shutting off the abscess cavity
from the rest of the abdomen. A finger should be gently
inserted to feel for and remove a concretion or the ap-
pendix; but no prolonged search should be made for the
appendix for fear of breaking down the adhesions. A
large rubber drainage tube should be inserted, and the
cavity will soon become clean and heal by granulation.
If, when the abdomen is opened, no adhesions to the an-
terior abdominal wall are found, the cavity should be
protected with gauze packing. The abscess will then be
found among a mass of matted omentum and intestine,
and can be opened by gently separating them. A drain-
age tube is inserted and the gauze packing is left in
for three days. By that time firm adhesions have
formed and the peritoneal cavity is safe from infec-
tion.
"When general peritonitis is present, the abdomen
must be opened and drained and the appendix removed;
but these cases are almost always fatal.
"In any case in which the symptoms are excessive,
especially with a rapidly increasing pulse rate, an oue'n-
tion should be done, as this gives the only chance in
cases where there is suppuration without adhesions, es-
pecially in those cases due to perforation or gangrene.
"Operation for removal of the appendix. — An incision
is made at right angles to a line (at the junction of the
outer and middle thirds) joining the umbilicus and
anterior sunerior iliac spine, one-third being above and
two-thirds be'ow it. The cecum is found, and the an-
terior longitudinal band is traced down to the appendix,
"hich usualb- comes off from the inner side and runs
inward and downward. If not found there it should
dp 1o"Vn<l for in the retrocecal pouch or on the outer
side of t>-e cecum. The meso-appendix should be liga-
tured and cut through, a collar of peritoneum turned
h»cV. and the mucms and muscular coat ligatured near
the base and cut off. The peritoneum should he stitched
ove>- the stump, and then the stump shou'd be invagi-
natpd into the wal' of the c°cum bv runnine a purse-
string stitch around it." — (Aids to Surgery.)
Aftertreatment. — This is mainly negative. "The pa-
tient snoUid Pe fed by nounsmng enemata, and water
should be supplied by continuous proctoclysis, which
may be repeated whenever thirst reappears, in case of
severe shock subcutaneous injection of from 500 to
1000 c.c. of normal salt solution should be administered.
In suppurative cases the Fowler position is indicated,
in cases of nausea or vomiting or gaseous dish ntwn of
tne abdomen, the pharynx snould be cocainized and gas-
tric lavage should be practised. This should be repeated
whenever these conditions recur. In case of pain, from
10 to 30 drops of deodorized tincture of opium dissolved
in 100 c.c. of normal salt solution should be given by
rectum as often as necessary to keep the patient com-
fortable. So long as no nourishment is given by mouth,
opium given in this manner is perfectly harmless. It
is well for the patient to chew gum in order to prevent
parotitis." — (Cyclopedia of Medicine and Surgery.)
3. Colles' fracture is a transverse fracture at lower
end of radius; it is due to falls on the outstretched
palm. The line of fracture is about an inch above the
wrist, and runs obliquely downward from behind. The
lower fragment is driven backward and upward, and
rotated to the radial side, carrying the hand with it
into the position of abduction and leaving the tip of
the radius at the same level as, or higher than, the
tip of the styloid process of the ulna. The internal
lateral ligament of the wrist is ruptured or the styloid
process torn off. The fracture is usually impacted, the
upper fragment being driven into the lower. The de-
formity is characteristic, viz.: (1) The hand is ab-
ducted; (2) the styloid process is on the same level
as, or lower than, the tip of the radius; (3) the upper
end of the lower fragment projects above the back of
the wrist; on the front is a corresponding depression,
while above it the upper fragment projects forward.
Union occurs readily, but it is common to get deformity
and adhesions about the site of fracture. Treatment:
Disimpaction and reduction are brought about by
grasping the hand by the "shaking-hands" grip, ex-
tending and adducting the hand and lower fragment.
The arm is then fixed on a splint. It is very impor-
tant in this fracture to start massage and passive
movement not later than the end of the first week, to
prevent stiffness. Union is firm in three weeks. — (Aids
to Surgery.)
4. Hip Joint Disease. — Sijmptams of first stage:
Night cries, lameness in the morning; a slight limp;
tendency to become tired on slight exertion; wasting;
spasm; pain; swelling and deformity (either real or
apparent).
Symptoms of second stage: Abduction; limping;
pain, which is worse at night; apparent lengthening
of the limb; abscess; atrophy of thigh muscles; flexion
of thigh; effusion into hip joint; and there may be
crepitation in the joint.
Symptoms of third stage: Flexion, abduction, and
shortening of the limb; the joint may be dislocated or'
ankylosed, or suppuration may occur.
"The cardinal symptoms of hip-joint disease are the
spasm, wasting, lameness, deformity (real and ap-
parent), pain, and swelling. Careful attention to these
will make the diagnosis easy. The tendency of the dis-
ease is toward recovery, but the prognosis is greatly
influenced by the age, type of disease, complications,
and treatment. Death usually occurs from amyloid
changes in the viscera.
"Constitutional treatment consists of improved hy-
giene, good food, fresh air, and the administration of
tonics, such as iron and the hypophosphites, and alter-
atives, such as cod-liver oil, iodine, and its salts. A
change of climate is sometimes beneficial. Locally,
iodine, blisters, hot-water bottles, or hot-water dressing
may be applied.
"The special treatments consist of the mechanical
treatment, treatment of the complications, and the sur-
gical treatment. The mechanical treatment consists of
recumbencv for two or three weeks in uncomplicated
cases, with fixation and traction. Continuous traction
may be first obtained bv Buck's or Savre's extension
apparatus, made of adhesive plaster, later bv means of
a traction snlint. with crushes, and still later by the
traction splint alone, a hieh shoe being worn on th°
sound side, which in a vear or two mav be discarded.
\ modified traction splint may be made of plaster of
Paris. Differences of oninion exist as to when the ab-
scesses should be incised, hut always the strictest asep-
sis or antisepsis is necpssarv. Irrigation of the cavi-
Hoq with sterile w+p- V>or'c aeH solution, or mercuric
chloride solution, 1:4000, and the infection of sterile
486
MEDICAL RECORD.
[Sept. 9, 1916
iodoform oil, 5 to 10 per cent., are commonly resorted
to. Osteotomy and fixation may be required for the de-
formity arising as a complication. The surgical treat-
ment consists of aspiration, incision, erasion, and ex-
cison." — {Pocket Cyclopedia of Medicine and Surgery.)
5. Gunshot wounds. Regarding probing*. Da Costa
says: — "The surgeon must not feel it his duty to probe
in all cases. In many cases it is better not to probe
at all. Explore for the ball when sure that it has
carried with it foreign bodies; when its presence at the
point of lodgment interferes with repair; when it is in
or near a vital region (as the brain) ; and when it is
necessary to know the position of the bullet in order to
determine the question of amputation or resection. If
the wound is large enough the finger is the best probe."
Regarding immediate operation, there is difference of
opinion, some authorities holding that unless the bullet
causes definite symptoms it should be let alone; others
advocate its removal to relieve the mind of the patient
and to obviate possible complications later on.
Gunshot wound of the knee should be treated con-
servatively, if possible; the wound should not be ex-
plored except to remove foreign bodies, loose frag-
ments, etc. Incision may be necessary for such re-
moval. The joint is irrigated with a weak antiseptic
solution, drained, dressed, and immobilized. Suppura-
tion calls for incision and drainage. If there is ex-
tensive laceration of tissue with much splintering of
bone and interference with blood and nerve supply the
condition may call for amputation.
ulljerajmrtir ijmtfi.
BULLETIN OF APPROACHING EXAMINATIONS
NAME AND ADDRESS OF PLACE AND DATE Op
STATE SECRETARY NF.XT EXAMINATION"!
llabama* W. H.Sanders, Montgomery. . . . Montgomery ... Jan. 9
Arizona* J. W. Thomas. Phoenix Phoenix
Arkansas T. J. Stout, Brinkley Little Rock ... Nov. 1 )
California . .C.B.Pinkham, Sacramento Los Angeles .. . Oct.
Colorado David A. Strickler, Empire
Building, Denver Denver Oct. 3
Connecticut* .... Chas. A.Tuttle. New Haven. . . .New Haven... . Nov. 14
Delaware J. II. Wilson, Dover Dover Der. 12
Dist. of Col'ba. . E. P. Copeland. Washington Washington.. . Oct. 10
Florida* E. W. Warren, Palatka Palatka Dec. 5
Georgia C. T. Nolan, Marietta Atlanta Oct. 10
Idaho* Charles A. Dettman. Burke Oct. 4
Illinois C. S. Drake, Springfield Chicago Oct. 10
Indiana W.T. Gott, Crawford!sville. .... .Indianapolis. . .Jan. 9
Iowa G. H. Sumner, Des Moines Iowa City
Kansas H. A. Dykes, Lebanon Lebanon Oct. 10
Kentucky . J. N. McCormack. Bowling
Green Louisville Dec . 1 *
I isiana E. L. Leckert. New- Orleans New Orleans . .Nov. 30
Maine ... F. W. Searle, Portland Portland Nov. 14
Maryland J. McP. Scott, Hagerstown Baltimore Dec. 12
Massachusetts*. W. P. Bowers, 1 Beacon St., Bos-
ton Boston Sept. 12
Michigan B. D. Hanson, 205 Whitney
Building, Detroit Lansing. . .. I let 10
Minnesota T. McDavitt, St. Paul Minneapolis . . Oct . 3
Mississippi.. J. D. Gilleylen, Jackson Jackson. ..... .Oct 24
Mi ,un .1. A. B. Adcock.jVtTerson Citv Kansas Citv . Sepl Is
Montana* .... Wm. C. Riddell. Helena Helena Oct. :<
Nebraska H. B. Cummins, Seward. . . Lincoln ..Nov. B
Nevada S. L. Lee. Carson City Carson City. Nov. fi
N.Hampsnire . Walter T. Crosby, Manchester Concord Dec. IS
Newjerse^ V Mac A lister, Trenton Trenton Oct. 1 7
NewMexico ^ E.Kaser, East Las Vegas SantaFe
New York
New York.. . .H. H. Horner, Univ of State ol Ubany . Sept. 19
New York, Albany Syracuse
Buffalo
■ iina II \ Rovster, Raleigh Raleigh . . June
\ Dakota G. M. Williamson, Grand Forks .Grand Forks. ... Ian. 1
Ohio (.,.,, II Matson, Columbus Columbus. . . Dec.
Oklal a R. V. Smith, Tulsa Oklahoma City .Oct. 10
B. E. Miller, Portland Portland . .Ian. ■>
Ivania .. N. C. Schaeffer, Harrisburg tSbur!
• Ishmd.. . G. T. Swarts. Providence Pi I ct. 5
rolina. Hi Boozer, Columl is I oluml ia Nov. 14
P. B. Jenkins, Waubay Pierre .Jan. 9
Memphis
Term* iset V !'■ DeLoach, Memphis Nashville
Km ixville.
M. P. McElhannon. Belton Fort Worth Nov.
i i ng -ah I ake( its Sail Lakel i
onl v\ Scott Nay, Underhill Burlington. . Feb. 13
Virginia 1. N. Barney, Fredericksburg Richmond I »>■<-, 12
C.N Suttner, Walla Walla Spokane .Ian. 2
ma ... S. L. Jepson, Charleston ..Clarksburg .Nov.
J. M. Dodd, Ashland Madison Ian. 9
II E. Mel 'ollum, I iaramie I aramie
ciprocity r ignized by th<
t Applicants should ii iry for all the
!
Privileged Communications. — In an action for per-
sonal in timony of a physician as t,i whether
the plaintiff was intoxicated was held to be excluded
where the doctor was called to attend the plaintiff as
a physician and became possessed of his information
through his professional employment. — V Y. ('. & St
I. . Indiana Supreme Court. Hi' \". K. 762.
Plantar Hyperhidrosis. —
R Acidi tannici, 5j.
Alumiriis, 5v.
Aquae, ,-,xxx.
M. fiat lotio.
Sig. : Apply once or twice daily.
If a fetid condition exists, a foot bath containing
potassium permanganate 1 1000 may be used for
ten minutes every three days. In the meantime
stockings may be powdered with the following :
R Pulveris talci, ox.
Bismuthi salicylatis, jjj.
Zinci oxidi, 5v.
Pulveris aluminis, 5iiss.
M. fiat pulvis. — Gazette des Hopitauz.
Treatment for Burns, Scalds, and Wounds. —
Soubeyran prefers the following prescription for
use in the treatment of scalds, burns, varicose ul-
cers, etc. :
R Balsami peruviani, ."x.
Acidi picrici, gr. vij.
Paraffini mollis, ,r,ij.
M. fiat unguentum.
Care should be taken to protect clothing and bed-
clothes from the stains which the above drugs pro-
duce.— Journal des Praticiens.
Dandruff. — The following prescription, while
not new, deserves repetition because of its ability
to produce such excellent results :
R B. naphthol, gr. xx.
Bergamot oil, m. x.
Vaseline, ,-,j.
M. fiat unguentum.
Apply to the scalp at night and thoroughly sham-
poo the scalp and hair in the morning with any good
soap. — Practical Prescribiyig and Treatment.
Pneumonia Treatment. —
I; Potassii iodidi, .~ij.
Creosoti, .">ss.
Spiriti recti, .">ij.
Extracti glycyrrhizae fluidi, ."iiij.
Aquam ad, .~>vi.
M. sig.: A tablespoonful every four hours until
the temperature reaches normal.
Trifacial Neuralgia. —
R Morphini hydrochloride gr. 1 6.
Antipyrini.
Potassii bromidi, aa, gr. ix.
Acidi citrici. 5ss.
Acidi tartarici. gr. xl.
Sodii bicarbonatis.
Sacchari lactis, aa, gr. Lxxv.
M. et fiat chartula No. 1. Sig.: Take in a half
glass of water. — Nouveaux remides.
An Easy Remedy for Constipation. — Bran bis-
cuits made according to the following directions and
eaten with meals until the desired action of the
intestines is obtained will assist in the treatment
of and in many cases entirely correct constipation:
Bran 3'- oz., agar 90 gr. or '2 oz., eggs 2, salt to
taste; put the agar into a small dish, cover with a
cup of water and boil until dissolved; while this
is still boiling hot, the warmed bran is stirred into
it to make a thick batter; beat the eggs until verj
light and add to the batter together with a little
sugar and the salt. Chocolate flavoring may be
added if desired, and the mixture is then poured
into gem-pans and baked. — American Journal of
Nursing.
Medical Record
A Weekly Journal of Medicine and Surgery
Vol. 90, No. 12.
Whole No. 2393.
New York, September i6, igi6.
$5.00 Per Annum.
Single Copies, 15c.
©rigtnal Arttrks.
SOME PRACTICAL NOTES ON BLOOD-
PRESSURE*
By GEORGE VAN NESS DEARBORN,
CAMBRIDGE, MASS.
PSYCHOLOGIST AND PHYSIOLOGIST TO THE FORSYTH DENTAL IN-
FIRMARY FOR CHILDREN, BOSTON; INSTRUCTOR IN PSYCHOL-
OGY AND EDUCATION IN THE SARGENT NORMAL SCHOOL.
CAMBRIDGE.
In the course of somewhat slow observations ( be-
gun in the Hemenway Gymnasium, Harvard, 1913)
on the relations of the mental process to the so-
called "pressures" of the blood in the arteries (in
reality, of course, there is but one every-varying
pressure), such extensive variability was obvious
in young and old, male and female, strong and weak,
normal and abnormal, that it became almost a duty
to report it to the rank and file of medical practi-
tioners— men and women too busy, for the most
part, to learn these matters for themselves.
Much as we have supposed we knew about the sig-
nificance of blood-pressure, a confidence almost in-
evitable in such a situation, I, for one, am con-
vinced that it is only now that we are beginning to
be really sure that the expression, "her blood was
up," means something — but then not too much!
The origin of the present fad in regard to blood -
pressure appears to be, in part, the old-fashioned
notion, almost a proverb, that one is as "old as
one's arteries" ; in part, the common fear or phobia
of apoplexy, which is now very commonly known
by the laity to be due to the "bursting" of an artery
in the brain; partly from the attention given Metch-
nikoff's decadent theory as to a means of keeping
the arteries elastic; and, finally, in part from the
very wide medical advertising of blood-pressure
gages. The universality of this fad is really worth
noting; the topic always excites almost "popular"
interest among laymen, and in some cases it has
been unduly catered to. An illustration of this was
in one of Dr. Evans' excellent and famous talks
on health (published as syndicate matter in some
of the newspapers of importance), in which he ad-
vised an old gentleman who was worrying about
himself to secure an instrument and measure his
own blood-pressure; theoretically, of course, this
advice is all wrong. We should never advise any
one who is worried about himself to make any such
quantitative study of his "condition."
The first thing we come to in discussing the
blood-pressure fad, as we know it at the present
time, is the mode of action of the mechanism for
locally changing the diameter of arterioles. Vaso-
motion, it is certain at the present time, is a very
complex and elaborate set of adaptations, which
*The basis of remarks made to the Massachusetts
Medical Society at its 135th annual session, June 6.
1916. •
requires careful and extensive study before we can
know anything worth while about the true meaning
of blood-pressure. And yet I boldly propose to sug-
gest certain of my own more practical gleanings
out of this great, and, for the most part, unfilled
field; this inconsistency is in part its own punish-
ment.
The methods of taking blood-pressure we will not
discuss here, as you are probably all familiar with
them. I merely suggest that the auscultation
method is the one now used. For the systolic read-
ings, the Korotkoff sound is extremely exact, pro-
vided one uses as the indicator a constancy of
rhythm — disregarding the first sporadic sounds so
frequently observed. For the diastolic determina-
tions, the Korotkoff sounds are far less accurate,
but still by far the best means that we have, save
in those cases in which (perhaps owing to a dilator-
spasm in the artery?) the third and fourth-phase
sounds wholly and suddenly disappear. In the
forty-eight hundred measurements" made by the
writer, this phenomenon has been observed many
times, and its occasion as well as its cause is an
interesting physiologic problem in itself, especially
in its psychologic relations (which are the particu-
lar interest of the present researcher).
The heart rate is taken just before the blood-
pressure measurements are begun ; always at the
end of the sitting, and as frequently as is expedient
throughout the series of measurements. With an
inexpensive stop-watch this can be readily done and
recorded in twenty seconds, so that these measure-
ments do not at all disturb the series of systolic and
diastolic measurements, both made every minute,
or, if preferred, every two minutes.
Gradually to get down to our main thesis, there
are at least two dozen normal things already appre-
ciated as determinants of blood-pressure readings
as they are commonly made by the average physi-
cian. These twenty-four normal modifiers and de-
terminants may be merely mentioned, their order
here not being significant. (1) First, there are the
still unknown and very complex vasomotor changes,
more or less important. (2) Emotional tones (pleas-
antness and unpleasantness), and especially anxiety.
(3) Muscular tonus, especially of the lower muscle
tissue of the upper arm. (4) The relative rigidity
of the arterial wall, this essential hardening com-
ing from the physiological vasoconstriction of the
artery as well as from its pathological induration.
(5) The either arched or broken-arched condition of
the brachial artery at the moment. (6) The posi-
tion of the individual, usually either standing, sit-
ting, or reclining. (7) Whether the right or the
left arm be measured. (8) The heart rate. (9)
Movements of any part of the arm. (10) The re-
cency of physical exercise, this feature bring, in
part, one of the local brachial agencies, and in par
one of general nervous excitement; and into this.
488
MEDICAL RECORD.
[Sept. 16, 1916
determinant comes to a considerable extent the de-
gree of "training." (11) Vasomotor neurosis, which
has been hinted at, if not described, by Consorti,
Cassirer, and others, and which I personally suspect
to be far more common and important than is real-
ized. (See charts.) (12) The recency of eating,
for Professors Weysse and Lutz13 have shown that
the systolic pressure, on the average, is eight mil-
limeters higher after eating. (13) The time of
day. The systolic-pressure mean progressively rises
during the day, while the diastolic apparently falls
as the autonomic tonus lessens during the day. ( 14)
In women, the menstrual period must be consid-
ered, the pressure being higher just before and in
atonic women lower just after. (15) Age; in gen-
eral, the pressure more or less evenly increases6 up
to about 65. (16) Sex; the pressures range a few
millimeters lower in females. (17) Atmospheric
heat, with humidity, seems sometimes to have a
marked lowering influence over blood-pressure.
(18) Voluntary relaxation of the body (a la Hindu)
readily lowers it to a very marked extent (see the
charts). (19) Involuntary and chronic mild col-
lapse of the psychomotor organism (commonly des-
ignated as a condition of being "run down"). (20)
the integrity and adjustment of the measuring in-
strument. (21) Breath holding; as the chart shows,
in one case the systolic blood-pressure was raised
119 millimeters of mercury in 2% minutes. (22)
The integrity of the heart, especially of the mitral
and the aortic valves. (23) Thinking, at least ex-
cited activity of the cerebral cortex, irregularly
raises the systolic blood-pressure, while widespread,
unexcited, more general brain action frequently low-
ers it. (24) This (in some respects, in the long
run, the most important of all, perhaps) is what
I shall have to call the algebraic local, or else central
balance of the neurochemical pressors and depres-
sors. These substances are largely internal secre-
tions, the best known of which are adrenin and
pituitrin; the most obvious depressors (Beifeld and
colleagues) are extracts of the pancreas and of
the salivary glands,1 and very likely extract also of
the pineal gland, the epiphysis. According to Bei-
feld, the increased irritability of the vasomotor
centers produces always a very great lowering of
blood-pressure. The intimate connections and inte-
grations of the internal secretions, being investi-
gated by Professor Cannon and his colleagues, are
obvious; on the one hand, consider the relationship
of these irritator and depressor internal secretions
to the increased pressure in the condition designated
as dynamogeny (due in part to an increased amount
of sugar and of adrenin in the blood) ; on the other
hand, they may explain in part the effects of that
important trained voluntary relaxation at which
iho Orientals and Hindoo; are especially expert, and
purely much needed in our supervital American city
life.
There are six kinds of uncertainty, at least, which
enter into every blood-pressure test, inevitably :
1. In the first place, there is to be considered
always the muscle tonus of the arm. The arm is a
fluid, but it is not the "perfect fluid" of physics,
-and. therefore, the relative rigidity of the muscles
and of the other tissues of the arm is continually
chanKinK. and thus causing uncertainty in every
measurement made by the present crude methods.
2. There is always uncertainty as to the degree
of tonus of the artery wall, and that whether the
arterial wall be hardened physiologically by active
vasoconstriction, or hardened pathologically by
actual but passive sclerosis. It is obvious that both
of these cases would lessen the arterial variability
and resiliency, and so tend to raise the blood-
pressure measurements above what they should be.
The pressure inside of the artery is not nearly so
great as the gauge-readings actually indicate, as
Brooks and Luckhardt' have recently emphasized;
in sclerosis, the error, I should judge, may well be
100 per cent.
3. A source of error in all blood-pressure tests is
the varying shape of the arterial cross-section at
any moment. When the artery is round it consists
of arches, and, therefore, is very resistant to com-
pression ; but when the arterial arch has been
broken, the tube becomes much more easily com-
pressible. It is a theoretical point, whose precise
importance remains to be worked out.
4. The training index (whether the individual has
been exercising recently or not) is always a prob-
able source of uncertainty." It is obvious from the
records which I have shown that even a small de-
gree of exercise very materially raises the blood-
pressure. Another respect in which the physical-
training index comes into the matter relates to the
promptness of the reaction from the exercise-raised
blood-pressure to the rest-normal, in that trained
individuals show a very quick reaction thither, while
in the untrained it is very slow. The climbing of a
flight of stairs is violent exercise!
5. The excitement index of the individual is a
large yet an almost continual source of uncertainty.
Most common in medical experience is the mild anx-
iety, plus the general excitement of having a medical
examination ; but, above all, true anxiety, worry,
especially a feeling of hurried, agitated worry. Any
of these, and especially all combined, serve actually
to increase blood-pressure very many (often forty i
millimeters above what it physiologically or patho-
logically really is.
6. Another uncertainty is the cerebration index
of the individual (as to whether he is thinking
actively or not). Many of my records show distinct-
ly that active thought of any kind, irrespective of
emotional tone, distinctly lowers or raises the blood-
pressure.
7. Occasionally there is a dilator spasm of the
artery, which immediately stops the "water-ham-
mer" Korotkoff sounds." and so makes impossible
any determination of the diastolic pressure.
8. At times, the still undescribed vasomotor neu-
rosis, which "boosts" high the blood-pressure for
weeks at a time.
Whatever may be the explanatory physiology, one
certainly finds at all ages a surprisingly large vari-
ability in the blood-pressure of the perfectly normal
individual. I have been greatly surprised, as my
measuring and experimental work has gone on, to
see that this very wide variability, which naturally
I thought at first to be exceptional, is not in reality
exceptional, but common to all normal blood-pres-
sure.
I have plotted 140 relatively continuous readings
of blood pressure, systolic and diastolic, so far,
ranging in time from a few minutes to something
above one and a half hours; the figures of the pro-
tocols have been merely plotted. They represent
a more or less chance selection of at least 4800
measurements of blood-pressure which I have per-
sonally made the last three years. I have arranged
these charts in nine illustrative groups.
The first group. A, is to be used to exemplify the
wide clinical initial variation, to show how widely
the first measurement, made in a doctor's office, may
vary in some cases from the mean at that visit ;
Sept. 16, 1916]
MEDICAL RECORD.
489
often (and this, too, without any apparent cause
whatever other than those noted) it is thirty or
more millimeters.
Group B consists of three records, which show a
progressive fall of blood-pressure from the initial
Hemobarogram 1. — This patient was a woman nearly sixty
years old. normal, but typical of the Yankee women, who
are always busy and usuaily worrying about something, im-
aginary or real. The variations here are wholly spontane-
ous, with a systolic maximum of 42 mm. Hg iii 5 minutes
and a diastolic maximum of 15 mm. Hg in 7 minutes. The
diastolic curve shows the relatively small variation character-
istic of the arteries after fifty years. The heart-rate re-
mained about 60.
measurement. In one case, Bl, with no apparent
cause at all, except those already considered, there
was a fall of 46 millimeters in 13 minutes. Do the
rank and file of the country's clinicians outside the
scientific societies discount such a change and give
their patients, in any event, the great benefit of
the great doubt? I should fear that they as yet do
not do so.
The third group, group C, demonstrates the ex-
treme rise of systolic pressure during exercise, and
the fall after exercise is concluded. For example,
going rather fast up a single flight of stairs but not
more quickly than many people habitually climb
stairs, will make a rise of blood-pressure from 20 to
30 millimeters ; and then add hurry, excitement, and
anxiety — !
The fourth group, group D, demonstrates a few
of my preliminary records of influence of some of
the mental conditions on the blood-pressure. It
may be seen even from these preliminary charts that
the mental, especially affective, influences are both
quick and powerful ; 20 millimeters upward is no
uncommon rise from a spontaneous, unpleasant
thought or unpleasant momentary grief; 30 odd mil-
limeters is often seen in records when the grief is
recent and acute, for example, in the case of a young
woman whom I quite unintentionally reminded of
the recent death of her mother. But do observe
that such memories (and others far different, but
not less dynamic) are liable to come into the minds
of patients in your own offices, at any instant, thus
entirely destroying the significance of the measure-
ment.
The fifth group, group E, of these blood-pressure
records demonstrates how easy and powerful is vol-
untary relaxation, on one hand (lowering the pres-
sure), and, on the other hand, holding the breath
(which raises the pressure). The most noteworthy
of all these particular records (Fig. 4) is that of a
medical man in a suburb, a man in first-class physi-
cal condition and nearly fifty years old, who volun-
tarily reduced his pressure in fifteen minutes from
his general basis of 135 to 111 mm. Hg; and then
raised it in the course of two and one-half minutes
of breath holding to 230. It is obvious that this
marked lowering of blood-pressure by a voluntary
relaxation might be used by unfit and unscrupulous
candidates for life insurance to make a false read-
ing, unless readings be taken seriatim, many times
and systematically.
Group F of these records shows how very consid-
erable the normal variation is at all ages, in both
sexes, and in the diastolic as well as systolic. The
systolic average variation is 15 or 20 millimeters
at least, and the diastolic pressures vary only less.
Especial attention is called to the record (Fig. 1) of
a woman about 59, perfectly "normal" so far as is
known, but of a type popularly known as "a nervous
woman." Her systolic pressure spontaneously va-
ried 43 millimeters within eight minutes, and her
diastolic pressure 15 millimeters within seven min-
utes. In another case, a perfectly normal and beau-
tifully trained athlete, nearly 42 years old (Fig.
2), showed a spontaneous diastolic variation around
13 millimeters within three minutes, and within
seven minutes a fall of 18 millimeters. In an active
girl of 16 2/3, the diastolic fell (as shown by ten
measurements) (Fig. 2), 23 millimeters in fourteen
minutes; and so on more or less in every one's ar-
teries always, life without end!
The seventh group, group G, shows that the sys-
tolic blood-pressure in nitrous-oxide anesthesia
Hemobarogram '2. — This patient was an athlete of 6 feet
and 42 years, in fine condition. The heart-rate remained be-
tween 88 and 85. The first marked systolic variation coin-
cided in time with the turning of his attention to the meas-
urements being made. The last marked rise (21 mm. Hg)
was due to the exertion of ascending a flight of ordinary
stairs. In these charts the long rhythm of the arterial ten-
sion is obvious as well as a parallelism between the systolic
and the diastolic series.
takes a small rise. The "authorities" differ in re-
gard to this, most supposing that this anesthetic
raises it to some extent. The work which I have
done on this matter in the Forsyth Infirmary indi-
cates that nitrous oxide produces a rise of blood-
490
MEDICAL RECORD.
[Sept. 16, 1916
pressure about equal to the exertion of going up
a flight of stairs, but that it may be almost instantly
reduced to normal, and kept at normal, by the proper
admixture of oxygen. It seems to be agreed at the
present time that nitrous oxide, mixed with oxygen,
120
110 .^
100
n Ho
o
5MINS
10
15 z|o
Hemobarogram 3. — This systolic record was made from ft
normal girl of 10 years 4 months. It shows a fall of 34 mm.
ir in 19 minutes; the heart-rate meanwhile stayed up to its
initial 12S for seven minutes and then fell gradually to 101
at the end. The chute is plainly, in a way. an index of the
patient's loss of apprehension and occurs in adults as well
as in children !
produces no rise at all worth noting, and certainly
no lowering. A chart in this group well shows how
instantaneous is the control of the systolic blood-
pressure by the addition of oxygen to this anesthetic.
(Ether, as is well known, makes a marked rise in
systolic; chloroform makes a marked fall, owing to
its typical depression of the heart action. Cocaine
produces a general rise of
blood-pressure. It is pos-
sible at least that it pro-
duces this effect by its in-
hibition of the depressor1
salivary secretion, thus al-
lowing the adrenin or what
not in the blood to raise
the pressure.)
Group H is a tentative
set of records from men-
tally defective adults, mo-
rons, imbeciles, and idiots,
as graded by the Binet, or,
less often, by the coming-
in point system of Yerkes.
I am not ready to report
this preliminary work as
yet. but its psychologic in-
terest is very great, and
bids fair to furnish a key
to the mental influences.
Group J of these records
shows the least variation
which can be found in my
records made from normal
persons. It is seen that
even under these circum-
stances the systolic varia-
tion is, on the average, 8
or 10 millimeters at the
lowest, and more or less
rhythmic. There is obvi-
ous a tendency to a regular
rhythm, with a double-vi-
bration period of from two
or live minutes. In general
"all kinds" of rhythms are
to be seen suggested in
these hemobarograms,
it is as yet far too early to
Suggest either their numer-
ical natures or their etiol-
ogy. Inthis group. J. where
the emotional, et al.. varia-
230
23!
210
200
190
B0
170
160
150
140
130
120
110
.-•
100
0
5nuft 1 to
15
I ' ROORAM 4. A
rugged doctor of medicine
and . . its 6
month: During the first
lively
nuscularly, ner-
. and
lira-
Hg. Then he
his breath for 2.5 min-
his pre
llv at
last.
mm. i Jul
their arterial ten-
thus, but
few who could i . ■
with
ereat benefit i did they
try.
bility is relatively small, the rhythms appear most
plainly. Rhythm, of course, is inevitably inherent in
all vegetative muscle, and its relation to the rhyth-
mic action of the pressor and the depressor ductless
glands has enticing interest for men in the promis-
ing vivisectiona! work, already so productive of use-
ful knowledge.
A summary survey in brief of the charts shows:
1. Extreme and still unaccountable variations in the
blood-pressure, both systolic and diastolic, in both
adults and children.
2. Blood-pressure is raised by tones of unpleas-
antness, and notably by anxiety.
3. Iii some cases, but by no means in all, it ap-
pears to be lowered by all relaxing pleasant feelings
and pleasurable sensation.
4. It is raised by ideational brain action, espe-
cially by the voluntary work of the entire cortex.' 10
5. The blood-pressure appears to be an index of
anxiety in the person's mind, conscious or subcon-
scious, and may be so used, to some extent, for diag-
nostic purposes in psychopathology, etc.
6. The blood-pressure is, in general, as variable
in adults as in children; in fact, the widest normal
variation I have ever seen was in an individual,
160
150
K0
130
120
no
V
100
s\
90
\
V
A
^J
\_
k 1
80
r~
w
>— *"
r
0
5n«
10
15
20
25
30
Hbmobarogram No. 5. — This is the thirty-minute record
nl a woman of 42 years who tests only L.6 • the
Yerkes point-scale system of tests. When the cuff was first
distended (170 mm. Hg.) she burst quietly into tears, emo-
tionally shocked at the novelty of tin- painless sensation.
Within the next 13 minutes her systolic brachial-artery ten-
spin had fallen to 16 mm. Hg., her diastolic 11 mm., her heart-
rate falling meanwhile from 112 to 88, where it remained.
Within seven minutes from the beginning she was in her
usual good humor. This record, typical of the hemobaro-
grams of mental defectives, t! I solely to illustrate
the p] i] '•limit" of blood-pressure rise (due purely
to office Apprehension) and its spontaneous fall under the
more usual office conditions. Very many ; both
adults and youths, some of whom would "test up" rather
better than i 6 years yerkes', show just this kind of blood-
Mi-. ■ phenomenon however little the "tank and file" of
physicians as yet realize it.
apparently normal, who was approaching the age of
sixty.
7. There is a marked degree of reciprocity be-
tween different parts of the body.
8. The diastolic is as variable, in many cases,
as is the systolic pressure.
9. The deliberate relaxation of the voluntary mus-
cles readily and greatly lowers the pressure.
10. There are evidences of the frequency of a
vasomotor neurosis1 : whose pressor effect is greal
and lasting enough to thoroughly mislead the clini-
cian who mistakes it for the "anticipation of a
nephritis." for arteriosclerosis, or for a sign of gout
or of Raynaud's disease. Low blood-pressure sel-
Sept. 16, 1916]
MEDICAL RECORD.
491
dom has any sinister significance any more than
has low heart rate.
11. Frequent suggestions, especially in the dias-
tolic records, of a rhythmic pressure variation of
from 15 to 30 millimeters in waves from ten to
twenty minutes long.
But some of my readers certainly are asking, most
naturally, two questions as they look back over this
material.
First, "Is it not perfectly true, none the less,
that each individual does have a consistent
blood-pressure base or standard, whether there be
such for every particular age or sex or not?" The
answer is as obvious as the question: Certainly there
is such a base for each person at any one time, but
it is not easily determined in most cases.
The second question which might well be asked
would be "Do not vascular ( i.e., interstitial )
nephritis, arteriosclerosis, gout, obesity, Raynaud's
disease, etc., have a high blood pressure, which
stays up and stretches the arteries?" We
may answer, with some promptness: Certainly,
again, but with so many common idiopathic and wide
variations, and with the likelihood of a perhaps
purely vasomotor pressor neurosis, any one given
measurement of this pressure is inadequate because
uncertain.
There are certain theoretic corollaries which I
may mention in regard to these observations : The
need of a widespread, broad-minded study of vaso-
motion in its entirety, one of the very foundation
functions of the intricate body marvel. Then we
should know about the actual physics of the arm ;
more about the kinesthetic, perceptual, impulsive,
emotional relations of the muscles of the arm and
other parts of the body; and we should study the
mental influence very much.
The blood-pressure in the brain is far more im-
portant than the very variable pressure in the arm,
and means should be devised to measure the pressure
there, where it is most important.
There are, too, certain practical corollaries or
points which perhaps will interest the average prac-
titioner more than do the foregoing theoretic desid-
erata :
1. Twenty minutes instead of one should be used
in determining a blood-pressure, and the procedure
should be carried out on several days, instead of on
one day only, as is the common custom.
2. No one should interpret any measurement of
the blood-pressure save as an algebraic balance of
two dozen or so factors and modifiers.
3. A patient must not be acutely anxious or
"scared." He must not be made to worry about
anything, for anxiety raises the blood-pressure and
may even sustain it indefinitely.
4. Keep in mind the frequent occurrence in per-
sons of chronic-nephritis age of a pressor vasomo-
tor neurosis — or at least something that acts like
one.
In general, we may say, as a conclusion, too wide
to be quite accurate, but perhaps, none the less, of
some useful significance: Blood-pressure measure-
ments, as they are taken at present by the majority
of busy practitioners, are apt actually to be more
misleading than significant; it is only by repeating
the measurements each minute (or each two min-
utes) for a half hour or less, and on several suc-
cessive days, care being taken in interpretation to
avoid all known sources of high pressure, that one
can be sure of having a significant set of measure-
ments.
Addendum, August, 1916. — Extensive and sub-
stantial evidence derived from the numerous rela-
tively continuous hemobarograms of this research,
especially from their demonstration of the relative
independence of the systolic and the diastolic pres-
sures ; from the muscular structure of the left lower
heart (ventricle) and from its known volumetric
movements; from the cerebral relations of the car-
diac control in comparison with the autonomic
neurology of the arteries; from the striking phe-
nomena of the blood-tension observed in true emo-
tions involving all parts of the body as compared
with voluntary imitations thereof; from the ob-
served relations of pressure to heart-rate; from the
observed frequent vasodilator and vasoconstrictor
"spasms"; from the phenomena of nephritic and
sclerotic high diastolic tension; from Cannon's far-
reaching work on adrenin, etc. ; and from analogy —
this evidence already makes it probable that the ob-
served changes in the systolic pressure are chiefly
due to variations in the size, and hence the systolic
output, of the left ventricle, and that the diastolic
variation in tension is primarily dependent on
(arterial) vasomotion, the blood-pressure being al-
ways an algebraic balance of these two distinct but
complementary sets of neuromusculo-glandular
actions, and thus an index of the perfect integration
of the organism.
REFERENCES.
1. Beifeld, A. J., Wheelon, H., and Lovellete, C. R:
"The Influence of Hypotensive Gland-Extracts on Vaso-
motor Irritability," Amer. Jour. Physiol., Vol. XL, No.
2, April, 1916, pp. 360-365. (A very suggestive re-
search.)
2. Bishop, L. F.: "Blood-Pressure," in "The Refer-
ence Handbook of the Medical Sciences," third edition,
Vol. II, pp. 201-211. William Wood & Co., New York,
1913. (The best available short summary.)
3. Bonser, F. G.: "A Study of the Relations Between
Mental Activity and the Circulation of the Blood,"
Psychol. Review, Vol. X, No. 2, March, 1903, pp. 120-
138.
4. Brooks, C, and Luekhardt, A. B.: "The Chief
Physical Mechanisms Concerned in Clinical Methods of
Measuring: Blood-Pressure," Amer. Jour. Physiol., Vol.
XL, No. 1, March, 1916, pp. 49-75.
5. Consorti, D.: "La sindrome vasomotoria fun-
zionale," Policlinico (Sezione Practica), Vol. XXIII,
No. 4, January 23, 1916, pp. 106-108.
6. Dearborn, G. V. N.: "The Blood Pressure in the
Leg in Various Positions ; the Brachial Pressure After
Short Maximal Exercises; and the Normal Pressure
in Physically Trained Individuals. With an Appended
Preliminary Note regarding the Blood Pressure's Auto-
nomic Rhythm." Amer. Phys. Educ. Rev., Vol. XX,
No. 6 (June), and 7 (October), 1915.
7. : "The Importance of Blood Pressure," edi-
torial in Medical News, New York, LXXXII, No. 6,
1903, pp. 268-269.
8. : "A Sphygmomanometer of New Principle,"
the "Barhemeter," Medical Record, New York, Vol.
LXXXIV, No. 8 (August 23, 1913), p. 342.
9. : "Notes on the Neurology of Voluntary
Movement, Medical Record, Vol. LXXXI, No. 20, May
18, 1912, pp. 929-939.
10. : "Notes on Affective Phvsiology," Medical
Record, Vol. LXXXIX, No. 15, April 8, 1916, pp. 631-
641.
11. Erlanger, J.: "Studies in Blood-Pressure Esti-
mation by Indirect Methods," Amer. Jour. Physiol.,
Vol. XXXIX, No. 4, February, 1916, and Vol. XL, No.
5, March, 1916, pp. 82-125.
12. Hooker, D. R.: "The Influence of Age Upon the
Blood Pressure in Man," Amer. Jour. Physiol., Vol. XL,
No. 1, March, 1916, pp. 43-48.
13. Weysse, A. W., and Lutz, B. R.: "Diurnal Vari-
ations in Arterial Blood Pressure," American Journal
of Physiology, Vol. XXXVII, No. 2, May, 1915.
492
MEDICAL RECORD.
[Sept. 16, 1916
THE PATHOLOGICAL AND THERAPEUTIC
BEARINGS OF THE ELIMINATION
OF BODY HEAT.*
By JOHN BENJAMIN NICHOLS, M.D.,
WASHINGTON, D. C.
In order to afford energy for the vital activities,
oxidation of food and tissue material is constantly
in progress in the living animal organism. Even
when the body activities are at a minimum — during
sleep — an unremitting supply of energy is required
for carrying on the circulatory and respiratory func-
tions. This constant oxidation results in continuous
production of heat by the body, at the rate in the
human adult per kilogram of body weight of from
1 to 4 calories per hour, according to the degree of
muscular activity; or from 2,000 to 7,000 calories
daily in a medium-sized subject of 70 kilograms
(154 pounds) weight.
In order to maintain the temperature of the body
at a uniform figure it is necessary that the heat
generated be dissipated at a rate equal to that of
its production. If the heat is dissipated more rap-
idly than it is generated, the body temperatlre will
fall ; if less rapidly, the heat produced must accu-
mulate in the body and cause a rise in its tempera-
ture. A change of body temperature of 1° C. corre-
sponds to 0.83 calory per kilogram of body weight.
If the elimination of heat were entirely suspended,
the body temperature would rise at the rate of over
3° F. per hour. These considerations indicate the
constant necessity of proper elimination of the heat
continually being generated by body oxidation.
The main means by which body heat or energy is
discharged are three: (1) Radiation, conduction,
and convection; (2) vaporization of water; and (3)
external muscular work.
The elimination of heat by radiation, conduction,
and convection is accomplished by the imparting of
heat from the surface of the body to the surround-
ing atmosphere or other objects. This can be ef-
fected only when the temperature of the latter is
lower than that of the body, and the rapidity of the
heat discharge is proportional to the difference be-
tween the two. Ordinarily, the largest part of the
body-heat elimination takes place by this way, about
75 per cent, of it being thus discharged under ordi-
nary living and working conditions (temperature
of 20° C).
The loss of heat by evaporation consists in the
absorption of heat by water when passing from
liquid into gaseous form. Each gram of water
vaporized and so excreted by the skin or lungs re-
moves 0.59 calory of heat from the body. A large
amount of heat is thus eliminated, the proportion
varying according to the temperature and humidity
of the air; ordinarily about 15 to 25 per cent, of
the body-heat discharge occurs in this way.
The body energy gotten rid of in the form of
external work accomplished (which can lie measured
in terms of heat) varies in proportion to the muscu-
lar activity of the subject, and ranges from zero
to about 10 per cent, of the total heat discharge.
As in the case of mechanical engines, only a fraction
of the heat generated for the purpose reappears as
actual work. For example, the mechanical efficiency
of a steam engine is about 15 per cent.; that is, only
15 per cent, of the energy yielded by the burning
of the fuel is converted into actual work. Similarly,
*Rcad before joint meeting of the Baltimore City Med-
ical Society and the Medical Society of the District of
i uml'ia at Baltimore, Md., April 7, 1916.
the efficiency of the human body as an engine has
been determined as from 9 to 24 per cent. It fol-
lows that for every calory of external work that is
produced three to nine additional calories of extra
heat are generated in the body and have to be elim-
inated.
An example of the relative magnitudes of the
three main avenues of heat elimination is afforded
by the calorimetric observations of Atwater and
Benedict. The results of various tests made by them
average (per diem per person) as follows (Bulletin
175, Office of Experiment Stations, U. S. Depart-
ment of Agriculture, 1907, pp. 152, 179) :
Five Rest
Experiments
(10 Dai-
Srx Wohk
Experiments
(14 Days).
Calor-
ies
Per
1 i T 1
Calor-
ies
Per
Cent
Seal or energy production (from
oxidation of food ain! body mate-
rial) , as measured
2,258
.5,179
....
Heat or energy eliminated, as
mea suri d
1 1 * - : l t uf urine and i> b given off.
Given off by radiation and con-
17
1,741
512
.8
76.7
22.5
21
3,856
791
546
.4
74.0
( ■ i\ in off by vaporizal ion oi
15.2
External muscular work meas-
10.4
2 , 270
100.0
5,214
100.0
In the Eoregoing experiments the temperature of t( hamber occupied
by the subjects experimented on was 20 deg. C, ami the humidity of the
contained air ranged mostly from aboul 50 to 70. averaging 67 per cent.
The cutaneous surface and the respiratory tract
are the structures chiefly concerned in the elimina-
tion of heat. The body surface affords an extensive
field from which heat may escape by radiation, con-
duction, and convection, and from which the evapo-
ration of perspiration takes place. The respiratory
activities involve vaporization of water and convec-
tion of heat out of the body by the warm expired
air. A striking example of the participation of the
respiratory apparatus in heat elimination is af-
forded by an overheated dog breathing with exces-
sive rapidity ; the widely opened mouth and ex-
panded tongue increase the surface for heat dis-
charge, and the increased air currents carry away
much heat by convection and augmented evapora-
tion.
In infancy the burden of heat elimination is rela-
tively much greater and more urgent than in adults.
Heat production in young infants proportionately to
body weight is three times as great under similar
conditions as in adults; a proportion which gradu-
ally diminishes during the years of childhood. The
much greater amount of heat to be disposed of in
them makes interference with their heat elimination
much more potent for harm than in adults, and un-
doubtedly contributes largely to the increased mor-
bidity and mortality of young children in hot
weather.
Obesity exerts considerable influence on heat
elimination. An abundance of subcutaneous fat, by
relatively diminishing the body surface and inter-
fering with radiation-convection and evaporation,
lessens heat dissipation. Their heat discharge is
so much more interfered with that obese persons
suffer more distress in hot and humid weather than
slender subjects experience.
The principal external conditions that influence
heat elimination are (1) the clothing, (2) the tern-
Sept. 16, 1916]
MEDICAL RECORD.
493
perature of the surrounding air or other media, (3)
the humidity of the atmosphere, and (4) the move-
ment of the air.
Clothing protects against and lessens the escape
of body heat, and by varying its amount and char-
acter a considerable range of control and adjustment
of heat elimination is possible. The physiologic
action of clothing pertains largely to its influence
on heat elimination. Clothing (like the hair and
feather covering of animals and birds) owes its
protective power against heat loss largely to the
air imprisoned in its interstices, air being a poor
conductor of heat. Dry, porous clothing is the best
protection against cold. Water being a good con-
ductor, damp clothing facilitates loss of body heat,
and is less protective.
The temperature of the surrounding atmosphere
and other objects or media influences heat elimina-
tion by both radiation-convection and evaporation.
The greater the difference in temperature between
a body and the surrounding media, the more active
is the transfer of heat from the warmer to the
cooler. Consequently, the body gives off more heat
in a cold than in a warm environment; and as the
surrounding temperature rises, the heat loss by
radiation-convection correspondingly diminishes.
When the temperature of the air becomes as high
as that of the body no further loss of heat by radia-
tion-convection can take place.
Immersion in cold water actively removes heat
from the body; and one of the chief effects of hydro-
therapy relates to this action.
The effect of atmospheric temperature on the
vaporization of water is the reverse of that on
radiation-convection. At the lower temperatures
there is less evaporation, and hence less heat loss
in that way ; while at higher temperatures vaporiza-
tion and the resultant heat loss are proportionately
increased.
As an example of the effect of varying tempera-
tures on the distribution of heat loss between radia-
tion-convection and evaporation may be cited the
following results obtained by Rubner on the elimi-
nation of heat by a fasting dog exposed to different
temperatures (Max Rubner, Die Gesetze des Ener-
gieverbrauchs bei der Ernahrung, 1902, pp. 106,
193):
Table II
Total
Tem-
Heat
pera-
Given Off
Heat Given Off By
Heat Given Off by
ture
per Kilo
Radiation-Convec-
Vaporization of
of Body
tion
V* ater
Weight
C.
Calorii ss.
Calorics.
Per Cent.
Calorie*. Per Cent.
7°
86.4
78.5
90 9
7 !) 9.1
15
63.0
55.3
87. S
7 7 12.2
20
55.9
45.3
81.0
Id 6 19.0
25
54.2
41.0
75.6
13.2 24 1
30
56.2
33.2
59.1
23 . 0
-in 9
35
68.5
The humidity of the atmosphere influences the
escape of body heat mainly through affecting the
evaporation of water. In dry air, vaporization is
favored ; in humid air, evaporation is lessened ; while
in air saturated with moisture, escape of body heat
by evaporation would be entirely prevented. A cold,
humid atmosphere also favors heat loss, supposedly
by the increased conductivity for heat of damp cloth-
ing or skin covering.
Movement of the surrounding air, even imper-
ceptible air currents, greatly increase loss of heat
from the body. The air envelope contiguous to the
body, warmed by us heat and charged with its
moisture, is thus continuously removed and replaced
by cooler and drier air of greater heat-absorbing
capacity.
Variations in the rate of heat elimination result-
ing from fluctuations in the external conditions and
factors operative bring about through the action
of the thermic nerve centers a series of compensa-
tory and regulatory processes for the purpose of
maintaining proper thermic conditions in the body,
one significant manifestation of which is the main-
tenance of a uniform body temperature. The train
of vital activities thus brought into play covers a
wide field of the organic functions, and is of pro-
found consequence to the organism for evil or for
good. Within broad limits, the organism can ac-
commodate itself to the variations in heat dissipa-
tion brought about by changes in the external con-
ditions. Above and below these limits, pathologic
consequences result, ranging from mere discomfort
in the slighter degrees to fatal and fulminant over-
whelming of the organism. Two opposite groups of
conditions are to be considered, resulting respec-
tively from (1) excess or (2) deficiency in body-heat
elimination.
Excessive abstraction of body heat is brought
about by insufficient clothing, immersion in cold
water, exposure to cold air, and similar conditions.
In order to check the excessive escape of heat, con-
traction of the superficial blood vessels takes place
under the action of the nervous regulatory mechan-
ism, blanching the skin and lessening the amount
of blood at the surface, thus diminishing the radia-
tion and convection of heat from the skin, the action
of the sweat glands, and the consequent evaporation
of water. The pulse and respiration rates decrease.
Blood pressure increases, perhaps as a result of the
contraction of the cutaneous vessels. The largest
means of compensation for the excessive heat loss
is the incitement of muscular activity, which greatly
augments body oxidation and production of heat to
replace that lost. The cold individual naturally and
sponteneously engages in muscular action ; he
stamps his feet, or swings his arms, or otherwise
actively exercises. In the passive, chilled, individual
shivering or twitching of the voluntary muscles is a
similar means by which heat production is in-
creased.
The reaction of the organism to increased heat
elimination involves powerful stimulating effects.
The circulatory activities are stimulated, as shown
by the increase of blood pressure. An increase in
blood pressure of 10 to 30 mm. can be effected
by transfer of patients and individuals from warm
rooms to cold outdoor air, a stimulating effect much
greater than drugs produce. The nervous system is
markedly stimulated, partly from the direct action
of cold on the superficial nerve terminals, partly
pei-haps from increased central circulation. Mus-
cular activity is promoted. Metabolism is increased.
General invigoration takes place. The purposive in-
duction of these stimulating factors constitutes a
powerful therapeutic agency.
When, in spite of all regulatory and compensatory
reactions, the loss of heat exceeds the generation
of body heat, the temperature of the body must
progressively fall, leading eventually to fatal refrig-
eration. The treatment of such cases would consist
in the promotion of muscular action, the application
of external heat, hot drinks, and the like.
494
MEDICAL RECORD.
I Sept. 16, 1916
Decrease or deficiency of elimination of body heat
is caused by high surrounding temperature, high
atmospheric humidity, lack of movement of the air,
and excessive clothing; and the conditions are rela-
tively much aggravated when associated with mus-
cular activity and increased heat production. When
heat elimination is interfered with the thermo-regu-
lating centers set up conditions to increase it. The
superficial blood vessels dilate, bringing an increased
volume of blood to the surface, where its heat can
be dissipated by radiation and convection. The skin
is flushed and warmed, and the- secretion of sweat
is greatly stimulated to supply water for evapora-
tion. Blood pressure is lowered (perhaps from the
dilatation of the vascular channels), and the pulse
rate increases. The rate of respiration is in-
creased, partly perhaps in correspondence with the
pulse rate, partly also as a means for increasing
heat discharge. Marked nervous depression occurs
(partly perhaps from relative central anemia), as
manifested by lassitude, malaise, weakness, head-
ache, dizziness, nausea, faintness, syncope. Muscu-
lar activity is burdensome, on account of the great
increase thereby effected in the production of heat
to be gotten rid of. There is general depression
and embarrassment of the body functions and activi-
ties. The proper action of the cooling apparatus is
just as essential to the efficient working of the
human machine as to that of an automobile; neither
will run properly if overwarm.
When the rate of heat dissipation falls below that
of heat production the body temperature must nec-
essarily rise and pyrexia develop. These are the
conditions that bring about the most intense mani-
festation of deficient heat elimination — heat stroke.
With the atmosphere at a temperature as high as
that of the body, and saturated with moisture, the
escape of body heat by both radiation and evapora-
tion would be entirely prevented, and the body tem-
perature would rise at a rate of over 3° F. per hour,
the rate of increase being accelerated by the in-
crease of oxidation accompanying overwarming of
the body cells. The concurrence of heat and humid-
ity, especially if associated with muscular activity,
is well known as the special inciting cause of heat-
stroke, with its rapidly induced hyperpyrexia (up
to 110° or 112°) and fulminant overthrow of the
vital activities.
Body oxidation, or metabolism, runs closely paral-
lel with heal elimination, as the abstraction of heat
necessitates oxidation t cinder the control of the
thermic centers) to produce heat to replace that lost.
As heat dissipation is largely conditioned by the
external temperature, there is a close correspondence
between the surrounding temperature and body oxi-
dation. External cold greatly increases body oxida-
tion; metabolism decreases as the temperature rises.
reaching a minimum at about 30° C, above which
oxidation again increases (attributed to heightened
metabolic activity of ovi rwarmed cells). The influ-
ence of cold in increasing oxidation is to a certain
extent independent of muscular activity, and affords
a sanitary or therapeutic means of stimulating
metabolism in cases in which exercise is inadvis:
or impossible.
A potent influence is exerted by these conditions
the bodily vigor and disease-resisting power.
The increase of morbidity and mortality, especially
among children, in seasons of atmospheric heat and
humidity, is well known. Continued exposure to
the conditions that diminish heat elimination evi-
dently lessens the power of disease resistance. On
the other hand, the conditions that increase heat
dissipation and metabolism are associated with
heightened vigor, health, and recuperative power, as
exemplified in the difference between sedentary and
outdoor life, the energizing effects of open-air life
and treatment, etc. It is a reasonable supposition
that the basis of this relation and correspondence
between heat elimination and body vigor is to be
found in the amount of body oxidation, which is
conditioned on the former. Oxidation is life. All
vital energy and activity are derived from the com-
bustion of organic material. The more we oxidize
the greater is our activity and vitality, the more
we live. The conditions that diminish body oxida-
tion lessen vigor and disease-resistance; those that
stimulate metabolism energize the organism and
tend to the conservation of health and the cure of
disease; and this applies to passive increase of me-
tabolism caused simply by exposure to cold as well
as to increase caused by muscular activity.
A famiiiar manifestation of deficient heat elimi-
nation is afforded by the oppressive and injurious
consequences of hot and humid weather. The de-
pression, the malaise, discomfort, and distress, and
the difficulty of muscular exertion under such cir-
cumstances, are universal experiences; but of great
concern to the clinician is the fact that these condi-
tions materially increase susceptibility to the inci-
dence of various diseases, aggravate their character,
lower disease-resisting power, and increase the mor-
tality, especially in young children. Purposive
measures to promote adequate heat elimination
should, consequently, constitute an important part
in the prophylaxis and treatment of disease in hot
seasons.
The discomfort and other injurious conditions
that result from exposure to the vitiated air of
stuffy, crowded, or badly ventilated rooms, is an-
other manifestation of the effects of reduced heat
elimination. The belief, long prevalent, that the evil
effects of vitiated air are caused by chemical changes
and contaminations has been found untenable; and
it is now believed that it is interference with body-
heat elimination caused by the increased tempera-
ture, humidity, and stagnation that also develop in
occupied confined air that is responsible for these
evil effects. The cooling action of the atmosphere
is vitally essential to well-being and life, as well as
its respiratory function; and it is the air that cools
us, rather than the air we breathe, cool air rather
than pure air, that is most concerned in ventilation
and aerotherapy.
The treatment of deficient heat elimination and
its resultant conditions would consist in abstraction
of body heat, increasing the outlets for heat dis-
charge, and minimizing body oxidation.
The most vigorous abstraction of body heat is
effected by immersion in cold water, application of
ice, and the like, as in the customary treatment of
heatstroke and fever.
A slight cooling may be effected by the ingestion
of cold substances. A glass of water (250 c. c),
swallowed at zero temperature (Centigrade), when
warmed up to body temperature w:ll absorb about 9
calories of heat, enough, if generally distributed,
to low:er the body temperature about 0.3 F. A
hundred grams of ice (as in ice cream), swallow
melted, and raised to body temperature, would ab-
sorb nearly 12 calories. The gains thus obtainable
i perhaps inconsiderable, yet they afford an agree-
able sense of cooling.
When the conditions are such as to interfere with
i
Sept. 1G, 1916 J
MEDICAL RECORD.
495
heat elimination, it is important that body oxidation
(and hence the amount of heat to be gotten rid of)
be reduced to a minimum. Muscular activity should,
therefore, be minimized; and, theoretically at least.
a scanty diet (especially of protein) would be advis-
able, in order to obviate the increase of oxidation
involved in the specific dynamic action of the food-
stuffs.
Since clothing lessens the escape of heat, reduc-
tion, and even complete removal, of the body cover-
ings may effect a considerable increase in heat dis-
charge, and should be borne in mind in alleviating
the injurious effects of hot weather on ill patients,
especially children.
Atmospheric conditions that interfere with heat
elimination should be escaped from or corrected so
far as possible.
The preferable and most effective course, when
possible, is removal from hot cities or torrid locali-
ties to cooler places during heated seasons. The
beneficial effects of such a change for invalids, chil-
dren, and also the well, are generally appreciated.
When it is impracticable for the patient or indi-
vidual to remove to a more salubrious place, the
oppressive atmospheric conditions of the room occu-
pied should be mitigated so far as possible. Great
and frequently sufficient relief may be obtained by
setting up vigorous air currents in the room with
fans. Reduction of the temperature of the room air
is not so easily accomplished. Methods have been
devised for lowering room temperature through the
agency of evaporation, and cooling beds with ice
tanks. It is feasible, though expensive, to cool the
air supply of buildings by refrigerating apparatus,
humidity being also regulated; but such systems
have been put in operation only to a limited extent.
It is possible that the equipment of wards or rooms
in hospitals capable of being refrigerated, in which
very ill patients could, as an emergency measure, be
placed in hot weather, would result in the saving of
many lives, especially of children.
According to present conceptions, the primary
purpose of the ventilation of buildings is the regula-
tion of the temperature, humidity, and movement
of the air, so as to provide optimum conditions for
the heat excretion of the occupants. In the attain-
ment of this essential object, with the exclusion of
dust and of adventitious contaminations, a sufficient
degree of air purity is likely to be incidentally
achieved in ventilating systems. In ordinary places
of residence and assembly, where physical activity
is slight, a temperature of 68° to 70° F., with a
humidity of 60-65 per cent., rffords favorable con-
ditions for body heat elimination ; in industrial
establishments where workmen are subjected to
heavy exertion or high temperatures other arrange-
ments would be indicated. In many dwellings, in
winter, the temperature is kept too high, resulting
in deleterious overwarming of the occupants. The
matter of ventilation and heating is an important
aspect of this subject, well worthy the attention of
the sanitarian and therapeutist.
The therapeutic bearings of heat elimination re-
late not only to the removal of the injurious conse-
quences of deficient elimination, but also to the
utilization of the great therapeutic potencies of in-
creased heat removal. Amplified heat elimination
is a powerful circulatory, nervous, and metabolic
stimulant, promotes muscular activity, and is gener-
ally energizing and invigorating. Our daily vigor,
well-being, and efficiency are dependent on it, as is
shown by the debilitating effects of hot weather and
of sedentary indoor life as compared with the invig-
orating influence of outdoor life. The brilliant
results of the open-air treatment of tuberculosis and
other conditions are a demonstration of the thera-
peutic possibilities involved. The attempted ex-
planations of the modus operandi of the fresh-air
treatment on the basis of the chemical purity and
properties of the air have never been convincing,
and undoubtedly the true cause of the beneficial
action of salubrious atmospheric conditions resides
in their influence on the heat discharge of the body.
In general, the elimination of body heat, far from
being an academic physiologic abstraction, is a proc-
ess of fundamental importance to organic well-being,
and has wide pathologic, therapeutic, and hygienic
bearings. Without being directly appreciated, it
sets up a train of vital phenomena that are very
obvious and consequential. It affords a key to the
understanding of subjects formerly obscure. It is
well that its action and controlling factors should
be clearly appreciated and purposely regulated or
utilized.
1321 Rhode Island Avenue, N. W.
COINS AND MEDALS IN MEDICINE*
By WILLIAM J. MALLORY, A.M.. M.D.,
WASHINGTON, D. C.
INSTRUCTOR IN MEDICINE IN THE GEORGE WASHINGTON UNIVER-
SITY, DEPARTMENT OF MEDICINE. AND ATTENDING PHYSICIAN
TO THE OUTPATIENT DEPARTMENT OF THE UNIVERSITY
HOSPITAL.
Ancient history deals almost exclusively with af-
fairs of State and gives us comparatively little
insight into individual experience of its members,
their joys and cares, pleasures and privations, how
they dealt their "buried complexes" or adapted
themselves to the "kinetic drive" of their day.
In an attempt to fill in deficiencies and make a
complete and authentic story, the historian has
drawn from many different sources of information,
among others, numismatics.
The study of coins, medals, and jetons adds
many facts to history, not only as a memorial of
important events, but they furnish also likenesses
of persons, as well as parts of legends and pro-
verbs. As an example may be mentioned our own
penny, with its inscription of "Not one cent for
tribute, but millions for defense," or the Franklin
penny, with "Time flies; mind your own business."
The material available for a study of coins and
medals in medicine is enormous in amount and
variety, and may be found in books and papers,
as well as in collections which have not yet been
studied and described. There is in the Museum
of the Surgeon General's Clbrary a rich and at-
tractive collection of coins and medals waiting to
be described and discussed from this point of view.
In this brief sketch an attempt will be made
simply to call attention to some well-known coins
and medals of interest to physicians, and to name
some of the many interesting books dealing with
this subject.
As an example illustrating the kind of informa-
tion which may be derived from medals, Weber'
mentions the one relating to Dr. Wenzel Beyer.
He was the author of the first treatise on the
thermal waters of Karlsbad in Bohemia. Being
practically the first to recommend patients to take
the waters internally, he must have enormously
increased their utility. In this book above referred
to, "Tractatus de thermis, Caroli IV, Etc.," Leip-
*Read before the Medical History Club of Washington,
D. C, Jan. 29, 1916.
496
MI.DICAL RECORD.
[Sept. 16, 1916
zig, 1521, he wrote: "I have said that this water
must be drunk. As, however, until now it has
seldom been used for drinking, but more for bath-
ing, what I have said will appear to many as
something new."
Beyer was born at Elbogen near Karlsbad, as
appears from the title page of his book, where his
name is given as Venceslaus Payer de Cubito, that
is to say, of Elbogen. Not much more would be
known or surmised about Beyer were it not for
the existence of two medals commemorating his
death in 1526, examples of both of which exist in
the Imperial Collection at Vienna. Like most Ger-
man portriat medals of this time, they are doubt-
less the work of some goldsmith and aie both cast
and chased in silver.
The first one, of a diameter of 2.2 inches, bears
on the obverse the portrait of Beyer, in profile to
left, at the age of 38 years, with an inscription.
On the reverse, in a bare landscape with one tree,
is a steaming chasm, into which a horseman (Mar-
cus Curtius) is about to plunge. In the fore-
ground is a book, and upon that rests a skull; there
are loose bones lying about, and in some specimens
the date 1526 occurs in the field. The inscription is
"lam portum inveni, spes et fortuna valete." The
more usual quotation is "Inveni portum; spes et
fortuna valete! Sat me lusistis, ludite nunc alois."
That is to say, "I have found the haven; Hope and
Fortune, farewell. You have made sport enough
of me, now make sport of others." It is said to be
the translation of a Greek epitaph ascribed to Janus
Panonius. The reverse type certainly suggests a
reference to Marcus Curtius, the Roman legendary
hero, who, when he heard that the chasm in the
Forum could be filled only by throwing Rome's
greatest treasure into it, mounted his horse and
leaped into the abyss, declaring that Rome pos-
sessed no greater treasure than a brave and gal-
lant citizen.
The second medal, two inches in diameter, bears
Beyer's bust on the obverse, with a similar in-
scription to that on the obverse of the first medal,
but the portrait is nearly a full-face one. The re-
verse represents a bier, standing on stony ground,
with a decaying corpse stretched at full length
upon it. Above this is the inscription: "Cum pari-
ter Omnibus moriendum non tarde sed clare mori
optandum." — "Since all alike must die, it is de-
sirable to die not tardily, but illustrously." On the
field of the reserve is the date, 1526.
Nothing seems to be known with certainty as to
the cause of Beyer's death, but the reverse designs
on these two medals, especially that referring to
the legend of Marcus Curtius, suggest that his
death was the result of (or at the time supposed
to be the result of) an injury or disease acquired
when examining the source of the great hot spring
(Sprudel) at Karlsbad.
At the present day, close t<> this spring along
the sides of the River Tepl, clouds of steam arise
from the ground itself. The rocky ground on which
the bier stands (in the second medal) probably
represents the bed of the Tepl, and the book (on the
first medal) is probably an allusion to Beyer's book
on the Karlsbad Springs.
Beyer's patron. Count Stephan Schlick, to whom
he dedicated the treatise in question, was heredi-
tary lord of Elbogen and doubtless owned Karls-
bad itself; therefore. Beyer's book, by increasing
the use of the thermal waters, was probably of
some financial service to the Schlick family, who
apparently had these commemorative medals made.
They are, as already stated, made in the ordinary
manner of the period, that is to say, cast and
chased, probably the work of some goldsmith pat-
ronized by the Schlick family. Count Stephan
Schlick himself was one of those who perished
with their sovereign, King Louis II of Hungary
(and Bohemia), in the disastrous battle against
the Turks (under Soliman II) at Mohacs on Aug.
29, 1526.
It was by this Count Stephan Schlick and his
brothers that the large silver coins were issued
at Joachimsthal, called Joachimsthaler, from
which the words thaler, daler, and dollar are de-
rived.
The correct explanation of the types on these
medals is chiefly due to J. de Corro, who wrote an
account of them in a Karlsbad Almanac published
in Prague in 1841.
There are some Greek coins of the fifth century
B. C. illustrating a medical and hygienic attitude
towards preventable disease and death. Two silver
coins of Selinus in Sicily date from about 466-415
B. C, and commemorate the freeing of Selinus
from some kind of pestilence, probably malaria,
by the drainage of the neighboring marshlands.
One shows on the obverse Apollo and Artemis
standing side by side in a slowly moving quadriga,
the former discharging arrows from his bow. On
the reverse is represented the river god Selinus,
naked, with short horns, holding patera and lustral
branch, sacrificing at an altar of Aesculapius, in
front of which is a cock. Behind him on a pedestal
is the figure of a bull, and in the field above is a
selinon leaf. Apollo is here regarded as the heal-
ing god who, with his radiant arrows, slays the
pestilence as he slew the Python.
On the reverse the river god himself makes
formal libation to the god of health, in gratitude
for the cleansing of the waters whilst the image
of the bull symbolizes the sacrifice offered on that
occasion.
The other of these two coins shows on the ob-
verse side Heracles contending with a wild bull,
which he seizes by the horn and is about to slay
with his club. On the reverse the river god Hypsas
is seen sacrificing before an altar, around which
a serpent twines. He holds a branch and a patera.
Behind him a marsh bird is seen departing. In
the field is a selinon leaf.
It is said of this piece that here, instead of
Apollo, it is the sun god Herakles, who is shown
struggling with the destructive powers of mois-
ture symbolized by the bull, while on the reverse
the river Hypsas takes the place of the river
Selinus. The marsh bird is seen retreating, for
she can no longer find a congenial home on the
banks of the Hypsas, now that Empedocles has
drained the lands.
It seems that the philosopher Empedocles, who
at that time was at the height of his fame, put a
stop to the plague by turning two neighboring
streams into one. The Seluntines conferred divine
honor upon Empedocles, and these above-described
coins still exist as a wonderful monumental rec-
ord of the events in question.
The study of coins and medals adds something
to our incomplete knowledge of the early epidemics,
not only with regard to dates and places, but also
gives hints of what was at that time believed with
regard to the nature, cause, and methods of pre-
venting epidemic diseases.
However, it is only since the sixteenth century
that the knowledge of the varied nature of epi-
Sept. 16, 1916]
MEDICAL RECORD.
497
demies were "pests" or "plagues." Smallpox was
described by a few physicians in the eleventh and
twelfth centuries, but became generally known only
in the sixteenth century. Scarlet fever and measles
were differentiated from smallpox in the sixteenth
century, but not from each other till 1627. In 1700
the difference became generally known, and in 1790
was entered in the official statistics.
Bubonic plague was not known as a specific dis-
ease in the Middle Ages. Only the particular form
known as the "black death" was accurately described
and characterized by its incomparable mortality.
Typhus has been known since 1584; malaria
was known as a specific disease in 1600 ; yellow fever
in 1635.
As examples of Roman coins3 alluding to disease,
may be mentioned several gold, silver, and bronze
pieces of about A. D. 250-254, having on one side
the head of the emperor, with his name and title
around the margin, and on the opposite side Apollo
standing with a laurel branch in the extended right
hand, and inscribed about the margin, "Apollo.
Salutari."
These pieces are considered to have been struck
under Valerian, and seem to refer to the so-called
"Cyprianic Pest," which was brought out of Ethio-
pia in the time of the Emperors Hostilianus and
Trajanus Decius, numbering the son of the latter
among its victims. The character of this pest is
uncertain, but according to the writings of St.
Cyprianus, it resembles exanthematic typhus with
diarrhea. Of the next plague, the "Pest of Justi-
anian," 531-580, buboes and petechise are expressly
mentioned. Contemporaneous coins bear no mark
referring to this epidemic.
Of the second and most severe outbreak of epi-
demics of oriental bubonic plague there is no numis-
matic memorial. It is said that during that griev-
ous period of the "Black Death," 1346, till near the
end of that century the coining of moneys was, as
in the whole Middle Ages afterward, limited to im-
mediate necessities of commerce and daily traffic.
Only after 1390 appeared some memorial medals.
Even after this time some of the most important
epidemics passed without leaving behind any re-
minders on the coins. Perhaps many of the skilled
artists were the victims of the plague. Perhaps the
misery and depression were so great and universal
that no one had the zest or desire to make any
such souvenir.
In later years, that is in the 16th century, coins
bearing some reference to plagues become more
numerous. The "Wittenberger Pest-thalers" fur-
nish a good example of the period. They consist
essentially of a representation of Christ on the
cross, a marginal biblical quotation, at the foot of
the cross, worshippers, and on the opposite side the
prototype — the serpent as lifted up on the cross by
Moses in the Wilderness. Here also is the appro-
priate scriptural quotation. The distinct biblical
motive in these pieces indicate that they were not
mysteriously working amulets, but pious faith to-
kens. In striking contrast to these were "Pest-
pfennigs," which appeared in South Germany about
a hundred years later. Instead of the scriptural
figures appear wonder-working saints — Benedict
and Zacharia with their spells and exorcisms, "Get
behind me, Satan," "Drink the poison yourself,"
etc. Here we have a transition, or a relapse, to
the amulet and talisman against disease and other
evils, which still persist in our present day as good-
luck pennies.
Coins and medals relating to smallpox and inoc-
ulation are numerous, but do not appear till after
the practice had become established. Although
something of the relation between cowpox and hu-
man smallpox had been known for years, and Lady
Montague, as early as 1717, had caused her son to
be successfully inoculated and in 1720 introduced
the practice in England.
The first medal that I have found record of as
relating to this subject were struck in 1756. This
was ordered by the Count Tessin in honor of his
wife, who introduced the practice into Sweden by
having her children inoculated. Medals were also
issued in nearly every European country in honor
of Jenner and others who practiced inoculation.
There are medals referring to cholera, some com-
memorating the appearance of Asiatic cholera in
certain cities, as, for example, one with the inscrip-
tion:
"Berlin von der Asia. Cholera Enricht, D. 31,
Aug., 1831—
(Humble yourselves now under the mighty hand
of God.")
"Demutiget Euch Nun Unter Die Gewaltige Hand
Gottes."
And another by the citizens of Goldigen "in mem-
ory of Dr. Kupffer and Rv. Schmidt, helpers in
need."
There were numerous amulets to be worn for pro-
tection against disease. One appeared in Munich
in 1836, bearing on one side the inscription: "This
medal is to be worn in region of the stomach next
to the skin."
The history of the touch pieces,4 that is, coins
used in connection with the ceremony of touching
for the cure of King's Evil, forms one of the most
interesting chapters in the history of medical nu-
mismatics. King's healing of the Evil probably be-
gan with the first king; for just as disease was
attributed to evil spirits, so has healing in all times
and nations been accorded a divine parentage; and
since kings ruled by divine right, their powers were
divine, so, logically, healing was early included
among other attributes of sovereignty. Phyrrus,
king of Epirus, in the early part of the third cen-
tury B. C, cured disease of the spleen by the touch
of the patient with the great toe of his right foot.
Vespasian restored sight to a blind man, and Adrian
cured the dropsy by the touch of his finger tips.
Coins were first used not directly as touch pieces,
but as alms, when King Guntran, during the plague
in Marseilles, gathered the people into the churches
and bade them offer prayers, vigil and fasting, while
he himself distributed his alms broadcast, and ap-
parently the plague was stayed.
The' first reliable record in French or English
history of healing by royal hands is four centuries
later, when Robert the Pious (996-1031), who gave
each of the sick folk with his own hand a sum of
pence, touched their sores, and made the imprint
of the sign of the holy cross. The household ac-
counts of Edward I show numerous entries of
monies disbursed to persons sick of the King's Evil
— a pence per head.
The circumstances under which a certain coin —
The Angel — became definitely associated with heal-
ing by the royal touch, are very interesting. Craw-
ford credits Henry VII with being the first to initi-
ate the practice of giving to each applicant a golden
Angel, a current coin of the value 6s. 8d. After a
century of comparative neglect it was he who re-
stored the currency to its original dignity. With
498
MEDICAL RECORD.
Sept. 16, 1916
no just title to the throne by descent, and too proud
to accept the crown as a mere king consort, Henry
spared no pains to fortify his position by other
means. To throw lustre on himself as a scion of
the house of Lancaster, he even sought to canonize
the pious imbecility of his Lancastrian predecessor
Henry VI. The requisite miracles were forthcom-
ing, wrought at his shrine, but it is said that in
addition to other difficulties Henry's thrifty soul
shrank from the expenditure of 1500 gold ducats,
the least amount that would satisfy the legitimate
expectations of a horde of greedy menials on so
important an occasion. Thus minded, it is no mat-
ter for surprise that he should have desired to pop-
ularize a ceremonial which, in the eyes of the com-
mon people at least, stamped him as being the
Lord's annointed.
It is important to consider briefly the origin of
the Angel, because in spite of the generally accepted
tradition, it suggests the possibility that its be-
stowal on the sick may have been initiated by Ed-
ward IV and merely revived by Henry VII.
The Angel was first ordered to be struck by Ed-
ward IV in 1465 A. D., but it does not seem to have
been absolutely minted until 1470. Its name, "An-
gel," is derived from the figure, on the obverse, of
the Archangel Michael piercing the dragon, sur-
rounded by the words "Edward, Dei Gra. Rx. Angl.
Et Franc." On the reverse was a ship with masts
in the form of a cross surmounted by sunrays and
surrounded by the legend: "By thy Cross save us
Redeemer Christ." This is the first appearance of
this legend on the coinage, and suggests an asso-
ciation with the ceremony of healing. There is,
however, nothing to confirm this conjecture in the
original warrant for its minting. Henry VI, dur-
ing his brief restoration, 1470-1471 A. D., Edward
V, and Richard III. all issued an almost identical
Angel. On succeeding to the throne, Henry VII in
his first issue of 1485 A. D., retained the same Angel
with the essential modifications, but also issued an
alternative form, bearing the legend: "And the an-
gel said unto her. Fear not, Mary, for thou hast
found favor with God." taken from the Noble of
Edward III. which was much used as an amulet in
battle. The double issue shows that from the com-
mencement of his reign Henry VII proposed using
the Angel in the ceremony of healing and consid-
ered the legend selectd by Edward IV appropriate
for such a use. In 1489 he issued a second Angel
with trifling variations and again with the same
alternative legends.
The quaint old herbalist of later days, Nicolas
Culpeper, has a jibe at physicians anent the Angel,
that, like Balaam's ass. they will not speak till they
have seen an "Angel" — an habitual fee.
James I seems to have been the first sovereign
to have Angels specially minted for healing in ad-
dition to those to be circulated as current coin.
A document in the Public Record Office dated April
10, 1611, is a warrant to the Treasurer and Under
Treasurer of the Exchequer, and shows that healing
Angels were specially minted to his order. The
omission of the cross from the ship's masthead and
also a part of the inscription, is said to indicate
the sceptical trend of his mind. Charles I used An-
gels specially minted for the purpose. These An-
Rels bore the legend, "The love of his people is the
King's safeguard." After 1634 no more Angels
were minted.
Medalets were also used as touch pieces, for there
is in the British Museum a bronze medalet about
the size of the touch piece of Charles II. It has on
the obverse a hand stretched out over four human
heads, with the words "He touched them," and on
the reverse a rose and thistle under a crown, with
the words "And they were healed." And in the
accounts of the Wardens of the Exchange and
moneys within the Tower 1625-1642, there is to be
found under date of 1635-6, Allowance of a payment
to the chief graver for making token for the heal-
ing of the King's Evil, and delivered to William
Clowes, Sergeant Chirurgeon at 2d the piece: these
numbering 5500.
It is said that with the accession of the house
of Hanover, the ceremony of healing, as a preroga-
tive of the Sovereign, died a natural death in Eng-
land, George I having declined to touch a sick child.
but the touch pieces continued to be used, being
passed from patient to patient.
In France healing by royal touch was practiced
by Charles X, who revived the whole ancient cere-
monial at his coronation in 1824. But who shall say
the custom has entirely passed away? There is at
least one good old physician in an Eastern city who.
after prescribing for his patient, sometimes remarks
that he, during his summer vacation, visited a fa-
mous shrine in Canada — he brought back with him
some interesting little medals — would the patient
like to have one — "Take it, then, perhaps it will help
you!"
REFERENCES.
1. Weber F. Parks: Illustrations of Information Fur-
nished by Medals. Small Bronzes, &c. Internat. Cong.
Med., XVII, Lond., 1914, pp. 425-431.
2. Weber, E. P.: Aspects of Death in Art and Epi-
gram, London, 1914. T. Fisher Unwin, pp. 220-329.
3. Pfeiffer, L. und Ruland, C: Pestilentia in Numis,
Tubingen, 1882, H. Laupp, pp. 73-185.
4. Crawfurd, Raymond: The King's Evil, Oxford,
1911, The Clarendon" Press, pp. 1-161.
5. Rudolphie, Carl Asmund: Index Numismatum
(four parts), Berlin, 1826-68.
6. Storer, Horatio R.: Medals, Jetons and Tokens,
Am. J. Numismatics. 1887-1911:
17211 Connecticut Avenue.
GENERAL PRINCIPLES TO BE OBSERVED IN
BONE TRANSPLANTATIONS.
By CLARENCE A MrtVIU.lAMS M.D.. F.A.C.S..
NEW YORK.
1. Most scrupulous asepsis is an absolute essential
to perfect success. To assure with the greatest cer-
tainty that no infection be introduced into a clean
field at the time the graft is transplanted, the
operator, assistants, and nurses should all wear
rubber gloves and the same scrupulous Lane tech-
nique should be employed as in operating on frac-
tures, i.e., nothing that has been touched by the
hand should go into the wound or touch the graft
and all instruments and gauze wipes should be han-
dled by instruments alone. It is advisable not to
tie vessels but to allow the artery forceps to remain
hanging in situ during the operation, after which
they can be removed with little danger of bleeding.
All sutures should be tied by means of clamps to
avoid touching the suture with the hands. Instru-
ments once used should be laid aside and reboiled
before using again. Sterile towels should be
clamped all about the edges of the wounds so as to
exclude the skin from the operative field. All this
applies both to the site of the graft as well as to
the field from which the graft is removed. A new
knife should be used after the skin is incised and
the old one should be laid aside. Tincture of iodine
i
Sept. 16, 1916]
MEDICAL RECORD.
499
may be applied to the cut skin edges immediately
after incision.
2. In general it may be said that all sinuses should
be perfectly healed for two or three weeks before
grafting is attempted so as to prevent infection of
the graft. While infection does not necessarily
mean the death of the whole graft, yet the danger
that it may entirely die is very great. Lewis has
demonstrated in two cases that a transplant may
be inserted into an infected area with the object of
acting merely as a mechanical support to prevent
deformity, even if it is necessary to remove it later.
In some instances such grafts may remain viable
and hasten convalescence.
3. The graft should be taken living from the same
individual who is to receive the graft (i. e. an auto-
plastic or autogenous graft), if the best and surest
means for success are followed. If this be not pos-
sible, which is very rare, then it should be taken
from as near a blood relative as possible. Animal
bone should never be used, because such a graft will
be absorbed, owing to the changed serological and
chemical relations. If taken from another indi-
vidual, syphilis should be ruled out by the Wasser-
mann reaction, as well as tuberculosis should be
excluded.
4. A living graft should be transplanted always
with as much periosteum covering it as possible.
Without the periosteum the life of a graft has
proved to be uncertain. Its retention will insure
success if asepsis be attained and immobilization
maintained. The question of just what the function
of the periosteum is is an academic one. Practically
the periosteum seems necessary for success in the
greatest number of cases. Less important for suc-
cess but still advantageous is to have endosteum
also on the graft, for the whole of a thing is
greater than any of its parts. The value of marrow
seems to be small; according to some authorities,
it is disadvantageous.
5. The success of a graft seems to depend upon a
speedy adherence of the periosteum to the sur-
rounding parts that the blood supply may be as
quickly established as possible. Effused blood will
prevent this adhesion, hence bleeding and oozing
should be checked to the greatest extent possible.
In addition a blood-clot about a transplant does not
permit of a permeation of serum into the bone and
also prevents vascularization. Lewis gives several
instances in which hematomata caused absorption
after graftings. On account of the subsequent ooz-
ing a tourniquet had better not be employed.
6. No drain should be used, since this predisposes
to infection.
7. A motor saw is of inestimable value in bone-
grafting operations. The best is Albee's motor saw-
made by the Kny-Scheerer Co., New York.
8. In taking a graft from the tibia, its crest
should not be employed, for this is the strongest
part of the bone and its removal will predispose to
subsequent fracture. Before this was appreciated,
McWilliams had two fractures of the tibia from
whose crests grafts had been taken, while other
fractures have been reported, thus, Dyas reports
such a fracture, also Rhodes, while Morris reports
two cases. At a recent meeting of the American
Roentgen Ray Society six cases were shown of frac-
tures of the tibia? following the removal of bone
for transplantation. If the crest is used the limb
should be strengthened by a plaster splint for sev-
eral months after the transplantation, as new bone
in such a defect is but slowlv reformed.
9. All foreign non-absorbable material, wires,
nails, celluloid, horn, rubber, etc., should be avoided
as implants unless under very exceptional condi-
tions. Encircling wires will erode the bone and a
fracture will result. These non-absorbable foreign
bodies tend to irritate, if not invite suppuration,
and often produce sinuses which will usually require
their removal to cure such sinuses. Chromic gut or
kangaroo tendon should be used to fix the graft in
position.
10. When the head of the humerus, or radius, or
femur is fractured and dislocated and the joint is
opened, then the head should be replaced and at-
tached to the freshened lower fractured surface,
even though the head be dead, provided it is still
aseptic.
11. A graft increases in size according to the de-
mands put upon it by the organism. Experience has
taught that it is unnecessary to laterally fill up a
defect completely with a graft. It is essential to
fill up a defect vertically, leaving to nature to do
the remainder.
12. After transplantation absolute immobilization
is essential for success. This should be maintained
for at least three or four months, or longer if roent-
genograms show its necessity.
13. The periosteum of the bone into which the
graft is inserted is an important element and should
be preserved and brought into contact with the per-
iosteum of the graft or over the ends of the same,
if possible.
14. The inlay graft in the treatment of fractures
is to be preferred theoretically to the intramedullary
splint, since endosteum comes in contact with
endosteum while the periosteum of the graft can
be sutured to the periosteum of the bone. A much
more successful method of treating non-union in
fractures than a Lane plate is the bone graft. The
intramedullary splinting has, however, given good
results in the hands of many surgeons, particularly
Murphy.
15. Transplantation of long bones with their joint
surfaces has been successfully performed, as has
been the case with half joints and with whole joints
in a few instances. In most instances, however,
the transplantation of joints has not been better
in results than those accomplished by resections.
16. A suggestion by Huntington seems valuable.
He has found that the periosteum of a graft may be
preserved in situ during operation by wrapping the
fragment closely with zero catgut. Before closing
the wound the strands of gut are divided and re-
moved or cut short.
17. In operating on comminuted fractures,
whether simple or compound, replace the fragments,
if possible, in their original positions. If this be
not possible, fragment the pieces, retaining all the
periosteum possible on the fragments and replace
them about the fracture spot.
18. The site from which a free graft may be ob-
tained seems to depend upon the individual pref-
erence of the surgeon. The majority seem to have
used the tibia, while the fibula has been preferred
by fewer others. In a few instances grafts have
been taken from ribs, clavicle, scapula, crest of the
ilium, and bones of the hands and feet.
19. Do not transplant a graft into the midst of
dense connective tissue, since the nourishment of
the graft will suffer. Excise the connective tissue
and check the bleeding by packing before inserting
the graft.
20. The bed into which the graft is to be trans-
500
MKDICAL RECORD.
[Sept. 16, 1916
planted should be prepared first. Then the graft is
obtained and placed in its new bed just as quickly
as possible that its cells may not suffer from lack
of nourishment for any longer period than is abso-
lutely necessary to make the transfer. In order that
blood and serum contained in the graft be not
washed away, theoretically it were more scientific
not to immerse the graft in salt solution, but to
wrap it in gauze wet in salt solution if there is to
be any delay in its transfer. This will prevent the
drying out of the graft by evaporation.
33 East 63d Street.
STATE MEDICAL SERVICE AS CONTRASTED
WITH THE PANEL SYSTEM FOR THE CARE
OF INDUSTRIAL WORKERS.
By A. C. BURXHAM, M.D.,
NEW YORK.
When a popular English dramatist, writing a de-
cade ago, prophesied the State control of medical
care for the individual, his statements were made
the butt of many derisive remarks and, as it hap-
pened, the comments of the medical profession
were the most bitter.
It is a well-recognized fact that the physician is
a member of one of the most, if not the most,
conservative of professions. Only a short resume
of medical history convinces one that in the medi-
cal profession there is an overdeveloped sense
of conservatism, not to say obstinacy, which makes
its appearance upon the introduction of radically
different methods of treatment and new social
developments. From a medical point of view this
is perhaps right and proper, for it is only by this
spirit of conservatism that useless, and in many
cases harmful, methods of treatment are kept
within reasonable limits, and the exploitation of
the public by means of spurious "cures" is made
more difficult. If in this process the advancement
of medical science is somewhat delayed the final
results are probably beneficial.
In respect to the socialization of medical serv-
ice, however, the situation has been handled much
less satisfactorily. The medical profession is to-
day in many respects where it was twenty years
ago. While science has progressed, the economic
aspects of the practice of medicine have remained
practically stationary, and it is only within the
last few years that the social and economic aspects
of medical service have begun to impress them-
selves upon the profession in general.
With the conservatism for which it is noted the
profession has combined an ignorance of non-
medical affairs which is inexcusable, the result
being that they now find themselves face to face
with a condition which is easily comparable with
the State control of all medical service as fore-
seen by the English dramatist and which is called
"sickness insurance," or better, "health in-
surance."
In Germany more than thirty years ago the in-
surance of the industrial worker began with
workman's compensation insurance for industrial
accidents and the limits of this insurance have
gradually increased until the benefits are now open
to almost every wage earner in the entire country
for every case of accident or ill health occuring
during the period of employment. It includes not
only the wage worker but his family and depend-
ents as well.
In England the Insurance Act has been in force
since January, 1913, nearly 15,000,000 persons
being included under its provisions. Upon its in-
troduction the British Medical Association ac-
cepted the terms of the act and in July, 1913, it
was estimated that nearly 20,000 physicians (about
90 per cent) were employed by the State in the
administration of the law. It has been estimated
that over $20,000,000 was paid in fees to physi-
cians on the panels, the average amount being a
little over $1000 to each physician.
If a similar law is to be enacted in New York
State, and such a law has already been introduced
in the State Legislature, it is evident that before
the medical profession undertakes the State serv-
ice it would be wise to examine into the relations
between the physician and wage earner under the
English act, thereby attempting to settle upon the
plan adapted to the best interests of those parties
most concerned, namely, the physician, the insured
employee and the State.
With the introduction of the act in England
physicians who were willing to treat patients un-
der the act were placed upon a panel and patients
were allowed to choose their own physician, the
proviso being made, however, that the choice must
be made for a period of not less than one year.
Physicians are paid a per capita fee of seven shil-
lings a year, this being understood to include or-
dinary medical care but not to include surgery or
any special treatments. No limit is placed upon
the number of patients on a given physician's
panel, nor is any limit placed upon the amount of
attention which the insured may demand.
Recent records are unreliable for purposes of
forming an opinion as to the working of the law,
principally because of the war which has dis-
located industries and thrown the medical pro-
fession in confusion since August, 1914. At that
time the act had been in force nineteen months and
numerous articles had appeared in the British
Medical Journal in praise and criticism of the
law. At that time the discussion centered almost
entirely upon the determination of the best system
for the care of the insured.
The panel system had been found wanting and
something more was required to accomplish the
desired ends. Immediately two opposing camps
sprang up; those who believed in the retention
of the panel system — with improvements and ad-
ditions it is true — but in the main, the old panel
system; and those who believed that the best ends
would be served by the inauguration of a State
health service along the lines of medical service
in the army or navy.
Sir John Collie,' a strong advocate of a system
of State medical service, says in part: "Under the
panel system many physicians are overworked.
One physician stated that during one week he
treated 320 people for colds. This was less sur-
prising when it was shown that this same man
with his five partners had 7000 workmen on their
panel. Dr. Cox stated that during the year (">") to
70 per cent of those on the panel make some call
upon their physicians. A Dr. Salter stated he saw
on an average of 168 patients a day. Allowing
nine hours a day. this worked out 'il \ minutes
per patient of which 1% minutes were taken up
in clerical work. The patients were obliged to
wait an average period of over two hours."
It is apparent that a system such as the above
is far from ideal. It was believed, before the
1. Collie, Sir John : A State Medical Service vs. A
Panel System. British Medical Journal, August 8, 1914.
Sept. 16, 1916]
MEDICAL RECORD.
501
panel system went into effect, that because the
panel included almost all of the practising phy-
sicians, the workmen would be more or less evenly
divided among the panel members. This, however,
has not proven true. Physicians began to be di-
vided into two classes, those who, so to speak,
specialized in panel cases, and those who were
willing to undertake little or none of the insur-
ance practice. The inconveniences to the physician
were many. The clerical work was considered ex-
cessive, the work was exacting, and vacations were
difficult to secure. When treatment is contracted
for during the entire year for less than two dollars
per capita it becomes a hardship to devote the
required time to this type of practice unless the
number of patients under the physician's care is
sufficient to guarantee a yearly income of at least
fifteen hundred or two thousand dollars. That is
to say, it may be very difficult to secure treatment
for fifty or a hundred patients, even when they
can be easily handled in addition to a physician's
regular private practice, while it is comparatively
easy to secure a man who will devote his entire
time to the care of this type of practice when the
quarterly check amounts to five or six hundred
dollars.2
An additional disadvantage of the panel system
is seen in the giving out of disability certificates.
Physicians become very lax in this respect and a
certain type of workmen flocks to the man who has
the reputation of giving many disability certifi-
cates. To quote further from Sir John Collie: "It
has been said by one who is a strong advocate of
the panel system that it is good because 'medical
men compete with one another for increasing re-
muneration by pleasing the patient which makes,
the administration of the act so difficult.' " Once
inaugurated in America, the panel system will
find as many adherents as it has found in Eng-
land, and it will have as many, if not more ob-
jectional features.
It may be, and indeed has been, urged that a State
medical service is socialistic in character. This
may be true, but, if it is, then the system of State
insurance is socialistic, and so are many of our
modern institutions. We have to do to-day, not with
scholastic discussions of what constitutes a social-
istic medical service, but rather what type of
service is best adapted to the so-called socialistic
institutions of the present. State health insurance
is surely destined to a trial in the United States
before many years have passed, and when it does
come it would be well to find the medical pro-
fession prepared.
The profession is handicapped by division in its
ranks and by lack of organization in dealing with
economic problems. The point has not yet been
reached where a State medical service for the en-
tire population is either wise or advisable; but the
nationalization of the medical services to the in-
dustrial army is urgently called for. Such service
should include, in order to make an arbitrary
boundary, all wage workers earning less than one
hundred dollars monthly. Whether the medical
service should be whole-time service exclusively,
or whether it should include part-time workers in
addition to the whole-time staff, can be decided
later.3 "There is, however, one sine qua non in
"Sir John Collie mentions one physician who had
2,800 patients on his panel and who worked from 9 a.m.
to 11.30 p.m. 365 days in the year.
3The writer has published elsewhere a plan for a
State medical service which he believes to be open to
few objections.
such a service," writes Sir John Collie, "and that
is the medical officer must be well paid, have a
good position, and the number of patients allotted
to him must not be excessive. I have yet to learn
that salaried whole-time medical officers of health
are not enthusiastic, progressive and capable and
that the fact of their not being paid by fee has
militated against their attaining their deservedly
high position. The salaries for whole-time services
would be graduated and there would be as in the
army and navy, positions of increasing responsi-
bility and remuneration." He further outlines the
State service as having facilities for laboratory
examinations, X-rays, etc. Consultants and hos-
pitals would be easily available." The service would
entail regular hours and regular holidays, more time
for the enjoyment of the home, more time for post-
graduate study, and a permanent freedom from
anxiety caused by fluctuations of income; in fact,
entire freedom from the commercialism of the
present system.
Even were these facts given under a lesser au-
thority than the above they would be striking
enough to demand consideration, but they are
emphasized because of their potency rather than
because of their origin. They represent the trend
of thought in a country where state insurance
under the panel system has had a trial of more
than a year, and the result is unsatisfactory to all
parties concerned. The patients are dissatisfied
because the service is inadequate; the physicians
are dissatisfied because the pay is small and the
clerical work is arduous; and finally, the State is
dissatisfied because the expenses are high (espe-
cially for drugs) and because of the belief that the
periods of disability are unduly prolonged. To the
outside observer it is apparent that science is not
being advanced to the same extent it is in the army
medical service or as it is in the very excellent med-
ical services of the Board of Health in most of the
larger American cities.
If changes in medical customs and practices are
wise and advisable, it is desirable that the sug-
gestions for such changes come from, rather than
be forced upon, the medical profession.
In an address before the Associated Physicians
of Long Island, Rubinow states the whole situation
clearly and concisely, saying in reference to social
insurance, "In this the medical profession is hope-
lessly behind the times. In its worst phase private
medical practice is medically from twenty-five' to
fifty years behind the present status of medical
practice and surgical skill. In its best phase it is.
a luxury which, like automobiles and private
yachts, can be purchased only by the selected few.
The socialization of medical service has been
woefully delayed as compared with other functions
of lesser importance, but at last it is on its way.
The purpose it must accomplish is twofold — im-
provement in quality and cheapening of cost. These
purposes cannot be easily accomplished in the
face of obstinate opposition from the medical
profession."
It were wise if the profession as a whole were
more interested in the subject of medical eco-
nomics. Are we really as scientific as we claim to
be if we allow many of our efforts to go to waste
because of lack of organization? Concerted action
and co-operation will do more to advance medical
science and the wellfare of man than will even the
best type of individual effort. Consequently it is
advisable that organizations composed of medical
men throughout the United States combine to lay
502
MEDICAL RECORD.
[Sept. 16, 1916
before the law makers what we, the profession,
consider the ideal provisions for the medical ad-
ministration of an industrial health insurance law.
1 in West Seventy-ninth Street.
SPEECH, ITS CULTURE AND REFINEMENT;
WHAT IS DONE FOR IT IN HOLLAND.
By N. J. POOCK VAX BAGGEN,
THE HAGUE. HOLLAND.
My readers, did you ever meet with that certain
handsome young lady, dressed by a first-rate Paris
dressmaker, smart and "Ciln soignee" from top to
toe, who moves about so gracefully and looks so
extremely distinguished and refined? Fascinated
by so many charms you are only too happy to ob-
tain an introduction and to be allowed to speak to
her. When she opened her lips to respond to your
modest flattery, I noticed a sort of bewildered look
in your eyes, which bye and bye changed into an
ironical smile. What was the matter — this out-
wardly distinguished and refined young person
betrayed only too distinctly her low origin both
by her voice and accent.
Poor young lady! She had spent so much for
her general refinement and culture, and only for-
got an essential matter: the culture and refine-
ment of her speech.
Sometimes you go to church, I suppose. Going
home you want to think over the beautiful words
which the clergyman uttered, but it is too much
for you. You got a bad headache while listening
to the sermon. You overstrained yourself in the
effort to understand the speaker, and you came
to the conclusion that the sermon failed to make
the desired impression because of the fatiguing
resonance of the clergyman's voice and his want of
distinct articulation.
And the clergyman himself ... He did his
utmost effort to make himself understood in the
spacious church; but before he had finished half
of his sermon, he had the desperate feeling that
his voice was losing its clearness and became
hoarse and indistinct. He came home with a sore
throat and the unpleasant feeling that his audi-
ence had not come under the spell of his eloquence.
Yet he had carefully meditated his subject and his
sermon was well prepared. He only never thought
of training and preparing his voice for its strenu-
ous task. And this is the same case with ever so
many speakers. How often does it not occur that.
in the midst of an electioneering campaign, the
candidate is forced to renounce speaking at a
meeting because his voice has given out entirely.
And no wonder! What fighter, gymnast, pianist,
violinist or any other performer will go in for a
performance without having thoroughly prepared
and trained his muscles by appropriate and effi-
cient exercise? They know too well that their
success depends on the readiness of their muscles
for the task. While in the United States, I noticed
that the public speaker, as a rule, never thinks
of getting his voice ready lor the work.
The American speaker does not seem to realize
that the voice and speech is the result of the action
complicated and delicate set of muscles, which
need more than any of our muscles to be properly
trained when we demand a great exertion of them.
Y. l tin- sneaker who masters the right employment
of the voice will meet with the pleasant experience
that his voice lasts till the end of his task. Se-
renely, in full possession of his faculties, he faces
his audience, who follows with pleasure his in-
telligible and comprehensible speech.
It is a matter of course that the training of the
voice includes its refinement. Vicious accents, as
for instance the nasal twang, disappear altogether
or are diminished sensibly when the muscles be-
come more supple and tractable by their exercise.
How do we train the voice? I mean the funda-
mental training, which has in view the exercising
and strengthening of the muscles used when speak-
ing and singing and the furthering of the har-
monious co-operation of the different groups of
muscles.
When we observe a speaker or singer, we notice
that, before he begins to produce a sound, he in-
hales more or less deeply. This inhalation pro-
cures him the provision of air which he uses as the
motor power to put his instrument into action.
We can compare this inhalation with the work
which the bellows blower does for the organist.
Without the necessary provision of air the organ-
ist is unable to play his instrument. Only after
the bellow:s are put in action and he has the man-
agement over a sufficient quantity of air or, what
is here the same, a sufficient ouantity of motor
power he can draw sounds from his instrument.
Exhaling, the speaker or singer uses this provi-
son of air to make the tented vocal cords vibrate.
This vibration engenders the sound, which we call
"the voice." From the voice box the voice or sound-
ing breath is driven into the pharynx, the mouth,
and the nose. Those parts assume by means of
the articulating muscles the different attitudes
and shapes necessary for the formation of vowels
and consonants, which as such leave the mouth
and reach our ear.
The sonorous vibrations of the voice cause the
co-vibrations or resonance from the partitions of
the vocal instrument, i.e., of the thorax, the larynx,
the pharynx, the mouth, and the nose with its
cavities. This co-vibration or resonance gives the
tone, its characteristic quality or "timbre," its
brilliancy, and its fullness.
From the above results we learn to distinguish
in the speaker and singer four elements : ( 1 ) A
motor element (the breath) ; (2) a vibrating ele-
ment (the voice) ; (3) a forming element (the ar-
ticulation) ; (4) a resonant element (the co-vibra-
tion of the walls of the vocal instrument).
Thus for the training of the speaker and singer
we consider in the first place the breathing. If
the breathing is faulty and weak, it is corrected
and strengthened by appropriate exercises, after
which the pupil is taught how he can best use
his breath on behalf of his voice and articulation.
Secondly, the articulating muscles are examined
and the different vowels and consonants reformed
so far as necessary. Nearly at the same time the
amelioration of the action of the vocal muscles is
undertaken ; while finally the resonant element is
developed.
Normal speech and singing depend on the fault-
less action and the exact harmonious co-operation
of the four elements. This co-operation is so strict
that even the least deviation of one of the parts
is of direct influence on the other elements.
A faulty articulation, for instance, impedes the
action of the vibrating element and requires a
greater effort on the part of the breathing
muscles; while, on the other hand, a wrong use of
the breath thwarts the distinct pronunciation of
the vowels and consonants as well as the voice pro-
duction. And also a non-developed resonance or
Sept. 16, 1916J
MEDICAL RECORD.
503
gaps in this element are an important impediment
to the clearness and purity of the voice.
Very many times I have been asked in America
if, when I speak of the training of the voice, it
is elocution that I mean.
It is not. The training of the voice precedes the
lessons of the elocutionist. This training is given
by what we call here the "leeraar in het me-
thodisch spreken," which means: "Specialist or ex-
pert in normal speech and voice hygienics."
The sphere of action of the expert implies not
only the training of the healthy voice but also the
treatment of all the voice afflictions which appear
after serious diseases of the throat such as diph-
theria, angina, etc., and after those affections
caused by the too general misuse of the voice as
well as by speakers as by singers. Most of the
time the expert is also specialist for correcting
speech impediments and for gymnastics of the
respiratory organs.
The expert works in combination with the medi-
cal specialist in diseases of the throat and respira-
tory organs. No serious expert begins his work
before the patient has gone through a judicious
medical examination.
The studies of the student-specialist for voice
hygienics include the exact anatomical knowledge
of the vocal instrument, the pathology of the
throat and of the voice, the diagnosis, the modes
of treatment, and the application of the exercises
in the different cases, tone production, acoustics,
and phonetics. If he goes in for the breathing and
the speech impediments, he studies also the dis-
eases of the respiratory organs and the central
and peripheral speech affections, their origin and
treatment.
With regard to the treatment of the voice, af-
fected through misuse or illness, I can say that I
have found it nowhere so complete as in Holland
During my investigations regarding the care for
the voice and the culture of speech in the different
countries, I have been astonished to find that in
some countries this special treatment is altogether
unknown, as for instance in France and in the
United States ; while in other places, as in Berlin,
it was introduced by Dutch specialists and re-
ceived with general appreciation.
Since the last twenty years the culture and re-
finement of speech in Holland has largely im-
proved. The conservatories for singing at Amster-
dam and at the Hague, as well as the school for
actors and actresses have long had their own
expert specialist and every pupil is obliged to go
through a severe treatment for general voice hy-
gienics and purification of the accent.
Particular care is also given to the training of
the voice and the refinement of the speech of the
teachers. To every Dutch training school for
teachers is attached nowadays a specialist for
voice hygienics who is salaried by the government
or by the municipality to which the school belongs.
Moreover, in the large towns, as in the Hague and
Amsterdam, the municipality has appointed a spe-
cialist for voice hygienics, who gives courses free
of charge to the teachers of the municipal schools.
Those courses were started to combat the throat
disease (the same as clergymen's sore throat)
to which the teachers, in the exercise of their
profession, are so frequently subject.
When the teachers suffer from the throat the
visiting physician of the school examines them
and, if necessary, sends them to the courses for
voice hygienics. For the teachers with a healthy
voice those courses are not obligatory but on his
(or her) demand, he (or she) can follow the
course. Generally all the teachers of the munici-
pal schools take a course because it gives them a
better chance for an appointment and for promo-
tion when they have a well-trained voice and re-
fined speech.
It is a matter of course that those trained
teachers exert a favorable refining influence over
the speech of their pupils. I have often noticed
that the young teachers, who have followed the
course take pleasure in correcting the speech and
purifying the accent of the children, who are un-
der their care and demand from them a faultless
pronunciation.
Besides the care for the voice and for the re-
finement of the speech in general, the speech de-
fects are specially attended to.
In every town of some importance there is now-
adays a specialist for speech impediments, attached
to the public schools and salaried by the munici-
pality. In the large towns, as Amsterdam and the
Hague, the specialist has a staff of assistants.
They visit the public schools regularly and at the
request of the teacher examine the pupils who
suffer from any speech defect. After the diagnosis
is made the children go to the municipal institu-
tion, where they receive free of charge the treat-
ment which their case demands.
Some years ago the specialists for voice hy-
gienics in Holland founded the Dutch association
for the speech culture, which meets regularly. In
those meetings special cases are discussed, and
in particular the measures to be taken to further
the general culture and refinement of speech are
advocated.
The influence of the refinement of speech is not
merely external. I have explained above how-
speech is produced by the action of some groups
of muscles. Those muscles are stirred by the vi-
bration of the nerves. They vibrate under the im-
pulse of the action of the brain, which is the ut-
terance of the soul. Thus speech comes from the
soul to go to the soul.
And so the culture and refinement of speech
mean the smoothing down of the obstacles which
hinder the free communication of the souls.
The culture and refinement of speech mean the
furthering of the better understanding between
mankind; and that better understanding between
mankind is what we require nowadays, essen-
tially; there is no doubt about that.
Plaats 10.
MEDICAL EDUCATION IN CHEMISTRY.
By FREDERICK S HAMMETT, PH.D.,
r.OS ANGELES, CAL.
COLLEGE OF PHYSICIANS AND SURGEONS. MEDICAL DEPARTMENT.
UNIVERSITY OF SOUTHERN CALIFORNIA.
That the average physician possesses but little if
any applicable knowledge of chemistry is lamentably
self-evident. To one trained in chemistry, and es-
pecially trained in the applicability of chemistry to
medicine, this general lack of information on a
subject so vital to efficient understanding of the
reactions of the body is prominently apparent.
This elemental deficiency in education is shown
by the absence of reported productive discussion, in
cither council or publication of the needs of the
physician for a well-grounded knowledge in the ap-
plication of the principles of chemistry to medicine.
504
MEDICAL RECORD.
[Sept. 16, 1916
Personal conversation with several physicians of
more or less successful practice has invariably
brought the information that they "never knew
chemistry and never could understand it anyhow."
This lack is also obvious when one glances over
the examination questions asked in chemistry by
various State Boards. To what practical use can
a physician put the formula for common salt? Why
should he know a test for ferrous salts? Of what
value to him is the knowledge of the names and
structures of three hydrocarbons? This is high-
school chemistry and belittles the value of the
science in the eyes of the young graduate instead
of showing him that there is a definite correlated
knowledge of chemistry which he is expected to
know as capable of direct application by his pro-
fession.
Then turn to the requirements of the Association
of American Medical Colleges as set forth in their
Constitution and By-Laws. Here again lack of
scientific viewpoint obstructs the vision and con-
fuses the desired end, due in its entirety to im-
proper conception of the science and hence inability
to so plan a curriculum as to bring out the coordina-
tion necessary for just appreciation. The unneces-
sary and pedagogical redundancy requiring 192
hours of premedical training in college grade chem-
istry (not to mention that required in high-schools),
presumably inorganic and organic, and then re-
quiring 180 hours of inorganic and 75 hours of or-
ganic chemistry during the medical course is so
obviously an example of the lack of perception of
values as to require no further comment. And then
to top it off only seventy-five hours are given over
to instructing medical students in the applications
of chemistry to medicine, that is, physiological
chemistry.
This, however, does not constitute or imply a
lack of appreciation of the value of the science of
chemistry to medicine. In fact the mere inclusions
of the subject in both premedical and medical
courses show that it is a valued adjunct to the pro-
fession. The very requirements of the Association
of American Medical Colleges show this apprecia-
tion, not only by the generous time alloted to the
subject, but also by the equipment demanded and
the fact that research is encouraged and expected.
The constant occurrence of articles in the scien-
tific journals founded on chemical studies of both
normal and pathological organisms; the establish-
ment of laboratories in hospitals for the chemical
study of the cases at hand and the routine analytical
procedure as follow-up of the treatment; the em-
ployment in these hospitals of chemists trained in
medical research ; the trend of medical schools to-
ward preferring men trained in the .science and
especially in the practical applications of the science
to medicine, to instruct their students, rather than
employing as teachers practitioners whose only ex-
cuse for teaching lies in the desire to be connected
with a medical school and thus enlarge at one and
the same time their prestige and their practice; the
establishment by medical schools of laboratories for
research along chemical lines and the requirements
that the instructors be capable of contributing some-
thing to Ihe advancement of medicine; the many in-
stitutions devoted to medical research alone; the
eagerness with which the average physician grasps
these discoveries and applies them to his experi-
ences, especially at present evident in the use of the
glands of internal secretion; all of these and many
more bear fruitful evidence that in spite of the gen-
eral lack of definite information there is specific ap-
preciation of the value of chemistry to medicine.
Now, what are the causes of the general lack of
knowledge of the practicability of chemistry as ap-
plied to medicine?
In the first place the study of biochemistry or the
chemistry of the living organism is comparatively
recent. That is, the accumulation of evidence of a
chemical nature relating to the processes of life has
not been sufficient, until within the last few years,
to warrant the application of the principles evolved.
Consequently the training of medical students has
been along the lines of straight chemistry with but
little, if any, practical application, and the subject
was looked upon, and justly so, as a waste of time.
It is only within recent years, and even then at
only a few of the more advanced medical schools,
that advantage has been taken of the progress in
chemistry in its use for medicine and the subject
given its full value. Hence we have the majority of
physicians possessing a false conception of the sci-
ence and exerting their influence upon the minds of
the present-day medical student to make difficult the
instillation of its practicability.
Moreover, the insufficiency of the premedical
training along the lines of definiteness, adds to the
difficulties of imparting understandable informa-
tion. This is encouraged by the lack of scientific
attitude and understanding in the profession gen-
erally.
Chemistry as largely taught either is in the hands
of some practitioner whose chemical training has
been received from other similarly situated indi-
vidual, or else is in the hands of a chemist whose
training has omitted the medical viewpoint. The
former lacks chemical understanding; the latter,
medical understanding. From the first man the
student gets neither chemistry nor its application.
From the second man the student gets chemistry but
no practical usage.
Another cause for the present day inadequacy of
chemical knowledge is the type of questions asked by
State Boards. By the very fact of their impracti-
bleness they cast their shadow upon the subject and
thus oppose a barrier to progress by removing in-
centive. As the chairman of one State Board said
to me recently, "Chemistry is the last subject to be
given out, and it is always shoved off on someone
because no one wants it." And I say no one wants
it because the average physician has no understand-
ing of its applicability to his profession.
Furthermore, there is a certain group of phy-
sicians who, having specialized in one branch of
medicine, have had no opportunity to keep up with
the progress made in other lines, and because of
their lack of preparation and improper instruction
fail to see the importance of chemistry. These men,
otherwise broad-minded, by derogatory statements
exert an inhibitory influence upon the minds of the
younger and less experienced men, who, revering
the older and wiser heads, imbibe their point of
view and bring to the subject a wholesome contempt
that is the part of youthful prejudice.
The sum total of lack of preparation, impractical
instruction, impractical State Board examinations,
and unappreciative critics has tended, and at the
present time tends, to bring disrepute upon a sub-
ject that, if properly understood, is an invaluable
practical asset to the physician.
A little intensive thought will make clear why a
greater appreciation is due the subject, why a better
understanding is necessary, and how much the medi-
Sept. 1G, 1916]
MEDICAL RECORD.
505
cine of to-day is dependent upon the fundamental
principles of chemistry.
Anatomy teaches how the body is put together.
Physiology teaches how it works; but Biochemistry
teaches why it works. The how is only controlled
by an understanding of the why.
The body, composed as it is of an indefinite num-
ber of units called cells, is a vast chemical factory
each unit of which has a purpose of its own and the
successful carrying on of whose function is gov-
erned by the laws of chemical reaction. It is thus
obvious that a knowledge of the why of bodily activ-
ities is ultimately grounded upon a knowledge of
the principles of chemistry. And as both structure
and mechanism are but supplementary to motive
power, so a knowledge of chemistry is a prime essen-
tial to the understanding of the living organism.
The maintenance of life depends upon an adequate
supply of energy-producing material to the body and
the removal of the products of its combustion.
Hence a correlated knowledge of the chemical nature
of what goes in, what changes it undergoes during
its passage through, and in what forms it is ex-
creted is essential to the understanding of bodily
processes. Without this information the physician
lacks just as much and even more of being ade-
quately prepared to deal with the human body as if
he knew nothing of anatomy or any other kindred
subject.
If this were all it would be sufficient to command
not only a deep respect and appreciation of the
value of chemistry to medicine, but to also show the
necessity for a greater understanding. But this is
not all.
The work of Dakin on body oxidations, of Knoop
on fat decomposition, of Moore and Rockwood on
fat absorption, of Jones on nucleic acids, and of
Folin on protein metabolism are but a few of the
innumerable examples that could be cited wherein
Biochemistry has opened up new views for medicine
and afforded a working basis for future treatment
that can be equaled by no other science.
The development of microchemical methods for
the analysis of urine, blood, and feces has put into
the hands of the physician rapid, easy, and accurate
means for studying body processes and following
through pathological progress to its completion.
Combining the use of these methods with an under-
standing of the causes giving rise to the results ob-
tained affords the clinician invaluable diagnostic
measures. It is accordingly obvious that those
schools whose aim it is so to train their students
that on entering the practice of medicine they shall
he equipped to take their place in the front ranks
of their profession, must take cognizance of the
value of biochemistry and so incorporate it into
their course of study that it becomes second to none
in importance.
Admitting then that the average physician does
not understand the practicability of chemistry for
his profession ; that present methods of curriculum
planning fail to allow opportunity for the develop-
ment of this understanding in the medical student;
that the present type of State Board questions in
chemistry fail to demand a careful knowledge; and
that in view of the usefulness of the science to
medicine radical reformation is needed, the follow-
ing suggestions are offered for consideration:
The premedical requirements should be definitely
outlined. The progressive medical schools of this
country are requiring of their students a two-year
college course as a premedical requisite. Without
undue elimination or too strenuous endeavor on the
part of the student the following courses could well
be required before granting admittance to medical
schools : One year in general inorganic and physical
chemistry, one year in organic chemistry, and one
half-year in quantitative analysis. With a founda-
tion of this sort any intelligent medical student is
ready to commence the study of biochemistry and is
capable of understanding its applications. The re-
quirements of the Association of American Medical
Colleges as regards chemistry in medical schools
should be changed.
With a foundation as outlined above, or even with
the present requirements of the Association, it is
not only unnecessary but even a waste of time to
include in the medical curriculum inorganic and or-
ganic chemistry. It is a waste of time, because in
the first place the student is supposed to have had
these subjects before entering upon the study of
medicine, and in the second place because the pur-
pose of the medical school is the study of the human
body. Nay, more, it is a wicked waste of time. For
here we are clamoring for a fifth year of medical
training and claiming that four years is too short,
and then valuable time is filled up with repetition.
Change this, eliminate the elementary branches in
chemistry from the medical curriculum and apply
the time thus released to the study of biochemistry.
This is not a plea for more time for chemistry in
the medical schools, but is a plea for more time for
its practical application and the elimination of sub-
jects properly supposed to be taught in the pre-
medical course.
Concomitantly with these changes there must
come a recognition of the responsibilities of the
State Board Examiners as regards chemistry. They
must realize that what a student knows is what he
thinks he is going to be asked on examination, and
not what his instructor has tried to teach him. From
the standpoint of the teacher this is pernicious; but
how eradicate it? We cannot teach all men the
value of high ideals. We can tell the student that
the deeper his knowledge goes the better service it
will be to him. But with all the present day strug-
gle of competition, the rush and hustle, and the
crowded curriculum, the average medical student has
but little inclination to dig deep and find the sweet
water of knowledge. Rather he is so thirsty, so
hurried, that he drinks from the braken surface
pool of information, content in having assuaged his
thirst for the moment, not considering that the more
wholesome water of learning lies deeper, only await-
ing his efforts to obtain it.
It is not a difficult thing to set a high standard
of questioning that will be reasonable and at the
same time demonstrate the practicability of the sub-
ject. For instance, why not find out if the young
doctor knows the sources of the acetone bodies in
the blood and urine, or why gelatine is an imperfect
food, or what becomes of the nitrogen we eat, how
and in what form it is excreted? Even the physical
chemistry of indicators as applied to the determina-
tion of urinary acidity would not be too intricate.
Nor to know something of the mechanism for the
maintenance of the neutrality of the blood. Should
he not know that cane sugar is not utilizable as a
food when injected intravenously and why?
Why not be logical? Why not look the proposi-
tion squarely in the face, admit the incongruities,
and eradicate the present absurd condition? Why
continue to hamper the future medical student by a
dogmatic clinging to moss-grown ideas?
506
MEDICAL RECORD.
[Sept. 16, 1916
Let the attitude of the physician be to cure, not
merely to relieve. And just as the understanding
of the how and the wky of the cure rests upon a
knowledge of the reactions of the body, and as this
knowledge is firmly based upon a knowledge of
chemistry, so does the efficient education of the
physician depend upon an efficient instruction in the
applicability of chemistry to medicine, which can be
obtained only by a broad-minded acknowledgment of
the present systemic deficiencies and an earnest
attempt to bring about the necessary changes.
4HrttaiUr.al Sfafrn.
Use of X-Ray in Diagnosis. — In an action for mal-
practice it appeared that the plaintiff fell off a ladder
about 15 feet, injuring his ankle. He was given a hypo-
dermic injection to relieve the pain, taken to a hospital,
placed upon an operating table, and the defendant and
another doctor made an extended examination of his
ankle, spending over half an hour in doing so. They
diagnosed the injury as being a severe sprain. The
ankle was placed in splints and the patient placed in
charge of a nurse, who was instructed to pour liniment
upon it. The case was then given over to the defendant.
Three or four days after the injury the splints were
removed, the foot placed on a pillow with a sandbag to
support it, and the nurse was directed to massage the
ankle and move it as much as the patient could stand.
This was done each day. He remained under the de-
fendant's care in the hospital 17 days. At the time
he left he was unable to bear his weight upon the
injured foot without pain or to walk without crutches,
and finally the foot remained fixed in such a position
that the front part of the foot was left at a downward
angle from the normal position. Two months after the
injury he suggested to the defendant he would like an
.r-ray taken. This was done by another doctor. It
disclosed that the fall had caused a slight impacted
fracture of the forward part of the astragalus and a
rupture or raising of the periosteum on the posterior
portion of this bone. A fluid exuded which afterwards
hardened into a bony substance and formed a wedge
between the articulation of the tibia and astragalus,
thus causing the abnormal position of the foot. Four
physicians were called by the plaintiff. One of them,
who took the x-ray pictures, testified that an .'-ray
picture taken at or about the time of the injury would
not have disclosed the condition with reference to the
periosteum or the effusion of the fluid; that the proper
I reatment for the impacted fracture would have been
to keep the foot at rest by means of splints for six or
eight weeks. He also testified that if, when the de-
fendant examined the plaintiff's ankle and found swell-
ing, mobility, no displacement, no dislocation, and no
crepitation, his diagnosis in the first instance that his
injury was a severe sprain would have been the diag-
nosis of an ordinary practitioner of the allopathic school
of medicine in Omaha about that time, May. 1912. The
other three witnesses called by the plaintiff testified
substantially to the same effect, though one or two said
that patient would stand the expense he would,
in case of doubt, or under such circumstances, have
had an r-ray picture taken. None, however, testified
that this was the usual method. It was held that the
testimony did not establish that the failure to have an
.r'-ray picture taken as an aid to diagnosis constituted
lack of reasonable care and skill under all the surround-
ing circumstances, and that if the plaintiff1 isted
upon the claim of negligent diagnosis aloni
would no! ' a verdicl i". his favor.- Vai '
v. Pinto, Nebraska Supreme Court, 155 X. W.
Prescriptions of Unusual Amounts of Narcotics. — The
eral district court, X. D. New York, holds that
under the exception in Section 2 of the Harrison Nar-
cotic Law of lions by physicians, a physician
who issues a prescription for an unusually large amount
of the drugs, which prescription shows on its face that
the quantity prescribed is unreasonable and unusual,
or a dealer who fills such a prescription or order i
by a physician, is guilty of an offense, unless the pre-
scription indicates the necessity for such an unusual
quantity. — United States v. Curtis, 229 Fed. ^88.
C( nstruction of Sarrison Xarcotk- Act — Sending
Medicine Through Mails. — The federal dista
S. D. Ohio, holds that, while the Harrison Naixotic Act
of December 17, 1914, permits a physician in the course
of his professional practice to dispense and distribute
the mentioned narcotics to a patient by whom he is
employed to prescribe, without being subject to the
prescribed regulations, although he does not personally
attend the patient, the act must be construed with ref-
erence to the known usages and modes of practice in
the profession in which the prescribing for patients
without personal examination is the rare exception and
not the rule; and under the provisions of Section 1,
requiring the Commissioner of Internal Revenue, with
the approval of the Secretary of the Treasury, to make
all needful rules and regulations for carrying the pro-
visions of this act into effect, the commissioner has
authority to prescribe what shall constitute "personal
attendance" and "professional practice" by a physician
within the meaning of the act, and a regulation which
denies the right of registration and exemption to one
who, although a licensed physician, does not see most
of his patients, who bases most of his prescriptions on
their written statements sent to him through the mails,
and who prescribes the same remedy for all alike, is
within the power conferred and valid. — Tucker v. Wil-
liamson. 229 Fed. 201.
"Chiropractics" Is "Practising Medicine" in Utah. —
Utah Laws 1911, c. 93, provides that any person shall
be regarded as practising medicine who shall diagnose,
treat, operate upon, prescribe, or advise for any physical
or mental ailment or any abnormal mental or physical
condition of another after having received or with in-
tent to receive any compensation, or who holds himself
out as a physician or a surgeon. The Utah Supreme
Court holds that a "chiropractor," one professing a
system of manipulations which aims to cure disease by
the mechanical restoration of displaced or subluxated
bones, especially the vertebrae, to their normal relation,
who advertised as a "Graduate chiropractor — no drugs
or surgery, or osteopathy — try chiropractic," and who
endeavored not so much to cure ailments as to permit
the natural "vital forces of the body," impeded by lux-
ation of vertebrae, to proceed unhindered to any dis-
eased part upon readjusting the displaced vertebras with
his bare hands, for which he received compensation, was
"practising medicine" within the statute, since he "diag-
nosed" the symptoms of his patients by recognizing the
presence of disease from its signs or symptoms in de-
ciding as to its character, and thereafter treated them
for compensation. "There are," the court said, "many
ailment? in their acute stages which, if correctly diag-
nosed and properly treated, yield most readily, but if
not recognized and not properly treated become in their
chronic stages most stubborn and unyielding. The de-
fendant undertook tc treat various ailments of children
without even professing any knowledge of pediatrics,
and many other ailments where knowledge of histology,
biology, pathology, and other branches of science was
essential to properly recognize and understand them. It
needs no argument to show the harm that may result by
anyone without knowledge of opththalmology attempt-
ing to treat some acute and virulent disease of the eye
by attributing the cause of the disease to a subluxal
vertebra of the neck causing "nerve pressure, or that the
manipulation to reduce the pretended subluxation might
itself do harm, but that in the meantime the disease, for
want of recognition and proper attention, may have pro-
gressed to a stage where it no longer can be arrested."
— Board of Medical Examiners of the State of Utah vs.
Freenor, 154 Pac. 941.
Testing Cocaine.- — In proceedings against a physician
for unlawfully selling cocaine, the physician testified
that he gave a person (who appeared to have been given
to the use of cocaine and liquor) a powder composed
chiefly of chloretone, and which contained no cocaine.
This person's evidence as to whether he asked for co-
caine was contradictory. Two physicians, both admit-
tedly unfriendly to the defendant, testified that they
tested the powder by tasting the contents only, and
upon such test pronounced that it contained cocaine.
Upon cross-examination each of these witnesses was
shown a medical work and his attention called to the
following statement: "Cocaine responds to all the gen-
eral tests for alkaloids, giving precipitate for tannic
acid, picric acid, solutions of iodine, etc., but these are
not distinctive, nor, unfortunately, do we possess at the
present time any one characteristic test for this alka-
loid." Neither of the witnesses disputed the correctness
of this statement. It was held that on such evidence a
conviction could not be sustained. — Stadler vs. People
Colorado Supreme Court, 147 Pac. 658.
Sept. 16, 1916] MEDICAL RECORD
Medical Record.
A Weekly Journal of Medicine and Surgery
507
THOMAS L. STEDMAN, A.M., M.D., Editor.
PUBLISHERS
WM. WOOD & CO., 51 FIFTH AVENUE.
See fourth page following reading matter for Rates of Subscription
and Information for Contributors and Subscribers.
New York, September 16, J9I6.
SPLENECTOMY IK PERNICIOUS ANEMIA.
The occurrence of enlargement of the spleen in cer-
tain anemic conditions, such as hemolytic jaundice
and Banti's disease, and the absence of any rational
method of treatment led inevitably to the therapeu-
tic removal of the spleen in some of these cases. The
spleen has long been considered as the center for
normal red cell destruction, and in some instances
of splenectomy for rupture of the organ in other-
wise normal individuals there followed the develop-
ment of a polycythemia. A very definite improve-
ment was seen in many cases of anemia associated
with splenomegaly after the spleen had been re-
moved and naturally that measure began to be
adopted in the treatment of other more or less
closely allied conditions. It was tried in a number
of cases of pernicious anemia and the results were
at first remarkable. The operation is a serious one
and many of the patients in grave condition so
that the mortality was rather high. But when the
patient survived there followed a marked stimula-
tion of the whole bone marrow and a remission in
the course of the disease. With the appearance of
the reports the operation became immensely popu-
lar and large numbers of spleens were removed,
often, it is feared, without sufficient justification.
Then reports began to tell of later deaths and re-
currences and the method was decried as dangerous
and of only temporary value. As usual the truth is
somewhere between the two extremes.
The subject has been reviewed in two recent ar-
ticles by Lee, Minot and Vincent and by Krumb-
haar (Jour. Amer. Med. Assn., 1916, Vol. LXVII,
pp. 719-723). A critical study of the reported
cases has shown the authors that the immediate
mortality of the operation is probably much less
than the apparent 20 per cent, if the cases are prop-
erly selected. A red cell count of less than 1,000,000
is apparently a rather strong argument against op-
eration. A true estimation of the effect of splen-
ectomy in pernicious anemia is somewhat difficult
because the disease is characterized by the occur-
rence of remissions which may come on at any time
and be marked and lasting. It is because of this
fact that so many therapeutic measures have had
such brief vogue in this condition. Still it is shown
that a remission practically always follows the op-
eration and that splenectomy is probably the great-
est bone-marrow stimulant at our command.
So far there is little difference of opinion. It is
in the later study of these cases that the important
information is to be obtained. In about one-third
the improvement extended over a period of two
years although there was no evidence that there oc-
curred any real cures. Better results were seen in
those patients in whom the spleen was definitely
enlarged and Krumbhaar points out the possibility
that in the future it may be shown there are two
or more distinct diseases which are now called by
the one name and that splenectomy is indicated in
one but not in the others. It is pointed out that
transfusion also results in stimulation of the bone
marrow and that it is a measure not serious in it-
self and which can be frequently repeated. For
that reason it is generally preferred to the opera-
tion. Our lack of definite knowledge concerning
many of the important factors in the problem pre-
vents our arrival at any conclusions of much force
At the present time it seems to be the opinion of
the majority that splenectomy is more apt to have
a favorable result in those cases with clinically en-
larged spleens, icteroid appearance, and increased
urobilin output (increased hemolysis) without in-
creased resistance of the erythrocytes. While it is
properly considered as an operation to be under-
taken only as a last resort still the results are bet-
ter in those patients in whom the disease has pro-
gressed for not more than a year and who still have
a relatively good blood picture. The operation
should be preceded by one or more transfusions and
may be followed by them if necessary. It is prob-
able that the next five years will see fewer splenec-
tomies done for pernicious anemia than did the last
three years, but the results will be much more fa-
vorable and it is possible that with increased knowl-
edge it may become feasible so to select cases that
a favorable result can be predicted with some
suretv.
ACUTE ANTERIOR POLIOMYELITIS IN
SWITZERLAND.
This scourge is now existing in mildly epidemic
form in portions of Switzerland. During the two
years, 1914-15, 130 cases occurred. As 40 cases oc-
curred in the Canton St. Gall, 36 of which were in
1915, the affection may be regarded as epidemic for
that locality. The same may be said of the Cantons
of Lucerne and Zurich, although the number at-
tacked there was much smaller. The total of vic-
tims of the three Cantons was but 75. The fact
that many of the cases appeared in the autumn of
1915 did more to justify the notion of epidemicity
than the number of cases.
In the Correspondenz-Blatt fiir Schweizer Aertze
for July 29 Androussieur gives his experience with
the Lucerne cases. The smallness of the material
in the community made it easy to trace the apparent
contagion. Thus one boy of 6 was believed to have
given the disease to a playmate aged 4, and the
latter to have infected a brother aged 13. The in-
cubation period was apparently two and three days
respectively. The first victim contracted his dis-
ease from a source wholly unknown. The symptoms
were much the same in all — headache, stiff neck,
vomiting, marked sweating, pains in the limbs,
508
MEDICAL RECORD.
[Sept. 16, 1916
fever, etc. The disease ran a relatively mild course
and the prospects of functional recovery seemed to
be good. One patient made a complete recovery in
two or three days. In a second group of ten cases a,
woman of 32 came down suddenly with high fever,
headache, stiff neck, and profuse sweating. The
symptoms went from bad to worse, death occurring
on the sixth day with respiratory paralysis. A man
aged 41 met the same death in four days. He came
down suddenly with fearful abdominal pains, chills,
and fever. He complained also of headache and
weariness. Later he suffered from unbearable pains
in the back. In a boy of 10 one of the first symp-
toms was follicular angina. In a youth of 16 the
only symptoms at first were malaise, chills, and
fever. The other phenomena developed very slow-
ly. Another youth of the same age fell ill very sud-
denly with high fever, but at no time showed any
cerebral symptoms, and several other children had
the same type of disease.
Certain cases, not necessarily fatal or severe,
showed rectal and vesical troubles during the dis-
ease. The fatalities were in cases which would ordi-
narily be termed Landry's paralysis. The two
deaths made the mortality of the second group 20
per cent. In this group contagion could apparently
be traced in half of the cases, either direct or
through healthy carriers. The other five exhibited
no epidemiological features. Through these cases it
was possible to place the ordinary limits of incuba-
tion at from 2 to 7 days, but in two exceptions
the length of this period was extended to 13 days
and 5 weeks respectively. The epidemic lasted
over three months and had its maximum in No-
vember.
During the past twenty-five years the author has
treated 79 cases in the children's hospital at Zurich,
nearly all in children under five years of age. From
what we actually know of the virus it behaves much
like the virus of rabies. A powerful toxin is pro-
duced, as shown by the changes in the nerve cells,
i.e. it has a striking affinity for the latter. Epi-
demiologically it seems related to epidemic cerebro-
spinal meningitis.
ANESTHESIA AS A SPECIALTY.
In certain quarters the impression seems to prevail
that any medical student or nurse who knows enough
to pour ether out of a container drop by drop and
watch a patient's respiration and pulse knows
enough to give anesthetics. The presence of the
surgeon too seems to be considered sufficient pro-
tection, for, ask the supporters of this system, would
the surgeon let his patient die from the anesthetic?
The writer gave his first anesthetic in a large
hospital in a large city. He had just been gradu-
ated from a class A medical school where he had
seen about thirty administrations of an anesthetic,
that is, he had witnessed about thirty operations at
which he had been bidden to watch every move of
the operator. He had never even assisted at the
giving of an anesthetic, but nothing of this was
asked of him. Instead he was given a can of ether
and turned loose on a helpless child in an anesthetic
room, with no help available but nurses. Fortu-
nately the child lived through it and proficiency
came with practice. Several years ago the leading
surgeon in a large city — a man with a national repu-
tation— was operating in a hospital where student
anesthetists were the rule. The patient, an only son
about twelve years old, died on the table from the
anesthetic and the hospital and surgeon were sued.
As a result a force of three expert anesthetists to
serve in rotation were added to that hospital's staff.
No man can attend to two complicated procedures
at one time. No surgeon can give his full attention
to the operation in progress and at the same time be
fully cognizant of the state of the anesthesia. It is
not fair to the patient to be operated on by a man
whose mind is only partly on his work, neither is it
fair to submit anyone to a narcosis, stopping short
only of paralysis of the vital faculties, induced by a
non-medical person supervised by an occasional
glance from a very busy man a few feet away. The
technique of anesthetization can be acquired by
practice by anyone, doctor, nurse, or student. But
when we realize that the first sign of some difficulty
with the patient may be so slight as to be observable
only by a skilled anesthetist and yet so grave that
immediate and appropriate treatment is required if
the patient is to live, we at once realize that the
knowledge of the expert is indispensable and should
be available.
The expert anesthetist should have especial train-
ing in the diseases of the chest, he should be well
versed in the particular drugs he uses, such as anes-
thetics, stimulants, and depressants of all kinds. He
should, of course, be letter perfect in the mechanical
details of his specialty and familiar with all the com-
plications which may arise in the course of an an-
esthesia. Furthermore he should understand some-
thing of psychology and have a pleasing personality
which inspires confidence in the patient. Possessing
all these qualities such a man need never find him-
self idle. The surgeon who approaches an opera-
tion with a mind at rest about the welfare of his
patient under the ether is in condition to do much
better work, and the hospital which has the reputa-
tion of furnishing such expert anesthetists will be-
fore long be the hospital of choice of the well-in-
formed physicians and surgeons in that community.
SALONICA FEVER.
The war has brought out another disease of a
somewhat new type, or, at any rate, of a new type
to Europeans. Captain I. C. McWalter contributes
a paper in the Medical Press August 9, 1916, on
Salonica fever, presumably a malady indigenous to
Salonica and its vicinity or which has appeared and
been closely observed only since the allied armies
made a base of that Grecian port. McWalter de-
scribes it as resembling a cross between malaria and
typhoid, aggravated by bronchopneumonia. With
the exception of the presence of parasites in the
blood corpuscles the affection exhibits none of the
characteristics of malaria, no cycle of events, no
regular stages, no enormous spleen, no definitely
specific effects of quinine. McWalter questions
whether every pyrexia where Peyer's patches are in-
flamed, as is the case in Salonica fever, should be
Sept. 16, 1916]
MEDICAL RECORD.
509
classed as typhoid. Widal's reaction is sometimes
negative, but this may be attributed to antityphoid
inoculation. None of the postmortem signs of
typhoid fever, malaria, or pneumonia are observed
in fatal cases of Salonica fever, that is, to say, no
such signs as an observed postmortem at home in
cases of these diseases. Most of the cases of Sa-
lonica fever, as said above, resemble a complication
of typhoid and malaria, with the supervention of
bronchopneumonia; others are more like dysentery
with malaria and lobar pneumonia, and still others
closely simulate sunstroke.
Perhaps the most interesting point mentioned by
McWalter in connection with this disease is that it
is largely due to diet. It appears to him that much
of the severity of the fever is due to the lack of
vitamines. Where patients have been living for ten
or twelve months in a hot, dusty, insanitary en-
vironment on canned food and chlorinated water and
they are taken to a hospital where they get a canned
food diet, it is difficult for the blood to become
charged with that fresh abounding viltality which
will enable it to shake off a fever.
The war, and especially the war waged in the
East and Far East in which the conditions are
peculiarly enervating to the unacclimated European
and the food is seldom fresh, has brought out the
fact that after all diet is an important factor in
the preservation of health. Moreover, many hap-
penings would seem to favor the theory that sev-
eral diseases are caused by a lack of the vitamine
element in food while other diseases are injuriously
influenced by this same lack. It has been demon-
strated to the satisfaction of most authorities that
beriberi is a malady caused by absence or lack of
vitamines. In this country a great deal of evidence
has been brought to show that pellagra is caused
by a deficiency or absence of vitamines in the diet.
Scurvy has also been stigmatized as probably due
to an insufficiency of vitamines, and many are in-
clined to the belief that rickets may also be a de-
ficiency disease. There is no doubt that the presence
of vitamines in a diet is essential to the preserva-
tion of good health. The mortality from Salonica
fever is believed to be greatly increased by the low-
ering of the patient's resisting powers and it seems
not unlikely that McWalter is correct in attributing
the severity of this fever to an insufficiency of the
vitamine element of the food.
Educational Menus.
The medical profession has been described as being
the only altruistic one in the world, that is, it is
constantly endeavoring to deprive itself of its
means of livelihood. When preventive medicine has
achieved its final victory, the family physician can
take in his shingle and bring up his children to
be wireless operators or aviators. We are of course
a long way from this millennium, but there is no
doubt that the public is becoming better educated
in health matters. Such terms as bacillus, salvar-
san, and the calorie are mentioned in the best so-
ciety now. For centuries mankind has dimly
realized that the average individual eats too much
and many aphorisms have gathered about the sub-
ject, as "Man lives on one-third of what he eats,
the doctor lives on the other two-thirds," and
"Leave the table always feeling that you could have
eaten more." It is only comparatively recently,
however, that the exact requirements of the human
machine has been estimated with an arbitrary unit,
the calorie, as a standard. The next step will be
the familiarization of the lay public with the caloric
value of various foods. A move in this direction has
already been taken by the Public Health Depart-
ment of New York City which furnishes educational
menus to its employees at its lunch-room at head-
quarters. The menu cards are ruled vertically into
five parts containing respectively the name of the
food, its price, the quantity in a single order, the
number of calories, and the protein content. Thus
we have a glass of milk: four cents, seven ounces,
160 calories, seven grams of protein. Apple pie,
five cents, one-sixth of a pie, 300 calories, four
grams of protein. To be sure it would seem better
to use the metric system all the way through if it
is to be used at all, but this is of small moment.
The important fact is that these employees can eat
intelligently (if they wish to do so), something of
which Americans are notoriously incapable, accord-
ing to the Continental belief. When this custom is
extended to private dinner parties we shall begin
to realize its full benefit as an aid to conversation,
as well as its possibilities as a guide to correct
methods of living.
£faua of tfo> 3$wk.
The Poliomyelitis Epidemic. — The decline in the
epidemic of poliomyelitis, though perhaps not quite
so marked as was hoped, has continued steadily.
The death rate from the disease has risen during
the last two weeks somewhat alarmingly. For the
week ending September 9 there were reported 351
new cases and 132 deaths, as compared with 477
cases and 157 deaths for the previous week. The
total number of cases to September 9 was 8486,
with 2100 deaths. It is estimated that the total
cost of the epidemic will be about $1,000,000. The
surgeons of the United States Public Health Serv-
ice, who have been issuing certificates to persons
leaving New York for interstate travel, have dis-
continued this service. The call for immune serums
from persons who have recovered from the disease
has met with a satisfactory response, and up to
September 9 seven gallons of blood had been drawn,
yielding three gallons of serum. The supply has
not yet, however, been sufficient to meet the demand.
An outbreak of the disease has been reported
among the Crow Indians on the reservation near
Billings, Mont., sixteen cases having appeared up
to September 6. The openings of Williams College,
Rutgers College, Amherst College, and Wellesley Col-
lege have been postponed, in most cases until after
the first of October, because of the prevalence of the
disease. In New York State outside of New York
City 2,575 cases, with 271 deaths, had occurred up
to September 9. Commissioner of Health Emerson
spoke before the League of American Municipalities
in Newark on September 7, on the subject of infan-
tile paralysis, reviewing the history of the present
epidemic and the steps which had been taken by the
Department of Health in the attempt to control it.
Poliomyelitis, Ptomaine Poisoning, and Sour-
Grass Soup. — A writer in one of the New York
newspapers has recently advanced the theory that
the epidemic of infantile paralysis is due to the
eating of spoiled food, and that many of the so-
called poliomyelitis cases are merely cases of pto-
maine poisoning. This is denied by the Health
510
MEDICAL RECORD.
LSept. 16, 1916
Commissioner, who says that in the present epi-
demic very few wrong diagnoses have been made,
but that on the other hand the diagnosis of ptomaine
poisoning often is wrongly made. It is stated that
several cases of illness occurring in the East Side
of the city and reported as ptomaine poisoning were
on investigation found to be due to indulgence in
sour-grass soup. This is prepared from sour-grass,
a species of sorrel, otherwise known as "qchav" or
"schav" leaves, which are rich in oxalic acid salts.
The soup is a common dish in some of the East Side
restaurants. In one restaurant visited by the Health
Department inspector it was found that the method
of preparation was as follows: The leaves were
stripped from the stalks and well washed, the wash-
ings being thrown away; they were then soaked
over night in cold water, and later boiled for fif-
teen minutes. This water also was thrown out.
The leaves were then boiled for the second time,
eggs and cream were added and the dish was ready
to serve. Chemical analysis of the finished soup
showed about 10 grains of oxalic acid to the pint.
Sick Rate on Border. — Statistical reports from
medical officers in charge of troops on the Mexican
border show that the percentage of sick among both
regular troops and National Guardsmen was less
than 2.5 per 100 for the week ending September 2.
During that time six deaths occurred. The army
medical officers regard the condition as unusually
satisfactory for this season of the year.
Typhus in Mexico. — An epidemic of typhus fever
is reported in the State of Zacatecas, Mexico. Phys-
icians are being sent from Mexico City to fight ths
disease and precautions are being taken to prevent
its spread to other parts of the republic.
War on Mo.squitos. — The Princeton, N. J., Board
of Health is planning a general clean-up movement
for the extermination of mosquitos in the marsh
lands near Lake Carnegie. Thousands of loads of
fill have been dumped on the low ground and the land
has been graded so that excess water will drain oft
into the lake. It is estimated that between $5,000
and $10,000 will be needed for the work.
Is Whiskey a Medicine? — The question how to
mi et demands for whiskey and brandy for medicinal
purposes was discussed at the American Pharma-
ceutical Association in session at Atlantic City last
week. Both have been deleted in the new pharma-
copoeia of the United States, and it was feared that
this action might prevent the sale of all alcoholic
stimulants in drug stores.
Gift to Charities. — In lieu of rent for Shadow
Lawn, the summer White House at Long Branch,
N. J., President Wilson has sent to the committee
in charge his personal check for $2,500, the mom
to be distributed among charitable institutions in
Monmouth County. This was the stipulation made
by the President when he agreed to accept Shadow
! awn as a residence without rent.
Typhoid Epidemic. — Altoona, Pa., is threatened
with an epidemic of typhoid fever, six deaths having
occurred to September 8. The State Department of
Health has inspected the city's watershed and has
found evidence of serious contamination. The city
has been placarded with warnings that water i'<>r
all purposes should be boiled as a precautionary
measure. It has been predicted that five hundred
cases may occur before the epidemic reaches its
ht.
Memorial to Poliomyelitis Victim. — The Phila-
delphia Department of Health has begun plans for
the erection of a memorial to Dr. Earle i who.
as reported in the obituai in, died last week
from poliomyelitis contracted in the course of his
service as chief resident physician in one of the
Philadelphia hospitals in charge of infantile pa-
ralysis cases.
Strike in Hospital. — The nurses and students at
the Philippine General Hospital, Manila, went on
strike on August 31, as a protest against the dis-
cipline of the hospital, and on the following day
the disturbances became so serious that it was
necessary to call out American reserves.
Dr. Julius E. Foehrenbach has been appointed
assistant bacteriologist in the Department of Pub-
lic Health and Charities of Philadelphia.
Civil Service Examinations. — The Civil Service
Commission of the State of New York announces
examinations on September 30, 1916, for the pur-
pose of filling vacancies in the following positions:
Laboratory assistant in bacteriology, State De-
partment of Health. Men and women, $720 to
$1,200 a year. Only candidates who have satisfac-
torily completed a systematic course in bacteriology
and have had not less than eight months' practical
experience will be accepted. The examination will
cover the technical procedures used in the study of
pathogenic bacteria, and immunity, and the stand-
ard methods used in the examination of milk, wa-
ter, sewage, air, and soil.
Laboratory apprentice, State Department of
Health, $600 to $720. Candidates must have a
collegiate education or its equivalent. A knowledge
of bacteriology and practical laboratory experience
are desirable but not essential.
Assistant physician, regular or homeopathic, in
State hospitals and other State and county insti-
tutions. Salary in State hospital $1,200 to $1,600
with maintenance. Open to men and women who
are licensed medical practitioners in New York
State, and graduates of a registered medical school,
and who have had since graduation one year's
experience on the resident medical staff of a gen-
eral hospital or as medical interne or clinical assis-
tant in a state hospital or institution, or have been
engaged for three consecutive years in the practice
of medicine.
Woman physician, regular or homeopathic, in
State hospitals and institutions. Salary $1,000 to
$1,500 a year and maintenance. Candidates must
be licensed medical practitioners in New York State
and have had at least one year's experience on the
medical staff of a hospital or three years' experi-
ence in the practice of medicine.
Further details and application blanks will be fur-
nished, until September 18, by the State Civil
Service Commission. Albany, N. Y.
Sentenced for Fake Cure. — The New York City
Department of Health has secured the conviction
of an imposter in this city on the charge of
selling as a cure for infantile paralysis a bag of
cedar shavings and advertising this in the news-
papers as a cure. In the Court of General Sessions
last week the man was sentenced to serve thirty
days in .jail and pay a fine of $250. The bags were
similar to those in which tobacco is sold and
were labeled with a red cross and "Infantile Pro-
tector" in red ink. They were sold at ten cents
each and were said to confer immunity when worn
about the neck.
U. S. Cruiser to Transport Supplies. — The medi-
cal supplies for the hospitals in Palestine, which,
r since an embargo was put on shipments to
that part of the world, have been in charge of
the American Consul at Alexandria, will soon be
forwarded to their destination on the U. S. cruiser
Sept. 16, 1916]
MEDICAL RECORD.
511
Des Moines, by order of the Secretary of the Navy.
The need for medicines and medical supplies in
the districts about Jaffa and Jerusalem has become
very great, and for this reason the Allies at the
instance of the Department of State have con-
sented to the forwarding of the detained shipment.
Typhus Fever Germ. — A newspaper dispatch
from Berlin recently contained the announcement
of the discovery of the germ of spotted typhus by
Dr. Eugen Czernel, bacteriologist, at Budapest.
Portraits for Hospital. — Through the generosity
of Dr. Howard Kelly and Mr. Blanchard Randall,
the Johns Hopkins Hospital, Baltimore, is now
in the possession of a collection of portraits of
medical men, giving it one of the finest portrait
galleries of the sort in the world. The collection,
which is valued at $ 100,000, consists of forty-eight
portraits, some of which date back to the early
part of the sixteenth century.
Charitable Bequest. — By the will of the late ('.
Cresson Wistar of Philadelphia, the sum of $2,000
is bequeathed in trust to the Howard Hospital
of that city.
Rebuilding City Institutions. — The Commission-
er of Charities of New York City has had prepared
plans, involving an expenditure of $1,400,000, for
the rebuilding of the institutions on Randall's
Island and the enlarging of Sea View Hospital
on Staten Island. When the improvements at Sea
View are completed its capacity will be increased
from 1,000 to 2,000 patients. The buildings on Ran-
dall's Island, some of which were put up in 1848.
are all of wood and brick and will be replaced as
far as possible with fireproof structures.
Obituary Notes. — Dr. Earle Curtiss Peck of
Philadelphia, a graduate of the Jefferson Medical
College, Philadelphia, in 1914, interne at the Ger-
mantown Dispensary and Hospital, died at the
hospital, after a short illness, from poliomyelitis
contracted in the course of duty, on September 5,
aged 25 years.
Dr. Sterling Barrows, formerly of Amherst,
Mass., a graduate of the College of Physicians and
Surgeons, New York, in 1906, and a member of the
Massachusetts and Hampshire District Medical So-
cieties, died at his summer home in Worthington,
Mass., after a long illness, on August 16, aged 36
years.
Dr. Joseph Logue Lockary of Boston, a graduate
of McGill University, Medical Faculty, Montreal, in
1897, formerly assistant professor of obstetrics at
Tufts College Medical School, Boston, and a mem-
ber of the American Medical Association and the
Massachusetts Medical Society, died, after a short
illness, on August 13, aged 46 years.
Dr. Albert Currier Buswell of Epping, N. H.,
a graduate of the Medical School of Maine, Port-
land, in 1878, and a member of the New Hampshire
and Rockingham County Medical Societies, died at
his home, after a long illness, on August 12, aged
63 years.
Dr. James H. McLaughlin of Sutter Creek, Cal.,
a graduate of the Kentucky School of Medicine,
Louisville, in 1891, and a member of the Medical
Society of the State of California and the Amador
County Medical Society, died in Stockton, Cal., on
August 22, aged 54 years.
Dr. Michael Lewinski of New York died at his
home on September 1, aged 54 years.
Dr. Stacey Watkins Boyle, formerly of Middle-
burg, Vt., a graduate of the New York Homeo-
pathic Medical College and Flower Hospital, New
York, in 1908, died suddenly at Panama, on August
20, aged 39 years.
Dr. William Henry Baker of Lynn, Mass., a
graduate of the Hahnemann Medical College and
Hospital of Philadelphia, in 1880, died suddenly at
his home on August 22, aged 72 years.
Dr. Edward L. Estabrook of Minneapolis, Minn.,
a graduate of the Long Island College Hospital,
Brooklyn, N. Y., in 1878, died at the Corey Hill
Hospital, Brookline, Mass., after a short illness, on
August 20, aged 70 years.
Dr. M. J. Newberry of Lizella, Ga., a graduate
of the Atlanta Medical College, Atlanta, Ga., in
1886, died at his home from paralysis, after a lin-
gering illness, on August 27, aged 54 years.
Dr. John H. Roebuck died recently at Bethlehem,
Pa., at the age of 76 years. He was graduated from
the medical department of the University of Penn-
sylvania in the class of 1865.
Dr. Clarence James Lockhart of Freedom, Pa.,
was killed by a disappointed patient on August 20,
aged 28 years. He was a graduate of the Cleveland-
Pulte Medical College in the class of 1912.
©btluary.
RUDOLPH H. VON EZDORF, M.D.,
UNITED STATES PUBLIC HEALTH SERVICE.
Dr. R. H. von Ezdorf, surgeon in the United States
Public Health Service, and at the time of his death
in charge of the United States Marine Hospital at
New Orleans, La., died at Lincolnton, N. C, on Sep-
tember 8. He was born in Pennsylvania and was a
graduate of the George Washington University Med-
ical School, Washington, D. C, in the class of 1894,
and entered the Public Health Service in 1898. Dr.
von Ezdorf was widely known for his researches in
.yellow fever, typhoid fever, and particularly ma-
laria, of which he had made a special study and on
which he had written much in the Public Health
Service Reports; he was also the author of the
article on Malaria in the Reference Handbook of
the Medical Sciences. He had at various times been
in charge of the quarantine stations at Savannah,
Mobile, New Orleans, and other places. He was a
member of the Medical Association of the State
of Alabama and of the American Medical Associa-
tion.
(Ecrreapnttitettrp.
LIABILITY FOR PROFESSIONAL SERVICES
RENDERED TO ANOTHER.
To the Editor of the Medical Record:
Sir: — The following letter from Mr. A. Frank
Cowen may be of interest to your readers. I am for-
warding it to you exactly as Mr. Cowen has written
to me. - I thought that perhaps it would be well for
the protection of the profession if this decision and
Mr. Cowen's instructions were published.
Samuel Lloyd, M.D.
12 West Fiftieth Street.
My dear Doctor :
In the belief that the medical journals have over-
looked the importance of a comparatively recent de-
cision of the Court of Appeals on the question of
the liability of a person for professional services
512
MEDICAL RECORD.
[Sept. 16, 1916
rendered to a third party who is neither the wife,
husband, nor minor child of that person, I am call-
ing your attention to the same trusting that it will
be of interest to you and to your colleagues in the
profession.
The decision was rendered in the case of McGuire
v. Hughes, 204 N. Y., 516. A physician was called
upon by the defendant, a widow, to render profes-
sional services to her daughter, a married woman
who was then living with her husband. At the time
the physician was called into the case the patient
was stopping at the defendant's residence. With-
out any definite understanding or without any in-
quiry as to who was to be responsible for the bill
to be rendered, the physician proceeded on the
theory, since the patient was the defendant's daugh-
ter and was being treated at home and that the re-
quest that she be treated had come from the defend-
ant, it was all right for him to assume that she, the
mother, was responsible for the bill.
In due course of time he rendered a bill to the
mother and after payment was refused proceeded to
bring suit. The case was eventually carried to the
Court of Appeals at Albany. Throughout the litiga-
tion the physician made no pretense that there was
any express promise or agreement on the part of
the mother to pay for her daughter's treatment but
instead relied on the facts in the case to raise an
implied agreement on the mother's part to do so.
The Court said as follows :
"The only question upon this appeal is whether the
defendant came under any obligation to the plaintiff.
That turns upon whether the law will imply a promise
on her part to compensate him. If we might assume
the existence of a moral obligation, that would not de-
termine that a legal, or enforceable, obligation existed.
The general rule, that where a person requests of an-
other the performance of services, which are per-
formed, the law implies a promise by the former to
pay their reasonable value, has no application in the
case of a physician, rendering professional services to
a third person, if the relation to the patient of the
person, who requests them, be not such as imports the
legal obligation to provide them."
Now in the case before the Court there was no
legal obligation on the part of the defendant to pro-
vide professional services for her daughter. She
was not only over 21 years of age, but she was mar-
ried and living with her husband.
The Court held further:
"The fact of a request to a physician to attend a
patient is not, alone, sufficient for the inference of an
agreement to pay for the services rendered (citing
cases). We are, therefore, of the opinion that it should
be taken as the rule of law, too well settled upon au-
thority to be now questioned, that a physician, in the
absence of a special contract, may recover upon an
implied agreement to pay for his services quantum
meruit, where they have been rendered at the request
of the patient or of a person who, in the eye of the law,
is regarded as being under a legal obligation to pro-
vide such professional services for the patient; such as
a husband, wife, or the parent of a minor child."
From a reading of the decision, it becomes appar-
ent that in a case similar to the above where the
relation of parent, wife, or minor child does not
exist so as to import a legal obligation for the pay-
ment of the physician's services, it is absolutely es-
sential that an express promise to pay shall be
clearly evidenced in order to sustain in the courts a
claim for such services. A promise of this kind
is best expressed in writing and I submit a short
form that leaves nothing to the imagination but
effectually binds the party executing the same.
Very sincerely yours,
A. Frank Cowen.
Form.
This is to certify that I have this day engaged
M.D., to render professional services
for and that I obligate myself to
pay for the services so rendered.
Date.
OUR LONDON LETTER.
(From Our Regular Correspondent.)
CITY MEDICAL REPORT — SHORTAGE OF RESIDENT MEDI-
CAL OFFICERS AT VOLUNTARY HOSPITALS — LOSS OF
MEDICAL OFFICERS AT THE FRONT — ST. JOHN'S
AMBULANCE AND RED CROSS SOCIETIES.
London. Aug. 17. 1916.
The City of London medical officer has just issued
his report for 1915. Referring in it to the evil of
coal smoke he declares it cannot be satisfactorily
dealt with by law until the enactments at present
in force are amended. The dirt and discomfort con-
tinue, though in less degree than in former years.
For this the enormous number of chimneys in sur-
rounding "Greater London" are largely responsi-
ble. During 1914, with the concurrence of the Sani-
tary Committee, a critical examination of the air
in the city was begun in conjunction with the Com-
mittee on Atmospheric Pollution, appointed by the
International Exhibition of 1912. A large rain
gauge placed in a convenient position was used to
collect the rainwater from a known area. This rain-
water containing the soot, grit and dust washed
from the air was submitted to the public analyst.
In the month of November the solids falling in
the city were estimated at 58 tons, of which 35 tons
were soluble. An observation has been made daily
of the purity of the air by a new method. The
amount of impurity at noon has varied from a mere
trace up to 3 milligrams per cubic metre of air,
including times when there has been a slight fog,
but no dense fog has at present been tested.
The scarcity of resident medical officers in the
voluntary hospitals has been discussed at one or
two meetings lately, and there is an impression that
it will become more acute with the progress of the
war. As a result of inquiries at 50 hospitals, Mr.
Courtney Buchanan reported a great excess of ex-
penses. Where only two or three residents were re-
quired the vacancies were easily filled up, but where
four or more were needed there was difficulty, and
in some instances out-patient work had been re-
stricted. General practitioners had in some in-
stances been called to assist in other cases by lady
doctors. The non-teaching hospitals, with salaries
of £150 or £200, could not compete with the War
Office, which offered twice as much, besides other
attractions. Graduates of our Canadian and Aus-
tralian schools had found occupation in this direc-
tion. In July, 1914, there were 104 resident medi-
cal officers in 26 London hospitals; now there are
only 81. King Edward's Hospital Fund has made
representations to the War Office, it being thought
that some engaged in official positions might be
transferred with advantage. More cooperation be-
tween the civil hospitals and the military authori-
ties would probably be beneficial. The British Hos-
pitals Association is collecting information as to
the number and qualifications of men available for
service, and arrangements could surely be com-
pleted for transferring officers from places over-sup-
plied to positions where there is any deficiency.
The losses of medical officers in the present war
are very heavy. In the Franco-Prussian War out
Sept. 16, 1916]
MEDICAL RECORD.
513
of 4962 German doctors with the army only 9 were
killed and 69 wounded. In the present struggle
up to Jan. 15, the German doctors killed numbered
56, the wounded, 216, and prisoners, 40, besides
which 94 are missing, 29 have died of disease or
wounds, 5 have met with accidents and 2 are sick,
out of the total number of about 12,000 actually
with the army, not including those in military hos-
pitals. Besides these, 10,000 are employed in re-
serve hospitals, sanatoria, prisoners' camps and am-
bulance trains. Germany has some 32,000 members
of the profession, so only about 8000 appear to be
available for civil practice.
General Sir J. Maxwell has issued from head-
quarters (Irish command) an expression of his sin-
cere appreciation of the services rendered in the
late disturbances in Dublin by the medical, surgical
and nursing staffs of the hospitals and especially
to the gallantry of some nurses who exposed them-
selves to heavy fire in attending and removing the
wounded. Further, to members of St. John's Am-
bulance and the Red Cross Societies, as well as
many medical men and private individuals who gave
assistance to the wounded or placed their houses at
the disposal of the military for use as dressing sta-
tions. In numerous instances these services were
rendered at considerable personal risk and under
circumstances reflecting the greatest credit on those
engaged in them.
OUR LETTER FROM ALASKA.
(From Our Regular Correspondent.)
IMPETIGO CONTAGIOSA AMONG THE NATIVE ESKIMO.
SOME DIFFICULTIES IN COMBATING IT.
St. Michael, August 5. 1916.
Those readers who have followed these letters from
Alaska have, we hope, gained a fair insight into the
mode of life of the Eskimo in Northwestern Alaska.
If so it will readily be appreciated that it is a very
difficult proposition indeed to combat any form of
epidemic disease among these poor, ignorant, super-
stitious, dirty people. Their bedclothing is usually
composed of a few skins or dirty old blankets
thrown on the floor, and their wearing apparel, too,
is composed of skins, sometimes mixed with cloth
garments. However, the Eskimo has usually but
one outfit of clothing, and he wears that all the
time, day and night. The children dress in the
same way, even very small children. The babies
often wear no form of diaper at all, and it is an
interesting fact that the Eskimo children learn to
use some form of commode at a very early age.
Since they wear the same clothing day and night,
rarely washing these clothes or themselves, and
sleeping huddled together among these dirty bed-
clothes, epidemic diseases spread very rapidly
among them and are very difficult to check. One
cannot boil the bedclothing or the clothes they are
wearing. They have but one set and nothing to use
while these are being cleaned; besides furs cannot
be boiled. Their houses, too, are as dirty in pro-
portion as their clothing.
With the above conditions existing in the Native
Village — which village is said to be one of the
cleanest in Alaska — impetigo contagiosa appeared
in an epidemic form among the children in April
in 1916, and it soon gained great headway in the
native school as well as in the village. The disease
soon spread into the town of St. Michael, appearing
in the school for white children as well as in isolated
cases throughout the entire community. It was an
easy proposition to handle the white children. They
were isolated and their clothing was boiled or placed
in the sun; the patients were treated, school visited,
and search made for new cases.
An effective quarantine among Eskimos in an
Eskimo village is impossible without armed en-
forcement, and the nature of this malady did not
justify such drastic action. However, the village
and native school were frequently searched for new
cases. An out-patient dispensary was established
at the schoolhouse where the native children were
seen daily and treated. A roster was kept, entering
new cases and discharging others when cured. If
the native did not report for treatment, he was
sent for and brought to the dispensary. Records
were kept and the village plotted, showing where
each infected house was. Isolation of infected chil-
dren was attempted by talking to the mothers and
fathers and explaining how the disease spreads;
this undoubtedly did good though isolation could
not be enforced; however, the "medicine man" was
instructed in the beginning to keep his hands off
or he would be put in jail.
There are 56 children in the village under the
age of fifteen years and about 25 of them became
infected with this disease. The lesions were prin-
cipally upon the face and hands, but the trunk was
often affected. Infection around the nails was
common and a mixture of scabies and pediculosis
with impetigo contagiosa was several times noted.
The lesions were vesicopustular, with thin scabs, no
infiltration or hyperemic surrounding zone; no
itching and apparently no toxemia as the children
seemed to feel well at all times; they were super-
ficial and left no scars but a dark pigmentation was
often noticed at the site of a former impetigo
lesion. Several cases showed lesions on the scalp,
and one an eruption in the mouth.
The treatment consisted in boiling the clothing
wherever possible, scrubbing the body with warm
water, tincture of green soap, and a brush and an
application of mercurial ointment, sulphur oint-
ment, and vaseline in equal parts. This was rubbed
in well daily. The white children responded
promptly, but it required about three months to
suppress the epidemic in the Native Village. The
continuance of this disease among the Eskimos was
due to the fact that it was impossible to establish
an effective quarantine, due to autoinoculation, and
the transfer of infection through the medium of
clothing and their dirty hands.
There was one house in the village where the in-
fection persisted. Five children lived in this one-
roomed house. Impetigo contagiosa was detected
here at the beginning of the epidemic and remained
for about three weeks after all other houses ap-
peared free of it. One child named Hilma Otten
who lived here and is about 7 years of age, was
three times under treatment during the three
months that this disease was present in the Native
Village, being discharged as cured and readmitted
to sick report. This illustrates the difficulty of
treating such diseases among the Eskimos.
Although we do not know whence this infection
came, how long it has been among the natives of
this section, its cause, the details of its transmis-
sion or its exact status when apparently suppressed,
it is believed to be but a question of a short time
before there will be a reappearance of the disease
among the natives of St. Michael.
514
MEDICAL RECORD.
LSept. 16, 1916
ipmgr^fifl of f&rfctral i^rmtr?.
Boston Medical and Surgical Journal.
.1 \iguai 31. 1916.
1. Contact Points Between Tuberculosis and Syphilis. James
A. l.yon.
2. Tuberculosis Carriers. Charles E. Perry.
3. What Constitutes Clinical Tuberculosis in Adults'.' George
I. Schadt
1. Contact Points Between Pulmonary Tubercu-
losis and Syphilis. — James A. Lyon, in order to test
the supposition that a definite number of so-called
tuberculosis patients would be found to possess definite
pulmonary syphilitic lesions, tested 471 patients in the
Rutland Sanatorium by the Wassermann test. Of these
430 were negative, 10 were doubtful, two were unsatis-
factory, and 29, or six per cent., were positive. Of the
430 negative cases, 140 had incipient pulmonary tuber-
culosis, 105 of these had repeated negative sputum,
and 35 had positive sputum. Of the moderately ad-
vanced cases there were 222, and of these 75 had nega-
tive sputum, and 149 had positive sputum. The re-
maining 68 weie far advanced, and of these seven were
negative and 61 had positive sputum. The sputum was
negative in four and positive in two of the doubtful
cases in the incipient stage; two had negative and two
positive sputum in the moderately advanced stage.
There were no doubtful cases in the far advanced stage
of their pulmonary disease. A positive Wassermann
was obtained in 10 incipient cases, and of these eight
had negative sputum and two positive. In the moder-
ately advanced stage, four had negative and 11 posi-
tive sputum. In the far advanced stage there were
only four that gave a positive Wassermann, and in
each instance the sputum was positive. From his expe-
rience the writer believes a careful inquiry should be
made into all cases of pulmonary disease as to the
possibility of a latent syphilitic infection, and, if there
is a suspicion of syphilis, the search should not be
abandoned in a case of pulmonary diseases with a
positive or even a negative Wassermann without first
having a careful radiograph taken of the lungs and
the long bones. The presence of cavity signs in the
lung and the expectoration of large amounts of sputum
persistently negative to tubercle bacilli should alwayi
suggest pulmonary syphilis. If a positive reaction to
tuberculin occurs in a given case of pulmonary disease
with a marked positive Wassermann, it is difficult to
make a correct diagnosis because the two diseases may
coexist while the .•'-ray examination may not be of
assist:
3. What Constitutes Clinical Tuberculosis in Adults?
— George L. Schadt emphasizes the belief that it is not
only in the beginning cases of tuberculosis that we err
in our diagnosis, but just as much in the diagnosis of
the moderately advanced and advanced cases. He urges
a consideration of the percentages of wrong diagnoses
as cited by Ash and the fact that during only the past
year a matter of 1.6 per cent, of the individuals enter-
ing the State sanatoria of Massachusetts were either
non-tuberculous or not diagnosed. The responsibility
is just as great in the diagnosis of the patient pre-
senting with what seem to be all the necessary signs
and symptoms for the diagnosis of advanced tubercu-
losis as in the doubtful case. The necessity of ap-
proaching the examination in these cases with a mind
as free and unprejudiced by the history of cough or
hemoptysis as is possible should be emphasized, re-
membering that almost any pathological condition in
the pulmonary tract may simulate tuberculosis in every
respect. Pottenger, in suggesting the consideration of
the symptomatology from the etiological viewpoint,
has made it easier to analyze the disease conditions.
The essayist agrees with Lawrason Brown and others
that the importance of physical examination in the
diagnosis of pulmonary tuberculosis has been over-
emphasized in that symptoms are a better guide to
activity than physical signs and that symptoms with-
out physical signs demand treatment, and physical
signs without symptoms require only careful watching.
It does not seem possible or probable that we can
ever outline a symptom complex of certain signs and
certain symptoms and say that these signs and symp-
toms in every case mean tuberculosis. It seems rather
that we must value each symptom and each sign for
itself and in conjunction with other symptoms and
signs, for every case is a different one and has a dif-
ferent complex. Though deeming that certain out-
standing symptoms, such as hemoptysis, cough, ele-
vated temperature, increased pulse, and emaciation
are suspicious of infection, we are not qualified to say
that this is a case of active tuberculosis in an adult
without proper and due consideration to other factors
present.
New York Medical Journal.
September 2, 1916.
1. Pyorrhea Alveolaris. A Review of 1496 Cases John A.
Roddy. Elmer H. Funk and David W Kramer.
2. The Pre-existing Condition ot the Injured. A Medicolegal
Study from the Standpoint of Employer's Liability and
Accident Insurance. G. R. Pore.
3. Therapeutic Applications of Human Thyroid extract.
S. P. Beebe.
4. The Syndrome of Asthenia of .Mental Origin. U
Solomdn.
".. Dr. S. Weir Mitchell. A Short Sketch of His Life. W. A.
Boyd.
6. Spasmus Nutans. Murray H. Gordon.
7. Primary Perithelial Sarcoma of Spermatic Cord. Adolph
Brand.
8. Heart Disorders in Children. J. Epstein.
9. Graves's Disease. A Report of a Case with Post-opera-
tive Amblyopia. Chester Henry K
1. Pyorrhea Alveolaris. — John A. Roddy, Elmer H.
Funk, and David W. Kramer state that if this disease
did no more than interfere with mastication, it would
be serious enough to deserve the attention that has
been given it by the dental profession, but an indis-
putable mass of evidence has accumulated which shows
that the complications of this disease develop in por-
tions of the body remote from the head, and seriously
injure or destroy important organs. Their conclusions
are that: (1) Pyorrhea Alveolaris is not a specific
disease; its chief etiological factors are (a) an exces-
sive bacterial flora of the mouth; (b) deviations from
the normal of the afflicted tissues brought about by
certain diseases. (2) Oral sepsis is the first stage of
pyorrhea; the etiology of both is the same. (3) Pyor-
rhea can be prevented by regular cleansing of the
mouth and teeth. (4) The detection of all the etiolog-
ical factors in the majority of the cases of pyorrhea
requires a thorough dental and medical examination.
Whene\er possible an .r-ray examination should be
made. (5) Acute recurrent gingivitis or chronic gin-
givitis or a persistent excessive bacterial flora of the
mouth is a clinical sign of the disease. (6) Systemic
complications are rare in the early stages and frequent
in the late stages. (7) Coincident systemic diseases
are frequently associated with pyorrhea. (8) There
are no specific methods of treatment. (9) The three
indispensable factors in the treatment are: (a) Train-
ing the patient regularly to cleanse the mouth and
teeth; lb) the institution of whatever dental treat-
ment may be indicated; (c) medical treatment of co-
existing systemic disturbances or disease. ( 10) Emetin
may be well employed as an adjunct on the principle
that it will de no harm and may possibly in some cases
be beneficial. (11) When infectious systemic complica-
tions exist, an autogenous vaccine is indicated and even
in uncomplicated cases will at times accelerate im-
provement.
1. The Syndrome of Asthenia of Mental Origin. —
Sept. 16, 1916]
MEDICAL RECORD.
515
Meyer Solomon states that worry over somatic or ex-
ternal factors may lead to insomnia and the syndrome
of asthenia. Worry concerning these symptoms may
now take the place of the original causative factor,
the patient as a rule not appreciating the relation-
ship. This may be the starting point of true psycho-
neurotic states. Once the symptoms have appeared
there is a veritable vicious cycle — the emotionalism
with suggestion increasing the symptoms, in degree or
number or both, and the accompanying symptoms in-
creasing the emotionalism and suggestibility. The
diagnosis is easy, with the aid of the history and the
exclusion of physical disease as the primary cause.
The differentiation, however, must be made between
this form of asthenia and tuberculosis, arteriosclerosis,
syphilis, etc. The prognosis in uncomplicated cases is
most favorable, treatment being simple and results
prompt. The mental factor should be thought of, in-
vestigated, and weighed in every case of the asthenic
syndrome, especially when no apparent cause exists.
Insomnia is most potent in producing symptoms and
must be boldly and unhesitatingly treated by drugs
and otherwise. In these cases successful treatment
means that a psychoneurosis or minor psychosis may
frequently be aborted.
(i. Spasmus Nutans. — Murray B. Gordon reports
three cases of this rather unusual condition out of
4,000 general cases which have come under his per-
sonal observation at the Polhemus Memorial Clinic. He
says that spasmus nutans is a rare functional neurosis
found in children, which consists of an almost contin-
ual nodding or shaking of the head. In some cases
there is a rotary movement of the neck. Generally
there are no other rhythmic movements or other phen-
omena of nervous irritability, though in some cases,
as in one of those reported, there may be an accom-
panying spasm of an arm or a leg. The mentality
of the child is not impaired. During the attack there
is no loss of consciousness. In many instances at-
tacks are brought on by the child turning its head,
or concentrating its attention, in an endeavor to look
upon a particular object, or in a certain direction. In
the majority of cases reported, nystagmus has been as-
sociated with the spasm of the head. Some observers
hold that nystagmus is present in every case of spasmus
nutants, and that their contentions can be proved if
every case is seen long enough and observed minutely.
In two of the cases in this series nystagmus was not
observed. This condition is in no way connected with
or related to epilepsy, tetany or any tetanoid hyer-
irritability of the nervous system. It is insidious in
its onset, and may not be noticed in the first stages.
The course of the condition varies; the longest period
in which it persisted was reported to have been two
years. The treatment should be directed to the cor-
rection of malnutrition and faulty hygiene. Thyroid
extract has been found efficacious. This may be given
alone or in conjunction with calcium lactate. The
elixir glycerophosphates of lime and soda may be
given alternately with the thyroid.
7. Primary Perithelial Sarcoma of Spermatic Cord. —
Adolph Brand reports the case of a young man, 29
years of age, who had suffered a year previously from
urethritis followed by a hemorrhagic and suppurative
orchitis. He was in apparently good ht^.th for during
this year when he returned with a mass in the left
side of the scrotum. A diagnosis of tumor of the
spermatic cord was made and the growth removed.
This was found to be a perithelial sarcoma of the
spermic cord. Brand states that very little is known
of the etiology of spermic cord neoplasms. Recent
injuries are credited with being the causative factors
in a small percentage of cases, and it is denied that
venereal disease plays a provocative role. It is stated
by many authors that neoplasms of the spermic cord
usually develop secondarily to such growths in the tes-
ticle, but it is conceded by some that the primary
origin of the tumor may be within the cord itself. In
this case a thorough examination of the removed
testicle, by a pathologist of unquestioned ability,
failed to show evidence of malignancy, and it must be
argued that in this instance the spermic cord was
the primary seat of the growth. Another point in
this case is the etiology. Since recent injuries are
looked upon as the causative factors in the produc-
tion of tumors of the spermatic cord in 25 per cent, of
the cases, the question may be raised whether the
suppurative process in the testicle and the surgical in-
tervention acted the role of trauma in the subsequent
development of the neoplasm of the spermatic cord.
Journal of the American Medical Association.
September 2. 1916.
1 Ringworm of the Hands and Feet. Oliver S. Ormsby and
James Herbert Mitchell.
2. The Effect of Potassium lodid on the Luetin Reaction.
John A. Kolmer, Toitsu Matsunami, and Stuart Broad-
well.
3. Splenectomy in Pernicious Anemia : Studies on Bone
Marrow Stimulation. Roger I. Lee, George R. Minot,
and Beth Vincent.
4. Late Results of Splenectomy in Pernicious Anemia:
A Statistical and Critical Review. Edward B. Krumb-
haar.
5. Splenectomy in Splenic Anemia, Hemolytic Icterus and
Hanot's Cirrhosis. Joseph L. Miller,
fi. The Results of Treatment in Arterial Hypertension Due
to or Associated with Syphilis. Louis A. Levison.
7. The Intensive Treatment of Syphilis. Lloyd Thompson.
8. Complete Vocational Disability from Muscular Imbalance
of the Eyes. Lloyd Mills,
'.i. Painless Labor. J. Clifton Edgar,
in. A Case of Testicle Grafting with Unexpected Results.
Robert T. Morris.
11. Lumbar Puncture for the Relief of Convulsions in Puer-
peral Eclampsia: 'Report of Two Cases. W. T.
Wilson.
U. A Case of Progressive Neural Muscular Atrophy. Robert
F. Sheehan.
1. Ringworm of the Hands and Feet. — Oliver S.
Ormsby and James Herbert Mitchell present an analysis
of 65 cases seen in the routine of private practice who
did not present the ordinary clinical symptoms of
ringworm of the body, but are examples of what is
ordinarily termed dyshidrosis or eczema of the vesicu-
lar-vesiculo pustular or intertriginous type. The
diagnosis depends on the microscopical examination of
the tissues. All vesicular or desquammating areas of
the interdigital or volar surfaces of the hands and
feet should be carefully examined for the presence
of fungi. Eczematoid and dyshidrotic lesions of the
volar surfaces due to myotic infection are much more
common, at least in the Middle West, than the num-
ber of reported cases indicates. The disorder occurs
much more frequently in men than in women, on the
feet than on the hands, and more frequently in the
warm and damp than in the cold and dry season. The
essential lesion is a deep-seated vesicle, in the roof
of which mycelial threads may be found. The areas
affiected in the order of frequency are the fourth in-
terspace of the foot, the plantar surface of the arch,
and over the tuberosity of the fifth metatarsus. The
disorder frequently follows or precedes eczema mar-
ginatum, and is due in many cases to the same organ-
ism. The pathogenic organism may remain dormant
in the cutaneous folds of the feet throughout the win-
ter months. With the advent of warm weather an
acute attack of vesication, desquammation, and macer-
ation may occur. The treatment included the use of
three preparations. In the severe cases of eezematois-
dermatitis, a preliminary soothing treatment of nafta-
lan, combined with zinc oxide and starch, was used.
This was followed by 5 per cent, chrysobarin in trau-
maticin which is painted on until a good reaction oc-
curs. Five daily applications were usually given. In
516
MEDICAL RECORD.
[Sept. 16, 1916
another series of cases an ointment containing two
parts of salicylic acid and four parts of benzoic acid in
30 parts of ointment base were used. This was applied
daily over several weeks.
2. The Effect of Potassium Iodid on the Luetin Re-
action.— John A. Kolmer, Toitsu Matsunami, and Stuart
Broadwell have been studying the effects of the iodids,
bromids, chlorids, ether, chloroform, and other drugs
on the luetin, tuberculin, and other skin reactions.
The results with the iodids have proved definite and
confirmed Sherrick's observations in practically every
particular. The study warrants the following con-
clusions: 1. Well marked positive luetin reactions
were observed among a group of healthy nonsyphilitic
persons following the administration of potassium
iodid. 2. Similar results were observed among non-
syphilitic persons suffering with various other dis-
eases. 3. Somewhat severe reactions were observed
following the intracutaneous injection of 0.1 c.c. of 0.5
per cent, agar-agar. 4. The strongest reactions were
observed when the luetin was injected during or im-
mediately after the ingestion of potassium iodid.
5. Positive luetin reactions were observed among nor-
mal nonsyphilitic persons as late as one month after
the ingestion of large doses of potassium iodid. 6. In
some instances the administration of potassium iodid
caused the site of a former luetin injection to develop
inflammatory phenomena progressive to pustulation.
7. Similar but less marked reactions to luetin and agar
ware observed among guinea-pigs and rabbits following
the oral administration of potassium iodid. 8. Accord-
ingly, a positive luetin skin test has little value in the
diagnosis of syphilis among persons who are taking
or have recently taken potassium iodid. The amount
of iodid capable of producing these reactions varies
considerably; also the length of time following the in-
gestion of iodid when this reaction to luetin may fol-
low. For these reasons physicians should very care-
fully rule out the possible influence of iodid before
conducting the luetin skin test.
3. Splenectomy in Pernicious Anemia: Studies on
Bone Marrow Stimulation. — Roger I. Lee, George R.
Minot, and Beth Vincent. (See Medical Record, July
1, 1916, page 32.)
4. Late Results of Splenectomy in Pernicious Ane-
mia: A Statistical and Critical Review. — Edward B.
Krumbhaar. (See Medical Record, July 1, 1916,
page 32.)
5. Splenectomy in Splenic Anemia, Hemolytic Icter-
us, and Hanot's Cirrhosis. — Joseph L. Miller. (See
Medical Record, July 1, 1916, page 36.)
6. The Results of Treatment in Arterial Hyperten-
sion Due to or Associated with Syphilis. — Louis A.
Levison has collected a group of 18 cases in which
syphilis and hypertension were associated of which he
has made a careful study, more particularly with
reference to as ociated kidney lesions. He concludes
that anti-syphilitic treatment is not expected to re-
duce the high blood pressure in syphilitics who have
also arterial hypertension. Occasional reductions in
the blood pressure, however, do take place in such
cases. The association of arterial hypertension with
syphilis does not contraindicate the treatment of the
latter. The careful use of mercury and salvarsan
has not had bad results on kidneys damaged by ar-
terial disease.
7. '1 lie Intensive Treatment of Syphilis. — Lloyd
Thompson review e as to the efficacy of the
three syphilitic remedies and states that with this
evidence the logical method of treating this disease is
to administer mercury and salvarsan as intensively as
the patient can tolerate in all eases, anil iodin in some
form where indicated. He has been able to reduce a
four plus Wassermann to a negative which remained
negative from one to six weeks with intramuscular in-
jections of mercuric benzoate or intravenous injections
of mercuric chlorid. It is the opinion of the writer
that all cases of syphilis of the central nervous sys-
tem should have intraspinal medication. For these
injections he employs a method which is a combina-
tion of those described by Ogilvie and Wile. This con-
sists in the withdrawal of 10 c.c. of blood by venipunc-
ture and centrifuging it at once. One c.c. of this
clear serum is removed and placed in a sterile test
tube. The salvarsan is then prepared by dissolving
in water, neutralizing, and diluting so that each 0.1
gm. is diluted to 40 c.c. One c.c, the dose usually
required, is placed in the hemostat 37.5°C. for forty-
five minutes. It is then removed and placed in a
water bath at 55°C. for thirty minutes. The intra-
spinal injection should be made as soon as possible
after the serum is prepared. The injection is made
in the arachnoid space, the skin having first been in-
filtrated with 5 per cent, novocain. When about 15 c.c.
of spinal fluid have been collected, one or two c.c. of
5 per cent, novocain are added and thoroughly mixed
with the fluid which is allowed to run back into the
spinal canal. After three minutes the fluid is again
allowed to flow into the syringe and the salvarsanized
serum added and injected. By using the novocain as
described for both the salvarsanized serum and the
mercurialized serum, the pains in the legs and back
which so frequently follow these injections are elimi-
nated to a great extent. Much has been written and
said with regard to the wonderful cures of syphilis
which have been affected at the great watering places
of the world. It does not seem that the waters of
these springs possess any specific value in the treat-
ment of syphilis; the benefit is found in the pleasant
surroundings, outdoor exercise, regularity of treat-
ment, and the fact that the patient makes a business
of getting well. It is a fact, however, that most pa-
tients bathing daily in the waters can tolerate more
mercury without untoward effects than those not bath-
ing.
11. Lumbar Puncture for the Relief of Convulsions
in Puerperal Eclampsia: Report of Two Cases. — W.
T. Wilson says he used lumbar puncture in these
cases because he had seen convulsions controlled in
his cases of cerebrospinal meningitis by drawing the
fluid from the spinal canal before injecting serum. In
both of the cases reported the patients had had over
twenty convulsions and this procedure was followed by
recovery. Lumbar puncture is a treatment only for
the convulsions of exlampsia and not for the toxemia
of pregnancy. However, with the convulsions con-
trolled one is in a better position to treat the toxemia.
Puncture seems to be indicated in those cases in
which the convulsions are severe and frequent. It does
not interfere with other forms of treatment for the
disease, and proper treatment should be instituted as
soon as the convulsions are controlled.
The Lancet.
1 gust 12. 1916.
1. Observal the Effects of Trinitro-Tol'i Women
Workers \.gn Li to e-Learmonth and Barbara
Martin Cunningham.
2. An Address cm the Psycho-Pathology of the War Neuroses.
M D Eder.
3. Tli. I: i i I Suppurating War Wounds.
I tuthei i oi ii Mot
•1. An Anomaly in the Wida] Reaetion. A. K. S. Sladden.
5. Tht "i Typhoid Inoculation on Endenic Goitri
tin- Lawrence Military Asylum, Sanawar, Punjab. M.
\ Nicholson.
6. A Contribution to the Etiology of Kpidemic Cerebro-
spinal Meningitis. M. P. H. Gamble.
Sept. 16, 1916]
MEDICAL RECORD.
517
7. Shiah Pilgrimage and the Sanitary Defenses of Meso-
potamia and the Turco-Persian Frontier. F. G.
Clemow.
1. The Effects of Trinitro-Toluene on Women Work-
ers. — Agnes Livingstone-Learmonth and Barbara Mar-
tin Cunningham have made careful observations of
the symptoms complained of by women working on
trinitro-toluene in the munition factories in which they
have been acting as medical officers. They are con-
vinced that the frequency with which these symptoms
occur among workers cannot be a mere coincidence
and must point to irritation by and absorption of
some toxic product of the explosive used. The irrita-
tive symptoms described are referred to the respiratory
tract, the alimentary tract, and the skin. The toxic
symptoms include digestive, circulatory, cerebral, and
special symptoms. From their observations they are
convinced that the careful selection of workers is of
the greatest importance and that women inclined to be
anemic, those that have had liver or gastric trouble,
those who sweat freely, those who have had chest
trouble, those even slightly addicted to alcohol, and
persons of lowered vitality from fatigue, malnutri-
tion, etc., should be excluded from this kind of work.
No person under 21 or over 40 years of age should be
employed on trinitro-tuolene. Workers should not be
employed more than twelve weeks continuously and
not too long daily. A routine weekly examination of
all these workers is essential and any that show signs
of fatigue or toxemia should be taken off the work.
If respirators are worn they should be impregnated
with some alkaline antidote.
3. The Treatment of Infected Suppurating War
Wounds. — Rutherford Morison described a simple
method of treating suppurating war wounds which he
has developed which consists in covering the wound
and surrounding area with gauze wrung out of 1:20
carbolic acid, opening the wound freely, cleansing the
cavity with dry sterile gauze, removing foreign bodies,
mopping the wound and surrounding skin with methy-
lated spirit, and then filling up the whole wound with
a paste made of bismuth subnitrate, one ounce; iodo-
form, two ounces, and paraffin liq. q.s., to make a thick
paste. For this preparation the writer suggests the
name "Bipp." This dressing requires no change for
days or weeks if the patient is free from pain and
constitutional disturbance. A case of hernia cerebri
is cited which healed readily with the employment of
this procedure and it is claimed that under this treat-
ment septic wounds heal by first intention with infre-
quent dressings and without drainage further than
that allowed for through gaps left by interrupted
sutures. Acute abscesses, opened, cleansed, filled with
"Bipp" and closed by interrupted sutures can heal
by first intention without further pus formation. It
appears to be safe to plate compound fractures by
adopting this method. Up to the present time no bad
results have been observed after the employment of
this treatment.
4. An Anomaly in the Widal Reaction. — A. F. S.
Sladden calls attention to the fact that in following
Dreyer's standard method of agglutination testing for
suspect enteric cases in the lower dilutions a negative
(inhibition) zone is frequently seen and that this is not
peculiar to Dreyer's method. A feeble agglutinating
power, if opposed by a well-marked inhibition zone,
may only be visible over a short range of dilutions,
and unless a large number of dilutions be tested the
presence of agglutinin may be missed. In the experi-
ments recorded the sera have been those of subjects
inoculated against B. typhosus within 18 months. Ad-
dition of another serum, non-agglutinating to the bacil-
lus under test, will increase the zone of inhibition.
The presence of sodium chloride in the test augments
but does not cause the negative zone. By using dis-
tilled water as a dilutent in place of normal saline
the negative zone is diminished and the test rendered
more delicate. The zone effect is exerted on all three
members of the typhoid group but in varying degrees.
Its extent tends to increase with the progress of the
infection. No definite relationship between zone effect
and clinical aspect is established, but the inhibition
zone does not appear to be of unfavorable omen.
6. A Contribution to the Etiology of Epidemic
Cerebrospinal Meningitis. — M. F. H. Gamble states
that epidemic cerebrospinal meningitis was unknown
in Victoria until May 27, 1916, when an outbreak
originated in the military camp at Seymour. The
organism causing the disease was practically identical
with the gonococcus, a mutant form perhaps. A study
of this epidemic gives convincing evidence that cere-
brospinal meningitis in epidemic form may be a true
gonorrheal inflammation of the arachnoid membrane
of the brain and spinal cord, set up by the bites of
infected pediculi corporis. During the winter the sol-
diers are reluctant to take the daily cold shower in the
open and thus provide a soil on which the pediculi
corporis thrive vigorously, and gonorrhea is always
prevalent in a large training camp near a city. The
real carriers of the meningitis were the lice ladened
with gonococci or full of serum from a meningitis
patient. The futility of prophylactic measures directed
to the nasopharynx and the fact that no specific organ-
ism has been proven to be the cause of epidemic cerebro-
spinal meningitis, in the opinion of the author, lend plau-
sibility to his theory as to the etiology of this epidemic.
The British Medical Journal.
August 12. 1916.
1. Contractures of the Hand After Wounds of the Upper
Limb. W. M. Macdonald.
2. Xote on the Distant Effects of Rifle Bullets ; with Special
Reference to the Spinal Cord. Judson S. Bury.
3. The Treatment of Gunshot Fractures. D. McCrae Aitken.
1. The Treatment of Convalescent Soldiers by Physical Means.
R. Tait McKenzie.
• . Trismus During Serum Sickness (Septic Finger). R. F.
Bolt.
6. Babinski's Sign from the Point of View of Comparative
Anatomy. M. Astwazaturof.
2. Note on the Distant Effects of Rifle Bullets; with
Special Reference to the Spinal Cord. — Judson S. Bury
relates two cases which confirm the experience of the
present war that the effects of high velocity bullets
with rapid rotary spin are rarely limited to the parts
through which it passes; as a rule there is evidence of
either indirect or secondary lesions and sometimes of
remote lesions. Of particular interest are the effects
on the spinal cord of the passage of bullets in its im-
mediate vicinity, in cases in which there is no evi-
dence of direct injury to the cord. In some instances
there was an impact of the bullet upon some portion
of vertebra; in others, however, it was probable that
the bullet did not strike the bone, but passed through
the tissues outside of it. In both conditions the dam-
age to the cord may be either severe or slight. In one
of the cases cited the bullet entered near the top of
the left shoulder and came out on the right side of
the spine. The main points of interest in this case
were the temporary incontinence of urine; the im-
plication of some of the dorsal roots; the signs of a
lesion of the right pyramidal tract, the fibers which
convey impulses to the dorsoflexors of the ankle being
chiefly affected. In the group of "spastic paralyses,"
cases are not uncommon in which no paralysis can be
detected, the lesions of the upper neurones being rep-
resented clinically only by exaggeration of the deep
reflexes. The explanation of this is difficult; it may be
that a lesion too slight to produce paralysis that can
518
MEDICAL RECORD.
I Sept. 16, 1916
be detected is sufficient to cut off the cerebral impulses
which are inhibitory to muscle tonus, when there will
be overaction of the spinal centers which is probably,
the author thinks, the result of the unopposed action
of the cerebellum.
4. The Treatment of Convalescent Soldiers by
Physical Means.— R. Tait McKenzie describes the work
of the "command depots to which are sent men for
whom there is some hope of cure or improvement with-
in a period of six months. Among those usually sent
are cases of profound neurasthenia, the result of
sleepless nights and arduous days; shock in all its
forms — tremulous hands and tongue, stammering speech
or deafness, persistent nightmares and fears by day;
disorders of sensation, contractures, and paralyses;
rapid and weak heart action, hearts that were over-
strained and that are unable to sustain the effort of
the lightest gymnastic exercise or the shortest march ;
rheumatism, real and unreal, in all its forms; lungs
suffering from the bronchitis of gas poisoning, asthma,
and even tuberculosis; profound debilities following
typhoid fever, dysentery, and malaria, requiring
months of good food, light duty, and progressive ex-
ercise to build them up. For all of these cases the
treatment comes under what may be called physical
therapy, electricity, hydrotherapy, massage, mechano-
therapy, collective exercises, physical training, and
marching. The procedures employed in the various
conditions are described in detail and it is pojnted out
that many cases of disordered heart action can be
brought up to the full physical training but not into
it. Several cases were brought up to this point three
or four times and then had to be returned to lighter
duty. Not more than 30 per cent, succeeded in passing
into Class A. This same experience has been shared by
some cases of shock, of bronchitis following exposure to
gas, and cases of frostbite. An analysis of the classi-
fied cases sent out from Heaton Park up to date shows
that nearly 50 per cent, have been returned fit for
active service. About 15 per cent, have been sent to
lines of communication abroad. About 15 per cent,
have been sent to useful work of a sedentary nature
a! home, and over 20 per cent, have been discharged
as permanently unfit, many of these being untreatable
from the first. A fact which is not to be lost sight of,
McKenzie says, is that even though these men may not
be sent back as first class men their opportunities for a
useful career in civil life after the war have been
enormously increased.
5. Trismus During Serum Sickness (Septic Fin-
ger).— R. F. Bolt relates the case of an officer who
pricked his finger while operating on a case of em-
pyema. His temperature rose on the following day
to 102° F., whereupon the finger was incised and a
dose of 18 c.c. of antistreptococcus serum was admin-
istered. No antitetanic serum was injected. A week
later an enlarged and tender gland was noticed in the
rignt axilla and fourteen days after receiving the
prick trismus developed. At this time an urticarial
rash appeared over the arms, chest and abdomen. The
possibility of the patient's symptoms being due to
tetanus was seriously considered, but it was decided
that he was already suffering from serum sickness and
it was not advisable to give antitetanic serum. Under
the administration of chloral hydrate and sodium
salicylate the patient recovered. A careful review of
the history of the wound made it seem unlikely that
infection with the tetanus bacillus could have occurred,
while the course el' the symptoms and the vapid re-
covery, the author believed, made it very much more
probable that the condition had been entirely due to the
antistreptococcus serum.
Journal de Medecine de Bordeaux.
August, 1916
Strangled Diaphragmatic Hernia; Laparotomy;
Death. — Vitrac states that, evolution of symptoms in
a case treated by him was almost pathognomonic.
They comprised epigastric pain, acute thirst, painless
retraction of the abdomen, precocious dyspnea uni-
lateral thoracic symptoms, such as bulging of the
chorax, tympany, etc. The squatting attitude is also
quite characteristic. Let us suppose that we have a
strangulation of doubtful origin. Laparotomy reveals
a complex of empty and distended intestinal loops, so
that we have to think of the possibility of more than
one strangulation. In such a case we must always
think of the possibility of a diaphragmatic hernia, and
introduce the hand beneath the concavity of the dia-
phragm. A stop should be made to examine the thorax,
if necessary by puncture. If the diagnosis is made a
thoracotomy should be performed in order to liberate
the strangled intestine. If reduction has been effected
the lips of the hernia opening must be sutured. The
prognosis depends on early diagnosis and early
laparotomy. If simple suture cannot be effected a por-
tion of lung tissue may be fixed into the opening.
Strcphanthus and Strophanthin. — Mallie discusses
at considerable length the physiological action, the
clinical results, toxicity, indications, contraindications,
modes of exhibition and posology of these substances.
Before giving the drug the kidneys must be tested and
blood pressure measured. All other medication must
be suspended. Then on the first day 1/10 mgm.
crystallized strophanthin should be injected into a vien
in 10 c.c. freshly distilled water. The dose should be
repeated on the second, third and fourth days. If the
result is not as desired the treatment is suspended.
The leading indication is cardiac insufficiency, either
subacute or fatally progressive. In such cases stroph-
anthin acts directly on the tonicity and contractility of
the heart muscles. Given in a vein for this condition
the drug action is more heroic than that of digitalis.
In pulmonary asystole it is a better drug than the
latter, overcoming the stasis more rapidly. In asystole
of valvular origin the results obtained are not har-
monious. On the other hand it may be invaluable in
pure myocarditis, not as a functional stimulant of
normal fibers but when the latter have become altered
and delicate. Hence it is much used in France in the
myocarditis of infectious fevers including pneumonia.
It may succeed in a variety of conditions in which the
rationale of its action is none too clear. Such successes
are sometimes the exception. Here belong palpitation
tachycardia, Graves' disease, old cardiac lesions with
deeply altered myocardium, senile heart, etc. In cer-
tain well-known degenerations of the myocardium its
use is contraindicated, as it is in angina pectoris,
cardiorenal disease, arteriosclerosis, etc. Digitalis, as
is well known, is a drug the employment of which is
greatly subject to abuse and it is evident that
strophanthus shares the same lot; all because the ac-
tion and indications are not sufficiently studied.
Action of the Interossei Muscles. — Masse sums up
an original study of these muscles as follows: One
may consider that the action of the interossei is not
limited to the fingers, as has always been held by the
classic authors. They contribute almost wholly to the
lateral movements of the metacarpals. Their insertions
upon the articulations of the carpus, intermetacarpals,
and metacarpophalangeals cause them to act as im-
portant, active ligaments to these articulations. They
concur in maintaining the normal palmar concavity
in two directions — length and breadth. This action
therefore plays a role in the morphology of the hand.
Sept. 16, 1916]
MEDICAL RECORD.
519
Le Bulletin Medical.
August 12, L916.
Primary I'aludism in Salonica. — J. J. in a letter to
the Bulletin gives information about the forms of
malaria in this sphere of warfare which he thinks
should prove of general interest. Some soldiers com-
ing from France became contaminated on their arrival,
diagnosis being determined in the bacteriological
laboratories of the Eastern Army. A study of the
blood shows three principal forms of parasite, the
Plasmodium vivax (tertia benigna), Plasmodium ma-
larix (quartan), and Plasmodium falciparum (tertia
maligna). Aside from certain regions affected with
malaria, this so-called primary paludism is not seen
in France to-day. It is unknown save in regions where
the disease is endemic, like Salonica. It always ap-
pears a few days after the sting of an anopheles, the
injury often being completely overlooked. At times
it is masked as a febrile gastric disturbance, or even
as a mild or severe typhoid. In such cases the patient's
welfare is greatly prejudiced because he does not re-
ceive his quinine at the outset of the disease. These
attacks of primary paludism are followed at an early
date by a series of daily intermittent attacks, even in
the absence of a reinfection. These attacks are not as
cleanly defined as frank outbreaks of secondary pa-
ludism. They appear in periods of 5 or 6 days each,
whatever the intensity of the treatment. A remis-
sion then occurs and the attacks reappear about
every 12 days. If the patient has not been treated
at all, or treated insufficiently, anemia appears, fol-
lowed by enlargement of the spleen, and may pass on
to a true cachexia with anasarca or simple edema of the
legs and face, oliguria, palpitation, anorexia, diarrhea,
apathy, and torpor. If such a patient is stung at any
time by a fresh mosquito, the tendency is toward a con-
tinued fever.
Responsibility of the Army to the Civil Population
When All Medical Supplies Have Been Commandeered. —
A. M. writes to the Bulletin, referring to several re-
cent articles on the subject. The lot of the rural
dweller is particularly severe and the writer concerns
himself solely with this aspect of the case problem.
The countryman is deprived of the services of the
better class of physicians, and must depend often upon
a class of men who under normal conditions would
have little to do. When a well qualified practitioner
finds himself in such a situation, his difficulties are
almost insuperable, if he is ignorant of the ways of
the peasant, who, slovenly and indifferent, does not
send for him until after the disease has a good start.
The speech of the peasant is so full of local idioms,
which vary even within small distances, that it becomes
almost unintelligible. For example, a Paris physician
assigned to practice in a certain sector remote from
the metropolis, was summoned to attend a child who
had been coughing for a month. He was informed
that the child had been suffering from some affection
with an unfamiliar name which turned out to be
measles.
Le Caducee.
.1 uiiust 1.",. 1916.
Case of Anterior Spinal General Paralysis in a Sol-
dier Due to Malaria. — Blin and Kerneis relate the case
which they ascribed to a malarial infection. The
patient, aged 20, had a good personal history. As an
officer of the Senegalese he left Bordeaux for Africa
and developed malaria during the 18 days he had spent
in the tropics, probably because on one night he slept
without protection against mosquitos. Interned in
the nearest hospital the severe symptoms of the attack
gave way to quinine, but at this juncture a severe
dysentery developed but soon yielded to treatment. He
continued to have mild febrile attacks as brief inter-
vals, hardly severe enough to incapacitate him, but
soon was seized with a very sharp attack of chills,
fever and sweating which after three hours left him
prostrated. The next day the fever returned and after
the seizure the patient was found to be paralyzed. Th •
entire lower extremities were stricken en masse, and
the upper extremities progressively. On the next day
the muscles of the face and trunk became paralyzed.
Within the next 24 hours speech and swallowing be-
came embarassed. The lips and jaws and eye muscles
were not involved, nor were the sphincters, while sensi-
bility was intact. The paralyses were followed by a
certain amount of muscular atrophy which later at-
tacked most of the voluntary muscles. An intercurrent
attack of orchitis was without apparent cause. Grad-
ually there was noted a return of power to some of
the muscles — in general those last to be attacked, and
despite the muscular atrophy a considerable restora-
tion of function was noted elsewhere, and the reflexes
which had been totally abolished began to reappear.
The treatment had consisted of hypodermics of quinin ■
and large doses of potassium iodide. Returning to
France he eventually recovered completely. In this
case a malarial polyneuritis could be excluded. The
condition resembled anterior poliomyelitis in many
ways and in fact was regarded as this disease, but due
to malarial infection of the nerve cells of the anterior
horns of the cord.
La Presse Medicale.
.1 ugust 10. 1916
The Cardiac Rhythm in the Fighting Soldier. — Binet
states that numeious peculiar modifications of cardiac
rhythm have been noted in troops and their relatives
as well. Those who have near relatives at the front
or whose status in life has been inverted by the war,
suffer from constant tachycardia, from 90 to 120, with
inversion of the oculocardiac reflex. Those actually at
the front show a much greater variety of pulse, due
to the operation of various distinct causes. From mere
extreme fatigue we see all the manifestations of
asystole, with a small, filiform pulse, or perhaps
paroxysmal tachycardia, or tachycardia with an-
hythmia or bradycardia (6 or 7 per cent, may show
the latter alone). The state of suppression the
emotions of warfare, as when men force themselves to
be calm in a bombardment, is not accompanied by
arrhythmia but bradycardia frequently follows a heavy,
sudden explosion. When the sympathetic is chiefly in-
volved acceleration of the heart beat is seen, and in-
dicates that the soldier is naturally emotional and not
very strong of heart. Emotional tachycardia is per-
haps due to overproduction of thyroidin, especially
when it becomes permanent. Another factor appears
in the wounded, namely traumatic shock which should
be largely psychical in nature. In some cases we see
commotion without traumatism. In traumatic shock,
much depends on the character of the wound, whether
it is very painful or attended by much hemorrhage:
and on the seat of the injury. Tachycardia commonly
follows any wound in the chest. On the contrary
slowing of the pulse is seen in cranial wounds. One
who is shocked physically by an explosion may show
tachy- or bradycardia, according as his sympathetic
nerves or vagus react most strongly. Among aviators
a rapid ascent or descent tends to lower the frequency
of the pulse. In other words, so-called aviators' disease
appears to depend on a functional disturbance of the
vagus.
520
MEDICAL RECORD.
[Sept. 16, 1916
3)nsnranr? ffltbitwt.
Respiratory Symptoms in Heart Disease. — Dr.
J. S. Lankford says that one of the earliest symp-
toms of important disease of the heart is undue
shortness of breath on exertion. It may be the
sole symptom causing the patient to seek advice
and the question must be determined whether it
is simple or serious, for it may be the beginning
of the gravest myocardial or other cardiac dis-
ease, or may be due to less important conditions.
It occurs in unimportant vague disturbances, such
as sinus arrhythmia, transient indigestion, and
various irritable conditions of the nervous system.
It may occur in a sound heart, which is out of
proportion to the body in size. We occasionally
find a man normal in all respects except that the
heart is too small. If a man is perfectly free
from all indication of disease, but is inclined to
shortness of breath on exertion, his heart is prob-
ably too small for his body. This condition is
especially likely to result from that form of in-
fection in children which is generally character-
ized, "growing pains." It occurs also, in repeated
infections of other kinds, especially in the throat.
The heart may not have been inflamed, but has
been sufficiently embarrassed in nourishing itself
to prevent the proper growth. A like limitation
of growth occurs in the young inveterate cigarette
smoker. A similar condition exists where a man
weighs 130 pounds at 25 years of age and 230 at
the age of 40. His heart has attained the growth
necessary for a small body and is always tired
from carrying such a heavy burden, and yet it
may be a sound heart. There is grave danger of
high blood pressure and a breakdown in the heart
or kidneys, in this kind of case after the age of
45, because the heart cannot nourish itself prop-
erly and do the work of such a heavy body. These
patients should be cautioned to live rigidly within
the reserve power of the heart, to avoid stimu-
lants, to drink water sparingly, and especially
should they be directed to steer clear of excess in
starches and sugars, the fat producers. It is bet-
ter for them to take the chances of an albuminous
diet than to put on more flesh. There is here
some disturbance of the internal secretions not
yet fully understood, but it is probable that the
thyroid and other ductless glands are involved in
the accumulation of flesh. No insurance appli-
cant requires a more thorough examination than
the heavy-weight. Serious organic disease may be
confused when testing by means of exercise and
the manometer, with a poisoned heart, but the
absence of the usual signs and the collateral symp-
toms of poisoned heart, as autointoxication,
marked indicanuria albuminuria, or some infecti-
ous condition, especially from the teeth, will point
the way to the truth, the blood pressure is low
and the pulse pressure very limited. This condi-
tion may be relieved by treatment and the heart
saved from organic disease. In very grave heart
disease of any kind, there is always shortness of
breath on exercise and sometimes air hunger on
exertion. In nearly all cases there is inability to
stop breathing, a very significant symptom. Con-
tinuous labored breathing is also characteristic of
serious heart disease, indicating an exhausted
myocardium. Unconscious, rapid breathing is a
symptom that is often overlooked both in chronic
heart disease and in heart complication in infec-
tious diseases of various kinds, especially typhoid
fever and tuberculosis. Aortic insufficiency is al-
ways attended by embarrassed breathing in some
form. Mitral insufficiency is accompanied by
short breathing on exercise or it may be continu-
ous if the myocardium has become involved, dila-
tation taken place, or dropsy occurred.
Mitral stenosis is usually accompanied by short-
ness of breath on exercise, which may become a
dominant characteristic late in the disease when
the myocardium is in serious trouble. Angina
pectoris leads to great embarrassment of breath-
ing on account of pain in the intercostal muscles
and the nerves of the skin over the region of the
heart, on the inside of the left arm and some-
times the right, and down back of the left ear. Of
all the distressing conditions that fall to the lot
of the physician to handle, there is none that
equals that condition of advanced cardiarenal dis-
ease, with high blood pressure, auricular fibrilla-
tion, and heart block, where the Ceyne-Stokes re-
spiration has appeared and is persistent.
The blood pressure is low or high in serious
heart disease, in proportion to myocardial change
or kidney complication. In rapid degeneration of
Lhe cardiac muscle the systolic pressure may drop
a hundred millimeters in a few months. It is a
grave mistake to reduce the systolic with nitrites
or other depressants; for the diastolic pressure
tension is not correspondingly reduced and the
heart is depressed. Some cases attended by high
blood pressure are greatly relieved by free car-
tharsis with salts. A full dose of cream of tartar
at bed time is useful, and some patients are
greatly benefited by a mighty blue mass pill for a
long period. As a general treatment for serious
heart disease, where respiratory difficulties occur,
rest in bed is important, but in some cases where
cyanosis is absent the patients do better with a
little exercise gradually increased. — Texas State
Journal of Medicine.
Thinness and Life Assurance. — The presence or
absence of thinness is of definite importance to the
medical officer of life insurance companies, since
one of the factors on which estimation of risk is
based is the constitution of the assured, of which
thinness is one type. Some companies exact an
extra premium on account of thinness on those
whose weight is 20 per cent below the standard,
others take into account the relation between the
height and the chest measurement; while others,
again, rely on a "constitutional coefficient" calcu-
lated from a comparison of height, thoracic cir-
cumference, and weight. Dr. Romanelli, in 7/ Pol-
iclinico (February, 1916), draws attention to the
great practical importance of the "bi-acromial di-
ameter" in calculations of this kind. This diam-
eter is measured from the extremity of one acro-
mion to the other, passing in front of the thorax,
and has the merit of having two fixed and easily
found bony points and of being a fairly accurate
estimate of the development of the body in breadth
and of the thoracic development. Dr. Romanelli
places the lives to be insured into two classes in
this respect; those whose weight is 15 to 20 per
cent, below the standard and those whose weight is
over 20 per cent, below. He endorses the opinion
of Dr. Haviland Hall that thin lives not exceeding
15 per cent, of underweight should not be refused,
but that those who pass this limit should only be
accepted after a rigorous examination, and that if
there is tuberculosis in the family a life below 30
years should be rejected. — The Lancet.
Sept. 16, 1916]
MEDICAL RECORD.
521
look 2ktrirtii0.
The Proceedings of the Charaka Club. Volume IV.
New York. William Wood & Company. 1916.
While the study of the history of medicine cannot, per-
haps, be considered an essential part of medical educa-
tion, it certainly is the most desirable of its embellish-
ments. The Charaka Club has long held an enviable
position because of its successful work in the collection
and dissemination of information on medico-historical
subjects and literary and artistic matters bearing on
medicine, and the appearance of the fourth volume of
its proceedings is therefore a welcome occasion. The
papers presented cover a wide range of topics of much
interest. A botanical view of the Shakespeare-Bacon
controversy, the University of Alexandria, the medical
publications of the Elzevirs, medical data from old
church history, Saints Cosmo and Damian, and other
titles of fascinating interest head articles that well
repay attention. This volume contains twelve articles
in all by eight contributors, namely, Drs. Gerster, Wal-
ton, Collins, Mumford, Dana, Bailey, Pilcher, and
Streeter. The Charaka Club deserves the thanks of the
profession for its efforts to keep alive in us the history
of our medical forefathers and the memories upon which
our modern practice is founded.
Alcohol — Its Influence on Mind and Body. By
Edwin F. Bowers, M.D. Price, $1.25 net. New
York: Edward J. Clode, 1916.
This book is intended for popular consumption rather
than as a contribution to medical literature and is a
palatable presentation of the case against alcohol.
Statistical studies are diluted and disguised until they
are made to appear entertaining reading. Examples
of the writer's facility in coining trenchant phrases
are such chapter headings as "The Emperor of Drugs"
and "Beer, the Brutalizer." The greater part of the
evidence against alcohol is furnished by Kraepelin's
well-known studies, which are, of course, familiar to the
profession by this time. The crux of the alcohol prob-
lem, that is, the fact that alcoholism is a symptom, is
not mentioned by Dr. Bowers, wisely enough. He like-
wise does not allude to the studies of Haycraft, who
found an increase in the admissions to poorhouses and
insane asylums in States where prohibition had been
in force several years. A fact of this kind is difficult
to present to a lay audience on account of the necessity
for explaining away the obvious inferences. The con-
sensus of opinion of students of inebriety is that, even
apart from his alcohol, the inebriate is not normal, but
here again an investigation of this circumstance would
lead into rather deep waters, so it is not attempted in
the present volume. Dr. Bowers' book is, however, in-
teresting and should find a large circle of readers.
A Textbook of Fractures and Dislocations. With
Special Reference to Their Pathology, Diagnosis, and
Treatment. By Kellogg Speed, S.B., M.D., F.A.C.S.
Associate in Surgery, Northwestern University Med-
ical School; Associate Surgeon Mercy Hospital; At-
tending Surgeon Cook County and Provident Hospi-
tals, Chicago, 111. Octavo of 88S pages. Illustrated
with 656 engravings. Price, $6 net. Philadelphia
and New York: Lea & Febiger, 1916.
This is a very satisfying book, among other reasons
because the author, as he states in the preface, has
himself performed the labor of writing the text; there
is very little of the flavor of compilation and relatively
few pages that do not bear the unmistakable imprint
of the author's personality. There is also everywhere
evidence of the author's thorough study of the litera-
ture as well as of his comprehensive grasp of the sub-
ject on the basis of actual personal experience. The
author very properly insists upon the value and neces-
sity of a thorough knowledge of the histology and
pathology of bone, at least in so far as fractures are
concerned, and upon this the development of the sub-
ject is based.
There are no sweeping criticisms that can be made,
although, in common with most first editions, there are
occasional errors of omission and of commission. One
rather common fault in first editions is incompleteness
of the index and upon looking up a number of sub-
jects at random we find that this book furnishes no ex-
ception in that regard. There are relatively few typo-
graphical errors, but proper names are occasionally
misspelled. Hey Groves, for instance, is sometimes
spelled correctly, sometimes Hey Grooves. In discuss-
ing the Rainey wooden splint the method of applica-
tion is not adequately described and the photographic
representation of a patient in bed with the Rainey
splint applied throws no light upon the matter. As to
the author's remarks on the operative treatment of frac-
tures, we must say that the advantages of the inlay
graft do not seem to be appreciated, and we trust that
this section will be found much revised when a second
edition appears.
On page 69 he says: "Volkmann's ischemic contrac-
tion is the term applied to a type of contraction of th&
muscles and the changes in the soft parts distal to
the point of fracture." Since in many instances this
condition affects the muscles of the forearm in cases
of Colles' fracture, it is evident that the lesion need
not necessarily be distal to the point of fracture.
In spite of these and a few other matters calling for
criticism the fact remains that Speed has written not
only a good book but one of the best devoted to thil
subject. The subject matter is well presented, practi-
cally all methods of treatment in general use are well
described, illustrations are abundant and generally to
the point, and the book is equally well fitted for the use
of student, general practitioner, and surgical spe-
cialist.
Ophthalmologie du Medicin Practicien. Avec 347
Figures Dans le Texte et Une Planche Hors Texte
en Couleurs. Price, 12 fr. Paris: Masson et Cie,
1916.
This work appears in a volume of 480 pages. It is well
illustrated by many figures in the text and one colored
plate. The book is for the use of the general practi-
tioner particularly. After defining the desired position
of the general practitioner regarding ophthalmology as
to his knowledge of the subject and his relation to the
ophthalmic patient, the direct consideration of the sub-
ject is entered into. The necessary instruments to be
procured by the general practitioner are designated,
methods of examination with systematic chart. Reme-
dies employed and their application. A chapter is de-
voted to injuries to the eye and its adnexa. The dis-
eases of the eye are then systematically considered in a
brief and concise manner. A chapter is devoted to the
consideration of eye affections complicating general dis-
ease. A short chapter on the hygiene of the eye and
prophylaxis follows. The work is well adapted to serve
the purpose for which it was written, namely, for the
use of the general practitioner.
Progressive Medicine. A Quarterly Digest of Ad-
vances, Discoveries, and Improvements in the Medi-
cal and Surgical Sciences. Edited bv Hobart
Amory Hare, M.D. Professor of Therapeutics, Ma-
teria Medica, and Diagnosis in the Jefferson Medical
College, Philadelphia. Assisted by Leighton F.
Appleman, M.D. Instructor in Therapeutics, Jef-
ferson Medical College, Philadelphia. Price, $6 per
annum. Philadelphia and New York: Lea & Febiger,
June 1, 1916.
The current number of Progressive Medicine contains
the following contributions: "Hernia," by W. B. Coley;
"Surgery of the Abdomen, Exclusive of Hernia," by
J. C. A. Gerster; "Gynecology," by J. G. Clark; "Dis-
eases of the Blood, Diathetic and Metabolic Diseases,
Diseases of the Tryroid Gland, Spleen, Nutrition, and
the Lymphatic System," by A. Stengel, and "Ophthal-
mology," by E. Jackson. We have so frequently drawn
attention to this admirable publication that there is no
need to enlarge on its merits. But it is a pity that the
present number should be marred by such a wretched
index. Under the heading "Uterus, Cancer of," not one
of the references is correct; "Cancer" is similarly mis-
handled, and many other entries give the impression
that the index does not belong to the present volume.
The Involuntary Nervous System. By Walter
Holbrook Gaskell, M.A., M.D., F.R.S. Author of
"The Origin of Vertebrates," etc. With colored
figure*. Price, $1.80. New York: Longmans, Green
and Co., 1916.
This volume by the late Dr. Gaskell is one of a series
of monographs on physiological subjects which is being
edited by Professor Starling. Unlike several recently
issued works on the sympathetic and autonomous nerve
systems the present volume deals principally with the
innervation of non-striated muscle in the entire verte-
brate kingdom, beginning with the reptiles. Having
purely an experimental foundation, the work does not
include mankind. Doubtless it represents an outgrowth
of his book on the origin of the vertebrates.
522
MEDICAL RECORD.
I Sept. 16, 1916
NEW YORK ACADEMY OF MEDICINE.
Stated Meeting, Held April 20, 1916.
The President, Dr. Walter B. James, in the Chair.
The Council of the Academy submitted the following
resolutions which were unanimously passed:
Resolved, That the New York Academy of Medicine
approves of the establishment of dental colleges in con-
nection with universities having medical departments.
Resolved, That the New York Academy of Medicine
views with regret the inadequate provision made for the
medical service in the bills now before Congress for in-
creasing the Army of the United States, which gives
less than five medical officers to one thousand combat-
ants, whereas experience in the present war in Europe
indicates that ten medical officers to one thousand com-
batants are necessary under conditions of actual war-
fare. The ratio in the Army of the United States in
peace time should not be less than seven medical officers
to one thousand combatants, to be increased to ten per
thousand in war time.
The subject of the evening was the "Discussion of
Some Recent Developments in Our Knowledge of Food
Values, and Their Bearing upon the Causation of Dis-
ease and upon Its Management."
Vitamines a New Factor in Nutrition. — Dr. CasimiR
Funk read this paper in which he said that recently suf-
ficient evidence had accumulated to warrant the state-
ment that besides the ordinary food constituents, such as
proteins, fats, carbohydrates, lipoids, and inorganic
salts, to the presence of which with the exception of
salts the caloric value of our food was due, a number of
substances could be found in very small quantities which
were as indispensable to life as the former constituents.
These substances were elaborated in both the lower and
higher plants, but could not be synthetised by the animal
organism, and this was one of the reasons why animal
life depended upon plants. These products were present
in all our foods, in all our organs, and in all vital parts
of the plant without a single exception. Their presence
had been revealed to us by the modern technic of cook-
ing and by the refinement of food due to the introduction
of machinery for the industrial preparation of foodstuffs
on a large scale. After referring to the etiology of beri-
beri as due to polished rice, the writer stated that an-
other origin of the same disease was in other refined
foods like sago, tapioca, white bread, especially when
baked with baking powder, consumed in disproportion-
ately large quantities, or if our usual food was subject-
ed to prolonged boiling as sometimes happened when
food was prepared in very large quantities as in the
army and in prisons and in other institutions. The in-
sufficiency of these substances had also been noted in
cases of mental disturbance in which a fancy was taken
to one particular food. Without going into the detail of
the extraction and preparation of these substances, it
might lie slated that they were dealing here with products
showing a good deal of instability under ordinary labora-
tory conditions. This point might be best illustrated by
referring to the time it took to isolate adrenalin from
the suprarenal glands, which was partially due to the
fact that this base was present in small quantities, and
that an insufficient amount of starting material was
taken for fractionation, and also to the fact that adre-
nalin was easily oxydizable in alkaline solution. When
precautions were taken to eliminate these factors the
isolation of adrenalin was successfully accomplished.
It then took a number of years to inform them of its
chemical properties and constitution, and then further
time for its successful synthesis. It would take even
longer to ascertain the constitution and composition of
the vitamines, since as yet the difficulties of 1he first
stage had not been overcome, and this had liminted the
value of investigations with reference to the second
stage to some extent. However, sufficient evidence had
been accumulated to warrant the designation of these
substances by the term "vitamines" and the diseases
which arose from their lack or insufficiency as deficiency
diseases or "avitaminoses." Dr. Funk expressed sur-
prise that the introduction of this term had aroused so
much animosity, since it was quite customary to give a
name to substance the presence of which was merely as-
sumed before its actual isolation, and such terms were
usually accepted until further evidence disputed their
presence. The evidence for the existence of the vita-
mines was many times stronger than in most cases where
similar terms had been introduced. The chemical evi-
dence for the existence of these substances could be seen
from the methods of their detection. After calling at-
tention to the difficulty of fractionating and identifying
substances obtained in such small quantities, the writer
said that the vitamines were sometimes stable at higher
temperatures in the presence of acids and could be
thrown down by phosphotungstic acid or analogous re-
agents which were so largely used for the isolation of
nitrogenous substances, and afterward could be frac-
tionated by means of mercuric chloride and silver ni-
trate and baryta. From this final precipitate a crystal-
line fraction could be obtained which in relatively small
quantities cured beriberi in pigeons. This precipitation
was specific for vitamines, and they were not merely
carried down as was supposed by some investigators.
Other precipitating agents which also yielded heavy pre-
cipitates did not carry down the vitamines. While this
work had been confirmed by many observers it must be
admitted that further chemical evidence was desirable,
especially as regards the mode of combination of the
vitamines in the tissues. With reference to the action of
the vitamines nothing very definite was known except
that they bore a certain relationship to the carbohydrate
metabolism. Dr. Funk had found that feeding animals
on a food composed largely of carbohydrates brought on
an earlier appearance of the symptoms of deficiency dis-
eases. For instance, if a pigeon was fed on polished
rice it was possible to estimate approximately when the
symptoms of beriberi would appear when a given quan-
tity of rice was metabolized. The writer had confirmed
this with an artificial diet composed of variable amounts
of carbohydrates, and it was also found that the blood
sugar content in avian beriberi was greatly increased.
This fact had a practical bearing in infant feeding. It
must be borne in mind that a certain amount of vitamine
could only take care of a limited amount of carbohy-
drates, and when starch was increased in the diet the
amount of vitamine-containing foodstuffs must be in-
creased in proportion. A second fact which had been es-
tablished in connection with the metabolism in deficiency
diseases was that in the absence of vitamine we obtain
not only a negative nitrogen balance, but the whole me-
tabolism goes wrong. This was particularly noticed in
the negative balance of inorganic constituents, like cal-
cium, phosphorus, and sulphur. Schaumann had recent-
ly shown that the addition of vitamine put the whole
metabolism again on a normal basis, and this fact was
of special importance for the understanding of certain
conditions like rickets in children. It was found further
that vitamine when properly prepared and added in suf-
ficient amount to polished rice would make the latter
diet complete. The writer had shown in addition that no
animal was yet found able to live more than a short time
on a vitamine-free food, and that an artificial diet com-
posed of casein, starch, lat, sugar, and all the necessary
salts would produce a deficiency disease of some Kind,
according to the animal chosen, provided sufficient care
was taken to purify the ingredients. To this diet all
known lipoids, cholesterol, various proteins, and all sorts
of salts could be added, but nothing could save the ani-
mal or man from certain death unless vitamine was add-
ed. Dr. Funk then proceeded to discuss certain points
in reference to the relation of the vitamines to the de-
ficiency diseases, calling special attention to the experi-
ments of Morgen and Beger, who found that rabbits fed
on oats, a diet supposed to produce scurvy in them, could
remain in good health when sodium bicarbonate was
added. They considered therefore that the condition
produced was an acidosis, and certain experiments which
the author had performed seemed to confirm this state-
ment to some extent. However, the same experiments
in guinea pigs produced a condition that was possibly
scurvy, but certainly not acidosis. As to pellagra, when
he first expressed the opinion that this was a deficiency
disease he had met with great opposition, but now the
etiology of this disease as a deficiency disease seemed to
be clearly established. It seemed possible that pellagra
was nothing but a chronic scurvy, and that we knew as
scurvy was the acute form of the same disease. The vi-
tamine theory as to the etiology of rickets was at pres-
ent a mere working hypothesis. The results of animal
experiments suggested that they were dealine with a
deficiency disease due to a deficiency of vitamine which
was not essential for life, or to a partial deficiency of
the ordinary vitamine. The opinion of certain workers
that rickets had its cause in a lack of calcium was very
largely due to a misinterpretation of their experiments.
From the point of view of the vitamine theory there was
no objection to congenital rickets when the mother's-diet
Sept, 16, 1916]
MEDICAL RECORD.
523
was deficient, and there was no objection to rickets in
breast-fed babies, in adults as osteomalacia, and in old
age perhaps under another name. The writer next con-
sidered the problem of growth, worked up in conjunction
with Dr. A. B. McCollum, and referred to the work of
McCollum, Osborne, and Mendel who had tried to dem-
onstrate that butter had a very decided effect on the
growth of rats, and had stated that butter-fat did not
contain nitrogen. He was now able to demonstrate that
rats could grow very well without butter when a suffi-
cient amount of vitamine was added to the diet of the
rats, and hence he was utterly unable to confirm the re-
sults of McCollum. When working with yeast it had
been noticed that rats oh dried yeast grew well, but had
shown slight symptoms of scurvy, which, however, dis-
appeared when autolyzed yeast was used. This possibly
showed that rats required for their wellbeing both the
beriberi and scurvy vitamines. Successful growth was
also obtained by using phosphotungstate precipitate de-
composed from autolyzed yeast, while the filtrate had no
action whatever. The fraction used was entirely free
from material which could not be extracted with lipoidal
solvents, and this alone proved that the water-soluble
portion of yeast was the only one responsible for the
growth of rats in direct contradistinction with the re-
cent statement of McCollum. Experiments which the
writer had conducted in association with Dr. Morris
Stark showed also that McCollum's assumption that
casein lost, when heated with alcohol, its nutritive value
was baseless. At present they were not able to say
whether autoclaved casein heated at higher temperature
had a full nutritive value or not, and it was possible that
the latter casein would require an addition of tryptophan
and cystine. Dr. Funk and Dr. McCollum had found,
however, that by means of a suitable diet they could
make rats grow twice as fast as on a diet regarded hith-
erto as normal. At the same time they were able to
stunt animals on a diet that might be designated as nor-
mal. This result had been obtained in chickens fed on un-
polished rice, and still better by feeding unpolished rice
and codliver oil. The same could be accomplished with
rats on a diet of oats. These results could be applied to
the growth of children. It was of interest in this con-
nection to know that they had been able to show that tu-
mors in rats and chickens did not grow so extensively on
such a diet as on a rich diet, and also that the tumor had
a greater affinity to these substances than somatic cells.
While cancer had nothing in common with the deficiency
disease and was if anything a disease entirely opposed
to avitaminoses, it seems extremely probable that can-
cer was not of infectious origin, but was due to a chemi-
cal cause, and the study of diet in cancer will be in the
future one of the most important lines of research.
Group Similarities of the Deficiency Diseases, as
Illustrated by the Clinical and Experimental Study of
Infantile Scurvy. — Dr. Alfred F. Hess presented this
communication, in which he first called attention to the
fact that infantile scurvy almost never developed among
breast fed babies, but was encountered among those
who were fed on cow's milk, and more especially those
who received in addition some of the proprietary foods
which were so commonly resorted to in the preparation
of milk formulae. There had been a difference of
opinion as to whether the use of pasteurized milk could
induce the scorbutic condition. The commission on Milk
Standards, in its report of 1912, stated that pasteur-
ization did not destroy the chemical constituents of milk
and that it was not altered by exposure to heat under
145° F. Dr. Hess determined to test the validity of
this statement and, accordingly, among a certain num-
ber of inmates of an infants' home, where all babies
were fed on Grade A pasteurized milk which had been
heated to 145° F. for thirty minutes, the use of orange
juice was discontinued. No other change was instituted.
The results of this apparently minor dietary change
might be summarized by the statement that almost
all the infants who did not receive orange juice devel-
oped a more or less marked form of scurvy, whereas
those who continued to receive orange juice remained
entirely free from this disorder. Most of these infants
had been in the institution from birth, so that their
condition, both before and subsequent to the change,
could be thoroughly observed. The results of this in-
vestigation, which was published some two years ago,
were questioned by some who were loathe to believve
that pasteurized milk could in any way lead to scurvy,
and hence the investigation was extended somewhat in
the subsequent year. The results were the same, so that
the writer felt safe in saying that a diet of pasteurized
milk led to the production of scurvy in infants unless
some antiscorbutic food was also given. This scurvy
was not as a rule of the florid type met with in infants
fed for months upon proprietary food, but might be
described as latent or rudimentary scurvy. There was a
gradually increasing pallor, a failure to gain in weight,
the development of some petechial hemorrhages, and in
more marked instances, the subperiosteal hemorrhages.
It would seem probable that this insidious type of the
disorder was far more common than was generally
recognized by physicians and that there were many
infants suffering from slight nutritional disturbances
which might be ascribed to this cause. When the pas-
teurized milk was replaced by raw milk the scorbutic
condition improved, although it might be added that raw
cow's milk was by no means comparable to orange juice
as an antiscorbutic. It was not to be inferred from
these conclusions that the use of pasteurized milk was
fraught with danger, but merely that it was an incom-
plete diet for babies and must be given with antiscor-
butic food. There were also secondary factors con-
tributing to the development of scurvy, such as the
individual variation depending upon hereditary char-
acteristics, that was, upon the amount of antiscorbutic
material which the infant brought with it when it came
into the world. Secondary food factors also seemed
to play a part, malt preparations seemingly predis-
posing to scurvy and it also seemed probable that there
was an intimate relation between the development of
scurvy and the amount of carbohydrate in the dietary.
Infantile scurvy differed clinically from the other de-
ficiency diseases mainly in the fact that it was char-
acterized by the production of hemorrhage in various
parts of the body, which a study of the pathogenesis
showed to be due not to alterations in the blood itself,,
but to alterations in the blood vessels which were prob-
ably to be regarded merely as a part of the general
cellular and tissue changes which occurred in this dis-
order. In considering the clinical relationship between
beriberi and infantile scurvy he expressed the opinion
that the current clinical viewpoint which regarded in-
fantile scurvy almost as one of the hemorrhagic dis-
eases and the current pathological viewpoint which cen-
tered its attention on the changes in bone structure
were far too limited in their scope. Signs of involve-
ment of the nervous system were the characteristic
manifestations of beriberi and a study of the cases
which came under his observation showed that infan-
tile scurvy was not entirely free from nervous signs.
The knee-jerks were frequently found exaggeratd, and
in some instances there was slight involvement of the
optic discs and sensitiveness of the cutaneous nerves
seemed to be present. These symptoms disappeared
when the nutrition became normal again. Again dilata-
tion of the right heart had frequently been described in
beriberi, and this was noticed by Andrews in infants
who were nursed by women with this disease and had
been found to occur likewise in infantile scurvy, as had
been demonstrated by numerous Roentgen ray exam-
inations. Edema was also a common symptom of the
two conditions. Further evidence was also available
showing the interweaving in the symptomatology of
these two diseases. There was also evidence demon-
strating essential differences in the vitamines con-
trolling the development of these allied disorders. The
sovereign cure of scurvy was orange juice, which was
efficacious even when boiled for ten minutes; potato,
one of the best antiscorbutics for adults, might be em-
ployed in infant feeding where orange juice could not
be readily obtained. For this purpose milk could be
diluted with potato water, one tablespoonful of mashed
potato to one pint of water, instead of the usual cereal
decoctions. In connection with this work observations
were carried out as to the effect of infantile scurvy
on growth, the study embracing an interval of one year
or more. Three periods might be distinguished in this
investigation, a preliminary period of about three
months, during which the infants were weighed daily
and measured every two weeks; a second period em-
bracing about four mouths, during which the infants
received a liberal diet of pasteurized milk and cereal,
which differed from the previous diet only in the fact
that no orange juice was given; and an after period,
lasting about six months, which dated from the time
when orange juice or other antiscorbutic was once more
added to the food. During the period when the anti-
scorbutic was discontinued particular attention was
given to furnishing a sufficient quantity of food, and
more cereal was given or the strength of the milk mix-
ture was increased. It was found that although the
infants continued to gain in most instances for a few
524
MEDICAL RECORD.
[Sept. lG, 1916
weeks following the discontinuance of the orange juice,
they soon reached a stationary plane and for months
were unable to rise above this level, but increased in
weight promptly when the antiscorbutic food was again
added to their diet. This gain took place in some defi-
nite cases in spite of the fact that the infants did not
take an increased amount of food, showing that the
orange juice either brought about a more perfect metab-
olism, or what was more probable, contained sub-
stances capable of stimulating the growth promoting
function. It was very probable that infants frequently
ceased to gain at about eight months of age, during
the third quarter of the first year of life, for the
want of this essential addition to their food, and failed
to progress until mixed feeding was begun some months
later. At present the rule might be said to be to add
fruit juices to the dietary at about the sixth month,
probably because scurvy seldom developed during the
first six months of life. At this time incidence was
due to the fact that the infant had been protected for
the first few months of life by the supply of antiscor-
butic material which it had inherited from the mother,
and that there must have been a constant negative
balance of these essential substances dating from the
earliest beginning of artificial feeding. It would there-
fore seem that a corrective dietary, that was an anti-
scorbutic should be given as soon as possible. There
was no reason why an infant should not receive orange
juice when it was a month old, and there were strong
arguments in favor of such a procedure. A number
of the infants were not only weighed, but were fre-
quently measured. This group included about twenty,
one-half of which number received orange juice, where-
as the others did not. As a result it was found that
scurvy not only had a direct effect on the weight, but
.also upon the growth in length, and that orange juice
contained properties corrective in both respects. This
fact was of greater biologic interest than failure to
gain in weight, for as had been shown by Freund
and Variot growth in length was a physiological im-
pulse to which the human species clung with great
tenacity, and which was rarely affected even when
other functions were held in abeyance. Although it
was true that infantile scurvy and lack of growth went
hand in hand, such was not always the case, as one
of the infants in this series gained steadily in weight
in spite of the fact that it was developing scurvy. In-
stances such as this showed that lack of growth did
not play an essential part in the constitution of this
disorder. A deficiency of scurvy vitamine was one
cause of stunting; lack of sufficient or adequate food
another, and no doubt there were other factors.
Whether or not growth occurred and to what extent.
depended upon the resultant stimulation brought about
by these various impulses.
Dr. L. Emmett Holt said that his remarks were made
from the standpoint of the clinician and were based
only on observations made at the bedside. His interest
in this .question was not whether the substances under
discussion were vitamines or amino acids, or what
particular name should be given to the substances
the lack of which produced deficiency diseases, but
rather as to the clinical manifestations of these con-
ditions. He believed that scurvy was much more fre-
quently seen since the general introduction in this city
of pasteurized milk. To his mind the evidence was con-
clusive that the connection was one of cause and effect.
Boards of health were properly impressed by the part
that milk had played in the transmission of septic sore
throat and typhoid fever, but it was unfortunate that
they should have neglected to warn the public that
pasteurized milk might produce scurvy. It had been
claimed that if scurvy occurred in an infant on pasteur-
ized milk it was always the fault of the milk formula
used and could not be ascribed to the heating. This was
a difficult position to maintain. While it was certainly
true that the occurrence of scurvy showed that the
food was not proper, this was far from proving that
other proportions of the fat, carbohydrate, and pro-
tein used would have given a different result. Dr. Holt
did not think that the addition of cereals to milk
as commonly employed in infant feeding gave any pro-
tection against scurvy if milk was heated; but rather
that additions of considerable amounts of carbohydrates,
particularly in the form of starchy foods and maltose
mixtures, increased the liability to scurvy in heated
milk. He did not wish to be understood as voicing an
indictment of pasteurized milk, whose great advantages
he fully appreciated, but simply to call attention to the
disadvantages which must be considered as well. The
use of pasteurized or sterilized milk over long periods
was always attended by the risk of producing scurvy
unless some antiscorbutic was added.
Dr. Warren Coleman said that one of the most
interesting phases of the vitamine problem for the
clinician was the question whether the diets used in the
treatment of any of the commoner diseases with which
we had to deal were deficient in these important sub-
stances. There was no common disease of adults,
occurring in this latitude, which was recognized to be
due to the lack or insufficiency of vitamines. Yet it was
not impossible that ill-defined types of disorders now
thought to be disturbances of function, or some of the
symptoms of well-established diseases, might have this
origin. He was the more ready to credit this possibility
because of his experience with typhoid fever. For ex-
ample, he believed that the very course of the disease
had been altered by giving patients all of the food
they required instead of only a part of it. He no
longer considered diarrhea a symptom of typhoid fever,
except perhaps in the prodromal stage, but thought that
it was the result of improper diet and it ceased when
the diet was properly arranged. Delirium and the
typhoid state were not essential symptoms of the dis-
ease. Delirium might occur, but when it occurred it
was due either merely to the fact that the temperature
was elevated beyond a certain height for a particular
individual, or to the elevated temperature plus starva-
tion. If in so well known a disease as typhoid fever
such prominent symptoms could have been considered
essential symptoms of the disease, it was Quite pos-
sible that some of the symptoms of other diseases, or at
least some disorders not now understood, might be
found to be due to diets deficient in vitamines. Atten-
tion should be directed to this point, however, that the
so-called bland diets of the text-books ordinarily con-
sisted of foods with a high vitamine content such as
milk, eggs, and meat extracts, unless they had been
heated too high.
Dr. Morris Stark said that in the course of the eve-
ning's discussion in referring to the deficiency diseases,
not much stress had been laid on the possibility of
rachitis being considered as a deficiency disease, as had
been suggested by Dr. Funk and others some time ago.
There was enough evidence in the literature of rachitis
to say nothing of as yet unpublished work now going on,
to tempt one to assume that rachitis was a metabolic
deficiency, at least until it could be proven or disproven
to be such by further work along the lines of metab-
olism experiments upon the human infant. If such ex-
periments could definitely show, as he had not the
slightest doubt they would show, a change in the min-
eral metabolism as a result of the administration of
substances designated by Dr. Funk as vitamines, sub-
stances in themselves free from these salts in any appre-
ciable amounts, in addition to the uiet which produced
the deficiency disease, a diet in itself not lacking these
salts in necessary amount for the needs of the body, but
lacking in vitamines, their point was proven and the
mystery surrounding rickets solved. The literature al-
ready published by Dr. Funk showed ample evidence
in justification of the term vitamine as applied to these
substances. That this group of substances was just as
necessary to life as those amino-acids which had proven
themselves also necessary for the normal existence of
the organism, would readily demonstrate itself to any-
one making as careful chemical and physiological tests
as Dr. Funk and his collaborators had made, tests
which, though questioned, had never been disproven in
publications by anyone so far as he knew. As to
whether the boiling of milk diminished its nutritive
value, at least the nutritive value of the casein, it
seemed so far as their experiments had shown that boil-
ing casein did not destroy its food value, as supposed
by McCollum, but it undoubtedly did destroy the vita-
mines, as shown by the cessation of the growth of rats
fed upon it and their return to normal growth when a
vitamine containing substance, such as yeast, was added
to the food. McCollum's findings as to the necessity of
butter for growth seemed to be controverted by Dr.
Funk's experiments referred to in his paper. From
many authoritative sources they were led to believe
that yeast contained a large proportion of vitamine, and
accordingly, observations upon the effect of the admin-
istration of autolyzed yeast to rachitic children were
now being conducted by the speaker at one of the out-
patient departments with the possible finding that a
distinct increase of appetite was the result. Rachitis
in breast fed babies and also its occurrence very early
in other infants artificially fed was being further in-
Sept. 16, 1916]
MEDICAL RECORD.
525
vestigated by a careful study of the diet of the mothers
during pregnancy and lactation. However, they were
still far from saying the final word upon this subject
and upon the relation of vitamines to rachitis.
Dr. Abraham Jacobi said it was an undisputed fact
that scurvy was very frequent nowadays when so many
babies were being artificially fed. Forty or fifty years
ago it was very rare. Scurvy was apparently produced
by over-sterilization of the milk. Pasteurized milk
would not cure or even prevent scurvy, but it did not
by itself cause it. Pasteurized milk with a cereal would
do better and would sometimes prevent or cure scurvy,
but not every over-refined cereal would do this, only
cereal in the raw state. If there was no husk left on it
there was no advantage to the baby. Raw barley
or oatmeal were the most efficacious materials to add to
the milk. A second point to be noted was that breast
fed babies rarely had scurvy and for the reason that
the milk from day to day, from morning to evening,
was never the same; it had the advantage of being
changed frequently. As long as a baby was fed on
uniformly the same food, eventually he would get
scurvy.
Stated Meeting, Held May 18, 1916.
The First Vice-President, Dr. Edward D. Fisher,
in the Chair.
This meeting was held in association with the Ameri-
can Society for the Control of Cancer.
The Interests of the Community in the Problem of
Cancer. — Louis I. Dublin, Ph.D., statistician of the
Metropolitan Life Insurance Company, presented this
communication. Contrasting cancer with tuberculosis,
he stated that the average age at death from tuberculo-
sis was about 37 years; from cancer it was about 20
years later. Tuberculosis primarily affected the
economic interests of the community. The decedent
was usually at the highest point of his efficiency; his
productive period was still largely in the future; his
children were either still young or yet unborn. In can-
cer, on the other hand, the productive period was for
the most part in the past; the children had been born
and the family unit was only slightly disturbed econom-
ically by the death, since in the majority of cases the
offspring had reached the age of self support and in-
dependence. It was, therefore, the emotional interest
• that was uppermost. To-day cancer was responsible
for one death out of every 14 among men and one death
out of every nine among women after the age of 50
years. The present interest of the public in cancer was
further accelerated by the mystery that surrounded the
disease and which had thus far baffled all efforts of the
physician and the scientist. Additional interest re-
sulted from the disquieting fact that the cancer rate
might be increasing. The chief sources of information
indicated an increase. This held true not only for the
registration area of the United States, and for those
of our states whose records were most reliable, but also
for the United Kingdom, for Switzerland, for Germany,
and, indeed, generally throughout the civilized world.
Equally good authorities were divided as whether this
increase was real or only apparent. The speaker was
of the opinion that there might very well be an in-
crease. The figures, however, seemed too striking to
be true. In the ten year period from 1901 to 1910,
there was an increase of 30 per cent, in the male can-
cer rate and of 22 per cent, in the female cancer rate,
at all ages, beginning with 25 years, in the states in-
cluded in the registration area in 1900. At certain
periods this increase was very considerable, as much as
40 per cent. The unreliability of these figures was at
once apparent when we thought of cancer as a disease
of long standing in our civilization. By projecting
such increases in the rates forward or backward a few
generations in time one was led at once to an absurdity;
for if cancers are capable of increasing at such a pace
it would either have been a negligible disease in the
past or would seriously threaten the existence of the
race in the near future. The marked improvement in
registration must be taken into consideration and the
greater certaintv in the diagnosis of cancer by physi-
cians. We should have to wait at least ten years under
present conditions of registration in this country to
know definitely what had happened. Whether cancer
was on the increase or not was secondary to the fact
that the rate at present was extremely high, and con-
ditions to-day a real menace. In order to demonstrate
the extent of the problem the essayist presented cer-
tain data which he stated were valuable because of
their intrinsic value. They had also the merit of being
based on a large exposure, there being represented over
ten million persons, both white and colored, men,
women, and children, of all ages, above one year. From
this table it was shown that the rate at all ages was
69.7 per 100,000 exposed. This table showed, among
many interesting details, that the cancer rate was much
higher among females than among males; that the can-
cer rate began to be significant only with the decade
25 to 34; that thereafter the rate increased very rap-
idly, until the maximum was reached at the age of 75
and over. This was true for both sexes and for both
white and colored persons. The rates were lower for
the colored than for the whites, and this applied more
to males than to females. It had often been said that
cancer was a disease of the well-to-do; the figures
showed, if anything, that the industrial classes enjoyed
no advantage. It seemed that no large groups in the
ccmm unity enjoyed any special immunity. The Jews
had been singled out as enjoying a special or partial
immunity. The rate for Jews was sometimes higher
than for the native born Americans of the correspond-
ing age periods. Another table illustrated the relative
importance of the several forms of cancer which oc-
curred among males and females of the two races. This
table showed that among white males about one-half of
the cancers affected the stomach or liver; about 20 per
cent, more related to other parts of the digestive sys-
tem, namely, the buccal cavity, the peritoneum, the in-
testines, or the rectum. Together over 70 per cent, of
the cancers among males were so accounted for. Among
females cancer of the genital organs and cancer of the
breast were very prominent. The former was respon-
sible for 43.1 per cent, of all the cancer deaths occur-
ring among the colored; 15.9 per cent, in addition were
due to breast cancers. Cancers of the skin were much
more numerous among males than among females; the
rate was extremely low for colored persons, being vir-
tually negligible among colored females. In general,
there was clearly a larger proportion of external and
surgically accessible cases among females than among
males. Hospital statistics showed that the cancers
which were responsible for the large part of the female
mortality, those of the genital organs and the breast,
were most susceptible to treatment. Therefore, a large
reduction in the female cancer mortality might be ex-
pected from organized efforts to bring cases to early
treatment. A third table showed the average ages at
death of the persons who had died of cancer of the
various forms. The average age of females at death
was about two and one-half years lower than that of
males: 54.8 years as against 57.2 years. The highest
average age was 63.7 years for cancer of the skin
among females; the lowest 51.1 years for cancer of the
female genital organs. A discussion of the average
age at death was important because it was an indica-
tion of the loss to the community that was occasioned
by cancer deaths. At the present time a conservative
estimate placed the total number of cancer deaths in
the United States at 80,000 a year. This meant an ag-
gregate loss to the community of 1,200,000 years of
life, basing the life expectation as accepted at the pres-
ent time in New York City. Not considering the mone-
tary value of this loss, it would be a gain to civilization
of no mean value to extend to persons of middle life
and early old age a few additional years of peaceful
enjoyment. That the happiness of thousands of fami-
lies would he preserved and that thousands of indi-
viduals would be spared unbearable pain meant more to
the community than cou'd be estimated in dollars and
cents. To accomplish this end two lines of effort were
clearly indicated. The first was to reduce at the best
means at our disposal the suffering and premature
death of cancer patients. At the present time the
rreatest nromise of success was held out by the sur-
op. The statistics indicated that with early diag-
nosis followed by immediate operation the average
rlurat'on of life of cancer patients could be appre-
ciably prolonged. If an average of five years could be
added to these lives, this would be equivalent to a re-
duction of more than one-third the total loss. This was
clearly the community's immediate program. The sec-
ond line of effort lav in investigating into the basic
facts of cancer, the etiology of the disease, its method
of dissemination, the nroblem of inheritance, and finally
the measures of relief. This was the field of the
pathologist and the surgeon. A contribution to this
MEDICAL RECORD.
[Sept. 16, 1916
effort was being made by the life insurance companies,
which pionused to cast valuable light en tne entire
problem. They had made all the necessary prepara-
tions to carry on a special study of the life insurance
returns from two forms of cancer which were readily
diagnosed — cancer of the buccal cavity and cancer of
the breast. Forms had been drawn up for this pur-
pose, which it was planned to send to the physician
who signed the death certificate on the claim papers
and to ask him for more information in reference to the
case. In closing the essayist expressed the hope that
these forms would receive the careful and enthusiastic
attention of physicians.
Our Present Knowledge of the Nature of Cancer. —
Dr. Francis C. Wood made this contribution. He
stated that the interest of investigators in cancer was
almost wholly due to the fact that they wanted to cure
it, interest in the discovery of the cause being largely
scientific and academic. It might be quite possible to
discover a cure for cancer before the cause was known,
as was the case with malaria, anemia, and syphilis.
Unfortunately, at the present time, the only cure
known was complete and early removal of the tumor
by surgical operation before it had spread throughout
the body. Before they could intelligently devise or
even attempt to devise a cure, they must know a great
deal about the nature of cancer: What it was, how it
grew. Why it did not disappear of itself. Put in its
simplest terms, a cancer might be described as a wild
growth of some tissue of the body. It was extremely
important to remember that these cancer cells did not
come from outside the body, nor were they due to bac-
teria or to any parasite; but they were the cells of
one's own body. Hence the difficulty of finding a cure,
because to destroy these cells meant to destroy also the
cells of the tissue or organ of the body from which
they grew. The diagnosis of internal cancers was still
the great difficulty in their treatment, for almost any
internal cancer could be removed, except one which was
in the interior of an important single organ, such as
the brain or liver. Until some medicinal cure was dis-
covered, it was important to develop every possible
means of diagnosis. This was the portion of the can-
cer problem that belonged to the practitioner of medi-
cine and surgery. The question of discovering what
cancer was and the details of the way in which it grew
belonged, on the other hand, to the scientific workers
in laboratories. This investigation must of necessity
be confined to animals, and fortunately for the human
race the antivivisectionists had not yet rendered it im-
possible for us to study the disease in animals. Most
animals suffered from cancer in one form or another,
and these cancers could be transplanted easily and
painlessly by the simple process of injecting hypoder-
mically a small portion of the fresh tumor tissue. This
cancer tissue when placed in an animal of the same
species would often grow much as the original cancer
did, but unfortunately it did not grow in exactly the
same way because it was implanted in a new healthy
strong animal. Tiiis animal frequently resisted the
introduction of the cancer and either refused to permit
it to grow at all or offered such resistance to the
growth that after a few months the tumor disappeared.
This absorption greatly complicated the study of can-
cer, because in trying out a cure they had to be very
careful that the disappearance of the tumor was not
due to other causes than the remedy administered
Only such tumors as went on and grew steadily until
the death of the host resulted should be used in testing
out a supposed cancer cure. The tumors which snon-
taneously disappeared often left the animal immunized
against a second implantation and this fact had en-
abled them to study the conditions which led to the
refusal of the animal's tissues to adapt themselves to
the new growth. The study of ! its led to the
•hat. if the minor was to take.
the animal tissues quickly provided the small mass
of cells injected with suitable blood vessels to nourish
it. thus showing that the tumor cells did not cause any
against themselves, as did ordinary cells such
as the cells from the surface of Hie skin. If Hies- latter
were injected thee would be promptly destroyed by
the active cells of the bodv. The cancer cell was the
one then which had lost this power of inciting resist-
to itself and the animal's tissues did not recogi
'be is invader until it was to .
late. On the and. if the animal was re is tan!
to a particular tumor cell the tissues refused to sunplv
'his nourishment. "Why do cancers start?" 1' v.
said they were still unable to answer this com-
pletely. Certain experiments seemed to show that a
chronic irritation inauceo by an x-ray burn would pro-
duce a cancer when a person carrying tnat burn
reached the cancer age. but there were other factors,
besides age, tor everyone who had an x-ray burn did
not develop cancer. In the same way they knew that
ulcer of tne intestine or stomach frequently, but not
always, gave rise to cancers. Still they did not know
exactly why irritations started a cancer. Possibly
these areas got free and grew just as they would grow
in a cultuie tube and learned to go independently of
the influences which kept normal tissue cells within
their natural boundaries, but this was a mere surmise.
Their experimental work on animals had shown that
the growing of a cancer was entirely different from the
beginning of a cancer. A mouse could be rendered in-
susceptible to inoculation of cancerous tissue by suit-
able treatment before inoculation, but the same mouse
might develop a cancer of its own while still resistant
to implantation, so that the conditions of growth and
the conditions of origin weie entirely different things.
It had recently been shown that a certain amount of
resistance to cancer could be produced by very small
doses of x-ray, just enough to stimulate the bone mar-
row and cause it to send out certain kinds of cells
which had been recognized as in some way related to
the spontaneous disappearance of tumors in animals,
but this did not mean that the original tumor which
this animal had did not keep on growing. The only
way in which one could use a:-ray or radium to treat a
tumor which was already fixed and had a start was to
kill the cells of the cancer and this was very difficult
because large quantities of radium and prolonged ex-
posures to x-rays weie required, and there was always
the danger of stimulating the tumor instead of killing
it. Tumors spread to the body through the blood ves-
sels or lymph channels, and this spreading could be
hastened by manipulation of the tumor, as in examina-
tion, either by the patient, the physician, or the sur-
geon. The surgeon should be very careful in excising
a tumor to go wide of the tumor itself and not to open
up any of the cancer bearing tissue itself. Despite the
most earnest and painstaking study by laboratory
workers during the last fifteen years, the amount of
knowledge acquired had been small. They had had to
do a great deal of unlearning, because at first it was
thought that cancer cells might grow in the same way
that bacteria grew, but it had become evident that no
such parallel could be drawn; the bacterium destroyed
by its poisons as it grew, the cancer cell insinuated it-
self without causing the slightest disturbance until if
destroyed some important organ or blocked the way for
circulation, or nourishment. Thus it might be seen that
the surface of the last great problem of medicine was
still almost unscratched. and they still had no indica-
tion as to the direction in which the solution was to be
obtained.
The Place of Surgery in the Treatment of Cancer. —
Dr. George D. Stewart made this address. He took as
his thesis "Surgery Is the Only Cure for Cancer." This
he endeavored to demonstrate, speaking first of the so»
called "cancer cures.'' These he said were so numerous
that scarcely a day passed that one did not hear of a
new one. The truth was that toxins, extracts, and
serums had not given a single cure or. if they had cures
bv these means, they were as rare as spontaneous cure s.
The most that could be said by those who had used
these methods was that they thouoht the growth had
-] in size; here too often, the wish was father
to the thought. The various methods that had been
used in the cure of cancer might lie divided into three
groups: The first group included the escharotics, the
cautery, and fulguration; the second group included the
radioactive agents, radium, thorium and mesothorium;
the third method was by some effort of surgery. The
agents belonging to the first group might occasionally
cure a benign growth. When this happene 1 th» testi-
mony of the patient so cured was sent broadcast and
many flourished on this kind of exploitation. It should
be renumbered that drugs which caused sloughinf?
affected healthy tissue as well as diseased tissue and
one could not accurately limit the field of their action,
i mterization by means of fulguration was also a means
of tissue destruction that one could not accurate! v con-
trol, and there were other similar methods, as the super-
heating method of Percv. This method was devised for
destroying cancer of the cervix uteri, and was also a
forni of tissue destruction that was not. safe. Aside
from the danger of hemorrharre which Percv claimed to
have overcome by cutting off the blood supply, rectal
Sept. 16, 1916]
MEDICAL RECORD.
527
and bladder fistula; were not uncommon. This method
was oniy a variant of the cautery method which had
been used for some years by Dr. Burns of Brooklyn ;
furthermore it was only applicable to cancer of one
variety. Fulguration with the high frequency currect
in cancer of the bladder was still extolled by some and
had cured some cases in the early stage, but it had
never cured a case in which the bladder wall was deeply
involved. Taking up the second group of agents,
radium had some very ardent advocates. In the How-
ard Kelly Hospital, Dr. Kelly associated with Dr. Burn-
ham reported 1300 cases, some treated five years ago
and most of them two years ago. These statistics did
not carry conviction because two years was not suffi-
cient time to say whether a cancer was cured or not.
Speaking of cancer of the body of the uterus, Burn-
ham said" no case was cured, but there was a decrease
in the size of the growth; it must be remembered a de-
crease in the size of a cancer was not a cure. Burn-
ham said further that they would not advise radium
unless operation was impossible in cancer of the cervix
uteri, and that it gave the best results in cancers of
slow growth. If operable, cases should be operated
upon. They found radium less satisfactory in ovarian
cancers. In papiilomata of the bladder it had given
favorable results and it had cured rectal adenocarci-
noma. Dr. Stewart said he had seen two cases of carci-
noma of the rectum made distinctly worse after radium
treatment. The statistics given this evening showed the
large number of cases of cancer of the stomach, liver,
thorax, and intestines, and to these radium was not
applicable. The basal celled carcinoma of the mucous
membranes of the mouth were milder and more amen-
able to treatment than similar growths of the skin. The
need was for something to cure cancer in cases in which
radium did not give any help. Burnham concluded that
he did not advocate the use of radium in operable cases,
but only in inoperable cases and following operation.
Others had found radium effective in carcinoma of the
skin, papiilomata, nevi, and in all superficial forms of
the disease, except malignant pigmented moles in which
the growth was very rapid. Albutt stated that radium
had kept cases of mammary cancer alive for from
three to seven years, but that one ought not to deny
these patients the help that operation might offer. One
must not expect too much from radium or thorium :
they were effective in round celled carcoma, basal celled
epitheloma, and superficial cancers of the face. It
should be remembered that these were not true cancers.
Koenig and Gauss, at Frieberg, after an experience
with a very large number of cases stated that in carci-
nomas with metastases they could not report a single
cure with radium, thorium or mesothorium, but they
believed that these inoperable cases should be submitted
to the radium treatment. After reviewing the results
of still other observers who had employed the radioac-
tive agents in the treatment of cancer, Dr. Stewart
said that, summing up their evidence, it seemed that
radium cured some cases of superficial epithelioma and
that it had an effect on sarcoma, but that it had no
effect on hard cirrhous growths. Of the x-ray and
radium, in general it might be said that they had some
curative properties, but they could not be applied in the
cavities of the body and there was some question
whether the x--ray did not in some cases have a stimu-
lating effect upon the growth of the cells. Taking up
the question of surgery in cancer, a few cases might
be cited. Metropolitan Life Insurance Company showed
that of 75,000 cases of breast cancer operated upon
18,000 died in one year. Lynburg reported 183 can-
cers of the breast, some very advanced, which were
operated upon and 77 survived after three years. In
cancer of the stomach Schauter reported 20 to 30 per
cent, alive after three years; Altschult 14 per cent, of
cancer of the stomach, and May 38 per cent, after
three years. Of course it was recognized that earlier
diagnosis had improved the statistics of operations, that
had often been stated and would have to be affirmed and
reaffirmed. It must further be emphasized that opera-
tive removal to be effective must be radical. No other
method had so far succeeded in displacing surgery.
Every cancer patient should be given the chance for
cure that surgery held out. Cancer was a local con-
dition only before there were any metastases, and
surgery offered hope of cure provided it could be re-
moved before that time. Those that held that cancer
was a general blood disease were absolutely wrong
inasmuch as it did not grow until the tumor material
was transplanted to other parts of the bodv. If seen
in the early stage radical surgical removal offered a
fair prospect of permanent cure in a certain per-
centage of cases.
Dr. John A. Hahtwell said it seemed to him that the
function of the man who discussed a paper was to sum
up what had been said rather than to bring out any-
thing new. The first paper was statistical and there-
fore it was impossible to discuss it, but these figures
in spite of what Dr. Stewart had said, were unassail-
able. Dr. Dublin had said that the interest in the can-
cer problem was not so much from the standpoint of
economics as from that of sentiment. On the other
hand he thought cancer took men at a time of life when
they were still much needed and that the economic side
of the question was very important. Dr. Wood had told
them what he knew of cancer and, so far as he had been
able to grasp it, their knowledge seemed to be very
meagre, but they must not feel that it was through the
laboratory that cancer would be controlled or miti-
gated. It would be in the laboratory associated with
clinical work that salvation would be found. Dr. Stew-
art had given them the results of operative methods
of treatment and had shown that there was a very much
better outlook for the cancer patient through surgical
interference than by any other method, yet no operating
surgeon ever approached a case of cancer without seri-
ous misgivings. The surgeon got successes but he also
got failures and the failures were more numerous than
the successes. When one got statistics reporting 75
per cent, of cures in cancer it was well to see if there
was not something that made them different from the
average group of cancer case, for cancer was curable in
only a small percentage of cases. A certain number
could be cured if we got them at an early date. The
surgeon could do little after cancer had passed the local
stage. However, it was a common experience of the
surgeon that early cases did remain cured. Therefore
this was the line along which they must direct their
efforts toward the control of cancer and the problem
must be worked out by a combination of the labora-
tory and the clinic, by a study of mouse cancer and
human cancer. The cure of cancer was not to be sought
in radium or the x-ray though there was some evidence
that these agents had actually accomplished cures; they
therefore must not be set aside, but must be studied
with intelligence. There was now a difference of
opinion among radiologists as to the dosage and the fre-
quency with which treatment should be given, and also
with reference to the duration of the treatments and
whether it should be, applied locally or generally. It
seemed from observations made at the Rockefeller In-
stitute that the lymphocytes were increased above the
normal by the .r-ray treatment and the lymphocytes
seemed to have an influence on cancer growth. In treat-
ing cancer by the .r-ray or radium the patients should
be observed by an expert surgeon, who by watching the
results of these methods and the results of surgery
would be able to make comparisons. By such a method
there was reason to hope that definite conclusions might
be reached and in the meantime it was well to avoid
methods that savored of exploitation or that had not
been well worked out.
Dr. David BovAiRn, Jr., said that if one added to-
gether the cancers of the alimentary tract, cancers of
the stomach, intestines, liver, and rectum he would
find that these formed about 50 per cent, of all cancers.
These cases were regularly examined first by the gen-
eral practitioner, so that the fate of those suffering
from cancer depended upon the physician, and it was he
who should be brought to an appreciation of the gravitv
of the situation and the need for proper action. Dr.
Stewart had shown that the percentage of persons sur-
viving operation for cancer of the stomach for from
two to three years varied from 14 to 38 per cent., but
such results were obtained in very few clinics in the
world. A search of the literature would convince one
that cancer of the stomach was one of the gravest
things that could befall any one. Friedenwald of Bal-
timore reported 1.000 cases. 266 of which were brought
to operation. Of these 138 were merely exploratorv
operations. The remainder were subjected to suitable
operative procedures, such as gastrectomies, pvlorec-
tomies. etc., and not one of these patients was alive to-
day. Dr. Lambert and Dr. St. John in going over the
records of the Presbyterian Hospital covering opera-
tions for cancer of the stomach found 15 or 16 cases in
which partial gastrectomy had been done and of these
only two patients were living at the present time. One
of these was apparently heaHhv but in the other the
condition was not so clear. These were the results in
most surgical clinics in this city. The responsibility
528
MEDICAL RECORD.
[Sept. 16, 1916
for these results did not rest on the surgeon — surgical
skill does not vary so greatly in different places — but
on the stage of the disease when brought to operation.
As an aid in making an earlier diagnosis in cancer of
the alimentary tract Dr. Bovaird urged the early and
adequate use of the x-ray. He said lie felt thoroughly
convinced that the radiograph added more to the possi-
bility of early diagnosis of carcinoma than any other
one thing that they had tried in recent years, it there-
fore behooved them as physicians whenever they were
dealing with a case of gastric disturbance not to rely
wholly on the usual clinical methods but to have a
thorough radiographic examination of the stomach and
intestinal tract made. If that was done and the result
correlated with the clinical findings the diagnosis might
be made sufficiently early to give the surgeon a fair
opportunity of effecting a cure. The radiograph also
had a value on the negative side as well as on the posi-
tive side. It had been their experience that when a
radiograph had given negative results and the patient
had been subjeected to operation the radiograph was
shown to be right. The radiograph could generally be
relied upon to establish the diagnosis of gastric carci-
noma, and when that was done no time should be lost in
referring the patient to the surgeon for operation as
that offered the only hope of cure.
Dr. Eugene H. Pool said it was important to de-
fine what one meant by cancer in this discussion. We
had roughly two types of cancer, first, the relatively
benign which rested relatively tranquil at or near the
site of its inception, to this type belonged basal cell
epithelioma; second, the truly malignant type, which
was a creature of mushroom-like growth, a prolific
breeder, a voracious and predatory despoiler and
ravager. This type was represented by cancer of
breast, cervix uteri and tongue. The benign type was
like a cub lion which usually we might play with and
fondle with impunity; this type might be treated in-
differently with radium, x-ray, cautery, or the knife.
The pathologist and the average surgeon usually could
recognize clinically this type. Yet the lion cub could
not always be depended upon and sometimes matured
unexpectedly and caused injury and even took life.
This benign type, however, was not what we had in
mind in speaking of cancer in such a discussion as this.
We had in mind the well defined malignant type, trifling
with which was like fondling a serpent. It was un-
fortunate that the term cancer was used indifferently
for these two types of tumor which clinically and in
their life history were so different. In considering the
malignant type, Dr. Pool said he had recently heard
an eminent surgeon say in a carefully prepared paper,
in discussing the treatment of carcinoma of the cervix
with radium that in addition to numerous non-operable
cases he had treated three operable cases with radium.
He claimed these three cancers had disappeared and
stated that this suggested that radium and not opera-
tion might prove to be the method of election in the
treatment of these growths. Such was an example of
the statements made by the enthusiast; one would not,
however, expect such a statement from a surgeon. Such
suggestions were extremely dangerous teaching. Why?
Because they engendered in the mind of the sufferer a
hope of success from other means than the knife; they
consequently encouraged delay. Now practically the
entire progress in the treatment of cancer had been
di -pendent upon training the profession and the laity
that early diagnosis and early radical operation offered
the sole chance of cure. Dr. Pool claimed that radium,
• niy, mustard applied inside or outside, or any other
pet therapeutic agent of the experimenter, commereial-
izer, or scientist had not been put on a basis sufficiently
firm to warrant recommending them to a sufferer with
an operable malignant type of cancer. On the other
hand we must continually emphasize the salutory effect
if the knife was employed early. One must picture in
his imagination the cancer beginning from a single cell
or an extremely limited collection of cells, not initially
as a diffuse lesion. Obviously if such is correct the
disease may be eradicated by early operation; and more
surely in direct proportion as the time of operation ap-
proached the time of the inception of the disease.
Therefore we must insist that these patients be sub-
mitted to the surgeon, not only with an early diagnosis.
but, better, when there was merely a suspicion of the
presence of a malignant type of cancer.
Dr. J. C. B dgood of Baltimore said he had not
come prepari d to speak but to listen and to learn. How-
ever he could give a few impressions with reference to
the change that had taken place not only in their knowl-
edge of cancer, but in their attitude toward it. Dr.
Wood had spoken of the workers with the x-ray getting
cancer; workers with the x-ray to-day did not develop
cancer. That was definite evidence that some forms
of cancer could be prevented. We knew that some
forms of cancer were more frequent in men than in
women, in this instance the only difference was the
question of the use of tobacco, and there was no reason
why men should not learn to smoke without getting
cancer of the mouth. Dr. Pool made the point in the
difference in the results of operative treatment in ear:y
and late cancer, that was the difference between the
early and late stages as far as one could tell from the
macroscopical appearances. They had made a study
along this line and at the end of five years compared the
two groups, and there was a great difference in the
results ; but surgery did cure a certain number of fairly
advanced cancers, though one could not put great hope
in surgery in advanced cases. His figures demon-
strated that education could bring to the surgical clinic
cancer in their locality in a much earlier period of the
disease. Their results were not due to the fact that
surgery had improved but were due to the different
stage of the disease at the time of operation. Their
report on cases of cancer of the stomach showed three
and five-year cures in 19 per cent, of the cases. In can-
cers of the stomach that were operable, some of which
were shown to be operable by exploratory operation,
in the last six years they had increased their per-
centage to 38 or 39 per cent. A large per cent, were
living but it was not five years since all of them were
operated upon. The increase, however, showed that
with the education of the public and the physician in
regard to the early diagnosis and the importance of
early surgical interference better results could be ob-
tained. The importance of this would be recognized
when he said that 51 per cent, of these cancers were in
regions in which it was difficult to recognize cancer
early, and to detect the difference between advanced
benign and distinctly malignant types. In a series of
2000 cases the percentage of those brought to early
operation had increased from 32 to 57 per cent. From
the time they began their campaign of public education
until 1913 the proportion of breast lesions brought to
operation early had increased from 47 to 59 per cent.
These figures showed very definitely what education
could do. Until six years ago they had never had an
operable cancer of the right colon. In cancer of the lip,
tongue and skin there must have been a period when
the individual had known that he had a local affection
and if he had sought treatment at the hands of the
surgeon he could have been cured in almost every case.
Cancers of the lip and tongue within three months had
become hopeless. There was no more reason why a
patient with a growth on the lip or tongue should allov)
it to go three or four months without seeking relief
than there was why a patient with appendicitis should
wait three or four days for peritonitis to set in before
consulting a surgeon. The percentage of inoperable
cancers that they were getting was decreasing. No one
should die from cancer of the skin or lip as these were
generally small growths, and they had had only about
100 pigmented mole cancers to 1500 lip and skin cases.
Therefore correct information for both the public and
the profession would increase the number of cures
in cancer and the number of late cases would be
decreased. To illustrate, breast cancer for the first
time in the last five years was relatively on the de-
crease in the clinic in Baltimore. The laboratory work-
ers were having a tremendous influence on the surgeons
in their investigations. Surgeons had not known how-
to use their material for the development of knowledge
of cancer. The workers in the laboratory would influ-
ence the surgeon to use their methods to advance knowl-
edge in respect to the cure of cancer.
Poisoned Bait for Controlling the House-Fly. — Malley,
in an article in the Smith African Journal of Science.
refers to a mixture of sweetened water and arsenite of
soda which is sprayed on detached branches of trees
which have firm foliage, the latter then being placed
upon strategical situations, as mami'- heaps and
garbage cans. Other bait carriers in use are old bacs
and the like. Finallv the bait may be sprinkled directh-
on the dunghills, and on the ground near by. The full
formula for the bail is arsenite of sodium 1 nound,
suear 10 pounds, water 10 gallons. The insects die be-
fore they can deposit their eggs. The idea seems to
have been anticipated by Berlese of Italy in 1913. —
Tropical Diseases Bulletin.
Medical Record
A Weekly Journal of Medicine and Surgery
Vol. 90, No. 13.
Whole No. 2394.
New York, September 23, 1916.
$5.00 Per Annum.
Single Copies, 15c.
(Original Arttrbfi.
THE PRESENT STATUS OF CHRONIC MUL-
TIPLE ARTHRITIS, WITH SPECIAL CON-
SIDERATION OF INFECTION AS AN
ETIOLOGICAL FACTOR.
By GEORGE R. ELLIOTT, M.D.,
NEW YORK.
ASSISTANT FBOFESSOK OP CLINICAL ORTHOPEDIC SDRGERT, COL-
LEGE OP PHYSICIANS AND SURGEONS, COLUMBIA UNIVERSITY.
N. Y. : ATTENDING ORTHOPEDIC SURGEON, MONTEFIORE
HOME AND HOSPITAL ; ST. FRANCIS AND ST. JOSEPH
HOSPITALS ; MEMBER OF THE AMERICAN OR-
THOPEDIC ASSOCIATION.
The object of this paper is to present the subject
of chronic multiple arthritis as generally accepted
to-day. Prominence is given to methods that are
appearing to unravel this difficult subject. We
shall omit full consideration of the arthritis urica
and tuberculous types of arthritis, referring to
them as only part of the general subject.
To make the subject comprehensible, we shall
discuss it under two chief heads or types. The
two types the observing clinician would find him-
self dividing his patients into were he shown a
large number of cases. In fact, the two main types
of the older clinicians to whom we find ourselves
coming back for a working basis.
Out of the great chaotic clinical mass of poly-
arthritis of recent years, we feel that we have
something here very tangible, and a knowledge of
the two chief types clearly in our mind will enable
us to more clearly understand the irregular types.
The chief subject discussed in this paper is that
of infection; how it plays its part.
The two types we are to consider give entirely
different clinical pictures. These are: (1) Prolif-
erating, or ankylotic type of chronic multiple
arthritis; (2) degenerative or non-ankylotic type
of chronic multiple arthritis.
We shall refer to the true infectious types of
arthritis together with the mixed types. Out of
this a working classification will be given, based
on our study and presentation of the subject, which
classification we hope will be understood by the
physician.
1. Proliferating, or ankylotic type of chronic
multiple arthritis, called by some rheumatoid arth-
ritis, by others atrophic arthritis. This constitutes
the large class of polyarthritis now being studied
as never before, attracting and engaging the atten-
tion of world-wide laboratory research. It attacks
as a rule the young adult; its febrile onset is ir-
regular and freqaehtly entirely overlooked; its best
external signs are seen in the small peripheral
joints which tend to become fusiform in shape; it
is apparently steadily progressive; ankylosis tends
to occur and the patient becomes bedridden. This
type of patient may linger on for years, a hope-
lessly deformed invalid, dying finally of cardio-
vasculorenal disease with profound anemia. Even
at this day such in brief too truly pictures a large
class now filling our institutions for the treatment
of chronic invalids and private homes throughout
the land.
As a result of intelligent research now going on
this picture is changing. We are rescuing patients
and staying the progress of the disease, cutting it
short so to speak and repairing damage done. In
a certain way, we may compare this disease with
poliomyelitis. In the latter, however, we have a
distinct infection doing its work quickly and ceas-
ing action. The resulting damage is left to nature
and the surgeon for repair. In chronic multiple
arthritis, on the other hand, the active agent seems
to act intermittently, but no less effectively, and
the semblance of progression characterizes the
clinical picture. The etiological factor stamped
out, however, and the polyarthritic becomes as the
poliomyelitic amenable to the restorative power of
nature and the intelligent properly directed skill
of the surgeon. All this leads us at once to infer
that at the etiological root of this type of arthritis
lies an infection — the generally accepted view to--
day.
What is the basis for accepting belief of infec-
tion? In order to comprehend the nature of the
evidence forcing upon us the infection theory of
polyarthritis, an understanding of the nature of
some of the comparatively recent work done in
rheumatic fever is necessary.
Of the several promulgated theories of the etio-
logy of rheumatic fever only two schools appear to-
meet with recognition: One that it is a specific
disease due to a specific germ ; the other that there
is no specific organism but a form of septicemia of
staphylococcal or streptococcal origin, and bearing a
close analogy to pyemia. Much has been produced
in the support of both of these views.
Regarding the single germ theory, which now
seems the favorite, several workers have isolated a
specific germ and confirmed the specificity through
cultural inoculations. Achalme, in 1891, discovered
a bacillus. Triboulet, in 1897, isolated a germ from
the blood in rheumatic fever, and grew it anaerobi-
cally. In 1899, Westphal, Wassermann and Wal-
koff published their findings regarding a diplococ-
cus. Soon after this, Poynton and Payne began to
publish some of their research work along this
line describing a germ isolated by them — a micro-
coccus identical with those of other observers. To
Poynton and Payne we are indebted for a mass of -
work which has excited a great deal of scepticism
among laboratory students. Many have failed in
any way to duplicate their findings. This has led
to their work being discredited by some. But just
now it can be safely stated that their work is being
recognized, and of great assistance in bringing to
530
MEDICAL RECORD.
[Sept. 23, 1916
the front much to support the single germ theory
of acute rheumatic lever, and that germ a micrococ-
cus identical with that discovered and described by
Triboulet and by Wassermann and more recently
by Rosenow. All the observers point out the ex-
treme difficulty in isolating the germ, and here
doubtless is the explanation of so many failures on
the part of laboratory workers who have made their
cultures from the blood stream and joint cavities.
It is not in the joint cavity for example, the
place usually examined, that organisms are found.
The joint effusions both in rheumatic fever and
in arthritis experimentally produced are usually
sterile. It is in the areolar tissue about the joint —
that binding the endothelial tissue to the fibrous
capsule, the site of cellular exudation — where the
organisms are found. The organisms find difficulty
in getting into the free-joint cavity in any num-
bers. They here encounter the endothelial cells
and leucocytes and are rapidly destroyed. They
locate themselves then outside about the joint, and
Fig. 1. — Proliferative or ankylotic type of chronic multiple
arthritis. Age of patient 27 years. Onset of disease at age
of 20 years. Illustrated further by x-ray, Figs. 2 and 3.
it is just this fact that has made the bacteriologi-
cal study of joint infection so difficult and so long
in being understood. It opens to us, as we shall
show later, a better means of understanding chronic
polyarthritis. The blood stream is simply a car-
rier containing only now and then organisms
gathered from the original focus of infection;
hence also the repeated failures in getting a speci-
fic blood culture. This definite organism has been
isolated from the human subject afflicted with
rheumatic fever and injected into rabbits produc-
ing a disease identical with that in man; the micro-
organism has been recovered and again injected.
This has now been confirmed by many observers
(Triboulet, Wassermann. Poynton and Payne,
Rosenow and many others).
Evidence Supporting the Teaching of the School
Advocating the Septicemic Theory. — Kronenberg,
in 1889, expressed the view that rheumatic fever is
not a disease sui generis, but rather a reaction of
the joints and other tissues to a series of bacterial
influences, e. g., streptococcal, staphylococcal, gono-
coccal and allied infections. Those holding this
view were confronted with absence of suppuration
characterizing its clinical manifestations. This ab-
sence is striking. Frequently in rheumatic fever
the reaction is pronounced, and the febrile move-
ment marked, yet suppuration is rare.
To meet this absence of suppuration, it became
necessary to attenuate the organism and speak of
attributes which had ceased to be pus-producing.
This pyogenic germ in its transformation to a joint
environment must have materially changed its
attributes and ceased to be pus-producing. This
is especially interesting, and has an important
bearing in chronic multiple arthritis, as we shall
see later.
How the Theory of Infection is being Worked
Out; Meaning of Mutation, Focal Infection and
Elective Localization. — As we have just stated,
since the pus-producing organisms have played the
chief role in the rsearch work of arthritis, it has
become necessary to modify in some way the spe-
cific attributes of the organism. And we have re-
ferred to the recognized attenuation need of the
pyemic school. To explain this attenuation gave
rise to the use of mutation and focal infection.
Herein lies much that is promising toward the
solution of our arthritic problems.
Mutation. — The repeated failures to obtain cul-
tures from the blood and joint cavities in active
forms of rheumatic fever led bacteriologists into
side fields of investigation. Ruediger,' in 1906,
called attention to fermentation and morphologi-
cal changes of certain streptococci; later noted by
Buerger and Rittenberg,' Anthony,2 Walker,3 and
others. Davis,6 after a great deal of work, stated
that transformation of one member of the strepto-
coccus group into another within certain limits ap-
peared to be not an uncommon phenomenon. Rose-
now8 says: "Davis and Rosenow have shown that
the encapsulated streptococcus from "septic sore
throat" can be converted into streptococcus mucosus
on the one hand and hemolytic streptococcus on
the other." Rosenow also calls attention to a pre-
vious paper where he has shown that streptococcus
viridans isolated chiefly from the blood in cases
of subacute endocarditis may by animal passage
take on the properties of the typical pneumococ-
cus.
He summarizes thus : Altogether twenty-one
strains isolated originally as hemolytic streptococ-
cus from a wide range of sources, including
erysipelas, scarlet fever, puerperal fever, arthritis,
tonsillitis, etc., in one way or another, have been
converted into streptococcus viridans; 17- strains
isolated as streptococcus viridans chiefly from the
blood and tonsils in cases of infective endocarditis
have been converted into pneumococci. Eleven
strains isolated from the sputum, blood and lung
in pneumonia and empyemia have been made to
correspond to hemolytic streptococci. The strepto-
cocci from three of the strains acquired all the
essential features of the streptococci of rheuma-
tism, two into hemolytic streptococci, the strepto-
coccus of rheumatism, streptococcus viridans and
back again into the pneumococcus. Rosenow as-
serts that the various strains of the streptococcus
group may be converted each into the other.
Here then the change appears as nothing short
of a real mutation. To enable one to grasp the
subject intelligently, it may not be amiss to refer
to what biologists mean by mutation. Like pre-
Sept. 23, 1916]
MEDICAL RECORD.
531
Raphaelism in art, the mutation theory is a re-
vival, sc to speak, in a new dress of the theory of
the origin of species of pre-Darwinian times. The
terms mutation, mutability, immutability, etc.,
were completely driven out of use by the theory
Fig. 2 — Radiogram of left hand of patient shown in Fig. 1.
Note selective character of the disease in the hands — proximo-
medial joints chiefly ; also great amount of destruction.
of natural selection. While Darwin used the term
mutability, he used it in a restricted sense from
that of the modern biological school of mutation.
Mutation in the modern sense means that species
arise by saltations or jumps, and these individual
saltations can be observed like any other physiologi-
cal process. These saltations or mutations occur
without transitional gradations. This is readily
seen to stand in marked contrast with the gen-
erally accepted selective theory that species of
animals and plants have arisen by imperceptible
gradations, the changes being so slow that the life
of a man is not long enough to enable him to wit-
ness the origin of a new form. The mutation
theory means that the attributes of organisms con-
sist of distinct, separate and independent units.
Each new unit, forming a fresh step in this process,
sharply separates the new form as an independent
species from that from which it sprang. The new
species appears all at once. It originates from
the parent species without any visible preparation,
and without any obvious series of transitional
forms. Natural selection, Darwin says, chooses
"slight variations." Natural selection, he says,
works on "chance variations" (Life and Letters,
II, page 87 et seq.). Unless such occur, natural
selection can do nothing ("Origin of Species," p.
64). Wallace is still more precise than Darwin in
his selective theory. He dwells upon rapid multi-
plication and the premature death of innumerable
individuals; variability and survival of the fittest.
He says: "It is therefore proved that if any par-
ticular kind of variation is preserved and bred
from, the variation itself goes on increasing in
amount to an enormous extent, and the bearing of
this on the question of the origin of species is
most important."
Without going further into the details of the
selection theory, it holds that "species have arisen
by natural selection resulting from the struggle for
existence" requiring long periods of time. Accord-
ing to the theory of mutation, species have not
arisen gradually as the result of selection operating
for hundreds or thousands of years, but by sudden,
however small, changes. De Vries'7 experimental
work with the primrose (Oenotheria lamarkiana)
is interesting as well as illustrating the full mean-
ing of the mutation theory as set forth by one of
its chief exponents. DeVries brought over 100
plants into cultivation, and only one, as he terms
it, was found passing through the mutation period.
In seven generations his experiments dealt with
50,000 plants and of these over 800 mutated. As a
result of these experiments, DeVries formulated
laws, some of which are here given :
1. New elementary species arise suddenly with-
out transitional forms.
2. New elementary species are, as a rule, abso-
lutely constant from the moment that they arise.
3. Mutability appears periodically.
So much for the mutation theory which has by
no means been fully accepted by the great class of
biologists. This lack of acceptance applies also to
the special primrose work of DeVries just alluded
to.
Fig. 3. — Radiogram of right hand of patient shown in Fig. 1.
See also Fig. 2.
While the work of the bacteriological transfor-
mationists fails in certain important facts in meet-
ing the strict requirements of the mutation school
of biology, yet it is clearly seen that they fall back
upon that school for any approximate scientific ex-
532
MEDICAL RECORD.
[Sept. 23, 1916
planation of their experimental findings. This is
not the place to discuss the biological placing of
the bacteriological mutationists, but it is well to
observe that the claimed attributes of bacterial
organisms do not arise in accordance with some
of the established laws of the mutation school
— one especially that "new elementary species are
as a rule absolutely constant from the moment
that they arise." This constancy is dwelt upon
with no trace of reversion. But, according to
Rosenow, especially members of the streptococcus
group are by means of oxygen regulation and ani-
mal passage made to pass one into the other in a
sort of "Jack-in-the-box" manner — now I am
hemolytic and now I am not, and now again I am
hemolytic; now I am soluble in bile and now I am
not. Rosenow's changes occur practically over
night.
It is interesting right here to mention the
tenacity with which some bacteria cling to their
attributes. Quite recently Dr. Rufus Cole of the
Rockefeller Institute told me that one of his well-
known types of pneumococcus had at that time
made 226 animal passages, with complete retention
of all its attributes and without change. It had
not, however, been subjected to the Rosenow
technique or mutational experimentation. This is
of interest only as showing the stability of this
particular member of the streptococcus group, and
in no manner is intended to reflect upon Rosenow's
work.
We have especially emphasized the "species" and
what a change of this means. It i.iay be found that
the changes are not so great after all. That the
organisms are all of the same species and only
variants; that, for example, the Streptococcus hemo-
lyticus, Streptococcus mucosas, Streptococcus pneu-
mococcus, Streptococus viridans, are all variants of
the same species. This is much easier to reconcile
with the rapid changes resulting from changed en-
vironment. We must await further development and
confirmation to clear up the subject and make for a
complete reconciliation with the established laws of
biology.
And now to the practical work of the bacterial
transmutationists along this line. The following
table by Davis1 showing the relation of streptococci
is interesting at this point.
I IN OF STREPTOCOCI I
Organisms
Hemolysis
Green
Colonies
Blood Agar
Solubility
in Bile
c
■2
<
.2
c
1
+ + +
0
0
0
0
+ + +
=fc
tdemicus..
+4-
0
+
±
0
+++
+
3. Str. in!.
±
+ +
+++
+++
++
++
*
4. Str. pneumoniae
0
+++
+
++
++
:fc
+?
5. Btr. viridans . . n
0
0
+
;t
+++
Sign - indicates particular property may occur
rarely or to a slight degree.
Sign ± Rives a general idea of intensity of frequency
of the property.
The plus signs give general idea of the intensity
or relative frequency of the property. The first
members of the group are hemolytic. Descending
the series, this property vanishes.
The relative solubility in bile of this group of
organisms first called attention to by Neufeld in
1900, is regarded as of much value in differentiat-
ing. The bile solubility and hemolytic attributes
may be styled the two chief factors making for dif-
ferentiation. To make a hemolytic become a non-
hemolytic, for instance, is certainly striking.
To bring about the transformation Rosehow de-
vised a certain technique. The fact that lesions in
rheumatism occur in relatively nonvascular regions
suggested to him that the infecting organism might
be sensitive to oxygen pressure. To meet this he
made his inoculations into tall tubes containing
acites-dextrose agar. Thus giving near the top of
the tube aerobic conditions and near the bottom
anaerobic. He found that the oxygen requirement
was the chief factor, since the largest number of
colonies developed between 1.5 cm. from the top and
3.5 cm. from the bottom of the tube. He further
found that growths in symbiosis with other bac-
teria, and injection into cavities in animals called
forth mutational forms. Rosenow's work is most
interesting and it is well to note how he adapts his
experimental transitional work to the practical solu-
tion of the arthritic problem.
Fig. ■). — Proliferative or ankylotic tyj £ chronic multiple
arthritis. Patient ael 27 years. Onset 2V4 years ago. im-
mediately following pregnancy.
Davis" states as a fact "that injection of Strepto-
coccus hemolyticus intravenously into a rabbit prac-
tically always gives rise to arthritis and tenosyno-
vitis which may be monoarticular or polyarticular.
When given in moderate doses rarely do the strep-
tococci localize elsewhere. In large doses prone to
produce myocardial abscess and hemorrhages."
Rosenow1, through his technique, has obtained
three types of cocci from the joints in rheumatism.
One type corresponds with that found by Poynton
and Payne and might lie called Mirrnmcciis rheu-
maticus. Another type corresponds to the descrip-
tion of Beatty and might quite properly be desig-
nated as Diplococcus rheumaticus. And a third
group, which forms long chains and may be desig-
nated as Streptococcus rheumaticus. All types are
quite susceptible to phagocytosis and probably have
not the power to grow in the free circulation. In
from 24 to 48 hours after a large intravenous in-
jection in rabbits and dogs the blood is sterile. The
affinity of the Streptococcus viridans, especially as
Sept. 23, 1916]
MEDICAL RECORD.
533
isolated from cases of chronic infectious endocardi-
tis, for the endocardium of animals and of the hemo-
lytic streptococcus for the joints is now well estab-
lished. Rosenow has been able to produce endo-
carditis and arthritis in the same animal by inject-
ing mixed cultures in pure form.
Fig. 5. — Proliferative type of chronic multiple arthritis. Ad-
vanced type. Male aet. 56 years. Onset at 24 years. Note
especially selective character of this type involving chiefly
the proximo-medial joints. Also note comparatively good
condition of other finger joints after 30 years. Note also
that in this very advanced case joint destruction is not much
greater than in the case of comparatively short duration.
(Figs. 1-3.)
The arthritis is multiple, never suppurative. The
endocarditis produced from the strains from rheu-
matism, just as has been found to be the case in
Streptococcus viridans is embolic in origin.
Rosenow found virulence of his three types of a
low order. When first isolated all are characterized
by a marked capacity to multiply at a low tempera-
ture and all very sensitive to oxygen pressure. He
makes the following statement: "Strains of the
three varieties have been converted each into the
other." By means of animal passage strains of each
group have been converted into typical pneumococci.
Rosenow in his rheumatism experiments confirmed
also the findings of Beattie and Poynton and Paine
that a low temperature favors their growth. This
is in keeping with the well-known clinical fact that
cold aggravates the symptoms in rheumatism.
Rosenow's experimental work suggested to him the
reasoning that cold causing vasomotor constriction
might favor the growth of organisms by causing a
lack of blood and leucocytes and in consequence a
lowered oxygen pressure.
The results, then, of cultures in man and of the
animal experiments support the view that acute
articular rheumatism is due to streptococci having
peculiar properties. The workers have found that
affinity for joints, endocardium, pericardium, and
muscles characterizing these organisms when iso-
lated tends to disappear on cultivation. It may be
restored by animal passage. When the rheumatic
strains have acquired the cultural features of hemo-
lytic streptococci they lose the affinity for the endo-
cardium and pericardium and acquire an even
greater affinity for the joints.
Focal Infection and Elective Localization. — The
literature for a considerable time has been filled
with infective data and attempts at localization as
the underlying cause of arthritic involvement. The
tonsils, the oral cavity, especially the gums and
teeth with concealed abscess cavities, have given us
from both dentists and physicians a real bombard-
ment of literature dealing largely with clinical ob-
servations and rather positive statements; yet be-
yond the localization of the foci very little real
scientific data. No inconsiderable part of this litera-
ture deals with cultures taken from the mouth —
alveolar cavities, tonsillar crypts, etc. — so-called
autogenous vaccines made and injected into the
patient. In the light of our present knowledge such
superficial work only does ill to the patient and re-
flects upon the scientific bateriological knowledge of
the physician. It is needless to say that to be of
any promise whatever autogenous vaccines must be
obtained from closed cavities under proper aseptic
precautions. Many workers are now adhering to
this and the results are more promising.
Focal sites in connection with the teeth illustrate
this part of the subject well and we reproduce here
some of these concealed foci.
The nasal sinuses have attracted a great deal of
attention, the appendix, the seminal vesicles, the in-
testines— all these and many more have figured as
sites of focal infection. That such focal sites ex-
ist as points of toxic entrance has long been known,
but it remained for Rosenow to emphasize some-
thing that had escaped recognition — that focal sites
furnished a place where bacteria may acquire new
properties. These new properties are in keeping
with those of the transmutationists already men-
tioned.
It is believed that previous to an attack of rheu-
matism various types of the streptococcus group, es-
pecially the hemolytic streptococcus, acquires in the
tissues of the infected individual the factors which
give them the affinity for joint, endocardium, and
Fig. 6. — Dental roentgenograms for publication of which I
am indebted to S. M. Getzoff. D.D.S., N. Y.. showing concealed
septic foci. Apical abscesses and resultant bone atrophy are
well shown. Also stripping of roots from pyorrhea. Note
especialy the concealed foci which here were due to failure
to empty and fill the canals.
pericardium. These cavities so to speak, are human
test tubes in which many of the mutation experi-
ments outside the body are duplicated. In short,
the streptococcus in these concealed cavities under
low oxygen pressure and in the presence of other
bacteria loses as it were its virulency and acquires
MEDICAL RECORD.
[Sept. 23, 1916
534
new properties, giving it a special affinity for joints venous injections of streptococcus strains indicate
and endocardium or joints alone, as the case may be. that the organisms may gam entrance into the lymph
The intestinal tract has long been looked upon as structures of the intestinal tract.
a focal site. Experiments have shown lesions of Subinfection.—Adami covers a part of the field
Fio. T.-Tracings illustrating the proliferative or an! pe of chronic multiple »^tjgL"** 6^^. a(8o£
a proximo-midphalangeal joint — the so-cal
ted We have
of hands from wl are taken.
r lu. I . iiiiMi.i,^ win. ii .in nt, Mi- i'> j ; — , • : . . • ,
onset and ankylo ' ''' u- JhTvrVomDlete"x-rays""p"hoY6Braphs. and casts
also the 1 utage of i ted. We have complete a: rajs, V""^'"!1
the appendix, diarrhea due to cellulitis, ulceration, of infection in a way that seems worthy of a great
and the enlargement of the mesenteric glands deal of consideration and can be corelated with tnat
tlvniph, observed commonly in animals after intra- which has gone before. Much of his work may bet-
Sept. 23, 1916]
MEDICAL RECORD.
535
ter belong to the non-proliferative type of arthritis,
to be referred to later, but it is of practical interest
right here inasmuch as he is dealing with infec-
tion. He, too, has recognized the fact that the bac-
teria in the more chronic manifestations under con-
sideration are changed; have lost some of their at-
tributes. The streptococcal group is especially
mentioned. He says : "Fourteen years ago I showed
that lymph nodes of the respiratory and alimentary
tracts in normal animals constantly afforded cul-
tures of pathological and non-pathological bacteria;
that through leucocytes bacteria are constantly be-
ing carried into the system and constantly being
destroyed in the healthy animal. That with inflam-
matory conditions in the alimentary canal and
greater accumulation of leucocytes in its walls there
must be greater passage of these from the surface
into the system. According to virulence these set
up other foci of active infection or a condition
which I term subinfection." He distinctly states
that bacteria so carried do not set up suppuration—
a fact all intelligent observers have noted. Adami
says the bacteria do not accumulate to any extent
but die with liberation of toxins. These toxins
cause a poisoning of the tissue cells in which they
lie and through reactive stimulation a replacement
by fibrous tissue. That tuberculous and other ba-
cilli fed to the young animal by mouth are found
in the thoracic duct one to two hours afterwards.
That by the eighteenth year whether point of en-
trance is the respiratory or alimentary tract 95
per cent, of persons examined respond to tuber-
culo-cutaneous tests, though only 10 per cent, die
of the disease. In 85 per cent, of the population
the disease becomes arrested and latent.
Coordination of Foregoing Views. — From the
foregoing it has been seen that the views of
the different workers can be largely reconciled,
and although traveling different roads they
ultimately appear to meet. They all have
recognized the need of getting rid of the
pus-producing attributes of the organism with
which they worked. Poynton and Paine, Was-
sermann, Walkoff, and others found it unsatisfac-
tory to try to get any real cultures from the joint
cavities or blood. That the joint effusion is fre-
quently sterile. They went outside the joint cavity
in the areolar tissue, in connective tissue attach-
ments, in the non-vascular spots. Here they found
the bacteria thriving best; from this source they
made their cultures. From these points they ob-
tained bacteria whose attributes had in a measure
been changed.
The mutationists also recognized the need of in
some way changing the attributes of the organisms
of the streptococci group and especially the pus-
producing factor alluded to. Rosenow conceived the
idea that a low oxygen pressure might account for
the changed attributes of the organisms. That if
a number of the streptococci were made to live in
anaerobic rather than aerobic conditions, the proper
selective affinity for joints and certain other tissues
might be brought out. That through concealment
in human test tubes, such as an apical abscess cavity
of the tooth, an enclosed circumscribed pocket in
a tonsil or appendix, the proper selective qualities
of the organisms were brought out. To duplicate
this in the laboratory Rosenow devised the experi-
ments and technic alluded to above. All this is
readily seen to reconcile itself with the avascular
findings of Wassermann, Walkoff, Poynton and
Paine, and others.
Further, Adami's findings in a measure, too, can
be reconciled with these views. He follows the line
of changed attributes of his organisms and deals
with it in his so-called subinfection. So much for
the working out of the bacteriological etiology of
the subject along lines that ultimately coordinate.
Further Observation Bearing on the Subject of
Infection (Myositis and Fibrositis). — The physician
is constantly called upon to treat some localized
muscle pain, especially at or near its tendonous in-
sertion or some hardness in the muscle substance
and we have long sought for a rational pathological
explanation. Recently Rosenow has produced ex-
perimentally such myositis and given us a rational
explanation. He produced lesions in numerous rab-
bits, dogs, and one monkey. In no instance was
there suppuration. In order for the non-virulent
strains of streptococci to localize in the muscles he
found 12 to 21 animal passages necessary. When
the various strains produced myositis their affinity
for the muscle was so marked that each of the series
of animals developed lesions in proportion to the
dose.
A study of a section of muscle showed: (1) A
small hemorrhage; (2) muscle fiber becomes gran-
ular and breaks up into fragments as a rather
sharp leucocytic infiltration appears. The number
of organisms are greatest at this time, after which
they gradually disappear without causing suppura-
tion. The leucocytes now give way to larger mo-
nonuclear cells, and as connective tissue is being
formed there is found a deeply basic staining ma-
terial in which bacteria are no longer demonstrable.
Adami says that this is the very thing he has
been calling subinfection results — a chronic inter-
stitial fibrosis, as he styles it. Streptococci of a
particular grade of attenuation become arrested in
the muscle capillaries, more especially those situated
near the tendinous attachments.
Infection as Related to Certain Recent Etiological
Theories of Chronic Multiple Arthritis. — The joint
lesions of chronic multiple arthritis are commonly
destructive and pronounced. There is frequently
so much loss of bone and cartilage or formation of
new bone that the blood-vessels have figured as
playing the chief role. Wollenberg" especially has
dwelt upon disease of the blood-vessels supplying
the joint as explaining the lesion. The disturbed
balance between arterial and venous supply causing
the regressive and progressive changes character-
izing the anatomical picture. In short, a localized
arteriosclerosis.
Much discussion has arisen over the arterio-
sclerosis finding. Arteriosclerosis is commonly
found in advanced cases of chronic multiple arthri-
tis and by most observers believed to be a secondary
finding. Even Wollenberg, the author of the so-
called "vascular theory," does not claim that the
sclerosis is primary, but that it stands as a "mid-
dleman" through which traumatism and inflamma-
tion produce the characteristic lesions of chronic
multiple arthritis. Wollenberg has produced animal
experiments upon which he largely bases his views.
Walkhoff, Ewald, and Preiser" have repeated his
experiments and are unable to corroborate his find-
ings. Wollenberg's admission of inflammation
necessarily restricts his theory to explaining the
grosser findings only.
It remained for Rosenow13 here to give the blood-
vessel disease a logical cause and establish the
blood-vessel lesion as primary, and primary through
the source of infection. He found microscopic sec-
536
MEDICAL RECORD.
[Sept. 23, 1916
tions of tendon muscle and thickened capsule ex-
amined in a number of cases of chronic multiple
arthritis showed marked thickening and not infre-
quently complete plugging of the blood-vessels ap-
parently not the result of organized thrombi but
rather of a primary endothelial proliferation. Bac-
teria were found in these areas of endothelial pro-
liferation. In rabbits the exudate in the joints
after intravenous injection and in the abdominal
cavity after intraperitoneal injection usually show
a preponderance of endothelial cells. For these rea-
sons Rosenow regards the changes observed in the
blood-vessels as primary rather than secondary.
He says: "It would seem as if in arthritis defor-
mans (chronic multiple arthritis) the microorgan-
isms are taken up from the circulation by the en-
dothelial cells which proliferate freely so that event-
ually the blood supply is reduced or cut off, in con-
sequence of which there result areas of lowered
oxygen tension, diminished nutrition, and atrophy."
Such conditions would favor the growth of organ-
isms which on isolation are sensitive to oxygen.
He has found clumps of old bacteria, some alive, in
the thick layers of old fibrous tissue in the capsule
of the joints in which there was no sign of recent
inflammatory reaction.
If these findings of Rosenow regarding the pri-
mary pathological origin of the joint blood-vessels
are fully confirmed and accepted, much of the dis-
puted anatomical picture of chronic multiple arthri-
tis will be thoroughly cleared up.
The Role Infection Plays in Producing Lesions
of the Nervous System in Chronic Multiple Ar-
thritis.— For years many writers clung to a nerve
origin for so-called arthritis deformans. This was
largely based upon the rather bilateral nature of
the arthritis. A great deal was said about the
probable implication of anterior horn cells, motor
and trophic. This theory has gradually fallen into
disuse and can be said to be practically dropped.
The arthritis is not alway bilateral; in fact, often
very irregular in its distribution. The past few-
years have brought forward a new theory which
clinically has been generally accepted. This has
come with the generally accepted view of the in-
fective etiology of arthritis — that the organism
causing the arthritis may also attack the nervous
system ; that a common infection is the cause of
the different lesions. Poynton and Paine, Triboulet,
and others have dwelt upon this. Triboulet's" case
which he reports with autopsy illustrates this very
well.
The patient, a woman aet. 19 years, afflicted with
chronic multiple arthritis complicated with nerve
and muscle findings. He found degeneration of the
lumbar posterior nerve roots and the resultant de-
generation of the posterior columns of the spinal
cord the result of a localized meningitis. The his-
tory showed that both the arthritic and neural
changes were the common result of a puerperal in-
fection.
This case, supported by similar findings by other
authors, strongly supports the belief that both
the nerve and arthritic phenomena of chronic mul-
tiple arthritis are the result of an infection having
special affinity for these structures. Recently Dr.
P. W. Nathan presented before the New York Neu-
rological Society some of the results of experi-
mental work he had been making along this line.
II is findings are striking, and corroborate the clin-
ical findings referred to and strongly support the
belief above expressed.
Where Does the Theory of Infection Logically
Lead Us in Classifying Our Cases of the Prolifera-
tion Type? — We see, then, how far-spreading the
subject of infection becomes the moment we begin
to deal with the organism changed, attenuated, or
mutated, as the case may be; that the organism in
the vicinity of the joint active is quite different
from the organism when originally produced and
imprisoned in its cavity, be that connected with the
teeth, tonsil, appendix, or elsewhere in the body;
that in its cavity it has acquired new attributes, and
as a joint invader it takes up a new life. It has
been suggested that the common failure of autog-
enous vaccines is attributed to this very fact;
that a vaccine made from the organism at the focus
of origin is useless against the organism after it
has acquired the new life and in action about a
joint.
The question is often asked, if we accept the
view that chronic multiple arthritis has an infec-
tious origin, how do we know that it is not, after
all, a late manifestation of acute arthritis? In
other words, if we admit an acute rheumatism of
infectious origin is chronic multiple arthritis, not,
after all, a chronic rheumatism? Some hold this
view, and much can be said in its favor.
It would appear that the text-books have long
erred in teaching that little permanent damage is
done to the joint tissues by the lesion of rheumatic
fever. Experience teaches us that there are dif-
ferent types of the disease which seem to grade im-
perceptibly one into the other, giving markedly dif-
ferent local conditions and constitutional results.
English authorities, for example, recognize three
distinct types without entering the so-called rheu-
matoid field :
1. Where the organisms first gain access to the
synovial membrane by means of the blood stream
which do not get through the endothelial into the
joint cavity. The connective tissue is swollen, the
blood-vessels distended ; even exudation occurs ; but
the organisms ultimately are destroyed by the endo-
thelia and leucocytes, absorption takes place, and the
function of the joint is restored.
2. The arthritis is more severe. Tendon sheaths
in the neighborhood are implicated. The endo-
thelial synovial lining becomes damaged and a cer-
tain amount of joint exudation occurs. For a long
time the joint remains stiff.
3. Process less acute. A cellular exudation oc-
curs around the blood-vessels and arterioles, pro-
ducing what is called a perivascular fibrosis. Con-
traction follows, tending to diminish blood supply
and nutrition of the synovial tissues, explaining
probably the clincal phenomena such as feeble cir-
culation in such joints, dropsical condition, slow re-
action to all treatment. Effusion is passive here,
hence cultures negative.
If such a pathological picture is accepted for so-
called rheumatic fever, then it would seem but a
step to enter the field of chronic polyarthritis and
see one condition after another engrafted upon it,
depending upon the attenuated or mutated organ-
ism acting; the resistance offered by the patient;
the factors of trauma, of static disturbance, of
arterial involvement, and of consequent joint
changes.
We have, however, no such proof limiting the
chronic types of arthritis to a single organism, as
in rheumatic fever. On the contrary, there is much
pointing to the probability of its multiple origin
from many germs.
Sept.
23.
1916J
MEDICAL RECORD.
537
We know that arthritis is produced by several
infections, such as gonorrhea, puerperal infection,
influenza, and allied diseases. These are usually
regarded as dve to a distinct invasion of the or-
ganism, producing a rather violent reaction com-
monly to the extent of pus producing, and are to be
considered later under a separate heading. On the
other hand, chronic arthritis is the resultant of the
organism attenuated, mutated through elective lo-
calization— a variant or mutant of the original.
It is not generally conceded that there is any ex-
ternal expression by which we can diagnosticate
the particular organism acting. After showing one
of our well-known surgical teachers a series of cases
of chronic multiple anthritis he asked, "Now please
show me a well-marked syphilitic type." If we ex-
clude the arthropathy of locomotor ataxia it is quite
impossible to make such a showing. In the present
state of our knowledge on the subject the external
joint expressions of most of the forms of chronic
multiple anthritis are not distinctive enough to
make an etiological-organism diagnosis, tuberculosis
excepted.
We confidently expect that the classical type with
which this paper deals will ultimately give such a
showing. That is to say, with our increased under-
standing we shall be able to recognize it. We will
allude to this later. At the present time, then.
many hold that the primary etiology of chronic-
multiple arthritis is due to a variety of organisms,
the streptococcus group, with its variants, being by
far the most common. Some think that, like rheu-
matic fever, chronic multiple arthritis will ulti-
mately be found due to a single organism, and are
working to that end.
There is no doubt that we have many different
types of chronic multiple arthritis where different
organisms have played an etiological part. We are
able to separate many of these and set them apart
as types of chronic arthritis. In the midst of these
types we have stood confused. To the observing
student, however, there remains one type having a
rather clean-cut clinical history with a clean-cut
external joint picture. It is the type I have illus-
trated by photographs and drawings in this paper —
the proliferating or ankylotic type. We believe that
signs point here to a distinct entity — that entity
may mean the streptococci group and variants or
one member of the group.
In a second paper we shall deal with another
striking .type of chronic multiple arthritis referred
to in the beginning of this article — the so-called
degenerative type. In this latter type infection
proper is a doubtful factor.
REFERENCES.
1. Ruediger: Journal of Infections Discuses, 1906,
Vol. Ill, p. 663.
2. Anthony: Ibid., 1909, Vol. VI, p. 332.
3. Walker: Proc. Royal Soc, 1911, S.B. 83, p. 541.
4. Buerger and Rittenberg: Jour. Infect. Dis., 1907,
Vol. IV., p. 609.
5. Davis: Ibid., 1913, Vol. XII. p. 386.
6. Rosenow: Journal of Infectious Diseases. 1914,
Vol. XIV, No. 1.
7. DeVries: "The Mutation Theory," Vol. I, p. 217.
8. Davis: Jour. Am. Med. Assn., April 27, 1912, p.
1283.
9. Rosenow: Journal-Lancet, January 1, 1914.
10. Adami: British Med. Journal, January 24, 1914.
11. Wollenberg: Zeitschr. f. orthop. Chir., Bd. 2 1.
12. Walkhoff, Ewald, and Preisser: Ibid., Bd. 28,
1911, p. 231.
13. Rosenow: Preliminary Note from the Mem. Inst.
of Infec. Dis., Chicago.
40 East Forty-first Street.
MALIGNANT TRANSFORMATION OF BENIGN
INTESTINAL GROWTHS.*
By FRANK C. YEOMAN'S, AH. M.D., F.A.C.S.,
NEW YORK.
The benign tumors of the colon and rectum to
engage our attention are of the polypoid type and
appear clinically as the solitary polyp, multiple poly-
posis, multiple adenomata and villous tumor. All
of these growths have a common origin from the
mucous membrane and both in children and in
adults are of the same histologic structure, namely,
glandular with connective tissue intermingled. They
differ only in form (sessile or pedunculated), in
number and in size, and in the relative amounts of
glandular and of fibrous tissue present.
The etiology of these growths is shrouded in the
same gloom as is the true cause of cancer itself.
Meyer holds that multiple adenomata are due to
congenital malformation of the connective tissue of
the mucosa and submucosa of the bowel wall ; that
the epithelial changes are secondary, inflammatory
in nature, and not due to a disturbed physiology.
Liebert and Schwab concur in the opinion of Meyer
that connective tissue proliferation is primary but
consider it due solely to chronic irritation. Their
examination showed that the process was independ-
ent of the epithelium and began by the formation of
new blood vessels in the connective tissue.
G. Hauser, on the other hand, basing his observa-
tion on four cases of multiple adenomata, all of
which were combined with carcinoma, three in the
rectum and one in the sigmoid, states that prolifera-
tion of the mucous glands is primary and influenced
by chronic irritation, though this may not be the
only cause. The glandular epithelium loses its
differentiation and physiological function and is
replaced by degenerated and physiologically indif-
ferent epithelium.
H. C. Ross (Induced Cell Reproduction and Can-
cer, 1911) observed in vitro leucocytes divide after
absorption of certain chemical agents. The active
agents or auxetics he employed are contained in the
remains of dead tissue, namely kreatin, xanthin,
and globin. Rose says: "Irritation is always fol-
lowed by cell proliferation. Irritation means dam-
age and damage means cell-death. Cell-death sets
free kreatin, xanthin, and other auxetics, and the
cell proliferation is caused by their absorption by
the neighboring living cells. Cell-division is ap-
parently an automatic phenomenon in the sense that
the death of one cell will cause the reproduction of
its living neighbors. The knowledge that dead tis-
sues cause cell-proliferation is sufficient to give an
inkling as to the cause of benign growths. Sup-
posing for some reason, such as a slight injury, a
local cell-death takes place, it would cause increased
proliferation of local cells, and so form the basis of
a tumor. Once this growth started, it will go on un-
til, by causing "irritation," or to be more accurate,
extensive cell-death, it may now induce the cell-pro-
liferation of healing around it, and so, by the for-
mation of connective tissue, cause its progress to
be arrested by a capsule." He cites in illustration
the formation of fibroids of the uterus.
The different theories of causation would be of
academic interest only, were it not for their bearing
on prognosis. Clinical experience, I believe, justi-
fies the opinion that most of these tumors are in-
flammatory in origin. As evidence of this is the
*Read at the eighteenth annual meeting of the Amer-
ican Proctologic Society, Detroit, June 12, 1916.
538
MEDICAL RECORD.
[Sept. 23, 1916
frequent history of dysentery or colitis preceding
the development of adenomata. Ball states that the
ova of Bilharzia hsematobia deposited in the mucosa
may give rise to adenomata and that other intes-
tinal parasites may produce new growths by irrita-
tion.
Fig. 1. — Multiple adenomata of the colon as seen through the
proctoscope.
Positive evidence of the role of irritation in the
causation of multiple adenomata is also furnished
by therapy. In some cases retrogression and dis-
appearance of the growths have followed the re-
moval of the irritating substances by colonic lavage.
In other and more resistant cases, diversion of the
fecal current and irrigation have been efficient. As
an example of the latter is the following case:
Mr. T., aged 30 years, referred to me in August, 1913.
Fourteen months earlier he had suffered an attack of
diarrhea, lasting four months, relieved by medical treat-
ment. He remained well about six months when the
diarrhea returned and had persisted four months when
he first visited me. Movements then occurred hourly
by day and once to three times at night, and contained
considerable mucuc, pus, and blood. His weight-loss
was ten pounds, he was anemic and felt very weak.
Proctoscopy showed typical multiple adenomata,
the growths mostly sessile and varying in size from a
pea to a hazelnut, extending beyond the reach of the
tube (Fig. 1). During the next month he lost ten
pounds in weight in spite of local and constitutional
treatment, and I then did a colostomy in the transverse
colon, no tumors being palpable above the sigmoid. Un-
fortunately when the bowel was opened on the fifth day
it was found that the adenomata extended to the hepatic
flexure and presumably to the cecum. By irrigations
through the colostomy the greater number of growths
below the artificial opening have disappeared, while
retrogression has occurred in those remaining. Those
growths above the colostomy have to a lesser degree
been influenced by the operation, yet the patient's bow-
els act only once to thrice daily, he has regained hi?
strength and most of his weight, has lost his toxemia.
and is regularly employed as an elevator man. There
is no evidence of malignancy.
Maligyiant transformation. — The answer to the
question of why benign growths change into ma-
lignant ones is as of absorbing interest as is the
enigma of cancer. That such transformation oc-
curs is beyond cavil. Charles W. Cathcart illus-
trates such transformation admirably in his illumi-
nating work on "Innocent and Malignant Tumors,"
1907. He chose bony, cartilaginous and medullary
neoplasms. In each class the growths were arranged
in gradation series from innocent to malignant. He
concludes that "No theory of the causation of tumor
growth can be satisfactory which does not apply
equally to innocent and to malignant tumors. No
hard and fast line of demarcation can be drawn be-
tween the innocent and the malignant representa-
tives of many different types of tumor; that the
same tumor may be at one time innocent, at another
time malignant ; and that the power of dessemina-
tion, instead of being limited to malignant tumors
as was formerly supposed, is possessed also by many
innocent tumors."
Ball notes the close analogy between the change
of a cutaneous wart into a malignant epithelioma
and the transformation of a long standing purely
adenomatous growth into a cancer of the rectum.
So long as the proliferation continues in an orderly
manner and the growth is limited by a capsule or
the basement membrane, we may speak of it as
benign; when, however, the cells break through
their limiting membrane and infiltrate adjacent tis-
sues, growth is anarchic and the tumor is ma-
lignant.
In 1867, Waldeyer stated that all carcinomas were
epithelial growths, originating from corresponding
epithelium, and that the secondary deposits were
derived from transplanted cells, to which Virchow
assented. The marked resemblance of beginning
malignant growth to inflamed tissue so impressed
Waldeyer that a few years later he asked: "Is it
possible that the excessive nourishment and loosen-
ing of the connective tissue thereby involved, as-
sist in the advance of the epithelial cells? Is it not
possible that in this way local chronic inflammatory
processes, especially those arising from repeated
irritation which cause circumscribed inflammation,
may eventually pass over into cancerous degenera-
tion?"
Thiersch, Cohnheim, Ribbert, and other investi-
gators have proposed theories as to the causation
of cancer.
Adami, Benecke, Marchand, von Hausemann, and
others seek the cause of cancer in the changed bio-
logical properties of the cells, namely, differentia-
tion, function, and growth or vegetation. They rec-
ognize the individual cell as the unit containing and
disseminating the disease. The question with them
is the nature of the influences at work which in-
hibit differentiation while permitting growth, or
vegetation. Adami considers several agents re-
sponsible, e.g. senescent loss of function and chronic
inflammation, either mechanical or microbic in
nature.
Oertel conceives the chromatin of the nucleus as
of two orders, one controlling growth, the other
PIG. i — Adenocarcinoma of the rectum.
function. The latter may be lost while the cell still
retains the power of proliferation. But these
theories lead into the difficult field of biochemistry.
Finally experimental work in the transplantation
of tumors in animals of the same and different
species and the work of those who believe in the
Sept. 23, 1916]
MEDICAL RECORD.
539
parasitic causation of cancer have been pursued
with great zeal. The evidence adduced, however,
has been largely of a negative character and the
true cause of cancer is still undiscovered.
A striking fact of common knowledge is that the
cancer cell, when transferred through the blood or
lymph stream, is capable of reproducing a neoplasm
similar to the parent growth. For example, meta-
static carcinoma of the liver, secondary to adeno-
carcinoma of the rectum, as Cripps says, "cannot
only be identified as consisting of the columnar
cells of the rectum, but they actually in the liver
grow into a gland tissue identical with Lieberkuhn's
follicles of the rectum."
In a word, all that can be stated positively is that
cancer begins as a small local process; that it ex-
cites no reaction in the blood whereby a diagnosis
can be made; that the individual cancer cell is the
parasite of cancer, and whatever eventually explains
the origin of cancer will also explain the transfor-
mation of a benign into a malignant growth.
Malignant change in simple polyp is rare indeed,
but I know of one instance in which the pathologist
reported such transformation in the pedicle at its
point of attachment to the mucosa. I have also to
report the case of Mr. K., aged 76 years, referred
Fig. 3. — Transformation of an adenoma into an adenocarci-
noma.
April 26, 1915, with a history of rectal bleeding
of eight years' duration, progressive constipation,
and a protrusion which at first occurred only at
stool and could be reduced, but in recent years re-
mained permanently outside and forced the patient
to sit on one buttock. Examination showed a reni-
form tumor BVo x 2 inches attached just within the
anal verge of the left side and to both commissures
for about two-thirds of the circumference of the
canal. (Fig. 2.) On April 30, 1915, the tumor was
removed under local anesthesia. Both the clinical
and the histological diagnosis was adenocarcinoma.
(Fig. 3.) This is a clear example of a simple
adenoma which, as a result of repeated and pro-
longed trauma, became malignant. The lesson is
that both single and multiple polypi or adenomata
should be removed at the earliest possible moment
after the diagnosis is made.
Villous tumor or adenoma differs in no way from
a simple adenoma except in form and in its greater
size. Histologically it is of the same structure. Its
tendency to bleed may render it clinically malignant
though microscopically benign. Allingham and
others have reported cases as recurring in a malig-
nant form after operation. Hence these growths
should be extirpated early, thoroughly, and radi-
cally.
Multiple adenomata are the most important and
serious type of benign growths of the intestine.
Their usual site is the lower colon and rectum.
They may, however, literally stud the mucosa of the
entire colon, as- in my case detailed above. At the
1909 meeting of this society, Tuttle reported eight
cases of multiple adenomata, four of which in the
hands of others and one in his own developed malig-
nancy after local treatment by snaring, curettage,
or cauterization; whereas in three children the
growths were controlled by local flushing and snar-
ing of the pedunculated forms. One of these chil-
dren, irrigated through a cecostomy, developed re-
currence five years later. Tuttle sagely asked:
"May we not obtain better results by prolonged
functional rest, especially when the growths are
not well defined?"
Multiple adenomata, as such, may have a malig-
nant effect as a result of the symptoms, diarrhea,
hemorrhage, etc., to which they give rise, but the
chief danger in their neglect or improper treatment
is their liability to change into adenocarcinoma.
In a large number of cases collected from the litera-
ture, more than 40 per cent, had undergone malig-
nant transformation.
' Treatment is palliative or operative. Palliative
measures, as irrigation, suitable diet, tonics, etc.,
have kept the disease in abeyance for many years
in certain cases — even some cures are reported.
Enterostomy above the growths prevents the feces
from irritating the tumors. Thev shrink and some-
times disappear but the liability to recurrence is
very great unless the enterostomy is maintained a
long time after the disappearance of the growths.
Removal of the tumors singly by the snare or
en masse by curettage or cauterization is very un-
satisfactory, for, as pointed out, these measures are
apt to be followed by a local malignant recurrence.
Radical extirpation of the portion of the colon in-
volved is the ideal treatment. Practically the gen-
eral condition of these patients precludes such radi-
cal measures at first for this would usually mean
colectomy, partial or total. Lilienthal obtained a
cure by operating in two stages, first ileosigmoid-
ostomy and later colectomy. The curative, opera-
tive procedure indicated, then, is enterostomy,
either in the colon above the growths, or in the
terminal ileum when the entire colon is affected.
If the tumors disappear, the enterostomy may be
closed. If they persist, after prolonged trial of
irrigations, and the patient's general condition war-
rants it, partial or total colectomy is indicated with
implantation of the ileum low down into the sig-
moid, the operation being performed either in one
or preferably in two stages.
230 West Fifty-ninth Street.
FRACTURE AND DISLOCATION OF THE
PROXIMAL END OF THE FIRST META-
CARPAL BONE AND FRACTURE OF
THE TRAPEZIUM.
Bt C. WINFIELD PERKINS. M.D.,
NEW YORK.
ASSISTANT SURGEON AND ROENTGENOLOGIST, CUMBERLAND BT.
HOSPITAL, DEPARTMENT PUBLIC CHARITIES.
The comparative rarity of such injuries, the ob-
scurity of the diagnostic signs, and the necessity of
Roentgenological examination suggested to the au-
540
MEDICAL RECORD.
[Sept. 23, 1916
thor the possibility that these two cases might be
of interest to the general profession.
Sprains, fractures, and dislocations at the base
of the first metacarpal bone and the trapezium are
frequently met with in athletes — in fact any form of
violence sufficient to tear the ligament either of the
carpal or the metacarpal phalangeal. joint, associated
with violence in the direction of the long axis of the
bone, is sufficient to produce the injury. The symp-
toms are pain, effusion, and stiffness in the joint. If
a fracture be present, it is exceedingly difficult to de-
termine crepitas on account of the swelling and the
diminutiveness of the injured bone. The necessity
of distinguishing a sprain from a fracture of the
base of the first metacarpal bone and trapezium be-
comes immediately apparent.
Fig. 1 shows a case of fracture and dislocation
through the base of the proximal end of the meta-
carpal bone of the thumb. This type of fracture
was first described by Bennett of Dublin and has
received the name of Bennett's fracture. The gen-
eral diagnostic signs of fracture were absent at the
time of the injury, and the symptoms suggested
more of a sprain or dislocation than a fracture.
If the z-ray had not been available a positive diag-
nosis would have been impossible. The following
is the history of the case:
Case I. — J. B. athlete, high pole vaulter, fell on the
outstretched hand and thumb at the Princeton Uni-
versity sports in the Spring of 1908. At the time of
the injury there were only the usual diagnostic signs of
sprain, and no fracture at the time could be detected.
Only after the usual methods for the treatment of
sprain had failed to remove the cause I was consulted
for a radiograph. The Roentgenogram shows a fracture
at the proximal end of the first metacarpal bone of the
Fig. 1. — Fractui .n at the base of the metacar-
pal bone — Bennett's fracture.
thumb. Whitelocke of Oxford University reports a
similar case in person of the University wicket keeper.
Case II. — Fig. 2 illustrates a fracture of the trape-
zium due to a fall on the outstretched thumb and hand.
The usual symptoms were parallel to the above case,
that of pain and swelling at the base of the thumb-
joint, without deformity. The question as to the possi-
bility of fracture immediately presented itself. The
Roentgenographs examination cleared the diagnosis,
showing a transverse fracture of the trapezium at the
outer end of the bone.
Fig. 2. — Fracture of the outer end of the trapezium
The object of this article is to illustrate the close
parallelism between the two cases in the objective
symptoms and the method of receiving the injury.
The positive diagnosis, however, rested absolutely
on the Roentgenographic findings, these findings be-
ing necessary to clear away all doubt as to the con-
dition. Strange as it may seem in this modern era
of accurate diagnosis, there is still tendency to neg-
lect the .r-ray examination of so-called sprains. I
trust this brief review will emphasize again the
necessity of the Roentgenographic examination of
every sprain; for the possibility of a hidden frac-
ture must be always considered.
I desire to thank Dr. H. E. Wright of Princeton,
N. J., for the courtesy of reviewing the first case.
Case II is from the service of Dr. H. H. Schall, Cum-
berland Hospital D. P. C, New York City.
234 central Park v
REPORT OF 77 CASES OF ACUTE POLIOMY-
K LITIS TREATED IN THE NEW YORK
THROAT, NOSE AND LUNG HOSPITAL
BY INTRASPINAL INJECTIONS
OF ADRENALIN CHLORIDE.
BY
M. LEWIS, M.D.,
NEW YORK.
V NEW YORK THROAT. NOSE AND LUNG HOSPITAL;
FORMERLY DEMONSTRATOR OF PHYSIOLOGY" IN THE ATLANTA
ic'AI. COLLEGE, EMORY UNIVERSITY. ATLANTA. OA.
It may be asked why an eye, ear, nose and throat
hospital has been treating cases of infantile paraly-
sis; in July, when the epidemic was rapidly grow-
ing, the city hospitals were not able to take care
of all of the cases, and the board of health made
an appeal to the private and semi-private institu-
Sept. 23, 1916]
MEDICAL RECORD.
541
tions of the city to take and care for some of the
little patients. This institution opened its doors
to the service and has treated seventy-seven of the
cases.
Symptoms. — The prodromal or preparalytic dis-
or attempts at vomiting are infrequent as initial
symptoms. Perspiration often appears and may
be very copious. Rigidity of the neck is a very
important symptom, and with this is usually found
hyperextension, which is rather marked at times
Fig. 1. — Left facial paralysis of 5 weeks' duration. For
the first few days of the disease the patient had general
paralysis with respiratory embarrassment. All the paralysis
has cleared up except the facial
turbance's are varied, and may extend over a period
of time varying from a few hours to six or eight
days. In none of the cases did paralysis develop
without some premonitory symptoms.
Fever is one of the most constant of the initial
symptoms. It usually ranges from 100 to 105°,
and is maintained from two to six days as a rule.
There were noted a few cases where the temperature
went above 106:. The fall in the temperature
is most frequently rapid, as in crisis. In most
cases the subsiding temperature not only reaches
normal but oscillations from normal to a subnor-
mal level continue for a few hours or a few days.
A second rise in temperature is infrequent unless
as a consequence of some complication. The
height of the temperature offers no index as to the
extent of the subsequent paralysis. Accompany-
ing the temperature are other initial symptoms
which, however, are present in numerous other
conditions, but are more or less constant in polio-
myelitis and should arouse suspicion on the part
of the examiner. The patient presents a history
of becoming very irritable, and this may be the
first indication of illness noted by the relatives.
With this indispisition and averseness is found
acute tenderness, which may be diffiuse or localized.
In a large percentage of the cases the pain and
tenderness are localized over the spine and the
extremity or extremities which will subsequently
be involved in the paralytic stage. The patient
often expresses anxiety and protest if an attempt
is made to disturb it. There is a great restlessness
in bed, the child turning from side to side and
refusing to lie on the back, which is hyperextended.
Headache may or may not be present ; vomiting
Fig.
-Same as Fig:. 1, during a feeble attempt at smiling.
and lasting up into the paralytic stage of the dis-
ease, constantly keeping the attendant looking for
a probable meningitis. Great pain is experienced
by the patient upon trying to bend the head for-
ward. The spinal rigidity usually clears up by
the time the temperature has abated.
Valuable information of the impending disease
can be acquired by a careful study of the reflexes,
both skin (superficial) and tendon. Reflex distur-
bances are noted during the preparalytic stage and
last for varying lengths of time, depending upon
the severity of the paresis, but there is a marked
predisposition toward the return of the reflexes.
The skin reflexes are more important in infants,
as it is often difficult to determine the integrity of
the tendon reflexes in these patients. They are
readily elicited when present and their absence is
easily affirmed. Absence of the plantar and cre-
masteric reflexes, the ones most frequently per-
verted, indicates some disturbance of the reflex arc
between the second and third sacral and the first
and second lumbar segments of the spinal cord,
respectively. In one case were found the right plan-
tar and the left cremasteric reflexes absent, while
the left plantar and the right cremasteric were nor-
mal. Some cases, however, where the testes have not
descended into the scrotum, would eliminate the
testing for the cremasteric phenomenon. This was
true in two children between the ages of 2 and 3
years. Absence of the abdominal, epigastric, and
scapular reflexes which occurs in the majority of
cases, is conspicuously determined. Both abdominal
and epigastric may be absent in the same individual,
or either one of them may be absent with the others
intact.
One case exhibited an increase in the knee jerk
on the right side and an absence on the left side,
542
MEDICAL RECORD.
[Sept. 23, 1916
with a beginning paralysis in both legs. After a
day's progress of the paralysis the right knee jerk
disappeared. Another was one of general paraly-
sis, slight bulbar involvement and an increase in
both patellar and tendon reflexes. Still another
patient, in which there was a partial paralysis of
the right arm only, showed an absence of the scap-
ular reflex and the right elbow tendon reflex, with
an increase in both knee jerks. The paralysis in
this case cleared up in a few days, accompanied by
a return to normal of all the reflexes.
Various skin eruptions are frequently found and
may occur during any stage of the disease, but are
more prominent in the first few days. The rash
is transient, rarely lasting over a few hours, and
occurs on any or all parts of the body. However,
the face and chest are the parts more frequently
affected. Quite interesting were two cases, in a
brother and sister, 3 and 2 years of age, respec-
tively, who were admitted with very severe impet-
igo contagiosa and paralytic involvement also. The
impetigo lesions were to be found on all parts of
the body; in fact the disease was so marked that
attention was directed more toward its treatment
than to that of the paralysis. The impetigo re-
sponded rapidly to the application of ammoniated
mercury, and within two weeks was completely
cleared up.
The preparalytic stage may show various respira-
tory symptoms. Bronchopneumonia was present in
one case. Bronchitis is frequently found. Only a
very few cases showed any inflammation of the ton-
sils. This is contrary to the findings of other men,
for a majority of the writers on the subject have
reported tonsillar involvement in most cases. More
frequent than tonsillitis are pharyngitis and laryn-
gitis, usually occurring simultaneously with some
inflammation of the nasal mucous membrance. Con-
junctivitis was often present. It has been infre-
quent to obtain a positive history of gastrointes-
tinal disturbances prior to admission in the hospi-
tal. There have been a few cases of persistent con-
stipation, in both the preparalytic and paralytic
stages. Flatulence is a more frequent disturbance
than either constipation or diarrhea, and is found
in both stages of the disease.
It is usually ascertained, both subjectively and
objectively, that there is an existing weakness in
all the muscles that will subsequently be paralyzed.
This phenomenon is sometimes noticed several days
before the actual paralysis appears. As will be
described later, this may be the only motor distur-
bance in the abortive cases.
Paralytic Stage. Many of the initial symptoms
continue uninterrupted into the paralytic stage.
The fever is always present when the paralysis
appears and usually subsides within a few days un-
less kept up by some complication. The motor dis-
turbances are found to occur some time during the
first two or three days. As was previously stated,
the first impairment in motion, noticed by the pa-
tient or relatives, is an existing weakness. The
muscles are easily fatigued. Active movements
soon disappear and the affected limbs become pas-
sive if the paralysis is complete or nearly so. The
patient no longer moves the involved extremity. If
the paresis is partial the motion is conspicuously
limited. In case of affected legs, standing is im-
possible. If only one leg is involved the patient
may be able to stand on the sound one. When at-
tempts are made to stand on an affected limb, the
marked hypotonicity of the leg muscles allows ex-
tensive hyperextension at the knee.
It is frequently observed that before the paresis
has made much progress there is a decided diminu-
tion in the resistance offered to passive motion. This
fact is of special consequence in the case of infants,
for it is often difficult to determine whether or not
there is any loss of active motion in these little
patients. In the most severe cases it is rare to find
complete paralysis of all the limb muscles, for there
usually remains, if but slight, the power either to
flex or to extend the toes or fingers, as the case may
be. The reflex anomalies are found during the pa-
ralytic stage of the disease, but they usually pre-
cede the paralysis. There is marked hypotonicity
of the affected muscles. This is noted by the flac-
cidity to touch and the abnormally slight resist-
ance offered to passive movements. The hypotonic-
ity is sometimes not only found in the paralyzed
Fig. 3. — Girl 9 years old with marked atrophic changes in
the muscles of all the extremities after 7 weeks' duration of
the disease. There is also a talipes equinovarus present in
both feet
muscles, but even the unaffected muscles may show
loss of tone. In the cases of general paralysis, when
the patient is lifted out of bed the head and ex-
tremities fall about as if in a lifeless state.
Inside of two or three weeks as the disease pro-
gresses, it is noticeable in connection with the motor
disturbances and the hypotonicity, that trophic
changes are beginning to take place in the paralyzed
muscles. The atrophy progresses rapidly and may
reach an extreme degree within a few weeks. The
atrophic changes are due to the trophic disturbances
and disuse. (See Fig. 3.)
The skin over the paralyzed muscles soon be-
comes extremely dry and adherent to the underlying
connective tissue, and when one tries to pinch up
the skin it cannot be separated from the underlying
tissues as in health, but the whole mass is brought
Sept. 23, 1916J
MEDICAL RECORD.
543
up together. All reports state that bed-sores are
never found. One patient, however, came in with
a very bad bed-sore over the left gluteal region;
this patient had been in bed with the disease for
about three weeks. The temperature of the limb
is very much lowered, there frequently being two
or three degrees difference between the sound and
paralyzed limb.
Incontinence of urine and feces is rare, except
in the extreme cases approaching death. In some
few cases retention of urine occurs. The longest
time of retention in any case was fourteen hours.
Catheterization was not necessary in any of them.
The circulation in the affected limbs is greatly dis-
turbed, the capillary circulation being sluggish,
giving rise to a dusky purplish hue of the skin.
Very frequently the surface has a mottled appear-
ance.
The paralysis generally develops rapidly. The
following table will show the distribution of the
paralysis : Paralysis of one or both legs, 34 cases ;
Paralysis of one or both arms, 6 cases; Combined
paralysis of leg and arm, 10 cases ; General paraly-
sis, 8 cases; Facial paralysis (.see Figs. 1 and 2),
3 cases; Combined paralysis of leg and trunk, 8
cases; Laryngeal paralysis, 1 case; Abortive
cases, 7.
The extensor muscles are by far the most fre-
quently affected.
A few rare anomalies are sometimes seen. Spas-
tic hemiplegia was found in one case. The sense
of pain was absent in the same patient for about
two weeks after the onset of the paralysis. The
patient was a girl four years old and she did not
complain of any pain when lumbar punctures were
made to give the intraspinal injections of adrenalin.
After about two weeks the sense of pain gradually
returned to normal. In one case, for about thirty-
six hours before death, there existed a paralytic
diverging strabismus of both eyes. I have just
learned that a physicion friend of mine has a little
boy 4 years old with paralysis of the upper and
lower extremities, and a few days ago there de-
veloped a converging strabismus of both eyes, but
the condition is gradually clearing up. One pa-
tient 8 months old developed typical Cheyne-Stokes
respirations, which lasted for about twelve hours
before death ensued. The spleen seemed to be en-
larged in a few cases.
Certain deformities of the. feet occur in some
cases where there is marked paralysis in the lower
extremities. These conditions are minimized to a
great extent by putting the feet up in plaster casts,
but even then there will be found deformities in
some cases. A few cases were admitted to the
hospital with deformities, after having remained at
home several days without the proper treatment.
The feet anomalies observed are as follows: Equi-
nus, 10; valgus, 2; varus, 5; equinvarus, 6; equino-
valgus, 2. Contraction of the planta fascia is found
in most all the cases with equinovarus.
The following case was unique from the involve-
ment of the laryngeal muscles and the complica-
tions which later occurred, causing death as we
were contemplating dismissing the case:
Female, aged 17 years; admitted to the hospital July
29, 1916. Gave a history of having had an organic heart
lesion for eight years as diagnosed by several physi-
cians. Six days previous to admission she became vei y
hoarse with no other noticeable symptoms of any dis-
turbance except headache; on the night of July 28, she
complained of some spinal pain and later found that the
left leg and arm had suddenly become paralyzed, and
she was admitted with complete paralysis of those two
extremities. There was also a complete wrist-drop on
the left side. Other than the foregoing there were no
alarming paralytic symptoms with the exeception that
the laryngeal muscles seemed to be involved and patient
talked only with difficulty and then just above a whisper.
Examination showed that there was a paralysis of the
left thyroarytenoid muscle and during the act of phona-
tion the vocal band on the left side did not approximate
the median line as did that of its fellow and as a conse-
quence the rima vocalis was not reduced to its minimum
size and the speech was impaired. Sections would have
shown some inflammatory lesion at the origin of the left
inferior laryngeal nerve whose fibers arise in connec-
tion with the spinal accessory.
The patient was given the routine treatment, im-
pioved rapidly and was walking in a few days, the
wrist-drop having cleared up and the voice slightly bet-
ter. The patient did have a slight mitral regurgitation
which was only heard in the mid axillary line.
On Aug. 21, about 6 P. M., patient began complaining
of difficulty in breathing and had to sit up so as to avoid
the extreme suffocating feeling which came on if lying
down. At this time examination showed the heart beat-
ing at the rate of 140 per minute with a marked mitral
regurgitation; respirations 31 per minute, and no lung
lesions. At 11 P. M. patient had not been able to lie in
bed at all and was kept in a chair in as comfortable po-
sition as possible; all the valves of the heart were leak-
ing; pulse 160; blood pressure very low; respirations
more laborious and there were to be heard piping and
bubbling rales all over the chest. She complained of se-
vere abdominal pains and it was found that the abdo-
men was greatly distended by the presence of fluid in
the abdominal cavity. The ascites had developed within
an hour and a half. At 11.30 P. M. she vomited the
copious meal which she had eaten at 5 P. M. when she
was feeling normal. The heart and lung condition grew
rapidly worse. I made a puncture into the pleural cav-
ity and drew off 40 c.c. of turbid fluid; oxygen was ad-
ministered under pressure by the Meltzer apparatus.
The oxygen gave great relief while it was being ad-
ministered, but I saw it was only prolonging life by
mechanical means and discontinued it. The patient died
at 1 a. M. She could move all the extremities freely,
held the head up and was perfectly conscious, talking all
the time to within a minute and a half before death
came. Immediately after death I lowered the head and
drained off several ounces of hemorrhagic fluid from the
lungs.
The immediate cause of death was a failure of com-
pensation in the organic heart lesion and edema of the
lungs. It is probable that the inflammatory area in the
neighborhood of the left inferior laryngeal nerve re-
vived and spread to the origin of the vagus and the
heart was affected as a consequence.
Spinal Fluid. Due to the fact that we have not
yet got a systematic report on all of the spinal fluid
examinations, I shall not relate any of the data
other than say that the most characteristic feature
of the fluid examinations was the positive Noguchi
reaction. Usually the spinal fluid is under an in-
creased pressure in these cases, several cubic cen-
timeters being removed at times. (P. M. Lewis.
Medical Record, July 29, 1916.) From one case
30 c. c. of fluid were removed at three different
times, and from 15 to 25 c. c. were removed from
several patients. The fluid was mostly clear when
removed from the spinal canal ; in some few cases
it was opalescent. In only one case was there found
a true hemorrhagic fluid, and it was a case where
meningitis caused by the Friedlander bacillus com-
plicated the poliomyelitis.
Complications are not very infrequent in this mal-
ady. The following complications were encountered
in the cases under our care in the hospital:
Measles, two cases; one of these developed early in
the disease and was probably contracted before
the poliomyelitis. Whooping cough developed in
four cases after from three to six weeks' duration.
Meningitis complicated two cases, one of which was
caused by the Friedlander bacillus. Cultures of the
organism were made from specimens of the spinal
544
MEDICAL RECORD.
[Sept. 23, 1916
fluid and the blood. The patient died after about
eight days' duration. The etiology of the other
ease was never determined. The prognosis was
very grave, but there was complete recovery in
about ten days. Various rashes sometimes occur
on different parts of the body. As would naturally
be expected, there were marked gastrointestinal and
nutritional disturbances in most of the little infants
who had previously been breast-fed.
Abortive Cases. Of the seventy-seven cases seven
of them were diagnosed as abortive cases. There
are no signs or symptoms that will differentiate the
abortive form of the disease from that of the true
paralytic type during the initial stage, and not until
paralytic disturbances occur can you tell whether or
not the case will be abortive. There may be found
all the initial symptoms that accompany the typical
paralytic cases, e.g. fever, malaise, headache, pain
in various parts of the body, spinal rigidity, and as
was previously mentioned, there may be a distinct
weakness to be found in various muscles. Instead
of the condition progressing with an ensuing pa-
ralysis all the symptoms clear up and the patient
is again normal. These patients were given the
routine intraspinal injections of adrenalin until they
proved to be abortive cases.
Prognosis. The figures and data that are given
below could have no special importance when taken
alone, for we have had only seventy-seven cases, as
compared to the several thousand cases in various
other hospitals. The essentials to be shown regard
the mortality and the morbidity in these cases after
treatment by intraspinal injections of adrenalin.
Conclusions favorable to the adrenalin treatment
can be reached by comparing the results with the
results of others where adrenalin was not used.
This is more satisfactory, since they are cases of
the same epidemic and in the same locality. The
following figures show that the mortality varies in
different epidemics E. Austria, 1908, 22.5 per cent ;
N. Austria, 1908, 10.8 per cent; Germany, 1909.
(Arnesberg), 12.3 per cent; Sweden, 1905, 16.7 per
cent; Syria, 1908, 13.16 per cent; Norway, 1905,
14.56 per cent; Germany, 1909 (Hanover), 20.55
per cent.
Up to the present writing the mortality in the
city of New York has been 23.9 per cent. It is
hardly fair to include the deaths that occur after
the first twelve or fifteen days of the disease, for
if death occurs later than this it is usually due to
some complication. Considering this, the mortality
percentage due entirely to poliomyelitis would prob-
ably be decreased. Nor is it doing justice to the
adrenalin treatment to include the mortalities that
occurred within a short time after admission to the
hospital, some of them not getting any and others
only a few injections of adrenalin.
We may summarize the fatalities occurring in
the seventy-seven cases, which form the basis of our
study, in the accompanying table.
We would conclude, therefore, that out of the
eighteen deaths only five children (6.49 per
cent) died from poliomyelitis under the adrenalin
treatment. The decision of all fair-minded critics
will harmonize with the above figures.
The correct statistics as to the morbidity in
these cases cannot be compiled until the end of
from six to twelve months, for cases have been
shown to recover several months after the onset of
the disease. Of the fifty-nine cases surviving, the
prognosis as to complete recovery is exceedingly
gratifying.
Deaths. Per Cent.
Number of deaths that occurred between 5 and 20
hours after admission, in moribund cases ! 3 3 . 89
Number of deaths that occurred between 20 and 46
hours after admission, in moribund cases :i 3. 89
Number oi deaths occurring after the third day in
the cases admitted in a moribund condition, hut
having had i fair chance under the adrenalin
treatment 5 0.40
Number of deaths occurring in infants from gastro-
intestinal and nutritional disturbances (having been
previously breast fed) between 20 and 49 days after
admission with complete or partial recovery from
poliomyelitis .... ."> 6-49
Number of deaths occurring on tin' 24th day after
admission from an organic heart lesion (recovery
from paralysis except in the case of some of the
laryngeal muscles) probably aggravated by the
poliomyelitis 1 1.28
Number of deaths occurring on the loth day from
cerebrospinal meningitis 1 1.29
In the epidemic in New York in 1907, in only
5.3 per cent a complete, and 1.8 per cent almost com-
plete disappearance of the paralysis occurred.
The following table briefly outlines the condition
of the fifty-nine case after six to ten weeks' dura-
tion from the onset of the disease:
Complete recovery . 21
Greatly improved with all indications that complete
recovery will soon follow 21
Probably permanent disability in one or more groups
of muscles 17
Total 59
I'.i ( ".tit .
35.57
35.57
28.79
Of the twenty-one cases in which there was com-
plete recovery four of them were admitted in an
extremely moribund condition, and little or no hope
was entertained as to their surviving. Their re-
covery may or may not be attributed to the action of
adrenalin. The fact that it did them no harm has
been well demonstrated.
Treatment. In searching medical literature for
some remedial measure to be used in the treatment
of acute poliomyelitis, about the only information
found was this: No specific therapy is yet avail-
able and the treatment must be purely symptomatic.
Facing this predicament on one hand, the numerous
little innocent victims of the disease on the other,
we would naturally use any rational measure sug-
gested.
On the first day that we received any of the
paralytic cases, Dr. S. J. Meltzer of the Rockefeller
Institute, after having reached certain experimental
results (S. J. Meltzer, Medical Record, July 22,
1916) advised the intraspinal injections of adren-
alin.
The remedy has been given a fair trial in our
cases and its use is highly recommended.
The 1-1000 solution of adrenalin contains 0.5 per
cent of chloretone. In order to get rid of this, a
bottle of adrenalin, with the cork removed, was
placed in a bath of boiling water for two or three
minutes. The solution was then allowed to cool
and the injections were made without diluting the
adrenalin with anything. A fresh preparation of
the drug was used each time.
In order to increase the space between the inter-
spinous processes, a bottle 6 in. in diameter with a
small pillow on it was placed on the table and the
patient flexed across the contrivance. The skin over
the area where the puncture was to be made was
painted with tincture of iodine, normal strength,
Sept. 23, 1916]
MEDICAL RECORD.
545
and a moist dressing of saturated boric solution
placed on after the injection. This procedure con-
trolled the infection wonderfully well. As a result
of the frequent punctures, most cases had a bit of
traumatic exudate collecting under the skin, but
only a very small percentage showed even the slight-
est signs of infection. A medium-sized, stout as-
pirating needle is best used, for a small flexible
needle is hard to control and takes to the bone easily.
The punctures are best made between the fourth
and fifth lumbar vertebrae. It is not wise to give
more than one injection through the same skin punc-
ture for fear of carrying infection into the spinal
canal. If infection occurs it is always superficial.
The skin can be moved over a limited radius, so it
was pulled down, up, or to the side at will and new
punctures made in order to miss the infection. If
the traumatic exudate occurring under the skin
tends to prevent the location of the spinous processes
of the fourth and fifth lumbar vertebrae, the punc-
ture can be made higher up or lower down. This
was frequently done and as the wounds began to heal
sufficiently the punctures could be made over the
same area again. The individual skilled in making
spinal punctures can always tell the moment his
needle has reached the spinal canal and he can go
as high up as the first and second lumbar inter-
spaces without fear of doing damage to the cord.
Intraspinal pressure, if it was present, was always
relieved and then 2 c. c. of adrenalin (1-1000 sol.)
injected. The injections were given every six hours,
day and night, until the temperature had remained
normal for forty-eight hours unless kept up by some-
thing other than the poliomyelitis.
In the cases with respiratory involvement it is
best to give the injections with the patients in the
lateral prone position, for to put them face down
embarrasses the respirations and marked cyanosis
follows. If this does occur the condition can be
cleared up by the administration of oxygen.
A local anesthetic was not used before the injec-
tions, for it would produce about as much pain in
its administration as making the puncture.
By giving the adrenalin one clears the way for
three very important measures, viz., one relieves
any intraspinal pressure that may be present; the
fluid can be collected for examinations, and adren-
alin, the most valuable therapeutic remedy yet
used in these cases, is given.
Urotropin was given in moderate doses during
the acute stage of the disease. As soon as a ten-
dency toward deformity was noticed in any extrem-
ity it was put up in plaster casts.
It being the hottest time of the year when the
cases were brought in, it was exceedingly difficult,
in the case of the little infants which had previously
been breast-fed, to keep them in a normal state of
nutrition.
■J3:i East Fiftt-seventh Street.
Adrenalin in the Treatment of Anaphylaxis. — Parhon
and Buzgan have believed for a long time that adrenalin
was indicated in anaphylaxis because in part of the
hypotension present in anaphylactic shock. In a severe
case of the latter following a cholera immunization,
with cold extremities, extinction of voice, dilatation of
pupils and other severe symptoms the body was sur-
rounded by hot-water bottles and ether and caffeine in-
jected. It was then adrenalin was first tested, fifteen
minutes after the onset of the symptoms. Within five
minutes the symptoms of shock had quite vanished. In
two subsequent cases adrenalin was the sole remedy
used and the results were the same. — Comptes rendus
de la Societe de Biologie.
REFLECTIONS ON POLIOMYELITIS.
By D. W. WYNKOOP, M.D.,
HEALTH OFFICER. BABYLON. N. Y.
It may be of interest to the profession to have a
statistical report of twenty-four actual cases of an-
terior poliomyelitis that have come under my observ-
ation as Health Officer of the Village of Babylon, N.
Y., during the month of August, 1916. When I say
"actual" I am excluding all cases where there was
doubt and only accepting those where the puncture
diagnosis was made by the State Board of Health.
The average age was 5% years; extremes, 16
years and 1 year. The average lapse of time from
onset of the disease to examination and diagnostic
puncture was three days; extremes 7 days and 1 day.
The number of cases showing paralytic symptoms
was 8 out of 24. The number of deaths was 1 out of
24 cases. There was partial cr complete recovery
from paralysis during the first month in 7 out of 8
cases.
Situation of paralysis: Both legs, 30 per cent;
both feet, 10 per cent; right arm, 10 per cent; right
leg, 10 per cent ; deltoid, 20 per cent ; lumbar mus-
cles, 10 per cent; cervical and respiratory muscles,
10 per cent. (These last cases are usually fatal.)
Symptom of coryza or discharge of nose and
throat were conspicuously marked by their absence
in most of the cases I examined. This does not sup-
port the contention as to the probable source of in-
fection.
Prodromal symptoms: Strawberry tongue, 90 per
cent ; fever, 100 per cent ; pain in head, 90 per cent ;
stiff neck, 80 per cent ; vomiting, 75 per cent ; drows-
iness, 80 per cent; pain in back, 40 per cent; gastro-
enteritis, 25 per cent ; irritability, 30 per cent ; con-
junctivitis, 40 per cent.
(I have noticed the last symptom to persist for
one and two weeks after the onset of the disease.
It is in a mild form and may only be indicated off-
hand by the patient rubbing its eye frequently.)
The average time from the first symptom of illness
to paralytic manifestation was one week. The most
rapid case, ending fatally, apparently ran its course
in forty-eight hours from the onset.
The average number of lymphocytes found in
microscopic field was 233 ; the highest count showed
690; in this case there was no paralysis following;
the lowest count showed twelve lymphocytes. A
week following puncture in this case the child came
down with a paralysis of both legs. That the count
of lymph cells was not greater can be attributed to
early puncture (day of onset). Had puncture been
made four or five days later we would have undoubt-
edly found a larger count.
Therapeutic value of puncture. In 80 per cent of
the cases where there was a marked increase of
pressure of the spinal fluid, pain in the neck and
headache ceased altogether or were greatly improved
immediately following the operation of lumbar punc-
ture. Where pressure was slight there was no
noticeable improvement. Cases of paralysis in which
no lumbar puncture was made were more severe than
those occurring after puncture was performed. This
latter may be accounted for, however, by the fact
that the earlier cases of the epidemic seemed more
severe than the more recent ones. Personally I am
inclined to the belief that puncture is a distinct me-
chanical aid in relief of the disease through diminu-
tion of intraspinal pressure. Puncture is of no use
after symptoms of paralysis have set in.
Puncture is of no diagnostic value after the tenth
546
MEDICAL RECORD.
[Sept. 23, 1916
day from onset. From this time on the microscopic
examination will prove negative even with paraly-
tic symptoms present.
Operation of Puncture. It is best in every instance
to have the State Board of Health perform the opera-
tion. In a good many cases where the disease has
run a light course the parents will begin to express a
doubt that the little one was ever stricken. An unof-
ficial surgeon without verified records will have some
little difficulty in satisfying the family or a jury as
to what he found under the microscope.
The sudden withdrawing of too much fluid when
under high pressure may produce unfavorable symp-
toms (probably due to temporary hernia of the
pons). The risk of this can be avoided by inserting
the trochar back into the needle occasionally so that
the ilow shall not be continuous.
A second puncture made on following day, in
doubtful cases, is apt to prove unsatisfactory, it
being often difficult to obtain sufficient fluid to make
a proper examination. It is better to allow two or
three days to elapse between punctures. The use of
cocaine in young children before inserting the spinal
needle seems useless. They make just as much trou-
ble over the hypodermic needle as the other. In
children over eight years cocainizing the parts is ad-
visable. An experienced person in holding a child
greatly facilitates the operation. It is advisable not
to have any of the members of the family present
when the operation is performed. If the periosteum
is scraped by the needle (it frequently happens) con-
siderable indefinite pain is experienced. I have seen
no ill effects following puncture.
Postparalytic pains occur in 100 per cent of the
cases and are exceeding intense for the first week.
The onset of the pain gives the sensation that the
skin is being pricked by pins in the portion para-
lyzed. This pain is not well controlled by opiates and
for the general condition they should be avoided.
Massage of any kind is also contraindicated in this
acute stage. The simpler analgesics and enveloping
the paralyzed parts in cotton will probably prove the
most effective. Except where paralysis has been
very extensive the pains completely subside after one
week from the onset of the paralysis.
The administration of drugs in an attempt at cure
can be considered as a waste of time and in some
cases most harmful. In particular I refer to urotro-
pin in large continued doses. I have seen an acute
bloody nephritis and cystitis following which was
most painful. There were two doubtful cases in my
scries. In one it was necessary to exclude a possible
diagnosis of epileptic hysteria. The other case was
one in which a tertiary syphilitic condition of the
meninges near the base of the brain was present. In
both these cases, spinal puncture showed a low count,
but the general symptoms were of an intense polio-
myelitic character.
The theory of contagion is one that I should hesi-
tate to accept without reservation. That the disease
is highly infectious there can be no doubt. That it
is selective to a high degree is also self evident. In
one family of ten children, all under sixteen years of
age, only one child developed the disease. This one
was susceptible and the balance were immune.
I believe that a six weeks quarantine is unneces-
sarily harsh and does not accomplish much towards
stamping out the disease. The fear of this rigid
quarantine tempts the family to hide the presence
of the disease. Were I asked what I considered the
best means of stopping an epidemic, without quali-
fication I should suggest the adoption by all families
and doctors of the following rule: — "If a child is ill
for twenty-four hours and household remedies, such
as castor oil or calomel, have failed to ameliorate the
condition, the family doctor should be called at once.
If in turn the doctor is unable to make a positive
diagnosis within twenty-four hours let him ask the
State diagnostician to make a lumbar puncture. If
this were done in every case we would soon get hold
of the ambulatory ones who are only sick for a few
days and are true carriers of the infection.
If the quarantine by the State is going to work
unnecessary hardship to the family it will be impos-
sible for the three elements ( family, doctor, and
State diagnostician) to work in harmony. I believe
that a child who has this disease is only a carrier
during the acute stage and that a three weeks quar-
antine is all that should be demanded. I think it
extremely doubtful that a healthy adult or healthy
child can be the carrier of the disease. These are
all, however, individual opinions and as such can be
considered for what they are worth.
THE CLINICAL DELIMITATION OF
HYSTERIA.
By MEYER SOLOMON, M.D.,
CHICAGO.
In the New York Medical Journal for November 6,
1915, appeared a previous paper on this subject by
the writer in which it was pointed out, as is so
well known to all, that the term hysteria, like so
many other terms in medicine, has been so gener-
ally abused by specialists in nervous and mental dis-
eases as well as by the average physician, that nowa-
days one hardly knows what a particular physician
means when he employs this term as a clinical diag-
nosis. And this in spite of the acknowledged fact
that dismemberment of the hysteria concept of other
days has been proceeding in progressive fashion in
recent years. I need not here repeat the brief dis-
cussion which was entered into in the first paper
when considering the clinical concepts of hysteria
maintained by others, particularly by Babinski and
by Dejerine and Gauckler.
It may be stated as a general proposition that in
most cases, even in the writings of neurologists and
psychiatrists, the term hysteria is by no means used
with that definiteness which scientific medicine
really demands. In truth, since there are a number
of different clinical concepts of hysteria, it is im-
possible for the reader to know in what sense this
term is being used by a writer, unless an explana-
tory note or apologia is added. No matter in what
sense this name be applied, it is none the less true
that from the etymological and scientific standpoint
it is entirely out of place and actually has no mean-
ing to fit into the clinical concepts of hysteria, be
they what they may. It is an etiological diagnosis
of the days gone bj when the uterus was supposed
to be the basic factor in the causation of the symp-
tomatologic pictures classified under this disease-
heading. Aside from the Freudian school, which,
unwarrantedly and without proof, in fact, in spite of
a mass of proof to the contrary, still attributes this
disease to a so-called sexual etiology, the mass of
physicians, specialists in neurology and psychiatry
and the rest, generally agree that the insistence on
such a one-sided and exclusive causative agent is
baseless and contrary to fact and observation.
Nevertheless, it is questionable whether this word,
as a clinical diagnosis, can be dislodged from its
Sept. 23, 191GJ
MEDICAL RECORD.
547
prominent place at this time, even if our wishes be
limited to the specialists in this field. Moreover,
until another more desirable and generally accept-
able term is proposed or gains currency, it is neces-
sary to adhere to this term, provided it be given
some definite, clean-cut and undeniable clinical
meaning, so that it will represent a clinical concept
or syndrome which can be called to mind imme-
diately and which will stand in our minds for such
a manifest cut-off group of symptoms that we can
impart our concept to another without annoying
preliminary and circuitous explanation and elab-
oration. In the previous paper on this subject I en-
deavored to present such a clinical concept of this
disease. The gist of it may be here repeated.
I advocated the limitation of the term hysteria to
the gross sensorimotor, including the special sense
disturbances which are the bodily affects of a last-
ing nature, flowing out of emotional upset; the pure
or true crises being included in this picture.
In true or pure hysteria we may agree with
Dejerine and Gauckler that a state of relative in-
difference or passivity with respect to the physical
condition be required as the typical mental state
accompanying the somatic picture. Where psychic
states of another kind are present, an appropriate
name, in accordance with present or current psycho-
pathological or psychiatric nomenclature or other-
wise, may be added as a diagnosis, to complete the
clinical picture.
In other words I would speak (1) of true, pure,
genuine, uncomplicated, typical hysteria (present-
ing the phenomena mentioned in this paper, and
consisting sometically of functional or psychoge-
netic or emotogenetic disorders of the voluntary
nervous system, and psychologically of a mental
state of relative passivity or indifference) ; and (2)
of false, complicated, atypical hysteria (presenting
the somatic phenomena but a different or super-
added mental state). The second group would thus
include such complex syndromes as are found in
dementia precox, where pronounced somatic phe-
nomena are so frequently present in addition to the
more frank mental states of protean nature.
It is thus seen that it is the somatic manifesta-
tions which are here considered as the real indica-
tion or stamp mark of what we have agreed to call
by the old name, hysteria. And since the dividing
line must be drawn somewhere between the asso-
ciated mental states, I would provisionally agree
with Dejerine and Gauckler and require an asso-
ciated mental state of relative passivity or indif-
ference for what we may call the pure, typical
cases, while the mental states found present in
what are called in this communication the atypical
cases should receive their appropriate names.
In the physical sphere the following conditions
should be carefully excluded from the syndrome or
disease-picture which I have mentioned as being
reserved for socalled hysteria: organic disease of
the peripheral or other parts of the body, includ-
ing the nervous system; syndromes belonging under
the nosological label of the other psychoneurotic or
psychotic (minor or major) states; simulation, de-
ceit, and deception; Babinski's pithiatism (which
includes symptoms due to suggestion and curable
by mere suggestion-persuasion) ; Babinski's emo-
tive ( including for the most part the visceral mani-
festions of emotional origin and of a functional
nature) and reflex phenomena (the reflex manifes-
tations consisting, for example, of pilomotor, sweat
gland, and other cutaneous phenomena of this type).
Dismembering the hysteria of old in this manner
we find that there remains as the ear-mark of
hysteria, the group of symptoms above given:
namely, the sensorimotor disturbances, including
the disturbances of the special seiises, and the pun'
major attacks, these not being due to suggestion or
simulation, but being of the nature of protracted
symptoms not removable by the suggestion-persua-
sion of Babinski.
In brief, we find that hysteria is here limited to
functional disturbances of the voluntary nervous
system, produced by emotion, and not due to mere
suggestion or the like. The other features men-
tioned hitherto may complicate the picture, but the
additional diagnosis necessary to a full understand-
ing of the picture would make things so much
clearer and more scientific. For instance, there
may be true hysteria, complicated by simulation or
deceit and deception, or by organic disease, or by
by an anxiety state, or by some other somatic or
psychic syndrome. But the presence of true hys-
teria, as given in this paper, would not be confused
with these other conditions, and the term hysteria
would not be employed to include these other con-
ditions, but they would each be separately named.
None of these other groups is characteristic of all
hysterics, but their occurrence varies with the
makeup of the individual in the particular case we
may have under consideration and with the special
circumstances there existing.
In this connection I may refer to the classifica-
tion of diseases of the nervous system adopted by
Jelliffe,' White/ and both of them together.3 The
division of the phenomena of diseases of the nervous
system into those of the vegetative or involuntary
nervous system, those of the sensorimotor or vol-
untary nervous system, and those of the purely
psychical sphere harmonizes quite well with the
viewpoint adopted in this paper. Considering this
classification in relation to the functional disorders
of the nervous system, as a result of emotion, hys-
teria would correspond to the middle group — func-
tional sensorimotor syndromes, due to disorder of
the voluntary nervous system, while functional dis-
orders of the other two groups (the vegetative or in-
voluntary nervous system and purely psychic mani-
festations) would be excluded from it.
In a paper on "Physiological Considerations in
the Differential Diagnosis of Neurasthenic, Hyste-
rical, and Psychotic Symptoms," I find that Donald
Gregg' assumes the same standpoint.
Does not this give one a clinical concept of hys-
teria which is recalled without effort and of a far
more definite nature than can be had from most
previous clinical concepts of this disease? One can
adopt this clinical concept without in any way com-
mitting one's self as to the exact nature of hysteria.
And, to be frank, one can do away entirely with the
word or name hysteria, and, without lessening the
definiteness of our diagnosis, call this group of
symptoms by its full name — functional or psych-
ogenetic disorders of the voluntary nervous system.
REFERENCES.
1. Jelliffe: Address as Retiring President of the New
York Neurological Society, Feb. 7, 1916, Journal of
Nervous and Mental Diseases, July, 1915.
2. White: Symbolism, The Psychoaymlytic Review,
January, 1916.
3. White and Jelliffe: Principles Underlying the
Classification of Diseases of the Nervous System,
Journal of American Medical Association, March 11,
1916, and "Diseases of the Nervous System," Phila-
delphia and New York, 1915.
4. Gregg: Boston 71/. and S. Jour.. Feb. 24, 1916.
548
MEDICAL RECORD.
[Sept. 23, 1916
A FATALITY FOLLOWING ACUTE OTITIS.
Bt IRVING WILSON VOORHEES, M.S., M.D.,
NEW YORK.
In January, 1916, the writer was consulted by a
well-to-do gentleman from a Western city regard-
ing pain and discharge in the right ear. Some
three or four weeks previously he had passed
through a fairly mild attack of grip (respiratory
type) which had kept him in bed for a few days
only. At the time I saw him he had come East
for the Christmas holidays, and had been able to
enjoy the festivities with friends in a suburb of
New York city.
There had been considerable discharge of muco-
pus from the nose and a persistent cough brought
the same kind of material from the chest. Appe-
tite was fair, bowels regular, and general health
good in a man of forty-one who had been always
well. There had been no previous aural disease of
any kind.
Two days preceding my examination the patient
experienced severe pain in the right ear which
lasted for three or four hours, followed by dis-
charge. This pain had then practically disappeared,
but a sensation of fullness remained. He com-
plained of deafness, slight noises, and moderate
discharge.
Examination of the nose showed swelling of the
mucosa and a small amount of viscid yellowish
discharge in the middle meati. The nasopharynx
was red and swollen, yet the tubal orifices could
be distinctly seen. The larynx was normal, but
the tracheal mucous membrane was red, swollen,
and plastered here and there with exudate. The
left ear was normal in all respects. The right
drum was red and somewhat swollen, but the chief
landmarks were still present. There was a per-
foration in the antero-inferior quadrant through
which a small amount of thin discharge was pulsat-
ing on its way outward. There was no mastoid
tenderness.
The usual expectant treatment was instituted
and the patient was advised to return in forty-eight
hours. This he did not do, however, and I did not
see him until the fifth day following. He then
came to my office and a thorough examination was
carried out, including tuning fork tests, etc. The
condition was much the same in every respect.
There was no pain or discomfort.
The patient sailed for Bermuda on the day fol-
lowing and no more was heard from him until
two weeks later when the writer was summoned
by cable to "come and do a mastoid at once."
Within six hours I was aboard the steamer fully
prepared for any complication that might be en-
countered. Fifty-two hours later I entered the
hotel and was informed that the patient had died
eight hours after my departure.
Going over the history the following was gleaned:
The voyage was marred by rough weather, con-
stant rain and cold I it was the middle of Jan-
uary). The patient "caught cold" and when he
arrived consulted a doctor. His ear was inspected,
but nothing was related of its condition. At this
time there was pain, but not much discharge.
Symptoms in nose, throat, and chest were marked.
The physician stopped the treatment outlined in
Now York and gave the patient a nose wash to be
snuffed up "out of the hand." The ear was to be
syringed with a solution of peroxide every two
hours.
From this time on the patient did poorly. He
suffered much from right-sided headache and com-
plained of general malaise. The daily temperature
range averaged 101° F., mounting a little higher
as time wore on. The patient, a graduate of Har-
vard and a highly intellectual man, kept a secret
daily record of his condition, which in the light of
subsequent facts proved of great interest. He tried
to conceal his symptoms from his wife, because
this was "a second honeymoon" and they had
planned to remain on the island for three months.
Nevertheless, headache, high temperature, and
weakness continued until he was driven to bed with
a nurse in constant attendance. As yet no definite
diagnosis had been made, so at the insistence of
the patient's wife a surgeon was brought in from
one of the great British cruisers lying in the
harbor. At this time the temperature was 104° F.,
the unilateral headache was intense, there was be-
ginning paralysis of the right external rectus, and
the surgeon looked upon the case as one of extreme
gravity. After much effort an ambulance was
secured and the unfortunate man was hauled some
two miles to a hospital. While shaving the head
preparatory to operation the patient suddenly died.
The nurse tells me that respiration stopped and
could not be again started, but the heart continued
beating for some minutes. Temperature at this
time was 106°. No autopsy was performed. The
consensus of diagnostic opinion was: Mastoiditis,
brain abscess, rupture into the lateral ventricle
of the brain.
I publish this clinical note because the case bears
a tragic significance from which we may draw
profitable conclusions:
1. Any apparently "simple" acute otitis media is
capable of producing dire results.
2. The appearance of the drum may be very
misleading. Behind it may be lurking the deadly
streptococcus mucosus.
3. A culture should be taken in every case and
the predominant germ identified if possible.
4. Any abrupt cessation of discharge accom-
panied by severe unilateral headache is an unfailing
sign of some complication calling for operation.
5. Np patient with an acute otitis should be
allowed to get away from the watchful eye of a
trained otologist until all symptoms have disap-
peared and a condition of restitutio ad integum
has been obtained.
1 I I 'KNTH.M. I'AUK WEST.
Favorable Action of Hypertonic Solutions and Mineral
Oil in the Treatment of Infected Wounds. — Goubaroff of
Moscow uses the following treatment for infected
wounds. The skin is first painted with iodine, the
wound laid open, foreign bodies, etc., extracted and the
wound irrigated with isotonic saline solution 1-200 or
Dakin's solution. If there is much fetor or gangrene,
hot air up to 300° C. is applied (method of Vignat) ;
this resource is seldom necessary. Subsequently hyper-
tonic solution of common salt 8 per cent, or 10 per cent,
is used regularly for irrigation. These are well sup-
ported, cause no pain, have an intense hemostatic action
as well as antiseptic and deodorant properties. The
solution also causes the secretion of a flux of lymph
which is a favorable milieu for leucocytosis. Large
gutta percha tubes are used for draining and the wound
cavity is now filled with dry eauze or gauze dipped in
liquid paraffin. Another good resource is the application
of direct solar light or therapeutic rays. — La Presse
Medicate.
Sept. 23, 191 6|
MEDICAL RECORD.
549
Medical Record.
A Weekly Journal of Medicine and Surgery.
THOMAS L. STEDMAN, A.M., M.D., Editor.
PUBLISHERS
WM. WOOD &. CO., 51 FIFTH AVENUE.
See fourth page following reading matter for Rates of Subscription
and Information for Contributors and Subscribers.
New York, September 23, 1916.
THE MEDICAL RESERVE CORPS OF THE
ARMY.
During the past few years much has been heard of
the need for military and naval preparedness, and
it has been pointed out repeatedly that this coun-
try is in no sort of a condition to repel a thor-
oughly organized, well equipped foe with any cer-
tainty of success. Especially stress has been laid
upon the inadequacy of the Army Medical Depart-
ment to cope with any untoward situation. It is
a fact that the Army Medical Department, the mem-
bers of which are able and well trained, is woefully
inadequate in numbers. Even in times of peace
this is evident, and if war were to come, unless mat-
ters were considerably bettered in the meantime, in-
finite trouble would ensue.
The means suggested, and to some extent carried
into practice, to provide against this calamity, is to
procure surgeons from civil life to supply the de-
ficiency. The Medical Reserve Corps of the army
will effect this to a limited extent, but in order to
be prepared for war on a large scale the services
of civil surgeons must be more largely called upon.
However, there is another question of great im-
portance. To be prepared implies being efficient and
therefore the members of the Medical Reserve Corps
should be so thoroughly trained in their military
duties that they may attain at least a fair degree
of efficiency.
As First Lieutenant L. D. Frescoln, Medical Re-
serve Corps, U. S. Army, points out in a paper pub-
lished in The Military Surgeon for August, 1916,
the Medical Reserve Corps stands for a body of
military surgeons held as an additional force in case
of emergency to aid in the same duties as the regu-
lar force, having necessarily a working familiarity
with the duties of the Medical Corps of the army.
Inasmuch as the medical forces connected with the
army and navy try to furnish the greatest physical
efficiency to the fighting forces, themselves non-
combatants, it behooves the reserves in this branch
of the service to acquire efficiency themselves along
these lines and then instil the same in the com-
batants.
A medical officer of the army is required
to possess knowledge of a wide-reaching and of a
somewhat peculiar nature, which is beyond the
scope of this article to go over in detail. In par-
ticular, however, attention may be drawn to the
fact that he must be a more or less expert sani-
tarian and must be well acquainted with sanitary
matters as applied to the army. Unfortunately,
Frescoln says, the members of the Medical Reserve
Corps generally do not possess sufficient knowledge
to warrant them in undertaking military duties,
and they are therefore not fitted to take the field
as army medical officers. Thus the Army Medical
Department may be said to be in a state of unpre-
paredness.
The happenings in Europe during the past two
years and more have afforded a terrible object lesson
on unpreparedness and in the case of Great Britain
especially on unpreparedness of the Army Medical
Department. Great Britain's position in this re-
spect was somewhat analogous to that of this coun-
try. She had an army medical corps just adequate
for the needs of her small army, and when she was
compelled to raise an immense army civil medical
practitioners with little or no military training had
to be called upon.
Undoubtedly the members of our Medical Reserve
Corps have volunteered with the highest patri-
otic motives, but they should also fully understand
that in so doing they have incurred great responsi-
bilities, and that it is their bounden duty to their
country and to themselves that they live up to these
responsibilties. They should avail themselves of
every opportunity for training in the duties of a
medical officer, in order that in case of war they
may serve their country with efficiency. This is true
preparedness.
MILK GRADING.
The physician is particularly interested in the
quality and safety of milk, because it forms the
largest, and often the sole, food element of his
commonest patient, the child. The quality, the solid
content, of the milk is of lesser importance, except
that if it is not of some degree of uniformity the
calculation in respect of milk modification will not
be accurate. Often that is a very important con-
sideration. But the chief thing of interest to the
physician is the disease factor in milk. Of all
foods, it is the one most likely to carry infection,
because it is itself such an excellent medium for
the development and for the growth of pathogenic
organisms. Wherever there is an opportunity for
the initial introduction of even a slight amount of
infection into the milk, the probability of these bac-
teria multiplying, especially when improperly main-
tained at a temperature conducive to the incubation,
is very large indeed. The variety of pathogenic
bacteria carried and maintained in milk covers
nearly the entire gamut of bacteria. They include
especially the tubercle bacillus, the typhoid bacillus,
the Klebs-Loeffler bacillus, and the organisms caus-
ing scarlet fever, septic sore throat, and other infec-
tions.
About 50 per cent of all tuberculosis present
in children is believed to be bovine in origin, and
coming from the cow's udder; milk is a greater
factor in typhoidal infection than water, because
it affords a better pabulum for the Eberth bacillus.
550
MEDICAL RECORD.
[Sept. 23, 1916
and because in water the bacillus becomes attenu-
ated by exposure in a poor medium, and reaches the
consumer in a very diluted form. Because of the
wide distribution of the milk, any infection must
reach a great many, yet the limits of such infec-
tions can nearly always be definitely determined by
those using the particular supply infected, provided
milk from good and bad dairies is not indiscrimi-
nately mixed.
The aim and the problem with respect to the milk
supply is to raise the quality of all the milk. This
is a reform which, because of the very magnitude
of the problem, cannot be accomplished at once, but
gradually only, through the education of the public
to the dangers of unwholesome milk. There should
be a demand for higher grade milk at higher prices.
The cost of handling milk in properly equipped and
properly maintained dairies is higher than in care-
lessly maintained ones. Various communities have
already established compulsory requirements in the
handling of milk products with respect to equip-
ment, handling, health of cows, the tuberculin test
for the herd, bacterial count, and the temperature
at which the milk is maintained. When all milk
products — butter, cream, and cheese — are embraced
in all these requirements, the ideal will nearly have
been reached. The one-grade milk or milk product
should be discouraged, since it does not lead to bet-
ter handling and higher standards.
Perhaps the most forward step in the movement
for better and safer milk is the certified milk move-
ment, wherein the index of quality is based on the
very lowest bacterial count, carried out in labora-
tories maintaining uniform bacteriological tech-
nique. The height of the whole bacterial content
is in proportion to the height of the pathogenic
bacterial content. Besides, the bacterial count is the
best index of the amount of foreign, extraneous mat-
ter introduced into the milk. Milk handled with
the least amount of care naturally has the most
dirt, the highest bacterial content, and is of the
greatest danger. But even the very best milk will
always be a source of danger if it is not immedi-
ately cooled to a proper temperature and not al-
lowed to rise above this temperature until it
reaches the consumer.
For infants who depend almost entirely on milk
for their food supply the milk problem during the
summer months is a double one, unless the milk is
Of the highest quality. The heat-exhausted infants
are better targets for the bacteria in the milk than
during cooler seasons of the year; and the boiling
of bad milk does not solve the problem, since spore-
forming organisms are not killed by boiling, and.
particularly, because boiled milk has not the food
quality of raw or pasteurized milk. While pas-
teurization kills most of the few pathogenic or-
ganisms contained in good milk, it is generally be-
lieved not to destiny the food quality, although this
has been disputed. It is quite certain, however,
that the tendency to general malnutrition and even
ri'kets is enhanced by feeding boiled milk over a
long period. At any rate, where it is not possible
t<> get the higher grade milk it is better to run the
risk of malnutrition than of the many infections
caused by bad. mishandled, and generally low-grade
milk.
LEECHES IN THE LARYNX.
It is said that Hippocrates mentioned the leech as
an occasional cause of blood spitting and writers on
foreign bodies in the air passages have often in-
cluded the leech among the parasites found at times
therein. Nevertheless, it is very seldom that a mod-
ern laryngologist has an opportunity to see these
cases, although they are by no means rare in parts
of Spain, Portugal, Italy, and North Africa. The
leech often enters the mouths of those who drink
certain nonpotable waters, especially when there is
no knowledge of the dangers involved. The victims
may drink directly from wells, pools, ditches, etc.,
or water which is fetched and allowed to stand in
dirty earthen jugs with narrow necks. The victim
drinks from these with no opportunity to see the
contents. The victims often know when they have
swallowed leeches and apply first aid in the shape
of tobacco smoke, vinegar gargles, etc. If the leech
does not come away the local practitioner is sought.
The nasal fossae, nasopharynx, pharynx, larynx,
trachea, or bronchi may shelter the creature. In
some cases considerable tolerance is shown, while
in others the picture of incessant cough, strangula-
tion, and hemoptysis, with secondary anemia, de-
mands immediate relief. Violent coughing some-
times expels the creature. When the symptoms are
of some duration tuberculosis is readily simulated.
The small punctures made by the leech do not pour
out blood, but the latter is said to be forcibly sucked
into its body and expelled at the caudal end.
Silverio Hernandez contributed an article on this
subject to the Revista Ibero-Americana de Cieiicias
Medicas for July. The author relates a personal
case, in which the leech had been in the throat for
twelve days. The victim had drunk from a narrow-
necked earthen jar. Since then he had suffered from
dyspneic paroxysms, incessant cough, and hemop-
tysis. When he could expel large quantities of blood
he felt some relief. There was constant and severe
distress in the larynx. The nasal chambers and
nasopharynx were empty. The laryngoscopy pic-
ture, however, could not have been more alarming.
To facilitate exploration the throat was cocainized.
The epiglottis and arytenoids were congested and
much swollen, but the author could perceive a por-
tion of the leech beneath. While an assistant drew
forward the epiglottis the author by means of for-
ceps grasped the buccal end of the leech and made
traction in the anteroposterior, direction. He was
fortunate in extracting it at the first attempt.
Since this experience the author has acted in five
similar cases.
In 1910 Gallegos of Seville reported 112 cases of
leeches in the air-passages seen by him in ten
years. Of this number 84 involved the larynx. It
should be stated that in Andalusia this leech danger
is more in evidence than elsewhere in Spain, far
more so than in Madrid. Reference to some Ameri-
can standard works shows almost no allusion to this
subject, although leeches must be common enough
in certain kinds of water which are also, no doubt,
used for emergency thirst-quenching. The reason
for this is probably that the local leeches, as they
are commonly met with in this country, are much
too large to enter the rima glottidis readily, and if
taken in at all would be swallowed.
Sept. 23, 1916J
MEDICAL RECORD.
551
PURE AIR AND AIR IN MOTION.
Views with regard to the physiological action of
atmospheric conditions have changed considerably
in recent years. It was formerly thought man
needed pure air, that is to say, air containing but
a small proportion of carbon dioxide and organic
matter and a due amount of oxygen, but nowadays
any kind of air seems to be acceptable if only it is
kept stirred up.
Frederic S. Lee read a paper by invitation before
the American Pediatric Society on May 8, 1916, in
which he said that the most potent of the at-
mospheric agencies is undoubtedly temperature,
but high temperatures exert greater effects when
they are accompanied by great humidity. When an
existing external temperature is fairly comfortabk
to the individual an elevation of it, especially when
such elevation is accompanied by an increase of
humidity, causes distress, and the disagreeable ef-
fects are more pronounced when the air is stagnant.
Such effects may be modified if the air next the skin
be put into motion, but an effective antidote is a
reduction in the temperature of the air and this may
be assisted by a reduction in its humidity. All ex-
perimentation and observation go to demonstrate
that a moderately cool and moderately dry air in
motion constitutes the most physiologically helpful
aerial envelope of the body. Lee holds that arti-
ficial ventilating systems should not necessarily be
condemned, but should be operated intelligently and
may advantageously be combined with window ven-
tilation. As to the merits of what is termed "fresh
air," it should be pointed out that the freshness
of so-called fresh air lies, not in more oxygen, less
•carbon dioxide, less organic matter of respiratory
origin, and the hypothetical presence of a hypo-
thetically stimulating ozone, but rather in a low
temperature, a low humidity, and motion.
Leonard Hill was the first, or one of the first, to
demonstrate that the harmful properties of stag-
nant air, containing a comparatively large amount
of carbon dioxide ( in the most greatly vitiated air
the quantity of carbon dioxide, he claims, is very
small) had been immensely exaggerated. The dele-
terious effects of the air in a closed room lie more
in its stagnancy than in any injurious matter it
may contain. Keep the air in motion, say these new
theorists, and it will be comfortable and to a large
extent harmless.
The Avoidance of Industrial Diseases.
The slogan "safety first" should be extended from
its original application as a safeguard against ac-
cidents to safeguard against disease. There is for
instance a tremendous economic loss going on
yearly which might be largely prevented by hy-
gienic measures. Dr. Schereschewsky in a recent
Public Health Report has outlined a plan for the
prevention of industrial diseases which is worthy
of note. Estimating that there are from 25 to 30
million industrial workers in the United States and
that each one loses from eight to nine days' work
a year from illness, that would make the annual
loss 600,000 years, or an economic loss of $360,000,-
000, supposing the workman's average pay was $50
a month. A great part of this loss is undoubtedly
preventable and Schereschewsky calls attention to
several ways to prevent it. He believes that more
attention should be given in medical schools to the
interrelations of occupation and disease — in fact he
would give a chair to this subject. Death certifi-
cates, too, should be filled out with greater exact-
ness and should indicate correctly and exactly the
occupation of the decedent. Also information re-
garding industrial hygiene should be disseminated
as industriously as crusades against tuberculosis
and alcohol are being carried on now. He suggests
six main parts of such an educational campaign:
permanent exhibits, popular lectures, bulletins, pop-
ular articles in the lay press, and instruction in th<
public schools. In a great many cases investigated
among industrial workers it has been found that
disease has been the result of neglect of personal
hygiene rather than from inattention to any sani-
tary precautions connected with the particular oc-
cupation. These fundamentals of hygiene should of
course be taught in the home and, that failing, in
the schools, but it does not seem that the instruc-
tion there has hitherto been sufficiently convincing
to bear much fruit. When we consider that about
one-third of our school children later become indus-
trial workers the importance of including persona!
hygiene in every public school curriculum becomes
evident.
A Yankee Trick in England.
There has come to our notice recently a description
of a bit of commercial shrewdness which is of the
kind commonly spoken of as "Yankee" although the
scene is laid in the lanes of the Old England, in-
stead of the New. It is not known whether or not
the enterprising individual in question was English,
but the whole thing sounds very much like one of
the amazing tales with which Sam Weller regaled
the ears of Mr. Pickwick. It seems that every
autumn a man used to bring to a large wholesale
drug house in London a quantity of hemlock seed
which he sold at half the market price. Finally,
says Garden in a recent issue, the curiosity of one
of the members of the firm became aroused and he
asked the man how he could afford to sell the drug
so cheaply. The stranger was loath to tell at first,
but after being promised that nothing would be
done to interfere with his business, he described
his method. Every spring he filled his pockets with
the seed and went out into the country. Wherever
he saw a good, wide hedgerow he sowed the seed
broadcast. Then he went his way and worried no
more over his crop until the fall when he revisited
the scene of his labors. He would then call the
farmer's attention to the "weeds" in his hedge, of-
fering to cut them down for a shilling a hedge, an
offer which the farmer gladly accepted. Thus was
the ground furnished free and he was paid to cut
the harvest. In view of the great shortage in drugs
owing to the war a few such ingenious minds should
be turned to the question of domestic drug-raising,
not necessarily on some one else's land, but at least
on United States land.
Diabetes Mellitus in Japan.
According to various contemporary authorities
diabetes runs a mild course in Japan and seldom
leads to coma. Polyuria is absent throughout, and
with it the symptoms which announce the onset of
the disease. This behavior is the more singular
because of the preeminently carbohydrate diet of
those people. Where the disease is most severe,
552
MEDICAL RECORD.
[Sept. 23, 1916
on the other hand, the people are meat-eaters. Le
Goff, whose researches into this subject were re-
cently presented before the French Academy of
Sciences {Gazette hebdom. des sciences medicates
de Bordeaux, July 8) tested both healthy and dia-
betic Japanese for carbohydrate tolerance and found
a better utilization of sugar in comparison with
other races. It is not made clear to the reader why
the benign diabetes of the Japanese cannot straight-
way be termed a glycosuria.
Steam of tto Wetk
Poliomyelitis Epidemic Continues. — The de-
crease in the number of cases of poliomyelitis
during the past week was not so great as had
been hoped for, 254 being recorded up to Septem-
ber 16, as against 352 for the preceding week.
The total number of cases to that date was 8,731,
with 2,172 deaths. Because of this continuance of
the disease, the United States Public Health
Service decided that it would be unwise to dis-
continue its work of inspection of travel, which
will, therefore, be carried on for an indefinite
time, or as long as present conditions prevail.
The theory that the disease is conveyed by rat
fleas has been advanced, and is being studied in
several laboratories. Fifty monkeys, to be used in
studying infantile paralysis, were shipped last
week from San Francisco to the Rockefeller In-
stitute. They are the survivors of a shipment of
100 received in San Francisco from the Orient a
few days before. Mr. Nathan Straus has called
attention to the record of the Straus milk depots
in New York, as suggesting the theory that in-
fantile paralysis may be carried by milk. It is
stated that not a single case of the disease oc-
curred among the 2,500 children who received
pasteurized milk from the milk stations. As good
a guess as any is that the disease is due to a
protozoan parasite, with an exogenous cycle in the
mosquito, or some other invertebrate host, which
is active in hot weather, and becomes more torpid
during the cool spells, following which there is
usually a temporary decrease in the morbidity rate.
For breaking the quarantine regulations imposed
by the Board of Health, because of the occurrence
of a case of poliomyelitis in his family, a citizen of
Long Island City was fined $5 in the Long Island
City Police Couil; on September 14. The total
number of cases in New York State outside of
New York City to September 16, was 2,865, with
302 deaths. In New Jersey, up to the same date,
3,390 cases had occurred.
Some Practical Notes on Blood Pressure. — In
the legend of Hemobarogram No. 5, in the article
with the above title, published in the issue of Sep-
tember 16 (page 490), the word typical should
have been atypical.
Sir Thomas Lauder Brunton of London died on
Saturday of last week at the age of 72 years. He
was widely known as a graceful writer on medical
penally therapeutics. He was an
M.D. of the Royal University of Ireland, LL.D. of
tne Uni\ f Edinburgh, a fellow of the Roval
College of Physicians, and of the Royal Society
of Medicine, of which he was also vice-president.
He was knighted in 1900 and made a baronet in
1908.
Lectures at Yale.— The Silliman lectures for
1916 of Yale University will be given by Prof.
J. S. Haldane, LL.D.. F.R.S., on October 9. 10.
12, and 13, at the Lampson Lyceum, New Haven.
Prof. Haldane's title will be: "Organism and
Environment as Illustrated by the Physiology of
Breathing."
New Psychopathic Hospital. — The directors of
the Bureau of Social Hygiene, and the Board of
Managers of the New York State Reformatory
for Women, announce the opening on September
16, of the Psychopathic Hospital of the Laboratory
of Social Hygiene at Bedford Hills.
The Wellcome Prizes. — The Henry S. Wellcome
prizes, offered through the Association of Mili-
tary Surgeons, and open for competition to all
present and former medical officers of the Army,
the Navy, the Public Health Service, the organized
militia, United States volunteers, the Medical Re-
serve Corps of the Army and Navy, and the Offi-
cers' Reserve Corps of the United States Army, will
not be awarded until after December 15, 1916, the
council of the association having voted to extend
the time of entry for competing essays to that
date. This has been done because of the large
number of members now on duty with the troops
at the border. Two prizes are offered, the first,
a gold medal and $300, and the second, a silver
medal and $200. The subject for the first prize
is: "The most practicable plan for the organiza-
iion, training, and utilization of the medical of-
ficers of the Medical Reserve Corps, United States
Army and Navy, and of the medical officers of the
Officers' Reserve Corps, United States Army, in
peace and war." For the second prize the subject
is: "The influence of the European war on the
transmission of the infectious diseases, with spe-
cial reference to its effect upon disease conditions
of the United States." The essays (.five copies
signed by a nom de plume), not to exceed 20,000
words exclusive of tables, must be addressed to
the secretary of the Association of Military
Surgeons, United States Army Medical Museum,
Washington, D. C.
Murphy Field Hospital Disbanded. — In conse-
quence of the death of Dr. John B. Murphy, the
field hospital organized by him as the Chicago
medical unit, and forming a part of the general
field hospital of the British expeditionary force
in France, has been disbanded. The unit had the
distinction of winning the royal Red Cross medal,
and of being twice mentioned in dispatches for
effective work.
Sick Rate Among Troops.— The health of the
New York division of the National Guard on duty
in Texas was reported recently to have been
slightly better during August than during July,
notwithstanding the epidemic of paratyphoid, the
respective percentages being given as 1.52 and
1.57. There were during August about 19,000 New
York troops on duty near the border. The highest
daily rate of illness during the month was 2.76
per cent. There has been a marked decrease in the
number of cases of paratyphoid.
Gifts to Charities.— The $2,500 presented to New
Jersey charities by President Wilson when rental
for Shadow Lawn, his summer residence, was re-
fused by the owner, has been divided among eight
institutions, including the following: $500 each
to the Monmouth Memorial Hospital, Long Branch,
the Ann May Hospital. Spring Lake, and the Paul
Kimball Memorial Hospital. Lakewood; $200 to
the Methodist Episcopal Home for the Aged,
Ocean Grove, and S100 each to the Home for the
Aged, Asbury Park, and the Long Branch Visiting
Nurses' Association.
Sept. 23, 1916J
MEDICAL RECORD.
553
By the will of the late Alice E. Lathrop, of
Hartford, Conn., the Hartford Hospital receives a
bequest of $2,500.
Tuberculosis in War Camp. — The Canadian
Military Hospital Commission is investigating the
conditions in the military camps of the Dominion
as regards the incidence of tuberculosis. It is
stated that the proportion of soldier's tuberculosis
has been larger in the military camps than at the
front.
Adopts Physical Training Program. — The New
York State Board of Regents has given unanimous
approval to the program for physical training as
recommended by the State Military Training Com-
mission. The program, which is intended for the
use of every school in the State, calls for a mini-
mum of twenty minutes a day to be devoted to
physical exercise, and is said to be the most com-
prehensive plan for health education and physical
training ever adopted by a State.
Physicians Licensed. — As a result of the recent
examinations for admission to practise medicine
in the State of Maine, certificates were granted
to nine physicians. Twelve candidates took the
examinations. In addition, three physicians were
granted certificates without examination through
reciprocity with other States.
Personals. — Dr. Hermann F. Biggs, Commis-
sioner of Health of the State of New York, was
operated upon at St. Mary's Hospital, Rochester,
Minn., on September 13, for chronic appendicitis
and gallstones. The operation was successful and
Dr. Biggs is reported to be on the road to rapid
recovery.
Reports from Paris tell of the illness of Dr.
Joseph A. Blake, as a result of the strenuous work
he has been doing among the wounded in his
hospital in that city.
Dr. John B. MacDonald has been appointed su-
perintendent of the Danvers State Hospital, Dan-
vers, Mass., succeeding Dr. George M. Kline, who
was recently made chairman of the newly-created
State Commission on Mental Diseases. Dr. Mac-
Donald has for a time been assistant superintend-
ent at the hospital.
To Head Lunacy Board.— Dr. Charles W. Pil-
grim, superintendent of« the Hudson River State
Hospital, Poughkeepsie, N. Y., has been appointed
by Governor Whitman to serve as president of
the New York State Lunacy Board. Dr. James
V. May, former head of the board, resigned some
time ago to accept a similar position in the State
of Massachusetts. Dr. Pilgrim served as presi-
dent of the board also in 1906-07, having been
appointed at that time by Governor Higgins. The
salary of the position is $9,000 a year.
Plagues in Mexico. — An apparent increase in
both typhus fever and yellow fever is reported in
official dispatches from Mexico. The diseases are
prevalent especially in the coast ports, and the
quarantine authorities are keeping a close watch
on the situation.
Hospital Needs Funds. — The New York Oph-
thalmic Hospital, it is announced, may shortly be
compelled to close its doors because of lack of
funds, a marked falling off in subscriptions hav-
ing occurred since the beginning of the war. Two
of the free clinics for children have already been
closed, and it is feared that it will be necessary
still further to curtail the work.
Medical Colleges to Open.— The College of Phy-
sicians and Surgeons, Columbia University, New
York, will open on September 27 the decline in
the epidemic of poliomyelitis making unnecessary
the postponement of the opening date.
The Long Island College Hospital, Brooklyn, N. Y.,
will begin the session of 1916-17 on September
25. The college courses given by Columbia Uni-
versity at the Long Island College Hospital will
open on September 28.
The British Medical Association. — The annual
representatives' meeting of the British Medical
Association was held on July 28 and 29, and trans-
acted the routine business, no scientific meetings
being held. Mr. E. B. Turner of London was re-
elected chairman of representative meetings, 1916-
17, and Mr. T. W. H. Garstang of Altrincham,
deputy-chairman. Sir Thomas Clifford Allbutt,
K.C.B., LL.D., was elected president of the Asso-
ciation, 1916-17. A resolution was also passed
congratulating Sir Clifford Allbutt on the attain-
ment of his 80th birthday. Dr. G. E. Haslip of Lon-
don, was elected treasurer of the Association for
the period 1916-19.
Dover (N. H.) Medical Society. — At the annual
meeting held in Rochester on September 8, the
following officers were elected for the ensuing
year: President, Dr. Thomas J. Morrison, Somers-
worth; Vice-President, Dr. John H. Bates, East
Rochester; Secretary -Treasurer, Dr. Roland J. Ben-
nett.
Teaching Hygiene to School Children. — A sys-
tem of health care and instruction in hygiene is
to be introduced into the New York City schools
this fall under the direction of Dr. C. Ward Cramp-
ton, director of the department of physical train-
ing, hygiene, and athletics of the public schools.
A program of hygienic events of the day has
been prepared, including directions as to bathing,
mouth hygiene, care in eating, exercise, etc., and
in the school children are to be placed in seats
suited to them, the matters of ventilation and tem-
perature are to be carefully attended to, and pupils
are to be organized in squads whose duties will be
to care for order and cleanliness in the schoolroom,
building, and neighborhood. All pupils are to have
their eyes tested, and the parents will be supplied
with copies of a pamphlet on "How to Safeguard
the Health of the Child."
The Legality of Pay Clinics. — In response to a
request of the Medico-Economic League, the office
of the Attorney General of the State of New York
has recently given the opinion that it is lawful
for a dispensary which is conducted in compliance
with the standards, requirements, and purposes of
Section 291 of the State Charities Law, to make
a charge of one dollar per visit. Whether a person
who pays one dollar for treatment at such a dis-
pensary, is a fit object for charity depends, the
opinion states, entirely upon the circumstances in
the individual case. If all that the patient can
afford to pay is one dollar, and he can obtain treat-
ment by a specialist at a dispensary for that
amount, while treatment by the same SDecialist
elsewhere would be beyond his means, there is no
reason why he should not avail himself of the
opportunity. Since Section 296 of the State Chari-
ties Law provides that "Any person who obtains
medical or surgical treatment on false representa-
tions from any dispensary licensed under the pro-
visions of this article shall be guilty of a misde-
meanor and on conviction thereof shall be punished
by a fine of not less than ten dollars and not more
than two hundred and fifty dollars," there seems
554
MKDICAL RECORD.
[Sept. 23, 1916
no reason to fear that the dispensaries will be
abused by persons who can afford to pay the full
quota for specialized surgical or medical treatment.
In the opinion of the Attorney General's office, the
establishment of dispensaries of the standard con-
ducted by such institutions at Mt. Sinai Hospital
and others, should be encouraged and assisted,
rather than hampered and hindered.
Obituary Notes. — Dr. Enrique Nunez, secretary
of sanitation for the Republic of Cuba, died on Sep-
tember 16 in the Presbyterian Hospital, New York,
after a few days' illness from infection following a
cut on his foot. Dr. Nunez was graduated from the
University of Havana in 1886, and received his doc-
tor's degree from the same institution in 1893. For
many years he had been one of the most prominent
physicians in Cuba. He was in his forty-fifth year.
Dr. James R. Cannon of Irvington-on-Hudson.
N. Y., a graduate of the College of Physicians and
Surgeons, New York, in 1903, visiting surgeon to
the Tarrytown Hospital, and a member of the
Society of the Alumni of St. Luke's Hospital and
the Alumni of Sloane Hospital for Women, died
suddenly at Walker, Minn., on September 5.
Dr. Eugene Potter Stone of New York, a grad-
uate of the Medical School of Harvard University,
Boston, in 1884, medical director in the United
States Navy, retired, and a member of the Ameri-
can Medical Association and the New York State
and County Medical Societies, died suddenly, at
North Sutton, N. H., on September 5, aged 55
years.
Dr. Solomon Baruch of New York, a graduate
of the New York Homeopathic Medical College and
Flower Hospital, New York, in 1876, died at his
home, from arteriosclerosis, on September 6, aged
60 years.
Dr. Joseph Samuel Chagnon of Willimantic,
Conn., a graduate of Victoria University, Medical
Department, Toronto, in 1883, died at his home,
from edema of the lungs, on August 29, aged 57
vears.
©bttuarg.
ADONIRAM BROWN JUDSON, M.D.,
NEW YORK.
Dr. A. B. Judson, one of the first generation of
orthopedic surgeons in this country, died of diabetes
at his home in New York City, on Wednesday of this
week. He was born in Burma, where his father
long lived as a Baptist missionary, in 1837. After
graduating in arts from Brown University, he
studied medicine at the Jefferson Medical College,
from which he was graduated in 1865. Before
graduation he served as assistant surgeon in the
Civil War. After coming to New York he took a
course at the College of Physicians and Surgeons,
where he obtained a second degree of M.D. in 1868.
He was a fellow of the American College of Sur-
geons, of the New York Academy of Medicine, and
of the American Medical Association, and a mem-
ber of the New York State and County Medical So-
cieties, and the New York Pathological Society, and
ex-president of the American Orthopedic Associa-
tion. During his period of active practice Dr. Jud-
son wrote many journal articles and some books,
and even after retirement he retained a keen inter-
est in his profession and continued to contribute to
its literature, having published a brief article in
these columns as late as January of the present year.
vlnrrcsjimtDnir?.
OUR LONDON LETTER.
( From Oui Regular Correspondent. )
TREATMENT OF CONVALESCENT SOLDIERS — COMMAND
DEPOTS — LIGHT DUTIES ON LINES OF COMMUNI-
CATION— BALNEOLOGY COMPRESSED AIR — TRAIN-
ING OF MUSCLES AND JOINTS.
London, August 26, 1916.
The treatment of convalescent soldiers by physical
means has been discussed at the Royal Society of
Medicine a propos of a paper by Major Tait Mc-
Kenzie, R.A.M.C. He compared a great military
hospital to a general post office as the sick and
wounded are, as it were, sorted out in several classes.
Cases that may be called first-class matter are at
once on reception distributed to the regular hos-
pitals, either Red Cross or military, when after a
short course of treatment by operation or other
wise they may be able to return to the front. Sec-
ond-class matter is composed of cases requiring a
stay at a convalescent hospital where they can re-
ceive a longer course of treatment by an officer of
the R.A.M.C. A large number of these patients
eventually find their way back to the front. The
third class comprises cases difficult to deal with as
they are too tedious for hospitals or convalescent
camps. Early in the war they were passed from
one depot to another without giving satisfaction to
any of the medical officers under whom they spent
short periods. Last autumn the director-general ar-
ranged a series "command depots," under a com-
batant officer for discipline and general manage-
ment. A medical officer was attached to each. To
these depots were sent to all patients as to whom
there was a reasonable prospect of recovery within
five or six months. From there it was hoped to re-
turn every available man to service; those only tit
for light service abroad might replace others in
Lght duties on lines of communication and release
others for more active service. So others again
from whom no further service could be expected
might be discharged from the army.
With the help of the society's committee on
Balneology the ordinary hut was converted into an
ideal hydrothertherapeutic establishment. The hot
and cold douche had both rendered good service in
treatment and also proved useful in diagnosis — -es-
pecially in cases of suspected rheumatic origin.
Serious cases of rheumatism were treated by a
daily tub bath, of 15 to 20 minutes duration, at a
temperature of 98 F., followed by general massage.
The pool bath was kept at 94 F. and would hold
twelve men sitting up to their necks on in the water.
In it they staid an hour. This was the practice
in all cases of shock with disordered cardiac action.
The whirlpool bath was used for limbs with pain-
ful scars or frost-bitten, the water being kept at
110' F. and violently agitated. Compressed air
introduced into the stream provided bubbling,
effervescent envelope for the painful limb.
After twenty minutes of this immersion the part
would be flushed, but the patient would express him-
self as comfortable and the circulation would be
accelerated and remain so for hours. This is a
good preparation for massage and other manipula-
tions which often cannot be borne without it. When
a sodden scar is undesirable dry heat should be used.
Zander machines for passive movements are com-
plicated and far too expensive. Following manipu-
lations the muscles and joints require systematic
Sept. 23, 1916J
MEDICAL RECORD.
555
re-education by tasks of progressively increasing
difficulties and in time a patient should be thrown
more on his own resources and made to practice
free gymnastics without the help of machine or
operator. At this stage men suffering from shell
shock or debilitated in any way may begin the
exercises and gradually increase them up to the
stage of nearly but not quite full training. A pulse
which by faradism, baths, and rest had been re-
duced to 80 would mount up again to 120 or even
140 on attempting anything arduous. The com-
mand depots have given results which must be satis-
factory to the director-general, for half the cases
have been rendered fit to return to active service
and have rejoined their units in the fighting line,
12 per cent, have been sent to lines of communica-
tion abroad, 12 per cent, to useful sedentary work
at home, the residue of 28 per cent, being discharged
as permanently unfit. These command depots, since
their establishment seven months ago, have re-
turned a full Army Division to the fighting line.
OUR LETTER FROM ALASKA.
(From Our Special Correspondent.)
ALASKANITIS ENDEMIC IN NORTHWESTERN ALASKA.
St. Michael, July 31, 191 fi.
To many readers this will be an unfamiliar term,
but to persons who have passed at least one closed
season in northern or northwestern Alaska the
word "Alaskanitis" will remind them of many in-
stances that have come under their observation.
Just as with general paresis, this condition seems
to be more prevalent in the better class, the words
"better class" in this sense meaning the white peo-
ple in contradistinction to the native Eskimo or
Indian, who seems immune. The condition probably
prevails all over northern and northwestern Alaska,
at least where white people have settled. It affects
both sexes alike, and no age seems exempt. Al-
though the condition is endemic with sporadic cases
occurring the year around, it reaches an epidemic
form after the close of navigation when Alaska is
shut off from the outside world. The number of
cases increases progressively from February to
June and by this time all the white population has
become more or less affected. Persons new in the
country seem particularly prone to "Alaskanitis,"
but prolonged residence does not establish absolute
immunity as the writer has seen a person forty-four
years in the country have it in an acute form.
Now what is "Alaskanitis?" I don't know, but a
description will be based upon the outward manifes-
tations. As above said, "Alaskanitis" prevails after
the close of navigation, that is when no new faces
are to be seen. The various communities are but
sparsely settled, necessitating the same faces to
meet many times a day. Should you go to the store
you meet the same faces ; should you go to the post
office, skiing, snow-shoeing, mushing, calling, or
what not, the same faces are there, and, worst of
all, there are no other faces. The outside world is
cut off; there is no news, the days become progres-
sively shorter and shorter until but three or four
hours of light remain. The nights grow longer and
longer until about twenty hours out of the twenty-
four are consumed with the quietude and mystery
of darkness almost continually hovering over you.
You hear almost daily others' experiences of last
summer and relate yours ; the experiences of sum-
mer before last are also told, even experiences dat-
ing back to early childhood are in like manner re-
lated without the slightest emotion, humor, or wit.
After a few months of these experiences one hesi-
tates to meet another, knowing what will be related,
so one seeks more or less solitude, but this, too, be-
comes tiresome. At this stage, you have become sen-
sitized or highly susceptible to "Alaskanitis." About
this time some one will start gossiping and with
lightning-like rapidity you will grasp this piece of
"news" — being the first in a long time — and with
such additions and subtractions as seem necessary
to make the story more interesting it passes from
one to another. Finally the story reaches the orig-
inator, who does not even recognize it as his story,
so there are two stories in the field. This will cause
sociological segregation and retaliating stories will
start. As the majority of the population is made
up of persons about whom you may readily believe
reports of questionable nature, divisions and sub-
divisions occur, until by June, or the opening of
navigation, each person may represent a society of
his own.
With the opening of navigation there is a great
influx of new faces; gold seekers, tourists, and oth-
ers come into the country by the hundreds. The
bright, warm, sunshiny days with the wind in the
right direction soon drive out the ice, and ships ap-
pear bringing news, new faces, new associates. The
Sourdough's ( a white person who has been in Alaska
more than one year) troubles are forgotten and the
condition of his mind that seemed chronic now dis-
appears, only to relapse, however, during the coming
fall or winter. This is "Alaskanitis" in a typical
form and is more conducive to discontent during
the long winters than probably all other elements
combined which enter into the life spent in this part
of the world.
"Alaskanitis" differs from "Philippinitis" in not
presenting in so marked a degree the symptoms of
nostalgia.
Boston Medical and Surgical Journal.
Si ptember
1916.
1. Some Theoretical Considerations of the Present Status of
Roentgen Therapy. Joseph Shohan.
2. Some Efficiency Problems in Country Medical Practici
Frank H. Washburn.
3. Circulatory Disturbances in the Obese. Clifton J. Buck.
4. Jean-Pierre David : The Man who Potted Pott. John
Ridlon.
5. Report of the Clinical Symptomatology and Laboratory
Findings in Three Cases of General Paresis under In-
travenous Arsenobenzol Treatment. G. E. Mott and
S. M. Bunker.
3. Circulatory Disturbances in the Obese. — Clifton L.
Buck says that beneficent results have been noted as a
result of the method he uses in preventing the first
signs of cardiac weakness in the slightly obese; in all
cases suffering from diseases entailing an increased
burden upon the circulatory system, and in the cases of
extreme obesity. He believes that this is a particularly
good field for prophylaxis and that it should be con-
sidered one of the most important duties of the family
physician to prevent the development of obesity in all
cases in which he recognizes cardiac weakness, as for
instance, valvular trouble developing from some of the
acute infections of childhood, and in families which
show an hereditary tendency toward obesity. In severe
cases with edema absolute rest is insisted upon for two
or three weeks or longer. Digitalis or tincture of
opium may be used as indicated. The diet at first
should consist of skim-milk, cooked fruits, and eggs.
When the condition has improved the diet may be in-
556
MEDICAL RECORD.
[Sept. 23, 1916
creased by adding solid food at short intervals, but
there must be no overloading of the digestive organs.
In the beginning a loss of three to five pounds a week
may be obtained, but when the effects of this become
evident, the diet should be adjusted so that but three
to five pounds a month are lost. After a few months'
treatment more freedom in diet may be allowed for a
few months. Then the diet should again be restricted
so that a gradual loss of weight results. This method
should be persisted in until the weight normal for the
individual is reached. The essayist finds that after ,a
patient has undergone the course of treatment his
dietetic habits have been corrected to such an extent
that he is not likely to resume the habits responsible
for his obesity as he so frequently does after a few
weeks' treatment in a sanatorium under artificial sur-
roundings. A number of cases are cited illustrating
the course and results of this treatment.
5. Report on the Clinical Symptomatology and Lab-
oratory Findings in Three Cases of General Paresis un-
der Intravenous Arsenobenzol Treatment. — G. E. Mott
and S. M. Bunker state that hitherto the diagnosis of
general paresis has been made upon the appearance
of such classical symptoms as the Argyll-Robertson
pupil, altered knee-jerks, ataxia, loss of judgment,
emotional instability, etc. Now they have come to look
for the following six laboratory tests in confirmation
of the diagnosis of general paresis: 1. Positive col-
loidal gold reaction of Lange. 2. Globulin — present and
increased, Noguchi — butyric acid method. 3. Albumin
— present and increased. 4. Number of lymphocytes
per c.c. increased from 10 to 400. 5. Wassermann re-
action of the blood serum, (i. Wassermann reaction in
the spinal fluid. The recent work of Southard and
other observers tends to show that the six positive
laboratory findings are present months and perhaps
years before the appearance of the classical clinical
symptoms. In the cases reported arsenobenzol has been
given bi-weekly, intravenously, in the arms. Following
the earlier treatments there occurred a distinct reac-
tion, namely, chills, fever, headache, nausea, and vomit-
ing. The most constant symptom was a nervous chiil
lasting from ten to twenty minutes and appearing
from ten to thirty minutes after treatment. Frequent
urinalyses have shown only occasional traces of albu-
men in one case. After the injections there was some
local reaction which readily yielded to the application
of ice and massage. A summary of the cases shows
that in one case the onset of the disease occurred ten
days prior to admission to the hospital; in another
case, fifteen days prior to admission, and in still an-
other, one year. In the light of subsequent treatment,
early diagnosis of general paresis, or at least of syphil-
itic involvement of the central nervous system, is of the
utmost importance. Following treatment a definite
clinical improvement has occurred in two of these
patients. One patient has shown restiveness and a lack
of cooperation to such an extent as to classify him as
not improved. The definite results observed in the
laboratory findings were: 1. The gold chloride test,
although still positive, was much reduced in two cases.
It was slightly increased in the case refusing treatment.
2. The albumen tests were reduced in all three cases
from three pluses to one plus. 3. The globulin tests
were slightly increased in one case; unchanged in the
other two cases. 4. The cytological count was reduced
in one case from 125 to 3 cells per c.c. There was a
low normal count in both of the other cases. 5. The
Wassermann reaction in the spinal fluid in one case
changed from positive to unsatisfactory. In the other
two cases it was unchanged, remaining positive.
6. The Wassermann reaction in the blood sera showed
three negative and one doubtful reaction in one case;
one unsatisfactory reaction in a second, and in the
third case one unsatisfactory reaction and all the others
positive.
New York Medical Journal.
September 9, 1916.
1. Tuberculosis in Relation to Feeblemindedness. I'eter
Bryce.
2. Some Thoughts on Prostatectomy. Henry H. Morton.
3. A Case of Hypopituitarism. L. Napoleon Boston.
4. Quartz Light in Cutaneous Diseases. Edward Pisko.
5. The Svmptom Ataxia : Its Successful Treatment. Hein-
rieh P. Wolf.
6. Dysentery in Serbia. J. Rudis-Jicinsky.
7. The Pre-existing Conditions of the Injured. A Medico-
legal Study from the Standpoint of Employer's Lia-
bility and Accident Insurance. G. R. Dore.
8. A Test for Syphilis. Mercury Bichloride in the Blood
Serum and Cerebrospinal Fluid. George B. Ubel.
9. Drug Addiction : A Study Made in Essex County Prison
and Home of Detention. Edward W. Markens.
1 0. Recovery from Tetanus. B. Scheinkman.
1. Tuberculosis in Relation to Feeblemindedness. —
Peter Bryce quotes from the observations of Tredgold
and Goddard to bring out a fact frequently forced upon
the attention of those who have had much to do with
the tuberculous, and that is the relation of tuberculosis
and what for the lack of a better term is called "nerve
instability." He holds with Tredgold that primary
amentia is a manifestation of a pathological germinal
variation which has been produced by environment, and
the germinal change is of the nature of a vitiation, that
is to say, it consists of an impairment of the intrinsic
potentiality for development, which may be widespread
and affect the germ as a whole or which may be less
extensive and confined to the neuronic determinant.
This impairment is primarily due to the action of en-
vironment. Ancestral tuberculosis is but rarely the
direct sole cause of amentia, but, like alcoholism, has an
important indirect and possibly contributory influence.
This indirect effect is seen in its potency to produce the
milder and initial forms of nervous instability in the
offspring, such as migraine, hysteria, and neurasthenia.
The change in the mental and physical environment
incident to the rapid urbanization of such a large pro-
portion of the population of the United States and
Canada during the past fifty years is the environ-
mental condition that is largely responsible, operating
against normal and physical causes. Among the
other vices of civilization an irrational dietary and
the use of foods of imperfect nutritive elements, clue
to the robbing of our common foods of their salts and
vitamines, is not the least important. The effects of
this changed environment on two generations are now
becoming apparent and the question may be seriously
asked whether phytogeny will disappear in its old
normal developmental influences to be replaced by some
modern man-created eugenics, adequate to cope with
the changed environment, including habits of life, hous-
ing, occupation, and education. If by artificial methods
we may greatly limit tuberculosis, the problem of
feeblemindedness still remains to be attacked and will
for an unknown period under modern conditions, give
our legislators, educationists, clerics, and physicians
ample occupation if they are to solve the problem satis-
factorily.
2. Some Thoughts on Prostatectomy. — Henry H.
Morton gives the results of their work at the Long
Island College Hospital where, during the last three
years, forty-three patients have been operated upon
for hypertrophied prostate. The ages ranged from
fifty-seven to eighty-two years. Of these forty-three
patients, six died, two of the deaths being directly
due to the operation, while the others were due to
various other causes not dependent upon the operation.
Thus the mortality rate for the series may be said to
be 1° per rent. One should choose the route, supra-
Sept. 23, 1916]
MEDICAL RECORD.
557
pubic or perineal, which is best suited to the condition
of the patient. The ideal anesthetic for old men is
gas-oxygen with a little ether. Ether, if carefully given
in small quantities, can also be safely used as an
anesthetic. The after treatment of these cases is ex-
tremely important. The patient should be immediately
put into a hot bed with an electric baker and the
Murphy drip started at once. Water should be forced
by the mouth as soon as the patient is able to swallow.
The most dangerous symptom as a complication after
prostatectomy is septic anuria. Its approach is
heralded by the blowing up of the intestines, tympan-
ites, dry brown tongue, scanty urine, and drowsiness.
It demands the forcing of the water by the Murphy
drip and by mouth. After suprapubic prostatectomy
the writer uses silver wire sutures, which he leaves in.
A big Freyer tube takes care of the clots. This is
taken out on the fourth day. He also makes use of
a rubber dam apron with a hole in the middle through
which the urine runs out and is caught by gauze. This
has proved a great comfort to the patients. He has
found that incontinence of urine is more frequent after
perineal section than after supropubic. As to the
cause of death after operation, suppression of urine
heads the list. Shock is rarely the occasion of death
and hemorrhage ought never to cause death.
4. Quartz Light in Cutaneous Diseases. — Edward
Pisko calls attention to the value of the Bach-Nagel-
schmidt modification of the Kromayer lamp in the
treatment of cutaneous diseases. He says its use is
indicated in all skin affections in which there is a
dilatation of the blood vessels. He emphasizes, how-
ever, that the lamp's utlity is restricted to the treat-
ment of small circumscribed lesions, such as are of an
area no larger than the area through which the rays
emerge. Conditions most amenable to treatment are
furunculosis, folliculitis, acne vulgaris, and small
patches of alopecia areata. Another group of skin
diseases that can be influenced only by the deeper and
more penetrating action of the rays includes lupus
vulgaris, lupus erythematosus, naevus unius lateris,
naevus vasculosus, naevus pigmentosus, and telangi-
ectasis. The results obtained in the treatment of these
cases have invariably been excellent, some times even
startling. Gratifying results have also been obtained
in cases of leg ulcer, intertriginous eczema, in a case
of Duehring's disease, and in cases of obstinate and
chronic eczema and psoriasis.
8. A Test for Syphilis; Mercury Bichloride in the
Blood Serum and Cerebrospinal Fluid. — George B. Ubel
bases this test upon the following facts: First, that
bacteria react in accordance with all the established
facts pertaining to colloids; secondly, one colloid may
be absorbed by another colloid, preventing its precipi-
tation when a mild precipitant is added. By assuming
that normally there is a colloid present in the blood
serum which is not present in the cerebrospinal fluid,
the test may be satisfactorily explained. The addition
of a 1 to 100 solution of mercury bichloride to the non-
syphilitic blood serum will precipitate the colloid
which is normally present, and a turbidity will result,
but if the serum is syphilitic the colloid of Spirochseta
pallida protects or absorbs the colloid normally present
in the blood serum, and hence the serum remains clear
when the precipitant is added. The reaction on the
spinal fluid is just the reverse, that is, normally there
is no colloid present, hence when the bichloride is
added no precipitate is formed, but in a syphilitic
spinal fluid the colloid of the spirachete is present and
is precipitated by the solution. The technique is de-
scribed and a series of cases tabulated which show
that the results of this test are similar in most in-
stances to those obtained by the other tests in common
use.
10. Recovery from Tetanus. — B. Scheinkman reports
a case of tetanus in which the administration of one
dose of tetanus antitoxin of G,000 units followed by
three successive doses of 10,000 units failed to effect
any change for the better in the condition of the
patient. Five c.c. of a 2 per cent, carbolic solution
were then injected and powders were prescribed con-
sisting of quinine sulphate 2 grains, phenacetin, anti-
pyrin, and caffeine citrate, each 1% grains, and codiene
1/15 of a grain. These powders were given every two
hours and the antitoxin discontinued. This treatment
was continued for a period of two weeks, during which
time the patient gradually recovered. Noteworthy
features in this case were the facts that the patient's
temperature never reached above 101° F., and only on
a few occasions did the pulse show any erratic tenden-
cies. The intellect remained unimpared throughout
the entire attack.
The Journal of the American Medical Association.
September 9. 1916.
1. Removal of the Right Colon : Indications and Technique.
Charles H. Mayo.
2. The Value of Ileosigmoidostomy and Similar Procedures
in the Treatment of Chronic Multiple Arthritis. John
T. Bottomley.
3. Splenectomy for Hemolytic Jaundice. Charles H. Peck.
4. Indications for Splenectomy in Certain Chronic Blood Dis-
orders : The Technique of the Operation. Donald C.
Balfour.
5. Pernicious Anemia Treated by Splenectomy and Syste-
matic, Often-Repeated Transfusion of Blood : Trans-
fusion in Benzol Poisoning. Roy D. McClure.
6. The Status of Physical Therapeutics in the Medical Col-
lege Curriculum of To-day. E. L. Eggleston.
7. Report of Two Cases of Scoliosis, Accompanied by Pressure
Paralysis of the Lower Limbs. John Ridlon.
S. The Heart and Active Service : Treatment of Convales-
cent Soldiers at Heaton Park. H. J. Seeuwen.
9. Trichinosis : A Study of Fifteen Cases. W. T. Cummins
and G. R. Carson.
1. Removal of the Right Colon; Indications and Tech-
nique.—Charles H. Mayo. (See Medical Record, July
1, 1916, page 37.)
2. The Value of Ileosigmoidostomy and Similar Pro-
cedures in the Treatment of Chronic Multiple Arthritis. —
John T. Bottomley. (See Medical Record, July 1, 1916,
page 38.)
3. Splenectomy for Hemolytic Jaundice. — Charles H.
Peck. (See Medical Record, July 1, 1916, page 36.)
4. Indications for Splenectomy in Certain Chronic
Blood Disorders. — Donald C. Balfour. (See Medical
Record, July 1, 1916, page 36.)
5. Pernicious Anemia Treated by Splenectomy and
Systematic, Often-Repeated Transfusion of Blood;
Transfusion in Benzol Poisoning. — Roy D. McClure.
(See Medical Record, July 1, 1916, page 37.)
6. The Status of Physical Therapeutics in the Medi-
cal College Curriculum of To-Day. — E. L. Eggleston
says that it occurred to him that it would be interesting
to know what attention was given to certain subjects in
the medical schools of the United States, and the ma-
terial he gathered forms the basis of his paper. He
sent to each of the medical colleges listed and classified
by the American Medical Association an inquiry as to
the number of hours devoted to the presentation of the
subjects of hydrotherapeutics, electrotherapeutics,
mechanotherapeutics, massage, medical gymnastics, and
dietetics. The replies to his inquiry indicated a decided
interest in the subject. In summarizing the collected
information, he finds that the average time devoted to
the non-pharmacal subjects exclusive of psychotherapy
was 62 hours, or about four times that recommended
in the model curriculum. The majority of the schools
were giving special courses in electrotherapeutics, a few
considering the subject only in connection with other
courses, such as neurology. Very few of the schools
558
MEDICAL RECORD.
[Sept. 23, 1916
were able to demonstrate the proper technique of the
physical measures because of a lack of suitable equip-
ment. The empiric use of hydrotherapeutic measures
is fraught with grave danger in many cases of organic
disease, and the same might be said with reference
to massage and other physical measures, but this should
not condemn them as of no value. When an individual
has learned by experience of the fallibility of drugs,
he has not infrequently lost confidence in his physician
and has been led to employ as his advisor some one
professing to cure physical ills without resorting to
drugs. The number of such individuals has become
so large as to provide a considerable field for the drug-
less healer. The day is past when the public is willing
to be treated by medicines solely. Is it necessary that
the patient be compelled to consult, in addition to the
physician, a food expert and a gymnasium di lector to
find out what to eat and how to exercise, or to consult
an osteopath or a professional masseur to obtain
the benefit from manual movements? It is high time
that the physician be able to direct in all the activities
having to do with the well-being of his patient, and
that he so minister to all his physical needs that never
again will the patient think of him as a dispenser of
drugs only.
9. Trichinosis. — W. T. Cummins and G. R. Carson re-
port of study of fifteen cases. The average incuba-
tion period was three weeks. One-third of the cases
presented no orbital edema ; three-quarters, no erup-
tion; four-fifths, no bronchitis; none showed splenic
enlargement. Eleven cases showed a disproportion-
ately low pulse rate, to which little attention has been
called. The maximum eosinophilia was 75 per cent.
Of nine cases, eight showed trichina? in the muscles;
of the fifteen cases, none were found in the blood or
feces; of twelve cases, one showed an embryo in the
cerebrospinal fluid ; of eleven cases, none were found
in the urine; of fourteen cases, ten showed albumin
in the urine. The mortality was 6.6 per cent. The
fatal case presented a hypostatic pneumonia and a large
pleural effusion. Evidently the parasites traverse the
venous channels in very small numbers for mechanical
reasons and probably none in some cases. It would
appear that in many cases they suffer partial or com-
plete disintegration in the intestinal tract. A routine
spinal fluid examination may show that the nervous
tissues are invaded in many instances; but it does not
seem likely that this will serve as a useful diagnostic
procedure in the study of the disease. If routine uri-
nary examinations are made for parasites, it seems not
improbable that invasion of this tract may be demon-
strated.
The Lancet.
Am/list 19, 1916
1. Rivers as Sources of Water Supply, a. C Houston.
2. Observations of the Effect on the Addi i i Fresh iiu-
man Bl I Serum to Artificial Media. Leonard S
Dudgeon, F Bawtree, and Dudley Corbett.
3. Three Cases of Entamoeba Histolytica infection Treated
with Emi B muth Iodine. George C. Low and
Clifford Dobi U
4. The Intravenous Injection of Oxygen Gas as a Thera-
peutic Measure !■' W. Tunnicliffe and G F Stebbing.
... On the Gluteal Fold in Sciatic Neuritis. Hildred Carlill.
6. A Case o1 Dilatation of the Hepatic Flexun oi the Colon,
Giving Rise to the Physical Signs Usuallj
with Subphrenic Pj umothorax. w J Morrish
7. The Shiah Pilgrimage and the Sanitar; D i
potamia and the Turco-Persiar Frontier. F. C
Clemow.
2. Observations of the Effect on the Addition of
Fresh Human Blood Serum to Artificial Media. — Leon-
ard S. Dudgeon, F. Bawtree, and Dudley Corbett, in
view of the fact that the ordinary media which are
employed for the cultivation of bacteria outside of the
tissues are not ideal, have tested the effect of the
addition of human blood serum to various media. They
find that this procedure has the following effects:
1, It provides a most favorable medium for growth
where culture under artificial conditions may otherwise
fail. 2. It greatly increases the amount of growth
in those media to which it has been added compared
to those prepared without it. 3. It stimulates the
growth of pathogenic organisms as opposed to non-
pathogenic. 4. It prolongs the life of organisms which
are prone to die out under artificial conditions as shown
in the case of the meningococcus. 5. It greatly facili-
tates the culture of the diphtheria bacillus, and in its
combination with different media helps to illustrate all
aspects of the morphology of this organism. 6. It ex-
ercises considerable influence upon other organisms of
variable morphology tending in the case of the pneumo-
cocci to reproduce the true types as found in the body
fluids. 7. It profoundly alters the fermentation re-
actions of the streptococci and pneumococci, tending to
obliterate the finer differences between types or the dif-
ferences due to particular environment.
4. The Intravenous Injection of Oxygen Gas as a
Therapeutic Measure. — F. W. Tunnicliffe and G. F.
Stebbing state that one of them (Tunnicliffe) has made
it a practice for some time, when using saline venous
injections, either simple nutrient or medicated, to use
not simple saline solution but oxygenated saline solu-
tion. They have found that when pure oxygen gas
is introduced into the veins of animals the latter do
not necessarily succumb to gas embolism. More recent
observations have been made on man, as a result of
which it has been demonstrated that oxygen gas can be
introduced into the veins in quantities from 500 to
1000 c.c. at the rate of 600 to 1200 c.c. per hour.
Cyanosis and the dyspnea attending it are rapidly re-
lieved. The more cyanosed the patient, the better is
a rapid rate tolerated. As the cyanosis is reduced the
rate should be diminished. During the administration
the pulse should be watched and the heart auscultated
frequently. Loud cardiac murmurs, more allied to
stomach or intestinal rumbles in character than to ordi-
nary heart murmurs, may, in fact often do, develop dur-
ing the administration. These murmurs are not an in-
dication to stop the administration, but with careful
administration they need not occur at all. The phe-
nomenon to be feared as likely to cause serious symp-
toms during the injection of oxygen is dilatation of the
heart. The ideal case for reaping benefit from this
treatment is one in which the cyanosis and dyspnea
are due to respiratory difficulty and in which the heart
is fairly healthy. In the opinion of the writers the
method is not likely to be of benefit in the cyanosis
and dyspnea occurring in marked degeneration of the
myocardium. Under such conditions if gas injections
are deemed advisable digitalin and strophanthin should
be given first. The object of the authors is not pri-
marily to point out conditions in which the injections
of oxygen are suitable but to point out that this method
is available to the clinician and will give therapeutic
results.
5. On the Gluteal Fold in Sciatic Neurits. — Hildred
Carlill calls attention to the obliteration of the gluteal
Cold in sciatic neuritis, and says it must depend on
flexion of the thigh or upon some alteration in the con-
dition of the underlying structures beneath the fold.
In his cases there was no flexion of the thigh. In
some cases Lasegue's sign was also negative — that is
to say the thigh could be flexed on the trunk, with the
leg extended, without causing pain. When the sign is
positive, from stretching of the nerve, it is a certain
indication of a degree of affection in the nerve fibers
or their sheath. The test is employed in the same
manner as that employed in testing Kernig'.- sign
in cases of meningitis, but the significance of the posi-
Sept. 23, 1916]
MEDICAL RECORD.
559
tive test differs in the two instances. It has been shown
that Lasegue's sign may be accompanied by momentary-
dilatation of the pupil, together with a raised blood
pressure and an increased pulse rate. These signs
occur in association with pain and serve to support
a diagnosis of sciatica when malingering is suspected.
Those patients with neuritis in whom the writer has
found the fold absent, invariably had abolition of the
ankle jerk. This is an important point in the diag-
nosis between neuritis on the one hand and pain,
whether local or referred, in the distribution of the
nerve, on the other. It is submitted that the condition
of the gluteal fold may be of considerable diagnostic
value in these cases, and may, indeed, be of great im-
portance in those patients in whom it is not possible
to test the ankle jerk. The absence of the gluteal fold
in people with peripheral neuritis would go to prove
that the whole length of the nerve is affected, including
the roots of the sacral plexus.
6. A Case of Dilatation of the Hepatic Flexure of
the Colon, Giving Rise to the Physical Signs Usually
Associated with Subphrenic Pyopneumothorax. — W. J.
Morrish reports this case, not only on account of the
rarity of the condition, but also because of the im-
portance of recognizing the possibility of its occurrence
when deciding the question for or against laparotomy
in any case in which the normal liver dulness is re-
placed by a resonant note, but in which other evidences
of intraabdominal or intrathoracic suppuration are ab-
sent. The patient, a soldier 20 years of age, com-
plained first of diarrhea and after three weeks jaun-
dice came on. He became emaciated, had moderate
pyrexia, and peripheral neuritis of the lowrer extremities.
Over the right lower quadrant of the thorax, which was
considerably bulged, the liver dullness was replaced
by a tympanitic note. It was unlike pneumothorax and
was certainly not a pulmonary cavity. An ai-ray ex-
amination showed the ascending and transverse colon
much distended with gas coinciding with the
tympanitic area. A skiagraph taken after a bis-
muth meal showed that the hepatic flexure of the colon
corresponded exactly to the tympanitic area marked out
on the first examination. On making a median incision
it was found that there was marked distention of the
cecum and ascending colon to the middle of the transe-
verse colon. The cause of this was an extensive ad-
hesion implicating the great omentum and passing from
the great curvature of the stomach across the trans-
verse colon to the duodenojejunal flexure. The portion
of the great intestine distal to the adhesion was col-
lapsed. The patient eventually died, and at the autopsy
there was no evidence of ulceration or inflammatory
thickening or abscess. The mucous membrane was
atrophied and denuded of epithelium. There were simi-
lar changes in the small intestine. The condition was
one of chronic enterocolitis. To find practically the
whole of the liver dulness replaced by a tympanitic
area giving rise to a well-marked coin percussion note,
without either acute atrophy of the liver, transposi-
tion of viscera, or evidence of some inflammatory con-
dition in the abdomen or thorax, is unusual.
Andrew
British Medical Journal.
August 19. 1916.
1. Injuries of the Bladder and Urethra in War
Pullerton.
2. A Case of Cyst of the Intestine. Charles Bolton and T. W.
P. Lawrence.
3. Three Cases of Gastroptosis Treated by Gastropexy (Rov-
sine). Middleton Connon.
4. Perforation of a Gastric Ulcer Occurring in the Sac of a
Large Congenital Diaphragmatic Hernia. Lennox
Gordon,
a. Injuries and Destructive Effects of Aeroplane Bombs : With
Suggestions on the Precautions to be Taken During
Hostile Aerial Raids. Hardy V. Wells and H. Graeme
Anderson.
6. An Appliance for Use in Severe Injuries of the Upper Ex-
tremity. Gilbert Arnold.
7 A Note on a Simple Method of Repairing Defects of the
Scalp. Cuthbert Wallace.
8. A Simple Method of Putting up Fractures in the Region of
the Elbow Joint in the Fully Flexed Position. Louis
C. Rivett.
1. Injuries of the Bladder and Urethra in War. — An-
drew Fullerton finds from his experience that there
are practically only two lines of treatment adopted for
these injuries at the casualty clearing stations, namely,
the tying in of a catheter or suprapubic cystotomy.
Though these procedures have a definite place there
seems to be a want of appreciation of the objects to
be attained and the dangers attending their indiscrimi-
nate use. He emphasizes the value of aseptic urine in
cleansing and irrigating a fistula, and in summing up
expresses the opinion that suprapubic cystotomy is not
necessary in many cases of wounds of the bladder, pro-
vided the latter can be kept clean and the external
wround adequately drained. If there is likely to be
much sloughing of the bladder walls, if there be severe
and continuous primary or secondary hemorrhage, or
if there be uncontrollable sepsis of the bladder, systot-
omy will be the correct treatment. Cystotomy is per-
formed not so much for the benefit it will have on the
original wound, which must be dealt with on ordinary
surgical principles, but in order to drain a badly in-
fected bladder and to prevent the spread of infection
to the kidneys. In the treatment of wounds of the
urethra, the usual method of treatment seems to be
catheterization, and if that fails cystotomy. The per-
formance of this operation is quite unnecessary, except
perhaps in those rare cases in which blood finding its
way back into the bladder forms large clots incapable
of being evacuated. If the urethra is so damaged that
either the patient is unable to void urine or is likely
to have extravasation in attempting to do so, perineal
section is performed. In all cases of doubt the same
procedure is adopted. When one is unable to find the
proximal end of the urethra except by poking around
in the perineal wound a perineal section should be
done, clots and tags removed, hemorrhage arrested,
free vent for the urine provided, and the wound cleansed
and left wide open. If then the patient is unable to
pass urine, an aseptic puncture of the bladder in the
suprapubic region should be resorted to till micturition
is established through the perineum. Here the normal
urine of the patient acts as an efficient cleansing lotion
and flushes the wound.
3. Three Cases of Gastroptosis Treated by Gastro-
pexy.— Middleton Connon records the history of three
patients who were the subjects of well-marked gas-
troptosis. They were all males, not females as is com-
monly the case, and they were not neurasthenics — the
usual type of patient in this disease. Occupation
seemed to be a predisposing factor in each case, as they
were all workmen who, over long periods, had, from the
nature of their work, to lift heavy weights. Gas-
tropexy, according to the method of Rovsing, was em-
ployed in all three cases. Great benefit has accrued
from the operation after three years in one case, after
one year in another, while in the third case the opera-
tion has been comparatively recent. Scott Riddell, in
commenting on these cases, calls attention to the
marked similarity of symptoms in cases of gastroptosis
and gastrostasis from pyloric obstruction; to the
marked assistance in diagnosis which may be obtained
by means of the skiagraph after a bismuth meal, par-
ticularly by screening and skiagraphing in the erect
position; the remarkable benefit which followed on the
operation of gastropexy, and which appeared likely to
be permanent, and the great ease and success with
which Rovsing's operation can be performed as com-
pared with Beyea's and other operations.
560
MEDICAL RECORD.
[Sept. 23, 1916
4. Perforation of a Gastric Ulcer Occurring in the
Sac of a Large Congenital Diaphragmatic Hernia. —
Lennox Gordon reports this case in which it was evi-
dent that there was an acute abdominal condition, but
no satisfactory explanation of the lung signs could be
arrived at. These consisted in a hyper-resonant note
over an area extending from the costal margin as high
as the lower border of the second rib; above this the
percussion note became normal. Over this area of
hyper-resonance the breath sounds were absent, but
were present and normal at the apex. Posteriorly the
hyper-resonant note extended from the costal margin
to the seventh costal interspace, with deficient breath
sounds over the same region. No moist sounds were
heard in any area. The patient grew worse rapidly
and died with signs of acute general peritoneal in-
fection. At the autopsy it was found that half of the
stomach passed up through a large opening in the
diaphragm and occupied a high hernial sac extending
into the pleural cavity, and that the perforation had
occurred within the sac at the pyloric end of the
stomach. Few reported cases of congenital dia-
phragmatic hernia have been diagnosed during life. The
signs and symptoms which would make one suspect
that such a hernia was present are: 1. Restricted
respiratory movement on one side of the thorax.
2. A tympanitic note on percussion with breath sounds
limited in some part of the thorax. If the bowels
which occupy the hernial sac contain contents, then no
tympanitic note may be obtained. 3. The heart is
usually displaced, the displacement, of course, depend-
ing on the relationship of the heart to the ring of vhe
hernia. 4. Signs of intestinal obstruction if strangu-
lation of the hernia occurs. 5. Borborygmi may be
heard on auscultating the tympanitic ring. 6. The
most certain sign is that obtained from x--ray after a
bismuth meal. The bismuth will show the position of
the bowel above the level of the diaphragm. The first
four of the above signs were present in this case. An-
other sign which in this case was of interest, and
which may be of some diagnostic value, was the peculiar
attitude the patient adopted. He stood, or sat up in
bed, with the body bent well forward and the knees
bent. This attitude appeared to be one which most
relieved the tension of the diaphragm. The large con-
tents of the sac and the large hernial ring (4 inches
in diameter) made it evident that operation would have
offered little hope of recovery. The hernial ring in
this case was situated in the right anterior portion of
the central tendon of the diaphragm in front of the
liver, which is a rare position, and does not fall in with
what we know of the development of the diaphragm.
II Policlinico.
I iigusl 1. 1916
Clinical Studies of Pernicious Anemia. — Roccavilla re-
ports three cases of this affection. The first patient
presented clinically the Biermer-Ehrlich syndrome. Tin-
second died eighty days after admission to the hospital,
and the clinical diagnosis had been anemia perniciosa
luetica, the Wassermann having been intensely positive
throughout. Antiluetics could not prevail over the
symptoms, and there was a positive intolerance toward
mercury. The number of hemorrhages made any plan
of intravenous medication difficult. There seems to have
been nothing in the autopsy to suggest syphilis. In
the third case the clinical diagnosis was anemia aplas-
tics. All cases were hopeless from the start, and the
author for personal reasons declined to make a trial of
splenectomy. At autopsy lesions were found throughout
nearly all the important organs, in part because of the
generalized punctiform hemorrhages and transuda-
tions. Nephritis was a constant find and interstitial
hepatitis with or without cirrhosis was present in all
cases. Radical changes in the heart and great vessels
were not of constant occurrence. The gastroenteric
system generally suffered, and dryness of the mouth,
throat and fauces is especially mentioned along with
vomiting, anorexia and gastralgia. The finds in the
blood, spleen and bone marrow are those to be ex-
pected in pernicious anemias.
Simulation of Typhoid Fever by Leucemia. — Bolaffi re-
ports a case of subacute leucemia with small lympho-
cytoids, and another of chronic myeloid leucemia simu-
lating typhoid fever. The last-named is of special in-
terest, the author having been requested to make an
autopsy on a victim of typhoid fever with broncho-
pneumonia. There seemed to have been no doubt as
to the clinical diagnosis; the patient had high con-
tinued fever, diarrhea, abdominal meteorism, enlarged
spleen, etc., along with the pulmonary complications.
However, the widal had been negative, and blood cul-
tures negative, although the latter find could not ex-
clude typhoid. The liver was swollen greatly. Aside
from numerous small hemorrhages and a general hyper-
trophy of viscerial and superficial lymphnodes, there
had been nothing to cause suspicion of leucemia. How-
ever, a careful histological study of the visceria showed
evidence of the myelocytic form of this disease. Was
the syndrome of an infection due to some unknown com-
plication, or was it a phase in the evolution of leucemia?
The author holds to the second possibility.
EI Siglo Medico.
August 5 and 12, 1916.
Hemopathies. — Pittaluga writes on the proper method
of classifying diseases of the blood and introduces
some innovations. For example, he recognizes a class
which he terms hemodystrophies, which comprises
hemorrhagic diathesis, polycythemia and chlorosis,
Anemias (oligohemias) comprise the dysplasias (pro-
gressive pernicious anemia) and the orthoplastic forms.
Eight forms of leucemia are enumerated. Under lym-
phoid hyperplasias, including splenomegalies, eight
forms are also given. Under this group we find in-
cluded the status lymphaticus. Here also belong the
splenic anemias. Under granulomatoses we find the
blood states of non-tuberculous scrofula and other con-
ditions which simulate Hodgkin's disease, excluding all
the leucemias. To a sixth group belong lymphosarcoma
and congeners which are styled neoplastiform, in con-
trast with true neoplasms of the lymphatics. Blood
parasites form a separate class, and from this the
author naturally passes to bacteriemias, etc., closing
with the blood states of non-infectious general diseases.
The author discusses especially the dystrophies, as a
new conception of blood pathology. Under hemorrhagic
diatheses he includes all the acute, acquired forms, such
as purpura, scorbutus, Barlow's disease, acquired hemo-
philia, Winckel's disease, paroxysmal hemoglobinuria
and icterus hemolyticus, the two latter, however, be-
longing only partly in this group. Polycythemia is
placed in the dystrophies because of its possibly neuro-
trophic character, as shown by the coexistence of vaso-
constriction and vagotonia, and also by reason of the
biochemical changes in the blood plasma. There can be
no doubt that chlorosis is of dystrophic origin because
of its nervous substratum, and endocrinic and meta-
bolic factors.
Case of Encephalopathia I'aludica. — Fernandez Sanz
relates the following case. Four years earlier, when
patient was nine years old, she suffered from typical
attacks of intermittent fever. These at the outset oc-
curred daily for a week. At first diurn"al the attacks
Sept. 23, 1916]
MEDICAL RECORD.
561
became nocturnal. There were in both cases periods
of remission. At the period of highest temperature
there was slight delirium. The child recovered spon-
taneously and exhibited some mental confusion and
pareses, attributed to weakness. There had been no
marked evidence of organic brain lesion. About three
years later the fever reappeared, and on the ninth
day, when temperature was highest, patient was
seized with loss of consciousness and convulsions which
became continuous (status epilepticus) , and were fol-
lowed by pareses of the face and extremities which
slowly improved. When first seen by the author (Feb-
ruary, 1916) she seemed in some ways remarkably well,
but was seen to suffer from cough, tachycardia and
tachypnea. The face was turned slightly to the right,
and the innervation of the left side was inferior. There
was weakness in some of the muscles of the extrem-
ities, and ataxic gait. The left half of the tongue
showed paralysis, which was also notable in the left
velum and left vocal cord. The tendon reflexes in all
four limbs were exaggerated. Foot clonus was absent.
Plantar reflex weakly positive with foot in plantar
flexion. The patient probably had received some qui-
nine during her last malarial attack, but exact data
were lacking. A review of the case for its entire
four years showed first the very insidious inception of
nervous disorders dating from the periods of high
temperature with delirium. The earliest nerve symp-
toms represented a left-sided paresis of the tongue,
velum and larynx, and the isolation of these symp-
toms suggested a Jacksonian epilepsy, due to a bulbar
lesion, perhaps a slight hemorrhage. The vagus was
clearly implicated as shown by the behavior of the
thoracic organs. This focal lesion was apparently the
sole intracianial accident of the first attack. Three
years later the nervous manifestations appeared sud-
denly as a convulsive crisis. The bilateral involvement
of the muscles of the limbs suggested a second hemor-
rhage of unknown locality, producing temporary pres-
sure symptoms, and capable of a considerable degree of
recovery, in contrast with the Jacksonian lesion which
left permanent consequences.
La Presse Medicate.
August 17, 1916
Radical Cure of Cancer of the Pylorus. — Panchet
writes in the interest of gastrectomy with gastro-
jejunostomy (termino-lateral). The first pylorectomy
was done by Pean in 1879. In 1895 Doyen published a
full technique of the subject. The author has operated
several hundred times by gastric resection. Cancer of
the stomach is the most frequent of all cancers and
80% of it is pyloric. This location really has the ad-
vantage of giving the patient a much better chance
for recovery under radical procedure. Precocious
diagnosis may often be made by the combined aid of
the a--ray and tubage followed by cytologic study. Ex-
ploratory laparotomy is practically without risk. It
should be done, on a large scale, under local anesthesia
and many cancers may be discovered in the early stage,
and radically cured. Gastric chemistry is secondary in
importance. Early operation means a benign operatio".
It is necessary that the four groups of gastric glands
in association with the four vascular groups should be
thoroughly extirpated, the vessels having been
ligatured. The so-called benign operation need not last
over 40 minutes; while for the more severe eases up to
an hour and a quarter is required. The author is
strongly opposed to two stage operations as favoring
cancer grafts in the suture line in preliminary gastro-
enterostomy, while the secondary gastrectomy must be
done within narrower limits and in general is rendered
more difficult by the adhesions which result from the
first stage. Again, many patients, once the gastro-
enterostomy is established, refuse to submit to gas-
trectomy; and a simple gastroenterostomy is indicated
solely when metastases are present. It is seldom that
exploratory laparotomy is contraindicated; this occurs
in the main only in inoperable cases recognized to be
such without its need (peritoneal metastases, adhesions
to ribs, etc.) . After the exploratory incision has been
made, various conditions may be disclosed which render
the cases inoperable, such as secondary nodules in the
liver or peritoneum. In such cases, if there is pyloric
obstruction in a small adherent stomach, jejunostomy
should be performed; if there is no pyloric obstruction
nothing should be done. If the case is operable save
for hepatic and peritoneal metastases an anterior
gastroenterosty (Y) or posterior gastroenterostomy
should be performed according to location. If there
are no metastases the case is radically operable. Gas-
trectomy may be simple or difficult according to cir-
cumstances. The former is the case in mobile pylorus.
If numerous adhesions are present it is a question be-
tween pylorectomy and gastroenterostomy, and the
majority of operators prefer the latter because of its
low mortality, especially when done under local anes-
thesia. Other surgeons, like the author, prefer the
added risk of a resection, because even if it be only
palliative, the result is far better. Instead of a few
months' survival we often get a year or more. The
mortality from "mutilating gastrectomy" may vary
from 4 to 30 per cent. On account of the short survival
inevitable in gastroenterostomy the author would as-
sume the 25% operative mortality risk in order to give
a much longer survival to the others. Long survivals
from gastroenterostomy are sometimes seen in chronic
gastric ulcers which have finally become cancerous, but
this is quite a special class of cases. The following
rational signs aid in directing suspicion to a cancer:
Loss of appetite and vigor, digestive disturbances not
sufficient to account for the asthenia. Examination of
stomach contents shows slight stasis and diminution of
HC1. The .r-ray examination shows either stasis or
motor disturbance, thickened wall or a lacuna cor-
responding to the tumor. If cumulation of evidence
justifies the step, exploratory lapurotomy is made. If
a chronic ulcer is found which has not developed can-
cerous degeneration, it should be removed (71% of
cancers are grafted upon ulcers). A simple resection
of the pylorus may be regarded as a preventive of
cancer. Before gastrectomy the patient should have his
teeth scaled and gums painted with iodine, the colon
evacuated and the stomach washed out with hydrogen
peroxide. For 8 days before operation the patient
drinks sterile drinks from sterile receptacles. He also
practices respiratory gymnastics in the interest of pre-
vention of post operative (hypostatic) pneumonia.
Even in the most radical of operations the author does
not use ether or chloroform anesthesia, but relies upon
local or spinal analgesia with only brief inhalations of
ethyl chloride. Gastrectomy is first done and the gastric
stump at once implanted into the jejunum. The incision
for resection is done with the thermocautery after
previous use of the ecraseur. The duodenum has pre-
viously been treated with the latter instrument and
Iigated, the stump being covered with a bit of omentum.
At the close of the operation the patient is at once
fed. Temperature and vomiting mean a clot of blood
in the stomach and the latter should be irrigated with
hydrogen peroxide solution until all washings come
away clear. This condition may delay feeding, which
consists of hot drinks, slightly alcoholized, followed
after a few days with milk.
562
MEDICAL RECORD.
[Sept. 23, 1916-
Snaurattre Mtbitixw.
The Size of the Fee and the Value of the Ex-
amination.— Dr. C. L. McClellan says that the in-
surance companies should get what they pay for,
although country practitioners unfortunately are
not always prepared to give the companies what
they should have for the money. Nevertheless,
whenever the five dollar fee is cut down, the value
of the examination is cut down. Instead of the fee
being cut down, he would ask for an increase in
certain cases. If an additional fee, say, only one
dollar apiece, was given, when it was necessary to
make a blood pressure test, then it would be some
inducement for the country practitioner to buy a
testing machine, for which he has little use outside
of life insurance work. He further believes that if
the insurance companies would insist on a tuber-
culin test in every case in which the policy was
over five thousand dollars, or where the applicant
was of tuberculous tendency, it would be inex-
pensive and it would be the best investment they
could make. — Texas State Journal of Medicine.
The Full Duty of the Examiner.— Dr. H. C.
Black says we make an examination of a man and
find he is a good physical risk and we answer all
our questions; have we done our full duty then?
He was referee for a New York Company at one
time and all examinations made in Texas came to
him to see if there were any omissions, etc. An
examination by a good reliable man came to Dr.
Black with the statement, "this man is worthy of
a ten-thousand dollar policy." Physically he was;
he was a farmer and there was no doubt that he
was in perfect health, but the writer happened to
know him. He knew that when at home this man
did not drink whisky, but every time he went to
the city he would go down into the tough district
of the town and stay there for weeks, drunk from
the time he got there until he got home. Dr. Black
wrote the facts to the company. — Texas State Jour-
nal of Medicine.
Life Insurance in the Tropics, Romer says, is
profiting by the progress of recent years in trop-
ical medicine. Life expectancy for officials in the
Dutch East Indies is 5 years less, up to 35; 4 years
less at 40; 2 years less at 50; while at 70 it aver-
ages the same as in the Netherlands. No statistics
are available for non-officials. The intestines are
in a condition of lessened resistance, the result of
errors in diet, especially overloading with rice. The
mortality among Europeans seems to be highest the
third year of their, residence in the tropics, then
the fourth and fifth. On return to a temperate
climate they are liable to pneumonia, and amebic
dysentery may be responsible years later for an
abscess in the brain or liver. Chronic malaria,
sprue, heart disease and, especially, gout may re-
duce the life expectancy after return to Europe.
An assumed simple cardialgia or gastritis may be
the first manifestation of an ulcer or cancer. He
urges that careful records be kept of persons who
have returned from a residence in the tropics.
Tuberculosis runs a particularly malignant
course in the tropics, attributed to the fact that the
heart beat is accelerated on an average ten beats a
minute and the respiration often by 4.5. Especially
in the tropics, married men are better risks than
the unmarried, as there is more attention to hy-
giene. Lands newly opened to colonization reduce
the life expectancy somewhat. A tendency to cor-
pulence is particularly risky in the tropics on ac-
count of the disinclination to exercise and the ten-
dency to overeat. — Nederlandsch Tijdschrift voor
Geneeskunde, January,. 1916.
Life Insurance as a Specialty. — Dr. Irving Mc-
Neil says that there is a need for more careful se-
lection of risks as shown by the mortality statistics :
For instance, as Smith has brought out, quoting
from figures given by W. R. Harrison, 60 per
cent, of the deaths from tuberculosis in fraternal
insurance companies occur within the first two
years after being insured. Again, the statistics of
the United States Government show a greater
longevity among women than among men, yet the
mortality tables of insurance companies show a
lesser longevity. Why is this so? It is because
women applying for insurance, as many do upon a
premonition of their being something wrong, as a
rule, are less carefully examined than are men.
But why, it may be asked, do life insurance com-
panies accept examinations alike from the compe-
tent and incompetent, the careful and the careless,
the painstaking and nonpainstaking examiners? It
is because life insurance companies in spite of the
large philanthropic element in their make up, are
after all merely business organizations, like other
business organizations and out for business and
competition is so keen between the rival companies
that they are inclined to forget some of the finer
points and ideals. Whether in future the philan-
thropic element will get the better of the purely
commercial, remains to be seen, but it is safe to-
predict that either on account of a lofty idealism
or else because it will be found to pay in plain
dollars and cents, life insurance companies will be-
come more particular as to who makes their ex-
aminations and how and the physician who is prop-
erly equipped and who is willing to give his time
and attention to this kind of work will find himself
appreciated. A closer relationship between the
medical director and his examiner should improve
matters. — Texas State Journal of Medicine.
Metabolic Diseases in Relation to Obesity. — In
a paper on the relation of disease to obesity,
read before the Assurance Medical Society in
London, Dr. F. Parkes Webber said that the not
uncommon association of obesity with gout, uric
acid gravel, and diabetes mellitus was so well
recognized that there was no need to enter into
any detailed discussion of the subject. Such asso-
ciations could not seem surprising, if we remem-
bered that obesity itself, whether inherited or
acquired, was a metabolic disease or a metabolic
abnormality. Moreover, over-eating and sedentary
habits were certainly not rarely factors in the
causation of gout and diabetes mellitus, as they
were in the causation of obesity. It was espe-
cially the mild form of diabetes mellitus occur-
ring in middle-aged and elderly persons that was
associated with obesity.
The Relation of the Medical Examiner to the
Medical Director.— Dr. M. B. Grace criticises
somewhat severely the attitude frequently assumed
by the medical directors of insurance companies to
their medical examiners. However, Dr. Grace says
this attitude of the medical director is undergoing a
rapid change for the better and he believes that the
time is not far distant when both eyes of the medi-
cal directors will be wide open and their sensitive
appreciation of honest work carefully executed will
reduce them to reward instead of castigating medi-
cal examiners for their work. — Texas Journal of
Medicine. »
Sept. 23, 1916]
MEDICAL RECORD.
563
Sank KroiruiH.
Tuberculosis, a Preventable and Curable Disease;
Modern Methods for the Solution of the Tuberculosis
Problem. By S. Adolphus Knopf, M.D. (New York
and Paris), Professor of Medicine, Department of
Phthisiotherapy, at the New York Post-Graduate
Medical School and Hospital. New Edition. Octavo;
394 pages, with 115 illustrations. Price, $2.00 net.
New York: Moffat, Yard & Co., 1916.
This book comes from one whose authority on the sub-
ject is so unquestioned that his unwavering optimism
is like a call to victory for the race. Dr. Knopf is far
from minimizing one iota of the dread details of this
frightful scourge; he knows it from its insidious be-
ginnings to its fatal end, but his whole book is written
to show that it need have no beginning, or, if too late
for that, that it may be balked of its end ; in short, it
is both preventable and curable. The author's style is
of the clearest; it would be as impossible for the plain
man to misunderstand him as for the literary to fail
to enjoy him. He frankly gives to the public all neces-
sary data. . . . Dr. Knopf outlines with a vivid
clarity all his own the duty of every member of the
community in this crusade, and ends in a note of splen-
did optimism that, coming for such a source, may well
put heart and hope into the most fearful.
We have repeated here what was said in our review
of the first edition of this work. The reviewer has noth-
ing to add in reference to the new edition, except to
state that in it many of the typographical and some his-
torical errors of the first edition have been corrected and
a chapter which might be called a reply to the criticisms
on the first edition, with comments by prominent au-
thors, has been added. If anything, this should make
the new edition even more interesting than the first.
For those who are not familiar with the former edition
we reproduce the titles of the twelve principal chapters,
which speak for themselves: What a Tuberculosis Pa-
tient Should Know of His Disease ; What Those Living
With Patients Should Know Concerning the Disease;
The Duties of the Physician Toward His Patient, the
Family of the Patient, the Community He Lives in, and
Other Communities; How the Sanatorium Treatment
May Be Adapted to and Imitated in the Home of the
Consumptive; How Sanitation and Proper Housing May
Help Toward the Prevention of Tuberculosis; The Du-
ties of Modern Municipal Health Authorities; The Du-
ties of State and Federal Authorities in the Combat of
Tuberculosis ; What Employers, of Everv Kind, Can Do
to Diminish Tuberculosis Among the Men and Women
Working for Them; The Duties of School Teachers,
Educators in General, and of the Public Press in the
Combat of Tuberculosis; The Duties of the Clergy,
Philanthropists, Charitable Individuals, and Charity Or-
ganizations ; The Duties of the People in the Combat of
Tuberculosis.; Prospect of Ultimate Eradication of Tu-
berculosis.
International Clinics. A Quarterly of Illustrated
Clinical Lectures and Especially Prepared Original
Articles on Treatment, Medicine, Surgerv, etc.
Edited bv H. R. M. Landis, M.D. Volume II. Twenty-
sixth Series, 1916. Price $2. Philadelphia and Lon-
don: J. B. Lippincott Company.
In this issue of the Clinics there are twenty-four
articles of treatment, medicine, psychiatry, obstetrics,
public health and surgery. The subjects range from a
timely article on venesection and its indications by
Beardsley through interesting discussions of auricular
fibrillation by Canby Robinson and immobility of the
diaphragm by Pryor to the first portion of an extensive
analvsis of fifty cases of dysthyroidism by Swan. Other
articles on varied topics help to make this number one
of the more interesting and instructive issues of the
International Clinics.
The Kinetic Drive, Its Phenomena and Control. By
George W. Crile. M.D., Professor of Surgery, West-
ern Reserve University: Visiting Sureeon to the
Lakeside Hospital. Cleveland. Wesley M. Carpenter
Lecture, 1915. Edited by Amy F. Rowland B.S.
Price, $2 net. Philadelphia and London: W. B.
Saunders Company, 1916.
To those who are familiar with the writings of Dr.
Crile upon this subject this small book will bring noth-
ing especially new. It is in effect an epitome of his
larger work "Man — An Adaotive Mechanism." such as
could be presented in a single lecture and embodies the
same ideas and suggestions, put forward in the author's
always interesting and attention-compelling style. The
book makes a handsome appearance but is quite small.
Studies in Ethics for Nurses. By Charlotte A.
Aikens, formerly Superintendent of Columbia Hos-
pital, Pittsburgh, and of the Iowa Methodist Hos-
pital, Des Moines; formerly Director of Sibley Me-
morial Hospital, Washington, D. C. Price, $1.75.
Philadelphia and London: W. B. Saunders Company,
1916.
The author of this work is well known as a writer of
books for nurses; the present volume is probably the
most useful of the set. The author has evidently ob-
served carefully and pondered deeply over the many
factors which enter into the life and success of nurses.
In this volume will be found a discussion of such topics
as Loyalty, Responsibility, Habits, Temper, Truthful-
ness, Obedience, Economy, Tact, Hospital Accidents,
Honesty in Bedside Records, Response to Calls, Picking
Cases, Too Much Dignity, The Nurse Who "Tells
Things." The book is well and brightly written and is
well worth reading. Many a patient can indorse what
the author has to say about "preventable noises," the
"hospital manner," and the nurse "with a commanding
presence." There is much in the book which should
make readers stop and think; and the result will be
appreciated by doctors and patients.
Refraction of the Human Eye and Methods of Esti-
mating the Reaction, Including a Section on the
Fitting of Spectacles and Eyeglasses, etc. By James
Thorington, A.M., M.D., Emeritus Professor of Dis-
eases of the Eye in the Philadelphia Polyclinic and
College for Graduates in Medicine; Member of the
American Ophthalmological Society; Fellow of the
College of Physicians of Philadelphia, etc. Price,
$2.50. Philadelphia: P. Blakiston's Son & Co., 1916.
The author's preface gives an excellent idea of the
aims and scope of the book. It is to teach the student
the necessary physics and mathematics for an under-
standing of his subject, and then give him the methods
by which refractive errors may be found, analyzed, and
corrected. It is an excellent book for beginners, because
it is written with unusual clearness, gives necessary
details as to technique, and yet is not overburdened
with mathematics. The organization of the book is
good, leading from detail to detail of the study and
work logically and clearly in spite of the marked con-
densation necessary to cover a large subject in 400
pages.
A Manual of Gynaecology and Pelvic Surgery for
Students and Practitioners. By Roland E. Skeel,
A.M., M.S., M.D., Associate Clinical Professor of
Gynaecology, Medical School of Western Reserve Uni-
versity; Visiting Surgeon and Gynaecologist to St.
Luke's Hospital, Cleveland; Fellow of American As-
sociation of Obstetricians and Gynaecologists; Fellow
of American College of Surgeons. With 289 illustra-
tions. Price, $3.00. Philadelphia: P. Blakiston's
Son & Co., 1916.
Dr. Skeel's book adds one to the present list of good
texts in gynecology. It is a convenient size and the
type is good. The illustrations are numerous, clear,
and well chosen. Operative technique is adequately
illustrated and explained, and diagnosis is carefully
covered. The book, as Dr. Skeel planned, is a satisfac-
tory one to put into the hands of student or practitioner.
The discussion of "Treatment of Menstrual Disorders"
is brief and unsatisfactory. No mention is made of the
value of exercise, both intermenstrual and at the onset
of pain, nor of the value of belladonna in the spasmodic
type of dysmenorrhea.
The Medical Clinics of Chicago, March. 191fi. Vol-
ume I, No. 5. Price $8 per year. Published bi-
monthly. Philadelphia and London : W. B. Saun-
ders Company.
This number contains eighteen case presentations from
seven different clinics and follows the style of the
previous numbers. The cases are given a little more
space than in some of the previous numbers which is a
decided improvement. The best contribution is the
discussion of congenital syphilis by Abt. One good
feature of this issue is the subsequent report of two
cases previously presented. This is a good thing, but
one cannot help feeling that the report would be a
little more instructive if it had been withheld until the
whole case could be presented at once. The serial
method lacks impressiveness.
564
MEDICAL RECORD.
LSept. 23, 1916
^oririij Sports.
AMERICAN THERAPEUTIC SOCIETY.
Seventeenth Annual Meeting, Held at Detroit, June
9 and 10, 1916.
The President. Dr. Robert T. Morris, New York
City, in the Chair
President's Address. — Dr. Morris stated that in the
midst of rapid advancement in special studies he
would ask the question whether the physician to-day
really cared to know what was the matter with a pa-
tient, or did he prefer to find in the case something in
which he was very much interested. A concrete ex-
ample was diabetes mellitus, which was only a symp-
tom. Did the physician attend to make a diagnosis of
diabetes as a diagnostic entity? No; it was a signal
or sign to him, and he now proceeded to find out what
was the matter with the patient. He knew that dia-
betes mellitus was always due to hyperglycemia. He
knew that some peripheral irritation or some focal in-
fection might be exciting the adrenals, which in turn
excited the whole thyroid, the chromaffin system, the
liver, causing disturbances of function, so that in con-
sidering diabetes from a therapeutic standpoint one
should begin with the question of what peripheral ir-
ritation or what focal infection might be driving the
adrenals up to the point where there was cough as a
symptom of diabetes mellitus. If one did not do this
and was interested only in the symptoms, the patient
as a whole was left out. In the rapid advance of
laboratory methods one man did not know what an-
other man was doing. This was true not only in med-
icine but in chemistry. The layman in trying to select
a competent medical adviser to-day was very much like
a client in a court of law trying his own case. The
time was coming when we should have a new kind of
consultant, one who took the word of the analyist, ap-
plied the lines of his synthetic mind, and brought to-
gether parallel rays in such a way as to focus them
upon the case as a whole. When we had the new
ideas of Lane with regard to colonic infections pre-
sented to us, we all became intensely interested, and
it was soon found that Lane had struck the germ of
a great truth; but something was behind the colon or
the enteron causing functional disturbance, and if one
merely took out the red flag he did not try to deter-
mine what the red flag stood for. If he took a lot of
cases of gastric ulcer and of goiter that were sent to
him for operation, the patients having decided that an
operation was the thing to be done, he found by put-
ting them through the laboratory and making a careful
study of their cases they were not surgical cases at
all. He had found this over and over again. He
doubted if he operated upon one-half of the patients
who were sent to him for operation at the present
time. We were dealing with very deep questions when
we were working out those of peripheral irritation and
focal infection, and the patient should be considered
from every point of view.
What Therapy Means. — Dr. OLIVER T. OSBORNE of
New Haven, Conn., stated that practitioners should
not forget to use every means to prevent the spread of
contagion and the infection of others, if the disease
was contagious. If the disease was not contagious,
the general hygiene and care of the secretions of the
nose and mouth and of the excreta were always of
more or less importance. If the cause of a disease
could be removed or actively combated, that was the
part of the treatment that took precedence of all
others. If the disease, or its localization, or its lesion,
or a simile condition, as a cold or a headache, could
be aborted, that was another primary object of treat-
ment. The direct treatment of the cause might do
this or local measures, as ice, heat, hyperemia, leeches,
purses, simple surgical measures, or various drugs
might so act as to prevent, control, or abort an im-
pending: lesion of functional disturbance. A lesion
having occurred, the patient would not be well until
it had disappeared, resolved, or been removed, and
hence as soon as a lesion had been established, it was
the aim of all of our science to eradicate it. Time
and nature's own antagonistic and recuperative powers
might unaided accomplish this object, but very fre-
quently we could aid and hasten nature's processes by
various means. Frequently, only surgery could remove
a lesion. At other times a lesion became permanent
and the patient was permanently damaged to that ex-
tent. He might be apparently well in spite of this
defect, or he might be well as long as he modified his
food, life, and activities; or he might be an invalid;
or the lesion might be the cause of his death sooner
or later. However, in any of these eventualities the
treatment or management of the lesion and its path-
ological results was the main object of treatment.
Whether or not the lesion could be successfully treated,
objectionable or disturbing symptoms must be stopped
or ameliorated. Students were not sufficiently taught,
and the practitioner did not often enough consider the
disturbances of function due to or caused by the dis-
ease that was present. The diet must of necessity be
modified by the intensity of the illness, the character
of the illness, and the condition of the organs of diges-
tion. The food and drink must always be carefully
considered, regulated from day to day to meet the
conditions and then gradually increased during con-
valescence, or perhaps be modified by a lesion that
was permanent.
Dr. Francis M. Pottenger of Monrovia, Cal., stated
that one should not only consider the lung, the heart,
the stomach and intestinal tract, but the nervous sys-
tem in dealing with cases that presented themselves.
Modern medicine centered its attention largely on
scientific facts and forget the fact that the patient was
not a thinking being, and in so far as this fact was
forgotten did the practitioner fail. The idea of the
essayist was broad and he was following out the best
of what modern therapeutics stood for.
The Relationship Between the Nervous System and
Therapy in Pulmonary Tuberculosis. — Dr. Francis M.
Pottenger of Monrovia, Cal., said there were several
facts which led him to believe that the more important
factor in the production of temperature was an in-
terference with normal heat dissipation, rather than
an unusually active heat production. In support of
this theory he offered the following facts: (1) The
experimental introduction of protein produced a gen-
eral sympathetic stimulation. (2) The manifestations
of clinical toxemia were those of general sympathetic
stimulation. (3) It had been noted on experimental
animals that when protein was injected parenterally
that there was a constriction of the vasomotors of the
surface, as determined by the constriction of the ves-
sels of the ear of the rabbit (Jona). (4) A rise of
temperature was accompanied by other symptoms of
toxemia, and was accompanied by constriction of the
superficial blood vessels, which, at times, manifested
itself by a sensation of chilliness. (5) The action of
toxins and adrenin was practically the same; both
acted chiefly upon the nervous system. The introduc-
tion of adrenin caused a constriction of the superficial
blood vessels, and a rise in body heat. From these
facts he was led to believe that the rise in temperature
which occurred in natural infections, or whenever a
foreign protein of any type was introduced parenter-
ally into the body of either man or animal, would not
occur apart from their action through the sympathetic
nervous system, which produced a general vasocon-
striction of the superficial blood vessels, and interfered
with the dissipation of heat. He was further convinced
of this from the fact that emotional states, particu-
larly the depressive emotions, such as those of fear,
disappointment, anxiety, discontent, and worry, pro-
duced a general sympathetic stimulation; and that all
of these depressive conditions were associated with a
rise in temperature, at least in the tuberculous indi-
vidual. Since sympathetic stimulation was produced
by toxins, no matter what their source, we might find
it in tuberculosis as a result of the absorption of pro-
tein from the bacillus itself, probably also as a result
of the absorption of destroyed tissue and from any
other bacteria that might complicate the process. While
toxemia could not be caused by the deDressive emo-
tional states, yet these produced sympathetic stimula-
tion and acted in the same manner as toxins; conse-
quently, they must also be relieved the same as tox-
emia, if we would relieve the organisms from the in-
hibiting action of the sympathetic system.
Rest was an essential in treating toxemia. It was
valuable whenever exercise increased the sym lathetic
stimulation by pouring forth into the tissues an in-
creased amount of toxins. Thus we note that patients
with rapid heart's action, poor appetite, deficient di-
gestive activity, constipation and rise of temperature
might experience an improvement, or even lose all of
these symptoms under rest; and, as they disappeared,
encouragement followed and a general improvement
took place.
Sept. 23, 19161
MEDICAL RECORD.
565
The influence of food might be greatly enhanced by
relieving the sympathetic stimulation due to toxemia
and depression. He usually noted that the appetite
and digestion, and, therefore, nutrition of the patient
improved when he was put at rest in the open air
and given hope and encouragement.
There was a time when exercise had an important
and beneficial influence upon the patient. Exercise
called for increased metabolism. Increased metabolism
was met by increased food intake; consequently, after
toxemia had passed and the patient could exercise with-
out producing toxic symptoms we could greatly im-
prove his nutrition by permitting exercise.
The effect of baths, either air, sun, or water baths,
was exerted through the nerve endings in the skin and
extended to every cell of the body. If the reactivity
of the skin was well cared for, as it might be through
the stimulating effect of water, light, or air, upon it,
the vasomotor tone was improved, the metabolic ac-
tivity of the patient's cells was hastened, and the elim-
ination of heat, moisture, and various toxic products
was hastened.
Dr. Ernest Zueblin of Baltimore. Md., was grat-
ified that Dr. Pottenger had discussed the problem of
therapeutics and of therapy in general on such a broad
basis. In connection with the therapy of tuberculosis
and varied manifestations of the disease the sympa-
thetic nervous system played an important role. From
personal study and observation, the speaker had found
that in most infections the sympathetic nervous system
was deranged. A very interesting fact was that the
rise of temperature in cases of tuberculosis could be
explained by the retention of heat. We could explain
certain psychogenic causes in connection with the rise
of temperature by the existence of toxemia and dis-
turbed action of the sympathetic nervous system. It
was known how the gastrointestinal tract was affected
under the influence of disturbed reaction of the sym-
pathetic nervous system.
Dr. Oliver Thomas Osborne of New Haven thought
the time had passed when we should have a series of
books on the practice of medicine or anything else
when treating disease of this or that particular type.
We should simply consider that we had types of in-
fection, and with specialization that particular view
should be held. Headache, backache, fever, dry tongue,
nausea and vomiting were all symptoms of infection.
The treatment of the condition depended on what the
future prognosis was and how actively the patient
was treated.
Oxygenated Milk. — Dr. Clifford G. Grulee of Chi-
cago read a paper on this subject and drew the follow-
ing conclusions: "(1) It would seem from our ex-
perience that oxygenated milk has a definite place in
hospital regime. It offers us the safest milk from all
standpoints at a very much lower expense than that
at which certified milk — with which it compares very
favorably — can be obtained (about six cents to the
quart). (2) There is always fresh milk to be had, a
great advantage to a diet nurse who is rushed for
time. (3) All danger of infection from pathogenic or-
ganisms present in the milk is removed. (4) There is
no danger to the infants from sour milk which con-
tains no specific pathogenic microorganisms, what-
ever this danger may be." As to whether it would
be possible to market this milk on a large scale or
whether this would be desirable, he was not willing to
put himself on record. Certain things had led him to
think that this could be done and possibly to advan-
tage. That it had worked out to entire satisfaction in
the Presbyterian Hospital of Chicago he had no hesi-
tation in asserting.
Dr. Francis M. Pottenger asked Dr. Grulee what
was the process of aeration.
Dr. Grulee replied that the milk was heated to 122-
128° F. for one half hour, and was stirred by a fan in
the reservoir so that it was kept in motion the whole
time.
Dr. Noble P. Barnes of Washington, D. C, asked
Dr. Grulee if he found that the natural enzymes were
destroyed by this process, or whether the lactic acid
bacillus was killed from prolonged heating in these
cases, as was sometimes observed in feeding ster-
ilized or pateurized milk.
Dr. Grulee in speaking of whether there was kill-
ing of the lactic acid bacillus in the milk, stated he
had not observed any harm from it. This milk was
being used with increasing frequency in the hospital,
and some of the men in the internal medical service
thought that this milk was better in feeding typhoid
cases than ordinary milk. They got the milk in ten
gallon tanks from the farm and it cost five cents a
quart.
Hi-. Robert T. Morris asked as to the effect of
sterilized milk when given to babies.
Dr. Grulee replied that he could not answer the
question satisfactorily, but he had always felt that
the danger of sterilized milk given to babies had
been exaggerated. He happened to know of only one
case of scurvy which occurred in the practice of a col-
league who gave the child raw milk. He then boiled
the milk, gave it to the child, and the scurvy cleared
up.
The Therapeutics of Cerium. — Dr. Reynold Webb
Wilcox of New York said we could safely assert that
cerium oxalate resembled bismuth subnitrate in its
therapeutic action, with the advantage that it did not
give rise to such an unpleasant odor to the breath as
did the latter, owing to the tellurium contained in it, and
that it was not so likely to be contaminated with arsenic
as was the latter. The therapeutic uses of cerium oxa-
late were very similar to those of bismuth, which were
for local effect, and success required that the doses
should be of a magnitude commensurate with the re-
sults which it was desired to obtain, namely, 10 grains
every four hours. Further than this, this dose should
be frequently exceeded, as it was known that it could
be done with safety, 30 grains having been adminis-
tered with good results. Bearing these facts in mind,
the results of twelve years' experience in the use of this
remedy had been confirmed by skillful therapeutists in
internal medicine, and had shown conclusively that
cerium oxalate was an agent which, when used in
proper dosage and with due discretion, would produce
typical and satisfactory results, and its therapeutic
value could not be disputed.
Experimental Pathology of Goiter.— Dr. Ernest
Zueblin of Baltimore called attention to the point that
Kocher had already reached the conclusion that goiter
must have a certain etiological relation to certain ad-
mixtures and impurities of the soil, which must be of an
organic or organized nature, of a short lifetime, since
the disease only increased as long as the suspected
water was used. Wilms, based upon the experiments
of Bircher, expressed the following theory: He admitted
as the cause of goiter a toxic substance not of parasitic
nature but containing the dried animal residues found
in the geological layers characteristic for the periods of
marine submersion. The water passing through these
layers became polluted by these substances and became
goitrogenous. Heredity and disposition played no
doubt a role in endemic cases of goiter, while changes
in the internal secretion must be thought of, particu-
larly in cases of sporadic, to a lesser extent in instances
of endemic, goiter. The suprarenal bodies, ovaries,
pancreas, etc., no doubt influenced each other in their
functions and a diseased condition of these organs must
have a disturbing influence upon the general functional
equilibrium. As regards the influence of heredity,
opinions differed considerably. The general impression
gained from the present knowledge of the goiter prob-
lem was, that we had not yet reached a satisfactory un-
derstanding of the etiological factors. Further contri-
butions studying the possible influence of geological
strata, of colloid substances, the water suoply, the in-
fluences of altered internal secretion, and of other possi-
bilities upon the production of goiter would certainly
help our understanding of the complex goiter problem.
Suggestions for Locating Focal Points of Infection. —
Dr. Noble P. Barnes of Washington, D. C, pointed
out that beginning with the introduction of bacterial
vaccines, when Koch recommended and used tubei-culin,
practitioners witnessed one reaction after another and
had failed to take advantage of one very important
practical apolication. Koch's tuberculin treatment was
then a failure because of misapplication. Time after
time was a focal smouldering ember fanned into an
active and destructive inflammation because of an over-
dose of tuberculin. This focal reaction had presented
itself in most every injection he had carefully observed.
The flaring up of a boil or carbuncle after administer-
ing a suitable vaccine, the appearance of urethral dis-
charge, frequent urination, or strangury, after using
gonorrheal vaccine, and the bursting forth of embryo
pimples after injection of acne vaccine were common
observations. Having these facts in mind, after pro-
longed treatment of a case of gonorrheal arthritis with
prostatic massage, irrigation, and carefully measured
doses of vaccine, in which there were days of encour-
agement, although the end result was nil, the author
decided to give the patient an unusual dose of the vac-
cine and thus incite an intense reaction in the joints
566
MEDICAL RECORD.
[Sept. 23, 1916
from which he always experienced a marked improve-
ment. Within twenty-four hours his patient had a
temperature of 103.5° F. with all the symptoms of a
general infection. Pain in the affected parts was se-
vere. Interesting and suggestive was the stimulation
of an unsuspected focal point of infection resulting in
a most distressing epididymitis. The patient informed
the author at this time of a similar inflammation of the
same structure during one of his outbreaks of unpleas-
antness over twenty years ago. Here then was a focal
point of infection he had overlooked. Upon this sug-
gestion of locating focal points of infection by obtain-
ing a reaction following a larger than the therapeutic
dose of vaccine, he had been working with a number of
cases. Focal reactions were caused best, if not only,
by injection of the killed infecting microorganisms,
and, as some of these organisms had a wide range of
affinity and adaptability, the selection of the vaccine
was very important. Vaccines and serums prepared
with due regard for tropic conditions would be the re-
quirements of the future and no doubt many of the
failures to-day would be successes to-morrow.
The Means of Prevention and Retardation of Cardio-
vascular Disease. — Dr. Charles Lyman Greene of St.
Paul, Minn., drew the following conclusions: (1) It
has now become possible measurably to retard and, to
a considerable degree, prevent cardiovascular diseases.
(2) That it is imperatively necessary in the interests
of the cardiopath and of the race that a justifiable
optimism should replace the almost universal pessim-
ism now existing. (3) A knowledge of the specific
bacterial origin of diseases of the heart should be pro-
mulgated together with the means best adapted to con-
trol of causative conditions. (4) Our old ideas with
relation to cardiac dimensions should be radically re-
vised and brought into correspondence with the actual
facts as at present definitely established. (5) Modern
methods of percussion, accurate and definitive, should
replace the older practice still in vogue. (6) The cardi-
nal value and importance together with the nature and
diversity of subjective symptoms of cardiac inefficiency
should be given their full value as means of early diag-
nosis and indicators for therapeutic initiative. (7)
The extraordinary usefulness of test doses of digitalis
with or without reinforcement by physical rest consti-
tute the very foundation of timely diagnosis. (8) A
thorough understanding of the anatomic peculiarities
of the drop heart, its association with a definite consti-
tutional state, its remarkable prolificacy with respect
to the production of symptoms of a most varied and
obscure character, together with the misleading narrow
diameters present even in dilatation, making the con-
dition one of great clinical importance. (9) The com-
mon occurrence of the drop heart, its constant rela-
tionship to general visceroptosis of which it is a part,
its frequent association with so-called nervous dyspep-
sia, and the almost universal tendency to lose sight of
the true cause of its symptoms by referring them to the
bastard symptom conglomerate long known as "neu-
rasthenia" are facts of decided clinical importance.
(10) The existence of the drop heart in the male is a
matter of great importance with respect to the fitness
of its possessor for hard manual labor and actual serv-
ice in warfare. (11) An application of such of the
newer discoveries in the cardiovascular field as are
here enumerated cannot fail to exercise a striking ef-
fect both with relation to the prevention of cardiovas-
cular disease and the retardation of established cases."
Notes on the Blood and Its Vessels in Epilepsy, and
Their Treatment. — Dr. Thomas E. Satterthwaite of
New York contributed a paper on this subject, in which
he pave a brief survey of the relation of cardiovascular
phenomena to epilepsy, and then drew the following
conclusions: "(1) Abnormalities of cardiovascular phe-
nomena occur in the vast majority of epileptic seizures.
(2) The grosser forms of cardiac disease occur rarely
in epilepsy. In fact, they are present in so small a
proportion as to indicate that they are accidental inci-
dents rather than determining factors of it. (3) That
a cerebral disease or abnormality may produce epilensv
is well established. The evidence of it has been that
removal of enlarged veins or nevoid growths adjacent
to the base of the skull has been followed by cessation
of the seizure. (4) There is. therefore, a' reciprocal
relation between circualtory disorders and epilepsy to
this extent: thai epilepsy causes circulatory disturb-
ances and that abnormalities of blood or vessels cause
epilepsy. This reciprocal relatii I believe to have
been overlooked hitherto. (5) In most forms of epi-
lepsy there is cerebral anemia, and this is relieve. 1
effectively by various heart stimulants, the high fre-
quency current, and radiant electric light. The impor-
tance of the use of cardiac stimulants in epilepsy I
believe has not been properly appreciated by the pro-
fession at large. In a certain number of cases, of
course, permanent relief is obtained only by antiluetic
treatment or some surgical procedure."
Mercurialized Serums. — Dr. F. E. Stewart of Phila-
delphia drew the following conclusions: "(1) Corrosive
sublimate becomes non-corrosive and non-irritating
when dissolved in normal serum. (2) The compounds
thus formed are just as toxic and probably therapeu-
tically as efficacious as mercuric bichloride itself. (3)
When prepared from heterologous serums, mercurial-
ized, serums must be regarded as heterologous serum
preparations, requiring conformity to the same rlues in
their administration as applied to other heterologous se-
rums, such as diphtheria antitoxin, and antibacterial se-
rums. (4) Mercury in the form of mercurialized serums
is an ideal form foV administering mercury subcutane-
ously, intramuscularly, intravenously, and intraspinally.
(5) Subcutaneous and intramuscular administration are
the methods of choice. Intravenous and intraspinal
administration should be the methods of resort only
when especially indicated, as outlined in the publica-
tions of Dr. Byrne and Dr. Thompson, who have made
a special study of the subject, and whose papers in con-
tribution to this symposium will inform you in regard
to their use."
The Comparative Toxicity of Mercurialized Serum
and Bichloride of Mercurv When Injected Intramus-
cularly, Intravenously, and Intraspinally. — Dr. Paul
S. Pittenger of Philadelphia drew the following con-
clusions: (1) Mercurialized serum whether injected
intramuscularly, intravenously, or intraspinally, is
equally as toxic as corresponding amounts of plain
bichloride of mercury. (2) The addition of an excess of
serum to bichloride of mercury does not reduce its toxic
properties but merely deprives it of the property of
destroying tissue by precipitating and then dissolving
the albumin of the tissue, without changing its toxicity
or therapeutic efficiency. (3) Intramuscular or sub-
cutaneous injections of mercurialized serum are prac-
tically painless and are not followed by sensitiveness,
pain and sloughing which usually accompany injections
of the plain bichloride. (4) Intravenous injections of
mercurialized serum are not followed by pain or sensi-
tiveness at the site of injection. (5) Overdoses of mer-
curialized serum when administered intravenously
produce the same untoward effects, such as blood in the
stools, vomiting, retching marked increased and
troubled respiration, etc., as plain bichloride of mercury
and care should be used, therefore, not to produce toxic
effects by overdosage or administration at too frequent
intervals. (6) Mercurialized serum in proper doses
may be safely injected directly into the spinal canal.
(7) In systemic syphilis very favorable results can be
obtained by the intramuscular or subcutaneous injec-
tion of mercurialized serum. (8) Intramuscular
or subcutaneous administration of mercurialized
serum is to be preferred in the treatment of sys-
temic syphilis except in patients where quick results are
imperative in which case the serum may be administered
intravenously."
Mercurialized Serums. — Dr. Lloyd O. Thompson of
Hot Springs, Ark., said that upon reading Byrnes' orig-
inal article upon the intradural injection of mercurial-
ized serum in syphilis of the central nervous system the
thought suggested itself to him that if mercurialized
serum could be injected intradurally without irritation,
it could be infected intravenously without causing phle-
bitis. He had tried it with perfect success and in May,
1915, reported 66 injections in 8 cases,. The method of
procedure was as follows: From 40 to 50 c.c. of blood
were collected by venepuncture and placed in a large test
tube which had been boiled in salt solution. After
separation the serum was poured off and thoroughly
centrifugalized. A watery solution of mercuric chloride
was prepared so that each cubic centimeter contained
22 mg. (1/3 grain) of the salt. The serum was then
measured and divided into two parts, one-third of the
amount placed in one tube and the remainder in an-
other. The mercury solution was added to the first
part in the proportion of 1 c.c. to each 2 c.c. of the
serum. A heavy precipitate of albuminate of mer-
cury appeared which was comdetely dissolved on the
addition of the remainder of the serum. It would be
seen that the mixture would contain 22 mg. ( 1 3
grain) of mercuric chloride in each 7 c.c. At
first there was great difficulty encountered in keep-
Sept. 23, 1916J
MEDICAL RECORD.
567
ing the albuminate in solution for any length of time,
and it was necessary to prepare the solution fresh
before each injection, but later it was discovered that
if the mixture was heated in the water bath for one-half
hour at 55CC. it would remain in solution indefinitely.
Mercurialized serum for intravenous injection prepared
from horse serum had been placed upon the market,
but owing to the danger of anaphylaxis he had not em-
ployed this serum and did not recommend its use-
Recently, he had used ascitic and hydrocele fluids in the
preparation of mercurialized serum for intravenous
injection with very favorable results. These fluids,
however, varied somewhat in their ability to hold the
mercury albuminate in solution, some of them requiring
as much as 10 c.c. to each 22 mg. (\'3 grain) of the
bichloride. It had occurred to him that the use of
these fluids might present an opportunity for placing
mercurialized serums upon the market from the use of
which there would be no danger of anaphylaxis. It
might be well to state parenthetically that ascitic and
hydrocele fluids should be tested for the presence of
tubercle bacilli before using for intravenous injections.
He had not used mercurialized serum intravenously as
a routine procedure in the treatment of syphilis but had
used it mainly in those cases in which the pain of in-
tramuscular injection was so great that the patient
would not tolerate them.
Head Colds; Their Results and Treatment. — Dr.
Thomas F. Reilly of New York in a paper on this sub-
ject emphasized the following conclusions: (1) That
there was a special type of head cold that preceded by
from four to eight days most, if not all, cases of so-
called muscular rheumatism, lumbago, etc., and that
this was more satisfactorily treated by treating the
original site of infection in the nose than by the usual
methods of treatment. (2) That bronchitis following
such head colds was likewise more satisfactorily treated
by taking care of the original source of infection in the
nose. (3) That this field of nasal treatment was quite
as much the province of the internist as the use of the
stomach pump in gastric lavage. (4) That a fair pro-
portion of post-operative pneumonias was due to in-
fection of the patient by the anesthetist who was suffer-
ing from a severe head cold.
Strychnine As a Tonic. — Dr. W. F. Milroy of Omaha,
Neb., said that one of the most gratifying therapeutic
results he personally had ever witnessed had been in
the use of strychnine in pneumonia. There was no
more reliable sign of approaching trouble in this
disease than the appearance of edema in the dependent
portion of the sound lung. He had observed this edema
disappear promptly after the injection of 1/40 grain
strychnine and, recurring after a few hours, again van-
ish with the injection of the drug. He had observed this
happen repeatedly in the same case and believed he
had seen patients by this means carried over a crisis to
recovery. The mode of action of strychnine he must
mention as concisely as possible. It acted primarily
upon the nervous system, including the sympathetic
system, probably most strongly upon the medulla and
spinal cord. Without discussing the precise mode of
action, whatever this might be, it resulted in a stimula-
tion of the physiological activity of practically the whole
body. Admitting that cardiac muscular power and
blood pressure were not influenced by strychnine, the
fact nevertheless remained that the heart action was
influenced favorably in certain conditions. For in-
stance, he knew a doctor with a crippled heart which
became irregular and intermittent, with distressing sub-
jective symptoms, whenever he overtaxed it a little.
Invariably a few doses of strychnine, in this condition,
restored the action to normal with disappearance of the
unpleasant symptoms. Now. cellular nutrition was not
a process of passive absorption. It was an active, vital
process which was under the direct control of the
nervous system. Therefore, the profound stimulation
of the nervous system by full doses of strychnine, di-
rectly promoted a new and vigorous cell activity of the
whole body, thus tending to restore the opsonic index.
The nervous disorders to which he had referred as capa-
ble of being successfully treated bv strychnine, repre-
sented conditions of depression. The nervous system
still retained the ability to respond to powerful stimu-
lation which the big doses of strychnine supplied. In
reference to administration he would add that though
the drug might not be wholly eliminated from the body
for as long as eight days, it was mostly gone at the end
of twelve hours and therefore the doses must not be too
infrequent. Also it was worth while to mention that
there was no tendencv to habit formation and the
largest doses might be abruptly broken off with im-
punity. Further he would state that this method of
treatment was not dangerous. A perfectly safe margin
existed between the first appearance of muscular spasm
and a really poisonous dose. He had by no means
attempted to enumerate the many conditions in which
ascending doses of strychnine were indicated. He was
convinced that it should be given in much larger doses
than was customary and this he was hoping to en-
courage.
Chronic Appendicitis and Chronic Intestinal Toxemia;
Their Association and Differentiation. — Dr. G. Reese
Satterlee of New York said that a careful study of all
cases diagnosed as chronic appendicitis was necessary
as was also the use of the a--ray in every case. The
symptoms of chronic appendicitis and cecal disease was
often very similar. Cooperation between surgeon and
internist was necessary in the study and treatment of
these cases, before and after operation. The proper
treatment for chronic intestinal toxemia might clear
up symptoms resembling chronic appendicitis. Auto-
genous colon vaccines should be tried in every case.
The internist should be always on the guard for appen-
dicitis in every case of chronic intestinal toxemia, and
the surgeon for chronic intestinal toxemia in the case
of appendicitis. Medical students should have instruc-
tions along these lines and not be taught to diagnose
intestinal conditions on symptoms alone.
AMERICAN GYNECOLOGICAL SOCIETY.
Forty-first Annual Meeting, Held at Washington, D. C,
May 9, 10, and 11, 1916.
The President, Dr. J. Wesley Bovee, Washington,
D. C, in the Chair.
An address of welcome was delivered by Dr. Harvey
W. Wiley of Washington, D. C, which was responded
to by Dr. Edward P. Davis of Philadelphia.
Syphilis in Its Relation to Obstetrics. — Dr. Edward P.
Davis of Philadelphia said that modern knowledge on
this subject dated from the discovery of the Spirocheta
pallida in 1905-6 as the cause of syphilis. The dis-
covery of the Wassermann reaction as a means of
diagnosis and that of salvarsan in treatment were im-
portant factors. Syphilis could be positively diagnos-
ticated in a newborn infant by finding the character-
istic germs in blood taken from the umbilical vein and
from the tissues about the umbilicus and umbilical
cord. Examination of the bodies of infants dying soon
after birth from syphilis showed this germ abundantly
present in the important organs of the fetal body. _ A
woman apparently healthy giving birth to a syphilitic
infant was herself syphilitic, although she might show
for some years no clinical signs or symptoms. In these
cases syphilis was conveyed from the ovum to the
mother through the medium of the placenta. The
mother was said to have latent syphilis and could nurse
her child without disturbance in her own health, and
with positive benefit to the child. She might, however,
at any time develop symptoms of secondary or tertiary
syphilis. The Wassermann reaction was unreliable as
a positive test for syphilis in parturient women. It
might give a positive reaction in cases of severe tox-
emia and eclampsia where syphilis was absent, and in
some other conditions where the mother's general
health was seriously disturbed. In the lack of a more
reliable means of diagnosis, the Wassermann test should
invariably be made in selecting wet nurses, and in all
suspicious cases. Syphilis in the acute stage attacking
a pregnant woman could often by the use of salvarsan
be promptly checked. While the germs causing syphilis
would be destroyed, the toxins which they produced
would usually cause death of the fetus. If syphilis
occurred early in pregnancy, the best result for mother
and ehi'd would be obtained by mercurial treatment ac-
companied by the use of iodide of potassium. Where
skin lesions were present, hypodermatic o>- intravenous
injections of mercurial solutions were useful. In treat-
ing active syphilis in the newborn, salvarsan had been
given in the cubital vein with good results. Where
salvarsan was used with mother and child, the urine
of the patient should be repeatedly examined to deter-
mine the presence or absence of arsenic, and the pres-
ence or absence of signs of irritation of the kidneys.
Should traces of arsenic disappear from the urine,
arsenical poisoning might be feared. Syphilis in par-
turient women greatly increased the mortality and
568
MEDICAL RECORD.
[Sept. 23, 1916
morbidity for the mother through mixed infection and
lesions of the genital organs. Unless promptly de-
tected and treated, it was one of the most important
causes of fetal death. No syphilitic man or woman
should be allowed to marry unless such had been under
observation for six years after the last appearance of
symptoms of syphilis.
Syphilis in Kelation to Some Social Problems. — Dr.
Sigmund Pollitzer of New York City under the above
title dealt with three distinct subjects: (1) Heredi-
tary Syphilis in the Light of To-day. The fact that
syphilis could be transmitted from the syphilitic mother
to her unborn child was recognized four hundred years
ago; but the fact that syphilitic children were born of
apparently healthy mothers led to the conclusion that
syphilis might be transmitted to the offspring by way
of the semen of the father without infecting the
mother. In fact, paternal syphilis was regarded as the
most frequent form in syphilitic heredity. More ex-
tended and definite clinical observation, the discovery
of the spirochete on the maternal aspect of the pla-
centa, and the results of the Wassermann test had com-
pletely changed our views in this respect. Transmis-
sion of spirochete to the ovum might be regarded
virtually as a physical impossibility; a spirochete was
three times as long as the diameter of a spermatozoid
head, and, furthermore, an infected ovum would not
develop into a fetus. Colles' law and Profeta's law
were true only in the sense that the mother of a syph-
ilitic child and the child of a syphilitic mother already
had syphilis, and therefore apparently could not ac-
quire it. The apparently healthy mothers of syphilitic
children invariably had a positive Wassermann reac-
tion and generally presented symptoms of syphilis if
we followed them long enough. The failure to show a
history of the infection in these cases was not very
remarkable in view of the statistics of syphilis in
women ; in only about one-third of the cases that were
seen with definite tertiary lesions could a history of in-
fection be elicited. The author emphasized the impor-
tance of making a Wassermann test in every case of
unexplained abortion instead of" resting content with
the inadequate explanation of deflections, adhesions,
etc. CD When May the Syphilitic Marry? Recent
progress, Dr. Pollitzer said, had greatly changed our
view on the gravity of syphilis, especially with refer-
ence to lesions of the heart and central nervous sys-
tem, and at the same time had greatly improved prog-
nostic and therapeutic possibilities. The question of
the medical sanction to marriage of the syphilitic had
been most earnestly considered forty years ago by
Fournier and the principles laid down by him generally
followed. The syphilitic might marry when there was
a reasonable certainty of his cure. No criterion of cur-;
being possible, formerly a definite period of time and
treatment were arbitrarily fixed upon, based on clin-
ical experience. The syphilitic might marry if he had
received three years of treatment and had remained
free from symptoms for another year or two. Millions
of happy marriages proved the wisdom of the rule, but
the thousands that resulted in infection of their wives
and the birth of syphilitic children proved its inade-
quacy. The Wassermann test afforded a reliable crite-
rion of cure. The syphilitic woman might marry with-
out risk of infecting her husband after she had reached
the tertiary stage of the disease, but she could not bear
children without the risk of bearing syphilitic children
until she was permanently Wasserman negative. (3)
rhe Control of Syphilis. The attempt to conti-ol the
incidence of syphilis by segregation, he said, had
proved of slight value and, moreover, in Anglo-Saxon
count lies met with too much prejudice to permit of its
enforcement. The control of syphilis must come
through education of the public in the risks and dan-
gers of illicit intercourse and education of the physi-
cian in the importance of early diagnosis and proper
tment. Various educational bodies were under-
taking a campaign of instruction in these matters;
even the public press which a few years ago had never
printed the word "syphilis" to-day contained edu
lional articles which dealt with the subj ■ kly.
The public was oe.ng educated. How far know
of the risks and dangers of illicit intercourse would
serve as rent was a mooted question. The
speaker referred to the excellent results obtained by
the prophylactic use of calomel ointment in the armies
and navies of the world, a procedure which, if gen-
erally employed, would as effectively control the great
pox as the smallpox had been controlled in- vaccina-
tion. The author confrasted the generous' provision
made for the care of the syphilitic in the hospitals of
European cities with the attitude of our American hos-
pitals in most of which the patient with an active syph-
ilis was refused admission. He concluded with a plea
to his hearers to exert their personal influence to the
end that better hospital facilities be provided for the
syphilitic.
Syphilis of the Internal Genital Organs in the Female.
— Drs. George Gellhorn and Hugo Ehrenfest of
St. Louis, Mo., contributed a joint paper on this sub-
ject, saying that syphilis had always been assumed to
be considerably commoner among men than .rnong
women; but from certain investigations this supposi-
tion could not yet be accepted as conclusive. At any
rate, syphilis was common enough in women to consti-
tute a gynecological problem in the widest sense. Not
every disease in a syphilitic woman was syphilitic in
nature, but syphilis, if present, would exert an influ-
ence of its own upon coexistent diseases. Latent syph-
ilis prevailed more in women than in men. The course
of syphilis in men differed in many points from that
in women. To instance but one of the differences, the
relative frequency of tabes and paresis in the two sexes
was well known. Primary chancres of the vagina were
rare, probably because of certain histological and bio-
logical characteristics of the vagina. Tertiary luetic
manifestations of the vagina were also extremely ;are.
They represented, as a rule, the continuation of sec-
ondary lesions in the vulva, uterus, or adjoining or-
gans. The isolated submucous gumma broke down
early and appeared in the form of a more or less char-
acteristic ulcer. The more destructive processes which
eventually led to the formation of fistula? and stric-
tures, almost always originated in strictures surround-
ing the vagina. Tertiary lesions of the vagina did not
exhibit characteristic symptoms, such as pain or dis-
charge. The primary chancre of the cervix represented
the best known and most common type of syphilitic
affections of the female internal genitalia. Its fre-
quency had probably been overestimated. Statistics
based on a large number of observations had never
shown a frequency over 1.5 per cent, of all primary
chancres found on the genitalia. Eight personal ob-
servations were added by the authors to the few cases
found in literature of secondary lesions of the cervix.
Syphilis manifested itself upon the cervix in the form
of macules, papules, and ulcerations. These forms
probably represented three successive stages in the
development of a lesion caused by scattered accumula-
tions of the Spirochetes pallida in the squamous mucosa
of the cervix. The parasite could readily be recov-
ered from the secretion of any of the three forms, and
this explained the great infectiousness of secondary
lesions. Wassermann reaction was positive in this
stage. Syphilis of the pelvic cellular tissue appeared
in the form of a diffuse gummatous infiltration which
secondarily involved the pelvic peritoneum. To the few
cases on record the authors added a personal observa-
tion. In almost all instances a diagnosis of malig-
nancy had been wrongly made. In their own case the
positive outcome of the Wassermann reaction together
with other unmistakable signs of tertiary syphilis
about the outer genitals aided in arriving at the cor-
rect diagnosis. Specific treatment produced amazingly
quick improvement of an apparently hopeless condition.
Familiarity with syphilitic lesions in the genital tract
must needs prove of eminent practical value to the
gynecologist in view of the frequent confusion in the
diagnosis of cancer and syphilitic ulcerations or gum-
mata. That occasionally a patient is subjected to a
serious radical operation who could have been cured
by antiluetic treatment there could be no doubt.
The Specificity of the Wassermann Reaction. — Dr.
RUDOLPH BUHMAN of St. Louis, Mo., gave the results
of the Wassermann reaction in a series of diseases
from individuals supposed to be free from syphilis,
with especial reference to malignant diseases. Of 132
cases of malignant diseases, including carcinoma, sar-
coma, and malignant adenoma, nine gave a positive re-
action; six of these nine cases suffered from both ma-
lignancy and syphilis: the other three cases were not
under observation long enough.
Occurrence nf Syphilis in the University of Michi-
gan Obstetrical and Cvnecological Clinic. — Dr. Reuben
PETERSON of Ann Arbor. Mich., presented the follow-
ing summary and conclusions: (1) Only by routine
Wassermann tests would the obstetrician and gvnecol-
ogist best serve the interests of his patients. (2) Es-
peciallv was this true in hospital practice where even
careful histories failed to arouse suspicion of latent
Sept. 23, 1916J
MEDICAL RECORD.
569
syphilis. (3) Out of 2,000 in-patients in the Univer-
sity Hospital, excluding two services, the proportion of
syphilitics was 6 per cent. (4) The nature of the hos-
pital material would determine the percentage of lues,
but in the average hospital the ratio would not be far
from 8 to 10 per cent, if the entire hospital population
be included. (5) The same held true for the propor-
tion of syphilis in any special clinic, the percentage
varying according to the nature of the material. (6)
The percentage of lues in 381 cases in the University
Maternity was 4.7 as shown by the Wassermann re-
actions and expert physical examinations. (7) In 18
cases of syphilis among the number examined, only
eight or less than half gave a history of lues. (8) In
only the same number (eight) were there positive
physical signs of lues. (9) As shown by the histories
of the 18 cases, there was a greater chance for the
syphilitic mother treated by salvarsan and mercury to
give birth to a living full-term child than where no
treatment be given during pregnancy. (10) The new-
born infants of the mothers so treated did not give
positive Wassermann reactions, although undoubtedly
they were syphilitic and later would probably show
signs of the disease. (11) A certain proportion of the
newborn children of untreated syphilitic mothers
would give positive Wassermanns. (12) Out of 390
gynecological patients subjected to the Wassermann
test, 22 or 5.6 per cent, gave positive reactions. (13)
In only five of the 22 luetic patients was there a his-
tory of syphilis. (14) Hence the importance of such
examinations, or a serious general disease would be
overlooked and the gynecological patient would remain
uncured.
Relationship of Syphilis to Miscarriage and Fetal
Abnormalities. — Dr. Fred L. Adair of Minneapolis pre-
sented data from a series of cases showing the rela-
tive frequency of miscarriage in cases giving evidence
of syphilis and those showing no signs of lues. The
frequency of luetic manifestations in mothers who
gave birth to monstrosities and malformed childi-en
was considered, after which he presented some observa-
tions on the relationship of syphilis to habitual abor-
tion.
How Closely Do the Wassermann Reaction and the
Placental Histology Agree in the Diagnosis of Syphilis?
— Dr. J. Morris Slemons of New Haven, Conn., stated
that in 360 consecutive confinements the Wassermann
test had been made on the mother's blood and the pla-
centa had been studied for evidences of syphilis. The
most notable disagreement occurred in cases of toxemia
of pregnancy which not infrequently presented a faint-
ly positive Wassermann reaction, though the placenta
was normal. Except for this fact, the results of the
Wassermann test and of the placental examination
stood in very close agreement.
Experimental Syphilis. — Dr. F. W. Baeslack of De-
troit stated that the causal relationship of the trepo-
nema pallidum to lues was established (a) by the ob-
servation of the occurrence of the organisms in the
syphilitic lesions incident to the various stages of the
disease; also, the distribution of the pallida in the le-
sions of acquired and congenital syphilis. (6) The
successful inoculation of lower animals from human
lesions, thereby producing syphilis experimentally in
rabbits, monkeys, and other animals; the methods em-
ployed and discussion of the character of the lesions,
and the observation of generalized syphilis in experi-
mentally inoculated animals, (c) The growing of the
treponema pallidum in culture media free from con-
tamination, the transfer of these cultures through
many generations, and the successful inoculation of
lower animals with the cultivated organisms; the loss
of virulence of the organisms against the lower ani-
mals after extended cultivation ; and the cultural char-
acteristics and morphology of the pallida. (d) Im-
munological studies, pseudoprimary lesions, and true
reinfection, as well as superinfection, as expressed in
the lesions in the various stages of syphilis, which do
not harmonize with our conception of immunity. The
author spoke of attempts at immunization by means
of pallida vaccines, and described the occurrence of
agglutinins in the serum of animals treated with sus-
pensions of dead pallida. He spoke of the absence of
immunity as demonstrated by the ability to reinocu-
late animals which had recovered spontaneously or
subsequent to treatment. He pointed out that an
altered reactivity of the body was the possible explana-
tion for the occurrence of the lesions peculiar to the
various stages of syphilis.
Syphilitic Fever. — Dr. Frederick J. Taussig of St.
Louis, Mo., read a paper on this subject, in which he
presented the following summary: "(1) The diagnosis
of syphilitic fever can rarely be made with absolute
certainty, but we should more often consider it as a
possibility and institute antiluetic measures in suitable
cases. (2) Secondary syphilitic fever occurs in a mild
form in 20 per cent, of patients at the outbreak of the
rash and at times is prolonged and more severe in its
course. (3) Late secondary syphilitic fever is occa-
sionally seen in a pronounced form after confinement
or in gynecological patients. (4) Tertiary syphilitic
fever is practically never due to syphilitic lesions in
the female genital tract. One such case is reported by
the author. It may, however, complicate a gynecolog-
ical or obstetrical condition, and, owing to the diffi-
culty in locating the site of the tertiary lesion, lead to
a wrong diagnosis as to the cause of the fever. All
doubtful cases should be subjected to a Wassermann
test and, if positive, given antiluetic treatment. (5)
Syphilitic fever is probably due to the reaction of the
body to the toxins produced by the spirochete which,
under certain circumstances, or in certain individuals,
gain an entrance into the circulation.
Syphilis of the Body of the Uterus. — Dr. Charles
C. Norris of Philadelphia stated that it was only since
the discovery of the Spirochete pallida and the de-
velopment of the Wassermann test that the true fre-
quency of syphilis had been recognized. Probably 1 to
4 per cent, of women were syphilitic. The disease was
rare in the body of the uterus. Theoretically chancres
might occur in the body of the uterus as the result of
spermatozoic infection and this avenue of ingress
might account for some of the cases of syphilis which
developed without demonstrable primary sore. No
chancre had, however, ever been demonstrated in this
location. Some authors believed mucous patches might
occur in the endometrium. This, however, was un-
proven. There were two varieties of syphilitic en-
dometritis: (a) gummatous, and (6) a less charac-
teristic form in which the blood vessels were especially
affected. Syphilis of the myometrium occurred as (a)
gumma and (6) a diffuse metritis, the most charac-
teristic lesions of which were in the blood vessels.
Many cases were reported as syphilis on insufficient
grounds. Hemorrhage in the form of menorrhagia was
a frequent symptom. Leucorrhea and pain occurred.
The author reported the following case: Patient aged
36 years; married 12 years; Ill-para; last child seven
years ago. Six years ago she contracted syphilis, and
since then had had three miscarriages, two, three, and
five months respectively, the last six months ago; mixed
treatment until nine months ago. Menorrhagia de-
veloped five months ago; hemorrhages profuse and pro-
duced severe anemia with its accompanying symptoms.
When brought to the hospital she had been bleeding for
12 days. Physical, abdominal, and pelvic examinations
negative; hemoglobin 52; red blood count 5,000,000;
white blood count 4,500; Wassermann strongly posi-
tive; diagnostic curettage during which fundus was
perforated. Because of age of patient, three living
children, history of intractable bleeding, and perfora-
tion of uterus, supravaginal hysterectomy was per-
formed; convalescence normal; salvarsan adminis-
tered; pathological examination of specimen showed
uterus normal in size and shape, but so friable that
its walls could be squeezed through at any point with
thumb and forefinger. Histological examination
showed the endometrium slightly thickened and infil-
trated, with chronic inflammatory products. Angio-
sclerosis of vessels ; myometrium more or less in-
flamed; much edema; marked angiosclerosis of ves-
sels and complete obliteration of some; inner coats of
vessels chiefly affected; lymphatic spaces dilated. In
many fields muscle fibers partially separated from one
another. The diagnosis of syphilis in this case was not
positive, as the Spirochcta pallida was not demon-
strated or searched for. Etiology was suspected, and
the Wassermann report was not secured until some
days following operation, by which time specimen had
been fixed in formalin solution, thereby making the
demonstration of the Spirocketa pallida very difficult.
The diagnosis was based upon the following: that the
patient contracted syphilis six years ago, and since
then had had three miscarriages; that the symptoms
referable to the uterus developed three months after
cessation of antisyphilitic treatment, and one month
after the last miscarriage; that these were the symp-
toms usually produced by syphilis of the uterine body;
that the histological findings, especially blood vessel
changes, were those of syphilis. The hemorrhage and
570
MEDICAL RECORD.
[Sept. 23, 1916
discharge were not the result of pyogenic infection fol-
lowing a miscarriage as they did not occur with either
of the two former miscarriages, but developed one
month after the last. These facts led the author to
ascribe the uterine lesions to syphilis. Three similar
cases were recorded in the literature.
Incontinence of Urine in Women. — Drs. Howard C.
Taylor and Charles H. Watt of New York City con-
tributed a joint paper on this subject, in which the
following conclusions were drawn: (1) While inconti-
nence of urine is due to a lesion of the sphincter
vesica? only, it is relatively an infrequent symptom.
(2) Incontinence of urine due to a lesion of the
sphincter vesicas associated with other lesions is a fre-
quent and important condition. (3) In pelvic opera-
tions for lesions associated with incontinence of urine
as a symptom, care should be used to remove all drag
or downward traction on the anterior vaginal wall and
frequently to infold the sphincter vesica?.
(To be continued.)
&tate iHp&iral ICimtsing (Unarms.
STATE BOARD EXAMINATION QUESTIONS.
State Board op Medical Examiners of Maryland.
June 20, 1916.
anatomy.
1. Describe articulations of superior maxillary bone.
2. Describe the elbow joint, name the ligaments, and
give their attachments.
3. Give location and size of stomach when empty.
4. Superficial and deep origin and arrangement of
fibers in commissure, of optic nerves.
5. Where would you locate lesion in a case of
aphasia?
6. Describe valves of heart.
7. Give origin, insertion, action and nerve supply of
following muscles: (a) Obliquus internus. (6) Obtura-
tor externus. (c) Omohyoideus. (d) Serratus magnus.
8. Through what vessels would circulation be estab-
lished after ligation of brachial artery in lower third?
9. Where are semicircular canals located, and by
what bony openings do they communicate with the mid-
dle ear and with the cranial cavity?
10. What is the mesentery?
physiology.
1. (a) Describe the normal flow of blood through
the arteries, capillaries and veins, and factors which
cause the flow of each. (6) Give the relative rates of
circulation in the arteries, capillaries and veins, and
state how long it takes the blood to make a complete
circuit of the body, (e) What is the total quantity of
blood as compared with weight of the body?
2. (a) Define absorption and secretion. (6) Give
some of the theories of absorption, (c) State differ-
ence between internal and external secretions, and give
examples.
3. (a) Define animal heat and give sources. (6)
State some of the conditions which produce variations
in the normal temperature, (c) Give normal temper-
ature in axilla, mouth, and rectum.
4. What is accomplished physiologically by the portal
circulation?
5. Where is the respiratory center located and what
is internal respiration?
6. (a) What are the functions of the bile— the in-
gredients and how secreted? (6) Give tests for bile
salts and bile acids.
7. Describe the function of the Eustachian tube, ret-
ina, iris, cornea, and tympanic membrane.
8. Give the locations at which the various heart
sounds can be best heard and state the cause of each
sound.
9. Discuss briefly the physiology of the nervous sys-
tem and give a classification of the nerve cells.
10. What is blood pressure — mode of ascertaining —
the average blood pressure in male and female.
CHEMISTRY.
1. Give symbol, valence and one important compound
of each of ten elements.
2. Describe nitrogen. In what form is it chiefly
eliminated from the body? Name several compound's
containing nitrogen and give formulae.
3. Describe lead, (a) Which of its compounds is used
in medicine? (6) From what sources may chronic lead
poisoning come?
4. Give two antidotes for phosphorus and explain
their action.
5. Give a chemical antidote for each of the following
and explain mode of action: Phenol, nitric acid, oxalic
acid, mercuric chloride.
6. Wood alcohol and grain alcohol: (a) Give for-
mula? and state the class of chemical substances to
which they belong. (6) How would you treat a case of
poisoning by the former, supposing the case were seen
shortly after ingestion of the substance?
7. Why is a salt of mercury incompatible with KI?
8. What is synthesis? Name three synthetic organic
substances used in medicine.
9. Describe method of determining the sugar content
of the blood.
10. What substance is used as an antidote for most
alkaloids and how does it act?
MATERIA MEDICA.
1. Mercury; the official preparation, doses, and in-
compatibles.
2. Lead; the official preparations and incompatibles.
3. Write a prescription using official terms, contain-
ing at least three ingredients, for diarrhea in an adult.
Also one for a child 2 years old containing three in-
gredients.
4. Give the average hypodermic dose for an adult of
apomorphine, morphia sulphate, nitroglycerin, atropine
sulphate, and pituitary extract.
5. Ergot; the official preparations and doses.
6. Potassium: the official preparations and doses.
7. Name three drugs which are motor nerve depres-
sants; three which are sensory nerve depressants, and
give adult dose of each.
8. (a) Define antiseptics and name three that are
used internally with adult dose, (b) Name three that
are used externally and give strength of same, using
official terms.
9. Write a prescription as a diuretic containing three
ingredients, using official terms.
10. Define antitoxins and vaccines. Name those in
most general use, give source and method of adminis-
tering.
THERAPEUTICS.
1. Flexile collodion, and eantharidal collodion; their
therapeutic uses.
2. Give the therapy of boric acid and methods of use.
3. Acid salicylicum, its therapy and usual combina-
tion for internal administration.
4. Sodii bicarbonas, properties and uses, incompati-
bles.
5. Spiritus aatheris nitrosi, its properties, uses and
adult dose.
6. Aethylis chloridum, properties and uses, and objec-
tions to its use.
7. Alumen, properties and uses, value of the exsic-
cated.
8. Arseni trioxidum, therapy, liquid preparations and
state which can be administered with acids.
9. Hexamethylenamin, properties and uses, mode of
action and danger from large doses.
10. Write a prescription in Latin, without abbrevia-
tion, containing four ingredients (with "Fowler's solu-
tion" as one) stating condition for which used.
ANSWERS.
ANATOMY'.
1. The superior maxillary bone articulates with'. The
frontal, ethmoid, malar, nasal, lacrimal, palate, vomer,
inferior turbinated, and the superior maxillary of the
opposite side; sometimes it articulates also with the
sphenoid.
2. The elbow-joint "is a ginglymoid articulation
formed above by the lower extremity of humerus, below
by upper extremities of ulna and radius. Its ligaments
are external and internal lateral, anterior and posterior
ligaments. External lateral arises from external con-
dyle of humerus and is inserted into outer margin of
ulna. Internal lateral, much stronger, consists of two
portions; anterior arises from fore part of internal con-
dyle to be inserted into coronoid process, and posterior
from back part of condyle to inner margin of olecranon.
Sept. 23, 1916]
MEDICAL RECORD.
571
Anterior ligament arises above coronoid fossa, and is
inserted into coronoid process of ulna and orbicular
ligament. Posterior ligament, attached above olecranon
fossa, and below to olecranon process of ulna. The
anterior and posterior ligaments become continuous
with the lateral to encircle the joint." — (Young'»
Anatomy.)
3. The stomach, when empty, lies in the epigastric
and left hypochondriac regions, at the back part of
the abdomen, and is immediately below the diaphragm;
its length is about 10 inches, its breadth 3 to 4 inches,
and its antero-posterior diameter about 2 to 3 inches.
4. The optic nerves arise from the forepart of the
optic commissure, which is the decussation of the fibers
in the optic tract; most of the fibers decussate (these
are arranged internally), a few pass to the eye of the
same side, and a few of the posterior fibers do not de-
cussate but pass across the commissure from one cere-
bral hemisphere to the other.
5. In aphasia (in a right-handed person) the lesion
would be located in the posterior part of the third
frontal convolution of the left cerebral hemisphere.
6. The valves of the heart are: In the right auricle,
the Eustachian and coronary valves; the former is
situated between the anterior margin of the inferior
vena cava and the auriculoventricular orifice. In the
fetus it directs the blood from the inferior vena cava
through the foraman ovale into the left auricle; the
coronary valve prevents the regurgitation of the blood
into the coronary sinus during the auricular contrac-
tion... In the right ventricle are the tricuspid and semi-
lunar valves; the former prevents the blood in the right
ventricle from flowing back into the right auricle dur-
ing ventricular cystole; the latter guards the orifice of
the pulmonary artery. In the left ventricle are the
mitral and semilunar valves; the former acts similarly
to the tricuspid; the latter guards the orifice of the
aorta. The tricuspid valve consists of three cusps, or
segments, the bases of which are attached to a ring
around the auriculo-ventricular opening, while the
edges are free in the ventricle and are attached to the
upper end of the chorda? tendineae. The pulmonary
semilunar valve is composed of three segments, attached
at their bases to the wall of the pulmonary artery and
having on their free edges a nodular projection, the
corpus Arantii. The initial valve has two cusps, and
is otherwise of similar structure to the tricuspid valve.
The aortic semilunar valve resembles the pulmonary
valve in structure.
7. Obliquus internus. Origin: Outer half of Pou-
part's ligament, anterior two-thirds of crest of ilium,
and from lumbar fascia. Insertion: Crest of pubis,
pectineal line, linea alba, and cartilages of seventh,
eighth, and ninth ribs. Action: Compression of ab-
dominal viscera (thus aiding in vomiting, urination,
defecation, and parturition), compression of thorax
(thus aiding in expiration). Nerve supply: Lower in-
tercostal nerves, and iliohypogastric.
Obturator externus. Origin: Body and ramus of
os pubis, ramus of ischium, and obturator membrane.
Insertion: Digital fossa of femur. Action: External
rotator of thigh. Nerve supply: Obturator nerve.
Omohyoideus. Origin: tipper border of scapula.
Insertion: Body of hyoid bone. Action: Depresses and
retracts hyoid and larynx. Nerve supply: Descendens
and communicans hypoglossi.
Serratus magnus. Origin: Eight upper ribs. In-
sertion: Inner margin of dorsal border of scapula.
Action: Elevates ribs in inspiration, is used in pushing,
and raising the arm. Nerve supply: Posterior thoracic
nerve.
8. When the brachial artery is ligated in the lower
third, the collateral circulation is carried on as follows:
The superior profunda anastomoses with the radial
recurrent, and posterior interosseus recurrent ; and
the inferior profunda anastomoses with the posterior
ulnar recurrent and anastomotica magna.
9. The semicircular canals are located in the internal
ear, above and behind the vestibule. They open into
the vestibule by five apertures: The ampulla ossea
superior, crus commune, ampulla ossea posterior, ma-
cula cribrosa inferior, and ampulla ossea lateralis.
10. The mesentery is the fold of peritoneum which
connects the jejunum and ileum with the posterior ab-
dominal wall.
PHYSIOLOGY.
1. The circulation of the blood is the course or cir-
cuit of the blood from the heart, through the body and
back to the heart. Beginning at the left ventricle of
the heart, the blood flows through the left semilunar
valve into the aorta, from which branches are dis-
tributed to every part of the body, through the capil-
laries to the veins, from the veins to the venae cava?,
thence to the right auricle of the heart. From the
right auricle, through the tricuspid valve to the right
ventricle, thence through the right semilunar valve to
the pulmonary artery to the lungs, from the capillaries
in the lungs to the pulmonary veins, thence to the left
auricle, and through the mitral valve to the left ven-
tricle, to begin the circuit again.
The circulation of the blood is regulated in (a) the
arteries by: (1) The elasticity and tone of the arteries,
(2) the force and frequency of the cardiac contractions,
(3) the resistance in the capillaries; (b) in the capil-
laries it is regulated by (1) the action of the heart, (2)
the action of the arteries; (c) in the veins it is regu-
lated by (1) the action of the heart, (2) aspiration of
the thorax, (3) the contraction of the muscles, and (4)
slightly by the valves in the veins.
The velocity of the blood current is about 1 foot per
second in the arteries; about 1 inch per minute in the
capillaries; and about 8 inches a second in the veins.
The complete circulation around the body is said to
occupy a little less than half a minute.
The total quantity of blood was formerly said to be
about one-thirteenth of the weight of the body; re-
cently this figure has been altered to one-twentieth of
the body weight.
2. Absorption is the process by which the products of
digestion are taken up into the general circulation. It
occurs with greatest activity in the villi of the small
intestine.
The products of digestion find their way into the
blood by two routes: (1) By the blood-vessels of the
gastrointestinal tract, which unite to form the portal
vein; and (2) by the lymph vessels of the small in-
testine, which converge to empty into the thoracic duct.
The water, inorganic salts, proteids and sugar go by
way of the portal vein to the ascending vena cava;
and the fats go by way of the thoracic duct to the
junction of the left subclavian and internal jugular
veins.
The process by which absorption is accomplished is
partly physical (osmosis and filtration), and is also due
in part to selective action. To be absorbed by the blood-
vessels or lacteals the substances must be in a fluid
state, and the more dilute the solution the more rapid
the absorption. The absorbed matter must be rapidly
removed and fresh blood supplied to the capillaries.
Secretion means the process by which some of the
constituents of the blood are separated from the blood
stream (by the activities of the capillary endothelium,
as the blood passes through the capillaries) and elabo-
rated into other material. The products of secretion
vary with the gland or membrane where it occurs.
Thus : Saliva, tears, milk, bile, gastric juice, synovial
fluid, serous fluid, pancreatic juice.
Internal secretions: It is generally held now that
the glandular organs, chiefly the pancreas, liver, and
the ductless glands, produce a secretion, peculiar in
each case to the particular gland producing it, and
which is supposed to be given off to the blood or lymph,
and to have some peculiar value in the general metabo-
lism of the body. Such secretions are called internal
secretions, in contradistinction to the previously known
secretions, which are carried off by a duct, and are
known as external secretions.
3. Animal heat is the heat produced in living or-
ganisms by the processes of oxidation.
Heat is produced in the body by: (1) Muscular
action; (2) the action of the glands, chiefly of the liver;
(3) the food and drink ingested; (4) the brain; (5) the
heart; and (6) the thermogenetic centers in the brain,
pons, medulla, and spinal cord.
Conditions which produce variations in the normal
temperature: Age, time of day, position, whether sleep-
ing or awake, whether working or resting. The normal
temperature, in axilla, is about 37° C; in mouth, about
37.5° C; in rectum, about 38° C.
4. The function of the portal circulation is to carry
the venous blood from the stomach, intestines, pancreas
and spleen to the liver. The blood thus carried is
loaded with the products of absorption. In the liver
this blood enters into close relation with the hepatic
cells, and is finally carried to the inferior vena cava.
Further, the ordinary functions of the liver are due, in
part, to the portal circulation. These functions are:
Manufacture and storage of glycogen; formation of
urea, uric acid and creatinin; formation of bile, and
manufacture of heat.
572
MEDICAL RECORD.
[Sept. 23, 1916
5. The respiratory center is situated in the lowest
part of the floor of the fourth ventricle, at the calamus
scriptorius. Interval respiration is the interchange of
gases between the blood or lymph and the cells of the
various tissues of the body. The term is used in oppo-
sition to external respiration, which is the interchange
of gases occurring in the lungs.
6. The functions of the bile are: (1) To assist in
the emulsification and saponification of fats; (2) to
aid in the absorption of fats; (3) to stimulate the cells
of the intestine to increased secretory activity, and so
promote peristalsis, and at the same time tend to keep
the feces moist; (4) to eliminate waste products of
metabolism, such as lecithin and cholesterin; (5) it has
a slight action in converting starch into sugar; (6)
it neutralizes the acid chyme from the stomach, and
thus inhibits peptic digestion; (7) it has a very feeble
antiseptic action.
Bile is composed of water, sodium glycocholate,
sodium taurocholate, mucin, cholesterin, lecithin, fats,
pigments (bilirubin and bilverdin) and inorganic salts
(chiefly sodium chloride, potassium chloride, calcium
phosphate, magnesium phosphate, and iron phosphate).
"The secretion of bile is a continuous process, and in
periods when digestion is not taking place, bile ac-
cumulates in the gall-bladder. About the third hour
after a meal is taken the gall-bladder is emptied into
the lumen of the duodenum, but the mechanism by
which the contents are expelled has not yet been ascer-
tained. Bile continues to flow into the intestine during
the digestive process, and, later, again accumulates in
the gall-bladder. ... So far as is known, the secre-
tion of bile is independent of nervous action, and is
excited (1) by the reabsorbed bile salts, and (2) by
secretin." — (Bainbridge and Menzies' Essentials of
Physiology.)
Test for bile-salts: Sprinkle some flowers of sulphur
on the surface of a solution containing bile salts; the
sulphur will sink, whereas on most other liquids it will
float.
Test for bile-acids: To a thin film of bile in a capsule
add a drop of solution of cane sugar and a drop of
concentrated sulphuric acid; a purple color is obtained.
7. Function of the Eustachian tube is: (1) To main-
tain equilibrium between the atmospheric pressure in
the middle ear and the outside air. (2) The cilia on
the epithelium lining the tube filter the incoming air
from the pharynx and so aid in keeping bacteria out
of the middle ear. (3) It may act as a drainage tube
for the middle ear. (4) It may possibly have some
function as a resonating tube, as may be observed when
it is closed in catarrhal conditions, when the voice
sounds strange both to the patient and to others.
Function of the retina is to receive the stimulus of
light and transform it into a nervous impulse which is
carried to the brain by the optic nerve.
Function of cornea is to allow light to pass from out-
side to the retina.
Function of iris is to regulate the amount of light
which enters the eyeball and falls upon the retina; it
also regulates the size of the pupil, and reduces both
spherical and chromatic aberration.
The function of the typmanic membrane is to receive
the vibrations of the atmosphere which are transmitted
to it.
8. There are two normal heart sounds which follow
in quick succession, and are succeeded by a pause. The
first, or systolic, sound is dull and somewhat prolonged,
the second, or diastolic, sound is sharper and shorter.
The sounds may be expressed by the syllables lubb —
dup.
The first sound is heard best at the apex beat in the
fifth left intercostal space; the second sound is heard
best over the second right costal cartilage.
The causes producing the first sound of the heart are
not definitely ascertained; the following are supposed
to be causatory factors: (1) The vibration and closure
of the auriculo-ventricular valves, (2) the muscular
sound produced by the contraction of the ventricles, and
(3) the cardiac impulse against the chest wall.
The second sound is caused by the vibration due to
the closure of the semilunar valves.
9- Phy : t< m: "The primary
elements of the nervous system are the neurones and
the neuroglia, the former being the discharging and
conducting structures, and the latter the supporting.
The neurone is the essential element of the nervous
system, which may be regarded as built up of an
enormous number of them arranged in series, and oc-
cupying definite tracts. A neurone consists of a nerve
cell and its branches (axon and dendrons or dendrites).
The dendrons belonging to a single cell may be many,
or there may be but one; in either case they are short
processes, soon subdivided into many terminal branches
forming an arborisation. They are made up of fibrillae,
and of granular matter lying between the fibrillae,
which are continuous, through the body of the cell
itself, with the fibrillae of other dendrons or of the
axon. This process, entirely composed of fibrillae, gives
off collaterals at right angles to its course, and these,
like the axon itself, often end in an arborisation around
the dendrons of another nerve cell. These places of
linkage of one neurone with another are called
synapses. An axon may be either long or short; in the
former case it does not branch for a considerable dis-
tance, becomes surrounded with myelin, and passes as a
nerve fiber into the white matter; in the latter it breaks
up into branches close to its cell, which is known as a
"link cell," and is confined to the gray matter alone.
The dendrons conduct impulses toward the cell, the
axons away from it.
"The nerve cell itself, besides its nucleus and nucle-
olus and the fibrillar which traverse it, contains a series
of angular granules (Nissl's bodies) similar to those of
the dendron. They stain deeply with methylene blue,
and are an index of the state of health, or degeneration
of the cell. The multiplication of nerve cells ceases
shortly after birth, but their growth is active, and they
have great reparative power.
"The neuroglia is composed of a network of delicate
interlacing fibrils containing a number of nucleated
cells (Deiter's cells) embedded in it. It everywhere in-
terpenetrates the nervous elements, but is most abun-
dant round the central canal of the cord and the ven-
tricles of the brain, and in the substantia gelatinosa of
Rolando, which lies at the tip of the posterior cornu
of the cord. In the various "scleroses," it is increased
at the expense of the nervous elements.
"A neurone is 'efferent' or 'afferent,' according as its
axon carries impulses from the central nervous system
toward the periphery, or from the periphery toward
the center. By the superposition of one efferent neurone
upon another, or of one afferent neurone upon another,
efferent, descending, or motor, and afferent, ascending,
or sensory paths are built up, which occupy definite
positions in the spinal cord and brain." — (Wheeler and
Jack's Handbook of Medicine.)
Classification of nerve cells. — Schafer classifies nerve
cells as follows: "1. Afferent cells, which receive im-
pressions at the periphery to convert them into im-
pulses. The latter then pass toward the central nervous
system. 2. Efferent cells, which send out nervous im-
pressions toward the periphery. 3. Intermediary cells,
which receive impressions from afferent cells to trans-
mit them directly or indirectly to efferent cells. 4. Dis-
tributing cells, which occur near the periphery and, re-
ceiving impulses from efferent cells, distribute them to
involuntary muscles and secreting cells. The cells of
this class belong to the so-called sympathetic system."
10. Blood pressure is the pressure of the blood due to
the ventricular systole, the elasticity of the arterial
walls, and the resistance of the capillaries. The normal
arterial blood pressure varies; the systolic pressure be-
ing (in males) about 120 to 150 mm. of mercury, and
the diastolic from about 90 to 120 mm. of mercury. In
females, the pressure is from 10 to 15 mm. lower.
Blood pressure is maintained by the contraction of the
heart, the peripheral resistance, and the elasticity of
the arterial walls.
Blood pressure is estimated by a sphygmomanometer.
The individual whose blood pressure is about to be
led should be placed in such a position that his
heart, the artery the blood pressure of which is to be
determined, and the manometer are at the same level.
It is usual to record the pressure in the brachial artery.
The india-rubber bag of the instrument should be
wrapped round the bared arm, the metal covering of
the bag should then be adjusted, and firmly strapped
in position. The india-rubber tube leading from the
bag is then adjusted to the proximal limb of the U-
shaped manometer which contains mercury. The ex-
perimenter places the index finger of his left hand over
the radial pulse of the subject, and with his right hand
he compresses the syringe and so drives air into the
india-rubber tube and the india-rubber bag around the
individual's arm. The pressure of the air in the bag
around the arm is recorded by movement of the mer-
cury from the proximal to the distal limb of the mano-
meter. The operator keeps on pressing the syrings
until oscillatory movements are seen at the surface
Sept. 23, 19 16 J
MEDICAL RECORD.
573
of the mercury in the distal limb of the manometer;
the mean point of maximum oscillations registers the
diastolic pressure. If the pressure in the bag is still
further increased, the oscillations diminish in ampli-
tude and finally disappear, and at this point the pulse
can no longer be felt at the wrist. The height of the
mercury supported then registers the amount of systolic
pressure. It will then be noted that the mercury has
descended in the proximal limb of the manometer, and
has ascended in the distal limb of the manometer: the
difference between the two mercurial levels will be the
blood pressure of the brachial artery. The normal
systolic pressure in man is about 120 mm. Hg, and the
diastolic pressure about 100 mm. Hg. In women the
pressures are about 10 per cent. less. In children the
systolic pressure may be as low as 90 mm. Hg, with a
diastolic pressure of about 80 mm. Hg. — (R. Hutchi-
son.)
1. CHEMISTRY.
Element.
Symbol.
Valence.
One Compound.
Hydrogen
H.
1
Hydrogen monoxide, H20
Oxygen
O.
2
Nitrogen monoxide, N:0
Carbon
C.
4
Ether (C3Hr.)30
Nitrogen
N.
3 or 5
Ammonia, NH3
Chlorine
CI.
1
Hydrochloric acid, HC1
Potassium
K.
1
Potassium iodide, KI
Sodium
Na.
1
Sodium chloride, NaCl
Arsenic
As.
3 or 5
Arsenic trioxide, As203
Calcium
Ca.
2
Calcium sulphate, CaSO,
Iron
Fe.
2 or 4
Ferric chloride FezCle
2. Nitrogen is a colorless, odorless, tasteless gas, non-
combustible, very sparingly soluble in water, very slow
to enter into combination; it is not poisonous, but it
does not support respiration.
It is chiefly eliminated from the body in the form of
urea.
Compounds containing nitrogen: Urea, CON2H4; am-
monia, NH3; nitrogen monoxide, N-O; nitrogen dioxide,
NO; nitrogen monoxide. N.03; nitrogen tetroxide, N=0,;
nitrogen pentoxide, N=0.-.; nitrous acid, HNO,; nitric
acid, HN03; hydrocyanic acid, HCN; lead nitrate,
Pb(N03):; ethyl amin, C.H5NH2.
3. Lead is a bluish-white metal, soft and pliable; not
very ductile or malleable, a poor conductor of electricity
but somewhat better conductor of heat, is readily oxi-
dized when exposed to air; its atomic weight is 207,
and its valence 2.
The compounds used in medicine are the acetate,
oxide, iodide and nitrate.
Sources of chronic lead poisoning : Contamination of
drinking water which has been in contact with lead;
the use of food or chewing tobacco which has been
wrapped in tinfoil containing excess of lead; drinking
of beer or other beverages which have been in contact
with pewter; handling of lead or its alloys; manufac-
turing processes in which lead or its compounds are
used.
4. Two antidotes for phosphorus: I. Old, acid, un-
rectified French oil of turpentine, which forms with the
phosphorus an inert compound of phosphorous acid.
2. Copper sulphate, which, besides being an emetic,
may coat the phosphorus with copper.
5. Chemical antidote for phenol, sodium sulphate,
which with phenol forms the insoluble phenolsulphonate.
Chemical antidote for nitric acid is magnesium oxide
or hydroxide, which will dilute and neutralize the acid.
Chemical antidote for oxalic acid is syrup of lime,
which forms the insoluble calcium oxalate.
Chemical antidote for mercuric chloride is milk,
which forms an insoluble albuminate.
6. Wood alcohol is methyl alcohol, H.CH:OH;
alcohol is ethyl alcohol, CHCH;OH. They both belong
to the class of hydrocarbon hydroxides.
Treatment of poisoning by wood alcohol: Wash out
the stomach, and administer a hypodermic of pilocai--
pine; strychnine is a serviceable tonic, and the iodides
are said to benefit the amaurosis. Rectal injections of
normal saline solution are useful.
7. Mercurous chloride is incompatible with KI be-
cause by the union of these two the soluble mercuric
iodide is formed, which is poisonous. Thus Hg=Cl2 +
2KI = 2KC1 + Hg2L.
8. Synthesis is the chemical building up of a com-
pound out of simpler compounds or elements.
Three synthetic organic substances used in medicine:
Salicylic acid, antipyrine, and urotropin.
9. To detect sugar in the blood: A small amount of
blood, obtained by wet cupping, is first freed from
proteids, by adding an equivalent weight of sodium
sulphate, and then boiling, and filtering, the filtrate
thus obtained being used for the test. A solution is
now made in a test-tube, by mixing two parts of
phenyl-hydrazin hydrochloride and four parts of sodium
acetate with about six cubic centimeters of water, and
gently heating the fluid, if necessary, to effect solution.
Five cubic centimeters of the proteid-free filtrate, while
still warm, are added to an equal volume of the test
solution. This mixture is then placed in a test-tube
half filled with water, heated for half an hour in a
water-bath, and allowed to stand until cool. When
cooling of the mixture has occurred, it shows under
the microscope the presence of the characteristic yel-
lowish crystals of phenyl-glucosazon, either detached
or in clusters, together with colorless crystals of sodium
sulphate. (DaCosta's Clinical Hematology) .
10. The antidote for most alkaloids is tannin; it pre-
cipitates the alkaloids and their salts and forms tan-
nates which are comparatively insoluble.
MATERIA MEDICA.
1. Mercury. Preparations and doses: Emplastrum
hydrargyri; Hydrargyrum cum creta, dose 4 grains;
Massa hydrargyri, dose, 4 grains. Unguentum hydrar-
gyri; Unguentum hydrargyri dilutum; Hydrargyri oxi-
dum rubrum; Unguentum hydrargyri oxidi rubri; Hy-
drargyri oxidum flavum; Unguentum hydrargyri oxidi
flavi; Oleatum hydrargyri; Hydrargyri chloridum cor-
rosivum, dose 1/20 grain; Hydrargyri chloridum mite,
dose (laxative), 2 grains; (alterative) 1 grain; Pilulse
catharticae composite, dose 2 pills; Hydrargyri iodidum
rubrum, dose 1/20 grain; Liquor arseni et hydrargyri
iodidi, dose 1% minims; Hydrargyri iodidum flavum,
dose, 1/5 grain; Liquor hydrargyri nitratis; Unguen-
tum hydrargyri nitratis; Hydrargyrum ammoniatum;
Unguentum hydrargyri ammoniati.
Incompatibles: Mercuric chloride is incompatible with
alkalies and their carbonates, potassium iodide, tartar
emetic, silver nitrate, lead acetate, lime water, and tan-
nic acid; with mercurous chloride, mineral acids, alka-
lies, ammonia, carbonates, chlorides, cocaine, iodides,
lead salts, lime water, sodium bicarbonate, and sugar.
2. Lead. Official preparations : Plumbi acetas,
plumbi iodidum, plumbi nitras, plumbi oxidum, liquor
plumbi subacetatis, liquor plumbi subacetatis dilutus,
ceratum plumbi subacetatis, emplastrum plumbi, em-
plastrum adhassivum, unguentum diachvlon.
Incompatibles: Alkalies, mineral acids and their
salts, opium, potassium iodide, vegetable acids, bro-
mides, carbonates, choral hydrate, glucosides, salicylic
acid, sulphates, tinctures.
S. For diarrhea, in an adult:
R Salolis, 5j.
Bismuthi subnitratis.
Creta? preparatse aa 3iv.
Pulveris acacia; q.s.
Aquse cinnamoni q.s. ad 5VJ- M.
Sig. : A dessertspoonful every 2 or 3 hours.
For diarrhea, in a child 2 years old:
R Bismuthi salicylatis, 3ij.
Glycerin, ?ij.
Misturaa cretas, q.s. ad Jiij. M.
Sig.: One teaspoonful every 2 or 3 hours, as neces-
sary.
4. Average hypodermic dose: Of apomorphine hydro-
chloride, gr. 1/10 (as an emetic) ; of morphine sulphate,
gr. Vs ; of nitroglycerin, ttr.j ; of atropine sulphate, gr.
1/150; of pituitary extract, irp.x.
5. Ergot. Official preparations and doses: Ex-
tractum ergotse. gr. iv; fluidextractum ergota?, Tl^.xxx;
vinum ergotse, 3ij.
6. The potassium salts, with doses, are: The acetate,
gr. xxx ; bicarbonate, gr. xxx; bitartrate, gr. .xxx; bro-
mide, gr. xv ; carbonate, gr. xv; chlorate, gr. iv; citrate,
gr. xv ; effervescent citrate, gr. Ix; cyanide, gr. 1/5;
dichromate, gr. 1/5 ; ferrocyanide, gr. vij ; hypophos-
phite, gr. vij; iodide, gr. vij; nitrate, gr. vij; perman-
ganate, gr. j; sulphate, gr. xxx; and potassium and
sodium tartrate, 5ij.
7. Three motor depressants: Aconite (dose of tincture,
10 minims) ; digitalis (dose of infusion, 31 j ) ; camphor
(dose of monobromated camphor, gr. ij).
Three sensory depi-essants: Opium, dose gr. j; bella-
donna (dose of tincture, Tlj. viij) ; chloral hydrate, dose
gr. xv.
8. Three antiseptics used internally: Phenol, dose
gr. j, well diluted: creosotum, dose rrp. iij; hexamethyl-
enamine, dose gr. iv.
Three antiseptics used externally: Phenol, 1 to 5 per
574
MEDICAL RECORD.
[Sept. 23, 1916
cent, solution; hydrargyri chloridum corrosivum, 1:1000
to 1:5000 solution; iodoformum.
9. A diuretic:
R Potassii acetatis.
Potassii bitartratis.
Potassii citratis, aa 3ij.
Aqua; q.s. ad 5viij. M.
Sig. : One tablespoonful in half a glass of water after
each meal.
10. "A serum is a product obtained by injecting into
an animal, usually a horse, a culture (e.g. Diph-
theria) or the toxin from a culture (e.g. Streptococcus)
of the organism. Serums may be subdivided into — (a)
Antitoxic serums, such as Diphtheria and Tetanus,
which are obtained by injecting filtered cultures into
the animal used to provide the serum, (b) Anti-bac-
terial serums, such as Anti-Streptococcus and Anti-
Gonococcus, in the preparation of which unfiltered cul-
tures are used. Serums are usually injected in the
flank or between the shoulder blades, the skin having
previously been cleansed and the syringe carefully ster-
ilized. Cases are on record where they have been given
intravenously with normal saline solution and also per
rectum.
"A vaccine is a finely divided suspension of killed
cultures of a microorganism which is injected directly
into the human subject. The object is to stimulate the
individual to elaborate his own antibodies, which re-
sults in increased resistance to the ravages of bac-
terial infection. Vaccines are of two kinds — (a) Autog-
enous— prepared from the organism isolated from
pathological material taken from the patient, (b)
Stock prepared from virulent cultures of the organism,
isolated from other cases of similar bacterial origin.
Vaccines are administered by subcutaneous injection by
means of an all-glass hypodermic syringe. The site of
injection may be the flank, thigh, shoulder, or back.
The skin is first sterilized by a pledget of cotton wool
saturated with a suitable antiseptic, e.g. lysol.
"Briefly, the difference is that with a serum the oppos-
ing influence to the toxins is produced outside the
human body, while with the vaccine it is produced in-
side and the degree of immunity conferred is greater
with the latter than the former. It should also be
noted that the dose of a serum is much higher, from
the standpoint of the amount of fluid injected, than in
the case of a vaccine. With the former the dose usually
ranges from 10 c.c. to 50 c.c, while with the latter
it is, as a rule, not more than 1 c.c." (Holland's Phar-
macy Handbook.)
THERAPEUTICS.
1. Flexible collodion is used as*a protective applica-
tion, also to prevent bedsores, seal wounds, close punc-
tures made by aspirators. Cantharidel collodion is used
as a blistering agent.
2. Boric acid is a feeble disinfectant; in dilute solu-
tion it is antiseptic and soothing to mucous membranes;
it is used as a dusting powder and in lotion and oint-
ment in cases of ulcers, eczema, wounds, burns; in
cystitis it may be used to wash out the bladder; it is
also used as a disinfectant in conjunctivitis.
3. Salicylic acid is used externally as an antiseptic;
internally, it is given for rheumatism, migraine, gout,
sciatica, cholelithiasis. It is a specific for rheumatic
fever. It is generally given in the form of sodium
salicylate, but the lithium, ammonium, and strontium
salts are also used.
4. Sodium bicarbonate is an odorless white powder,
with a salty taste, soluble in 12 parts of water, in-
soluble in alcohol. It is used as an antacid, antipru-
ritic, and analgesic; internally, it is sedative to the
stomach, but in large doses it stops the gastric diges-
tion. Given after meals it relieves hyperacidity of the
gastric juice. It is incompatible with acid substances,
heavy metals, and alkaloidal salts.
5. Spiritus setheris nitrosi is a transparent liquid with
a peculiar penetrating odor and a sharp and sweetish
taste; it is inflammable. It is used as a diffusible
stimulant; it is also diaphoretic and diuretic and slight-
ly antipyretic. Dose 15 to 60 minims.
6. Ethyl chloride is a gas at normal temperature
and pressure, but it is usually supplied condensed into
a liquid which is volatile, colorless and inflammable. It
has a pleasant ethereal odor. It is used as a general
anesthetic in short operations where ether is not desir-
able. It is not so safe as nitrous oxide, and is fol-
lowed by headache and vomiting. It does not relax the
muscles. It is said to give rise to erotic sensations.
7. Alumen is alum, a crystalline solid, of sweet
and astringent taste, and acid reaction; soluble in about
ten parts of water, freely so in glycerin, insoluble in
alcohol. It is used as an astringent and styptic, and
is useful in stopping bleeding from the nose, gums and
superficial cuts. The exsiccated alum absorbs more
moisture, and so is somewhat caustic as well as more
powerfully styptic, and has been found useful in bleed-
ing tooth cavities, hemorrhoids, and soft corns. Inter-
nally alum is used as an astringent mouth wash or
gargle; also as an emetic.
8. Arsenic trioxide is antiseptic, irritant and caustic;
it causes inflammation, severe pain and necrosis of
tissue; it is used as an aid to digestion, in dyspepsia,
in the vomiting of alcoholism or pregnancy; in anemia
and leukemia it increases the number of the red cells;
it is a general tonic and improves the appetite, diges-
tion, bodily vigor and body weight. The liquid prepa-
rations are: Liquor acidi arsenosi, liquor potassii ar-
senitis, liquor sodii arsenatis, liquor arseni et hydrar-
gyri iodidi. All of these liquid preparations (except
the liquor potassii arsenitis) can be administered with
acids.
9. Hexamethylenamine is a crystalline solid without
odor, and of a sweetish taste. It is readily decom-
posed by acids and by heat, is insoluble in ether,
slightly soluble in alcohol and in water. It is used in
infections of the genitourinary tract, bacteriuria,
typhoid, infections of the gall-bladder and in cerebro-
spinal meningitis. Its action is due to the splitting up
of the compound, and the release of formaldehyde. The
danger of large doses lies in the fact that the patient
may suffer from frequent micturition, hematuria, pain
in the bladder, irritating urine; sometimes the kidneys
may be irritated; headache, skin eruption and gastric
irritation may also follow large doses.
10.
R Liquoris potassii arsenitis 5jss.
Sodii salicylatis 5v.
Glycerini, 5j-
Aquae menthae piperita; q.s. ad 5iv. M.
Sig.: Take one teaspoonful in water, gradually in-
creasing to a dessertspoonful, after meals.
This prescription may be used for cases of diabetes
mellitus.
(To be concluded.)
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SYPHILIS OF THE NERVOUS SYSTEM*
By JOHN A. FORDTCE, M.D.,
NEW YORK.
PROFESSOR OK DERMATOLOGY AND SYPHILOLOGY, COLLEGE OF
PHYSICIANS AND SURGEONS, COLUMBIA UNIVERSITY,
NEW YORK.
The number of patients who show involvement of
the spinal fluid in the secondary period of syphilis
bears u certain relation to the total percentage of
cases with lues of the nervous system. In a series
of cases of secondary syphilis examined in my hos-
pital service two years ago less than 20 per cent, re-
vealed abnormalities in the spinal fluid. Recently
another series of 63 cases were punctured; 10
showed very slight changes as to lymphocytosis and
globulin content, coming well within the borderline
cases, while 15 exhibited a definite increase in cells
and globulin with a positive Wassermann reaction
in 7. Thus 25 per cent, of the cases gave evidence
of a definite pathological condition of the cerebro-
spinal axis, while 16 per cent, showed trifling ab-
normalities. The significance of the latter we are
not prepared at this time to state, but it may be
assumed that they are only transient and part of
the systemic affection.
The standard used was a cell count over 5, a
globulin content demonstrated by the Pandy test, a
positive Wassermann reaction in amounts to 2.0 c.c.
of fluid, and the color changes elicited by the Lange
test. Statistics in the literature treating of ab-
normal fluids in the secondary stage of lues are
variously quoted at from 10 to 90 per cent. In
criticism of this disparity, it is possible that too
much significance has been attached to minor
changes as increased pressure, increase of a few
cells or a trace of globulin. My belief is that only
such individuals who show very conspicuous changes
as evidenced by a definite cell count, globulin and
positive Wassermann are candidates for one or the
other of the different clinical types of cerebro-
spinal syphilis and that in a large majority of pa-
tients the spirochaetae must be destroyed spon-
taneously or by therapeutic agents administered in
the ordinary way. It is said that from 9 to 25 per
cent, of all syphilitics develop disease of the nervous
system. These figures have little value at present
as they were compiled before the era of laboratory
diagnosis and must be revised on the basis of more
exact data. With our modern aids of diagnosis we
are in p. position not only to differentiate the specific
from the non-specific types of disease but also to
make the diagnosis of syphilis in many cases that
would otherwise go unrecognized.
Our greatest hope in the cure of syphilis of the
*Read before the fortieth annual meeting of the
American Dermatoloerical Association at Washington,
May 8, 9 and 10, 1916.
nervous system lies in the adequate handling of the
infection in its early inception. In other words it
must be prophylactic. Failing this, too great stress
cannot be laid upon the early recognition of signs
or symptoms which point to involvement of the
cerebrospinal axis. The syphilographer and derma-
tologist by contact with cases of secondary syphilis
are in a position to discover the earliest clinical
signs of involvement, such as irregularity of the
pupils and irresponsiveness to light, exaggeration
of the knee jerks, headache, auditory and ocular de-
fects, or oculomotor paralyses. These are all positive
indications for lumbar puncture. If dermatologists
and genito-urinary surgeons were familiar with the
earlier manifestations of nerve involvement they
would uncover many cases of nervous syphilis
against which a therapeutic attack could be made
and the patient rendered secure from future de-
generative changes.
The treatment in the early active stage must be
intensive and systematic and should consist of a
combination of salvarsan and mercury, for we have
learned that salvarsan alone is apt to be followed
by neuro-recurrences. It has also been shown that
in patients inadequately treated a pleocytosis,
marked increase of globulin and a strongly positive
Wassermann reaction may be present without
evincing any subjective discomfort, the condition
remaining latent for years until symptoms of tabes
or paresis make their appearance. When these
cases are clinically developed irreparable damage
has already been done to the nerve tissue. It is
therefore incumbent upon the syphilographer to
treat the fresh infection energetically and wherever
practicable to examine the spinal fluid at the com-
pletion of the treatment or, in the absence of phys-
ical signs, after a provocative injection of salvarsan
which should be given one year after the Wasser-
mann reaction has been continuously negative.
In the treatment of luetic affections of the ner-
vous system it is important to properly instruct pa-
tients that the procedure is a long drawn out one
and unless they are willing to place themselves un-
der the care of a physician for one or two years it
is hardly worth while to undertake it. It is true that
the progress of certain types can be arrested by in-
travenous therapy alone combined with mercury and
potassium iodide. I have had under observation for
the past five years cases of cerebrospinal syphilis of
the basilar meningovascular type where salvarsan
was administered only intravenously and the fluid
findings have become negative, the symptoms have
disappeared, and there has been no relapse. In a
few cases of tabes and optic atrophy the condition
has been brought to a standstill and even shown
marked improvement. This method, however, is in-
adequate for the great majority of sufferers for I
have repeatedly seen patients who have had 10 to 15
intravenous injections of salvarsan with the pro-
576
MEDICAL RECORD.
[Sept. 30, 1916
longed use of mercury and potassium iodide with
little or no change in the fluid findings or clinical
symptoms. After a course of subdural injections
both symptoms and serological findings greatly im-
proved.
great to justify their continuance. The method,
however, seemed a logical one and if a therapeutic
quantity of the drug could be used which would
accomplish the desired result short of an irritating
effect it was well worth a thorough trial. The rea-
Chart I — Spinal Fluid Findings in Early Secondart Syphilis.
Serum
1 31
!
Date II.
W : i
Cells.
Glob. W Lunge.
Remarks.
M. B.
1 lh
3 15 16
Sluggish pupils.
+ + + +
(i
*
Negative Luetic curve
\ ery marked maculo-
pap. rash.
.1. B.
in 1 . , 1 -,
in 15
1 iizziness; exag n
+ + + +
L'7
■ ■
Negal ive Luetic cm ve
n B
Hi L5
1 16
Dilated fixed pupil
+ + + +
7
+
ive Luetic cun e
Grouped papuli.-'M'i i m
rash
M. K.
111.".
II 15/1 5
None
+ + + +
2
+
Negative Negative
P. M.
Ill 15
2 In
None
+ + + +
li
Negative
Negative Nea
J. F.
9 in 15
l 15 16
Pupils sluggish
+ + + +
11
Negative Negative Negative
Papulo-pustulai
- G
1L' 15
1 16
lull-
+ + + +
1
Negative Negal i1. e Negal ' ■ ■
E. G.
12 15
i i ii
Righl disc hazy
+ + + +
li
Negative Negative Negative
M. M.
1 2 1 5
1 16
1 mpaired hearing
+ + + +
1_'
Negative
Negal ive Nega
i , M
1 li,
2 16
[rreg. fixed pupils
+ + + +
iil
+
Negal ive Luetic curve
Generalized papular rash
1 .
1 16
:; 16
\ ■
+ + + +
4
Negative
Negative Negative
:* chancres.
J. P.
3/ 16
1 Hi 16
None
+ + + +
■"i
Negative
Negal ive Negative
H. I:
[2 3/15
1 16
1 u 1 1
+ + + +
-•
Negath i
e Negative
T. i{.
?
9 15 15
1 [eai [ache; exag. knee jerks ; fixed
pupils; com lusions
+ + + +
:(!
+ +
\ — 0.2 Paretic curve
Mucous patches; II rash,
9 IS 15,
J. li.
1 2 1 5
1 29 16
Hi M. sea exag.; choroiditis; papilli i-
edema lefl disi
+ + + +
jiiti
+ + +
i 0.4 1 .<■>■ i u curve
J. U.
12/ L5
2 16
Fundi congi bed; righl disc hazj
+ + + +
0
Negative Negative Luetic curve
.1. U.
L2, 15
1 16
Pains temporal region
+ + + +
ii
Nega i ive
Negal ive Neg i
M. K.
1 16
:; 15 16
1 [eadaches; refli
+ * + +
:i
Negal ive
Negative Negative
I M
6 15
s 15
\'
+ +
l
=t
N gath e Negative
A 1
Hi 15
1 16
ng papillitis; .mil' reflexes
+ + + +
2
Negative Negative
A. R.
9/ 15
?
Tinnitus; dizziness; riL'ht .lis-/
+ + + +
(1
+ + + +
i 0.8 Luetic cui \ e
Symmetrical, ulcei
ted; LH cloud}
lesionE arms two mos.
duration. Malignanl
i'lir icious syphilis.
In outlining the course to be pursued I have found
the best procedure to be the following:
In patients with a negative blood and a positive
fluid a provocative injection of salvarsan should be
administered and the Wassermann reaction taken
at stated intervals. If it remains negative sub-
arachnoid treatments may be begun at once. When
both blood and fluid are positive two or more injec-
tions of mercury should precede the intravenous ad-
ministration of salvarsan and after two or three
doses of the latter the intraspinal injections insti-
tuted, supplemented by the intravenous, [n paresis
my usual practice is to begin the intraspinal injec-
tions after the first intravenous treatment. The in-
tervals between doses, and this applies to both
routes of introduction, are regulated by the reaction
produced in the patient. Where subdural injections
are well borne they may be given in series of four
to six one to two weeks apart with a rest period of
four to six weeks and then another course. Fre-
quently tabetics are met with in whom intraspinal
medication cannot be repeated oftener than once a
month.
Since the introduction of the intraspinal method
in 1912 by Swift and Ellis we have treated in my
private work and at the Vanderbilt Clinic 110 cases
of tabes, 13 of taboparesis. 12 of optic atrophy, 25
of paresis and 20 cases of other types of cerebro-
spinal syphilis. At first the original method of
Swift i nd Ellis, namely, the use of auto-salvar-
sanized serum was adhered to; for the past two
years the modification of Ogilvie with the direct
addition of salvarsan to the blood serum. In the
earlier work it soon became apparenl thai salvarsan
in quantities of one, two or three milligrams often
acted as an irritant and caused traumatic irritation
the lower cord which manifested itself in bladder
paralysis, numbness of the gluteal region and ex-
tremities with an inn he ataxic state. Some
patients bore these large amounts of the drug with-
out apparent injury and even marked improvement
in their symptoms, but we felt that the risk was too
sons for employing this technic instead of the auto-
salvarsanized serum recommended by Swift and
Ellis were, first, that a definite quantity of salvarsan
can be introduced and the dose more easily con-
trolled; second, the addition of a definite amount of
the drug with a smaller quantity of serum, and
third, the possibility of preparing several doses with
the blood serum removed from a single patient. The
last is i f decided advantage in treating a large num-
ber of hospital patients. Then, too, the intraspinal
injections often have to be repeated more frequently
than the intravenous injection and in cases with a
negative serum there is no indication for the latter.
Experience has shown that the blood serum re-
moved indifferently from patients acts equally as
well as the autogenous serum. The most important
step in the technique, besides absolute asepsis, is
the use of a salvarsan solution which is nearly neu-
tral. The blood is removed from an arm vein and is
centrifugalized, the serum pipetted off and then cen-
trifugalized again to insure complete removal of
any red cells. To 8 to 10 c.c. of this serum 1 20 to
1 2 milligram of salvarsan according to indications
is added. This mixture is incubated at 37 ('. for 40
minutes and inactivated at 56 C. for one half hour.
As to dosage, patients with general paresis toler-
ate larger doses than those suffering from tabes or
other forms of cerebrospinal syphilis. For tabetics
the initial dose should be 1 20 to 1 10 milligram,
depending on the bladder involvement and the
amount of pain present. The quantity is gradually
increased; in some patients never exceeding the
dosage of 1 10 milligram; in others 1 5 or 1 3 milli-
gram maj be injected without producing much dis-
comfort. The intervals depend upon the reaction
and vary from ten days to a month. In paretics the
primarv dose may be ' i milligram running up to Vo
milligram and repeated at intervals of a week to
ten day? to two or three weeks. In patients in whom
the cord is not involved weekly injections of ' \ milli-
gram have not produced any irritative symptoms.
There is apparently no limit to the number of in-
SeDt "-0, 1916J
MEDICAL RECORD.
577
jections that can be given. An activation of the
lesions after the first injection is not a contra-
indication to the use of the drug but calls for care.
The reactions incident to the treatment of ner-
vous syphilis fall under two headings: (a) Those
dependent upon the intravenous injection and {!>)
those occurring after intraspinal medication. The
majority of patients, providing small initial doses
are given, preceded by two or three injections of
mercury, are able to take the intravenous treatment
without bad effects. Patients are met with from
time to time, however, who from the first do not
support it well even in small doses. They become
actively ill an hour or two after treatment, with
chill and vomiting and complain of malaise for the
next day or two. A woman with paresis and a man
with tabes under observation had this type of re-
action each time they were treated. A reaction of
an anaphylactoid nature characterized by flushing
of the face, rapid breathing, with cardiac or tho-
racic oppression is also seen in a certain number of
patients. More rarely severe reactions are encoun-
tered with alarming symptoms as chill, fever, head-
ache, and mental excitability succeeded by coma.
Several years ago I noted such a reaction in a pa-
tient with cerebrospinal syphilis. In two or three
days he entirely recovered and subsequent treatment
was well tolerated. Another patient who had a hemi-
plegia several years before and who at the time un-
der discussion was being treated for choroiditis and
atrophy of the retina, became unconscious three
days after an intravenous injection of 0.35 gm. of
salvarsan. He regained consciousness after several
hours but was disoriented, mentally confused, and
unable to speak. The next day he was normal. As
part of the intravenous treatment an intensification
of the lancinating pains, girdle sensation, or bladder
symptoms is not uncommonly met with in tabes if a
large dose is administered. With the exceptions
noted reactions can usually be obviated by keeping
well within the dosis tolerata for that particular pa-
tient, if necessary making the intervals a little
shorter in order to get the desired effect.
days, and is relieved only by the recumbent position.
Usually it can be avoided by rest in bed for forty-
eight hours after treatment, but occasionally pa-
tients suffer in spite of this precaution. Rarely
vomiting as an isolated symptom comes on two or
three hours after treatment and lasts until the next
day.
Of the second group by far most of the discom-
forts occur in tabetics and usually manifest them-
selves as exacerbations of their lancinating pains,
gastric or rectal crises. They appear within a few
hours, last for a day or so, and are often severe
enough to require the administration of opiates.
These paroxysms are then followed by longer inter-
vals of freedom from pain. It is well to bear this type
of reaction in mind and to give very small doses for
the first few treatments as its severity is often pro-
portional to the size of the dose. Since we have been
using 1 10 to 1 8 or even as low as 1 20 milligram
patients have complained of less inconvenience.
Alcoholics and morphine habitues tolerate both in-
travenous and intraspinal treatment very poorly as
a rule. Among the severer types of reaction bulbar
symptoms sometimes make their appearance, that
is, shock with marked laryngeal crises, irregular
respiration and partial loss of consciousness. In a
paretic this train of symptoms developed each time
after the first three injections, becoming less in-
tense and then ceasing altogether. He is now treated
with amounts of 1 5 to 1 4 milligram without any
discomfort. It is interesting to note that his first
intravenous treatment was followed by mental con-
fusion. In another case, a woman with general
paresis, aphasia and mental confusion lasting sev-
eral hours developed two days after the fourth in-
traspinal treatment of 1 TO milligram. There was
no paralysis. In yet another case a fatal hemorrhage
ensued within twenty-four hours after the introduc-
tion of % milligram. The patient was a man, aged
47, markedly alcoholic.
From the foregoing it will be seen that while in
the larger percentage of cases there is little risk
attending either intravenous or intraspinal treat-
Chabt II — Serological Findings in Treatment <> Syphilis of Nervous System.
1 diagnosis.
Before Treatment
Amount of Treatment.
Vfteh Treatment.
Case.
Cei ebi
jspirj 1 1 Fluid.
Cerel >rospina!
Flui 1.
Bl i 1 1
Salv.
Salv.
i l
Blood
'A i
Cells.
u ass.
I. V.
I. S.
w ass
Cells.
W. G.
Tabes
44-
34
2 +
4+ 0.2
19
1
17
+
3
+
Neg
T. C.
Tabes
Neg.
9
44-
2+ 1.0
11
6
12
Neg.
:i
Neg.
Neg.
I. G.
Tabes
4 +
160
44-
4+ 0.4
li
5
12
Neg.
0
+
Neg.
S. G.
Tabes
1 +
7.:
44-
0 i
">
6
S
Neg.
(i
Neg.
Neg.
I.. F.
Tabes
i +
128
1
4+ 0.2
10
7
12
4 +
0
4-
Neg.
J. 11.
Tabes
4 +
150
1
0 1
11
9
20
-1 -
0
±
Neg.
W. R.
T:il'i'-
Neg.
81
44-
1+ 0.4
2
7
Neg.
i>
4=
Neg.
E. M.
Tabes
Neg.
12
2 +
+ 1.0
12
Neg.
(i
Neg.
Neg.
G. R.
Tabes
t f
711
4^
1+0.4
12
11
12
Neg.
li
Neg.
Neg.
I.. C.
Optic atrophy
Neg.
60
4 +
! II 2
5
6
Neg
0
+
Neg.
S. G.
Optic atrophy
Neg.
33
4 +
4+ 0.6
3
1
2 +
1
-'
Neg.
H. K.
Cerebrospinal syphilis
1 -
46
4 +
4+ 0.0
12
HI
Neg.
0
Neg.
Neg
II. II.
Cerebrospinal syphilis
4 +
235
44-
4+ 0.6
13
1
211
4 +
s
2 +
E. li.
Cerebrospinal syphilis
4 +
90
4 +
0
7
7
8
44-
0
+
Neg.
M. G.
Cerebrospinal .-> philis
4 +
96
44-
1+ 0.4
1
11
4t
0
Neg.
.
L. T.
• 1 - ihilis
4 +
51
3 +
4+ 0.2
9
111
26
2 +
3
Neg
The reactions following subdural injections form
two groups : ( 1 J Those incidental to puncture, and
(2) those due to the medicated serum itself. In the
first class belongs chiefly the headache which some-
times develops twenty-four to forty-eight hours
after the treatment, coming on shortly after the
patient gets up. It is very annoying, lasts several
ment in disease of the nervous system it is not al-
together a harmless procedure and it cannot be em-
phasized either too strongly or too frequently that
every precaution be carefully carried out in regard
to preparation, size of dose and sufficient rest in bed
after treatment. Whether in the subdural injections
the untoward effects mentioned are due to the irri-
578
MEDICAL RECORD.
[Sept. 30, 1916
taling action of the arsenic or to a change in pres-
sure acting on the diseased vascular walls cannot
be positively asserted.
The results of the treatment may be grouped ac-
cording to their effect on the biological findings and
the clinical status of the patient. Cure, ameliora-
tion, or failure is dependent upon the extent and
type of the morbid process, i.e. whether an active
meningeal inflammation is present or degeneration
of the essential nerve structures. While the same
physical signs may be produced by both processes
their prognosis is quite different. Where the symp-
toms are due to an active inflammation with strongly
positive fluid the outlook is very encouraging.
Where, however, the underlying process is one of
degeneration with atrophy and sclerosis with nega-
tive or weakly positive fluid findings the prognosis
is not so hopeful.
Of the laboratory findings the pleocytosis is most
susceptible to therapy and usually disappears after
a few injections; in many cases with intravenous
treatment alone. The Wassermann reaction and the
globulin content are more refractory, the latter per-
sisting even after the Wassermann reaction has be-
come negative. The influence of treatment on the
Wassermann reaction in the fluid depends upon the
type of the affection met with. In cerebrospinal
syphilis it is more quickly affected by the combined
treatment than in tabes or paresis. In some cases
13 injections intravenously and 1 injection intra-
spinally brought about a reversal. In others 16 in-
travenously and 15 intraspinally were required.
Treatment should be continued for a time in spite
of a negative reaction as I have seen it become pos-
itive again after several months where it had been
intermitted with the first negative findings. In
tabes with the reaction positive with 0.2 c.c. or less
of fluid it is usually very slow to disappear but grad-
ually grows weaker under prolonged treatment. Its
persistence is suggestive of taboparesis. This can
be confirmed by the colloidal gold test. In tabo-
paresis and paresis the reaction is most resistent;
in some cases fixed. In the greater number of cases
1 have under observation it has only been influenced
in the higher dilutions remaining +- 1— f- f- with 0.4
or 0.6 c.c, even where 30 to 40 or more intraspinal
injections have been given. In a few cases the re-
action has become completely negative to 2.0 c.c,
the globulin has been reduced to a trace and the
colloidal gold test has been changed from a paretic
to a luetic curve. These in my experience are excep-
tions. In one case where the serological findings
have become practically negative the patient has
steadily deteriorated clinically. The gold sol reac-
tion usually runs parallel with the other findings
and changes from a luetic curve to normal in
cerebrospinal syphilis and tabes, and from a paretic
curve to a luetic curve, rarely normal, in general
paresis and taboparesis.
The clinical achievements may be summarized as
follows : In active progressive tabes the lancinating
pains are ameliorated or disappear entirely. The
gastric and rectal crises are usually controlled or
regress and the ataxia is markedly decreased and in
some cases has disappeared. Disturbances of sensa-
tion partially or completely clear up. Spincter con-
trol and sexual power have improved or returned to
normal. The patients feel better, put on weight and
are able to resume their occupation. I have noted
no return of absent reflexes. The following cases
are illustrations of the therapeutic results obtained :
Case I. — Tabes; man (40). Syphilis eight years ago.
For one year severe pains in legs, girdle sensation, and
marked ataxia ; absent reflexes, Argyll-Robertson pupils.
Blood ++++; cerebrospinal fluid (3/11/13): Cells 70,
globulin -| — (-++> Wassermann ++H — h to 0.4. Treat-
ment, 12 intravenous; 10 intraspinal injections. Patient
could not take mercury and was unrelieved by intra-
venous treatment. Under subdural therapy leg and
girdle pains disappeared. He is able to walk without
assistance, has gained considerably in weight, and for
two years has been back at his work. Serological find-
ings have remained negative.
Case II. — Tabes; man (32). Syphilis fourteen years
ago. Tabetic symptoms four years. Loss of coordina-
tion; most pronounced ataxia; lancinating pains, rectal
and vesical control impaired. Blood -I — | — I — 1-. Fluid
(2/10/12) : Cells 34, globulin ++, Wassermann ++++
to 0.2 c.c. Treatment, 15 salvarsan injections intra-
venously; inunctions and injections of a soluble mer-
curial salt. Result: Freedom from pain; spincter con-
trol regained; sexual power improved; most marked
change in ataxia, which is now scarcely perceptible,
and patient is able to walk several miles a day.
Case III. — Tabes and optic atrophy; woman aged
thirty-two. Syphilis probably fifteen years ago. For
four years severe headaches; manual incoordination and
slowly progressing numbness. For two years girdle
sensation and ataxia. Reflexes absent; marked Rom-
berg; gait very ataxic, patient almost unable to walk.
Eight months before treatment vision of left eye be-
came impaired and then failed entirely. Right eye
showed irregular pupil, sluggish to light and accommo-
dation; fundus slightly Dale, vision 40/20. Blood Was-
sermann -J — | — |— 1-, spinal fluid cells 67, globulin ±,
Wassermann -f-j — j — f- to 0.4. Treatment, 19 salvarsans
intravenously; 16 mercuries; her last salvarsan injec-
tion was given 7/24/14 and the last mercury 1/5/15.
The latter drug she did not tolerate well. In March,
1915, she gave birth to a child. She was seen again on
April 27, 1916; a most remarkable improvement in her
gait had taken place; only a very slight ataxia re-
mained. The condition of her right eye has remained
stationary. Her general health is very much better
and she has gained 12 pounds in weight.
Case IV. — Tabes; man aged forty-one. Syphilis
Chart III— Serological Findings in Paresis Bepore and After Treatment.
Tkv\tmf:\t.
After
Treatment.
Cerebrospinal Fluid
Trbatuknt.
Cerebrospinal Fluid.
Blood
Date.
Blood
Wass.
a .
Bl 1
Hg.
Cells.
Glob.
Was?.
Laoge.
Injts.
Cells.
Glob.
Wass.
Lange.
H.II.
12-12-13
+
4+ 0.6
5555554100
++++
30
34
7
1-12-lf,
2
++++
4+ 0.4
5555555430
*
E. R.
ISO
++++
4+ 0.05
i Ml 4 13200
++++
31
41
6
++
4+ 0.2
5555542000
+++
E.N.
16
++++
5555543100
+ ++ +
14
23
4 5-16
13
+
4+ 0.4
5555430000
++++
30
44- 0.05
6555543100
++++
12
20
6- 1-15
8
++++
5555543000
++++
C.J.
3-29-15
7.-,
++++
4+ 0 4
5555543200
++++
10
15
29
4 21 16
12
++
4+ 0.4
5555553000
Neg.
W. A.
2-20-15
290
++++
4+ 0 05
5555542100
++++
23
25
22
4 26 16
7
++++
++++
W.R.
6-2S-15
100
+ +++
4+ 0.05
5555542000
++++
7
5
10
4-29-16
2
++
; 0 i
5555432000
++++
11-27-15
++++
D 1
5555555543
++++
5
18
4-19-16
10
++++
4+ 0.1
5555555400
++++
H.W.
5-19-15
a
++++
4+ 0.1
112100
++++
11
20
11
12-22-15
0
±
2+ 1.0
1134330000
Neg.
V. P.
10- 5-15
60
4+ 0.2
5555555200
++++
10
16
2
3-29-16
6
+ +++
4+ 0.2
5555554300
++++
B.A.
++ +
4+ 0.1
5555542000
++++
6
9
16
4-19-16
7
++
4+ 0.4
5555430000
++++
\\ I..
110
++
4+ 0.1
5555554400
++++
4
3
6
4 12 16
24
++++
4+ 0.1
5555554400
++++
M.H.
8- 9-10
35
+++
4+ 0.6
5555543000
++++
4
4
3
4-19-16
10
+++
4+ 0.4
5555543000
++++
F. 11.
1-22-16
40
+++
4+ 0 2
5555555520
++++
4
4
4-29-16
11
++++
4+ 0.1
5555555300
++++
T. R.
34
++
4+ 0.2
5555.542200
++++
13
50'
4-26-16
3
++
4+ 0.6
5555530000
++++
Sept. 30, 1916]
MEDICAL RECORD.
579
nineteen years ago. For two years has had rectal
crises. Knee jerks normal; station good; bladder slow;
sexual power weak; pupils unequal and sluggish to
light. Blood Wassermann ++++. Spinal fluid: 150
cells, globulin -| — |-, Wassermann -| — | — | — |- to 0.4; Lange:
luetic curve. He has had 11 intravenous and 9 intra-
spinal injections of salvarsan in dosage of 1/10 to 1/5
milligram and two courses of mercurial injections. Ex-
cepting a trace of globulin his serological findings are
negative; his blood remains -\ — | — | — |-. The crises which
were intensified by the first few intraspinal injections
have cleared up entirely.
Case V.- — Incipient tabes; man, aged forty-three.
Syphilis twenty years ago. Was first seen January,
1911, at which time he exhibited the symptoms of in-
cipient tabes. Two years before he had had double
vision. His serum was ++++. His fluid examination
on November 21, 1912, showed 14 cells, positive
globulin, negative Wassermann. Serum, negative.
Treatment, 10 intravenous injections of salvarsan and
several courses of mercurial treatment. Clinically the
pains which had been a pronounced symptom have en-
tirely disappeared. The patient was again punctured
April 27, 1916, and showed a normal spinal fluid and a
negative blood.
The results in optic atrophy depend upon whether
the nerve substance is primarily affected or whether
there is an extension from the meninges. In pri-
mary optic atrophy the essential tissue it attacked
either by gummata or Huebner's arteritis (Nonne).
It is, however, more often affected secondarily and
the vast majority of cases show positive findings
in the fluid with symptoms of tabes. In the former
treatment at first appears to be effective in arrest-
ing the process but some cases slowly progress in_
spite of the apparent improvement. In the secon-
dary form energetic treatment is especially indi-
cated and gives a more encouraging prognosis.
Case VI. — Optic atrophy; woman, aged forty-eight.
Syphilis six years. One year after infection double
vision and strabismus. When seen in October, 1912,
vision of right eye 20/50; left, fingers at 4 inches.
Cerebrospinal fluid: Cells 24, globulin +, Wassermann
++++ with 1.0 c.c. She has had 23 intravenous in-
jections of salvarsan, 1 intraspinal, several courses
of mercurial injections, inunctions, and mixed treat-
ment. Under treatment her headaches ceased; vision
in right eye was 20/20, and in left, fingers at 2% feet.
August 21, 1914, the report on her eyes was as follows:
Vision of the right 20/20, of the left, fingers at 5 feet.
The condition has remained stationary and at the pres-
ent writing the fields of vision are normal in the right
eye and somewhat improved in the left. The paleness
of the left disc is apparently about as before.
Case VII. — Optic atrophy; man, aged thirty-five.
Syphilis denied. June, 1911, blurring of left eye; pupils
irregular, sluggish to light and accommodation; both
discs pale, left markedly so. Vision of left 50/20, right
40/20. Spinal fluid October 6, 1912: Cells 15, globulin
±. Wassermann — ; serum ++++. Treatment, 17
salvarsan injections intravenously, several courses of
mercury and mixed treatment. February 16, 1915,
ophthalmologist's report read as follows: Accommo-
dation has increased in both eyes; vision has improved;
the irides react to the stimulus of light but they are a
little sluggish. Optic disc improved somewhat in color
and fields of vision improved.
Case VIII. — Optic atrophy; man, aged fifty. Syphilis
denied. Gonorrhoea twenty-five years ago. In June,
1914, complained of pains in legs and double vision.
Disturbance in walking; slight headache. Impairment
of vision of right eye, 20/70 — . Blood ++++. Spinal
fluid: 0 cells, globulin +, Wassermann ++++ to 0.8;
Lange: luetic curve. Treatment, 3 intravenous, 12
intraspinal injections of salvarsan besides mercury.
The patient feels better in every respect, his mind is
clearer, he has no pain, and no fatigue after exercise.
The vision in this right eye is now 20/30. Spinal fluid :
12/1/15 cells 2, globulin +, Wassermann ++ with
1.0 c.c.
Summarizing the cases of paresis, all showed the
typical biological findings ; namely, a positive serum ;
an increase of cells varying from 18 to 290, strongly
positive globulin content and a positive Wassermann
in dilutions of 0.2 or less. The colloidal gold test
gave a typical paretic curve, that is, complete decol-
orizaticn in the first four to eight tubes. The num-
ber of intraspinal injections administered varied
from 6 to 41 alternating with intravenous injections
of salve rsan.
In the following abstracts are cited the average
type of case met with and from these can be gauged
the hope to be held out for amelioration of the con-
dition :
Case IX. — Paresis; man, aged 38. Syphilis in 1902.
No symptoms until 1912, when he conmlained of head-
aches. No treatment. In April, 1914, mental symptoms
with marked excitability and grandiose ideas developed
and he was placed in an institution. On February 20,
1915, he came under my care. His serum was -\ — | — 1 — |-;
spinal fluid: cells 290, globulin -| — |— ) — |~, Wassermann
i — h++ to 0.05; gold reaction paretic curve. Since
that time he has had 23 intravenous and 25 intraspinal
injections of salvarsan, inunctions and intramuscular
injections of mercury. In June, 1915, a marked im-
provement in his mental condition had taken place, he
was able to leave the sanatorium, and the treatment
was then carried out on the ambulatory plan. In
August, 1915, he seemed normal mentally and went
back to work. His fluid became normal as to cells,
globulin remained strongly positive, and Wassermann
positive to 0.4; the Lange showed a luetic instead of
the paretic curve. His remission lasted until July,
1916, when he became careless about his work in the
office, destroyed letters, and exhibited kleptomaniac
tendencies.
Case X. — Paresis; man, aged fifty. No history.
Mental symptoms began the early part of 1912. May
8, 1914, serum +++-|-; spinal fluid: cells 48, globulin
++, Wassermann — ( — J — | — |— to 0.2 ; gold test positive. He
has had 15 intravenous and 24 intraspinal injections of
salvarsan. Clinically, he has not returned to his former
mental condition but is able to remain with his family,
takes part in their social affairs, goes to the theater,
etc. In other words, for the past two years he has led
a comfortable vegetative existence and excepting an in-
creased irritability now and then has had no mental
outbreaks. His fluid is normal only as to cells.
Case XL— Paresis; man, aged forty-five. Primary
lesion in 1905 for which he had three years' treatment.
In 1904 he developed continuous headaches, was un-
able to attend to business, became very nervous, discon-
nected and rambling in his talk. May 13, 1914, blood
— h++, spinal fluid cells 30, globulin ++++, Was-
sermann ++^+ to 0.05; goldsol, paretic curve. He
received 12 intravenous injections and 20 intraspinal
injections from % to 1 milligram. The first few in-
jections were followed by short periods of improvement
during which his mental condition cleared up somewhat
but never returned to normal. The latter treatments
produced no change whatever and in April, 1915, he de-
veloped attacks of weakness, became progressively
feebler until the latter part of June, when he died.
Serologically there was only a reduction in the cell
count.
Case XII. — Paresis; physician, aged thirty-eight.
Chancre 1904. No treatment. In July, 1914, change
in personality. Wassermann at that time ++++;
grandiose ideas, filthy habits, forgetful. Spinal fluid :
August 23, 1914, cells 180, globulin ++++, Wasser-
mann -j — \--\ — I- to 0.05, colloidal gold reaction positive.
Had 30 intravenous injections of salvarsan, several
courses of mercurial injections, and 41 intraspinal in-
jections from Vi to % milligram. His mental improve-
ment was quite marked after the second intraspinal in-
jection and progressive improvement was noted until
the latter part of March, 1915, when he had a severe
headache; became talkative and excitable, with gran-
diose ideas and delusions, some disturbance of speech,
memory very poor. Under continued treatment this
phase passed over. He went about his ordinary affairs,
attended lectures and clinics, and had a remarkable in-
sight into his condition. Excepting a tendency to be-
come easily excited and quarrelsome, with two attacks
of transient aphasia, his remission lasted nearly a year.
On February 22 of this year he had an attack of
aphasia which did not clear up, and two days later a
hemiplegia. He died on the 26th. A post-mortem was
not obtained.
In estimating the results obtained in the treat-
580
MEDICAL RECORD.
[Sept. 30, 1916
ment of paresis the benefit to be looked for, it seems
to me, depends on the duration and the anatomical
involvement. In the type with the preponderant
changes in the meningo-vascular structures with a
high cell count, a rather sudden onset and marked
mental disturbance, good results can be obtained
and the process perhaps kept stationary. Where the
parenchymatous tissue is chiefly involved with
atrophy or sclerosis, attended by a low lymphocy-
tosis, and an insidious onset, the degenerative
changes have probably advanced too far and at most
only temporary improvement can be expected with
almost certain relapse. No one can tell when paresis
begins and by the time it is clinically manifest the
damage is irretrievable. Cases that respond to treat-
ment and those where therapy yields but indifferent
or no results give the same gold reaction with decol-
orization in the paretic zone. We have, therefore, in
this test not a means of distinguishing possible dif-
ferent types but a method of separating true paresis
from forms of meningo-vasculitis which simulate
it.
While a promise of cure cannot be held out in
cases which are clinically developed, the treatment
is of value in inducing remissions, making the pa-
tients socially possible and amenable to home care
and in a few cases restoring them partially, at least,
to economic efficiency. If the diagnosis of paresis
can be established through the colloidal gold reac-
tion when the affection is in its incipiency we may
be justified, perhaps, in speaking of a cure.
Conclusions. — In order to develop a successful
plan of treatment in syphilis of the central nervous
system it is necessary to have a clear idea of how
infection takes place. In the secondary period of the
disease about 25 per cent, show marked changes,
while a lesser number reveal slight abnormalities in
the spinal fluid. We conclude, therefore, that a cer-
tain percentage of such cases are cured spontane-
ously or during the general treatment of the disease.
It is impossible to estimate the number of syphilitics
who later develop manifestations on the part of
the nervous system but it is probably larger than
the statistics show. A careful examination of af-
fected individuals would probably reveal a larger
number with abortive or rudimentary tabes or
paresis or involvement of the fluid without objec-
tive signs.
All patients at the end of the first year of their
infection should be punctured whether or not they
have manifestations or positive signs of the disease.
If the fluid remains negative to all of the tests they
can be assured with a reasonable amount of cer-
tainty that they are not menaced by the possibility
of a later development. Furthermore a positive col-
loidal gold test with a persistent positive Wasser-
mann 'n the high dilutions points to an impending
paresis whether or not the patient shows mental im-
pairment. In other words, years before the stigmata
of degeneration appear the pathological process is
at work in the central nervous system. When the
clinical symptoms of paresis develop like memory,
speech, hand writing defects, etc., the disease has
already existed for years. This statement also ap-
plies to tabes. The results obtained in the treatment
of tabes would seem to confirm the hypothesis that
this affection is primarily an inflammatory process
involving the meninges rather than a degenerative
process, for if the latter assumption were correct we
could not hope to derive benefit from the treatment.
v West Sk\ enty -seventh Street.
PRESENT METHODS OF EXCRETA DISPOSAL
IN RURAL SCHOOLS.
A SERIOUS MENACE TO HEALTH.
By J. A. NYDEGGER.
BALTIMORE, MD.
SURGEON. U. S. PUBLIC HEALTH SERVICE.
Every American child is entitled to the best that
we can give him in everything — good food, good
clothing, a good home, good training and teaching,
good sanitary school houses and environs — to fit
him to grow up into a healthy citizen well equipped
to fight the battle of life. When we fail to provide
these we fail in our public duty — we fail to give the
child a square deal — the square start in life. We
give him a handicap, we start him in life with the
worst possible handicap he could have — a poorly de-
veloped and poorly nourished body, with lessened
resisting power to the inroads of disease, and sooner
or later he falls an easy prey. It is, therefore, of
the very highest importance that those who have to
do with the rising generation of children should
have uppermost in mind that the greatest asset of
a State is its healthy citizens, and that unless we do
provide proper surroundings and safeguard the chil-
dren with all these precautions, we cannot expect
the children to grow up into healthy adults.
Formerly we were taught that the country is
more healthful than the city, but recently the sani-
tarians have called attention to the fact that the
death rate in the cities is falling more rapidly than
in the rural districts. The cause of this is simply
a matter of sanitation. While sanitary provisions
have been made for the cities, the rural sections
have been neglected. When the country was first
settled, the population was scattered, the virgin
soil was not polluted, and the water was pure, and
many of the communicable diseases, which now
claim thousands, were practically unknown.
How frequently have we heard the country district
schools spoken of as the bulwark of the nation, and
yet how little has apparently been done for the pub-
lic schools of the rural communities? In the cities
and larger towns the schools are, as a rule, fairly
well administered, and the buildings are fairly well
constructed and equipped in accordance with
hygienic measures, but how about the sadly neg-
lected rural schools? When we come to the question
of hygiene in the rural schools, this is one of the
supreme questions of the hour, I take it.
It is highly important for us to understand that
these schools are provided for that part of our popu-
lation which is peculiarly susceptible to the influ-
ences of bad hygienic surroundings. It is a sad
fact that the schoolhouses in many of our rural
communities are far from sanitary. The majority
of the rural school children spend from 25 hours to
30 hours weekly in the schoolroom for a period of
several months each year for 8 to 10 years. Such
being the case, the need of hygienic schools, en-
virons, and a good personal hygiene must be ad-
mitted.
The filth and foul air of the toilet rooms of many
schools in decent town communities are at times
unspeakable, but if we venture into the remote rural
districts we are wont to observe rather frequently
the total absence of this important sanitary ac-
commodation of the schools, and the scholars re-
sponding to the daily calls of nature must make use
of whatever privacy is afforded by objects or ir-
regularities of the ground surface in the vicinity of
Sept. 30, 1916]
MEDICAL RECORD.
581
the buildings, with necessarily resulting soil pollu-
tion, and the great liability of dissemination of dis-
ease germs contained in the excreta thus deposited
on the* ground. In this manner pathogenic germs
may and do easily gain access to the source of sup-
ply of the drinking water for the school, and illness,
many times of a serious nature, results from the use
thereof.
The dangers of the drinking water are thus two-
fold: from the impure water and from the common
drinking cup, still so obviously in use in the rural
schools. Numerous instances are on record where
typhoid fever has been spread in schools in this
way.
The unscreened and unprotected privy constitutes
a grave and serious menace to the health of any
community. Sooner or later it is bound to 'become
the depository of typhoid and at that moment it
becomes a hazard to ev°ry resident in the vicinity,
for that very environment has created an insect
host and otherwise capable of disseminating the
scourge to every point of the compass.
The water supply of the rural school generally
comes from a shallow well or surface spring. Drink-
ing water coming from such a well is liable to be
more dangerous than that from a spring, as it is
frequently located very near the school building,
and is more liable to receive surface drainage from
the vicinity of the school, the outhouses, if any, and
consequently it is more likely that it will be polluted
and its use will be a greater risk to health.
Hookworm is another plague of the rural schools
of the Southern States. In the South many of the
country school children go barefooted, and the
young hookworm or larva gains entrance to the
body, usually through the skin of the unprotected
feet, and after a circuitous route through the body
finally reaches the alimentary canal, and attaches
itself to the wall of the bowel, and feeds and grows
to mature size. It is not the loss of blood, as is
popularly supposed, that causes the severe anemia,
paleness, and other symptoms in the victim of hook-
worm infection, but the toxin introduced into the
system by the hookworm. These sufferers are pale,
and appear bloodless. Many deaths result from it
in the warm, semitropical, and tropical countries
all around the world. This disease is disseminated
by means of human excreta, containing the eggs,
reaching the ground.
In some rural schools in the United States, the
surveys made by the Public Health Service have
shown that from 82 to 98 per cent, of the children
were suffering from hookworm. In other schools
the infection of children with hookworm has been
shown to be as low as 10 to 12 per cent.
Hookworm is not the only intestinal parasite
found in school children, the eggs of which, reach-
ing the ground soil in the excreta, are disseminated
by wind, dust, hands, feet, flies, hogs, dogs, fowls,
and birds, and gaining access to water and food,
after having undergone development to the larval
stage, again enter the body and produce diseases.
Chief among these are the Amoeba histolytica or
tetragena, the cause of dysentery; Balantidium coli
and Trichomonas, causing diarrhea; Oxyuris ver-
micularis, Ascaris lumbricoides, Triehuris trichiura,
and Hymenolepis nana or dwarf tapeworm, which
produce intestinal troubles. The direct effect of
these infections on the child, aside from other bad
effects, is reflected in physical dwarfing and mental
retardation. Especially have these conditions been
observed in school children, as shown by studies
made in those ill with the ineffection by the Public
Health Service.
The Rockefeller Sanitary Commission, in the
course of its surveys, found the rural schools a
marked factor in producing diseases. In the case of
46,743 school children examined, who were harbor-
ing intestinal parasites, 22,782, or 48 per cent., had
hookworm infection; 7,991, or 20 per cent., had
ascarides; 2,915, or 15 per cent., had Trichocephalus
dispar; 1,246, or 18 per cent., had dwarf tapeworm;
134, or 0.2 per cent., had Strongyloides, and 48, or
0.09 per cent., had Oxyuris.
Of most interest is the fact that many of the
cases of ascaris infection presented marked symp-
toms of mental retardation and anemia.
The Public Health Service, in an extensive sur-
vey of sanitary conditions, in from 1,200 to 1,300
rural schools, conducted in 13 States, with the ex-
amination of some 175,000 school children, during
the past three years, has shown that in the terri-
tory covered there is a general lack of sanitary
supervision in the construction and maintenance
of rural school buildings and outhouses, and of med-
ical supervision of the pupils. In the course of
these investigations we failed to find the installa-
tion of a scant dozen of sanitary privies for the usp
of rural school children.
Recent investigations conducted by the writer
showed in 66 rural schools in Indiana that only 6
outhouses out of 132 were in good sanitary condi-
tion, while 42 were in fair condition, and 84 were
in bad sanitary condition. A more recent survey
of the schools of Manatee County, Florida, also con-
ducted by the writer, showed a somewhat better
sanitary condition of the privies in the urban
schools as also in the 11 rural schools visited. Here,
out of the total number of outhouses examined, 6
were found to be in good sanitary condition, 2 in
fair sanitary condition, and 14 in bad sanitary con-
dition. The results as shown by these two surveys
with respect to the insanitary condition of the out-
houses will serve as the standard of index of the
insanitary condition of outhouses at all of the rural
schools inspected by the service during the afore-
mentioned period. A description of one of these
outhouses will practically apply to all, as also the
insanitary conditions found to exist about them.
The majority of these wooden buildings are simply
set upon the surface of the ground, with no attempt
at closing them up beneath or at the back to pre-
vent the free access of domestic animals and flies,
and they were noted in all stages of deterioration —
from newly constructed to dilapidation. The ma-
jority of these outhouses were found to be in a hor-
rid condition. In many the conditions were un-
speakably dirty and insanitary, being filled with
excreta almost to the seat. In a considerable num-
ber of the outhouses objectionable odors were so
strong as to make it practically impossible to re-
main within. Almost 50 per cent, of the outhouses
were found to be without screens in front of the
doors, and at many schools the outhouses for the
boys and girls were placed near each other on the
premises. At some schools they were placed near
each other on the premises. At some schools they
were built double for the use of the two sexes, and
some of these double outhouses were noted to have
no screens in front of the doors. In a few outhouses
a urine trough had been provided for boys, while in
others the seats and floors were urine soaked, and
the odor of urine was all-pervading. In some in-
stances an attempt to suppress the strong arising
582
MEDICAL RECORD.
[Sept. 30, 1916
odors by the use of lime was noticed. In a very
few instances was it observed that any attempt at
cleaning up and removal of the excreta had been
made at the beginning of the school year, or in fact
at any time.
The question may, therefore, be asked what is the
real method of excreta disposal at rural schools,
which, in the main, are provided with outhouses, as
have been described. The answer is a very simple
one — no method, but a trusting to luck and nature's
elements. The excreta are allowed to accumulate
in the most of instances until the space below the
privy seat is filled to overflowing and conditions be-
come intolerable. Then the outhouse is removed
to another spot near by, a few shovelfuls of earth
or none at all, usually the latter, are sprinkled over
the accumulated excreta of years, and the same
process is gone through with again until the privies
are again filled and require further removal.
What is happening in the meantime? Aside from
the dissemination of disease-producing bacteria and
parasites by flies, animals, fowls, and other means
there is an infiltration of liquid excreta, rain, and
urine washings from the excreta on to the surface
and into the soil constantly going on, with the re-
sult that in the course of time the surface as well
as the subsurface water becomes polluted, and there
is percolation of any pathogenic organisms that may
be present in the excreta, through the subsoil into
the water of the shallow wells or springs, frequently
located, as our surveys have shown, dangerously
near the outhouses. How great is the danger of
pollution of the drinking water of rural schools in
this manner is strikingly shown in some instances
observed during these surveys. At one school the
source of water supply, a shallow dug well, some
seven or eight feet deep, was noted as being but
sixty feet away from the nearest outhouse, and the
natural drainage of the outhouse was directly
toward the well. There was grave danger of the
pollution of the drinking water from the outhouse,
which was in a highly insanitary condition. At an-
other school, the well, a shallow driven one, eighteen
feet deep, was found to be located less than 100 feet
from the two outhouses, with natural drainage to-
ward the former. These houses were found to be in
bad sanitary condition with years of accumulated
excreta on the ground beneath them. The outlet
from the outhouses was an open, shallow ditch, and
infiltration of sewage into the soil along the whole
course of the ditch was constantly going on, with
constant clanger of percolation of disease-producing
organisms through the subsoil into the water of the
well.
Glaring instances of indecency, as also grave
danger, were noted during these surveys, through
the privies having been located in close proximity
to the school buildings. In one such instance it was
observed that the privy, a highly insanitary one. by
actual measurements, was but eight feet distant
fri in an open window of the schoolroom, thus allow-
ing the malodors from the privy to permeate the
air of the room, and in addition offering an excel-
lent opportunity for (lies, which having fed on the
possible germ-laden excreta but a few feet away, to
transfer the infection to the food of the school chil-
dren. Numerous other instances of a similar na-
tive and equally as hazardous were noted.
The above are but instances of what was con-
stantly being encountered during these surveys,
showing the wide extent of dangerous negligence
that exists to-day in rural schools in the United
States.
The remedy for this menace to the health of the
children of the public rural schools is not hard to
find, but is difficult to apply, by reason of the fact
that competent medical inspection of schools k still
in its infancy in this country. True, it is that in
our larger cities, and in some of the smaller ones,
as also in a few rural communities, there is a regu-
lar medical inspection of the schools, but in the vast
majority of the latter such a thing as medical in-
spection is still unknown.
In many sections of the United States the sani-
tary conditions surrounding many rural schools are
scarcely other than medieval. Because of the ab-
sence of a privy, or almost equally as bad, a privy
where the excreta are deposited on the ground soil,
pollution of those places will spread disease to the
pupils, and the infection may be carried to unin-
fected homes. An immediate and radical reform
in the sanitary surroundings of these schools is
urgently needed. If sanitary privies were used and
intelligently supervised at the rural and urban
schools there would be an immediate and marked
reduction of hookworm disease, typhoid fever, and
many other diseases produced by intestinal para-
sites.
In a word, a great step forward will have been
accomplished when sanitary conditions surround-
ing the schools are improved to a point where the
country school will not form — what it is to-day —
the great disease-spreading center for rural and
semi-rural communities.
Such as I have described are the insanitary con-
ditions too often found in our everywhere neglected
rural schools — among the school children of the
people of our own land and of our own blood, of
Anglo-Saxon lineage and intelligence.
It is no mere dream to describe here, though
briefly, "The Country School of To-morrow." The
little red or white one-room one-teacher school,
about which we heard so much, located here and
there, to the extent of a dozen or even more, in a
single township, will be replaced by one consolidated
school, placed as near the center as possible, and
for the more distant pupils a daily to-and-from con-
veyance in groups will be provided. For the school
ample grounds, of many acres, well laid out and
beautified, with recreation grounds, will be needed.
The building will be modern in every respect, and
will represent the latest appliances in school sanita-
tion and equipment, fireproof, roomy, of attractive
architectural design, an excellent building, kept in
excellent sanitary condition throughout, provided
with well heated, properly lighted and ventilated
class and recitation rooms, laboratories, agricultural
and domestic science departments, manual training,
music, with gymnasiums, showers, sanitary toilet
rooms, with crematory or water sewage excreta-
disposal facilities, and a large and attractive assem-
bly room; and the school, in addition to being the
educational center of the township, will be also the
social improvement center of the community. These
forces will then be working in harmony for the bet-
ter education and greater uplift of the community,
affording better health and greater happiness, and
all for the creation of better citizenship, for a better
State, and a better country.
Cause of Death in Intestinal Obstruction. — Snow con-
cludes that neither starvation nor bacterial activity is
responsible for death in intestinal obstruction, but that
a toxic substance exuded from the duodenal mucosa is
the cause of the lethal symptoms. Subcutaneous saline
infusion prolongs life by replacing the fluids lost by
vomiting and diarrhea. — N. Y. State Journal.
Sept. 30, 1916]
MEDICAL RECORD.
583
THE ECONOMIC VALUE OF SPEECH
CORRECTION.*
By IRA S. WILE, M.D.,
NEW YORK.
As man is essentially a social animal his speech
is probably his most important social characteristic
and activity. As the main instrument of inter-
communication, its full development is essential for
the fullest evolution of human relations. While
writing is valuable for self-expression, speech alone
serves to promote spontaneous self-expression
through thought utterance.
The political economist might object to the title
"the economic value of speech correction" on the
grounds that speech is not wealth, but merely
one of the means of acquiring wealth. Technically
speaking, value is a power which an article confers
upon its possessor of commanding in exchange
for itself the labor or the product of labor of
others. The degree of efficiency of labor depends
upon many causes, including the physical organiza-
tion and the mental equipment of the laborer.
However, regardless of the capital invested in
speech improvement, the social economist will hard-
ly deny that health, intelligence, and the power of
communicating ideas are essential and better than
wealth and are paramount phenomena in pro-
moting the activity of man in acquiring and
making just use of his wealth. Correct speech is
not necessarily an essential in the acquisition or
utilization of money, but adds a tremendous force
for living well and wisely.
From the standpoint of the school, speech cor-
rection is indicative of the centering of thought
on the education of children rather than upon the
importance of the subjects taught. It is a new
manifestation of the idea that educators must con-
sider the subjects whose minds are to be developed
as of equal importance to the subject matter to be
taught. Obviously, the most vital phase of speech
improvement lies in the organization of elementary
school instruction and methodology, so that bad
speech habits may be checked during the school life
of children. Trie prevention of speech defects, in
so far as slipshod teaching is responsible for them,
is a large field which has scarcely received adequate
cultivation.
Recognizing the social economic value of speech,
it is patent that the attainment of fluent unim-
paired habits of speaking represents a distinct gain
to the community. The value, therefore, of speech
correction would be represented by the saving to
the community of expenditures now involved as a
result of existent or future speech defects. It is
exceedingly difficult to establish with even approx-
imate mathematical precision the economic cost of
speech defects. In this country, data are not avail-
able to determine the total number of persons
suffering from speech defects. The economic
importance of speech defects depends upon the
functional ability of individuals, and at various ages
the importance of speech defects varies. It is
obvious that the importance of a speech defect
in a child of 5 is less than in a man of 20.
Speech defects cannot be considered as isolated
phenomena. There are no reliable estimates of
the number of individuals suffering from speech
defects without the complication of an organic or
functional derangement such as further decreases
*Read before National Educational Association, New
York City, July 6, 1916.
the economic value of an individual. Speech de-
fects among the deaf and the feeble-minded, for
instance, constitute only a portion of the potential
weakness of the individual and their speech defects
therefore can be considered simply as a part of
the general disability lessening the economic worth
of the afflicted.
All speech defects represent abnormalities. In
a wide sense abnormal children are "those afflicted
with anything whatever that unfavorably affects
their lives in relation to the social medium in which
they live." Consequently speech defects represent
abnormalities which per se limit the possibilities
of children and adults to realize to the utmost their
potential power for uniting in the activities of
the world.
In the London County Council report of 1909,
there is presented an investigation of 19,303 chil-
dren showing 1.95 per cent, to have speech defects
and 1.3 per cent, to be stammerers. Rouma reported
in the children of Belgian cities 11.5 per cent, with
speech defects and 1.4 per cent, stammerers. Con-
radi, in 1904, studied 87,444 children in American
cities and found 2.46 per cent, among them with
speech defects and 0.87 per cent, to be stutterers.
On this basis, there would be in our American
schools over 500,000 with speech defects and at
least 200,000 stutterers. Some defects such as
lisping are known to decrease as school life pro-
gresses, while stuttering increases while children
are in the classroom. This represents the field of
activity whose economic value we are to consider.
In general, the ratio of boys to girls possessing
speech defects is as three to one. The total number
involved is in excess of the number of blind and
deaf in our population and fully equal to the num-
ber of mentally defective children and insane.
Speech defectives and particularly stutterers are
likely to be backward and even retarded in their
school work, although there are many who maintain
excellent position as measured by ordinary stan-
dards of school progress. A large proportion of
stuttering, probably 50 per cent., could be prevented
by adequate provision for improvement in methods
of school instruction. A large proportion of the
stutterers are curable. The limitation of the stut-
terer is marked, not so much in his powers of
acquisition and appreciation as in his ability to give
verbal expression to his thoughts. His mentality
may be intact but his opportunities for giving
evidence of his mental power are hampered by
virtue of his explosive expression which deprives
him of an attentive audience. Frequently he may
be regarded as stupid or dull when he is suffering
from sensitiveness, self-consciousness, embarrass-
ment, or anxiety because of his affliction. Attempts
at speech improvement likewise are of service in
detecting early organic disorders of cerebration and
may at times lead to the prevention of irrational
extravagances.
Speech improvement in schools is productive of
the saving which may be secured through pre-
venting what Fletcher of Clark University referred
to as "the leakage of energy" on the part of both
teacher and class, which ensues during the at-
tempted recitation of a stutterer. Systematic
speech improvement classes save the time of the
teacher and the class. They promote more rapid
progress and secure more concentrated attention
upon the subject matter being taught by preventing
the diversion of attention to the peculiarities of
the individual child reciting. To this extent, they
584
MEDICAL RECORD.
[Sept. 30, 1916
are productive of a monetary .saving in the cost of
teaching, though mathematically this would be dif-
ficult to estimate.
It is patent that the average sufferer from a
speech defect is deprived of his fullest opportun-
ities of education and self-expression. This is
manifest, particularly, in those unfortunates who
are actually willing to be deemed dull and backward
rather than suffer through reciting; and under
ordinary circumstances the very act of recitation
increases and tends to protract the disability.
The various types of speech defects which are
dependent upon malformations, such as harelip,
cleft palate, hypertrophied tonsils and adenoids, and
dental deformities reveal an economic loss which
must include the cost of operations, nursing care,
and hospital treatment. While speech improve-
ment classes will not tend to reduce these expendi-
tures, they will save valuable time by securing
prompt attention to them. Unfortunately, perma-
nent defects may result even after medical and
surgical aid have been afforded, but under these
circumstances the potentialities of the sufferers
are less circumscribed than before and their activ-
ities in occupations may be encouraged to a greater
extent than was previously possible.
The majority of speech defects are combined
with defects of vision, hearing, and muscular co-
ordination, or cerebral mal-developments. Of the
twenty million children in this country it has been
estimated that five per cent, have impaired hearing
and twenty-five per cent, have impaired sight. It
has been adjudged that some impediment in speech
exists in three per cent, of the school children.
There is no differentiation, however, in so far as
I have been able to ascertain, as to the nature of
these various impediments.
The character of speech defects and their im-
portance varies according to the degree of deafness.
Mutism results if deafness occurs before speech is
developed. This subject however is beyond our
present interest.
Studies in speech correction may indicate in
numerous instances that stuttering has been in-
creased by the attempt to make sinistrals dextrals;
and the speech defect thus resulting may actually
serve to impair the industrial progress of the child
for the sake of securing uniformity in classroom
methods. Experience in our own schools has dem-
onstrated that stuttering and lisping children may
lie restored to normal speech and participate with
naturalness and greater effectiveness in the work of
their classes.
In Germany, investigation has shown that of the
15,000 children in special schools for defectives.
li per cent have associated speech detects. It is
thus obvious that the economic importance of
speech defects is bound up in considerations of the
importance of such causative conditions as feeble-
mindedness, deafness, and neuropathic manifesta-
tions.
Assuming that estimations by Van Sickle, Wit-
mer, and Ayres are correct in that 4 per cent, of
our public school children are feeble-minded, it
would mean that there are 800,000 feeble-minded
children in the United States, although it must be
appreciated that of this number 100,000 are genu-
inely mentally deficient and should be treated in
institutions instead of public schools. If, then,
investigation should show that the German per-
centage, 6 per cent., would apnly to all our defec-
tives, there would be in the United States fortv-
eight thousand defective children with speech de-
fects. Ninety-four cities in the United States have
special classes for defectives, 46 make special pro-
vision for the deaf and semi-deaf, and 3 have
classes for stammerers, stutterers, lispers, and the
dumb.
The economic cost of speech defects is registered
in the limitations of occupations that are available
for individuals who have speech deficiencies. The
more pronounced the defect, the more limited the
field of activity. Few employers desire deaf-mutes
and their industrial situation is most difficult.
Law and medicine, or even the ministry, are opened
occasionally to those talented individuals who have
risen above their speech limitations and have been
able to submerge their sensitiveness and self-
consciousness. Their self-expression depends upon
what they have to say rather than the way they
say it.
Where feeble-mindedness is the basic condition,
the occupation is naturally limited by the scale of
intelligence to which the individual child can rise.
In the New York Institute for the Deaf and
Dumb, instruction is given in the shoe shop and
tailor shop, while carpentry, printing, gardening,
and similar occupations are made available. State
institutions for the deaf and dumb require 5 to
7 years of training at a per capita cost of three
hundred and twenty-five dollars per year. It has
been estimated that one in every twenty-four hun-
dred of the population in the United States is a
deaf-mute. This would indicate that there are
about 37,500 deaf-mutes in the United States.
This would mean that the mere cost of education
in the State institutions for all of these deaf-mutes
cost approximately twelve million dollars per
annum. How few are taught to speak! We cannot
actually cure blindness, nor mutism, nor idiocy.
Recognizing the industrial limitations of those
suffering from speech defects and appreciating the
obstacles to professional life, their undesirability
as teachers, their handicaps as physicians, their
limitations as pleading lawyers, and their impos-
sibility as preachers, it is but natural that we
should seek to preserve or secure their potential
utility by restoring them to normal speech function.
To what extent can this possible economic loss be
prevented? In the experience of the elder Gutzman
in 46 German cities, 72.7 per cent, of stutterers
were cured, 23.6 per cent, were improved, and in
only 3.7 per cent was there complete failure. Dr.
H. Gutzman found 89 per cent, cured. 9 per cent
improved, and in 2 per cent, failure. Coen, in
Vienna, cured 60 per cent, improved 30 per cent.,
and had only 10 per cent, of failures. Chervin
claims that success is almost certain if the general
conditions are favorable and fulfilled. Under such
circumstances, failure to promote speech improve-
ment is an indication of indifference to or ignor-
ance of the possibilities of reclaiming to full use-
fulness victims of this speech derangement.
Another economic gain is to be secured through
speech correction in the prevention of industrial
accidents. The relation of speech defects to the
cost of industrial accidents has been hinted at in
those reports which attribute a part of the acci-
dents to the inability of employees to speak the
prevailing language of the factory, mine or shop
There are numerous positions where quick utterance
is required and in which stuttering might and does
jeopardize the lives of fellow workmen in times of
emergency.
Sept. 30, 1916]
MEDICAL RECORD.
585
The importance of discouragement, anxiety, fam-
ily distress, embarrassment, diffidence, and shyness
upon the development of high moral character can-
not be estimated. Wherefore, among delinquents
speech deficiencies are noted with greater fre-
quency than among the normal population. This
may be due possibly to the fact that there is a
greater amount of feeble-mindedness among delin-
quents and the speech defect is coincidental. If
speech correction can prevent any children from
moral degeneration, its economic usefulness is en-
hanced.
The relation of speech defects to normal delin-
quency has not been determined, although it is
possible to appreciate that speech defects, if in-
terpreted as closely related to mental abnormality,
probably play some part in the problems of de-
linquency. It is apparent that self-expression
through speech is a most important factor to con-
stitute the mental defective a social asset. It is
doubtful if the cost of securing this result can be
segregated. It would be unfair to guess at an
allowance out of the computed costs of educating
the feeble-minded.
In the ordinary public school system, the educa-
tional cost for correcting speech defects has not
been estimated. A special teacher is necessary,
an ungraded class is important. The development
of normal speech must be facilitated through per-
sonal analysis of the underlying causes of the
speech deficiency. It is vitally important, both for
the benefit of the individual child with a speech
defect and for the rest of the children in the class,
that special classes for stutterers, stammerers, and
lispers should be maintained with a view to devel-
oping normal speech for them.
Finally, in estimating the economic importance
of speech defects, I can but repeat what I have
already stated. The actual cost of speech defects
to society cannot be estimated at the present time
in dollars and cents. The limitations of self-
expression is a loss to the individual and to the
community. Speech defects which interfere with
the fullest expansion of consciousness along the
lines of culture and industry are anti-social. They
decrease the social worth of the individual and rob
the community of the full fruits of human men-
tality. They retard and pervert economic power.
In conclusion, I can but suggest that the work
of speech improvement now scarcely begun must
make tremendous gains during the next few years.
The monetary expense is negligible in view of the
possible gains to society. School systems should
recognize that it is part of their function to devel-
op to the full the latent possibilities of school
children. This is impossible while we are neglect-
ing a single type of those handicapped in learning.
In the education of mental defectives, society can
scarcely be repaid for the cost of education because
so much of it is now spent upon those who will
never be able to make adequate economic returns.
In the case of speech defectives, particularly in
the case of stutterers and lispers, this state is
reversed. The improvement of speech defectives
enhances both their economic and social value.
Well may we paraphrase the statement of Dr. Caro-
line Yale to the instructors of the deaf, "The
plea now should be not for more speech but for
better speech." The plea should now be for more
speech, for better speech, and for the prevention
of speech defects.
230 West Ninety-seventh Street.
TREATMENT OF INOPERABLE CARCINOMA
BY BIPOLAR IONIZATION."
By G. BETTON MASSEY. M.D..
PH1L.ABBL.PHIA.
While the unipolar method of ionic destruction re-
mains a most valuable agency for the immediate
eradication of small epitheliomas of the skin and
mucous membranes, 93 per cent, of this classifica-
tion having been reported as cured by this method
in a somewhat recent communication to the Phila-
delphia County Medical Society,! grave cases of
carcinoma and sarcoma have of late been placed
by the writer under an improved bipolar technique,
permitting of more thorough and more controllable
destruction, and with a material lessening of the
time during which the patient is under anesthesia.
In the bipolar technique the active needles are
inserted just beyoud the peripheries of the growth
while the indifferent, negative, electrode is inserted
in its center, instead of being a pad on a distant
body surface, thus confining the current and its
chemical and thermic activities to the growth itself
and its edges. As no material amount of current
traverses the general body structures in this ar-
rangement we are free to push the method to the
point of producing a boiling temperature in the
larger growths, thus adding the valuable agency of
heat to the devitalizing chemical action of the dis-
persed ions of zinc from the erosion of the zinc
electrodes attached to the positive pole. Both posi-
tive and negative electrodes are made of zinc, but
the positive only for the electrochemical purpose
of being dissolved into ions and dispersed through-
out the growth. The negative electrodes are made
also from sheet zinc for mechanical reasons, since
thin plates of this metal may be readily cut by
shears into self-retaining corkscrew, fish-hook, or
crab's claw shapes for attachment to the center of
the growth.
Heat alone is the destructive agency in both the
diathermy and the Percy methods of treatment of
cancer recently introduced. In the author's method,
as outlined above, heat is merely an addition to the
electrochemical destructive process, and is invoked
only in large growths when heavy currents are
needed. In small growths the ionization alone is
sufficient, applied in the unipolar method; and so
simple is this variation of the method that any phy-
sician who has the ordinary direct or galvanic cur-
rent in his office has no excuse for permitting small
epitheliomas of the skin surface to grow large from
neglect, as he can destroy them in a few minutes by
easily devised electrodes.]:
The following unpublished cases, in which the
major bipolar ionization was employed, illustrate
the varied technic demanded at times:
(303) Mrs. , aged 67, was referred by Drs.
Rimer and Clover, of Clarion, Pa., September 23, 1913.
Enjoying excellent general health, a lump had appeared
on the scalp behind the right ear about eighteen months
before, which had been removed by excision in Decem-
ber, 1912, the pathologist examining the specimen, pro-
nouncing it carcinoma. Three months later recurrence
was noted. On admission to the Sanitarium a growth
the size of a horsechestnut emerged from the scalp
*Read before the American Electrotherapeutic Asso-
ciation, September 13, 1916.
-(■Ionization Treatment of Cancer; End Results of
Twenty Years' Work. — American Journ. Surgery, Sep-
tember, 1914.
JFor further details of method, see "Ionic Surgery
in the Treatment of Cancer," by G. Betton Massey,
New York, A. L. Chatterton Co., 1910.
586
MEDICAL RECORD.
[Sept. 30, 1916
slightly posterior to the scar of former operation. It
was firmly adherent to the underlying structures, ap-
parently including the periosteum, and was beginning to
break down. In the upper portion of the neck there
was an enlarged gland, the size of a marble, situated at
the posterior edge of the occipital insertion of the
sterno-mastoid.
September 26, 1913. Under chloroform a bipolar
ionization was done, a number of fine zinc needles being
inserted beneath the growth and connected with the
anode, and with the cathode attached to its center, a
current of 500 milliamperes was gradually turned on.
Infiltration with the ions occurred rapidly and complete
devitalization was apparently complete in four minutes,
when the current was turned off. Two minutes of
maximum current of the same strength sufficed for the
gland, with the needles similarly applied.
The sloughs separated duly under diluted zinc oxide
ointment; but three months later, January 22, 1914,
two more nodules were found, nearly as large as the
original recurrence, just beyond the edge of the scar.
A second major bipolar application was made at this
time similar to the first, except that a current of 700
to 1000 milliamperes was used for a total of seven
minutes.
The high malignancy and wide spread of the cell
colonies was shown in this case by a third major
bipolar ionization under ether being needed two weeks
later, when 500 milliamperes were used for thirty
minutes. The final resulting slough revealed a small
portion of the outer table of the skull denuded. The
healing of the wound appeared to be assisted by photo-
therapy, and the patient was discharged finally from
the sanitarium to the care of home physicians three
weeks after the last ionization. At this time there was
a sinus leading to the periosteal denudation. A scale
of bone separated spontaneously later under the oint-
ment, permitting final healing of the wound from the
bottom.
A letter dated April 20, 1916, states that the patient
continues free from evidence of the disease.
™ (311) 4 /armer> aged 39, was referred by Dr. C. L.
u j ■r'J°. ox' Pa'' Aueust 14> 1914. The patient
had had increasing nasal obstruction for years. Six
months ago the right nostril became entirely obstructed
and discharge and odor appeared, both of"which were
steadily increasing. One month ago the hearing also
became impaired. He has had no severe pain" On
admission the voice was nasal and choked, the hearing
was impaired in the right ear, and there was a pro-
nounced cancerous odor. Visual inspection of the an-
terior nares showed the posterior portion of the right
nasal cavity obstructed by a smooth neoplasm. Visual
inspection by the mouth showed little; but the vault of
the pharynx, when cocainized, was readily explored by
the forefinger and middle finger inserted behind the
solt palate, palm upward. This procedure revealed a
large growth the size of a lemon split in half attached
to (he vault by a slightly constricted base, the attach-
ment extending further on the right than the left and
involving the right Eustachian opening. The free sur-
face was cauliflower-like, eroded, and bled freely on
touch. No enlarged glands were found at this time
A specimen removed at operation was pronounced car-
cinoma. r
August 15, 1914. Major bipolar ionization was em-
ployed under ether with the following technique- Three
long, slender zinc electrodes, readily curved, with their
soft rubber coverings, to a shape that would permit
their inch-long bare tips being passed up behind the
soft palate and into the base of the growth, parallel
with the vault, were attached to the positive pole A
single negative, suitably insulated to near the tip 'was
then inserted into the growth through the riHit nostril'
and a current of 500 to 1,000 milliamperes was gradu-
ally turned on and maintained for twenty-eight minutes
( onsiderable heal developed. The separation of slouch
and healing of wound were uneventful, and followed
by improved breathing and voice.
Five months later, January 9, 1915, the patient had a
wfflf t?2°fi and thv,e "*? °f .the K,owth «*en explored
v-ith the finger showed a healthy cicatrix. A lartre
movable growth was discovered in the neck below the
ear at tins time, being apparently composed of a group
of infected cervical glands beneath the edjre of the
sternomastoid muscle. A major bipolar application
was made at th,s date with needles passed through the
skin and beneath the growth, the negative being at-
tached to the skin above it. A current of 1,000 to 1 100
milliamperes was employed for fourteen minutes The
slough came away in due time without hemorrhage, and
appeared to include the whole of the affected group of
glands. In May the scar was excellent, and appeared
free from disease.
In August, nevertheless, a little over a year after
the first application, a consultation with Dr. Clover re-
vealed an even larger group of infected glands deeply
seated in the neck, and it was decided that the external
carotid should be ligated before another attempt at
ionic destruction. A cutting operation was objected to
by the patient, however, and the ionization was begun
by the use of 1,000 milliamperes bipolar, under ether,
for two minutes, it being the intention that this should
be followed by minor applications after the separation
of the slough. Severe secondary hemorrhage super-
vened on the fifth day, followed by death from repeated
hemorrhages on the seventh day.
(331) A hardware clerk, aged 51, was referred by
Dr. Omar Morgner of St. Charles, Mo., October 13,
1915. His general health had been good in spite of
convivial habits until one year ago, when a carcinoma
of the right side of the base of the tongue and floor of
the mouth was diagnosed. Competent surgeons in St.
Louis declined to operate. On admission, the left half
of the tongue was found to be indurated beyond the
middle line from tip to base, with a deep erosion on the
lateral surface that was continuous with an equally
extensive erosion on the right side of the floor of the
mouth. The posterior edge of the growth extended to
the fauces. He could swallow liquid food only. Pain
in the tongue and in the left temple was constant. Two
submaxillary glands were enlarged and protuberant.
Oct. 14, 1915. Under general anesthesia Dr. War-
muth ligated the external carotid artery, the operation
being followed immediately by a bipolar application
with active electrodes passed through the tongue just
beyond the indurated portion, the completeness of the
fixation being guided by a rubber-gloved finger in the
pharynx ; other electrodes were passed beneath the
lower portion of the growth, and still others just be-
yond the buccal edge. These electrodes were insulated
except the portions actually inserted in the tissues.
Retracting the lips with a miniature lamp covered with
a slender test tube and with a hard rubber retractor,
a negative electrode was placed in the center of the
growth and a current of 1000 milliamperes was turned
on and maintained for thirty minutes. A boiling
temperature accompanied the usual chemical effects.
Destruction of the glands was postponed until the liga-
tion wound had healed. The patient was fed through
a stomach tube during convalescence. A week later the
glands were destroyed by a bipolar application of 200
milliamperes under local anesthesia.
In December and January additional minor applica-
tions were made to remnants of disease in the floor of
the mouth. The patient's condition being greatly im-
proved, save for persistence of the neuralgic pain in
the temple, he was sent home, but returned later show-
ing increasing growth at the upper portion of the
buccal edge and increasing pain. This growth caused
a bulging of the cheek in the parotid region.
April 26, 1916. Major bipolar application of 500 to
1000 milliamperes for 30 minutes to the buccal growth
in the parotid region, all electrodes being passed into
the growth through the oral opening, with the lips re-
tracted as before. The immediate result was a flat-
tening of the distended cheek and parotid region and
disappearance of the neuralgic pain that had hitherto
been unaffected by the treatment. During the separa-
tion of the slough there was a severe hemorrhage, ap-
parently from a reestablished collateral circulation,
which was controlled by pledgets of cotton wet with
Monsell's solution. Further active treatment was
abandoned June 9, 1916, as there was distinct evidence
of disease below the scar of the ligation wound in the
neck, and the patient was sent home in a temporarily
improved condition.
(332) J. F. L., aged 72, real-estate dealer. About
Dec. 1, 1915, a small, whitish growth was found on the
under side of his tongue by his physician, Dr. D. W.
Levy of Philadelphia, who called in Dr. Franklin Brady,
chief surgeon to the Roosevelt Hospital. At Dr.
Brady's suggestion the patient was referred for ioniza-
tion as he hesitated to excise one half the tongue on
account of the patient's age, and of the further fact
that the patient was then under treatment for a growh
within the bladder which had caused several severe
vesical hemorrhages.
January 3, 1916. There is a proliferating epithelioma
on the under surface of the right side of the tongue,
Sept. 30, 1916]
MEDICAL RECORD.
587
near its middle, about 2 centimeters in diameter. No
enlarged glands could be found. A minor bipolar ap-
plication, that is one under local anesthesia, was car-
ried out as follows: With the tongue held in extension
by the operator's left hand encased in a sterile lisle
thread glove to ensure a good but painless grip, the area
beyond the growth was carefully infiltrated with a 2
per cent, solution of quinine and urea hydrochloride.
At the end of seven minutes small zinc needles, six-
teen in number, were inserted concentrically beneath
the growth and a bipolar application of 200 to 350 milli-
amperes was made for eleven minutes, without material
pain.
May 24. Scar in tongue perfect. No sign of disease.
Patient has had another vesical hemorrhage and is in
bed.
June 3. Patient died of uremia due to bladder trouble.
1823 Wallace Street.
THREE CASES OF ACUTE ANTERIOR POLIO-
MYELITIS TREATED SUCCESSFULLY
BY TRANSFUSION OF CITRATED NOR-
MAL BLOOD OF ADULTS.
By G. A. RUECK, M.D.,
NEW YORK.
I NEVER had had any patients suffering with acute
anterior poliomyelitis and I knew the first and later
symptoms of this disease only from books. Natu-
rally I had seen patients after they had been crip-
pled for life and when they were trying to diminish
the effect of the abated disease by orthopedic treat-
ment. Nevertheless, I was fortunate enough to be
able to make an early diagnosis of the cases to
which I was called when the epidemic of acute an-
terior poliomyelitis started this summer in New
York City. But after the diagnosis was made it
was rather discouraging to think that there was
no curative treatment known and that even physi-
cians who were considered to be authorities in the
scant study of the virus could only make sugges-
tions in regard to the treatment of this disease.
Every suggested remedy had to be tried first and,
strange to say, normal blood and its serum was de-
clared not to be curative.
The serum of patients having recovered from an
attack of acute anterior poliomyelitis and injected
into the spinal canal, as suggested by Dr. Simon
Flexner, seemed to me a rational remedy and has
since given some good results, to judge from the
reports in the lay and medical press in cases where
it has been used in the Willard Parker Hospital and
in hospitals which imitate its treatment. But not
being connected with a hospital where anterior
poliomyelitis cases are gathered together from the
entire city although they are by no means all treated
with blood serum, I should have had the greatest
difficulty in procuring the blood and I should have
needed first-class laboratory facilities in order to
prepare the serum. These facilities I did not have.
Besides the preparation of the serum would have
taken too much time. But help had to be brought
early and quickly before the large motor cells in the
spinal cord and brain of my patients were com-
pletely destroyed, as nerve cells never can be re-
placed, and as we never can know in advance
whether a patient will be killed or crippled by this
disease or whether he will entirely recover. Com-
plete recovery is a matter of chance and we should
take no chances in such a serious disease. Then I
wanted to help quickly before the Board of Health
could take the children to an isolation hospital
where they are kept comfortably in bed but where
in the beginning nothing was done to cure them.
I decided to treat my patients by transfusion of
blood taken from healthy adults and prepared ac-
cording to my method (reported in the Medical
Record, February 27, 1915 and April 15, 1916),
with 2 per cent, sodium citrate solution. The rea-
sons for this treatment which I used before the
Board of Health began with the serum treatment,
were the following:
1. Most healthy adults and children are immune
to acute anterior poliomyelitis.
2. The blood of most people must contain anti-
bodies or it must at least be able to produce anti-
bodies rapidly when the virus tries to invade the
body.
3. If most normal adults and children would not
have any protective elements in their blood they all
would contract the disease in case of an epidemic.
4. The transfused blood reaches brain and spinal
cord quickly by way of the blood current.
5. The transfused blood is a ready food for the
tissues (the nerve cells included) and the sick or-
ganism does not have to use up its energy to elabo-
rate this blood from the ordinary nourishment
passing through the alimentary canal and it can
use this energy to fight the disease.
6. The method of transfusion of blood of adults
seemed to me superior to the method of injection of
serum of convalescents into the spinal canal of sick
children, as there must be different strains of the
virus just as in epidemic cerebrospinal meningitis.
And as Dr. Flexner's polyvalent serum of cerebro-
spinal meningitis is not curative in all cases of the
disease for which it is made, so the serum of peo-
ple having suffered with acute anterior poliomye-
litis which contains antibodies for only one strain
of the virus cannot be curative in all cases. Besides
we get in whole blood the action of the injected
phagocytic cells.
7. People having been sick with acute anterior
poliomyelitis are defective in some way or other.
Naturally their whole blood or serum, the protec-
tive element against one strain of anterior polio-
myelitis not counted, is inferior to that of normal
adults.
8. Whole blood of adults is a protective agent
and acts at the same time like a vaccine in most, if
not in all, infectious diseases of children.
My cases were the following:
Case I.— Kenneth S., Jamaica, 5 years old, of Swed-
ish descent, weighing about 45 lb., was taken ill July
2, 1916. He had headache, chills, and vomiting. After
the action of a cathartic he seemed to be well the fol-
lowing three days. In the evening of July 5 he had a
high fever. Julv 6 his temperature was in the morning
104° and in the evening 105.4°. He was treated
for "poisoning of the stomach" and received within two
days seventeen enemata of two quarts each. The tem-
perature during this time was about 104°. On July
8 he had muscular twitchings of the entire body, espe-
cially of hands and feet. July 9 he was delirious,
drowsy, very restless during the night, and had a high
fever. I saw the boy the first time July 10 at 2 p.m.
His pulse was then* 96, regular, of low tension and
small volume; the temperature per rectum was 101°
and the respiration 40 to 45. His eyes reacted to light
and accommodation. The tonsils were not inflamed and
the nostrils not obstructed. The tongue was heavily
coated, the posterior half of its dorsum being brownish.
The lips were dry and cracked. Heart and lungs were
negative. He was drowsy, had a stiff and painful neck,
and a painful back. The right side of the face and the
right arm were slightly paralyzed. He could move the
right fingers and the forearm, but could raise the upper
arm only to the height of the shoulder. The left arm
was normal. Left leg: reflexes present, ability to raise
the leg is decreased — can stand on left leg. Right leg
painful; he can bend but not extend the toes. All re-
588
MEDICAL RECORD.
[Sept. 30, 1916
flexes except the plantar are absent. Can raise the
thigh to an angle of 45° to the body, cannot stand
on right leg. Sphincters normal. Skin reflexes pres-
ent. Skin clammy, of a bluish hue, no eruptions.
The cerebrospinal fluid, sent to the Board of Health
and reported on a few days later, showed a few white
cells, a slight reaction for globulin and a very slight
reaction of Fehling's solution. July 11 at 1 A.M. he
received a slow transfusion of 350 c.c. of maternal
blood in 2 per cent sodium citrate solution (4 parts of
blood and 1 part of solution) into the resected left me-
dian basilic vein. The amount of blood transfused was
equal to 1211 c.c. in an adult of 150 lb. body weight.
After the transfusion the boy had a slight cough, belch-
ing of gas, and an evacuation of the bowels. The feces
were thin, brown, and offensive. He was talkative,
conscious, and felt much better. At 8 A.M. he asked
for food and received a cereal, milk, a soft-boiled egg,
and bread.
July 12. Sleeps much and has little appetite. The
neck is slightly stiff*. The face is normal and the tongue
clear. He can raise the right upper arm to the level
of the vertex of the head and move it in all directions.
The right leg is paralyzed; he can move the toes only.
He can move the left toes and foot. The left plantar
reflex is present, the knee jerk absent. He can bend
the left thigh with difficulty, but not extend it. He
was transferred to Willard Parker Hospital. On Sep-
tember 7, I examined the boy in this hospital. He
looked bright and had red cheeks. Neck, face, arms,
and trunk were normal. The left leg was normal, but
the knee jerk was absent. He could stand on the left
leg. The right thigh could be moved in all normal
directions. The right knee jerk was absent and the
right leg from the knee down was paralyzed. He could
not stand on the right leg.
In general the outcome is satisfactory, considering
the grave infection and the comparatively late date
at which the blood transfusion was performed.
Case II.— Ruth S., a sister of Kenneth S., fifteen
months old, still nursed by the mother, became sick
July 11 and died July 13. A blood transfusion which
I offered to do six hours after the onset of the disease
and which would have saved the child was refused by
the father. Thirty-six hours after the onset of the
disease I found her in a stuporous condition. The right
arm was paralyzed. The other extremities were very
painful and the neck stiff and painful. The tempera-
ture was 104 :.
The older brother and the two older sisters of
Kenneth S., remained well in spite of the great ex-
posure to the disease.
Case III. — Willard J., Jamaica, twelve months old,
weight 21 pounds, breast fed, of Swedish descent, had
for the last two days a high fever, was very peevish,
restless at night, and seemed to have pain in arms and
legs when touched, but took food. I saw the patient
first July 12, at 10 a.m. He had motor paralysis of the
extensors of the left thigh and leg. Sensation was
present. He could not stand on the left leg. The neck
was stiff and painful. He had adenoids and phimosis.
The temperature per rectum was 100, the pulse 120 and
the respiration 30.
July 12 at 1 p.m.. he received 250 c.c. of citrated
maternal blood into the resected left median basilic
vein. When 200 c.c. were given the bowels moved and
he passed gas and urine. The amount of blood injected
in this case was equal to 1,786 c.c. of citrated blood in a
man of 150 pounds of body weight. After the trans-
fusion was completed he had a slight chill and took
the breast. Extension of the left leg was possible. He
could put the leg to the floor.
July 14. Extension of the left leg is not quite pos-
sible. There is no fever. The boy is playful. There
is twitching of the muscles in sleep.
July l(i. The boy can walk about twelve steps. Then
he gets tired and has to sit down. He can extend the
leg. The neck is normal. Appetite, bowels, urination
and temperature are normal.
July 19. The boy was taken to the Jamaica New
Hospital for Infectious Diseases because the family,
no) following instructions, had communicated with the
child's uncle and his family, whose child was taken 111,
too. The boy remained in the hospital eight weeks. He
can walk and feels fine. The outcome in this case is a
complete cure.
Case IV.— A boy, patient of Dr. S., 3% years old,
breast fed, became sick July 5, 1916. He had anorexia,
fever, was restless, peevish and crying most of the
time. He had no appetite for five days, and was
treated for malaria. July 6 to 8 he was playing on the
street. July 9 he vomited and was feverish. July 9,
10, 11, and 12 the boy had fever, was restless during the
night and crying when awake. The legs, especially the
left leg, were painful when touched. He was in bed all
the week.
July 15 the mother noticed that the boy could not
stand on the floor, and that the left leg was flexed.
Examination shows that the boy is well nourished, looks
bright, has a good appetite, weighs about 40 pounds.
He has adenoids and enlarged tonsils, is a mouth
breather, and has phimosis. The legs, especially the
left, are painful when touched or moved. The left leg
is flexed. He cannot put the left foot on the floor and
cannot walk. The tendon reflexes of both knees are
absent. There is spasticity of the flexors of the left leg,
the extensors of the left leg being paralyzed. He cries
when sitting on the table and complains of pain in the
back and legs, but feels comfortable when the legs are
hanging down. The temperature is 99% the pulse 120,
the respiration 30.
July 18. The boy received a transfusion of 300 c.c.
of maternal blood in sodium citrate solution into
the left median basilic vein. The transfusion
lasted one hour and was equal to 1,125 c.c. in an adult
of 150 pounds of body weight. July 26. The boy can
extend the left leg and walk on it. The blood trans-
fusion was followed by an excellent result in this case.
Con-elusion. — The firm belief in the curative ac-
tion of normal adult blood in acute anterior polio-
myelitis which caused me to perform a transfusion
on the above three cases in the very beginning of
this year's epidemic has been crowned with success.
I am only sorry that circumstances did not allow
me to treat a greater number of cases. But the
good results with normal human blood serum which
are obtained now in the Willard Parker Hospital,
two months after my blood transfusions, confirm
my statements concerning the curative action of
normal adult blood. I consider normal human whole
adult blood superior to sera. It is a remedy to cure
acute anterior poliomyelitis when used early and
to prevent it 1 1 believe) when used before the onset
of the disease. Naturally it will be difficult to
transfuse all children with blood in order to pre-
vent a new outbreak of an epidemic of acute an-
terior poliomyelitis and of other infectious diseases
of children, but whole human adult blood is the
remedy.
633 EAST TWO HUNDRED AND PORTT-pirst Stp.eet.
THE DISCHARGING EAR.
By ALBERT BARDES, M.D.,
NEW YORK.
OTOLOG FLUSHING HOSPITAL.
Chronic suppuration of the middle ear is fre-
quently, one of the most intractable disorders that
we are asked to treat. Thanks to modern methods
of dealing with acute ear infections and to the
general removal of diseased tonsils, adenoids, and
other disturbing nasal affections, running ears are
not encountered nearly as often as formerly. There
is no excuse for allowing an ear infection to lapse
into the stage of chronicity, where its control be-
comes difficult or impossible. The German Em-
peror is reported to have a leaking ear which has
caused and is causing much annoyance. It started
in infancy, at a time when such complaints received
but scant attention. To-day the poorest person is
able to receive better care for an ear affection than
the German ruler received fifty years ago.
Practically all middle ear infections start in the
nasal chambers, after an acute febrile disorder,
notably the grippe, tonsillitis, scarlatina, or measles.
Sept. 30, 1916J
MEDICAL RECORD.
589
Surf bathing and the highly popular but pernicious
nasal douche are also accountable for many infec-
tions.
When a middle ear infection follows a febrile dis-
order, it usually occurs in the second week, when the
febrile attack begins to abate. This is the period
of reaction, during which the engorged vessels be-
come relaxed and inflammatory exudate is thrown
out. At this stage the systemic vitality is low and
resistance to disease is poor. Ear infection after
the grippe is especially to be feared, on account of
the virulence of the infecting medium and the danger
of mastoiditis and cerebral involvement.
The nose and the throat at all times harbor in-
numerable disease germs. Ordinarily these are kept
out of the ear by certain safeguards, which protect
the integrity of the middle ear and keep it sterile.
It is difficult to infect the healthy middle ear. Ex-
perimentally, infectious material can be passed
through the Eustachian tube and into the healthy
middle ear without inducing disease. The foreign
substance is promptly expelled into the nose. When,
however, the Eustachian tube becomes involved in
the general disorder, its protective influence is in
abeyance and the middle ear is vulnerable to attack.
Sneezing, coughing, and blowing the nose violently
are the acts by which infectious substances are
usually forced into the ear.
The middle ear of infants is extremely assailable
on account of its nearness to the nose, only a short
wide tube separating them. The slightest physical
derangement in a baby is apt to react upon the
middle ear. The mere cutting of a tooth, an at-
tack of tonsillitis, or a slight intestinal disturbance
may be the cause of a serious middle-ear infection.
Whenever an infant is ill from any cause in which
the distress is acute and the fever is high, it is
well to think of the ear. Quite often a physician is
puzzled regarding a baby's ailment until the ear sud-
denly starts to flow and discloses the seat of dis-
ease.
Of the disorders of child life, scarlatina is the
most destructive to the ear. Under the influence of
this virulent streptococcic infection, the drumhead
and the ossicles are soon eradicated, unless the in-
fection is speedily combated. Twenty per cent, of
the deaf mutes and a large proportion of the people
who are compelled to go through life with a disabled
ear owe their misfortune to scarlatina. Measles
and diphtheria are also answerable for many dis-
charging ears, but they are much less injurious to
the hearing than is scarlatina.
A discharging ear usually begins this way. When
the middle ear becomes infected it becomes filled
with serum or exudate. Frequently the secretion
escapes into the nose and no harm results. Nearly
every one has experienced the deafness and fulness
in the head during a heavy cold. It comes from the
fluid within the middle ear. If perchance the fluid
is unable to escape into the nose it soon fills the
various compartments of the middle ear, including
the mastoid cells. In seeking an exit the exudate
presses against the drumhead and gives rise to the
distressing pain known as earache. It is said that
convulsions in babies are more often caused by ear-
ache than by anything else. The convulsions are
the result of meningeal irritation. Fortunately the
suffering of infants is seldom prolonged. Their
frail drumhead soon yields to the pressure and
breaks. The moment the tension is relaxed, pain
and fever cease as if by magic. Occasionally, owing
to the presence of scar tissue from former infec-
tions, the drumhead is resistant and the exudate is
forced to seek another place of exit, wihch is usual-
ly through the mastoid cells. It must be borne in
mind that in infants the shell of bone that separates
the middle ear from the brain cavity is extremely
thin and sometimes it is absent, its place being
taken by a fibrous membrane. It is thought that
the infecting agent of most cerebral affections in
babies enters the skull at this point.
Generally an ear discharges for about a week be-
fore it stops. If, however, reinfection occurs, or
if the process of repair is interfered with, the dis-
charge may last indefinitely. An ear that continues
to discharge longer than a month can be considered
a running ear. As a rule, the hearing becomes im-
paired in proportion to the duration of the flow.
The anvil and the mallet are the ossicles that first
yield to the corroding influence of the suppuration.
The stirrup, the tiniest and most essential of the
ossicles, happily resists destruction the longest. Its
loss is followed by profound deafness.
The amount and the consistency of aural dis-
charges vary greatly. Owing to the glandular ac-
tivity of youth, the younger the person the more
profuse is the flow, as a rule. Most ear discharges
teem with disease organisms. As many as ten kinds
of germs have been found in the ear of a single per-
son. The commoner pus cocci are generally found
in large numbers in nearly all ear discharges. Even
in tuberculous infection of the middle ear, so com-
mon in children, the tubercle bacilli are found only
at the onset of the discharge, for presently the more
prolific and ever-present pus cocci predominate and
the tubercle bacilli lose their identity. Furuncu-
Iosis and eczema of the ear canal often result from
the contamination of the aural suppuration. Cer-
tain kinds of fungi thrive on the debris of a run-
ning ear and impart to it a musty, nauseating odor,
which becomes noticeable to the sufferer whenever
the wind blows into the ear, or when the discharge
drops into the throat. Frequently it gives to the
breath an offensive odor. In many instances an
aural flow drains wholly into the throat, whence it
is swallowed and absorbed. A sallow complexion,
malaise, headache, nausea, and diarrhea are some
of the consequences of autointoxication from swal-
lowing the pus.
Many individuals have an intermittent aural flow
that starts up only when the health is below par, as
in the presence of a head cold. It is indicative of
latent disease in the middle ear. Whenever a dis-
charge is slight, say a drop a day, it clings to the
roof of the canal and spreads out like a fan. A leak
such as this is often overlooked, the accumulation
being mistaken for hard wax. Generally a slight
discharge is more to be feared than a copious one,
because it is more readily intercepted. A discharge
that is thin and malodorous comes from disinte-
grated bone and is destructive to the hearing. The
presence of polyps or of granulations in the middle
ear is also indicative of diseased bone. Blood in
the discharge comes from the granulations. Pain
in a running ear denotes defective drainage.
In dealing with discharging ears, watch should be
kept for cholesteatomatous formations. These may
be dangerous. In this condition the moisture in the
ear causes the cast-off epithelium to collect about a
core or nucleus, like the layers of an onion. In-
sidiously the augmenting mass destroys everything
it comes in contact with. It is capable of perforating
the skull as neatly as a drill, although it may take
years to do so. Frequently the cholesteatomatous
590
MEDICAL RECORD.
[Sept. 30, 1916
mass breaks up into a brownish foul-smelling fluid
and escapes from the ear.
A leaking ear is such a commonplace complaint
that generally it is not given the attention it merits.
It is regarded as an annoyance rather than as a
disability which is likely to become serious at any
moment. Many of the laity believe that it is perilous
to stop a running ear. The belief is based on the
knowledge that the sudden cessation of an active
aural flow is fraught with danger. Recently a case
of this kind came to my attention. The ear of a
man was filled with an astringent powder to check
a. slight discharge. The powder, uniting with the
discharge, was converted into a hard caked mass
which prevented the escape of the pus. Alarming
septic symptoms arose which had to be relieved at
once.
Quite often the parents of a child with a running
ear are advised to leave the ailment to Nature and
that eventually it will be outgrown. Such advice is
erroneous and even dangerous. Most of the crippled
ears that give so much trouble in after years are
the aftermath of neglect in infancy. Childhood is
the time to apply those preventive measures that
are the most brilliant achievements of scientific
medicine. There are numberless people with aural
defects who place the blame upon their parents.
The organ of audition is the most delicate piece of
mechanism in the body, not excepting the eye, and
like any piece of fine machinery it easily gets out of
adjustment, especially in infants. A blow on the
head, a fall down stairs, or disease in both ears is
liable to cause irreparable damage to the ears in a
short space of time. Much of the ear disease of
babes that robs them of their hearing is avoidable.
All newborn babes are mute, so far as talk is con-
cerned. They learn how to speak by hearing others
and imitating them, but if their hearing is gone
they remain mute. Even young children who have
partially mastered the art of speech and have be-
come deaf soon forget how to talk, and lapse into
silence.
Children who are hard of hearing are slow in
learning to talk. Many a child, thought to be
stupid is really not so, but is hard of hearing.
Much of a child's education is acquired through the
sense cf hearing. When audition becomes an ef-
fort, a child soon loses interest in its studies and
turns its attention to something less exacting. Nat-
urally it soon falls behind in its work. It is im-
perative that children's ears be watched and tested
with the same care that is given to the eyes. Fre-
quently a child with a leaking ear seems to hear
well despite its defect. Inquiry usually shows that
the hearing is done with the other ear. Whenever
one ear is forced to do the work of both ears it is
apt to suffer.
Insurance companies, through their losses, have
learned to rate persons with a discharging ear as
bad risks. Not only is the health affected, the life
is endangered as well, both from disease and from
accident. The deafness and the dizziness that at-
tend many discharging ears may place the life in
peril if they occur at a time when good hearing and
steadiness are required. Persons with a diseased
ear should exercise care in swimming. When water
gets into the middle ear of certain individuals it
causes a. dizziness and t'aintness. Getting water
into a diseased middle ear has cost the life of
many good swimmers who were thought to have
succumbed to cramp-.
Running ears are treated with far more encour-
aging results than formerly, and with simpler
methods. The sooner treatment is begun the bet-
ter. A few words about the prevention of dis-
charging ears may not be amiss. A beginning
ear infection can frequently be aborted by means
of the ice bag, a mild cathartic, fluid food, and rest.
If the pain is severe, one dose of an opiate is per-
missible. More than this might mask the symp-
toms. The hourly irrigation of the ear with a warm
solution of boracic acid is also allowable. Ear drops
and applications in general are apt to be more harm-
ful than beneficial. The ear should be kept clean.
An earache should not be permitted to last longer
than twelve hours. It is the symptom of an active
and perhaps a serious infection, and prompt relief
is demanded. It is decidedly unwise to wait for
the drumhead to rupture or even to bulge. It is
far better to open the drumhead prematurely than
to allow the infection to spread. If, on opening the
drumhead, no fluid is found, the incised drumhead
soon mends and no harm is done. It is needless to
state that all work upon the ear should be done un-
der the rules of surgical asepsis.
Many lives have been sacrificed through delay in
dealing with a middle-ear infection. Within a short
time I saw three persons with meningitis from
neglected ears. There are other disadvantages in
waiting for the spontaneous rupture of the drum-
head to take place. The opening is apt to be faulty.
Either it fails to provide adequate drainage or else
the drumhead is needlessly lacerated. Such an aper-
ture heals with difficulty, and if repair does take
place, the hearing eventually becomes affected, by
reason of the intratympanic adhesions.
Never should the drumhead be incised without the
aid of a general anesthetic, preferably a whiff of
chloroform. This is used both to obviate the intense
pain of the procedure and to keep the patient from
moving and deflecting the scalpel. The incision
should be a free one, not merely a stab. Beginning
in the lower posterior quadrant, the incision should
sweep upwards and backwards, behind the ossicles
and near the rim of the drumhead, ending outwards
into the swollen periosteum of the canal. The final
sweep has been termed the internal Wilde incision.
It depletes and drains the edematous tissue and
helps to avert mastoiditis. In the left ear the in-
cision resembles the letter S; in the right the let-
ter Z.
When an infected middle ear is opened, serum is
released, seldom pus. In a few hours the discharge
becomes copious and purulent. The more active the
flow the better the result. Generally, relief follows
the operation. If. however, the symptoms do not
abate, it is evident that the infectious material
within the mastoid cells is unable to escape into the
middle ear proper, and that more drastic measures
are required.
Ordinarily the after treatment of an incised drum-
head is simply to keep the ear dry and clean. Irri-
gations should be used sparingly, if at all. Used
too freely they keep the drumhead in a soggy state
and hinder repair. A saturated solution of boracic
acid with the addition of some alcohol makes a good
cleansing lotion. A poisonous solutin, such as the
bichloride of mercury should never be employed in
infants, lest it escape into the throat. The cotton
wipe is the best implement for cleaning the ears.
The patient can assist the cleansing process by in-
flating the ear after Valsalva's method.
Regarding the treatment of a running ear, the
prescribing of ear drops without first ascertaining
Sept. 30, 1916]
MEDICAL RECORD.
591
the precise nature of the lesion in the ear, is as un-
scientific as it is generally unavailing. The use of
peroxide of hydrogen is especially objectionable. If
it gets into the middle ear it may not be able to
escape.
It is useless to attempt to check a discharging
ear by local measures so long as reinfection from
the nose is apt to occur. It is first necessary to cure
the nasal disorder. The removal of diseased tonsils
and adenoids in children will do more toward pre-
venting an ear infection and stopping a running
ear than anything else will. It is my plan, when
removing tonsils and adenoids of a child with a
running ear, to supplement the procedure by re-
moving the granulations from the middle ear and
freshening the edges of the drumhead. Most run-
ning ears are controlled by doing so.
Frequently there is an obstacle in the middle ear
which favors the continuance of the aural discharge.
To overcome this, it may be necessary to enlarge the
opening into the middle ear for better drainage;
to sever adhesions in the middle ear, or perhaps re-
move aural polyps or granulations. Frequently an
aperture in the drumhead can be made to close by
slitting or by freshening the edges of the perfora-
tion or perhaps by placing a piece of paper over the
opening. If the middle ear can be kept dry the dis-
charge generally ceases. In the hands of the phy-
sician the suction pump and the wick usually ac-
complish this end.
The local remedies used to control an aural dis-
charge have for their object the stimulation of the
sluggish mucosa to healthy action. Quite often a
discharge of long standing can be brought under
control in a short time by the daily use of an alco-
holic solution of boracic acid dropped into the ear.
A persisting discharge may require something
stronger, perhaps a twenty per cent solution of iodin
or else a ten per cent solution of chromic acid. Stim-
ulation by the use of heat after Beers' method of
inducing hyperaemia is most useful in certain stub-
born cases.
Much of the difficulty encountered in the treat-
ment of these diseases is owing to the fact that the
affected parts are out of sight. The tiny attic
syringe is helpful in many of these cases.
A decade ago it was hoped that the radical mas-
toid operation of Stacke would enable us to cure all
discharging ears, but these expectations have not
been realized. In this operation the various com-
partments of the middle ear are thrown into one
kidney-shaped cavity. Besides, the Eustachian ori-
fice is closed and the ossicles are removed, together
with all diseased and cellular bone in the middle
ear. Unquestionably the procedure is an invaluable
one in selected cases, but generally its performance
should be deferred until simpler measures have
been tried. At the present time the operation finds
less favor than it formerly did. The operation has
many objectionable features which are usually with-
held from prospective patients. The best statistics
of the operation show a cure of but 50 per cent.
One-tenth of the persons operated upon finally die
of meningitis. Others develop facial paralysis and
nearly all eventually lose their hearing. The asser-
tion that the radical operation does not affect the
hearing can safely be challenged. Any procedure in
which the ossicles are removed and the middle ear
is covered with scar tissue is bound to seriously
disturb the hearing. In many instances it takes a
vear or more for this to occur.
A better operation for most cases is the mastoid
operation of Schwartze, which provides for the re-
moval of the mastoid cells and establishes a free
connection between the mastoid antrum and the
tympanic chamber. The ossicles are not disturbed
and the better drainage and stimulation generally
cause the discharge to cease.
164 West Seventy-third Street.
CLIMATE: ITS USE AND ABUSE IN THE
TREATMENT OF TUBERCULOSIS.
By J. B. FISH, M.D..
MEDICAL DIRECTOR JEWISH CONSUMPTIVES' RELIEF ASSOCIATION
OP CALIFORNIA.
LOS ANGELES, CAL.
Does the tuberculous patient need a change of cli-
mate? What factors should be paramount in the
climatic selection? Where shall this haven of health
be? And — how shall he derive the greatest bene-
fits from it?
These questions give but a glimpse into the haze
surrounding the all-important subject of climate.
And yet, difficult as is the proper solution of these
questions, the lack of discrimination evidenced in
deciding them, really is astonishing. Not infre-
quently the patient takes it upon himself to decide
upon the change of climate; or he may follow the
admonition of some fellow-sufferer, some misguided
friend or neighbor, perhaps the milkman or coal-
man or any one — in fact, except the proper advisor
— his physician.
From time immemorial to the present day —
the era of serum-therapy — climate always has
ranked high in the treatment of tuberculosis. Dur-
ing this time, it is true, many a drug has earned
short-lived fame as a positive cure for consumption.
It is equally true that since 1882, when Koch put
his index on the tubercle bacillus, many a serum
has met a similar fate. But climate has held its
own.
And while we feel that the time is not far distant
when we shall have a specific for tuberculosis, we
must necessarily continue to place our faith in such
factors as have stood the test of time. Chief among
these are: Climate, rest, diet, general hygiene.
But have all these been accepted without qualifica-
tion ? Hardly. All of us are familiar, for example,
with the changes affecting the rest-cure idea. It
is not so long ago that the general pracitioner urged
the tuberculous victim to "Go West and rough it."
Then came a sudden swerve in attitude when abso-
lute rest and quietude were deemed essential. Ancf
now we are confronted with the experience of
Bernstein of England and his followers in Europe
and America, who — by subjecting the patient to
carefully graduated labor and so inducing autoinoc-
ulation — have effected cures even in febrile and
advanced cases.
A not dissimilar condition existed, and, for that
matter, exists still, in the question of diet. For a
time we believed that the intake by the patient of
an extraordinary quantity of food assisted mate-
rially in combating the disease. This led eventually
to the idea of "forced-feeding." To-day, however,,
we take pains to select a diet applicable to the
particular condition of the patient; we make it a
point not to abuse the digestive organs; we are
careful not to unduly burden the eliminative organs
that already are overtaxed by the tuberculous toxins.
So we see how time has wrought changes even
in this accepted creed of treating tuberculosis. But
climate, considered as an integral factor, alone has
held its place in the sun. Why?
It is quite beyond the scope of this article to
592
MEDICAL RFXORD.
[Sept. 30, 1916
detail the reasons that should prompt a climatic se-
lection in any given case or to differentiate between
low and high altitudes, cold and warm regions, and
their relative advantages in the treatment of tuber-
culosis. Nor is it feasible here to discuss the various
physiological factors involved — such as humidity,
precipitation, rarefication, the degree of solar inten-
sity, quickened circulation and respiration, the in-
crease in red blood corpuscles — and their effect on
health. Rather will we concern ourselves with the
psychological effects of climate, and particularly
with the influence it exerts on the nervous system.
For, in tuberculosis, as in any other prolonged
disease, the mind as well as the body suffers. But
in tuberculosis, particularly, the nervous system
suffers doubly. It shares in the morbid effects
resulting from the functional disturbance incident
to the disease and, in addition, is taxed by the work
it must necessarily perform in connection with the
recuperative process. The rigid mode of life re-
quired of the tuberculous patient subjects the nerves
to a form of restraint to which they have been
unused and at which they naturally revolt. The
patient is told that he must rest so many hours a
day; he must have his temperature taken so many
times a day; he must take only so much exercise,
if any; he must awake and retire at a certain hour;
he must do this and must not do that. All these
mandates that constitute the decalogue of tubercu-
lous regimen cannot help but grate upon the already
vitiated nervous system of the patient.
But in our zeal to help the vital organs regain
their strength we are unmindful of this additional
levy placed upon the nervous system.
Clearly we need a remedy for this — we need
something that will bridge the gap — that in itself
will generate the necessary nerve force. Climate
does this!
The change of climate itself is a glimmer of hope
exerting a salutary effect upon the mind of the
patient. It helps him, in great measure, to regain
his poise. It means a fresh start — a rekindling of
that combative spirit that should dominate each
patient and that never must be allowed to droop.
He is confronted with new faces, new scenes, new
backgrounds for the commonplaces of everyday life.
He is gratified to find many who, like himself, had
come there looking to the high heavens for hope
and health, and had found them. He acquires more
energy, more buoyancy. His black despair gives
way to roseate hope. As a result, he ceases to be
so introspective — he is less likely to keep thinking
about his own condition — and, instead, begins plan-
ning for the new life that will come with complete
restoration to health. In fine, the patient is elated
to find that Nature is, indeed, a helpful ally in his
fight against the enemy that is threatening his very
existence.
The mental effect — or, if you will, the psycho-
therapy— of climate unquestionably merits greater
consideration than ordinarily is bestowed on it.
This is instanced by the fact that often a patient's
condition will show improvement directly after his
arrival and obviously before the physiological effect
will have had time to manifest itself. On the other
hand, should a patient develop an antipathy to a
certain prescribed climate, he will seldom make
good progress there and will do better elsewhere —
even if the physical elements seem less auspicious.
In prescribing a climate for a consumptive, the
mental element, therefore, deserves serious delib-
eration. Worry, fretting, anxiety, or other depress-
ing condition militates against improvement in
health. Much of the success of the attending physi-
cian will depend on his grasp of the mental charac-
teristics of the patient. This phase of treatment,
certainly, is no less important than the regulation
of rest, exercise, food, and general mode of life.
In the very nature of things, the first question
confronting the medical advisor will be, Is the
change of climate absolutely essential? In consid-
ering this phase of the matter, the physician will
do well to remember that countless cases of tubercu-
losis have been "arrested" without any change of
climate.
Having satisfied himself on this score, the medical
advisor may then proceed with the following prac-
tical catechism based on extended clinical expe-
rience:
Assuming that the change is essential, will the
probable results outweigh the sacrifices involved —
the breaking of home ties, the loss of business, the
countless inconveniences and the not inconsiderable
expenditure? Again, what vital resources does the
patient harbor in himself? Is he fitted for travel?
Will competent medical guidance be available? Will
the food and sanitary arrangements be thoroughly
satisfactory? Will the proposed environment har-
monize with his mental make-up? Some like a quiet
place, others prefer an animated place. Some are
irritated by necessary association with strangers,
others prefer company. One may not be happy
unless his wife is at his side, another may not know
what peace of mind is unless she is away.
Often a case will present itself where it seems
advisable for a patient to locate permanently in a
different climate. Here we are confronted with the
additional question, Will he be able to earn his
livelihood there?
In short, a thorough knowledge of the patient's
habits and characteristics, together with an intimate
insight into his peculiarities, is essential; for, in
the final analysis, we are treating not consumption
but the consumptive.
But, perhaps, the most dominant point to remem-
ber in connection with prescribing a climate for
a consumptive is that there is no one best climate-
for all cases and that some patients will fare well
in any fairly good climate providing they adhere to
a suitable mode of life.
With these salient thoughts in mind, little diffi-
culty indeed will be experienced in determining
upon the proper climatic selection.
7i fi haas Building.
A DEVICE FOR DRAWING SMALL AMOUNTS
OF BLOOD.
By HAVENS BREWSTER BAYL.ES, M.D.,
BROOKLYN. -S'. Y.
I wish to offer to the readers of the Medical
Record who have occasion to draw small quanti-
ties (,6 c.c-30 c.c.) of blood (Wassermann) the de-
scription of a small, compact outfit, an improvement
on that furnished by the New York Health Depart-
ment. It is the usual experience, when the blood is
drawn either by the physician unaided or with the
assistance of patient or nurse, that more or less of it
is spilled on the patient, doctor or floor, after the
needle enters the vein and before the receptacle is
procured and placed in proper position.
As seen by the accompanying diagram, a rub-
ber stopper is inserted in place of the ordinary
cork. This stopper is fitted with a short, hollow
Sept. 30, 1916J
MEDICAL RECORD.
593
needle, protected by a flange which is inserted
through a small opening in the stopper and which
acts as a vent. Another opening is made at the
outer margin of the stopper, opposite the vent, for
the insertion of the needle furnished by the depart-
ment, and is so placed to put it in line with the
vein ; the beveled point must face the operator when
the needle is inserted.
The technique is simple: Remove the cork from
tube, insert rubber stopper, push needle through
the rubber stopper as indicated by mark on stopper
as shown in diagram. We thus have a needle fitted
into a tube, the latter serving as a handle, and the
outfit is used much the same as one would use an
awl. After the desired quantity of blood is with-
drawn the rubber stopper is removed and the origi-
nal cork inserted. The outfit is then ready to return
to the laboratory for examination.
The rubber stopper should be washed under a
faucet, sterilized, and placed in alcohol, ready for
future use.
125 SEVENTH AVENUE, CORNER CARROLL STREET.
iHrfjinilrgal TSatta.
Having Possession of Opium. — Under the revenue act
of 1914 requiring- all persons who produce, import, man-
ufacture, compound, deal in, dispense, sell, distribute, or
give away opium to register and pay an annual tax an
indictment charged the defendant with conspiring with
one Martin to have a dram of opium in the possession
and under the control of Martin; and as the overt act
charged that the defendant issued to Martin a prescrip-
tion therefor, in bad faith, knowing it was not given for
medical purposes, but for supplying one addicted to the
use of opium. It was held that the indictment was in-
sufficient. The unlawful thing charged consisted in hav-
ing the drug in the possession and under the control of
Martin, but the word "person" in the statute refers only
to those required to register and pay the tax, and it was
not alleged that Martin had the drug in his possession
for any of the purposes for which he would have to reg-
ister and pay the tax. — United States vs. Jim Puey Moy,
225 Fed. 1003.
Burden of Showing Sale of Cocaine Not Unlawful on
Defendant. — Section 808 of the Chicago Code of 1911
provides that "no druggist or other person shall sell or
give away any morphine, cocaine, alpha or beta cocaine,
chloral hydrate, or any salt or compound or derivative
of any of these substances, or any substance, prepara-
tion, or compound containing any of these substances,
or any of their salts or compounds or derivatives except
upon the written prescription of a duly registered physi-
cian. It is held that the burden of proving in proceed-
ings under the act that the sale was within the excep-
tion of the statute (because made on a physicians's pre-
scription) is upon the defendant. — City of Chicago vs.
Montgomery, 191 111. App. 558.
Keeping Opium for Personal Use — Burden of Proof —
Registration and Taxation. — The federal district court,
W. D. Tennessee, W. D., holds that under the Harrison
Anti-Narcotic Act, the mere keeping of a small quanti-
ty of opium for personal use does not constitute an of-
fence within the meaning of the act. Where a narcotic
is found in a person's possession, he is presumptively
guilty of violating the act, and then the burden of proof
is upon the defendant to show affirmatively that he is
not one of the class mentioned in Section 1 as required
to register, or, if so, that he had registered and paid the
special tax.
In a prosecution under the act, the uncontradicted evi-
dence showed that the defendant obtained the opium
found in her possession from a Chinaman, and that she
had it for her personal use and consumption, and that
she never sold, gave away, or dealt in it in any form.
This evidence was held to overcome the presumption of
guilt arising from the possession of opium under Section
8 of the act, providing that possession or control of
opium shall be presumptive evidence of a violation of
the act. — United States vs. Wilson, 225 Fed. 82.
Harrison Anti-Narcotic Law — Elements of Offence. —
Section 1 of the federal act, Dec. 17, 1914, provides that
every person who produces, deals in, etc., opium or coca
leaves, or any compound or preparation thereof, shall
register with the collector of internal revenue and pay a
special tax. Section 8 provides that it shall be unlaw-
ful for any person who has not registered and paid such
tax to have in his possession any of such drugs, and that
possession thereof shall be presumptive evidence of a
violation of both Sections 1 and 8. The federal district
court, D. Montana, holds that, as taxes can be imposed
and statutory offences created only by direct, clear, and
apt language, the act does not impose the duty of regis-
tration and the payment of taxes upon mere consumers
of the drugs, and only makes unlawful possession of the
drugs by persons required to register and pay the tax,
who have not done so. Indictments under the act, for
not having registered and paid the special tax, but not
alleging that the defendants were in any of the classes
thereby required to register and pay the tax, were held
to be fatally defective in substance and too uncertain to
be sustained. — United States vs. Woods, 224 Fed. 278.
Harrison Anti-Narcotic Law — Application to Physi-
cians.— The federal district court, W. D. Tennessee, W.
D.. holds that the Harrison Anti-Narcotic Law does not
limit the amount of drugs a physician may prescribe,
and an indictment charging a physician with prescrib-
ing drugs in quantities more than was necessary for the
immediate needs of his patient, and not in good faith,
is subject to demurrer. There is no duty imposed upon
a physician by the act other than to keep a record of all
such drugs dispensed by him, and the name and address
of the patient, except those to whom he may personally
administer, and that he must preserve the records for a
period of two years. — United States vs. Friedman, 224
Fed. 276.
Regulation of Sale of Opium — Validity of Federal
Statute. — The federal district court, W. D. Washington,
N. D., holds that Congress may prohibit the importation
of opium and regulate its relation to interstate com-
merce, as is done by Act of Dec. 17, 1914, providing for
registration with collectors of internal revenue of deal-
ers in opium, imposing a tax on dealers, and making it
unlawful for any person who has not registered and paid
the tax to have in his possession any opium or derivative
thereof, and providing that such possession shall be pre-
sumptive evidence of a violation of the act. — United
States vs. Brown, 224 Fed. 135.
Expert Testimony Based on Evidence. — The authori-
ties differ as to the wisdom of permitting experts to
express their opinions based on the evidence in a case
instead of submitting hypothetical questions to them,
but in Maryland it is permissible. In a prosecution for
abortion, where there were several medical witnesses
in the case who had treated the deceased, there being
no conflict between them, the admission in evidence of
the opinion of an expert who heard all but one of such
witnesses testify was held proper. — Damm vs. State,
Maryland Court of Appeals, 97 Atl. 645.
594
MEDICAL RECORD.
[Sept. 30, 1916
Medical Record.
A Weekly Journal of Medicine and Surgery.
THOMAS L. STEDMAN, A.M., M.D., Editor.
PUBLISHERS
WM. WOOD A. CO., 51 FIFTH AVENUE.
See fourth page following reading matter for Rates of Subscription
ind Information for Contributors and Subscribers.
New York, September 30, 1916.
LOANS TO PHYSICIANS.
One of the Sherlock Holmes stories tells of a young
practitioner who wished to specialize in a rather
obscure branch of medicine. He was fortunate
enough to meet with a rich, eccentric old gentle-
man who set him up in practice as a speculation;
so much of his income went to his backer, who
realized in time an excellent return on his money,
while the young practitioner was thus assisted over
what are usually the darkest days of a professional
career. A case of that sort is exceptional, perhaps
unique. Most of us live somehow through the first
years of practice, maintaining clean linen and an
automobile on an income varying from $5 to $50
a month in cash, $200 on the books, and untold
thousands in experience. Of course, there are those
favorites of fortune whom we envied in college
days, the rich man's son on the one hand who will
step into an office furnished from top to bottom in
the best style, and on the other hand the physician's
son, whom I think we envied even more — that lucky
individual who was able to start out under the
sheltering wing of the wise G. P. — who found his
practice ready-made and expanded to fill it. The
moralists may rave as they will about the bless-
ings of poverty and toil and the curse of unearned
ease; few of us who sat in our simply furnished
offices reading Osier or worse and waiting for the
ring at the bell which turned out to be the install-
ment man, did not envy the colleagues whose first
years were devoid of worries.
A medical education is coming more and more to
represent a large outlay of money besides the time
involved. As medical colleges have practically abol-
ished the night school it means that for four, five,
or six years the student must live without work-
ing and in addition pay tuition fees, which grow
higher all the time, buy books, instruments, etc.
It was formi rly the case thai an enterprising young
man with a good constitution could work his way
through medical college; it often kept him on the
edge of a breakdown, but it was done. Now, if a
student can obtain a job of some kind during his
vacation and find chances here and there during his
school year to pick up a few dollars he considers
himself lucky. Such a student, however, finds him-
self upon graduation face to face with a serious
problem. He may, and often does, go in a hospital
for a year or two, but this is only postponing the
problem for most hospitals pay nothing or very
little, certainly not enough from which to save any-
thing. He is confronted with the task of fitting out
an office, buying a machine perhaps, and undertak-
ing to pay living expenses for several years before
his practice shall become large enough to support
him. The practicing physician, too, must present
a good appearance, somewhat as the minister must.
His clothing must be neat and not too threadbare,
his linen clean, his machine, even though a rented
flivver, must be kept in good order, although he him-
self should never be seen working on it, and a doc-
tor must always be well fed and not appear to do
any other work than his professional duties. Some
optimistic souls accept this problem gaily, furnish
apartments on the installment plan, buy a car on
the same principle, run up a tailor's bill, and put
themselves in the hands of Providence. Sometimes
their faith is justified, patients flock in, and a year
or so later they begin buying bonds and mortgages.
Too often, though, the first two years are full of
such nightmares as dodging the collector, placating
various creditors, and at the same time showing a
smiling, unruffled front to patients.
Now for a solution. We are inclined to think
that it may lie in the direction of loans to physicians
on their notes. The question of unsecured loans
has always been a vexed one. Salaried employees
are often driven to the loan sharks in large cities
on account of the impossibilities of securing loans
from banks. In some places cooperative companies
have been formed which specialize in such loans
and these have, as a rule, been fairly successful,
but they necessarily deal in small sums, $25 to
$100, as a rule. It would seem that a company
might be formed to make loans to young physicians
which would combine the advantages of being good
investments and filling a real need. Dealers in
medical books, drugs, and instruments are always
ready to sell to the young doctors on the deferred
payment plan ; tradesmen, as a rule, trust them glad-
ly : but all this does not solve the problem. It mere-
ly means a number of small debts for the doctor
which all demand payment at the same time, and if
one of them is neglected for a few months it
amounts up alarmingly.
The details of the scheme hinted at above would
require elaboration, but the main idea would be as
follows: The company should consist partly of
doctors and partly of business men. Some members,
if possible, should be both. When a physician ap-
plied for a loan strict investigation should be made
into his antecedents, his school record, etc. The
locality in which he wished to practice would also
have a bearing on the question. Then the company
could rent and furnish his office, provide him with
a car, and allow him so much a month. A re-
port should be furnished by him every six months
of his actual expenses and income. The extent to
which the former exceeded the latter should be made
the basis for the allowance for the next six months.
This procedure should be repeated every half year,
and as soon as the income exceeded the expenses ar-
rangements could be made for paying back the prin-
cipal. Besides the intangible security of character,
the physician's note might be endorsed by two other
physicians, a chattel mortgage taken on his furni-
Sept. 30, 1916]
MEDICAL RECORD.
595
ture and automobile, and an endowment policy pay-
able to the company for, say, four or five times the
amount of the loan, be kept up by the physician.
When the loan was repaid this policy could be as-
signed to the physician, who would then have a start
on a savings account. This scheme is undoubtedly
impractical, being devised by a physician, but at
least something of the sort, differing possibly in
some of its details, might be arranged for the doc-
tor who hesitates to take the plunge into the
doubtful waters of general practice.
PELLAGRA AND SENSITIZATION TO MAIZE
AND SUGAR-CANE PRODUCTS.
Perhaps the most popular and best established
theory at the present time regarding the nature of
pellagra is that it is a deficiency disease, one due
not to a lack of food in itself, but rather to a lack
of substances in the food which are essential to a
good state of nutrition.
At the third triennial meeting of the National
Association for the Study of Pellagra at Columbia,
S. C, Oct. 21 and 22, 1915, Dr. Roy Blosser read
a paper dealing with the phenomena of sensitiza-
tion to maize and sugar-cane products, in which he
advanced the new theory that pellagra was due to
this sensitization occurring in certain individuals.
His claims as to the pellagra producing properties
of the non-refined or partially refined sugar prod-
ucts were based on (1) a careful study of the diete-
tic habits of more than two hundred pellagrins; (2)
the results obtained in such cases by the exclusion
of certain articles of food; and (3) the effect of the
experimental administration of these products to
dogs. Blosser's experiments have differed from
other attempts to produce pellagra experimentally
in that meat and other foods were given with the
sugar-cane ration, thereby eliminating any ques-
tion as to the results being due to a lack of
vitamines or to an unbalanced or unnatural diet.
The result of his experiments appeared to show
that a sugar-cane ration brings out unmistakable
symptoms of pellagra.
PLATES AND BONE GRAFTS IN FRACTURES.
In the hands of the introducer, Sir Arbuthnot
Lane, the steel plate has had much success in the
operative treatment of simple fractures, and it may
be said that when Lane's technique has been closely
followed, others have had excellent results from this
mode of treatment. However, since autogenous bone
grafting has come more or less into vogue various
strictures have been passed upon the use of the steel
plates. Among the many objections brought against
their employment are that they act as foreign
bodies; that they have a destructive influence on
bone formation which may prevent the fractured
ends from uniting; that a rarefying osteitis, or os-
teoporosis, or necrosis usually develops around the
metal screws or nails, causing them to loosen and
drop out; that metal favors infection, absorption,
and disintegration of the tissues, and that the plates
do not answer the purpose for which they are em-
ployed because they bend or break.
In the Practitioner, March, 1916, Lane ably de-
fends his manner of treating fractures and in the
Canada Lancet, July, 1916, E. R. Secord speaks very
highly of steel plates as compared with the auto-
genous bone graft in the operative treatment of sim-
ple fractures. He points out that the first grand
objection to the use of the bone graft is the amount
of manipulation necessary to obtain the graft, and
to prepare a suitable bed for its reception. The
next great objection to the graft arises from the
difficulty of fixing it in place with any degree of
security. Consequently, the time required for a
bone grafting operation is considerable. While a
reasonably expert operator can "plate" a broken
femur in half an hour, it will take him probably two
hours to put in a bone graft. Secord states that at
the Brantford General Hospital during the past few
years they have operated on a considerable number
of fractures by both plate and bone graft meth-
ods. They have never had to remove a plate, and
have never seen any irritation result from its pres-
ence. All their cases have been radiographed sub-
sequently, and no evidence has been seen of rarefy-
ing osteitis, or of loose, bent, or broken plates. He
concludes that the use of the Lane plate appears to
be safe, simple, and expeditious, but that a most
rigid technique must be followed both during and
after the operation, and that the great majority of
failures after its use are due to faulty methods at
the time, or to a failure to understand what may be
expected of an internal fixation in any form. That
the bone graft can be made to perform the same
function is granted, that its use has certain advan-
tages is admitted, but it is held that the difficulty of
application and retention more than counterbalances
these advantages.
SEASICKNESS.
Seasickness has existed as long undoubtedly as
men have traveled by sea and during this time,
despite the countless remedies suggested for the
distressing condition, no cure has as yet been dis-
covered. In the Medical Press of July 12, 1916, is a
paper by John F. McMillan in which he explains the
sensations of seasickness as follows: Vertigo is a
reflex condition due to some divergence from the
normal of the semicircular canals, whereby through
the auditory nerve abnormal impulses are carried to
the medulla, and thence to the heart by the pneu-
mogastric through its cardiac branches; and so far
as the derangement that is common to the good
sailor when he is confined below amidst oil smells,
galley odors, etc., constitutes that form of the mal-
ady associated with vertigo, the main system, that
is to say, the sympathetic, is unaffected. But do the
waves pass beyond, to the gastric branches of the
vagus, then are the original abnormal impulses
from the semicircular canals communicated through
its gastric branches to the center of the sympa-
thetic system, the solar plexus, and then a second
impulse is carried back to the stomach and causes
the latter organ to evacuate its contents; and, al-
though the whole may constitute one reflex move-
ment, it is possibly a double one, the second being
complete when food, actually placed within the
stomach, during the first reflex is rejected; and
then occurs the never-to-be-forgotten feeling of a
596
MEDICAL RECORD.
[Sept. 30, 1916
blow in the stomach. The spinal cord has been said
to be concerned in the reflex or reflexes, and there
has been mention made of muscular incoordination;
but it is an easily solved question that beyond the
movement caused by the lurch of the vessel, there
is no muscular affection other than the inactivity
due to vertigo and the gastric distress.
.McMillan recommends nitrite of amyl to be in-
haled with caution as required as efficacious with
regard to the syncope associated with vertigo while
as regards the solar plexus he thinks that the most
useful remedy is an effervescent mixture, such as a
Seidlitz powder, with the addition of a couple of
drops of dilute hydrocyanic and 15 minims of spirit
of chloroform.
The Alleged Increase of Cancer.
With regard to the increase of cancer, the views
of those who have studied the subject closely are
somewhat curiously at variance. While, perhaps,
nearly all authorities are agreed that cancer has in-
creased, many stoutly deny that this increase has
assumed the alarming proportions ascribed by some
writers and statisticians. At any time statistics are
to some extent confusing and unless collected with
great care and uniformity are apt to mislead. More-
over, in those countries in which there is not a uni-
form system of collecting and collating statistics,
such figures cannot be taken as accurate and must
be regarded with a certain degree of suspicion.
Again, there are many things which enter into the
question of cancer statistics, which render dog-
matic statements unwise and even foolish. There
is no space to discuss all of these here, but it may
be said that some of the widely advertised state-
ments that cancer is largely on the increase must
not be taken without reservation. A part of this
increase is apparent and a part real. Recently, Mr.
Frederick L. Hoffman has brought out a book' with
the rather ambitious title of "the mortality from
cancer throughout the world," in which he states
that the actual frequency of malignant disease
throughout the civilized world has been ascertained
to be much more of a menace to the welfare of man-
kind than has been generally assumed to be the case,
and that, in contrast to a marked decline in the gen-
eral death rate, cancer remains one of the few
diseases actually and persistently on the increase
in practically all of the countries and large cities for
which trustworthy data are obtainable. Hoffman
has collected and set down a mass of statistics and
evidence bearing upon his point of view, and the
book is a monument to his untiring and painstak-
ing energy. While his work is not conclusive, it at
least serves to show that cancer is unduly prevalent
and that steps should be taken everywhere to control
its spread, that is so far as is possible.
Treatment of Fractured Jaws.
Onf of the features of the treatment of wounds in
the present war has been the success of the treat-
ment of jaw wounds. In the American hospital in
Paris the results obtained by the cooperation of sur-
geons and dentists in rectifying the effects of
wounds of the jaw have been remarkable. Some of
these results were shown on the screen in this city
'The Mortality from Cancer Throughout the World bv
Frederick L. Hoffman, LL.D., F.S.S., F.G S \ Newark-
The Prudential Press, 1915.
by Bainbridge after his return from the seat of
war. In the British Journal of Surgery, August,
1916, Major A. C. Valadier gives a few sugges-
tions for the treatment of fractured jaws. He
draws attention to the fact that wounds caused by
bullet or shrapnel will generally be complicated;
that is to say, a piece of metal may lodge in a most
vital spot. The following points have then to be
determined: (1) Whether or not it is right im-
mediately to attempt the removal of the foreign
body. (2) Whether the patient will stand the
strain of an anesthetic. (3) Whether the region of
the glottis may be so inflamed as to contraindicate
the use of a general anesthetic. (4) Whether the
patient's oral cavity is so lacerated that food cannot
be introduced. Should he be surgically treated at
once to overcome this condition ; or should pros-
thetic interference for the reduction of his frac-
tured jaw be applied before surgical interference?
These questions can only be answered by the oral
surgeon in charge. Valadier points out that it is
absolutely necessary for the sucecss of the proced-
ure that the oral surgeon should work in perfect
unison with the surgeon who is doing the plastic
part of the operation.
Sfaofi of tip? fflnk.
Epidemic of Poliomyelitis Near End. — The
rapidly decreasing number of new cases of polio-
myelitis in the city encourages the belief that
the epidemic is nearly at an end. During the
week ending September 23, only 160 new cases and
58 deaths were reported, as compared with 254 cases
and 84 deaths during the previous week. The total
number of cases in the city to September 23, was
8,885, and the deaths numbered 2,233. After con-
sultation with the Health Commissioner and the
President of the Board of Education, Mayor
Mitchell decided to have the public schools of the
city open on Sepember 25, having reached the deci-
sion that the opening of the schools would be, not
only safe, but actually beneficial to the children.
The Health Commissioner has stated that during
the school months of last year there were reported
20,668 cases of measles, 5,797 cases of scarlet fever,
and 13,725 cases of diphtheria, the number of cases
of each increasing month by month from October
to June. The conclusion was drawn that if too
great attention were paid to the spread of disease
the schools would never be opened. More than $40,-
000 dollars has already been sent in voluntary con-
tributions to the Health Department as a fund for
the aftercare of children who have suffered from
poliomyelitis. Surgeon L. D. Frick of the United
States Public Health Service, who has been inspect-
ing interstate travel through New York, has been
ordered to Boston to assist the Health Commis-
sioner of Massachusetts in the fight against infan-
tile paralysis in that State. The statement that no
cases of poliomyelitis developed among the babies
receiving pasteurized milk from the Straus milk
stations has been questioned by the officials of the
Health Department. According to the records of
the Department, out of 200 children under two
years of age admitted to the Willard Parker Hos-
pital during the epidemic, six were reported to have
been users of the Straus milk up to the time of
their admission.
Medical Colleges Open. — The Medical Depart-
ment of the University of Georgia, Augusta, opened
on September 14, with twenty-six men in the first
Sept. 30, 1916]
MEDICAL RECORD.
597
year class, and a total registration of over fifty.
Dr. William H. Doughty, Jr., dean of the College,
made the opening address.
The University of Tennessee, College of Medicine,
Memphis, opened its new term on September 21,
having added to its faculty three new members, Dr.
Frank Maltaner, in the department of bacteriology
and public health; Dr. W. E. Evans, in the depart-
ment of biology, and Dr. John A. Mcintosh, Jr., in
the department of pathology.
1915 a Healthy Year. — A preliminary report of
the Director of the Bureau of the Census gives the
death rate for 1915 as 13.5 per 1,000 of population
in the registration area of the United States. This
is the lowest rate on record. The rate is based on
909,155 deaths returned from 25 States, in one of
which (North Carolina) only municipalities of 1,000
population and over in 1910 were included, the Dis-
trict of Columbia, and 41 cities in nonregistration
States, the total population of this area in 1915
being estimated at 67,337,000, or 67.1 per cent, of
the total estimated population of the United States.
In 1914 the death rate per 1,000 of population was
13.6; and in 1913 it was 14.1; while for the five
year periods from 1901 to 1905, and from 1906 to
1910, the average rates were 16.2 and 15.1 respec-
tively. In New York State the death rate for 1915
was 14.6, as compared with 14.7 for 1914, and 15.0
for 1913. In New York City, with an estimated
population on July 1, 1915, of 5,468,190, the death
rate for the year was 13.9, as compared with 14.1
in 1914, 14.3 in 1913, and 19.0 as the average for
the five year period from 1901 to 1905.
American Ambulance Service Extended. — The
American Ambulance Field Service announced
recently from Paris that there would shortly be
formed a section of ambulances to serve with the
French Army in the Balkans. The section will in-
clude thirty ambulances of the latest model, repair
cars, a kitchen car, tents, and other accessories. As
American volunteers have already served on the
Yser, Aisne, and Somme, in Champagne, at Verdun,
in Lorraine, and in the reconquered parts of Alsace,
the establishment of a Salonica section extends the
service to include almost all of the great campaigns
of the French Army.
Gifts of Ambulances to Russia. — A motor ambu-
lance, the gift of American and English women resi-
dent in Petrograd, was formally presented to the
Russian Red Cross in that city on September 20,
On September 24, fifteen motor ambulances of the
field hospital presented by a group of Americans
were formally accepted by the Empress of Russia.
The presentation was made by Capt. Philip Lydig
and Dr. Philip Newton. The new cars will be known
as "The American Ambulance of Her Imperial
Highness Grand Duchess Tatiana Nicolaieva."
They will be sent to the front under command of
Dr. Newton.
Austria to Admit Red Cross. — Austria-Hun-
gary, it is announced from Washington, has decided
to grant permission for the reestablishment of
American Red Cross units in the dual monarchy.
The units were withdrawn a few months ago be-
cause of lack of funds. It is probable that Ger-
many will take similar action. The Allies have
agreed to pass the units and their supplies through
the blockade. It is estimated that each unit of four
surgeons and eight nurses will cost $40,000 for six
months, and the number sent will depend upon the
amount of money available.
Memorial to Dr. Murphy. — Plans are under foot
for the erection in Chicago of a memorial to the
late Dr. John B. Murphy. It is probable that the
memorial will take the form of an institution for
surgical research, and it is hoped that at least half
a million dollars can be raised for the purpose.
A Memorial Hospital. — In memory of his
brother, Herbert Barber, Mr. James Barber of New
York is erecting the main building of the Broad
Street Hospital, at Broad and South streets, New
York, and will furnish the equipment also. The
institution will serve the district south of Fulton
Street which has not heretofore had a general
emergency hospital.
Gifts to Charities. — The Hospital for Deformi-
ties and Joint Diseases, New York, has received
from Mr. Herbert Kaufman of Pittsburgh, through
Dr. H. D. Frauenthal, a gift of one million dollars,
to be used for the erection of a new building and
as an endowment fund.
By the will of the late Theresa Scott of Phila-
delphia, the sum of $5,000 is bequeathed to St.
Christopher's Hospital of that city for the endow-
ment of a free bed.
In the distribution of the estate of the late Mr.
Eugene I. Sauter of Philadelphia, awards are made
as follows : St. Christopher's Hospital and Dis-
pensary for Children, $2,500; Children's Seashore
Home, Atlantic City, $2,500; Presbyterian Hos-
pital, Philadelphia, $5,000; Rush Hospital for Con-
sumptives, Philadelphia, $5,000.
The Flushing Hospital, New York, receives by
the will of the late Mr. S. Vernon Mann of New
York a sum sufficient for the endowment of a free
bed.
Police and Fire Surgeons. — The New York
Municipal Civil Service Commission will shortly
hold an examination, applications for which must
be filed before October 6, for the purpose of filling
vacancies in the position of surgeon in the New
York Police and Fire Departments, at a salary of
$3,500 per annum for part time service. The
duties of the twenty surgeons of the Police De-
partment and of the ten surgeons of the Fire De-
partment consist of examining all successful can-
didates for the services prior to their final accept-
ance, caring for all members during sickness and
disability, and recommending for retirement those
unfit for duty or beyond the age limit. In addi-
tion, the Fire Department surgeons maintain one
active clinic where the members of the department
receive treatment and medicine free of charge.
Surgeons have the rank of battalion chief in the
Fire Department and of Inspector in the Police
Department and are eligible for retirement at half
pay after twenty years of service. Applicants for
the examination must be citizens of New York State
and between the ages of twenty-six and forty years,
and have had five years' experience. Further de-
tails may be obtained by application to the Munic-
ipal Civil Service Commission, New York.
Personals. — Dr. L. D. Bristol, for the past two
years director of the State Public Health Labora-
tories at the University of North Dakota and pro-
fessor of bacteriology and hygiene, has accepted the
newly created Boston Dispensary Fellowship in
Public Health in the Department of Preventive
Medicine in the Medical School of Harvard Uni-
versity, Boston.
Mr. Barnett Cohen has resigned his position as
laboratory assistant in the Health Department of
Savannah, Ga., to become research assistant in pub-
lic health in Yale University.
598
MEDICAL RECORD.
[Sept. 30, 1916
Medical Societies Combine Meeting. — The 152d
semi-annual meeting of the Litchfield County Med-
ical Association will be held in conjunction with the
ninth semi-annual meeting of the Connecticut State
Medical Society at the Charlotte Hungerford Hos-
pital, Torrington, on Tuesday, October 3. Guests
will be given an opportunity to inspect the new
hospital between eleven and twelve o'clock, and ad-
dresses will be made by Dr. D. D. Reidy, president
of the County association, and by Dr. Samuel M.
Garlick, president of the State society. Dr. Joseph
I. Linde of New Haven will give the results of ob-
servations on cases of infantile paralysis in New
Haven, and Dr. Herbert K. Thorns of New Haven
will speak on postpartum hemorrhage.
Medical Society of the State of Pennsylvania. —
At the annual meeting of this society held in Scran-
ton on September 19 and 20, the following officers
were elected for the ensuing year: President, Dr.
Samuel G. Dixon, Philadelphia; 1st Vice-President,
Dr. John B. Corser, Scranton ;2nd Vice-President,
Dr. Joseph W. Albright, Muncy ; Crd Vice-President,
Dr. George H. Boyer, Allentown; Dth Vice-Presi-
dent, Dr. John 0. Wagner, Beaver Springs; Secre-
te r a, Dr. Cyrus Lee Stevens, Athens; Assistant
Secretary, Dr. Clarence P. Franklin, Philadelphia;
Treasurer, Dr. George W. Wagoner, Johnstown. The
next annual meeting will be held at Pittsburgh.
Southwestern Texas Medical Society. — The
annual meeting was held at Laredo on September
13 and 14, the following officers being elected:
President, Dr. Robert Lee Graham, Cotulla; Vice-
president, Dr. Homer T. Wilson, San Antonio;
Secretary-Treasurer, Dr. Louis J. Manhoff, Aransas
Pass.
Obituary Notes. — Dr. Louis C. Ford of Milo, Me.,
a graduate of the Medical School of Maine, Port-
land, in 1877, and a member of the Maine Medical
Association and the Piscataquis County Medical
Society, died at his home on September 11.
Dr. James H. Shannon of Saco, Me., a graduate
of the Jefferson Medical College of Philadelphia in
1884, and a member of the Maine Medical Associ-
ation and the York County Medical Society, died
suddenly at his some on September 13, aged 74
years. Dr. Shannon was a veteran of the Civil War.
Dr. William Henry Yeager died at Philadelphia
on August 4 at the age of 44 years. He was grad-
uated from Hahnemann Medical College of Phila-
delphia in the class of 1900, and was an associate
professor of therapeutics and clinical medicine in
his alma mater.
Dr. Leo Dinkelspiel of New Rochelle, N. Y., a
graduate of Columbia University, College of Physi-
cians and Surgeons, New York, in 1883, and a mem-
ber of the American Medical Association and the
New York State and County Medical Societies, died
at his home on September 12.
Dr. Daniel Hennessy of Bangor, Me., a grad-
uate of the Geneva Medical College, Geneva, N. Y.,
in 1866, and a member of the American Medical As-
iation, the Maine Medical Association, and the
Penobscot County Medical Society, died on Septem-
ber 10, aged 79 years.
Dr. Elisha Dyer Leffingwkli, of Oswego. X. Y.,
a graduate of the Bellevue Hospital Medical College,'
New York, in 1877, died at his home on September
12, aged 67 years.
Dr. Frances Merriam MYERS of Mount Vernon,
X. Y„ a graduate of the Woman's Medical College of
Ihe Xew York Infirmary for Women and Children,
New York, in 1892, and a member of the Medical
Society of the State of New York, the Mount Vernon
Medical Society and the Westchester County Medical
Society, died at her home on September 14, aged 46
years.
Dr. Reuben Willis of Somerville, Mass., a gradu-
ate of the Medical School of Harvard University in
1867, and a member of the Massachusetts Medical
Society and the Middlesex South District Medical
Society, died at the Robert Brigham Hospital, Bos-
ton, on September 6, aged 74 years.
Dr. George C. Parker of Winthrop, Me., a gradu-
ate of Dartmouth Medical School, Hanover, N. H.,
in 1881, and a member of the Maine Medical Asso-
ciation and the Kennebec County Medical Society,
died at his home on September 8, after a short ill-
ness, aged 65 years.
Dr. George H. Turner, Jr., until recently of Port-
land, Me., a graduate of the Medical School of
Maine, Portland, in 1903, and a member of the
American Medical Association, the Maine Medical
Association, and the Cumberland County Medical So-
ciety, died suddenly from acute indigestion, on Sep-
tember 9, aged 38 years.
Dr. William P. Pariseau of Ware, Mass., a grad-
uate of Laval University, Faculty of Medicine, Que-
bec, in 1904, died in Hampton Hospital, Springfield,
on September 1, after a short illness, aged 37 years.
Dr. Philip P. Carlon of New York, a graduate
of New York University Medical College in 1890,
died in St. Mary's Home, West Hartford, Conn., on
August 31, after a long illness, aged 54 years.
Dr. Martin Giesy of Aurora, Oregon, a graduate
of Willamette University, Medical Department,
Salem, in 1868, died recently at his home, aged 83
years.
Dr. John N. Preston of Pawtucket, R. I., a vete-
ran of the Civil War, died at his home on September
8, after a long illness, aged 69 years.
Dr. Edward A. Schmitz of Wauwatosa, Wis., a
graduate of the University of Illinois, College of
Medicine, Chicago, in 1884, surgeon of Milwaukee
County and city health commissioner of Wauwatosa,
died at his home on August 30, aged 56 years.
Dr. Azaire M. J. Provost of Berlin, N. H., a
graduate of the Dartmouth Medical School, Han-
over, in 1898. and a member of the American Medi-
cal Association, the New Hampshire Medical So-
ciety, and the Coos County Medical Society, died
at his home, from pneumonia, after a short illness,
on September 10, aged 46 years.
Dr. William G. Brede of Minneapolis, Minn., a
graduate of the University of Minnesota Medical
School, Minneapolis, in 1906, and a member of the
Minnesota State Medical Association and the Henne-
pin County Medical Society, died at his home from
septic pneumonia, after a short illness, on Septem-
ber 5, aged 40 years.
Dr. Samuel Moore Reynolds of New York, a
graduate of the Berkshire Medical College, Pitts-
field, Mass., died suddenly at St. Luke's Hospital,
New York, on September 7, aged 74 years.
Dr. Marcus Francis Brown of Billings. Mont.,
a graduate of the University of Illinois, College
of Medicine. Chicago, in 1908, and a member of
the Montana State Medical Association and the
Yellowstone Valley Medical Society, died at his
home, from acute dilatation of the heart, on Au-
gust 28. aged 35 years.
Dr. Howard S. Justice of Hutchinson, Kan., a
graduate of the College of Physicians and Sur-
geons. Keokuk. Iowa, in 1865, and a member of
the Kansas Medical Society and the Reno County
Sept. 30, 1916J
MEDICAL RECORD.
599
Medical Society, died at his home, after a long
illness, on August 24, aged 80 years.
Dr. Edward Louis Duer, formerly of Phila-
delphia, a graduate of the University of Pennsyl-
vania, Department of Medicine, in 1860, and a
member of the American Medical Association, the
Medical Society of the State of Pennsylvania, the
Montgomery County Medical Society, the Phila-
delphia Obstetrical Society, and the Philadelphia
Pathological Society, died at his home in Odessa,
Del., on September 6, aged 80 years.
Dr. Henri Iskowitz of New York City, a gradu-
ate of Columbia University, College of Physicians
and Surgeons, New York, in 1905, died at his
home on September 8, aged 31 years.
Dr. Enoch T. Jones of Hampton, Ark., a gradu-
ate of the Memphis Hospital Medical College, Mem-
phis, in 1901, died recently at his home, aged 49
years.
Dr. Aaron J. King of Atlanta, Ga., a graduate
of the Southern Medical College, Atlanta, died in
a private hospital on September 8, aged 68 years.
Dr. L. L. Crump of West Point, Miss., died on
September 5 from injuries received from a fall from
his horse.
Dr. Albert James Mackay of Peacham, Vt, a
graduate of the University of Vermont, College of
Medicine, Burlington, in 1897, and a member of
the American Medical Association, the Vermont
State Medical Society, and the Caledonia County
Medical Society, died on September 11, following an
operation for appendicitis, aged 50 years.
Dr. William Henderson Mayfield of St. Louis,
Mo., a graduate of Washington University Medical
School, St. Louis, in 1883, died in the Mayfield
Memorial Hospital on September 17, after a short
illness, aged 64 years.
Dr. William L. Rogers of Atlanta, Ga., a gradu-
ate of the University of Georgia, Medical Depart-
ment, Augusta, in 1879, died at his home on Sep-
tember 15, aged 63 years.
Dr. John W. Estes of Georgetown, Ky., a gradu-
ate of the Cincinnati College of Medicine and Sur-
gery, Cincinnati, Ohio, in 1890, died suddenly on
September 12, aged 68 years.
Dr. Adam W. Hubschmitt of New York, a gradu-
ate of Columbia University, College of Physicians
and Surgeons, New York, in 1900, and a member of
the Alumni Association of the New York Hospital,
died on September 20.
Dr. Patrick Francis Hogan of Brooklyn, N. Y.,
a graduate of the University of Michigan Medical
School, Ann Arbor, in 1872, died at his home on
September 16, aged 65 years.
Dr. Josiah Herbert Keenan of Elizabeth, N. J.,
a graduate of New York University Medical Col-
lege in 1895, died suddenly at his home on Sep-
tember 18.
Dr. Floyd Lee Van Wert of New Castle, Pa.,
32 years old, was killed in an automobile accident
on September 18. He was graduated from the
medical department of the University of Pennsyl-
vania in the class of 1910.
Dr. Thomas B. O'Reilly died at Philadelphia on
September 18 at the age of 47 years. He was grad-
uated from the Medico-Chirurgical of Philadelphia
in the class of 1893, and then served a term as in-
terne in the Philadelphia General Hospital.
Dr. Alexander Williams Biddle of Philadelphia
died at Isleboro, Me., on September 19, at the age
of 65 years. He was graduated from Jefferson
Medical College in the class of 1879.
NITROUS OXIDE-OXYGEN ANESTHESIA.
To the Editor of the Medical Record:
Sir: — In correction of Dr. Baldwin's statement
in your issue of July 29, regarding deaths under
nitrous oxide-oxygen anesthesia in this hospital,
we beg to make the following references from the
records of the hospital: During his short interne
service in the hospital, Dr. McCormick never gave
a gas anesthetic alone, although our anesthetizer
attempted to teach him its administration and was
always present throughout the entire anesthesia.
No patient died in the hospital directly or indirectly
as a result of nitrous oxide-oxygen anesthetic or
under other anesthetic during his stay. During
the past five years several thousand gas anesthetics
have been administered in this hospital, 99 per cent,
of which were given by a woman physician who
has specialized in the administration of anesthetics
for seven years. Instead of "seven or eight deaths"
during nitrous oxide-oxygen anesthesia, as stated
in Dr. Baldwin's article, we have never, until a
few months ago, had a death that could be in any
way, directly or indirectly, attributed thereto.
About five months prior to this date, one death oc-
curred during nitrous oxide-oxygen anesthesia in
a patient who submitted to an operation as a last
resort and was physically incapacitated from taking
ether. The records of this hospital are open to Dr.
Baldwin or to any interested physician or surgeon
who cares to investigate any medical or surgical
condition or make scientific inquiry in reference to
our work.
W. L. Babcock, M.D.,
Superintendent, The Grace Hospital.
Detroit. Mich., Sept. 20, 1916.
OUR LONDON LETTER.
(From Our Regular Correspondent.)
LOCAL GOVERNMENT BOARD — PROPOSED SCHEME AS TO
VENEREAL DISEASES — DISTRIBUTION OF SALVARSAN
— QUALIFICATION OF PRACTITIONERS DISTRIBUTING
— MORTALITY OF MEDICAL OFFICERS — OBITUARY.
London, September 1, 1916.
The Local Government Board has had the City
Corporation and the County and Borough Councils
addressed in regard to venereal diseases. A scheme
embodied in a circular has been approved by the
profession who will cordially cooperate with the
government department. It is suggested that it
would be a great advantage if committees of local
authorities invited the medical men in their sev-
eral localities to nominate representatives to attend
all meetings at which schemes may be discussed and
to assist with their special knowledge of the needs
of their particular areas. One of these representa-
tives should in the usual way also represent the
medical staffs of the hospitals and another the
general practitioners in each administrative area.
Mr. Long is anxious that each scheme shall meet
the local needs in the fullest possible way and thinks
the plan likely to secure the cooperation of the
profession.
Questions have been raised as to the safeguards
which ought to be taken in the distribution of sal-
varsan or its substitutes. The Local Board intends
to supply those drugs for the purpose of intraven-
ous administration to patients free to practitioners
who produce satisfactory evidence of training or
experience in their use. It is not thought desirable
600
MEDICAL RECORD.
LSept. 30, 191G
to lay down hard and fast lines, but it is considered
that as a general rule the drugs might properly be
distributed by the medical officer of health or his
agent, who should be required to satisfy himself
before issuing a supply that the applicant is a reg-
istered practitioner who possesses one of these
qualifications: (a) holds a certificate of having sat-
isfactorily fulfilled the duties of clinical assistant
in a hospital department recognized by the L.G.B.
in connection with the scheme of the local authority,
to) holds a certificate of attendance at a course of
instruction in the diagnosis and treatment of these
diseases in their communicable stages, including
intravenous medication, this to be in a recognized
medical school or post-graduate college; (c) is or
has been within the last five years a member of the
permanent staff of a hospital of not less than fifty
beds ; ( d) has had, in addition to the preceding
adequate experience in intravenous medication.
The mortality of German medical officers in the
present war has been heavy. Up to the middle of
January the deaths are reported to have been 56.
There were, in addition, 216 wounded, 40 made pris-
oners, and 94 are missing, while 29 have died of
disease or wounds, 5 from accidents, and 2 are sick.
These figures have been published as out of a total
number of 12.000 serving with the army, but not in-
cluding those in military hospitals, besides a further
10,000 in reserve hospitals, sanatoria, prisoners'
camps, and ambulances. As Germany has about
32,000 medical men, this would leave only about
8,000 available for civil practice.
The death has occurred of Lieut.-Col. George M.
J. Giles of the Indian and Canadian Medical Serv-
ices. He took part in the South African war of
1878-9 and received the medal with clasps. When
the present war broke out he was living at Kingston,
Ontario, and joined the Canadian Army Medical
Service. Returning to England he became medical
officer to Burcote Hospital, but retired in March
last on account of ill-health. He was author of
"Climate and Health in Hot Countries" and one of
the editors of the Journal of Tropical Medicine.
OUR LETTER FROM ALASKA.
(From Our Special Correspondent.)
UNUSUAL INTOXICATING BEVERAGES USED IN ALASKA.
St. 'Michael, Alaska. Aug. 24. 1916.
It is probably not known how long the human race
has been addicted to alcoholism, but the first paper
on the subject was written in 1789 by John Coakley
Lettsom, one of the original founders of the Med-
ical Society of London. With the advancement of
science many new intoxicating beverages have come
into use. .Many other liquids containing from a
fraction of 1 per cent, to 50 per cent, or more of
alcohol are used as intoxicating beverages, although
they are not put on the market for that purpose.
The Territory of Alaska is not "dry," but the
sparsely settled country with limited and slow trans-
portation has invited many persons who long for the
physiological effects of alcohol and cannot obtain it
in the usual beverage form, to attempt to manufac-
ture or to use some other liquid which contains
alcohol. It is not uncommon in some places in
Alaska where there are no saloons to see a man go
into a trading post or general merchandise store
and say that he wants something to drink and ask,
"What have you that contains the largest per
cent?" "How much has this?" "How much has
that?" meaning the percentage of alcohol and point-
ing to some medicine, perfume, toilet water, flavor-
ing extracts, etc., on the shelf. There are many
persons in Alaska, both white and native, who re-
sort to various means of securing alcoholic intoxi-
cants. The most common of these unusual alcoholic
drinks in places which are in touch with civilization
are the flavoring extracts. I mean by places that
are in touch with civilization, a place that has a
store or a trading post. In towns that are large
enough to have a saloon, the saloons are patronized.
It appears not to make any difference whether the
extract be lemon, ginger, vanilla, pineapple, or what.
It is sometimes drunk straight and at times mixed
with cider, grape juice, milk, "sourdough," root-
beer, or hot water. Sugar may or may not be
added. Most of these extracts contain about 80 per
cent, alcohol and their consumption in Alaska as a
beverage has become so great that it is now a
violation of the law to sell them to a native or to
any one for drinking purposes. It w7ould be inter-
esting, indeed, to know- just how much of these ex-
tracts is consumed in Alaska annually for drinking
purposes, but it must be a large quantity, as every
one seems to know of them and talk about them as
intoxicating drinks. Through this port alone the
amount of extracts shipped appears all out of pro-
portion for their use for flavoring purposes consid-
ering the population.
In places that are not in touch with civilization,
especially native villages, "sourdough" is the favor-
ite intoxicating drink. This is sometimes called
"hootch" or "hootchinoo." The latter term is
thought to have originated in Kamchatka, across
Bering Sea, in Russia, from whence the art of mak-
ing sourdough probably spread to Alaska. The
term "hootch" is a slang expression and is at times
used to designate any intoxicating liquor, while
hootchinoo is more properly distilled sourdough.
Sourdough is made by mixing a very thin dough
of flour and water, adding yeast, and setting
aside to ferment. This fermentation is facilitated
by placing the vessel in warm water or in a warm
place. As the fermentation takes place, the liquid
turns an amber color and large flakes of starch float
to the top, later to settle to the bottom leaving a
clear colored liquid on top. Rice and barley are
sometimes used instead of flour, and it has been
said that the addition of molasses to the fermenting
mass makes a stronger preparation. The entire
mass has a sour smell, hence the name sourdough.
Alcohol is formed during this fermentation and
after it has reached the required percentage, the
liquid is strained. Some persons drink the liquid
just as it is strained off, and this is the usual way.
Sometimes the liquid is distilled, giving it a better
smell and taste and making it clearer and more
concentrated. As this method requires some ap-
paratus, time, and experience, it is the uncommon
form. This liquid appears to be much more intoxi-
cating than beer and the laws of Alaska prohibit its
manufacture. The writer has seen persons so in-
toxicated from its use as to threaten the lives of
others and require confinement. A "sourdough
fiend" told the writer a few days ago that the addi-
tion of a teaspoonful of wood ashes to a pint of
sourdough very materially increased its intoxicat-
ing qualities.
Although it requires some apparatus to make
hootchinoo — the distilled sourdough — it is remark-
able what simple apparatus may be used for this
distilling purpose. A common homemade still is
made by taking two coal oil cans and connecting
Sept. 30, 1916]
MEDICAL RECORD.
601
them with a pipe. The pipe enters one and passes
through the other. The sourdough is boiled in the
former and condensed by ice in the latter, the hoot-
chinoo dropping out of the end of the pipe as a
colorless alcoholic liquid. In the absence of a pipe,
gun barrels have been used for this purpose, and it
is believed that there are many houses in Alaska
which have some such apparatus in them.
When the materials can be obtained the follow-
ing is a favorite method of manufacturing hootch:
about a pint of sourdough is mixed with about a
gallon of cider or grape juice and the mixture is left
open for several days in a warm place. This mix-
ture become quite intoxicating. As these liquids
are not consumed for their taste but for their ef-
fects only, a great deal of trouble results in Alaska
from their use. There are special agents for the
suppression of intoxicating liquors among the na-
tives of Alaska and probably no other alcoholic
drink gives these agents as much trouble as sour-
dough. It may be interesting to note that a white
man who spends more than one year in Alaska is
called a "sourdough." The "sourdoughs" say this
is due to the fact that the white men make sour-
dough (yeast) hot cakes, while the natives say it is
because of the early adaptation of the w^hite man's
taste to "the native drink."
JJrogrrBB of Ulriitrai l§>ronr?-
Boston Medical and Surgical Journal.
September 14, 1916.
1. Portraits of Florence Nightingale. Maude E. Seymour
Abbott.
_. The Present Status of Alveolar Osteomyelitis. Leon S.
Medalia.
3. The Use of Emetine. Alfred C. Reed.
4. Peripheral Neuritis Following Emetin Treatment of Ame-
bic Dysentery. A. R. Kilgore.
5. Dystonia Musculorum Deformans. Isadore H. Coriat.
3. The Use of Emetine. — Alfred C. Reed presents the
salient features of the history, pharmacology, toxi-
cology, and use of emetine, and, in summarizing, states
that in so far as emetine has a beneficial action in
tuberculosis, it would seem to be due to its expectorant
properties, and if so, other preparations are preferable.
In so far as emetine has a beneficial action in hemor-
rhage, it would seem to be due to the indirect result
of decreasing the blood pressure, and if so, other drugs
would be more effective, in that they would produce a
similar result more safely and without the specific ac-
tion of emetine on coagulation. Levy and Rountree
make the suggestion which can hardly be taken seri-
ously from the clinical point of view, that emetine
enemata would serve a useful purpose in the treatment
of constipation. Such enemata have an undoubted value
when properly used for the sake of their amebicidal
action, but their use as here suggested does not seem
well advised. Emetine will hardly replace Leonard
Rogers' hypertonic infusion in Asiatic cholera, and few
of its other applications will bear the test of careful
experimentation. Whether emetine alone will cure pyor-
rhea is an open question. It will, without doubt, cure
the amebic infection, and to this end its use hypoder-
mically and locally is indicated. But it cannot be said
that emetine is a specific for pyorrhea, or that pyorrhea
cannot be cured without it. This statement is also ap-
plicable to certain bony and oral abscesses and infec-
tions other than pyorrhea. Emetine has proved service-
able in the treatment of certain other diseases caused
by animal parasites, especially protozoans, but its main
action is on the ameba, for which it is a specific rem-
edy, provided the specific agent is not walled off in an
abscess.
4. Peripheral Neuritis Following Emetine Treatment
of Amebic Dysentery. — A. R. Kilgore reviews the main
by-effects of emetine hydrochloride and reports a num-
ber of cases which serve to call attention to the fre-
quency of the occurrence of peripheral neuritis after
emetine. He finds that peripheral neuritis after emetine
is not uncommon. The symptoms most commonly met
with in post-emetine neuritis are general muscular pain
and weakness, usually most pronounced in the legs,
sometimes going on to paresis. One case is here re-
ported of hyperesthesia of the soles of the feet without
other symptoms. The neuritic symptoms often develop
after the emetine injections have been stopped, and may
grow progressively worse for some time with no more
administration of the drug. The total amount of emetine
necessary to produce neuritis varies greatly. The total
amounts received by the cases of Levy and Roundtree
and of the writer varied from 21.3 grains in an adult to
4 in a child of four years. On the other hand many
patients received larger amounts and had no symptoms.
The prognosis is good. The symptoms clear up grad-
ually, usually over several weeks, leaving no traces
apparent. Experiments now in progress suggest that
peripheral neuritis may be produced by emetine in
healthy dogs.
5. Dystonia Musculorum Deformans — Oppenheim's
New Disease of Children and Young Adults. — Isadcre
H. Coriat reports three cases of a disease described by
Oppenheim in 1911 as occurring in young people of
Russian or Galician Jewish parentage, which he termed
dysbasia lordotica progressiva or dystonia muscu-
lorum deformans. He attempted to separate the dis-
order from the tics, athetoses, and the various muscular
spasmodic states occurring in hysteria. At first the
racial predilection of the condition suggested a com-
parison with amaurotic family idiocy, but more recent
studies have shown that while the disease is pre-
eminent among young Hebrews, yet it is not absolutely
limited to them. The first two cases reported strongly
resembled an hysterical dysbasia, but without any cor-
responding sensory disturbances; in the third case
there was evidence of some organic affection of the
nervous system, as shown by spasticity, gait, bulbar
symptoms, and the variations in muscular tonicity, yet
lacking the usual pathological reflexes of the spastic
groups of diseases. In one case the condition followed
a slight trauma, in another it appeared after a ton-
sillectomy, while in the third, it was engrafted on a
highly neurotic and probably latent hysterical indi-
vidual. The prominent features in all the cases were
the peculiar gait, the changes in the muscular tonicity,
and the rapid onset of the disease without any patho-
logical reflexes or changes in sensation. All reported
cases show that it begins in an extremity. The dis-
order presents certain difficulties in diagnosis because
of its obscure relationship to hysteria, on the one hand,
and to organic diseases of the nervous system on the
other. For this reason it is difficult to place the con-
dition in any definite nosological entity.
New York Medical Journal.
September 16, 1916.
1. Epilepsy. Charles A. L. Reed.
2. Reed's Bacillus of Epilepsy. A. J. Hinkelmann.
3. The Pathogenesis and Treatment of Epilepsy. Henry A.
Cotton, E. P. Corson-White and W. W. Stevenson.
4. Toxic Manifestations of Epilepsy and Their Rational
Treatment. Ralph H. Spangler.
5. Pelvic Infection. A. J. Walscheid.
6. Hemiplegia. William Martin.
7. Secondary Syphilitic Lesions of the Tongue. Constant
Saison.
8. Medicine and Surgery in Modern Warfare. Benjamin
Jablons.
9. Treatment of Bladder and Urethral Papillomata. Geza
Greenberg.
in. An Invariable Blood Stain. B. G. R. Williams.
602
MEDICAL RECORD.
[Sept. 30, 1916
1. Epilepsy. — Charles A. L. Reed reviews the evi-
dence that he has brought forward to show that there
is present in the blood of epileptics an organism not
present in other individuals, that this organism is forced
from the alimentary canal into the circulation by the
anatomical disturbance of mechanical stasis, and that
this sequela has been shown to be present in 100 per
cent, of his cases of epilepsy. If these things are true
the immediately consecutive stages of the pathological
process intervening between absorption and convulsion
become matters of interest. The toxemia of epilepsy is
shown by the constant tendency to a subnormal tem-
perature and by the elimination of various toxic prod-
ucts in the urine. Chronic acidosis, profound, always
obstinate, often almost irreversible, exists in 100 per
cent, of epileptics. It is but natural that acidosis of
this character should be followed by edema especially
marked in organs and structures upon which the pri-
mary infection exercises a selective action. It would
seem that the Bacillus epUepticus exercises its terminal
effects by producing a terminal deinsulating edema of
the conduction paths of the brain, as in purely convul-
sive disturbances; or of both the conduction paths and
the cortex, as with convulsions with psychic explosions.
It seems therefore that if diagnostic studies of epilepsy
are really to be made, it will be necessary to broaden
the usual methods of investigation. Actual examina-
tion of the cases must embrace, first, the blood with
reference to the presence or absence of B. epUepticus,
and for the further purpose of determining the blood
values; next, the careful x-ray examination of the ab-
dominal viscera with reference to determining more
particularly the position of the stomach and intestines
and the transit of ingesta through them; third, the re-
peated analysis of the urine and saliva with reference
more particularly to the existence and degree of acid-
osis. In the light of the evidence in the hands of the
profession it may now be said that any examination of
epileptics that stops short of these features necessarily
stops short of diagnostic accuracy.
2. Reed's Bacillus of Epilepsy. — A. J. Hinkelmann
states that, on the basis of experiments made during the
summer of 1915, and before he had any knowledge of
the pathology of the organism, he found it a frequent
inhabitant of the intestinal tract. The universal pres-
ence of the organism in the intestinal flora is no argu-
ment against its probable pathology, but simply adds
to the importance of the gateway through which it
enters the blood stream, in considering the treatment.
Observations show that the organism is highly hemo-
lytic and to this fact may be due a part of the patho-
logical conditions present in epileptics. Cultures made
on blood agar plates will show a hemolytic spot long
before the colony itself becomes visible. In the opinion
of the author the fact that the organism does enter the
circulation and there multiplies into great numbers,
and is so generally found in the blood of epileptics,
makes the conclusions of Reed as to its specific nature
at least very plausible.
•'!. The Pathogenesis and Treatment of Epilepsy. —
Henry A. Cotton, E. P. Corson-White, and W. W. Stev-
enson present this preliminary report from the Labora-
tory of the New Jersey State Hospital from which they
conclude that: 1. At least one type of epilepsy is prob-
ably a disease process dependent upon absorption of
toxic or poisonous products from the intestinal canal.
2. This stasis may be produced by an overaction of the
suprarenal gland. 3. Hyperactivity of the adrenal
gland may be caused by, a, dysfunction of pituitary,
b, dysfunction of pancreas, c, irritation of duodenum,
d, severe fright or emotional disturbance. 4. Treat-
ment by administration of pancreatin should be em-
ployed in preference to surgical procedures. 5. Surgi-
cal procedures should be employed in long standing
cases where other treatment fails.
4. Toxic Manifestations of Epilepsy and Their Ra-
tional Treatment. — Ralph H. Spangler records his
clinical observations and the results of various blood
tests made in over 300 cases of epilepsy. He concludes
that in many of the so-called idiopathic cases of epi-
lepsy, the attacks are caused by a toxin carried in the
blood. The accumulation of this toxin in an epileptic
will cause an attack, associated with general leu-
cocytosis, but not an eosinophilia. The blood of an
epileptic injected into an animal causes a general leu-
cocytosis with a marked eosinophilia. A patient af-
flicted with epilepsy in most instances does not produce,
or has lost the power to produce, an eosinophilia; the
toxin is not antagonized and an attack occurs, that is,
in a patient afflicted with epilepsy the toxin is nega-
tively chemotaxic for eosinophile cells. The clotting
time of the blood is shortened before an epileptic seiz-
ure. The range of clotting time of the blood in 85 per
cent, of the cases in a series of 100 patients was shorter
during interparoxysmal period (1.5 to 4.5 minutes)
than it is in normal subjects (three to eight minutes
as given by most investigators). The alkalinity of the
blood is lower in cases of epilepsy than in control, non-
epileptic subjects, on the same diet. The hypodermic
injection of crotalin in properly regulated doses has
produced moderate degrees of eosinophilia, has length-
ened the clotting time, and increased the alkalinity of
the blood in certain epileptic patients, thus greatly
modifying the character of the seizures and in some
cases holding the attack in abeyance indefinitely.
10. An Invariable Blood Stain.— B. G. R. Williams
recommends the following method of blood staining be-
cause the technique is simple, rapidly completed, gives
results which are invariable and sufficient for diagnostic
purposes, and it is practically impossible to overstain
with it. The hematoxylin used is the Ehrlich formula:
Mix:
Hematoxylin 2
Glacial acetic acid 10
Glycerin 100
Absolute alcohol 100
Distilled water 100
Potassium alum (an excess).
The invariable stain is made by adding to this filtrate
0.1 gram of water soluble eosin. This stain is not self
fixing; the author uses the alcohol flash method of
fixation, though he says it is possible that other good
methods may answer. The picture is that given by
any hematoxylin and eosin methods. By this stain it
is easy to diagnosticate the various anemias, leucemias,
eosinophilias, etc. Differential counting is much more
satisfactory than with Wright's because of the excellent
nuclear staining.
Journal of the American Medical Association.
x. pti ,i,h. i- 16, 1916.
1. The Trcvalence of Chronic Mouth Infections and Their
Management Frederick B. Moorehead.
i'. The Principles involved in Focal infection :is Related to
Systemic I >1 Frank Bin
3. Dental Infections ami Systemic Disease: Treatment and
Results. Ernest E. Irons.
4. Methods and Results in Gastric Surgery. George W.
5. A Roentgenological Study of the Gastro-Intestlnal Tract
in Diabetes : A Report on Seventy-two Ca-ses. James
T. < '
•'.. Direct anil Indirect Hay-Fever: Preliminary Report of
tli- Research Department of the Amen lever
Prevention Association on the Etiology of Hay-Fever.
\v. Scheppegrel.
7. Brachial Plexus Surgery. Arthur Aver Law.
S. The Interest amunity in Cancer. Louis I.
Dublin.
9. Hemoglobinuric Fever Treated by Infusions of Quinin.
William O. Ott
10. Dont's to be Emphasized in the Management of Hyper-
tensive Cardio-vascular Disease. Henry Farnum Stoll.
Sept. 30, 1916]
MEDICAL RECORD.
603
1. The Prevalence of Chronic Mouth Infections and
Their Management. — Frederick B. Moorehead has exam-
ined the histories of 718 cases, including 498 cases of
chronic arthritis, 70 cases of chronic infections not joint
lesions, and 150 private office cases referred for mouth
examination because of some systemic disease, with
the object of determining the incidence of chronic mouth
infections. In the first group 89 per cent, had alveolar
abscess; in the second group 74 per cent., and in the
third group 69 per cent. The overwhelming majority
of chronic abscesses were associated with previously
treated root canals, a fact which serves to emphasize
the importance of root canal technique. The essayist
concludes that both in diagnosis and in determining the
extent of tissue lost, the Roentgen ray is of paramount
value. The involvement of the peridental membrane is
the crux in deciding between conservative and radical
treatment. Faulty root-canal technique, the careless use
of arsenic as a devitalizing agent, and irritating drugs
in the treatment of root canals are strong predisposing
factors of chronic alveolar abscess. In carefully selected
cases, conservative measures should be employed both
in the treatment of chronic abscess and chronic sup-
purative pericementitis. Where root canals have been
disinfected and filled, portions of roots resected, etc.,
the process of repair should be checked up by roentgen-
ograms made at frequent intervals. Regardless of
whatever form of treatment may be employed, the re-
moval of infection is imperative in all cases, whether
the patient at the time may be well or ill.
2. The Principles Involved in Focal Infection as Re-
lated to Systemic Disease. — Frank Billings discusses
the principles of infection under the following three
headings: 1. The pathogenic microorganisms and the
conditions which modify their virulence and pathogenic-
ity. 2. The host, or infected individual, and the con-
ditions which modify his susceptibility to infection.
3. The nature and result of the reactions between the
infectious agents and the tissues of the host. He con-
cludes that the laws which govern the perpetuation
of the pathogenic microorganisms involve a life of
parasitism harmless to the host or of varying degrees
of pathogenicity. Apparently any specific type of bac-
teria which causes focal infection may attain the bio-
chemic qualities which permit them to live in the host
as harmless parasites or as injurious agents possessed
of a special or general pathogenicity of varying viru-
lence. The varying pathogenic qualities, special and
general, may be acquired apparently in the host or in
the passage from host to host (man or animal), or may
be brought about in culture mediums. Confined infec-
tion (focal) seems to be a site in which infectious
agents may attain specific pathogenicity, chiefly in
the nature of tissue tropism (elective tissue affinity).
This special quality is oot recognized necessarily by
cultural characteristics. The power to hemolyze or to
produce green color in agar blood plates by some mem-
bers of the streptococcus group does not necessarily
indicate that specific pathogenicity or degree of viru-
lence. The special or general pathogenicity of the in-
fectious agents of focal infection, and the suscepti-
bility of the host, measured by many factors, such as
age, environment, social condition, occupation, habits,
domiciliary and occupational environment, climate,
physical well-being, etc., may determine the severity,
acute or chronic, the extent, local or general, and the
site, election of tissue, of the systemic infection. The
writer believes that these conclusions are sustained by
clinical observations and bacteriological research.
4. Methods and Results in Gastric Surgery. — George
W. Crile. (See Medical Record, June 17, 1916, page
1111.)
5. A Roentgenological Study of the Gastrointestinal
Tract in Diabetes: A Report on Seventy-two Cases. —
James T. Case, in this series of 72 diabetics, found gall-
stones in six eases, or 8 per cent., and in eight more
cases there were very suspicious shadows, some of
which were proved to be gallstones at subsequent opera-
tion. Evidence of gallbladder region adhesions existed
in 26 of these cases and there was a correspondingly
large percentage of cases of transverse stomachs. The
findings in relation to the motor function of the stom-
ach agree very well with the clinical studies of various
investigators. Duodenal stasis was a rare finding in
this series of cases, being observed only once. An in-
crease in the dimensions of the duodenum, either In
length or caliber, was not observed. There was a strik-
ing relation between the severity of the disease and
the degree of ileac stasis. Ileocecal valve incompetency
is a common finding in diabetics, but in this series
there seemed to be no relationship between the degree
of ileocecal valve incompetency and the severity of the
disease. Adhesions of the terminal ileum, stasis in the
cecum, and evidences of appendical diseases, were
somewhat more frequent in the severe cases than in the
mild cases in this series. The average emptying time
of the colon was delayed in about the same proportion
of cases as one would expect from a perusal of the clin-
ical histories. A majority of the patients showed a
low grade of colonic stasis. Extreme colonic stasis was
found in only two cases, and both of these showed
carcinoma of the distal colon.
6. Direct and Indirect Hay-Fever: Preliminary Re-
port of the American Hay-Fever Prevention Association
on the Etiology of Hay-Fever. — W. Scheppegrell states
that their investigations show that there are two forms
of pollen causing hay-fever; the first, spiculated in
form and low in protein, causing direct hay-fever; the
second, unspiculated in form and high in protein, caus-
ing hay-fever by absorption of the protein (indirect
hay-fever). In direct hay-fever, the severity of the at-
tack and its duration depend on the number of pollen
grains in the atmosphere, and the length of the pollen
spicules. The rag-weeds form the type and principal
cause of this form of hay-fever. In indirect hay-fever,
the severity of the attack and its duration depend upon
the amount of protein contained in the pollen and on
the number in the atmosphere. The grass pollens have
the highest percentage of protein and form the type and
principal cause of this form of hay-fever. Pollens with-
out spicules and with an inappreciable amount of pro-
tein are innocuous in hay-fever.
7. Brachial Plexus Surgery. — Arthur Ayer Law.
(See Medical Record, July 1, 1916, page 35.)
8. The Interest of the Community in Cancer. — Louis
I. Dublin. (See Medical Record, September 16, 1916,
page 525.)
10. Don'ts to Be Emphasized in the Management of
Hypertensive Cardiovascular Disease. — Henry Farnum
Stoll formulates the following list of "dont's": 1. Don't
tell the patient with moderate hypertension, few symp-
toms and whose kidneys are functioning well to stop
eating meat, or go on a milk diet. 2. Don't tell him to
give up his business immediately; try to readjust his
life so that unnecessary cardiovascular strain is reduced
to a minimum. 3. Don't tell him his kidneys are "all
right," just because his urine exhibits neither albumin
nor casts. 4. Don't miss the significance of nocturnal
polyuria and a persistently low gravity. 5. Don't give
nitroglycerin tablets to your patient the moment you
discover that he has hypertension. Perhaps he requires
a high pressure to get the blood through his small in-
elastic vessels. 6. Don't be satisfied with the systolic
pressure — the diastolic is often of more significance. 7.
604
MEDICAL RECORD.
[Sept. 30, 1916
Don't attribute the insomnia, nervousness and head-
aches in the middle aged woman to "the change" — take
her blood pressure and examine her eye grounds. 8.
Don't make a diagnosis of neurasthenia till after a blood
pressure estimation and a Wassermann test. It may
save subsequent embarrassment and even be of ad-
vantage to the patient. 9. Don't think you are doing
your whole duty to your pregnant patient when you
have examined her urine. She may have hypertension
but no albumin today and eclampsia next week. 10.
Don't consider hypertension solely a condition of middle
life; it is occasionally present in childhood. 11. Don't
forget the old man's enlarged prostrate. It may be
the cause of the nephritic syndrome. 12. Don't hesitate
to give digitalis when symptoms of cardiac failure are
evident. It will not raise the blood pressure. 13. Don't
wait until the patient is water logged and the heart
dilated before suspecting a failing myocardium. 14.
Don't deny your sleepless, gasping patient, whose
course is nearly run, the relief that only morphine will
give. 15. Don't make a prognosis solely on the blood
pressure or phenolsulphonephthalein test. Each tells
but part of the story. 16. Don't overlook the fact that
cardiovascular disease is to a certain degree a familial
condition sometimes present in several generations;
nor neglect to explain the importance of a yearly blood
pressure estimation of all members of the family. 17.
Don't exclude syphilis, especially a parental infection,
as the cause of hypertension solely because the Was-
sermann is negative. Study the family history; exam-
ine the brothers and sisters, and your patient's children
for signs of hereditary syphilis. 18. Don't fancy that
the management of hypertension consists in watching a
column of mercury or that success is measured in
millimeters.
British Medical Journal.
August 2'':. L ^ 16.
1- A I .'. ii Wound. Lionel F. West, with Note bv
Arthur Keith.
L'. On the Suit Pack Treatment of Infected Gunshot Wounds
J i: H, Roberts and R. S. S. Statham.
A Ilea for Ignoring "Laudable Pus" in the Treatment of
Septic Wounds. M. Donaldson, E. Alment and \ J
Wright
I. Secondary Infection of Joints in Acute Medical Ailments.
I I. H. Edington.
•V D.-ath under Nitrous Oxide Oxygen and Spinal Anesthesia
\\ illiam E. Robinson.
6. Treatment of Wounds by Nascent Ozone. John Jeffrev
• . A Case of Abdominal or Bilocular Hydrocele. F O
i .:: sbrey.
2. On the Salt Pack Treatment of Infected Gunshot
Wounds.— J. E. H. Roberts and R. S. S. Statham state
that the method of dressing wounds with a firm pack
of gauze and sodium chloride tablets, devised by Col.
H. M. W. Gray, combined with a primary free excision
of the wound and lacerated and infected tissues, has in
their hands given results which have effected revolu-
tionary changes in their methods of treatment. During
the last twelve months it has gradually supplanted
other methods of treatment until now it is employed in
the majority of cases. They have found that wounds
dressed in this way became clean at least as speedily
as those treated by other methods and that the gen-
eral condition of the patients improved owing to the
undisturbed sleep, increase of appetite, and absence of
mental apprehension of frequent painful dressings. In
all cases side tracks and pockets are opened up so that
they can be packed to the bottom. Where a fracture
exists, fragments, unless they are small and completely
detached, are not removed. These proceedings are not
really so heroic as they at first sight appear, since
most of the muscle excised has been infected and that
not infected has lost its striation and contains hem-
orrhagic areas for a considerable distance around a
gunshot wound. Such muscle will not regain its func-
tion and will ultimately be replaced by fibrous tissue.
With the exception of iodine for the skin no antiseptic
is applied to the wound. The salt pack is applied in
the following manner: A piece of plain gauze, six to
eight layers thick, is lightly wrung out of 5 per cent,
salt solution and carefully laid in the wound so that
it is in contact with the whole of the surface. No spaces
should be left, as they rapidly fill up with pus. A few
40-grain tablets of salt are placed in the deepest re-
cesses of the wound. The interior of the gauze-lined
wound is then firmly packed with a roll or long strip
of gauze moistened in the same way. The strip is
carried alternately from one end of the wound to the
other and numerous tablets of salt are laid between the
successive layers. When the pack becomes flush with
the surface a few more layers are applied and over that
a thick wool dressing. Really firm pressure is used in
applying both the pack and the bandage. In an ordi-
nary fairly severe wound the pack is left undisturbed
for five or six days, when the wound is redressed, usu-
ally under an anesthetic. The indications that the
wound is not doing well and the pack should be changed
are a continuously rising pulse rate, increasing edema
of the limb, sudden onset of severe pain, persistent rise
of temperature, a change for the worse in the patient's
general condition, and oozing of pus from under the
edge of the dressing. The salt pack has given very
good results with flush amputations and in excised
joints. It seems to be of great value at times when it
may be impossible to renew dressings for several days.
3. A Plea for Ignoring "Laudable Pus" in the Treat-
ment of Septic Wounds. — M. Donaldson, E. Alment, and
A. J. Wright claim that their experience has taught
them that the presence of pus in a well-drained septic
wound is no impediment to healing, whilst the dis-
turbance necessary for its frequent removal retards the
process of repair. They state that cases have been left
considerably more than a week without change of
dressing, and during that time the temperature and
pulse remained normal and the patient's appetite rap-
idly improved. Charts are presented to show that the
temperature and pulse, although possibly very alarm-
ing in the first few days after the operation of drain-
age, soon settle down without any dressing being
changed. After nine months of trial they have adopted
the salt pack in the majority of septic wounds, except
those of the head, thorax, and some septic arms and
legs which are opened up and put straight into a saline
bath.
4. Secondary Infections of Joints in Acute Medical
Ailments. — G. H. Edington reports three cases of joint
infections occurring as a complication in medical ail-
ments. In the first case pneumococcic abscess of the
knee and buttock occurred as a complication rather
than a sequela of bronchopneumonia; in the second
case a streptococcic coxitis followed a pneumococcic
empyema, in which it was probable that the chest con-
dition was a mixed infection; in the third case suppura-
tion in the knee joint occurred during alleged cere-
brospinal fever. The writer says it is usual to explain
the implication of the joint as a metastasis occurring in
a part whose natural power of resistance has been low-
ered, and in support of this explanation trauma is
usually invoked. In none of these cases was there any
history of injury to the joint. It would seem that the
story of precedent injury, frequently trifling, of which
so much is made in the light of subsequent events, often
rests on a slender foundation. Even if it is assumed
that secondary implication of a joint points to severity
of the primary infection — large dose or particularly
virulent strain — the question is still to be answered as
to the choice of location of secondary infection. The
influence on the primary disease of the occurrence of
Sept. 30, 1916]
MEDICAL RECORD.
605
joint infection is discussed and the treatment of an
infected joint outlined. The importance of keeping in-
fected joints at rest in a proper position; of aspiration,
if distension by effusion occurs, and more especially of
strict antisepsis if operation is undertaken, are empha-
sized. Observation shows that in some minds the pres-
ence of pus seems to indicate that antiseptic precaution
may be avoided. It should not be forgotten that to
secure an aseptic result in a case of abscess is a proof
of surgical skill greater than that required for the suc-
cessful termination of a case of abdominal section.
5. Death Under Nitrous Oxide-Oxygen and Spinal
Anesthesia. — William E. Robinson reports this case
which is quite similar to one recently reported by W.
J. McCardie in the British Medical Journal of July 22.
The patient was a fat, unhealthy subject, very anemic
and nervous, with a history of many attacks of bron-
chitis. The pulse was small, rapid, and thready, and
the case unsuitable for a general anesthetic. The
patient was operated on for a uterine fibroid. Ten
minutes after the injection of 0.6 ex. of stovaine (10
eg. stovaine in 1 c.c. of normal saline) the administra-
tion of gas and oxygen was begun. Fifteen minutes
after the injection of the stovaine the patient vomited
and became partly conscious. After vomiting was
over, the gas and oxygen was restarted and the patient
was apparently doing well. A few minutes later she
again vomited, but this time did not regain her breath.
Her color was perfectly good; her pupils dilated, and
there was no obstruction by vomit in the larynx. All
efforts at resuscitation failed. It seems to the writer
that the stovaine was not directly responsible for this
fatality, for the time limit when its toxicity gives
cause for anxiety had passed. The shock of pulling up
the uterus could not have been responsible for this
occurrence. The anesthesia was perfect and all sensory
nerves must have been blocked. This left, therefore,
the nitrous oxide gas as more directly the cause of
death. It seems probable that, owing to the anemic
condition of the patient, the oxygen was not able to
enter into her tissues to any extent and the nitrous
oxide gas therefore acted on her heart muscle, causing
it to fail at the critical moment, when, owing to the act
of vomiting, there was again increased intrathoracic
pressure and so a dilated right side. The practical sug-
gestion to be drawn from this experience is that one
should be guarded in the choice of gas and oxygen
added to a spinal anesthetic in the presence of marked
anemia.
Le Bulletin Medical.
August 2H. iai6.
Primary Operations on the Skull. — There has been a
most promising union between the Societies of Surgtry
and Neurology under one president, Godari. To facili-
tate a debate various questions were asked, the first
being in regard to primary intervention in cranial
wounds. The questions were as follows: Should one
always operate ? What are the types of operation per-
missible? In simple fissure of the external table, ought
one to examine the state of the inner table ? Is the
flap operation preferable to crucial incision ? What are
the indications, technic and results of primary extrac-
tion of intracerebral projectiles? These questions were
answered by different members, one of whom, Rouvil-
lois, may be quoted because of his categorical answers.
He states in regard to operation that an exploration
procedure should always be made as soon as possible,
preceded if possible with an .r-ray. How we should
operate and how far should we go in this direction de-
pends on the degree of injury. If the dura is not in-
volved the trephine should always be used in theory;
but as an opening has already been made in the skull,
it is sufficient as a rule to trim its edges until it con-
forms to a trephine opening. If the dura and brain
substance are involved the flap operation seems to give
better remote results, as compared with crucial in-
cision, but there is much to be said in favor of the
latter which gives better visual control of the brain, and
better conformation between the wound of the skull and
that of the scalp. We have to think of immediate as
well as remote results, and each operation doubtless
has a separate field. In regard to inspection of the
inner table in connection with simple external fissure
this should be done always. In regard to projectile ex-
traction, the presence of a bullet, etc., within the cer-
ebral tissue is always a great menace, and hence im-
mediate extraction should be made irrespective of depth.
Secondary extraction is indicated in two conditions (1)
when there is full infection, usually in the midst of a
cerebral abscess, and (2) when the ball lies in a scar
or is simply encapsulated in the brain.
La Presse Medicale.
August :'4, 1916.
Signs of Apex Pleurisy. — Sergent considers this sub-
ject with especial reference to pulmonary tuberculosis
and supra clavicular adenitis. All schematic categories
are inconvenient and dangerous and each observer
should report his own finds without making them con-
form to classifications intended to bestow on the vic-
tim a particular status upon which treatment is to be
based. The clinician has or should have a thorough
technique and knowledge of semeiology, and therefore
should rank as a phthisiologist. Now the same symp-
toms may belong to quite different disease types. We
have but one certain test of tuberculosis — the presence
of bacilli in the sputum. We do not refer here to
latent tubercle, which is all but universal, but to the
active manifestations. Our knowledge of phthisiology
is in the midst of a revolution, and much false teaching
is being relegated to the scrap heap. The great ques-
tion of the day is "to what extent may a patient with-
out bacilli in the sputum suffer from latent tubercu-
losis?" All who make many autopsies are familiar
with apical adhesions of the pleura. The degree of
adhesion may vary within wide limits. The author does
not refer alone to pleurisy which is secondary to some
lesion of the parenchyma of the lung, but to cases in
which the pleural lesions predominate, even to the ex-
tent of complete symphysis. There are a number of
individuals not actively tuberculous who suffer from
apical lesions, as shown by the stethoscope and .r-ray,
all other regions of the lungs being intact save perhaps
for old calcified lymphnodes at the hilus. Let us
examine the symptoms of these patients. There are
certain pains — between the shoulders, in the inner as-
pects of the supra — and intraspinous fossae, supra —
and infroclavicular fossae — which show not the slight-
est resemblance to neuralgia or myalgia, but represent
pleurodynia. This is not constantly present and is
aggravated by deep inspiration and coughing. It i.-
absent in complete symphysis and is perhaps due to
the cicatrization which produces adhesion. Symptoms
are very numerous. There are various degrees of flat-
ness on percussion; absence of fremitus, muscular at-
rophy in the subclavicular and subspinous regions. The
auscultatory signs are very difficult to interpret and
are responsible for many incorrect diagnoses. This also
holds good for radiography, especially when the oper-
ator is not a skilled interpreter. With a sufficient
autopsy experience and knowledge of pathologic an-
atomy, it should be possible to interpret correctly the
finds of the stethoscope and v-rays. Two objective
606
MEDICAL RECORD.
[Sept. 30, 1916
signs possess considerable value, to wit, pupillary in-
equality associated with paralysis of the sympathetic
of the affected side and supraclavicular adenitis, the
latter the subject of many researches. The inflamed
gland is elongated in shape, lies just behind and parallel
with the clavicle and opposite the border of the sterno-
mastoid muscle. The size and consistency, also the
number of glands involved, may show great variation.
This affection has nothing in common with ordinary
cervical adenopathy. During the past 2 years the au-
thor has made a routine research for this symptom.
Very often it means the existence of a pleurisy, less
often of a pulmonary lesion. The gland often felt is
the end of a chain which leads to the inflamed pleura.
If the pleuritic process is acute the gland should be
large and soft; if chronic, small and firm. Pleurisy of
the apex is not a new disease, but one which has been
forgotten. When well developed it has usually passed
for a tuberculous lesion, and no less when only im-
perfectly developed. When adhesions alone remain it
is called a stigma of old tuberculosis. But it is often
a benign lesion, which diagnostic ignorance has termed
an active focus. Hence the diagnostic significance of
the supraclavicular lymphnode which, according to the
case, may show the absence of an active pleurisy. In
any case, however, such a subject is never tuberculous
in the sense that one is who suffers from anemia, loss
of weight, weakness, low blood-pressure, etc., etc.
Gazette Hebdomadaire des Sciences Medicales.
August 27, 1916.
Simulation. — Blum begins a study of this subject and
the qualifications which the military medical expert
must possess to reveal it. A circular to this effect
was sent out in 1915 by the Undersecretary of State for
the Sanitary Service. The medical men were warned as
to weakness, negligence, indecision, laxness and in-
capacity. In private life the physician is governed by
his conscience. In military life he is governed by his
duty to the State. In private life probity in regard to
the best interests of his clientele comes first, but in
military life he is responsible to his superiors. The
civil practitioner, placed at the bedside, gives a diag-
nosis warranted by the symptoms subject to revocation.
The military practitioner has to think always of sim-
ulation. He may pronounce it simulation or leave the
question open. He also must look out for the aberrant
types of disease, while in civil practice he must search
for normal types. The military man must be especially
familiar with the influence on disease of trauma, which
plays a minor role in civil practice. The civil practi-
tioner reckons on an ordinary cure, while the military
man thinks chiefly of functional recovery, which is
often remote. For the expert tact will always beat
great learning, and tact is unthinkable without quick-
ness. The learned man overburdened with scientific
data hesitates and wavers. The word "savant" has two
meanings which fit the case, namely, "learned" and
"clever." The clever man hits the nail on the head,
goes straight to the mark, while the erudite doubts,
fears, clips off branches, but lets the trunk grow.
Sometimes the adenopathy has suggested syphilis, espe-
cially syphilitic scrofula so-called, which is believed to
represent mixed infection. But while these glands do
not yield in any plan of syphilitic treatment they have
been seen to disappear spontaneously after treatment
of the teeth. In school children it is almost a law that
cervical and tracheobronchial adenopathy occur in chil-
dren who have already caries (about 15 per cent.). Of
the others it may be said "No caries, no adenopathy."
It is a long known law in medicine that candidates for
tuberculosis have not sufficient lime retention — that
they are demineralized as to calcium — a condition
which naturally favors dental caries. A tuberculous
lung may be shown to have lost (or never to have
had) one-third of its normal mineral content. The
resistance of the teeth to caries is a good measure of
the general resistance of the body to disease. "Recalci-
fication" has long been one of the leading remedies for
tuberculosis. Otherwise stated dental caries is a testa-
ment of the presence of tuberculosis and pre-tubercu-
losis. We do not invalidate this statement if we add
that dental caries also paves the way for infection. It
may even do this indirectly by interference with proper
mastication. Without the latter one cannot be in per-
fect health. Bad prosthesis may also interfere with di-
gestion. The sixth year molar is known to be the first
to become careous; this is because it has been infected
from the fifth tooth of the first dentition. Carfous
molars are premolars of the first dentition, again are
often the starting point of tuberculosis through re-
sulting errors or nutrition. The modes by which carious
teeth can contribute to tuberculosis constitute a sur-
plus— they exist in such numbers that some modes are
superfluous. For example, a simple lymphangitis from
an infected gum may pave the way for tuberculous
lymphnodes. The inflamed node takes on specific char-
acters, becoming a bacillary granuloma, and this in turn
may become secondarily infected with pyogenics. Thus
mere scaling of the teeth often causes suppuration of
tuberculous glands. Again dental caries may be the
direct cause of pulmonary lesions by the lymphatic
route. At present a remedy for this sequence of events
must lie with the dentists.
Colloidal Silver and Puerperal Sepsis. — Willette sums
up as follows: Colloidal therapy should be used intra-
venously in puerperal sepsis and may render great serv-
ices. Aerobic infection (chiefly the streptococcus) is
much more frequent and more amenable to colloidal
therapy. Anaerobic and mixed infections require an
oxidizing or mixed treatment. To attain success large
dosage should be used — one should not fear possible ill
consequences. Figures show that this treatment lowers
the mortality, shortens the course of the disease and
prevents a certain amount of complications. The ra-
tionale of the treatment is due chiefly to the entrance
into the blood of matter in the colloidal state which
behaves as an alterative, and brings about a crisis syn-
drome, with its temperature fall, leucocytosis, augmen-
tation of urine.
Journal de Medecine do Paris.
August, L916.
Dental Caries and Pulmonary Tuberculosis. — Rosen-
thal states that proper dental treatment is at times
seen to do away with bacillary adenopathies (submaxil-
lary) after failure of general management. This re-
sult has even followed the treatment of a single cavity,
perhaps very small; or the extraction of an abandoned
root, without any gingival reaction. The gland paquet
is often very large. Mere toilet of the buccal cavity
has also caused amelioration in these glandular cases.
Acids of Gastric Fermentation. — Pron has examined
194 specimens of washings from' the diseased stomach
in the fasting state and in the absence of food residues.
In 167 cases or 86 per cent, he obtained evidence of
acids of fermentation, divided up as follows: In ninety-
three cases the lactic acid was found by Uffelmann's
method, while in the balance the sole acids present were
volatile. In order that these finds be pathological there
must have been present before lavage a splashing stom-
ach which at the same time contained no food residues,
i.e. a strictly fasting stomach. When found after a
trial breakfast the presence of fermentation acids has
no necessary pathological significance. — Comptes rendiis
dv la Societe de Biolocjie.
Sept. 30, 1916]
MEDICAL RECORD.
607
look 2&trirwH.
Nervous Children. Prevention and Management. By
Beverley R. Tucker, M.D., Professor of Neurology
and Psychiatry, Medical College of Virginia, Rich-
mond, Va.; Consulting Physician of the Juvenile
Court, Richmond, Va.; Physician of the Tucker Sana-
torium, Richmond, Va.; Neurologist to the City Hos-
pital, Richmond, Va.; Consulting Neurologist to the
State Epileptic Colony, Lynchburg, Va.; Neurologist
to the Johnston- Willis Sanatorium, Richmond, Va.;
Editor of the Old Dominion Journal of Medicine and
Surge>~y, etc. Price, $1.25. Boston: Richard G.
Badger; Toronto: The Copp Clark Co., Ltd. 1916.
The average mother of to-day seeks eagerly for knowl-
edge as to the best care of her child, and the need for
books on all subjects of children is gradually being
filled. Dr. Tucker's book on nervous children is an ex-
cellent addition to the group. The mother who seeks
methods of controlling and teaching her child must read
elsewhere, but for an understanding of the needs of the
child and a suggestion of possible abnormalities she
may well peruse Dr. Tucker's book carefully. The book
is a good introduction to further reading, for it gives
a simple presentation of embryological development and
short explanations of elementary physiology and psy-
chology.
The chapter on heredity and environment is excellent,
and might well stimulate to further reading and study.
The chapters on habit, and eugenics and sexual hygiene
are also worthy of note. Enough is said at various
points to waken a mother to the importance of the ac-
tivity of the glands of internal secretion, and thus win
her cooperation with the physician if treatment is
necessary. Increased knowledge on the part of a pa-
rent is always helpful to the best medical work, and
the understanding by parents that certain examinations
are necessary will make such examinations more uni-
versal and thus be a great help to the sick child.
Elementary Bacteriology and Protozoology for the
Use of Nurses. By Herbert Fox, M.D., Director of
the William Pepper Laboratory of Clinical Medicine
in the University of Pennsylvania; Pathologist to
the Zoological Society of Philadelphia, etc. Second
edition, revised and enlarged. Illustrated with 68
engravings and five colored plates. Price, $1.75.
Philadelphia and New York: Lea and Febiger, 1916.
This book is well adapted to the use of nurses and of
such members of the laity as are desirous of obtaining
a general idea of the nature of microorganisms and
their relation to disease. The author has performed
his work well, and has avoided the common error of
trying to tell too much. The new edition contains more
detailed information on general disinfection, the trans-
mission of infection, especially in regard to those
diseases spread by insects, and the peculiar phenomena
of hypersusceptibility. The volume is a valuable ad-
dition to a useful series.
Treatise on Fractures. By John B. Roberts, A.M.,
M.D., F.A.C.S., Professor of Surgery in the Phila-
delphia Polyclinic and College for Graduates in
Medicine; Sometime Chairman of Fracture Commit-
tee of American Surgical Association; Membre de la
Societe Internationale de Chirurgie; and James A.
Kelly, A.M., M.D., Attending Surgeon to St. Joseph's,
St. Mary's and St. Timothy's Hospitals; Associate in
Surgery in the Philadelphia Polyclinic and College
for Graduates in Medicine. Octavo of 677 pages with
909 illustrations: radiograms, drawings and photo-
graphs. Price, $6. Philadelphia and London: J. B.
Lippincott Company, 1916.
"The object of this book is to supply student and med-
ical practitioner with a clear, concise, and systematic
presentation of the subject of fractures." This is the
first sentence of the preface and we may say at the
outset that the authors have accomplished their task;
and this was essential if the book were to be a success,
since there are already so many standard works on this
subject. There are many good points about this book,
not the least of which is that the time a fractured arm,
elbow, etc., should be kept in splints is usually definitely
stated in terms of days and weeks — a matter of much
help to the practitioner who handles comparatively few
such cases and is not in a position to call in a surgeon.
Most books furnish explicit directions regarding diag-
nosis and the application of a proper retentive dressing
but fail to state, except in the most general terms
when, if ever, the splints are to be removed. So far as
the diagnosis and non-operative treatment both of frac-
tures in general and of special fractures are concerned,
the material is presented most systematically and is
admirably arranged for teaching purposes.
On the other hand, the chapter on the operative treat-
ment of fractures seems surprisingly weak — the full
possibilities of the autogenous bone graft in these
cases apparently have not been grasped by the authors.
The illustrations are generally good but often un-
necessarily multiplied, particularly as regards radio-
grams of special fractures; and the addition of the
words "right" or "left," "anterior" or "posterior view"
to the legends under illustrations will often clarify
matters. Figure 353 on page 315 is a conspicuous ex-
ample of this need, for it requires considerable study
of the figure to avoid the impression that the musculo-
spinal nerve is depicted as running from without in-
ward on the anterior surface of the humerus. Irre-
spective of these and other criticisms that might be
made, the book deserves and should enjoy general
approval, especially for classroom work.
New Concepts in Diagnosis and Treatment. Phy-
sico-Clinical Medicine. The Practical Application
of the Electronic Theory in the Interpretation and
Treatment of Disease. With an Appendix on New
Scientific Facts. By Albert Abrams, A.M., LL.D.,
M.D., F.R.M.S. San Francisco: Philopolis Press,
1916.
The author presents here a series of methods for the
diagnosis and treatment of disease, methods radically
different from those now in use and based largely on
certain electrical reactions which he claims to have dis-
covered. Time and further research alone will deter-
mine the true value of his work. The results which
he claims to have obtained are nothing short of mar-
velous but it is impossible to accept them merely on the
statements presented. They call for demonstration and
substantiation in the hands of many careful and scien-
tific workers and it is probable that it will be long be-
fore such confirmation is received. The author is evi-
dently an enthusiast. As is natural in a work dealing
with a new subject one encounters many neologisms but
the number seems greater than necessary.
Those About Trench. By Edwin Herbert Lewis.
New York: The MacMillan Company, 1916.
After a good deal of unnecessarily technical talk the
author gets started on his story which is really one of
great interest. The principal character is a Serb who
passes himself off as a Persian and is first met in a
polyglot community living with Doctor Trench in
Chicago. The interesting part of the story takes place
in the near East and has much to do with the incidents
immediately preceding the outbreak of the present war.
Actions and conversations are described with what
seems to be authority so that the average reader will
see little that is improbable in the tale. There is much
philosophy that is apparently set up to be knocked
down, but the author, after having set it in place, of-
ten loses interest in it and neglects or forgets to knock
it down again. In spite of the confusion of the pic-
ture which is presented the story is a fascinating one
and will easily fill up a little spare time.
Text-Book of Anatomy and Physiology for Train-
ing Schools and Other Educational Institutions.
By Elizabeth R. Bundy, M.D., Member of the Medi-
cal Staff of the Woman's Hospital of Philadelphia;
Gynecologist, New Jersey Training School, Vineland;
Formerly Adjunct Professor of Anatomy, and
Demonstrator of Anatomy in the Woman's Medical
College of Pennsylvania; Formerly Superintendent
of Connecticut Training School for Nurses, New
Haven, etc. Fourth Edition, revised and enlarged.
With a glossary and 243 illustrations, 46 of which are
printed in colors. Price, $1.75. Philadelphia: P.
Blakiston's Son and Co.
Previous editions of this work have been noticed in th«
Medical Record, and we are pleased to observe that
some of the suggestions made on these occasions have
been adopted by the author. The fact of the book
reaching a fourth edition is evidence that it fills a
want in our educational literature. Dr. Bundy's book
takes an intermediate place between the elementary
works and those which aim at teaching nurses and
others all that is known (or even surmised) on the
anatomy and physiology of the human body. In view
of the prominence of sexual hygiene at the present
time, the chapter bearing on that topic might be en-
larged with advantage. We notice that the author still
clings to the idea that the ear has four bones.
608
MEDICAL RECORD.
[Sept. 30, 1916
£>nmtg Sparta.
AMERICAN GYNECOLOGICAL SOCIETY.
Forty-first Annual Meeting, Held at Washington, D. C,
May 9, 10, and 11, 1916.
The President, Dr. J. Wesley Bovee, Washington,
D. C, in the Chair.
{Concluded from page 570.)
Variations in the Blood Supply of the Ovary and
Their Possible Operative Importance. — Dr. John A.
Sampson of Albany, N. Y., stated that the study of the
blood supply of the ovary was undertaken for its ana-
tomical interest, and also for its bearing on conserva-
tive ovarian surgery when a tube was removed without
removing the ovary of that side, or the uterus was re-
moved leaving one or both ovaries. The intrinsic blood
vessels of the ovary and resection of that organ were
not considered. The material consisted of six fetal
tubes and ovaries, and thirty adult ones in which the
arteries had been injected with bismuth, and ten adult
tubes and ovaries in which the veins had been injected.
The specimens were studied by means of stereoscopic
radiographs, and for the sake of comparison ink trac-
ings were made of the blood vessels on prints, using
the stereoscope as a guide in following the course of
the individual vessels. The prints were then bleached,
leaving the tracing. The terminal portion of the
uterine artery presented variations in its branching
and distribution of these branches. This artery di-
rectly or indirectly through its branches supplied a
varying portion of the ovary in all, the entire tube in
six, the greater portion of the tube in twenty-three,
the round ligament and greater portion of the broad
ligament in all but one. In twenty-four of the thirty
specimens the uterine supplied the proximatl portion
ovary divided into two main branches, a lateral tubo-
ovarian or tubal branch, and a mesial ovarian, the lat-
ter anastomosing with the ovarian branch of the
uterine. In six specimens the lateral tube branch was
absent. The ovarian artery supplied a varying por-
tion of the ovary in all, the distal portion of the tube
in twenty-four and portions of the broad ligament in
all, but the latter to a lesser degree than the uterine.
The actual blood supply of the ovary was a divided
one — uterine and ovarian. In twenty-six of the thirty
specimens the uterine supplied the proximal portion
of the ovary and the ovarian the distal. In four speci-
mens (four of six in which the lateral ovarian branch
to the tube was absent) the lateral tubal artery arose
from the main tubal artery (uterine origin) and sup-
plied the distal portion of the ovary, taking the place
of the lateral tuboovarian branch from the ovarian
artery. In these four specimens the distal portion of
the ovary was supplied by the uterine, the middle by
the ovarian, and the proximal by the uterine. The
blood supply of the broad ligament being both uterine
and ovarian, the usual blood supply of the tube being
both uterine and ovarian, and as the arteries of the
broad ligament communicate with each other and with
those of the tube and round ligament, and as the tubal
arteries communicate with each other, all these struc-
tures must be looked upon as containing a potential
blood supply to the ovary. Thus the uterine and
ovarian arteries communicate with each other not only
through the well-known uteroovarian anastomosis, but
also through the above-mentioned vessels. The actual
venous outlet of the ovary was partly through the
ovarian veins, partly through the uterine. Its poten-
tial venous outlet was evident in the various communi-
cations between the venous channels of the utero-
ovarian plexus, the free anastomosis of the veins of
the broad ligament and tube, and the communication
of the plexus with the epigastric vein of the round
ligament. The removal of the tube always encroached
upon the potential blood supply of the ovary, and when
the distal pole of the ovary was supplied by the tubal
artery (four of thirty specimens), the actual blood
supply of that portion of the ovary might be cut off.
These anatomical studies suggested that if it was nec-
essary to remove a tube without removing the ovary,
it should be done with the least possible disturbance of
the broad ligament, and even then occasionally the
blood supply of tin distal pole of the ovary would be
cut off; also in hysterectomy with conservation of the
ovary, the accompanying tube should be saved, if pos-
sible.
The Clinical Course of Cancer in the Light of Cancer
Research. — Dr. Harvey R. Gaylord, Director of the
State Institute for the Study of Malignant Disease,
Buffalo, said that cancer was not one disease, but a
great group of diseases. The various types of sar-
coma in chickens caused by filterable viruses had taught
us that there were neoplasms with specific agents
which determined the character of the tumor. Progress
required that cancer of different organs must be
treated as individual diseases and studied individually.
The study of immunity to inoculated cancer threw new
light upon the clinical course of the disease. Success-
ful surgery, x-ray, and radium treatments were all
dependent upon immunity. Early operation owed its
success to the fact that immune reactions in spon-
taneous cancer were strongest in the early stages of
the disease. The effect of chloroform and ether anes-
thesia and loss of blood, dependent upon surgical opera-
tion, was shown to exercise a destructive effect upon
the immunity. The author pointed out the directions
in which cancer research offered promise of better
treatment.
Cancer of the Uterus and Its Treatment. — Dr. John
G. Clark of Philadelphia classified cancer under three
divisions as regards its treatment: (o) the radicalh
operative; (6) the radical use of the cold cautery, and
(c) the use of radium or mesothorium. Statistics as
to surgical results were now upon an accurate basis
and demonstrated a higher percentage of cures from
the radical abdominal operation than achieved by the
less radical vaginal and abdominal methods. In re-
buttal there might be offered the much higher pri-
mary mortality and the greater number of disabling
sequelae from the former over the latter operation.
The dangers of the radical operation were great even
in the hands of the expert, and prohibitive when per-
formed by the surgeon of limited experience. Many
so-called radical operations were mere makeshifts, the
patient being subjected to much greater hazards with-
out any appreciable gain over simpler methods, by an
attempt to execute an operation which failed lamenta-
bly short of an ideal standard. As yet the use of the
cold cautery was in the proving ground and was a
procedure which, to be successful, must be radical,
and, therefore, was likely to be attended with a high
primary mortality as well as serious sequelae. It must,
therefore, show a higher percentage of ultimate cures
to make it a worthy competitor of the radical opera-
tion. In the author's experience of two years with
radium, it had given encouraging promise, first, as a
palliative remedy, and, secondly, as a tentatively cura-
tive one. It was in no sense a miraculous panacea, for
a considerable number of cases were not helped, for
the malignant process did not appear to be halted, but
might actually be expedited. The sequelae, however,
following its judicious employment, were comparatively
insignificant as compared with the foregoing methods,
and, therefore, if the patient was not helped she was,
at least, spared the added miseries of unfortunate ac-
cidents. Because the radium was not a dependable
agent in all cases, and because as yet the type of can-
cer which would be helped could not be forecasted,
surgical measures must still be invoked, but might be
supplemented by radiozation. The dictum of the last
few years, "In case of doubt, extirpate the uterus."
was now modified, for in all such instances we now
applied radium. Thus far in no instance had hys-
terectomy been performed when radium had acted ben-
eficially, for it did not appear logical that an operation
could accomplish anything further. As experience now
pointed, it would appear that radioactive agents were
to serve an excellent supplementary remedy to surgery,
offering better results in the operative cases and a
definite hope in the inoperable.
The Extended Operation for Carcinoma of the Uterus.
— Dr. Reuben Peterson of Ann Arbor presented the
following summary and conclusions: (1) Further ex-
perience with the radical abdominal operation for can-
cer of the uterus confirmed the belief that it was an
exceedingly dangerous procedure and would always be
attended by a high primary mortality. (2) Even if
the percentage of operability of cases of cancer of the
uterus markedly increased in this country and else-
where, there would always be borderline cases attended
by a high primary mortality. (3) This was true be-
cause it was not always possible, even with the greatest
care in examination of the patient prior to operation,
to estimate the extent of the disease. (4) Errors in
judgment meant death from shock if the disease was
too far advanced or failure to complete the radical re-
Sept. 30, 1916]
MEDICAL RECORD.
609
moval of the cancerous uterus. (5) However, in spite
of a high primary mortality, it was the only procedure,
with the possible exception of the extended vaginal
operation, which held out any reasonable promise of a
permanent cure. (6) Primary and end results of the
radical operation for cancer of the uterus must be con-
sidered together in order to judge of the good accom-
plished in a given series of cases. • (7) Unless the
operations were radical, the end results would be poor,
and if they were radical the primary mortality must be
high. (8) If the end results were poor, the burden
of proof was upon the radical abdominal operator to
show why he did not choose a much safer palliative
procedure. (9) Since 1912, experience with 14 ordi-
nary panhysterectomies for cancer of the fundus
showed worse primary and end results than in 11 cases
previously reported where radical removal was per-
formed. (10) This showing and the results following
removal of fundus carcinoma by various methods in
the Wertheim clinic, as reported by Weibel, led to the
conclusion that, because carcinoma of the fundus was
more easily cured than when the cervix was involved,
we were not justified in thinking it could be treated
any less radically than carcinoma of the cervix. (11)
The primary mortality in 59 cases of cancer of the
cervix and fundus treated by the radical abdominal
operation was 23.4 per cent. (12) The extent of the
involvement in cancer of the uterus could only be de-
termined definitely after the abdomen had been opened.
If the parametria were not too much involved and the
condition of the patient's kidneys, heart, and blood
vessels warrant a prolonged and depressing operation,
it was justifiable to attempt the radical operation. (13)
During the past four years 124 cases of cancer of the
uterus had been seen in the university and private
clinics. The disease was so far advanced in 36 cases
that operation was refused or nothing was done. The
cautery method was tried in 58 cases and proved value-
less except as a palliative procedure. (14) In spite
of attempts to educate the public regarding cancer,
the cases of cancer of the uterus seen during the past
four years were more advanced than had formerly
been the case. (15) The end results in 51 patients
operated upon five or more years ago were most grati-
fying. Combining fundus and cervix cases, 27 of the
51 patients were alive and well after five years, or
56.2 per cent, of all cases operated upon, while 69.2
per cent, of all those surviving the operations were
alive after five years. (16) Of 40 cases of cancer of
the cervix operated upon five years or more ago, 18
of those surviving the operations are alive and well
to-day. Thus 47.3 per cent, of the total number re-
main cured after five years, while 62 per cent, of those
surviving the operation remain cured. (17) These per-
centages were obtained by Wertheim's formula where
patients dying of intercurrent disease, or those lost
track of, were subtracted from the total number of
operative cases or from the number surviving. (18)
The length of time elapsed since the operations upon
the 18 patients who were alive and well varied from
five to thirteen years. There was every reason to
think these patients were permanently cured, although
one patient did have a recurrence and died between
five and six years after the radical operation. (19) In
spite of the high primary mortality, the end results in
those surviving the operation encouraged us to continue
with the procedure in suitable cases.
The Problem of Heat As a Method of Treatment in
Inoperable Uterine Carcinoma. — Dr. James F. Percy
of Galesburg, 111., said there were three stages to be
recognized in the development of the cautery in the
treatment of carcinoma of the uterus: (1) where it
was merely used to stop hemorrhage and limit offensive
discharge; (2) in the galvanocautery excision of the
cervix uteri, developed by the late Dr. John Byrne of
Brooklyn, N. Y. ; in this technique a high degree of
heat was used sufficient to cut the tissues; (3) in the
dissemination of a coagulating degree of heat through
the widest possible area of the cancer mass, with no
attempt at immediate excision of the parts. The tech-
nique of Byrne was not designed for the advanced
inoperable cancer patient, the one in which the utero-
cervical junction was fixed, with extensive malignant
and inflammatory infiltration of both broad ligaments
and the parametrium. As classified to-day, Byrne op-
erated only in the first stage of cervical cancer in-
volvement. Dr. Percy stated that his technique
brought the practitioner back to the days before Byrne,
to the treatment of the otherwise hopeless case, and
in addition he stated that his technique opened up new
possibilities in the way of further improved results,
in the type of case in which Byrne secured his best
results. The author emphasized the point that the
stage of operability with his present technique was
easily 90 per cent., and he confidently expected that
the stage of operability would be without limit in
strictly pelvic cancer. He would not have the prac-
titioner believe, however, that the ideal was mere op-
erability. Back of it all was the hope and promise
of results never before obtained by any method so far
developed in that disease which had always stood as a
synonym for incurableness — pelvic cancer. In conclu-
sion, he reemphasized (1) that the Percy technique,
so-called, was not a cautery operation. He removed
nothing. The tissues following the application of the
moderately low degrees of heat were literally coagu-
lated and slowly dissolved. It usually took two weeks
for a healthy granulating surface to appear beneath
the gradually dissolving mass of inert cancer debris.
(2) The operation of Byrne was a high galvanocautery
incision of the cervix. There could be but little pene-
tration of heat. Byrne recognized this when he ad-
vised that the surface left after the removal of the
gross mass be seared over with the cautery knife, in
order to get all the heat penetration possible. But
Byrne never thought of applying heat to the degree of
obtaining penetration sufficient to render movable the
fixed tissues in the pelvic basin. If the fixed tissues,
malignant and inflammatory, were not made freely
movable, as they were normally, the heat penetration
had not been sufficient, and, therefore, was ineffective.
(3) To coagulate a large mass of uterine cancer re-
quired from thirty to sixty minutes, and if the broad
ligaments still remained stiff or fixed, an additional
ten minutes. (4) In the author's effort to emphasize
the importance of avoiding the burning temperatures
he feared that he had led many surgeons to the oppo-
site extreme, and that they were trying to destroy the
activity of an inoperable mass of cancer with a tem-
perature so low that days, rather than hours, would
be required to make the heat effective. Byrne fried the
tissues; whereas the author broiled or pasteurized
them. The Byrne technique was based on the use of
heat as an acute process; while the author's was not
acute, but chronic, both as to time and degree. Heat,
more heat, and yet more heat; but heat, not fire; broil-
ing, not frying; not roasting, but curdling; pasteuriza-
tion, not desiccation ; coagulation, not carbonization.
In its practical application the whole technique could
be summed up in the one statement: that one should
not carbonize the tissues, for in the degree that this
was done, in that degree was heat penetration inhib-
ited; and heat penetration was the vitally essential
thing.
High Heat Versus Low Heat in the Treatment of
Cancer of the Uterus. — Dr. Herman J. Boldt of New
York City said that he had expressed himself fully on
the relative value of high degree of heat compared
with low degree, heat as a palliative therapeutic
agent in the advanced stages of cancer of the uterus,
in an article published in the American Journal of
Obstetrics in the January (1916) issue, and judging
from the communications he had received from physi-
cians who had had experience with the treatment his
position was amply justified. It was also corroborated
by another autopsy, in addition to the one he had, by
Dr. F. W. Bancroft of New York. He did not wish to
detract from the usefulness of low heat, but it should
be reserved principally for a second application, after
rapid destruction had been accomplished with high heat,
and the charred eschar that was caused by the high
heat had been thrown off; and for those cases in which
the cancer had so far advanced that the proper appli-
cation of high heat would endanger the bladder or
rectum. The danger from secondary hemorrhage was
not less with low heat than with high heat. No evi-
dence had been presented that showed the superiority
of one method over the other. Heat, properly used,
and applied in selected cases, sometimes gave remark-
able good palliative effects; but it had been conclusively
shown that cancer cells were not destroyed any appre-
ciable distance from the surface of application, cer-
tainly not deeper with low heat than with high heat.
This was proved by the examination of tissues pro-
cured at the autopsies mentioned. Dr. Charles Mayo,
when discussing the paper alluded to, published in the
American Journal of Obstetrics, asserted that the proof
of the deep destruction of low heat was shown in cases
that had been operated upon in the Mayo clinic, lay in
the fact that at the time of cauterization the disease
610
MEDICAL RECORD.
[Sept. 30, 1916
had too far advanced for the patients to be operated
upon radically, but later the uterus became mobile and
was extirpated, and when these uteri were examined
by the pathologist, he failed to find any evidence of
malignant disease in them. This hypothesis was not
acceptable to Dr. Boldt as valid proof, since the mo-
bility might have become impeded by an inflammatory
process which, as the result of the heat treatment, be-
came dried out, as it were, and mobility of the uterus
resulted; a result seen also when high heat was, *sed.
The inflammatory infiltration might subside, out the
carcinomatous infiltration remained. To disprove this
it was necessary for the operator, when the abdomen
had been opened, to remove a part of the suspicious
infiltrated area in the pelvis a reasonable distance away
from the cervix, and have it examined by a competent
pathologist. If that showed cancer nests, and the
uterus became mobile subsequently, so that a radical
operation might be done, and the specimen then re-
moved by a radical operation failed to show cancer
elements in the parametria, we were in the position to
grant the deep destruction of cancer elements by the
heat applied, but not until such proof had been shown.
Attention was called to those instances in which re-
covery followed when a simple extirpation of the uterus
had been done, despite some parametrial infiltration,
and in which, after a period of a few months a re-
examination failed to show any evidence of infiltration.
He recalled two such cases.
Abdominal Myomectomy and Hysteromyomectomy by
Morcellation. — Dr. Charles G. Child, Jr., read a paper
with this title in which he drew the following conclu-
sions: The advantages of myomectomy or hysteromy-
omectomy by morcellation were many. The original
morcellation by the vaginal route enjoyed great popu-
larity because of the smoothness of the subsequent con-
valescence and freedom from postoperative complica-
tions, both immediate and remote. The abdominal re-
moval of these tumors by morcellation now that we had
to-day improved our abdominal technique gave just as
smooth a convalescence and just as great a freedom
from complications as was secured by the vaginal
operators in the past. The advantages of the tech-
nique which he described were considered both from
the point of view of the patient and of the surgeon.
To the patient it afforded greater safety, a shorter
and a smoother convalescence. This was by reason
of the fact that as the surgeon worked practically ex-
traperitoneally the intestines were kept out of the
way without recourse to laparotomy pads; thus was
the intraperitoneal traumatism minimized and post-
operative shock, distension or peritonitis was seldom,
if ever, seen. In hysteromyomectomy the danger of
secondary hemorrhage from slipped ligatures on the
broad ligaments was very materially decreased because
of the ease and safety with which the relaxed broad
ligaments could be ligated. The smaller incision and
the stronger resulting scar, especially when the trans-
verse incision was used, reduced to a minimum the
danger of hernia. The high percentage of primary
union resulting when the transverse incision was closed
with non-infectible suture material, meant a much
shorter hospital residence. A large granulating median
line incision, where primary union had not been se-
cured, meant a prolongation of the convalescence by
many weeks, with a good prospect of a subsequent hos-
pital stay when the ventral hernia, almost certain to
occur in such a case, was operated upon. The advan-
tages to the surgeon were that during the greater part
of the operation the tumor was in contact with the
abdominal wall, and the work wa» extraperitoneal. Thus
was the surgeon able to see definitely each pathological
condition as it arose and to take the necessary time
to meet the indication, for by this technique the length
of time which the patient was under the anesthetic was
not nearly of the importance that it was when a large
median incision had been made with all the consequent
exposure of intestines, and use of laparotomy pads that
went with the older technique. In hysteromyomectomy
the ease with which the broad ligaments could be
ligated, and the cervix removed when a complete hys-
terectomy was necessary was very marked. Although
the transverse suprapubic incision might be so small
as to handicap many an operator at the start, still as
skill in anything was acquired only by repetition, so
here with experience one became quickly proficient.
A Study of the Pathology in Its Relation to the Eti-
ology With the End Results of Treatment of Sterility.
— Dr. John Osborn Polak of Brooklyn, New York,
gave a personal review of 798 cases — histories of
patients from his private practice, and analyzed the
many etiological factors which had entered into the
causation of sterility. He discussed the individual case
based upon an etiological diagnosis, and finally sum-
marized his end results. This study had shown (1)
that a very large number of cases of sterility apply-
ing for relief had no chance whatever of becoming
pregnant, as the .pathology was such as to make con-
ception impossible. (2) That the male was largely
responsible for the poor results in treatment. (3)
That there was a definite chemico-pathological factor
in conception, at present unexplainable, which was a
cause of preventing conception. (4) That operative
procedures on the uterus, except amputation of the
nypertrophied portion, had but a slight influence on
the end results in the treatment of sterility; and (5)
each case must be individualized and both contracting
parties carefully studied before any treatment was
inaugurated.
Rupture of the Scar Following Cesarean Section. —
Dr. Palmer Findley of Omaha gave a survey of the
literature on this subject with a digest of case reports
for the purpose of determining whether or not one
cesarean section called for another in the event of a
subsequent pregnancy, and then drew the following
conclusions: (1) A perfectly healed cesarean wound
might be relied upon to resist the forces of labor, but
in view of the fact that the integrity of the wound
was an unknown factor in all cases, he was constrained
to exeicise the utmost caution in the conduct of every
case of pregnancy and labor following cesarean sec-
tion. (2) Failure to secure perfect healing was ac-
counted for by departure from the principles of suture
proposed by Sanger and by septic infection of the
uterine wound. If we were to obtain the uniformly
good results in respect to wound healing that were
secured in the decade following the introduction of the
Sanger method of suture, we must not deviate from
these principles. (3) The possible existence of latent
gonorrheal infection might defeat the most painstak-
ing efforts to secure perfect wound healing; hence it
followed that the healing of a cesarean wound was
always an uncertain factor. (4) When cesarean section
had been followed by a fever course, the uterine wound
should be regarded as insecure in the event of a subse-
quent pregnancy, and should call for a repeated
cesarean section at the onset of labor. (5) Steriliza-
tion and hysterectomy should replace conservative
cesarean section when infection was known to exist.
The alternative invited faulty wound healing, if not
more disastrous results. (6) Transverse fundal, extra-
peritoneal and cervical incisions had not lessened the
liability of rupture in subsequent labors, but, on the
contrary, had probably increased the hazard. (7) The
possibility of rupture of the scar following cesarean
section did not justify sterilization, but rather called
for the exercise of masterly control in the event of a
subsequent pregnancy. All such cases should be hos-
pital cases and labor should be anticipated by timely
repetition of cesarean section at the onset of labor if
the uterine wound was known to be defective, or if
some cause for obstruction to the delivery of the child
through the natural passage existed. Version, high
forceps, uterine tampons, hydrostatic bags and
pituitrin should never be employed in the presence of
a cesarean scar. (8) We might conclude that in view
of the evidence that not more than 2 per cent, of
ruptures occurred in subsequent labors, we were not
justified in voicing the slogan, "Once a cesarean sec-
tion, always a cesarean section"; neither were we to
rely solely upon the integrity of the uterine scar in
any case. Furthermore, he would conclude that the
liability of rupture was a real danger and should stand
as an argument against the increasing tendency to
widen the scope of elective cesarean operations.
The Constitutional Factor in Gynecology and
Obstetrics. — Dr. CHARLES P. Noble of Philadelphia
spoke on this subject and presented these conclusions:
(1) The theory of environmental, constitutional hypo-
plasia or arrested development from unfavorable en-
vironment, operating at any period from the precon-
ceptional state of dual life in the ovary and testis, to
that of the youthful period in ontogeny, which was
presented to the profession as a medical hypothesis in
1908, and which the writer believed to be proven upon
human clinical and pathological evidence, was now
shown to be equally supported by the clinical and the
pathological facts of antenatal pathology, and by the
facts of comparative pathology, and to be demonstrated
by the facts of experimental teratology. (2) The wis-
Sept. 30, 191GJ
MEDICAL RECORD.
611
dom of the fathers of medicine, as expressed in their
discriminating analysis of the facts of the hereditary
nature of the diatheses or dyscrasias, together with the
theory of environmental hypoplasia, constituted the law
of devolution in its relation to medicine. (3) In order
to obtain a comprehensive understanding of the practice
of medicine, it was necessary to reject such of the teach-
ings of Virchovv and of his followers as were fallacious,
and to combine the clinical wisdom of the fathers of
medicine, from Hippocrates down, with the known facts
of experimental medicine and their correct interpreta-
tion, and thus to arrive at the true point of view from
which to study and to deal with the clinical problems
which were the concern of practitioners of medicine
and of each of its specialties. (4) The constitutional
factor in gynecology and obstetrics, as was equally
true of the other departments of medicine, was the
chief element in the clinical problems which confronted
the practitioner in dealing with disease and with
atypical organs and tissues and their functions. (5)
The recognition, comprehension, and employment of the
foregoing principles would greatly enlarge the powers
of the practitioner of medicine in diagnosis, prognosis,
and in therapy, and which would enable him to avoid
many common, if not habitual, errors, and positively
to substitute general nutritional and developmental
measures for the local measures currently employed,
and thus effect the cure, instead of the amelioration,
of his patient's condition when due to environmental
arrest. Further, it would enable him to give scien-
tifically based advice as to methods of living when
the biological type of the patient was recognized; to
promote the development of environmentally arrested
patients, and to enable them to maintain their health
by living within their particular potential or capacity
to produce energy, instead of attempting to live as was
physiological for typical individuals, but which would
cause disease in the arrested or hereditary and en-
vironmental devolutes. (6) There remained unsolved
two problems: (1) the process or mechanism whereby
atypical morphology and function of environmental
origin in ascendants became, at least, hereditary in
descendants. Apparently its solution would be found
in the facts of the maleficient consequences of urban-
ization in human stocks, which escaped extermination
by degeneration and disease, and the variations and
adjustments which ensued, whereby acquired immunity
was attained; and similar facts concerning the conse-
quence of the long continuance over generations of
other unfavorable environment, such as insufficient
nourishment, malaria, the hookworm, and food deprived
of some element necessary to nutrition, or so mistreated
as to be relatively poisonous. It might become demon-
strated by subjecting short lived animals to definite,
unfavorable environment, for twenty or more genera-
tions, and observing and correlating the facts thus ob-
tained. Facts from biology as to species of animals
and plants subjected for generations to inimicable en-
vironment would also aid in the solution. (2) The
eradication of degeneracy and its prevention would
probably find its solution in the development of euthen-
ics and in the segregation, or the sterilization, of indi-
vid. als manifesting the more marked degrees of de-
generacy, more especially of the hereditary types.
A Resume of Results in the Radium Treatment of
347 Cases of Cancer of the Uterus and Vagina. — Drs.
Howard A. Kelly and Curtis F. Burnam of Balti-
more said that after seven years' experience, and with
a full knowledge of similar work in other parts of the
world, they could now say without hesitation that the
use of radium in sufficient quantities greatly enhanced
the chance of permanent recovery of patients with
uterine and vaginal cancers. In early and good
operable cases the use of radium combined with opera-
tion added greatly to the prospect of recovery without
a recurrence. This was shown in a series of twenty
such cases in which they had as yet seen no recur-
rence. The most remarkable fact about the radium
treatment of uterine and vaginal cancers was that it
often cleared up those cases which had extended too
far locally and became firmly fixed to the pelvic wall;
in other words, in a class of cases which were utterly
inoperable. They had had 327 patients, including bor-
derline cases, cancers fixed to the pelvic wall, great
massive cancers choking the pelvis, and many with
general metastases, where the radium was used only
to afford relief; and yet over 20 per cent, of this
remarkable group had been apparently cured. They
did not pause here to dwell upon the great alleviation
afforded a large number of those who were not cured.
but where discharge stopped, pain ceased, and health
was built up. Their conclusion then was that radium
had come to stay and was a most efficient agent in
treating these cancers of the uterus and vagina.
X-Ray Treatment of Uterine Hemorrhage. — Dr.
Robert T. Frank of New York City said that x-ray
treatment was indispensable in gynecology, but under
strict indications and limitations. The rays worked
mainly by destroying ripening ovarian follicles, pri-
mordial follicles showing great resistance. When no
ripe follicles were present, menstruation ceased. In
fibroids there might also be a direct effect on the tumor.
Fractional exposure implied frequently repeated treat-
ments of small amount. This took more time, but per-
mitted of finely graded dosage. Intensive treatment
by use of small multiple fields permitted of rapid at-
tainment of amenorrhea. The rays could be used in
all functional hemorrhages (menorrhagia or metror-
rhagia) in which expert examination revealed normal
pelvic organs, and in which the curettings were free of
malignant changes. This saved the uterus of
adolescents and women in their sexual ripeness because
the bleeding could be "foned down." It also saved
women in the pre-climacteric age from operation, if
they were bad operative risks. The writer used x--ray
in about 5 per cent, of fibroids. Only 45 per cent, of
fibroids required any treatment. Bleeding was most
readily checked by raying. In order to permit of the safe
employment of x-ray, the writer postulated that no
cases should be rayed in which a suspicion of carcinoma
or sarcoma could be entertained, that no complications,
such as ovarian or adnexal tumors were present, that
no urgent symptoms were present. This limited the
treatment to clear cases of uncomplicated fibromyoma.
Preference should be given to the rays when extreme
psychical unrest or severe cardiac, renal or pulmonary
disease contraindicated operative measures. The ex-
pense entailed by raying precluded its use except in
well-to-do patients or in endowed institutions.
Precancerous Changes in the Uterus. — Dr. William
S. Stone of New York City pointed out the evolution-
ary character of the different types of cancer of the
uterus as beginning in definite benign lesions, such as
erosions, leucoplakia and glandular hyperplasia, which
showed variable quantities and qualities of epithelial
overgrowth and metaplasia that might differ little from
the regenerative activity observed in the benign lesions,
or after a longer or shorter time might show atypical
features that were differentiated with difficulty from
the alterations we knew typified malignant neoplasm.
To such pathological changes the author thought the
term precancerous might be appropriately applied, as
they appeared to represent changes that were neither
cancerous nor non-cancerous, but were in the stage of
becoming cancerous. Their relation to the development
of a cancerous growth was shown by the fact that their
morphological features included, in different combina-
tions of quantity and quality, the numerous histological
criteria upon which the diagnosis of a fully established
cancer was made, lacking only in some instances the
features of destructive activity and purpose. The
strongest support of this conception was derived from
the reproduction of types which were seen in the differ-
ent stages of their progress. In the author's material,
for example, he found the atypical features of a healing
erosion determined by the original type of the lesion
simple, papillary, follicular, and the atypical types
again reproduced in the different types of' fully estab-
lished uterine cancer. There were atypical erosions
which were prototypes of either an epidermoid cancer
or a papillary adenocarcinoma. There were leuco-
plakias which were prototypes of adult acanthomas.
There were glandular hyperplasias which led to
adenoma or adenocarcinoma. Finally, there were
focal areas of leucoplakia, combined with adenomatous
hyperplasia which might well furnish an origin for
tumors designated as adenoacanthomas. In short, for .
each type of fully developed carcinoma there was a
corresponding type of benign and intermediary change.
The literature had been critically reviewed, showing
increasing evidence confirmatory of the sequence of
benign lesions in the uterus and cancer, but the efforts
to define their histogenetic relation had been limited
to a few writers. To more fully verify the assumption
that morphological features of intermediary stages ex-
isted, a closer cooperation between the clinician and
the pathologist would be required. For the present, it
was no argument against such an assumption because
no tumor process was present or followed in a given
case. The evidence in the literature was already suffi-
612
MEDICAL RECORD.
LSept. 30, 1916
cient to show that a fully established cancer might exist
for a certain time without giving gross evidence of its
presence, and numerous cases were recorded in which
the curette had completely removed the disease. There
was no reason to assume that precancerous changes
without treatment must always develop into malignant
growths. Different types of fully established tumors
had a different capacity to grow and destroy rapidly
or slowly, and it did not seem reasonable to assume
that a developing cancer had the same momentum that
a fully established tumor possessed. In the study of
beginning cancer of the uterus several authors had di-
rected attention to the fact that a certain type of early
cancer might spread superficially over a wide area be-
fore showing marked invasive features, and it had
occurred to the author that such a mode of growth
might account in some measure for the extent of the
process before it received the attention of the clinician.
With the description of the author's cases there were
sufficient clinical data to show the practical side of the
problem, that the decision regarding the proper thera-
peutic procedure in such cases should be assumed by a
competent clinician.
Painless Labor. — Dr. J. Clifton Edgar of New York
City pointed out that shock from the pain of labor in
the highly civilized neurotic woman must be reckoned
in general child-bed mortality. Painless labor in these
women was a life-saving measure. The problem was
the control of the pain in the first stage, the longest
stage, after lasting a day or more. For the moment
there was no ideal single method of painless labor. The
only absolutely painless labor was one terminated by
surgical means with complete anesthesia. Conditions
would always arise, for example in early rupture of
the membranes in which the necessity for painless labor
would demand such surgical termination. The most
satisfactory painless labor method of the moment com-
bined opium and antispasmodics for the first stage,
with possible vapor narcosis towards the end of this
stage; vapor analgesia and anesthesia for the first and
terminal parts of the second stage respectively. The
narcosis aimed at should, until the perineal stage, be
analgesic and not anesthetic in character, whether by
drugs or vapor — a difficult or impossible object to at-
tain unless one had had considerable experience. In
analgesic work, there was the tendency of the patient
coming out from under the influence of the gas and to
suffer from the effects of shock due to the acuteness of
the suffering, or of anesthesia being produced with its
dangers in the hands of the novice. To sum up, nitrous
oxide-oxygen analgesia or "obstetric" ether or chloro-
form should be used for the second stage, pushed to
anesthesia for the perineal stage; possibly forceps de-
livery with vapor anesthesia to eliminate part of the
second stage. Nitrous oxide-oxygen analgesia or anes-
thesia was superior to any other during labor because
of its oxytocic action. Eventually an established
method of painless labor might be related to public
health questions. Lessening or abolishing the pain of
labor might in the future limit birth control and crim-
inal abortion. Drug addiction, after a pro'onged drug
narcosis in the neuropathic, was a possible contingency.
The dangers to the newlv-born child were negligible
when drug narcosis was limited to the first stage.
NEW YORK ACADEMY OF MEDICINE.
SECTION ON PEDIATRICS.
Stated Meeting, Held April L3, 1916.
Dr. Royal Storks Havnes in the Chair.
Meningococcus Meningitis with Unusual Hemorrhagic
Symptoms. — Dr. C. T. Sharpe reported this case, which
occurred in a child showing very severe symptoms of
meningitis. In addition to the symptoms typical of
meningococcus meningitis, hemorrhagic areas appeared
at various locations on the surface of the body. The
bacteriological examination of the blood from these
lesions revealed the presence of the meningococcus. Dr.
Sharpe said he believed that this was the first instance
in which the meningococcus had been isolated from a
skin lesion. He exhibited lantern slides showing the
appearance of the lesions.
Dr. HENRY Heiman said this case was of extreme
interest, and he had never seen anything just like it, one
so severe. If it had occurred during an epidemic one
would have said that it was a fulminating case, or if
there had been a number of similar cases one might
have thought they were due to a particularly virulent
strain of meningococcus, but this was the only case,
and he could only explain it on the theory that there
was a low degree of resistance in the individual. He
did not believe that the injection of serum into the
blood would have been effective in this case as the child
was lost from the beginning.
The Deficiencies in the Slate Law Regulating Over-
crowding in Institutions for Infants and Children. — Dr.
Thomas S. Southwokth opened the discussion. He
said that it was admitted on all sides that the mortality
among young infants placed in institutions was mucn
greater than it should be, and greater than if the in-
fants remained at home. Boarding out had been sug-
gested as a means of relief, but while boarding out
showed much better results than those of the poorest
institutions, the results did not notably exceed those
of the best institutions. Even if it were desirable in-
stitutions could not be done away with at once. Over-
crowding was one of the fundamental factors which
was definitely contributory to the mortality, but which
could be remedied. Overcrowding was permitted and
indorsed by their present inadequate and loosely drawn
State law which, for lack of anything better, was ap-
plied to children of very divergent ages, conditions, and
needs, and was largely robbed of whatever value it
might possess by a "joker" clause. Chapter XLV of
the Consolidated Laws defined the application of the
law in question as follows: "To every institution in this
State incorporated for the express purpose of receiving
of caring for orphan, vagrant, or destitute children, or
juvenile delinquents, except hospital." This law went
on to say: "The beds in every dormitory in such insti-
tution shall be separated by a passageway of not less
than 2 feet in width, and so arranged that under each
the air shall freely circulate, and there shall be ade-
quate ventilation of each bed, and each dormitory shall
be furnished with such means of ventilation as the
local board of health shall prescribe. In every dor-
mitory 600 cubic feet of air space shall be provided and
allowed for each bed or occupant, and no more beds
or occupants shall be permitted than are thus provided
for, unless free and adequate ventilation exists ap-
proved by the local board of health, and a special per-
mit in writing therefore be granted by such board."
The inference was that this law was framed to regu-
late the sleeping quarters of asylum or reformatory
institutions for older children who might reasonably be
supposed to spend a considerable part of their time
in other quarters during the day. There was no trace
of implication that it was intended to apply to infants
or to wards in which more or less sick infants lived
practically all the time, both day and night, during
a very considerable part of the year. It would appear
that it was the intention of the framers of this law
that there should be not less than 600 cubic feet of air
space per inmate, but this intention was nullified by tho
final or "joker" clause, which was perhaps appended
as a compromise. This clause granted to any local
hoard of health in the State the power to issue permits
for any larger number of inmates under certain con-
ditions as to "free and adequate means of ventila-
tion." Such adequate means of ventilation should
exist. When it came to the practical working of
the law in New York City one found that framed
permits were hung upon the walls of each ward stating
the number of infants allowed therein. Permits were
until recently granted by the Board of Health based
upon the number of square feet of floor space, allow-
ing about "ill square feet or slightly over, for each
inmate of the ward. This had recently been changed
to cubic feet, allowing about 500 cubic feet per in-
mate, and affording at times less than 50 square feet
of floor space in certain institutions, depending upon
the height of the ceilings. Dr. Southworth said he-
had been informed authoritatively that this amount
might be and was reduced legally as low as 200 cubic
feet per inmate in certain other types of institutions
covered by the law, and there was nothing to prevent a
further reduction below 500 cubic feel in wards for
infants. Whether the 600 cubic feet of air space per
inmate was or was not adequate for the dormitories or
sleeping quarters of older and presumably well children
he was not here to discuss, but he did with all earnest-
ness contend that the application of the law for the
lack of a better, to wards containing infants under
two years of age a n I i peciallj bottle-fed infants under
one year of age, since an allowance of only 500 cubic
feet, and perhaps less than 50 square feet of floor space
per infant, tended directly to increase both the morbid-
ity and consequently the mortality among such infants,
Sept. 30, 1916J
MEDICAL RECORD.
61!
a mortality which, in part at least, was preventable.
The origin and authority for the 600 cubic feet stand-
ard appeared to be lost in obscurity, but judging' from
the answers received in response to a questionaire sent
to the American Pediatric Society and compiled and
published in the Archives of Pediatrics, September,
1915, such space allowance fell far short of the 1,000
cubic feet demanded by the majority of pediatric opin-
ion throughout the United States. In all except pos-
sibly the most modern and enlightened institutions, bot-
tle-fed infants who remained for any considerable
length of time did not continue to be well infants, even
though they were admitted as such. The wards in
which such infants were cared for demanded the larger
nursing staff and adequate cubic air space of sick
wards. In whatever type of institution they were situ-
ated they were to all intents and purposes hospital
wards, not dormitories. Overcrowding meant a pro-
portionately decreased care of the individual infant and
undercare made for an increased mortality. With ex-
actly the same methods of feeding infants that had been
doing well with ample air space, when owing to new
admissions the point of overcrowding was reached,
ceased to gain, some lost rapidly, and there were a
number of deaths until the census of the infants was
again reduced. In short, modern feeding methods
failed, or availed only temporarily, to prolong the lives
of infants where overcrowding was permitted. With
our present knowledge it was not necessary to argue
that infections, both the more subtle respiratory types
and the openly contagious types, were more readily
spread by permitting closer proximity of the infants'
cribs. The question might be asked: "Why, if this
overcrowding so manifestly contributes to the mor-
tality, are not steps taken by the physician of each in-
stitution to reduce the numbers in the wards?" The
answer was that it was obviously difficult to convince
lay managers that the permits issued by recognized
authorities concerned with the enforcement of health
regulations did not represent the last word in the most
enlightened pediatric opinion concerning the needs of
infants. The Pediatric Section of the Academy of
Medicine had been asked to review this matter as a
section and from the pediatric standpoint. Dr. South-
worth said that he would suggest that the law be re-
vised ; that certain sections should be framed for orphan
asylums, reformatories, and older children; and sepa-
rate sections framed for young children and infants;
that provision should be made for ample space in sick
wards; that wards containing bottle-fed infants under
eighteen months of age should be specifically classed as
sick or hospital wards; that the amount of cubic space
allowed to each of these main groups should be based
upon modern pediatric opinion, and that there should be
no qualifying clauses permitting the purport of the law
to be nullified to suit individual caprice; that after basic-
space, which was sufficient with the windows closed had
been specified, further provision might then be made
for inspections and enforcement by local authorities,
with a view to assuring reasonable employment of tha
usual available means of ventilation. In closing, Dr.
Southworth stated that he did not claim that additional
air space was a cure-all which would remedy all the
difficulties in rearing infants in institutions, but he did
maintain that increasing the cubic air space was the
surest, most direct, and most feasible way of correcting
a number of the evils of institutional life.
Dr. Charles Gilmore Kerley said that the mortality
of young children depended on so many other factors
in addition to that of cubic air space that he felt that
this was comparatively speaking but a small part of
the subject. If the air was undergoing active ven-
tilation a smal cubic air space might answer very well.
One of the worst features met in institutions was thai
there was but one room for a group of children, and
there they must play, eat and sleep, and this was the
factor that did not obtain in ordinary dwellings. An-
other matter was with reference to an adequate sys-
tem of ventilation. In his experience with systems of
ventilation he did not know of one that reallv did ven-
tilate; when one wanted ventilation he still had to re-
sort to the open window.
Dr. Henry Dwight Chapin said that Dr. Kerley had
brought out the two points which he would emphasize.
We might have 1,000 or 10,000 cubic feet cf air space,
and if everything was shut un the supply of air might
be insufficient. The essential factor was to have an
adequate supply of freely moving fresh air and then
the cubic air space was not so important. It seemed
that the best way of dealing with institutions for in-
fants was to abolish them as far as possible. It had
been said that lay boards made the rule and doctors
followed them. The doctors should say that if con-
ditions were not improved they would no longer re-
main on the staffs of such institutions. We might as
well recognize the fact that the trouble was a lack of
force on the part of the doctor.
Dr. Floyd M. Crandall said this question had been
brought up for very definite reasons, particularly for
opinions with reference to accommodations for infants
and children in institutions as measured by cubic air-
space. This was what the discussion should bring out.
The question had come up whether the Public Health
Committee of the Academy of Medicine should take up
the modifying of this law. The question should be con-
sidered by pediatricians first, and the doctors who dis-
cuss it should bring out something definite and tangible.
Dr. Haynes suggested that the best way of obtain-
ing the opinion of the members of the Section would
be to appoint a committee which should submit a ques-
tionnaire to the members individually and then present
the results to the Public Health Committee of the
Academy.
This suggestion was acted upon.
The Hospital Control of the Infectious Diseases of In-
fancy and Childhood. — Dr. Dennett L. Richardson of
Providence, R. I., read this paper by invitation. He
presented some facts on the transmission of contagious
diseases learned by hospital observations. He said it
was pretty well established that the sources of any in-
fectious disease were three, namely, the clinical case,
the missed case, and the carrier. The disputed ques-
tions related to the methods by which the virus found
its way into the healthy person. Formerly the role
of air infection was given more attention than the
avoidance of infection by contact. Through the ob-
servation of some of the French investigators, the con-
clusion had been reached that the infectious diseases
were seldom air borne, and that isolation of the patient
was not complete unless rigid antisepsis was carried
out. The practical results obtained at the Pasteur and
other French hospitals had shown that the employment
of antiseptic nursing had made it no longer necessary
to house different diseases in separate pavilions. In
consequence of this there had developed several meth-
ods of construction by which one might obtain physical
separation of patients suffering from different in-
fectious diseases and yet treat them in the same ward.
These systems were: (1) The cubicle system, having
its origin in the Pasteur Hospital and consisting of
single rooms, the partitions being complete or only par-
tially reaching to the ceiling and arranged on both
sides of a common corridor; (2) the barrier system,
consisting of bed isolation of different diseases in a
large open ward; (3) the cellular block plan as con-
structed at the Plaistow Hospital, consisting of two
rows of rooms, back to back, with glass partitions be-
tween them, each room leading to an open veranda on
either side of the building. The statistical records of
London hospitals into which these systems were intro-
duced demonstrated the success of aseptic nursing. They
showed, however, that measles and chickenpox were
the most difficult of the infectious diseases to care for
by aseptic nursing. In March, 1910, aseptic nurs-
ing was first undertaken by the Providence City Hos-
pital, which, through the efforts of Dr. Charles V.
Chapin, who had made a study of contagious disease
hospitals abroad, was constructed in accordance with
the theories of medical asepsis. In this hospital pa-
tients suffering from contagious diseases were accom-
modated in three pavilions, arranged parallel and con-
taining about 140 beds. Two of these buildings were
duplicated, each floor being so arranged that about
one-half the patients could be placed in rooms off the
central corridor and containing from one to three beds
each, while there was a convalescent ward with fourteen
beds at the south end of the building. At the present
time one of these dunlicate buildings was devoted to
scarlet fever. The first floor of the other building
housed the diphtheria patients; the second floor was
used for an isolation ward in which various infectious
diseases except measles and chickenpox were cared
for. These latter highly transmissible diseases were
not included because the nursing in these buildings was
largely done by pupil nurses. The third building pro-
vided for the care of any infectious disease, including
smallpox. Every room was provided with a lavatory,
where the water must be turned on by forearm or foot
levers, and where nurses and physicians must wash
contaminated hands in running water with soap and a
614
MEDICAL RECORD.
[Sept. 30, 191G
scrub brush. Immersion in an antiseptic solution was
also required after such diseases as measles and chicken-
pox and smallpox, and very septic cases of other infec-
tious diseases. Elaborate construction alone was quite
unable to prevent cross infection ; proper management
was of far greater importance. The latter resolved itself
into proper admission of patients to prevent mistakes
of diagnosis, securing a history of other infectious dis-
eases in the home, active and intelligent observation of
the patients for signs of secondary disease, careful
attention to the health of all employees, and the proper
and efficient sterilization of hands, utensils, and linen
between different infectious units. At the time of ad-
mission all doubtful cases were isolated until the diag-
nosis was clear. Nurses were impressed with the im-
portance of asepsis and taught the details of its ad-
ministration. When a patient was ready for discharge
he was given a soap and water bath and shampoo.
This bath was given the day before discharge, and the
patient was then put into a clean room set aside in each
ward as a discharging room. When the mother came
for the child clean clothes were put on him, and if he
presented no symptoms after a careful examination he
was taken away. The rooms had never been fumigated
since the opening of the hospital, but the floors an&
furniture, and in the isolation wards, the walls within
easy reach, were washed with soap and water. A care-
ful record had been kept of the room or rooms occupied
by each patient, and he had never been able to trace
any cross infection to this source. Infected linen was
collected under aseptic precautions and placed directly
into the washers, where it was washed by boiling water
and its sterility tested by cultural experiment. No
sterilizing washers were used. All the elaborate tech-
nique of caring for the patient was supplemented by
careful supervision of the nurses and the entire hospital
personnel. Resident physicians wore white suits. Over
their shirts they wore a short-sleeved washable vest,
outside of which was worn the usual white coat. When
visiting patients the coat was removed and a gown was
worn only when making careful physical examinations.
The doctor always scrubbed his hands when going from
one infectious disease to another. From March 1, 1910,
to January 1, 1916, 6,748 patients had been discharged
from the hospital. Among these there occurred 166
instances of cross-infection. The diseases contracted
were as follows: measles, 48 instances; chickenpox, 78:
scarlet fever, 19; diphtheria, 10; rubella. 4; whooping
cough, 4, and mumps, 3. The total incidence for the
whole hospital was 2.4 per cent. If from the total
number of discharges 2,029 adult patients suffering
from tuberculosis and syphilis were subtracted, leaving
4,689, the incidence was 3.5 per cent. There had never
been a cross-infection between the tuberculous and
syphilitic patients. Nearly all instances of infectious
diseases arising among employees had occurred among
pupil nurses. Aside from the nurses, among 229 em-
ployees, only five contracted an infectious disease.
These results demonstrated that rigid asepsis was of
primary importance. Hospitals for infectious diseases
and for children should not have wards of over six to
ten beds, and should have sufficient smaller units to ac-
commodate all patients for an observation period. Con-
servative and accurate diagnosis of patients on their
admission and careful supervision would prevent the
entrance or continued residence in the same unit of
patients suffering from more than one transmissible
disease. Among forty-two house officers serving dur-
ing the period under consideration, two developed diph-
theria and one both mumps and rubella.
Dr. GEORGE DRAPER discussed the hospital care of
poliomyelitis. He said that a most notable feature
with reference to Dr. Richardson's paper was that no
mention was made of poliomyelitis. There were two
reasons why there were so few cases of these cases in
this great institution: First, poliomyelitis had essenti-
ally a rural distribution, and, secondly, sporadic cases
in the city unusually came into the large general hos-
pital. The care of poliomyelitis in such a hospital as
Dr. Richardson had described was a simple problem.
The management of this disease was essentially the
same as that of scarlet fever and diphtheria. Perhaps
particular stress should be laid upon caring for secret a
and excreta. There had been a number of instances of
cross-infection recorded in Sweden, and among nurses
a number of cases had been reported in Europe and
America. Their protection, as far as our present
knowledge went, depended upon the rigid care of the
hands, nasal passages and mouth. The control of the
disease in hospitals must be similar to that of other
diseases. Possibly in addition there hould be special
care given to the nose and throats of contacts. The at-
tendants should use a spray of peroxide solution, or of
menthol in oil. Quarantine was at present their best
defense in the control of the disease in the community.
While most of the means of transmission of polio-
myelitis had been determined, some apparently still
remained hidden. It had not yet been determined why
one infant in a family contracted the disease and not
others in the same family; why some sections of a com-
munity had a number of cases and others not, and why
at another time it would be found in that section of
the community which before was free. The part played
by abortive cases and healthy carriers must still be
cleared up. Contacts must be thoroughly controlled
and likewise the carriers and the patients, and the same
rigid quarantine must be maintained as in other in-
fectious diseases, though it had not been definitely
demonstrated that the virus found in the nose and
throat of healthy carriers transmitted the disease. The
duration of the activity of the virus in convalescent
patients was important. A case had been reported of
a child having two attacks of the disease two years
apart, and five months after the second attack it still
harbored the virus. In monkeys the virus usually dis-
appeared in five or six weeks, but in certain individual
monkeys it might persist four or five months. The in-
cubation period of poliomyelitis was normally two to
seven days, but there might be a very long latent period,
as in one case which had been recorded of a young wo-
man who was committed to prison and who developed
poliomyelitis two months after her admission to solitary
confinement.
Dr. Henry Heiman spoke of the epidemiology of
meningococcus meningitis, and said that this presented
features at times so strange and puzzling and so dif-
ferent from the characteristics usually associated with
other contagious diseases that its contagiousness had
been questioned by not a few observers. As a rule
there was no regular progression or extension of the
disease. It moved by leaps and bounds and struck
haphazard. In considering the hospital control of in-
fectious diseases from the standpoint of meningococcus
meningitis, it was advisable to consider first the mode
of transmission of the disease. It was well known
that the disease was a communicable one, and that it
occurred in epidemics. It was also endemic in New
York, as were most of the other communicable dis-
eases. It was generally conceded that the mode of
transmission was by means of Flugge's droplet infec-
tion; that was, that the meningococcus was transmit-
ted to the exposed mucous membranes of previously
healthy persons. Meningitis might or might not be the
result of this transmission, depending upon the sus-
ceptibility or resistance of the individual. A study of
the natural history of the meningococcus made it im-
probable that the disease was transmissible through
the agency of the atmosphere of lifeless objects, but
from one individual to another. This did not neces-
sarily mean from patient to patient, but it did mean
that in most cases the source of contagion was a
healthy or apparently healthy meningococcus carrier.
Experiments had shown that there were from ten to
twenty times as many healthy carriers as there were
diseased carriers or patients. Therefore, in order to
properly control the spread of meningococcus menin-
gitis, they must devote their attention to prophylactic
measures. In hospitals these measures were the gown,
the hand brush, and disinfectants; and it would seem
rational to add the usual measures, the gargle, and
the cleansing of the naso-pharynx of the physician, the
nurse, or of any one coming in contact with the patient.
The disinfection of all the excreta of the patient, es-
pecially those of the respiratory tract, was of the utmost
importance. Experience had shown that absolute quar-
antine in a hospital was not necessary, as transmission
of the disease in hospitals was comparatively rare; how-
ever, the infection of nurses attending cases had been
reported. School infections, though rare, had been re-
ported by Bolduan and Goodwin and Netter and Debre.
The latter observed 10 cases, six of which attended a
common school. Among 231 pupils in this school, 40
were found to be meningococcus carriers, that was,
21.21 per cent. Flugge reports that 70 per cent, of
those living in close proximity of a meningitis patient
became carriers. Netter and Debre found 41.66 per
cent, of those coming in contact with patients having
meningitis became carriers during the months of
March. April and May, while during June, July and
August onlv 26.66 became carriers. It would not be
Sept. 30, 1916]
MEDICAL RECORD.
615
amiss to have occasional cultures of the nasopharynx
taken from doctors and nurses attending cases of
meningitis. Overcrowding in hospitals during an epi-
demic of meningitis should be avoided. The advisa-
bility of sending meningococcus meningitis cases to the
hospital should be urged upon the public, not only for
the sake of preventing the spread of the disease, but for
better observation and better control of the disease by
laboratory methods. If patients remained at home, they
should be isolated, and intermingling between mem-
bers of the family and the outside world restricted as
much as possible. Children belonging to the family
of the patient should not be permitted to attend school
for about three weeks from the onset of the disease,
unless they could be proved by bacteriological methods
to be non-carriers. In concluding, Dr. Heiman empha-
sized the importance of the healthy carrier in the
transmission of meningococcus meningitis, and said
that attention should be directed to these almost as
much as to the patients themselves. Prophylactic
measures directed along these lines would probably
help to lessen the dissemination of this disease.
Dr. William H. Park discussed the control of diph-
theria. He said it was interesting to observe how a
paper like Dr. Richardson's was received. Ten years
ago they would have thought that the methods de-
scribed were not efficient quarantine. They would have
thought that caring for two kinds of infectious diseases
with only a partition open at the top between them
was not effective quarantine. As to diphtheria and the
Schick test, a negative Schick test could be absolutely
relied upon as evidence that an individual was immune
to diphtheria, except in very young infants. Dr. Hess
had had one baby that gave a negative Schick test and
three months afterwards developed diphtheria. This
was because in early infancy the child still had its
mother's immunity, which it lost later. Dr. Park said
their views with reference to active immunity had
changed. They had found that about 90 per cent, of
those who were given immunizing doses of toxin-anti-
toxin did not develop antitoxin for some weeks, so that
in hospitals the production of active immunity was only
of practical value for physicians and nurses, but for
the protection of the patient they must still rely upon
passive immunity. Up to the present time nothing had
been discovered that was effective in the treatment of
diphtheria carriers. A careful antiseptic toilet of the
nose and throat simply covered up the bacilli and after
a few days without treatment they again showed them-
selves. The only measure that seemed to be effective
was the removal of the tonsils. The production of
active immunity to diphtheria had a wide field of use-
fulness.
Dr. Bertram H. Waters discussed the subject of
whooping cough in relation to hospital control. He
said it was rather difficult to speak on this subject since
so few cases of whooping cough were sent to the hos-
pitals. It was estimated that only about 50 per cent,
of the cases of whooping cough were reported and only
a very few oi these came under the control of the hos-
pitals. Whooping cough presented a rather difficult
problem, and the Department of Health did not super-
vise cases of this disease because of the difficulty of
obtaining early reports and since the period of infec-
tivity of the disease was during the time before a
diagnosis was made, and also because of lack of men
and funds to carry out such work, all of these being
needed to look after the more severe forms of infec-
tious disease. At the present time they were consid-
ering the advisability of requiring a two weeks' quar-
antine for whooping-cough cases, that would cover the
first week and aid in controlling the infection during
the second week. Dr. Waters expressed the opinion
that the use of the vaccine gave very promising results
in immunity, as was shown by the work of Dr. Park
and Dr. Hess.
Dr. Alfred F. Hess, in discussing the hospital con-
trol of measles, said that this subject was particularly
interesting because the mortality of measles in hos-
pitals was so different from the mortality in the homes.
The hospitals^ however, were not so much to blame for
their high mortality. They had found that about one-
third of the hospital cases of measles were under two
years of age. Again the mortality from measles was al-
most entirely due to pneumonia. During: March they had
had 25 deaths due to pneumonia; 21 of these cases were
admitted to the hospital with pneumonia and four de-
veloped in the institution. In February there were 17
cases of pneumonia admitted and two developed the
disease after admission to the hospital. The high mor-
tality from measles and penumonia in contagious dis-
ease hospitals was largely due to the fact that they
received the very severe cases, and that the very severe
cases were transferred to the hospital from homes and
institutions. Since there was no specific treatment for
measles and penumonia, it might be advisable to direct
their treatment to the pneumonia and give the patient
the treatment for this disease. They had always been
afraid of fresh air for cases of measles and shut these
patients up, but when measles was complicated with
pneumonia it would be well to make an exception and
give the patient the benefit of fresh air. Furthermore,
unless it was absolutely necessary, no case of measles
under two years of age should be sent to the hospital.
A mother would be willing to care for a child with
measles if told that children with measles did better
at home than in a hospital. They should get the co-
operation of the community to keep these young chil-
dren with measles out of the hospitals.
Dr. Haven Emerson said that New York as well as
the rest of the country was indebted to our teachers
from Providence. The fact that the New York De-
partment of Health had abandoned fumigation might
be attributed to the teachings of Dr. Chapin. In their
new hospitals for infectious diseases they had prac-
tically followed out his plans of construction with very
slight modifications. When it came to confining infec-
tion to the individual they must establish the same
teaching among medical nurses that they had been em-
phasizing in the training of surgical nurses, that was,
they must be taught aseptic technic. If this were
possible there was no reason why these diseases could
not be treated in a department of a general hospital.
If this could be done it would effect a great economy
since it cost a great deal to keep up a large number
of beds simply on the possibility that they might be
needed at certain seasons. It would be a great econ-
omy if they could use these beds all the year around,
and this could be done by absorbing the acute infectious
diseases of childhood during the season when they were
most prevalent, and then caring for chronic cases, such
as tuberculosis and syphilis when the acute infectious
diseases were less prevalent. Dr. Emerson also empha-
sized the desirability of having physicians teach the
people to keep children under two years of age with
measles at home. He said it was really a question
whether they ought to be admitted under any condi-
tions, certainly only when the home conditions were
such that it was absolutely impossible to give them the
first elements of decent care. There would always
be a need, however, for some hospital that would care
for measles in New York City. There was also the
question of the advisability of admitting cases of
whooping cough (and they would make every effort to
admit these cases) when they occurred in a family in
which there was a child under two years of age who
would be exposed to the infection. Dr. Emerson also
suggested that it might be proper to provide a hos-
pital care for cases of gavus and ringworm, since a
number of children lost a great deal of time from school
on account of these conditions.
Dr. Richardson, in closing, said that from what Dr.
Park had said it seemed that their work was more or
less misunderstood. They had a ward for scarlet fever
and one for diphtheria, into which they had introduced
other diseases occasionally. They also had three iso-
lation wards for various infectious diseases. The plan
of admission which they carried out was a process of
filtration, keeping all the new patients in small units
for a one-week period of observation. Their plan
meant more to the small town or the small city that
could not afford to have a hospital for each infectious
disease. In a small city where there was a necessity
for economy,, this plan could be carried out if one knew
the underlying principle, that was, that contact infec-
tion, infected human beings, and not environment, wan
the soui-ce of infection, and if they could control the
contacts, the mild cases and the clinical cases, they
could have much better control of infectious diseases.
Dr. Haynes asked Dr. Richardson how his statistics
with reference to cross-infection compared with those
of other hospitals.
Dr. Richardson replied that few American hos-
pitals had published reports on that point. The only
one he knew of was Dr. Auker of the St. Paul County
Hospital: he gave the number of cross-infections and
the number of cases of infectious disease among em-
ployees and nurses. This was the only report beside
that of the Providence City Hospital in this country
that gave this data, but some of the foreign reports
616
MEDICAL RECORD.
[Sept. 30, 1016
showed that for scarlet fever and diphtheria the num-
ber of cross-infections had been as high as 7 per cent.
Dr. Kerley asked Dr. Richardson if he had had any
experience with reference to the incubation period of
scarlet fever.
Dr. Richardson replied that the shortest incubation
period he had known was thirty-six hours, and as to the
other limit he did not think anyone knew. If a child
came into the hospital with scarlet fever, and if at
the end of four weeks it was necessary to detain him
for a day or two, and then another child came in from
the same family, one could not say whether he was
infected by some other child at home — a mild case that
had escaped detection — or whether the incubation period
had been long, that patient having been infected by the
hospital patient admitted four weeks before. Had the
hospital case returned home, the second case would
have been looked upon as a return case.
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Pathology of Tumours. By Dr. E. H. Kettle.
Published by Paul B. Hoeber, New York, 1916. Illus-
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Localization by X-rays and Stereoscopy. By
Sir James Mackenzie Davidson. Published by Paul
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Price $3.00.
Bacteriology, General, Pathological and Intesti-
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Published by Lea & Febiger, Philadelphia and New
York, 1916. Illustrated with 98 Engiavings and 9
plates. 651 pages. Price $4.50 net.
The Treatment of Diabetes Mellitus, with Ob-
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by Lea & Febiger, Philadelphia and New York, 1916.
Illustrated. 440 pages. Price $4.50.
A Manual of Otology for Students and Prac-
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and New York, 1916. Illustrated with 120 Engrav-
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A Manual of Fire Prevention and Fire Protec-
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State Department of Health. Published by John Wiley
& Sons, Inc., New York, 1916. 69 pages.' Price $1.00
net.
Diseases of Occupation and Vocational Hygiene.
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Published by P. Blakiston's Son & Co., 1012 Walnut
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The Practice of Obstetrics. Designed for the Use
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Simple Treatment for Cleansing in Otitis Media.
— Coble recommends the following on account of the
materials being found in every home as well as for
the known antiseptic properties: Carbolic acid,
minims 40-60; water, one quart. Where the per-
foration is large or the drum membrane almost de-
stroyed, and the discharge has a foul odor, the
following prescription has decided beneficial quali-
ties:
K Boracic acid, grs. xx
Ethyl alcohol, ,-,j
The canal must be first thoroughly cleansed with
boric acid solution, dried, and then a diluted solu-
tion of the above dropped well into the canal and
allowed to remain until the smarting ceases. A
one to three solution should begin the treatment
and the strength gradually increased until the orig-
inal prescription is employed. — Indianapolis Medical
Journal.
Gargle for Adults. — For an astringent and anti-
septic gargle Coble recommends :
K Ethyl alcohol, gij
Cinnamon water, .-,ij
Formaldehyde, Tinij
Glycerin, ."v
Distilled w:ater, q. s. ad. §viij
Simple Rules for the Prevention of Chronic Dis-
eases of Metabolism. — Greely, in discussing dia-
betes, offers these suggestions for rational living
and the prevention of metabolic conditions: The
training should begin for the child with the parents
and continued until the son or daughter is able to
control his or her own life: (1) Thorough masti-
cation prevents indigestion, overeating, and bad
teeth. (2) Thorough mastication does away with
excessive drinking at meals and thus overcomes a
tendency to avoirdupois. (3) The amount of
starches, meat, and sugar in the diet should be
reduced to a minimum and a corresponding in-
crease made in the amount of vegetables and fruits
eaten, especially in adults performing but a moder-
ate amount of work. One cereal food is sufficient
at each meal. (4) The final rule of health offered
is to live more slowly, and to encourage every man,
woman, and child to cultivate a hobby, a resource
for happiness in their hour of need, when the real
work of life must be suspended. — Wisconsin Medi-
cal Journal.
Simplest Cure for Scurvy. — Fruit juices, orange
or prune, are the time-honored remedy for infantile
scurvy, but the white potato has proved just as
efficacious and within the reach of the poorest
family. The proportion generally used is one table-
spoonful of mashed potato to one pint of water, and
added to the twenty-four hours' feeding of milk in
place of the usual cereal diluent. The potato should
be pared very thin and an average-sized potato
when mashed covers the amount needed. The
mashed potato can be added to the water in which
it is boiled and thus all of the vitamines conserved.
Remedy for Carbuncles. — Apply collodion over
hyperemic area except the central one-fourth inch
space. Cut crucial opening in this space from
center toward periphery and inject the following
solution:
i; Acidi carbolici sat., gtt. xx.
Glycerin, .~ij
Aqua dest.. ."ij
Dress with sterilized gauze dipped in bromine, 1 —
500, or chlorinated soda in 10 to 25 per cent, solu-
tion. Remove all sloughs. — Medical Summary.
Medical Record
to
A Weekly Journal of Medicine and Surgery
Vol. 90, No. 15.
Whole No. 2396.
New York-, October 7, 1916.
$5.00 Per Annum.
Single Copies, 15c.
©rtQtnal Artirks.
THE PROBLEM OF REST OR EXERCISE IN
THE TREATMENT OF PULMONARY TU-
BERCULOSIS; A PLEA FOR LESS
ERGOPHOBIA.
By CHARLES L. MINOK.
ASHEVILLE, N. C.
In the treatment of pulmonary tuberculosis there
are no more important measures than rest and ex-
ercise. On their wise and judicious use rests a
large part of the success of our therapeutic meas-
ures. In the past a vast number of consumptives
have come to their end directly through an injudi-
cious use of exercise, and the advice "get a horse
and ride out West" so frequently given thirty years
ago was undoubtedly of more benefit to the under-
taker than to the patient. Reacting from this rash
and foolish use of excessive exercise, our profes-
sion have learned the priceless lesson that in the
beginning of the treatment of tuberculosis rest is
always indicated and the reclining chair and the
cot have replaced the mountain climb and the horse-
back ride with the happiest effect. Twenty years
ago many patients came to me suffering from the
effects of excessive exercise. I recall two slender
young Irish girls from a large Massachusetts town
who called me in when one had fainted as the result
of a five-mile walk. They were advanced cases of
active tuberculosis with excavation, yet the only
advice their home doctor had given them was to
avoid doctors, to eat freely, and to walk as many
miles daily as they could. This advice they had
proceeded to carry out, with afternoon temperatures
of 103° and over and with the result noted. By
absolute bed rest their fever was brought down,
their symptoms greatly ameliorated, and the ac-
tivity in their lungs decreased, and while one was
past any cure the other lived for many years a
happy if semi-invalid life. Probably any of my
auditors could duplicate such a history, but even
among general practitioners, to-day there are few
to be found who would give such advice. The pro-
fession have at last painfully learned that rest is
good in the treatment of tuberculosis and patients
get much more careful attention on this score than
formerly. But doctors, like all other men, are
prone to run to extremes, and, while I realize how
heretical it may seem to say so, I find that to-day
many men are tending to push rest to an unwise
extreme. I see patients so indoctrinated by their
medical advisors with the idea of the essentiality
of rest that when they are discharged they are
afraid to move, and they live a useless life, recum-
bent on the sofa, refusing to exert themselves in
any way, and for all the good they are to them-
selves or the community they might as well have
died rather than recovered, if such a life can be
called recovery. Patients with normal temperature
are kept flat on their backs laying up useless pounds
of fat rather than turning that fat to muscle by
judicious graduated exercises. Weight as weight
and not as representing vitality and working effi-
ciency is looked on as the summum bonum and good
in itself, and such stall-fattened patients are only
fit for the eternal quiet and contemplation of a
Thibetan monastery.
If I were talking to a body of general practi-
tioners I would not speak in this way, for they
might misunderstand it, and it is far safer to
overdo rest than to return to the former overdoing
of exercise. But before a body of clinicians and
specialists like this, I can speak freely and not be
misunderstood, and for such I believe it is wise to
stop a moment and consider in how far rest and
in how far exercise are desirable in the treatment
of pulmonary tuberculosis.
It is needless in studying this question to go
back in the history of medicine to show how intel-
ligent were the views of Hippocrates and Celsus,
or to review the dispute between Brehmer, with his
theory of the small heart in tuberculosis and the
consequent need of active exercise, and the wiser
view of his pupil Detweiler, who, seeing the bad
effects of over-exercise, advocated recumbent rest.
We need only go back to the time when our great
American leader in Phthisiotherapy, Dr. Trudeau,
as he has so graphically told in his autobiography,
went in the 70's to the Adirondacks for his health,
and, as we can now realize, wasted much of his
superb vitality and his opportunity of permanent
cure in over-exercise. By degrees, by the experi-
ence of his own case and that gotten with many
patients, he was brought to use the rest he had so
neglected, and among his followers, not merely in
Saranac but all over our land (for he was verily
the medical father of all American phthisiothera-
peutists whether they had worked under him or
not), we find a realization of the value of rest, a
healthy fear of the danger of exercise, which in that
day was most certainly justified.
The Adirondack recliner soon dominated the hy-
gienic management of the disease, and many were
saved who, had they exercised, would have been
lost.
What is the basis for the success of rest? First,
it lessens circulation and hence toxin absorption.
Second, it lessens oxidation and lowers temperature
and so decreases tissue waste. Third, it puts tfte
diseased lung at rest. Fourth, it rests the heart.
Fifth, it lessens cough and expectoration, probably
because quiet decreases physical and pathological
activity in the diseased foci. Sixth, it encourages
weight gaining. Seventh, if properly managed, it
helps to put the mind at rest.
Now, all these things are admirable, and, in
618
MEDICAL RECORD.
[Oct. 7, 1916
certain stages of the treatment, essential, but there
comes a time when disadvantages show themselves
and when too long continued rest ceases to be of
value and becomes harmful.
When the temperature falls, when the afternoon
figure is not over 99.4°, when the pulse slows, show-
ing a decrease of toxin absorption, when strength
is improving, when the trouble is less active and
we desire to develop the compensating functtion of
the healthy part of the lung by the quiet, deep
breathing, or by judicious exercises, when cough
and expectoration are much reduced and we can,
therefore, assume that there is less ulceration and
activity in the diseased area, when the patient needs
the stimulus of hope and the encouragement of a
positive proof of his improvement, when his gain
of weight is marked and without exercise is apt to
produce fat rather than muscle, then I believe we
should take up exercise, not merely on the theory
of Pattison, in which I concur, in order that the
patient may undergo an autotuberculin treatment,
but to prepare him, when he shall be restored, to
resume his life in a normal way and not to be
turned, as too many now are, into pulmonary hypo-
chondriacs. Because it has been abused many men
are afraid to mention the word exercise, just as
bleeding was unjustly discredited from its one-time
over-use, but exercise is just as essential in phthisi-
otherapy as is rest, and should be dominant in the
latter months of any successful cure. Beginning
with from one to five minutes, according to the case,
and increased by from one to five minutes a day
and guarded by a careful record of symptoms,
fever, and pulse, kept by the patient, which the
doctor should see twice a week, and stopped or de-
creased just as we would tuberculin if a reaction
occurred, it need subject the patient to no risk.
It should be worked up very gradually through the
course of weeks and months to as much as three
hours on a stretch of walking or eighteen holes of
golf. This brings the patient to the end of his cure
fit and strong rather than fat, with a weight not
over or even slightly under his insurance standard,
full of healthy vigor, not afraid of himself, know-
ing how much he can do and what he cannot do, and
ready to resume his work with a chastened knowl-
edge of his former hygienic sins and a confidence
that in the future he will know how to combine
health with work.
And how shall we safely gauge the use of rest
and exercise? First, it is essential that the doctor
keep a close tab on his patient's life, at first bi-
weekly, then weekly, and never less than once in
two weeks, so as to detect and remove over-exer-
tion.
Temperature. — Of our guides, temperature is the
first and best. Every patient, whether febrile or
not, should, when first beginning treatment, go
through a period of absolute rest not merely for
its therapeutic effect, but that we may become fa-
miliar with his normal run of temperature. If we
find after a few days a normal temperature, and if
the other data are favorable, we can allow him up,
and give him increasing graduated walks, to be
measured carefully by the watch. If the tempera-
ture in the afternoon is as high as 99.4° he can be
gotten up at first in the morning only, then in the
afternoon as well, and finally all day, the graduated
walks coming a little later when he has proved that
his trouble is inactive enough not to show a fever
rise after talking, reading, or visitors. If it is
99.6° to 100.6°, bed rest, while not absolutely essen-
tial, is best till it gets and keeps the temperature
down as it usually does, but if the patient is of a
restless, fretful, high-strung temperament it is
often wise to allow an hour or so in the morning
in a reclining chair. If the temperature is 100.6
or over, absolute bed rest is necessary, though I
cannot agree with those extremists who insist on
the use of the bed pan and the urinal and absolute
recumbency without motion, for I think, for psy-
chological reasons, this is undesirable. In cases
where persistent bed rest fails to reduce tempera-
ture, and yet where the general condition is fair
or good, I, at times, experiment with getting the
patient up, and occasionally find that the tempera-
ture will thereupon disappear. It is scarcely neces-
sary to note that the doctor must be sure that the
patient is not running a concealed night tempera-
ture. During bed rest it is most important to keep
the patient heartened up and to teach him mental
relaxation and resignation, for many patients who
are at physical rest in bed are in a constant mental
turmoil, and kicking against the pricks, which is
as bad, or worse, for them than physical exertion.
Pulse. — Unduly rapid pulse (100 or over) is a
good indication for rest, but when on experiment
we find that moderate exercise causes no rise, it
need not be an absolute indication for rest, but only
for the reclining chair. Further, some people run
constitutionally fast pulses, and if we can be sure
of this it can be discounted.
Cough and Expectoration. — Abundant cough and
expectoration are made worse by talking, laughing,
and walking, but such cases are apt to be febrile, so
we do not need this as a guide. Blood streaked or
pink expectoration is an absolute contraindication,
but I have seen patients in whom such blood streak-
ing was apparently a permanent habit, even when
they were febrile and doing well, and after long
tests I have, with great benefit, allowed walking in
such cases.
Weight. — Any patient who is losing weight, save
unduly fat ones, where we wish to allow a slow and
cautious reduction, must be at chair rest, or at
times bed rest. A poor weight, however, is not
necessarily a contraindication in a patient who is
normally spare but is wiry. In considering weight,
I find it of great value to record not merely the
patient's average weight, but his average best
weight, his absolute best, and his insurance stand-
ard as gotten from the tables, and I like to keep
the latter before me as my ideal for him; and I con-
sider it unfortunate for him to surpass that ideal
very much, a really fat patient not being a good
result of our treatment.
Fatigue is one of our best guides. A little healthy
tire, passing off rapidly, has no significance, but to
get really tired or fagged is bad, whatever the
temperature or pulse may be. However, if the
patient's exercise is increased by a little each day,
this can be entirely avoided, save as an indication
of an intercurrent congestion.
Mental Attitude. — A patient who has been treated
by prolonged bed rest is usually much afraid of
. n\ exercise, and has to be brought to it very grad-
ually, for to make him do what he considers dan-
gerous is unwise; but since the proof of the pud-
ding is in the eating, he will soon be converted if
he finds the one, two, or three minutes have no bad
effects. Of course, mental rest is much more diffi-
cult to obtain than physical. A patient may be
lying quiet in bed, and yet, unknown to us, may
be worrying or suffering, and fearing terrible
things. This is difficult to find out. Yet, if we
are to help our patients, it is up to us to discover
Oct. 7. 1916J
MEDICAL RECORD.
619
it, and it is at this point that the phthisiothera-
peutist must take on the character of the kind and
sympathetic, but firm, father confessor, in order
that the patient may practise with him that mental
catharsis which alone can put his mind at rest. In-
deed, so essential is mental rest that we should
never be satisfied until we have secured it for our
patients, if possible.
Methods of Exercise. — In the bed patient, it may,
though very seldom, be necessary to give artificial
exercise in the form of abdominal or limb massage
(never chest) to keep his digestion going and to
burn up waste products. The first step toward
exercise is in sitting in a reclining chair for half
an hour, the time to be lengthened each day, two-
thirds of it spent recumbent, one-third erect, and
for this a proper chair, which will lie back flat, or
come straight up by the motion of the patient's
body, is essential; and such a chair must have an
absolutely fiat back, to encourage erect shoulders,
which I believe to be most important for the tuber-
culous patient. For the patient who has to be con-
stantly recumbent there is nothing better than the
Adirondack recliner, but when he reaches the stage
of sitting up he cannot let down his legs, and, its
adjustment not being automatic, it discourages fre-
quent change of position, which is important to
prevent tiring of a single set of muscles and to
prevent fatigue or monotony. In this case, the
Bloch chair is much better. The next step in exer-
cise is crocheting for women, solitaire for the men.
and reading for both of them, but any of these can
raise temperature if overdone. Next comes walk-
ing, according to the rules already noted. To my
mind, no other exercise can compare with it, and
it can be perfectly graduated from the very short-
est, quiet stroll to a brisk morning's walk uphill
and down dale, as indicated. Driving is not as
passive and easy for patients as short walks, and
no one drives for less than fifteen minutes or half
an hour. Moreover, the temptation to overdo is
much greater, and the patient does not have the
natural warning of his overdoing. Autos are easier
than carriages, but I allow neither one or the other
until the patient can walk from one-half to an hour
without bad effect. When a patient has been
afebrile for a long time, when the process is inactive,
with no moisture and little or no expectoration, I
allow, in selected cases, short rides on a racking or
pacing, but never a trotting horse. This is espe-
cially good for dyspeptics, and can be worked up
by degrees from one to two hours. To those of
limited means, trolley riding is enjoyable, and it
can be allowed sooner than carriage driving, if the
trolley is near the house. After the patient can
walk easily for an hour on the level, I have him
begin the ascent of increasingly steep hills until
the rather steep hills in Asheville can be easily
taken, and I am never fully satisfied with the pa-
tient, on discharge, if he is unable to walk three
hours over our hills with no undue dysconea. with
no loss of weight, fatigue or tachycardia. This is
the nearest I can come to a test of his ability to
stand the tax of his work, and his ability to do
this easily shows me that his physical force is re-
established and that he should have such vitality
as to enable him to complete the fibrosis of his case
and to resume a normal life. What a difference
between such a patient, rosy, strong, with firm
muscles and bright eyes, with full knowledge of
the possible dangers of relapse, yet also with the
knowledge of how to prevent it, and, on the other
hand, the fat, puffy, timid one, just up from his
couch, afraid to make any exertion, and prizing
each pudgy pound of fat, which, if he but knew
it, represents a burden rather than an asset.
After all, we are not trying merely to save our
patients' lives but to return them to normal, useful
activity so strengthened that they can reasonably
be expected to stand its strain, and so instructed
that they will take the happy mean between a timid
anxiety lest they relapse and that foolhardy over-
doing, and return to old indiscretions, which is so
sure to land them into trouble.
Aside from the physical advantages of handling
our cases with a less unreasonable fear of exercise,
are its manifest psychic advantages. It breeds
courage instead of timidity, hope instead of fear,
and thus it makes the mental attitude much more
favorable for getting a good result. We doctors
are too apt to treat our patients' bodies and not
their minds, but every patient that leaves the cure
must not only be physically rebuilt; he needs, with
rare exceptions, to be mentally rebuilt, to be a
better man, with more will power, with more knowl-
edge, with more determination, with more self-
mastery than he had before, and in the mental
education which leads to this I believe that a less
timid use of exercise can play a large part.
61 French Broap Avenue.
HISTOPATHOLOGICAL CHANGES IN FIVE
CASES OF MYELITIS.
By G. B. HASSIX. M.D..
ATTENDING NEUROLOGIST, COOK COUNTY HOSPITAL.
i From the pathological laboratory of Cook County Hospital,
Chicago.)
That the histopathological changes in various or-
ganic nerve lesions are not confined merely to the
nerve structures, but are also to be found in the
neuroglia tissue, is a fact established principally by
the late Alzheimer and his pupils. Indeed, the
pathological findings in the glia so far are even of
a greater variety and interest than those furnished
by the nerve tissue proper. It is, therefore, of great
importance to follow up the possible changes in the
glia, as well as in the nerve elements, in each or-
ganic nerve lesion and point out their characteristic
features.
As I have had the opportunity to study five cases
of myelitis, three of which were due to Pott's dis-
ease, I wish to give a brief outline of my findings,
as they pertain principally to the changes in the
glia.
Case I. — Woman, 31 years old, entered Cook County
Hospital April 17, 1915, with a spastic paraplegia of
eight months duration. The paraplegia was associated
with a total anesthesia of the lower half of the body,
incontinence of the bladder and rectum, exaggerated
tendon reflexes in the lower limbs, bilateral patellar and
foot clonuses, positive Babinski and Oppenheim, and a
positive so called "defense'' reflex, i.e. flexion of the toes
(down) caused various spontaneous movements of
flexion — extension of the paralyzed lower limbs. The
abdominal reflex was absent. The anesthesia reached
the umbilicus in the form of a circular line around the
body, and three weeks later it was found at the level
of the nipples. At the same level a kyphosis was pres-
ent. A Roentgen examination showed a large abscess
in the region of D 3 — 8 vertebrae and a post mortem,
done May 23, 1915, the day following the patient's
death, revealed an abscess in the above area, project-
ing anteriorly into the chest cavity. The sack of the
abscess was thick filled with cheesy yellow tuberculous
pus. The bodies of the vertebrae, at this level, were
eroded, and the cord compressed, in fact was almost
620
MEDICAL RECORD.
[Oct. 7. 1916
totally severed, and hardly any substance suitable for
sections was here left. The meninges, at this level,
showed no infiltration, which was very pronounced in
the lowest portions of the spinal cord and around the
cauda equina. The gross examination of the spinal
cord showed, at the level of 5th and 6th dorsal verte-
absence of reactive activity on the part of the glia, the
presence of patches of myelin with relatively good con-
dition of the axones and the presence of methyl blue
granula.
The microscopical examination of the patches them-
selves shows them surrounded by a wall of glia fibers
1 w&
L'lG. 1. — Patch of softening in the lateral column, at /.
bra?, a triangular cavity, protruding into the posterior
columns and the posterior horns. In other places, below,
instead of a cavity a round or oval patch of softening
could be detected occupying the same place, but in
other sections it occupied the lateral columns between
the posterior and anterior horns (Fig. 1). In other
places the spinal cord appeared collapsed and disfigured.
Thus, on Fig. 2 the upper portion of the spinal cord
can be seen turned toward the right in the form of an
arch ending in a patch of gray matter consisting of
Rolando's substance and remnants of gray matter. A
part of the latter is to be found also back of the central
canal. Such changes are known as heterotopic changes,
and are considered as artefacts, due to the handling of
the spinal cord which in this case was extremely soft,
resembling a thick milky fluid.
The microscopical examination showed, above and
below the destroyed areas, the usual picture of ascend-
ing and descending degenerations, which were studied
along with the patches of softening with various meth-
ods: Weigert-Pal, Mallory's anilin-blue, Mann, Biels-
chowsky, Marchi, Herxheimer, Nissl and combined
Marchi-Mallory methods.
1(
V/ I-
' \
Kio. 2. — Heterotopic changes in the spinal cord.
On Mallory anilin-blue and Mann methyl-blue — eosin
specimens the degenerated and healthy zones showed
preserved medullated axones, but in many places the
myelin appeared in the form of yellowish patches or
leaves. Many portions of axones therefore were totally
uncovered, and the visual field appeared dotted with
numerous yellow patches of myelin scattered amidst
blue axones.
In the diseased areas, some of the latter were some-
what swollen, spindle shaped, and on anilin-blue speci-
mens counter-stained with osmic acid, they clearly
showed the crossings of Ranvier around which the
myelin patches were especially numerous.
Chromed sections counterstained with anilin-blue re
vealed quite numerous blue granules scattered all along
the axones and the neighboring glia tissue. These
granules are evidently what Alzheimer described as
thy] blue granula" (Pig. .'!). The glia libers were
very thin, forming delicate meshes studded with numer-
ous glia cells and amyloid bodies. The characteristic
feature of the spinal cord changes of the regions not
directly involved in the softening, were almost total
my el
Fig. 3. — mg, methyl blue granules . «x, axone ; mycl, myelin
globules.
and consisting of enormous amount of fragments of
axones and myelin. Some of the broken axones are
tortuous, swollen, thickened, but are not surrounded
by glia. The latter shows the usual network of some-
what thickened and proliferated fibers and protoplasma
poor glia cells, containing nuclei with numerous dots
within ("caryolysis"). Occasionally, but very rare,
so-called granular bodies ("Gitterzellen") could be seen
within. In general, the patch impresses one as an order-
less mass of debris of broken up axones and myelin
scattered among the meshes of glia tissue which does
not show the reactive changes as observed in cases of
secondary degeneration. Neither Marchi nor Herx-
heimer scarlet red stains show the presence of fat in
the patches. It is an established fact that when a nerve
fibre is damaged, i. e. is broken up in smaller frag-
ments, the gila quite early (during the first few days
according to Jacob) begins to manifest various reactive
changes of proliferative nature. Thus, the glia cells
are transformed into complicated structures — myelo-
clasts, myelophags — which break up the scattered
debris into smaller particles and transform them in
lipoid substances which, in their turn, are picked up by
other gliogenous cells, the so-called granular, honey-
combed, bodies ("Gitterzellen" of various types) and
thus finally removed to the blood vessels. The field is
then cleared away from the damaged tissue, is as the
German authors say, "abgeraumt."
As it can be seen, in this case the damaged nerve
tissue, the debris of axones and myelin were not
removed, were not buried, as it were, because there
were no signs of activity shown by the glia tissue.
The latter was evidently rendered by some patho-
logical process as helpless as the nerve tissue itself,
and we must assume that the pathological condition
of the spinal cord was that of partial necrosis or
softening, also known as myelomalacia.
In myelomalacia we thus find lack of reactive
activity on the part of the glia, in the presence of
broken up fragments of nerve tissue. Somewhat
of a different character are the pathological changes
as found in another case of Pott's disease.
Case II. — Man, 22 years old, entered Cook County
Hospital June 5, 1915, with a paraplegia which rapidly
developed within the last two weeks. He became totally
helpless during the last ten days. About eight months
previously he fell on his back, but was not confined to
bed. The previous and family histories were good.
Examination. The patient is extremely pale and
emaciated with normal mentality and normal cerebral
nerves. In the left supraclavicular space, and just in
front of the left trapezius muscle there was a
painless mass, the size of a hen's egg, freely movable.
It anpeared five days before the patient became para-
lyzed. A similar mass was present in the left pectoralis
major near its origin, extending from the 2d to the 5th
rib. Below this mass there was another swelling the
size of a half dollar. The puncture showed the presence
Oct. 7, 1916]
MEDICAL RECORD.
621
of pus which was removed, but the mass filled up again.
The neurological examination showed a complete spas-
tic paraplegia with increased tendon reflexes, positive
Babinski, Uppenheim, and a bilateral patellar clonus.
The defense reflex was very marked, but the abdominal
and the cremasteric reflexes were absent. There was
incontinence of bladder and rectum. The paralysis was
associated with complete anesthesia up to the navel,
while from the latter up to the ensiform process the
pin pricks were perceived as "finger touch." A couple
of weeks later, the anesthesia reached the level of the
fourth rib. The Roentgen examination done repeatedly
proved negative. The luetin, Wassermann in sp. fluid
were negative (blood gave a positive Wassermann). In
the further course of the disease, bed sores rapidly de-
veloped, and the patient died December 12, 1915.
The post mortem was performed four days later and
among other findings, it revealed diffuse tuberculous
masses in the lungs, a large tuberculous abscess over
the 5th and 6th dorsal vertebra? and an extensive peri-
pachymeningitis over the dorsal and lumbar regions.
Nowhere was the spinal cord compressed or disfigured
as in the Case I. Weigert-Pal stain showed marked
ascending degeneration especially in Goll columns and
a descending degeneration in the pyramidal tracts. In
addition, there was a "patch" of softening involving
one of the posterior horns and a portion of the posterior
columns in the lower cervical region.
Longitudinal and transverse sections of various por-
tions of the spinal cord were studied on frozen, celloidin
and paraffin sections with the staining methods of
Mann, Mallory's anilin-blue, Hevxheimer, Weigert-Pal
and Alzheimer's Lichtgrun-Acid Fuchsin.
glia
Fig. 4.— am, Ameboid glia cells ; axoph, axophags ; ax,
axone ; v, blood-vessel with granular bodies (g) in the ad-
vential space ; fk, fiillkorperchen.
The patch contained enormously swollen axones (Fig.
4), pale and homogeneous in appearance, bluish in color.
Occasionally there could be found axones unusually thin
and densely red. Some of the axones showed excava-
tions (Fig. 4) filled with glia cells, so-called axophags
first described by Buchholz in a case of myelitis in 1S99.:
Everywhere there were scattered, in large quantities,
granular bodies which on scarlet red specimens stained
according to Herxheimer showed the presence of fat.
No glia cells or glia fibers could be detected, these hav-
ing been replaced by pale homogeneous protoplasma
rich cell bodies with a densely stained, so-called pyc-
notic, and eccentrically located nucleus — ameboid glia
cells (Fig. 4, am). In other places the glia tissue was
replaced by small round or quadrangular in shape bodies
described by Alzheimer as "Fiillkorperchen (Filling
bodies) Fig. 4. The same ameboid glia and Fiillkor-
perchen were in evidence in the degenerated columns
of Goll and the pyramidal tracts which were packed
with the above-mentioned granular bodies.
The striking feature, in every soecimen, was the so-
called ameboid transformatior of the glia tissue, in the
form of the ameboid cells and Fiillkorperchen. On
Lichtgrun-fuchsin specimens numerous red, dust-like
granules covered the ameboid glia, so-called fuehsio-
phile granules of Alzheimer.
The patch thus shows in this case findings en-
tirely different from those in the previous case.
We do not see here the broken up fragments of
nerve tissue helplessly scattered among the meshes
of glia fibers as if waiting to be removed, but we
find here lipoid substances enclosed within numerous
granular bodies, so-called "Gittezellen." Instead of
neuroglia tissue we find ameboid glia cells and Full-
bodies of Alzheimer, both these elements actually
dominating the histopathological picture. In this
ease the broken up or damaged nerve elements evi-
dently were already transformed into lipoid sub-
stances and partly removed. Accordingly we see
here along with signs of primary nerve degenera-
tion those of secondary degeneration, both being in
evidence on the same specimen. The secondary de-
generation is represented by vacuoles, which con-
tain fragments of axones, myelin or gliogenous for-
mation described by A. Jacob as myeloclasts, myelo-
phags, while the primary degeneration is repre-
sented by swollen and excavated axones, axophags,
and lack of glia proliferation. The glia, as I said,
was here universally replaced by ameboid glia and
Full-bodies, which types being entirely foreign to
typical secondary degeneration were present on
every specimen of the gray and white matter. We
can therefore speak of universal ameboid trans-
formation of the glia in this case, as it was present
in every portion of the spinal cord even where the
axones and myeline were undamaged.
The biological significance of the ameboid glia is.
according to Alzheimer,3 to help "liquefying" the
damaged nerve tissue and thus to clean up the latter
from various catabolic products, the so-called "Ab-
baustoffe." The ameboid glia does not produce
fibers, and it is not certain whether it picks up
broken up nerve tissue. At any rate, the presence
of ameboid glia indicates, according to Alzheimer,
a profound, far-gone destruction of nerve elements,
a possible serious infection or intoxication. There-
fore, Case II, with its universal ameboid trans-
formation of glia, must be considered of much more
serious character than Case I, where no ameboid
glia was present and where the clinical symptoms
and the course were as compared with Case II con-
siderably milder in character.
Case III. — The pathological findings varied again in
the third case, a woman, 35 years of age, who entered
Cook County Hospital July 26, 1915, with complete
paraplegia which she stated existed for fifteen _ days.
About two years previously her spine was badly jarred
from a fall, for which she has been treated for 18
months in a hospital (had a cast) . Six years previously
she had pleurisy. The examination showed an emacia-
tion, kyphosis in the upper dorsal and lumbar regions
and some rales in the base of the lungs. The lower
limbs were totally paralyzed, but as in the previous two
cases the so-called defense reflex was present. The
paraplegia was spastic, with exaggerated tendon re-
flexes, Babinski, Oppenheim, and total anesthesia up to
the level of the fifth dorsal vertebra, combined with com-
plete paralysis of the bladder and rectum.
The Roentgen examination revealed a marked bone
degeneration of the 4th, 5th, 6th and 7th dorsal ver-
tebras which showed signs of caries and collapsed bodies.
The 12th dorsal and the first lumbar vertebra? also were
extensively involved.
Enormous bed sores developed and the patient died
December 14, 1915, after two years of illness.
The post mortem revealed among other findings an ex-
tensive peripachymeningitis covering the D 3-5, the
entire lumbar region and the cauda equina ; caseous
tuberculosis of D 3-12 and L 1-3 vertebras; marked
compression of the spinal cord adjacent to D 3-5; a
slight encapsulated nodular right apical tuberculosis,
tuberculous abscess (bilateral) of the psoas muscles and
necrosis of the D 2-4 vertebras bodies.
The spinal cord appeared microscopically perfectly
normal on transverse sections, but the microscopical
examination studied with various methods, mostly on
622
MEDICAL RECORD.
[Oct. 7, 1916
frozen sections, revealed all over the spinal cord a
typical picture of myelitis. On every section the so-
called Swiss cheese appearance of the spinal cord was
clearly seen, the fields of vision having been every-
where covered with numerous vacuoles. A great many
of these were empty, i. e. without any contents, but
some contained remnants of axones and myelin sur-
rounded by normal or modified glia tissue. The changes
in the axones themselves were confined to their tume-
faction which, however, was not so pronounced as in
the previous case, but as in the latter the most inter-
esting changes were found in the glia. The marginal
glia, the white and the gray matter showed presence
of numerous ameboid glia cells, frequently in a condi-
tion of so called cystic degeneration, or in the form of
minute granules. Numerous minute blue granula were
scattered all over the grey and white matter, so-called
methyl blue granula (on Mann specimens). Full-
bodies, so numerous in the previous case, were here
scant, but the granular bodies, the so-called 7 variety
of "Gitterzellen" were present in large amounts. On
Herxheimer specimens they showed enormous quanti-
ties of lai-g drops of fat. The vessel walls showed in-
filtration with lymphocytes. In some areas the micro-
scopical picture was that of typical secondary degen-
eration which, at the first glance, very much resembled
that in amyotrophic lateral sclerosis, but differed from
the latter by the presence of the ameboid glia which is
foreign to amyotrophic lateral sclerosis.4
The typical picture of myelitis, combined with
that of pronounced secondary degeneration, is the
characteristic feature of this third case, contrary
to the focal necrosis and the pronounced phenomena
of primary nerve degeneration found in Case II.
Before we proceed with the discussion of the variety
of the microscopical findings in these three clinically
similar cases I wish to briefly mention the findings
in two other cases apparently of different etiology.
Case IV.— Mrs. J., 36 years old, married, with a good
previous and family history, entered the Cook County
Hospital August 13, 1915, with a spastic paraplegia.
The latter existed for about ten months and developed
gradually during the previous six months after a severe
fall on her back. At the time of her admission to the
hospital she has been complaining of severe, sharp, cut-
ting pain in the limbs, in the back and a tingling sen-
sation in the left forearm.
Examination showed a well-nourished white woman
lying with the thighs flexed on the abdomen, and the
legs on the thighs. Any voluntary movements in the
lower limbs were impossible and the passive greatly re-
stricted. Thus the right leg, by using great force, could
be straightened almost in full, while the left leg, even
with a considerable effort used, could be extended but
to a limited extent. The upper limbs were normal in
every respect. The abdomen showed a marked rigidity
on the left side where a hard mass, somewhat nodular
in shape and enlongated, was felt rising from the pelvis
up to the level of the costal margin (rigid muscles).
The abdominal reflex was absent, the tendon — patellar
and Achilles — greatly exaggerated, with a right ankle
clonus, positive Babinski and Oppenheim. Patellar
clonus could not be obtained on either side. Flexion of
the toes caused flexion-extension movements in both
lower limbs ("defense reflex"). Sensibility examination
revealed anesthesia for pain up to the seventh rib, and
a marked hyperesthesia up to the second. The tempera-
ture senses (heat and cold) were lost up to the second
rib. The muscle sense was present. The bladder and
rectum — paralyzed. The spinal fluid was under the in-
creased pressure, gave a positive Wassermann, positive
Ross Jones and Noguchi and 30 lymphocytes per cubic
millimeter. A Roentgen examination by Dr. E. S. Blaine
revealed a shadow of increased density on the left side
of tin seventh cervical vertebra covering the trans-
\. rse process. The latter was seen to be complete, how-
ever."
Syphilis was denied, and there was but one preg-
nancy that ended on the third month in a spontaneous
abortion.
The patient suffered greatly from pain in the rigid
abdomen that resembled a tumor, and from the in-
voluntary discharges.
Mercury inunctions and potassium iodide given for
a month were without effect.
The history and the ..-ray findings suggested an
extradural lesion which was interpreted as a possible
tumor, or bone changes caused by the fall, but which
was shown by the post-mortem to be a hypertrophic
pachymeningitis of the upper dorsal region. An ex-
ploratory laminectomy was suggested which the patient
readily consented to. It was done on November 27,
1915, by Dr. Morf in the region of the third, fourth
and fifth dorsal vertebra?. The dura was slit for two
inches in the mid line, but no tumor was found. The
patient made a nice post-operative recovery and a
month later she was transferred back to the neurological
service in practically the same condition as before the
operation. The anesthesia was found almost complete
up to the level of the fourth rib.
In the further course of the disease, the patient de-
veloped a cystitis, bedsores in the lower limbs, and a
hypostatic pneumonia to which she succumbed March
14, 1916.
The post mortem done within the first 24 hours
showed numerous calcified, bony plaques all along the
posterior portion of the pia, and an enormusly thickened
dura in the region of the seventh cervical segment
stretching down to the middle dorsal region. The thick-
ening was Vz inch in width and comprised the posterior
and lateral surfaces of the spinal cord, but was more
pronounced in the posterior portion. The spial cord
was greatly reduced in size in the region corresponding
to the thickened membrane.
There were customary changes of secondary degenera-
tion found in the cervical and lower dorsal as well as
in the lumbar regions, while in the upper dorsal, corre-
sponding to the area of the thickened dura, there were
changes of a different character. A very small patch
of softening was present near the posterior commissure,
in the posterior columns involving but one segment
(approximately the fourth dorsal), and the micro-
scopical examination on frozen sections stained with
Mallory's anilin blue, Mann's methyl blue-eosin, Biels-
chowsky and Herxheimer's scarlet red gave findings as
follows: Numerous well retained axones surrounded by
an undamaged myelin sheath ; many of the axones were
tumefied, tortuous, with knobby thickenings, and fre-
quently.broken up in small fragments enclosed within
Vacuoles. Numerous so-called Marchi globules ("Marchi-
Schollen") situated in long rows were present in the
places of former axones.
More interesting were the findings in the glia, where
a great number of protoplasma rich glia cells could
be seen, but where the glia fibers were frequently re-
placed by so-called Full-bodies of Alzheimer.
These Full-bodies entirely filled, on some sections,
the spaces between the nerve fibers, and were distinctly
seen on every specimen stained with Mallory's anilin
blue, Mann and Bielschowsky's silver nitrate method.
On the latter specimens, the visual field was totally
covered with these bodies among which solitary well-
preserved axones could be seen running. Ameboid glia
cells were also frequently found, of large size and
occasionally cystic in appearance, but surrounded by the
Full-bodies. Other glia cells showed in the form of myelo-
clasts, myelophags and various forms of granular bodies,
so-called "Gitterzellen," principally of a and y varieties.
These granular bodies were surrounded by Full-bodies,
but not by glia fibers as in amyotrophic lateral sclerosis,
though in less damaged areas glia fibers could be dis-
tinctly seen.
The most characteristic feature was the ameboid
transformation of the glia which is almost pathogno-
monic for the various forms of degeneration to be found
in myelitis. The silver-nitrate specimens stained ac-
cording to Bielschowsky show, with the low power,
numerous islands resembling those in the degenerated
posterior columns of tabes.' However, with the high
power, the islands appear in myelitis consisting of a
mass of Full-bodies among which run solitary axones,
which in tabes, at least on my specimens, are sur-
rounded not by Full-bodies, but a mass of delicate glia
fibers.
Outside the foci, in the dorsal region, for instance,
the spinal cord shows completely preserved axones, but
profound changes in the glia — its ameboid transforma-
tion. The transverse sections of such areas, not dam-
aged by the myelitis, shows a network of ameboid glia
that ev( rywhere surrounded the normal nerve fibers.
The vessel walls, the adventitial spaces, were infiltrated
with numerous granular bodies and surrounded by Full-
bodies, while in the posterior columns numerous methyl
blue granules could be seen.
The microscopical picture thus showed a localized
myelitis with combined involvement of the neuroglia
Oct.
1910J
MEDICAL RECCKD.
623
and nerve elements. The peculiar features were, in
this case, the widespread neuroglia changes even
where the nerve fibers were well preserved, and the
etiology, in the form of a pachymeningitis. Whether
the latter caused the myelitis by edema or direct
pressure or toxins I will not discuss this question,
but will point out the relatively mild findings in
the nerve fibers as compared with those in the glia.
That this case was not a tuberculous myelitis is
proven by the absence of any primary foci any-
where in the body and by the absence of peripachy-
meningitis which was so pronounced in the previous
three cases. Yet in this case the pathological pic-
ture of myelitis, though less severe, was somewhat
resembling that in the previous three cases with a
different etiology. In Case V we have the most
interesting clinical as well as the histopathological
findings.
Case V. — Man, 31 years of age, cook by occupation,
entered the Cook County Hospital with a flaccid para-
plegia, retention of urine, and feces and anesthesia up
to the inguinal region on both sides. The paralysis set
in suddenly three days before he entered the hospital,
preceded by a burning sensation all over the body and
retention of urine which lasted for two days previous to
the paralysis. Five days previous he contracted a gon-
orrhea. Fifteen years ago had a chancre. The patient
was married, but had no children. His wife had one
miscarriage.
Examination showed a well-nourished male, with
normal mentality, normal pupillary reaction and normal
cranial n.n., normal heart and lungs. The abdomen was
greatly distended, tympanitic, no tenderness, no tumor.
Inguinal glands palpable. A purulent discharge con-
taining gonococci from the urethra. The lower limbs
were in a condition of flaccid paralysis with complete
loss of the tendon reflexes, absence of Babinski and
Oppenheim, loss of abdominal and cremasteric reflexes.
Marked anesthesia up to the inguinal region, and hypo-
esthesia up to the level, midway between the umbilicus
and ensiform process. The patient suffered much from
persistent vomiting, great abdominal distention and
labored breathing. The condition grew worse and the
patient died March 15, 1916, one week after he entered
the hospital, and ten days after the onset of the
paralysis. A diagnosis of lumbar myelitis was made,
probably of gonococcus origin. Wassermann in the spinal
fluid was positive, Nonne and Noguchi also positive. Lym-
phocytes in the spinal fluid showed 30 cells per c.mm.
The post mortem showed a diffuse myelitis of the entire
lower half of the spinal cord and a large focus of sof-
tening in the lumbodorsal region. The lumbar enlarge-
ment of the spinal cord was the seat of a large soften-
ing, one inch long, occupying the posterior half of the
spinal cord. The adjoining dura showed no changes.
In the lower dorsal region another focus of softening
was present. In the remaining portions of dorsal region
of the spinal cord a diffuse infiltration was noticed,
obscuring the distinction between the white and gray
matter.
Transverse and longitudinal sections from various
levels were stained with Nissl, Mallory, Mann, S-
fuchsin-lichtgriin, Mallory's hematoxylin and Herx-
heimer.
The most interesting findings were in the glia, which
in some places (in lumbar region, for instance) was
totally replaced by ameboid glia and Full-bodies which
could be found even in the normal areas. The ameboid
glia cells were unsually large, excavated, eaten away, as
it were, the excavations having been filled with glia
cells. In other places the ameboid cells appeared cystic,
in the presence of a large number of unchanged pro-
liferated, glia cells. The blood vessels were unusually
proliferated, hyperemic, their lumen often restricted,
the adventitial spaces — packed with a large amount of
Imyphocytes (Fig. 4) and granular bodies filled with
fat (Herxheimer scarlet red stain). The gray matter,
especially the posterior postions in the damaged areas,
was rich in Full-bodies, ameboid glia, and methyl blue
bodies, the changes in the ganglion cells and axones
having been not very pronounced.
The areas, not directly involved, as the upper dorsal
and cervical regions, also showed glia changes, in the
form of ameboid glia. The anterior, the lateral columns
which practically contained normal fibers showed ame-
boid transformation of the glia. Some of the ameboid
cells were cystic, granular, containing a shrunken
nucleus eccentrically located. Full-bodies in the un-
damaged areas were exceptional.
As this case was posted on the fifth day after death,
there were, as in Case II, numerous changes present
due to post-mortem changes as described by Rosenthal,"
especially on lichtgriin-fuchsin specimens. I will not
touch upon these findings which I shall report in full
some time in the future.
The glia changes in this case were of much graver-
character than in any of the previous four cases —
they were more pronounced and more widespread.
The question arises whether the severity of the
clinical symptoms, of their course, reflects in any
way upon the condition of the glia, or vice versa,
whether the degree of glia changes can give any
idea of the seriousness of the nerve lesions. This
problem was studied experimentally by F. Lotmar'
on rabbits, in which he produced myelitis and
encephalitis by injecting the dysenteric virus either
in the form of sterile agar cultures of B. dysen-
teric or in that of a solution of toxins. The in-
jected animals were left alive from fifteen to twenty-
one days, some having succumbed to the infection,
some having been killed by bleeding. Of fifty-five
animals thus experimented upon twenty-four were
killed and showed pathological changes in the cen-
tral nervous system, which changes he divides in
two types. To type I he refers those cases of acute
myelitis, where the degeneration of the nerve fibers
was associated with the ameboid transformation of
the glia; to type II he refers cases in which the
destruction of nerve tissue was combined with glia
changes of progressive or proliferative character.
Lotmar found a clinical and pathological difference
in both these types. The pathological features in
type I were hemorrhages in the tissues and around
the vessels, exudation of fibrin, of polynuclear leu-
cocytes, thrombosis of the vessels, degeneration and
vacuolization of the, ganglion cells, swelling of the
axis-cylinders and ameboid transformation of the
glia with changes of the marginal glia in the form
of so-called glia reticulum. The glia in this type
of myelitis lacks reactive activity. It does not and
cannot replace the defects caused by the dying or
dead nerve tissue.
In type II the glia, on the contrary, shows re-
markable activity and replaces the damaged nerve
elements, the vessels, the endothelium and the ad-
ventitial elements proliferate. The glia is in this
type stimulated, forms numerous granular bodies
rich in lipoid substances, while in type I the glia
is insufficient, is unable to replace the dead nerve
tissue, and thus must necessarily reflect upon the
clinical picture. Indeed, in myelitis type I the ani-
mals live a very short life, only one rabbit could be
kept alive for seven days, while with type II the
animals could be kept alive up to twenty-one days,
and then their life was cut short artificially.
The course was very mild in type II, the paralysis
and other clinical phenomena having disappeared
at the time of death, while in type I the symptoms
showed no retrogressive signs. The prognosis was,
therefore, bad in type I and comparatively good in
type II. Such pathological and clinical manifesta-
tions much depended upon the dose injected and
also upon the individual resistance of each animal.
Small doses of the dysenteric toxin usually caused
the milder type II, the large doses, type I, while
medium doses would cause either type or a mixed
type, depending upon the individual resistance. In
the mixed type lesions peculiar for either type may
obtain or in the same focus of myelitis lesions of
624
MEDICAL RECORD.
[Oct. 7, 1916
both types may be present. The reason why type I
gives a bad prognosis Lotmar sees in the fact that
the ameboid glia, though able to retain in loco the
products of the broken up nerve tissue, cannot
transform them into lipoid substances, which pro-
cess is accomplished by the mesodermal elements
of the blood vessel walls. Therefore, this type of
myelitis is rich in so-called prelipoid substances
which are not yet converted in fat and which on
suitable specimens show as various granula — fuch-
sinophile, lichtgriin, methyl-blue granula, etc. In
type II a powerful glia proliferation takes place
with enormous production of fat into which the
dead or broken up nerve tissue is transformed and
thus rendered harmless, which is not the case in
type I. In the latter the glia is "insufficient," and
cannot transform the products of plasma desintegra-
tion into lipoid substances. These products may
thus reach the blood and create a general danger
for the entire body. Such an occurrence is im-
possible in the type II, where the glia is "sufficient,"
producing granular bodies, which retain the dan-
gerous products until rendered harmless.
F. Lotmar's instructive conclusions were arrived
at from experiments on animals. It was, therefore,
interesting and even imperative to determine
whether human pathology ofiers any facts similar
to those established by F. Lotmar. In the five cases
of myelitis I studied with the same methods used
by Lotmar the pathological findings as I showed
somewhat varied in each case, but one feature was
common, namely, the ameboid transformation of the
glia, which was very pronounced in four cases out
of five. In one case (Case I) the dead focus was
sequestered and walled off from the rest of the
tissues, and no ameboid glia could be demonstrated
in this case, while in two cases (II and V) with
especially severe and rapid course the ameboid
changes were equally severe. Yet in both these
cases the pathological findings were different from
those in Lotmar's experiments, i.e. in none of my
cases was type I of Lotmar present, but always
combined with type II. In other words, the mixed
type of myelitis, as given by Lotmar, was the char-
acteristic feature in every case where the ameboid
transformation of the glia was pronounced. This
was very severe in the cases II and V, which also
clinically showed a rapid malignant course (Case V)
and a profound general intoxication (Case II). The
clinical facts are thus in complete accord with the
serious pathological changes of the glia. The con-
dition of the latter may probably indicate the extent
of the lesion of the nerve tissue, the extent of intoxi-
cation or infection or, as Alzheimer puts it, "the
more the neuroglia resembles the ameboid type the
more profound are the pathological changes in the
central nervous system which changes may, to a
certain extent, be measured by the degree of the
ameboid glia formation."
REFERENCES.
1. Jacob, Al tons: Ueber die feinere Histologic der
Sekundaren Faserdegeneration in der weissen Substanz
des Riickenmarks (mit besonderer Beriicksichtigung
der Abbauvorgange) in Nissl-Alzheimer's Histolog
und Histo-patholofjische Arbeiton iiber dip Grosshirn-
rindo, L912, Vol. V, Helte 1-2.
iuchholz: Ein Beitrag zur Patholog. Anatomic
der Myelitis (Montaschr. fur Psychiatrie und Neurol-
ogie, 1899, Vol. V. p. 346).
3. Uzheimer, Alois: Beitrage zur Kenntnis der
pathologischen Neuroglia und ihrer Beziehungen zu den
Abbauvorgangcn im Nervengewebe (Nissl-Alzheimer's
Arbeiton, 1910, Vol. Ill, Heft 3).
4. Hassin, G. B.: Beitrage zur Histopathologie der
Tabes Dorsalis (Neurol. Centralbl., 1914).
5. Hassin, G. B.: Histopathological Changes in a
Case of Amyotrophic Lateral Sclerosis (to appear in
the Journal of Nervous and Mental Disease).
6. Rosenthal, Stefan: Experimented Studien iiber
Amoeboide Umwandlung der Neuroglia (Nissl-Alz-
heimer's Arbeiten, 1913, Vol. VI).
7. Lotmar, Fritz: Beitrage zur Histologic der akuten
Myelitis, etc. - (Nissl-Alzheimer's Arbeiten, 1913, Vol.
VI).
3059 Jackson BOULBVABD.
BRAIN-TUMOR OR HYSTERIA.
By J. VICTOR HABERMAN, A.B., M.D., D.MS. (Berlin,,
NEW YORK.
INSTRUCTOR IN CLINICAL PSYCHOLOGY AND PSYCHOTHERAPY.
iSOF PHYSICIANS AND SURGEONS, COLUMBIA UNIVER-
SITY ; ATTENDING PHYSICIAN IN NECROLOGY, VAXDER-
EILT CLINIC. NEW YORK.
The following case is one of peculiar interest from
the point of view of diagnosis — and the frailty of
diagnoses — and of considerable importance in
elucidation of the difficulty that may at times arise
in differentiating an hysterically patterned clinical
picture from one actually and pathologically occa-
sioned. This history also points to discrepancies in
hospital observations, difficult to explain.
The patient, L. R., 31 years of age, was first seen
by me at Roosevelt Hospital in mid-September, 1913.
The history given by the patient at that time was
that she suddenly became sick in March, having been
entirely well previous to this, and after trying home
treatment, or no treatment at all, for a few months,
and not improving, finally went to the Hospital.
The symptoms complained of throughout these months
and because of which she finally applied for admission
to the latter hospital, were: continuous vomiting, head-
aches, buzzing in the head, dizziness, "spots before the
eyes," and great weakness of the right hand and foot,
"almost paralysis," as the patient put it. Vision of
the right eye seemed entirely gone. She remained
several weeks under observation at this hospital, where
brain tumor was diagnosed and operation advised. The
patient refused operation and left the hospital. A little
while after she applied for admission to Roosevelt.
On inquiry it was learned that the patient's urine on
her admission to the Hospital contained abundant
albumin and casts, that the fundi showed changes, and
that her vomiting had been projectile. Nephritis in
addition to the brain tumor had been thought of.
At Roosevelt, our patient gave in addition to the
above, the history of having vomited blood on three
occasions, 7, 3, and 1 week before admission (which no
doubt came from her throat, which was severely con-
gested— from constant vomiting and coughing) , that
she had frequent choking sensations, frequent attacks of
hoarseness, and that she often saw double.
On my visit I made the following anamnestic notes:
Her parents and grandparents appeared to be normal
individuals. There were neither alcoholism, psychoses,
epilepsy, hysteria, nervous disease, nor eccentricities in
the ascendants. Six children of these parents, however,
were very nervous, two of them being sleep-walkers and
another having varied fears. A cousin of the patient
is insane.
Infancy was normal save for convulsions "from teeth-
ing." She walked and talked at the proper age. As a
child she had measles, scarlet fever, and pneumonia, and
recovered from each without residuals. She did not
have chorea, strange spells of any kind, somnambulism,
enuresis, nor headaches. But from the age of six on she
would occasionally get hoarse without apparent cause,
off and on. even up to the present. Convulsions,* which
"began early," continued "once in a while" up to her
eighth year (never thereafter). No reason could be
given for the convulsions, which, the patient assured me
were not accompanied by tongue bite, enuresis, or in-
jury.
During adolescence some stomach trouble occurred
(nature and cause not known). She bore two healthy
children. There were no miscarriages. She never took
intoxicants nor drugs nor came in contact with any
metal poisons, nor experienced a shock at any time,
either physical or psychic. Bowels have been regular.
"These were not the same "teething" convulsions
which occurred in his infancy.
Oct. 7, 1916J
MEDICAL RECORD.
625
Menses regular up to three months ago, then became
irregular. She occasionally finds it impossible to void
urine though the desire to do so is imminent. She
. knows of no cause whatsoever for her illness, and be-
lieves she lost at least 100 lbs. ( ?) since it began. She
grew worse at the first hospital (?) (and no better at
the second). Uranalysis at Roosevelt was negative
(also on several later examinations at Vanderbilt Clinic
laboratory). It appears, however, that after my first
visit a number of uranalyses were made in which a
"heavy trace to a cloud of albumin" was recorded, no
sugar, never any casts, pus considerable, sp.g. 1017-
1030. (Report kindly furnished by Dr. Martin.)
The facies of our patient showed no apprehension (in
spite of the "brain tumor" and the advised operation)
but looked flushed and "hysterical." This hysterical
look was given by the eyes, the lids of which were not
entirely raised ("pseudo-ptosis" one might have said).
For her age, her face was also decidedly girlish or even
childish, her lips constantly pouting. (This I later put
down as "hysterical pseudo-infantilism.")
On examination, at this visit, I made the following
notes: The head-contour was normal. There was some
tenderness on pressure and percussion over the left side
of the crown. No stigmata of lues or degeneracy were
present. On standing with closed eyes, the patient
swayed decidedly (on later examinations she even oc-
casionally fell when tested) . Her gait was decidedly
and exquisitely cerebellar. On being told to close her
eyes while walking she would stagger badly. Both at
Roosevelt and at Vanderbilt Clinic it appeared to us
that the patient's gait was much worse when she was
being observed. She did not stagger to any particular
side.
Vision tests showed (monocular) diplopia of the right
eye (this had also been noted at the hospital).
On the left there was no vision at all in parts of the
field, and the patient saw two objects as one (!) with
this eye. Absolute shaft-vision obtained (using both
eyes) . There was also great and rapid vision fatigue.
The color fields were irregularly inverted and much con-
tracted. Ocular movements were normal. There was
some nystagmus on extreme lateral excursions. There
was no real ptosis (though it sometimes looked as if
there might be. At all times the eyelids could be raised
in the normal way if the patient was asked to do so).
There was frequent and abnormal trembling of the lids.
The pupils reacted normally to light and accommoda-
tion. The fundi were examined by Dr. Holden, who
reported clear macula, no choked discs.
The sense of smell was absent on the right side.
Motor and sensory fifth were normal. The corneal re-
flex was present and prompt. The facial seemed to
show a slightly weaker innervation on the left side.
(At the — Hospital it was found that the patient's
mouth was drawn slightly to the left when smiling or
whistling.) Cochlear and vestibular appeared normal.
(Hearing test with fork and watch showed L<R.)
The tongue, which was coated, trembled considerably at
times and was anesthetic on the right half. It did" not
deviate. The right side of the mouth was also anes-
thetic. The pharyngeal reflex was absent. (This re-
flex, however, I find wanting in so many normal indi-
viduals that I do not lay much stress upon its
absence.) The palate rose normally on phonation.
Speech was entirely normal, though always a trifle
hoarse. The neck (tonus, glands) and thyroid were
entirely negative.
Examination of the upper extremities showed the
following: There was a paresis of the right side. The
right hand registered nothing with the dynamometer
on the first test and only 3 K. on spurred effort. The
left hand was also weak, though not as bad, registering
6 and 8 K. There was no spasm. Coordination was
normal, also diadochocinesis. There was a strong, non-
intentional tremor present, equal on both sides. Tac-
tile, pain and thermal sensation were completely absent
on the right side. (They had been only "diminished"
when the patient entered the Hospital.)
On testing for deep muscle sense it was my opin-
ion that the patient was malingering. This was also
the opinion of the house physician at Roosevelt. It
was this, in fact, that made him suspect something
functional in the case, and because of which he called
me in to examine the patient. There was no pain on
pressure over the nerve trunks. There were no trophic
disturbances. Reflexes were normal (muscle and ten-
don). There were no contractures and no abnormal
movements. In spite of the absolute anesthesia on
the right side, stereognostic sense was normal.
The lower extremities, examined while prone, showed
paresis and ataxia of the right leg. Asked to move
the toes, the patient did so on the left, but scarcely
on the right. The left side was entirely normal. There
was complete anesthesia, analgesia and thermaesthesia
on the right side. On testing for deep muscle sense
the patient's responses again suggested malingering;
in fact, this seemed almost positive. There was no
pain on pressure over muscles or nerves, nor any
hie disturbance. The patellar reflex was present,
not very strong, equal on both sides. The Achilles was
present and normal on the right, but obtained with diffi-
culty on the left. Babinski and Oppenheim were nega-
tive. The plantar reflex was brisk on the left, weak
on the right side. There was no clonus.
The entire trunk showed the same complete sensory
disturbance on the right side as did both upper and
lower extremities. The abdominal reflex was not ob-
tained (but this may have been due to the flabby con-
dition of the abdomen).* The spine showed no abnor-
mality. The report as to the visceral examination
(examined at the hospital and later at Vanderbilt
Clinic, and later again at other hospitals) was negative.
The pulse was 96, regular, not very strong.
Mentally the patient appeared of moderate intelli-
gence. Her memory (on tests) was excessively poor;
otherwise the mental examination, rapidly carried out,
however, was normal. There were no delusions, hal-
lucinations, etc.
As to diagnosis, it was necessary in this case
first to say whether or not a cranial tumor was
present, and if so, to locate it, whether the hys-
terical symptoms were caused by the tumor (or
whether we had a tumor here in an hysterical indi-
vidual), or finally whether it was pure hysteria —
and no tumor whatsoever. The question of nephri-
tis would also have to be considered.
We concluded that this was a case of pure hys-
teria (plus renal disease?) and because of the fol-
lowing reasons: The absence of heightened re-
flexes and of clonus on the right side, and the com-
pleteness of the sensory disturbance (especially the
complete involvement of the face, almost never
found in brain tumor, also of the mucous membrane
of the cheek, of the half of the tongue, and appar-
ently also of the mucous membrane of the right nos-
tril to smell — that of touch being maintained), ar-
gued against brain tumor. That the sensory dis-
turbance should be so complete and yet no astereog-
nosis whatsoever be present is also scarcely con-
ceivable in brain tumor. Just this, however, is very
common in hysteria. Some months later on exam-
ining the patient at Vanderbilt Clinic we could
push a needle into the skin of her right hand with-
out her feeling it, yet on this occasion stereognosis
was normal and electricity could also be normally
■ It. One had to admit that none of the findings
spoke absolutely for organic disease, and all could
be accounted for by pure hysteria. The monocular
diplopia, the seeing of two objects as one, the shaft-
vision and contracted color fields, all spoke for hys-
teria. Inversion of the color vision, however, could
not be used diagnostically as it has also been ob-
served in brain tumor. The responses given on
testing for deep muscle sense surely showed
malingering (a condition observed often enough in
hysteria) .
Besides, the fundi were normal (examined on 2
or 3 occasions). Had abnormalities of the discs
due to nephritis been present, the diagnosis would
have been more difficult.)
( In preparing this history for publication, and
only after the above had been written, further data
concerning the patient's condition on her admission
to the Hospital were very kindly supplied to
*The patient appeared to have lost some weight, pos-
sibly even considerable weight; but by no means the
amount she thought she had lost.
626
MEDICAL RECORD.
[Oct. 7, 1916
me. As to the eyes, Argyll-Robertson pupils were
noted, and beginning choked discs. Four days af-
ter, it was thought that the choked discs in both
eyes were increasing. The veins of the right eye
were much swollen and tortuous; small hemorrhages
were present. The left eye showed "enormous size
of optic disc." How shall we reconcile these diverse
findings? Could a cyst filling, and being absorbed,
or a meningitis serosa account for it? In the lat-
ter case where optic nerve changes occur, the head-
aches are often agonizing; and if choked discs oc-
cur they do not again disappear, or if the changes
are inflammatory, even then the nerve does not so
rapidly become normal. The first hospital findings
were in August; normal backgrounds were reported
at Roosevelt, in September.
A stereoradiographic examination of the head
was also made at the first hospital and the bony
structures at the base of the skull were found to
be normal in contour. There were no bone defects.
The sella turcica and mastoid cells were normal. A
note was added that this examination excluded any
brain tumor which was of a very dense nature or
which contained any calcium salts; but that it did
not exclude the presence of any cystic or soft tu-
mors in the brain tissue proper.)
The patient was later discharged, and visited me
on October 30. Her symptoms and signs were
about the same. I induced her to come to the Van-
derbilt Clinic where Dr. Starr was at the time lec-
turing on brain tumor, and she was shown to the
students as a case of hysteria resembling brain
tumor. All her symptoms were still "intact." I
then began treating her with hypnosis* with appar-
ently good result, for Dr. Starr was able to show
the patient at his clinic one week later, with all her
anesthesia, in fact all her sensory disturbances,
gone. The paresis had also cleared up, and the
grip was fairly good, though the dynamometer reg-
istered but 8 k. to 19 k. on that occasion. Head-
aches and vomiting, however, though improved, still
persisted (these have continued to persist, at times
getting worse, at times improving).
In the next week or two I tried to allay these
symptoms with different methods, using mental
therapy, drugs, electricity — all to no very good pur-
pose. At this time the patient contracted a cold
and took to bed with an elevated temperature. 1
sent one of my clinic associates to see her at her
home. He reported that though he could hear only
a few rales here and there in the chest and noted
but little fever, the patient appeared quite sick and
he suggested her going to St. Luke's Hospital,
thinking she was making for pneumonia. Whether
through the association of "hospital,"" or through
the shock of the mild bronchitis her hysterical
symptoms returned, cannot be said, but at any rate,
It was quite impossible to treat this patient with
persuasion, direct suggestion, etc. One could nol make
any impression whatsoever upon her.
cording to Pawlow's studies on dogs (Vorlesun-
. Bui. d. Akad., St. Petersburg, No. 14, 1907)
a non-related stimulus (,'J) through concomitance to
(o) while (a) is producing the effect (c), may, after a
brief time, become in itself a direct stimulus, acting
precisely as (a). Hence ringing a bell will produce
gastric juice in the dog if for a time he heard it ring
while being fed. Mental associations may not in the
same way (the psycho-reflexes of Bechterew), and (/3)
be made to associate (c) without the individual recall-
ing (a) at the lime. It is very probable that many of
the symptoms and return of symptoms in hysteria may
be explained in this way. How actual this' mechanism
is in the behavior of children, A. Czerny has pointed
out.
the "tumor syndrome" came into evidence again and
so convincingly that the receiving physician at St.
Luke's ( Dr. Lambert's service) at once diagnosed
brain tumor and advised immediate decompression.
Dr. Mount of St. Luke's was kind enough to give
me the following facts concerning the patient's con-
duct while at the hospital:
She vomited practically every day and had to be
catheterized most of the time. The urine at times had
a trace of albumin, with hyaline and granular casts.
Blood pressure remained at 160 systolic and 115 dias-
tolic. Several Wassermanns were negative, even after
a provocative dose of neosalvarsan. A luetin test was
also negative. Lumbar puncture showed clear fluid,
low pressure, cell count 10 per cubic centimeter, all
lymphocytes, Wassermann negative. Nothing devel-
oped in the chest and the patient was discharged on
February 24.
During the last week of her stay at the hospital the
patient showed a strange mental condition which had
not cleared up at the time of her discharge. She be-
came rather noisy and difficult to control, apparently
had some delusions of persecution (?), believed that
all the patients thought she was pregnant or, at an-
other time, that she was infected with syphilis. She
said her sister was dead in the ward and that she was
not permitted to see the body; talked about woman's
suffrage; issued commands to children as though con-
ducting a kindergarten, etc. [Nothing of this sort had
been noticed before.]
A few days after, she again appeared at Van-
derbilt Clinic. She knew nothing of having had
any of the above delusions and acted no differently
than when at our clinic previously. On treatment
her general condition improved considerably and
after a while I again lost sight of her.
On my return to the clinic in September, our pa-
tient showed up again. It appears that she had
looked for me in the neurological room a few days
before, and was seen by one of the men, who after
examining her, gave her a slip which she was to
present on her next visit. Her next visit, however,
was to my psychotherapy room (at that time in the
Applied Therapy Department). She showed me the
slip with rather a peculiar expression on her face.
The slip read, "examine for possible brain tumor."
The patient told me she was again very sick, vom-
ited, coughed, and had severe headaches, etc., all,
she believed, brought on by some baths which had
been prescribed for her. She very probably had
taken cold.
Examination on this occasion (Oct. 12, 1914)
showed the following:
Station and gait similar to former visits, though im-
proved. Smell normal. Vision normal (the shaft-
vision has entirely disappeared; no dyschromatopsia,
no visual contraction, etc.). Ill, IV, and VI nerves
normal. Reaction to light and accommodation normal.
Occasional nystagmoid movements on extreme lateral
ocular excursions. For the first time one notices a
tendency to a positive Von Graefe (occasionaly met
with in hysteria), but there is no Moebius or Stellwag.
Looked at from above, the eyes protrude a very lit-
tle (?). The lids "blink" excessively on closing. Cor-
neal reflex normal. Facial is normal, the right inner-
vation slightly stronger than the left. Motor fifth is
negative. There is a "burning feeling" in the fore-
head. On the left check there is an irregular area of
anesthesia.
The upper extremities: Movements, coordination, and
diadochocinesis normal ; but there is almost complete
adynamia of the hands on both sides (with dynamom-
eter: average of 2% K. on the right and IVi K. on the
left). On the left hand the interossise evidence no
power at all. Electrical examination of all muscles
of hands is negative. Reflexes normal.
Sensory examination with needle and brush on the
right side shows a complete and typical glove anes-
thesia and analgesia up to the wrist. On the forearm
a few irregular small patches of anesthesia. The upper
arm and shoulder are negative. On the left side there
Oct. 7, 1916J
MEDICAL RECORD.
627
is a glove anesthesia up to the wrist, a few very small
spots of anesthesia on the forearm, and complete anes-
thesia and analgesia from the elbow to the shoulder.
Stereognostic sense on the right hand normal!
On the left, astereognosis; but on suggestive treat-
ment with electricity (high frequency) the astereog-
nosis disappears immediately (test made with a piece
of lead, coins, pencil, cotton, pen, etc).
The lower extremities were entirely normal.
The picture has now, one year later, lost its brain-
tumor resemblance.
For a few days I lost sight of the patient, and
then learned that she had been sent to Bellevue
Hospital. It appears that she had had several "hys-
terical" attacks the night after she had visited the
clinic, seemed very ill, and was sent by her family
to the hospital. She came on Dr. Norrie's service —
and Dr. Norrie at once diagnosed the case as hys-
teria. She remained two weeks — having an anuria
during the entire period. She was allowed to go 56
hours on one occasion, without catheterization. The
uranalysis showed some albumin, some pus, but no
casts, sp. gr. 1030. The fundi were found normal.
Color vision was considerably contracted, and gen-
eral vision strongly on the nasal side. Another
Wassermann was found negative.*
Again she returned to me — her hands now quite
normal, but complaining of the same emesis and
headaches, spots before the eyes, and visions. She
saw faces, whether she opened or closed her eyes.
These she knew were only fancies, yet they were
there, revertheless, and extremely distressing. This
was her chief complaint on one or two visits.
The patient not returning, we made inquiry and
were told that she had gone to friends in the coun-
try, and that she was feeling very much improved.
As a matter of fact, however, our patient had gone
to the Mount Sinai Hospital. This I learned much
later, and only after the foregoing part of this pa-
per had been prepared for publication.
Reviewing the case thus far, certain facts of in-
terest may be noted. The diagnosis "brain tumor"
in the first hospital made the patient worse. At
Roosevelt she no longer had a hemihypesthesia, she
had a complete hemianesthesia, etc. The bronchi-
tis and examination by one of my associates and the
transference to St. Luke's, and later again the slip
of paper with "brain tumor" written upon it, made
her decidedly worse. My own second examination
(rather fully carried out, and made in the presence
of a psychologist visiting the clinic), even though,
remembering Babinski's admonition, I took great
pains to avoid suggesting any symptoms into the
patient, was followed that night or the next by "at-
tacks" and a feeling of being very ill. Had the pa-
tient been neglected, had her various examinations
been but superficial (a thing out of question, con-
sidering that brain tumor had to be excluded) she
would probably have improved instead of gotten
worse — for in several ways she did get worse. Her
hypesthesia became anesthesia (this finally was
cured by hypnosis). Later she had hysterical de-
lusions, and when I last saw her, fancies of seeing
faces. The headaches and vomiting continued. Are
these latter due to some (intermittent) renal
trouble? How shall we explain the divergent
uranalyses at the various hospitals and clinics, some
reports entirely negative, some noting albumen and
pus, but no casts, again casts but no pus? Can we
rely on the examination by internes who often are
novices in the laboratories, and possibly more often
overworked? But the ophthalmoscopic examina-
tions in hospitals are usually made by ophthalmolo-
*I am indebted to Dr. Norrie for these facts.
gists of experience. Can it be that what one sees
with the ophthalmoscope is after all not a definite
picture but something which must be "interpreted"
and hence may be interpreted differently by differ-
ent eyes? Think of the gravity of this! A diag-
nosis of choked discs means intracranial pressure,
and this most probably means decompression, a
most serious operation (and looking for a brain tu-
mor fearfully serious). On the other hand, think
how disastrous such an operation could prove to an
hysterical individual — and our patient is that with-
out question — and how many "post operative" ad-
ditions might be linked in to the neurosis!
Finally, why do the hospitals discharge a patient
directly the diagnosis hysteria is made? Is this not
indeed a serious disease at times, and did not this
patient of ours really need hospital treatment? I
have found it quite impossible even to get my
younger clinical charges taken into any of the hos-
pitals when the diagnosis of hysteria was made.
And yet, out of their homes, they could be so much
more easily cured. And was not possibly some kid-
ney abnormality neglected in the final conclusion
that here was an hysteria? To many physicians
hysteria is almost synonymous with malingering —
and such a patient treated as if she were "putting
on" or "imagining" her troubles. Hysteria, whether
entirely functional or not, is surely as really patho-
logical as is brain tumor. Lastly, what was the cause
of so serious a disturbance in this apparently strong
woman? Is some viscus at fault, or some abnormal
process, waking up a congenital, latent hysterical
disposition? Much remains unanswered in this in-
teresting case — though I believe we may safely ex-
clude the presence of a brain tumor.
It was after the above had been put together,
that, as already mentioned, I learned our patient
had been at Mt. Sinai Hospital (between October 30,
1914 and January 16, 1915).
Through the kindness of Dr. Sachs and Dr.
Strauss an outline of the hospital record of the case
was sent to me. From this very thorough account I
shall be able merely to give the important facts.
The symptoms for which our patient sought relief
were the same as in the beginning: headaches, pro-
jectile vomiting, and defective vision.
In the history given the patient maintained that she
had been at St. Luke's Hospital, suffering from pneu-
monia (which, as we know, was not the case). The
eye complaints referred now mostly to the left eye (in
my own history it was the right eye that had been
affected).
The sensory chart accompanying the Mt. Sinai his-
tory showed, indeed, the very remarkable fact that tin
sensory symptoms, formerly all noted on the right side,
were now on tlie left side of the body! The patient
staggered, falling to the left (this was noted several
times in the subsequent history) . There was lateral and
verticular nystagmus. The right eye was somewhat
sunken, tremor of lids. Reaction to light and accom-
modation normal. Corneal reflex diminished. Mod-
erate stasis of lids. Weakness of right external rectus.
Tongue: marked tremor; ears: diminished hearing
on the left side. Lungs, heart, liver, spleen: normal.
Abdomen: pendulous; no tenderness. Reflexes: diffi-
cult to elicit.
Upper extremities: tremor, mostly right side. Weak-
ness of left hand. Finger-nose test: overpoints to left.
Adiadochocinesis.
Lower extremities: knee-jerk present, diminished,
especially on right side. Achilles reflex diminished
both sides. No abnormal reflexes. Slight tremor.
On November 2 there was noted astereognosis of left
side, with loss of position. Right side normal. Slight
facial palsy. Fundi normal (several examinations were
made at this hospital, and with one exception, all re-
ports were normal).
On November 3 the following facts were noted :
Hoarseness, forgetfulness, head in cerebellar attitude,
tendency to fall to left while seated. Cog-wheel phe-
628
MEDICAL RECORD.
LOct. 7, 1916
nomena both arms; must marked on right. Hemi-
anesthesia left side; recognition of position present on
right side. Imitation on left side poor. Sense of
weight lost on left side. Flattening of right side of
face. Faradic response of facial nerves equal both
sides. Change of chronic catarrhal otitis media.
Watch : right, % ; left, 3. Fork 512 lateralized to good
ear. Air conduction within normal limits.
November 4: Complete fixation right half of larynx;
right, recurrent paralysis. Patient says she has been
constantly troubled with visions of cats, dogs, corpses,
which she tries to drive out of her mind. No olfactory
or gustatory hallucinations. Has auditory disturb-
ances. Hears dead relatives converse with her, mak-
ing references to her children and consulting her as to
her husband's condition. The patient is fairly con-
scious during these hallucinations and tries to drive
them away by covering face with her hands. Sees
bright stars and lights, black circles like snakes, and
tries to hide from them. An hour ago she saw children
being brought in on stretchers.
November 8: Occipital headache, burning and ham-
mering in character. All objects appear contracted.
Vision normal. Choking sensations. For past three
days generalized chilliness and elevated temperature
(ranging between 99° and 101°). Has to be cathe-
terized.
November 11: Lumber puncture. Five cubic centi-
meters of fluid obtained under 160 mm. pressure. Was-
iermann and globulin tests negative. No cells. Was-
sermann of blood also negative.
November 13: Patient attempts to get out of bed.
Five minutes after knows nothing of occurrence (spell
noted as of "epileptoid" nature) .
November 14: Still has visions as before. Has fal-
len out of bed several times. Remembers nothing of
this. Vomiting constant. Tremor as before. Occi-
pital headache constant. Urine shows albumin and
casts.
November 16: Left chronic Babinski position of toe.
No Oppenheim nor Kernig. Distinct hypotonia and
diminution of power in left upper and lower extremi-
ties. Weakness of right external rectus distinct. Hemi-
anesthesia as marked as before. Symptoms point to
a lesion involving right optic thalamus and posterior
third of internal capsule and symptoms of cerebellar
order. Double ptosis. There appears to be, by rough
estimation, a right hemianopsia.
November 21 : Quieter. Right facial hemispasm,
followed by increased movement and then rigidity of
right side. Marked increase in tremor on right side.
Tremor of right face; right side catalepsy.
December 5: Ophthalmoscopic examination: Left
fundus normal; right disk shows slight blurring at its
upper and inner border. May be developing optic neu-
ritis.
December 6: Difficulty in moving left lower limb.
Burning sensation in entire right side of body. Diffi-
culty in rotating head because of pains in back of
head. Tremor of right upper and lower limbs. Can-
not smell through left nostril. Memory failing.
December 9: Suddenly developed pain in right chest.
Chills, fever, sweats, cough. Physical examination re-
veals a patch of dulness, bronchovesic. breathing and
crepit. rales in lower right axilla. Temp. 102°, resp.
60; W. B. C. 12,000; polymorphonuclears 64 per cent.;
lymphocytes 36 per cent.
December 10: Temperature, etc., as previous day.
Resp. 32 (previously 60). Rales gone. Breathing di-
minished.
December 12: Ulceration of nasal septum on both
sides.
December 14: Temperature normal. Pains worse.
No signs present. Patient says she smells pepper.
December 17: Patient was observed breathing. Res-
piration rate considerably increased. Later again ob-
d (this time unawares), breathing found normal
(24). When physician entered room again increased
(to 60). Ten p. m. nurse takes respiration rate (100).
Pulse 90, and feeble. Occasional deep breath. Com-
plains of a sticking in the left side of the chest. Noth-
ing found. Patient acts peculiarly. Always wants phy-
sician. Asks for him constantly, asking foolish ques-
tions. Says she smells with one nostril: then the right
half of body is numb, then the left. Hour after hour
the physician is annoyed in this way.
I n-t ember 18: Complete hemianesthesia, even nasal
half. No Babinski. Nystagmus to left distinct.
The question comes up whether there is not a func-
tional exaggeration of symptoms. After to-day's ex-
amination there is suspicion of a possibility that there
may be an exaggeration of functional element in this
case.
Though hemianesthesia present, patient, caught un-
awares, responds to pinprick. Tremor of left lower
limb and even right brought on by suggestion.
December 19: Larynx cords fail to approximate
with much more mobility on the left than right side,
so that the condition is rather to be regarded as a
double adductor paralysis than a recurrent.
December 21 : Patient tumbled over sideboard and
fell to floor. When asked why she did this she replied:
"I was sending the children to school and wanted to
get their rubbers." Asked how many children she had
she replied: "How many do you think I have?" and
burst out into hysterics.
December 31 : Sat up out of bed ; did not fall. Later
asked to walk. Physician noticed that she would either
attempt to fall or jump ahead when she thought she
was not being noticed.
January 4, 1915: To-day symptoms appear largely
functional.
January 16: Fundi normal. The following note:
Patient first thought to have a lesion in the right optic
thalamus involving the adjacent part of the inter-
mediate capsule. It is now evident that condition is
one of hysteria. Contracted fields of vision. Left
hemianesthesia; pinprick not perceived as pain, but
causes a reaction, i.e. deep inspiration. Many of pre-
vious symptoms have disappeared. Now able to walk.
At times falls suddenly, apparently intentionally. Dis-
charged improved.
I have not seen the patient again, and after con-
siderable search, during the last year, have given
up trying to locate her. It would be interesting in-
deed to learn how many more hospitals gave her a
night's lodging and how this story ended.
60 West Eightt-fifth Street.
A REVIEW OF THE HISTORY OF CHEMICAL
THERAPY IN CANCER.
Bv WILLIAM S. STONE. M.D..
NEW YORK.
The presentation of a method of cancer therapy-
other than operation with the knife has usually
been conceived either in ignorance or in the hope
of financial gain. In the case of the chemical
caustics, unfortunately for progress in the treat-
ment of the disease, the unqualified condemnation
of the manner of their exploitation has repeatedly
prevented educated surgeons from learning how to
use them and excluded a scientific study of their
possible efficiency.
It is a remarkable fact that, so far as "cancer
cures" relate to the local treatment of the disease,
they have almost invariably been found to consist
of arsenic, zinc, or the alkaline caustics. Arsenic
is known to have been the effective ingredient of
the applications made to cancerous tumors by the
Indians, Egyptians, and Persians, and a salve,
designated as Unguentum Egypticum, consisting
of arsenic and vinegar, was in general use until
the middle of the fourteenth century, when two
notable surgeons of the University of Avignon,
Henri de Mondeville and Guy de Chauliac, made ef-
forts to improve the methods of diagnosis and
treatment. Prior to this period it is clear that all
classes of people — physicians, scholars, mendicant
friars, and old women — treated all kinds of tumors
with escharotic pastes and solutions, the most ef-
fective of which contained arsenic. The most skill-
ful applications were undoubtedly made by the
friars. The Hippocratic theory of the nature of
cancer, "the atra bills," was recognized in all thera-
peutic efforts, but exerted little influence on the
methods of treatment. Diagnostic error, as a factor
in the determination of successful results, applied
alike to the use of the knife and to caustics. While
Oct. 7, 1916|
MEDICAL RECORD.
629
Galen and others of the Greek school supported this
theory, two kinds of growth were differentiated:
(1) the so-called scirrhus, which evidently included
both benign tumors and the hard, slowly growing,
and more definitely localized malignant growths;
(2) those growths which were plainly evident to
both patients and physicians as the more rapidly
growing and destructive neoplasms. It is probable
that chemical caustics were more generally used
than either the knife or the heated iron, especially
with the ulcerating growths.
Guy de Chauliac (1368), a great writer on
surgery, as well as a skillful operator, directed at-
tention to the use of caustics as an adjuvant to the
use of the knife. He used arsenic mixed with clay
and noted no toxic symptoms from its employment.
Ambroise Pare (1510-1590), by his development of
the use of ligatures and sutures, created a fresh
enthusiasm for the use of the knife in the treatment
of cancer, and, although using mild salves and solu-
tions on ulcerating growths, tried to discredit the
use of arsenic because of the baleful effects of its
indiscriminate application. In Germany, Fabricius
Hildanus (1560-1634), who was known as a skillful
operator, and is reported to have excised the axil-
lary glands in amputation of the breast, also tried
to discredit the use of arsenic. We find, however,
little evidence during the succeeding centuries that
surgery profited much by the possibilities which
the work of Pare and Fabricius had indicated.
Clowes, physician to Queen Elizabeth, advocated as
an additional therapeutic procedure the laying on
of the Queen's hand. In Germany, theories regard-
ing the nature of cancer simply became more nu-
merous, and under the designation of "systems"
their chief practical achievement was the exploita-
tion of a constitutional cure in the form of conium
maculatum by a Dr. Storck of Vienna, in 1761, an
account of which eleven years later extolled its
merits and the discoverer in terms of the highest
praise. In 1779 a society in Bantzen offered a prize
of 30 ducats for a cure of cancer without the use of
the knife, mercury, cicuta, stramonium, belladonna,
napello, and aconite, but there is no record of any
award of the prize. In France the efforts to apply
the recent discoveries in chemistry to the study of
the nature of cancer had elicited the fact that
tumors arise from the same tissue in which they
appear. In 1773 Bernard Peyrilhe, in a thesis
offered for the prize question by the Academy of
Lyons, "Qu'est-ce le cancer," presented a scientific
interpretation of the subject, and is credited with
being the first to make use of animal experimenta-
tion in the study of the disease. The dog, however,
into whose back the cancerous material had been
injected, howled so continuously from the resulting
lesion that its keeper removed him from the field
of Peyrilhe's observations. In regard to treatment,
he recommended for cancer of the breast the re-
moval of the breast, excision of the axillary glands,
and the removal of the pectoralis major muscle.
For the treatment of nasal cancer he advocated the
use of the recently discovered "kohlsaure."
The beginning of the nineteenth century was
marked by efforts to overthrow ancient philosophy
and medieval empiricism, and a new era in the con-
ception and treatment of cancer appeared through
the English and French anatomical researches.
While John Hunter's (1786) lymphatic theory domi-
nated the minds of the majority of the great sur-
geons, it included a new conception of cancerous-
growths as being the result of some vital activity
on the part of normal tissues and subject to the
same laws of life, growth and nourishment as the
normal organism. In London (1771) the Middle-
sex Hospital had established a special ward for
cancer patients, and in 1802 a committee of London
surgeons was formed for the investigation of the
nature and cure of cancer. During the three years
of its existence its chief attainment was the dis-
tribution to the medical profession in England of
an elaborate questionnaire, the result of which was
as futile as it probably would be to-day if a similar
method was pursued. Among the practical sur-
geons there were two factions regarding the theory
of cancer — the "localists" and the "constitutional-
ists." The latter did not hold to a specific theory,
but their ranks were largely derived from the ortho-
dox surgeons of the day who had been so uniformly
disappointed with the results of their operative
work.
A publication by Young in London appeared in
1805 on cancer and the use of chemical caustics in
its treatment, in which a remarkably clear summary
is given of the fallacious arguments of those who
maintained that cancer has a specific virus, is con-
tagious or hereditary, and its action constitutional.
His own conception of cancer presents with aston-
ishing accuracy the present views of scientific men.
"Morbid and natural structures, having the same
principle necessary to each and governing both,"
he says, "a morbid alteration should never be
viewed independently of the natural organization
and functions of the part, or as beyond the laws of
life." Briefly summarized, he considers cancer as a
growth arising from acquired actions about a local
structure that has been altered by injury or disease.
On the recurrence of cancer, he says: "It must be
obvious that the disease arises from such small be-
ginnings, unfortunately, that it can never be de-
tected until the obstruction has made considerable
progress ; and, as no specific virus is with it so as to
offer any peculiar evidence from which one might
take alarm, the disease thus proceeds securely in
the minute parts of structure until such a circle of
alteration is acquired as to make the change evident
to the touch ; so that when a surgeon takes out such
a scirrhus tumor it is impossible to act beyond
the reach of his perceptions, and to discover
changes which can only be imagined, which may be
there, or may not. . . . It is impossible to as-
certain the distinct line between health and disease,
and . . . some portions may be left, from
which . . . the disease may ultimately recur."
Based upon this conception of the disease, Young
directed the attention of the educated physician to
the advantages which he believed the chemical
caustics possessed if they were more discriminately
and skillfully applied. He says: "It must be very
evident to the most sanguine expectations that this
disease, although the treatment of it in the future
may be greatly improved, must still, in many in-
stances, fall short of all possibility of cure. But
. . . are we to relax in effort because effort is
more required? Shall we withhold what can be
done, merely because all that we wish cannot be
done? Such, however, seems to have been the des-
perate sentiment in which science has left the dis-
ease almost to itself. It appears to have been con-
sidered as a thing so deeply rooted in its own sin
and wickedness as to be beyond reprieve — a hard-
ened malefactor, denied every consolation but that
of the knife. This negligence on the part of sci-
ence has given proportionate scope to the invention
630
MEDICAL RECORD.
[Oct. 7, 1916
of the quacks: they have seized upon the arms the
regulars threw away, and have certainly played no
unsuccessful part. Even old women, enlisted under
the banners that were deserted, have proved at least
(as far as their knowledge of the question went)
that there is just as much orthodoxy in a piece of
caustic as in a piece of iron."
As illustrating the attitude of the regular sur-
geon at that time toward the use of caustics, Young
narrated the story of a published correspondence
between two surgeons of the time. A regular sur-
geon, Mr. Guy, had purchased a nostrum, known as
the "Plunket remedy," which he had been using
extensively and apparently successfully without dis-
closing its composition, but claiming it had none of
the qualities of a caustic. The surgeon to the King,
Mr. Gataker, who, it afterward was ascertained,
had also been using a caustic without the same suc-
cess as had his colleague, publicly and vehemently
denounced Mr. Guy because he was using a secret
remedy. The efficient ingredient of the "Plunket
remedy" was eventually ascertained to be arsenic.
Young says: "Thus posterity seems equally obliged
to these two gentlemen; to the one for condemning
a thing which it is very evident he was totally
ignorant; and to the other for the warm support
of what it is equally clear he did not understand,
or (which would seem still less innocent) of what
he did not choose to understand." Young indicates
that a more general use of caustics became intro-
duced from this remedy, which considering the un-
qualified and indiscriminating way in which they
were applied, were attended with more success, he
says, than could have been looked for.
Young conceived that the advantage gained by
the proper use of caustics was derived from their
power of exciting newly formed tissues into an ac-
tivity beyond their power, which is always less than
normal structures. For this purpose he considered
arsenic as particularly well suited because its action
extended to all of the tumor tissue without rapidly
producing a superficial eschar, the formation of
which prevents the extension of the action to the
deeper parts. An old preparation, known as Magnes
Arsenicales, which he regarded as most efficacious,
consisted of equal parts of antimony, sulphur, and
arsenic, the antimony, he believed, adding to the
extent of the area affected. Young urged the im-
portance of applying treatment during the early
stages of the disease, and, in order to avoid con-
cealment of these tumors until it is too late, he
writes as follows: "So long as the extirpation of
scirrhi of the breast is performed by the knife, so
long shall we have the disease fostered in secret,
and, in too many instances, procrastinated beyond
the point of safety, through the dread of an opera-
tion that is inevitably dreadful. For the operator
may argue until doomsday ere he shall persuade his
patient that cutting the breast with the knife is a
mere nothing. . . . This rhetoric never gained a
jot on the fears of ignorance, or on the quick feel-
ings of diseased delicacy. The truth is that, when
the operation is submitted to, the mind is seldom
made up to it but as a last resort — seldomer from
the convictions of reason, and never from an abso-
lute command over the natural terrors of the
heart."
There is no reason to doubt that Young's pres-
entation of the subject had a favorable effect on
the professional mind in both England and France.
He was a graduate of the Middlesex Hospital, and,
although not a member of the staff of that institu-
tion, he was a protege of Mr. Brodbeck, who made
the first financial contribution to the establishment
of its cancer ward. He became better known by a
publication in 1815 on the treatment of cancer by
compression, a method which received wide atten-
tion for many years. Recamier was enthusiastic
about its efficacy, and devoted two volumes to a dis-
cussion of its principles and technical application.
From the beginning of the nineteenth century we
find that all of the noted surgeons felt the need of
some adjuvant to or substitute for the use of the
knife, and until the last quarter of the century the
use of caustics in cancer therapy was regularly dis-
cussed in the standard surgical textbooks. There
are, however, few contributions to their technical
application and very little discussion of the kind
of cases to which they are applicable. Of all the
noted surgeons of his time Velpeau seems to have
made the most use of them, a paste designated as
"caustique noir," consisting of concentrated sul-
phuric acid made into a paste, being his favorite
formula. He says: "I have frequently employed
caustics in the treatment of cancer, and I have fre-
quently thought, I must confess, that they have
more certainly prevented secondary cancerous af-
fections in the neighboring glands than the ex-
tirpation with the knife. I have twice seen volu-
minous and indurated glands in the axilla diminish
in a remarkable degree during the period I was de-
stroying a cancer of the breast by caustics, and I
have observed the same effect on the submaxillary
glands, while cancer ... of the lower lip was
treated in a similar manner." Maisoneuve also re-
fers repeatedly to the efficiency of caustics, espe-
cially of the chloride of zinc, in the removal of can-
cerous tumors, and of the long interval before they
recurred. Dupuytren, as a part of his armamenta-
rium, used a paste consisting of two parts of arse-
nic and 200 parts of calomel, which Parker refers
to as generally too feeble in its action. Manec, of
the Salpetriere Hospital, Paris, used a paste con-
sisting of one part arsenous acid, eight parts of
cinnibar, and four parts of burnt sponge, made into
a paste with a few drops of water. The results
from its use were favorably commented upon by
Lebert, who, Parker says, was not an ardent advo-
cate of caustics. All of these cases had been re-
ferred to Manec by other distinguished surgeons as
incurable.
Sir Astley Cooper is quoted by Parker as follows:
"It behooves medical men to direct their minds to
the trial of the numerous agents which chemistry
and botany have lately abundantly discovered and
simplified." Most of the pastes used during the
first third of the nineteenth century consisted either
of arsenic or the mineral acids, chiefly the former,
and numerous accidents resulted from their use.
Parker observed arsenic in the urine twelve hours
after the first application, which continued to be
detected during a period of eight or ten days. Toxic
symptoms are recorded as occurring after the use of
such strong pastes as the very old one, known as
Frere Gome's, which is said to have cured Pope
Gregory X of a cancer of the face. Maisoneuve
mentions several cases in which its employment
produced vomiting, precordial anxiety and other
symptoms.
During the years 1834-1838 Canquoin of Paris
reported the results which he had obtained from the
use of a paste, the essential ingredient of which was
chloride of zinc. He described four formulae, as
follows: (1) equal parts of zinc and flour; (2) zinc
Oct. 7, 1916]
MEDICAL RFXORD.
631
one part, flour two parts; (3) zinc one part, flour
three parts; (4) zinc one part, muriate of antimony
one part, flour 1% parts. Water from 20 to 30
drops for each formula. In 1838 a complete ac-
count of his results in 600 cases was published, in
which the recurrences were given as 12 per cent,
as compared with 75 per cent, after the use of the
knife. Regarding the details of its application he
says that formula (1) applied four lines in thick-
ness for 48 hours destroys the parts to a depth of
lx2 inches; that the same formula three lines in
thickness applied for the same length of time acts
only to about the depth of an inch. The depth to
which the paste acts can, he says, with a little prac-
tice be regulated to the utmost nicety, depending
upon its strength and the time it is applied. Plas-
ter of paris may be substituted for flour, thus ren-
dering it less delinquescent. The antimony was
added in formula ( 4 ) to give it the same consistence
as soft wax that it may be applied more uniformly
over an unequal surface, such as is presented by an
ulcerating growth. The advantage of the Canquoin
paste over the arsenical preparations is attested by
the fact that, with few exceptions, chloride of zinc
has been the effective ingredient of all pastes since
used by surgeons and quacks. Parker (1867) says:
"The chloride of zinc will effectually remove the
chief evil attendant on the application of caustic
remedies to the destruction of cancerous growths —
the amount of prolonged pain they occasion. It
may be applied with a degree of precision unob-
tainable by any other caustic ; it destroys the tissue
in direct relation with the thickness of the layer
applied; it never runs or fuses; it destroys only
those parts which it covers, and these it divides
from the surrounding structures as cleanly as
though they had been cut with a knife. The crust
or scab formed by this caustic is hard, dense, and
white; there is no sanguinous or other discharge
produced by it. The eschar separates at the end of
twelve or fourteen days, leaving a clean, healthy
granulating surface underneath." In 1855 there ap-
peared in the Dublin Quarterly Journal a method
introduced by Llandolfi, chief surgeon of the Sicil-
ian army and Clinical Professor of Cancerous Dis-
eases in the Trinity at Naples, in which he used
bromine, either alone or in combination with the
chlorides of zinc, antimony and gold. The introduc-
tion of this method was not enveloped in any mys-
tery, and Llandolfi's personality and method of
presentation produced such a favorable impression
in Paris, Germany and Vienna through which he
traveled that his paste was tried by many and
used with considerable success.
The efficiency of chloride of zinc is illustrated by
the story Parker relates of a Dr. Fell, an American,
who went to London and so successfully treated nu-
merous cases of cancer that a certain number of
patients at the Middlesex Hospital were placed at
his disposal under the condition that he reveal and
publish the composition of his remedy. This was
ascertained to consist of equal parts of chloride of
zinc and a decoction of sanguinaria canadensis, with
enough flour to make a suitable paste. The hos-
pital staff were apparently favorably impressed with
the results. A little later, a Dr. Pattison, a London
homeopathic physician, in association with an
American from Louisiana, vaunted a remedy as a
sure cure for cancer without the use of the knife
or caustics, the results of which had evidently ob-
tained for the exploiters considerable fame and for-
tune. Their refusal to reveal the nature of their
remedy prevented its being tried at the Middlesex
Hospital, but it was subsequently found to be a
combination of chloride of zinc and hydrastis cana-
densis. Both Fell and Pattison administered the
"novelty" in their preparations also internally, the
latter in a dilution commensurate with his
homeopathic traditions.
It is clear that the staff of the Middlesex Hos-
pital, as well as surgeons of other hospitals, must
have had innumerable experiences of this kind, but
the results were evidently sufficient to make the use
of caustics — in the earlier years of arsenic, and
later, after the work of Canquoin, of the chloride
of zinc, an important adjuvant to the use of the
knife. Moore and De Morgan, of the Middlesex Hos-
pital, the former of whom is known especially for
his work in the development of the radical operation
with the Jtnife, used weak solutions of chloride of
zinc — 20, 30, 40 grains to the ounce of water, after
their cutting operations in order to destroy cancer
cells that may have been disseminated through the
wound or the neighboring tissues. De Morgan
was so well satisfied with the improved results from
this method that he expresses the hope that it will
be more extensively applied. They found that the
use of these solutions made no appreciable differ-
ence with the primary healing of their wounds.
A disadvantage in the use of the chloride of zinc
was its failure to satisfactorily remove the normal
skin over the tumor site, and for this reason in part
the alkaline caustics and mineral acids retained
their vogue. The well-known Vienna paste consisted
of five parts of potassium hydrate and six of quick
lime. The "Filhos" caustic contained the same
ingredients in different proportions, and was fused
and run into leaden tubes like nitrate of silver or
potassa fusa. Of the mineral acids, nitric acid was
introduced by Rivallie (1850), in the form of mono-
hydrated nitric acid made into a paste with scraped
linen or charpie. For cancer of the servix uteri,
Routh (1866) advocated to the Obstetrical Society
of London the use of bromine — five grains to the
ounce of spirits of wine. Tilt indicates that in his
hands and others the application of the acid nitrate
of mercury to a cancer of the uterus produced satis-
factory results.
Reviewing the situation from the text-book litera-
ture of the sixth and seventh decades of the nine-
teenth century, we find Thomas (1869) expressing
the opinion that, if it should be impracticable to re-
move completely a cancer of the cervix by amputa-
tion with the ecreseur, scissors, or the galvano-
cautery, it should be destroyed as completely as pos-
sible by the actual cautery, potassa cum calce, or one
of the mineral acids. Erichson says : "The employ-
ment of caustics . . . requires neither knowl-
edge of anatomy nor of operative surgery, and so
they have always been popular with many who
would hesitate to use the knife. In this country,
however, . . . they have not perhaps been
legitimately employed to the extent they deserve.
The chief argument in favor of caustics is that
when cancers are thus destroyed they are less liable
to relapse than when extirpated with the knife.
There is, however, no positive proof of this before
the profession; but it is not improbable that the
chemical action of the caustics may extend so widely
into neighboring structures as to destroy or render
unproductive the cancer cells by which they are in-
filtrated, and on the development of which the local
recurrence of the disease depends. Another advan-
tage urged in favor of caustics is that enlarged
632
MKDICAL RECORD.
LOct. 7, 1916
glands are more likely to go down under their use
than when the primary cancer is extirpated by the
knife." In 1872 Bougard, a prominent Belgian
surgeon, wrote most enthusiastically of the advan-
tages in the use of caustics, stating that recurrences
were less frequent than after the use of the knife.
His formula, consisting largely of chloride of zinc
with a small amount of arsenic, was used by nu-
merous surgeons for several years. Willard Parker
(1873), in a paper on cancer of the female breast,
says: "In the superficial cancer of the breast it is
very well to use caustics. The same thing might be
said with regard to cancers upon the face. The
treatment with caustics in that region is good sur-
gery. When the tumor is situated to any extent
below the surface, the idea of caustics is bad sur-
gery." He referred to two cases of fatal poisoning
from their use. In the discussion of this paper
Fordyce Barker says: "Because of the general use of
caustics by charlatans a great majority of the surgi-
cal world have been satisfied with regard to their
uselessness. My own prejudices have always been
against this method of treatment." As a result of
his observations in the St. Bartholomew's Clinic in
London, the whole process seemed so revolting that
he did not pursue his investigations further for
some time. In 1870, however, he became so pleased
with the work which he saw in the London Cancer
Institute by Marsden that he applied this method
of treatment successfully in two cases — one a can-
cer of the breast in which an operation with the
knife had been refused, the other a cancer of the
cervix uteri. He used the Marsden paste, which
consisted of equal parts of arsenious acid and
acacia. Sands, in his discussion of Parker's paper,
said that he had had no experience with the use
of caustics, but used the knife for the following
reasons: (1) Nature of the tumor can not be de-
termined prior to its removal; (2) now and then
undoubtedly a malignant tumor is cured by opera-
tion; (3) expediency. J. Collins Warren says: "I
have had little experience with the use of caustics.
I find little difficulty in persuading patients to re-
sort to more radical measures." About the face,
to rodent ulcer, he preferred the use of the cautery,
especially near the angle of the eye, because there
resulted less of a scar, it being more difficult, he
thought, to be economical of tissues with the knife,
and more deformity resulted than when nature is
allowed to borrow skin from all directions.
Stephen Smith (1880) describes his use of the
anhydrous sulphate of zinc in the form of a powder,
using a strong sulphuric acid paste for the removal
of the skin. He says: "This remedy, though all but
discarded by surgeons in the treatment of cancer,
has a place in the therapeutics of cancer not yet ac-
curately defined. It is one of the destructive meas-
ures which we may resort to, having capacities
limited only by the possibilities of its application.
As ordinarily employed, its real virtues are not
fairly nor adequately defined. We are advised, or
rather permitted by authorities to apply caustics to
ulcerated cancerous surfaces, the growth no longer
being amenable to the knife. That is. caustics are
recommended as a last resort, when the disease has
taken such deep root that it is certain to prove
fatal. If useful under such circumstances, may they
not be far more serviceable at an earlier period?
In my experience caustics judiciously selected and
thoroughly and persistently applied give the best
results of any method of treatment yet adopted."
Dabney (1882) also reports favorable results from
the use of this powder. Billroth (1889) expressed
his preference for the use of the knife, but in very
old, anaemic, or timid patients, thought caustics
may be employed, and, if the treatment be continued
until all the diseased portion is destroyed, the result
will be favorable. "Physiologically," he says, "caus-
tics would have some advantages; for it is sup-
posable that the cauterizing fluid may enter the
finest lymphatic vessels, and thus more certainly
destroy the local disease. But this does not occur
readily, because the tissue with which the caustic
comes in contact instantly combines with it, and its
further flow is thus prevented." For a caustic Bill-
roth preferred chloride of zinc. Robinson ( 1892), in
discussing the treatment of cutaneous epitheliomas,
says that caustics with less scar remove more tissue
than the knife. He used caustic potash and the
formula of Bougard. Lewis (1893~) used the Mars-
den paste for a number of years in the treatment
of superficial cancer of the skin. Snow (1893)
writes of the advantages obtained in the use of caus-
tics on small superficial lesions, and in chronic
epitheliomas, or rodent ulcers. He considered
potassa fusa to be the most thorough and rapid, its
action being instantaneously checked by the use of
water, and causing no subsequent pain or shock.
Parmenter (1894) says that it has not been proved
whether caustics are better or worse than the knife,
but he believes that the intelligent application of a
proper caustic to easily accessible and definitely
localized tumors, such as those of the skin, lip and
external ear, has many advantages. Bulkley < 1894)
has found use for Marsden's paste, the potassa fusa,
and Bougard's formula in early superficial malig-
nant growths. Allen (1904) takes exception to
White's statement that "the caustic treatment in
the form of injections, pastes, and all other kinds
of mixtures, rarely prove of any service, and usually
only deceive and render more uncomfortable the ex-
istence of a patient. They have been discarded by
almost all except charlatans." Impressive evidence
of the value which the proper application of caustics
may still possess in cancer therapy is furnished by
the following words of Halsted (1907), in a paper
on Carcinoma of the Breast: "I am indubitably
convinced that the local and regionary recurrences
after incomplete operations, which come with amaz-
ing rapidity when the knife has been used, are, to
say the least, relatively late in making their appear-
ance when chemical or actual cauterization has been
employed. I have several times had to operate upon
cancers which had been vigorously and repeatedly
treated with caustics, and to note the comparatively
admirable condition, the freedom from cancer
premeation of the surrounding tissues and of the
axillary nodes; whereas, after incomplete operations
with the knife the local manifestations of recur-
rence were almost invariably deplorable and the
prognosis, of course, invariably hopeless." He also
says, "I doubt if any melanotic tumor of the skin
should be removed with the knife."
From this review we learn that since the begin-
ning of the nineteenth century chemical caustics
were an increasingly valuable resource of all the
noted surgeons in cancer therapy until Langston
Parker (1867) in the Annual Address in Surgery,
before the British Medical Association, showed that
they had become a fair rival of the knife. In spite,
however, of the undoubted success which attended
their use during this period, we find that they were
being applied less frequently by the skillful surgeons
during the last quarter of the century. During the
Oct. 7, 1916]
MEDICAL RFXORD.
633
early years of the twentieth century their position
in cancer therapy is not unlike that described by
Young over one hundred years ago. "Caustic appli-
cations," he says, "were ushered in under the
equivocal sanction of a nostrum, they were pursued
as a nostrum, and then they were turned out as a
nostrum. All regular inquiry has been withheld
from the merits of the practice, and because it did
not succeed in all things its efficacy was not allowed
to any. Thus transferred from the irregulars to
the regulars it was turned back to its original
holders."
In the light of this history it may not be un-
profitable to ask if they have a field for use at the
present time?
Regarding the continuation of their use by the
"original holders," we may hope that our educa-
tional propaganda and a more intelligent legislative
restraint will ultimately solve that part of the prob-
lem. The question of renewal at the present time
of the consideration of their efficacy by the educated
surgeon naturally reverts to an estimate of their
value when previously used and to the reason for
their abandonment.
Their value as compared with the operation by
the knife was apparently not satisfactorily defined
at the time they were given up. No statistical data
were available. We know that operations with the
knife during a greater part of the nineteenth cen-
tury were almost invariably incomplete and that the
cures were few. Sands says, "Now and then a cure
was accomplished." After the use of the chemical
caustics, however, we have the evidence of numer-
ous competent observers that the interval before re-
currences appeared was often long, and there is
much reason to believe that cures were more fre-
quent than after operations with the knife. The
danger from poisoning was made a negligible factor
by the very general substitution of zinc chloride for
arsenic.
We do not find therefore that their value in the
hands of competent surgeons was discredited, but
the reason for their abandonment appeared to be
in the new conception of the possibilities which
scientific medicine furnished to the practical sur-
geon during the closing years of the century. Patho-
logical anatomy was making an early and exact diag-
nosis more available, the results of bacteriological
research promised to make primary mortality a
negligible factor and primary healing of the wound
a definite certainty, thus encouraging the surgeon
to believe that ultimately the development of his
technique would preclude the necessity of using
chemical methods which were less attractive and ex-
tremely difficult to apply. Frequent and early recur-
rences could not obliterate the attractiveness of the
primary result, and, until the past decade, sufficient
solace could always be obtained in the idea that con-
stitutional taint or heredity were compelling factors
in the unfavorable progress of the disease.
The result is that the "salvage," as expressed by
Clark in regard to uterine cancer is greater, but,
owing to our failure to increase appreciably the
number of patients applying for treatment in the
earliest stages of the disease, the primary mortality
has markedly increased, operative sequelke are fre-
quent, and recurrences are still discouragingly large.
The words of Peterson (1912) are important, who,
after expressing his strong belief in the radical
operation for carcinoma of the uterus, says, "My
added experience has not made me any more confi-
dent that the next patient I operate upon will either
survive the primary operation or will ultimately be
cured." Finally, there is the important fact that
the availability of surgical skill sufficient to effect
a respectable salvage is extremely limited — as much
so as is that of radium.
We believe, therefore, that the evidence of the
value of chemical caustics is sufficiently strong to
justify a new study of their technical application
and a discussion of the kind of cases in which they
may be most efficiently applied. In so doing they
may afford a valuable adjuvant to the use of the
knife and become applicable to a number of well
developed growths, the extirpation of which at the
present time results in a high primary mortality
and a high percentage of recurrences.
Regarding the educational propaganda of cancer,
it seems to the writer that the study and applica-
tion of all reasonable methods of treating cancer
will be of aid in encouraging the public to seek early
relief from competent hands. While anaesthesia
and skill have diminished the dread of the knife, the
fear of an operation still remains an important rea-
son for the frequent delays in asking for advice.
BIBLIOGRAPHY.
Allen: The Treatment of Cancer by Caustic Pastes.
Medical Record, 1904, 64, 935.
Arndt: Historisch-kritische Uebersicht ueber die zu
den Verschiedenen Zeiten in der Krebshandlung erziel-
ten Erfolge. Inaug. Dissert. Berlin, 1884. (Contains
literature.)
Barker, Fordyce: Discussion of Willard Parker's
paper.
Billroth: Surgical Pathology, Hackley, 1899.
Bougard: Sur la guerison du Cancer, Bruxelles,
1872.
Bulkley: On the Use of Caustics in Malignant Dis-
ease. Journal Am. Med. Assn., 1894, 22, 982.
Canquoin : Memoire sur un nouveau Mode de Traite-
ment des Affections Cancereuses. Paris, 1835.
Canquoin : Traitement du Cancer.
Chauliac, Guy de: Arndt and Wolfe.
Clark, J. C: The Radical Operation for Cancer of
the Uterus. Trans. Amer. Gyn. Soc, 1912, 37, 269.
Clowes : Wolfe.
Come: Langston Parker.
Cooper, Sir Astley: Lectures on Surgery, 1802.
Dabney: The Use of Anhydrous Sulphate of Zinc as
Caustic in Cancerous Ulcers. Med. News, 1882, 40, 401.
Dupuytren: Cited by Langston Parker.
de Mondeville, Henri: Arndt and Wolfe.
De Morgan : Brit, and Foreign Medico-Chir. Review,
Jan., 1866, 201.
Erichsen: The Science and Art of Surgery, 1860.
Fell: Cited by Langston Parker.
Filhos: De la Cauterisation du Col de 1'Uterus avec le
Caustique Solidifie de Potasse et de Chaux, Paris, 1847.
Halsted: The Results of Radical Operations for the
Cure of Carcinoma of the Breast. Annals of Surgery,
1907, 46, 1.
Hunter, John: Wolfe.
Hildanus, Fabricius: Wolfe.
Llandolfi: Dublin Quarterly Jour., Nov., 1855. Trans-
lation of Lasegue's Review of Llandolfi's Treatment of
Cancer.
Lewis: The Use and Place of Caustics in the Treat-
ment of Cancer. Annah of Surgery, 1893, 17, 392.
Maisoneuve: Lecons Cliniques sur les Affections Can-
cereuses, Paris, 1852-4.
Manec: Cited by Langston Parker.
Marsden : Cited by Langston Parker.
Moore: Jour. Brit. Assoc., April 21, 1866, 406.
Pare, Ambroise: Arndt and Wolfe.
Parker, Langston: The Modern Treatment of Can-
cerous Diseases by Caustics or Enucleation. London,
1867. Annual Address in Surgery Before the Brit. Med.
Assoc. (Contains literature.)
Parker, Willard : Cancer of the Female Breast. Its
Character, Diagnosis, Prognosis, and Treatment. Med-
ical Record, 1873, 8, 431.
Parmenter: On the Use of Caustics in Malignant
Disease. Journal Am. Med. Assn., 1894, 22, 982.
Pattison : Cancer : Its Nature and Successful and
Comparatively Painless Treatment, 1866.
634
MEDICAL RECORD.
[Oct. 7, 1916
Peterson: Primary and End Results of 51 Radical
Abdominal Operations for Cancer of the Uterus. Trans.
Amer. Gyn. Soc., 1912, 37, 295.
Peyrilhe: Cited by Wolfe.
Recamier: Recherches sur le Traitement du Cancer
par les Compression, etc. Paris, 1829.
Rivallie: Traitement du Cancer par l'Acide Nitrique
Solidifie. Paris, 1850.
Robinson: Some Considerations on the Treatment of
Cutaneous Malignant Epitheliomata. International
Jour. Surgery, 1892, 5, 179.
Routh: A New Mode of Treating Cancer of the
Cervix Uteri. Obstet. Soc. of London, Oct. 3, 1866.
Sands: Discussion of Willard Parker's Paper.
Smith, Stephen : The Treatment of Cancerous Ulcers
and Growths Not Removable by the Knife. Medical
Record, 1880, 17, 165.
Snow: The Path of Improvement in Cancer Treat-
ment. Med. Press and Circular, 1893, 1, 659.
Storck: Cited by Arndt.
Thomas, T. G.: Diseases of Women, 1869.
Tilt: The Change of Life in Health and Disease.
Velpeau: Traitement des Maladies du Sein, et de la
Region Mammaire, etc., 1854, 63, 676.
Warren, J. Collins: Personal Experience in the
Treatment of Cancer. Boston Med. and Surgical Jour.,
1887, 116, 154.
Wolff: Die Lehre von der Krebskrankheit, 1907.
(Contains the older literature and a historical review
of the use of caustics among the ancients and during
the middle ages.)
Woelfier: Zur Geschichte und Operativen Behand-
lung des Zungenkrebses. Archiv. f. kl. Chir., 26, 314.
(Contains literature.)
Young: An Inquiry into the Nature and Action of
Cancer. London, 1805.
CYSTOSCOPY AS A DIAGNOSTIC AID IN
SPINAL CORD DISEASES.
By GEZA GREENBERG, M.D.,
NEW YORK.
CHIEF OF CLINIC OF THE GENITO-URINARY DEPARTMENT OF THE
NORTHWESTERN DISPENSARY ; ATTENDING UROLOGIST
GERMAN HOSPITAL DISPENSARY.
It has long been known that lesions of the spinal
cord give rise to bladder disturbances, in some
cases early, while in others late in the disease. This
is due to the innervation of the bladder. The
lower the lesion in the cord the earlier the symp-
toms.
To understand fully the mechanism of it it is
necessary to describe the anatomy and physiology3
of the bladder. The bladder is a muscular organ
serving as a reservoir for the urine until it is fully
distended, when it empties itself completely; this
process repeats itself at regular intervals, it is an
elastic body made up of a mucous layer of tran-
sitional epithelium, a muscular coat arranged in
three incomplete layers, viz., an outer longitudinal,
a middle circular, which is strongly developed at
the internal sphincter, and an inner longitudinal;
the outermost layer is the serofibrous coat. There
are motor and sensory nerve ganglia in all the
three coats. The plexus supplying the bladder is
called the vesical plexus, which is an offshoot of
the hypogastric plexus of the sympathetic nervous
system. The hypogastric plexus divides into the
pelvic plexuses and these in turn give off plexuses
to the various viscera, to wit, the vesical, prostatic,
seminal vesicle, and cavernous plexus. The various
plexuses are connected with one another by means
of ganglia, and with the sacral nerves by the rami
communicantes ; and lastly with the lumbar nerves
through the hypogastric nerves and the inferior
mesenteric ganglia.
In order to get perfect contraction of the bladder
the afferent, central, and efferent neurones must
be intact. It is still a mooted question how the
process of micturition takes place. According to
Goltzi the series of events is as follows: The dis-
tention of the bladder by the urine causes a stimu-
lation of the sensory fibers of the organ and pro-
duces a reflex contraction of the bladder mus-
culature, which squeezes some urine into the
urethra; this in turn stimulates the sensory nerves
in the urethra, giving rise to a desire to urinate.
If no obstacle is present the bladder empties itself,
aided partly by the abdominal muscles and partly
by the bulbocavernosus. The emptying of the blad-
der can, however, be prevented by the voluntary
contraction of the external sphincter, thereby coun-
teracting the contraction of the detrusor muscles
of the bladder; and if the bladder is not too full,
then the desire will eventually pass off. Hence it
is seen that the voluntary control of the process is
limited to the action of the external sphincter and
the abdominal muscles, while the contraction of
the bladder itself is an unconscious reflex act tak-
ing place through the sacrolumbar center. Goltz
and others proved by severing the spinal cord in a
dog at the junction of the thoracic and lumbar
regions that micturition still took place, and that
it was a reflex act with its center in the lumbar
region. The same author adduces evidence to show
that the sensation to urinate and of fullness comes
from stimulation in the bladder itself caused by
the pressure of the urine. He points out that the
bladder is very sensitive to reflex stimulation ; that
every psychic act and sensory stimulus causes a
contraction and an increased tone of the bladder.
The bladder is subject to continual changes in size
from reflex stimulation, and the pressure within
it depends not only on the quantity of urine, but
on the condition of bladder tonicity as well. It is
easy to understand from this viewpoint how it
happens that we may at times have a strong desire
to urinate with but little urine in the bladder — for
instance, under emotional excitement.
Again Langley and Anderson* have shown by
experiments on dogs, cats, and rabbits that the
bladder receives two sets of motor fibers; first,
from the lumbar nerves, the fibers passing out in
the second to the fifth lumbar nerves and reach
the bladder through the inferior mesenteric gang-
lion and the hypogastric nerve; second, from the
second to the third sacral nerves, being contained
in the nervus erigens. Stimulation of the hypo-
gastric nerves causes comparatively feeble contrac-
tions of the bladder, while that of the nervus
erigens brings forth powerful contractions.
According to Nawreckf, the spinal sensory fibers
to the bladder are found in the posterior roots of
the first to the fourth sacral nerves, and when
these are stimulated they reflexly stimulate the
anterior roots of the second and third sacral nerves,
these being the motor fibers.
The bladder is governed by the same laws of
physiology as all other striped and unstriped mus-
cles, the vitality of the tissues depending on the
uninterrupted nerve supply, while that of the nerve
fiber on the integrity of its cells and ganglia. If a
nerve be cut, the part which is separated from the
cell degenerates. The irritability at first increases,
but soon diminishes, being wholly lost in three to
four days. As the nerve regenerates, the irrita-
bility returns gradually, and not until the axis-
cylinder has grown down into the fiber is the nerve
capable of responding to induction shocks. The
muscle will likewise be affected; at the end of a
fortnight the irritability of muscle lessens. For
Oct. 7, 1916]
MKDICAL RECORD.
635
about six to seven weeks the response to mechanical
irritants and direct battery currents increases, while
to the faradic current diminishes; then the irri-
tability lessens progressively until it is entirely lost
at about the eighth month. This is followed by
muscular degeneration.
When the posterior spinal ganglia are diseased
as in tabes, the posterior columns degenerate; in
the course of time the ganglia themselves atrophy.
The peripheral nerves undergo some changes the
process of which is not thoroughly understood. As
a result of all these changes the arc of conductivity
is broken, and the deep reflexes are either dimin-
ished or completely abolished. When during this
process the bladder centers are involved, then the
sensitiveness of the bladder will be reduced to such
an extent that the desire to urinate will not arise
until there is more than the average amount of
urine in the bladder. This finally results in vesical
distension, and the process of micturition will more
than ever be executed by the will, since the fibers
from the anterior horns are not affected at all.
The contractions of the feebler and the emptying
of the viscus is largely carried out by the aid of the
abdominal muscles. In the course of time second-
ary changes in the bladder and kidneys will follow
stagnation and infection. Imperfect contraction of
the bladder musculature is probably just as much
responsible for circulatory disturbances in the blad-
der wall as the residual urine. However, long be-
fore symptoms of infection manifest themselves
marked changes in the bladder take place. The
changes are not unlike those found in heart diseases
where dilatation and hypertrophy go hand in han.d.
Owing to the peculiar arrangement of the muscle
bundles in the bladder wall, where they run in vari-
ous directions, some of these muscles become
markedly hypertrophied and project into the lumen
of the viscus, resembling the fleshy columns of the
heart. In some places numerous diverticula? of dif-
ferent sizes result from it. In spinal cord cases I
found the trabecular and the diverticular forma-
tions more commonly on the roof and lateral walls
than on the fundus, while in cases resulting in
similar changes from long-continued obstructions
due either to hypertrophied prostate or to an im-
pervious stricture, I found them more often and
better developed on the fundus of the bladder. As
the disease progresses the muscle fibers atrophy and
degenerate, resulting in atony of the bladder. When
this stage is reached the bladder becomes enor-
mously distended and then an overflow (inconti-
nence) follows. When the lesion starts in the an-
terior horns, then the atrophy and muscular de-
generation set in earlier, resulting in incontinence
due to paralysis of the sphincter.
All these changes occur in practically every cord
lesion where the sacrolumbar segment is diseased,
but the time of occurrence depends on the extent
and progressiveness of the lesion. As a rule the
urinary symptoms arrive late in the disease, al-
though their early presence may be overlooked by
the symptoms of palsy. Occasionally one may see a
patient with no symptoms referable to the cord but
to- the urinary organs, namely, difficulty of micturi-
tion, and on examination find a considerable amount
of residual urine. Cystoscopy in such cases shows
marked trabeculations and diverticula? formations.
When one finds such a group of symptoms in the
absence of any physical signs pointing toward a
stricture or an hypertrophied prostate, even though
there are no signs other than urinary, one may
reasonably suspect an oganic disease of the cord.
The lesion may have started in the bladder center,
but it has not advanced far enough to give evidence
of other forms of paralysis.
It behooves us, therefore, in every patient who
presents himself with urinary disturbances to
examine his nervous system, and if no signs be
present, provided the local condition is not account-
able for it, to cystoscope him, and if such physical
signs as I have just described are present, and if
they in addition are associated with chronic consti-
pation which started at about the same time as the
urinary difficulties, then it is almost certain that
the patient is afflicted with a grave nervous lesion
of the cord, which will sooner or later manifest
itself with all the other characteristic symptoms.
The following cases will illustrate the effects of
cord lesions on the bladder :
Case I. — B., 34 years, denied venereal history; pre-
sented himself for difficulty of micturition and a small
stream. Urethra and prostate normal. Residual urine
12 to 16 ounces. Cystoscopy showed a markedly tra-
beculated bladder with numerous diverticula on the
roof, lateral walls, and fundus. His superficial reflexes
were present, but the knee jerks absent; pupils reacted
sluggishly to light. He had no ataxia; marked atony
of the rectum. Wassermann negative. I followed him
up for about three months with no improvement in
his condition. His lesion probably started in the sacro-
lumbar region about the bladder and rectal centers
before invading the other parts.
There is another class of patients who have abso-
lute loss of sphincteric control caused by either a
paresis of the sphincter or exaggerated reflexes in
the bladder, where a few drops of urine are suffi-
cient to set up contractions in the bladder, or, per-
haps, by a combination of the two, as might occur
in ataxic paraplegia, where the lesions are in the
dorsal and lateral columns of the cord.
Another illustrative case showing an absolute
paralysis of the sphincter:
Case II. — A young man of about 26 came to me
with the following history: About five months prior to
this he became paralyzed in both legs, this being fol-
lowed two months later by incontinence of urine. He
wore an improvised urinal for the relief of this con-
dition. On examination I found the head of the penis
and part of the frenum were macerated, and sloughing
on account of the irritation by the escaping urine.
Cystoscopy was futile on account of the sphincteric
paralysis, and the bladder could not be distended. He
had atrophy of his limbs with loss of reflexes. His
lesion was in the anterior horns.
Case III. — M., 27, had gonorrhea but no syphilis;
used alcohol excessively. He presented himself for
treatment for what he thought was gonorrheal arthritis
and a weak bladder. He complained rather of stiff-
ness and weakness in his right hip and knee than actual
pain. On examination I found a spastic gait, fibrillary
contractions of his right thigh muscles, marked increase
of both knee reflexes, no ankle clonus; no ataxia of his
arms or legs; pupillary reflexes normal; loss of tem-
perature sense in his right leg and foot. Wassermann
negative. He had difficulty in starting to urinate, and
had nocturnal eneuresis. At times he lost his sphinc-
teric control of both bladder and rectum; at other
times he had frequency caused by an overdistended
bladder. Examination of the urethra showed an an-
nular stricture of 22 French calibre at the penoscrotal
junction; residual urine eight ounces. Cystoscopy re-
vealed marked trabeculations of the bladder. In this
case the trabecule could not be attributed to the stric-
ture alone, for it was of a fairly large calibre; and
had they been caused by the stricture without any cord
lesion, then there would not have been any residual
urine in the bladder, for young healthy individuals even
though they develop such marked changes in the blad-
der from impervious strictures, regain the normal tone
of the bladder as soon as the obstruction is removed
and practically expel every drop of urine. He sustained
636
MEDICAL RECORD.
[Oct. 7, 1916
a severe burn of his right foot while bathing it, due to
his loss of temperature sense.
REFERENCES.
1. Cunningham: Anatomy.
2. Howell : American Textbook of Physiology.
3. Goltz: Archiv fitr die gesammte Physiologic, 1874.
Bd. VIII. S. 478.
4. Langley and Anderson: Journal of Physiology,
1895, Vol. XIX., p. 71.
5. Nawrecki: Archiv fur die gesammte Physwlogie,
1891. Bd. 49 S. 141.
120 East Thirtt-foi'UTh Street.
THROMBOPHLEBITIS IN THE TUBERCU-
LOUS, WITH AUTOPSY.*
By ETHAN A. GRAY, M.D..
CHICAGO, m,.
MEDICAL DIRECTOR, CHICAGO FRESH AIR HOSPITAL.
While thrombophlebitis is of every day occurrence,
its incidence in the tuberculous appears to have es-
caped the attention of writers on tuberculosis. And
yet, even as a complication of tuberculosis, it is not
rare. We have observed it at the Chicago Fresh
Air Hospital no less than seven times in 1400 cases.
My material comprises three men and four
women patients at the Chicago Fresh Air Hospital;
three of the women were in the far advanced stage
of their disease, as was the fourth, who was, how-
ever, of the chronic type; the three men and two
women had thrombophlebitis of the lower saphe-
nous of both legs.
One woman (autopsy) had thrombosis of the in-
ferior vena cava and of both iliac veins. One
woman developed thrombophlebitis of the arm
which extended upwards into the external jugular
vein. In the cases of the two women and three
men the phlebitis began in one leg and, after sub-
siding here, attacked the other leg. The patient
with thrombosis of the basilic and jugular im-
proved after leaving the hospital. No subsequent
history was obtainable except that she died some
months later. The other women died with throm-
bophlebitis still active. One man is well, his pul-
monary condition under control by artificial pneu-
mothorax ; he is working steadily as dining-car con-
ductor; the second man is an invalid but free of
vein symptoms; the third man is convalescent as
regards his pulmonary condition, his thrombosis be-
ing manifest only through the thickened veins, pal-
pable under the skin.
Case with Autopsy. — Mrs. D. S., age 30, housewife,
was admitted to Fresh Air Hospital, May 21, 1914.
Father living and well, mother died of "dropsy." Patient
has had three children, one dead born and twins which
died aged 3 days and five weeks, respectively. Patient
has had rheumatism. Five years ago the "present
trouble" (pulmonary tuberculosis) began with cough;
bleeding from the lungs has occurred several times;
there have been night sweats. Patient is constipated
and suffers from "stomach trouble;" appetite bad;
menses absent. Appearance of patient cachectic; face
sallow and much emaciated.
Sputum contains tubercle bacilli corresponding to
Gaffky II, urine cloudy, sp. gr. 1020 — some albumin.
Pulse 112; temp. 39.2° C. Blood pressure, systolic, 79.
Physical examination. — Right Lung — Anteriorly:
Amphoric respiration, Moist rales, Wintrich sign I, II,
I. C. S.; Tympany down to III rib.
Posteriorly: Tympany, Amphoric respiration from
apex to III rib.
Left Lung Anteriorly: Amphoric respiration, apex
to IV rib.
Posteriorly: Cavernous respiration with amphoric
character II — IV ribs, creaking and moist rales.
*Read before the German Medical Society of Chicago,
April, 1915.
June 15, 1914, the patient was attacked by severe
pain in the left leg. On examination there was found
redness along the long saphenous vein which was pain-
ful on pressure. June 20, the inflammation was recog-
nizable in the femoral vein. July 1, the pain was less
and on the 11th of the same month was nearly gone.
August 1 pain was felt in the region of the inferior
cava which was aggravated by deep pressure over the
vessel; pressure also elicited pain in the pelvis.
Diagnosis: thrombophlebitis of the iliac veins.
On September 1 the disease attacked the long saphen-
ous of the right leg. From this last named date until
her death, October 1, the patient was never free from
pain; temperature was constantly around 38.5° C.
Autopsy (by Dr. Olga Pickman). Body of an ex-
tremely emaciated woman ; hips and abdominal walls
very edematous, feet and lower legs edematous. The
saphenous and femoral veins were felt, cordlike, under
the skin.
Thorax: Left, many pleuritic adhesions, extensive
consolidation ; several walnut sized cavities in both
lobes; much scar tissue — Right lung: here, also, many
cavities and extensive consolidation; the lungs were
heavy as the result of much cicatrization. Heart small,
musculature pale and flabby, valves competent.
Kidneys congested and degenerated (fatty). Spleen
congested and enlarged. Liver congested and degen-
erated.
A piece of the long saphenous vein of the right leg
was removed, the vein found to be thickened and en-
tirely filled with thrombus. The left leg was not exam-
ined. The inferior vena cava was smaller than usual —
thickened and partly blocked with thrombus, the clot
extending down into both iliac veins from the cava; the
lumen of the cava, as of the iliacs, was also about one-
half filled by the thrombus.
Miscroscopical : The excised portions of the veins
were examined by Dr. Oscar Nadeau, to whom my
thanks are due. The specimens were stained with car-
bol fuchsin for tubercle bacilli which were not found,
however, by this method. With the picrin stain, a few
tubercle bacilli were found in the thrombus. In one
section a bacillus was found in the intima of the iliac
vein. With the Much stain, granules were found in
many sections of the vena cava.
Bacilli are not constantly found in the circulating
blood. According to the observations of various
students of this subject, the blood may be flooded
with tubercle bacilli in the death agony. It is not
certain that the bacilli circulate in the blood in mod-
erate infections. Brieger, experimenting on guinea-
pigs, found that the bacilli were solitary in the
blood, never in clumps. Also, in his experiments,
he determined that the intravenous inoculation was
mostly negative.
Klopstock and Seligmann (Ztsch f. Hygiene, Bd
76 H. i.) examined the blood of four consumptives.
In no case did they produce definite signs of tuber-
culosis in guinea-pigs by the inoculation of these
bloods. Bandelier and Roepke refer repeatedly to
the presence of tubercle bacilli in the circulating
blood in far advanced cases and cite the occurrence
to explain tuberculous infection of other structures.
It will thus be seen that variance of opinions
exists regarding the infectiousness and incidence of
tubercle bacilli in the blood stream.
Nevertheless, infection of the venous vessels in
the tuberculous is here shown to be of sufficiently
frequent occurrence to give rise to inquiry as to the
mode of production.
2744 Pine Grove Avenue.
Alcoholic Insanity in Kansas. — Newcomb states that
but 1.7 per cent, of insane committed in Kansas during
1915 were suffering from uncomplicated alcoholic in-
sanity. He contrasts this figure with the general aver-
age of 10 per cent, throughout the country, some special
hospitals giving a minimum of from 4 to 5 per cent.
The incidence in rural communities of alcoholic psy-
chosis is very low — 2.6 per 100,000 inhabitants — and it
may be urged that Kansas is much more rural than
urban, but about half the cases came from counties
adjoining wet States. — Pennsylvania Medical Journal.
Oct. 7, 1916J
MEDICAL RECORD.
637
A CASE OF PAN-SINUSITIS, COMPLICATED
WITH ACUTE SUPPURATIVE APPENDI-
CITIS AND ACUTE MASTOIDITIS.
By JOSEPH EASTMAN SHEEHAN, M.D..
NEW YORK.
INSTRUCTOR IN DISEASES OF THE NOSE AND THROAT, NEW YORK
POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL ; CONSULT-
ING EAR AND THROAT SURGEON, ST. FRANCIS' HOSPITAL,
PORT JERVIS. N. Y. ; ATTENDING EAR AND THROAT
SURGEON, ST. MARY'S HOSPITAL.
ORANGE, N. J.
The following case seems to be worthy of per-
manent record :
Miss M. H., age twenty-six, consulted me July 23,
1915 for a continual discharge from her nose. For the
past two years she has had more or less continual dis-
charge from the nose of a purulent nature. During the
past eight months she has complained of headaches,
principally on awakening in the morning, of a frontal
character, which lately have become occipital, and which
were gradually getting worse; they would last well
into the afternoon. Coughing with expectoration fol-
lowed with loss of weight amounting to eighteen pounds
within one year. The past history reveals nothing of
importance. Her father and mother are alive and well,
and two brothers and one sister are still living.
Examination shows a pale girl with drawn features
and an anxious expression. There is extreme tender-
ness over the right frontal sinus with swelling and
tenderness over the right antrum. The left frontal
sinus and antrum also are somewhat tender to pres-
sure. Transillumination reveals dark shadows over the
antra and both frontal sinuses.
Examination of the nares showed much mucopurulent
discharge with markedly enlarged turbinates, and there
was a high deflection of the septum. Probing both
sphenoidal cavities showed that they were diseased.
The antra were opened and found to contain pus. The
patient was advised to go to the hospital and submit
to an operation. She agreed and an operation, followed
by many more, resulted.
Herewith is the blood picture: Blood Wassermann
negative. Complement fixation test for gonorrhea
negative. Luetic test, negative. Von Pirquet and
Morro reactions negative.
Blood Count: Hemoglobin, 60 per cent.; red cor-
puscles, 2,800,000; white corpuscles, 13,000; polys, 72
per cent.; small lymphocytes, 16 per cent.; large
lymphocytes, 10 per cent.; eosinophiles, 1 per cent.;
transitional cells, 1 per cent. No malarial parasites.
The smear of discharge from the nares showed a
staphylococcus and a streptococcus with a large
bacillus present. A combined vaccine was made and
given with little or no effect on the discharge.
The sputum was negative for the tubercle bacillus.
The urine showed a faint trace of albumen. There
were no casts present.
On August 15, 1915, both middle turbinate bones
were removed with a total eradication of the anterior
and posterior ethmoid cells on both sides. These cells
were found to be wholly diseased. Both frontal sinuses
were opened, irrigated, and drained, much purulent
matter being exuded. The smear of the frontal sinuses
showed a staphylococcus, a streptococcus, and a small
bacillus present.
On September 13, 1915, both inferior turbinate bones
were removed and the antra opened and curetted. The
sphenoid cavities were opened also and curetted. For
three weeks following injections of arsenic and iron
were given.
On October 5, 1915 the blood examination showed the
following result: Hemoglobin, 75 per cent.; red cor-
puscles, 3,200,000; white corpuscles, 11,000; polys, 69
per cent.; small lympocytes, 21 per cent.; large lympho-
cytes, 8 per cent. ; transitional cells, 2 per cent.
On November 5, 1915, both frontal sinus openings
were enlarged. The smear showed a streptococcus, a
staphyolococcus, and a small bacillus present. A com-
bined vaccine was made and given with little result.
On January 3, 1916, the antral openings were en-
larged and curetted, and both sphenoid cavities were
curetted again.
On January 15, 1916, both frontal sinus openings
were again enlarged.
On March 20, 1916, on account of the persistence of
the discharge from the right antrum a radical oper-
ation was resorted to.
On March 22, 1916, the patient complained of severe
pain in the right side of the abdomen and on March 24
an appendectomy for suppurative appendicitis was
performed, a smear from the appendix showed a strep-
tococcus, a staphylococcus, and the colon bacillus pres-
ent. Ten days after the appendix was removed, pa-
tient complained of pain in both ears. A 10 per cent,
ichthyol solution in glycerin was instilled in both ears
with no results. Twenty-four hours later both ear
drums were incised, with a complete amelioration of
the symptoms in the left ear. The pain continued in the
right ear and suppurative mastoiditis developed.
On account of the weakened condition of patient, I
was inclined to temporize with this new surgical con-
dition. On April 10 the symptoms became so urgent
the mastoid was opened under cocaine anesthesia and
later ether was resorted to. A total eradication of the
mastoid cells was performed and the lateral sinus was
laid bare as there existed a perisinus abscess. A
smear from the opened mastoid showed a streptococcus
and a staphylococcus. A combined vaccine was made
and the patient improved under this treatment.
Ten days after the mastoidectomy the patient was
discharged from hospital.
The blood examination showed at this time the fol-
lowing: Hemoglobin, 80 per cent.; red corpuscles,
4,000,000; white corpuscles, 9,000; polymorphonuclears,
68 per cent.; small lymphocytes, 24 per cent.; large
lymphocytes, 7 per cent.; eosinophiles, 1 per cent.
An examination of patient at present time (June
20, 1916), shows her to have gained much in weight.
The sinuses have all ceased discharging with the
exception of the right frontal sinus, which at times
discharges a thin mucoid substance. The patient
has had no fever for the past four weeks and is
about to resume her former duties.
24 East Forty-eighth Street.
Jfleiitailrr.ai -Notes.
Competency of Physician's Testimony. — After filing
objections to the probate of the scrip purporting to
be the last will of his wife, the objecting husband died,
and the executor of the deceased husband, who was
made a party, offered to prove by the physician who
attended the testatrix immediately prior to her death
that at the time she executed her will she lacked testa-
mentary capacity. New York Code Civ. Proc. § 836,
relating to waiver of the privilege of a physician by
enumerated persons, declares that any other party in
interest may waive such privilege. The Surrogate's
Court, King's County, held that the executor of the
deceased husband was a party in interest, entitled to
waive such privilege, for the probating of the will
would affect the husband's estate, and so the testimony
of the physician was competent. In re Mele's Estate,
157 N. Y. Supp. 67.
Liability of Private Hospitals for Negligence. — A pa-
tient voluntarily entered a private sanatorium, and
after once leaving without permission returned and
voluntarily consented to be removed to another ward
where he would be practically a prisoner. Those in
charge did not, during the process of removal, forcibly
restrain the patient, though an attendant walked by his
side. The patient suddenly broke away and fled from
the sanatorium half-dressed. He entered a house where
were a woman and two small children, so frightening
the woman that as a result, the evidence tended to show,
she was afflicted with neurasthenia and cystitis (!) for
which she sued the proprietor of the sanatorium. The
Wisconsin Supreme Court held that the evidence did
not show negligence on the part of the proprietor, and
that the plaintiff could not recover. — Torrey v. River-
house Sanitarium, 157 N. W. 552.
Verification License to Practise. — The Texas Court of
Criminal Appeals holds that a license issued to a phy-
sician by a member of a medical examining board in
1892, certifying that the physician had been examined
by such member of the board, and was thereby licensed
to practise medicine and surgery until the next regular
meeting of the board, showed on its face that it was
a mere temporary license, good only until the next
regular meeting of the board, and under no circum-
stances could be considered the verification license re-
quired to be filed under the present law, Acts 30th Leg.
c. 123, regulating the practice of medicine in Texas.
That statute has been held constitutional by the United
States Supreme Court and many times by the State
courts.— Gay v. State, 184 S. W. 200.
638
MI-'DICAL RECORD.
[Oct. 7, 191G
Medical Record.
A Weekly Journal of Medicine and Surgery.
THOMAS L. STEDMAN, A.M., M.D., Editor.
PUBLISHERS
WM. WOOD &. CO., 51 FIFTH AVENUE
See fourth page following reading matter for Rates of Subscription
and Information for Contributors and Subscribers.
New York, October 7, 1916.
PATHOLOGICAL ANATOMY OF UNDULANT
FEVER.
The symptomatology of this affection is extremely
varied, and our knowledge of the pathological an-
atomy correspondingly scanty. The low mortality
(in medium cases) is doubtless responsible for lack
of interest in this subject. Each case should there-
fore be subjected to close scrutiny during life and
every fatality should lead to a careful autopsy. In
La Riforma Medica of June 26, Lunghetti reports
a fatal case, in part as follows: The patient, a
man of forty-four, had been ill for about a month,
the chief symptoms having been fever and abdom-
inal pain. Interned in the University Hospital,
Sienna, he began to show prostration with attacks
of vomiting and later became stuporous. An ery-
thema, hemorrhagic, appeared on the face. Exami-
nation of the thorax and abdomen gave negative re-
sults. The heart's action was feeble, pulse small
and frequent. The Widal test was negative. Lum-
bar puncture showed slightly increased tension.
The patient's condition became progressively aggra-
vated, and the pulse rate was increased to 180. The
mental state likewise became worse. At no time
was there any elevation of temperature. The pre-
cise method of death is not stated. Autopsy begun
30 hours after death showed a very emaciated
cadaver in incipient putrefaction. There was slight
congestion of both brain and meninges. The ab-
dominal contents appeared to be normal. There was
slight dilatation of the heart, especially of the right
side. There was some induration of the myo-
cardium. The lungs were the seat of pronounced
edema. The spleen weighed 200 grams and had a
reddish brown pulp. The liver weighed 1550 grams
and presented incipient fatty degeneration. All
the other viscera were without alteration. The
gastrointestinal canal with exception of the colon
showed a slight catarrh and the mesenteric lymph-
nodes were tumefied. Peyer's patches were swollen,
pale, and softened.
In order to exclude the possibility of a typhoid or
paratyphoid infection, a careful bacteriological
study of the intestinal contents was made, but only
the normal bacterial flora was present therein.
The Micrococcus melitensis was, however, after some
difficulty, cultivated from the splenic pulp. The
cultures were agglutinated in the blood serum, 1 to
200, but not by control fluids of various kinds.
Microscopic studies of tissues involved could hardly
be termed sufficient for an autopsy diagnosis. Much
time was devoted to Peyer's patches, the mesenteric
lymphnodes, the remains of the thymus, and the
spleen. Other organs investigated were the liver
and kidneys. The micrococcus was found in the in-
testinal wall and mesenteric lymphnodes. It is
conceivable that in the course of its absorption by
the intestine the coccus caused local alterations and
that once in the circulation it produced those alter-
ations in the viscera which have caused the disease
to be termed a form of septicemia. Marked changes
were noted in the central portion of the mesenteric
nodule where the tissues were constituted of ele-
ments of the most variable nature. In most of the
cells the nuclei would no longer take their proper
stain and the protoplasm was opaque, granular, and
disintegrated. Between the individual elements was
much detritus, including fragments of red cor-
puscles. In certain areas these were all the evi-
dences of recent necrosis.
The finds in the spleen and viscera in general,
while inconclusive enough, may be brought into
definite relationship with those of other recent in-
vestigations and with the view that Malta fever is
a form of septicemia. Not so many years ago Man-
son stated that the pathological anatomy of the
disease could be summed up by "tumefaction of the
spleen." Occasional local phenomena, as well as the
various dominant symptoms, resemble those seen in
various well-know severe infections. This is borne
out by the cerebral symptoms, the hemorrhagic rash,
the intestinal symptoms, the severe and terminal
intrathoracic symptoms, and involvement of abdom-
inal viscera, all present in the author's case. Cer-
tain severe lesions of general infection, as endo-
carditis and nephritis, were notably absent in this
case, although occasionally found by others. Malta
fever occasionally masquerades as a pneumonia or
other severe local affection. Taking the clinical
with the autopsy finds the author would place this
fever nearest to paratyphoid or to colisepsis.
MEDICAL MATTERS IN MADAGASCAR.
From remote corners of the world, if any place can
be called remote nowadays, come reports of medical
discoveries, sanitary measures, successful opera-
tions, and other bits of news which make us look
forward to the time when in the darkest district of
the Malay Archipelago the witch-doctor shall have
been supplanted by the good old G. P. The Sultan
of Sulu no longer invokes a familiar when he has
the tummy-ache; he has a leucocyte count and the
court physician betakes himself to his office and
sharpens up his favorite scalpels. The name of
Madagascar is somehow associated in our minds
with long, low, rakish-looking canoes manned by
ten or twenty savages, crinky kreeses dripping with
blood, cannibal feasts by moonlight, and all the
other sanguinary appurtenances of barbarism. It
would seem, however, that in hygienic matters at
least this island is fully up to date, thanks to the
efforts of the late French governor, General Gallieni,
whose work is described by Dr. Kermorgant in the
I!, rut cPHygi&ne for June.
Oct. 7, 1916J
MEDICAL RECORD.
639
When General Gallieni first assumed charge of
the island in the early nineties he was horrified at
the insanitary conditions prevailing, the fearful
mortality from preventable diseases, and the low
birth-rate. With an enthusiasm suggesting rather
a doctor devoted to his profession than a military
man he set himself to remedy these conditions.
His chief work and his happiest results were
along the line of infant mortality. He had native
women trained as midwives and he established and
popularized maternity institutions. He regulated
marriage and restricted divorce. He exempted the
fathers of five children or more from taxation and
taxed bachelors instead. He gave prizes to the
mothers of large families and organized hospitals,
dispensaries, and orphanages.
In 1896 Gallieni founded a medical school for
the natives which, after many vicissitudes, due
largely to native prejudice, is now turning out well-
trained physicians. In 1899 a Pasteur Institute
was founded for the production of smallpox vaccine
and the treatment of hydrophobia. Lazarettos
were established for the segregation of lepers, a
central pharmacy for the supervision of drugs, and
information about disease and its prevention was
disseminated in a popular way.
Gallieni's services, it is gratifying to record,
were appreciated by his subjects as well as by his
mother country. The former named him "Ray
Amandreny," meaning "both father and mother,"
and the French Academy of Medicine awarded
him a gold medal, the highest gift in its power.
These labors of the general in the cause of human
welfare will overshadow, in the mind of the medi-
cal profession at least, his military achievements,
glorious though they undoubtedly were in the
present war.
THE DAILY MORNING HEADACHE OF
HYPERTENSION.
Daily morning headaches have been said to occur
under a variety of conditions. In the malarial days
of New York it often meant "dumb ague" and re-
sponded readily to quinine. Occurring early in the
forenoon in a man in his forties it betokened the
need of glasses. Waking early with a headache
could mean alcoholism or uremia. There is much
reason to look with scepticism on this pigeonholing
arrangement. There is reason to believe, for ex-
ample, that headaches "due to uremia" may often
arise simply from hypertension, or conditions which
cause or follow the latter.
For fifteen years Rathery kept track of morning
headaches, and associated them with interstitial
nephritis of scarlatinous origin, syphilis, nicotin-
ism, and excess in protein consumption. As acces-
sory factors he recognized sedentary occupation,
excessive mental labor, and great responsibility.
Renon, in an equally long observation period {Jour-
nal de Medecine et de Chirurgie, etc., August 25),
in which Pachon's oscillometer was used, found the
presence of excessively high tension. This head-
ache may involve the entire cranium or only por-
tions of it (it is eeldom occipital). It comes on
early in the morning and may waken the patient at
5 or 6 a.m. It is intense, and he does not feel like
getting up. It has a maximum at 9 or 10 A. M., and
may disappear at noon. The subject, unfitted for
labor or even for coherent thinking, rushes for the
headache powder or equivalent. He has tried them
all. One gives him relief for an hour and a half,
and three may keep him free during the forenoon.
Meanwhile he becomes the victim of the drug and
its toxic effects, until the remedy is worse than the
disease. Such a man shows an enlarged left heart,
accentuated second sound, and polyuria with traces
of albumin. In other patients there is only a dull
morning headache augmented on slight mental or
physical exertion ("painful thinking"). The con-
dition is progressive and Renon has never seen a
recovery. Often death occurs with great prompti-
tude after the diagnosis is made. Nevertheless in-
tensive treatment will give relief.
First, the coal-tar derivatives must be shut off,
as well as tobacco. Mental rest must be ordered.
For a week at least the patient must go on a milk
regimen as the sole diet. Then he may have milk
days and live for the rest on fruits and vegetables
for two weeks more. He is then placed on a light,
low protein regimen for several weeks. If the blood
tension has not come down, and if headache still
persists, Renon advises certain harmless hypoten-
sives, such as thiosinamine. Iodides are given only
if a syphilitic basis can be shown. Otherwise they
aggravate the symptoms.
A Warning.
We are obliged to call attention of our readers once
more to the taking of subscriptions to the Med.-
CAL Record, The American Journal of Obstetrics
and Diseases of Women and Children, or the British
Journal of Surgery, by unauthorized persons. There
has for a long time been an organized band of these
rascals working the cities and larger towns in many
sections of the country. Their scheme, or one of
their schemes, is to represent themselves as an as-
sociation of indigent students (the latest one we
have heard of calls itself the "Western Students'
Benefit Association") who are given free tuition in
a medical college in return for a certain number of
paid subscriptions, new or old, to either or all of
the above-mentioned journals. They thus work
upon the sympathies of their dupes who feel they
are helping deserving young men to get a medical
education, while at the same time they are treat-
ing themselves to some of the best obtainable medi-
cal literature. The latest trick is to offer a physi-
cian whose subscription happens to be overdue a
receipt in full for the payment of $4.25; naturally
such a generous offer is accepted in many cases.
We would again warn our present subscribers not
to give money for renewals to any but our author-
ized agents, or preferably (as a forged authoriza-
tion may be presented) to send it direct to the sub-
scription department of one or the other journal. As
to the intending new subscribers, we are doing our
best to protect them by notifying the police of the
cities where these gangs of sharpers are working.
We would also suggest to our friends that they
would be doing a favor not only to us, but, and espe-
cially, to their colleagues if they would speak of
this matter in their society meetings, cautioning
their fellow-members never to pay money for books
or for subscriptions to this or any other journal to
640
MEDICAL RECORD.
[Oct. 7, 1916
any but authorized agents of the publishers. By
giving such warning they would help the readers
not only of this but of other journals, for the sub-
scribers to several of our contemporaries have been
defrauded in the same way and by the same persons.
Another Theory Exploded.
Solomon Yacovitto of Brooklyn, a lamplighter of
that city and a victim of rheumatism in the legs, his
vocation suffering as a result, was told by a friend
that if he would bathe in water in which a certain
drug had been dissolved his rheumatism would be
cured and, in addition, his skin would be whitened.
This wonderful drug the friend said, or so Solomon
understood, was calcium carbide ; so he purchased
a can of this, filled his bathtub, seated himself in
it, and then emptied the contents of the can into the
water. Perhaps there was some mistake. At any
rate, there was an explosion and a flash of flame,
and Solomon instead of curing his rheumatism
added severe burns to his other troubles, and so far
from bleaching his skin came out of the tub much
blacker than when he went in. Which all goes to
show that amateur prescribing is not always suc-
cessful.
2faufl nf Xhf
Poliomyelitis Epidemic Decreasing. — In New
York City, for the week ending September 30, 140
new cases of poliomyelitis were reported, a decrease
of 14 as compared with the previous week. The total
number of cases in the city to the same date was
9,029, and of deaths 2,286. So far as any serious
danger to children is concerned, the health officials
believe that the epidemic is now a thing of the past.
The course of the epidemic since July 1 is shown
by the following table, giving the number of new
cases reported each week since that time:
k ending
Julj 8 557
July 15 979
July 22 795
July 29 9(52
August 5 1,168
August 12 1,210
Week "'ii'ling
August 19 922
August 26 744
Septi mber 2 487
3i pti mber 9 351
Septi-mher K> 254
September 23 160
The forcible removal by the Department of Health
of a nineteen-months' infant believed to be suffering
from the disease, from its home in Jamaica to the
Queens Borough Hospital, has caused some bitter
feeling in the town, and the Civic Association of
Jamaica is threatening to bring before the next
Legislature an act to restrict the powers of the
Board of Health.
Poliomyelitis Serum Collected. — The Harvard
Medical School has recently appointed a commission.
consisting of Dr. Robert W. Lovett, professor of
orthopedic surgery, chairman; Dr. Milton J. Rose-
nau, professor of preventive medicine; and Dr.
Francis \V. Peabody, assistant professor of medi-
cine, to supervise the collection of blood serum from
persons who have recovered from infantile paraly-
sis, and its distribution among physicians, in an
attempt to stop the spread of the disease. The
serum will tie distributed to physicians free of
charge.
City Death Rate Low. — For the week ending
September 23, the death rate in New York City was
"iily 11.17, as compared with 11.79 for the corre-
sponding week of last year. The rate for the first
thirty-nine weeks of the year, however, is slightly
higher than that for the same period of 1915, the
respective figures being 14.33 and 14.26 per 1,000
of population. The increase is due in part, of
course, to the epidemic of poliomyelitis.
Sick Rate Among Troops. — Slight increases in
the sick rate of the troops on the Mexican border
are shown in a report made on September 25 to the
War Department. For the week ending September
16 the morbidity percentage among the men of the
National Guard was 2.13, as compared with 1.91
for the week preceding. Among the regular troops
the rate for the same week was 2.16, against 2.15
for the preceding week. The deaths during the
same time numbered five among the National Guard
and two among the regulars.
Civil Service Examination. — The New York
State Civil Service Commission will hold an exam-
ination on November 4 for the purpose of filling
a vacancy at Sing Sing prison in the position of
assistant physician, and of other vacancies as they
occur. The examination is open only to men who
are licensed medical practitioners in this State, and
since graduation have had at least one year's expe-
rience on the resident medical staff of a general
hospital. The salary is $1,500 without mainte-
nance. Further details and application blanks may
be obtained from the State Civil Service Commis-
sion, Albany, N. Y.
Association for the Study of Internal Secre-
tions.— With the object of correlating the work
of physicians and other students interested in the
investigation of the internal secretions, this asso-
ciation was recently formed. The plans of the
society include the establishment of libraries and
the publication of a scientific bulletin containing a
resume of the work being done in this field. The
secretary of the Association is Dr. Henry R. nar-
rower, Glendale, Los Angeles, Cal., who will be
glad to send full details in regard to membership,
etc., to those interested.
Cost of Disease. — At one of the meetings of the
American Chemical Society, held last week in New
York, it was stated that this country is losing close
to one billion dollars a year through preventable
occupational diseases, in spite of the growing move-
ment in the direction of better working condi-
tions. A paper by Dr. W. A. Lynott of the Fed-
eral Bureau of Mines contained statistics showing
that every worker in the United States loses an
average of nine days' work a year through occupa-
tional diseases that could be prevented by the use
of proper machinery and through sanitation.
Health Exhibit Popular.— The New York Social
Hygiene Society, which is conducting a campaign in
this city for the prevention of venereal diseases, an-
nounces that between July 21 and September 20 of
this year 19,390 persons visited this society's ex-
hibit at Coney Island.
Physicians Oppose Compensation Act. — A num-
ber of physicians, representing the members of the
Massachusetts State and Massachusetts Homeopa-
thic Medical Societies, met in Worcester on Sep-
tember 20, and made formal protest against one sec-
tion of the workmen's compensation act of that
State. It was declared that the law, as it now
stands, works a hardship on the workman as well
as on the physician, in that it deprives the former
of the right to call in a physician whom he knows —
the family doctor. Plans were formulated for an
active campaign before the next session of the Leg-
islature to have the act amended.
Medical Colleges Open. — The College of Physi-
cians and Surgeons, Columbia University, New
York, opened on September 27 with a total registra-
Oct. 7, 1916J
MEDICAL RECORD.
641
tion of 480, the entering class numbering 142. At
the opening exercises, Dr. Warfield T. Longcope,
Bard professor of medicine, spoke on "Milestones in
Medicine."
The thirty-seventh annual session of the Col-
lege of Physicians and Surgeons of Boston began
on September 20, with an enrollment said to be the
largest in the history of the college.
Lectures on Mental Hygiene. — The New York
City Department of Education, in conjunction with
the Mental Hygiene Committee of the State Chari-
ties Aid Association, has arranged a course of six
lectures on mental hygiene, to be given on Wednes-
day evenings during October and November, in the
Young Men's Christian Association Hall at 5 West
125th Street, New York. Among the lecturers will
be Dr. Stewart A. Paton of Princeton University,
Dr. Ira S. Wile of New York, and Dr. William
Mabon, superintendent of the Manhattan State Hos-
pital, New York.
Yellow Fever Commission Returns. — Gen. Wil-
liam C. Gorgas, chairman of the commission sent
out by the Rockefeller Foundation to investigate
the occurrence of yellow fever in South America,
returned to New York with other members of the
commission on September 25. The commission has
already made investigation in Chile, Peru, Bolivia,
Ecuador, and Panama, and will shortly sail for Bra-
zil to continue its investigation of the disease in
that country.
Gifts to Charities. — By the will of the late Mrs.
Juliet C. Percival of New York the Hahnemann
Hospital of this city receives a bequest of $40,000,
to be used for the establishment in the children's
ward of beds in memory of the giver's son, George
Sidney Percival.
A number of New York institutions are remem-
bered in the will of the late Mr. H. B. Dick of this
city. The Presbyterian Hospital receives $7,500, the
Roosevelt Hospital, the Manhattan Eye and Ear
Hospital, the Babies' Hospital, and St. Luke's Home,
$5,000 each, and St. John's Guild $3,000 for the
floating hospital.
By the will of the late Eckley Brinton Coxe, Jr.,
of Philadelphia, bequests are made as follows: Chil-
dren's Hospital, $100,000 as an endowment, and in
addition $10,000, the income of which is to provide
for Christmas presents and an annual dinner for
the children patients, the nurses, the servants, and
members of the dispensary staff; Orthopedic Hos-
pital and Infirmary for Nervous Diseases, $50,000;
Pennsylvania Epileptic Hospital and Colonv Farm,
$25,000.
By the will of the late Stephen B. Colladay of
Philadelphia the sum of $2,000 is bequeathed to
the Samaritan Hospital.
Personals. — Dr. Bernard Glueck has been ap-
pointed physician and surgeon at Sing Sing prison,
succeeding Dr. Amos O. Squire, who recently re-
signed. Dr. Glueck has recently been conducting
the psychopathic clinic founded by Mr. John D.
Rockefeller at the prison.
Dr. Murray H. Paterson of Chatham, Ontario,
returned to New York on September 30 from active
service in France, where he won the Military Cross
for bravery under fire. On July 1, when the allied
offensive began, Dr. Patterson led a party of bear-
ers out under a heavy fire and succeeded in bring-
ing a number of wounded soldiers safely within
the lines.
The death of Dr. A. Magnan, chief of the Bureau
of the Insane in Paris, and director of the French
School of Advanced Research, has recently been
reported.
Dr. Paul E. Bechet has removed to 40 East Forty-
first Street.
Dr. Raimundo Menocal has been appointed Secre-
tary of Sanitation in Cuba, to succeed Dr. Enrique
Nunez, who died recently in this city.
Medical Society Elections. — Colorado State
Medical Society: Annual meeting at Glenwood
Springs, in September. Officers elected : President,
Dr. A. C. Magruder, Colorado Springs; first vice-
president, Dr. S. B. Childs, Denver; second vice-
president, Dr. A. L. Trout, Walsenburg; third vice-
president, Dr. W. W. Frank, Glenwood Springs;
fourth vice-president, Dr. A. J. Nossoman, Pagosa
Springs; delegate to the American Medical Asso-
ciation, Dr. Oliver Lyons, Denver; alternate dele-
gate, Dr. C. W. Plumb, Grand Junction; councillors.
Dr. M. R. Fox, Sterling, and Dr. Samuel French,
Meeker; member of the Publication Committee, Dr.
Philip Hillkowitz, Denver. The next meeting will
be held at Colorado Springs in September, 1917.
Utah State Medical Association: Annual
meeting at Salt Lake City on September 12 and 13.
Officers elected: President, Dr. Samuel C. Bald-
win, Salt Lake City; first vice-president, Dr. Joseph
R. Morrell, Ogden ; second vice-president, Dr. P. M.
Kelly, American Fork; third vice-president, Dr.
David C. Budge, Logan; treasurer, Dr. T. A. Flood,
Salt Lake City.
Oregon State Medical Association: Forty-
second annual meeting at Portland on September
14 and 15. Officers elected: President, Dr. R. C.
Yenney, Portland; first vice-president, Dr. H. J.
Clements, Salem; second vice-president, Dr. Leo
Chilton, Canyon City; secretary, Dr. Clarence J.
McCusker, Portland; treasurer, Dr. Katherine R.
Manion, Portland.
Washington County (Vt.) Medical Society:
Annual meeting at Northfield on September 19. Of-
ficers elected: President, Dr. George S. Bidwell,
Waterbury; vice-president, Dr. Clarence H. Burr,
Montpelier; secretary-treasurer, Dr. Harlow A.
Whitney; auditor, Dr. De F. C. Jarvis, Barre.
New England Association of Jefferson Medi-
cal College Graduates : Tenth annual meeting at
Farmington, Conn., on September 9. Officers
elected: President, Dr. Eckley R. Storrs, Hartford,
Conn.; vice-president, Dr. Albert C. Getchell, Wor-
cester, Mass.; secretary, Wallace P. MacCallum, Bos-
ton; treasurer, Dr. Frank I. Payne, Westerly, R. I.
Obituary Notes. — Dr. John Wayt Poindexter
of Prairie Home, Mo., a graduate of the Medical
College of Virginia, Richmond, in 1875. died at his
home recently, aged 65 years.
Dr. Edward Reese Fell of Philadelphia, a gradu-
ate of the medical department of the University of
Pennsylvania in the class of 1861, and assistant sur-
geon in the United States Army during the Civil
War, died at his home on September 15, at the age
of 77 years.
Dr. Thomas A. C. Kephart of Altoona, Pa., 47
years old, was killed in an automobile accident on
September 18. He was graduated from the Uni-
versity of Pittsburgh School of Medicine in the
class of 1912.
Dr. Frank Webster of Dayton, Ohio, a gradu-
ate of the Pulte Medical College, Cincinnati, Ohio,
in 1882, died on September 21, aged 62 years.
Dr. John H. Wilson of Bethlehem, Pa., a gradu-
ate of the University of Pennsylvania, School of
Medicine, Philadelphia, in 1860, and a member of
642
MEDICAL RECORD.
[Oct. 7, 1916
the American Medical Association, the Medical So-
ciety of the State of Pennsylvania, and the North-
ampton County Medical Society, died at his home
on September 12, after a long illness, aged 81 years.
Dr. Sanford Hanscom of Somerville, Mass., a
graduate of the Medical School of Harvard Univer-
sity, Boston, in 1868, and a member of the Ameri-
can Medical Association, the Massachusetts Medi-
cal Society, and the Middlesex South District Med-
ical Society, died at his home on September 20,
aged 75 years. Dr. Hanscom was a veteran of the
Civil War.
Dr. Thomas Fitzgibbon of Milwaukee, Wis., a
graduate of Rush Medical College, Chicago, in 1882,
a member of the American Medical Association, the
State Medical Society of Wisconsin, and the Mil-
waukee County Medical Society, and formerly pro-
fessor of gynecology in Marquette University Medi-
cal Department, Milwaukee, died at his home in St.
Francis on September 17, after a long illness, aged
62 years.
Dr. Richard Mott Moore of Rochester, N. Y., a
graduate of the University of Buffalo, Medical De-
partment, Buffalo, N. Y., in 1878, died at his home
on September 13, aged 59 years. Dr. Moore was a
member of the American Medical Association, the
Medical Society of the State of New York, the
Monroe County Medical Society, the Rochester
Academy of Medicine, the Rochester Academy of
Science, the Board of Health of Rochester, the
Monroe County Milk Commission, and was physi-
cian to the Rochester General Hospital.
Dr. John Lester Keep of Brooklyn, N. Y., a
graduate of the Hahnemann Medical College and
Hospital of Philadelphia, in 1860, and of the New
York Homeopathic Medical College and Flower Hos-
pital, New York, in 1866, consulting physician to
the Cumberland Street Hospital, a member of the
American Institute of Homeopathy, the Brooklyn
Medical Society, and the Associated Physicians of
Long Island, and a former president of the Alumni
Association of the New York Homeopathic Medi-
cal College, died at his summer home on Shelter
Island, New York, on September 30, at the age of
seventy-eight.
THE BROAD STREET HOSPITAL.
To the Editor of the Medical Record :
Sir: — In the News column of the Medical Rec-
ord for September 30 there is an item concerning
the Broad Street Hospital, in which it is stated
that "the institution will serve the district south
of Fulton Street which has not heretofore had a
general emergency hospital." Your informant is
evidently in error in respect to this matter, for
the House of Relief of the New York Hospital,
known as the Hudson Street Hospital, served that
district for many years, and provided an ambulance
service that was apparently quite adequate. Dur-
ing the past year a portion of the district served
by the Hudson Street Hospital was given to the
Volunteer Hospital, whose ambulance district in-
cludes that mentioned in the paragraph. So far as
it is possible to learn from unprejudiced sources,
the Volunteer Hospital is rendering complete and
satisfactory general emergency service at the pres-
ent time, so that the statement quoted is inaccu-
rate as it stands.
R. G. S.
OUR LONDON LETTER.
(From Our Regular Correspondent.)
BRITISH ASSOCIATION — FATIGUE AMONG SOLDIERS —
DECIMAL COINAGE — WEIGHTS AND MEASURES — ■
CASES OF PLAGUE — CERTIFYING SURGEONS — COUN-
CIL FOR COMBATING VENEREAL DISEASES — OBIT-
UARY.
London, Sept. 15, 1916.
The meeting of the British Association closed last
week. Of its twelve sections that on Economic
Science obtained a good deal of attention, as it con-
sidered the subject of fatigue among our soldiers
as well as among munition workers. Dr. Hunter
urged that it is time to consider decimal coinage
and weights and measures if Great Britain is to
hold her own after the war, for neutral countries
would naturally deal with those who used those to
which they were accustomed. The United States
were aware of this. The French had adopted our
meridian, why should we not change our weights
and measures for the system adopted by every other
civilized nation? We should save immensely by so
doing and no other nation would try our system.
The colonies would follow, and in fact only waited
our lead. Professor Kirkaldy (presiding) wished
it to go -forth that in the view of this section, the
Anglo-Saxon world should come together and try
to bring about this reform. The next subject of
discussion was fatigue, on which a report was pre-
sented of a committee of investigation and another
by Dr. Maitland, who had special opportunities for
observation during the war in Serbia. He said
military necessities and the impossibility of pro-
viding reliefs, rest and uninterrupted sleep prevent
an army getting the utmost value out of the unit.
In fact, long continued strain in the trenches re-
sulted in cases of breakdown ; these recovered after
rest, but on return to the trenches broke down
again and had to be discharged as of no further
use. We could not hope to obtain an ideal working
day for each military unit, but with the increased
ability to supply reinforcements we could diminish
the strain and it was most important that one should
do so.
The announcement that cases of plague had oc-
curred in England gave rise to considerable public
excitement and doctors in all directions have been
closely questioned about it. Three cases were re-
ported last week at Bristol and two at Hull. The
rat-flea is the carrier of the toxin to man and our
seaport towns are in the chief zone of danger. The
vessels carrying grain are so commonly rat-in-
fested that they transmit plague over long distances
and it is probable that the cases at Bristol and
Hull were ship-borne.
Certifying surgeons have been relieved of some
of the duties that have been long carried on in
respect to accidents, but notice of poisoning by lead,
phosphorus, arsenic or mercury has still to be sent
to the inspector as must also notice of toxic jaundice
and of anthrax.
The National Council for Combating Venereal Dis-
ease has issued a synopsis of its report made by
Captain Douglas White. In a prefatory state-
ment the chairman of the commission (Lord Syd-
enham) hopes it will be found a convenient com-
pendium of the whole subject of this disease as
elucidated by the inquiry of the commission and it
seems probable that this hope may be realized. The
synopsis is very well described as only "a shortened
report," the shortening being effected, not by whole-
Oct. 7, 1916]
MEDICAL RECORD.
643
sale omissions, but by systematic abbreviations,
while the economic effects of the disease are stated
in full and the summary of recommendations is
given verbatim. This report will be of great as-
sistance to those who have charge of local schemes
and may serve as a hand-book to their deliberations.
At the first meeting of the National Council for
combating the disease, Dr. Fred. Taylor, President
R. C. P., explained the attitude of the profession
toward this important campaign and pointed out
that the National Council has for one object an
inquiry into medical education in reference thereto.
He remarked that medical education is a life-long
occupation of the profession and suggested that it
might be carried on more actively, though at pres-
ent there is a shortage of clinical material in the
schoels which would serve the purpose. Unfor-
tunately at some institutions there is prejudice
against the admission of venereal cases, but it is
hoped that this is fading and in time will be
eradicated.
Lieut-Col. Wm. Selby, I.M.S., Principal of King
George's Medical College, Lucknow, Hon. Surgeon
to the Viceroy of India, died September 8. Born
18G9, he took the double qualification 1892, pro-
ceding to F. R. C. S. Eng. in 1905. He was in
the relief force in Chitral in 1895, for which he had
the medal and clasp. In 1897-98 he was in the oper-
ations of the Northwest Frontier of India and in
the Tirah campaign, for which he was mentioned
in dispatches. He was awarded the companionship
of D. S. O.
CANADIAN LETTER.
(From Our Special Correspondent.)
ONTARIO MEDICAL ASSOCIATION — PERMANENT DIS-
ABILITY OF INVALIDED SOLDIERS — ELECTION OF
OFFICERS — CONFERENCE OF HEALTH OFFICERS OF
ONTARIO — MILITARY HOSPITALS' COMMISSION —
POLIOMYELITIS— OBITUARIES.
Toronto, September 30, 1916.
Although now somewhat ancient history, it may
be said, more especially as little notice has been
taken of the matter in American medical journals,
that the meeting of the Ontario Association, which
was held at the end of May last, was one of the most
successful from all standpoints ever held. Several
causes combined to bring about this result. The
annual meetings of the Canadian Medical Associa-
tion which should have taken place in 1915 and
1916 have been postponed and consequently the lack
of exchange of views and opinions, rendered possi-
ble to a large extent only by such meetings, was
felt by members of the Canadian medical profes-
sion. Moreover, the war in Europe had supplied
an abundance of military and surgical topics of
which full advantage was taken. Dr. H. B. Anderson
of Toronto, the president, delivered an able address
to which it would be impossible to give due credit
within the limits of a letter. Sir James Grant, the
nestor of medicine in Canada, in the course of an
appreciation of the address paid an eloquent tribute
to the splendid work being done both at the front
and at home by Canadian medical men and nurses.
It will not be out of place when mentioning Sir
James Grant to call attention to the fact that he was
a pioneer in the employment of serum therapy. Re-
cently in American Medicine he described his work
in this direction which has now been generally
recognized throughout Canada.
The Hon. Senator J. C. McLennan, M.D., gave an
address on "Problems and Plans of the Military
Hospitals' Commission in Dealing with Invalid
Soldiers." Among other facts that Dr. McLennan
stated was that out of 200,000 soldiers who had
gone from Canada, only six had returned totally
blind and only five wholly unable to work. Tuber-
culosis had not been nearly so prevalent among
Canadian soldiers as had been anticipated. The
military commission had provided for 1,700 con-
sumptive men, but the hospitals had never been
more than two-thirds full.
At the business session Dr. A. Dalton Smith of
Mitchell was elected president for the ensuing year,
and Toronto was decided upon as the place of meet-
ing. The other officers elected were: Vice-Presi-
dent, Dr. C. L. Starr, Toronto; Treasurer, Dr. J. H.
Elliott, Toronto; Secretary, Dr. R. A. Clarkson, To-
ronto; Representatives to the Canadian Medical As-
sociation, Dr. H. B. Anderson, Dr. H. J. Hamilton
of Toronto and Dr. G. S. Cameron of Peterborough;
Executive Committee, Dr J. D. Wishart of Toronto
and Dr. F. C. Neal of Peterborough.
The fifth annual conference of the health officers
of Ontario was held at the University of Toronto,
on the last two days of May. Dr. A. J. Macauley,
medical officer of health of Brockville, vice-presi-
dent, presided in the absence of the president, Dr.
Macpherson of Peterborough, who was on active
service. Of the many instructive discussions given
none was of greater interest than a lecture upon
sanitation in Serbia given by Major W. D. Sharpe
who served as surgeon with the British Naval Hos-
pital in Belgrade in the first year of the war. The
next meeting will be held in Toronto. The officers
elected were: Dr. A. J. Macauley, president; Dr.
T. W. Vardon, vice-president; Dr. J. W. S. McCul-
lough, secretary.
A year ago the Military Hospitals' Commission
of Canada was appointed and since its inauguration
there have sprung into being no fewer than 22 mili-
tary convalescent hospitals. The convalescent hospi-
tal in the building formerly used as Bishop
Strachan's girl school in College Street, Toronto, is
certainly the best equipped in Canada and probably
as well equipped as any military hospital in the
world. It contains mechanical means for treating
injuries and conditions of every description, under
the charge of Mr. F. Davies, who is experienced
and skilled in the employment of such modes of
treatment. I shall have occasion to refer to the
convalescent hospital and to the excellent work of
Mr. Davies in greater detail in a future letter. It
has been suggested, and the suggestion seems
worthy of consideration, that a series of military
hospitals should be established throughout Canada,
not for convalescents who have already received
abroad such surgical treatment as their condition
called for, but for soldiers, who while they will be
unfit for further active service, are yet capable of
making the sea voyage to Canada to receive surgical
treatment at the hands of Canadian surgeons.
This procedure would tend to relieve the already
overtaxed capacities of British hospitals and would
also possess the advantage of bringing the men
back to home and friends sooner.
Col. Herbert Bruce of Toronto, who has just been
made a full colonel in the Canadian Army Medical
Corps, has received a commission to inspect all the
Canadian hospitals and medical institutions to
which the Canadian Government is contributing, to
report upon their work, and to offer any recom-
mendations in regard to the same which he may
644
MKDICAL . RECORD.
[Oct. 7, 1916
think fit. According to the lay papers Colonel Bruce
has inspected the hospitals and institutions in Great
Britain, has criticized some features of their man-
agement, and has made certain recommendations.
He will afterward proceed to France to inspect the
various base and stationary hospitals, casualty
clearing stations, and field ambulances, and will then
visit Salonica. Colonel Hodgetts, head of the Cana-
dian Red Cross in England, has announced the in-
tention of the society to establish another hospital
of 1,000 beds, probably on the Kentish coast.
Poliomyelitis is more or less rife in different
parts of Ontario. Toronto has been comparatively
free, in fact there have been only one or two iso-
lated cases. In Hamilton the epidemic was some-
what serious. However, every precaution was
taken by the officers of health to prevent the spread
of the disease. Dr. Charles Hastings, M.H.O., of
Toronto, has stated recently that despite the ex-
cessive heat and continued drouth of the past sum-
mer, the death rate of Toronto has been lower than
in 1915. This is especially true of diseases of chil-
dren.
Prof. Thomas Gregor Brodie, F.R.S., who was
associated with Prof. A. B. Macallum in the de-
partment of physiology at the University of To-
ronto since 1908, died suddenly in London, Eng-
land, on August 20. Dr. Brodie was born in
Northampton, in 1866, and was educated at Cam-
bridge and London. He had held several impor-
tant appointments in England, including that of
director of the Research Laboratories of the Royal
College of Physicians and Surgeons. Dr. Brodie
had done some important original work in the
sphere of physiology.
Dr. Harry Goodsir MacKid of Calgary, one of
the best known medical practitioners in the north-
west of Canada, died suddenly at his home in Cal-
gary on Aug. 17.
Capt. D. Watterson, C.A.M.C, of Montreal was
killed recently in action in France.
UmgrrBB of Mtbital §*>tiewt.
Boston Medical and Surgical Journal.
Septl mbrr 21, 1916.
1. The Hat and Infantile Paralysis: A Theory. Mark W.
Richardson.
2. Some Medical Aspects of the Workmen's Compensation
Act Francis D. Donoghue.
3. The Major Divisions of Mental Hygiene — Public. Social.
Individual. E. E. Southard.
4. What Recent Investigations Have Shown to be the Rela-
tion Between Mental Defect and Crime. A. Warren
Stearns.
.".. Epilepsy. Everett Flood.
6. Idiosyncrasy to Cow's Milk: It's Relation to Anaphvlaxis.
Fritz R. Tall. i it.
1. The Rat and Infantile Paralysis: A Theory. —
Mark W. Richardson, who was intimately concerned
in the investigation of infantile paralysis from 1909 to
1914 as secretary of the Massachusetts State Board of
Health, calls attention to facts that are against the
transfer of infantile paralysis by direct or indirect
human contact and presents those supporting the theory
that the disease is transferred by rodents, insects, or
both. Militating against the transfer of the disease
by personal contact, direct or indirect, are the summer
incidence of infantile paralysis; the maximum preva-
lence of the disease in country districts, where per-
sonal contact is least intimate at all times; failure to
spread in general hospitals; extreme rarity of the
disease in doctors, nurses, and other attendants; en-
tire absence of infection in laboratory workers with the
virus of infantile paralysis; comparatively rare occur-
rence of more than one case of the disease in large
families of children; the cessation of epidemics in mid-
career, so to speak, before the human material has
been exhausted and the opportunities for direct or in-
direct contact are at their maximum; the long-con-
tinued immunity of cities and towns in close commercial
relations with infected centers, even though inter-
change of population is marked; the observation that
the disease travels radially from centers of infection,
and that it is very common to find the later cases on
the outskirts of the infected area, and finally the prac-
tical immunity of severely infected districts for a con-
siderable period of years in spite of the fact that new
material is constantly being furnished. Facts support-
ing the theory that the rat and its parasite, the flea,
are the principal agents in the spread of infantile
paralysis are that the rat has a world-wide distribution
and is found in the habitations of all classes of the
community; in the winter time it keeps largely to its
hole coming forth with the advent of warm weather;
it is highly probable that the rat is more common in
the country than in the city; the great increase in polio-
myelitis during the past twenty-five years may be ex-
plained by the increase in facility of transportation; the
distribution of the disease near railroads may be due
to the rat-infected cars and the dropping of rats from
freight cars. In the study of the epidemiology of in-
fantile paralysis it has been a common observation
that the disease occurs in foci, cases spread more or less
radially, the intensity of the infection rises in one
neighborhood, while it is decreasing in a focus in the
immediate vicinity. These facts are hard to explain
through human transmission, which would result in
irregular distribution of cases. In the transfer of the
infection from the rat to man the agency of the flea is
assumed, although the possible contamination of food
by rodent excretions might well be considered. The in-
sect transfer may be simply mechanical or it may re-
quire a preliminary cycle of development of the virus
in the flea. Furthermore, the possible role of cats, dogs,
and other animals, or even human beings, as carriers
of infected fleas, would be apparent. In grossly un-
sanitary surroundings the fleas might carry the infec-
tion from one child to another directly.
3. The Major Divisions of Mental Hygiene — Public,
Social, Individual. — E. E. Southard, after analyzing a
group of over 2,000 admissions to the Psychopathic Hos-
pital, finds that many of the considerations in mental
hygiene may be grouped under three headings. There
is a mental hygiene of a public or governmental na-
ture; a mental hygiene of a social nature, and the far
more familiar and well-known mental hygiene which
considers the individual as such. A certain large pro-
portion of the cases are routine cases, whose public,
social and individual features are obvious and clear,
immediately suggesting an appropriate disposition and
appropriate measures of treatment. They may not be
successfully treated from the standpoint of the in-
dividual, but from the standpoint of society and the
public authorities; they may be successfully handled on
the basis of familiar and well-understood rules of gov-
ernment, society, and medicine. There are a minority
of cases which may be called the intensive group, as
cases of mental complications of pregnancy or of brain
syphilis, requiring special treatment. There is a small
but perturbing group of public service cases, in which
one may have to deal with a family dispute with re-
spect to will making and the like, with superior court
cases given over for medical examination and decision,
or with cases from the police or juvenile courts. There
is in addition what may be called a social service group
of cases in which the legal problems are not prominent,
but in which economic, domestic, and other environ-
Oct. 7, 1916]
MEDICAL RECORD.
645
mental difficulties predominate. Finally, there are a
great number of individual cases which do not belong
exclusively to any of these groups. The writer points
out that the mental hygienist usually starts out with
the problem of improving the outlook of the individual,
while lawyers, judges, and many probation officers need
go a long way before they will arrive at what medical
men would regard as a proper individualization of the
material. He discusses the important functions of the
social workers, who form the intermediary body be-
tween all the various agencies, carrying the decision
of the physician to the lawyer, and the decision of both
to the family, and carrying back news from the indi-
vidual to the family, from the family to the judge, to
the probation officer, to the physician, and to the pub-
lic institution administrator. Development of the public
branch of mental hygiene is in the hands of the law-
yers and the institution administrator, upon whose ex-
perience, judicial decisions, and statutory provisions
will gradually develop the power of society over the
psychopath and his family.
6. Idiosyncrasy to Cow's Milk: Its Relation to Ana-
phylaxis.— Fritz B. Talbot reports two cases of pro-
nounced idiosyncrasy to cow's milk occurring in breast-
fed infants. He discusses the phenomena of anaphy-
laxis and points out that in certain instances it is nec-
essary to so space the doses of the foreign protein as
to sensitize and not immunize the individual. Just as
when a laboratory animal has its dose of foreign pro-
tein given it at stated intervals during the process of
sensitization, so much the foreign protein (in the case
of the baby, cow's milk) be given the infant. This
might happen when a baby was given a bottle of cow's
milk only once in ten days. In other instances the
first cow's milk, and all subsequent bottles, that are
given the baby are vomited immediately, in which case
it may be assumed that the sensitization was hereditary
and present at birth. Foreign proteins may pass
through the intestinal wall of infants shortly after
birth, and in later infancy, when the mucous mem-
branes are injured. Idiosyncrasy to cow's milk can be
demonstrated, at least in some instances, by a specific
skin test. The treatment consists in giving the infant
milk from another species of animal, preferably that of
the goat; goats' milk was well taken by the infants in
the cases reported.
New York Medical Journal.
September 23, 1916.
1. The Psychology of Diseases of the Respiratory Tract.
G. Hudson-Makuen.
2. The Hospital Treatment of Simple Chorea. Pearce
Bailey.
3. Infective Pulmonary Endarteritis Occurring with Patent
Ductus Arteriosus. Morris Manges.
4. Acute Anterior Poliomyelitis. Alfred Gordon.
5. Anterior Poliomyelitis: The Aftermath. Lucy Osborne
Wight.
6. Occupational Specialization in the Defective. Henry M.
Driedman.
7. Congenital Syphilis. Walter James Heimann.
8. The Problems of Adolescence in Relation to Social Hy-
giene. Harold W. Wright.
9. Bothriocephalus Latus Infestation. A. I. Rubenstone.
10. A Cystourethroscope for Diagnosis and Therapeutics. C.
Morales-Macedo.
1. The Psychology of Diseases of the Respiratory
Tract. — G. Hudson-Makuen emphasizes the importance
of a recognition of the interdependence of specialties
in medicine and of the broad general principles which
should underly all specialism in medicine and states
that the specialties upon which laryngology chiefly de-
pends for its future progress and development are those
of psychology and neurology. In no other specialty of
medicine is the psychical element so great a factor in
the causation, not only of functional, but of organic dis-
orders as well as in laryngology. It must not be over-
looked that faulty methods of breathing, vocalization,
and articulation, although at first of psychical origin,
frequently result in organic diseases which cannot be
differentiated from diseases having purely physical
bases. Many a tonsil has been sacrificed and many
a turbinate bone for no other reason than that the
patient is suffering from some purely psychical disabil-
ity, and the sooner this fact is fully realized by the
laryngologist and the rhinologist, the better it will be
for all concerned. It is not enough, either in acute or
chronic cases, to do operations for the correction of
disturbed functions without at the same time studying
the psychological aspect of the case and immediately
thereafter doing something in an educational way to
correct the faulty habits which accompany, either as
cause or result, the condition to be modified or cured.
The same principle applies to the disorders of speech.
Education and re-education should always be used in
addition to the necessary medical and surgical measures
for the relief of disturbed respiratory phonatory and
articulatory functions. The new psychology teaches not
merely how to treat diseases of the special organs, but
how to treat the patient himself or the reactions of the
patient to these particular diseases.
2. The Hospital Treatment of Simple Chorea. —
Pearce Bailey relates his experience with the hospital
treatment of forty-eight cases of simple chorea. The
treatment consisted in rest in bed and isolation, no com-
munication with other patients or visitors being per-
mitted. In certain cases cold packs were given, and
in the presence of rheumatic history, and even with-
out it, rheumatic remedies, especially aspirin, were pre-
scribed. In a few violent cases lumbar puncture was
resorted to. It was found wiser, whenever possible,
to insist on three or four weeks' treatment for the
purpose of re-establishing the tone of the nervous sys-
tem. From his experience with these cases the writer
is inclined to believe that relapses are rare among
cases treated in a hospital by rest and seclusion.
3. Infective Pulmonary Endarteritis Occurring with
Patent Ductus Arteriosus. — Morris Manges reports
this case because of the rarity of ineffective pulmon-
ary endarteritis, this being only the fourteenth case
which has been reported or observed of which he has
been able to learn. The occurrence of patent ductus
arteriosus and infective endarteritis is very rare. Al-
though the case did not come to autopsy, the clinical
features agree in nearly all ways with the case reported
by Hamilton and Abbott. The striking feature in this
case was the mild course of the disease over a long
period of observation. It was only when the patient
had a rise of temperature to 104° F., and also when
she had a pulmonary infarct that she was willing to
consider herself sick. That infective pulmonary en-
darteritis should occur in congenital cardiac lesions
is by no means astonishing, as the conditions which
favor bacterial infection are identical with those that
exist in the hearts and vessels in acquired endocarditis
and endarteritis. The low grade of fever in this case
and the low blood count serves to emphasize the im-
portaance of the rule which is followed at Mount Sinai
Hospital to take blood cultures of all cardiac patients
who have even low temperatures. A number of cases
of infective endocarditis have thus been discovered
whore the clinical course would not have led to a sus-
picion of its existence. There were no cardiac symp-
toms previous to the patient's illness and she had borne
two children without the manifestation of any cardiac
symptoms. Four additional cases are cited to show
how erroneous is the view that the diagnosis of con-
genital cardiac disease is improbable unless there are
more or less cyanosis, dyspnea and clubbed fingers, as
646
MEDICAL RECORD.
[Oct. 7, 1916
well as a history which goes back to early childhood.
When the congenital lesions exist singly, without other
complicating congenital defect, very few circulatory
symptoms are present, the only evidence of them being
the physical signs. This patient brings up another
point which is also true of two other cases of patent
ductus arteriosus referred to by the essayist, and that
is the ease with which these women bore children.
What is true of these women with congenital cardiac
disease is also true of acquired cardiac disease. There
is only one condition which gives trouble, and that is
uncomplicated mitral stenosis. This view with refer-
ence to cardiac women refers to hospital patients. In
private practice it is different. The prevailing views
of the profession do not encourage such women to
marry or have children. The poor patients, whose lives
have not been made miserable by the chance of finding
a murmur and whose compensated hearts have not been
so needlessly and harmfully disturbed and coddled
by over-solicitous physicians, usually fare better than
their rich sisters. The writer does not wish his remarks
to be misunderstood as too sweeping, but urges that
compensated hearts should be regarded in a much more
favorable light as regards marriage and pregnancy
than is now the rule.
9. Bothriocephalus Latus Infestation. — A. I. Ruben-
stone reports this case which illustrates the futility of
attempting to diagnose vague clinical manifestations
without the aid of laboratory study. The treatment em-
ployed consisted in starvation for twenty-four hours,
during which only weak tea or water was allowed. The
patient then received the following prescription: Oleo-
resin of aspidium 45 minims, tincture of fanilla 45
minims, powdered acacia half a dram, and water enough
to make one ounce. This was followed one hour later
by fractional doses of calomel, one-half grain each,
until three grains were administered. About eight
hours later the patient sent a mass of tapeworm into
the laboratory. Four fish tapeworms were entangled,
varying in length from three feet six inches to five
feet four inches. In a case recently reported castor oil
was administered before and after aspidium and it was
stated that the patient was severely ill after the treat-
ment. This may be explained on the ground that the
oil caused the absorption of some of the male fern.
Oils increase the absorbability of filix-mas, and thus
may lead to acute constitutional disturbances.
Journal of the American Medical Association.
September 23, 1916.
Sarcoma of the Intraabdominal Testis, with Report of a
Casi W TO fjrant
The Surgical Problem of Unilateral Symptomless Hema-
turia : Us Cause and Surgical Relief. R. L. Payne,
Jr.. and William B. MacNider.
Comparative Results in Antirabic Treatment with the
Pasteur Method and with Dessicated Virus. D. L.
Harris.
Uremia: A Differentiation of Types. Nellis B. Foster.
The Value of Recent Laboratory Tests in the Diagnosis
and Treatment of Nephritis, with Special Ri i i nee to
the Chemical Examination of the Blood. Arthur F.
Chace and Victor C. -Myers.
A Comparative Studj oi Tests for Renal Function:
Phenolsulphonephthalein, Nonprotein Nitrogen and
Nitrogen of the Blood Ambard's Coefficient of
Tie. i Excretion, and the Test Meal for Renal Function.
Herman O. Mosentl il tnd D Sclater I .<
The ROle ft the Anteposed Uterus in the Causation of
Backache and Pelvic Symptoms. Henry T Hutchins.
Colonic infections: Some Rarely Observed I
Types. Jerome Morley Lynch and W. Landram Mc-
Farland.
The Paralysis of Poliomyeliti Us Treatment in the
Stages. II. B. The
A Child Weighing Twenty-live Pounds at Birth D P.
Belcher.
The Cautery in Treatment of Jacksonian Kpilepsy.
rick A. Rhodes.
1. Sarcoma of the Intraabdominal Testis.— W. W.
Grant. (See Medical Record, July 1, 1916, page 38.)
2. The Surgical Problem of Symptomless Hema-
turia, Its Causes and Surgical Relief. — R. I.. Payne and
9.
10.
11.
William B. MacNider. (See Medical Record, July 1,
1916, page 39.)
3. Comparative Results in Antirabic Treatment, —
D. L. Harris. (See Medical Record, June 17, 1916, page
1111.)
4. I'remia: A Differentiation of Types. — Nellis B.
Foster. (See Medical Record, July 1, 1916, page 31.)
5. The Value of Recent Laboratory Tests in the
Diagnosis and Treatment of Nephritis, with Special
Reference to the Chemical Examination of the Blood. —
Arthur F. Chace and Victor C. Myers. (See Medical
Record, July 1, 191G, page 31.)
6. A Comparative Study of the Tests for Renal
Function. — Herman O. Mosenthal and D. Sclater Lewi-.
(See Medical Record, July 1, 1916, page 31.)
7. The Role of the Anteposed Uterus in the Causa-
tion of Backache and Pelvic Symptoms. — Henry T.
Hutchins. (See Medical Record, June 17, 1916.)
8. Colonic Infections: Some Rarely Observed, Un-
classified Types. — Jerome Morley Lynch and W. Land-
ram McFarland. (See Medical Record, July 8, 1916,
page 80.)
9. The Paralysis of Poliomyelitis: Its Treatment
in the Early Stages. — H. B. Thomas calls special atten-
tion to the advantages of less vigorous and more closely
supervised treatment in the case of weak muscles. He
agrees with Lovett and others who have pointed out
that the greatest danger to the convalescing infantile
case is fatigue of the weak or paralyzed muscles. These
weak and paralyzed muscles are sick muscles, with de-
ranged nerve and blood supply, and should be treated
as such. Sick muscles tire easily, not only by active
use, but also by passive use and massage, and when
they tire they are less likely to functionate the follow-
ing day. Their ultimate usefulness is also harmed. In
each case a study should be made of the result follow-
ing treatment. It is better to undertreat rather than
to overtreat. Fatigue should be avoided.
10. A Child Weighing Twenty-five Pounds at Birth. —
D. P. Belcher reports this case and states that a search
of the literature shows that of all the cases cited in
which the weight of the infant was unusual it has been
less than in this instance. This case is remarkable be-
cause it was a girl child, and the maternal measure-
ments, taken after delivery, were not abnormal save for
circumference at the hips, which is rather large. The
baby was stillborn, but perfectly formed. It was born
without mechanical assistance and caused but slight
perineal laceration. The greatest difficulty was encoun-
tered in the delivery of the shoulders. The measure-
ment across the shoulders was 12 inches and the length
28 inches. The nearest approach to these measure-
ments found in the literature occurred in a case re-
ported by Ortega, in which the measurement across the
shoulders was 7% inches, the length 27 inches and the
weight of the child 24.8 pounds.
11. The Cautery Treatment of Jacksonian Epi-
lepsy.— Frederick A. Rhodes reports a case of Jack-
sonian epilepsy, giving a history of having been injured
twice in the right motor area. The motor area was
removed by cautery with such satisfactory results that
the writer has continued its use in other cases with
equally good results. He finds removal of the motor
area by the cautery much more satisfactory than by the
knife as it is followed by less bleeding and there is
less possibility of as many adhesions. There is little
doubt that the motor area of the opposite side takes
on the functions of the destroyed area. The operation
should produce a paralysis of the affected part by which
one knows that he has been successful in cauterizing
the right area. This paralysis disappears rapidly after
the first week.
Oct. 7, 1916]
MEDICAL RECORD.
647
The Lancet.
September 2, 1916.
1. An Experimental Study of Latent Tuberculosis. Chung
Yik Wang.
2. The Diagnosis of Enteric Fevers in Inoculated Individuals
by the Agglutinin Reaction. Georges Dreyer and E.
W. Ainley Walker.
3. A Method of Drop-measuring Liquids and Suspensions. R.
Donald.
4. A Note Upon the Employment of Blood Transfusion in
War Surgery. Edward Archibald.
5. Three Cases Illustrating the Functional Consequences of
Head Injuries. T. E. Harwood.
G. The Heart and Active Service. Treatment of Convalescent
Soldiers. H. J. Seeuwen.
7. The Use of Picric Acid in War Surgery. T. F. Brown.
V The Shiah Pilgrimages and the Sanitary Defenses of Meso-
potamia and the Turco- Persian Frontier. F. G.
Clemow.
2. The Diagnosis of Enteric Fevers in Inoculated
Individuals by the Agglutinin Reaction. — Georges
Dreyer and E. W. Ainley Walker state that in a cer-
tain number even of the mildest cases of these infec-
tions the rise and subsequent fall in the agglutinin titre
are so definite that the diagnosis could never be in
doubt. In other cases the rise and fall of the curve
are much less marked and differences of opinion may
exist as to whether the case is one of active infection
or not. In order to assist in the elucidation of such
cases the following points are of importance in the
interpretation of the agglutinin curves: 1. The maxi-
mum agglutinin titre of active typhoid or paratyphoid
infection occurs between the sixteenth and twenty-
fourth day of the disease, and most frequently about
the eighteenth to twentieth day. 2. If the maximum is
reached at what appears to be an earlier date, it is im-
portant to institute a careful inquiry into the actual
date of onset of the illness. 3. If it is clear that the
maximum falls markedly outside the limits given above
(day 16-24) a diagnosis of typhoid or paratyphoid fever
should not be based on a rise in titre of only moderate
extent — i.e. a 100 or 200 per cent, increase in agglutinin
titre. Because experience is not at present sufficient
to exclude the possibility that a rise of this extent may
be due to other ferbrile conditions. 4. In following out
the titration of the patient's serum on several succes-
sive occasions it will frequently be found that the maxi-
mum has fallen between two dates of observations.
And two successive observations at about the same level
do not mean that the curve is stationary at this point,
but merely that the maximum has occurred between
there. Similarly, if the two highest observations are
at different levels, it does not follow that the highest
titre observed represents the maximum of the agglu-
tinin curve. But it does follow that the maximum has
occurred between these points. 5. In inoculated per-
sons among whom mild and atypical attacks of typhoid
(or paratyphoid) fever are likely to occur with fever
of perhaps only a few days' duration, and with few if
any of the usual symptoms, the diagnosis of typhoid
or paratyphoid fever must not be rejected without the
most careful consideration. As far as experience at
present goes, if a regular rise and subsequent fall, even
of only 100 or 200 per cent., occurs in the typhoid (or
paratyphoid) agglutinin titre of the serum, and its
maximum clearly falls between the sixteenth and twen-
ty-fourth day from the onset of illness, the case is
likely to be one of typhoid (or paratyphoid) infection.
6. The Heart and Active Service. — H. J. Seeuwen has
treated some 60 per cent of the most serious cases of
heart trouble in convalescent soldiers by a combination
of physical training and electricity. All these men were
given daily open-air exercise by Major McKenzie's
method, which includes gymnastic training and route
marches. The light training includes slow movements
of limbs and trunk and some deep breathing exercises;
the full training consists of more vigorous movements
and of running and jumping. For the route marches
there is a light one, a walk at easy pace for about two
miles, and the full route march, which is a sharp walk
in quick time for from one-half to one hour. The elec-
trical treatment consists of a daily faradization with a
light current of long wired coil over the thyroid gland
and heart. This treatment is often used on the conti-
nent for exophthalmic goiter. It consists in an applica-
tion with two-inch botton electrodes for three or four
minutes on the thyroid, followed by three or four
minutes with one electrode over the heart region, the
other in the neck. Deep applications of x-ray on the
thyroid gland may also be very useful, and especially
on those men with hypertrophied thyroid (25 per cent,
out of the total). Tachycardia, excessive sweating, and
nervous uneasiness, are the symptoms which are the
most quickly and completely removed. The results ob-
tained after an average of two months' treatment were
as follows: Of the 60 men, 14 were quite fit and re-
turned to their unit; four others are fit and will return
soon; others are on full physical training and will be fit
for return in a short time; over a third, or 35 per cent.,
will be able to return to the firing line. From 10 to 15
per cent, have to be discharged; the other 50 per cent,
have improved and may be able for home service.
7. The Use of Picric Acid in War Surgery. — T. F.
Brown treated 3,000 cases during the Gallipoli cam-
paign with picric acid, since learning that this agent is
four times more potent than carbolic acid in bacteri-
cidal properties. The routine treatment consists in the
application to superficial wounds of 1 per cent, picric
acid solution applied on thin gauze. The wound is thus
left practically exposed to the air. Usually one dress-
ing a day was sufficient. Suppurating sinuses were
syringed with 0.5 to 1 per cent, of the solution twice
daily, and hydrogen peroxide solution was used every
two or three days to remove the debris. Arm and leg
baths of a 0.5 per cent, solution for thirty minutes were
used for suppurating fractures and crushed tissues,
with an occasional bath of hypertonic saline as a
change. A 1 per cent, solution was found too strong
for the delicate epithelium of new skin. The author
believes that his experience justifies the opinion that
picric acid solution kills bacteria without corroding
effect and prevents suppuration; it stimulates granula-
tion of the tissue; it has marked anodyne properties,
eliminating the need of aspirin or morphine in most
cases; it saves much time by dispensing with hot fo-
mentations, cotton wool lint, gutta percha tissue, etc. It
may be used for the sterilization of the skin in surgical
cases. It shortens the convalescent period. The contra-
indication to its use usually cited are, first, coagulation
of the tissue; this with the solutions used is so slight
that it is unnoticeable and there is no evidence of re-
tardation in healing. A second contraindication is sup-
posed to be its poisonous effect. In the 3,000 cases
treated not one showed any signs of poisoning. A third
objection is the discoloration of the skin ; this is per-
sistent, but the muscles and subcutaneous tissues ap-
parently do not stain.
British Medical Journal.
September 2, 1916.
1. The Distribution of Typhoid and Paratyphoid Infections
Among Enteric Fevers at Mudros. C. J. Martin and
W. G. D. Upjohn.
2. Brilliant Green and Telluric Acid in the Isolation of
Typhoid Paratyphoid Bacilli. Archibald Leitch.
3. The Local Treatment of Burns on a Naval Hospital Ship.
R. J. Willan.
4. On the Extension Treatment of Gunshot Fractures. E. W.
Hey Groves.
".. The Mechanism of Saline Dressings. Kenneth Tavlor.
fi. Recent Outbreaks of Acute Poliomvelitis. A. Gardner
Robb.
7. Three Cases of Bubonic Plague Arising in England. A
Rendle Short.
648
MEDICAL RECORD.
[Oct. 7, 1916
1. The Distribution of Typhoid and Paratyphoid In-
fections Among Enteric Fevers at Mudros.— C. J. Mar-
tin and W. G. D. Upjohn have tested the serums of 627
patients and 151 normal persons at the large general
hospital at Mudros during November and December,
1915. They give the details of the tests with varying
degrees of serum dilutions. Of the (527 cases, the total
number in which agglutination with one or more of the
bacilli of the enteric group was observed was 464. Of
these, 213 serums agglutinated B. paratyphosus A and
gave definite evidence of paratyphoid A infection. For
parallel reasons 113 might be regarded as paratyphoid
B infections. The determination of the number of
typhoid infections is not so simple. Though typhoid
agglutinins were found in 138 cases, these were not
necessarily typhoid fevers, for all but five had been in-
ocluated. These five exceptions were placed to the
credit of typhoid infection. In seven other cases li.
typhosus was isolated from the blood or excreta either
during life or after death, leaving 125 cases in which
the serological observations might be interpreted either
by previous inoculation or by recent infection. There
were in this group a number of cases which subse-
quently proved to be dysentery, pneumonias, malaria,
influenza, or relapsing fever, and also 35 cases of epi-
demic jaundice, in which observations were made be-
cause there was a widespread impression at first that
the disease was associated with paratyphoid infection.
After eliminative procedures had been applied it was
found that the number of cases whose serum aggluti-
nated only B. typhosus was 25, or 7 per cent., while 61
per cent, agglutinated paratyphoid A, and 32 per cent,
paratyphoid B. If it is assumed that the distribution of
typhoid fever during the whole period of the Gallipoli
campaign is that which this study shows, the invali-
dating rate from typhoid fever represents less than
one-half per cent, of the total sickness during the
period. This result may presumably be attributed to
antityphoid inoculation, since conditions were not un-
favorable to the spread of enteric disease.
3. The Local Treatment of Burns on a Naval Hospi-
tal Ship. — R. J. Willan describes the plan of treatment
employed in 28 cases of burns occasioned by an explo-
sion on a naval vessel. Of these 28 cases, the burns
were septic in 15. Five of the series died, four of these
deaths being due to acute sepsis. The keynote in the
treatment of burns is the prevention of sepsis. A burn
must be regarded and treated with exactly the same care
as a fresh operation wound. Further sepsis added to an
already septic burn of the fourth degree and upwards,
will probably kill the patient. Picric acid as a first
dressing has been found to be unrivaled. For an asep-
tic case, equal parts of vaseline and boric ointment,
plentifully spread upon white lint, makes a good, com-
fortable, and easily removed subsequent dressing. Im-
mediately a burn is known to be septic hot boracic fo-
mentations should be begun. Unless loosely applied a
roller bandage put on at the first dressing will cause
severe pain and it may lead to gangrene. To prevent
this a new outside dressing, which is simple, efficient,
comfortable, and quickly applied and changed is used.
It is made of a sheet of antiseptic wool (corrosive wood-
wool or alembroth) with a layer of gauze on either side,
folded over the burn. If it is too tight any one near can
loosen the tape, which is an easy matter compared to
the finding of the actual point of constriction of a too
tight roller bandage.
5. The Mechanism of Saline Dressings. — Kenneth
Taylor points out that, while the use of saline solution
for dressing has come into very extensive use in Eng-
land and France, there has been but little discussion
of the theoretical and experimental evidence indicating
its use as a dressing for wounds. In discussing what
may be expected from the use of a strong saline solu-
tion in a wound, he says that by a process of osmosis
water is extracted from intact cells, blood vessels, and
closed lymph spaces. The same interaction increases
the sodium chloride content of the intact cells and those
lymph spaces which may be slowly drained. When a
strong salt solution is diluted or withheld, a rapid in-
crease of water within the cells is to be anticipated. If
continued for a long period, the colloid constituents of
cells imbibe water and the basis of edema is established.
A small amount of dialyzable albuminous substances
will emigrate from the cells, due to the absence of such
substances in the dressing solution. This emigration
will be unaffected by the sodium chloride concentration
of the solution. By a process of diffusion an inter-
change of sodium chloride and water will occur between
the free fluids in the intercellular spaces and cut lymph
channels, which are in contact with the dressing solu-
tion, resulting in a concentration of the salt in these
fluids. The sodium chloride concentration will not affect
the rate of diffusion of these substances, nor will an
outward current be px-oduced by interchange of sodium
chloride and water and thus carry with it the free
lymph. The normally brisk reaction of secretion upon
which would depend the increase in antibacterial sub-
stances may be seriously inhibited by the excess of
sodium chloride in the cells. The migration of leuco-
cytes will be checked, the tryptic digestion of sloughs
suppressed, and the antibacterial substances so altered
as to become inactive. The physiological saline solu-
tion is not open to these objections. Hypotonic saline
solutions are likewise open to serious objections. The
writer has seen hypertonic saline dressing used exten-
sively and has not been convinced that it produces the
results claimed for it. The theoretical indications for
the use of salt solutions appear to be based on an un-
tenable hypothesis of the structure of the tissues about
the wound and an erroneous interpretation of physical
and physiological laws. The chief beneficial character
held by strong salt solution, aside from the cleansing
property possessed by all watery solutions, is their mild
antiseptic action.
7. Three Cases of Bubonic Plague Arising in Eng-
land.— A. Rendle Short reports that two certain cases,
and one probable, of bubonic plague have been treated
at the Bristol Royal Infirmary between July 30 and
Aug. 5, 1916. Two of the patients and the father of
the third were workers in a rag factory in a poor part
of the city. The plague bacilli have been demonstrated
in a rat found in the factory and the theories that sug-
gest themselves in regard to the source of infection are
three: 1. Infection from rags, though it is said that
the rags do not come from abroad. 2. Infection carried
by rats escaping from ships entering the port. 3. De-
liberate inoculation of city rats by an enemy. If this
latter theory should be true other towns may have a
visitation of rat plague, with human cases following.
La Riforma Medica.
August 16, 1916.
Kenotoxins. — Ferrannini and Fichera have been
studying the fatigue toxins of the frog. They refer to
the work of pioneers in this field, notably Ranke, Kro
necker, Mosso and numerous others down to the time
of Weichardt, who is the chief contemporary authority,
and whose technique the authors have closely followed,
although they selected the frog or rather one muscle
of the frog, the gastrocnemius, the stimulation coming
from an induced circuit with automatic closure, and the
contractions recorded on a myograph. It is therefore
necessary only to tire the muscle progressively and
Oct. 7, 1916]
MEDICAL RECORD.
649
study the numerous myograms for evidence of fatigue
poisoning. In the first experiments no outside toxins
are injected. The contraction waves become shorter
and shorter with fatigue, but up to the last show per-
fect regularity, even in the so-called line of exhaustion.
If a little kenotoxin is injected as the experiment
begins, the influence on the myograms is shown in vari-
ous ways and the line of exhaustion is reached in 4
instead of 10 minutes. The combined results are stated
as follows: The presence of kenotoxin injected subcu-
taneously reduces notably the amplitude of the muscle
contractions and augments considerably the period of
latency in the same. It both shortens and renders
irregular the curve of muscular fatigue, and depresses
notably the excitability, contractility and force of the
muscle.
History of the Study of Malaria in Rome. — Marchia-
fava does not go back beyond his own first studies,
published in 1877. He took issue with some of the prev-
alent theories on the causation of melanemia. In 1879
he published accounts of studies of the blood in the
spleen and bone marrow of melanemic children. One
year later Laveran discovered the parasite and its
power of attacking the red blood globules. For a num-
ber of years Laveran was busy with studies and demon-
strations of the parasite, but it was not until 1890 that
rapid methods were evolved for its prompt recognition
for diagnostic ends. However, as far back as 1885
Golgi had studied the Plasmodium independently both
as to its morphology and its method of causing various
types of disease. This scientist was the first to study
Roman malaria from this viewpoint. Also, the author
and Celli had been making studies along the same line
and were the first to term the parasite the Plasmodium
malaria;. The author had really been studying the
parasite since 1883, so that with Celli and Golgi he
represented the beginnings of the Italian school of
malaria study in distinction with the French school as
founded by Laveran. Moreover, the Italians studied
native malaria. Because Marchiafava really studied
the parasite without knowing its nature, some would
give him credit alongside of Laveran for priority, his
work antedating that of the latter. However, from
1885 to 1889 notable Italian scientists opposed the
author and Golgi in regard to the parasitic nature of
malaria. They included Tommasi-Crudeli, Maragliano,
and Mosso. In 1889 the author submitted new demon-
strations of the parasite and its pathogenicity, and
some years later Koch corroborated the authors' finds
in connection with his work in Africa. It was now
realized that different Plasmodia produced different
types of malaria. While Laveran is credited with dis-
covering the Plasmodium as such, Golgi receives credit
for isolating the causes respectively of the tertian and
quartan fevers, while the author has an undisputed
claim to the discovery of the parasite of the tropical
estivoautumnal fever of the Italians. At a later period
the author, in addition to the parasite of the quotidian,
has identified himself with the demonstration of a ter
tian type which predominates over all others in im-
portance. He has received full credit for discovering
the causes of the fevers of the Roman Campana. His
treatise was translated into English by the Sydenham
Society and he wrote the article on malaria for Wood's
Twentieth Century Practice. Thus for nearly 40 years
the author has been the leading Italian authority on
Roman malaria.
appears in two stages. Jaundice is at the start accom-
panied by fever, the latter subsiding; but before the
icteric tint disappears fever recurs. It is to this type
of disease that Mathieu and Weil append the term in-
fectious icterus with febrile recrudescence. A soldier
of 23 was admitted for intense icterus of a week's dura-
tion. It had begun with headache, pain in the limbs,
diarrhea, and vomiting. He had been invalided for gas-
tric disturbance. The man seemed quite ill, his coun-
tenance anxious, respiration rapid, medium febrile tem-
perature, fever blisters on the lips, mahogany colored
urine. Next day he was considerably improved, and im-
provement persisted, save that for a number of days
icterus remained unchanged. It then began to vanish,
but while still perceptible the temperature began to
rise in connection with myalgia. Icterus did not in-
crease, but its disappearance was arrested. The pa-
tient perspired profusely and felt prostrated. After
six days the second febrile movement reached a crisis.
The urine was absolutely free from biliary coloring
matter. Fever lasted three days longer and there was
a final clearing up of the icterus. There had been 32
days of jaundice, and save for seven consecutive days
of apyrexia the patient had had more or less fever,
which had been around 40° C, for four consecutive days
in the second febrile period. Throughout, the urine was
scanty. On one day it was black coffee color. A study
of the urine showed that the unknown infection had
caused much disturbance of the liver on both febrile
periods, more marked, however, on the former. In the
febrile recurrence bile pigment may be present in the
feces. In a second patient the febrile recurrence came
when icterus was reduced to conjunctival tints. The
recrudescence may be either benign or severe. Natu-
rally this phase presents the greatest- interest. Fever
appears, the urine becomes scanty, and a biliary diar-
rhea is sometimes seen. These occur simultaneously,
and food and medication may be excluded as causes. In
fact, the milk regimen generally recommended is seen
to exert a favorable influence on the condition. The
patients often behave like typhoid cases, and some writ-
ers have associated the two clinically, but all diagnostic
tests have proved the complete absence of typhoid in
these cases, 23 of which were tried out on the typhoid
theory. In a few cases paratyphoid bacilli were pres-
ent in the blood, as shown by agglutination tests. De-
spite this fact the bacterial causation of the disease is
regarded as unknown. Whatever it is, it causes a bio-
genic reaction.
La Presse Medicate.
August 31. litlfi
Infectious Icterus with Febrile Recrudescence. — Gar-
nier states that primary infectious icterus sometimes
Case of Acute Yellow Atrophy of the Liver Treated
by Injections of Sodium Bicarbonate; Recovery. — C. P.
Longridge, Royal Army Medical Corps, relates the case
of a soldier aged twenty-five who having reported ill at
Gallipoli was sent to a hospital in Egypt. The symp-
toms pointed wholly to epidemic catarrhal jaundice,
which was prevalent at that time. In a few days severe
symptoms appeared, including syncope and vomiting.
Icterus became marked. Liver dullness increased. Re-
ceived by the rectum glucose injections, with sodium
bicarbonate by the mouth. Leucin and tyrosin were
present in the urine. Symptoms grew worse and de-
lirium set in. Glucose enemata no longer practicable.
Soda injected hypodermically. Patient was now unable
to receive food, and urine was almost suppressed. Diag-
nosis of acute yellow atrophy of the liver made in con-
sultation. The sole dependence was placed on the bicar-
bonate injections. One week after the patient was ad-
mitted to hospital he began to improve, the liver dull-
ness rapidly receding. The man was discharged cured
on the thirty-third day. — Journal of the Royal Army
Medical Corps.
650
MEDICAL RECORD.
[Oct. 7, 1916
Umik Stetrifuia.
Polish for Use in the Clinic. By the Rev. Francis
Bimanski, Cook County Hospital Chaplain, Chicago:
Published by the author, 1076 West Twelfth Street.
Price, 5 cents; $2 per hundred.
Italian for Use in the Clinic. By the Rev. Francis
Bimanski, Cook County Hospital Chaplain. Revised
edition. Chicago: Published by the author, 1076
West Twelfth Street. Price, 5 cents; $2 per hundred.
These are two very practical little phrase books for
use in examining Polish or Italian patients. They con-
tain lists of the simplest sort of questions in the fewest
words possible, which demand no extended answers,
but simply yes or no, numbers being indicated by the
fingers and* the location of pain or other subjective
symptoms being shown by pointing. The pronunciation
of the questions (which are in both English and Polish,
or Italian) is indicated by a simple phonetic system in
following which the physician cannot fail to make his
Polish or Italian patient understand. The little pam-
phlets ought to be of the greatest use in the dispens-
aries and hospitals of every town where there is a large
foreign population.
Progressive Medicine. A Quarterly Digest of Ad-
vances, Discoveries, and Improvements in the Medical
and Surgical Sciences. Edited by Hobart Amory
Hake, M.D., Professor of Therapeutics, Materia
and Diagnosis in the Jefferson Medical College, Phila-
delphia; Assisted by Leighton F. Appleman, M.D.,
Instructor in Therapeutics, Jefferson Medical Col-
lege, Philadelphia. Price, $6.00 per annum. Phila-
delphia and New York, March 1, 1916.
This number of Progressive Medicine contains chap-
ters on: Surgery of the head and neck, by C. H.
Frazier; Surgery of the thorax, excluding diseases of
the breast, by G. P. Muller; Infectious diseases, includ-
ing acute rheumatism, croupous pneumonia, and in-
fiuenzia, by J. Riihrah; Diseases of children, by F. M.
Crandall; Rhinology and laryngology, by G. B. Wood;
and Otology, by T. L. Saunders. This publication is
so well known that it is not necessary to do more than
draw attention to the current number.
The Practical Medicine Series, comprising ten
volumes on the Year's progress in medicine and sur-
gery, under the general editorial charge of Charles
L. Mix, A.M., M.D., Professor of Physical Diagnosis
in the Northwestern University Medical School.
Volume I. General Medicine. Edited by Frank
Billings, M.S., M.D. Head of the Medical Depart-
ment and Dean of the Faculty of Rush Medical Col-
lege, Chicago. Series 1916. Price, $1.50. Chicago:
The Year Book Publishers.
Again the Practical Medicine Series comes forward to
help the busy practitioner, to gain the newest informa-
tion in the various realms of medicine. "General Med-
icine" is a most satisfactory compend of the Year's
literature.
Mentally Deficient Children, Their Treatment and
Training. By G. E. Shuttleworth, B.A., M.D., etc.,
and W. A. Potts, M.A., M.D., etc. Fourth edition.
Price, $2.50 net. Philadelphia: P. Blackiston'', Son
& Co. 1916.
The fourth edition of this work is chiefly notable for
the changes made necessary by the recent passage of
the Mental Deficiency Acts for the British Isles, ex-
clusive of Ireland, and the revision of the Elementary
Education Act. A very interesting historical summary
fills the first chapter and a rather elaborate explanation
of the acts alluded to above and their applications takes
up the next two chapters. Then follow the pathology,
etiology, diagnosis and prognosis of the various forms
of mental deficiency — two excellent chapters. A chapter
has been given to the psychopathies of childhood, which
is a nev: departure from the previous editions and
which had better have been omitted or made much
longer. Thus the description of dementia precox conveys
little or no information. The chapter on the medical ex-
amination of defective children is good, especially the
inclusion of Pasmore's "Flag" chart, but the exclusion
of the Binet-Simon tests on the ground that the "space
will not permit" does not seem justified. The closing
chapters, devoted to the care and training of such
children, are very valuable; more might have been
said about sterilization, but what is said has the merit
of truth. A fairly complete bibliography is appended.
the book is well indexed and a number of the American
institutions for the feebleminded are listed in an ap-
pendix. Altogether the work is a notable addition to
the literature of the subject.
Cerebellar Abscess, Its Etiology, Pathology, Diagnosis,
and Treatment, Including Anatomy and Physiology
of the Cerebellum. By Isidore Friesner, M.D., Ad-
junct Professor of Otology and Assistant Aural
Surgeon, Manhattan Eye, Ear and Throat Hospital
and Post Graduate Medical School, New York, and
Alfred Braun, M.D., F.A.C.S., Assistant Aural
Surgeon, Manhattan Eye, Ear and Throat Hospital,
Adjunct Professor of Laryngology, New York Poly-
clinic, Adjunct Otologist, Mt. Sinai Hospital. Price,
$2.50 net. New York: Paul B. Hoeber. 1916.
Cerebellar abscess, while a fairly common condition,
is by no means readily recognized, especially in the
early stages. When we consider the heavy mortality
without surgical interference, amounting to nearly a
100 per cent., and the fairly good prognosis with
operation, the importance of diagnosis becomes obvious.
The present monograph on the subject by Dfs. Friesner
and Braun is excellent, both in its subject matter and
style. The book, too, is attractively gotten up, illus-
trations are numerous, and there are many full-page
plates. The first two chapters deal with the anatomy
and physiology of the cerebellum. In discussing the
physiology there is no attempt to be dogmatic, a
clear working knowledge of the fairly well established
facts only is presented in a concise way. There is a
good chapter on etiology and pathology. The longest
and most useful chapter is the one dealing with symp-
toms which is very complete, describing the methods
of eliciting them, and explaining their significance.
The book closes with a chapter on prognosis and treat-
ment which is also good. A bibliography, not com-
plete, but very extensive, is appended. There is also a
good index, although this is scarcely necessary, the
subject matter is so logically arranged. The book as
a whole is an excellent one; neurologists and otologists
should not be without it, and there is much to interest
the general practitioner and the surgeon.
Skin Cancer. By Henry H. Hazen, A.B., M.D., Pro-
fessor of Dermatology in the medical department of
Georgetown University; Professor of Dermatology in
the medical department of Howard University; some-
times Assistant in Dermatology in the Johns Hop-
kins University; member of the American Derma-
tological Association. With ninety-seven text illus-
trations, and one colored frontispiece. Price, $4. St.
Louis: C. V. Mosby Company. 1916.
A great variety of tumors appear in the skin, and of
these the carcinomata are the most important. They
vary enormously in morphology and clinical course,
from the basal-cell type which sometimes cure them-
selves to the melanotic tumors which are among the
most serious of the neoplasms which appear in the
human body. The author of this volume has prepared
a very useful book in which much information con-
cerning tumors of the skin can be readily obtained. It
is provided with an excellent bibliography, the newer
ideas are incorporated, and the only thing to criticize
is the reproduction of the photomicrographs, which is
very bad. The drawings are satisfactory and the gross
photographs are fair. The book ought to furnish a
valuable aid for the practitioner of dermatology or the
student of dermatological pathology.
The National Formulary. Fourth Edition. By Au-
thority of the American Pharmaceutical Association.
Prepared by the Committee on National Formulary
of the American Pharmaceutical Association. Official
from September 1, 1916. Published by the American
Pharmaceutical Association, 1916.
The authoritative formulary, extra to the Pharmaco-
poeia, containing the preparations of a non-secret
character which were commonly prescribed by physi-
cians under incomplete or varying formula? is in its
fourth addition. This edition assumes its place as a
legal standard and has been prepared with a view to
that position. It is a remarkably exhaustive and ac-
curate compendium of the formula? set down and re-
flects great credit on its compilers. The work provides
a valuable adjunct to the pharmacopoeia and of course,
is a very useful book of reference, considerably mor?
useful to the medical man, indeed, than is the other
work of which this is sometimes called a companion.
Oct. 7, 1916]
MEDICAL RECORD.
651
g>orotg Skpnrta.
THE AMERICAN CLIMATOLOGICAL AND CLINI-
CAL ASSOCIATION.
Thirty-third Annual Meeting, Held in Washington,
May 9, 10 and 11, 1916.
The President, Dr. James Alexander Miller of New
York in the Chair.
Tuesday, May 9 — First Day.
President's Address. — Dr. James Alexander Miller of
New York gave this address on "Some Physiological
Effects of Various Atmospheric Conditions." He said
that atmospheric environment was an interesting and
important factor in many medical problems, in which
no group of physicians was more directly interested
than were the members of this association, and, more-
over, none in this country had contributed more than
they had in the advancement of this phase of medical
knowledge. It was for this reason, and also as the
result of his own recent experience of three years in
the work of the New York State Commission on Ven-
tilation, that this topic had been chosen for presenta-
tion. It was his purpose to approach the subject from
the physiological point of view in the hope that by a
•consideration of certain fundamental principles a
clearer vision might be afforded to the problems in-
volved in the effect which atmospheric conditions exert
upon the comfort and efficiency of mankind, as well
as the role they played in the causation, prevention and
treatment of disease. The respiratory function of air
focussed the attention of physiologists for generations.
Consequently its effect upon the human body was in-
terpreted solely in respiratory terms, and rules of
hygiene were formulated upon this basis. Within doors
inadequate ventilation was gaged in terms of de-
ficient oxygen, or of excess of carbon dioxide, or later of
the presence of certain volatile poisons in the air
that was breathed. Out of doors, the general effect
in health and disease produced by variations in climate
or of its temporary representative, the weather, was
also ascribed solely to their influence upon the air they
breathed. To the truthful part of this hypothesis they
all paid tribute in the joy of the full deep breath and
upon a fine crisp morning. Certain substances in the
air such as dust, bacteria and odors, were recognized
as playing a part in its hygienic properties, but recent
investigations appeared to demonstrate that under ordi-
nary conditions they were not factors of sufficient im-
portance to materially effect the health. In general it
might be accepted that the chemical or bacterial content
of the air within any likely degree of variation was not
of material moment either hygienically or physiologi-
cally. Researches of the past decade had all led to the
appreciation of the physical as opposed to the chemical
feature of the air as the important physiological factor.
Adequate heat regulation of the body depended largely
upon the capacity for proper heat elimination which was
accomplished in three principal ways which varied in
their relative importance according to varying external
conditions. (1) Evaporation of water from lung and
skin surfaces. (2) Direct conduction by contact with
a cooler medium. (3) Direct radiation to a cooler dis-
tant surface. Taking, therefore, these more important
conditions together they found that the various factors
reduced themselves finally to four, namely, tempera-
ture, humidity, barometric pressure and velocity of
air movement. Fully as he appreciated the work of
men doing for the good of the child, there had been
a considerable amount of loose medical thinking upon
this subject, and they were sorely in need of more
scientific data based upon accurately observed clinical
phenomena. Fully as he appreciated their shortcom-
ings, he said he was not entirely in sympathy with
the popular denunciation of the ventilating engineers
and their artificial systems. He was convinced that
by a rational system combination of open windows, a
good heating plant and a proper air exhaust system
when necessary, that practically any desired condi-
tion of indoor air might be obtained. The two chief
faults appeared to be too high temperature and too
little variation in temperature. In closing Dr. Miller
made the suggestion that by breaking up into its com-
ponent parts the heterogeneous mass of physical and
physiological factors now included in the term "fresh
air treatment" and studying the effect of each, they
might be able to reach a point where the proper at-
mospheric conditions might be intelligently applied to
the suitable case of disease and results obtained which
would be far more satisfactory than at present, both
from a clinical and scientific point of view.
Some Features in the Control of Typhoid Fever in
New York State. — Dr. Linsly R. Williams of Albany,
N. Y., presented this communication, in which he said
that the control of typhoid fever by the sanitary au-
thorities consisted of a study of the source of infec-
tion and application of known methods of control. The
most frequent sources of infection were the water sup-
ply, milk, carriers, and contact. Steady progress "in
improving the water supplies had caused a constant
diminution in the number of cases and deaths from
typhoid fever, and water-borne typhoid was now far
less common than it was fifteen years ago. The re-
ports of epidemics of typhoid fever of milk-borne origin
continued. During the eighteen months ending Dec.
31, 1915, there were 111 cases of typhoid fever with
14 deaths due to milk-borne infection. Carriers played
a far more important part than was formerly assumed.
Until the past year practically no intensive epidemio-
logical work was done by the New York State Depart-
ment of Health, but during the past year over 20
carriers of typhoid had been detected and placed under
observation and supervision. Numbers of persons still
developed typhoid fever as a result of carelessness in
the care of a typhoid fever patient at home. The meth-
ods of control were obvious. The water supply should
be above suspicion — filtration or chlorination when
necessary; the milk should be pasteurized efficiently to
prevent milk-borne infection ; and carriers should be
determined and prevented from carrying on any work
which brought them in contact with food. Acute cases
should have proper care — given hospital care if pos-
sible to prevent the risk of infection to other members
of the family. All persons exposed in the family should
be vaccinated against the disease. All the discharges
should be promptly disinfected.
Hydrology in Military Practice. — Dr. Guy Hinsdale
of Hot Springs, Va., said that he had recently received
a letter from Dr. Margnat of Vichy in which he de-
scribed the effects of balneological treatment to the
troops in the present war. In case the springs be-
longed to the Government, the soldiers sent for treat-
ment were under the rules in force in military hos-
pitals; but in other cases arrangements were made
with the private owners for the use of the establishment
as might be required. The mineral spring hospitals
received, first, soldiers and sailors in active service;
next, soldiers and sailors in non-active service, either
invalidated or retired; and finally officials in the colonial
or custom house or the forestry service. Cases sent
for treatment were subjected to selection by army sur-
geons and were restricted to those in which ordinary
means of treatment had been used during a sufficient
length of time without success. They might, therefore,
be considered chronic cases. It was interesting to note
that bath trains were now used by the armies in the
field. These were in use in Austria und Hungary and
also in Serbia, doubtless as well in Germany and
France. They were provided with a sterilizing equip-
ment, usually a refrigerator car into which steam was
introduced. When baths were required, the hot water
was obtained from the locomotive. One of these trains
had two cars with 30 bath tubs each, two tank cars
to supply the water, one car for undressing, four freight
cars with clean linen, a sleeping car for the personnel
of the train, and two or three cars for the disinfection
of clothing. This arrangement permitted 1200 men in
the course of 10 hours to take a shower bath and have
all their clothing sterilized. Even in the trenches it
was possible to have needle shower baths. In the
United States, as in England to-day, it would doubt-
less be possible to arrange for the use of privately
owned spas for military purposes if it should ever
become necessary.
Hereditary Hemorrhagic Telangiectasia, with Report
of Two Families and a Review of those Previously Re-
corded.— Dr. Walter R. Steiner of Hartford, Conn.,
called attention to a syndrome which presented telan-
giectases associatd with hemorrhages. This was first
described by Legg in 1876, and was made a clinical en-
tity by Rendu twenty years later. It was an hereditary
affection, attacking both sexes equally, and being trans-
mitted alike by both. Pathologically it had been but
little investigated. The cautery was the best method
of treatment for the troublesome, bleeding telangiee-
tases. Twenty families had been recorded. An ac-
count of two additional families was reported, and in
652
MJ DICAL RECORD.
[Oct. 7, 1916
one of them the syndrome was traced through five gen-
erations.
Abscess of the Lung Following Operation on the Ton-
sils and Upper Air Tract.— Dr. Charles W. Richardson
of Washington, D. C, said that in previous papers he
had called attention to this serious complication. When
one considered the nature of the wound left after a
complete tonsillectomy, the wonder was not that serious
infection took place occasionally, but that such results
were comparatively rare. In conversation with work-
ers in this field, he had had narrated to him several
cases that had occurred of septic infarct of the lung
with resulting abscess which had never been reported,
and wherein the condition was never recognized until
the resulting pulmonary abscess had formed. The rea-
son why this complication was not more frequently re-
ported was probably two-fold: viz., Firstly, most oper-
ators, as workers in other fields of human endeavor,
prefer to report their successes, to minimize their un-
toward results and forget them; secondly, the serious
symptoms of pulmonary infection were not always im-
mediate, were frequently indefinite and not recognized,
and the patient was discharged by the operator with
the tonsillar wound healed. When the pulmonary evi-
dence became more pronounced the internist was called
into attendance, and the operator probably never heard
of the untoward pulmonary complications. The causa-
tion of pulmonary abscess secondary to tonsillectomy
was in all probability through embolism or infection of
the lung. At the time of operation a large number of
veins were opened, and these might remain patulous for
several days. Septic clots or septic material might
thus be carried into the lungs. After reporting several
cases Dr. Richardson said that one of the objects in
presenting the paper was for the purpose of again
calling to the attention of the profession the fact that
the performance of tonsillectomy was not the simple
innocent operation that the laity and many of the
internists seemed to consider it.
Appendicitis and Pulmonary Tuberculosis. — Dr. Hugh
M. Kinghorn of Saranae Lake, N. Y., read this paper.
He said that the facts which were presented in this
communication were obtained from his cases of pul-
monary tuberculosis which were treated at Saranae
Lake, N. Y., by the usual open-air method from Octo-
ber, 1905, to December, 1914. The majority of the
cases of appendicitis occurring in patients with pul-
monary tuberculosis had the usual classical symptoms.
During this period he treated 674 cases of well estab-
lished pulmonary tuberculosis, and all were under cli-
matic treatment at Saranae Lake. Of this number
there were 393 males and 281 females. The total num-
ber of cases of appendicitis in the 674 patients was
38 5/6 per cent. Of this number, 26 were males and 12
were females. Sex seemed to play an important part,
as the disease occurred in males more frequently than
in females, and there was as yet no satisfactory ex-
planation for this. Of the 25 cases that underwent
operation there were two deaths, 8 per cent. All of
the 25 cases seemed to act well during the operation,
and there were no deaths on the operating table. The
mortality of this series of 38 cases (operative and non-
operative cases) was 5.2 per cent. (That was, two
deaths in 38 cases.) Of the acute cases that under-
went operation there was a mortality of 11.1 per cent.
(1 death in 9 cases). Of the interval operations there
was a mortality of 6.2 per cent. (1 death in It: opera-
tions).
Wednesday, May 10 — Second Day.
Vice-President Philip King Brown of San Fran-
cisco in the Chair.
The Diagnosis of Pulmonary Tuberculosis Without the
Stethoscope. — Dr. H. LONGSTREET TAYLOR of St. Paul,
Minn., read this paper. He said that the successful
treatment of pulmonary tuberculosis depended pri-
marily upon an early diagnosis. This statement had
been made so often and in such a variety of ways that
its repetition became trite, and yet the enormous im-
portance of the subject made it necessary to call the
attention of the profession to these old axioms again
and again, and by repeated blows try to drive the nail
home. The morbidity caused by tuberculosis was enor-
mous. If recognized and untreated the morbid process
advanced, and constitutional strength became more and
more impaired by the progress of the disease until tin-
prognosis was absolutely hopeless. This disease, on
account of its insidious onset, deluded its victims into
believing that they were not seriouslv ill, and did not
require the services of a physician. In this class of
cases, and their name was legion, the profession could
in no wise be held responsible for the late diagnosis.
Many patients, too, were reluctant to go to a physician
lest their fears should be confirmed, and they would
leave the consultation room knowing that they were
victims of the great white plague. The number of un-
recognized cases might be demonstrated in variour
ways, by autopsies of persons who had died of other
diseases, or who had met violent deaths, which showed
an active or healed pulmonary tuberculosis in a sur-
prisingly large number of cases. The diagnosis of an
incipient case of pulmoanry tuberculosis was an exceed-
ingly difficult one to make if the case was truly an early
one. Physical examination of such a case could reveal
but little, as the signs were not pronounced and easy of
detection until actual destruction of the tissues of the
lung had taken place; but given a young adult with
vague and indefinite indications pointing to pulmonary
tuberculosis, the chances were decidedly in favor oi
tuberculosis being present, since it was an exceedingly
common disease at this age, and the profession should
not hesitate to make a tentative diagnosis of pulmonary
tuberculosis subject to the result of subsequent tests.
The absence of tubercle bacilli from the sputum proved
absolutely nothing, and their presence in the sputum
showed that an early diagnosis had not been made. It
was his personal impression that the profession was
too prone to rely upon the laboratory report of the
sputum almost entirely in making the diagnosis of
pulmonary tuberculosis to the exclusion of the clinical
picture presented. Laboratory tests "with the glamour
of science and the romance of novelty" could not sup-
plant entirely the study of each individual with the
sharpened observation due to long acquaintance with
the danger signals thrown out by this enemy while dig-
ging himself in and preparing for a long siege, which,
unless skillfully combatted, was destined to end in the
fall of the individual and his unconditional surrender
to the captain of the forces of death. The laboratory
had proved itself of immense value to the profession,
but, like everything else, was not infallible, and in the
question under discussion had too often delayed a posi-
tive diagnosis, which should have been made by a care-
ful analysis of the patient's symptoms and a painstak-
ing exclusion of other possible conditions. The diag-
nosis must often be made in the absence of signs in the
chest by the exclusion of other toxemic conditions that
might resemble the symptoms of the tuberculosis tox-
emia. The cases fell into one of the following cate-
gories, with neurasthenic onset, with anemic onset, with
hemorrhagic onset, onset with fever, the pleuritic onset,
the pneumonia onset, the laryngeal onset, etc. The
symptoms which should arouse suspicion of the presence
of tuberculosis and lead to a thorough study of the case
are: they had first and foremost cough, especially on
arising in the morning, at which time there might be
a few short coughs, with or without any expectoration.
At the same time the patient might be conscious of a
slight degree of debility, and the fact that he tired
more readily than formerly, that he had lost little
weight, and that his dyspeptic symptoms had grown
more annoying. A slight fever and rapid pulse, with
or without chills and sweating at night, pointed unmis-
takably to the necessity of thoroughly testing the pa-
tient for the presence of tuberculosis. The same was
true of anemic conditions not otherwise accounted for,
and of protracted convalescence from an acute disease.
Many cases of tuberculosis masqueraded under the name
of influenza. The object of this paper was to empha-
size the fact that the profession did not give the proper
value to the careful study of the patient's history, and
delayed making even a provisional diagnosis until the
stethoscope or the microscope revealed the condition.
The lesson was that a diagnosis of pulmonary tuber-
culosis cou'd be made from the patient's history and
symptoms, and should be made before the chest was
bared for an examination. In this way a man who
was not constantly making chest examination, or the
man whose hearing was defective, need not hesitate
about making a provisional diagnosis of pulmonary
irculosis. It was far better to suspect a patient of
having tuberculosis who was free from it, than to give
a clean bill of health to one whose chest was negative
but in whose lung tubercles were developing. A period
of careful observation and the use of the various tests,
especially the auto-intoxication test, would soon remove
all doubt.
The Advantages of Special Training in Tuberculosis
in Sanatorium Surroundings. — Dr. Edward R. Baldwin
cf Saranae Lake, N. Y., read this paper. He said that
Oct. 7, 1916J
MEDICAL RECORD.
653
no one would gainsay the fact that there was a steadily
increasing number of physicians who were known, or
called themselves, tuberculosis experts or specialists.
These were usually modest individuals who generally
became ill themselves and who became identified with
this field of medicine. These formed by a far greater
number, and they usually inhabited health resorts, or
became connected with some tuberculosis institution.
There had been no great enthusiasm in the past on the
part of other physicians to engage in the special work
of treating tuberculosis unless they were downright,
charlatans, like the cancer quacks, or were honest but
deluded individuals who believed that they had the
right "theory" of treatment or the best remedy if not
the only cure. There was now a rapid change taking
place owing to the well organized anti-tuberculosis
movement and the rapid multiplication of dispensaries,
sanatoria, and new health resorts. Public and private
sanatoria were being established, and a demand had
been created for trained men to take charge of them.
The supply of doctors competent and willing to take
up this work was being used to the utmost. The
specialty of tuberculosis or phthisiotherapy was an ac-
complished fact. It had already been recognized as
such in a few medical schools, and would doubtless be
soon by many others. If gastrology, dermatology, or
even proctology were entitled to recognition, no one
with justice to its importance could deny tuberculosis
a place on the curriculum. When an early diagnosis
was made an effort was now made to get the patieni
into a sanatorium, for a while a least, and this was
the rational thing to do. Men who lived with the pa-
tients, often themselves patients, were much better inter-
preters of the disease than those who had only the
academic attitude to it as teachers. Even though they
were most interested and enthusiastic teachers, they
could not carry the weight that the man did who had
personal experience with the disease or lived among
those who had it. In the present undergraduate course
in the best medical schools, the average student had
nearly all his attention occupied, and it was too much
to expect a really advanced course of instruction in
tuberculosis. Very much more was being done than
formerly, and very much better training for diagnosis
and the management of tuberculous patients was now
available, yet they did not find that it had brought
about any revolution in the care of these patients by
the recent graduates. It was not all the faulty or in-
sufficient training that was responsible for this. He
suspected that they took but little interest in this dis-
ease while they were in college. The disease had no
real appeal to them. It appeared from many stand-
points that to get a proper perspective of this disease,
a special study ought to be made under the most favor-
able surroundings where an atmoshere of hopefulness
prevailed among the physicians as well as the patients.
They all knew that there was no longer the excuse for
the neglected examination of the sputum, but they also
knew that the time had come when the physician was
called upon to find the disease before the sputum was
positive, and even when there was no sputum. This
meant a refinement of technique or of physical ex-
amination not yet attained by many. While the late
Dr. Trudeau was still living a gentleman from Cleve-
land, well known for his generosity and interest in
medical education, became interested in the subject
through his son-in-law, who was at that time at the
head of the Cleveland Tuberculosis Institute. This
gentleman offered a fund to support a post-graduate
school at Saranac Lake for three years, which the
trustees of the Trudeau Sanatorium accepted. The
experiment would be made to give a combined clinical
and laboratory course in the art of diagnosis, treatment
by sanatorium methods, and the organization and man-
agement of hospitals and sanatoria, both public and
private. The first trial would be for six weeks. For
those who contemplated city, county, or state institu-
tional work, the Ray Brook Sanatorium would furnish
facilities for study. The first session of the "Trudeau
School" would be given this spring. If the experiment
received encouragement, and was found to be useful
to the cause, it would probably become a permanent
adjunct of the sanatorium work in the Adirondacks. A
Foundation for Research and Teaching to the memory
of Dr. Trudeau was now being raised to further this
project, and Dr. Trudeau's friends had responded
loyally.
The Role Played by the Study of Tuberculosis in the
Development of Clinical Medicine. — Dr. H. R. M. Landis
of Philadelphia read this paper. He proposed con-
fining his remarks to those studies which, in all truth,
might be said to be epoch making. The first contri-
bution to which he wished to call attention was that
by Auenbrugger on "Percussion of the Chest." The
"Inventum Novem" was first published in 1761 and
forgotten for forty-seven years, when it was translated
from the Latin by Corvisart, physician to the first
Xapoleon in 1808. It was apparent on reading the
"Inventum Novum" that the major part of his observa-
tions was based on the various manifestations of this
disease. Important as Auenbrugger's discovery was
it became overshadowed when compared with the im-
mortal work of Laennec. When in 1819 Laennec gave
to the world the stethoscope, and his observations on
mediate auscultation and the pathological anatomy of
diseases of the lungs, he practically created clinical
medicine as they knew it to-day. Furthermore "to
Laennec will forever belong the honor of having fixed
definitely the clinical picture of the disease (tuber-
culosis), and of having separating it by means of aus-
cultation and his pathological studies from all similar
affections of the lungs." In this instance it might be
objected that the work on mediate auscultation did not
represent a special study of tuberculosis. Strictly
speaking, this might be true, but it was equally true
that Laennec's observations were based largely on the
manifestations of this one disease. The work on Medi-
ate Auscultation should be read, he believed, by every
student before his graduation. The late Dr. Austin
Flint said: — "Let the student become familiar with all
that is now known on this subject, and he will read the
writings of Laennec with amazement that there re-
mained so little to be altered or added." Sir William
Osier had written: — "By far the ablest and most scien-
tific of American students of the disease (tuberculosis)
was Austin Flint, whose contributions to the physical
signs and the symptoms were among the most im-
portant of his many clinical studies." (Tuberculosis,
edited by Klebs, 1909.) To Austin Flint belonged the
distinction of making the only addition to Laennec's
work which could ill be dispensed with. He referred
to his contribution on pitch in percussion and ausculta-
tion, a point to which Laennec paid no attention. At
the present time they were passing through another
revolution, namely, that which related to public sanita-
tion. Much of the work now being done on sanitation
had had its incentive in the modern crusade against
tuberculosis. Housing reforms, improvements in fac-
tory conditions, supervision of the health of workers,
school inspection, open air schools, and the crusades
against the social diseases, infant mortality, etc., all
might be traced, directly or indirectly, to the tuber-
culosis crusade.
Pulsating Spleen in Mitral and Tricuspid Disease. —
Dr. Morris Manges of New York reported this case,,
and reviewed the literature on this subject. In all the
cases the splenic pulsation was arterial and was syn-
chronous with the cardiac systole and increased or
diminished with the vigor of the cardiac action.
Thursday, May 11 — Third Day.
The Problem of Rest or Exercise in the Treatment of
Pulmonary Tuberculosis: A Plea for Less Ergophobia. —
Dr. Charles Minor of Asheville, N. C, presented this
communication, in which he stated that in the treatment
of tuberculosis there were no more important meas-
ures than rest and exercise. Formerly tuberculosis
patients were permitted to over-exercise; to-day there
was a tendency to go to the other extreme. Rest was
successful because it lessened circulation, and hence
toxic absorption ; it lessened oxidation and iowered tem-
perature, and so decreased tissue waste; it put the
diseased lung at rest, rested the heart, and lessened
cough and expectoration. Furthermore, it encouraged
weight gaining, and if properly managed helped to set
the mind at rest. All these things were admirable, but
there came a time when disadvantages showed them-
selves, and when a too long-continued rest ceased to be
of value and became harmful. When the temperature
fell so that the afternoon temperature was not over
99.4° F.; when the pulse showed a decrease of toxic
absorption; when strength was improving, and when
the trouble was less active and we desired to help the
compensating function of the healthy portion of the
lung by the quiet deep breathing that walking caused;
when cough and expectoration were much reduced and
we could therefore assume that there was less ulceration
and activity in the diseased area; when the patient
needed the stimulus of hope and the encouragement of
a positive proof of his improvement; when his gain in
654
MEDICAL RECORD.
[Oct. 7, 1916
weight was marked and without exercise he was apt
to produce fat rather than muscle, then exercise should
be taken up not only on the theory of Pattison that the
patient might undergo an autotuberculin treatment,
but to prepare him when he should be restored to re-
sume life in a normal way, and not to be turned, as so
many were, into a pulmonary hypochondriac. Exercise
might be begun with from one to five minutes, accord-
ing to the case, and increased from one to five minutes
a day and guarded by a carefully kept record of symp-
toms, fever, and pulse, kept by the patient. Exercise
should be stopped or decreased just as would be done
if a tuberculin reaction occurred. It was essential that
the doctor see the patient at first bi-weekly, and then
weekly, and never less than once in two weeks. Tem-
perature was the best guide to detect over-exertion. If
the temperature in the afternoon was as high as 99.4°
F., the patient could be gotten up in the morning only,
then if he progressed properly in the afternoon, and
finally all day. With a temperature of 99.6 F., if the
patient was restless and high strung it might often be
wise to allow him up in a reclining chair for an hour
or so in the morning. In cases in which persistent rest
in bed failed to reduce the temperature one might at
times experiment with getting the patient up, partially
for the sake of mental encouragement. Unduly rapid
pulse was an indication for rest, but when moderate
exercise caused no rise it need not be an absolute indi-
cation for rest, but only for the reclining chair. Blood
streaked or pink expectoration was an absolute contra-
indication to exercise, but there were some patients in
whom blood streaking was a permanent habit, and in
some of these cases walking had been beneficial. Any
patient who was losing weight must be kept at chair
rest. As to fatigue, a little healthy tire had no sig-
nificance, but to get really tired was bad, whatever the
temperature and pulse might be. The methods of exer-
cise allowed were first the reclining chair and then
walking, but he allowed neither a carriage nor an auto-
mobile until the patient could walk from one-half to
one hour without bad effect. The automobile was
easier than the carriage.
A Case of Spontaneous Pneumothorax Without Symp-
toms.— Dr. David R. Lyman of Wallingford, Conn., pre-
sented this paper. He stated that a case of spontane-
ous pneumothorax similar to those reported by Dr.
Louis Hamman at the meeting of the Climatological
Association, in 1914, had come under his observation.
He had been so fortunate as to secure radiographic
plates of the chest at the time the patient consulted
him and four weeks later. At the first examination of
this patient there was an apparent absence of breath
sounds on the right side, the thorax being apparently
normal. The patient had complained of a peculiar
pain in the right side three years before. The pain
disappeared and the patient did not return until a
couple of weeks later, when he returned complaining of
a peculiar dragging pain extending from the lower
border of the right axilla upward and inward toward
the mid-sternum. He had also observed a slight feel-
ing of oppression and suffocation just back of the
sternum. His family and personal history were nega-
tive. Upon examination an apparently almost com-
plete pneumothorax of the right side was found, with
complete loss of breath sounds, hypersonance, and typi-
cal coin sound. The heart was only slightly displaced
and the left lung was apparently normal. He did not
feel sufficiently ill to go to bed, and was only convinced
of the seriousness of his condition by the aid of an
.>- ray picture of his chest. At the end of four weeks
the .T-ray examination of the chest showed that the
pneumothorax had practically disappeared, save for a
slight hypersonance over the base of the right axilla.
However, there were signs of a latent tuberculosis. II
seemed probable that the trouble three years previously
was due to an unsuspected tuberculosis.
Syphilis of the Lung. — Dr. X K. WOOD of Boston read
this paper. He said that there was evidence of suf-
ficient weight to convince the pathologist either thai
he was overlooking something or calling something by
the wrong name. He reviewed the histories of 20
cases in which Wassermann and von Pirquet tests were
made. In the cases in which these signs were negative
he had radiographs taken of the chest, and the long
bones of the legs. From these he was able to select
seven eases that showed definite histories of lung im-
pairment and a positive Wassermann and with nega-
tive sputum and negative von Pirquet test. To these
20 cases were added four others who did not come
up to the requirements that would suggest syphilis, but
which were reported because of the marked effect of
mixed treatment. The writer analyzed this series of
cases and pointed out the evidence which was sug-
gestive of syphilis, such as miscarriages, still-births,
early infant deaths, history of chancre, glandular en-
largement, Hutchinson's teeth, or badly decayed teeth,
skin eruptions, etc. He found in these patients equally
strong evidence of disease of the lungs, such as marked
dullness, limited excursion, poor respiration, a varying
number of moist dry rales, confined more to the bases
of the lungs, with a history of cough and expectora-
tion. These cases had been under treatment for a
year, simply good hygienic treatment, with tincture of
nux vomica and gentian before meals and mixed treat-
ment after meals. The results of treatment had been
small gains in weight, improvement in the general
physical condition, a diminished tendency to take cold,
and an improvement in the chest findings. It seemed
very certain that there had been disease of the lungs
in these cases, and one must weigh the evidence fur-
nished by the history as to whether it was tuberculosis
or syphilis. The treatment of tuberculosis was not
given, but these patients improved on tonic and anti-
syphilitic treatment. When the treatment was stopped
they retrograded. While the evidence pointed to the
existence of such a condition as syphilis of the lung,
the evidence in the writer's opinion was far from con-
clusive. If there was such a thing as syphilis of the
lung it would have to be demonstrated at the autopsy
table.
Heliotherapy in Abdominal Tuberculosis. — Dr. J. H.
Elliott of Toronto, Canada, read this paper. He said
the value of heliotherapy in the treatment of certain
forms of so-called surgical tuberculosis had been def-
initely established and especially satisfactory results
had been reported in tuberculous disease of the bones
and joints, both in closed cases and those with dis-
charging fistula?. In the latter there was frequently
involvement of the skin as well, at the opening of the
fistulous tract. Contributions to this subject had been
presented to this Association by Brannan and Hins-
dale. Dr. Elliott said he had experience with three
types of abdominal tuberculosis which had yielded to
heliotherapy. (1) Tuberculous enteritis. (2) Tubercu-
losis of the ileocecal and appendix region. (3) Tuber-
culous peritonitis with ascites. Illustrative cases of
each group were reported. In summarizing he said
that in abdominal tuberculosis, heliotherapy would
seem to be a valuable addition to simple rest cure in
the open air. Good results could be secured at home
and in the hospital. The method was applicable even
in large cities which had no special climatic advan-
tages, as demonstrated in a city with 46 per cent, pos-
sible sunshine.
Appendicitis as a Complication of Pulmonary Tuber-
culosis. — Dr. Hugh M. Kinghorn of Saranac Lake,
N. Y., presented this communication. He stated that
from October, 1905, to December, 1914, out of 674 well-
established cases of pulmonary tuberculosis, there were
36 cases of appendicitis, or 5.33 per cent. There was
an incidence of appendicitis in the male of 6.1 per cent,
and against 4.27 in the female. Of these 36 cases 22
were operated upon and 22 recovered without opera-
tion. One death occurred from fulminating appendi-
citis three days after operation. From his experience
the writer believed that acute appendicitis in patients
suffering with pulmonary tuberculosis should be treated
as it would be treated in a normal healthy person.
Even feeble patients stood the operation well under
nitrous oxide and oxygen. When the appendicitis was
not acute and the patient was feeble the pulmonary
disease should be considered. These patients stood
operation in the interim well.
THE AMERICAN ASSOCIATION OF
IMMUNOLOGISTS.
Third Annual Meeting, Held in Washington, D- C,
May 11 and 12, 1916.
The President, Dk. James W. Jobling of Nashville,
in the Chair.
President's Address: The Relation of Lipoids to Im-
mune Reactions. — DR. James W. Jobling of Nashville,
Tenn., delivered this address, which consisted of a sum-
ing on his subject. He said
that according to Meyer and Overton the cell wall was
composed chiefly of lipoids, and if this view was ac-
Oct. 7, 1916|
MEDICAL RECORD.
655
cepted we must concede the possible importance of
lipoids in protecting bacteria and the cells of the body
against antagonistic substances. Petersen and the writ-
er had shown that bacteria were protected from the ac-
tion of ferments by the unsaturated fatty-acid com-
pounds present in the cell and that oxiding agents such
as iodine, hydrogen peroxide, etc., would destroy this
protective action. Treatment of bacteria with ttiermo-
stabile immune bodies also rendered them more sus-
ceptible to the action of ferments, and experiments
which were now being conducted by the writer sug-
gested that these substances acted in a manner some-
what similar to that of oxidizing agents. It must be
bcrne in mind that bacteriolysis was almost never ob-
tained with undiluted immune serum, while bacteri-
olysis in vivo, except in the peritoneal cavity had not
been demonstrated. Heiler and Rimpau found that
lipoid soluble substances were bactericidal, and that a
definite relation existed between this action and the
lipoid solubility, narcotizing action and the bactericidal
action of the substances tested. Frolin found that
lipoid-free corpuscles injected into animals produced
agglutinins, but no hemolysis, whereas the lipoids pro-
duced lysins. Bang and Forsman obtained complement
fixation with immune sera, using the lipoids of the
homologous cells as antigens. Thiele and Embleton
believed that the different results obtained by different
investigators with lipoid extracts from fresh tissues
were probably due to the fact that proteins were also
present. The differences in the results obtained by
the various investigators suggested that lipoids in
certain combinations might act as antigens, while the
pure lipoids had not this property. Stuber, Dewey,
Nuzum and others had shown that certain lipoids,
chiefly cholesterol, inhibited phagocytosis. Other ex-
periments suggested that the inhibition of Phagocytosis
was not due to injury to the cells. Muller, on the
other hand, concluded that bacterial lipoids were un-
important in the process of phagocytosis. Stuber be-
lieved that the agglutinins were produced as a result
of the stimulus afforded by the fats liberated after
destruction of the bacteria. He also found that im-
mune serum extracted with ether lost most of its
agglutinating power, and that normal serum to which
ether extract was added acquired an agglutinating
value almost equal to that of the immune serum from
which the extracts were obtained. The serum of
normal animals that received intravenous injections of
extracts of the immune serum also contained strong
agglutinins. Graham stated that ether anesthesia did
not affect the agglutination titre of sera. The writer
reviewed the literature with relation to hemolysins and
lipoids and stated that he and Dr. Bull had demon-
strated what they believed to be immune lipases in
hemolytic sera, but were unable to show that they were
essential for hemolysis. After reviewing the literature
in reference to the relation of the lipoids to anaphy-
laxis, the essayist said that it had been known for
some time that serum antitrypsin was increased fol-
lowing the recovery from anaphylactic shock. With
this in mind Petersen and he had investigated, first,
the action of lipoids when given with the intoxicating
dose of antigen, and secondly, the influence of in-
creasing the antitryptic power of the serum. They
found that increasing: the tryptic power of the serum
and the addition of scans to the intoxicating dose
enabled the animal to resist severnl times the amount
of the specific protein fatal for the controls, while a
smaller dose of the antigens was required when lipoid
free proteins were used. Thev had also shown that the
removal of the lipoidal antiferments from the serum
permitted the formation of toxic substances which they
hnd tevrred "serotoxins." These toxic substances were
formed through the action of the serum proteases on
the serum proteins as soon as the protective lipoidal
substances were removed. They found that while
there was no loss of nitrogen from bacteria treated in
this manner, there was absorption of serum-antifer-
ment from the serum, and accompanying this loss of
antiferment power, a proportionate increase in tox-
icity. Other experiments showed that the lipoid sub-
stances had been absorbed by the bacteria, which now
became more resistant to such ferments as trypsin. It
might be that similar toxic substances were formed
iyi vivo in some of the bacteremias, for instance, an-
thrax. The writer then discussed complement devia-
tion in reference to the Wassermann reaction and
stated that evidence would go to show that alterations
in the lipoid content of the serum had an important
bearing on the reaction. After reviewing the present
status of our knowledge with reference to the Abder-
halden reaction, he considered the relation of lipoid sol-
vents to general infections, and brought out a number of
factors that tended to explain the constantly manifest
influence of the lipoids in the various immunological and
physiological balances. These considerations indicated
that the fats and lipoids might play an important role
in at least some of the immunity reactions.
The Inadequacy of the Anaphylatoxin Theory of Ana-
phylaxis.— Dr. Richard Weil of New York read this pa-
per. The characteristic features of the test-tube re-
action were, (1) that it took place not only through
the interaction of an immunological couple, namely,
antigen and antibody, but of entirely unrelated sera;
(2) that the two factors must be in certain definitely
limited quantitive relationships; (3) that it was slow
and gradual; (4) that it required the presence of
complement. He said that in every one of these fea-
tures it differed from the anaphylactic reaction in the
living animal or in the suspended uterus. The crucial
test consisted in the fact that it was impossible to pro-
duce the anaphylactic reaction in the animal by con-
ditions which duplicated those in the test-tube, namely,
the simultaneous intravenous injection of the two
factors, antiserum and antigen. According to the
physical theory, the reaction was simply an expression
of the alteration of cellular equilibrium which resulted
when external antigen was brought into contact with
cellular antibody. The characteristics of the reaction
were all entirely in keeping with this interpretation.
The precipitation reaction in the test-tube, which was
not accompanied by the chemical destruction of either
factor, (1) was immediate; (2) proceeded in the
absence of complement; (3) required relatively large
amounts of antibody and relatively minute amounts
of antigen. In these respects it was perfectly analog-
ous to the anaphylactic reaction. If in place of the
visible alteration, expressed as precipitation in the
test-tube, interaction of the two factors in vivo was
supposed to produce an alteration of cellular equi-
librium, such as would act as a cellular stimulus, all
the requirements of the problem would be satisfied.
In view of the fact that precipitin had been demon-
strated to be identical with the sensitizing antibody,
this explanation of anaphylaxis seemed almost self-
evident. This conception obtained the necessity of
postulating an intermediate chemical product, namely,
anaphylatoxin; such a postulate was not only super-
fluous, but it was also entirely incompatible with all
of the characteristic features of the reaction.
Additional Facts Concerning the Protein Poison. — Dr.
Victor C. Vaughn, of Ann Arbor, presented this com-
munication in which he stated that since his last publi-
cation his students and he himself had ascertained the
following facts: (1) Casein yields a large percentage
of the protein poison. (2) The protein poison after
the removal of all traces of mineral acid is strongly
acid in and of itself. (3) The protein poison did not
give the ninhydrin test, but did so after beinsr split
up with the acid. (4) The poison gave a skin re-
action in all persons. (5) The poison is not without
harm when administered by mouth. (6) Animals
might be acutely or chronically poisoned by oi-al ad-
ministration. (7) In chronic poisoning by feeding, ex-
tensive fatty degeneration results. (8) The pvotein
poisons from diverse proteins were not identical. (9)
The protein poison from casein combined with certain
unbroken proteins. In this combination the acidity of
the poison is neutralized and its physiological action
diminished. (10) From the tissues of animals killed
with protein poisoning, it may be extracted with
acidified alcohol, its presence demonstrated, and the
amount roughly estimated by the intravenous injection
of guinea pigs.
Studies Regarding the Action of Different Blood Sera
Upon Various Tissue Substrates. — Dr. Oscar Berg-
HAUSEN made this presentation which was a transla-
tion of a paper on this subject by Prof. Emil Abder-
balden. He stated that every organism, whether of
the plant or animal kingdom, split up with the aid
of ferments, composite and possiblv also simple com-
binations into products of simpler molecular size.
They enabled the cycle of ubstances from plant to
animal and from the latter to the former to be ac-
complished. It seemed quite clear that when composite
substances appeared in the blood where thev did not
belong ferments appeared which changed their char-
acter and simultaneously produced products which
were taken up by the cells for further utilization. The
whole investigation regarding the existence of fer-
656
MEDICAL RECORD.
[Oct. 7, 1916
ments arose from the idea that every kind of cell con-
sisted of specifically confined units, which were acted
upon during anabolism and catabolism by ferments.
During normal conditions the cells did not give off
their integral parts, but in metabolic disturbances
integral cellular substances might appear in the blood.
Many new problems were opened by the finding that
after parenteral ingestion of proteins and peptones in
the blood plasma, ferments appeared in the blood
which could split up these substrates. They did not
know whether they were dealing with ferments which
had just appeared or whether there were always
present proteolytic and peptolytic ferments in the blood
plasma. It seemed plausible that existing ferments
were not inhibited in any way in their action. Every-
thing, however, pointed to the fact that ferments ap-
peared only after and as soon as the blood-foreign
material appeared in the blood. Whence they came
was not yet determined. Experimentation had been
undertaken to bring the ferments in relation with the
immune bodies. After discussing the possible rela-
tion of the substrate to the antiferment as held by
some he pointed out the weakness of their arguments
and said that much research was still necessary. They
had busied themselves with a series of experiments to
determine under what conditions the proteo- and pepto-
lytic ferments reached the optimum of their action.
It seemed tangible that during normal conditions cell-
specific ferments migrated from the cells to the blood.
They were possibly in some way immediately inacti-
vated. The presence of active ferments would in
this case point to a disturbance of inactivation. There
were many reasons why this view was not probable.
The opinion seemed to be unanimous that there was a
specificity in ferment action in relation to substrates,
but they could not maintain a priori that in the list
of proteases and peptases specific adaptation toward
definite substrates existed. This problem required
further examination. The possibility that during
definite disturbances in organs ferments were found in
the blood which were adapted to definite substrates had
caused much activity among investigators. In the
course of time from clinics, hospitals and physicians
they had received 1,000 specimens of serums with the
request to determine the splitting up of this or that
organ. Most frequently the question was one regard-
ing the existence of a tumor. All of the examinations
might be classified into three groups. In one the
clinical diagnosis was known and for these Abder-
halden made the examination himself. In the second
group he knew the clinical diagnosis; the reaction,
however, was carried on by some one who was pur-
posely allowed to remain ignorant of the diagnosis.
In the last group the clinical diagnosis was unknown
to them. In all cases several organs and tissues were
used. There were numerous examples of undoubted
specific actions. The quantity of serum in many
instances was insufficient for the examination of as
many substrates as they wished, so that many of the
examinations were not entirely satisfactory. It seemed
from this study not impossible that the several varieties
of tumors owed their origin to the cessation of func-
tion of definite organs. They had commenced in the
case of tumor carriers, to look for splitting up of
definite organs, such as tlryroid, pituitary, thymus,
sexual glands, etc. The existing material was still
too small to prophesy that research in this direction
would be successful. Included in this report were also
the results of experiments concerning the production of
ferments by parenteral injection of tumor cells which
reacted with degnite tumor substrate. It was of much
interest that in some isolated cases ferments did not
appear. If the serum was found infected, then with
regularity no specific action was discernible. If the
serum was sterile, then it split up, even after it was
kept eight months, that substrate with which it orie-
inally reacted. One thing they had learned in their
investigations and that was that it paid to investigate
the field of pathology with the methods they had used.
The Specific Character of Immunity Reactions. — Dr.
E. C. L. MILLER of Richmond, Va., sa'id that for m
years it had been recognized that immunity reactions
were specific. However, when more detailed study was
given to some of these reactions, their specific character
was less sharply defined. For instance, if a rabbit
were repeatedly injected with the blood of a sheep, its
serum would react not only to sheep blood but also,
to a less extent, to the blood of goats: if injected with
horse serum, it would react not only to horse blood
but also, to a lesser extent, to the blood of asses and
zebras; if injected with human blood the serum would
react to the blood of the higher apes. These had been
called group reactions and were taken to indicate that
the members of the group had somewhere in the past
a common ancestor. The blood was not the only tissue
that might be used. The cells of any organ if in-
jected into a rabbit would produce a serum that would
dissolve such cells. If completely organic specific sera
could be prepared they might be of great practical
value. Investigators had found that various organs
of guinea-pigs, dogs, cats, fowls, turtles, and mice,
when injected into rabbits, produced sera hemolytic
for sheep corpuscles. In some cases the blood serum
of these animals was effective, but in no case would the
red corpuscles so act. Strangely enough the organs
of sheep and goats produced such hemolysis but very
incompletely. Extensive search had been made to find
substances that as antigens would produce a common
antibody, namely, sheep hemolysin. The essayist re-
viewed the work of investigators in this search, and
said a suggestion looking towards an explanation might
be found in some work of Osborne and Wells. They
worked with Osborne's pure vegetable proteins and
used anaphylaxis for their biological reaction. A re-
view of this work indicated that the specific character
of the protein, at least for the anaphylactic reaction
and probably also for other biological reactions, de-
pended not on the protein as a whole but on certain
parts or qualities or chemical groups in the protein
molecule. The reason why biologically related proteins
reacted similarly was because they had inherited cer-
tain common groups from a common ancestor, but it
should cause no surprise that entirely unrelated speciei
occasionally possessed common groups.
Dr. H. Gideon Wells of Chicago said that in all the
problems of immunology, specificity was the vital point
which could never be overlooked without disaster. In
studying the principles of immunology there had been
great difficulties because of failure to grasp the es-
sential principles as laid down by Jacques Loeb,
namely, that in studying the fundamental principles
of biological processes one must reduce the elements
involved to the simplest possible, for at the best the
reactions were complex and beyond our interpretation.
Unfortunately we could not get below the whole protein
molecule as one end of our reactions and generally
must use the warm blooded mammals for the other
side of the equation, although possible work on cell
cultures might help us to simplify our materials. The
best one could do therefore was to use pure protein,
and fortunately there were some proteins that could
be obtained in a relatively pure condition, such as
non-coagulable ovomucoid of egg-white or alcohol
soluble proteins of the grains. Using such isolated
proteins, and others, the writer said they had found
evidence that, delicate as the specificity of immuno-
logical reactions seemed to be, immunological differences
did not seem to occur between proteins that could not
also be differentiated chemically. The specificity dif-
ferences of the different proteins seemed to agree with
differences in chemical composition, and as yet they
had not found finer differences such as might be ex-
pected, such as stereoisomeric differences with identical
chemical composition. Dr. Osborne and the writer had
found in many cases that proteins which were isolated
by chemical means could be checked up very nicely as
to their individuality by anaphylaxis and other im-
munological reactions, and immunological methods had
been found to be of much help in establishing the
chemical identity of unknown proteins.
Dr. John A. Koi.mer of Philadelphia said it would
be difficult to improve on the excellent resume presented
by Pr. Jobling on the relation of lipoids to immunity.
It had been amply proven that toxic substances might
be prepared of various animals and vegetable proteins
by the method employed by Dr. Vaughan : that likewise
toxic substances could be produced in normal and im-
mune sera by the addition of such substances as kaolin
and agar capable of producing anaphylaxis-like symp-
toms and lesions in experimental animals, but that it
was not yet clear wh;it relation these observations bore
to the mechanism of anaphylaxis, and particularly so
in view of the work presented by Dr. Novy within the
past few days. Dr. Kolmer said he would like to ask
Dr. Vaughan if he was prepared to make any further
statement in regard to the relation between his protein
»ii and the mechanism of anaphylaxis. He would
like to know whether Dr. Miller had made careful
titrations of the content of antisheep hemolysin in the
sera of his rabbits before immunization, as the sera of
Oct. 7, 1916J
MEDICAL RECORD.
657
a large proportion of these animals contained natural
antisheep hemolysin. Dr. Kolmer said that in his
opinion "group reactions" in immunity were best ex-
plained at the present time according to the views ex-
pressed by Dr. Wells in his discussion.
Dr. Jobling said that, as Dr. Weil had stated, recent
work showed that the intoxicating dose in anaphylaxis
probably acted first on the cells. In guinea-pigs it
caused a contraction of the muscle cells of the bronchi
to such a degree that immediate death ensued from
asphyxia. In dogs, however, death did not occur for
several hours, and the clinical picture was quite dif-
ferent. In the latter case they had observed definite
changes in the blood, and they believed that death was
probably due to the products of protein cleavage. The
ferments, which were greatly increased in amount,
were probably liberated as a result of the cell stimula-
tion, and their activity was dependent upon colloidal
changes which had taken place when the antigen was
brought into contact with the serum. They had ob-
served a definite increase in the higher and lower pro-
tein cleavage products in the blood. These they be-
lieved were derived from the serum proteins and not
from those introduced.
Dr. V. Vaughan said he had watched Dr. Novy's
experiment with the deepest interest and had observed
the appearing and disappearing and reappearing wave
of toxicity in serums being incubated with agar and
other foreign bodies. He had spent much time trying
to measure these waves and to catch the rhythm of the
toxicity, but without results. He was not yet ready
to abandon the idea that a protein poison was formed
in anaphylactic shock. No one could tell whether this
was due to a chemical or a physical process, for it was
difficult to draw a line between the two. He said that
he could conceive that a body so complex as the protein
molecule might be dissociated and a poisonous action
developed even by high dilution. If so stable a body as
sodium chloride could be broken down into its ions by
dilution, was it not possible that even more marked
alterations might occur in a highly complex molecule.
He felt convinced of the fact that the blood contained
proteins from which a poisonous group was easily de-
tached.
Dr. Weil, in closing the discussion, said he was not
particularly interested in establishing the universal
validity of any of the current theories of anaphylaxis.
Attempts of this sort had done more in the past to
obscure the truth than to advance it. Time, however,
had completely established the truth of the cellular
theory, so that in the guinea pig, at all events, it
seemed certain that serum changes, with the produc-
tion of so-called anaphylotoxin, could play no role in
the typical evolution of shock. It would, however, be
just as serious a mistake to assume that the process
which took place in the guinea pig must necessarily
be universally applicable to the anaphylactic phe-
nomenon throughout the animal kingdom, for it was
known with certainty that serum changes of chemical
nature accompanied anaphylactic shock in the dog.
This fact, however, by no means argued that these
changes were productive of the anaphylactic symptoms.
It still remained to determine whether serum changes
in the dog resulting in the production of some uniden-
tified substance described as anaphylotoxin were simply
an accompaniment of anaphylactic shock in that ani-
mal, or were actually productive of the symptoms
thereof.
The Phenomenon of Leucocytosis and Its Importance
as a Diagnostic Sign in Vaccine Treatment. — Dr. Joseph
Head of Philadelphia said that leucocytosis had always
been regarded as a symptom of serious inflammatory
infection. And yet it had appeared among his patients
so frequently as a passing phase of a few days' dura-
tion, coming and going without any apparent signifi-
cance, that he had come to regard a temporary
leucocytosis of from 30,000 to 40,000 with considerable
complacency. He had taken 54 of his vaccine patients
as they came, and had gone over their blood charts
with the purpose of getting data on this important
subject. Of these 54 cases 33 did not in the course
of the treatment give a leucocyte count of over 120.000,
but 21 did show transitory leucocyte counts that
jumped in some instances from five, six or seven thou-
sand to forty, sixty or one hundred thousand, only in
a few days to sink back to four or eight thousand, with
no symptoms to speak of or only a slight indisposition.
If these observations meant anything at all they cer-
tainly meant that a transient high leucocyte count
could not be considered of itself an infallible sign of
pus or even a semiacute inflammation of a serious na-
ture. Persistence of the leucocytosis accompanied by a
falling off of the red cells and hemoglobin would in-
dicate a condition of an entirely different significance.
The Action and Therapeutic Effects of Leucocytic Ex-
tract (Archibald).— Dr. W. E. Richard Schotsteadt of
Fresno, Cal., presented this paper, which was read by
W. J. Stone of Toledo, Ohio. He described the work
that he had carried on with the leucocytic extract pre-
pared from the blood of normal animals. Subcutaneous
injections in normal human beings and in patients suf-
fering from acute infections produced a marked
leucocytosis. The leucocyte increase was often 300 per
cent., and was highest within ten to twelve hours after
the administration. The increase in the neutrophile
elements was particularly marked and coincident with
it was a less marked increase in the eosinophile cells.
Clinically strikingly beneficial results in man had been
obtained* following its use in acute infections such as
furunculosis, pneumonia, bronchitis, and acute tonsil-
litis. Chronic infections had shown a less striking im-
provement, though the leucocytic increase had been as
marked as in the above cases.
Dr. George H. Robinson of Glenolden, Pa., said that
from a clinical standpoint the work of Dr. Head had
very important bearings. In mouth infections there
were two features that were very important, not only
was there a very high eosinophile count, but other con-
ditions as well that were difficult to explain. He had
used a bacterial extract unactivated made from the
discharges of old sinuses, and he thought this pro-
duced what might be called fixation abscesses.
Dr. William Lintz of Brooklyn said he had made
experiments in guinea pigs and rats, inoculating them
every two hours, and it had been interesting to note
the marked polymorphonuclear count that followed as
well as the marked leucocytosis. Out of fifteen or
eighteen cases of pneumonia in which there was a de-
cided leucocytosis, with but one exception, none were
benefitted bv the use of the leucocytic extract.
Allergic Skin Reactions as an Index of Immunity. —
Dr. John A. Kolmer of Philadelphia said that these
experiments were undertaken primarily to determine
if the sera of persons and animals reacting positively
and negatively to various allergic skin tests contained
lytic antibodies for the corresponding living micro-
organisms and, if so, whether or not these antibodies
bore a quantitative relationship to the allergic reac-
tions; secondarily to determine the relationship, if any,
among bacteriolytic, agglutinating, and complement-
fixing antibodies in the sera of persons and animals
reacting variously to allergic skin tests. He remarked
that the sera of normal persons possessed a marked
bactericidal power for B. typhosus; the bacteriolysin
content for B. typhosus in the sera of normal persons
and persons who had typhoid fever or had been im-
munized with typhoid vaccine was high but bore no
relation to the typhoid in skin reactions. The sera of
svphilitic persons in the tertiary stages who reacted
positively and negatively to the luetin skin test and
the sera of normal persons showed no appreciable
spirochetal activity for a pure culture of T. pallidum.
The sera of persons reacting positively and negatively
to the intracutaneous injection of a washed polyvalent
antigen of diptheria bacilli showed an abscence of
bactericidal power for B. diptherix. The sera of dogs
suffering with distemper and also the sera of healthy
dosrs and dogs immunized with B. bronchisepticus and
reacting positively and negatively to an intracutaneous
allergic reaction were found to be without appreciable
bactericidal power for B. bronchisepticus. Agglutinins
and complement-fixing antibodies in the sera of persons
and animals for these various microorganisms bore no
relation to the skin reactions. These studies demon-
strated that there was no experimental support for
the theory that allergic skin reactions might be taken
as an index to resistance and immunity in so far as
it was possible to determine the presence of antibodies
in v'tro.
(To be continued.)
Long Lives of the Presidents. — A writer in the Lancet
calls attention to the many instances of longevity among
the presidents of the United States, the average age of
whom was 69 years, and were it not for the cutting
short of the lives of Lincoln, Garfield, and McKinley by
assassination at 56. 49, and 58 respectively this average
would be even higher. Four of the twenty-four lived
to the ages of 80, 83, 85, and 90 years.
658
MEDICAL RECORD.
[Oct. 7, 1916
STATE BOARD EXAMINATION QUESTIONS.
State Board of Medical Examiners of Maryland.
June 20, 1916.
(Concluded from page 574.)
PATHOLOGY.
1. What are infective granulomata? .Mention several
and describe one.
2. Briefly discuss teratomata.
3. Describe ingrowing toenail.
4. What are anaerobic bacteria? Classify, and men-
tion an organism belonging to each class.
5. Describe keloid tissue.
6. Define the terms secretion, excretion, transudate,
exudate.
7. What is meant by "sensitization"?
8. What are the general characteristics of sarcoma in
contrast to carcinoma?
9. Describe the beef tape worm.
10. What are the means used to prove that death has
positively occurred? What is rigor mortis?
PRACTICE OF MEDICINE.
1. What diseases are liable to occur in the right in-
guinal region?
2. Give signs and symptoms of floating kidney.
3. Give causes of malaria and varieties of organisms.
4. Name the eruptive fevers and also give period of
incubation in each.
5. What is hemophilia and how treated?
6. Differentiate the terms delusion and hallucination
and also define the terms epistaxis, hemoptysis, and
hematemesis.
7. Give symptoms of diabetus mellitus and treatment.
8. Name causes of interstitial nephritis and the more
common complications.
9. Describe empyema; give diagnosis and treatment.
10. Give differential diagnosis between gout and
arthritis deformans.
OBSTETRICS AND GYNECOLOGY.
1. Define a trefoil, horseshoe, succenturiate, and bat-
tledore placenta.
2. What is a caput succedaneum and how is it
formed?
3. Describe your method of preventing lacerations of
the perineum during delivery.
4. What is your treatment in the delivery of twins
with heads interlocked?
5. What is the danger of a prolapsed cord and how-
do you treat it?
6. What is phlegmasia alba dolens, its cause and
treatment?
7. How do you diagnose a face from a breech pre-
sentation?
8. Why is a face presentation hard to deliver?
9. Give differential diagnosis between a retroflexed
gravid uterus, and a pregnancy complicated by ovarian
tumor.
10. What is the usual cause of salpingitis? Describe
its course and treatment.
SURGERY.
1. Give cause and treatment of chronic suppuration
of the middle ear.
2. Give diagnosis, symptoms, and treatment of gon-
orrheal conjunctivitis.
3. Give signs, symptoms, diagnosis, complications,
and treatment of phlebitis.
4. Give symptoms and treatment of Pott's disease.
5. Give the differential diagnosis between fracture of
neck of humerus and dislocation of shoulder joint. Out-
line the treatment of one.
fi. What are the causes of ischiorectal abscesses?
Give symptoms and treatment.
7. Describe a rodent ulcer. Give the structures in
which rodent ulcer mostly develops, and give surgical
treatment.
8. If called to a patient with a compound fracture of
a leg in the lower third, which had been kicked by a
horse in a barnyard, state in detail how you would trea!
such a case.
9. Give varieties of ileus, and some of the causes of
each. Outline treatment.
10. Give the symptoms and physical signs of carci-
noma of the breast.
ANSWERS.
PATHOLOGY.
1. Infective granulomata are inflammatory new
growths due to protozoa, bacteria or parasites. They
are found in tuberculosis, lupus, syphilis, leprosy, glan-
ders, and actinomycosis.
The tubercle is a mass of new formed connective
tissue cells, consisting of three layers: (1) lymphoid
cells externally, (2) epitheliod cells, in the middle, and
(3) giant cells in the center; the tubercle bacilli may
be found in (2) and (3).
2. Teratomata are "tumors which have a tendency to
the formation not only of irregular cell masses but also
of fully formed organs, such as brain, teeth, skin, hair,
bone, or secreting glands. Such growths may be due
to the development of two germinal areas on one ger-
minal vesicle, giving rise to double monsters, one of
which undergoes inclusion in the other — fetal inclu-
sion. They may result from the displacement of to-
tipotential cells — those capable of giving origin to an
individual — which become included in the growing or-
ganism. These cells may develop early, and grow elabo-
rately, giving rise to inclusions recognizable at birth.
They may lie latent and at a subsequent time grow
actively as abdominal inclusions, teratomata of the
genital glands, and certain mixed tumors. Dermoid
cysts, ovarian dermoids are the most common of the
teratomata. The cyst cavity is lined by squamous
epithelium, in which are found sweat and sebaceous
glands. Within the cavity is usually a varying amount
of fatty material in which are masses of hair. In the
wall of the cyst are found masses of bone to which
teeth, usually but poorly formed, are attached. In some
instances the extremities and genitalia have been seen.
Somewhat similar growths may be found in those parts
of the body where fetal clefts have united and in the
median fissures of the body. There is another type,
the sporadic teratomata, which grow in regions bearing
no relationship to the fissures, to the poles of the body,
or to the generative glands, as in the anterior mediasti-
num and the abdomen. These are probably due to the
development of a misplaced totipotential cell. They
generally consist of tissue from all three germinal lay-
ers. Sometimes the tissues are of adult appearance
and of limited growth. More frequently they appear
about puberty, grow rapidly, and tend to form second-
ary tumors." — (McConnell's Manual of Pathobi I
3. Ingrowing toenail. "This is more accurately de-
scribed as an overgrowth of the soft tissues along the
edge of the nail. It is most frequently met with in
the great toe in young adults whose feet perspire freely,
who wear ill-fitting shoes, and who cut their toenails
carelessly or tear them with their fingers. Where the
soft tissues are pressed against the edge of the nail,
the skin gives way, and there is the formation of ex-
uberant granulations and of discharge which is some-
times fetid. The affection is a painful one, and may
unfit the patient for work." — (Thomson and Miles'
Manual of Surgery.)
4. Anaerobic bacteria are such as either cannot exist
in the presence of oxygen or such as find the presence
of oxygen injurious to their growth. There are two
classes: 1. Obligatory anaerobes, which do not grow
except in the almost complete absence of free oxygen;
example, the bacillus of tetanus. 2. Facultative anae-
robes are those which can thrive in either the presence
or the absence of oxygen; example, the bacillus of
typhoid.
5. Keloid tissue is a tissue of fibrous formation which
occurs in scar tissue. It is characterized by somewhat
luxuriant growth, and is not confined to the site of
the original injury and scar formation. It is gener-
ally smooth, and is most often found in negroes.
6. Secretion is the process by which certain organs
(glands and membranes) separate from the blood cer-
tain constituents which are further elaborated and serve
some further office in the economy.
Exert Hon is a similar process by which there are re-
moved from the blood waste materials, and products of
no further use to the body, and which if retained would
be injurious.
Transudate is a fluid which is found in the interstices
of the tissues and which has passed through the walls
of the blood vessels. It contains very few cellular ele-
ments. A transudate which is the result of inflam-
mation is called an exudate.
7. Sensitization is the rendering of a cell liable to
destruction by a complement, through the action of a
specific amboceptor.
Oct. 7, 19161
MEDICAL RECORD.
659
8.
SARCOMA.
Origin; entirely mesoblas-
tic (Connective - tissue
type).
Stroma; intercellular.
Rarely forms alveoli.
Cells; granulation tissue
or embryonic connect-
ive-tissue cells; shape
and size vary.
Intercellular substance ;
may be present.
Vessels; embryonic in
character. They are in
direct contact with, or
may be formed by, the
special cells, slightly
modified, of which the
tumor is composed.
CARCINOMA.
Epiblastic and hypoblastic
(Epithelial-tissue type).
Vascular connective tissue,
which surrounds and
forms the walls of the
alveoli; these communi-
cate with one another,
and contain masses of
epithelial cells.
Epithelial cells contained
within alveoli; shape
and size vary.
Absent, or merely fluid.
Well developed; entirely
contained within the
connective tissue stroma,
and supported by the
walls of the aveoli. Sel-
dom in contact with the
cells.
— (Coplin's Pathology.)
9. The beef tape-worm or Taenia sagiyiata or Tseyiia
mediocanellata is from 10 to 30 feet in length, and
has several hundred proglottides. It has a rounded or
oval-shaped head which measures about 1/10 of an inch,
and has four strong and prominent suckers, but no
hooklets — whence the term "unarmed tapeworm"; the
neck is short and thick and the segments are larger,
stronger, and thicker than those of the Taenia solium.
The best way to distinguish a segment of Taenia sagi-
nata from that of Tsenia solium is to count the number
of lateral uterine branches.
In the Taenia saginata, there are 15 to 30 of them;
in the Taenia solium there are 5 to 10. — -(Hughes' Prac-
tice of Medicine.)
10. Phenomena and signs of death, are: The complete
and permanent cessation of circulation and respiration,
rigor mortis, loss of body heat, pallor of the body, putre-
faction.
For methods of applying the tests, see a good text-
book on medical jurisprudence.
Rigor mortis is the condlition of rigidity or contrac-
tion into which the muscles of the body pass after
death. It begins at a period varying from about 15
minutes to about 6 hours. It usually begins in the
muscles of the eye, neck, and jaw; then the muscles of
the chest and upper extremity, and last of all those
of the abdomen and lower extremity are affected. It
passes off in the same order in about 24 hours. It is
said to be due to the coagulation of the muscle plasma.
PRACTICE OF MEDICINE.
1. Diseases liable to occur in the right inguinal re-
gion: Appendicitis, inguinal hernia, psoas abscess, in-
tussusception fibroid tumor, fecal impaction, cancer of
cecum or ascending colon, floating kidney, cyst or
abscess or broad ligament or ovary, retroperitoneal
sarcoma.
2. Signs and symptoms of floating kidney : There
may be a dragging pain in the loin, which is made worse
by exertion ; there may be paroxysmal crises of pain
accompanied by rigor, vomiting and collapse (Dietl's
crises) ; neurasthenia, and dyspepsia may be present;
the kidney may be palpated in the abdominal cavity and
may be replaced. There may be no symptoms at all.
3. The cause of malaria is the Plasmodium malariae,
which is inoculated in man by the anopheles 'nosquito.
There are three varieties of parasite: 1. Tr.e quartan
parasite (Plasmodium ynalariae) ; 2. the tertian parasite
(Plasmodium vivax) ; and the astivo-autumnal parasite
(Plasmodium falciparum) .
4. Eruptive fevers, with period of incubation (ap-
proximate) : Typhoid, five to twenty-one- days;
typhus, three or four to fourteen days; measles, one to
two weeks; German measles, five to twenty days; scar-
latina, three to seven days; smallpox, ten to fourteen
days; ehickenpox, fourteen or fifteen days; erysipelas,
three to seven days.
5. Hemophilia is a condition characterized by a ten-
dency to severe hemorrhage, sometimes almost uncon-
trollable, and following any slight injury or abrasion.
Heredity is a common factor, and males are most com-
monly affected, but the disease is transmitted through
females. Treatment consists in protection from injury
or operation; adrenalin, calcium lactate, ergot, ferric
chloride, potassium chlorate, ice, tannic acid, fibrin fer-
ment, and other remedies have been suggested; trans-
fusion of blood may be necessary.
6. A delusion is a belief in something which has no
real existence, but is purely imaginary, and out of
which the person cannot be reasoned. An illusion is a
false or perverted impression, received through one of
the senses. An hallucination is the same as an illusion,
but without any material basis.
If an individual believes himself to be made of glass,
and is afraid of being touched lest he be broken, he is
suffering from a delusion. If the whistling of the wind
is mistaken for a voice telling a person to do a certain
thing, that would be an illusion. If a person fancied he
heard a voice when there was nothing at all to be
heard, that would be an hallucination.
Epistaxis is bleeding from the nose.
Hemoptysis is the spitting of blood.
Hematemesis is the vomiting of blood.
7. The symptoms of diabetes mellitus are: Weakness,
excessive thirst, frequent urination, and increase in the
amount of urine voided, the presence of glucose in the
urine. Hyperglycemia is a feature of the disease;
pruritus, emaciation, a dry and harsh skin, lost or dimin-
ished knee-jerks, coma, and air hunger are often pres-
ent. The urine also contains acetone, oxybutyric acid,
and diacetic acid, sometimes albumin and casts, and an
increased output of nitrogen.
The treatment is mainly dietetic. "The indications
are to maintain nutrition, to increase the tolerance for
carbohydrates, to lessen hyperglycemia, and to prevent
or diminish acidosis. In mild cases (except in child-
hood and adolescence) the diet may contain the full
amount of carbohydrate that can be tolerated without
causing glycosuria, but a week of strict (carbohydrate-
free) diet should be interposed every four or five weeks.
In severe cases with acidosis, the diet should have a low
nitrogen content and contain the carbohydrate best tol-
erated (oatmeal, potato, fruit) in such quantity that the
glycosuria is kept at a minimum and the body weight
is not reduced. Frequent periods of strict diet must be
introduced, however, to lessen the hyperglycemia, and
during these periods from % to 1 ounce of sodium bicar-
bonate should be given daily to control the acidosis. In
cases requiring rigorous treatment alcohol in moderate
amounts, in the form of whiskey, brandy, or white wine,
is useful in supplying additional energy and aiding in
the digestion of fats. General hygienic measures are
of great importance, especially the prevention of mental
and physical overexertion, worry, and excitement. A
moderate amount of regulated exercise is beneficial in
mild cases, but considerable rest is absolutely necessary
in severe forms of the disease. Drugs. — Tonics, like
arsenic, iron and strychnine are often useful. Opium
proves efficacious in some cases. It is best given in the
form of codeine (% grain three or four times a day).
Salicylates have been strongly recommended. Bromides
are serviceable in subduing nervous manifestations.
Alkaline carbonates and alkaline mineral waters have
long enjoyed a reputation. Upon the recognition of the
early signs of coma, a moderate amount of readily
digestible carbohydrate should be added to the diet.
Absolute rest should be enforced, saline laxatives and
diuretics (theobromine caffeine), should be adminis-
tered, and large doses (1 to 2 ounces) of sodium bi-
carbonate should be given daily. Developed coma is
rarely relieved by intravenous injections of 4 per cent,
solution of sodium carbonate (a liter, if possible, and
repeated if necessary at end of six hours)." — (Stevens'
Practice of Medicine.)
S. The causes of chronic interstitial nephritis are
practically the same as for arteriosclerosis. The dis-
ease may be traced to chronic alcoholism, gout, chronic
lead poisoning, syphilis, and diabetes. Age is, of
course, a factor; so too, are overwork, high living, and
worry. Complications: — Bronchitis, pleurisy, pneu-
monia, pericarditis, endocarditis, and other inflamma-
tory conditions, edema, and various hemorrhages.
i). Empyema is generally secondary to pneumonia,
tuberculosis, scarlet fever, or other exanthem, suppura-
tive inflammations, or traumatism. The pneumococcus,
streptococcus, and staphylococcus are the bacteria most
frequently found. The condition is diagnosed by find-
ing the symptoms of fluid in the pleural cavity; this is
withdrawn by a needle and on examination is found to
be pus ; a leucocytosis is also present.
The physical signs are those of fluid in the pleural
cavity; that side does not move well, the percussion note
660
MEDICAL RECORD.
[Oct. 7, 1916
is dull, there is absence of breath sounds, vocal fremitus
and resonance are diminished. Let alone, an empyema
may burst through an intercostal space, usually the
fifth. The lung is collapsed in extent according to the
amount of pus. The pleura, at first covered with
lymph, soon becomes covered with layers of granulation
tissue, the deeper part of which is converted into fibro-
cicatricial tissue, and the lung itself also undergoes
some fibroid change. If the pus is let out early the
lung and pleura soon expand, but if allowed to go on
the infiltration of the lung and the density of the scar
tissue covering it hinder expansion. Nature attempts
to remedy this in various ways. (1) The other lung ex-
pands and pushes the heart over to the opposite side;
(2) the chest wall falls in, the intercostal spaces are
obliterated, and the spine is curved, with its concavity
toward that side; (3) the abdominal viscera are pushed
up; and (4) exuberant granulations form on the pleura.
If a cavity still remains an operation is necessary.
Symptoms: Fever, sweats, chill, diminished breath
sounds and vocal fremitus, impaired mobility of chest,
dullness on affected side, heart displaced to opposite
side, leucocytosis.
Treatment: Aspiration, drainage, irrigation, resec-
tion of ribs (Estlander's operation), or resection of
chest wall (Sehede's operation). Operation of some
sort is the only treatment.
10.
GOUT.
Frequently hereditary.
Causes are chiefly dietetic.
Affects males and the bet-
ter classes most fre-
quently.
Begins in the big toe and
extends to other toes; it
is unilateral.
Attacks are periodic.
Deformity due to tophace-
ous deposits.
Uric acid in excess in the
blood.
Complications (nephritis,
arteriosclerosis) .
RHEUMATOID ARTHRITIS.
Not so.
Causes chiefly nervous.
Affects females and lower
classes most frequently.
Begins in the fingers
which point to the ulnar
side; develops in sym-
metric order.
More steadily progressive.
Deformity due to exosto-
sis and ankylosis, and
more marked.
Not so.
Very rare.
— (Anders' Practice of Medicine.)
OBSTETRICS AND GYNECOLOGY.
1. A trefoil placenta is a malformation of the pla-
centa in which there are three distinct portions of that
organ, more or less intimately united.
A horseshoe placenta is a placenta which has a cres-
centic form, seen in cases of placenta prsevia when the
placenta is found around the internal os; it is also
found in some cases of twin pregnancy where the two
placenta? are joined by a strip of placental tissue.
A succenturiate placenta is one which, in addition to
the usual placenta, has one or more subsidiary lobes.
Battledore placenta is one in which the cord is im-
planted in the margin instead of in the center.
2. Caput succedaneum is an edematous swelling de-
veloped on the presenting part in the course of birth.
It is formed by the serosanguineous infiltration of the
connective tissue of the presenting part and is due to
edema in the part which is not compressed by the
maternal structures.
3. To protect the perineum : The patient should be re-
strained from bearing down unduly; extension of the
head must be retarded, and the central part of the oc-
ciput must be allowed to be born first; pressure must be
made with the hand between the coccyx and the anus;
when the perineum has had time to stretch, extension
and expulsion are allowed; after the birth of the head
care must be taken to see that the perineum is not torn
by the birth of the shoulders.
•1. Management of twin labor complicated by inter-
locking. "If there is marked delay in the delivery of
the first twin, some form of interlocking should be sus-
pected and under anesthesia the hand should be passed
into the uterus and the exact conditions determined. If
both twins present by the vertex and the second has
become impacted in the neck of the first child, an at-
tempt should be made to push up the second head and
deliver the first child with the forceps. Occasionally,
the best procedure is to deliver the second head past
the first, always remembering that craniotomy on one
child in the hope of saving the other may be good
obstetrics. If the first child presents by the breech and
its body is born while its chin is locked with the chin
of its fellow, an attempt should be made to unlock the
heads, but if this attempt fails it is usually wise to
decapitate the first child, pushing up its head, and then
to deliver the second child, finally delivering the head of
the first. The reason for the wisdom of this course lies
in the fact that with failure of the attempt to dislodge
the second child's head, the life of the first child usually
ceases during the endeavor to extract the second past
it, and the second child's life is much more likely to be
saved if the canal is cleared of the first child. If the
first child lies transversely, and the second child sits
astride with feet in the vagina the best procedure is
usually to perform version and extraction upon the first
child, although each of these cases presents a problem
of its own and must be dealt with individually, some
cases justifying cesarean section and some crani-
otomy."— (Cragin's Practice of Obstetrics.)
5. Prolapsed cord. Danger: Compression causes
death of the fetus. Treatment of prolapsed funis con-
sists in : (1) Not rupturing the membranes prema-
turely unless there is some positive indication; (2)
postural treatment, in which the woman is placed on
her back or on the opposite side to that on which the
cord lies, with hips and pelvis elevated, or the knee-
chest position may be adopted; (3) reposition of the
cord, either manually or with some form of repositor;
(4) speedy delivery, by forceps or podalic version.
6. Phlegmasia alba dolens is a form of manifesta-
tion of puerperal sepsis in which there is a thrombosis
of the iliac or femoral vein. Sometimes it occurs after
a uterine phlebitis, in which clots are carried from the
uterine sinuses to the hypogastric veins, where they
cause obstruction to the blood flow in the crural veins.
The trouble may also begin as a crural phlebitis. It is
thus due either to cellulitis or to thrombosis. It usually
appears about the third or fourth week of the puer-
perium. Symptoms : Irregular chilliness and malaise,
pain in leg and abdomen, rigor and swelling of leg,
fever, skin is white and tense, and the vein feels hard.
Treatment: Rest in bed, support patient's strength, re-
lieve pain, and apply lead and opium wash to take down
the inflammation.
7.
breech.
face.
Abdominal palpation will
reveal the movable head
above, upon which ceph-
alic ballottement may be
practised.
The anus may be distin-
guished by the absence
of bony ridges, by its
small size, and by the
sphincteric action.
There is a discharge of
meconium.
The sharp spinous proc-
esses of the sacrum may
be felt.
There are no other promi-
nent bony structures to
be distinguished.
Abdominal palpation will
show the breech and ex-
tremities above.
The mouth may be recog-
nized by its large size,
by the presence of the
hard bony a 1 v e o la r
ridges, and by the ab-
scence of sphincteric ac-
tion.
No meconium is dis-
charged.
There are no correspond-
ing processes to be de-
tected.
There is to be noted the
presence of the hard or-
bital borders and the
smooth, broad forehead.
— (Dorland's Obstetrics.)
8. A face presentation is hard to deliver, because,
unless the head is fully extended large diameters engage
(e.g. vertico-mental diameter, of about 4% inches) ;
further, the face bones do not mould, the membranes
rupture earlv, and the face is a bad dilator.
9.
PREGNANCY WITH OVARIAN
TUMOR.
Absent or very late.
Absent or inconsiderable.
Usually asymmetric, hard,
and tense all over or in
places.
Often can feel pregnant
uterus above inlet and
to one side.
retroflexed gravid
UTERUS.
Symptoms of incarcera-
tion early.
Bladder symptoms pro-
nounced.
Tumor symmetric and soft
all over.
No other tumor above the
pelvis.
Oct. 7, 1916]
MEDICAL RECORD.
661
RETOKLEXED GRAVID
UTERUS
Moving the cervix im-
parts impulse to the
tumor.
The fornices are flattened,
at least not drawn up.
PREGNANCY WITH OVARIAN
TUMOR
The upper tumor (uterus)
can be moved independ-
ently of tumor.
The fornices are drawn
up high, sometimes even
above the pubis.
Never.
The tumor in the cul-de-
sac may contract.
May distinguish the fetal j Never.
parts. |
— (De Lee's Obstetrics.)
10. Salpingitis. The usual cause is septic infection,
or gonorrhea. Diagnosis : A dragging sensation in the
neighborhood of the affected tube; colicky pain, which
is increased on exertion or even on standing; abdominal
tenderness; menstrual disorders, as amenorrhea, metror-
rhagia, dysmenorrhea, menorrhagia; dyspareunia ; there
may be septic symptoms and peritonitis; sterility gen-
erally ensues. On examination there will be found a
fullness in Douglas' pouch and one or both lateral
fornices; in these latter will be felt either the tubes,
distorted and possibly adherent, or a sausage-shaped
tumor, which is very painful; the uterus is retroverted
or retroflexed, and may be bound down by adhesions;
there may be an intermittent expulsion of pus accom-
panied and preceded by a burning pelvic pain.
Treatment: Rest in bed, hot vaginal douches, saline
purgatives, liquid diet, morphine (if necessary) for
pain, removal of pathological conditions and complica-
tions; radical operation (salpingectomy, or salpingo-
oophorectomy) may be necessary.
SURGERY.
1. Chronic suppuration of the middle ear is due to
the permanent lodgment of staphylococci in the acutely
inflamed middle ear. This is usually brought about by
improper (i.e., excessive) treatment of acute otitis
media. Treatment: "Cotton must never be worn in the
discharging ear. The discharge must be mopped out,
but if very thick and copious, syringing by means of
sterile water or sterile water containing salt (gr. 5-3 1)
or carbolic acid (1:40), once or twice in 24 hours in
bad cases is permissible. After mopping the ear, 10
drops of an antiseptic solution may be instilled. For-
malin solution (1:1000-1:2000), carbolic acid solution
(1:40), or, if granulations are present, absolute alcohol,
may be dropped in and allowed to remain for a few
minutes, and then turned out into a towel. This treat-
ment should be continued once or twice a day in very
bad cases, and less often when the discharge decreases.
If, after several months, improvement does not take
place removal of the ossicles under general anesthesia
may be necessary." — (Pocket Cyclopedia).
2. Gonorrheal Conjunctivitis. Symptoms: Swell-
ing and redness of the eyes, the presence of a discharge
which soon becomes purulent, the conjunctiva of the lids
becomes thickened, the eyelids are edematous, pain is
severe, and there is some fever.
Diagnosis is made by the history, the symptoms, and
finding the gonococcus in the purulent discharge.
Management : Protect the sound eye. Wash the eye
carefully every half hour with a saturated solution of
boric acid ; pus must not be allowed to accumulate.
Two drops of a 2 per cent, solution of nitrate of silver
must also be dropped onto the cornea every night and
morning. The eyes must be covered with a light, cold
wet compress. The patient must be isolated, and all
cloths and compresses used must be burned. In adults
the irrigation must be frequent, about every half hour
or hour.
3. Phlebitis. Symptoms : A hard, painful, cord-like
swelling forms over the vein. Skin over this is dusky,
congested, and edematous. If the vein is superficial
there are no other signs. If it is the main deep vein of
the limb, massive solid edema occurs, with considerable
lymphatic engorgement (white leg). Superficial veins
enlarge in order to carry on the collateral circulation.
Fever, with rigors, occurs, and is proportioned to the
infectivity of the process. Abscesses develop round an
infective phlebitis. Complications: Cardiac or pul-
monary embolism follow the dislodgement of a throm-
bus. Pyemia results from the disintegration of a sep-
tic thrombus. Permanent edema with varicose veins is
left in the leg when the deep femoral is blocked. Treat-
ment: Rest and elevation in bed for six weeks. Bella-
donna applications for pain. Excision of the veins in
recurrent superficial phlebitis. Incision, removal of clot
with proximal ligature in infective phlebitis, e.g., in the
juglar vein following acute mastoiditis. — (Synopsis of
Surgery.)
4. Pott's disease is tuberculosis of the spine. The
symptoms are pain, tenderness on pressure, rigidity of
the back, and a sense of weakness, which may usually be
recognized by the child's actions. When suppuration
occurs, the pus may enter the sheath of the psoas, de-
stroying the muscle, and presenting in the iliac fossa or
groin as an iliac or psoas abscess; or it may pass back-
ward through or external to the quadratus lumborum,
and point in the loin, when it is known as lumbar ab-
scess. In the cervical region retropharyngeal abscess
may occur. Spinal paralysis may come on at any time
and myelitis develops in the latter stages. Treatment:
"Rest in bed, using sand bags as splints, is the first con-
sideration. After the acute symptoms have subsided a
Thomas splint, Sayre's plaster cast, or Cocking's felt
jacket may be applied to the back and the patient grad-
ually allowed to move about. To apply the plaster-of-
Paris cast, the patient should be suspended so that the
heels are just off the ground. A skin-fitting vest is then
applied to the trunk, under which a stomach-pad is in-
serted, which should be removed after the plaster has
become dry. Plaster bandages should now be applied
in the usual manner, extending from the level of the
axilla to just below the crest of the ilium. When the
case is dry, it may be divided down the front and per-
forated, so that it can be laced up or removed at any
time. Abscesses should be opened early and freely, and
injections of iodoform emulsion will be found very bene-
ficial. Laminectomy is sometimes advisable." — (Pocket
Cyclopedia.)
5. In fracture of the surgical neck of the humerus,
the head of the humerus will be found in the glenoid
cavity, but it will not rotate with the shaft; the arm
will appear shorter; and crepitus and abnormal mobility
will be elicited unless there is impaction.
In dislocation of the shoulder joint, the glenoid cavity
will be empty, and the head of the bone will be found
in an abnormal position; the arm will appear longer;
there will be no crepitus, and no abnormal mobility.
Recent dislocation of the shoulder. Kocher's method
of reduction is: to flex the forearm, press the elbow to
the side, rotate the arm outward. Bring the arm for-
ward and upward to a right angle with the body, then
rotate inward, while the elbow is brought down over the
body so that the fingers sweep the opposite shoulder.
6. Ischiorectal abscess. Causes: Infection of the
ischiorectal tissues with pyogenic microorganisms; skin
infection; infection from rectum; trauma. Symptoms:
Severe and throbbing pain in perineum and round anus,
great tenderness, edema, redness of skin, fever, and
signs of pus formation. Treatment: Free incision,
opening up every part of the abscess; do not wait for
fluctuation. Irrigate and drain.
7. "Rodent ulcer is a carcinoma beginning in sebace-
ous glands. It generally occurs in patients over forty,
and is of very slow growth. It begins as a smooth,
rounded knob in the skin about the nose, eyelids, orbital
angles, or cheeks, slowly increasing in size. In time
ulceration occurs. The ulcer has a smooth, depressed
base covered with ill-formed granulations, and bounded
by a slightly raised, indurated, rolled-over edge. There
is little discharge if sepsis is prevented, and little or no
pain. The Impyhatic vessels and glands are not
affected, and dissemination does not occur. The ulcer
spreads and destroys surrounding structures; even bone
is not spared, so that the brain may ultimately be ex-
posed. Microscopically the growth resembles epithe-
lioma, but the cells are never of the 'prickle-cell' type,
and no 'cell nests' are found. The cell columns spread
more laterally than deeply, and there is less small-celled
infiltration around. Treatment: Free incision, allow-
ing a margin of % inch all around. If the situation or
extent do not allow of this, Rontgen rays should be used
for ten minutes daily till healing occurs." — (Aids to
Surgery.)
8. "In the treatment of compound fractures the main
object is to render the wound aseptic and to give efficient
exit to the discharges. For this purpose the patient
should in all cases be anesthetized, the limb shaved, and
thoroughly purified, and the wound enlarged and thor-
oughly washed out with some reliable antiseptic. It
may be advisable to excise torn and dirty fragments of
skin, muscle, and tendon, especially when dirt has been
ground into them. Loose fragments of bone are re-
moved and portions denuded of their periosteum may be
taken away lest necrosis should ensue; where fragments
retain any considerable connection with the soft parts
662
MEDICAL RECORD.
["Oct. 7, 1916
they may be left without fear. When a sharp end of
one of the fragments is protruding through a small
opening in the skin it is first purified thoroughly before
attempting its reduction and then replaced, after en-
larging the wound in the skin, or a portion sawn off.
Hemorrhage is dealt with in the usual way, and the
fragments are placed as nearly as possible in their
normal position. If the fragments can be brought ac-
curately into position it is well to fix them by some me-
chanical appliance; but where the ends of the bone are
much comminuted the small portions must be arranged
in position as well as possible, and no attempt made to
wire them. A good-sized drainage tube is inserted,
and, if need be, counter-openings are made; the external
wound is closed or not, according to circumstances, and
dressed and suitable splints are then applied. Under
such a regime the majority of cases do well. Immov-
able apparatus may be used after a time, windows being
left in the plaster casing to allow wounds to be dressed."
— (Rose and Carless's Manual of Surgery.)
9. Ileus. Varieties, with causes: 1. Acute, caused
by strangulation by bands and through apertures, kink-
ing, volvulus, foreign bodies, and intussusception. 2.
Chronic, caused by stricture, fecal accumulation, and
tumors (either within or outside the bowel). Treat-
ment of the acute variety: "The only thing that can
give the patient the chance he ought to have is immedi-
ate operation. It is advisable to wash out the stomach
before the operation, so that intestinal contents may not
be vomited and inhaled during operation.
"Three objects are aimed at: (1) To empty the dis-
tended bowel above the obstruction; (2) to relieve the
obstruction; (3) to treat the strangulated intestine. In
cases that are almost moribund, the abdomen should be
opened with cocaine or eucaine anesthesia; a distended
coil is pulled out and tapped, a Paul's tube being sub-
sequently tied in. The peritoneal cavity is protected
with gauze packing during these manipulations. The
bowel is stitched to the abdominal wound after the feces
and flatus have drained away. No attempt at relief if
the obstruction can be made in these cases till a later
date, and, of course, a high death-rate must be expected.
"In less severe cases the abdomen should be opened in
the mid-line below the umbilicus, and a systematic
search made for the cause of the obstruction. The
hernial orifices are first examined, then the cecum. If
the cecum is distended, the obstruction lies below it; if
collapsed, above it. In the former case the sigmoid
should next be examined. If collapsed, the colon must
then be traced backwards till the obstruction is found.
If the cecum is collapsed, the intestine must be pulled
out a foot at a time and examined, beginning with the
ileum, and replacing it as each part is done with. If
the intestine is much distended, several coils may be
tapped and emptied, to facilitate the search.
"Bands and adhesions should be divided between liga-
tures. A volvulus should be untwisted if possible. If
it tends to rewind, the mesosigmoid must be stitched to
the abdominal wall. If it cannot be untwisted owing to
adhesions, or if the mass is gangrenous, it must be
resected if the patient can stand so severe an operation.
If not, an artificial anus must be made both in the
drawn-out loop and in the colon above it.
"Foreign bodies should be pushed back to a healthy
part of the intestine, and removed through an incision
at the antimesenteric border, which is afterwards
stitched up." — (Aids to Surgei i i
10. Carcinoma of the breast: "Scirrhous carcinoma
is usually met with in women between the ages of
thirty-five and fifty, and it often begins while the
patient is still menstruating regularly. It sometimes
occurs in patients below thirty. The most common site
is the upper and outer quadrant of the breast, but it
may occur in any part of the gland. Sometimes there
is more than one nodule in the breast. In its early
stages the condition is quite painless, and the existence
of the tumor is usually discovered accidentally. In some
cases indrawing of the nipple or dimpling of the skin
oyer the breast first attracts attention. It is often no-
ticed that there is a difference in the level of the two
nipples, that of the affected breast being at a higher
level than the other (Watson Cheyne). As the disease
progresses the patient experiences a dull, aching pain.
with occasional sharp twinges shooting through toward
the shoulder, up into the neck, or down the inner side
of the arm. Oil palpation, a more or less circumscribed
and fairly well-defined tumor of stony hardness may be
felt in the substance of the breast. Not being encapsu-
lated, it cannot be moved apart from the brei When
firmly pressed against the chest wall with the flat of the
hand the tumor becomes more evident, and its stony
hardness is fully appreciated. The skin over the
growth may for a long time remain free, but, as the dis-
ease progresses, it becomes tacked down, and is later
dimpled by contraction of the suspensory ligaments of
Cooper. When the skin becomes invaded by the tumor
it assumes a characteristically coarse and indurated ap-
pearance, aptly compared to that of the skin of an
orange or to pig's skin. When the tumor is near the
center of the breast, it causes retraction of the nipple
by dragging on the large ducts. It cannot be too
strongly emphasized that the presence of all or any of
these symptoms is not necessary for the diagnosis of
cancer, and that when there is any doubt the patient
should be given the benefit of an exploratory operation."
— (Thomson and Miles' Manual of Surgery.)
aljrrapnrtir i^inls.
Treatment of Eclampsia.— Knipe and Donnelly
show excellent results and a lower mortality rate
by 'the use of the following treatment than by any
radical operative measures: Lavage of the stomach;
2 oz. of castor oil given through the stomach tube;
20 to 30 minutes' sweat in the sweat cabinet; hypo-
dermic of morphia, ] ■> gr. is given if convulsions
are violent or frequent; hypodermoclysis after the
first sweat followed by proctoclysis midway be-
tween subsequent sweats; venesection if systolic
blood pressure is over 180 and more particularly if
the diastolic pressure is high; an initial dose of
veratrum viride (10 minims) followed by nitro-
glycerine 1 100 gr. at four-hour intervals. Punc-
ture of membranes if pregnant or in labor and ab-
stention from any operative interference to hasten
delivery, which was found to spontaneously termi-
nate in from eight to ten hours from the institution
of treatment. — American Journal of Ubstcti
Easily Procured Hot Compresses. — Elizabeth
Robertson suggests to wet the compress with tepid
water, then iron it rapidly with a very hot llatiron.
Sufficient steam is produced to hold more heat and
the hands are protected from wringing out exces-
sively hot cloths. — American Journal of Nursing.
Injection Treatment of Hemorrhoids. — A 20 per
cent, solution of carbolic acid in equal parts of
glycerin and water injected by means of a steril-
ized needle into the hemorrhoids produces excellent
results and removes the necessity for confinement
in bed, or an anesthetic, and the risk of stricture
or incontinence.
Treatment for Rhus Toxicodendron Poisoning,
K Resorcin, grs., xl
Pulverized starch, .~>iv
Zinc oxide, iiiv
Lanolin, ."iij
Vaseline, ."vj
M. Sig. : Apply on sterilized gauze to affected area.
— Medical Summary.
Exercise on All Fours for the Prevention of
Subinvolution and Retroversion. — Beck offers this
means as a prevention of these conditions after
childbirth, but only to be used when the patient can
have the opportunitly to rest for nine days after
the delivery. On the ninth day after labor the
patient is required to walk live or six yards on her
hands and feet with the knees held as rigidly as
possible; on the next day the distance is doubled
and the exercise is to be carried out both morning
and afternoon. The walk is increased gradually
each day until discharge from the hospital, and the
patient is advised to continue the maximum walk at
home for two more weeks. Any abnormal condition,
such as a bloody vaginal discharge, contraindicates
this exercise. — American Journal of Obstetrics.
Medical Record
A Weekly Journal of Medicine and Surgery
Vol. 90, No. 16.
Whole No. 2397.
New York, October 14, 1916.
$5.00 Per Annum.
Single Copies, J 5c.
(Original Arttrkfi.
A TUBERCULOSIS SURVEY OF AN ALASKA
ESKIMO VILLAGE.
USING CHILDREN UNDER THE AGE OF 15 YEARS AS AN
INDEX.
BY H. CLAY MICHIE, B.S., M.D.,
CAPTAIN MEDICAL CORPS, U. S. ARMT.
There is no disease that has received more atten-
tion than tuberculosis, and there is no disease that
demands more investigation on account of its high
morbidity and mortality rates. It has been said
that one-seventh of the total deaths of the world are
due to this disease. One-seventh is too low an esti-
mate in this portion of Alaska.
No one knows when or how tuberculosis was in-
troduced into Alaska, but it is most probable that it
was brought from Asia with the aboriginal tribes.
It is possible to obtain a history of pain in the chest,
emaciation, spitting blood, and "a long time sick" in
a tribe as far back as memory goes ; but as there are
no records, except the totem poles, history dates no
farther back than the memory of man. These totem
poles are records of family deeds and achievements,
as killing a certain kind of an animal, etc., and are
not health records.
The specific cause of tuberculosis, of course, is
known to all professional men, but we know of no
specific treatment. When these conditions exist we
lay great stress on the predisposing causes to dis-
ease and must rely on Nature for the therapy. In
both of these respects the Eskimo is unfortunate.
He is predisposed to tuberculosis from every aspect,
his ancestors have had it and most of his children
are now suffering with it. The natives live together
in small houses made of mud, logs, grass, or any-
thing they can get, averaging about 350 cubic feet
of air space per person. Some of these houses are
partly underground as illustrated in Fig. 1, from a
drawing of an Eskimo "igloo" of the Yukon Delta.
If they live near any trading station they will have
a glass window; if not, they will have a small open-
ing over which is stretched a translucent curtain
made by sewing together several strips of seal gut
after it has been scraped and dried.
Fuel is scarce; in fact, there is not a tree within
50 miles of here, and the Indian must rely upon
gathering driftwood from the seashore. As it is so
hard to obtain fuel, and he never provides his win-
ter supply of fuel during summer, he exerts every
effort to keep within his walls all the heat gener-
ated by the small amount of wood consumed. With
this in view you will find that every possible open-
ing has been closed and will be kept closed, and
that his house is a very small one indeed. The
house is usually composed of one room and a storm
entrance. Within these the Indian stores every-
thing he has except his means of transportation —
kyak, dogs, and sleigh. He dresses principally in
furs. These have been poorly tanned and are foul
smelling (old urine has been used in the tanning).
He sleeps in furs, sometimes upon improvised
benches and at other times sitting upright upon the
floor with his back against the wall, where he nods
all night without undressing. There is no form of
artificial ventilation, and there is no natural venti-
lation if he can prevent it; in fact, some of the In-
dians will even draw something over the window for
fear that "spirits" will see them while they are
asleep.
The white man of the United States knows very
little about Eskimo food, and may not be in a posi-
tion to believe a general description of it when he
reads it. In fact, to get the proper conception of
the Eskimo food, one must see it and smell it. The
native lives almost entirely on food obtained from
the water, and the villages are located on or near
the sea or a stream. In spring and summer they
catch fish by seining and with traps. These fish are
split from head to tail and hung up to dry, and in
some cases are smoked for preservation purposes.
They also catch seal (the hair seal), extract the oil
by boiling down the fat, and eat the meat. These
two articles of food are stored in their houses, the
fish in piles or bundles and the seal oil in such ves-
sels as they have. The fish may be cooked with a
little water and flour (if they have it), but are
usually eaten dry and raw. The seal oil is also
eaten raw. At meal time the family sits in a cir-
cle upon the floor and the squaw places a vessel of
seal oil in the center, convenient to all, and gives
each person a fish. They eat the fish straight, and
from time to time dip three or four fingers into the
seal oil up to their knuckles, then, placing their fin-
gers in their mouths, they suck the oil off. This is
repeated until the meal is completed. If any oil is
left over, this is saved for another meal. This is
about the most complete bath that some of their
hands get, and it is not uncommon to see children
with their fingers much cleaner looking than the
rest of their hands on that account.
Winter offers another kind of food — tomcod fish.
This is a fish with white meat, soft and compara-
tively free from bones. During the tomcod season
the natives can be seen daily out on the ice fishing
through a hole. They use a hook on a short string
and stick. A piece of red flannel or some other
article is used as bait. The fish are attracted to the
hole by the light and by vibrations created in the
water on moving the hook up and down. As they
appear at the hole in the ice the native moves the
hook up and down, catching the fish by the mouth,
side, or anywhere. These are thrown out on the ice
and rapidly freeze ; are then taken home and stored
in the storm shed. They are eaten raw in the frozen
state. The native also eats geese, duck, reindeer,
664
MEDICAL RFXORD.
[Oct. 14, 1916
and ptarmigan; in fact, anything obtainable. They
are poor providers, and in winter many of them
have to rely on the tomeod they catch daily or go
hungry. At times they will catch fish or game in
summer and bury it in the ground, possibly to pre-
sons living therein, garbage and sewage disposal,
and general sanitary conditions.
There are two villages at St. Michael, one com-
posed largely of "siwashes" and the other of "squaw
men." This latter village, although quite unsani-
FiG. 1. — Diagram of an Eskimo Igloo of the Yukon Delta,
Alaska, a, Entrance, covered to keep out rain and snow. b.
Curtain of fur to prevent draughts, c, Fire pit. d, Opening in
thatched roof, covered with seal gut for light, occasionally
opened to let out smoke when too concentrated, e. Under-
ground passage way. g, Ground.
vent access to flies. In winter this partly or com-
pletely decomposed mass will be dug up and eaten,
sometimes raw and sometimes cooked. They are
said to pull off the feathers or scales with their fin-
gers and eat the animal to the viscera.
Water is scarce in the native village, and the
native rarely bathes. In winter all water is ob-
tained by melting ice. The only form of bath that
they freely indulge in is the "sweat bath," and this
is almost entirely confined to the men. At certain
times during the year — usually fall, winter, and
early spring — the men gather in the kashim just
after the sun goes down for the purpose of taking
this bath. Each village of any size has a kashim, or
council house. This is built of logs, mud, grass,
etc., has no windows or doors, has an underground
passageway, that opens up into the center of the
room, through which the native enters. In the cen-
ter of the roof there is a small opening covered with
seal gut through which the small amount of light
enters. Ventilation is exceedingly poor, and the
walls are black from smoke. After the men enter
for their bath, a smouldering fire is started in the
pit through which they have entered and the smoke
and heat enter the kashim. The natives are naked
and seated or lying down on the benches around the
sides of the kashim or upon the floor. The smoke
is intense, and they cover their noses and eyes with
very fine wood shavings. They must remain in the
kashim until the fire is out in the pit, as this is the
only means of exit. When the bath is over, the
native rubs himself down or, if very hot, will go out
and roll in the snow first. He often rubs himself
with seal oil before dressing.
From the above insight into the Eskimo environ-
ment it is quite conceivable why any communicable
disease spreads rapidly among them, why their re-
sistance is low, why they are easy prey for epi-
demics, and why the odor of their person and shacks
is almost unbearable (to the untrained nose).
The United States Bureau of Education has, as
one of their duties in Alaska, the medical care of
the Eskimo. Their appropriation is small, and they
cannot reach many of the natives, and St. Michael is
one of the places where no medical attention is fur-
nished. In fact, the nearest doctor is about seven
days distant. The smell of these people and their
shacks, the filthy condition of their person and
clothing, and the presence of head and body lice,
make professional attention among them the most
disagreeable duty the writer has yet encountered.
In spite of the above disagreeable features, a tuber-
culous survey of the native villages on this portion
of St. Michael Island was begun on Feb. 16,
1916, and completed about two months later. This
survey consisted in going through every house, not-
ing the size, condition, number, and age of the per-
Fig. 2. — Eskimo house, one room ; fourteen persons live here.
tary, is far cleaner than a typical native village.
The other village is composed largely of Eskimo, or
siwashes, and is more nearly a typical one, but both
are considered among the cleanest villages ir>
Alaska. The native village is the one from which
the following statistics are taken.
Without exception a native village is the most
unsanitary place the writer has ever seen. The
Eskimo depends on the malamute dog for all of his
land transportation. These animals are tied out-
side of the house and given one fish daily for their
subsistence. The site around these dogs becomes
intensely filthy from urine and feces, but remains
frozen until about .May of each year. The native
eats almost everything that is set before him, so
there is little or no waste from that source, but the
men urinate just outside of their doors, and the
women and children urinate and defecate in such
vessels as they have and throw it out of the window
or door. The dogs eat the feces and the urine
freezes. In spring when the snow melts and leaves
all of this solid material, a native village is about
the filthiest and most foul-smelling place imaginable.
There are 107 natives in the St. Michael Eskimo
village, occupying 27 houses with an average of
about 350 cubic feet of air space per person. Of
the 107 persons, 46 are children under the age of 15
years. In fact, the absence of persons between the
ages of 15 and 25 is very noticeable, and this is also
true in the native villages of Sourdough and Steb-
bins that have recently been visited. Some persons
Fig. 3. — Modern (clean?) village.
claim this is because of an epidemic in 1900 that
killed thousands of natives, and others say that it
is a well-known fact among the natives that the six-
teenth birthday frequently is a death period, and
these people believe that if they can pass this birth-
Oct. 14, 1916]
MEDICAL RECORD.
665
day they will grow into manhood. The origin of
this belief has evidently come from the exceedingly
high death rate about this age from pulmonarj
tuberculosis. There are 10 other persons who live
in the St. Michael village a portion of their time,
and many others who visit here from other villages.
There is very little difference in size of the several
houses, but from one to fourteen persons oc-
cupy each. In one house there are eight adults and
six children. There is also advanced pulmonary
tuberculosis among them, but all live and eat under
the same conditions.
Realizing the difficulties of going into the houses
of these ignorant, dirty, and superstitious people
to make physical examinations, it was thought best
to turn to the schools and use these children as an
index. It has been said that once we contract tuber-
culosis, the tuberculous lesion remains, although
possibly presenting no symptoms but remaining in
a walled off state.
There are two schools at St. Michael, one "The
Native School" which native children attend, the
other, "The White School" for white children, but
which a few other children who have Eskimo blood
attend. These latter children live under conditions
more nearly approximating those of white people.
The cooperation of the several teachers was request-
ed, and the teachers in both schools brought their
pupils to the office, where they were examined phys-
ically. The von Pirquet tuberculin test was made
on each (using Koch's O. T.) and read the following
day. An attempt was made to examine the sputum
from each child, but was discontinued as unsatis-
factory except where the child had a cough.
Of the 46 children in the village, 26 were ex-
amined and tabulated as below. A greater number
could not be obtained without arousing antagonism,
as in some instances the parents were afraid to let
their children be examined.
Tuberculosis Survey — Children Native School
Tuberculosis Survey Children White School
Chest
,■
=
Sputum
z
p.
a
3
ft
Q.
1
Measure
*s
a
3
O
a
'_
Insp.
Exprn.
s
t-
T. B.
M.
C.T/
1
14
98.8
116
IS
39.5
30.5
80
66.25
<y
5
99.8
120
24
24 2 25
42
41.25
+++
3
6
99.2
110
19
22 7
38.5
44 2
+
4
6
9S
112
20
22
22 5
34 5
40 2
+?
5
7
99.6
105
22
33 2
23 7
44
42 7
+
6
7
99.1
104
24
23 7
24 2
44
46
7
7
99.8
132
32
26.5
53
46 5
+++
B
5
100
120
28
23.5
24 2
37
Id 7
++
9
8
99.8
72
26
27
48
r, 5
++
—
10
10
99
132
22
27
27 7
56
18 5
+?
—
—
11
12
99.3
80
18
28
29 5
75
55
+
—
—
1.'
11
99 .7
104
24
25 2
26
57
51.2
—
—
13
i
99 6
66
24
22.5
25 2
48 5
47
+
14
9
99 6
104
22
25
26 7 54
1" 7
—
15
11
98 2
92
26
26 2
27 2 59
47
+?
—
16
13
99
96
24
' 3
30 80
54 2
— —
17
S
98
104
32
24 2 25 5 53
46 5
—
18
5
99.4
104
36
26 26.7 M 5
43
+++
—
+
ID
11
99.4
104
24
27 7 28 7 7 ;
53
++
—
-
■jo
12
100
100
2 4
27 7 ^7 76
53
+?
—
21
10
99 5
98
18
28.7
1.7 62
51 5
+
-
—
11
98 6
64
IN
26
27 7 HI
54 2
+
23
10
99 4
30
25
-
28.5 63 52
52
+
24
13
99 6
80
20
SI)
++
+
25
7
99 .6
100
20
25 2
25 7 17
17 2
++
■
26
11
...
90
24
74 5
+
*T. B. -Tubercle bacillus. M.C.T. = Microcoecus tetragenus
Eight children were examined from the "white
school," and the results from this examination were
as follows:
This is a small number, and one should not draw
the conclusion that these figures represent condi-
tions all over Alaska for children under the age of
15, but it does give an insight into what exists
in the schools here.
Chest
=:
E3
Sputum
^
<
a,
1
3
ft
d.
S
PS
Measure
"S
at
Xt
-
Insp.
Exprn.
^
w
Eh
T.B. 1 M.C.T.
27
14.5
99.6
104
.'1
■32
32.5
100
60
(a)
28
7
99.4
no
26
24.7
25.5
51
17 5
29
13
98
96
26
29.5
30.2
98
60
30
8
99.2
88
20
25 2
26
60
49
+ +
31
10
99.7
96
24
26.5
28
62
54.2
+ + '
32
6
98
100
20
23
23.2
40
45.5
+ ?
33
12
98
80
22
27.7
2S.2
85
75.7
+
34
9
98
100
20 '
26
26 5
68
52
+1
(a>No sputum examinations made.
Comparison
Positive .
Negative..
Suspicious
There was occasion to examine 11 adults during
this survey, both the sputum and their physical con-
dition. All were positive for tuberculosis. How-
ever, all of them asked to be examined on account
of pain in their chest, and some on account of hemor-
rhage.
It is believed that at least one-half of the sus-
picious cases in the tables above would prove to be
positive if several examinations were made. In the
above tables, cases are called positive when they
presented positive signs with the stethoscope and
a positive tuberculin test ; are called negative when
neither of the above were present, and suspicious
when abnormal lung signs were revealed and the
tuberculin test was negative or inconclusive.
The following method was found most satisfac-
tory in applying the tuberculin. The jeweler's
swivel screw drivers are placed in 95 per cent, alco-
hol for sterilizing purposes; the left arm is scrubbed
with alcohol just below the insertion of the deltoid
muscle. The operator seizes the fleshy portion of
the under surface of the patient's arm and draws
the skin taut, then with a 4%-in. screwdriver,
as shown in the accompanying illustration with the
swivel in the palm of the hand, rapidly turn the bit
in first one direction and then the other until the
epidermis is removed and the true skin exposed.
This will take about six half turns, make a beautiful
scarification, and cause little or no pain. The de-
nuding of two areas is invariably done, the upper
used as a control with nothing applied and the tuber-
culin applied to the lower with a flamed platinum
loop. No dressing is used, and the patient reposits
the clothing as soon as the tuberculin is dry. The
patient returns in 24 hours and a comparison is
made of the two lesions. The control shows little
or no irritation, only a dry scab. If negative, the
lower lesion will resemble the upper; if positive
there will be a red papule at the lower lesion sur-
rounded by a hyperemic zone. Depending upon the
size of the papule and the hyperemic zone, the table
includes one, two, or three plus indicating the de-
gree of positiveness.
Sputum examinations were made in thirteen of
the twenty-six cases from the Native School, and
the tubercle bacillus was found in three of the thir-
teen. These three cases had consolidated areas,
many rales, cough, and sputum; also presented a
phthisical appearance. A careful search was made
666
MEDICAL RECORD.
[Oct. 14, 1916
for the Micrococcus tetragenus in all of the sputums
examined, and this organism was found in six of the
thirteen. The relation to the tuberculin reaction
can be seen on the accompanying chart.
The micrococcus has been spoken of as often
being an associate with the tubercle bacillus, and
from a limited experience the writer considers a
sputum more suspicious when it contains this or-
ganism. All professional men know that the find-
ing of even one tubercle bacillus diagnoses the speci-
men as positive for tuberculosis, but there are many
artifacts that unavoidably appear in microscopic
specimens, and the writer would not call a speci-
men positive on finding only one object that ap-
peared to be the tubercle bacillus. It has further
been the case in my experience that one will not
;ind only one tubercle bacillus. If this organism is
present, and the preparation is properly made, a
search for half an hour will reveal a number of them
or none at all. However, this may not be the ex-
perience of men more experienced in microscopy.
As the tuberculous percentage is high in this
w^
*
>.,
.^t
v^ft &
09C-
fcn i
Fio. 4. — Method of administering tuberculin with a swivel
screwdriver.
locality, a medical man practising here will neces-
sarily make many sputum examinations. The fol-
lowing is the procedure that has been followed in
this laboratory : The patient is instructed to collect
what is coughed up and not saliva, and is given a
paper sputum cup for this purpose along with a
metal frame to hold it. When the specimen is
brought in, the paper cup is removed from the
frame and opened. Suspicious particles are
smeared evenly and thinly on clean glass slides free
from scratches, the specimen is dried in the air and
passed through an alcohol flame 7 to 10 times, de-
pending upon the thickness of the slide, to fix it.
The slide is given a number which corresponds to
the sputum cup and the smear outlined with a wax
pencil so as to prevent the stain from spreading over
the ends of the slide. Four slides are made from
i specimen of sputum, and all are given the same
number. These slides are placed upon a level rack
that has an opening under each slide. Mure slides
are made in a similar manner until all the speci-
mens are ready for staining. Alcohol carbo] fuchsin
(alcohol 95 per cent., 20; phenol crystals, 8; fuchsin,
4 ; water, 100) in definite amounts, as indicated upon
a glass tube used for the purpose, is placed on each
slide. This completely covers the specimen be-
tween the parallel pencil marks and does not flow
upon the ends of the slide. After each slide is cov-
ered, an alcohol flame is passed under the slides un-
til they commence to steam and are left steaming
(not boiling) three minutes, care being taken to see
that none of the slides becomes dry. Wash with
water, commencing with the first slide stained, drain
off the excess and decolorize with acid alcohol (hy-
drochloric acid, 2; alcohol 95 per cent., 98) until
there is no red color left; wash and stain three min-
utes with Loeffler's methylene blue; wash, dry, and
examine.
Summary: — 1. More than 61.5 per cent, of the
Eskimo children under the age of 15 years are
tuberculous in one of Alaska's cleanest villages.
2. Their environment is such that tuberculosis
must increase among these people.
3. They offer one of the greatest fields for medi-
cal missionary work.
4. From a hygienic standpoint their entire sys-
tem of living is wrong, but will ignorance, super-
stition, and climatic conditions permit a change?
5. The only source of relief at present seems to
be the enactment of the necessary legislation to pre-
vent fur traders from robbing the Eckimo of his
small products, and larger medical appropriations
to the Bureau of Education for use in Alaska.
THE PRESENT STATUS OF CHRONIC MUL-
TIPLE ARTHRITIS, WITH SPECIAL
CONSIDERATION OF INFECTION
AS AN ETIOLOGICAL FACTOR.
By GEORGE R. ELLIOTT, M.D.,
NEW YORK.
ASSISTANT PROFESSOR OF CLINICAL. ORTHOPEDIC SURGERY. COL-
LEGE OF PHYSICIANS AND SURGEONS, COLUMRIA UNIVERSITY,
N. Y. ; ATTENDING ORTHOPEDIC SURGEON, MONTEFIORE
HOME AND HOSPITAL ; ST. FRANCIS AND ST. JOSEPH
HOSPITALS ; MEMBER OF THE AMERICAN OR-
THOPEDIC ASSOCIATION.
In a former paper we spoke of the proliferating or
ankylotic type of chronic multiple arthritis in which
the role of infection is evident; in the present we
shall consider the non-ankylotic type in which in-
fection is doubtful.
Degenerative or Non-ankylotic Type of Chronic
Multiple Arthritis. — This type, by some desig-
nated osteoarthritis, hypertrophic arthritis, is char-
acterized by degenerative joint changes and new
bone formation. It occurs chiefly in middle life.
There is slight, if any, tendency to ankylosis. It is
attended with little muscular wasting.
The prominent primary lesion here is cartilage
degeneration. In the proliferative type the cartilage
is destroyed by a pannus formation creeping over it
and gradually absorbing it, leading to fibrous tissue
formation and bony ankylosis. In the degenerative
type the cartilage is also destroyed but by a pri-
mary necrosis, leaving the ends of the bones free.
Friction of the exposed ends leads to condensation —
the so-called eburnation. Ankylosis does not occur.
We meet here no new cell proliferation as in the
other tvpe; in short no inflammatory findings. We
have the melting away of certain tissues with exces-
sive new bone formation. Pathologically, a true
degenerative process on the one hand with a slow-
heaping up of new bone on the other. Of the small
joints, the distal phalangeal joints are the first to
Oct. 14, 19161
MEDICAL RECORD.
667
be attacked in contradistinction to the proliferative
type, where the proximomedial joints are first im-
plicated. This clinical onset is striking and be-
speaks the strongest possible differentiation of the
two types.
Fig. 1. — Degenerative or non-ankylotic tvpe of chronic-
multiple arthritis. Onset at menopause. Note the enlarged
distal joints — Heberden nodes showing well. Note also
proximo-medial enlarged joint — a later manifestation of the
disease.
The subjects are older and many writers are fond
of using the term senile — at present a word of
doubtful scientific pathological meaning. This type
is exceedingly common at the menopause.
There is a disposition on the part of some to re-
gard the type as primarily due to bacterial infection.
At present we have no scientific basis for such a
sweeping belief. Its exponents produce no scien-
tific proof. Infection does not appear to explain this
type as it does the proliferative. Most of the signs
of infection here are wanting. There is an abscence
of fever, little or no glandular enlargement, little or
no leucocytosis — in short, there are no true inflam-
matory signs as in the other type. Absorption and
apposition here go hand in hand, but the absorption
is here due to degenerative changes leaving the
bones bare. These are ground into condensed sur-
face formation through friction changes much as
rocks are ground through glacier movement. In the
proliferative type the cartliage also disappears but
disappears through a live fungus-like pannus eating
into its very substance, absorbing it and leaving in
its place new granular tissue which becomes fibril-
lated, going on to true bony ankylosis. Here then
is the real pathological difference and this alone is
enough to stamp the types and explain much of the
clinical difference. New bone formation seems to
develop secondarily, the result of stimulation of the
osteogenetic cells. The acting irritation comes from
cartilage loss influenced by trauma and static con-
ditions.
To make the subject clear and to accentuate the
striking clinical characteristics arising from the
pathology just considered, let me mention the so-
called Heberden-node type as perhaps the most
classical illustration of the disease under considera-
tion. The distal phalangeal joints are here first in-
volved and as an early sequel to cartilage loss there
follows a new bone formation on the distal pha-
langes. This node contrasts with the spindle-shaped
or Haygarth nodosity of the proximomedial pha-
langeal joints so characteristic of the proliferative
type. This degenerative malady advances usually
through repeated slightly painful attacks in the
vicinity of the node and after the subsidence of
these attacks the node is found larger.
The malady, if unchecked, does not remain lim-
ited, but gradually extends to the more proximal
joints of the hands and to other joints of the body.
Sometimes this disease makes its first appearance
in one of the large joints as the knee or hip.
The cuts reproduced here well illustrate this type
of arthritis. They are after photographs of a pri-
vate patient, whose condition I have studied very
thoroughly.
This disease began at the menopause but inter-
mittently involving the distal phalanges and the pa-
tient began to point to the "knobs" on her fingers.
.O.M.MITC
H *M
.MflUI
Fig. 2. — Radiogram of hand shown in Fig. 1. Note in-
volvement of distal joints, also proximo-medial joint of lit-
tle finger — cartilage destruction and new bone formation.
Note good condition of remaining joints. Compare with ra-
diagrams of proliferative types shown in a former article,
noting especially selective character of each.
After several years the medioproximal joints of the
hands became involved together with the tarsal
joints of the feet. For the benefit of those prac-
titioners who in similar cases are wont to cut out
meat from the diet. I will say that this patient's
MEDICAL RECORD.
[Oct. 14, 1916
diet was during all the developmental period of the
malady almost entirely carbohydrate. Meat had
early been excluded.
If we study the x-ray picture of the hand and foot
here produced, we fail to find the wholesale bone
destruction so characteristic of advanced cases of
the proliferative type. This wholesale destruction in
the latter type led to its formerly being called
atrophic type — a term now largely given up. I may
say here that many confound the terms proliferative
and atrophic as applied to the same type — contra-
dictory terms apparently. The explanation lies here:
The term atrophic arose in the classification of the
early clinicians through finding the large bone de-
struction in advanced cases; this, together with
marked muscular atrophy, made up much of the pic-
ture. The word proliferative applies to the early
stage of the disease and refers chiefly to the soft
tissue cell formation affecting the synovial mem-
brane and capsule — a real increase stamping the
type proliferative. The late extensive bone destruc-
tion or wholesale bone atrophy or late atrophy term
is giving way to a term expressing the early patho-
logical process of proliferation. We may also here
refer to the type we are considering as by some still
designated hypertrophic from finding excessive new
bone formation. This term is still used a great deal
but is gradually giving way to the term degenera-
tive or non-ankylotic.
We have shown1 that new bone formation alone
is unreliable as a diagnostic factor since it may go
with any form of arthritis where the osteogenetic
cells have been exposed to prolonged irritation.
If we revert then to a careful study of the radio-
gram of the hand as shown in the cut, we do not
find the great bone destruction — and the cut repre-
sents an advanced case — characteristic of ad-
vanced types of the proliferative, ankylosing, or if
you please, the atrophic type. The apparent whole-
sale bone destruction is largely due to new marginal
bone formation deepening the joint cavity giving
the appearance of bone destruction. This is not un-
like the findings often characterizing arthritis
urica joints. I called attention to this in a paper
read before the American Orthopedic Association
showing the actual specimens dissected and well
illustrating just what is said here.
I wish to say that while extensive bone destruc-
tion is especially common in late stages of the pro-
liferative type of arthritis and condensation and
new bone in the degenerative type and in the
arthritis urica type, yet extensive bone destruction
does sometimes occur in the latter two types. Its
explanation may sometimes be found in extensive
lerosis or to a deposit of calcareous salts in
the blood-vessels leading to tissue loss, much as a
cerebral thrombosis leads to a brain loss.
As already said, this type of arthritis often in-
vades the large joints. We frequently see it affect-
ing the knees, especially of women. Again, the
familiar time of onset is at the menopause. Here
again we have the primary cartilage loss through
degeneration accompanied with formation of new
bone. Characterizing this are the subjective symp-
toms Of pain, stiffness, and disability, and the objec-
tive signs of grating, irregular swelling, and often
evidence of small loose detatched particles. The so-
called malum coxae senile is another form of the
malady under consideration. This degenerative
type is also very common in domestic animals, espe-
cially in old age. Diabetes is not infrequently asso-
ciated with it.
What Is the Primary Etiology Accounting for
This De ye iterative Type? — We have spoken of car-
tilage loss as being primary. Strictly speaking it is
secondary. In thj sense we use the term is meant
that cartilage loss is the first objective sign of the
malady. What causes the cartilage to degenerate?
We feel that enough has been said to show that
those who would regard true bacterial infection as
the basis of this malady are confronted with findings
markedly in contrast with those characterizing the
proliferative type. The picture is not at all one of
infection. All the ear marks of true bacterial in-
fection are wanting. We refer to the true strep-
tococcal infection or of its mutants or variants or
to infectious disease proper.
It is unfortunate that manv writers on true bac-
terial arthritic studies still stick to the general title
arthritis deformans, making no real differentiation.
At this time it bespeaks a lack of knowledge of the
subject. Even Rosenow has been justly criticised
for his lack of differentiation. His bacterial studies,
I am safe in stating, have not yielded in the degen-
erative type of arthritis now under consideration
any of the valuable findings he has given us else-
where. He is only one of many using the term
arthritis deformans in a loose way.
At the basis of the primary etiology there is much
pointing to the working of some chemical rather
than true infective factor.
As stated, if we study the joint changes we find
much reminding us of the joint changes character-
izing the arthritis urica or gouty type. There are
cartilage loss, eburnation, new-bone formation. In
fact findings which characterize that type less the
tophaceous deposits of biurate of soda. Many wri-
ters recognize in this type a certain relationship
with the arthritis urica type, and believe the under-
lying cause due to a faulty physiology rather than
to true infection — a chemical rather than a bac-
terial factor. It must be admitted that at the pres-
ent time we do not know just what gout is. We do
know, however, that it exDresses itself to us through
an abnormal prominence of uric-acid findings, while
in the degenerative type no such abnormal prom-
inence of uric acid is found. This is a point for
physicians to bear in mind.
Axhausen, an active worker in the arthritic field,
believes cartilage loss to be the primary factor ex-
plaining the changes found in chronic multiple
arthritis. We purposely omitted referring to Ax-
hausen's view while considering the proliferative
type believing that his findings have a closer rela-
tionship with the degenerative type we are now con-
sidering. What he says of cartilage loss is of great
interest here.
Axhausens contends that from the clinical and
macroscopial consideration of chronic multiple arth-
ritis it is impossible to expect a solution of the prob-
lem and turns to the histological picture. He places
the focus of total anatomical and histological
changes in primary cartilaginous necrosis, and holds
that the cartilage loss leads, in accordance with
laws, to reactive phenomena in the neighborhood
which anatomically and histologically make the
clinical picture of chronic multiple arthritis. He
says the idea that bone necrosis is always identified
with infection and sequestration is incorrect, that
there is a simple bone necrosis without infection
and sequestration playing an important role in bone
pathology ; that from whatever cause — bone trans-
plantation, fracture, bone tumor, or bone syphilis —
wherever bony necrosis exists, is established a pow-
Oct. 14, 1916J
MEDICAL RI'.CORD.
669
erful irritation upon surrounding ossification tis-
sues producing swelling and new-bone formation.
He experimented with normal knee joints of dogs
and produced circumscribed cartilage necrosis by
destroying portions of cartilage varying from the
size of a lentil to that of a small bean, and made
his examinations after longer and longer periods.
Beneath the cartilage loss he found the medullary
tissue changed to fibrous tissue and under the work-
ing of this tissue resorption and dissection in
progress, also sclerosis of the bone. He also found
cystic spaces, synovial villi, and marginal bone
osteophytes — in short, all the changes seen in
chronic multiple arthritis.
Axhausen reminds us of the fact that cartilage is
nourished through diffusion and that the diminished
nutrition of advancing years may lead to superficial
and even deep cartilage degeneration. He also re-
fers to Weichselbaum's demonstration that a de-
generation, even to necrosis of the superficial
cartilage cells, belongs to the physiological
changes of age. Axhausen believes that if
such changes increase and produce a deep car-
Pig. 3. — Right foot of patient whose hand is shown in Pig.
1 . degenerative or non-ankylotic arthritis. Note new bone
formation (shown by arrows) involving tarsus. Process
identical with that shown in hands — cartilage loss and new
bone formation.
tilage necrosis, then we have a pronounced pic-
ture of chronic multiple arthritis, and says that
Weichselbaum, through anatomical relationship, has
established in arthitis deformans none other than
a high grade of simple senile change; that where
nutrition has been interfered with we must recog-
nize many factors — trauma, acute joint inflamma-
tion, constitutional general disease, senium. The
binding factor in all these cases is cartilage necrosis.
Not all of the changes Axhausen describes as re-
sulting from his experiments are found in the de-
generative form of arthritis. I refer especially to
the fibrous tissue formation.
Von Manteuffel produced artificial sclerosis of the
vessels through freezing and congestion, and he
claims" as a result of his experiments final complete
disappearance of the cartilage and of the entire
joint with connective tissue ankylosis of the two
bones.
The connective tissue formation and ankylosis,
as we have said, are not present in the degenera-
tive type now under discussion. We are led to ask
how far we can accept the experimental destruction
of normal joint cartilage as the equivalent of its
loss through disease. Is not the reaction to de-
struction of normal cartilage through operative pro-
cedure quite different from the reaction incident to
degenerative conditions? To the pathologist there
is a wide difference and we do not believe such ex-
periments will ever give the true picture. At pres-
ent it is safe to adhere to the pathology of Nichols
and Richardson,1' which we have followed and which
is being generally accepted.
Much that we have just considered is placed by
the French school of medicine under the term
chronic rheumatism of toxic or dyscrasic origin
(gouty rheumatism but not true gout), and Ott ac-
cepted this in a report to the fifteenth Congress of
German Physicians. From the point of treatment
he classified it as due to general nutritional dis-
turbance— to an excessive acid production in the
system. This variety is well described by Teissier
and Roque.'
Teissier says it is not true gout, there is no
tophus, it is not hereditary as gout, but acquired
— an acquired uricemia. He further says that (1)
sometimes this uricemia is created by clogging of
the skin under the influence of damp cold; (2)
sometimes it is the result of prolonged digestive
disturbances, and (3) sometimes it is secondary to
renal insufficiency. But he admits that this does
not explain difference between this and gout, i.e.
between an hereditary uricemia and an acquired
uricemia. The French authors generaly recognize
a casual relationship between the type of arthritis
under discussion and a series of dyspepsias — the
so-called acid dyscrasia.
All signs point to the gastrointestinal tract as
playing a large role here. The intestinal role dif-
fers much from the part it plays in the prolifera-
tive type. Its role there is that of a septic focus,
such as foci lodged in the appendix, gall-bladder,
etc., while in the degenerative type it appears to
be some direct absorption from the tract proper.
This is said with full knowledge of the fact that
many leading thinkers are placing the real start-
ing point of arthritic urica in the alimentary canal
— a probable catarrhal condition of the mucosa of
bacterial origin. In the degenerative type of
arthritis faulty physiology of the intestinal tract
leading to deleterious absorption does seem to play
a large role. Clinically I have seen over and over
again outbreaks of painful joints with increase in
size associated with gastrointestinal disturbance
characterized by marked indicanuria and faulty
acid conditions, the attack subsiding promptly upon
correction of the digestive disturbance.
There remains only to be worked out what kind
of absorption takes place. Is it some toxin or a
true intestinal infection of bacterial origin? If
bacterial, we cannot think of it in the same line of
bacteria! infection which we fully considered under
proliferative arthritis. The studies of Adami al-
ready referred to are worthy of consideration here.
Elimination in this class of cases also plays an
important role. We have referred to the frequency
of this type of disease in women at the menopause.
We know at this time in many women there are
great disturbances leading to faulty elimination.
The systemic equilibrium is upset. The individual
for years has through her twenty-eight-day habit
been getting rid of material and now the system
must readjust itself. At this stage we often see
starting up the joint changes under consideration.
670
MEDICAL RECORD.
[Oct. 14, 1916
We shall only allude to the vast amount of work
done on calcium in connection with this period.
The subject is still to be worked out. But the great
frequency of this type of disease developing with
the menopause is certainly suggestive and must be
considered in the treatment of our patients. We
are here reminded of Aphorism No. 29 of Hippo-
crates: "A woman does not take gout unless her
menses be stopped." The old fellow may have mis-
taken Heberden nodes and boggy stiff knees for
gout. Many modern physicians do the same thing.
The modern physician may be right. Heberden,
himself a gout specialist, expressed the view that
the node described by him did not mean gout.
Charcot taught the same, pointing to the large num-
ber in the Salpetriere — 200 out of 400 old women.
As stated, many physicians believe that there is
some relationship; this I have already brought out.
Llewelen Jones regards the node as a senile dystro-
phy independent of rheumatism or gout. Leri ex-
amined 30 patients afflicted with chronic rheuma-
tism, as the term is used by the French, and found
that seventeen had Heberden nodes. I may say the
belief that the true Heberden node is in some way
allied with gout is growing. Supporting this view
I may mention Begbie, Hilton Fagge, Lecorshi,
Dyce Dukworth, Archibald Garrod.
There is much to show that a node may appear on
the distal phalanx, largely due to trauma, and re-
main in statu quo for many years. But the type
we arc considering and well illustrated in the cut
(Fig. 1) is certainly an entity, and while it is
not expressed through deposits of biurate of soda,
characteristic of gout proper, there is much show-
ing relationship with an allied condition. What-
ever our future studies may disclose as the primary
cause of this degenerative type of arthritis, and
we believe it will be found to be something besides
senility, we feel sure in stating that it stamps a
type of its own and has nothing to do with infec-
tion in the strict bacterial sense. We have here a
clean-cut picture, if not a specific disease entity, a
true pathological condition with characteristic
showings.
True Infectious Arthritis. — In this, the arthri-
tis of certain well-known infectious diseases,
we have a direct cause explaining many cases
of arthritis. Let me mention arthritis com-
plicating pneumonia, gonorrhea, typhoid fever. In
acute arthritis of this kind it is reasonable to
expect that the specific organism of the disease
giving rise to the arthritis may be present in the
joint. This has often been verified, as in gonor-
rhea, for example. The onset is usually sudden and
the signs are inflammatory in character. It is
possible that the activity of the organism may be
severe enough to be pus-producing.
Another type of arthritis, however, may compli-
these infectious diseases, not so acute, but of a
chronic character. It is this latter type that chiefly
concerns us in our study of chronic multiple arth-
ritis. The arthritis of gonorrhea well illustrates
what I am saying. I can do no better than to quote
from Brackett7 at this time. In his paper on
arthritis associated with lesions of the genito-
urinary tract Brackett refers to the two types of
gonococcal infection: "One usually monarticular, in
which there is a direct bacterial invasion of the
joint characterized by an arthritis of sudden ap-
pearance with evidence of inflammatory involve-
ment; and a second type, polyarticular and of a
mildly inflammatory character, slowly damaging the
joint from toxic infection. This latter type may
develop with an entirely quiescent external urethral
condition." You will recall here the writings of the
urologists on the part played in multiple arthritis
by vesicular foci, writings in number exceeded only
by those of our dental confreres. The term toxic
infection used by Brackett as the factor of the sec-
ond type has yet to be cleared up. It may be that
this toxic infection will be found to be a mutant or
variant of the gonococcus in keeping with the
teaching of the transmutationists fully discussed
under the heading proliferative arthritis.
If we study the arthritis of all the class of in-
fectious diseases now under discussion, we shall
find the dual expression so characteristic of the
arthritis of gonorrhea also more or less character-
istic of all. It is the second or chronic form of in-
fection that chiefly concerns us here. Both acute
and chronic arthritis do not necessarily manifest
themselves in the same patient. For example, in
gonorrheic arthritis we may meet with the acute
form only — the direct bacterial invasion. In the
absence of focal points of storage, as the seminal
vesicles, for instance, no points of chronic focal in-
fection existed. Again the acute form is wanting
and only the polyarticular manifests itself. I be-
lieve this is often true in both gonorrhea and
syphilis.
We see, then, opening up a rational explanation
of a great deal of chronic articular disease. At the
present time, excepting tuberculosis, it is difficult to
diagnosticate these chronic types and say what or-
ganism has been acting. Such types of arthritis
are apt to be irregular. At the present we believe
their external expression differs materially from
either of the main types already fully discussed.
In the infectious forms of chronic multiple
arthritis spinal involvement is common; note its fre-
quency following gonorrhea and typhoid fever, for
instance. In the proliferative type, where so many
of the joints become implicated, the vertebral col-
umn usually escapes. In an examination of ex-
tensive polyarticular bed-ridden patients affected
with the proliferative type, the spinal column gen-
erally gives striking evidence of mobility, and
usually remains unaffected to the end.
Factors Influencing All Types of Arthritis.
— 1. — Trauma. This factor is best seen when pain
is not severe. The proliferative type is apt to be
painful, compelling disuse on the part of the patient
and thus escaping external trauma and the spindle-
formed nodosities so characteristic of this type de-
velop with great regularity. There is, however,
also trauma of the deformity a constantly acting
factor in this type causing many irregularities —
contractures and dislocations, for example. It is
chiefly ir. the degenerative type, the slightly painful
type, where we see the result of external trauma.
This is the result of the painless form allowing
more use. This is well illustrated, usually by the
index and thimble fingers in cases of this degenera-
tive or nonankylotic type. See the little and index
finger in Fig. 1.
2. — Static Conditions. Some investigators have
gone so far as to put changed static conditions as a
chief factor for a great deal of chronic multiple
arthritis; their place in chronic multiple arthritis
is now well understood. The explanation of cer-
tain findings rests upon Wolff's law, that all pro-
longed alteration of the function of any part of the
body, either congenital or acquired, is surely fol-
lowed by anatomical change. If one leg is shorter
Oct. 14, 1916J
Ml DICAL RECORD.
671
than the other certain joints suffer through anatom-
ical change. If a person is knock-kneed or bow-
legged certain changes are set up in the knee joints
chiefly. If there is hallux valgus the cartilage of
the metatarsophalangeal joint of the big toe suf-
fers. The pathological changes following static
changes are apt to be allied with those spoken of
while discussing the degenerative type of arthiritis
— cartilage loss and new bone formation. The lat-
ter is often striking. Lane some years ago was
among the first to call attention to these static re-
sults. More recently Preiser worked them out with
great thoroughness.
Wear and tear, spoken of by McCrae we believe,
comes logically under this head. McCrae" refers to
the weight of the patient as a factor in influencing
his own joints; this becomes a marked factor after
degeneration begins.
Joint Arthropathies. — We will briefly refer here
to certain arthritic conditions complicating cer-
tain organic nervous diseases — arthritis of loco-
motor ataxia and syringomyelia, for example. By
some the former is considered as syphilitic joint
disease. Such grave trophic changes do not ap-
pear to warrant a place in a paper such as this
where we endeavor to restrict ourselves to consider-
ation of chronic arthritis proper. We can scarcely
think of a Charcot knee as a good example of
syphilitic arthritis. It is but one of the very many
manifestations of syphilis, but it is not a true
arthritis.
Working Classification. — How far then are we
in a position to get a mental concept of chronic
arthritis? What kind of a classification are we war-
ranted in making? In other words, what does the
present status of chronic multiple arthritis teach us
as a basis of classification? All sorts of classifi-
cations have been made, based on anatomical,
pathological, and clinical grounds, and new classifi-
cations are constantly being given us. Many of
these are erudite at first sight, but upon analysis
fall by the wayside, for clinicians are unable to
verify and make any practical use of them. At
the present time I think it is impossible to classify
chronic arthritis except under striking types. The
endeavor has been made to do this in this paper.
In other words, we have endeavored to fall back to
a simple classification, which is in part a classifica-
tion of some of the older clinicians but one now
better understood and more thoroughly worked out
and restricted.
1. — Proliferative or Ankylotic Type. We have
endeavored to show that this type has well-defined
characteristics due to infection of a modified kind.
It is a real disease entity — the true progressive mul-
tiple arthritis, and the diagnosis should always be
made. Its clinical expression is clean cut and well
defined.
2. — Degenerative or Non-Ankylotic Type. This
includes a large class of cases giving striking clin-
ical pictures. This is not so much a disease entity
as the former, but a secondary joint condition. The
word .Tthrosis may be found to express this type
better than arthritis. While not a distinct disease
entity ir the proper sense it is, however, a striking
clinical type with characteristic manifestations and
the diagnosis should readily be made.
3. — True Infectious Arthritis. The arthritis of
infectious diseases where the joint organism is
rather definitely known and sometimes recovered
from the joint. The chronic types here are apt to
be irregular. Diagnosis, as a rule, is more difficult.
but a careful study of the history and patient often
brings out a true etiological diagnosis.
4. — Mixed Types. One type, for example, may
be engrafted upon another. The degenerative type
may be engrafted upon the proliferative, to a cer-
tain extent complicating the picture. Leri brought
this out in his discussion of the Heberden node
under the head chronic rheumatism. The term
chronic rheumatism is a favorite term of the
French and with them covers a wide field. It is
not uncommon to find evidence of the degenerative
type er.grafted upon the proliferative, the latter af-
fecting the patient earlier in life and the degenera-
tive engrafted upon this later in life. This fact is
in itself a strong argument to show that the etiol-
ogy of the two types is entirely distinct. Again, all
types being influenced through static influences,
give many irregular pictures which may or may
not come logically under this mixed type heading.
5. — Arthritis Urica Type. This is chiefly char-
acterized by the deposit of biurate of soda.
6. — Tuberculous Type. I give tuberculosis a spe-
cial head rather than classify it under infectious
diseases, since we are familiar with its arthritic-
forms. I may say that the so-called tuberculous
rheumatism or Poncet's disease does not give any
external characteristic picture and there is no likeli-
hood that it ever will, since it is not an expression
of a tuberculous lesion proper. It is rather an ex-
pression of a tuberculous toxemia, at present not
fully understood.
The future will doubtless compel us to give spe-
cial heads to certain other diseases which at pres-
ent we are compelled to leave under the general in-
fectious type. As the hydra-headed showings of
tuberculosis looked upon by clinicians formerly as
different diseases cleared up, so the general subject
of arthritis is now clearing up. Certain well-
known diseases will yield to us as well-defined joint
pictures as tuberculosis has already done. This, I
believe, will be especially true of syphilis and gonor-
rhea. So of typhoid fever, pneumonia, and other
infectious diseases. I refer to the chronic polyartic-
ular types of these maladies.
The French writers, as the result of deep study of
this arthritic subject, have adopted simple classifica-
tions. One of Desternes illustrates, this: (1)
les rheumatismes dits d'infection, (2) les rheuma-
tismes dits dyscrasiques, (3) les rheumatismes dits
deformant progresif.
Under the latter, or progressive deforming, Des-
ternes has followed the French school in including
many forms that we believe belong in the degenera-
tive type. Differences in etiology and deforming
characteristics make for such differentiation. It
must always be borne in mind that the French use
the term chronic rheumatism for the great general
head.
I repeat that it is impossible to follow complex
classifications. I have spent many a weary hour
trying to comprehend such, only to find that I was
chasing some will o' the wisp. The more I study
the subject the more I find the classification becom-
ing simple. Simplicity is coming as a result of
study of the arthritic problem as it always comes
with knowledge of any subject. In simplicity lies
strengthiwif- _ ^f^tm. ^Av«. Vz^! (/)***£*, A~~*~
I especially urge the simple classification under
the six heads I have given as a good working prac-
tical classification, feeling that at the present time
we have no scientific basis for any other. Under
one of these six heads I believe all the types of
672
MEDICAL RECORD.
[Oct. 14, 1916
chronic multiple arthritis can be placed. I have
advisedly omitted the so-called traumatic arthritis
as not believing it comes within the scope of this
paper. Trauma as a factor has been considered.
To place the patient properly I follow in a gen-
eral way the following rule : When a case of chronic
multiple arthritis presents itself to study the
patient ; to take a careful history ; age of patient at
onset cf the disease and character of onset and
nature of progression. Has the onset occurred in
the 20's and 30's or 40's and 50's? To note the ob-
jective findings. Are there true Haygarth nodosi-
ties— the real spindle-shaped joints, or are there
bony outgrowths and irregularities, any Heberden
nodes for example? If the latter, are they alone or
engrafted upon some other condition? Is anky-
losis present? To take into consideration the occu-
pation of the patient and note effect of such; to
look for any static conditions and result of such. To
search for hidden focal sites, especially if our his-
tory and examination so far tend to put our patient
in the proliferative type — tonsillar, appendicular,
tubal, vesicular, or dental foci. Carefully to inves-
tigate the gastrointestinal tract, especially if our
examination tends to place our patient in the degen-
erative type. To seek evidence of a former infec-
tious disease and history of same. To look for
gouty tophi or other evidences of the gouty diathe-
sis— having a metabolic laboratory test made if the
diagnosis is doubtful; to search for tuberculous
evidence. To have good x-ray plates made. By a
process of inclusion and exclusion and careful anal-
ysis the patient can be properly placed with as much
certainty as the proper placing of a flower through
botanical analysis. Such a placing in chronic mul-
tiple arthritis is now necessary as so much here
depends upon a diagnosis. It is only through an
accurate diagnosis that we are directed to the logi-
cal course of treatment of our patient.
The chronic rheumatism and uric acid doctor be-
longs to the past. It is necessary to analyze, prop-
erly to exclude, and properly to place the patient.
Anything short of this is neglectful and deleterious
to the patient, making our treatment empirical
rather than scientific.
In concluding these papers, I wish to specially
emphasize one observation I have tried to bring
out — that after we are able to differentiate the spe-
cific type of arthritis belonging to infectious arthri-
tis proper as well as true degenerative arthritis,
we shall still have standing out clearly one great
type as a distinct disease entity. I refer to the
proliferative or ankylotic type — the real progressive
type of chronic multiple arthritis. As I have said,
its etiological factor will probably be found to be a
variant or mutant of the streptococcus group. This
belief seems to be the basis of the most approved
teaching to-day.
Much of the work upon which the foregoing
status is based is due to the facilities for study af-
forded me by the Montefiore Home and Hospital,
New York. The large number of arthritic patients
in the institution has enabled me to study clinical
types with the aid of the excellent laboratory facili-
ties, both chemical and pathological, together with
the very complete x-ray department, all of which
the directors of the institution have very fully
equipped for modern scientific study. And further,
I am indebted to the valuable cooperation of Dr.
Wachsmann, medical director, and his staff. I
wish, also, to thank Dr. S. W. Boorstein, adjunct
orthopedic surgeon, for valuable services rendered.
REFERENCES
1. Elliott: Am. Journal of Orthopedic Surgery,
November, 1911.
2. Triboulet: "Researches on Rheumatism," quoted
by Poynton & Paine, 1914, p. 155.
3. Elliott: Am. Jour, of Ortliop. Surgery, October,
1915.
4. Roque, J. Tessier et G. : Noveau Traite de Med. et
Thera /., Vol. VIII, p. 95.
5. Axhausen: Ztschr. f. Orth. Chit:, 1913, Vol.
XXXIII, Bd., 1-2 H.p.
6. von Manteuffel: Deutsche Ztschr. f. Chir., 1913,
Vol. CXXIV, p. 821.
7. Brackett: Boston Med. & Surg. Jour., July 9, 1914,
p. 63.
8. McCrae: Penn. Med. Jour., April, 1916.
9. Nichols and Richardson: Journal of Medical Re-
search, Vol. XXI, No. 2, 1909, p. 149.
I" Kast Forty-first Street.
RAGWEED POLLEN IN THE NASAL SECRE-
TION OF HAY-FEVER CASES.
Br W. SCHEPPEGRELL, A.M.. MP.
NEW ORLEANS
PRESIDENT AMERICAN HAY-FEVER-PREVENTION ASSOCIATION.
The direct relationship of the pollen of certain
plants to hay-fever has been established in many
ways. First, the commencing and disappearance of
the attack with the beginning and ending of the
Fig. 1. — Pollen of the ragweed, X 500 diameters. The upper
two (A) have a magnification of 1000 diameters. (From the
biological laboratory of the American Haj Fever Prevention
on.)
blooming of these plants. Also the development of
the attack when susceptible subjects come within
the potential area of the hay-fever plants. Then
the confirmation by the biological tests, by means of
which an attack may be induced at any season of
Oct. 14, 1916]
MEDICAL RECORD.
673
the year by applying a few grains of pollen to the
nostrils of the subject.'
While these have fully established this relation-
ship, the finding of the pollens in the nasal secre-
tions of the patient is an important corroboration.
m
rass^
Fig. 2. — Ragweed pollen in hay-fever nasal secretion. The
arborescences are salts in the secretion, crystallized in drying.
X 250.
and the following report of our biological depart-
ment will, therefore, be of interest.
On August 12, 1916, F. W., who suffers occa-
sionally from hay-fever, had an attack during the
night, this being due to a brisk northwest wind
which blew pollen from a large area of ragweed
about one-quarter mile distant. Shortly after re-
tiring, his nostrils became obstructed so that he
could continue nasal breathing only by propping up
his pillows and then only through one nostril.
The following morning, when the patient arose
and exercised, the nostrils became free, which was
followed by the discharge of a clear, viscid mucus
from the nostrils. By previous agreement, this
mucus was collected and sent to our biological labo-
ratory for testing. After the discharge of this
mucus, which lasted about ten minutes, the patient
was practically relieved from any further discom-
fort, as he left for his office which is in the central
portion of the city and farther removed from the
potential area of the ragweed pollens.
The mucus was divided into eight parts, each part
being separately examined. The secretion was
spread on microscope slides and covered with ordi-
nary glass covers, and a drop of iodine solution in-
jected for staining. The microscopic examination
showed that there was an average of seven ragweed
pollens (Ambrosia trifida, the Ambrosia elatior be-
ing very uncommon in this section) to each division,
or a total of 56 pollens in the secretion collected.
The following points are to be noted in this in-
vestigation: The direct relation of the pollen to the
attack, the number required to cause the reaction
described, and the relief afforded by the discharge
of the mucus containing the pollen.
'Scheppegrell, W.: Hav-Fever and Its Prevention,
U. S. Public Health Reports, July 21, 1916.
It has been suggested that the irritation of hay-
fever pollen might be due to the development of the
germinating tubes of the pollen. In no case was
there a germinating tube found among these pol-
lens nor could the pollen be distinguished, even by
the high powers, from the ordinary trifida pollen
i Fig. A).
After the discharge of the mucus containing the
pollen, the patient was relieved from the local irri-
tation and developed no constitutional disturbance.
The pollens in the mucus were usually found sin-
gle, but occasionally in twos and threes. A group
of two magnified 1,000 diameters is shown in the
accompanying photomicrograph (Fig. 1, B).
Ragwood pollen is frequently found in the nasal
secretion of hay-fever subjects at our biological lab-
oratory (Fig. 2), but this is the first instance in
which practically all the pollen of an attack of hay-
fever has been collected and examined.
THE SIGNIFICANCE OF INCREASED DUOD-
ENAL DILATABILITY.*
Br W. HOWARD BARBER. M.D.,
NEW YORK.
There is a tendency to ascribe all duodenal dilata-
tions to immediate constrictions, to obstructions
which are frequently located at the duodenojejunal
flexures. There are other factors, however, of duod-
enal dilatation or, more precisely, increased duodenal
Stump
of ileum
Coecam
Colon,
|<- Sife of
gauze ligature
Colon immediately after removal, showing markedly di-
lated cecum and cephalad colon following incomplete ob-
struction of rectum.
dilatability which are just as tangible, if not just
as comprehensible, which are not resident in the
duodenum, but in the terminal ileum.
*From the Laboratory of Experimental Surgery,
New York University.
674
MEDICAL RECORD.
[Oct. 14, 1916
Increased duodenal shadows have been observed
rontgenographically in individuals found to have at
operations pathologically involved caudad ileums.
The ileocecal regions of these individuals are com-
monly caught in the adhesions which apparently
represent the sequelae of acute appendicitis. The
appendix is normal, not often chronically inflamed,
but the end of the small gut is partially obstructed.
But after this appendix is removed and the neigh-
boring bands restricting the ileum freed, not only
do the gastric emptying and the duodenal clear-
ance improve, but the dyspeptic symptoms often dis-
appear at the same time. Clinically, therefore, these
postinflammatory bands interfere with the contrac-
tions and relaxations of the proximal as well as of
the distal ends of the small gut.1
The question arises whether any causal relation-
ship can be shown experimentally to exist between
this form of incomplete ileac obstruction and ap-
parent overdistensibility of the head of the duod-
enum.
An analogy, commonly known, is that habitual
constipation gives rise, after a period of time, to
increased dilatability of the cecum. Although such
a cecum has been called "crepitant," large, or di-
lated, pathologically one is often at a loss to find
anything structurally wrong with it. Furthermore,
anyone may produce such a hypotonic cecum in nor-
mal dogs by tying gauze ligatures about the terminal
colon so as to produce incomplete obstruction. When
this obstructing band or the habitual constipation
is removed, the tone of the head of the large gut
improves. (See illustration.) It is logical on the
same basis to expect similar disturbances with the
beginning of the small intestine from inflam-
matory interference with the end of the ileum. To
determine whether there is such an interrelation
of the oral and aboral ends of the small gut, the
conditions observed in humans were duplicated as
far as possible in dogs. The results of these experi-
ments have been published.2 From this series it
appeared that increased dilatability of the cephalad
duodenum followed incomplete obstruction of the
terminal ileum. Similar results have since been
obtained on cats. (See the table.)
Table Sbowing Dependence of Tone of Cephalad End of Small Gut
I" pon Caudad End.
Duration of
Obstruction,
Days.
Dilatability of Duodenal Loop, c.c.
Animal No.
Before Ligating
Colon.
After Ligating
Colon.
Cat 339
Cat 324
14
4
B
3
8
-'
1.5
1.7
3 33
3.33
2.5
2.9
2.15
3 8
3.7
There appears, therefore, to be some underlying
dynamic factor in increased ileac resistance that
reduces the tone of the cephalad portion of the small
intestine.
From these observations it seems logical, in the
presence of a markedly increased duodenal shadow
(as depicted by the s-ray during gastric emptying),
to consider upon inferential grounds at least the
possibility of a functionally obstructed terminal
ileum.
Another association developed during the same
two series of animal experiments; namely, de-
creased dilatability or increased tone of the oral
end of the small intestine and complete obstruc-
tion of the aboral end. When the distal ileum be-
came closed by inflammatory reaction or by fecal
accumulation, the size of the duodenum decreased.
The decrease in the duodenum appeared in both the
dog and cat series.
The time element requires especial emphasis. In
the experiments the duration of the terminal ileac
obstruction was four to nine days. Traumatizing
by handling or scratching the terminal ileum pro-
duced no immediate change in the tone of the duod-
enum so far as could be ascertained. In the humans
coming under our control the time factor is usually
longer. It is illuminative, however, to see that,
dynamically, duodenal tone appears to be influenced
by the tone of the terminal ileum.
In this light, the increased duodenal bismuth
shadow does not exclusively indicate immediate ob-
struction, but possibly obstruction at some distal
point, as in the terminal ileum.
REFERENCES.
1. Barber. W. H. : " Dilatation of the Duodenum, An-
nals of Surgery, October, 1915, pp. 433-440.
2. Barber, W. H. : Notes on the Surgical Physiology
of the Dog, Proceedings of the Society for Experi-
mental Biology and Medicine, 1915, XII, pp. 151-153.
61 fi JlAOISO.V AVENUE.
AN INTERMAXILLARY SPLINT.
Bt GEORGE MORRIS DORRAXCE. M.D.,
PHILADELPHIA. PA.
No special type of splint is indicated in all frac-
tures of the upper or lower maxilla. This splint is
indicated where it is impossible to obtain a swedged
intermaxillary or interdental splint. As shown in
the cut, it consists of a perforated plate of German
silver with perpendicular sides. Trie sides have an
opening in front, the plate being absent there to
allow for an over and under bite. It is pliable so
that the width between the plates can be made
greater or lesser according to the width between the
two sides of the jaw.
Application of Splint. — If the lower jaw is frac-
tured, the splint is fitted to the upper maxilla and
if too long is cut off. In case of fracture of the
upper jaw, the splint is first applied to the lower
maxilla. Trie sides are trimmed down or the edges
bent outward, if they press against the swollen
Fig. 1. — Anterior view of splint.
gums. The lower jaw is then pressed up in place
to see that it articulates normally. The splint is
then removed and dried. Kerr's modeling compound
is softened over a flame, being careful not to burn
it (it should never be softened in hot water). The
Oct. 14, 1916J
MEDICAL RECOKD.
675
upper and lower grooves of the splint are filled to
overflowing.
The plate with its contained compound is heated
until the compound is softened. It is tested for heat
against the patient's face; if it can be tolerated
by using warm water and slight traction. The
splint may be reapplied as many times as necessary,
always using new compound, Kerr's being the best.
The patient is able to obtain liquids through the
anterior opening and around the molar teeth. No
Fig. 2. — Splint filled with compound a ■■ for application.
against the face it will not burn the mouth. Now
dry the mouth by putting in rolls of cotton and
swab the teeth with alcohol. (If time permits, a
hypodermic of morphine and atrophine, one-half
hour before applying the splint, will help to keep
the saliva in check.) Now quickly remove the cot-
ton, introduce the splint with the hot compound and
press it against the jaw. Then press the lower jaw
against the upper, being sure that the normal bite
PIG. 3. — Anterior view of splint held in place by compound
is obtained and with the first finger press the com-
pound around the teeth. Syringe the mouth with
cold water to set the compound. A Barton bandage
is applied as an added security and to overcome any
muscular action. The splint can be easily removed
FIG. ! — Anterior view of splint applied.
hot liquids should be allowed. Wash and syringe
the mouth several times a day with permanganate
of potassium or a saturated solution of potassium
chlorate. Always remember the splint will hold the
fragments where you place them, but do not expect
it to reduce your fracture. This splint is applicable
to all fractures of the jaws within the alignment of
the teeth, angle, or ramus. Be sure the normal bite
is obtained.
I am indebted to Dr. A. deWitt Gritmau for val-
uable suggestions and to Mr. Dutcher, a student of
dentistry in the University of Pennsylvania, for
numerous modifications and the making of the first
splint.
W u.NLi Street.
AN APPARATUS FOR THE DIRECT AND
CONTINUOUS TRANSFUSION OF BLOOD.*
By ALFRED KAHN, M.D.,
NEW YORK.
The transfusion of blood by the syringe method
for practical purposes in most cases seems to be
more popular within the last few years than the
cannula method as practised by Sweet, Crile, and
others. The syringe method recently improved by
Libman requires the use of a number of syringes.
The donor is placed on one side of the operator and
the recipient on the other. The blood is drawn
from the donor, transferred to an assistant, who
injects this blood into the receiver. The syringe
is then passed to a third party, who cleans it with
salt solution, in order to have it ready again for
the operator. Meantime the operator uses a fresh
syringe, passing it along the circuit as above de-
scribed. This method offers a number of disadvan-
tages. Briefly enumerated these are: the number
of syringes used, number of assistants required,
chances of clotting, chances of infection, special
technical knowledge required, thus making it diffi-
*From the Laboratory of Experimental Surgery, New
York University and Bellevue Hospital Medical College.
676
MEDICAL RECORD.
LOct. 14, 1916
cult for the average surgeon to practise. The
method, therefore, has been variously modified. A
number of procedures and new instruments have
been tried. The most popular of these doubtless is
the instrument devised by Unger. This consists
1 - -Apparatus for direct transfusion
of a two-way cock arrangement. The blood is first
drawn from the donor, the cock is then turned into
its second position, and the blood is injected into
the receiver. Meantime in this second position a
way is left whereby an assistant washes the passage
through the needle leading to the donor with salt
solution, the idea being to prevent clotting. The
cock is then turned back to its first position, the
passageway being between the assistant and the
receiver is then washed with salt solution while the
operator is again drawing away another syringe
of blood, preparatory to repeating the cycle. Theo-
retically this method requires but one syringe. If
the transfusion is kept up for any length of time
more than one syringe is usually required. The
constant injection of salt solution is necessary in
order to keep the blood from clotting in the small
caliber needle, in the cock passages, and in the rub-
ber tubing by which the needles are attached to the
cock. The chances of clotting in the syringe are
greatly minimized by constantly spraying the
syringe with ether, but in order to keep the clot-
ting from taking place in the needles, rubber tube,
and cock passages, the injection of salt solution is
constantly necessary. As to whether a man uses
one or more syringes to my mind is not a very great
factor, as the syringes are cheap, and if they make
a clean operation it would be better to use several
than to use one.
The idea in the apparatus here described is an
endeavor to improve upon the instruments men-
tioned. The advantages which I desire to mention
for this apparatus are that there are no rubber
parts, the instrument being entirely of metal, that
there are no joints to harbor infection or possible
favorable localization for clotting. The instrument
is very simple in construction, and it requires no
special technical knowledge to use it. It can be
operated if necessary by one man.
Description of Apparatus. — The apparatus (Fig.
1) consist of a crossbar or gallows placed upon two
upright rods. The crossbar is made fast to one of
these upright rods at one end, and at the other end
is slotted so that it can be widened or shortened at
will, thus graduating it to a table of almost any
width. The two vertical rods holding the cross-
bars are held in two clamps respectively, one at
each side so that they can be fastened firmly by
hand screws to the table. The gallows is grooved
in two places (as shown in Figs. 1 and 3). These
grooves are made for a spring slot which closes
on the neck of the needle, which I am about to
describe. The crossbar can be notched on either
side by the slots in several places, thus allowing
several needles to be used if desired. The needles
illustrated (Fig. 2) are about 6 inches long and are
so curved that the point of the needle is nearly
at right angles to the head. I have arranged two
kinds of needles: one has a sharp point and the
other has an olive tip point. The heads of the
needles are made with a double collar and a neck
between. The caliber of the needle is made just
snug enough for the insertion of the tip of a Record
syringe at its top or a metal stopper of the same
diameter (Fig. 1 illustrates this feature). The
needle is held firmly in the slot.
Technique. — The arms of the donor and receiver
are placed under the gallows (Fig. 1), their hands
being in opposite directions. The arms are made
even, the gallows is screwed down to the height de-
sired, the first needle is inserted into the recipient
in the direction of the receiver's flow of blood stream
(pointed away from the hand). It is then raised
at right angles and the neck is pushed into the
clamp on the crossbar, where it is held firm, and
a metal stopper is pressed into the mouth of the
needle (Fig. 1). Another needle is inserted into
the vein of the donor pointing toward the hand.
It is likewise raised at a right angle and pushed
into the slot in the gallows, where it is held firmly.
The slipping into the groove in the gallows is done
very gently, and the position of the needle is not in
the least disturbed. After the head is once snapped
Ilea used Cor transfusion.
into its groove the needle is perfectly steady and
held firmly, flush with the upper surface of the
gallows. The apparatus is now ready for the trans-
fusion. The operator stands at the end of the table
on a box or any slight elevation, so that he is above
Oct. 14, 1916 1
MEDICAL RECORD.
677
the gallows. The syringe is inserted into the mouth
of the donor's needle, and the blood is withdrawn.
The operator then raises the syringe, sets the stop-
per, places the syringe tip into the mouth of the
receiver's needle, and injects the blood into the
receiver (Fig. 1). After the blood is injected the
syringe is raised out of the mouth of the receiver
needle and placed into the mouth of the donor
needle, and the cycle is ready to be continued.
The operator continues in this cycle until the quan-
tity of blood desired has been withdrawn. The whole
procedure is comfortably before him, much more so
than the keys of a telephone board are before the
eyes of a telephone operator. The syringe is raised
and inserted from one opening to the other, and
the procedure is very quick. There is no slipping
of the needles out of the blood-vessels as the dis-
tances are always uniform. Where any quantity of
blood is to be withdrawn, I recommend an olive
Fig. 3. — Apparatus for continuous transfusion.
tipped needle. In this case a small incision about
Vi inch long is made down to the vein, a stab
slit is made into the vein, the olive tip is then in-
serted and, if desired, can be fastened by ligature.
The transfusion is then highly satisfactory and
can be more easily performed.
Continuous Transfusion. — To do a continuous
transfusion the procedure is as follows (Fig. 3) :
The vein in both donor and receiver is cut down
upon by an incision about % inch long, the vein is
exposed, and the vein is opened. Now instead of
using two needles, I use four needles, one needle
pointing toward the hand and the other pointing
toward the heart, in both recipient and donor. The
blood is then withdrawn from the distal end of the
donor's vein and injected into the proximal end of
the receiver's vein and withdrawn from the distal
end of the recipient and injected into the proximal
end of donor. The whole procedure is just as com-
fortably before the eyes of the operator as in the
case of direct transfusion; the whole thing can be
done by one man. Continuous transfusion is as yet
only in an experimental stage.
Recapitulation. — There are no joints, no rubber
parts. The whole instrument can be sterilized.
The caliber of the needles is larger, clotting is less
apt to occur. The procedure is extremely simple
and can be carried out by one man.
50 East Forty-second Street.
RECURRENT ACRODERMATOSIS OF WARM
COUNTRIES.
By R. RUIZ-ARNAU, M.D.
SAN JUAN. PORTO RICO.
PRBSIDBNT OF THE ACADEMY OK MEDICINE OF PORTO RICO.
We propose to designate by the name of recurrent
acrodermatosis, an affection which is, by the way,
quite variously interpreted, especially from the
etiopathogenic point of view, and which may be
observed daily in our country.
Before entering on a special study thereof, cer-
tain observations relative to the generic idea in-
volving this as well as several other processes very
common in warm countries, are indispensable.
In another work1 we have endeavored to demon-
strate that in tropical lymphangiectasies, besides
the three stages of evolution noted by classical au-
thors, to wit: (1) Infection and inflammation of
the lymphatic vessels; (2) obstruction (or vice-
versa) ; and (3) terminal distention followed by
secondary lymphectasia it is necessary to consider
one more stage: primary lymhphectasia, purely
climatic, which, free of all infection or infestation,
always preexists, and becomes later the obligatory
companion of all tropical lymphangiectasic pro-
cesses.
Such primary lymphectasia, which, summarily,
is nothing more than a special manifestation of the
permanent general state produced in the human
system by the concurrence of different physical
elements that integrate intertropical surroundings,
comes as a substitute of that vague and undeter-
mined notion which over a quarter of a century
ago was introduced by Corre" under the term
lyniphatexia, provided all such matter as is to-day
well known to be derived directly from tropical
parasitism, is segregated from the former.
This lympectasia is responsible not only for the
greater intensity and frequency of lymphangio-
pathic processes in our zone, but also, and princi-
pally, for their recurrent character, and constitutes
a permanent state of condition of the inhabitants
of warm and damp countries. It requires a certain
period of time to establish itself in persons coming
from other latitudes, and relief is had and the con-
dition even disappears when the patient, whether
belonging to the tropics or not, either goes or re-
turns to extratropical regions.
In many persons, either because of perfect
adaptation, or because the different accessory causes
stated in the work above cited do not act upon
them, such condition persists latent during life,
while in numerous other cases, it becomes manifest
under various aspects and different localizations by
virtue of the concurrent action of those same cir-
cumstances. It then constitutes the substratum
upon which very often, though not always, infec-
tion and infestation occur, giving rise, together
>178
MEDICAL RECORD
| Oct. 14, 1916
with their accompaniment of inflammation, obstruc-
tion, and distention of the lymph vessels, to the
respective clinical manifestations of lymphangitis
or filariasis.
With respect to the clinical reality of this physio-
pathological substratum, pure and simple, or in
other words, free from infection or infestation, we
would again refer the reader to the above-mentioned
work, where he will also find ample explanation of
the matter. It is enough to state at present that
the tropical lymph stasis, pure or hygrothermic, is
clinically expressed by means of various forms cor-
responding to as many different localizations, ac-
cording to the part of the body where such lymphec-
tasia accentuates itself sufficiently to become evi-
dent, when certain circumstances of environment
provoke the lymphectasic attack. And thus, at
times, it is in the radical, again, in the reticular,
and lastly, in the ganglionar sections of the
lymphatic apparatus of the extremities, preferably
the lower, where, by recurrent outbreaks, simple
lymphectasia establishes itself. The different forms
ordinarily develop independent of each other, or in
other words, two different localizations of the
lymphectasic process are not found simultaneously
in the same patient, unless as an exception.
A peculiar clinical modality, therefore, corre-
sponds to each localization; and when the lymph
stasis occurs in the radicals of the apparatus, there
appear from time to time outbreaks of the derma-
tosis to which the present work refers.
Recurrent acrodermatosis, as frequently ob-
served in Porto Rico, is, without doubt, the clinical
expression of primary radical lymphectasia. This
relation being constantly unknown, such cutaneous
manifestations are often ascribed to uric acid con-
ditions, as well as to syphilis, on account of their
symmetrical or bilateral disposition in not a few
cases. This error, after all, should not cause sur-
prise, if we consider that patients call on their
physician at a very advanced stage of the process
of evolution of the dermatosic lesions, the real com-
mencement of which is the varicose enlargement of
the original lymphatic capillaries.
In private practice cases of tropical acroderma-
tosis are innumerable ; but we have had occasion to
study it specifically, particularly that of the feet,
in the infirmaries of the Boys' and Girls' Charity
Schools in Santurce, Porto Rico.
The total number of inmates of these schools
varies from 400 to 500, and catalogued cases of re-
current dermatosis of the feet number 101, cover-
ing 127 attacks from 1907 to 1912 in the Boys', and
from 1909 to 1912 in the Girls' infirmaries.
The number of dermatosic outbreaks occurring
iluring the period of unstable hygrothermic condi-
tions, that is, during the months between the two
yearly seasons— the dry and cool and the hot and
humid — was somewhat more than double the num-
ber of those occurring during the two seasons of
settled weather conditions— 87 against 40. Thus
for March, April and May, the total number was 39,
and the average 13; for September, October and
November, the total number reached 48, and the
average 16; while for December. January and Feb-
ruary, the total was 18, and the average 6. In June,
July and August, the total amounted to 22, and the
average to 7. We do not intend to base a general
rule on an insufficient number of observations, but
believe it is useful to state the facts.
Commonly, when the patient consults his phy-
sician, there are seen at the same time: blisters full
of serum or sero-pus, a great many of them broken,
thus exposing the mucoid layer of Malpighi, which
has been perforated in the center; softened and
cracked sections of epidermis; and lastly, partly
healed lesions alternating with others correspond-
ing to the first stage, that is, papuliform prurigin-
ous elevations, about to become vesicles.
The complaint commences by a violent itching in
the regions where later the ostensible manifesta-
tions of dermatosis are to develop, specially in the
interdigital spaces. This itching causes the patient
to scratch, thus contributing to the congestion of
the skin and to the rupture of its superficial layers,
from which a small quantity of ichorous lymph is-
sues, which, in turn, spreads the irritation and
pruritus over the surrounding parts. Shortly after-
wards there appear in the neighborhood of the bases
of the toes, on the heel and on the side of the foot —
the same not being confined exclusively to any of
these places — the circumscribed characteristic
lesions.
A small, hard, papuliform elevation of the size
of a common pinhead or little more, quite painful
under pressure, in a few hours becomes a some-
what larger vesicle whose contents, separating the
epidermic layers over a certain area, transform the
vesicle into a blister. Such blister soon either bursts
or is ruptured by the patient, or becomes sero-
purulent and increases in size until it reaches that
of a shirt-button. It finally bursts, disclosing a
background that has a central craterlike depres-
sion, from which exudate issues for a certain time,
although in some instances it dries rapidly.
In order to understand the successive linking of
these lesions, we should remember that the lym-
phatic vessels grow on the level of each papillary
layer, from a large central capillary which is joined
to neighboring capillaries, thus forming a sub-
papillary rete. The acrodermatosic lesion begins by
the varicose enlargement of these original lym-
phatic capillaries, which form, as is well known,
culs-de-sac in the papillary layer. As a result of
the excessive tension of their contents, the purely
endothelial walls of the vessels pregressively dis-
tend and become thinner until they permit the
serosity to reach the intercellular spaces of the
mucoid layer, to break the uniting filaments of
the cells of this layer; and to separate such cells
until lacunar spaces are formed under the granular
stratum. The granular layer is loosened in turn
and becomes thinner, raising before it the stratum
lucidum and the horny layers. It is easy to under-
stand that the epidermis is separated from the
papillary layer in two ways: either en masse, if
adherence between the Malpighian cells is very
firm, or otherwise, if it is weak, the cellular ele-
ments becoming separated from each other in order
to form circumscribed spaces filled with serosity.
and to constitute the vesicles and blisters from
the loosening of the epidermic layers. The process
is no other than that designated by dermatologists'
by the name of interstitial vesicular infiltration, to
distinguish it from parenchymatous infiltration, in
which the small phlyctena is formed, on the con-
trary, by intracellular edema.
The total evolution of each lesion lasts from
five to seven days, and the dermatosic eruption,
abandoned to itself or subjected to the sole
action of the numberless antiseptic or simply
drying applications may be prolonged for
weeks and even months; and the troublesome
manifestations are very often indefinitely repro-
Oct. 14, 1916|
MEDICAL RECORD.
679
duced, greatly to the discomfort of the patient.
In some instances, though not often, there is ob-
served a slight lymphangitis which, commencing at
one of the lesions does not, as a rule, extend beyond
the foot, nor does it become a true attack of lym-
phangitis of the leg, but is susceptible, nevertheless,
of producing a slight fever.
Generally, the attack extends to both feet, one
after the other. Sometimes it is simultaneous,
obliging the patient to interrupt his daily labor be-
cause it is impossible to wear shoes or to walk.
This condition may last for many weeks, unless the
only efficient means of shortening its duration and
of obtaining positive success with local treatment
are adopted. Such means should certainly not be
irritating antiseptics, as is commonly advised for
the sole purpose of combating infectious germs,
for although it is true that the same often intervene,
they do so during the later stages of the process,
and as a complication. The correct treatment con-
sists simply in the enforcement of the dorsal decu-
bitus maintained during such time as the acute
period of the lesions may last, and until there are
no further new lesions, which continue to appear
for a time after the patient is confined to bed, al-
though the latter are scarcer and less violent.
Such simple and efficient treatment having been
commenced, the real action of antiseptic topical
applications is produced and the involution of the
eruption takes place rapidly. The exposed and soft-
ened surfaces dry quickly, pain and congestion
cease, and finally the lesions heal without leaving
any durable signs, the dermatosic attack being thus
notably shortened, the patient being permitted to
resume his daily occupations.
Dermatosis of the hands presents analogous
characteristics, although different from dermatosis
of the feet — apart from being less frequent — be-
cause of features derived from anatomical condi-
tions which normally distinguish the skin of the
upper and lower extremities. The lesions, in an ad-
vanced stage, acquire in dermatosis of the hands,
an eczematous appearance, damp at times, but dry
in many cases. However, during the first evolutive
stages, it is identical with dermatosis of the feet,
the period of pruriginous congestion being possibly
more intensely manifest, and the papuliform eleva-
tions more noticeable; for example, it is easy to
see a sort of whitish thread formed by these eleva-
tions, when they appear in series, furrowing the
edges of the attacked fingers.
In dermatosis of the hands, the process extends
over a greater surface than in dermatosis of the
feet, where we found that it may finally adopt
phlyctenular forms of greater size. As occurs in
dermatosis of the feet, the affection rarely extends
beyond the joints of the hand and the rest of the
extremity, unless excessive fineness of the skin or
other aggravating circumstances in the patient per-
mit of its extension to the forearm.
As to the rest, dermatosis of the hands has the
same recurrent tendencies, at certain times of the
year, as that of the feet, and is just as rebellious
under treatment. It should be noted that the same
benefit may be had by confinement to bed, which,
as may be presumed, is difficult to obtain, since it
is not easy to convince the patient that a complaint
of such nature and localization requires treatment
which means to some persons a real sacrifice.
When both dermatosic eruptions coincide — which
is not rare — such fact should not be really inter-
preted as autocontagion. but simply as two almost
simultaneous manifestations of the same condition
in the same subject, due to analogous general and
local causes. And it is then possible to observe re-
lief in the dermatosis of the hands very much
sooner, if the patient, on account of the dermatosis
of the feet, accepts the sacrifice of confinement to
bed.
Apart from the general tonic-restorative treat-
ment, principally on the basis of phosphates and
strychnine, local treatment varies according to the
stage of the attack.
During the prevesicular stage we have obtained
excellent results by applying to the affected parts
a solution of picric acid, 12 to 1000. The keratop-
lasty action of this agent, so efficient in cases ol
burns, is as efficient in the disease under considera-
tion; to such extent that used in time it not seldom
serves to abort, one might say, the dermatosic
eruption. We have recently had occasion again to
confirm this in the case of a North American, in
whom we saw an attack of dermatosis of the hands
abort in less than one week, by the sole use of the
solution above mentioned.
The first stage having passed, it is then not only
unfavorable, but it might possibly be prejudicial
to employ this solution. We would then prefer to
prescribe a salve of ichthyol, 5 grams, in sterlized
vaseline, 30 grams.
Before applying the ointment we would advise
that the section be washed, or even better, fomented,
for a few minutes, with the following prescription :
Sodium borate 5 grams
Boric acid 40 grams
Boiling filtered water 1 liter
M. Sig. : To be applied twice daily.
During the last stage we prescribe dermatol ex-
clusively, in order to accelerate the drying of the
affected surfaces.
In ambulatory treatment we recommend to the
patient that he always place between the toes a
little absorbent cotton, which should be frequently
changed in order thus to aid in preventing irrita-
tion of the surrounding surfaces by the exudate.
Before adopting the simple local treatment above
stated, we experimented with a number of applica-
tions of all kinds in the infirmaries and in private
practice, without satisfactory results; on the con-
trary, in certain cases the state of the lesions was
aggravated. We must, however, except the follow-
ing salve, which appears to us to have been of some
benefit in the second stage :
I?
Zinc oxide 5 grams
Carbolic acid 50 grams
Lanoline ) .. , _
Vaseline [aa 15 grams
Sprinkle on this a good quantity of borated
talcum.
In our opinion, from the foregoing study it may
be inferred that recurrent acredermatosis of warm
countries, although etiologically and pathogenically
analogous to other lympectasic manifestations,
merely climatic, possesses sufficient anatomoclinical
characteristics to entitle it to nosographic per-
sonality in the extensive field of tropical pathology.
REFERENCES.
1. Ruiz-Arnau, R.: "La Lymphsectasie Tropicale
Primitive." A. Mocloine, Editeur, Paris.
2. Corre, A.: Traite clinique des maladies des pay?
chauds. Paris, 1887.
3. Brocq and Jaquet: Patologia General Ctitrfrtea
p. 34. S. Calleja, Editor, Madrid.
680
MEDICAL RECORD.
[Oct. 14, 1916
TREATMENT OF WOUNDS.
liv L. SEXTOX. B.S.. M.D.,
NEW ORLEANS, LA.
LEgTUREK ON MINOR SURGERY, TU1.ANE UNIVERSITY.
A wound is a sudden solution of the continuity of
the soft parts. There are fifteen adjectives de-
scribing wounds, which we will not burden the
reader to remember, but many of these descriptions
have a bearing on the treatment of the injury.
Immediately following this sudden solution of
continuity of tissue, we have discoloration, pain,
swelling, and hemorrhage.
The element of pain incident to such an injury
depends largely upon the location of the wound and
the character of the implement with which it was
produced. For instance, a steel-jacketed bullet
with high velocity may pass through the body un-
noticed, the wound being discovered later by the
blood trickling down from its opening. Incised
wounds made by sharp instruments, as surgeons'
knives, cause very much less pain than do lacerated
and contused wounds. Wounds of nerve trunks, of
the testicle, of the elbow, of the hands and fingers,
and of the abdomen are characterized by severe
pain. A wound in inflamed tissue, as produced in
lancing an abscess, is always attended with great
pain. Increased tension and pressure upon the sen-
sory nerve filaments is the explanation of these
painful injuries.
In all wounds there is a discharge of fibrin,
lymph, and serum from the vessels which must be
absorbed by some superimposed sterile gauze dress-
ing. The arrest of hemorrhage and removal of
foreign bodies is an important consideration in the
first-aid treatment to injured soft parts. If an
artery is severed which is too large in caliber for
the bleeding to be arrested by torsion, it should be
picked up, separated, and ligated. Very often if
such vessels are compressed by artery forceps for
a short time, they stop bleeding without other treat-
ment. If the wound is just above some bony prom-
inence, direct pressure will often arrest the hemor-
rhage better than the insertion of sutures or liga-
tures. Continuous oozing from the wound (as in a
large amputation) may be controlled by flushing
with hot sterile salt solution, or by fanning the
surface briskly while exposed to the air.
A suture often acts as a ligature in arresting
hemorrhage; this is particularly true if the suture
is cf the buttonhole variety. It should be remem-
bered, however, that we often strangulate tissue
by tying our sutures too tight in trying to
arrest hemorrhage by this method. Adrenalin
chloride 1 to 1000 on pledgets of cotton is a useful
hemostat; it may also be injected into cavities, as
the urethra, or sprayed into the nostrils to arrest
bleeding. In venous oozing, elevation and direct
pressure are effectual in many cases; if from an
artery, the tourniquet or ligature will act better.
It is embarrassing to have to open up a wound, as
in the scrotum, turn out blood clots, and catch up
oozing vessels at the second dressing which should
have been attended to at the first.
All chemical and constitutional remedies for the
arrest of hemorrhage are obsolete in wounds newly
made, but are admissible in hemorrhage from the
relaxed uterus and from ulcerated cancerous
growths.
The next most important step in the manage-
ment of wounds, after the hemorrhage has been
stopped, is to cleanse them. It depends largely
upon the location of the wound as to what method
of cleansing should be adopted; if, for instance,
it is under the clothing on a clean skin surface
partly covered with hair, the adjacent tissues should
be shaved to prevent the hair from infecting the
wound and keeping its edges separated. If the
wound is on the scalp it is best to shave the proxi-
mate skin and to lift up the edges of the flap in
order to remove any foreign body which might
have been forced under the scalp at the time of the
accident. While this is the general procedure, it
might be occasionally modified for cosmetic pur-
poses if the wound happened to be on the scalp of
a female, then under such circumstances strands
of hair on either side of the wound might be tied
across in order to approximate the edges.
I have had no personal experience with this
method.
In lacerated or crushed injuries use hot sterile
water or saline solution flushing to wash out for-
eign particles. A great many surgeons, however,
prefer a fifty per cent, solution of peroxide of hy-
drogen warmed and poured into the wound. The
oxidation with the blood boils out many small par-
ticles, carrying infection which might not other-
wise be detected. As a matter of course, any
splinters or other foreign bodies, such as iron fil-
ings, etc., should be carefully removed either with
forceps or a magnet. Blood-clots and tissue with
the life crushed out should be removed at the first
dressing while the parts are usually benumbed,
rather than wait for decomposition and sloughing
before removing them. We may safely assume that
most accidental wounds are infected, hence the im-
portance of thoroughly cleaning them at this first
dressing; stitches should be loosely applied and
drainage in the most dependent portion of the
wound provided for, as it is not good surgery to
seal accidental wounds hermetically with either col-
lodion or adhesive plaster, unless the absorption
of the wound secretions is first provided for. If
nerves or tendons have been severed, they should
be approximated by sutures whenever it is possible
to find the severed ends. If the wound is very ex-
tensive and there is likelihood of foreign bodies
being driven into sensitive parts it sometimes be-
comes necessary to cocainize or, in the severe cases,
to anesthetize the patient in order thoroughly to
cleanse and approximate the parts at the first
dressing.
In accidents from toy pistols, giant fire crackers,
or garden rakes, or in injuries inflicted around
dairies or barns and in any severe laceration and
contusion of the extremities, it is considered neces-
sary to give 2,000 units of antitetanus serum as a
prophylaxis against tetanus.
In very delicate skin that has been protected by
clothing in children and in females, the rough brush
scrubbing act has been overdone; in fact, in the
case of injuries incident to machinists, miners, rail-
road men, etc., with oil, grease, and iron dust or
rust ground into the tissue, it is almost a physical
impossibility to get rid of the foreign matter at
the first dressing either by scrubbing or any other
process.
A great many such cases are now dressed by
saturating a pledget of cotton with spirits of tur-
pentine or gasoline and rubbing off as much of the
grease and paint as the turpentine will dissolve;
then applying a 52 dilute tincture of iodine with al-
cohol into the wound after it has been thoroughly
flushed with any of the mild antiseptic lotions.
Oct. 14, 1916]
MEDICAL RFXORD.
681
Keeping such wounds dressed several days with
a moist half per cent, carbolic solution, or 1 to 10,000
bichloride will prevent infection, and so soften up
these calloused hands that what was impossible to
wash off at the first dressing is easily scraped off
after forty-eight to seventy-two hours' application
of these moist antiseptic solutions. In all deep
wounds involving large areas or injury to the bone,
drainage is advisable, at least for the first twenty-
four to forty-eight hours. The ordinary cigarette
drain, sterilized gauze, rubber turbing, or ordinary
rubber tissue may be used, according to the indi-
vidual surgeon's experience. Only one certain rule
should be observed, namely, the drainage must be
in the most dependent portion, even if this requires
a counteropening to get it. Dead spaces impossible
of obliteration require drainage as do amputations
of the breast and thigh and suppurative appen-
dectomies. It should be remembered, however, that
all drainage of abdominal wounds predisposes to
hernia.
In wounds in the pleural cavity to evacuate pus.
free drainage with double rubber tubing and, in
most cases, the resection of a rib become necessary
in order that the drainage may be complete. In
unhygienic surroundings with untrained help to
rely upon we should hesitate to close any lacerated
or contused wound ; under more favorable surround-
ings and with our individual inspection it is best to
close many of them, using drainage in the cases
which we would otherwise treat openly. Punctured
dissecting wounds should be very rarely closed,
and wounds in the palm of the hand and soles of
the feet are best treated openly; those in vascular
tissue where the skin is loose are perhaps better
stitched with silk worm gut. It has been found
best in recent wars to seal hermetically without
drainage gunshot wounds produced by the steel-
jacketed bullet. Whenever it is decided to close a
wound, the interrupted silkworm gut suture is
preferable on account of being non-irritating, less
likely to infection, and absorbing no moisture.
Horsehair is used with equal success in closing
many external surgical wounds. Some surgeons
prefer the continuous suture, others the Michel
clamp, while some use the subcuticular stitch for
cosmetic purposes. If the zinc oxide plaster is used
to approximate wounds, small fenestras should be
cut in the plaster just above the wound to provide
for the escape of the oozing or wound secretion,
which always follows. The collodion dressing is
applicable to superficial wounds about the face
where not much oozing is expected. Wounds well
sewed are half healed. Tight sutures constrict and
produce necrotic tissue. One can hardly tie a su-
ture so slack that the subsequent swelling will not
tighten it; the elasticity in the horsehair suture
causes it to yield when swelling takes place and it
is on this account that it should be more generally
used than it is. Fine silk and silkworm gut are
usually preferable to the catgut where infection is
feared. Any traumatic injury treated by the open
method should be covered with 1-10,000 bichloride
or some other antiseptic dressing. If the injury is
to the leg or foot the patient had better be confined
to bed to secure rest, the hand or foot placed upon
a Kelly pad and kept moist by applications every
three or four hours, or by the continuous hot 1 to
10,000 bichloride solution; if the wound is not in-
fected, on sensitive portions of the skin or in chil-
dren the solution should be further diluted or weak
iodine mixture or boracic acid be substituted for
the bichloride.
Physiological rest is important in the treatment
of all wounds. Splints to the hand and immovable
dressings to the joints are great time-savers in the
healing of wounds. Perfect rest means less pain,
reaction, and quick repair.
Whenever large raw surfaces are to be treated for
a long time, it may become necessary to change to
the boracic acid rather than the bichloride or car-
bolic. After these large raw surfaces are in proper
condition, skin grafting hurries healing and pre-
vents scar tissue. Thiersch's or any method the
surgeon is accustomed to may be used; usually we
inspect or remove the dressing from skin grafting
too early, often lifting up the graft with the dress-
ing. In large incised wounds it is just as essential
to suture the muscles as it is the tendons and
nerves. It may be difficult at times to find the
proximal end of the tendon, in which case the
wound should be enlarged until it can be found
and mended.
Most lacerated contused wounds are better packed
and left to granulate than sutured ; if, however,
they are sutured, a drain should first be put in, the
sutures being placed far apart and loosely tied.
Elevation and rest must not be overlooked in the
treatment of contused wounds as they lessen pain
and promote healing.
Lacerated wounds are an exaggeration of the
contused wounds, only shock is greater and hem-
orrhage and pain less.
If an extremity is literally amputated traumatic-
ally, it is usually better to secure the blood-vessels
so that there can be no more hemorrhage, treat the
shock by warmth and stimulation, and leave the
amputation for twenty-four or forty-eight hours
until reaction has set in. If the leg or arm is hang-
ing only by skin or tendinous attachments, where a
scissors amputation will remove the limb, this
should be done, but any extensive surgery had bet-
ter be postponed until reaction takes place ; other-
wise one may get the credit of having produced a
surgical death, when waiting might have saved the
patient. We should always remember that hemor-
rhage must first be controlled before any waiting
is resorted to, for hemorrhage is the most common
cause of shock ; however, nerve blocking with co-
caine permits amputation which we otherwise would
not attempt.
Punctured wounds should not be probed, if they
have opened the chest or peritoneal cavity. A lap-
arotomy should be performed and any injured vis-
cera mended, otherwise you may have a death from
shocks, sepsis, or hemorrhage, in abdominal cases.
In punctured wounds from blank cartridges, gar-
den rakes, or barn splinters, the parts should be
thoroughly cocainized or the patient given a gen-
eral anesthetic, the wound opened up by a crucial
incision, the foreign bodies, wads, or portion of
cloth driven into the soft tissue removed, dilute
tincture of iodine with alcohol dropped in, and the
part packed with iodoform gauze, leaving the wound
to heal by granulations from the bottom. As said
before, all such cases should have the additional
protection from tetanus by the injection of 2,000
units of antitetanic serum.
Gunshot wounds are usually treated without
probing and by the local application of 1 to 10,000
bichloride ; bullets may become encysted and do very
little harm.
Prevention of infection is far more important
than the removing of the bullet, which can be lo-
cated by the .r-ray and removed at any future date,
provided it gives no serious trouble.
682
MEDICAL RECORD.
LOct. 14, 1916
Direct penetrating wounds of the abdomen with
lead bullets demand an immediate laparotomy pro-
vided a competent surgeon is available, not so much
with the view of locating and removing the bullet
as of mending the tear in the viscera and checking
the hemorrhage. Bullet wounds in the thorax and
in the extremities are usually treated expectantly
without operation unless infection takes place. If
a bullet passes through the chest and lodges in the
spinal column, causing pressure upon the cord, im-
mediate extraction should be performed, provided
the bullet can be located by the z-ray.
All violently infected wounds of extremities
should be put at rest at once, the patient being con-
fined to bed; the bowels should be thoroughly
opened, and large antiseptic dressings should be
applied and be kept constantly moist. The less
handling the better. After forty-eight hours of
such continuous treatment one will often find the
inflammation subsiding or a local abscess formed.
Rest, in septic wounds, is more important than in
any other variety of injuries.
Conclusions. — Unless wounds are suppurating
very freely they are usually dressed too often.
Peroxide of hydrogen injected into cavities and
sinuses often carries the infection further into un-
invaded tissue. Peroxide is also too strong to applv
pure to newly healed tissue.
Sterilized gauze without dusting powder is suffi-
cient protection for any clean surgical wound.
Sterile water, saline solution, or a very mild anti-
septic solution should always be given preference
over the stronger antiseptics which, in destroying
the pus coci, at the same time destroy the new epi-
thelial tissue by which granulating wounds are
covered.
There is no better protection against infection
than the free application of large sterilized pads
or dressings with which they should be abundantly
covered.
Absolute physiological rest by a properly applied
splint or confinement in bed is a great time saver
in the healing of wounds.
Silkworm sutures are much less likely to produce
stitch abscesses and should be given the preference
over catgut wherever practicable.
Zinc oxide plaster has a wider field of usefulness
as a surgical appliance than has been given to it.
In redressing wounds, all materials should be
thoroughly softened by warm sterile water before
the dressing is removed. Two thousand units
antitoxin serum should be given with a local appli-
cation of equal parts alcohol and tincture iodine
at first dressing.
r>06 Medical Building.
fMtralpgal Nntm
Powers of Boards of Health in Prevention of Epidem-
ics. — The Kentucky Court of Appeals holds that the
State Board of Health or a county board has authority
to order that school children be vaccinated or excluded
from the schools when they believe there is reasonable
apprehension of an epidemic, and that the vaccination
of the school children is the only means by which it
can be prevented. The precise question had not pre-
viously come before the Kentucky court, but it has
frequently hern adjudicated by other courts, and the
uniform ruling: is that when there is reasonable appre-
hension of the outbreak of a communicatee disease such
as smallpox, health boards have authority to take such
action. What boards of health shall do to prevent epi-
demics, and how it shall be done, are matters lei'
their sound discretion, thought they cannot adopt un-
reasonable or arbitrary rules or regulations, or, with
out cause, harass the public unless they have rea-
sonable grounds to believe that the action is neces-
sary to prevent or suppress the disease sought t" be
controlled. Courts may restrain boards of health if
they undertake to exert authority not fairly within the
powers conferred by statute or plainly not needed for
the purpose of conserving or protecting the health of
the people or preventing the outbreak or spread of in-
fectious or contagious diseases. But the discretion
lodged in boards of health in the exercise of their powers
will not be interfered with unless plainly abused. —
Board of Trustee v. McMurtry, 184 S. W. 390.
Malpractice — Diphtheria. — In an action to recover
damages for death by diphtheria caused by malpractice,
because of the failure to administer antitoxin, it ap-
peared beyond dispute that it is not usual or custom-
ary for physicians to cause bacteriological or micro-
scopical examinations of the contents of the throat to
be made, except in cases where a membrane is present.
There was no evidence to show that there was at any
time any membrane present in the throat of the de-
ceased child, and, it appearing without dispute that
some cases baffle the most skillful diagnosticians, the
case at bar might have been such a case, in which event
the defendant could not be held liable for his failure
to make a correct diagnosis and consequent failure to
properly treat the patient. The law does not require
impossibilities, or even the exercise of the very highest
degree of skill or the utmost care, but only such rea-
sonable care and skill as is usually possessed by phy-
sicians in the same school in the locality. There was no
evidence tending to show that the exercise of ordinary
care and skill by the defendant would have prevented
the child's death. The medical testimony showed con-
clusively that the result, where antitoxin is not ad-
ministered in the early stages of diphtheria, is "uncer-
tain, and that no one can say in a given case what the
result would be if antitoxin were administered. It ap-
peared without dispute that the defendant made a
careful and thorough examination of the child more
than 24 hours after her illness began, in which he was
assisted by another physician, and that, in order to make
the examination thorough and complete, the child was
given an anesthetic and the cavity of the throat thor-
oughly explored, and that at that time there was no
membrane present, and according to the evidence a
microscopic or bacteriological examination was not indi-
cated. It was further undisputed that the defendant
examined the child on the evening before her death,
and at that time there was no membrane present in the
throat. The physicians further agreed that in the ab-
sence of a membrane or other symptoms pointing
directly to the presence of the disease, antitoxin should
not be administered. The other symptoms were not
present in the case. — Judgment for the plaintiff was
reversed, and judgment was directed for the defendant.
— Hrubes v. Faber, Wisconsin Supreme Court, 1"
N. W. 519.
Hernia Caused by Electric Shock. — In a railroad em-
ployee's action for hernia, alleged to have resulted from
an electric shock, expert testimony that it probably re-
sulted from a shock operating upon some weakness in
the abdominal wall was admissible, without preliminary
showing of such weakness; it being known and testified
that such weakness necessarily predisposes to all rup-
tures. A witness said he saw the plaintiff hanging on
the wire for two or three minutes and then, as he said,
when the current was turned off, "the static stopped,
and Murphy fell off into a safety." The plaintiff stated
that shortly after the accident he felt severe pains in
the lower part of his stomach, that grew worse, and
that finally he noticed a swelling below, which increased
until he went to the hospital for operation on June 9.
He was injured on Jan. 25, 1913, and worked for the
defendant full time, with the excention of two day3,
until March 17, stopping just before the strike on
March 21. He said that he felt the pains in the ab-
domen about three weeks after the accident, and that
the pain was increasing until the time of the operation.
The court concludes that the jury was justified in find-
ing that the plaintiff's hernias came from the accident,
and that the finding is not against the weight of the
lence. — Murphy v. New York. N. H. & H. R. R. Co.,
New York Appellate Division, 157 N. Y. Supp. 962.
Examination of Physician. — The New York Appellate
Division holds that, in an action for personal injuries,
a physician may be asked upon cross-examination in
whose interest he made an examination of the plaintiff,
to show the interest or bias of the witness, although his
answer discloses that an insurance company is defend-
ing the action, if not asked for the purpose of preju-
dicing the jury. — Di. Tomasso v. Svracuse University,
L58 N. Y. Supp. 175.
Oct. 14, 1916]
MEDICAI RECORD.
68?.
Medical Record.
A Weekly Journal of Medicine and Surgery.
THOMAS L. STEDMAN, A.M.. M.D., Editor.
PUBLISHERS
WM. WOOD & CO.. 51 FIFTH AVENUE.
See fourth page following reading matter for Rates of Subscription
• nd Information for Contributors and Subscribers.
New York, October 14, 1916.
HEALTH INSURANCE.
Since the passage of the Workman's Compensa-
tion Act it has been apparent to students of the
political situation that it would be only a matter
of time before the idea would be extended and
there would be adopted a health insurance, or bet-
ter a sickness Insurance law, not only by the State
of New York but also by many of the States of
the Union. The time is close at hand for such
action by the Legislature of the State of New
York. Whatever may be the arguments for or
against such a law, we surely shall be subject to
the provisions of one before many years have
passed. Such being the case, it is the duty of
every physician to familiarize himself with the
provisions of the bill presented before the Legisla-
ture last year, or the one that is to be presented
this year, and to study carefully the large amount
of information that has been accumulated in the
development of this particular phase of govern-
mental paternalism. Our large medical societies
have done their full duty in this respect. The
Committee on Social Insurance of the American
Medical Association presented to the meeting at
Detroit in June a voluminous report which covers
the whole subject in a thorough and very satisfac-
tory manner; the Committee on Publication of the
Medical Society of the State of New York pub-
lished last February the text of the Mills bill, then
before the Legislature, and commented on the spe-
cial characteristics of this proposed legislation;
Warren and Sydenstricker of the United States
Public Health Service have published an extensive
study of the subject, and the Committee on Legis-
lation of the Medical Society of the County of New
York have also considered and reported on the same
problem.
The information is thus near at hand. But there
is too great danger that the average practising
physician will fail to do his full share in bringing
about a satisfactory solution of the difficulties
which surround the subject. When the Workman's
Compensation Act was passed many physicians
ignored it entirely, since they had little to do with
the cases which were affected by it. A health in-
surance law, on the contrary, will affect the prac-
tice of almost every doctor in the State. His
financial future will depend very largely upon the
wording and construction of its clauses, and his
professional development may be very seriously in-
fluenced by it. The Mills bill, which was intro-
duced into the last Legislature, failed of passage,
and a commission has been working on the subject
this summer. It is not at all certain that a law
will be passed this winter, but it is certain that
it will advance further this year than it did a year
ago.
It is therefore of the highest importance that
each physician obtain the available information
and, so far as possible, reach a conclusion as to
what he thinks are desirable provisions for the
law. He should then express those conclusions and
discuss them with others, if possible, in such a
manner that the Legislature may become aware
of the result of the discussions. It is only by such
means that a law can be framed which will deal
justly with all of the parties to the transaction.
Some of the details which need especially care-
ful consideration ai'e the distribution of patients
among physicians, the method of payment of physi-
cians, the issuance of disability certificates, the
problem of malingering, the relation to State and
municipal health boards, the part to be played by
the hospitals in the diagnosis and treatment of
patients under the act, the extent to which bene-
fits shall be given and the position of specialists.
It is almost impossible to exaggerate the impor-
tance of such a law in relation to the medical pro-
fession.
There is scarcely a form of medical activity which
the law will not touch in some way. Under the wise
and intelligent administration of a carefully drawn
law there is great possibility for good in improv-
ing the quality of medical treatment given to those
who benefit by it and in the prevention of disease.
"To enact a health insurance law simply as a re-
lief measure without adequate preventive features
would be a serious mistake, but with a comprehen-
sive plan for disease prevention there is every
reason to believe that it would prove to be a
measure of extraordinary value in improving the
health and efficiency of the wage-earning popula-
tion." (Woodward and Warren.) It would be an
excellent idea if every medical society of whatever
size in this State should set aside one meeting
during the coming season for the discussion of
this subject. It would be a disgrace to the profes-
sion if the passage of this law should find them
unprepared to present and maintain their position
with their present opportunity to get themselves
ready.
THE USE OF HABIT-FORMING DRUGS BY
SOLDIERS.
It has long been known in a general sort of way
that drug addictions were comparatively frequent
among enlisted men. Without any reflection on
their capability for their duties, their potential fight-
ing abilities, or any of the qualities necessary to
make them an adequate part of a great war machine,
it is usually conceded that many of the privates come
from a low stratum of society, and in some cases
are actually inferior constitutionally, not to say
psychopathically predisposed. Men of this kind,
of course, are the natural prey of drugs. They
have few or no ethical considerations to restrain
684
MEDICAL RECORD.
[Oct. 14, 1916
them, consort freely during their leaves of absence
with prostitutes and their parasites, a class which
furnishes a large percentage of drug users, and
chafe under the restrictions of military life to
such an extent that it seems necessary for them to
have recourse to drugs to help them adjust.
An exhaustive study of the use of habit-forming
drugs by soldiers has been made by Capt. Edgar
King, M.C., U. S. A. {Military Surgeon, September,
1916), whose report, unfortunately, deals with sol-
diers under sentence only who would naturally be ex-
pected to furnish a large percentage of drug users.
He finds, as a matter of fact, 4 per cent, admittedly
so and 2 per cent more suspected. He believes
that among enlisted men not in this class about
1 per cent, are addicts. The majority of them
acquired the habit after enlistment. King dis-
cusses briefly the well-known fact that the drug
addict, in the great majority of cases, is abnormal
aside from his habit, and that he takes the drug
to enable him to deal adequately with the situation
which would otherwise overwhelm him, or to alle-
viate the mental suffering caused by his failure
to succeed in life. Few, if any, he found, acquired
the habit through a physician's prescription, al-
though this is the usual lay theory of its inception.
The three main ways in which they became familiar
with a drug was through prostitutes, through ven-
dors, and through association with addicts, either
soldiers or civilians.
It seems that in houses of ill fame the soldier
is surrounded by a drug-using atmosphere, and
often becomes intimate with a person who is an
addict. She talks to him about the drug, saying
that it "will make him fit" or "drive away the
blues." In some cases she actually suggests that
he use it. The second method of acquiring an
addiction is through illicit vendors of the drug,
who are usually to be found near a large camp.
These men naturally indorse the drug in glowing
terms to the soldier, suggest that he try it, and
even furnish samples free to non-addicts. The
third, and the most insidious, source comes from
soldiers who have become addicts and spread the
use of the drug among their companions. At first,
this is often done innocently. The men frequently
believe that the drug in question is really a panacea,
and before their eyes are opened many more become
contaminated. Of course, when the soldier has be-
come a confirmed addict his moral obliquity is such
that he has no hesitancy in recruiting new followers
of his divinity. Then, too, it is a sort of defense
reaction; he takes the drug, he must do no harm,
therefore the drug is harmless, therefore he recom-
mends it to others.
Captain King quotes a number of specific exam-
ples of soldiers who became addicts to the destruc-
tion of their efficiency. He finds that a great many
of these were what he calls "potential addicts";
that is, persons who only want an introduc-
tion to the drug and fair chances of ob-
taining it to become addicted. These persons ex-
ist, of course, in every class of society, and it is
unfortunate that in the army their opportunities
of going astray are so plentiful. Perhaps the
present report will effect some alteration in this
state of affairs.
VINCENT'S DISEASE AND PYORRHEA
ALVEOLARIS.
An apparently new malady has existed for months
among the Canadian and other British troops in
France, which might be described indifferently as
a form of Vincent's disease with essential localiza-
tion in the gums and as an acute form of pyorrhea
alveolaris occurring in the young and having no
necessary connection with Riggs' disease in the
elderly. The two organisms which apparently cause
Vincent's angina are known to be capable of excit-
ing an ulceromembranous stomatitis, the throat be-
ing spared. On the other hand the Entameba
gingivalis, alleged to be the cause, or a cause, of
pyorrhea alveolaris, is also present as an incon-
stant find, in marked contrast with the spirillum and
fusiform bacillus of Vincent which are constantly
present and usually freely present — even in many
cases in pure culture.
A preliminary report on this affection was made
by Bowman in the Proceedings of the Royal So-
ciety of Medicine, 1916, Vol. IX, No. 4. The men
applied for treatment chiefly for loosened teeth, dif-
ficulty in mastication, and in certain cases dys-
phagia. Vincent's angina of the usual type is re-
garded as extremely rare, although there is plenty
of evidence to show that it is contagious. It has
in fact at times been spread by common eating
utensils, as secondary syphilis may be, and even by
inoculation (biting). In the classical descriptions
of Vincent's angina we find sufficient mention
of the progression of the disease from the
fauces to the gums, which may show either the
ulcerating or membranous form of the disease. That
this affection may begin in the gums, with or with-
out extension to the throat, is, however, not yet
admitted. In the present epidemic the process ap-
pears to be localized to the gums — hence the ready
confusion with pyorrhea.
The patients who present themselves for treat-
ment of the stomatitis complain much of depression
and prostration. Fetor of the breath may even
precede the local manifestations and is marked
throughout. The gums bleed readily, are injected,
retracted, and spongy. Pus may be squeezed from
the gum margins. The teeth may be loose or sim-
ply tender and unequal to chewing.
Despite the fact that the Entameba gingivalis
appears b> play but a secondary role, if any, in the
genesis of this affection, a solution containing
ipecac gives the best results, whether introduced
into the pus pockets beside the teeth or applied to
ulcers in outlying zones. But cures are never ob-
tained until Vincent's organisms have disappeared
from the mouth. This is best effected by an injec-
tion of salvarsan which is a spirillicide. On ac-
count of its possible twofold etiology, a mixture of
ipecac and arsenic is recommended in chronic cases.
This same mixture is of great value in typical Vin-
cent's angina when chronic. A mixture of Fowler's
solution and wine of ipecac is kept in stock, as the
epidemic of gingivitis shows no sign of subsidence.
It would thus appear that the Vincent organisms, if
they are not actually a cause of pyorrhea alveolaris,
are at least powerful synergists to the entameba in
this relationship.
Oct. 14, 1916J
MEDICAL RECORD.
685
ERYTHEMA MULTIFORME LEADING TO
DEATH BY UREMIA.
Clinicians are familiar with a form of sympto-
matic erythema multiforme due to severe visceral
lesions. It is probable that the fatal ending in some
of these cases is due to the progress of the under-
lying disease, in which the cutaneous lesions play
a sort of terminal role, as in certain cases of septi-
cemia. Quite different is the status when an indi-
vidual who seems perfectly sound develops first
erythema multiforme and then nephritis.
In La Riforma Medica for July 10 Arullani re-
ports a case which may be interpreted at the pleas-
ure of the reader. A peasant woman of 30 entered
the clinic apparently healthy, save for the existence
of a dermatosis of three years' duration. It was
seated chiefly on the face and dorsal aspects of the
hands and forearms, and was not at all like an
eczema or other familiar dermatosis. It was quite
free from itching or scratch marks. Aside from
the attributes of an erythema, it presented an infil-
tration to the touch and at times vesiculation. De-
spite its chronic character the author regarded the
condition as an exudative erythema, but he evident-
ly reserved the privilege of changing the diagnosis
to eczema, and indeed the latter would doubtless
have been the diagnosis of the ordinary dermatolo-
gist, despite the absence of itching and scratch ef-
fects. In fact, he speaks of its eczematoid charac-
ter. It appears to have yielded readily to a tarry
ointment. The eruption returned, however, soon
afterwards without apparent cause in the form of
vesicles which itched intensely, the entire process
resembling an ordinary eczema. At the same time
the general condition was seen to be involved.
There was fever and albumin appeared in the
urine. Side by side with evidences of nephritis
vesicles continued to appear and disappear under
desquamation. In a few days oliguria, edema, and
uremic phenomena were in evidence and in the
course of a fortnight death took place. The disease
had resisted all treatment from the start.
In summing up the author concludes that the skin
lesion was originally an erythema exudativum com-
mune, evidently multiform to some extent. Its oc-
currence in a healthy woman is understood to mean
that in some way it led to a fatal nephritis. The
most plausible view is that it was due to local in-
fection and that the germ or its toxic products were
able to set up nephritis in connection with elimina-
tion. It is by no means necessary that the local
focus be a suppurative one, for pyogenic cocci do
not invariably cause suppurative lesions and
nephritis due to local infection is not usually a
suppurative process.
LUETIN IN THE DIAGNOSIS OF SYPHILIS.
IN certain regions where diseases prevail which can
give a Wassermann positive in the absence of syphi-
lis the diagnostician naturally turns to luetin to
check up the former. Thus in certain countries are
found side by side malaria, leprosy, and kala-azar,
each of which may have to be excluded in making a
diagnosis of syphilis because they too may give a
positive Wassermann. A year ago in the Milan
Serotherapeutic Institute and Marine Hospital at
Taranto Dr. G. G. Conte (Annali di medicina navale
e coloniale, March-April, 1916), began a compara-
tive study of the two diagnostic reactions, luetin
and the Wassermann, the former, as is known, be-
ing specific and intradermic. In primary syphilis,
7 cases, the luetin reaction was negative through-
out, while in 2 cases the Wassermann was positive.
In a second series of more advanced cases all the
Wassermann tests were positive and two reacted to
luetin. Summing up, the Wassermann was posi-
tive more than twice as often as the luetin test. In
testing secondary syphilis, in 20 cases, the luetin
positives slightly surpassed the Wassermann in fre-
quency; while in six tertiary cases the luetin pre-
dominated notably over the Wassermann. These
figures speak for themselves, but the material is of
course small for generalization. In tardy and ter-
tiary syphilis, especially in involvement of the nerv-
ous system, luetin may make the diagnosis after the
Wassermann has failed. At the same time in gen-
eral paralysis the Wassermann often gives 100 per
cent, positive. Kafka in 1915 found luetin positive
in 100 per cent, of tabetics and 90 per cent, of
cerebral syphilitics, while in general paralysis it
was positive in but 50 per cent. On account of the
trustworthiness of the Wassermann reaction in
metasyphilis it is perhaps best to reserve the use of
luetin for cases in which the Wassermann is nega-
tive. It appears that luetin, however sensitive the
reaction, has a slower response than the Wasser-
mann, so that after failure it may be repeated. In
very early syphilis, luetin is not likely to succeed
when the Wassermann fails, reversing the rule in
tertiary syphilis. A luetin reaction may be early
or late, may vary much in degree; especially may it
be delayed in tertiary syphilis; but, however it oc-
curs, it should be regarded as pathognomonic when
positive, although Conte prefers not to call it abso-
lutely pathognomonic.
Trench Fever, Pappataci, and Dengue.
When Prof. C. Martelli of Rome first read of
trench fever in a British periodical, he inferred
that this affection was nothing more than "three-
day fever," which in turn he held to be an abortive
or anomalous form of pappataci or of barrack fever.
Since this inference he has looked into the subject
and finds his original views strongly confirmed. In
II Policlinico for July 9, however, Filippini takes
some exceptions to Martelli's views. It is admitted
that trench fever and three-day fever have much in
common (headache, vertigo, pains in the bones and
muscles), but such symptoms are found in all acute
infections. A study of the fever curves, however,
shows dissimilarity, three-day fever usually ter-
minating in perspiration at the end of seventy
hours — exceptionally at the end of two or four days.
Trench fever, on the other hand, lasts seven or eight
days, though often with an intermission at the third
day. There is, indeed, a variation in which defer-
vescence comes on the third day, but in which fre-
quent periodical relapses occur, so that we have
practically a recurrent, not a three-day fever. In
both fevers we note the presence of the same blood
changes — lymphocytosis, basophilia. In regard to
etiology, there are differences. Three-day fever is
evidently due to a virus, a filtrable virus, of which
the ultramicroscope gives no information. In
trench fever there is some evidence that the virus
is associated with the corpuscular portion of the
686
MEDICAL RKCOR1).
LOct. 14, 1916
blood. Filippini associates trench fever with the
so-called seven-day fever known in India, which re-
sembles closely the more familiar type of the
former, in that it may show during this period a
remission. Now this seven-day fever is identified
by Castellain and Chalmers as a variety of dengue.
The author does not subscribe to this conclusion,
however, any more than to that of Martelli.
Jferoa of % Wtek.
Paralysis Decreasing. — The epidemic of polio-
myelitis in New York has decreased steadily since
the first of October. For the week ending October
8, there were reported only 90 cases, giving a daily
average of 15. On that date there were in the hos-
pitals 1,537 patients suffering with the disease. In
the other parts of the State and in New Jersey also
the same decrease was noted. Federal inspection of
interstate travel to and from New York, which was
begun last July, was discontinued on October 3,
under instructions from Surgeon General Blues
of the U. S. Public Health Service.
Red Cross Supplies to Europe. — A motor ambu-
lance, the gift of the Sons of St. George of Wilkes-
barre, Penn., was shipped from New York to Ser-
bia recently through the Red Cross, which for-
warded also hospital garments and surgical dress-
ings. Two large motor trucks are also on the way
to the Belgian Red Cross, and a large ambulance
for the French Red Cross is now in New York
awaiting shipment. This ambulance is the gift of
the Chicago Chapter, which has also recently for-
warded a carload of surgical dressings to the Amer-
ican Fund for French Wounded, Paris.
Prize for Artificial Hand. — Through the So-
ciete Nationale de Chirurgie of Paris, an anonymous
donor has offered a prize of 50,000 francs for a
mechanical apparatus best supplying the place of
the hand. Competitors must belong to the allied
or to neutral nations. They are to present to the
society crippled men who have been using the ap-
paratus for at least six months. The society will
also experiment with the apparatus on cripples for
as long a time as is thought necessary. The ap-
paratus to which the prize is awarded is to remain
the property of the inventor. The competition will
be closed two years after the end of the war. Com-
petitors are requested to send their apparatus and
a description to M. le Secretaire General, So-
Societe nationale de chirurgie, 12 rue de Seine,
Paris.
Personals. — Dr. Chevalier Jackson of Pitts-
burgh, Pa., has been appointed professor of bron-
choscopy and esophagoscopy and direct laryngoscopy
at the New York Postgraduate Medical School and
Hospital and will assume his official duties in No-
vember.
Dr. Isaac Levin of New York has resigned as as-
sociate in cancer research in the George Cricker
Special Research Fund, Columbia Univeristy, to ac-
cept an appointment as clinical professor of cancer
research in the University and Bellevue Hospital
Medical College.
Dr. A. I. Ringer, formerly assistant professor of
physiological chemistry at the University of Penn-
sylvania, has been appointed professor of clinical
medicine (diseases of metabolism) at the Fordham
University School of Medicine, New York.
Dr. James R. Hayden of New York has resigned
the chair of genitourinary diseases in the College of
Physicians and Surgeons, Columbia University.
Dr. Timothy Matlack Cheesman, because of ill
health, has resigned as a member of the Trustees
of Columbia University, an office which he had held
since 1904.
Christian Science Sanatorium. — In accordance
with the wishes of Mrs. Eddy, who in 1909 pro-
posed that the Christian Scientists should "estab-
lish and maintain a Christian Science resort for the
so-called sick," the directors of the church have re-
cently accepted a gift of twenty acres of land in
Brookline, Mass., and on this will erect buildings
as may be necessary. The plan is to have Christian
Science treatment given under ideal conditions, and
to give as well such instructions in practical meth-
ods of caring for those under treatment as may be
consistent with Christian Science teachings.
"Healer" Wins Point. — After a four years' fight
W. V. Cole of New York, a Christian Science prac-
titioner who was convicted of the illegal practice of
medicine, has been granted a new trial by the Court
of Appeals. In substance, the court decided that the
exception contained in the medical license law, to
the effect that its provisions should not prevent the
practice of the religious tenets of any church was
broad enough to include the methods used by the
followers of Christian Science, and, therefore, ex-
empted them from the requirement of passing med-
ical examinations and being admitted to practice as
physicians.
New Orleans Death Rate.— The Health Com-
missioner of New Orleans announces that during
the month of September the death rate in the city
fell to 13.79 per 1,000, the lowest rate recorded, it
is said, in one hundred years.
Ice Cream Starts Epidemic. — An epidemic of
typhoid fever is reported in Harrisburg, Pa., 400
cases having occurred in the city and its vicinity.
It is thought that ice cream made from contamin-
ated milk has been the main factor in the spread
of the disease.
Gifts to Charities.— The will of George H.
Schrader of Brooklyn, by which the bulk of his
estate, estimated at $2,000,000, is bequeathed to the
Caroline Rest, Hartsdale, N. Y., was admitted to
probate in Westchester County on October 3. Mr.
Schrader was lost at sea while returning to the
United States from Iceland, and the probate of his
will has been delayed until proof of his death could
be obtained.
The Nurse Endorsed. — A recent issue of Schoot
Health News, a publication of the New York City
Department of Education, contains the following
extract from an examination paper: "Question.
Tell why the children and parents should respect
the school nurse and follow her advice. Answer.
Whatever our nurse tells us we should bring the
news home and the mother should not say the nurse
is crazy, because she is not crazy. She would not
have the position if she was in that state."
Unusual Suit. — A physician of New York City
has recently filed in the Supreme Court a suit
against the New York Telephone Company for $10,-
000, alleging that because of the failure of the
company to list his office telephone in one of the
1915 directories, he suffered damage to this amount.
Gifts to Medical College. — At a meeting of the
trustees of Columbia University, New York, on
October 2, the following gifts to the College of
Physicians and Surgeons were acknowledged : For
the fund for surgical research, $5000 from Mr.
Clarence H. Mackay ; for salaries in the depart-
ment of pharmacology, $1385 from an anonymous
donor; for the medical school removal and rebuild-
Oct. 14, 1916J
MEDICAL RECORD.
687
ing fund, $1000 from Mr. W. V. King; for salar-
ies in the department of physiology, $1000 from
Prof, and Mrs. F. S. Lee. It was also announced
that about $7000 had been received for the pro-
posed new building for the recently established
dental school connected with the college.
Cornell University Medical College entered its
nineteenth session September 27, 1916, with a
total of 131 students. An address was made by
Dr. Frank Sherman Meara, professor of thera-
peutics, and the students were also welcomed by
the dean of the college, Dr. William Mecklenburg
Polk. The enrollment is as follows: For the de-
gree of M.D., first year, 37 (not including students
entering the Ithaca division for the first year) ;
second year, 37; third year, 26; fourth year, 25;
graduate students, not candidates for the degree,
4; candidates for the degree of Ph.D., 2; making
a total of 131.
Harvey Society. — The first of the twelfth course
of Harvey Society Lectures will be given on Satur-
day evening, October 14, at 8.30, in the New York
Academy of Medicine, by Prof. J. S. Haldane, of
the University of Oxford; title, "The New Physi-
ology."
New York and New England Association of
Railway Surgeons. — The twenty-sixth annual ses-
sion of this association will be held at the Hotel
McAlpin, New York, on Wednesday and Thursday,
October 18 and 19, under the presidency of Dr. D.
H. Lake of Kingston, Pa. Details as to the pro-
gram, etc., may be obtained from the secretary.
Dr. George Chaffee, Little Meadows, Pa.
The Late Dr. Judson. — At a recent meeting of
the Council of the New York Academy of Medi-
cine the following minute was adopted:
"Dr. Adoniram Brown Judson. who died on Sep-
tember 20, 1916, was born in Maulmain, Burmah
(where his father was stationed as a missionary),
on April 7, 1837, graduating from Brown Uni-
versity in 1859. He then attended lectures at Jef-
ferson Medical College. The Civil War breaking
out before he had completed his course, he en-
tered the navy as assistant surgeon in 1861, was
promoted to passed assistant surgeon in 1864, and
to be surgeon in 1866, resigning in 1868. He was
given the degree of M.D., 1865, by Jefferson Medi-
cal College, and in 1868 a similar degree ad eundem
by Bellevue Hospital Medical College. After sev-
eral years spent in work connected with the Health
Department of New York City, Dr. Judson devoted
himself to orthopedic surgery, and in 1887 assisted
in forming the American Orthopedic Association,
of which he was vice-president in 1889, and presi-
dent in 1890. For thirty years he was orthopedic
surgeon to the Out-Patient Department of the New
York Hospital, resigning in 1908.
"Dr. Judson was a man of lovable personality,
prone to see that which was good in every man, and
overlooking his failings. He was glad to extend
a helping hand to the younger men in his specialty,
and if he differed from his confreres on any topic
did so in a way that did not give offense. What-
ever Dr. Judson started to do he did it with his
whole heart and he did it thoroughly. In nothing
was this more clearly shown than in his connec-
tion with the New York Academy of Medicine.
From 1886 until the time of his death Dr. Judson
was our statistical secretary, and to his diligence
and painstaking accuracy we owe the exact record
which we possess of the part which every fellow of
the Academy has taken in its activities. While
chairman of the Section of Orthopedic Surgery,
he had full records made of the transactions of the
Section, and saw to it that these were published in
full in many journals both in this country and
abroad, as well as being filed on the shelves of
our own library, and in this and many other ways
he made this section one of the most widely known
throughout the medical world.
"In his death the New York Academy of Medi-
cine has lost one of its most faithful and conscien-
tious officers, and in acknowledgment of his serv-
ices the Council of the Academy desire this record
of their appreciation to be spread upon the min-
utes and a copy sent to his family and to the
medical press."
Obituary Notes. — Dr. George B. Wilson, medi-
cal director and commandant of the United States
Naval Hospital at Chelsea, Mass., a graduate of the
Dartmouth Medical School, Hanover, N. H., in 1889,
a captain in the United States Navy, and a mem-
ber of the American Medical Association, the
Massachusetts Medical Society, and the Norfolk
District Medical Society, died on Oct. 1, from blood
poisoning, after a brief illness, aged 53 years.
Dr. Bernard C. Gudden of Oshkosh, Wis., a
graduate of Rush Medical College, Chicago, in 1879,
and a member of the American Medical Associa-
tion, the State Medical Society of Wisconsin, and
the Winnebago County Medical Society, died sud-
denly at his home on September 15, aged 59 years.
Dr. Herbert Marshall Howe, formerly of Phila-
delphia, a graduate of the Medical Department of
the University of Pennsylvania, in 1865, died sud-
denly at his summer home, Ferry Cliff, R. I., from
heart disease, on Oct. 1, aged 72 years.
Dr. David Magie of Princeton, N. J., a graduate
of the College of Physicians and Surgeons, Colum-
bia University, New York, in 1863, and a mem-
ber of the Medical Society of the State of New
York, the Medical Society of New Jersey, the Mer-
cer County Medical Society, and the Association of
the Alumni of the College of Physicians and Sur-
geons, died at his home on October 3, aged 75 years.
Dr. Josiah Hornblower of Jersey City, N. J., a
graduate of the New York University Medical Col-
lege, New York, in 1860, and a former member of
the New Jersey State Legislature and of the Jersey
City Board of Education, died at his home on Octo-
ber 5, aged 80 years.
®bituan).
PROFESSOR VINCENZ CZERNY,
HEIDELBERG.
With the death on October 3, at the age of 74 years,
of Excellenz Wirklicher Geheimrat Dr. Vincenz
Czerny, professor of surgery at the University of
Heidelberg and director of the Institut fur experi-
mentelle Krebsforschung, there passed one of the
most notable figures of that great center of medi-
cal practice. He was born in 1842 and was educated
at the Universities of Prague and Vienna, receiving
the degree of M.D. from the latter in 1866. His
work in surgery began under Billroth in Vienna;
in 1871 he was called to Freiberg, and in 1877 went
to Heidelberg, where he remained until his death,
in spite of an invitation in 1894 to return to Vienna
to take the chair left vacant by Billroth.
Czerny was one of the few big figures of what
has been called the Billroth school, that coterie of
German surgeons, composed of Billroth and his
688
MLD1CAL RECORD.
[Oct. 14, 1916
pupils, which was really the advance guard of mod-
ern surgery. Until their advent, the French school
of surgeons, and even Langenbeck in Germany, had
dealt principally with surgery of the extremities,
and Billroth was practically the first to undertake
surgery of the viscera, the technique of which he
and his assistants developed. Among this group
Czerny himself was most remarkable for the broad
interest which he took in surgery ; his scientific work
embraced practically all its general and special fields
as we have them to-day, covering operations on the
larynx and esophagus, resections of the stomach and
intestine, gall-bladder surgery, hernia operations,
and the whole domain of gynecology. The impres-
sion he gave was that of a general practitioner
treating his patients by surgical methods; his in-
terest in the welfare of his patients, his anxiety for.
the well-being of his fellow men, contrasted strik-
ingly with the purely technical viewpoint of the
great 'majority of German surgeons. His desire
to alleviate suffering was, indeed, the main reason
for his early interest in cancer research. He had
seen, he said, during a single year nearly 400 cases
of cancer, and he felt that, while the surgical treat-
ment of the disease was constantly improving (he
himself had contributed largely to its progress),
the ultimate results were discouraging and other
means of treatment must be found. To this in-
tense longing for ability to relieve the numerous
sufferers who passed through his wards may be
ascribed, also, his enthusiastic reception of new
methods of treatment as they were suggested. It
was a wonderful proof of the energy, versatility,
genius, and devotion of the man that at the age of
sixty-five, a time when most men feel ready to lay
down their burdens, he undertook, in the face of
much opposition and many difficulties, the estab-
lishment of an institution for the treatment of can-
cer and research into its cause, carried it through
to a successful conclusion, and in 1906 had the sat-
isfaction of opening the Heidelberg Samariterhaus.
From that time until the day of his death his time
and thought were always at the service of that in-
stitution.
(£flrn»s;imta?nr?.
OUR LONDON LETTER.
fFrom Our Regular Correspondent.)
THE NATIONAL UNION — COMMISSION BEFORE PARLIA-
MENT— CHEAP DRUGS — STATE GRANT FOR MEDI-
CAL BENEFIT — CHOICE OF DOCTOR — PANELS — DR.
HAMILTON.
London, Sept. '.). 1910.
The National Medical Union has brought before
the Commission now sitting at the House of Com-
mons the working of the Health Insurance Acts.
urging the repeal of the medical benefit section on
the ground that the panel system must be regarded
as an admitted failure. This view will hardly be
generally accepted, but in support of it the follow-
ing defects, among others, are laid down: (o)
Pressure by committees leading to the prescribing
of cheap drugs and stock mixtures, with, in addi-
tion, what amounts to a pecuniary bribe (the "float-
ing sixpence"). In this way the attempt to keep
down the drug bill is sometimes obviously made,
(b) Perfunctory attention is alleged to be the re-
sult of excess of work, seen in congested waiting
rooms, and want of time for adequate examination
of patients, (c) Division of the profession, due
to one section of it being established a a ~tatc
monopoly at the expense of the other, (d) The
state grant for medical benefit has actually in some
cases been extended to unregistered persons and to
various quacks.
Further dissatisfaction is felt by insured persons
w7ho prefer to choose their own doctor, and as they
have to pay the panel doctor as well they feel they
are paying twice over. The occupation fees of these
persons go to the panel doctors, who are therefore
said to have an interest in transferring their liabili-
ties to others, particularly to poor-law, hospital and
public institutions.
The profession objects to interference from the
outside and the attempts to control medical cer-
tification in the working of the Insurance Acts has
led to a good deal of friction — in Ireland it
amounted to a deadlock at one time. The free choice
of a doctor has always been admitted as theoretic-
ally a necessity, and Mr. Lloyd George held this as
important until the Insurance Commission limited
it to men on the panel. Permission to make "own
arrangements" was refused by many insurance
committees. This brought about a surplus in the
medical benefit fund from the contributions levied
on insured persons who refused to select a panel
doctor. Those sums were distributed among panel
doctors but counsel's opinion pronounced such dis-
tribution to be illegal, and even declared it to par-
take of "the nature of a dodge."
Insufficient sanatorium accommodation leads to
unsatisfactory results. We have only 300 beds for
tuberculous insured persons in the County of Lon-
don; there is no provision under the Acts for con-
sultations, operations or special treatment or diag-
nosis. Under the compulsion through the state there
has been a wholesale transfer of private patients
to the panels — an unsatisfactory consequence to the
great majority of the profession. Insurance has
not been restricted to those properly entitled to it.
The Medical Union is not opposed to National
Health Insurance for the necessitous classes, but
the Commission of the Faculty indicates grounds
on which exception is taken to parts of the existing
scheme and administration of the benefit section of
the National Health Insurance Acts.
A Knighthood of the Order of St. John of Jeru-
salem has been conferred on Dr. Hamilton for serv-
ices rendered during the war. He is a B.A., M.D.
(Dublin) and D.P.H. (London). He is author of
"The Flora and Fauna of Monmouthshire," and has
been in practice in Monmouth for many years.
OUR LETTER FROM ALASKA.
(From Our Special Correspondent.)
POLAR ICE-PACK AND OCEAN CURRENTS AS A MEANS
OF SPREAD OF DISEASE.
St. Michael, Alaska, Auk. 2"., 1916.
In the year 1912, when the Swiss savant, De Quer-
vain, started to cross the great inland ice-cap of
Greenland from the west coast to the eastern shore,
in latitude about 70° North, he found the Danish
authorities in Jacobshavn were fully awake to the
dangers of infection, and he obtained permission to
cross this gigantic glacier, which covers the whole
of Greenland with an ice barrier almost impassable,
only by giving a solemn undertaking that he would
kill all the dogs in his expedition before leaving the
glacier to enter the village of Augmagsalik, on the
east coast.
This precaution was deemed necessary by the
Danes because it was feared that the expedition
Oct. 14, 1916]
MEDICAL RECORD.
689
might be the means of spreading to the villages of
the east coast of the island a disease which was
prevalent along the western shore, and which had
infected nearly all the dogs of the villages in that
vicinity. Thus it will be seen that the Danish gov-
ernment, whose methods of caring for the Eskimo
inhabitants of its Arctic possessions might be
studied with profit, was working to prevent the
spread of diseases among the domestic animals of
Greenland as well as among the people who inhabit
Danish America.
It has occurred to me, after listening to certain
discourses by a man who has had many years of
experience in the North, on the subject of polar
ocean currents, that these currents may possibly be
a means of spreading diseases from the Alaskan
natives to those of the east coast of Greenland.
It has been pretty well demonstrated, and it is
agreed by all who have studied the matter, that the
currents from Bering Strait flow across the Polar
area into the North Atlantic Ocean. This was
proven conclusively by the drift of the Melville-
Bryant casks, which were placed on the ice of the
Polar pack north of Bering Strait. Several years
later a number of them were picked up floating in
the North Atlantic. The only difference of opinion
on this subject for a number of years has been the
particular course taken by these casks in their long
journey across the Polar Sea, though the voyage of
the Karluk in 1913 has about settled that matter
to the satisfaction of all interested.
From my own observations, and from discussing
the matter with others who have had even better
opportunities than I for observation, I have con-
cluded, as has already been written in these pages,
that a large percentage of the native inhabitants of
Alaska are suffering with communicable diseases.
Tuberculosis especially is very prevalent, and the
almost entire lack of sanitary measures, which pre-
vails in Alaska, permits it to spread unchecked.
This absence of proper sanitary precautions may be
endangering the life of other tribes of dwellers in
the far North, as will be seen by a further perusal
of this letter.
The natives of the villages of Alaska, as well as
the white residents, are in the habit of placing
refuse matter, garbage, etc., upon the sea ice in
front of their habitations during the long winter
and spring months. This ice, carrying tons of gar-
bage and refuse matter from Alaska, floats away to
the northward with the breaking away of the ice
from the shore in early summer, to become incor-
porated into the great ice-pack which covers the
whole of the Polar area. Thus the disease-laden ice-
floes from Alaska, carried by the ocean currents,
after a journey of thousands of miles, come grind-
ing along the east coast of Greenland on their way
into the North Atlantic. This process has been go-
ing on through the ages, and it is the deposit of
the solid matter brought across the Polar Ocean by
the ice, which has formed the Grand Banks of New
Foundland at the point where this stream of ice
meets the warm waters of the Gulf Stream.
Is it not likely that these huge rafts of ice, as
they come crowding down against the rocky coast of
Greenland in the final stages of their long journey
across the Arctic seas, may deposit some of their
germ-laden filth, from the Alaska villages, on that
shore, and thus spread the diseases from our own
territory to the practically isolated people of East
Greenland? Of course, this ice-pack, drifting south
into the North Atlantic, appears to one who sees it
to be pure white. It has been covered with snow,
which obscured the vast piles of dirt which were
visible at the beginning of the journey, so that
while this ice appears to be about the purest thing
in the whole world, it may conceal unseen dangers,
even greater than the evident dangers to naviga-
tion, which are so well known and recognized by
everyone.
A traveler who has visited many of the native vil-
lages on the west coast of Greenland, as well as
most of those on the Alaskan shore, told me that to
a casual observer it would appear that there is
much more tuberculosis among the natives of
Alaska than among those of the west coast of
Greenland. He stated that while he had never vis-
ited the east coast of Greenland, he had heard that
the people there are much more subject to tuber-
culosis than those on the western side of the island,
thereby more nearly resembling the Alaskan na-
tives. This, too, in spite of the fact that they are
much more isolated, coming but rarely in contact
with the civilized world. The reason for this lack of
communication with the outside world is the flow of
the ice streams down that shore, making naviga-
tion very difficult.
It is probable that this journey of refuse matter
on the ice from Alaska to Greenland requires a pe-
riod of from five to seven years, and one might
suppose that the hard freezing to which any organ-
isms would necessarily be subjected through suc-
cessive years, might destroy their viability or viru-
lence so that there would be no danger of infection.
It is the opinion of the writer, however, that in view
of the high resistance of the bacillus of tuberculo-
sis, of anthrax, of typhoid fever, and of other in-
fections, such organisms incorporated into the
ice off the shores of Alaska could follow the ice
flowing north through Bering Sea and Strait, the
Arctic Ocean, across the Polar area, and thence into
the North Atlantic Ocean with their virulence but
little or not at all attenuated.
It would be interesting to get an expression of
opinion from some the Danish scientists who have
studied these matters, as well as some actual sta-
tistics regarding the prevalence of tuberculosis and
other diseases on the east coast of Greenland as
compared with the west coast natives. If it is
found on investigtaing this matter that Alaska is
a possible source of infection to the natives of this
barren Greenland shore, it would be the duty of
the United States to take steps toward the preven-
tion of the spread of diseases in this manner.
Not only the natives of the Greenland shore
would be endangered by this means, but the health
of the inhabitants of Iceland and even Labrador and
New Foundland is to be considered ; and when it
is realized that some of these organisms may not
sink to the bottom when the ice melts away, but re-
main in suspension and be carried with the current
of the Gulf Stream to the Scandinavian shore, the
matter might have a more far-reaching result than
above outlined.
It must be remembered that the last of the Mel-
ville-Bryant casks found was one picked up on the
shore of a small island just west of Tromso, Nor-
way. It was, in all probability, carried by the ice-
pack into the North Atlantic until it was freed upon
the melting of the ice on the New Foundland Banks,
tmd then floated with the Gulf Stream to the Nor-
wegian coast.
This theory of the spread of diseases from Alaska
to Greenland may appear unusual, but it is at least
worthy of thought, and much good might result
from a thorough investigation of the matter. In
690
MEDICAL RECORD.
[Oct. 14, 1916
fact, as Labrador and New Foundland (a Crown
Colony of England) as well as the Danish Colonies
in America and even the Mainland of Europe, are
possibly affected by the carrying of refuse matter
from Alaska by ice-floes, the services of an Inter-
national Commission of scientists from all the coun-
tries concerned might do much toward the preven-
tion of the spread of diseases in the lands border-
ing on the North Atlantic Ocean.
JUnmrrBa nf Uteiitral §>rimn\
Boston Medical and Surgical Journal.
Sevtcmbcr 28. 1916.
1. The Importance of Early Reduction of Fractures with Kit-
placement. William Darrach.
2. The Treatment of Hip Fractures. F. .1. Cotton.
3. Certain Facts Concerning the Operative Treatment ot
Fracture of the Patella. Charles L. Scudder and Rich-
ard H. Miller.
1. Some Aspects of the Treatment of Compound Fractures
Under Civil and Military Conditions. David Cheever.
'. The Flexed Spica and Wheel Chair in the Treatment of
Fracture of the Neck of the Femur. G. A. Moore.
6. Portraits of Florence Nightingale. (Concluded.) Maude
E. Seymour Abbott.
7. Restoring the Injured Employee to Work. Francis I)
Donoghue.
8. Hospitals and Workmen's Insurance. F. J. Cotton.
1. The Importance of Early Reduction of Fractures
with Displacement. — William Darrach holds that frac-
tures should be considered in the same emergency class
with ruptured ulcer and acute appendicitis, and that hos-
pitals should be so equipped that the x-ray plant is avail-
able at any hour of the day or night, including Sundays
and holidays. He believes that a more exact replace-
ment can be accomplished in the first few hours than if
the reduction be delayed, especially if that delay be a
matter of days. The percentage of perfect anatomical
results will be much higher with early reduction. The
ease of reduction to a large extent will vary inversely
with the time elapsed since the injury. The additional
trauma caused by manipulations during reduction will
be reduced. The evil effects of pressure of a displaced
fragment on adjacent structures will depend on the du-
ration as well as the amount of that pressure. With a
more perfect reduction comes a decrease in the amount
of new tissue necessary to repair the injury, which
means a lessening of the period of disability and a more
complete return of function. Lastly, the amount of pain
and discomfort subsequent to the reduction will be less-
ened.
2. The Treatment of Hip Fractures.— F. J. Cotton
says that it is obvious that there are two classes of hip
fractures — the trochanteric and the subcapital. There
is no question of union in the trochanteric cases; they
unite by massive callus, usually promptly. The question
is purely one of deformity. There is apt to be an out
ward rotation easily taken care of, but the real deformity
is a coxavara type. With this goes a tendency to ad-
duction contracture, muscle shortening, common to all
hip injuries. Any treatment that insures an adequate
amount of abduction is suitable for this class. The sub-
capital breaks, on the other hand, are essentially intra-
capsular, and therefore have no massive callus. Some
are impacted in the beginning, and if they stay impacted
they unite by bone slowly. If they start loose or work
loose they do not unite by bone and produce cripples.
It has been the author's idea to secure to the loose frac-
tures the advantages of impaction; to reimpact those
that needed correction, and to fix them all in moderate
abduction. This he has done in some thirty cases during
the past six years. The method has been of hammer im-
paction, after reduction, and the application of a pi.
spica. His results he considers encouraging since no one
has shown any better ones in intracapsular cases.
3. Certain Facts Concerning the Operative Treat-
ment of Fractures of the Patella. — Charles L. Scudder
and Richard H. Miller describe the operative treatment
of fractures of the patella which has been employed at
the Massachusetts General Hospital. This method has
consisted in approaching the joint through an ample in-
cision, removing gently all obtainable blood-clot, fresh-
ing the bony surfaces of the fracture, approximating the
fragments by manual pressure, suturing the capsule and
torn fascia with chromic catgut, closing the skin wound,
immobilizing the knee for a few weeks, allowing the pa-
tient to walk with the knee still immobilized, and using
active motion and massage early after operation. This
method was studied to see whether it was satisfactory or
not and how it could be improved. In a study of twenty-
two cases two facts stand out prominently. First, 81 per
cent, of the eases have demonstrated bony union of the
patella following the use of the absorbable suture com-
bined with digital and suture approximation. Thi-
means that there were 19 per cent, of failures in secur-
ing bony union and that the fracture was not reduced in
19 per cent, of the cases. The functional disability most
evident in this series was a very considerable limitation
of flexion of the knee, 39.5 per cent, of the cases having
less than full flexion. It would seem from this series
that in order to improve the results of the operative
treatment of patellar fractures more care must be taken
to secure bony union through accurate reduction of the
fragments of broken bone and that a more accurate and
secure suture must be used to maintain reduction. An
encircling suture of kangaroo tendon is most satisfac
tory. In such cases as need more than manual reduction
of the fragments the patellar clamp devised by Dr.
Scudder may be employed with gratifying results.
5. The Flexed Spica and Wheeled Chair in the Treat-
ment of Fracture of the Neck of the Femur. — G. A.
Moore describes a flexed spica which is a modification of
Whitman's method of treatment of hip fractures. Re-
duction of deformity and apposition of the fragments is
maintained by essentially the same means. The chief
difference is that instead of the abducted and extended
position of the leg it is immobilized in the abducted and
flexed position, permitting the patient to assume the sit-
ting posture. Seventeen patients have been treated in
this way, fifteen being over fifty years of age and nine
over seventy years. The results have shown that main
tenance of the leg and body in the same horizontal plane
are not essential to union or good functional results
This method was devised for old, feeble patients who are
able to tolerate some appliance for immobilization, but
in whom methods necessitating recumbency seem inad-
visable. With the exception of one old lady, upon whom
a double cast was applied, all have been in chairs daily
throughout convalescence. Strength and general nutri-
tion arc maintained by the exercise of pushing them-
selves about in a wheel-chair, so that when the cast has
been removed these patients have been able to use
crutches at once.
New York Medical Journal.
• ruber 30,
1. Injuries of the Chest During War. R. Murras Leslie
2. E.xteiisivr Subdural Hemorrhage After Trauma. B.
Sa< 'it and Charles A. Blsberg.
3. Infantile Paralysis. Herman C. Frauenthal.
t. Afterthoughts of the Epidemic of Infantile Paralys
Be* erlej Rol ilnson.
Pelvic Brassage. Ferdinand Herb
6. Inflammation with Regard to lis Stage. John !•'. x
i 'lies.
7. Rectal Operations Under Local Anesthesia. .1. F Saphlr
Treatment oi inebriates. Joseph M> k
\euie Middle Ear Suppuration. John J. O'Brien.
10. The Wake of tin- Wass< rmann Test. James Cabell Minoi
2. Extensive Subdural Hemorrhage After Trauma. —
i barles A. Elsberg reports the case of a man who, after
an automobile accident, was unconscious for several
hours and then seemed to have suffered little for a
Oct. 14, 1916]
MEDICAL RECORD.
691
period of nearly two months. The only change ob-
served was in his mental condition, which seemed to
have been somewhat altered. He was more talkative
and laughed immoderately without cause. He then
slipped in getting out of the bath tub and gave his
head another hard knock, after which he was uncon-
scious for forty-five minutes. As a result of examina-
tion at this time the diagnosis of extensive hemorrhage
or abscess was considered probable and the patient
was sent to the hospital. The mental condition of the
patient was puzzling. He was at first extremely noisy,
talkative, and made an effort to be funny. After a few
days he became" drowsy and the left upper extremity
became completely paralyzed, not spastic; the left half
of the face was involved, and the lower extremity was
paretic. The sensory disturbances were marked in the
upper extremity but less so in the lower. As the symp-
toms increased in severity and the right optic nerve
showed numerous small hemorrhages, an exploratory
operation was decided upon. A button of bone was re-
moved from the front of the middle of the right motor
area and the dura was incised. A large quantity of
dark colored fluid escaped. After the fluid had been
removed and more bone rongeured away for decom-
pressive purposes, the wound was closed without drain-
age. The patient recovered from the operation, but
his condition was not improved. At a second operation
a large osteoplastic flap was turned down in the right
frontoparietal region. On incision of the dura the cor-
tex was found to be covered by an organized blood clot
0.5 cm. in thickness, which had evidently compressed
the parietal and frontal lobes. This layer of organized
tissue was removed, when the brain began to expand
and pulsate, and was found covered by newly-formed
blood vessels. The dual incision was closed by inter-
rupted suture? and the bone flap returned to place.
The patient gradually recovered in every particular.
This case is recorded not only because of the unusually
satisfactory operative results, but also because the
mental symptoms were evidently the result of the in-
volvement of the frontal lobe. None of those who
witnessed the operation had ever seen so large a clot
removed from a living subject. It is probable that it
was produced by oozing since an initial hemorrhage of
the size indicated by the clot would have proved in-
stantly fatal.
4. Afterthoughts of the Epidemic of Infantile Pa-
ralysis. — Beverley Robinson writes that we are still
obliged to confess our ignorance as to the cause of in-
fantile paralysis and to fall back on the time-honored
statement that an epidemic influence has prevailed.
The proof of this assertion is that cases appear sud-
denly in widely separated tracts of country; that in
some cases children, young men and women, and occa-
sionally adults of a certain age have been attacked;
that not infrequently there is no evidence that a possi-
ble human carrier of the disease can account for it; that
healthy children who are most carefully looked after
take the disease and not merely neglected children.
No system of quarantine has prevented the disease from
attacking persons at a given time. In all these partic-
ulars and in others it is closely allied with the grippe.
So far as many symptoms are concerned it also re-
sembles the grippe more closely than any other known
affection. So far as precautionary measures are con-
cerned there is no reason to change what is rational
in the case of both diseases. By intelligent treatment
the worst effects of infantile paralysis may be warded
off and, in the opinion of the essayist, this intelligent
treatment consists in the internal use of ammonium
salicylate, supplemented by the local use of carbolated
petrolatum introduced into the nares night and morn-
ing. The employment of immunized blood serum in-
jected into the spinal canal has been of great service,
but should be given only by an expert. Ammonium
salicylate has been very valuable in the treatment of
grippe and much may be hoped for from its wider
use as both a preventive and a curative measure in
poliomyelitis.
5. Pelvic Massage. — Ferdinand Herb reviews the his-
tory of pelvic massage in gynecological cases and dis-
cusses the reasons why it gives brilliant results in
the hands of some gynecologists, while others fail en-
tirely to obtain any benefit with this method. Massage
should be as useful in removing remnants of inflam-
matory conditions, improving local circulation, freeing
nerves, blood vessels, or organs imbedded or distorted
and displaced by cicatricial tissues in the pelvis as it
is if such afflictions are near the surface of the body,
or where they are easily accessible. The principal rea-
son why pelvic massage is not successful in the hands
of some gynecologists is because the length of the
fingers falls below a certain measure. The varying
length of the fingers of the different physicians will
alone explain much of the difference of opinion apparent
in the literature on pelvic massage. To provide for
definite figures as to the length of fingers necessary
for pelvic massage, the writer states that his own
middle finger is three and fifteen-sixteenths inches. This
is decidedly more than the average length. Dr. Robert
Ziegenspeck of Munich, one of Europe's most ardent
advocates of pelvic massage, has fingers slightly longer
than the writer, while Thure Brandt, who first achieved
such remarkable results by the employment of pelvic
massage, had much longer fingers than Ziegenspeck.
As it is important if justice is to be done to these cases
that physicians be trained in pelvic massage in post-
graduate schools, it is essential to select from the
applicants for tuition only those who have the proper
physical as well as scientific qualifications.
7. Rectal Operations Under Local Anesthesia.
— J. F. Saphir reports a series of nineteen rectal
cases operated on at the Gouverneur Hospital under
the local influence of quinine and urea hydrochloride
solution, all of whom were relieved of their rectal ail-
ments, without inconvenience either during or after
the operation. They were all able to leave the clinic
immediately to attend to their usual duties. He does
not hold that all rectal cases should be operated upon
under local anesthesia, but maintains that about 75 or
80 per cent, of hemorrhoids, external, internal, and
thrombotic, rectal polypi, fissura ani, anal ulcers, der-
moid cysts, tight or hypertrophied sphincter ani, skin
tags, some cases of fistula ani, and some cases of pro-
lapsus ani, can and should be operated on under local
anesthesia. The cases reported prove that rectal con-
ditions can be cured under local anesthesia and that
the patients need not be confined to bed, a matter of
importance from an economic point of view, both to the
individual and the hospital. The method is suitable for
patients suffering with pulmonary tuberculosis, ne-
phritic, or cardiac diseases.
Journal of the American Medical Association.
September 30, 1916.
1. The Problem of the Chronic Cripple. Russell A. Hibbs
2. Treatment of Constipation bv Conservative Surgical Cor-
rection of Retardative Displacements of the Colon
Charles A. L. Reed.
3. Contributions to the Physiology of the Stomach • XXXV
The Newer Intepretation of the Gastric Pain in Chronic
Ulcer. Harry Ginsburg, Isidor Tumpowsky, and
V\ aiter W. Hamburger.
4. Carbohydrate Restriction in the Medical Treatment of
Gastric Hyperacidity and Ulcer. Willard J. Stone.
s. Syphilis as a Probable Factor in Vague Stomach Dis-
orders. Cabot Lull.
6. Syphilis in the Southern Negro. H. L. McNeil.
7. Surgical Aspects of Industrial Accident Insurance: Illus-
trated from California Experience. Emmet Rixford.
692
MEDICAL RECORD.
[Oct. 14, 1916
S. Health Insurance in Its Relation to Public Health. I. M.
9. Health Insurance : Its Relation to the National Health.
"O G \\r s V V P T\
10 Some Bacteriologic Observations on Epidemic Poliomye-
litis: Preliminary Report. George Mathers.
11 A Simple Device tor Locating Foreign Bodies in Fingers.
Roscoe C. Webb.
1. The Problem of the Chronic Cripple.— Russell A.
Hibbs says that as the knowledge of the fact that there
are a large number of people in every community who
need orthopedic care increases, and as methods of treat-
ment are perfected, a large number of men are going to
select orthopedic surgery as their speciaty. As a re-
sult of inquiries of various clinics in different parts of
the country, it has been shown that the percentage of
patients admitted to the hospital for operation of the
total number treated in the dispensary varied from
3 to 10 per cent. The average for the whole num-
ber was 10 per cent. Thus the large proportion of
orthopedic cases are chronic ones and require on the
part of the surgeon a chronic enthusiasm. Such enthu-
siasm is of slow growth and suggests that the ortho-
pedic surgeon, as compared with the general surgeon,
should have a longer period of preparation. It would
also seem that if a man's training is only in the hos-
pital, his preparation for the treatment of the 90 per
cent, of patients who never enter the hospital is poor.
There is a great deal more written about the 10 per
cent, who need operations than about the 90 per cent
who never enter the hospital, and herein lies a danger
to the development of this specialty. There is no ques-
tion of the importance of the operative work, but the
non-operative should not be neglected. With the proper
training of the orthopedist comes the question of the
best means of applying it to the cripple. There are
many communities throughout the country in which
such work is new and such places offer wonderful op-
portunities for men to initiate organizations ideally
fitted to the need of the cripple, unhampered by the
difficulties of attempting to do the work for the cripple
in a small orthopedic department in a general hos-
pital, the spirit and atmosphere of which is not helpful
to work of this kind.
2. Treatment of Constipation by Conservative Sur-
gical Correction of Retardative Displacements of the Co-
lon. -—Charles A. L. Reed. (See Medical Record, July
8, 19161 page 81.)
3. Contributions to the Physiology of the Stomach.
— Harry Ginsburg, Isidor Tumpowsky and Walter W.
Hamburger. (See Medical Record, July 1, 1916, page
33.)
1. Carbohydrate Restriction in the Medical Treat-
ment of Gastric Hyperacidity and Ulcer. — Willard J.
Stone. (See Medical Record, July 1, 1916, page 34.)
5. Syphilis as a Probable Factor in Vague Stomach
Disorders.— Cabot Lull. (See Medical Record, July 1,
1911'.. page 34.)
6. Syphilis in the Southern Negro. — H. L. McNeil.
(See Medical Record, July l. 1916, page 34.)
8. Health Insurance in Its Relation to Public Health.
I. M. Rubinow shows that while compulsory health
insurance must necessarily be limited to wage workers
or salaried persons, voluntary health insurance may be
encouraged with advantage among other social groups.
He lal the effect of the money benefit is evi-
dently not limited to relieving misery and destitution
for the time being, but is even more important in giv-
ing a better chance for recovery. The failure to under-
stand the difference between "disability" and "inadvisa-
bility to work," has caused many critics to deny the
preventive feature of sickness insurance in Germany.
It is pointed out that the health conditions in Germany
could not have improved because the average amount
ot' sickness disability has increased; as a matter of
fact, this indicates an increase in the days of inad-
visability to work, or in other words, a very much
improved care of the sick. It is obvious that the suc-
cess of health insurance depends on the effectiveness
of medical aid. A system of medical aid which fails
to provide for team work, which interferes with any
degree, of medical organization, either because of con-
siderations of economy or because of conservative cling-
ing to old standards, will utterly fail to make health
insurance a powerful fulcrum for lifting general health
conditions. Whether medical aid under health insur-
ance will accomplish all that it is capable of depends
on such details as availabality of consultant and special-
ist; arrangements for hospital care; additional care for
convalescents, and a liberal provision for drugs, appli-
ances, etc. It must be admitted that a capitation sys-
tem of payment for the medical profession, whether
small or large, has in it inherent tendencies for slip-
shod careless medical work, and neglect of those
patients who need aid more frequently. The writer
points out that good sickness statistics are not an au-
tomatic result of health insurance, and that they can-
not be perfected without the willing co-operation of
the medical profession.
9. Health Insurance: Its Relation to National Health.
— B. S. Warren suggests that it would seem feasible
under our form of government to provide a system of
health insurance for interstate employees by federal
law and for intrastate employees by state law. To be
adequate as a public health measure, a health insurance
system should provide for: (1) Adequate cash and
medical benefits to all wage earners in times of sick-
ness and death. (2) The distribution of the cost of
sickness among the groups responsible for conditions
causing disease, viz., the employer, the employee and
the public. (3) The stimulation of the co-operative ef-
forts for disease prevention on the part of the respon-
sible groups named above and the linking of their
efforts with existing health agencies. (4) The correla-
tion of the work of all agencies working for the relief
and prevention of disease. Such a law, if enacted by
the federal and state legislative bodies, would have
two distinct relations to the national health. It would
operate as a relief measure by providing relief for all
cases of sickness in this group and thereby would have
a decided effect in improving the health of the people.
It would operate as a preventive measure by fixing a
definite price for each day lost on account of sickness
and by providing a financial incentive to those paying
this price by preventing sickness; it would start a move-
ment for preventing disease, just as certainly as the
workmen's compensation laws have brought about the
nation-wide "safety first" movement. Properly coordi-
nated with existing health agencies, the machinery would
be ready at hand for advising and directing this move-
ment with respect to disease prevention. In view of the
experience in both Europe and America, it would seem
best to place the administration of the medical benefits
directly under governmental agencies, and to insert a
provision that no cash benefits be paid except on the
certificate of medical officers of the national or state
health departments acting as medical referees under
the regulations of the central governing boards. Such
medical officers should be selected under civil service
methods, and appointments should be based on a knowl-
edge of preventive as well as clinical medicine.
10. Some Bacteriological Observations on Epidemic
Poliomyelitis: Preliminary Report. — George Mathers
has made cultures from the brain and cord of fatal
cases of poliomyelitis. In seven or eight cases thus far
examined bacterial growth developed in aerobic ascites
dextrose broth and agar cultures after eighteen hours,
Oct. 14, 1916J
MEDICAL RECORD.
693
while in the anaerobic cultures made according to the
technique of Flexner and Noguchi, a definite growth
usually did not appear until after from three to seven
days, and then often very scantily. In six of the seven
instances a pure culture of a gram-positive micrococcus
was obtained. In one instance the culture gave also a
gram-negative bacillus. On blood agar plates the or-
ganism grows in small dry colonies, which produce
a faint green halo and a slight degree of hemolysis.
Cultures from the heart blood and from the cerebro-
spinal fluid after death thus far have not yielded this
micrococcus, but it has been obtained from the mesen-
teric lymphnodes. The organism is of low virulence for
rabbits, but when injected intravenously in large doses
lesions of the central nervous system are produced, with
paralysis which may resemble that of infantile paraly-
sis, especially as it affects the extremities. Intracere-
bral injection of the organism soon after isolation has
produced paralysis in the monkey. The author thinks
that in view of the accepted facts in regard to the
virus of epidemic poliomyelitis it would seem most
reasonable to regard the micrococcus described as a
secondary invader, but that further work is necessary
before its significance can be fully understood.
The Lancet.
September 9, 1916.
1. An Address on the Analysis of Living Matter Through Its
Relations to Poisons. A. R. Cushny.
2. Contributions to the Study of Shell Shock. Being an Ac-
count of Certain Disorders of Speech, with Special
Reference to Their Causation and Their Relations to
Malingering. Charles S. Mvers.
3. The Effect of Trench Warfare on Renal Function. J YV
McLeod.
-i. The Diagnostic Value of Tubercle of the Choroid. Sidney
Stephenson.
5. Trench Pyrexias: Their Prevention and Treatment. Basil
Hughes.
6. On the Dressing of Septic Gunshot Wounds. W. B. Davy.
7. The Schiah Pilgrimage and the Sanitary Defences of
Mesopotamia and the Turco-Persian Frontier. (Con-
cluded.) F. G. Clemow.
2. Contributions to the Study of Shell Shock.—
Charles S. Myers gives an account of certain disorders
of speech, with special reference to their causation and
their relation to malingering. The principal disturb-
ances of speech which he has encountered may be
grouped under three heads — aphonia, dysarthria and
mutism. This is the order of frequency in which, from
our experience of functional disorders in times of peace,
such disturbances of speech might be expected to occur.
In the class of cases occurring in war the order has
been exactly reversed. Dumbness is by far the com-
monest disorder of speech, occurring in about 10 per
cent, of all cases of shock which have come under his
notice. He has met with affections of articulation, stut-
tering or jerky speech, only in about 3 per cent.; while
loss of voice, as the result of shock, is of somewhat
rarer occurrence. In about one-third of the cases of
mutism caused by shock various predisposing affections
may be demonstrated, such as nervousness, fits, stut-
tering, wounds, or exposure to the enemy's gas. These
disorders of speech are not immediately due to physical
causes, but are the result of a functional inhibition, aris-
ing primarily from disorder in the personality; they
are not due to some fixed idea of paralysis. These func-
tional disorders are apt occasionally to simulate
malingering just as at other times they simulate organic
lesions. About 75 per cent, of the cases of mutism im-
prove rapidly while the remainder are slower in mak-
ing a recovery. In the treatment of these patients,
psychotherapeutic measures, that is, suggestion, per-
suasion, and encouragement, have been employed with
success.
3. The Effect of Trench Warfare on Renal Function.
— J. W. McLeod has made a study of over 4,000 British
and French troops with reference to the effect of war-
ware on renal function, with the hope that some reason
might be found for the frequency with which acute
nephritis has been observed during the present war.
He concludes that exposure alone probably has nothing
to do with the causation of a number of cases of
nephritis observed in France, especially the milder
ones, and that if it has a part in the etiology of the
severer ones it will be similar to that exhibited in
many infectious diseases, namely, that of setting up a
defective circulation in an organ so as to render it less
capable of resisting infection. The majority of the
transitory albuminurias so common among the troops
can be classed with the so-called "fatigue" albuminuria.
There exists, especially among the British troops, an
excess of cases of symptomless albuminuria, apart from
those just mentioned, which cannot be classified as
chronic nephritis. Diet appears to be the most likely
explanation of this excess of transitory albuminuria
and mild nephritis, and may also contribute toward the
development of the more severe cases. It has been
shown that the average soldier is consuming an amount
of protein food in excess of his requirements, and is
therefore throwing an undue strain on his excretory
organs. This statement is confirmed by the numerous
cases of gingivitis coming under observation, which
probably indicate that the men are suffering from a
restriction of fresh vegetables, which is usual and in-
evitable for troops in the front line. The resistance of
the kidney, in common with other organs, is lowered
by a slightly scorbutic condition, and gives out when, in
addition to this, it is required to make an excessive
metabolic effort, owing to a high protein diet, or is ex-
posed to bacterial intoxication, either by direct invasion
or by the establishment of an infective focus in some
other part of the body.
4. The Diagnostic Value -of Tubercle of the Choroid.
— Sidney Stephenson thinks there is a tendency in
modern times to overlook the general diagnostic value
of tubercle of the choroid. He reports three cases
which have come under his notice within a few months
in which an acute tuberculosis was diagnosed as such
by the discovery of tubercle of the choroid. In one
the diagnosis was made from an apical pneumonia;
in another, from a pneumococcal peritonitis, and in a
third, from typhoid fever. The finding of these three
cases within so short a time lends truth to the state-
ment that acute tubercle of the choroid is by no means
an uncommon manifestation if looked for in the right
places and in the right way. A more frequent ophthal-
moscopic examination of children in hospitals would
prove a great aid in diagnosis.
5. Trench Pyrexias: Their Prevention and Treatment.
— Basil Hughes writes that during August, 1915, and
the succeeding months, "pyrexia" was of common oc-
curence among officers and men living in the trenches.
The diagnosis given in these cases was pyrexia, not
yet diagnosed. A noticeable feature during the later
months of the year was the rapid spread of this pyrexia
when once started. With regard to its causation there
are the following facts: (1) The occurrence of the
disease was greatest during the time that conditions in
the trenches were worst. (2) On getting back to clean
huts in the rest billets, where the men could get a
bath, a clean change of underclothing, and could have
their uniforms and blankets disinfected, the number of
cases fell immediately. (3) On coming away from
trenches for a month to a place where personal hygiene
could be thoroughly carried out it was a simple matter
to eradicate it. There is, therefore, strong presumptive
evidence that this is a louse-borne disease, for when-
ever it was possible to carry out measures for the
eradication of lice the number of cases invariably fell
694
MEDICAL RECORD.
[Oct. 14, 1916
to a minimum. A possible explanation might be found
in the trench rat, which lives largely on decomposing
organic matter. The first step in prevention of the
conditions seems to be eradication of the vermin. The
drugs which have proved effective when the disease has
established itself are quinine and sodium salicylate,
administered after an initial purge.
he Progres Medical.
September 5, 1916.
Ocular Lesions Due to Tear-Producing Gas. — Gre-
meaux describes the symptoms and treatment of these
cases as follows: When brought in wounded the eyes
show photophobia and lacrymation and the lids are
swollen and reddened, as a result of rubbing. The
conjunctiva is injected finely, giving it a pinkish tint.
Shortly after exposure to the irritating gases the cor-
nea shows at its periphery a very fine exfoliation of the
epithelial layer; this phenomenon is present even in the
milder cases. There is an absence of secretion in the
lower cul-de-sac. After a stationary period of several
days the condition slowly recedes, although some lacry-
mation and photophobia may persist for three or four
weeks. If, however, the eyes were already the seat
of an infection of the lacrymal passages the erosion
of the corneal margin is more marked. The application
of an occlusive bandage also emphasizes the conjunc-
tival reaction to the smoke and favors infection, cor-
neal ulceration, etc. Treatment consists in irrigation
of the eyes with oxycyanide of mercury 1-6000, the in-
stillation of atropine 1-200 up to full dilatation, and the
instillation of 1 per cent, zinc solution. An occlusive
bandage should, of course, be omitted. Instead, poul-
tices of potato flour are recommended. A very loose
dressing, sufficient to exclude light, will serve when
poulticing is discontinued. No cocaine should be used.
During nine months the author treated 47 ambulance
cases, of which 28 were mild, 2 aggravated, as result
of preceding infection of tear passages, 3 aggravated
by wearing an occlusive bandage. There were 14 clean
recoveries. The duration of exposure to the gas ap-
pears to make no difference.
Phlegmons Produced by Injection of Gasolene. — Dil-
lenseger in a recently published thesis (Lyons) gives
an account of two of these cases and cites a number
of others. The subject is a new one, the first report
coming in 1915. The production of these phlegmons is
classed as a criminal procedure, as it is a matter of
simulation to avoid military duty or to secure a pen-
sion. The question of diagnosis is all important. A
section through one of these phlegmons much resem-
bles a section through a carbuncle. The pus which
exudes is, of course, sterile. Decoloration of bromine
water by the gasolene in the pus is the chemical test.
Pyrexia is practically absent. But despite all these
resources for diagnosis it is probable that in certain
cases the artificial nature of the condition is overlooked.
I>a Presse Medicale.
r 7. 1916.
Cure of Hard Edema Due to Trauma and Phlebitis.—
Denis reports cures of this affection as a result of
hypodermic injections of eau de Breuil, of which he has
now made some 2,000. This water is known to be pure
and sterile, and not one abscess resulted from the treat-
ment. It can be drunk very freely for weeks without
inconvenience. There was no definite relationship be-
tween the amount of water used and the duration of
treatment. The water may be classed as of a sodium
bicarbonate-ferruginous type. The water is drunk as
well as injected, but cannot be pushed in hypertensives
or in those with weakened circulation. These military
cases seem to be more amenable to treatment than sim-
ple hard edema in civil practice. The treatment is ex-
tremely simple, as the water may be injected directly
from the bottles. The usual quantity injected is 0.40
c.c. and the rest of the bottle is drunk. In the cases
treated there was no other form of treatment used —
neither massage nor rest. The location of these hard
edemas, notably about the ankles, makes radiography
of service, for the reduction in size of the soft parts is
readily apparent.
Treatment of Typhus with Colloidal Metals. — Bouyges
saw typhus in Serbia, having cared for 150 patients.
Some plan became necessary for the routine treatment
and from analogy the colloidal metals seemed worthy
of a try-out since typhus is clearly a sepsis. Further
intravenous injections of colloidal silver have seemed to
do good work in typhoid. An intravenous injection of
10 c.c. causes no typical results save that of a sense of
subjective improvement. Objectively some of the pa-
tients showed favorable modification of the disease. If
a chill developed it was brief. Colloidal gold, however,
provoked a reaction comparable with a severe malaria1.
crisis and is not to be thought of as a remedy. Col-
loidal silver in the absence of a serum is perhaps the
only known remedy which exerts any favorable in-
fluence on the disease. In so-called recurrent typhus
both metals seem to give results, especially colloidal
gold, which should be begun cautiously in small doses.
La Presse Medicale.
September 11, 1916.
Periodical Vomiting with Acetonemia Versus Appendi-
citis.— Marfan does not believe that these two conditions
have any necessary connection. The former is a disease
of early life and seldom occurs after the age of ten
years. The crises of vomiting appear to have the ef-
fect of ridding the body of some catabolic product
which acts on the vomiting center. These emetizing
substances may be the result of defective formation
of fatty acids by the liver. Intermediate products of
the Ketone series are formed as a consequence of in-
sufficiency of the latter. The entire process is an-
alogous to chloroform poisoning. There is a marked
predisposition, the children being of the neuro-arthritic
type and a diet rich in fat may be a contributory cause.
The author now relates twenty-one cases in which each
patient had submitted to appendectomy before develop-
ing the crises of vomiting wnth acetonemia. As the ap-
pendicitis was usually of a mild course the possibility
of error of diagnosis at once suggests itself. That is
the "appendicitis" for which appendectomy had been
done was in reality the earlier crises of the vom-
iting with acetonemia, and removal of the appendix
was naturally without effect on the course of the
disease. Ordinarily differential diagnosis is easy, but
it may be difficult and even impossible. In the crises of
vomiting the region of the appendix should always be
palpated, but the physician may neglect this precau-
tion. In acute appendicitis there is considerable fever.
In the same affection acetonemia may happen to be
present as a result of inanition, due to the disease.
There is usually meteorism with appendicitis, while a
flat or concave belly is the rule with cyclical vomiting
(the latter may simulate meningitis). Tenderness, hy-
peresthesia and muscular defence are never present.
But even the most careful research for appendicitis may
give equivocal results, as very slight rigidity and doubt-
ful pressure pain, while acetonemia may be a precocious
and notable feature. A possibility which should be
borne in mind is that of a coincidence of the two dis-
eases in one subject.
Oct. 14, 1916J
MEDICAL RECORD.
695
Le Caducee.
September 1"'. 1916.
An Ocular Compressor for the Oculocardiac Keflex. —
Roubinovitch describes the now well-known Aschner
phenomenon in which compression of the eye can be
made to cause changes in the cardiac rhythm. In the
normal individual there results a slowing of the heart
beat of from four to ten pulsations, while in many path-
ological states the rhythm is distinctly altered; brady-
cardia or acceleration may be produced. Hitherto the
clinician has made compression with his fingers, or,
rather, an assistant compresses the bulb while the
clinician investigates the rhythm of the heart. At
times three persons are required to make the test.
Hence the need for some mechanical device which will
replace the individual. Such would have to be abso-
lutely painless, supple, regular, measurable, durable
and aseptic. The base of the author's device is an
ordinary spectacle frame with frontal, nasal and ocular
attachments in which coaptation is accurate. Pressure
on the eye is effected by an automatic mechanism which
admits of perfect control, so that any degree of com-
pression may be obtained, and afterward maintained
by a spring device. Through the use of this compressor
all the results of digital compression have been veri-
fied. In epileptics the reflex is expressed in the great
majority of cases by an acceleration of the pulse rate.
Simulation of Deaf mutism for Five Months. — Ber-
ruyer reports a case of apparent deafmutism in a
young soldier, said to have been due to a great shell
explosion. In consultation the man seemed to be an
absolute deaf mute. Before the explosion his speech
and hearing were normal. He was at once told that
he would recover. Several days of closest watching
showed no evidence of simulation. The patient was
then placed in a state of semi-narcosis with chloroform,
and in this condition conversed without difficulty. A
dressing was applied to his throat for the psychic effect.
Afterward he admitted recovery but showed no normal
delight over his apparent good fortune. His former
physician was consulted and stated that he had treated
the man for six weeks by reeducation and had left the
hospital perfectly cured. The writer leaves us in some
doubt as to whether the original attack was simulated.
but doubtless it was genuine, as he was under the
charge of a competent neurologist. After this experi-
ence he must have thought of deliberate malingering
in order to keep out of the fighting line, for recovery
from shell shock of this type within the army zone is
notably tedious and uncertain.
Le Bulletin Medical.
September 5, 191G.
On Refusal by Soldiers of Operations Recognized as
Necessary. — Janicot relates that this question was first
started in connection with certain electrotherapeutic
procedures, but is seen to apply to many surgical opera-
tions which have been formulated under three heads by
the Direction of the Sanitary Service: (1) Refusal to
submit to a legal prophylactic prescription like vaccina-
tion; (2) refusal of a nonbloody intervention, and (31
refusal of a bloody intervention. It is recognized that
some surgeons are naturally timorous and hesitate to
go ahead with measures which they feel are heroic.
Others are not timid or hesitating, but doubt their right.
These attitudes on the part of the profession tend to
invalidate routine procedure, and it is happening more
and more that necessary measures are withheld. Some
soldiers even refuse to allow their stiffened joints to
be mobilized. Others object to the extraction of
small sequestra of bone which alone prevent the heal-
ing of fistulas. Others, again, will not consent to the
removal of projectiles from the tissues, although they
may be causing them inconvenience. Those badly in-
jured never refuse treatment, but the slightly injured
think things may go worse for them. Sometimes they
distrust the ability of the surgeon on duty or fear that
they will be interned in hospital until the end of the
war. Various learned bodies have rendered opinions.
The Medico-Legal Society states that refusal is not a
positive fact in law, such, for example, as is deliberate
mutilation. A wounded soldier cannot obtain positive
assurance as to the outcome of a given procedure. The
doctor cannot even guarantee that the patient may not
be worse off, or that he may not even die after the
intervention. A debate by the War Council with a de-
fense of the right to refuse would be sure to bring out
differences of opinion. Who would then decide the mat-
ter? Not the judges, who would be unable to decide
which views were correct. Nor could an expert or tech-
nician be able to decide as he is not above criticism.
Another opinion was rendered by the Commission of
Public Hygiene of the Chamber of Deputies, as follows:
If the wounded is rendered unfit for medical service
and if operation can diminish his infirmity the benefit
which thereby accrues will have to be charged against
his pension claim. If the treatment or operation re-
fused could make the disabled man fit to resume mili-
tary service, he shall by no means be maintained in a
hospital, but put to some work in the rear, in accord-
ance with his disability without leave of absence. At
the close of the war he should be mustered out, but
should not receive a full pension. Any gratification
sought would have charged against it the benefit he
should have derived from the operation. Professor
Hartmann, representing a Subcommission of the Su-
perior Consulting Commission, makes the following re-
port: Refusal to be vaccinated against smallpox,
typhoid, etc., is a breach of discipline and punishable,
because these officers are backed by the laws. Refusal
to be treated for syphilis is a breach of discipline and
the man must be penalized. Those ill with nervous dis-
turbances comprise many malingerers and must submit
to diagnostic tests of all kinds. All nonbloody inter-
ventions must be submitted to, including hydrotherapy
and electrotherapy. Retentive apparatus must always
be worn when necessary. In all such cases narrated
above the soldier has an expert opinion, which does
away with prejudice toward the regimental surgeon.
On the other hand, a soldier can protest against the
removal of an eye, testicle, hand (even a thumb), but
everything must be done formally and in writing. If
the operation refused is nonmutilating, the reasons for
refusal must be asked and the injured must be in-
formed as to the effect of nonsubmission on his pen-
sion. But if it is decided that recovery is practically
certain the soldier may be forcibly operated on for the
common good. Such a step is carefully determined in
advance by a medicolegal commission. Absolute re-
fusal to submit to treatment in the face of all these
precautions must be regarded as a breach of military
discipline.
Night Terrors. — Williams regards night terrors as
analogous to the phobias of older persons and quotes a
number of cases in which the symptoms could be traced
to definite incidents in the child's experience or to in-
judicious education or treatment. He advises not ex-
actly a psychoanalysis after the method of Freud, but
a careful interrogation designed to lay bare the root of
fear. If this is successfully attained no further treat-
ment may be necessary, but in some cases the child
benefits bv a sympathetic explanation of the symptoms,
a process of re-education, and exercises in mental con-
centration.— Edinburgh Medical Journal.
696
MEDICAL RECORD.
[Oct. 14, 1916
The Pathology of Tumors. By E. H. Kettle, M.D.,
B.S., Lond., assistant pathologist, St. Mary's Hos-
pital; assistant lecturer on pathology, St. Mary's
Hospital Medical School ; formerly pathologist to the
Cancer Hospital, Brompton. With 126 illustrations.
Price, $3. New York: Paul B. Hoeber. 1916.
There has been in English no very satisfactory book
of moderate size on the subject of the microscopical
structure of tumors, since the excellent volume pub-
lished by Powell White some years ago is concerned
rather with the general biology of tumors than with
their histological details. This volume of tumor path-
ology, however, covers the field very well. There is no
pretense that it is an exhaustive reference work on
cancer; it is intended rather as a student's text, not
only useful to the beginner in tumor pathology, but
also of great interest and value, to the surgeon who
wishes to fit himself for the intelligent practice of his
trade in that phase which has now become of such im-
portance, the operative treatment of tumors. Unfortu-
nately, at the present time the surgeon regards anatomy
as of much more importance than pathology, so that
he is more apt to operate on a tumor from an ana-
tomical point of view than from a pathological, with
the result that the statistics of operative surgery on
malignant tumors show that the accomplishments of
many individuals and hospitals are not as yet com-
mensurate with our knowledge of the nature and meta-
static distribution of tumors. There is still, even in
the large cities, too much partial surgery of malig-
nant growths, with the inevitable result of early and
inoperable recurrence. The first part of this book gives
a very good review of the general biology of tumors,
full credit being given to the recent admirable work
of the Imperial Cancer Research Fund in London. In
his discussion of the value of frozen section diagnosis,
the author, in his anxiety over a possible error by the
pathologist, seems to lose sight of the fact that it is
better for the patient to undergo an extensive operation
for the removal of a benign growth than an incomplete
operation for the removal of a malignant one. In the
first case, the patient has had possibly a serious oper-
ation, but still remains a useful member of society;
in the second, death is inevitable. There are many
growths which it is impossible to diagnose from their
gross appearance, and we can get the best results in
the treatment of carcinoma only by frozen section
diagnosis in the operating room, the pathologist being
allowed to state from what portion of the material
he desires a specimen, for very few surgeons have
sufficient laboratory knowledge to enable them to select
material suitable for microscopical examination. In
the chapter on the classification of tumors, the author
shows his self-control by refusing to add a new classi-
fication to those already in existence. Part III, devoted
to special pathology, is a little too compact; one wishes
that the author had seen fit to furnish more details.
Bibliographical references have been omitted entirely,
which is a matter of regret, also, because of the limi-
tations which it places upon the use of the book; but
presumably space did not permit the inclusion of what
would have made the book more valuable. The illustra-
tions are exceedingly good, and color has been used
very effectively to bring out certain points. The index,
also, is very satisfactory. Altogether the volume can
be highly commended both to the students and to the
practitioner of surgery as the best text in English on
the subject.
BEING WELL-BORN, An Introduction to Eugenics. Bv
Michael i Gi yer, Ph.D., Professor of Zoology, The
University of Wisconsin. Childhood and Youth
Series. Edited by M. V. O'SHEA, Professor of Edu-
cation, The University of Wisconsin. Price. $1.00
Indianapolis: The Hohhs Merrill Company,
1910.
HEREDITY and the part it plays as a direct influence
and factor in our lives is still a mooted question among
the philosophers of the varied sciences. Professor
Guyer has given us a book that is more than a compend
and less than a complete text-book on the subject of
heredity, environment and eugenics, and the interrela-
tion of each to i ho other. To those not well acquainted
with his topics, the book is somewhat confusing and
even for those with a reading knowledge of his mate-
rial there is a demand for very careful, intelligent study
of his text due to the difficult subject matter. Since
there is so much yet to be learned on this subject the
author naturally has matters very much his own way.
He quotes Professor Pearson as stating that statis-
tics show that heredity is five or ten times as important
as environment in the development of the individual.
The book is intensely interesting and is an evidence
that the author is thoroughly conversant with his sub-
ject as far as research has opened up this bewildering,
but fascinating study.
Makers of Modern Medicine. By James J. Walsh,
M.D., Ph.D., LL.D., Litt.D. (Georgetown) ; Sc.D.
(Notre Dame); L.H.D. (Catholic University) Pro-
fessor of Physiological Psychology at the Cathedral
College, New York; Sometime Dean and Professor of
the History of Medicine and of Nervous Diseases at
Fordham University School of Medicine; Member of
the P'rench, German and Italian Societies for the
History of Medicine, N. Y. Hist. Soc, N. Y. Acad.
Med., A. M. A., A. A. A. S., etc. Catholic University
Edition. Enlarged by the addition of the life of
Virchow. Price $2.00 net. New York: Fordham
University Press, 1915.
This is the third edition of this work since its first ap-
pearance ten years ago, which is an indication that per-
haps in due course of time a knowledge of the value
of the study of medical history may be appreciated by
students of medicine. Dr. Walsh offers a most de-
lightful book containing the biographies of fourteen
men who through original research have advanced
by enormous strides the knowledge of medicine during
the nineteenth century. He begins with Morgagni,
father of pathology, and concludes with Virchow,
father of cellular pathology, who is the one maker of
modern medicine whom Dr. Walsh knew personally and
intimately during a year spent in his laboratory in
Berlin some twenty years ago. There is also included
the Irish school of medicine represented by Graves,
Stokes, and Corrigan. The presentation of the biogra-
phies is full of vital spirit and an impression is given
that the author has not only a profound respect and
admiration for these men, but a love for the work which
he has so admirably written.
Monographs of the Rockefeller Institute for
Medical Research. No. 6, January 31, 1916. Torula
Infection in Man. A Group of Cases. Characterized
by Chronic Lesions of the Central Nervous System,
with Clinical Symptoms Suggestive of Cerebral
Tumor, Produced bv an Organism Belonging to the
Torula Group (Torula Histolytica, N. 8p.) By
James L. Stoddard, M.D. and Elliott C. Cutler,
M.D. New York, 1916.
This work is founded on the study of two cases of
cerebral pseudotumor and is devoted largely to a com-
parison of torula infection with blastomycosis and
coccidiosis. As a result the last named can be definitely
excluded, as can also a majority of cases originally re-
ported as blastomycosis. On the other hand, in certain
cases reported under the latter head, the solution of
tissue and production of gelatinous material in the
brain, there was a marked resemblance to one of the
authors. The second case, on the contrary, is still
anomalous in its relationships.
The Diagnosis and Treatment of Heart Disease.
Practical Points for Students and Practitioners.
By E. M. Brockbank. M.D. (Vict.), F.R.C.P.. Hon.
Physician, Royal Infirmary, Manchester; Clinical
Lecturer on Diseases of the Heart, Dean of Clinical
Instruction, Universitv of Manchester. Second Edi-
tion. With illustrations. Price, $1.25. New York:
Paul B. Hoeber. 1916.
This is a concisely and clearly phrased small reference
book for the use of students dealing with the elements
of cardiac auscultation. In the second edition numer-
ous additions and alterations have been made.
Aids to Bacteriology. Bv C. G. Moore, M.A. (Cantab.)
F.I.C. Captain 1st London Sanitary Company, Pub-
lic Analyst for the County of Dorset and the Bor-
oughs of Poole and Penzance, and William Par-
tridge, F.I.C. Joint Public Analyst for the County
of Dorset. Third Edition. Price, $1.25 net. New
York: William Wood and Company, 1916.
This is a third edition which has been thoroughly re-
vised and considerably enlarged. It is a valuable little
book dealing with bacteriology from various stand-
points in a concise yet lucid manner. The question of
the treatment of septic wounds is discussed and the
relative merits of the methods in vogue at the war
fronts are debated.
Oct. 14, 1916]
MEDICAL RECORD.
697
Coring imports.
THE MEDICAL SOCIETY OF THE STATE OF
PENNSYLVANIA.
Sixty-sixth Annual Session, Held at Scranton, Pa.,
September 18, 19, 20, and 21, 1916.
(Special Report to the Medical Record.)
Tuesday, September 19 — First Day.
The President, Dr. John B. McAlister of Harrisburg,
in the Chair.
The Society met in General Session in the Ball Room
of the Hotel Casey, and was opened with prayer by Rt.
kev. M. J. Hoban, Bishop of Scranton.
The Business Features of the Medical Society of the
State of Pennsylvania. — Dr. Charles A. E. Codman
called attention in his presidental address to the lack
of influence in medical legislation exercised by the
Medical Society of the State of Pennsylvania as evi-
denced in the passage of the Workmen's Compensation
Act in its present form. To overcome this lack of in-
fluence it was suggested that meetings of the Committee
on Public Health and Legislation be held in conjunc-
tion with similar committees of other medical organiza-
tions, and that there be also the co-operation of the
State Department of Health and the Bureau of Medical
Education and Licensure. Dr. Codman regarded as a
matter of much importance the effort in the so-called
Health Industrial Insurance Act to be introduced at
the next session of the Legislature to secure legislation
covering cases not provided for under the Workmen's
Compensation Act. This effort he believed would result
in the State Department of Health assuming the entire
care of such patients. He further suggested the advisa-
bility of the Pharmaceutical Association and the com-
bined medical profession uniting in an effort to secure
legislation covering the disputed points in the Harrison
Act. The plan of perfecting the organization of the
State Society along lines similar to those of the Amer-
ican Medical Association, and of making the salary of
the secretary-editor such that would allow him to devote
his entire time to the work of the society, was sug-
gested. Further suggestions included the establishment
of an endowment fund ; the practice of economies in the
matter of fewer committees; the use of the one letter-
head for the whole society; the appointment of a com-
mittee on archives which should prepare a history of
the society for its coming seventy-fifth anniversary;
the maintenance of the medical defense, medical benevo-
lence funds, and the establishment of a unit of physi-
cians and surgeons in each county toward national pre-
paredness.
The society adopted the following recommendations
contained in the address of President Dr. Charles A. E.
Codman: The endowment fund at once voted $1,200
per year for this purpose; uniform society stationery,
and the creation of a committee on archives. The sug-
gestion regarding medical instruction of the laity was
approved and referred to the committee on health and
public instruction.
Election of Officers. — The following were elected:
President-Elect, Dr. Samuel G. Dixon, Harris-
burg; Vice-President, Dr. John B. Corser, Scranton;
Secretary-Editor, Dr. Cyrus Lee Stevens. Athens; As-
sistant Secretary, Dr. Clarence P. Franklin. Philadel-
phia; Treasurer, Dr. George W. Wagoner, Johnstown.
The place of the next meeting will be Pittsburgh.
The organization of a section on pediatrics was
authorized by the trustees.
The legislative program to be favored by the society
included bills for the regulation of the sale of alcohol
and drugs under State supervision; for the amplifica-
tion of the Harrison Act; amendments to the Work-
men's Compensation Act; for a Milk Hygiene Law to
safeguard the milk supply at the source by State in-
spection.
A Criminal Epileptic, with Consideration of Epilepsy
as a Medicolegal Problem. — Dr. N S. Yawger of Phila-
delphia said that medicolegally the mental manifesta-
tions of epilepsy were divided into two groups: (1)
Paroxvsms in which the individual is not insane, but
in which he may be irresponsible (a) irresistible im-
pulses or impulsive acts; (6) the state of automatism;
(2) paroxysms in which the individual is insane; these
may be (a) acting under the domination of an insane
delusion; (b) in a maniacal epileptic outbreak. The
fact that epileptics are highly dangerous, despite long
intervals of lucidity, made it desirable that the insane
epileptic be committed by court procedure rather than
by certificate. Report was made of a patient who had
after six jail detentions been placed in a State hospital.
The attacks in this case had been for the most part but
momentary.
Dr. Hugh E. Meredith of Danville said that the
mental condition in epilepsy was dependent largely upon
the onset of the attacks. Long continuance of the
seizures resulted in epileptic dementia. He did not
believe that punishment should be meted to the epileptic
mentally defective and irresponsible. Institutions for
the insane were not in his opinion the proper places for
the detention of these people. The various classes of
epilepsy should rather be cared for in an institution
in which special treatment might be received.
Dr. William H. Carmalt of New Haven said that
in the endeavor to meet legally the matter of the care
of epileptics Connecticut had established for them a
farm where, if needed, they might be kept for life. In
his State also a fine of $50 was imposed upon a clergy-
man or justice of the peace performing the marriage
ceremony for epileptics and the feeble-minded. So far,
however, this legislation had been only a moderate
deterrent.
The Care of the Indigent Insane. — Dr. Charles W.
Burr of Philadelphia declared his personal conviction
that State care of the indigent insane was the only
efficient method of solving this problem, and he urged
that the physicians of Pennsylvania use every effort to
secure such legislation. Such State care, he believed,
should be adopted as a permanent policy by the com-
monwealth, a certain proportion of the income of the
State being appropriated to the care of the insane. In
outlining a feasible working plan, he said there should
be the appointment of a central board which should be
responsible for the expenditure of all moneys. This
board should be entirely separate from the Board of
Charities. Each local hospital should have its own
board of managers, to be appointed, however, by the
central board. To the medical member of the central
board should be referred the question of prolonged hos-
pital treatment of a given case. Separate hospitals
should be established for acute and chronic patients.
Only by a study of the acutely insane could in Dr.
Burr's opinion the cause of insanity be determined.
Hospitals for this class of the insane should have
highly efficient research workers. Such hospitals should
be small and preferably in large cities. Hospitals for
the cases of chronic insanity should also be small, but
situated in the country and in combination with farms,
thus giving opportunity for work which was often of
great advantage to chronic patients.
Dr. Charles H. Frazier of Philadelphia endorsed
Dr. Burr's plea for State care of the insane and re-
ferred to the work of the Public Charities Association
in the interest of the State's dependent people. A
survey made by this association had shown that in
many instances county institutions caring for the in-
sane were merely adjuncts to almshouses. The dis-
creditable argument that it was cheaper to care for the
insane in county hospitals could as well include the
statement that it was cheaper to care for these people
in the almshouse than in the county hospital. The
statement that the rate of recovery was higher in county
institutions was, in the words of Mr. Sydney Smith,
more uncertain than statistics. He urged that the
State Society, through its appropriate committees be
prepared to introduce in the next Legislature the meas-
ures proposed by Dr. Burr, and that the county societies
so familiarize themselves with the present conditions in
the care of the insane that they may adequately instruct
their representatives in Congress. Conditions prevail-
ing in some of the institutions he declared to be actually
inhuman, and called for immediate corrective legisla-
tion. A proposition made by the Public Charities As-
sociation in co-operation with the society's committee
for the promotion of more efficient laws for the insane
was submitted. Dr. Frazier referred to a resolution
adopted by the State Board of Charities almost twenty
years asro recommended that the State establish within
reasonable time an institution for the care of all insane
not cared for in private hospitals, and thought a
"reasonable time" had elapsed.
Dr. Owen Copp of Philadelphia, superintendent of
the Pennsylvania Hospital for the Insane, said that the
State alone could be reasonably expected to adequately
provide for the medical treatment and scientific study
698
MEDICAL RECORD.
[Oct. 14, 1916
of the insane and mentally defective. The so-called
economy of county institutions he regarded as delusive,
in that the saving was obtained at the cost of appro-
priate medical attention and facilities for care and
prophylaxis. In New York, Massachusetts, and in other
states, experience had demonstrated the wisdom of the
principle of state care of the insane. He believed that
the colony idea in the care of the insane would
eventually surpass the claims made by the advocate of
the county asylum. He cited the case of a daughter of
a syphilitic father who had died in a hospital for the
insane. The patient presented the early stages of
juvenile paresis. The mother and five brothers and
sisters, upon examination, were also found to be in-
fected. The case demonstrated the value of the medical
and scientific spirit in the care of the insane, the neglect
of which in this problem would prove a menace to
mental health and racial soundness.
Dr. John A. Lichty of Pittsburgh said that of the
nineteen to twenty thousand indigent insane in the
State probably ten or eleven thousand were cared for
in State institutions, the rest in county and municipal
hospitals. The number of alcoholics found in county
hospitals and frequently discharged as cured he thought
was a factor in the claim that the county hospitals
gave a higher rate of recovery. Just as by the State
tuberculosis movement it had been possible to "combat
and in a measure prevent tuberculosis, there was needed
a State organization for the care of the insane which
would provide facilities for the treatment and pre-
vention of insanity.
The Workmen's Compensation Law. — Dr. William L.
Estes of South Bethlehem, chairman of the Board of
Trustees, at the request of the board for suggestions for
amendments to the act, submitted the following: (1)
Define major operation as used in the wording of the
act. (2) Extend the period of direct payment for treat-
ing the injured workman to thirty days. (3) Increase
the limit of payment for "reasonable surgical, medical,
and hospital services." A definition of "major opera-
tion" recommended by Dr. Francis D. Patterson at the
request of the board for a definition Dr. Estes thought
would in all probability be adopted by the Commission
Board. In Dr. Estes' opinion the only efficient remedy
of the present business error in the matter of proper
fees, which apparently was the crux of the difficulty,
was thorough organization through the county medical
societies in demanding from insurance companies the
same rate of remuneration which each physician is en-
titled to and accustomed to receive for similar services
in his own community. It was to be remembered, how-
ever, that some of the clauses of the act were but
tentative and that any claims by phvsicians should be
made in a dignified manner; that while the law was
primarily for the benefit of the workman, so far as
possible without detriment to himself, the physician
should assist in this work. To be borne in mind, also,
was the probable enactment of a general social insur-
ance law. It was in his opinion the physician's right
to be consulted in the framing of such laws, and it
behooved him to be on the alert for self-protection and
for the common good.
Wednesday, September 20 — Second Day.
First Vice-President, Dr. J. Torrance Rugh of Phila-
delphia, in the Chair.
What Can Be Done to Improve (he Milk Supply in
Pennsylvania?— Dr. 1,. V Klein of Philadelphia pre-
sented this paper, in which he said that during 1911.
1912 and 1913 about one-fifth of the 190.000 dairy farms
n Pennsylvania had boon visited by inspectors" of the
State Live Stock Sanitary Board and classified as ex-
cellent, a small number; 30 to 40 per cent.; fair, 50 to
8 per rent., and bad, S to 15 per cent. Three groups
were involved in anv method of improvement, viz.. the
producers and distributors, the health officials and the
consumers. The producers had found in recent years
that many of the methods of improvement recommended
tor sanitary vasons were also good economically be-
cause they increased production, maintained the health
of the cows, facilitated the work and , i loss due
to spoiled milk. Duplication of inspection by various
authorities had not met with the producer's approval
Furthermore, he could not see why he should incur
extra expense without a corresponding increase in the
price realized for the sale of his product. The position
of the distributor was similar to that of the producer
I he economic conditions affecting the production of milk
had driven many farmers out of the business Short-
comings of regulation by local health boards were the
great variation in regulations imposed, lack of scientific
knowledge of the subject by such boards and the diffi-
culty of getting qualified inspectors. Consumers were,
as a rule, not sufficiently interested in the quality of
milk furnished them. Comparatively few wealthy peo-
ple bought certified milk. This indifference on the part
of the consumer had made it possible for the careless
producer to thrive. As reform measures there should
be a uniform system of inspection in charge of the
State, including grading and classifying of milk.
Dr. T. B. Appel of Lancaster said that the milk
supply of Lancaster was derived from 276 dairies and
supplied to the consumers by 55 dealers. The Board
of Health of Lancaster, as a member of which he had
had experience, had divided the dealers into three
classes: (1) Those who produced and marketed their
own product; (2) those who marketed not only their
own product, but who also bought new milk from other
farmers, who did not have any milk routes, and (3)
those who ran milk routes in town and had nothing to
do with production. In addition, they had one large
milk company which bought not only from their county,
but also beyond its borders. The milk was examined
at least once every two months by the city bacteriologist
as to its physical characteristics and number of bacteria
present. The average rating of repeated examinations
considered with the annual dairy inspection brought
out very markedly that the best milk and the best kept
dairies were those belonging to those dealers who mar-
keted their own product, while the poorest records were
those of the dealers who simply had a milk route. Their
attempts at grading and labeling milk had been violently
opposed by the dairymen, and the public had not been
educated sufficiently to be a factor in the case. It
had to be admitted that with a proper number of quali-
fied inspectors under the control of a central authority
and governed by definite standards an ideal result
would be obtained, provided always that the public
could be sufficiently educated to support the project, but
the inspection had to be continuous in character. He
believed, however, that the Bureau of Health should
control all food and milk questions rather than the
State Live Stock Sanitary Board.
Dr. H. F. Smyth of Wayne said that it was a matter
in which he was very much interested and he would
say that he lived in Radnor Township, to which Dr.
Klein had referred. They had been classifying milk
men in their community and they had found it working
out very successfully. They employed a trained veter-
narian, who made a splendid dairy inspector. All their
dairy scoring was done by this inspector. He had gone
out with him a number of times and he did splendid
work. They attempted to do as little policing as pos-
sible. All their efforts were on the educational line,
and they had succeeded remarkably well. They had
succeeded in getting the public with them largely.
They published the scores of their dairies every three
months in the local papers. They started first with
simply publishing the better classes, but now they pub-
lished the names of all classes. Their bacteriological
tests were made by the State Live Stock Sanitary
Board in Philadelphia. Their inspector worked in har-
mony with the laboratory. They preferred, though, to
have their own inspection so they could have their own
regulation.
Dr. G. B. Hoi.tzapple of York said that very much
the same conditions existed in York as in Lancaster.
In addition to inspection it would be well to lay em-
phasis upon systematic instruction of both the producer
and the distributor. If the State would supply printed
matter which would explain to the farmers just how
to improve their product and which could be preserved
and consulted and studied, it would do much good. It
would be looked upon by the farmers and distributors
as authoritative. Articles were printed in the public
press every now and then, telling how to improve the
condition of the milk. He did not think the farmers
would take to that nearly as well as if the State in-
spectors would supply literature so that they might
glean what they ought to know, because it would be
authoritative and there would be no question as to that.
Dr. W. S. Gimper of Harrisburg said that in the
paper by Dr. Klein it had been pointed out that 15 per
cent, of the dairies examined were in the "bad class";
they could more properly be classed as horrible. Classify-
ing these dairies as bad meant that all conditions were
such that they could not comply with even the most
moderate sanitary requirements, and that the milk pro-
Oct. 14, 1916J
MEDICAL RECORD.
699
duced and handled on the premises should be regarded
as unwholesome. The dairies of the bad class com-
prised the most serious phase of the milk improvement
problem. The owners were not amenable to suggestion
or moral coercion ; nothing but the heavy hand of the
law would bring them to a realization of their crimes
against public health. They were not only a constant
menace to health, but were also a detriment to the entire
dairy industry. Much time and effort had been spent
in an attempt to educate this class of dairymen, with
practically no good results. The improvement in meth-
ods to which Dr. Klein referred as "encouraging" had
not been found among the "bad" dairies, but in those
which were, classed as fair and more largely those in
the good class. This type of dairyman was usually
ready and willing to make any reasonable changes
which would tend to improve the quality of his products.
Embarrassing regulations had, he believed, retarded
rather than assisted improvement. A sudden increase
of milk-borne diseases would stir a local board of health
to activity, and drastic regulations which were far more
esthetic than practical were adopted. The dairyman
realized the hopelessness of complying with such regu-
lations at the price he received for milk, consequently
did nothing. Numerous investigations clearly showed
that a large amount of milk was now being produced at
a loss, and, if there was to be a general improvement
in the milk supply it would involve an increase in cost
of production which had to be borne by the consumer.
Dr. C. H. Miner of Wilkes-barre said that they, in
Luzerne and Lackawanna Counties, got a large propor-
tion of their milk from other parts of the State. What
annoyed him was that a large part of the good milk
from the farms in northeast Pennsylvania, along the
route of the Lehigh Valley, went into New York City.
It required certain standards, and all that good milk
went in refrigerator cars to New York City. All that
not inspected was shipped to Wilkes-Barre without re-
frigeration. The public health committee, through the
co-operation of the State Live Stock Sanitary Board,
had presented a resolution which would be voted on by
the house of delegates.
Dr. J. B. Caerell of Hatboro said that he had been
in the milk business himself. Unfortunately, he had
happened to have a farm, and he had been up against
the milk proposition, and he could say candidly that he
would not give the product of the chickens scurrying
around the farm for the product of twenty cows. That
was an absolute fact. The idea of any farmer trying to
produce hygienic or sanitary milk for 3% to 4 cents a
quart was out of the question. His suggestion was
that to overcome the difficulty the city in which the
milk was distributed should act as distributor, and it
would be carefully considered and provision should be
made for the farmer or the producer of the milk to see
that he got an honest and fair price for his milk.
Carriers. — Dr. H. J. Benz of Pittsburgh nresented this
paper, in which he said that if the carrier was found
and excluded from school one of the problems of school
infection would be solved. The carrier, except in diph-
theria, was most difficult of detection, but in most cases
a careful history and examination of those who had
been absent from school would reveal the presence of
infection. In respect to whooping cough all those with
doubtful coughs should be excluded. In culturing for
diphtheria in Pittsburgh schools the greatest number
of positives were obtained in October and November.
In school contacts 1.5 per cent, gave positive cultures;
in home contacts this percentage was 3.4. Antitoxin
has no effect on the life of the diphtheria bacillus.
The various methods of disinfection of the throat in
carriers were good onlv for their effect on the surface;
if the tonsils were infected thev should he removed.
Dr. B. F. Royer of Harrisburg stated that the system
in use in Pittsburgh was well worthy of the attention
of any who were actively engaged in medical school
work. Dr. Benz had pointed out that in many of these
chronic nasal and tonsilar carriers you got the germs
of diphtheria. He might well have pointed out that
the chikl recovering from scarlet fever having nasal
discharge was apt to be a carrier of diphtheria or of
scarlet fever. Public health authorities had long ceased
to be much disturbed about the late desquamation in
scarlet fever. Any child that had an extensive sheddins
of skin from anv of the soaps used in the homes would
have further flaking of that skin which would run over
many weeks. He doubted if the attention of the pro-
fession had been sufficiently called to that point. The
late sheddinc of the skin was perhaps not at all con-
tagious, and he doubted whether it was at all so after
thirty days. He would like to urge that medical men
should not release from quarantine cases that had a
discharging nose or running ears until they had been
carefully studied.
'I he Significance of Hunger Pain. — Dr. J. W. Luther
of Palmerton read this paper, in which he stated that
in regard to hunger pain he was inclined to agree with
Einhorn, who stated that Moynihan's symptom complex
might occur with or without ulcer, and favored the
theory that hunger pain was caused by a spasm of
the pylorus induced by hyperchlorhydria, which was
often associated with hypersecretion, and which was in
a large percentage of cases complicated by a justo-
pyloric ulcer. The causes of hypersecretion and hyper-
chlorhydria were too numerous to mention, nor did they
directly apply to his paper. When "hunger pain and
food relief" occurred with a painful pressure point and
occult or microscopic blood in the feces, the roentgeno-
logical examination showed gastric hypermobility and
a shortened duodenal cap and possibly also when Ein-
horn's string test, if used, was positive, a diagnosis of
duodenal ulcer might be made, though many author-
ities claimed that even then it could not be accurate,
and that a diagnosis of the position of the ulcer by the
lateness of the onset of pain was impossible.
Dr. William H. Howell of Altoona said that hunger
pain signified duodenal ulcer. This symptom meant
corroborative evidence of such disease. It was not
pathognomic, by any means, but helped to confirm
one's suspicions. The x-rays and a careful and thor-
ough history of the case were essential to a diagnosis.
The symptom should never be drawn from the patient,
but should be volunteered by him.
Dr. J. B. McAlister of Harrisburg said that as
hunger pain was most commonly encountered in cases
of duodenal ulcer it was a most valued symptom in the
diagnosis of that disease. Yet pain which closely re-
sembled it was often present when a patient was suf-
fering from other affections. Hunger pain was not an
accompaniment of any definite chemical state of the
stomach. As a rule, hyperacidity was high, but even
low degrees had been found. Hunger pain might be a
symptom of acid gastritis, and was also found in
catarrhal gastritis; also present in gastrectoptosis,
enteroptosis, or nephroptosis. In hyperorexia, or paro-
rexia, the sensation of hunger might become so intense
as to amount to actual pain. Physicians were warned
against making a diagnosis of gastric neurosis because
a patient, happened to be a neurasthenic. The patient
might present the appearance and symptoms of a
neurasthenic, and yet harbor a gastric ulcer or carci-
noma.
Dr. J. A. Lichty of Pittsburgh said that he fully
agreed that the etiological interpretation of this symp-
tom was not clear, and thought the interpretation
Luther had given was probably the correct one. There
was one point which he did not believe he could agree
with Dr. Luther upon, and that was that it was due
to a hyperchlorhydria. Pylorospasm could be caused by
other conditions than hyperchlorhydria. Mr. Moyni-
han's expression of some ten years ago that hunger pain
was duodenal ulcer could certainlv not be substantiated.
Dr. Ernest Laplace of Philadelphia said he
thought that by common consent the pain described as
hunger pain was usually contraction of the pylorus.
We realized the intimate nervous connection, cerebro-
spinal and sympathetic of the nerves supplying the
stomach. It was not to be wondered at that any irrita-
tion near by or at a distance resulted in spasm. He
knew that, surgically speaking, he had almost never
failed to find some sort of a lesion around the stomach,
or even down as far as the rectum, when there had been
hunger pain persistent.
Dr. Herbert B. Gibby of Wilkes-Barre said that there
was no doubt that the most prominent symptom in ulcer
was hunger pain. He could not agree with most of
the former speakers that pains of this character meant
only a duodenal ulcer. It might mean also a gastric
ulcer.
Facts and Fallacies Concerning Electrotherapeutics. —
Dr. W. L. Clark of Philadelphia read this paper, in
which he said that progress in the use of electricity in
therapeutics had been retarded by the ancient teaching
that electricity was purely psychic in its action, the
absence of teaching of the subject in the majority of
medical schools and the prejudice which had arisen on
account of the association of electricity with irregular
practice. He would urge upon superenthusiastic elec-
trotherapeutic advocates the necessity of being guarded
in their claims and that teaching in electrotherapeutics
700
MEDICkL RECORD.
[Oct. 14, 1916
be established in all medical schools on the same plane
as laboratories devoted to other subjects. Electricity,
though always the same force, when modified with
knowledge, intelligence, and skill, might be made to
produce different effects, and it was upon this principle
that the whole superstructure of electrotherapeutics
rested. The effects produced by electricity might be
classified as mechanical, chemical thermic, actinic, and
psychic. Some of the future possibilities of electricity
in therapeautis were the abstraction of metallic poisons
from the body by ionization, safe local and general
anesthesia, with loss of consciousness and relaxation,
and relief of pain and the production of sleep, thus
lessening the need of opiates.
Dr. H. C. Westervelt of Pittsburgh stated that there
was no question among those who knew electrothera-
peutics as to where the fault lay. The wealth of litera-
ture, unfortunately, did not exist in such form that tin-
average general practitioner could avail himself of it.
It was a special literature. Theologians stated that
you could read anything into the Bible and read any-
thing out of the Bible. It was the same with electro-
therapeutics. There was an amount of definte knowl-
edge which was readily available. The difficulty was
that electricity was used by ignorant people. The prac-
titioner came to these meetings, listened to the demon-
strators of electrical apparatus, went home and tried
it, and was disappointed and disgusted time after time
until he lost all patience. It was up to the medical
colleges to teach electrotherapy.
Dr. J. Torrance Rugh of Philadelphia said that the
trouble was with the profession. He wanted to say that
the trouble lay partially wim the electrotherapeutists
thenreH'cs, a5* ha'' been shown move especially from the
standpoint of reflexes. Electrotherapeutists spoke of
curing cerebrospinal meningitis. How did they know
they were doing it? They couldn't tell, because there
were abortive cases of it. There were all forms of
infection in between, and to make unguarded statements
such as he heard from some of the electrotherapeutists.
was unwise. There was need for such an article as
Dr. Clark had just given and for what he was doing to
educate the medical profession. He thought there
should be an educational propaganda for the general
profession.
Dr. G. G. Davis of Philadelphia said that general
medicine and surgery had occupied almost the complete
field of our medical school teaching. The consequence
was that the specialties were relegated to the back-
ground. We should bring them out and isolate them.
Our graduates know about certain minute points in
general medicine and surgery, but almost nothing about
the common affections placed in the specialties. There
was no reason why we should not have a chair of elec-
trical therapeutics in the same way that we had of the
other specialties.
Diabetic Gangrene. — Drs. -Ioiin H. .TOPSON and E II
Goodman of Philadelphia presented this paper, in which
it was stated that judging from the favorable result
of the treatment of diabetes by the Allen method was
perhaps not too much to hope that, with careful con-
sideration of every case of uncomplicated diabetes, dia
betic gangrene might be prevented. They believed that
diabetic gangrene was only a manifestation of an in-
fection.on the basis of lowered tissue resistance plus
arteriosclerosis in most cases. There was. however,
no specific oreanism of diabetic gangrene. The rational
treatment of diabetic gangrene should be dietetic and
local. Should the condition progress in spite of the
strict observance of Allen's dietetic method, together
with proper local measures, then the indications for
amputation had to be considered. These indications
were extension of the local process, with signs of septi-
cemia and high glycosuria; or extension of the local
with signs of septicemia in the presence of
However, in the presence of septicemia even
with low- glycosuria, or sugar free urine, operation
might be indicated. A high percentage of glycosuria
in no way contraindicated operation, although it was
better to reduce the urinary sugar it" possible. When
local and general conditions became grave, operation
lid not be deferred. Their experience hail shown
that fasting should eive place to free feeding some time
before operation. They favored the use of alkalies in
large enough dose to render the urine alkaline before
ation and preferred to administer the bicarboi
of soda by mouth and by proctolysis. Water was given
freely before operation and operation might be per-
forpied under local anesthesia. Ether and chloroform
were contraindicated with patients having glycosuria.
Dr. M. Behrend of Philadelphia said that it had been
his experience that results of operation after the Allen
treatment had been far superior to any other form of
treatment. There was another form of gangrene in
diabetes. It was an insidious form of localized gan-
grene which occurred around the extensor tendons of
the toes. It was a very grave symptom, and the prog-
nosis in all these cases had to be very guarded indeed.
Death resulted whether operation was performed or not.
Dr. Jopson said in closing that those who had the
most experience would get a little hazy in regard to
dietetic treatment before and after operation. His own
experience was that patients prepared for operation
with low fat-protein diet, in accordance with Council-
man, stood operation well. He found that a patient put
on starvation treatment in an attempt to get rid of
the sugar developed acidosis and coma, from which she
did not recover. Certain cases had convinced him that
we had to feed cases until convalescence was estab-
lished and the wound was healed. There was a certain
amount of exhaustion which went with starvation, and
we should feed until local reaction had been established.
Thursday, Sept. 21— Third Day.
Internal Secretions and Their Relation to Nervous Dis-
orders.— Dr. Seymour DeWitt Ludlum of Philadelphia
in this paper said that a study of nervous cases by
their physiological symptoms pointed toward etiological
factors which, considered with the morphology of the
patient and with Abderhalden's reactions done on the
blood serum for internal secretions, gave quite definite
conceptions of backwardness, some forms of insanity,
neurasthenia, dystrophies, etc.
Fecal Incontinence. — Dr. Samuel Goodwin Gant of
New York divided the cause of fecal incontinence into
nonoperative (brain and cord diseases, ulcerative proc-
titis, rectal cancer, injuries to the sphincters, etc.) and
surgical groups. He believed the condition would be-
come rare when surgeons acquired the ability to prop-
erly treat fistula-in-ano and ceased divulsing the
sphincter rapidly with the finger and mechanical dila-
tors and discarded Whitehead's operation for hemor-
rhoids. He had treated 25 patients for partial or
complete incontinence caused by this latter operation.
Non-operative treatment for fecal incontinence Dr. Gant
regarded as useless in the majority of cases. A routine
technique in surgical treatment was out of the question;
the operation which would re-establish sphincteric con-
trol should be selected. The writer's operation, per-
formed under local anesthesia, and in ten minutes,
was fully described. Of 17 cases operated upon by this
method fecal incontinence had been completely relieved
in 9; diminished in 5; slightly reduced in 2, and no
benefit had been observed in one. In cases in which the
incontinence was the result of Whitehead's operation,
or laceration of the sphincter from stretching by the
fingers or instruments, cauterization was substituted for
plastic operation.
Dr. Ira G. Shoemaker of Reading had seen pitiable
cases of fecal incontinence resulting from lack of care
in operations for fistula. With involvement of both
sphincters he believed the best results were to be
obtained by the use of elastic ligature. Although not
advocated by the majority of men doing rectal work, he
had used the method successfully many times. The
ligature cutting through the tissues produced an irri-
tation which formed a good base and promoted healing.
The ligature adapted itself to the fibres of the muscle
in the way of least resistance, which was squarely
across. The muscle was severed or the ligature might
be allowed to finish the operation. A case of nurelv
psychic fecal incontinence which had been under his
cue was cured by suggestive means and placebos.
The Cooperation of Physician and Surgeon in the Af-
ter-Treatment of Patients Operated Upon for Diseases
of the Gastrointestinal Tract — Drs. Edward H Goodman
and JOHN Speese of Philadelphia presented this naper,
which was read by Dr. Speese. In their opinion this co-
operation should begin immediately after the operation.
Even greater co-operation, they believed, indicated in
cases surgical from the first in which the physician was
consulted, but in which later the surgeon assumed
entire charge. The medical attendant to whom a hos-
pital patient returned from the hospital should be fully
informed bv the hospital physician of all facts relative
to his condition. They condemned the routine prescrip-
tion of diets employed in hospitals, regard'ess of the
gastrointestinal conditions of the patients The advice
of the internist in a surgical case should be followed
only with the sanction of the surgeon, and the mode
Oct. 14, 1916]
MEDICAL RECORD.
701
of living of such patients should be directed for from
six to twelve months subsequent to operation. Lack of
prolonged postoperative medical treatment, the authors
observed, was given by Hamburger and Leach as a
cause of absence of relief in operations for gastric and
duodenal ulcer.
Dr. John A. Lichty of Pittsburgh believed that the
co-operation recommended by Drs. Goodman and Speese
should be not only postoperative, but operative and
preoperative. While there might be opportunity for
meddling on the part of the internist, some surgeons
there were so dogmatic that cooperation was impossible.
These two types, however, were not found in the ranks
of reasonable men.
'lhe Clinical Interpretation of the Wassermann Test. —
Drs. John A. Lichty of Pittsburgh and James H.
Whitcraft of Wilkinsburg presented this paper, citing
eight cases illustrative of a few points in the inter-
pretation of the Wassermann test and calling attention
to the fact that in only one of the cases had the patient
any suspicion of his condition. This fact they had also
found to obtain in many cases. The following sum-
mary was given of their cases: "(1) The Wassermann
test, while not absolutely certain, is the most valuable
laboratory aid in the diagnosis of syphilis. (2) A
negative test in suspected cases should be repeated
before the suspicion is dropped, often after a provoca-
tive dose of salvarsan. (3) A negative reaction may
be due to previous treatment, which has not been
curative. (4) The influence of specific treatment upon
clinical manifestations of syphilis tends to show the
reliability of the Wasermann test. (5) The existence
of a positive Wassermann should not be construed to
mean that syphilis is the only condition present re-
quiring treatment."
Modern Diagnosis and Results, Clinically, Serologi-
cally, and Sociologically of Syphilis, Treated with Sal-
varsan and Its Substitutes.— Dr. B. A. Thomas of Phil-
adelphia presented a study of 510 patients in his
private and hospital practice, and emphasized the im-
portance of the heroic treatment of syphilis in its early
stages. In the early diagnosis of suspicious sores he
regarded the dark field illuminator indispensable.
Among the conclusions drawn from his study the fol-
lowing points were noted: "(1) The treatment of
syphilis remains empirical. (2) The ultimate proof of
cure rests rather upon complete freedom of symptoms
for a generation or more. (3) The Wassermann reac-
tion furnishes the best control of treatment and is the
most reliable index of cure subsequent to proper treat-
ment. (4) The sheet anchor in the treatment of syphilis
is salvarsan, neosalvarsan, or one of their substitutes.
It is of paramount importance, however, that the injec-
tions of arsenobenzol, in the beginning, be administered
as early as possible and intensively in full doses com-
mensurate with the physiological tolerance of the
patient. (6) Serologically, judged upon a three-month
to a five-year duration, syphilis in the chancre stage, if
diagnosed early, may be cured by two injections of
salvarsan or neosalvarsan ; if diagnosis be made before
the advent of a positive Wassermann one dose of either
of these drugs may be sufficient. (6) Secondary
syphilis seems to do just as well without as with mer-
cury, provided enough salvarsan or neosalvarsan be
given to produce a negative Wassermann. (7) The
best substitute for salvarsan and neosalvarsan is the
Polyclinic preparation of arsenobenzol. (8) Sociologi-
cally, since only 10 per cent, of syphilitics return for
hospital treatment until discharged cured, a problem is
presented urgently demanding cooperation on the part
of civil authorities and health boards for the control and
treatment of this disease, not, however, to be realized
until all hospitals receiving State aid are compelled to
maintain evening dispensaries with paid attendants for
the proper treatment, and admission when necessary, of
venereal patients."
Thp Treatment of Syphilis by Salvarsan Controlled by
the Wassermann Reaction. — Dr. John D. Wilson of
Scranton presented this report, based upon the study of
112 cases of svphilis seen in private practice in the last
five vears. His experience with these cases led him to
the belief that salvarsan was most useful during the
early active period of the disease, and that small, fre-
quently repeated doses, namely, gram 0.3 to 0 4 every
week or ten days for twelve injections, in conjunction
with active mercurial treatment, should constitute the
first course of treatment in any new active case. The
after treatment should be determined by the return of
susnicious symptoms and bv the Wassermann reaction
on the blood and spinal fluid.
Dr. George Morris Piersol of Philadelphia, in dis
cussing the preceding three papers, stated that the chief
result of the extraordinary advances in the study of
syphilis in the past decade had been to show that spiro-
chetal infection was the real cause of an ever-increasing
number of conditions formerly not recognized as of
syphilitic origin. It was to be remembered that the
Wassermann reaction was not a primary but a sec-
ondary aid to diagnosis. In many of the more obscure
visceral lesions of the nervous system, cardiovascular
apparatus and in latent hereditary syphilis, very defi-
nite clinical manifestations might be present, and yet
the blood Wassermann reaction be negative. Con-
versely, while a positive blood Wassermann reaction
meant that a syphilitic infection was present, it far
from proved that the condition present was due to this
infection. For example, some enthusiasts regarded
every case of chronic gastric disorder with a positive
Wassermann as due to syphilitic infection. While
syphilitic gastric ulcer was possibly frequent Dr. Pier-
sol thought 1' enwick correct in his conclusions that in
about one-half of the cases in which the two diseases
coexisted there was no direct relationship between them.
Dr. Piersol stated that no apparently cured case of
secondary lues should be discharged until spinal punc-
ture had demonstrated the absence of involvement of
the nervous system. Only in this way could early
meningitis be recognized. He emphasized the in-
adequacy of the present equipment of the majority of
State and hospital dispensaries for the treatment of
active syphilitics. The expense of their ultimate de-
pendence upon the State might be almost entirely
avoided by provision by the State for the control and
scientific management of this class of patients. He
believed that a cure could be pronounced only after a
repeatedly negative Wassermann reaction for at least
two years after a provocative injection of salvarsan and
a normal spinal fluid. The persistence of spirochetal
infection had been shown in the recent work of Warthin.
Out of 41 cases autopsied in 11 of whom syphilis had
been regarded as cured, 5 of whom har been under
recent active syphilitic treatment and in 25 of whom
syphilis had been clinically excluded, Warthin had
found active syphilitic lesions and spirochetes in the
tissues of all. In his work Warthin had also noted a
relationship between glycosuria and diabetes and
chronic latent luetic lesions of the pancreas.
Dr. John A. Kolmer of Philadelphia expressed his
pleasure that Dr. Thomas had found the arsenobenzol
prepared in the Dermatological Research Laboratories
of the Philadelphia Polyclinic of low toxicity, which
observation was in accord with those of many phy-
sicians throughout the country. This arsenobenzol, he
explained, was submitted to severe animal tests, in
amounts equivalent to 3.6 grams per 60 kilograms, or
about 125 lb. of body weight. Experimental and
clinical data indicated the superior spirocheticidal ac-
tivity of salvarsan and arsenobenzol over neosalvarsan.
In an experimental study of the toxicity of various
mercurials he had found that insoluble salts of mer-
cury as the salicylates were very slowly absorbed from
the subcutaneous and muscular tissues. For this
reason physicians should avoid administering such
preparations at close intervals. He believed the par-
ticularly favorable results reported by Dr. Thomas upon
the treatment of syphilis as judged by the effects upon
the Wassermann reaction to be due to the technic em-
ployed in the Wassermann reaction and more particu-
larly the employment of an alcoholic extract of syphi-
litic liver as antigen. These results were not in accord
with his own experience and that of many others. A
study of antigens since 1912 and covering over 3000
te^ts with a number of different antigens Dr. Kolmer
said had shown conclusively the superiority of cholester-
nized extracts as antigens in this reaction. He believed
it a serious error to discontinue treatment on the basis
of a negative test with an antigen of alcoholic syphi-
litic liver. Experience had taught him that a number
of such patients were still Wassermann positive and
could be rendered Wassermann negative with additional
treatment. The Hecht-Gradwohl reaction as a control
on the Wassermann had been found by him to yield
about 12 per cent, more true positive reactions than the
Wassermann. He regarded the Hech-Gradwohl reaction
as the best serological evidence of the cure of syphilis
with which he was familiar, and believed that no case of
svphilis should be discharged from observation until the
Wassermann reaction was negative with cholesternized
antigens and then negative in the Hecht-Gradwohl re-
action.
702
MEDICAL RECORD.
[Oct. 14, 1916
NEW YORK ACADEMY OF MEDICINE.
SECTION ON PEDIATRICS.
Stated Meeting, Held May 11, 1916.
Dr. Royal S. Haynes in the Chair.
Report of a Case of Chondrodystrophy (from the Van-
derbilt Clinic). — Dr. Jesse F. Sammis presented this re-
port. He stated that the patient was a child, 9 months
of age, whose chief complaint was inability to hold up
the head. This child was the youngest of four chil-
dren, the others being perfectly normal in both physical
and mental development. The family history was
negative. The child was born at 8% months intra-
uterine life, its weight at birth being given as 12
pounds. The labor was difficult and the child ex-
tremely cyanotic, having been resuscitated with dif-
ficulty. The child had been normal until four months
of age, when it was noticed that the head appeared to
be increasing in size very rapidly and that the child
was making no effort to sit up. At nine months of age
the child could hold up his head but could not sit up.
He played and laughed in a normal way and appeared
almost as happy as other children of his age. He was
presented because he exhibited all the characteristics
of achondroplasia in a typical way. The disproportion
between the trunk and the extremities was marked, the
hands scarcely reaching to the waist line; the skin,
owing to the shortness of the extremities, hung in folds.
There was the prominent forehead, the saddle nose,
and the protruding jaw characteristic of this condition.
The abdomen was prominent and an umbilical hernia
was present. There was a slight lateral curvature of
the spine and kyphosis. The hands were of the type
described as "trident." There was considerable relaxa-
tion of the ligaments and the child's muscular develop-
ment was poor. The liver and the spleen were both
easily palpable. The Wassermann was negative. The
measurements showed the great disproportion between
the head, the limbs, and the trunk characteristic of
chondrodystrophy.
Autoserum Treatment of Chorea. — Dr. Abraham
Goodman presented this communication. He first re-
viewed the literature of chorea, especially with refer-
ence to etiological investigations. He said his attention
was first attracted to the subject by two cases ad-
mitted to the German Hospital with a diagnosis of
chorea. In one of these cases the choreic movements
were augmented to a high degree in a short time and
the child developed an intense coma. It was suspected
they were dealing with a miliary tuberculosis of the
central nervous system. All the usual forms of medi-
cation were tried without avail. It had occurred to the
writer, in 1913, that if one could use the serum of a
patient with chorea and inject it into the spinal column
favorable results might be obtained; that possibly the
enzymes or the protein bodies might be a factor in the
disease. Realizing the dangers of such a procedure,
they made cultures of the blood and spinal fluid of
choreic patients and in none could they demonstrate
any organism. The use of salvarsanized serum had in
the meantime given additional encouragement to work
along these lines, so they determined to try it. The
first case was the one described above. They felt that
they would lose the case and that the use of the serum
was justified. They employed this method and the
child became quiet within two days. One should be
sine he was dealing with a case of chorea before apply-
ing- this treatment, since every case with choreiform
movements was not a case of true chorea. Another im-
portant factor in the treatment of cases of chorea with
autoserum was to be sure that all drug medication was
eliminated. To be sure that any treatment in chorea
was effective it must give quick results; if it was
slow in producing an effect one could not be sure
that the disease was not self-limited. With the
autoserum the effect was manifested within two or
three days. The method employed was briefly as
The child was allowed to lie in the ward
for three or four days and in the meantime other in-
fections, as syphilis, were excluded. They then drew
°" 45 °r Mood and centrifuged it. The serum
was then pipetted off and kept for two hours at room
temperature. A lumbar puncture was then done and
20 c.c. of the spinal fluid withdrawn. The serum was
then taken from the incubator and very slowly injected
into the spinal cord, allowing ten or fifteen minute
inject 15 C.C. It was very important that the injection
be made slowly so as not to disturb the equilibrium.
The patient was then put to bed and there was no im-
mediate reaction. At times there might be a rise in
temperature, but this was exceptional. Dr. Goodman
said they had thus far made from 20 to 25 such in-
jections without any serious results. It was amazing
to see how quickly these cases of chorea responded to
this treatment. Dr. Smith had a case at the Vander-
bilt Clinic that had been growing worse for three
months. The child exhibited most violent movements
and after two injections was cured and discharged. At
the present time they were engaged in trying to find
wherein the actual value of this procedure lay, whether
it was due to an antibody, an enzyme, a protein, or
what not. In the meantime any remedy that would
relieve this distressing malady was worthy of careful
consideration.
Dr. Samuel Feldstein of Brooklyn said that at the
Brooklyn Jewish Hospital they had recently treated a
case of chorea by Dr. Goodman's method with most
amazing results. This patient was a girl, 13 years of
age, who two months previously had begun to suffer
from rheumatic polyarthritis which necessitated her
stay in bed for three weeks. After ten days' relief
she was again compelled to take to her bed on account
of the recurrence of the articular symptoms. Three
days previous to her admission she was seized with
severe choreic movements, these being so violent at the
time of admission that a thorough physical examina-
tion could not be made. Her temperature was 100.4°
F., pulse 120, and respirations 26. There were
signs of a mitral regurgitation. After observing the
patient for three days and being compelled to give
dionin in Vs grain doses at night for the extreme rest-
lessness, the child's condition became aggravated.
They then removed 40 c.c. of blood from an arm vein
and kept it at room temperature, allowing the serum
to separate spontaneously. Most of the serum was
clear, the remainder was centrifuged. They then re-
moved 20 c.c. of clear fluid from the spinal canal and
injected 10 c.c. of the serum. Following the injection
there was considerable reaction, rise in temperature to
102° F., headache, and rigidity of the neck. These
symptoms disappeared the following day. The day
after the choreic movements were greatly decreased,
and by the third day had largely disappeared. A week
later the injection was repeated, this time allowing the
serum to separate spontaneously at room temperature
over night. The second treatment was followed by a
much milder reaction. A few days later the patient
was practically free from spontaneous choreic move-
ments, and had remained so up to the present time.
Dr. Charles H. Smith said he had seen the case of
chorea to which Dr. Goodman had referred and that if
he had cured that case he had performed a miracle, for
it was the most severe case of chorea he had ever
seen. Every attempt had been made to alleviate the
condition of that child. It had received maximum doses
of salicylates, bromides, chloral, arsenic, and tonics, and
it scarcely seemed possible that it could be cured.
Dr. Rudolph Moffett said he had been associated
with Dr. Goodman at the German Hospital and had ob-
served this treatment, and he could only say that it
worked wonderfully. After injecting a case it cleared
up within a few days. They had been using 10 c.c. in
making the injections, and he thought they should use
15 c.c. and that they might thus avoid the necessity of
giving a second injection.
Observations on Tuberculosis at the Vanderbilt Clinic.
— Drs. Charles H. Smith and H. Lambert Bibby pre-
sented this contribution, which was read by Dr. Smith.
He said that when a child was brought to them for
examination there were two questions which they
always asked: (a) "Has the child been infected with
tuberculosis?" This question was answered by the
skin test, (ft) "Is the infection latent or active?" The
terms latent and active were preferable to infection
and disease, since they were more accurate and since all
infection meant disease. An active tuberculosis in a
child was not like incipient tuberculosis in the adult.
In the child the lesion was not apical, often not pul-
monary, but by node or hilus infiltration. This made
the diagnosis extremely difficult and quite different
from making a diagnosis in the adult. The diagnosis
in the child was made on symptoms of impaired nutri-
tion and anemia, undersize. and failure to gain in
weigh.1 at the proper rate. The presence of an irregu-
lar fever lasting over a considerable length of time was
very suggestive. Other symptoms that were valuable
were anorexia, fatigue, languor, headache, and night
sweats. In some instances the fever seemed to incite
Oct. 14, 1916J
MEDICAL RECORD.
703
the child to unusual activity. In children cough and
positive chest signs were rare, but there might be tran-
sient bronchitis, asthmatic bronchitis, or enlarged bron-
chial lymph nodes. A latent tuberculosis ,was shown
by a positive von Pirquet test and no symptoms or
signs of the disease. The frequency of these various
symptoms in a series of 80 cases giving a positive von
Pirquet reaction were as follows: Fever in 16 cases;
no gain in weight in 9; loss of weight in 7; failure to
gain when at rest in 3. Among these 80 cases, 21 or
25 per cent, had tuberculosis in the active stage and
all were without the signs of the disease. With refer-
ence to the von Pirquet test there were several points
to be observed. It was better to perform the test with
a scarifier as one was less likely to draw blood in this
way. The skin should be properly sterilized before
making the inoculation and should be allowed to dry
before the dressing was applied. A protective dressing
should be applied to protect the puncture from contami-
nation from clothing or ringer nails. They had found
physical signs in the lungs in only 21 out of 150 cases,
and these consisted in slight changes in the breath
sounds. Dullness was difficult to detect and uncertain.
The physical signs detected in these 21 cases were
transient localized rales at the apex with a positive
von Pirquet in one case, localized rales in the axilla in
three cases, two with a negative and one with a positive
von Pirquet; general bronchitis (accidental) in two
cases, one giving a positive and one a negative von
Pirquet, asthmatic bronchitis in five cases, all positive;
pleurisy in four cases, all positive; consolidation with
cavity formation in four cases, three giving a positive
and one a negative von Pirquet reaction, and two cases
with pertussis. This gave 14 per cent, in 150 cases in
whom there was a probability of tuberculosis; the
larger number of these gave a positive von Pirquet re-
action but some gave a negative reaction. The signs
of involvement of the bronchial lymph nodes were dull-
ness, tender spines, and Despine's sign. Enlarged
bronchial lymph nodes and infiltration of the hilus
caused an increased conductivity of the sounds, but
this sign was not pathognomonic. There was some
confusion as to just what was meant by Despine's sign
and it was better to say whispered bronchophony to a
given vertebra than to say Despine's sign positive.
There were certain points to be observed in eliciting
Despine's sign. The room must be quiet; the sign could
not be elicited where persons were walking about and
talking. The child must be able to whisper well; it
was, of course, impossible to get the cooperation of a
child under the age of three or four years. It was well
to listen high in the cervical and low in the dorsal re-
gion and then to continue to listen above and below
until the point was reached at which one heard the
vesicular sound. This point varied considerably in dif-
ferent subjects. The x-ray, in making a diagnosis,
was either a brilliant aid or a great disappointment.
In order to get information one must get a good x-ray
with a short exposure. When there was a positive
tuberculous infection, the x-ray might show enlarged
bronchial nodes, or tracheobronchial involvement by
large central shadows, or small nodes might be shown
along the main bronchi. Small dark shadows well
separated from the root shadows were very suspicious.
Pleural thickenings might be noted which were inter-
lobar or from old pleural effusions or infiltrations.
There might be a fibrosis extending out from the hilus
region, but it must be remembered that there were
variations in the hilus shadows normally present. The
x-ray might show consolidation or cavities, but it had
been found that the cavities were much smaller than the
signs would indicate. In regard to treatment, it might
be said that children with latent tuberculosis needed
watchful care, extra rest, air, and food. Children with
symptoms of active disease should be put to bed in the
open air with careful feeding and kept in bed until the
temperature became normal. They must be watched
for months and years in order to detect any signs of
relapse. At the present time there were insufficient
preventoria and sanatoria. All children with positive
von Pirquet reactions needed careful watching: if such
a child ran a temperature it should be considered as
needing the same care and treatment as an active case
of tuberculosis. At the present time our sanatoria
took only children from homes in which there were
members with tuberculosis, but made no provision for
the child accidentally infected from some other source.
Dr. Franklin Morris Class said he agreed with
everything that Dr. Smith had said. He saw many of
his patients at the Vanderbilt Clinic Day Camp and
saw what he had accomplished. The most difficult
cases to diagnose were the early cases of tuberculosis
in children under twelve years of age. He was also
convinced that most children suffering from early
tuberculosis showed no signs in the lungs; and those
cases showing pulmonary signs generally suffered from
an infection other than tuberculosis. It was especially
difficult to make a diagnosis in a dispensary as one had
to see each case over a considerable period of time.
Dr. Leon T. LeWalu said the problem of making a
diagnosis of early tuberculosis in children was just as
hard for the roentgenologist as for one who based his
diagnosis on physical signs. There might be a small
focus in a bronchial gland which the x-ray did not
readily show. As to Despine's sign, there was consid-
erable variation in the vertebra and that explained the
difficulty in the location of the sounds. It was also
difficult to determine the presence of a small focus as
the shadow of the cross section of a bronchus might be
mistaken for an enlarged gland. It was advisable to
have stereoscopic radiographs not only in one plane,
but taken at different angles, at right angles, and at
oblique angles.
Dr. Maurice Fishberg said that an important point
had been omitted in the discussion of the Despine's
sign. In interpreting the findings in tracheophony we
must bear in mind certain anatomical peculiarities of
the bifurcation of the trachea, mainly according to the
age of the patient. In infants under three years of age
the bifurcation was on a level with the seventh cervical
vertebral spine, but with advancing age it sank lower
and lower. At the age of eight years it was on a level
with the third dorsal vertebral spine, and at twelve
years of age it was as low as the fourth dorsal spine.
In adults it might be as low as the fifth or even the
sixth dorsal vertebral spine. Under the circumstances
the sign was positive in a child under three years when
tracheophony was heard lower than the first dorsal
vertebra; in a child of six the sign was negative when
tracheophony was audible above the third spine. In a
child of twelve tracheophony might be audible as low as
the fourth or fifth dorsal spine without enlarged
thoracic glands. In many children this sign was nega-
tive though the glands were enlarged because the
trachea was situated more anteriorly than normally, or
only the anterior glands were tuberculous. After all
the sign was due to the interposition of anything be-
tween the trachea and the spine, and tuberculous glands
were the most common in childhood. In adults we
might find tracheophony on rare occasions as low as
the lumbar vertebra? with or without being able to
assign a plausible cause to the phenomena. In chil-
dren if these anatomical points were not borne in mind
the sign was of little value.
Dr. L. Emmett Holt said that, with regard to the
von Pirquet reaction in tuberculous meningitis, he
thought the impression had gained currency that it was
only exceptionally that one got a positive" von Pirquet
reaction in that disease. It had been their experience
that except in the last stages of the disease, when the
patient was extremely prostrated, the skin test had
almost always been positive. At other times a nega-
tive test might be of great value. This was illustrated
in the case of a child who was admitted to the hospital
because the mother had noticed a lump on the head.
This proved to be a bulging fontanelle. There was a his-
tory of convulsions, fever, and drowsiness. A lumbar
puncture was done and 120 c.c. of perfectly clear nor-
mal fluid withdrawn. In this instance the von Pirquet
test was negative and the child recovered. The symp-
toms in this case pointed to tuberculous meningitis but
the child certainly did not have that disease. It prob-
ably belonged to that type of meningitis sometimes
called serous meningitis. As to Despine's sign, Dr.
Holt said he had been impressed by the extreme varia-
bility of the sign in different children. He did not be-
lieve it was possible to fix on any one point and say
that this was the exact point at which the whispered
voice was significant. It was a valuable sign for diag-
nosis and was usually best obtained on the right side.
Early wasting was often absent with active tubercu-
losis in infancy. One might see a child with fairly
positive signs of tuberculosis and yet the child would
show no loss of weight for a considerable time, and a
child mie:ht have a fairly active tuberculosis and even
gain weight. Loss of weight in young children was
not so significant of tuberculosis as in older ones. Most
of the children with tuberculous meningitis were rosv
and plump up to the time when active symptoms of
meningitis developed.
704
MEDICAL RECORD.
[Oct. 14, 1916
Dr. Abraham L. Goodman said that one point that
had impressed him was the difference in tuberculosis in
the very young children and those betwen the ages of
ten and twelve years. He had ben amazed to see how
well nourished these young children were, and how ex-
tensive the tuberculosis otten was without any particu-
lar objective sign. In older children these objective
signs were usually present. Most of these younger
children had enlarged bronchial lymph nodes and the
von Pirquet reaction was usually positive. These cases
of early tuberculosis exhibited indefinite fevers accom-
panied by gastrointestinal disturbances, and were
treated often as such until the condition was recog-
nized. Every case of indefinite fever in early life
should be looked upon as a possible tuberculosis and,
with the added i-efinement in technique and execution in
detail of x-ray examination, the early appreciation of
tuberculosis was made possible. When one found en-
larged mediastinal glands together with a von Pirquet
reaction and an increased temperature from time to
time, one was justified in making a diagnosis of incipi-
ent tuberculosis. When such children were placed
under proper hygienic and sanitary conditions and
given daily doses of guiacol and arsenic for years, they
could be permanently cured. Guiacol and arsenic not
only had a favorable influence on tuberculous processes
in the lungs but had a direct influence in the process of
metabolism.
Dr. Charles H. Smith, in closing the discussion, said
that with reference to Despine's sign, it was difficult to
get a child under two years of age to whisper; one
could not usually get a child under three or four years
of age to whisper properly. By the time a child was
three or four years of age the bifurcation of the
trachea was approximately as far down as at the age
of twelve years. There must be some significance in
this sign as one gets it as low as the fourth or sixth
dorsal vertebra and, on the other hand, there were a
large number of cases in which it stopped at the first
dorsal or seventh cervical vertebra. Undoubtedly it
did occur without the presence of tuberculosis, but the
figures with reference to its occurrence were certainly
suggestive.
Stoflka Hrrrivri.
The Medical Record is pleased to receive all neu
publications which may be sent to it, and an acknowledg
ment will promptly be made of their receipt under thiz
heading; but this is with the distinct understanding tha-
it is under no obligation to notice or review any publica-
tion received by it which in the judgment of its editor «n.
not be of interest to its readers.
The Practical Medicine Series, Comprising Ten
Volumes on the Year's Progress in Medicine and Sur-
gery. Vol. V — Pedinatrics. By Isaac A. Abt, M.D.,
and A. Levinson, M.D. Orthopedic Surgery. By
John Ridlon, A.M., M.D., with the collaboration of
Charles A. Parker, M.D. Series 1916. Published by
The Year Book Publishers, Chicago. 232 pages. Price
$1.35.
The Sanitary Progress and Vital Statistics op
Hawaii. An Address Delivered Before the Medical
Society of Hawaii, Honolulu, March 5, 1915. By Fred-
erick I. Hoffman, LL.D., Statistician the Prudential
Insurance Company of America. Published by Pru-
dential Press, Newark, N. J., vtvf. . 82 pages.
Progressive Medicine. A Quarterly Digest of Ad-
vances, Discoveries and Improvements in the Medical
and Surgical Sciences. Edited by Hobart Armory
Hare, M.D., assisted by Leighton F. Appleman, M.D.
Published by Lea & Febiger, Philadelphia and New
York, Vol. XIX, No. 3, whole number 71, September 1,
1916. Illustrated. 394 pages, $6 per annum.
La Fievre Typhoide et les Fievres Paratyphoides.
Par II. VINCENT et L. Muratet. Published by Masson
e., Editeurs, Libraires de FAcademie de Medecine,
Boulevard Saint-Germain, Paris. 1916. 278 pages.
Prix, 4 fr.
Les Formes Anorm m.ks du Tetanos. Par M. Cour-
SUFFIT et K. GlROUX. Preface du Professeur
NAND WlDAL. Published by Masson et Cie., Paris,
174 pages. Price. 4 fr.
TRAlTEMENT des Fractures. Par Prof. R. LERICHE.
Published by et Cie., Paris. 1916. 189 pages.
Illustrated. Prix, 4 fr.
Tratado de Pediatria. Por el Dr. Andres Martinez
Varagas. Tip, Lit. J. Vivis-Barcelona, Tomo 1, 1915.
Illustrated. 959 pages.
iUiar^Uattg.
"The Most Notorious of All Medical Practi-
tioners."— Marat is notorious not for charlatan-
ism— for, as a matter of fact, he was never ac-
cused of quackery — but because he was one of
the moving spirits of the French Revolution. Un-
til quite recently laymen and most physicians
seem not to have realized that he was, for his
time, a distinguished scientist and physician. But
his entire life was a series of paradoxes. He was
racially Italian, not French, and his true name was
Mara. He was born and raised in Switzerland.
He became so good a Britisher that he practised
in London for ten or twelve years, was received in
its best literary and scientific circles, and pub-
lished in English many articles on physics. He
received a medical degree from St. Andrews. His
political and iconoclastic career was also begun
in England when he wrote "The Chains of Slav-
ery," in 1774. During his sojourn in London he
wrote three pamphlets on medical subjects, two
of which were devoted to affections of the eye.
About 1777 he removed to France, and wrote
works in French, but not until 1788 did he begin
to show activity as a revolutionist. His political
career, which lasted a bare five years up to his
assassination, was so momentous that it com-
pletely obscured his earlier activities. His health
suffered, chiefly as the results of an irritating
dermatosis which caused constant unrest and in-
somnia. It is not impossible that this distressing
disease may have had much to do with his apparent-
ly murderous mania which kept the guillotine work-
ing overtime. — C. Edward Wallis, in the Proceed-
ings of the Royal Society of Medicine.
The Ambulance Driver. — An American ambu-
lance driver, a Harvard student, has contributed to-
the October number of the American Red Cross
Magazine a thrilling account of ten days' experi-
ences before Verdun, immediately preceding the
Somme engagements. He tells a story of the rescue of
wounded soldiers on the French side, in the midst
of terrific shrapnel and gas fighting, so graphi-
cally that an editorial note says it "exceeds in
vividness and action anything bearing on indi-
vidual achievement that has come to our hands
from the Western war front in Europe." This
heroic young American, a member of the Harvard
section which was later honored with military
medals and crosses of war, "rolled" for ten nights
in his light auto ambulance bringing to field hos-
pitals badly wounded "blesses." He describes
plunging into gas clouds, wearing a gas mask,
with shrapnel shells whistling and exploding
about his car, and of rescuing at one time one of
his fellow ambulance men, the whole back of
whose car had been shot away. This man he
found in a pitiful plight, his nerves gone, and
unable to talk straight. With his car full of
wounded men, and shells exploding all about one
of the rear wheels, his ambulance became en-
tangled in barbed wire. His frantic efforts to
unwind this wire, now and then ducking under
his car because of the warning whistle of a shell,
are so realistically described that the reader might
easily imagine being at his side. The explosion
of one shell threw him on his face in a pool of
horse's gore, and another shell blew out both of
the rear tires of his car so that one trip back
was made on the rims over a road literally paved
with dead horses and men and wreckage.
Medical Record
Vol. 90, No. 17.
Whole No. 2398.
A Weekly Journal of Medicine and Surgery
New York, October 21, 1916.
$5.00 Per Annum.
Single Copies, 15c.
GDriginai Artirks.
THE MANAGEMENT OF POLIOMYELITIS,
WITH A VIEW TO MINIMIZING THE
ULTIMATE DISABILITY."
Br ROBERT W. LOVETT, M.D..
It occasionally happens that in the treatment of a
certain disease we allow ourselves too largely to be
governed by generally accepted ideas and some-
times tradition too greatly influences us. Such a
state of affairs does not make for progress and
chiefly pertains to those affections which are not
forced upon our attention by some undue preva-
lence.
Sometimes a more careful study of fundamental
facts with regard to such diseases changes our point
of view and gives us greater efficiency in our study
of their phenomena and in our therapeutics.
It is to such a consideration of poliomyelitis that
I would invite your attention in the present paper.
I have no startling facts to bring forward, no new
discovery, no revolutionary therapeutic measures,
but it seems to me that the data already at our
command are sufficient to warrant a renewed study
of them, to see if in them we cannot find encourage-
ment for greater hopefulness in our outlook and for
greater efficiency in our treatment. The situation
surely warrants an attempt in this direction, for
you have in New York City to-day several thousand
children paralyzed in the last few months and in
the rest of the country several thousand others, and
the problem of treating these children in the best
possible way is not only a surgical and humani-
tarian problem of great present interest and im-
portance, but an economic question of no mean di-
mensions. It is particularly incumbent, moreover,
on those of us who are concerned with the thera-
peutic side of medicine to remember that the best
brains in the country have been organized for the
study of the epidemiology and pathology of this
disease and are taking their task most seriously.
Although theirs is the more important work be-
cause prevention is better than cure, it is none the
less imperative for us clinicians to take our prob-
lem just as seriously and to inquire into the efficacy
of our present methods and the possibility of im-
proving them. Until the happy day arrives when
this disease may be controlled or prevented, it is
our business to see that the wreckage which is left
behind these epidemics is efficiently and economically
cared for.
Poliomyelitis in its paralytic form has been too
much regarded as a chronic condition of no great
interest except in its operative aspect, hopeless in
general so far as restoration of function goes, al-
*Read at a meeting of the New York Academy of
Medicine, October 5, 1916.
though recoveries are occasionally seen, but on the
whole a disabling condition best met by braces to
make walking possible and in the later stages often
to be helped by operations. We orthopedic surgeons
have largely prescribed braces with perhaps mas-
sage or electricity or muscle training as probably of
use and have been much interested in the operative
question. The neurologists have been less enthusi-
astic about braces, but have on the whole favored
electricity, about the value of which there has been
much controversy. The general practitioner has
often ordered braces from the instrument maker,
who has a free hand in their design and fitting and
has felt that electricity and massage were of use,
and all have on the whole regarded the affection as
an undesirable one 'to treat and a tiresome thing to
have anything to do with except in its operative
aspect.
The point of view which I shall advocate in this
paper is that the treatment of poliomyelitis is one
of the most gratifying and satisfactory problems in
surgery, for the reason that nowhere does the close
analysis of each case and the application to it of
commonly accepted anatomical and physiological
principles yield more satisfactory results, that the
problem in every case after the acute attack is a
problem in functional anatomy exact, clean cut, and
clear, that the final functional results are in most
cases largely influenced by the precision, efficiency
and persistence of the treatment, especially in the
early stages, and that certain phenomena of the dis-
ease, clinical and pathological, warrant us in hold-
ing out to these patients a much higher degree of
hopefulness than we have been in the habit of doing.
I am fully aware that such a statement requires
very decided substantiation and such substantiation
I hope to present to you in the form of figures,
hitherto unpublished, later on in the paper. But
for the moment I will ask you to join with me in
laying aside preconceived ideas about braces, to
omit for the time being controversial matters about
electricity, to postpone for a few minutes the dis-
cussion of operative measures and to consider first
what the clinical pathology of the disease really is
and what anatomical and physiological measures
based on general principles may most reasonably be
expected to be of therapeutic value.
Anterior poliomyelitis is to be regarded as an
infectious disease accompanied in a certain propor-
tion of cases by paralysis. Paralysis is not essen-
tial, but accidental, and the proportion of cases in
which it does or does not occur is at present unde-
termined, but most of the men who have most care-
fully studied the epidemiology of the disease believe
that the so-called abortive or non-paralytic form is
very common, possibly more common than the para-
lytic form. From the standpoint of public health
and of therapeutics this point of view of the dis-
ease is obviously much sounder than to regard it as
a paralytic affection often occurring without pa-
706
MEDICAL RECORD.
[Oct. 21, 1916
ralysis. The paralysis is purely accidental and in-
cidental, the infection is the central fact. In the
present discussion, however, we are dealing wholly
with the paralytic form of the disease.
The infectious agent, which is the cause of the
affection, having entered the system, shows a par-
ticular affinity for the cerebrospinal axis on which
it inflicts special injury, greatest in the spinal cord,
but only to a less extent in the brain. The signifi-
cant pathological changes in the cord are a peri-
vascular infiltration of the vessels supplying the
gray matter, edema, pifnctate or larger hemorrhages
in the anterior horns, degeneration or necrosis of
the nerve centers, and a widely distributed menin-
gitis. Commensurate changes also occur in the
medulla and brain. The posterior nerve root gan-
glion is also involved in the process, and in experi-
mental pathology is the first of the structures to
show changes. The clinical expression of these
processes is a widely distributed and erratic motor
impairment, accompanied in most cases at the out-
set by marked tenderness over the affected area.
The cause of this motor impairment is to be attrib-
uted to one or more of the following pathological
conditions which exist.
1. A mechanical anemia of the motor cells in the
affected areas of the cord results from the obstruc-
tion of the vessels from the perivascular infiltra-
tion. Such cells may recover or go on to necrosis,
depending on the extent and duration of the ob-
struction. If the effusion is soon absorbed, the
blood returns to the cell and it resumes function.
2. The edema of the affected part of the cord,
which is a prominent but temporary feature, inter-
feres with motor function in the edematous area.
3. The hemorrhages, if in the neighborhood of
motor cells, may abolish their function.
4. There is perhaps a direct toxic action of the
virus on the motor cells, causing their destruction.
If the patient lives, the perivascular infiltration
and edema subside gradually or quickly and the
hemorrhagic products are absorbed, leaving behind
the areas too much damaged to recover, which are
converted into focal scleroses.
Such in the briefest outline is the process in its
various stages that we are called on to treat. First
an acute hemorrhagic myelitis, second a convales-
cent myelitis with returning power, and third a
cord, in the motor area of which are scleroses, all
stages accompanied by more or less motor impair-
ment.
We surely cannot adopt or advocate any one treat-
ment for all these stages and we must clearly dis-
tinguish between the different phases of the process
in considering therapeutics.
Three phases of the clinical phenomena suggest
three pathological stages. These are:
1. The Stage of Onset. — Pathologically it is an
acute hemorrhagic myelitis and meningitis, and
clinically the child is suffering from that and from
a severe infection. It covers the period from the
beginning of the illness until the disappearance of
the tenderness, because tenderness must be accepted
as evidence of an active process still existent in the
cord. In those exceptional cases where tenderness is
absent, this stage may be counted as lasting from
four to six weeks.
2. The Stage of Convalescence. — Pathologically,
the products of the hemorrhage are being absorbed,
edema and perivascular infiltration are diminishing,
and physiologically the motor area of the brain is
trying to send impulses to the affected muscles to
find their path partly or wholly blocked. Clinically,
the child is more active and trying to use the affected
member, tenderness has gone, but the power to exe-
cute certain movements is impaired or lost. But
there is a continual gain and under all conditions of
treatment or neglect, improvement occurs, for a
while. So-called trophic disturbances begin to ap-
pear, circulation is impaired, affected members are
atrophied and do not grow as they should and de-
formities begin to develop. This stage begins with
the disappearance of tenderness and lasts for about
two years.
3. The Chronic Stage. — Pathologically edema and
perivascular infiltration have long since disappeared,
the meningitis has healed, and in place of the de-
stroyed areas in the cord are found focal glioses
(focal scleroses due to increase of neuroglia tissue).
These lesions are analagous to focal scleroses, such
as fibz-oses or areas of scar tissue due to increase
of connective tissue in other organs.
Clinically the case is apparently stationary, or
retrograding. Spontaneous improvement is much
less noticeable than in the previous stage and in
many cases seems to have stopped. So-called trophic
changes are present. Deformities from muscular
contractions and gravity have occurred in many
cases and further improvement without treatment
is not to be hoped for. This stage apparently be-
gins on the average about two years from the onset
and continues through life.
I shall next ask you to consider for a moment
certain general phenomena with regard to the
disease which seem to have a definite bearing on
the whole question of treatment before taking up
the question of a definite plan of treatment for
each of these phases.
We have been handicapped in our study of polio-
myelitis in the past by the absence of any adequate
quantitative method of examination. We have been
in the position of an oculist who had no lenses at
hand with which to examine his patients for errors
in refraction, or of a physician who was obliged to
treat typhoid fever without a thermometer. Now,
although the latter, if an experienced man, might
very probably carry the individual case through the
attack perfectly well, his general study of the phe-
nomena of typhoid fever would be of no great value
to himself or to others, because he would have no
more exact quantitative instrument than his hand.
We have been in exactly this position with regard
to poliomyelitis and our knowledge of the various
phenomena of the disease has been for this reason
necessarily inaccurate and on the whole loose.
In January. 1915, I was asked by the State Board
of Health of Vermont to undertake the treatment
of the cases of poliomyelitis occurring in that state
in the epidemic of 1914, and pursued the work in
connection with laboratory work under the charge
of the Rockefeller Institute. It became perfectly
evident on examining cases in large numbers that
without some quantitative standard, no reliable
study of the group could be made nor would it be
possible to present anything but impressions as to
the result of treatment. The problem was therefore
presented to the Physiological Department of Har-
vard University, and Professors Cannon and Martin
were good enough to take the matter up, and by
June Professor Martin had a method far enough
advanced for preliminary trial in Boston at the
Children's Hospital, and it has since then been used
in Vermont in all of our clinics.
The conclusions that I shall present rest on obser-
■ -» •
Oct. 21, 1916]
MEDICAL RECORD.
707
vations on about 15,000 muscular groups.* The
method has been already described in detail and
consists in ascertaining the strength of twenty-two
different muscle groups on each side of the body in
their resistance to the pull of a spring balance. The
method has proved reliable and has verified itself.
Under these conditions it is obvious that a much
more accurate study of the phenomena presented by
affected muscles was possible than before, and the
conclusions which I shall next present are the out-
comfiof that quantitative study.
1. Partial Paralysis is Much More Common than
Total. — The original manual examination of indi-
vidual muscles in the Vermont series showed that in
1452 muscles recorded, partial paralysis was two
and one-half times as eommon as total paralysis.
The spring balance muscle test subsequently used in
1069 muscular groups in the Vermont series showed
partial paralysis to be nine times as common as
total. This greater proportion was because of the
greater delicacy of the test over the hand examina-
tion which placed in the partly paralyzed class many
subnormal muscles which by the hand would have
been classed as normal. The practical outcome is
that partial paralysis is very much more common
than total.
Total paralysis, when present, in 82 per cent, of
196 cases existed below the knee. These data must
necessarily modify somewhat our conception of
poliomyelitis and its treatment. We are not dealing
with a total and hopeless loss of power except in a
small percentage of the muscles, but with a weaken-
ing which is of various grades. Now the treatment
of weakened muscles rather than the treatment of
totally paralyzed muscles comes at once to the front
as our main problem in poliomyelitis. It, therefore,
should be our aim to conserve and stimulate and
improve by every means in our power such weak-
ened muscles with a view of bringing them as near
to normal as may be. It is very important to a
patient who has, e.g. lost 80 per cent, of his gastro-
cnemius power whether that muscle gains 10 or 50
per cent, of that loss.
It is obvious that the conservation of muscular
strength and the utmost care for the affected mus-
cles should be our chief end in treatment. Certain
factors bear on this matter of how we may best
handle the muscles with a view of securing the
maximum improvement.
Spontaneous Improvement. — A factor of much im-
portance in this matter of securing muscular im-
provement lies in the existence of spontaneous
improvement which starts as soon as the tender-
ness has disappeared. The Vermont observations
have shown that this goes on much longer than has
been generally believed. In a series of cases one
year after the attack, measured at an interval of
two months, muscles which were not treated but
which had been affected, showed an improvement
ratio of 2 to 1 which must be put down to spon-
taneous improvement. Of 44 totally paralyzed mus-
cles in 7 cases affected over a year, 27 per cent, de-
veloped demonstrable power without treatment in
a two months interval.
We have then in our aim to improve the condi-
tion of muscles the fact that spontaneous improve-
ment even in badly effected muscles exists to a con-
siderable degree at periods later than usually stated.
Fatigue and Its Effect. — The overuse of convales-
cent affected muscles and the over-treatment of
* Lovett & Martin. American Journal of Orthopedic
Surgery, July, 1916.
such muscles by too much massage and too much
therapeutic muscular exercise is undeniably bad and
is being generally so regarded. It is a fact recog-
nized by the present advocacy of prolonged recum-
bency after the acute attack is over and the danger
of overuse is wholly borne out by the Vermont mus-
cle test figures. Not only does overuse delay favor-
able progress, but undoubtedly can lead to muscular
deterioration and may destroy apparently perma-
nently the returning power in convalescent muscles.
Consequently the worst possible advice that can be
given to parents is to encourage patients to be as
active as they can to "strengthen" the muscles.
The reason for all this is that the loss of power
in affected muscles in the first months of the disease
is a considerable one, leaving the muscle as a rule
with a degree of power quite too little to enable it to
come anywhere near performing its normal func-
tion. Very little activity, therefore, may be enough
to constitute gross overuse of the neuromuscular
mechanism, and such overuse is admittedly detri-
mental to any muscle, normal or abnormal. Conse-
quently, while we feel that we are safeguarding the
patient by restricting activity we may still be over-
taxing him. One must therefore remember that the
danger of over-exercising convalescent muscles is
very much greater than the danger of under-exer-
cising them.
Three salient facts, therefore, stand out from the
study of the Vermont and other cases by means of
a quantitative test. These are: (1) Partial pa-
ralysis is more common than total. (2) Spontane-
ous improvement goes on a long time. (3) Fatigue
and over-exercise, therapeutic or otherwise, are
dangerous.
We are now in a position to return to the ques-
tion of what should consitute the treatment of each
of the three phases of the disease already defined,
in the light of the pathology of each stage and in
view of these general and more or less fundamental
considerations.
1. Treatment of the Acute Phase. (From the
onset to the disappearance of tenderness.) — In this
stage Nature is attempting to repair the damage
done to the cord, especially to the motor area. Rest
and absence of irritation and of meddlesome thera-
peutics should constitute our treatment at this
stage. There is no evidence that drugs are of any
use, nor would one reasonably expect much from
counter-irritation, externally applied applications of
heat or cold, or from electricity.
It is not physiological to irritate and stimulate the
peripheral ends of nerves connected with affected
and hemorrhagic nerve centers by massage and mus-
cular exercise while the acute process, as evidenced
by tenderness, exists. Joints will not become anky-
losed, muscles will not hopelessly atrophy, and the
patient will not become bedridden because he is
kept quiet for as long a time as need be to enable
the damaged cord to repair without interference.
Deformities may occur in two or three weeks after
the onset and must be prevented by support of the
feet at a right angle (where the most common early
deformity appears) by plaster of Paris splints or
some similar simple contrivance. This policy of
doing nothing is trying to the parents who have
heard of the wonders of massage and of electricity
and are anxious that no time should be lost and
trying also even to the experienced surgeon when
the tenderness is of unduly long duration. There is
evidence to show that hexamethylenamin prevents
or delays the infection in monkeys, but no evidence
708
MEDICAL RECORD.
[Oct. 21, 1916
to show that it is of use after the infection has oc-
curred. Immersion in a warm saline bath is agree-
able and apparently beneficial toward the end of this
stage and may be comfortably carried out by im-
mersing the patient on a sheet. There is a reason
to hope that the administration intraspinously of
the blood serum of recovered patients as early as
possible in the onset of the disease is a therapeutic
measure of value in diminishing mortality and lim-
iting the paralysis.
The treatment of the acute stage may be sum-
marized as follows: Rest, the avoidance of meddle-
some therapeutics, the prevention of deformities,
and probably the early administration of the blood
serum of immune patients.
Treatment of the Convalescent Phase. — During
this period one faces squarely the question of mus-
cular care and development. The destructive process
has ceased, the harm has been done, the development
of the possibilities of what remains is our problem.
I believe that in this stage the amount of ultimate
function is largely determined and we must re-
member that nature is assisting us to the best of
her ability with the great asset of spontaneous im-
provement which is more marked in the first six
months than in the second six, and more marked in
the second six than in the last six months of the
two-year period arbitrarily allotted to this stage.
Perhaps certain data with regard to the gastroc-
nemius muscle may make clear what seems to me
to be the general behavior of muscles during this
time. The calf muscle should normally be able to
exert a force in pounds of from two to three times
the body weight of the individual. This muscle is
very frequently weakened by poliomyelitis. If it is
partially paralyzed and is immediately protected by
a high heel when the upright position is assumed,
this throws it out of use in walking. If walking is
restricted and if the muscle is judiciously exer-
cised, in all cases that I have observed it has gained
in muscular strength, and in two cases it has been
quantitatively recorded as returning to the normal
amount of power within two years. If it is not so
protected and exercised, it has in all cases which I
have observed lost power and stretched, with the
acquirement of a calcaneus deformity of greater
or less degree ; whether it goes on to a complete loss
of power cannot yet be said, because the quantitative
observations on which these statements rest have
not yet covered a sufficiently long period. But what
happens to the gastrocnemius muscle which is easily
measured and checked and observed, undoubtedly
points to a general rule governing the behavior of
other muscles not so easily observed and measured.
So that in formulating the treatment for this stage
the different reaction of this one muscle to protec-
tion and to over-fatigue may be borne in mind as
probably typical.
With regard to the specific treatment of this
phase, when the tenderness has wholly disappeared,
or at the end of six weeks or therabouts in cases
where there has been no tenderness, the question
arises whether we shall begin to get the patient up
or whether we shall continue recumbency, and here
re is ground for a perfectly reasonable difference
of opinion, probably soon to be settled here in New
York City by your immense experience in the pres-
ent epidemic.
Those who would keep the patient recumbent for
months argue that in that way they avoid fatiguing
the convalescent muscles, that the damaged nerve
centers have ample time given them for complete
recovery, and that muscle training and massage
can be carried on perfectly well while the patient is
in bed, all of which is perfectly true.
My own experience has led me, however, to feel
that soon after the acute stage is over it is on
the whole better to get the patient on his feet; that
is, in about two or three months after the attack.
The prolonged recumbency is not favorable to the
circulation, which is intended to work at least some
of the time in the upright position. The nervous
system of children is not desirably affected by such
prolonged confinement, and what is more impor-
tant is that when the patient is put on his feet there
is an instictive effort to balance and hold himself
upright, which exercises muscles not otherwise to
be reached. But this amb.ulatory treatment must
meet the objection that fatigue may be incurred by
an attempt to get about, which is perfectly true,
and this must be guarded against. If the people
are not intelligent enough to follow directions, pro-
longed recumbency would undoubtedly be the best
treatment, provided, of course, that deformities
were prevented. It has been too much the custom
in the past to allow children to sit around for
months and years with no treatment worthy of the
name until they acquired the deformities of flexed
hips, flexed knees and dropped feet, all favored by
prolonged sitting. Still, although this danger ex-
ists, it is not a serious objection to the treatment by
prolonged recumbency properly carried out. The
only danger is that the unqualified advocacy of pro-
longed recumbency might seem to sanction a method
which has been productive of great harm in the past
in the hands of inexperienced persons.
With regard to the use of braces, corsets, and
other forms of apparatus, it is necessary to define
clearly what their place should be. Braces bear
about the same relation to the treatment of polio-
myelitis that crutches do to the treatment of frac-
ture of the leg. They are compensatory rather than
therapeutic. In a fracture of the leg there is a
local injury which Nature is trying to repair. Now
in order that the patient may get about we use a
compensating appliance in the form of crutches,
while locally we use ice bags, local fixation and mas-
sage at the different stages as our real treatment.
If we are careless in our treatment, or in excep-
tional cases properly treated, we may get deformity
or non-union, in which case we shall have to oper-
ate, otherwise we get complete cure. Now in polio-
myelitis we have also an abnormal local process in
the cerebrospinal axis which Nature is trying to
repair. Unfortunately, this process cannot be as
efficiently treated locally as can the fracture of the
leg, nor does it spontaneously go on to a cure in
nearly so large a number of cases as in fracture.
But while it is progressing we use compensatory
appliances in the form of braces to enable the pa-
tient to get about, while we attempt to hasten the
repair of the local process by massage, muscle train-
ing, the avoidance of fatigue, and perhaps by elec-
tricity. Braces have, however, a further function
in preventing muscular stretching and deformity,
but then so do crutches in fractures, for if we al-
lowed walking without crutches in imperfectly con-
solidated fractures we should get deformity and
shortening. So if we regard braces as compensat-
ing and preventive appliances to be used in polio-
myelitis rather than as therapeutic agencies we shall
reach a more adequate idea of their proper place.
To speak of the "brace treatment" of poliomyelitis
would from this point of view be inaccurate.
Oct. 21, 1916]
MEDICAL RECORD.
709
The legitimate use of braces, however, is of great
importance and its disadvantages and advantages
must be carefully formulated.
Braces are heavy at best, and a weakened limb
is not helped by carrying extra weight, the bands
and lacings constrict the muscles, they induce an
unnatural gait and prevent normal muscular action.
On the other hand, they permit going about and
many a patient would be practically bedridden with-
out their use. They prevent muscular stretching
and the loosening of joints, and most important of
all they prevent or control deformity. The latter,
if allowed to persist, at first affects the soft parts
but later leads to serious bony distortion. Appa-
ratus must be used in the majority of cases in
poliomyelitis and much harm in the past has been
done by trying to go without it. In what has been
stated here I have in no way intended to criticise
the legitimate use of braces, but simply to call at-
tention to the fact that their chief value is com-
pensatory and preventive rather than therapeutic,
and that we must look elsewhere for our thera-
peutic aid. This consideration seems to me of
primary importance.
With regard to the use of braces and apparatus.
I find a very good rule as follows: If the patient
cannot walk without such aid, or if in walking or
standing he does so in a position of deformity, he
should wear apparatus. It is essential that appa-
ratus should be mechanically sound, light and prop-
erly fitted, for nowhere is nicety of adjustment so
important in its direct effect on gait as in this dis-
ease. In the convalescent phase I believe that
braces should be worn only for walking and then
removed, and as in the first year very few children
severely enough affected to require braces have any
business to walk much on account of the danger of
fatigue the braces will be worn but very little. If
crutches are also necessary they should be used.
Equilibrium must often be reckoned with by itself
in children who have been long confined to bed, and
such children must be taught to balance just as if
they were learning to walk for the first time. This
loss of balance is quite unrelated to the degree of
paralysis present.
We will now assume that the patient is up, pro-
vided with braces if he needs them, and we must
take up the most important question as to what we
can do to improve the condition of the neuromus-
cular mechanism, bearing in mind the fact that
most of the muscles are weakened and not totally
paralyzed. There are three chief measures indi-
cated, which are massage, electricity, and muscle
training, the rationale of which must next be dis-
cussed, and in this matter we are approaching what
I understand to be the real treatment of poliomye-
litis at this stage.
Massage promotes the flow of blood and lymph
from the affected limb and the displaced blood is
replaced by a new supply and the circulation of the
limb consequently stimulated. Waste products are
removed and muscular atrophy and atony appar-
ently delayed by it. But its effect is largely local,
for it does not promote the passage of an impulse
from the brain to muscle. Its overuse, either by too
long treatments or too heavy manipulation is un-
doubtedly harmful and in the past has been respon-
sible for more or less damage. A measure of un-
doubted use, we must not expect too much from
it; there is nothing magical or mysterious about it
and it can do harm as well as good.
Electricity. — This no place in which to enter into
a controversial discussion of the value of electricity
and I am only desirous of making what I believe
to be a fair presentation of present opinion and
to leave a definite statement to the time when I
can back it up by quantitative figures on a suffi-
ciently large number of cases with proper control
over an adequate period of time. Such a series of
observations has been provided for and will be soon
taken up. "Impressions" resulting from the obser-
vation of the recovery rate of cases of poliomye-
litis are unreliable, because the recovery rate of
apparently similar cases varies enormously.
Faradic electricity is a mild form of exercise to
muscles which will not contract voluntarily. It is
disagreeable, but probably mhJly effective under the
conditions named.
Galvanic electricity and the newer forms, such
as the high frequency, sinusoidal, static, Morton
wave current, etc., are supposed to work in a way
less definitely understood in increasing muscular
power and improving nerve conductivity. In my
own experience, where I have used electricity of
one form or another on only one side of the bilat-
eral cases, I have not been able to observe a faster
gain on the side thus treated.
The objection to electrical treatment is that it has
been extensively used, and for the most part in
such a loose way that even its advocates would not
expect much from its use, and that while this was
being done the parents have as a rule neglected
other measures, thinking that the patient was being
adequately treated by the electricity alone.
My claim would be that until the case of elec-
tricity was definitely proved, it was better that it
should not constitute the sole treatment and that
electricity was probably of no value at all when
carelessly applied by laymen.
That the use of electricity in connection with
other therapeutic measures may or may not add to
their efficiency, a matter which cannot be settled
until quantitative examinations have been made in
sufficient number.
Muscle training is the third of the therapeutic
measures under consideration, and more closely
than the other two meets the therapeutic require-
ments indicated by the pathology of this stage. In
essence, it is an attempt to reconnect a cerebral
motor impulse with a peripheral muscular contrac-
tion, a normal connection which has been impaired
or lost by the injury to the motor centers in the
cord occurring in the acute stage, so that cerebral
motor impulses are checked or diminished at these
impaired centers and the intended muscular con-
traction either occurs feebly or not at all. Now
the method of muscle training aims at two things,
first at forcing the efferent impulse to develop a
new path around the disordered nerve center in the
cord, and second to secure contraction of the de-
sired muscle, however feeble, which is of course the
best possible treatment of the muscle itself. These
two attempts rest upon a sound anatomical and
physiological basis. The motor nerve centers are
grouped in cigar-shaped bundles running in the
length of the cord and overlapping each other.
Each muscle connects with more than one bundle
and every bundle sends fibers to several muscles.
Moreover, the intercommunication between the
bundles is most extensive and intricate, conse-
quently unless the destruction in the cord has been
very extensive, the chance is that some new com-
municating path or some combination of paths can
be established to carry a motor impulse of some
710
MEDICAL RECORD.
[Oct. 21, 1916
degree around the damaged area. If there is a rail-
road wreck blocking the main line, communication
between terminals may be maintained by sending
trains around the wreck by means of a branch
track. So that there is no reason to believe that
in muscles not totally paralyzed there is every
prospect to expect continuous muscular improve-
ment from repeated attempts to drive a motor im-
pulse from brain to muscle, a permanent improve-
ment in conductivity.
So far as the second aim, muscular development
per se, is concerned, it is a matter of common in-
formation that muscular exercise in proper amounts
strengthens muscles. The athletic trainer does
not turn primarily to massage or electricity to
strengthen weak muscles but to muscular exercise,
which consists of active contractions. The muscles
partially paralyzed in poliomyelitis are simply weak-
ened muscles requiring an extremely small dose of
exercise.
The practical application of muscle training is
carried out by ordering the patient to execute a
special movement and at the time of the effort as-
sisting him manually to perform the movement.
Dorsal flexion of the foot, e.g. is performed with
assistance for perhaps ten times, each time at the
word of command with sufficient rest between the
attempts to prevent fatigue.
The exercise and position suited to the especial
muscle and its ability are selected.
Precision, care, and persistence are essential to
success.
As a rule, intelligent parents can carry out mus-
cle training by themselves with sufficient super-
vision to have the exercises changed as the muscles
improve. Bringing the parents into the case, more-
over, places the responsibility where it belongs, for
the treatment to be successful must be carried on
year after year to obtain the maximum results.
In six private cases, under muscle training at
home, measured last winter, whose acute disease
had been from three to nine years previous, with an
average duration of six years, the average monthly
percentage gain of strength in affected muscles was
8.2 per cent. These were the only cases of long
duration in my private practice whose measure-
ments were available. A woman with a weakened
abductor muscle of one thigh and who wore a brace
to correct a bad foot had never received other than
brace treatment. The duration of the paralysis was
thirty-six years. Under daily muscle training by
an expert she gained 125 per cent in the strength
of the gluteus medius muscle in six weeks. A pa-
tient in Vermont at the end of four years, who
had had no previous treatment beyond braces, was
started on home exercise in July, 1915. In two
months his affected muscles had gained 470 per
cent, in strength and his unaffected muscles 70 per
cent., a net gain of 400 per cent. These muscles
were severely affected. So that we may conclude
that muscle training requires long continuation if
the maximum results are to be obtained, and that
it is effective at a later stage of the disease than
generally supposed.
It is absolutely essential to success that muscle
training should be preceded by a thorough and com-
plete muscular examination. In brace treatment a
thorough muscular examination would seem to be
important, but paralysis or weakening of the ab-
dominal muscles is constantly overlooked, lateral
curvature of the spine in its early and curable stage
is missed and local weakening in the arms is not
looked for, as a rule, when the paralysis affects only
the leg. The only safety lies in a complete exami-
nation of all the muscles which can be reached,
whether they appear to be paralyzed or not. The
Vermont measurements have shown the affection to
be very widely distributed and that the affection of
one muscle alone is rare. When one leg is affected,
apparently alone, the. other leg is as a rule some-
what involved, the more delicate our means of meas-
urement the more widely distributed will be found
the paralysis, an observation which brings the clin-
ical phenomena of the affection more closely than
before in accord with the modern pathological find-
ings. For the most accurate type of work the
spring balance muscle test is necessary, but it is com-
plicated and requires practise on the part of two
assistants, and great care in its use. For formu-
lating the phenomena of the disease and analyzing
the effect of treatment it is obviously essential,
especially in connection with operative work.
As the problem in most cases is the problem of
making the patient walk better, every patient who
can walk should be made to do so and much will
be seen in this way which otherwise would escape
detection; lameness characteristic of certain mus-
cles is shown in walking as in no other way. Chil-
dren should walk naked and adults should wear
trunks, bandages or union suits, as it is essential to
have the whole body outline in view.
In entering here this plea for a thorough ex-
amination of every muscle in both arms, both legs,
back and abdomen in every case, I am simply stat-
ing a perfectly obvious requirement for any really
accurate treatment. In my own experience the re-
sults of the treatment are in large measure propor-
tionate to the care, precision and persistence with
which the treatment is given. Muscle training in-
accurately formulated and carelessly carried out is
of little therapeutic value.
Deformities as they occur in this stage should be
removed. It is a sound rule that no non-operative
treatment should be undertaken till fixed deformity
has been removed. It is of no use to put braces on
a child with flexion contraction of the hips, for he
cannot walk with any facility, nor can a child with
an equinus deformity (a dropped foot) use a brace
properly.
The examination for deformity should go hand
in hand with the muscular examination mentioned.
Deformity can generally be prevented, but if it
is recognized only after it has occurred it should
be treated as early as possible. The masures avail-
able are stretching, tenotomy, fasciotomy, myotomy,
and rarely osteotomy. As this paper is intended to
discuss principles and not details, this general state-
ment about deformity must suffice.
The convalescent phase may now be summarized.
It is the stage of muscular care and development.
Braces may or may not be needed; if deformity oc-
curs it should be removed. Of the three thera-
peutic measures available for muscular improve-
ment, muscle training has the best physiological
and anatomical basis. A thorough examination com-
prising every accessible muscle and a study of gait
is obviously essential for proper treatment.
3. The chronic static of poliomyelitis has in this
paper been arbitrarily assumed as beginning two
years after the onset, because it is only after this
period by common consent that the operative ques-
tion can be properly discussed. This has seemed to
set a proper time for assuming the beginning of
this stage. At this time the spontaneous improve-
Oct. 21, 1916]
MEDICAL RECORD.
711
ment is much less rapid than in earlier stages and
the prospect of gain from the therapeutic measures
described is less, but at no period of the disease can
it be assumed that the possibility of improvement
and sometimes of great improvement from the use
of suitable therapeutic measures has ceased. With-
out treatment the patient is likely to remain sta-
tionary or to retrograde.
Braces may be still needed and are subject to the
same rules as in the preceding stage, except that
they may be worn continuously at this time with
much less detriment than earlier in the disease.
The danger of harm from fatigue still exists and
must be guarded against if the best progress is to
be made. What has been said of massage, elec-
tricity and muscle training still holds at this stage
as in the former, except that improvement is less
rapid. Deformity must be cleared up when it oc-
curs or is found to be present.
In this stage first arises the important question
of operative interference and the settlement of this
question is in many cases the crucial feature of
this stage. Operations are performed first to im-
prove existing function and these are such opera-
tions as tendon transplantation and nerve trans-
plantation, while the second class are done to se-
cure better stability in badly paralyzed joints, and
to this class belong artificial ankylosis, the use of
silk ligaments, tendon fixation and the removal of
the astragalus with backward displacement of the
foot. Experience has shown, and all experienced
surgeons are agreed that it is unwise to do any op-
erations on poliomyelitis other than to correct de-
formity until two years have passed, because until
about that time conditions have not become stable
and it has served as a good working rule, but with
further experience has come the doubt in the minds
of many surgeons whether operation is not better
deferred until three or four years or even until
later childhood, and the latter point of view has
gained ground of late. It is hard, however, to set
a definite time other than the two-year limit for
such varied operations as are performed for polio-
myelitis. Some operations are merely the change
of tendons, to rebalance the foot, e.g. and if these
are deferred too long, bony deformity may be ac-
quired and deterioration of stretched muscles may
occur. It would seem as if a quantitative examina-
tion, such as the muscle test affords, might in the
individual case afford much information as to the
proper time for interference, and that in some cases
two years would be quite long enough to wait in
oWer children, while in others it might be wise to
defer the operation in an attempt to develop certain
muscles, and in younger children. On the other
hand, the more destructive operations necessitat-
ing the extensive removal of bone are better de-
ferred. In arthrodesis or artificial ankylosis, for
example, many early operations have been followed
by serious bony distortion resulting from the in-
jury to growing epiphyses, so that so sound an au-
thority as Robert Jones advises that no such oper-
ation should be performed until growth has been
nearly completed. Tendon fixation and silk liga-
ments are not so much open to this objection and
probably can be performed with safety in middle
childhood. But the removal of the astragalus im-
plies a good deal of disturbance in the mechanics of
the foot, and is not in my experience best performed
on young children, but rather in middle or late
childhood.
Extensive operation is not, in my opinion, de-
sirable in young children even in the case of tendon
transference.
On the whole, the operative treatment of polio-
myelitis is one of the most brilliant achievements
of modern orthopedic surgery. Fairly recent in its
development, it has passed through rather a florid
period of over-development, followed by a time of
undeserved depreciation, to emerge into a period
of greater stability with an increasing agreement
on the part of experienced men as to the relative
value of the different operative methods. It is by
all odds the most interesting part of the treatment
of poliomyelitis, and I for one have to struggle con-
tinually to keep from becoming too much interested
in this phase to the detriment of the routine treat-
ment of the early phase, where I believe that ulti-
mate function is more largely determined than in
any other period of the disease.
It seems obvious that operation can in many
cases be avoided by more accurate early treatment,
that it is desirable to avoid unnecessary operation,
and that when operation is to be done the results
are likely to be better (especially in tendon work)
if the case is exhaustively studied beforehand.
Many cases are destined for operation from the
end of the acute attack and must be carried through
the second stage with all care. The majority of all
cases are not operative and never will be, because
the paralysis is too severe or too slight, or so dis-
tributed as to render operation useless, while a
third class become non-operative or operative in
the third stage by the care, or lack of it, given them
in the earlier stages. It is manifestly sound sur-
gery to see that as many operations as possible are
avoided by careful treatment. When fixed deformity
is present it must always be corrected by operation
except in lateral curvature of the spine, but as de-
formity is as a rule to be prevented by efficient care
in the early stages, here again unnecessary opera-
tions are to be avoided by such care.
Table 1. — Result of Muscle Training
Patients treated daily at office by skilled assistants.
Average
Average
Time
Interval
Total
Monthly
Apparatus
Region
Age
Covered
Gain of
Gain of
Recorded
Attack
by
Affected
Affected
Tests
Muscles,
Muscles,
per Cent.
per Cent.
as
1 mo.
6 mos.
197
24
Sling
Arms
8
3 mos.
5 mos.
82
16
Corset, crutches,
braces
Legs
9
3 mos.
6mos.
146
21
None
Legs
9
10 mos.
200
20
Plaster jackel 1
crutches, braces
14
4 mos.
4 mos.
688
172
Corset, braces,
crutches
Legs
S
15 mos.
7 mos.
702
100
Corset, braces.
Legs
8
3 mos.
6 mos.
184
30
Corset
Legs
Patients treated at home by relatives or nurses (unskilled).
10
1
y-
6 mos.
13
2
Hieh heels
I leg
30
5
mos.
1 mo.
44
44
Sling
1 arm
24
6
yrs.
3 mos.
12
4
None
lleg
10
2>i vrs.
8 mos.
108
13.5
Corset, plate
lleg
11
6
yrs.
5 mos.
S9
17
Plaster jacket,
braces
Legs
4
1
vr.
7 mos.
30
4
Brace
lleg
11
9
yra.
2raos.
33
17
None
Arm and leg
10
3
yrs.
4 mos.
16
3.5
High heel
lleg
10
5
yra.
7 mos.
None
None
High heel
lleg
14
8
yrs.
8 mos.
67
8
Plaster jacket,
brace
lleg
16
2
mos.
3 mos.
620
206
Brace and cruteh-
lleg.
8
1
yr.
7 mos.
202
2S
Braces and crutch-
es
2 legs, 2 arms
The question naturally arises, what evidence is
there that the point of view here advocated is cor-
712
MEDICAL RECORD.
[Oct. 21, 1916
rect. What figures can be brought forward to show
that this treatment has proved of value in any con-
siderable number of cases. The figures presented
are first from private practice and are given in
Table 1.
Seven cases under daily treatment by an expert
showed an average net percentage gain in muscle
strength of 314 per cent, in treatment lasting from
five to ten months, the average net monthly gain
being 45 per cent. The duration of the paralysis
at the beginning of treatment was from one to
twenty-one months.
Twelve cases under treatment at home with un-
skilled assistance in the muscle training showed an
average net gain of 103 per cent., with an average
monthly gain of 29 per cent. These cases were of
from two months' to nine years' duration when
treatment was begun, with an average duration of
three and one-half years, so that they may fairly
be considered cases of the less promising class.
No cases where measurements were available
were omitted from either table.
The presentation of figures will next be made
from the Vermont observations. The cases in this
instance were seen at clinics, of which three were
held in eighteen months. Treatment was pre-
scribed to be carried out by the parents with occa-
sional supervision from one trained nurse skilled
in muscle training who covered the entire state,
encouraging patients to follow up treatment and
changing exercise as occasion arose. Many of the
families were ignorant and poor, living on farms
without many comforts, isolated in winter and
spring, and a less favorable ground for a thera-
peutic effort would have been hard to find.
In the cases seen in July, 1916, ninety-seven had
followed treatment and sixty had not followed
treatment to any degree. Certain data with regard
to the two groups are available dealing with their
progress in the previous year, or year and a half in
some instances.
Table II.
Treated Cases, 97
Untreated Cases, 60.
I nable to walk at outset 30 Triable to walk at outset . 13
Able to walk now* (27) <)0 per cent1 Able to walk n 15 per cent
I nable to walk now (3) 10 per cent, Unable to walk now 11 -;, pi r cent
Recoveries.
(13).
13.4 per a
E.3 P'-r eenl
Imp'" 100 per cent Impm . , (16).. 27 per eenl
Unimproved 0 Unimproved (44) 73 r
•I If the 27 now able to walk the conditions are as follows: Without support, 0: with
braces, 8; with crutches, 2; with braces ami crutches. 8.
Measurements as to muscle gain by quantitative
measurements taken at intervals of one year ending
in July, 1916, are available in fifty cases. Forty-si\
followed treatment to a greater or lesser extent and
four did not follow treatment.
The average net gain in muscular strength in
the affected muscles in the treated cases was 59 per
in in untreated cases 17 per cent.
The tern! "net gain" means that having reckoned
the percentage gain in the affected muscles the per-
centage of gain in the normal muscles was deducted
from this. So that the term "net gain" means that
the affected muscles gained faster than the normal
muscles. In ten cases, however, it was classed as
net loss, because although the affected muscles had
gained, the normal ones had gained faster. In one
case, however, there was a real loss of muscular
strength in one year amounting to 11 per cent.
This was a case of severe paralysis wearing two
caliper braces, but having little other treatment.
In no other case in the forty-six who followed any
kind of prescribed treatment was there failure to
gain strength in the affected muscles, and in thirty-
six of these forty-five the affected muscles gained
faster than the sound ones. The onset of these
cases ranged from 1908 to 1914. Treatment was
begun in 1915.
I have purposely avoided giving more detailed
figures for fear of confusing you, and whether or
not my figures bear out my contention in the be-
ginning of the paper, that we are justified in hold-
ing out a higher degree of hope than heretofore,
that thorough, persistent and long-continued treat-
ment will produce results which are encouraging, I
leave you to decide.
The impression that I should like to have you
carry away as the outcome of this paper is that
paralytic poliomyelitis is more often a weakening
of the affected muscles than a total paralysis. As
a result of this, conservation and improvement of
such muscles must be our main treatment. That
the use of braces is conservative and preventive
rather than therapeutic. That of the therapeutic
measures at our disposal for use in the convales-
cent stage, muscle training best meets the physio-
logical and pathological requirements, but to be
effective such treatment must be based on a thor-
ough and accurate muscular diagnosis, and must be
carried out with optimism, persistence and accu-
racy, and that the treatment under these conditions
is effective in influencing ultimate function.
234 Marlborough Street.
SOME ASPECTS OF SPECIAL INTEREST
BEARING ON THE ROENTGENOLOGICAL
DIAGNOSIS OF TUBERCULOSIS OF
THE LUNGS.*
By HENRY HULST. A.M., M.D.,
GRAND RAPIDS, MICH.
"The science of Roentgenology is in the interpre-
tation of the Roentgenograms as applied to the
diagnosis and prognosis of disease, just as the
science of pathology lies in the interpretation of
the slide" is the pronouncement of one who takes
special pride in letting it be known that he is a
specialist, that his specialty is that of Roentgen-
ology. He is a Roentgenological diagnostician,
therefore, of many medical and surgical specialties.
We have reached a stage in the evolution of
Roentgenology in which we look down condescend-
ingly upon the art of making Roentgenograms as
no longer deserving, because no longer requiring
the valuable time and personal effort of the physi-
cian. By a happy division of labor the technician
relieves the Roentgenologist of what formerly took
much of the doctor's attention, the mere making
of pictures, during the first period, in reality the
premedical period, of Roentgenology.
We have now entered upon the second period,
the genuinely professional period. But I see a
third period, the ultimate period, casting its
shadow before.
As Cohn pointed out, "He will derive most as-
*Read by invitation of the New York Roentgen So-
ciety at its joint meeting with the Philadelphia and
New England Roentgen Societies in New York, March
11. 1916.
Oct. 21. 1916|
MEDICAL RECORD.
713
sistance from Roentgenology who has acquired the
greatest proficiency in clinical and physical methods
of examination," so also the specialist, the real
specialist who devotes himself heart and soul to
one branch only of medicine or surgery, should be
best able to interpret Roentgenograms pertaining
to his particular specialty. This will constitute
the period of benevolent assimilation of Roentgen-
ology, and of the Roentgenologist too, by medicine
and surgery. The division of labor which resulted
in the differentiation between technician and Roent-
genologist in the second period will go on logically,
perhaps unmercifully, until every physician in the
final period interprets his own plates.
But before this millennium is fully upon us, be-
fore the second-period Roentgenologist shall dis-
appear from the face of the earth as an anachronis-
tic, superfluous, moreover necessarily superficial
and therefore more or less ridiculous middleman,
and only physicians and technicians remain, I
should like to remind you of two or three facts,
lest we forget, and then consider some of the points
of special interest just at present in connection
with the Roentgenological diagnosis of tuberculosis
of the lungs.
Roentgenology of the lungs dates back to the
very beginning of the use of the rays. Thus Dr.
Crane published in March, 1899, in the Philadelphia
Medical Journal, his article on "Skiaskopy of the
Respiratory Organs," one of the earliest detailed
presentations of the subject in this country. At
this period the fluoroscope was chiefly relied upon
and was more useful, without a doubt, than Roent-
genography, which was but poorly done. In 1899
but few Roentgenologists could take a lung in one
minute. More commonly five or ten minutes were
required.
It was in this same year that Rieder and Rosen-
thal (Muenchener medizinische Wochensehrift,
1899 No. 32, and Fortsckr. a. d. Geb. der Roent-
gensts., 1899, Band iii) reported their method of
making Roentgenograms of the lungs in one sec-
ond or less by sandwiching a film between two in-
tensifying screens. This constituted, not the begin-
ning of, but the first great stride in advance in. the
Roentgenology of the lungs. The beautiful atlas:
"Die Roentgographie in der inneren Medizin" by
Prof. H. Von Ziemssen and Prof. H. Rieder, pub-
lished by J. F. Bergmann in Wiesbaden in 1901,
was the first born fruit of this conception. How
I admired those pictures with their wealth of detail
as compared with the meager black and white gross
shadow pictures of earlier days!
At the third annual meeting of the Am. Roentgen
Ray Society, which was held in Chicago, Dec. 10
and 11, 1902, I was permitted to exhibit, though
not yet a member, Roentgenograms of the lungs
taken in one, one-half, and one-fourth second, with
and without the use of intensifying screens. These
were the first of the kind made and exhibited in
this country.
The next year I read by invitation of the society
at its Philadelphia meeting an article on "Skiag-
raphy of the Chest," which was published in the
transactions of the society for 1903, together with
a halftone reduction of the first one-second tuber-
culous chest without the use of intensifying
screens, ever published here or elsewhere so far as
I have been able to determine. As a rule my ex-
posures even then were shorter than one second, but
extremely short exposures were difficult to repro-
duce as halftone reductions. I have noticed, by the
way, that for some reason not clearly defined, Rieder
has gone back to long exposures for pulmonary
Roentgenography.
You will pardon me for thus lingering fondly
over this polliwog period of my Roentgenological
career. In fact, I may as well confess it, there is
still somewhat of the polliwog left in me, and at
times I feel that some of our frogs matured per-
haps rather prematurely.
As Snook took up a German idea and realized it
in the modern interrupterless transformer which
has made Roentgenography, especially of the lungs,
much easier; as Coolidge revolutionized the Crookes
tube and gave us the Coolidge tube, so we need
some one, some other American if possible, to per-
fect the Dessauer Blitz-Apparat — a thing I have
been urging manufacturers to do for years — and
furnish us with the real article, an instrument that
will enable us to take a lung, or stomach for that
matter, in say one five-hundredth of a second with-
out the aid of intensifying screens and without
boring the target. We need it, and therefore we
must confidently expect it will come about.
Now that we are graduating out of the first class
of Roentgenologists and delegate the picture mak-
ing business to assistants (nurses, "Sisters," boys,
young ladies, medical students, and here and there
perhap a genuine expert technician) and have more
leisure for the professional study of plates, it is but
reasonable to expect of us better interpretations.
It pleases me to state from personal observation
that some by their superior work have justified this
expectation. Too many, however, have not yet.
Now there is a very good reason for this. We read
marvelous tales of former polyhistors — men who
were preeminent in botany, zoology, geology, psy-
chology, mathematics, metaphysics, and theology —
who knew a dozen or more dead and living lan-
guages and who were besides accomplished artists
—artists in painting, music, sculpture, architecture
— and artists of the logos: poetry, oratory, and lit-
erature. I have also come across physicians who
serve as multi-specialists. The Dutch have a way
of dubbing such pan-prodigies as "men of twelve
trades and thirteen failures."
Now, it seems to me that the latter-day profes-
sional Roentgenologist is in a predicament some-
what similar to that of the encyclopedic polyhistor,
polyglot, polygraphia polypragmatic polyp of
scholastic, prescientific days. He has too many
irons in the fire. He has more specialties than he
can manage. The real specialist does not, and can-
not, take him quite seriously, and is only tolerating
him good naturedly until he can permanently dis-
pense with his services by taking upon himself to
do the work that naturally and by right and reason
belongs to him and to no one else. The Roentgenol-
ogist as such, according to my opinion and contrary
to that of some present, is an artifact, a temporary
by-product of medicine who in due time will fall by
the wayside or find his way back into the regular
ranks. Not until then shall the present Roentgen-
ological epicycle be completed and the mission of
the Roentgenologist be fully discharged.
It is as such a by-product myself that I approach
the consideration of certain Roentgenological topics
of pulmonary phthisis, as a Roentgenologist, that
is to say, who would make use of the Roentgen rays
as he may of the trocar, which likewise constitutes
one means of diagnosis and of treatment, but like-
wise a poor basis upon which to construct a spe-
cialty.
714
MEDICAL RECORD.
[Oct. 21, 1916
At once we meet with serious difficulties. The
average Roentgenologist, among whom I take my
place, is not yet chiefly, and first of all, pathologist,
as he should be. His knowledge of the underlying
pathological processes is second hand, or largely so.
He looks through other observers' eyes. His mind
is biased by what he learns directly or indirectly
from them. His apperception being determined by
the second-hand mental furniture thus casually ac-
quired, as much as by the dots, dashes, "splashes,"
"fans," "tobacco clouds," "interweavings," "mot-
tlings," etc., which constitute his own special con-
tribution to the work in hand, is it to be wondered
at that a study of the literature of Roentgenology
of the lungs, especially of incipient tuberculosis of
the lungs, reveals the fact that the progress made
is perhaps not quite satisfactory?
Until we can approach our subject from the view-
points both of macroscopic and microscopic ana-
tomical pathology and of clinical medicine, we
Roentgenologists, we peculiarly situated middlemen,
should be exceedingly cautious in our deliverances.
When a patient has a hemorrhage from the lungs
and the plate shows nothing wrong except a dense
spot in the hilus, it is not advisable to tell the at-
tending physician that the hemorrhage is due to the
spot opening a blood-vessel by scratching it by the
movements of respiration. Such stunts do not pro-
mote usefulness nor enhance reputation.
Again, whether pulmonary phthisis is to be con-
ceived of as primarily affecting the blood-vessels
and is, therefore, hematogenous, as Aufrecht holds,
or is of an aerolymphogenous nature, as Tendeloo
maintains, or whether the primary process is
acinousbronchial, are pathological questions which
we as Roentgenologists should not consider incum-
bent upon us to settle. Of one such attempt at the
third Roentgen Congress in Berlin, Holzknecht
spoke sarcastically as a "taking by storm the diag-
nosis not only of tuberculosis of the lungs, but of
its pathogenesis as well."
It is, however, an altogether different matter
when a Roentgenologist notes agreement between
his own observations and the findings of the pathol-
ogist, and undertakes to point it out. This I had
the pleasure of doing at the 1911 meeting of the
American Roentgen Ray Society, quoting Tendeloo
as saying: "It has been accepted for a long time
that pulmonary tuberculosis begins in the apex of
that organ. But this is an error that has caused
much confusion. Where do we find the foci? A
primary tuberculous pulmonary focus often begins
in the apex, but also often in other parts of the
lungs. By far the most foci are to be found in the
paravertebral cranial part of the lung, that is, in
the pulmonary sector close to the vertebral column,
cranial from the fifth rib about between the hilus
and the apex, including the apex. The physician
who examines but the apex and not the paraverte-
bral cranial part of the lung does not fail again and
again to overlook beginning tuberculosis."
This corresponds exactly with the region where
early radiography most frequently detected
changes. It is the domain of the vertebral branch
of the upper lobe bronchus, the posterior division of
which, according to the extensive investigations of
Rirch-Hirschfeld, is frequently stunted, distorted,
and kinked. Schmorl recognized a groove caused
bv pressure of the first rib in adults and sees in
this the cause of the stunting, kinking, and distor-
t 'ii of this particular division of the bronchus
whose linear markings Dunham sees behind the
first rib.
Bacmeister was able to produce in young rabbits
an isolated apical tuberculosis in the region of
Schmorl's furrow by causing a slowly increasing
pressure-stenosis and subsequent direct and indi-
rect hematogenous infection.
Tendeloo finds the primary foci in places where
the respiratory movements of the lymph are slight-
est— "in peribronchial perivascular tissue and the
under parts of the pleural and subpleural lymphat-
ics, or in lymphadenoid tissue. . . . These
movements depend on the respiratory movements of
the air vesicles, which are not equal in all parts of
the lungs: those of the paravertebral cranial vesi-
cles are the slightest, and from here they increase
in all directions."
Nikol accepts Tendeloo's observations on the re-
spiratory movements of the air vesicles and their
influence in creating a vulnerable zone which he
locates, as does Tendeloo (and upon his authority),
in the same region, though not in the same tissues,
Tendeloo using his observations on the respiratory
movements of the air vesicles to support his theory
of the lymphogenous origin of pulmonary tuber-
culosis; Nikol adapting the same observations of
Tendeloo for further development of his own bron-
chogenous theory. In inhalation experiments, dust
settles in this region first and mostly, and it is the
last region to clear up. Here Babcock locates his
primary clinical focus, "a point about an inch or an
inch and a half below the extreme summit of the
lung and somewhat nearer its posterior and outer
border." "From this," he continues, "it spreads
downward and backward and hence should be
sought for in the suprascapular region, since clin-
ical signs of disease may be discovered here before
they appear in front. From this primary focus the
lesions often spread downward along the anterior
aspect of the upper lobe, about three-fourths of an
inch within the margin, frequently occurring in
scattered nodules, separated perhaps by an inch or
more of healthy tissue. It is not unusual to find
in these scattered nodules the only evidence of dis-
ease of the lung when posteriorly excavation has
advanced to such a degree that but little more than
the pleura remains."
Such correlations as these are useful to the
Roentgenologist in his difficult task of reading
plates. But what we really need is a rounded-out
conception of the pathogenesis of pulmonary
phthisis, a macroscopic if not a microscopic consist-
ent pathology as a common basis upon which clini-
cian and Roentgenologist can meet, understand each
other, and cooperate. The language of the plate
is not in terms of rales and resonances, but refers
to visible lung changes; it is of sight, not of hear-
ing. Both constitute systems of symbols, and as
such both are more or less unreal. Unfortunately,
we cannot put them on a graphonola or Victor ma-
chine and by means of steel needle interpret by
retransformation. Nor can we profitably read
one set of symbols in terms of the other. Both
rales and resonances on the one hand and the caba-
listic configurations of the Rooentgen plate, on the
other, speak of more or less gross lung changes, the
exact character of which must be left to the pathol-
ogist, not the Roentgenologist, to determine. He
is the logical umpire.
If men like Aufrecht, Tendeloo, and Nikol would
add Roentgenology to the other physical methods
employed by them, we should soon be in possession
of a body of facts useful to both clinician and
Roentgenologist. And now that the pathologist can
hire a technician, there is nothing to hinder him
Oct. 21, 1916]
MEDICAL RECORD.
715
from doing this, and we may look to more rapid
progress in the future. Meanwhile we Roentgenol-
ogists shall have to continue to cross-question the
pathologist and try to correlate as best we may our
own hieroglyphics with the direct information he
may give us.
What, then, are some of these Roentgen signs
and what do pathologists offer that may help us to
recognize and to name them?
First of all, let us listen to Dr. Kennon Dunham:
"I am sure that the increase in the hilus shadows,
the thickening of the trunks, together with such
alterations in the linear markings as increase in
density and breadth, studding, interweaving, and
extension to the periphery, constitute a shadow
picture characteristic of early tuberculosis. . . .
If the linear markings in the limited area are
sharply defined and dense and show clear cut stud-
dings beyond the trunks, a healed lesion is sug-
gested. . . . The moderately advanced and ad-
vanced cases of pulmonary tuberculosis are readily
recognized. In the less advanced cases careful
study will disclose the alterations in the linear
markings, heavy trunks, and hilus shadows previ-
ously described. If in such cases the fine linear
markings of certain trunks are fuzzy or seem to
merge to form a cloud effect, such as a film of to-
bacco smoke, active tuberculosis would be sug-
gested." This describes in Dunham's own language
a Roentgenographic vision which all have seen, no
doubt, but which he has singled out as no one else
has done and which he uses as a key with which
to decipher the Roentgen code of pulmonary
phthisis. For this and for his volume of stereo-
roentgenograms illustrating his theory, he deserves
great credit, no matter what the final verdict as to
their significance may be.
By way of contrast let us now compare with Dun-
ham's characteristic Roentgen signs those of F. S.
Bissell and E. T. F. Richards: "The earliest and
only characteristic Roentgen signs of pulmonary
tuberculosis are minute islets of increased density
which tend to group themselves in a typical manner
in certain elected localities in the lung. . . .
These are Roentgenological tubercles. . . . Their
first points of election appear to be (a) in the first
and second interspaces near the median triangle
and (b) toward the periphery of the lung near the
angle of the scapula. ... As the process goes
on to repair, with hyperplasia of fibroblasts and the
formation of connective tissue, the field in which
the tubercles lie becomes much broken in appear-
ance and marked by interweaving striae of increased
density. This 'network' may remain after the
lesion has healed and all evidence of tuberculosis
has disappeared, so that we do not consider its pres-
ence alone of diagnostic value. We must remember,
too, that fibrosis and thickening of the bronchial
arborizations may be the result of other irritants
than those due to the bacillus tuberculosis, and as
we have encountered this 'network' so frequently in
other lung infections we have come to consider it
of little value except as a corroborative sign.
• . . It is apparent that many men rely entirely
upon this broken field for their early diagnosis, and
this must inevitably lead to many errors." These
authors, basing their conclusions on 219 cases,
recognize, as well as Dunham, that "an active or
recent lesion is much more prone to appear in con-
tinuity with a chain leading towards the hilus."
Assmann points out that whereas formerly the
examination of the apices was considered of prime
importance, the region below the apex, between
hiius and clavicle, at present receives more atten-
tion. But since he, too, considers mottling the most
important early Roentgen sign, as Grau has shown,
and since these mottlings are often obscured in this
region by dense hilus ramifications, he prefers the
apex plate to bring them out more clearly than is
possible elsewhere.
According to Rieder: "The extension of the
tubercular disease or the flaring up of a latent
tuberculosis acquired in infancy takes place, as
Roentgenological investigations prove, not only in
children, but also in adults, from hilus outward
and not from the apex. Its farther extension, often
on both sides, follows the three larger hilus rami-
fications, most frequently the upper, less often the
middle, seldom the lower branches."
Byshell regards "definite mottling and nodules at
the roots of the lungs as the only reliable evidence
of tuberculosis." Melville expresses himself thus:
"The one and absolute evidence is the presence in
part or parts of the lungs of the characteristic fine
mottling."
Jordan thinks that the linear shadows may be
traced even to the periphery of the chest in healthy
persons, but that mottling is the evidence of active
disease. Hence, he cautions us not to diagnose
phthisis "unless you can show mottling through a
small aperture and show it on a photographic
plate."
It would be instructive in more ways than one,
and besides highly interesting, to submit to all of
the authors quoted a series of plates of early tuber-
culosis for description and interpretation. Each
would go at it according to what psychologists call,
I believe, his apperceptive mass. That, of course,
is inevitable. I imagine Dunham gazing into the
mirror of the stereoscope and saying: "I see char-
acteristic fan-shaped densities which extend from
the pleura to the hilus with the apex of the triangle
toward the hilus; the base of the fan is outward
and backward behind the first interspace; the linear
markings are replaced by an intricate fine network
which is veiled somewhat as if by a cloud of tobacco
smoke. What I see is characteristic, that is,
pathognomonic of early tuberculosis,"
If his friend, Dr. Wolman, were present he would
undoubtedly remark (and this in his actual lan-
guage) : "I conceived at first a profound distrust of
diagnoses that had to be based on Dr. Dunham's
peculiar stereoscopic markings. But now I can tes-
tify to my conversion to a belief in these same
scorned markings, these mysterious markings for
which we know no acceptable explanation. How-
ever, after subjecting them to a severe clinical test.
I can state that undeniably they possess empirical
truth."
Baetjer, no doubt, on hearing this would repeat
what he has said before : "This method of diagnosis
is empirical, as Dr. Wolman may well say, and has
no known pathological basis, and has been sub-
stantiated by clinical findings only. Now it seems
to me that this is the point where error could so
easily creep in. Clinical findings do not constitute
absolute proof. Besides, it seems to me that any
chronic infection of the lungs could just as easily
produce changes in the bands which carry the ar-
tery, vein, and bronchus. In emphysema and
chronic bronchitis we see a marked thickening of
these bands extending throughout the lungs. I
agree with Dr. Dunham that the irregularities
along these linear markings, which he has termed
'fuzzy,' are collections of small tubercles, but they
are seen in a later stage of the disease."
716
MEDICAL RECORD.
[Oct. 21, 1916
Assmann looking over the same plates would
agree as to the final diagnosis, but not until he had
supplemented the examination of the stereograms
with a minute scrutiny of apex views of the same
case; because the hilus strands are dense and ob-
scure the mottling, which he also insists upon as the
characteristic, and only characteristic, Roentgen
sign, if there be such, of early tuberculosis of the
lungs.
All others present would concur in the final diag-
nosis, but they would reach it by different ap-
proaches. Even Rieder, while on the lookout for his
particularly own Roentgen signs of cavitation in
early tuberculosis — and probably finding them, too,
while others overlooked them through lack of equal
preparedness of their apperceptive masses — even
Rieder would not be likely to overlook Dunham's
"fan," for he seems to be quite familiar with it in
all of its details. In his book (Rieder and Rosen-
thal, Fig. 31, page 278) he gives one of his charac-
teristic schematic representations of it. His own
pathological bias, however, must be held responsi-
ble for his description of the interweaving part of
the fan as "net-like branchings of swollen lymph-
vessels."
The other day, talking with a friend about char-
acteristic Roentgen signs of early phthisis I noticed
he used the word "characteristic" in a sense pe-
culiar to himself. He contended that the words
"characteristic" and "pathognomonic" meant differ-
ent things. Nor would he yield the point until he
was shown in Webster: "Pathognomonic. Med.
characteristic of a disease."
Now, it occurs to me that after listening to all
of our Roentgenological authors with keen interest
and thorough appreciation of the excellence of their
work, many of us present might feel that their dif-
ferences, after all, were less vital than their agree-
ment and that the difficulties may perhaps be partly
due to misunderstanding — a matter of language, of
English, which Professor Wenley says is "entirely
inadequate for purposes of philosophical expres-
sion." Differences that cannot be accounted for on
this score may, for aught I know, be charged to di-
versity of apperceptive masses.
The question is still an open one, therefore,
whether there are such things as pathognomonic
Roentgen signs of pulmonary tuberculosis. Bande-
lier-Roepke, for instance, maintain that there is
nothing in an x-ray plate of a tuberculous lung
that is characteristic or pathognomonic of the dis-
ease. Strictly speaking, no doubt this may be true.
The direct diagnosis of tuberculosis of the lungs by
means of Roentgenography, like the direct positive
diagnosis of ulcer of the bulbus duodeni, may be,
"strictly speaking," unwarranted. For the sake of
argument we may admit that just as other lesions
besides an ulcer can produce "characteristic" bulb
deformity, so also the "characteristic" signs of pul-
monary phthisis may be produced by other patho-
logical processes. Well, neither are there, as Bab-
cock points out. auscultatory phenomena which are
pathognomonic of early tuberculosis. Practically,
however, we shall seldom go wrong in the case of
pulmonary tuberculosis, especially, if, instead of
;ng exclusively on one so-called characteristic
sign, we look with a thus enlarged apperceptive
mass for all of the characteristic signs known or
possible. For it is a fact of which we as Roentgen-
ologists may well be proud, that in spite of all diffi-
culties inherent in the problem itself and of those
growing out of the subjectivity of the examiner, a
striking unanimity of final diagnosis is reached
when variously disposed and predisposed experts
examine the same plates. This is in happy contrast
with what Babcock, himself a well-nigh preternatu-
rally expert percussor, says of percussion, which by
some is considered equal or superior to Roentgen-
ography : "So much depends upon the skill of the
examiner in practisting this mode of chest exam-
ination that two or more men may draw different
conclusions from percussion of a case at the same
sitting."
We are approaching, though we have not yet
reached, direct diagnosis. Careful Roentgenolo-
gists will render such tentatively only. But, of
course, we cannot rest satisfied until this, too, can
be done, both positive and negative, and that un-
hesitatingly. Some characteristic Roentgen sign
always present, always recognizable, never due to
anything else, even though empirical, would do.
But while waiting for pathology to determine the
archetypal basis needed for interpreting the ectypal
Roentgenogram, which must take some time, may it
not be possible to discover a heuristic principle,
some temporary working hypothesis to help us out?
Anything relatively fixed is better than wind and
waves.
Classification such as that of Cornet, which re-
duces the polymorphous lung changes of pulmonary
phthisis to two main processes — tuberculous peri-
bronchitis and caseous pneumonia — and which also
does justice to Orth's conception of the dualistic
nature of the histological changes involved as pro-
liferating and exudative, has in its favor that it is
at least simple.
The main objection to this division lies in the
vagueness of the conception "peribronchitis." This
also applies to Assmann's assumption that the peri-
bronchial tubercle constitutes the prototype of all
tuberculous lung changes. For the same reason
Nikol takes pains to show that Ziegler describes as
bronchopneumonic nodules lesions which Orth des-
ignates as tuberculous bronchitis and peribron-
chitis, while Abrikosof, who constantly speaks of
bronchitis and peribronchitis, seems to identify
peribronchitis with Lymphangitis tuberculosa peri-
bronchialis.
Assmann adds to the confusion when he classifies
his peribronchial tubercles as miliary tubercles, a
term which is reserved by common practice to the
hematogenous variety, though it is true that it may
be difficult at times to distinguish between the two
upon the Roentgenogram.
Assmann cautions us not to regard the Roentgen
appearance of miliary tuberculosis as pathog-
nomonic, and reports a case of bronchiolitis ob-
literans, diagnosed clinically and Roentgenograph-
ically as miliary tuberculosis, the real nature of the
lesions being revealed at autopsy. He also tells of
a post-mortem on a patient who had died of puer-
peral septicemia whose lungs were studded with
minute abscesses of the size of the head of a pin.
which probably would have appeared on the plate
like miliary tubercles. Unfortunately, a Roentgen-
ogram was not made. But aside from rare in-
stances such as these, and possibly of miliary car-
cinosis, the more or less distinct general mottling
of disseminate miliary tuberculosis constitutes a
Roentgen sign of tuberculosis that is well-nigh
pathognomonic.
A Roentgenogram of the lungs shows hilus. hilus
ramifications, and parenchyma. No matter how
biased, whether we believe the bronchi, the lymphat-
ics, or blood-vessels to be chiefly or primarily in-
volved, we satisfy the demands of bronchogenists.
Oct. 21, 1916J
MEDICAL RECORD.
717
lymphatogenists, and hematogenists alike if we ap-
proach the study of the Roentgenogram by way of
the hilus ramifications in all cases not clearly
miliary. These ramifications represent the triple
track military highways which the invading enemy
must take. In these or in their vicinity we must
expect to find the early signs of his trenches.
We may specify farther: Since Tendeloo, Birch-
Hirschfeld, and Nikol, though they disagree abso-
lutely on the pathogenesis of pulmonary phthisis,
are agreed that what Tendeloo has determined to
be the area of the greatest biochemical suscep-
tibility is also first involved, we have good reason
for concentrating our attention upon this area.
Tendeloo's region corresponds to the hilus and
hilus ramifications which follow the course of the
upper vertebral branch of the upper lobe bronchus,
and it is interesting to note that Roentgenologists
have long ago learned to look upon this indentical
region as the one to be suspected before all others —
not from any pathological or clinical bias ; in fact,
in spite of clinical teaching, but because their ex-
perience very soon taught them to look for changes
where they were found most constantly and most
abundantly in early cases.
Necessarily, the first changes to attract attention
were those of the regional glands, of the dustbins
and lethal chambers, as some one has aptly called
them, that drain the area of greatest biochemical
susceptibility.
With the, advent of short exposure technique,
changes were detected along this ramification
higher up as well, often of a more delicate nature.
until now the distal endings reveal even more char-
acteristic changes than does the hilus. At the
periphery the bacilli are first halted and the earliest
signs in adults are to be expected there.
In children, according to Gohn, and as is now well
regnized, the location of the primary focus is much
more inconstant, Gohn's tubercle may be found al-
most anywhere. According to Gohn himself, it is
located most frequently in the anterior portion of
the upper lobes — just the opposite from the adults
— and in the posterior portion of the lower. It may
be actively progressing or more commonly obsolete,
frequently very small, a mere little scar, though
the tracheal and hilus glands show extensive and
rapidly progressing involvement, as if on account
of the greater permeability of the mucous mem-
branes and better functioning lymphatics of chil-
dren the bacilli are swept almost immediately into
the dustbins at the roots of the lungs.
Not only as depending upon the age of the pa-
tient, but also as directly and inversely propor-
tional to the virulence of the infection, and the in-
herited and acquired resistance of the host, the type
of the disease must differ from the very start. We
should expect to find, therefore, early signs of acute
and of more chronic forms both, and look for them
not merely in one location but everywhere, accord-
ing to age and circumstances.
Combinations of various pathological conditions
occur in one and the same case. One form of the
disease may change into another. Chronic types
become acute, and vice versa. To note density dif-
ferences, hence to distinguish, constitutes the very
life and soul of Roentgenology, a reason the more
why we should purposely guard against making too
sharp distinctions, as against a tendency growing
out of the very nature of our work — lest it become
a bad habit.
With this caution and with the exception of
miliary tuberculosis and the special type of the dis-
ease common to children, we are justified in as-
suming, therefore, that the early lesions will be
found as described.
Of the several types of early lesions as well as of
more advanced forms of the disease, Assmann has
published good illustrations. Dunham has not
found it possible to reproduce the earliest lesions
as stereographic reductions on account of the diffi-
culty and expense, and gives only two illustrations
of "early" tuberculosis.
Since, as we have seen, the location of the early
lesion is determined by the hilus ramifications, that
is to say, by the anatomical structure of the lung
itself, the suggestion arises that its histology also
may depend upon the same general factor. The re-
sults of Nickol's investigations make it highly prob-
able that this is, indeed, the case. He finds that
the most typical of all lung lesions, the acinous
nodular focus, depends for its location and macro-
scopic and microscopic appearances upon the anat-
omy of the structural unit of all lung tissue, the
lobulus.
This lobule is made up of an intralobular bron-
chus giving off two or three collaterals and two
terminal bronchi with their dichotomous bronchioli,
each again giving off smaller branches. The termi-
nal structure is the acinous bronchiolus. This cor-
responds to the bronchiolus respiratorius, as given
in Quain's "Anatomy." Here the alveoli begin and
ciliated epithelium leaves off. Each bronchiolus
gives off three or four alveolar passages. An
acinus, therefore, is the domain of a bronchiolus
respiratorius with the alveolar passages appertain-
ing to it. Acini are more uniform in size than
lobuli. A lobule contains from fifty to one hundred
acini. Lobules do not anastomose, but interdigi-
tate with each other, as do also their accompanying
lymphatics and blood-vessels.
The bronchiolus respiratorius is first involved in
acinous tuberculosis, as well as in non-tuberculous
bronchopneumonia. The acinous foci conglomerate
into small and larger-sized nodules. From the start
there is apparent a tendency toward induration and
hence this form belongs to the chronic and sub-
acute variety.
Macroscopically the acinous nodular focus ap-
pears as a conglomerate of small greyish blue bodies
which look like miliary tubercles. They differ in
that miliary tubercles are more evenly distributed
over the entire lung, diminishing in size from apex
to base, while acinous foci occur in groups at the
end of the bronchi and form clover leaf and rosette-
like bodies.
These foci have hitherto been variously described
as peribronchial tubercles — Assmann ; or as walnut
sized and larger foci of fibrous groundwork, in
which gray or yellow nodules of the size of a millet
seed are imbedded — Orth.
The distal portion of Dunham's "fan" is probably
made up of acinous nodular foci of Nikol, the cen-
tral induration obscuring the nodules and account-
ing for the clouding.
The rosettes of millet seed sized nodules, softer
and earlier, may stand for the islets of mottling so
strenuously insisted upon by most others as an
earlier and even more characteristic sign.
The leaves (mottling) which hide the branches
in spring and summer, after falling, leave the bare
branches standing out boldly as against a clear sky
when healing has taken place.
Viewed after this manner, the acinous nodular
718
MEDICAL RECORD.
[Oct. 21, 1916
focus assumes preeminence as the prototype not
only of one form of chronic and subacute phthisis,
but of caseous bronchopneumonia and tuberculous
bronchitis as well.
The acinous nodular focus thus becomes the key-
stone which finishes and supports the entire patho-
logical arch and the key to the crypto-Roentgeno-
gram. How this is accomplished by Nikol for
pathology and how to correlate the data thus ob-
tained with those of the plates, we have no time
now to pursue any further.
Enough, if by condensing the fog I have suc-
ceeded in a measure in clearing the atmosphere, and
by pointing out a way toward a more consistent
and comprehensive view, I have contributed to a
better understanding among ourselves.
100 Fountain Street East.
THE MEDICAL MIND.*
Bt JAMES M. PUTNAM, M.D.,
BUFFALO, N. T.
During the thirty-odd years which have passed
since I received my diploma, I have naturally had
many opportunities for the study of the Medical
Mind, or if you please, medical psychology.
We are a curious mixture of heredity and en-
vironment— a curious blend of optimism and pessi-
mism. Our heritage is a glorious one for we pre-
sent an unbroken line of professional workers with
one ideal which was old before the Christian era.
From the time Hippocrates taught his disciples at
Cos to the present, the one great idea, the one great
controlling thought has been to find the truth and,
having found it, to use it for the benefit of mankind.
The truth sought for has never been sought that it
may be put to the base use of man's destruction.
Of all the sciences, medicine has always worked
and studied that the lot of man might be easier —
that the diseases which threatened the human race
might be checked, that the inhospitable climes might
be made fit for the human abode. But of all the
sciences, medicine alone has never had as its goal
the discovery of agents for the destruction of man.
We have never prostituted our mighty enginery to
the destruction even of an enemy. This is, indeed
a glorious heritage and one we must not lose sight
of. In all the ages and in all civilized lands we
have been bound together by this mighty purpose
into a common brotherhood. The discoveries and re-
searches of each are the common property and inter-
est of all — no discovery anywhere, by anybody, at
any time, in the healing art or in the preventive
art but is of vital interest to all. So true is this
that a common purpose has verily knitted the pro-
fession into a solidarity unknown to the theologians
or to the jurists. What does the lawyer care about
the law of another country — it does not effect his
practice nor his methods. With us, on the con-
trary, if a German, Erlich, discovers a method of
treatment as by salvarsan; if a Frenchman un-
locks the door of mystery and Pasteur gives the
key to the treatment of rabies; if an Englishman,
Lister, solves the riddle of wound infection; if an
American, Gorgas, by a system of sanitation makes
the pestilential Isthmus of Panama a health re-
sort and banishes the scourge of yellow fever —
these leaders proclaim truths of interest to the
medical world, and every physician of the world is
the gainer.
* President's Address delivered before the Buffalo
Academy of Medicine.
This brotherhood is, however, a far closer bond
than the bond of common possession of truth or
of aims. We have a sense of mutual aid. The
assistance which the humblest of us in time of
sickness can command from the greatest is another
of our blessed heritages. It is true that the bur-
den sometimes is heavy and that some have been
severely taxed, but as Weir Mitchell once said,
"I have cheerfully paid it all."
We have still another inheritance which we have
had so long that by common consent society does
not dispute it. I mean the care of the poor. It
is not enough to say that we are repaid by the
experience we gain, although it is true we gain
some experience, but no other profession so uni-
versally, so continuously does its charity on such a
wholesale scale. No, there is something else which
keeps us at the work, something else beyond scien-
tific ardor. It is the love of humanity. It is best
seen in the villages and small settlements. It is
best described in the "Bonny Brier Bush." The
Medical Mind is influenced by these strains of
heredity. Our environment has often caused serious
rifts in the brotherhood because, above all things,
we are human. We are critical, skeptical, credulous.
Let some toiler and earnest worker discover a
truth and give it to the world. Its reception
makes interesting reading and causes us to wonder
at the strangeness of the human mind. Harvey
announces the circulation of blood; Jenner gives
vaccination to us; Morton gives us 'anesthesia;
Oliver Wendell Holmes shows us the cause and pre-
vention of puerperal fever. All these and innumer-
able others are met by ridicule, angry opposition,
and abuse.
It is not that the medical mind does not welcome
the truth. It is that we are slow to see it — that
we have been thinking in grooves for so long that it
takes years before a new manner of thinking can
be developed. Also another psychic factor is in-
volved. Often a new view is discreditable to the
rest of the profession. Self-esteem is wounded.
Could any pronunciamento have hurt more than
Holmes' paper when he bravely announced that the
physicians themselves carried puerperal fever on
their hands from childbed to childbed. This is so
interesting a chapter that it will bear a little fur-
ther reading. Holmes published his essay on the
Contagiousness of Puerperal Fever in 1843. The
two leading professors of obstetrics in America,
Drs. Hodge and Meigs of Philadelphia, abused him
in language which has been described as something
worse than the fair severity of hostile arguments,
but fortunately the medical discussion did not lose
itself in personal quarrel; fortunately for the mul-
titudes of mothers. Holmes kept his temper, saying
"every real thought on every real subject knocks the
wind out of somebody. As soon as it comes back
he very probably begins to spend it in hard words."
He said, "I take no offense and I make no retort.
No man makes a quarrel with me over the coun-
terpane that covers a mother with a new-born babe
at her breast. There is no epithet in the vocabulary
of slight and sarcasm that can reach my personal
sensibilities in such a controversy. Let it be re-
membered that persons. are nothing in the matter.
Better that twenty pamphleteers should be silenced
than one mother's life should be taken. The teach-
ings of these two professors in the great schools of
Philadelphia are sure to be listened to. I am too
much in earnest for either humility or vanity, but
I do entreat those who hold the keys of life and
Oct. 21, 1916]
MEDICAL RECORD.
719
death to listen to me for just once. I ask no per-
sonal favor but I beg to be heard in behalf of the
women whose lives are at stake until some stronger
voice shall plead for them." He knew that he had
"planted the seed of truth and that it would grow
— the assaults only watered it."
These quotations are from Holmes' introduction
to the pamphlet which, in answer to his opponents,
he published in 1855, being a reprint of the publi-
cation of 1843. That this benefaction to mankind
was always a great satisfaction to Holmes is but
natural, and years later in an essay he referred to
it thus: "When by the permission of Providence
I held up to the professional public the damnable
facts connected with the conveyance of poison from
one young mother's chamber to another's — for do-
ing which humble office I desire to be thankful that
I have lived, though nothing else good should ever
come of my life, I had to bear the sneer of those
whose position I had assailed and as I believe at last
demolished, so that nothing but the ghosts of dead
women stir among the ruins."
I have quoted at length this passage at arms be-
cause it illustrates the difficulty which truth has
to gain admittance when it knocks at the doors of
professional prejudice, also because of the emphasis
it gives to the valuable heritage we possess in claim-
ing brotherhood with a spirit like this. It seems to
me that it is not altogether a fault that we are
slow to receive new ideas. It is far better to be
critical than credulous. All that is new is not true.
On the contrary, much more is false. One injunc-
tion of Holy Writ we must always follow, "Prove
all things." If there is any tendency at present
in the medical mind which must be guarded against
it is the too ready acceptance of things not proven.
An instance in point is the too ready acceptance of
new products of laboratories of sera and vaccines,
a great tendency of the present generation of physi-.
cians, and this is due to the environment and is a
tendency to let others do their thinking. It may be
better for the patients, but it is a habit which
dwarfs individual mental growth. It is difficult for
the medical mind to weigh evidence. Few of us
have analytical power. Many of us are too lazy
mentally to use what we have. Some of us are too
engrossed in the drudgery of the profession. The
reasons are many, but the tendency is one that must
be fought.
In the domain of psychiatry a recent idea known
as the Freudian theory is a good illustration of
my meaning. This theory is being carefully stud-
ied by practically every psychiatrist and neurolo-
gist. It is earnestly discussed. It has its advo-
cates and its opponents, but everywhere there is an
evidence of a desire to arrive at the truth. In ob-
stetrics the same scientific spirit is shown in the
study of the merits of so-called twilight sleep. In
ophthalmology the profession has patiently stud-
ied and weighed the evidence for and against the
effects of refractive errors and muscular imbalance
upon health.
Now dentistry is claiming the same earnest at-
tention and the influences of pyorrhea and mouth
infections are being weighed in the balance of criti-
cism. Our studies, because of the close environ-
ment in which we live, are bringing us nearer the
people. They know of the new discoveries as soon
as we do and they expect us to use them. Mental
unrest, therefore, is a psychic quality of the medi-
cal man. We were satisfied yesterday — to-day
someone announces the radiograph — to-morrow we
are asked to use it. The Curies discovered radium,
the lay press publishes it, and the harassed physi-
cian is asked what he thinks about it — so that the
psychology of the physician, due to his environment,
must include a certain alertness and up-to-dateness,
and right or wrong he is expected to have an opin-
ion. It seems to me that we need to counsel together
and get our bearings that a reasonable mental atti-
tude is that of "watchful waiting," but we are not
justified in sitting still and letting others prove it
to be false or true, if it is in our power to help.
Our environment is crowding us along lines be-
sides the healing art. Everything that tends to
the perfecting of the body development or to the un-
folding of the infant mind has come within our
province, so that to-day the physician must add to
his sphere of interest some knowledge of the prin-
ciples of physical culture, open air schools, and
systems of pedagogy. There is now no danger that
the medical men will become one-sided, because
the list of side interests is steadily growing longer
and more formidable. The law is now closely allied
to medicine so that the physician and the lawyer are
bound to have common interests in the future. This
is because it has been necessary for courts and com-
missions to have medical opinions on a variety of
subjects pertaining to jurisprudence in the probate
of wills, criminal cases, the extent of injuries, the
estimation of the defects of different disabilities —
this last being made necessary by our Workmen's
Compensation Acts.
These responsibilities are put upon us and we
must not shirk them. The cause of justice de-
mands that these duties be honestly and fairly met.
The physician must bring to bear judicial qualities
and he must bring all his experience and reading to
his aid. That the medical mind has failed to meet
the requirements is a common taunt — that it is the
fault of the environment and the method of the
court is our answer. That the physician means to
be honest but does not know how does not satisfy
either our critics or ourselves. It may not be un-
profitable to review a few of the scathing opinions
of experts as given by judges.
Of late years there has been a growing distrust of
all experts and a feeling against the admission of
their testimony. To better show how authors view
the subject I quote. Wharton on evidence, Section
454, says: "When expert testimony was first in-
troduced it was regarded with great respect. An
expert was viewed as the representative of a sci-
ence of which he was a professor, giving impartial-
ly his conclusions." Two conditions have combined
to produce a material change in this relation: (1)
In matters psychological, there is no hypothesis so
monstrous that an expert cannot be found to swear
to it on the stand and to defend it with vehemence.
(2) Then the retaining of experts by a fee propor-
tioned to the importance of their testimony is now
as customary as is the retaining of lawyers. Hence
it is that, apart form the partisan character of
their opinions, their utterances, now that they have
as a class become the retained agents of the parties,
have lost all judicial authority, and are entitled only
to the weight which sound and consistent criticism
will award to the testimony itself.
Lord Kenyon used the following language:
"Skilled witnesses come with such a bias on their
minds to support the cause in which they are em-
barked that hardly any weight should be given to
their evidence."
But that is an English opinion of English experts;
720
MEDICAL RECORD.
[Oct. 21, 1916
you may think we stand better over here. Let me
disabuse you by quoting Judge Davis of the Supreme
Court of Maine in the Neil case: "If there is any
kind of testimony that is not only of no value, but
even worse than that, it is, in my judgment, that of
medical experts. They may be able to state the diag-
nosis of a case more learnedly, but upon the ques-
tions whether it had at a given time reached a stage
that the subject of it was incapable of making a
contract or irresponsible for his acts, the opinions
of his neighbors of men of good common sense would
be worth more than that of all the experts in the
country."
Stephen in his criminal law, page 209, says: "I
object to the proposition of referring scientific
questions to them (experts)." In this way has the
medical profession of England and America dis-
honored the trust put upon it. Our judges say our
opinions are bought and sold like any other com-
modity, and after it is given it is worth nothing.
What has brought about this discredit? Is it that
we are less fair-minded and judicial, or is it that
we are less honest than are the experts of France
and Germany? For in those two countries we find
no such distrust.
Another point of contact with our environment
which vitally concerns us is our relation and our
duty to our country. The times in which we live
are no more strenuous and not so critical as those
first years when Dr. Benjamin Rush signed the
Declaration of Independence, or when Dr. Joseph
Warren commanded the troops at Bunker Hill, or in
the war of 1812, when Dr. Cyrenus Chapin led the
patriotic band in Buffalo. At no time has the need
of the country lacked the support of physicians.
We have no need to be ashamed of the professional
record. In all positions of danger and hardship the
doctor has never been accused of lack of courage or
of devotion to his duty. When the call has come
it has always been answered. To-day the call has
been issued again in no uncertain tones. We are
called to help in the cause of preparedness. That
preparedness is to put the country in such a posi-
tion of safety and security from invasion that we
are forever safe from .aggression and insult from
any nation on the face of the globe. There is no
call for preparedness to carry on a war of conquest,
but a preparedness to defend our shores. There is
a group of citizens who object to this. They are of
the same type of mind as those who object to vac-
cination against typhoid fever or smallpox. The
medical mind, by training, believes in prevention
and must necessarily believe in national as well as
individual preparedness. But faith without works
is dead; we must not only believe in this, but as in-
dividuals we must help bring about that prepared-
ness which will get us out of our present state of
defencelessness. We must help convince others. I
urge you that as a profession we present a solid
front on this question.
The medical mind, gentlemen of the academy,
must show itself true to its glorious heritage, loyal
to its environments and loyal to our country. We
should certainly consider the medical needs which
the enlarged army calls for. We must impress upon
our minds and the minds of the young men just
entering the profession the fact that the army and
navy medical service is an honorable and useful
scientific service. Many of the important medical
advances have been made by army surgeons and
none more notable than that of Surgeon Beaumont
upon Alexis St. Martin. I have always been as
much impressed by the mental caliber of Beaumont
by his patience, by his readiness to seize the won-
derful opportunity which presented itself, by his
real and untiring energy, as I have by the im-
portance of his observation.
In arranging my impressions of the medical mind
and the influences which have shaped it, my hope
has been that we might realize the great opportunity
for our influence that the present offers, and that
we should show that the united profession must
conscientiously labor for the preservation of peace
and the prevention of war, by a thorough national
and individual preparedness for war and that we
may do our share toward bringing about the Parlia-
ment of Nations and the Brotherhood of Man.
TREATMENT OF FLAT-FOOT IN OLD
PATIENTS.
By SIGMUND EPSTKIN. M.D.,
NEW TORK.
ORTHOPEDIC CHIEF, GERMAN POLIKLINIK ; ORTHOPEDIC ASSIST-
ANT. MOUNT SINAI DISPENSARY; ORTHOPEDIST TO THE
BRONX DISPENSARY-.
Albert Hoffa wrote that the treatment of flat-
foot was one of the most gratifying things in
orthopedic surgery; efficiency tests of clinical re-
sults of fourteen years' work, however, have
brought to notice a number of exceptions to the
smooth and prompt relief of pain, so that a study
of my early mistakes is valuable. In the bright
lexicon of youthful flat-foot there is no such word
as fail ; but in patients after middle age, we have
our limitations and complications — hence this
honest orthopedic confession.
In the wintertime of life painful affections of
the feet require careful differentiation. Our
patients are then most exacting, and it is possible
that they and their foot ailments are less under-
stood. More time is necessary in diagnosis, the
psychological element looms up as an important
factor, and in a busy orthopedic clinic, time does
not permit the personal and economic study of old
men and women. When the busy medical adviser,
to whom all burdens are brought, loses his patience
with his elderly clients and their chronic diseases,
they are prone to depression, accentuated by their
apparent helplessness.
To begin with, old age itself is a condition that
must be reckoned with when the treatment of a
case of foot disability is undertaken. Many
changes take place in all the bones, the cartilages
begin to atrophy, there is less joint lubricant, there
is a progressive thinning with calcification of the
capsular structures of the joints, and we say that
the patient is becoming stiff in these articulations.
Even the spine begins to stoop, the intervertebral
discs thin out. and the stature is diminished. The
angle of the femoral neck with the shaft becomes
more acute, and the stride becomes shorter; the
head droops a little and the knees bend. The .r-ray
shows that the bony striae are thinner and sharper
in the medullary poi-tions; "toothless old age" is
due to this essential atrophy. Furthermore, a
number of conditions, weaknesses, or dyscrasias,
can conspire to bring about serious arthritides of
longer or shorter duration after a slight trau-
matism. In youth, the effects of a strain are
scarcely noticed; bruises and wrenched joints
quickly clear up and are soon forgotten. In old
age, we have to consider senile arthritis, osteo-
arthritis and arthrosclerosis < Noscher") : these are
Oct. 21, 1916J
MEDICAL RECORD.
721
often traceable to nothing else but the altered and
delayed processes of growth, evolution and retro-
gression of cells.
Clinically, there are many types of senile osteo-
arthritis. Many authors have attempted patholo-
gical and bacteriological classifications; some have
as a basis chemical findings ; some attempt to group
them by their radiological appearances, while the
rheumatoid group have as a basis the mode of
onset. Sometimes we find that a given case pre-,
sents characteristics that place it in several cate-
gories. When each case is considered by itself,
then the patient receives the most benefit, exactly
as he should when chronic conditions make their
appearance in any other system of organs.
In the foot, a senile arthritis may affect any of
the tarsal or metatarsal joints; the ankle presents
swelling, effusion and stiffness, while pain on bear-
ing the weight of the body is an early symptom.
Later, there is bony thickening, creaking, limited
mobility, capsular tenderness, and all the signs of
partial or complete adherence of joint surfaces.
The metatarsal bones being thinner, smaller and
more subcutaneous, will show excresences in the
form of bunions and prominences of the instep and
of the ball of the foot. The experiences that
patients narrate, in their quest of the boon of pain-
less feet, illustrate the futility of treatment that
is not based on a sound knowledge of the anatomi-
cal and pathological changes at the bottom of the
difficulty in locomotion. One man told of having
consulted thirty physicians, masseurs, water-cure
and electric-cure practitioners.
If a flat-foot is swollen, and complicated by a
condition of affairs such as I have attempted to de-
scribe, it is useless to decree the wearing of a pair
of rigid Whitman plates without preparing the ex-
tremities for their reception and proper use. We
must not lose sight of the fact that the condition
is one of a progressive, painful, complication of
flat-foot, an inflammatory process attended with
exudate and bony thickening. The mechanical
principles of treatment must often be postponed
until accessory hygienic and medical aids are ap-
plied. For instance, we can have recourse to rest
in bed for a period, with or without plaster-of-
Paris retention, under a dietetic regimen; elimina-
tive and analgesic measures then do most good.
When function is again permitted some old peo-
ple would rather have a pad of corn plaster felt
under the arch of the foot than any plate that has
ever been designed. In other cases, especially after
ankle fracture, the wearing of an ankle brace ex-
t ending to the knee, is the only way of putting an
elderly man on his feet. Writers have repeatedly
drawn attention to the tendency of practitioners to
put up malleolar fractures without safeguarding
against this eventuality, and with reason.
I have applied a great many Whitman plates to
the feet of elderly patients and believe that many
of the criticisms of this form of support are due
to the lack of that careful judgment that should
be exercised in the selection of the case for an arch-
prop that is mechanically perfect, yet rigid and
unyielding. The metal insole of the old-fashioned
shoe-store variety, has a limited field of usefulness ;
when it is used in conjunction with a shoe, built
up on the inner side, it is comfortable, efficient,
and to be recommended in the event of dropsy from
cardiac or renal disease.
Gymnastics play an important role in the man-
agement of old patients with painful ankle and
tarsal trouble; a flat-foot exerciser affords much
comfort to sufferers from the arthritic complica-
tions. After a 15-minute use of the foot-circum-
duction machine there is experienced a new feeling
of strength and added confidence in the feet. The
exercises should be followed by skilfully adminis-
tered massage, and kneading of the muscles of the
sole, the tendons about the ankle, and the calf is of
much benefit. Resistance movements and manipu-
lation tend to strengthen the arch-raising muscles
and to restore the normal range of motion. In
some patients, experience is the only guide to
answering the question as to whether or not ad-
hesions are to be forcibly broken up. Occasionally
this very breaking up may result in increased stiff-
ness from intracapsular hemorrhage. The influ-
ence of a logical working diagnosis at the outset
of treatment will determine a successful outcome.
It is surprising to note the widening list of the
infecting ports of entry that may furnish the
starting point for the polyarticular diseases that
cripple so many old people. The teeth have been
written upon to great length by many observers in
the past few years. Some miraculous cases can be
related following radical removal of infective oral
foci. I have recently had under my care a woman
of 55, who had been unable to walk on account of
an infective osteoarthritis of the ankles and tarsus.
She had been subjected to several operative pro-
cedures for the relief of the pain in her stiff, flat
feet; plates were not tolerated. Her oral cavity
was cleaned by the wholesale extraction of abscessed
teeth, and she was very promptly enabled to walk.
Another patient had suffered from a most severe
septic form of articular rheumatism, frequently re-
curring; the trouble ceased when an abscessed bi-
cuspid was drawn. The sources for infection are
more numerous in older patients because resist-
ance is lowered ; thus we see in them more virulent
types of chronic joint affection. I have seen sev-
eral cases of polyarthritis in old men, traceable to
a chronic cystitis. Besides the ear we must not
overlook the accessory sinuses of the nose. Chronic
infections of the gastrointestinal canal are often
the cause of arthritis deformans.
The administration of medical adjuvants to
mechanical treatment is not to be omitted when a
case of intractable ankle arthritis complicates a
flat-foot; tonics, thymus extract, pituitary extract,
and even colchicum, should be employed in appro-
priate cases. For women at the climacteric I often
use thyroid extract, as recommended by the French
writers. Hot saline baths and spa treatment have
their devotees. The Bier artificial hyperemia or
dry hot-air baking is exceedingly beneficial as a
pain-relieving measure in the chronically stiff and
aching feet following subacute rheumatism in older
subjects. The procedure requires time and careful
attention to details, but the end often justifies the
means. A household substitute is the alternating
hot and cold foot douche.
Many flat-feet in older patients are not painful.
We see many cases of "kidney feet" and "splay
feet," which are the result of rickets in childhood.
The flat-foot of adolescence, sometimes attributed
to juvenile or adolescent rickets, is a more painful
proposition. In the true rachitic flat-feet, even
though much distorted, we find the joints accommo-
dating themselves to altered functions, and such
feet can bear their owners down the paths of life
without any symptoms and without any arch props.
Corns and calluses are common after middle life,
722
MEDICAL RECORD.
[Oct. 21, 1916
even in normal feet; it is not necessary to point out
the fact that a flat-foot encased in American shoes
of the prevailing mode is sure to acquire these
adornments if worn long enough. The busy family
doctor is prone to decree plate-wearing for such
clients. Corn-paring would prove more pain-spar-
ing. Sometimes the chiropodists can do more and
gain more friends than the careless general sur-
geon.
Metatarsalgia is very common in old people, but
the number of cases in which this affection can be
traced to flat-foot is in the minority. A great num-
ber of painful neuralgic cramps of the toes and the
forefoot, in the absence of bunions or other distor-
tions, are early symptoms of toxic or diabetic nue-
ritis. Many ills of this sort are sadly neglected.
After the diagnosis has been made and the patient
placed under the care of his family physician, dia-
betic metatarsalgia requires a protective strip in
the sole of the shoe, called by Cook the "anterior
heel." The weight of the body is shifted, by this
little device, backward to the less painful area of
the plantar muscles.
Other obstinate and annoying forms of metatar-
salgia are due to cerebrospinal disease. The
blood-vessels, too, give out, in the wear and tear
of life; obliteration and thrombosis are frequent in
the declining years, inducing very painful inter-
ference with locomotion. The diagnosis and man-
agement of the various forms of angeitis need not
be discussed here; but a plea for their early recog-
nition is always timely. Almost every case of senile
gangrene from localized arteriosclerosis that has
come under my observation has been previously
treated for something else.
Old patients cannot always stand a plate for the
treatment of metatarsalgia, that we find so useful in
the case of younger persons. Felt pads, strapped to
the under surface of the ball of the foot are very
much easier to tolerate. The shoemaker may line
the shoes with the same soft material. Physical
agents, such as massage, manual or even vibra-
tory, are to be recommended. A few cases have
improved with diathermia.
No type of patients discard the wearing of plates
so quickly as those who have tried them in the pres-
ence of spurs of the os calcis. When these exostoses
begin to torment by pain at the bottom of the heel
Cthe condition seems to be more common in elderly
women), their owners are soon forced to the con-
viction that the plates they have bought are pro-
voking unbearable pressure on a painful spot. The
logical treatment of a calcaneal painful spur is re-
moval ; yet conditions do not always warrant an
operative procedure. I am inclined to believe that
some of my patients suffering from these senile
deposits have been relieved by baking; some are
better off in the country, where they can walk on
soft turf. There is no doubt that a small number
of genuine exostoses on the under surface of the
heel lose their senstiveness after the lapse of years;
some of the elderly patients whom I have observed
seem to be able to pursue their duties in the pres-
ence of demonstrably large bony spicules, which
had been very painful during an earlier period.
People often wonder why their shoes become pain-
ful after fifty, even though the size, shape, last,
and material are the same that they have been ac-
customed to for years. Occasionally this condition
is felt most over the base of the fifth metatarsal
bone. At this time of life the foot becomes more
spare, fat that has protected bony surfaces before
commences to atrophy, and the shoe may easily ex-
ert painful pressure. Sometimes an exquisitely
tender bursa develops ; careful shoe construction
can, however, readily obviate these ills. It is often
necessary to change the last of the shoe from time
to time. It has been stated in articles on senility
that one of the effects of old age is a "dropping of
the arches" ; that the old man's foot becomes flat
as a result of universal muscular atrophy and weak-
ening. I have examined many feet with this in
mind and have come to an opposite clinical con-
clusion, as many, if not most, seem to present a
heightened or raised form of arch; and whereas
many of the plantar tissues atrophy after fifty, I
firmly believe that nature makes ample provision
against the so-called flat-foot of senility. She seems
to provide for an increase of the normal turned-in
position of the foot. Time and again I have been
able to detect a slight tendency to bowing of the
legs and actual outcurving of previously straight
shins has not been rare. The same can be noticed
in the works of some of our notable sculptors,
Rodin, for instance.
Old people should have carefully fitted shoes and
the only last that fills all requirements is that of
an orthopedic shoe. Scrupulous attention to detail
in fitting and selecting these will be found the best
preventative against corns, bunions, and hammer-
toes. Old people are prone to chilblains and frost-
bite; the stockings should be of thick wool in win-
ter and thin cashmere in summer.
Nacher says: "A serious difficulty in the treat-
ment of old age is the uncertainty of the action of
drugs on the senile organism. So little is known
of the therapeutic action of drugs upon diseased,
degenerating tissue. Drugs which are almost spe-
cifics in certain diseases in maturity may be in-
effectual in similar conditions in senility." Surgi-
cal and hygenic measures, however, as well as ortho-
pedic efforts, offer much hopeful result if judicious-
ly planned and carefully carried out.
15 West Forty-fourth Street.
CARDIAC CRISES IN TABES DORSALIS.
REPORT OF A CASE WITH SUDDEN DEATH.
By MAURICE F. LAUTMAN. M.D.,
HOT SPRINGS. ARK.
MEDICAL DIRECTOR, LEO N. LEVI MEMORIAL HOSPITAL.
Specific involvement of the sensory functions of
the pneumogastric nerves or sympathetic nervous
system in different locations is said to be the cause
of attacks of pain in the various organs, which are
known as visceral crises.
These crises are quite characteristic and easily
recognized, especially if an existing tabes has been
established as the etiological factor, and most fre-
quently involve the gastrointestinal tract. In addi-
tion to the gastric, intestinal, and rectal, crises have
also been known to occur in the nose, larynx, liver,
kidney, bladder, urethra, and clitoris.*
Attacks of pain about the heart in tabes are not
uncommon. These have usually been described as
girdle sensations, although real anginoid attacks
are occasionally encountered. True cardiac crises,
however, are extremely uncommon; in fact, their
existence as a manifestation of tabes is a matter of
dispute.
*I have under observation at present a young tabetic
with testicular crises which, like all tabetic pains are
aggravated, temporarily, following intraspinous treat-
ment.
Oct. 21, 1916J
MEDICAL RECORD.
723
Osier1 refers to cardiac crises, because he has
seen them in several cases, but inasmuch as these
patients were at an age when true angina pectoris
could not be excluded, their exact value as a symp-
tom of tabes had to be questioned. Starr" says
that cardiac crises may occur in tabes, but they are
extremely rare; he has never seen a case. Gaucher
seems quite certain that cardiac crises do occur,
and emphasizes the need of distinguishing them
from the rapidly curable syphilitic angina pectoris.
Massary* is of the same opinion, and quotes Hertz,"
who found in tabetics a degeneration of the medul-
lated fibers of the cardiac plexus.
The case to be reported occurred in a man (E. D.
No. 225), 46 years old, who had an initial lesion fol-
lowed by a rash twenty years ago. He had had no
constitutional treatment whatever, and felt in excel-
lent health until two years ago, at which time he be-
gan to Lave nocturnal headaches and double vision.
Since that time there have developed sexual impotence,
shooting pains in legs, rectal and vesical incontinence,
numbness and tingling in the legs, and failing mem-
ory.
He has noticed difficulty in pronouncing his words
of late. There has been an aggravation of all his
symptoms for the past eight months, since which time
he has been walking with crutches. He complains of
a constricting band sensation about two inches wide
encircling his body at the free costal margin and for
the past eight months he has had attacks of pain over
the heart. These pains come on quite suddenly, are
stabbing in character, and radiate up into the neck.
The pain is very severe while it lasts, the heart "seems
to stop beating," but the attack usually disappears
about five minutes after reaching its maximum in-
tensity.
On physical examination the patient was seen to
be poorlv nourished and developed. The pupils were
widely dilated, irregular, unequal, the right larger
than the left, and did not react to light. There was
a marked tremor of the face and tongue with dysarth-
ria. The lungs were clear, and no abnormalities could
be made out in the heart except a slight accentuation
of the second aortic sound. The abdomen and abdom-
inal viscera were negative. The gait was typically
tabetic, and pronounced inco-ordination and Romberg
sign were present; all the deep reflexes were abolished.
The systolic blood pressure was 130; the diastolic 94.
The Wassermann blood reaction was two plus, and
the spinal fluid, which contained 121 cells per cram.
and three plus globulin, gave a four plus inhibition
with 0.05 cc.
Four days prior to his death he received an intra-
spinous injections of mercury in his own serum from
which he had very little discomfort, only slight pain,
and the maximum temperature following the treatment
was 99.6°. He recovered very quickly and two days
following the injection felt quite well, was walking
about as usual, and remarked that the pains about
the heart were not so severe. He appeared as well
as ever on the morning of his death, when suddenly
while sitting on the bed, talking to a patient, he ut-
tered a cry, clutched at his heart, and fell back on the
bed. He was seen about a minute later and was pulse-
less; stimulation failed to revive him.
Postmortem Examination : The pericardial fluid
was increased in amount, the heart had stopped in sys-
tole and showed moderate hypertrophy. It weighed
305 grams; the left ventricle was 2.1 cm. thick, the
right 0.8 cm. The valves, as well as the coronary ar-
teries throughout their entire extent, showed no ab-
normalties. The aorta, with the exception of three
small atheromatous, calcified plaques on the posterior
wall, just above the ring, was negative. In addition,
the capsule of the liver showed a few cicatrices, there
was a Meckel's diverticulum, and there were only two
lobes in the right as well as the left lung.
Summary and Conclusions. — In a man with ad-
vanced taboparesis there occurred attacks of pain
about the heart, in the nature of cardiac crises.
There were no postmortem evidences to explain the
sudden death which occurred in one of the par-
oxysms, which renders quite plausible the assump-
tion that death was due to a cardiac crisis.
REFERENCES.
1. Osier: "Modern Medicine," Vol. VI, p. 098.
2. Starr: "Nervous Diseases, Organic and Func-
tional," p. 359.
3. Gaucher, E.: "Syphilis des visceres et de l'ap-
pareil locomoteur," p. 315.
4. de Massary, E.: "Le tabes et les maladies sys-
tematiques de la Moelle," p. 122.
5. Heitz, J.: "Les nerfs du coeur chez les tabe-
tiques, These de Paris," 1903.
LATE INFECTION FOLLOWING THE CORNE-
OSCLERAL TREPHINE OPERATION
FOR GLAUCOMA.
By CHAS. B. BRODER, A.B.. M D.,
NEW YORK.
INSTRUCTOR IN LARYNGOLOGY, POLYCLINIC MEDICAL SCHOOL ,
ADJ. OTOLARYNGOLOGIST, CITY HOSPITAL J VISITING OPH-
THALMOLOGIST AND OTOLOGIST. PEOPLE'S HOSPITAL.
The trephine operation for glaucoma by its sim-
plicity of technique and by its immediate favorable
results has appealed strongly to the average oculist
and has now become a well established operative
measure.
It is now about five years since Col. Elliot intro-
duced the operation and since then it has been prac-
tised extensively throughout the medical world. In
the enthusiasm of the moment and in the eagerness
of the profession to grasp at a procedure that will
cure or at least retard the course of some forms of
glaucoma not helped by an iridectomy, the secon-
dary and remote dangers resulting from this new
method have been overlooked.
Lately two cases of late infection of unusual
severity following the scleral trephine operations
have been seen by the writer.
Case I. — J. S., thirty-five years of age, was first seen
by me March, 1915, when he came to have his glasses
for reading changed. Examination showed evidence of
a trephine operation combined with an iridectomy in
each eye, which had been performed three years previ-
ously. The left eye had very little vision, hand move-
ments at five feet. The nerve was pale, atrophic, and
there was a deep depression. There was no increase of
tension. In the right eye vision was 20/30 with cor-
rection plus 1.00 spherical. Disc slightly cupped. Ten-
sion 22 mm. Hg.
The patient was not again seen by me until April
15, 1916, when he came to my office and said that while
working at his trade some aniline pigment got into
his right eye and he rubbed it to allay the irritation.
He awoke the next morning with the lids stuck together,
and the eye inflamed and painful. On examination the
eyeball was deeply congested and over the trephine
opening was a raised and circumscribed yellowish mass.
There was a distinct exudate in the anterior chamber.
The upper part of the cornea near the flap showed a
superficial ulceration and the rest of the cornea was
dull. The fundus could not be seen. Vision was re-
duced to light perception and tension was normal.
Under treatment the hypopyon gradually disappeared
and the cornea cleared up, revealing an active irido-
cyclitis with opacities in the vitreous and deposits in
the pupillary area and around the lens.
The patient was kept in the hospital for seven weeks
and the inflammation slowly abated. At present, vision
is greatly reduced (5/200) on account of the floating
vitreous opacities and the altered condition of the lens.
The intraocular inflammation in this case was evi-
dently secondary to the corneal ulcer, the infection in-
volving the conjunctival flap and spreading to the
ciliary body through the scleral opening.
Case II. — M. R., fifty-two years old, was first seen
by me June 15, 1916, and gave a history that the left
eye had been enucleated three years ago following two
operations for glaucoma, and the right eye had been
operated on shortly after for the same disease with
the preservation of good vision. Three days before
his next visit, the remaining eye suddenly became pain-
ful and red and the vision foggy. An examination
showed an acute conjunctivitis with infection of the in-
724
MEDICAL RECORD.
I Oct. 21, 1916
terior of the eye. The site of the flap over the trephine
opening was obscured by a yellowish elevated bleb.
Hypopyon was present. Signs of a severe iridocyclitis
were visible, fibrinous deposits in the pupillary area,
and on the surface of the lens capsule and opacities in
the vitreous. Very little vision was present. The in-
filtrate in the anterior chamber disappeared in a few
days, but the infection of the conjunctiva and ciliary
body was obstinate and persisted for several weeks in
spite of rigid treatment.
At the time of discharge from the hospital, the in-
flammation had subsided, but the vision, due to the iritic
deposits on the lens and the vitreous opacities, was
greatly reduced, the patient being barely able to find his
way about.
The unfortunate outcome in these two cases, the
infection in each instance involving the remaining
good eye and leading almost to total loss of vision,
together with the increasing number of cases be-
ing reported of secondary complications following
the trephine operation for glaucoma, should teach
us to be guided in our prognosis concerning the
ultimate outcome, and to use this method of pro-
cedure only as a last resort.
Besides late infection other pathological condi-
tions following the trephine operation have been
reported, such as opacification of the lens, and
closure of the trephine hole by proliferation of con-
nective tissue, or by being blocked by iris, ciliary
body, suspensory ligament or lens. In acute and
subacute glaucoma the consensus of opinion seems
to favor the ordinary iridectomy as the operation
of choice. In glaucoma simplex, the miotic treat-
ment should be persisted in as long as the intra-
ocular pressure is controlled, and the visual field arid
central vision are not on the decline. A majority
of these cases will yield to therapeutic measures.
In those cases of chronic glaucoma that are un-
influenced by miotic and constitutional treatment,
and operative measures are essential to save the
sight, a broad iridectomy properly executed will
often stay the course and should first be tried, of-
fering as it does more rapid healing and lessened
liability to infection.
In some cases an iridectomy will fail to control
the symptoms, on account of far advanced struc-
tural changes in the filtration area, in which event
the trephine operation is the only choice open, and
it should then be performed over the site of the
eoloboma. As a possible prevention against subse-
quent infection, the conjunctival flap should be
made as large as possible and quite thick.
221 Second Avenue.
iHrfrralmal SfatrH.
Treatment of Auricular Fibrillation. — Robert H. Bab-
cock states that there are three principal indications in
the treatment of this affection in addition to rest in bed.
First, the relief of insomnia and dyspnea, which is
almost always afforded by hypodermics of morphia.
One injection should be given each evening with an at-
tempt to reduce the dosage. If morphin fails for any
reason, heroin or codein may be employed. Second, the
relief of visceral congestion, which is accomplished by
the use of purgatives which are secondarily indicated
to antagonize the action of morphin. An alkaline pur-
gative on waking each morning should follow an initial
catharsis on the first evening of treatment; the author
prefers blue mass, 5 grains, for this purpose, combined
with a saline and a little hyoscyamus. The patient
should have two or three watery evacuations daily. The
third indication — which may not always be present —
is cardiac stimulation. In all severe cases, and sooner
or later in all cases, digitalis will be called for. At the
outset the Karell diet is recommended. Under this
management some compensation may return, perhaps
with ability to resume occupation in some measure.
This may require the daily use of digitalis, and the
patient in any case should be under constant supervi-
sion.— The Medical Herald.
Privileged Communications. — In a servant's action for
injuries, where defendant compelled plaintiff to give
testimony as to his statement to a hospital physician
regarding his injury, by recalling him to the stand and
exacting a statement that he had told the doctor at the
hospital how long he had had pain and when it first
started, the New York Appellate Division held that
plaintiff did not waive his privilege covering his state-
ment to the hospital physician. — Murphy v. New York.
N. H. & H. R. R. Co., 157 N. Y. Supp. 962.
Physicians Need Not Keep Records of Prescriptions
for Dangerous Drugs under New York Statute. — Under
section 248 of the New York Public Health Law, as
added by Laws 1914, c. 363, and amended by Laws
1915, c. 327, providing that all persons authorized by
law to handle dangerous drugs shall keep certain rec-
ords of such drugs when "dispensed, given away or in
any manner delivered," and declaring a violation of the
section a misdmeanor, and section 246, forbidding the
delivery of such drugs without a physician's prescrip-
tion, and providing for records of such delivery, a phy-
sician who wrote prescriptions for dangerous drugs
without keeping a record of the transactions was not
guilty of a violation of section 248, as he did not "dis-
pense" the drugs himself; the statute making a dis-
tinction between the "dispenser" of the drugs and the
physician who writes the prescription.— People v. Cohen.
157 N. Y. Supp. 591.
Punishment for Practising Without License. — Texas
Penal Code 1911, Art. 756, provides that the punishment
for unlawfully practising medicine shall be by fine of
not less than $50 nor more than $500, and by imprison-
ment for not exceeding six months. A conviction was
had and punishment assessed at a fine of $100. On ap-
peal this was reversed. On conviction the jury must
assess both a fine and imprisonment within the legally
fixed maximum and minimum. — Rutherford v. State,
Texas Civil Appeals, 187 S. W. 481.
Treating Patient with Cocaine. — In an action against
a physician for selling cocaine there was evidence that
the person to whom the drug was sold, though addicted
to the use of it, was suffering from a disease for which
cocaine was a known remedy, and that the defendant
sold him the drug as a treatment for it. It was held
that the Missouri statute making it unlawful for any
druggist or other person to retail or sell or give away
cocaine except on the written prescription of a licensed
physician or dentist was not intended to cover cases of
a physician selling and delivering cocaine in the course
of his practice and in his treatment of a patient. — State
v. Hesse (Mo.) 187 S. W. 571.
Waiver of Privileged Communications. — The Missouri
statute makes physicians incompetent witnesses as to
any information acquired from a patient, which was
necessary to enable them to prescribe. This statutory
provision is in derogation of the common law and cre-
ates a privilege which the patient may waive at will.
In an action for personal injuries the plaintiff, as a part
of his case, stated the advice given to him by his at-
tending physician as to his physical condition and
future fitness for work at the time he left the hospital.
This, the Missouri Supreme Court held, opened the door
for a full inquiry as to the knowledge of the physician
of the health and extent of the injuries of the plaintiff
at the time of the alleged statement by the physician,
and as to what advice he then gave the plaintiff in view
of the knowledge on which it was predicted. — Blanken-
baker v. St. Louis & S. F. K Co. (Mo.) 187 S. W. 840.
Liability for Services to Minor Child. — In an action
by a physician against a married woman for services
to her minor child, living with her, it appeared that she
and her husband, the father of the child, lived together.
The Texas Court of Civil Appeals held that in order to
make the wife personally liable for the services, she
must have entered into a contract therefor. Her mere
acquiescence or consent for the doctor to- treat her
child would not bind her personally or make her sep-
arate estate liable. It is not sufficient that she merely
give an order or call in the physician, for in such case
the presumption is that she does so as the agent of
her husband, whose duty it is to supply such things.
After the services were rendered a mere verbal promise
on her part to pay would not render her separate estate
liable for the debt of the community. She would not
be bound personally for the default of her husband by
such verbal promise to pay his debt. — Davenport v.
Rutledge (Tex.) 187 S. W. 988.
Oct. 21, 1916]
MEDICAL RECORD.
725
Medical Record.
A Weekly Journal of Medicine and Surgery.
THOMAS L. STEDMAN, A.M., M.D., Editor.
PUBLISHERS
WM. WOOD & CO., 51 FIFTH AVENUE.
See fourth page following reading matter for Rates of Subscription
and Information for Contributors and Subscribers.
New York, October 21, 1916.
THE VALUE OF THE MEDICAL RESERVE
CORPS.
It has not been so long that the Medical Reserve
Corps was regarded as something of a farce by the
civilian practitioner on one hand and the military
surgeon on the other. It was the custom to allude
to one's appointment as first lieutenant in that body
in the speech after the medical banquet, in a face-
tious vein, as being a rather good joke on the
army. Despite this playful attitude toward such
a commission there have always been title-loving
physicians who were not at all averse to adding
it to their names as they appeared on publications;
these were usually the ones who were especially
prolific with printed matter. The designation of
the original appointments to the Reserve Corps as
the "Distinguished List" served to animate the
fiction that the possessor of one of these commis-
sions had received a sort of honorary degree, in
recognition possibly of his superior attainments.
The Spanish-American War probably did more
to wake up the profession to a realization of its
responsibility to the country in the matter of mili-
tary medicine than any other event. It is a matter
of history now, and history that does not make
pleasant repetition, how the few trained military
surgeons were overwhelmed by an avalanche of
civilian physicians, ignorant of tactics, transporta-
tion, administration, in fact every branch of mili-
tary medicine. There were six of these untrained
doctors to every trained surgeon in that war. That
there has been a great improvement in this regard
has been shown by the prompt response of the sur-
geons of the Reserve Corps to the country's need
during our recent border trouble. At present there
are more than 250 reserve officers now on regular
duty. To quote Lieutenant-Colonel L. Munson, M.
C, U. S. A., editor of the Military Surgeon, "All of
these are selected men, many of them with a good
theoretical knowledge of the special duties of the
medico-military officer and not one without, at
least, a conviction that there are such special duties,
with good reasons for their existence."
The question of rank has often obscured the
real issue in the minds of some. We recall one prac-
titioner, known as one of the most successful in a
large city and professor of practice of medicine
in a large college, who related at a medical ban-
quet his experience at the time of the occupation
cf Vera Cruz. He held a commission as first lieu-
tenant in the Medical Reserve Corps, and went to
see an officer in the Medical Corps with some idea
of offering his service. "But," he said, "when I
found that I would be subject to orders from some
youngster of twenty-odd years old whom I had
quizzed in my classes I promptly resigned my com-
mission." This specimen of patriotic ideals was
related in a humorous way and was greeted with
more or less laughter. In pleasing contrast to this
attitude, let us quote a sentence here and there from
a speech by First Lieutenant Henry C. Coe of the Re-
serve Corps before an annual meeting of the Asso-
ciation of Military Surgeons (Military Surgeon,
September, 1916) : "We have been presented with
the honorable title of lieutenant in the regular serv-
ice, for which regular officers have worked. We owe
it to the Government to earn our right to the office
and its privileges. . . . The members should not
lie awake nights to think how they can add another
bar, or a leaf, or a spread eagle to their shoulder
straps. We are all doctors, thank God, as we are
all officers and gentlemen. If there is any nobler
title than this, I don't know it. The youngster
with the double hurdle is my superior officer, and
as such I expect to obey him promptly as if he were
the chief surgeon. Envy, distrust, self-importance
— these have no place in our corps."
This surely expresses the attitude of our pro-
fession toward our country. If we join the Medi-
cal Reserve Corps let us do it with no mental reser-
vations, but with a whole-hearted intention to give
the best that is in us to our country, to make that
gift valuable by preparation in time of peace and
self-abnegation in time of war.
THE DECLINING BIRTH RATE OF GREAT
BRITAIN.
A declining birth rate is generally regarded as an
index of decadence of a race or nation. This view,
however, is by no means universal among promi-
nent scientists, for many hold to the Malthusian
opinions that it is better to have a well selected pop-
ulation and one of a general high standard than a
larger but more mixed and, on the whole, inferior
class. Nevertheless the majority of individuals
still adhere to the Bible admonition "be fruitful
and multiply" and to other ethical principles as "do
not attempt to outwit nature," and "the public in-
terest demands a high birth rate, private selfish-
ness desires a small family."
It is instructive to turn to the British birth-rate
commission's report published recently, dealing
with statistical evidence on the matter. The com-
mission has found itself warranted in concluding
that in Great Britain, as in other countries of
Northern and Western Europe, there is unmistak-
able proof that a sharp decline is taking place in
the birth rate, and there seems no reasonable
ground for doubting that the countries included will
ultimately reach the state of France. The birth-
rate in England and Wales has declined approxi-
mately to the extent of one-third in the past thirty-
five years. Statistics seem also to show that in the
countries such as France in which the decline first
726
MEDICAL RECORD.
[Oct. 21, 1916
showed itself the downward progress has been slow,
while in those in which it has been recent, such
as Germany, the fall has been more precipitate. It
would seem as if in the statistical part of the report
the commission had tried to find other causes than
artificial restraint to account sufficiently for the de-
cline in the birth-rate. Nevertheless, the conclusion
was borne in upon them that the fall was not due,
at any rate to any important extent, to alterations
in the marriage rate, to a rise of the mean age of
marriage, or to other causes diminishing the pro-
portion of married women of fertile age in the pop-
ulation. Density of population was insufficient to
explain it, for the rural rate was not widely differ-
ent from the urban; food might exert some influ-
ence, but it would be difficult to get facts and
figures of any value in support of this view. The
theory of cyclical variations in the natural power
to conceive or procreate, the hypothesis of variabil-
ity of germinal vitality, as brought forward by Dr.
Chalmers of Glasgow and others, was very attrac-
tive, but it broke down in the face of Irish figures.
The commission was also compelled to give up the
view that the higher education of women had any
bearing on the decline. Statistics appear to show
that there is no physiological difference between
the fertility of college and non-college women, al-
though there surely must be a slight difference in
the probability of offspring being brought into the
world owing to the later age at which women edu-
cated at college, must of necessity, marry.
In short, while the commission was unable to dis-
cover any sufficient cause for the falling rate, be-
yond that of conscious limitation and artificial re-
straint, yet certain circumstances did affect
fertility, and brought it about that the decline must
be regarded as dysgenic and not eugenic. The fall
in the birth-rate in England and Wales had been
more marked in those districts in which a higher
standard of living was found ; the size of the family
tended to vary inversely as the social status of the
parents, professional and allied occupations having
a low fertility and laboring occupations generally
a. high one (that of coal miners being very nearly
twice that of physicians). Housing conditions, too,
had an influence, for fertility decreased regularly
as the size of the tenement increased, and infantile
mortality decreased along with it, but the saving of
infant life in more commodious and comfortable
tenements compensated, to a slight extent, for the
lower fertility of those living in them.
Thus it cannot be denied that fertility is closely
connected with social status, the relation being such
that the more prosperous the social class the lower
the fertility. Moreover there is no proof that the
higher mortality among the infants of the lower
social class suffices to adjust the difference. Conse-
quently the decline cannot he regarded as eugenic,
but is out and out dysgenic. That is to say that
the babies are not fewer and of a superior quality
but the contrary. It may be for the good of a na-
tion if babies are fewer and of a finer quality, but
when they are fewer and of an inferior quality it
is obviously and distinctly detrimental.
Three suggestions are made, for which the medi-
cal part of the commission is presumably respon-
sible. The first is that women should be assured
that the pains of child bearing can be mitigated.
The second suggestion calls for an increased knowl-
edge with regard to the ways in which quality as
well as quantity may appear in the expected babies.
The third suggestion is that infantile and child
mortality should be checked by means taken not
only after but before birth, that is, by a maternity
and child welfare scheme. Decrease of birth rate
appears invariably to go hand in hand with civili-
zation, and the more advanced the civilization the
greater the decrease of birth-rate. France is prob-
ably, regarded from all standpoints, the nation most
advanced in civilization, and it is in France that
the birth-rate is the lowest.
A PLEA FOR THE HOSPITAL INTERNE.
THE hospital interne occupies an exalted or a
subordinate position, depending on the point of
view. To the young nurses and orderlies he is
more or less of a little tin god — to the visiting staff
a useful adjunct or a necessary nuisance, accord-
ing to the personal equation involved. Possibly he
(with increasing frequency in these enlightened
times — she) is a more important part of the
hospital machinery than is realized. He occupies
an intermediate position between the hospital man-
agement and the visiting staff on one side and the
nursing staff on the other. He learns from the
one and teaches the other.
In an article in the Southern Hospital Record for
July, Dr. Emory Park speaks a few words on be-
half of the resident physician or interne. Some
of his statements should be quoted and applauded:
"The hospital shouldn't demand that the interne
write all the histories and do the other detail
work and then step aside when the operations are
performed and let some outsider be the assistant
at the operation." "Some hospitals let inconsid-
erate members of their visiting staff call residents
away from their meals or let them set their opera-
tions at that time as will make the interne either
miss a meal or choke it down in hunks." "They
should be well fed and provided with clean, com-
fortable rooms and bathrooms."
Internes seldom receive any money except in
some instances a nominal sum. The tacit arrange-
ment in vogue is in the nature of a fair exchange.
The hospital receives service which is in reality
indispensable; each patient is visited once, twice,
or more times a day, routine dressings are done
and the feeling is that the patients are protected —
that there is for twenty-four hours a day a staff
i>f trained men on guard, capable of interpreting
symptoms and knowing when to call in the more
experienced physicians. They may be likened in-
deed to the outposts of an army camp. They rec-
ognize danger at a distance, and it can be repulsed
before it threatens the heart of the army itself;
so that the general sleeps more soundly in his tent,
just as the famous surgeon is able now and then
to take a week-end knowing that Smith and Jones
at the hospital will not have him called needlessly,
but also that they will not let any of his patients
die for want of attendance. In return for these
services the interne expects and should receive ex-
Oct. "21, 1916]
MEDICAL RECORD
727
perience. Not the facility of inscribing "Mag.
sulph. §i" in an order book until he wakes from
dreams writing it in the air, not the holding of
the surgeon's coat while he puts on a plaster cast,
and not the bird's-eye view of the operation as
third assistant, but the actual diagnosis and treat-
ment of cases, the administration of anesthetics,
and the performance of operations. For each in-
terne in his hospital each member of the visiting
staff should feel the kindly interest which the old-
time preceptor had for his pupil.
We do not favor the loosing of a recent graduate,
full of theory, but deficient in practice, upon wards
of helpless sufferers. But certainly the interne
should have free scope with his stethoscope in the
wards, and he should be allowed to give anesthetics,
at first under supervision, but later alone, and there
is no reason why he should not be first assistant at
operations and even do a large part of them himself.
Many hospitajs and diverse ideals of manage-
ment pass before our eyes as the years go by. We
have seen hospitals where anesthetists were called
in from the outside to serve in rotation to the ex-
clusion of the resident staff, where each surgeon
seemed to have always some protege whom he
brought into operations to act as first assistant
while the interne who had examined the case, pre-
pared it for operation, and would later carry it
through the miseries of the postoperative period,
stood around and passed instruments. We have
seen hospitals where the tip went forth to potential
candidates that the food was bad, thus frighten-
ing away many a good man. Another one where
the doctors' home consisted of a ramshackle frame
building, which prospective internes took one look
at and fled. As Dr. Park reminds us in his article,
the hospital interne is not only a highly and spe-
cially educated person, but he is a gentleman. He
is entitled to the treatment accorded a gentleman
anywhere and, in addition, to the full amount of
the consideration for which he gives his services,
that is, all the experience which the hospital affords
together with the advice and oversight of the older
men attached to the staff. The hospital period is
probably the most valuable of the young doctor's
training if he is fortunate enough to get in the
right sort of a hospital, and with a little friendly
cooperation by those responsible for the manage-
ment of the hospitals all of them would be made
desirable in this regard.
The Rationale and Practice of Chemotherapy.
Our notions of chemotherapy are at present in an
unsettled state, for we do not know how many forms
of therapeutic activity are to be comprised under
this term, nor, so far as we have gone, are we sure
in practice even of the parasitotropic action of ar-
senic in infectious diseases, and chiefly of salvarsan
in syphilis. J. E. R. McDonagh believes that sal-
varsan is not truly parasitotropic, because it at-
tacks only a certain formation contained in the
spirochete by reason of an oxidizing action. Sal-
varsan is on the other hand organotropic and toxic
and attacks especially some of the intracranial tis-
sues. Much of McDonagh's reasoning is directed
against Ehrhch's side-chain theory which takes for
granted that chemotherapy is parasitotropic ther-
apy. On the other hand McDonagh may be correct
in his belief that chemotherapy is a matter of oxi-
dations and reductions. He has used non-toxic oxi-
dizing compounds of sulphur or iron in an attempt
to replace arsenic, but evidence of cure of obstinate
syphilitic lesions by such drugs is not yet regarded
as entirely conclusive. Dr. C. H. Browning has
claimed that chemotherapy really began thirty years
ago with the use of methylene blue, a sulphurated
compound, in malaria. Mr. John Ward holds that a
parasitotropic substance must be organotropic as
well. Arsenic, which in certain combinations is the
most powerful parasiticide, is also highly organo-
tropic, hence toxic. Iron is neither parasitotropic
nor organotropic, while sulphur, non-parasitotropic,
is organotropic in that it is a stimulant to organic
cells and tissues. McDonagh first passed from toxic
arsenic to its congener phosphorus, but finding this
likewise too toxic, made experiments with a third
metalloid, sulphur, which he incorporated into cer-
tain synthetics closely resembling in composition
salvarsan. Intramine, one of these, has been used
somewhat since the war began as a substitute for
salvarsan but is admittedly inferior to the latter
save, it is alleged, in recurrences. McDonagh in-
sists, however, that with it should be associated for
best results a reducing principle, namely colloidal
iodine, to be introduced into a vein or muscle. Mc-
Donagh has also prepared a synthetic of the sal-
varsan type in which iron enters. He insists es-
pecially on the value of intramine in intracranial
syphilis which is often made worse by salvarsan;
also in so-called neurorecidives which salvarsan has
been accused of causing.
Synesthesialgia.
This term is used by some neurologists as a con-
densation of synesthesia algica, a rare phenomenon
encountered in lesions of the median and sciatic
nerves, in which there is pain referred to the hand
or foot which is not in the area of distribution of
the affected nerve, and has no relation to the or-
dinary neuralgic or neuritic pains proper to the
nerve trunks themselves. Weir-Mitchell associated
certain pains (causalgia) with areas of glossy skin
and ascribed both to the presence of a neuritis.
Meige and Benisty referred this sympathetic pain
to a vascular component — alterations in the blood-
vessels. Leriche believed that both pain and
trophic changes (glossy skin) were due to inflam-
mation of the sympathetic fibers. Souques sug-
gested the operation of a reflex mechanism. An
article in the Rivista Critica di Clinica Medica for
August 12 calls attention to some recent work in
this field by Micheli who reported two cases of
causalgia from nerve injury associated with syn-
esthesialgia. The former symptoms could be as-
cribed to vasomotor and trophic alterations which
occur in specially disposed individuals, viz., those
with increased vasomotor excitability. Stimuli pro-
ceeding from these areas make themselves felt on
sound portions of the skin. The patients always
seek to relieve the burning pain of causalgia with
moist applications, hence the parts become macer-
ated. Micheli places a rubber glove or sock on the
affected hand or foot, and in this way protects the
surface from outside irritation. Leriche reports a
sympathectomy or resection of the perivascular
sheaths for a length of 8 or 10 cm., which has given
him good results.
72*
MEDICAL RECORD.
[Oct. 21, 1916
SfattiB of tUt Week
Army Medical Corps Examination. — The Sur-
geon General of the Army announces that a pre-
liminary examination for appointment of first lieu-
tenants in the Army Medical Corps will be held
early in January, 1917, at points to be hereafter
designated. Full information concerning the ex-
amination can be procured upon application to the
"Surgeon General, U. S. Army, Washington, D. C."
The essential requirements are that the applicant be
a citizen of the United States, between 22 and 32
years of age, graduate of a recognized medical
school, and of good moral character and habits, and
have had at least one year's hospital training, as an
interne, after graduation. In order that all ar-
rangements for the examination may be perfected,
applications should be forwarded without delay to
the Surgeon General of the Army. There are at
present 228 vacancies in the medical corps.
The Western Surgical Association will hold its
next session on December 15 and 16 at St. Paul.
Minn., instead of at Indianapolis as scheduled. The
change has been made because of the absence of
the chairman of the committee of arrangements,
Dr. Joseph Rilus Eastman of Indianapolis, who is
"somewhere in Austria" at the head of a surgical
unit.
Alvarenga Prize. — The College of Physicians of
Philadelphia announces that the next award of the
Alvarenga prize, amounting to $250, will be made
on July 14, 1917, provided that an essay deemed by
the committee on award to be worthy of the prize
shall have been offered. Essays intended for com-
petition may be upon any subject in medicine, but
must not have been published. They must be type-
written, in English or accompanied by a translation,
and must be in the hands of the secretary of the
college on or before May 1, 1917. Further particu-
lars may be obtained from Dr. Francis R. Packard,
secretary, College of Physicians, 19 South Twenty-
second Street, Philadelphia.
Dr. Bulkley's Lectures. — The governors of the
New York Skin and Cancer Hospital announce that
Dr. L. Duncan Bulkley, assisted by the attending
staff, will give the eighteenth series of Clinical
Lectures on Diseases of the Skin, in the Out-
Patient Hall of the hospital, on Wednesday after-
noons, beginning November 1, 1916, at 4.15 o'clock.
The lectures will be free to the medical profession
on the presentation of their professional cards.
Paratyphoid Carriers. — Forty-five members of
the 14th and 71st Regiments, just returned from
the border, are carriers of the paratyphoid bacil-
lus, according to examinations made by the Health
Department. The 14th, which had 130 cases of
the disease, furnished forty healthy carriers, and
the 71st. with fourteen cases, turned out five car-
riers.
Infantile Paralysis in New Jersey Institutions. —
A member of the freshman class at Princeton Uni-
versity died last Saturday from poliomyelitis, and
a case of the disease has been reported at the State
Normal School in Trenton.
Tin Sickness (?) in Germany.— The Amsterdam
correspondent of the Exchange Telegtavh in Lon-
don says that "a remarkable disease is spreading
in many parts of Germany, especially in Berlin,
Hamburg, Munich, and Cologne, caused by con-
tinual feeding from preserved foods. The sickness
is described as 'tin sickness.' It is considered a
serious form of blood poison. Thousands of cases
are reported in every large city, although the au-
thorities exercise strict control over the tin used
for preserved foods." If the story is true, it is
more likely that the trouble is a deficiency disease,
canned foods being notably lacking in vitamines.
American Ambulances for Balkans. — The re-
cently formed section of the American Ambulance
Field Service, which is to be attached to the French
Army in the Balkans, left Paris on October 13 for
Saloniki.
To Attack Christian Science. — The New York
County Medical Society, through the Comitia Mi-
nora, has determined to conduct a State-wide cam-
paign for the elimination from the public health
law of that section under which, by a recent ruling
of the Court of Appeals, Christian Scientists may
claim the right to practise.
Gifts to Charities. — Among a number of other
charitable institutions the Brooklyn Home for Con-
sumptives, Brooklyn, N. Y., receives a bequest of
$5,000 under the will of the late Mrs. Albert Bier-
stadt of that city.
Harvey Lectures for 1916-1917.— The first lec-
ture of the Harvey Society for the present season
was given on Cctober 14, at the New York Academy
of Medicine, by Prof. J. S. Haldane of the Univer-
sity of Oxford on "The New Physiology." The
other lectures of the series will be as follows: No-
vember 4. Dr. F. M. Allen, Hospital of the Rocke-
feller Institute, "The Role of Fat in Diabetes"; No-
vember 25, Dr. Paul A. Lewis, Henry Phipps In-
stitute for Tuberculosis, "Chemo-Therapy in Tuber-
culosis" ; December 16, Prof. Henry H. Donaldson,
Wistar Institute of Anatomy and Biology, "Growth
Changes in the Mammalian Nervous System"; Jan-
uary 13, Prof. E. V. McCollum, University of Wis-
consin, "The Supplementary Dietary Relationships
Among Our Natural Foodstuffs"; February 3, Prof.
.T. W. Jobling, Vanderbilt University, "The Influ-
ence of Non-specific Substances on Infections" ;
February 24, Prof. John R. Murlin, Cornell Uni-
versity, "The Metabolism of Mother and Offspring
Before and After Parturition"; March 17, Prof.
Francis W. Peabody, Harvard University, "Cardiac
Dyspnea" ; April 7, Prof. W. H. Howell, Johns Hop-
kins University, "The Coagulation of the Blood."
As in the previous years, the lectures will be given
on Saturday evenings at eight-thirty, at the Acad-
emy of Medicine, and will be open to the public.
Cartwright Lectures. — As previously announced
the Cartwright lectures of the Association of the
Alumni of the College of Physicians and Surgeons,
New York, will be delivered by Prof. Richard M.
Pearce of the University of Pennsylvania at the
college, 437 West Fifty-ninth Street, on October 24
and 25, at 5 o'clock. The subject of the lectures will
be "The Spleen in Its Relation to Blood Destruction
and Regeneration."
X-ray Victims. — A dispatch from Paris states
that Dr. Minard. radiologist at the Cochin Hospital.
has been decorated with the Legion of Honor as a
recompense for the loss of two fingers through ex-
posure to the .r-ray in the course of his work on
wounded soldiers.
Dr. Francis LeRoy Satterlee of New York has
recently undergone a third operation for the re-
moval of a cancer of the right hand, the result of
exposure to the .r-ray some years ago.
Dr. Maynard Ladd of Boston has been appointed
physician-in-chief of the children's department of
the Boston Hospital and Dispensary, succeeding Dr.
A. A. Howard.
Oct. 21, 1916J
MEDICAL RECORD.
729
College Opens. — The Medical School of Cincin-
nati University, Cincinnati, Ohio, opened on Octo-
ber 3, with an enrollment of 100 students, an in-
crease of twelve over last year. Ten of the students
are women.
Epidemic Waning. — The total record of the
poliomyelitis epidemic in New York on October 14
was 9,202 cases and 2,352 deaths, the decline in the
number of new cases having been marked during
the week.
Mrs. Olive H. M. Rutherford, sixth vice-presi-
dent of the National Society of Druggists, and said
to have been the oldest pharmacist in this country,
died at her home in Brooklyn on October 13, aged
85 years.
Rocky Mountain Spotted Fever in California. —
Dr. Frank L. Kelly, assistant epidemiologist of the
California State Board of Health, recently made an
investigation in Modoc and Lassen counties, Cali-
fornia, for the purpose of determining the preva-
lence and geographical distribution of Rocky Moun-
tain spotted fever in those localities. He found that
from 1903 to 1916 (the figures of the latter year
being, of course, incomplete) 6 cases occurred in
Modoc and 32 in Lassen County, the two counties
being in the northeastern corner of the State and
contiguous. Of these cases 11 occurred in Lassen
County in 1915 and 8 in the first part of 1916. Dur-
ing 1915 Modoc County had no cases, and during
the first part of 1916 two were reported. The total
mortality among the 38 cases was 6. Dr. Kelly's
conclusions are: 1. Rocky Mountain spotted fever
has existed in California for a much longer period
and to a far greater extent than has hitherto been
supposed. 2. There are probably five main infected
areas, one in Modoc County and four in Lassen. 3
The disease is not as severe in California as in Mon-
tana, nor as light as in Idaho. 4. The infection
probably entered California through Nevada rather
than Oregon.
Medical Society Elections. — Indiana State
Medical Association: Annual meeting at Fort
Wayne on September 28 and 29. Officers elected:
President, Dr. John H. Oliver, Indianapolis; Vice-
presidents, Dr. John W. Phares; Evansville; Dr.
Charles M. Mix, Muncie, and Dr. George L. Guthrie,
Indianapolis; Secretary-Treasurer, Dr. Charles N.
Combs, Terre Haute.
Medical Society of the Missouri Valley: An-
nual meeting at Omaha, Neb., on September 22.
Officers elected: President, Dr. Charles R. Wood-
son, St. Joseph, Mo.; Vice-presidents, Dr. E. W.
Rowe, Lincoln, Neb., and Dr. C. B. Hickenlooper,
Winterset, la.; Secretary, Dr. Charles W. Fassett,
Kansas City, Mo.; Treasurer, Dr. Oliver C. Geb-
hart, St. Joseph, Mo.
Orleans County (Vt.) Medical Society: An-
nual meeting at St. Johnsbury on September 12.
Officers elected: President, Dr. B. D. Longe, New-
port; Vice-president, Dr. P. C. W. Templeton, Iras-
burg; Secretary-Treasurer, Dr. James F. Blanch-
ard, Newport.
Burlington-Chittenden (Vt.) Clinical So-
ciety: Annual meeting at Burlington on Sept. 28.
Officers elected: President, Dr. E. H. Buttles; Vice-
President, Dr. Fred W. Sears ; Secretary-Treasurer,
Dr. O. N. Eastman, all of Burlington.
Obituary Notes. — Dr. Matthews Woods of Phil-
adelphia, a graduate of the University of Pennsyl-
vania, School of Medicine, Philadelphia, in 1873,
and a member of the Medical Society of the State
of Pennsylvania, the Philadelphia County Medical
Society, the American Medical Association, and the
Philadelphia Psychiatric Society, died in Philadel-
phia on October 14, aged 63 years.
Dr. George Carleton Dominick of New York,
a graduate of the New York Homeopathic Medical
College and Hospital, New York, in 1904, attending
physician to the Metropolitan and Volunteer Hos-
pitals, and a member of the American Institute of
Homeopathy, the New York State Homeopathic
Medical Society, and the Academy of Pathological
Science, died at sea, from tuberculosis, after a long
illness, on October 2, aged 39 years.
Dr. Tobias John Green of Mexico, N. Y., a
graduate of the Geneva Medical College, Geneva,
N. Y., in 1845, died suddenly at his home on Octo-
ber 4, aged 98 years.
Dr. Grace A. Murphy Curry of New York, a
graduate of the Woman's Medical College of the
New York Infirmary for Women and Children, New
York, in 1897, formerly assistant pathologist at the
City Hospital, Troy, N. Y., died suddenly on Octo-
ber 3, aged 47 years.
Dr. John Joseph Thompson of Webster, Mass.,
a graduate of Jefferson Medical College, Philadel-
phia, in 1887, and a member of the American Medi-
cal Association, the Massachusetts Medical Society,
and the Worcester District Medical Society, and a
trustee of the Webster School Board for nine years,
died at his home after a long illness, on September
16, aged 56 years.
Dr. William D. Moore died at Philadelphia on
September 28 at the age of 49 years. He was grad-
uated from the medical department of the University
of Pennsylvania in the class of 1893, and was a
member of the Medical Society of the State of
Pennsylvania, and the Philadelphia County Medical
Society.
Dr. Harry Huston Whitcomb of Norristown,
Pa., died at Atlantic City on September 28 at the
age of 61 years. He was graduated from the medi-
cal department of the University of Pennsylvania in
the class of 1880, and he was president of the Mont-
gomery County Medical Society, a member of the
Medical Society of the State of Pennsylvania, and a
Fellow of the American Medical Association.
Dr. W. H. Barry of Hot Springs, Ark., a grad-
uate of the Memphis Medical College in 1858, died
at his home, after a lingering illness, on September
26, aged 80 years.
Dr. Nathan A. C. Mackie of Golinda, Texas, a
graduate of the University of Tennessee, College of
Medicine, Memphis, in 1881, died at his home, from
apoplexy, on September 26, aged 64 years.
Dr. George Jacob Pierce of Worcester, Mass-
died from heart disease, on October 2, aged 76
years.
Dr. John William McNamara of Denver, Col.,
a graduate of the Medical College of Ohio, Cincin-
nati, in 1901, and a member of the Colorado State
Medical Society and the Denver City and County
Medical Society, died at his home after a long ill-
ness, on September 19, aged 39 years.
Dr. Delbert Claude Adcock of Warrensburg,
Mo., a graduate of the University Medical College
of Kansas City in 1904, and a member of the Mis-
souri State Medical Association and the Jackson
County Medical Society, died suddenly on September
21, aged 36 years.
Dr. John A. McLeod of Milwaukee, Wis., a grad-
uate of the University of Michigan, Department of
Medicine and Surgery, Ann Arbor, died suddenly
at his home, on September 21, aged 60 years.
730
MEDICAL RECORD.
[Oct. 21, 191C
(Harrtapatibttitt.
SURGEONS WANTED FOR THE EUROPEAN
ARMIES.
To the Editor of the Medical Record:
Sir: — May I venture to ask that attention be
called to the great scarcity of medical men in some
of the armies of Europe — notably on the Eastern
frontier. I am prepared to guarantee full officer's
pay and traveling expenses to 150 competent sur-
geons for six months' service, or for the period of
the war. An item to that effect would be highly
appreciated and would probably lead to the preven-
tion of much suffering.
Louis L. Seaman, M.D.
247 FIFTH AVENUE, NEW YORK.
OUR LONDON LETTER.
(From Our Regular Correspondent.)
ANNUAL REPORT — COUNTY OF LONDON— INFECTION
IMPORTED — VERMIN — SCARLET FEVER — TYPHOID —
KITCHEN ARRANGEMENTS — EPIDEMICS.
London, Sept. 21, 1916.
The annual report on the health of London has ap-
peared as usual with the other statistics. There is
a further decline in the population on that recorded
for 1911, but it is only slight and is conjectured to
be perhaps due to the difficulty experienced by poor
persons with several children in obtaining suitable
tenements within the county and being obliged to
seek accommodation outside. This migration is
also held to explain various other anomalies, e. g.
those of sex distribution. At the age of 25 to 35
more females than males are attracted to London,
unless ill health is present, when the reverse move-
ment is observed. The mortality of young adults,
especially females from phthisis, is understated in
large towns, but, on the contrary, overstated in
rural districts, because immigrants to towns re-
turn to their country homes when fatally ill, and
the same may be said as to other chronic diseases.
The expectation of life for London is greater in the
last than in any previous returns, the increase be-
ing for all periods for women and for nearly all for
men. The marriage rate for the year was higher
than it has been since 1874, which is being at-
tributed by many to the effects of the war. The
birth rate continues to decline; it is now 24.3 per
1,000 as against 25 for the years 1909-13. In only
one London borough (Chelsea) is there a rise, and
that slight. We have again a very low death rate —
only 14.4 per 1,000. The first quarter of the year
had the highest incidence; the second, the lowest.
Migration has an important effect on the birth rate.
Domestic servants in London, who come from the
country, frequently return to their homes on mar-
riage. The infant mortality was 104 as against 107
for the previous quinquennium. The greatest
number of deaths was due to wasting diseases, pre-
mature birth being a primary cause, followed by de-
bility, marasmus, diarrhea, and afterward infec-
tious diseases. The registrar-general's report for
L913 showed a low mortality from abdominal tuber-
cle in London, but there is a heavier mortality from
meningeal tubercle, though this is considered by
some as only apparent through improved certifica-
tion.
Great care has been taken to prevent infection
being brought from abroad during the war and
though some cases were scheduled at the port of
London prompt measures were taken and so far
seem successful. In the last report 41 per cent, of
the children born were unaccounted for as concern-
ing vaccination. The scarlet fever rate was higher,
the females being more often affected, but the death
rate was higher in the males.
In regard to this disease the prevalence of vermin
has been studied. The waves of scarlet fever show
crests every few years — say six to eight — and there
is a correspondence of this with one showing the
prevalence of fleas and also waves of dryness. A
contrast of the curves of two sets of schools shows
curves for London boroughs — -one with the worst
social conditions; the other with the best. In the
worst the fever was highest in the youngest
years and the decline fairly rapid; in the best the
rise was delayed and the decline slower. The chil-
dren in the poorer class of schools had less fever
than those of the better class. It is conjectured
that the poorer class had had the fever previously
or had become immune to flea bites.
There was an outbreak of typhoid fever at the
turn of the year 1913-14 and the infection was.
traced to one establishment and suspicion was di-
rected to the kitchen arrangements — then to the
food supply, but it could not be shown that this was
certainly the source of infection. Out of 789 cases
notified information was obtained about 400. The
"trash" sold in London streets is almost certainly
a frequent source of infection and in some large
towns the water supply is blamed; so is fish, espe-
cially shellfish coming from a distance.
The great improvements in the sanitation of
London during the last 30 or 40 years have done
much to hinder the growth of the typhoid germ
and deliver us from epidemic outbreaks, but the
importation of cheap and "nasty" food must be con-
stantly guarded against.
{frogrrfia nf iHriitral £>rmtrp.
Boston Medical and Surgical Journal.
October 5. 1916.
1. Address Awarding the John Harvard Scholarships — 1916
Abner Post.
2. Treatment of Diabetes. F. Fremont-Smith.
3. Insufficient Oxygen Supply an a Factor in Disease. Francis
EL McCrudden.
4. Roentgentherapy in Hypertrophy of the Thvmus Gland.
Philip H. Cook.
5. Guillaume Dupuytren. 1 7 7 7 - 1 ^ :i r. William Pearce Coues
2. Treatment of Diabetes. — F. Fremont-Smith re-
views the literature with reference to the starvation
treatment of diabetes and calls attention to a new sign
in persons developing coma, namely, the rapid decrease
of intraocular tension, this lowered eye tension run-
ning with equal pace the advance or recession of coma.
He says that since the diabetic fails to a greater or
lesser extent to metabolize starch and sugar, and since
his ability to convert these into fat, or to elaborate any
form of food, to the extent of one with healthy tissues,
is impaired, it is apparent that he must restrict both
amount and quality of food below that taken in health
by one of similar weight and height. The limitation
of the carbohydrate will be determined from time to
time by the glycemia and presence of sugar in the urine.
Hyperglycemia and urinary sugar do not run pari
imssu, since permeability of the kidneys to sugar differs
in different patients and at different times. The
dietetic system recommended requires about 50 grams
or 200 calories of carbohydrates daily; the average man
takes six or eight times this amount. The carbohydrate
intake must be begun at this low point and gradually
increased, the rate being dependent upon hyperglycemia
Oct. 21, 1916J
MEDICAL RECORD.
731
and the appearance of glycosuria. The writer finds
Kellog's graduated tables, reckoned on the standards of
Chittenden, Lusk and Folin, a very practical guide for
feeding carbohydrates, fats, and proteins, increasing
or decreasing each element as the uranalysis indicates.
For each pound of body weight one should give daily in
calories, to begin with carbohydrate 0.5 calories,
protein 1.5 calories, fat 0.2 calories, and grad-
ually increase, if sugar-free, up to carbohydrate
4 calories, protein 1.5 calories, and fat 10 calories. On
this basis a person weighing 130 pounds, reaching this
intake at the end of two weeks, will be taking 2,015
calories in twenty-four hours. Fasting days are
ordered weekly or less frequently, followed by two or
three green vegetable days. Abundant water is neces-
sary even up to 4 quarts daily and exercise should be
graduated according to strength and results. The bowel
movements must be kept free by bulky vegetable food,
containing abundant cellulose, also by bran and
paraffin oil, and the skin must be kept active by cold
friction and hot baths, or, if under institutional treat-
ment, by electrical and hydrotherapeutic means. This
method of treatment once appreciated, becomes quickly
simple, easily managed, and offers renewed courage and
enthusiasm to both physician and patient.
3. Insufficient Oxygen Supply as a Factor in Disease.
— Francis H. McCrudden urges that in the training of
physicians more emphasis should be laid on the prac-
tical aspects of physiology. He says that the best evi-
dence that the medical student does not receive adequate
instruction in the practical aspects of this important
subject are the primitive notions of physiology so fre-
quently exhibited in the explanations of the mechanism
of disease and the mode of action of different forms of
treatment given in our clinical journals. As an example
of this he cites the constant recrudescence of the myth
of "insufficient oxygen supply," for over a century a
favorite explanation of pathological symptoms. The
belief in "insufficient oxygen supply" is based on an
erroneous notion of the nature of metabolism, accord-
ing to which the amount of oxidation is regulated by
the respiration. The source of this error may be traced
to Lavoisier, whose writings also contained a germ of
the truth. Voit (1866) was the first to incline physi-
ologists to the belief that respiration is not the cause
of metabolism, but the result of the needs of meta-
bolism. He pointed out that the carbon dioxide elimi-
nated is independent of the ventilation of the lungs.
In the cell alone lies the essential secret of the regula-
tion of the oxygen used by the body; it is not determined
by blood pressure, the velocity of the blood stream, the
activity of the heart, or the activity of the respiration.
No physiologist has contended that the products of in-
complete oxidation will result from either poor respira-
tion or poor circulation. It seems that sufficient time
has elapsed for these facts to have filtered into clin-
ical medicine and that more active emphasis will be
placed on the practical aspects of physiology which will
purge clinical medicine of ideas generally recognized
by physiologists as incorrect.
4. Roentgentherapy in Hypertrophy of the Thymus
Gland. — Philip H. Cook discusses the anatomy, develop-
ment, and physiology of the thymus gland and reports
several cases of enlarged thymus successfully treated
by roentgen irradiation. He emphasizes Lang's con-
clusions: 1. Roentgen irradiation of the thymus pro-
duces artificial involution of the gland. 2. X-ray
therapy is the method of choice in cases of enlarged
thymus in children, whether the symptoms be mild or
urgent. 3. Urgent cases should receive repeated mas-
sive doses. 4. Recurrences due to regeneration of the
gland are to be watched for and controlled by further
treatment. 5. Children whose physical or mental de-
velopment is retarded should, if suspicion is directed
toward the thymus, receive tentative x-ray treatment,
even though a positive diagnosis cannot be established.
6. X-ray therapy as a precautionary measure, or pre-
operative treatment may enable children of the so-called
lymphatic type to withstand intercurrent disease or an-
esthetics, which would otherwise prove fatal. 7. Pre-
operative exposure of older children and adults, where
there is a suspicion of enlarged thymus, might lessen
operative mortality. 8. Routine preoperative .c-ray
treatment in cases of hyperthyroidism should be re-
sorted to with a view to lessening operative mortality.
9. X-ray exposure of the thymus gland has been proven
harmless, whether in normal or abnormal individuals.
A therapeutic test with the x-ray is, therefore, always
permissible.
New York Medical Journal.
October 7. 1916.
1 The Therapeutics of Hay Fever. A. Parker Hitchens.
2 Acute Intussusception in Infants. Benjamin T. Tilton.
3. Roentgen Ray Therapeutics. A. Judson Quimby and Will
A. Quimby.
4. Occupational Thecitis. Adolph Cohn.
5. The Psychology of the Faddist. B. S. Talmey.
6 Iritis and the Gsneral Practitioner. William L. Rhodes.
7. Labyrinthine Inflammation. Charles B. Broder.
8. The Epileptic Syndrome and Glandular Therapy. James
Li. Jonghin.
9. Chronic Gonorrhea. William S. Barnes.
10. Verify Your References. Frank Place.
1. The Therapeutics of Hay Fever. — A. Parker Hitch-
ens presents a historical review of the various theories
as to the causation of hay fever and of the types of
treatment that have been employed. He suggests the
following plan of treatment: First, a thorough rhino-
scopic examination in order that any condition requiring
surgical treatment may receive attention. In the mean-
time a diagnosis is made with regard to the varieties of
pollen to which the patient is susceptible. As an aid in
identifying the pollens inhaled by the patient a special
button should be worn by the patient or kept in his vicin-
ity, consisting of a metal frame in which is held a mi-
croscope cover-glass coated with the glycerine mixture
used by Blackley. The microscopic examination is made
after about twenty-four hours' exposure. Prophylactic
treatment may be begun two or three months before the
hay-fever season. An initial dose of extract containing
0.0025 mg. nitrogen is sufficient to elicit some immuniz-
ing response without producing disagreeable effects.
Subsequent injuctions are given at five to seven day in-
tervals and may be increased to 0.01 and 0.02 mg. If
the area of redness about the point of the first injection
has been only slight the second dose is increased to twice
the original amount. No further increase is advised.
During the season the period of relief following an in-
jection has been found to be variable. A few persons are
relieved for only twenty-four hours; in such cases daily
doses are necessary. In others the five or seven day in-
terval between injections may be satisfactory. If the
symptoms persist in spite of an apparently accurate di-
agnosis and specific treatment bacterial vaccines are well
worth trying.
2. Acute Intussusception in Infants. — Benjamin T.
Tilton believes that the mortality of operation within
twenty-four hours after the onset of acute intussuscep-
tion in infants should not be materially higher than that
of appendicitis operated upon in the same period — that
is, practically nil. Fatal results are due to two factors
working separately or in conjunction, failure to make
the diagnosis early, and faulty operative technic. As re-
gards the differential diagnosis the only condition which
comes into consideration is acute colitis. Here the onset
is not so sudden or painful. Furthermore the passages
are more copious and contain bile, while in intussuscep-
732
MEDICAL RECORD.
[Oct. 21, 1916
tion the movements are not large and contain only mu-
cus and blood. The diagnosis should be followed by im-
mediate operation, which should be performed with the
minimum amount of handling of intestine and trauma-
tism. The best inciison, in the author's experience, is
one that splits the rectus at the junction of its middle
and inner third, and extends one-third above and two-
thirds below the umbilicus. If possible the tumor mass
should be grasped with two fingers and brought out
through the incision, and all further manipulations per-
formed outside the abdomen. Reduction of the intus-
susception is successful in between 80 and 90 per cent
of the cases. Any other procedure besides reduc-
tion is so extremely unsatisfactory that every effort
should be made to complete reduction. If reduction
fails, resection with end to end anastomosis probably
offers the best chance of recovery; but the mortality is
excessively high, as the case is usually a neglected one.
The formation of an artificial anus is attended with
practically 100 per cent mortality. The efficacy of at-
tempts to prevent recurrence by such means as anchor-
ing or shortening the mesentery are doubtful and pro-
long the operation. In closing the abdomen, tension
sutures of silkworm gut should be inserted through the
skin and aponeurosis, in addition to the layer sutures.
Special efforts should be directed to combat shock.
4. Occupational Thecitis.— Adolph Cohn states that
thecitis is common as a result of occupations such as
dressmaking, cutting, pressing, and working in sheet
metal. When one encounters this condition he should
always look for a focus of infection and eradicate it.
On the whole, the extensors are more commonly affected
than the flexors. Extensors are also more commonly
affected in those using shears, while the flexors are
more commonly affected in those using sadirons. The
symptoms clear up in a short time under proper treat-
ment, while untreated they become chronic and result
in impaired motion and function. Occupational thecitis
is differentiated from tuberculosis thecitis by a history
of tuberculosis, fever, and longer duration, irrespective
of occupation; from suppurative the«itis, by fever,
swelling, and history of digital or palmar abscess ; from
osteitis, periostitis, or osteoperiostitis, by swelling,
fever, history of injury, and ar-ray; from arthritis, by
limited or impaired motion of the joint, history, and
.r-ray. Locally the author prescribes the following:
Iv Tinctura iodi r>i ;
Unguenti belladonna? ] - - =
Unguenti ichthyolis j aa -,ss-
M. fiat unguentum.
In addition, baking is of great benefit. Internally,
syrupus ferri iodidi, half a dram, and syrup of hydri-
odic acid dilute, half a dram, is prescribed.
6. Iritis and the General Practitioner. — William L.
Rhodes calls attention to the frequent failure of the
general practitioner to recognize iritis, with the result
that the patients are not treated or mistreated and per-
manent loss of vision in one eye follows. The symp-
toms in iritis are typical, consisting in a change in the
color of the iris. It has a muddied appearance, and the
luster and striated appearance of the healthy iris are
lost. There is frequently a fine meshwork of blood ves-
sels forming a halo around the cornea and perceptibly
diminishing the further from the cornea they are situ-
ated. Miosis is in evidence and the reaction of the pupil
to light and to mydriatics is diminished or lost. Pos-
terior synechia appears and can be demonstrated by
the installation of a mydriatic. The subjective symp-
toms comprise pain and photophobia, together witli a
decrease in visual power. Transient myopia and astig-
matism are noticeable in all cases of iritis. The treat-
ment is governed by the cause. In the rheumatic type
atropine and dionin, together with hot, moist applica-
tions, constitute the local treatment, while internally
sodium salicylate is given. A focus of infection respon-
sible for the condition may be found in the tonsils.
10. Verify Your References. — Frank Place empha
sizes the importance of accuracy in references, and
gives reasons why it is desirable that medical writers
should always verify their references. He states that
the experience of writers and bibliographers has shown
that the efficient bibliographic reference is the one con-
taining the complete and correct answer to the ques-
tions, "Who wrote it?", "What is it about?", "When
and where was it published?" Answering these ques-
tions, the citation should stand as it does in the Index
Mcdicus and in the Index Catalogue of the Library of
the Surgeon General's Office. In referring to a book
the details are these: (1) Author's name, with initials;
(2) title of book; (3) edition, other than the first;
(4) place, publisher and date (imprint); (5) volume,
and page therein if a particular statement is to be
quoted. Unless references are verified from the origi-
nals, marvelous results are sometimes attained. Veri-
fying references means work, but if they are not worth
the work they are not worth printing.
Journal of the American Medical Association.
October 7. 1916.
1. The Relation of Choked Disk to the Tension of the Eye-
ball: An Experimental Study. Walter R. Parker.
'1. Report of Five Cases of Tertian Malaria Treated with
Diarsenol Intravenously. Frank C. Neff.
3. Bronchiectasis of the Upper Lobes, with Report of Five
Cases with Necropsies. Thomas McCrae and Elmer N
Funk.
t. Posture in Obstetrics. J. W. Marcoe.
5. Premature Ventricular Systoles: Their Clinical Signifi-
cance. .T. E. Griewe.
6. Pelvic Infections in Women : Comments on Some Special
Pathology with Application to Treatment. Thomas .1.
Watkins.
7. Intestinal Obstruction. John William Draper.
S. The Fractional Examination of the Stomach Contents.
Elbridge J. Best.
9. Trichinosis: Immediate Result Following Intravenous In-
jection of Neosalvarsan .1. B. McNerthney and William
B. McNerthney.
10. Blood Cultures in Epilepsy. William B. Wherrv and
Wade W. Oliver.
11. A Bacteriological Study of the Blood of Seventy Epilep-
tics, with Special Reference to the Bacillus Epileptlcua
of Reed. H C'aro and D. A. Thorn
12. New Method of Antral Cleaning with Trocar. A. C
Neath.
1. The Relation of Choked Disk to the Tension of the
Eyeball. — Walter R. Parker presents this experimental
study on dogs and monkeys to prove, if possible, the
relation between choked disk and the tension of the eye-
ball in the case of artificially increased intracranial
pressure. Three theories have been advanced to ac-
count for the causation of choked disk, namely: the in-
flammatory, the toxic or chemical, and the mechanical.
These three factors alone or in combination have been
urged as the possible cause of the swelling of the disk
in cases of intracranial pressure. In conclusion he state-
that (1) choked disk can be produced in the dog and
monkey by artificially increasing the intracranial pres-
sure. The most satisfactory results are obtained by the
use of sponge tents. (2) When the intracranial pres-
sure is increased by artificial tumors placed in the oc-
cipitoparietal region, one element in determining which
disk will be affected first is the tension of the eyeball.
(3) When the intracranial pressure is increased by ar-
tificial tumors placed in the oceipito-parietal region, the
nerve in the eye of least tension is the first to show the
choked disk. (4) When the intracranial pressure is
increased by artificial tumors placed in the occipito-
parietal region, there is no direct relation between the
location of the tumors and the eye first affected.
2. Report of Five Cases of Tertian Malaria Treated
with Diarsenol Intravenously. — Frank C. Neff. (See
MEDICAL Rkcord, June 24, 1916, page 1163.)
Oct. 21, 1916J
MEDICAL RECORD.
733
3. Bronchiectasis of the Upper Lobes. — Thomas Mc-
Crae and Elmer N. Funk report five cases with ne-
cropsies. (See Medical Record, July 1, 1916, page 32.)
4. Posture in Obstetrics. — J. W. Marcoe. (See Med-
ical Record, July 8, 1916, page 84.)
5. Premature Ventricular Systoles: Their Clinical
Significance. — J. E. Griewe. (See Medical Record, July
1, 1916, page 33.)
6. Pelvic Infections in Women. — Thomas J. Watkins
comments on some special pathology with application
to treatment. (See Medical Record, July 8, 1916, page
83.)
7. Intestinal Obstruction. — J. W. Draper. (See Med-
ical Record, July 8, 1916, page 82.)
9. Trichinosis. — J. B. McNerthney and William B.
McNerthney report immediate result following the in-
travenous injection of neosalvarsan. The scientific
paper of Van Cott and Lintz and their unfavorable
results in the use of salvarsan and neosalvarsan made
them slow to use neosalvarsan; however, in their re-
ported case they were rewarded with a most favorable
result, which seems to prove beyond a doubt that in
certain stages of the disease, at least, neosalvarsan in-
travenously is a rational method of treatment in trichi-
nosis.
10. Blood Cultures in Epilepsy. — William B. Wherry
and Wade W. Oliver state that in cultures from the
blood of six cases of epilepsy they had failed to isolate
the organism described by C. A. L. Reed as the Ba-
cillus epilepticus. Dr. Reed gave them one of the cul-
tures isolated by Dr. Hyatt from a case, and, so far as
they could tell, this organism belonged to the B. subtilis
group. It formed terminal and subterminal spores
which, when mature, were almost central. It grew rap-
idly at 37° C. or 24° C. with a smooth or wrinkled dirty
white layer on any of the ordinary mediums. Blood
serum was rapidly digested, as was also the case in
clot in milk. Acid was produced from dextrose, levu-
lose, galactose, saccharose, and mannite. They decided
to test its pathogenicity after they had proved to their
satisfaction that it really could be isolated from the
blood of epileptics. Dr. Reed kindly offered to allow
them to make cultures in his cases; this was done by
them in conjunction with Dr. Hyatt. Not only could
they not isolate such an organism, but they also failed
to find any bacteria in smears stained by the Gimesa
stain and by Abbott's spore stain and other methods.
Dr. Hyatt had shown them smears containing the spores
of B. epilepticus, but they had been unable to find simi-
lar bodies in the smears which they made. Notes on
the cases from which cultures were made are pre-
sented.
11. Bacteriological Study of the Blood of Seventy
Epileptics, with Special Reference to the Bacillus Epi-
lepticus of Reed. — H. Caro and D. A. Thorn present this
study, from which they found that in this series of 70
cases, with a total of 160 blood cultures, 156 proved to
be sterile. The remaining four showed contaminations.
Four cases with either myoclonus or hemiplegia also
gave sterile blood cultures. In a series of 17 necropsies
on epiliptics, Dr. Canavan was unable to find any or-
ganism resembling B. epilepticus. It seemed evident
that in the 70 cases studied the epileptic syndrome wa<
not due to the B. epilepticus of Reed.
The Lancet.
September 16. 1916.
l. The Question as to How Septic War Wounds Should K>-
Treated. (Being a Reply to Polemical Criticism pub-
lished by Sir Watson Cheyne in the "British Journal
of Surgery.) Almroth E. Wright,
'■t. Differential Leucocvte Counts in Enteric and Dysenteric
Convalescents. I. Walker Hall and D. C. Adam.
3. Notes on the Vaccination of Guinea Pigs with B. Perfnn-
gens. Muriel Robertson.
4. Infective Jaundice. (Spirochaetosis Ictero-hemorrhagica).
A Preliminary Report. N. B. Gwyn and J. J. Ower.
:.. l'neumococcus Meningitis with Recovery following Vaccine
Therapy. A. Carnarvon Brown.
6 A Crossed Hip Reflex in Enteric Fever. E. B. Gunson.
7. The Ground Level Latrine. F. E. Fremantle.
2. Differential Leucocyte Counts in Enteric and Dys-
enteric Convalescents. — I. Walker Hall and D. C. Adam
have made differential blood counts in a number of
healthy men as a basis for comparison, and then ex-
amined the blood films from convalescent cases of
amebic and bacillary dysentery, typhoid, and paraty-
phoid fevers. They have not observed the distinct
eosiniphilia which they had expected to find in these
cases, the eosinophile percentages not having exceeded
those met with in routine examinations of other forms
of convalescence. This feature does not seem to offer
much aid in the differentiation of an inoculation and
an infective agglutinin when only one agglutinin is pres-
ent in the blood. With regard to other types of cells,
the evidence accumulated suggests that extended ob-
servations, with the addition of other important hema-
tological procedures, may show that some information
will be gained by the examination of blood films in cases
of difficulty and especially in continuous fever in men
who have been inoculated with mixed vaccines against
typhoid, paratyphoid A and B, and cholera. It seems
probable that when the agglutinin present is due to in-
oculations, the blood films will yield approximately nor-
mal films, while in the case of an infective agglutinin
the typical leucocytosis or polynuclear leucopenia asso-
ciated with the causal organism will be found. The
counts obtained from recently inoculated healthy men
would lead to the supposition that the cells which react
to dead typhoid and paratyphoid bacilli may be proved
to be of a different order from those which act upon
living infective typhoidal organisms. These writers are
not yet satisfied that the figures they have obtained
from their paratyphoid examinations are really repre-
sentative. There has been a difference between the
counts yielded by the convalescents from the various
war areas which are more than should arise from errors
of technic or from personal factors. In the cases from
the French area there is a persistence of mononuclear
increase and polynuclear decrease in the paratyphoid A
which is different from those in the Mediterranean area.
The purely typhoid and paratyphoid cases show counts
which differ from those yielded by the typhoid plus pro-
tozoa and the paratyphoid plus protozoa. The para-
typhoid cases from the Mediterranean are approximate
to the mixed type of counts both in their polymuclears
and mononuclears as well as in the eosinophile cells.
There is evidence pointing to the possibility that the
cases in which the leucocyte counts differ materially
from those of French origin may be ascribed to a mixed
infection and put in a class by themselves. It is also
possible that the lack of eosinophilia in the post-para-
typhoidal cases may arise from the coexistence of am-
ebic infection. It has been observed that leucocyte
counts made a few weeks after the injection of a mixed
typhoid-paratyphoid vaccine show a greater number of
eosinophiles than do those obtained after a pure typhoid
inoculation. If the results of these examinations are
confirmed it would establish the contention of the
writers that when clinical diagnosis is not upheld by
serological findings the matter may be cleared up by
timely examination of the total and differential leuco-
cyte contents.
3. Notes on the Vaccination of Guinea-pigs with B.
Perfringens. — Muriel Robertson gives an account of ex-
periments carried out with B. perfringens, from which
the general conclusion may be drawn that previous
vaccination with killed or attenuated cultures of B. per-
734
MEDICAL RECORD.
[Oct. 21, 1916
fringens does not cause any appreciable raising of the
resistance of guinea pigs against a subsequent lethal
dose of living bacilli. Recovery from a previous infec-
tion with the organism does not prevent a reptition of
the illness upon reinoculation with living bacilli, nor
does it apparently in any way alter the symptoms or
influence the course of the disease.
4. Infective Jaundice: A Preliminary Report — N. B.
Gwyn and J. J. Ower have been making a study of this
condition since November, 1915, from which it appears
that typhoid and paratyphoid bacilli can be excluded as
causal agents in these cases. Japanese authors have
described a spirochete in cases of epidemic jaundice,
and the writers have made a search for this kind of an
organism. They describe the method used, and state
that aerobic cultures were negative, but on the fifth day
examination of the material from the deep agar anas-
robic culture on the dark stage showed a few spirochete-
like bodies. Similar bodies were found in the first ex-
amination of another specimen. These presented much
the appearance of the spirochxta pallida, except that
they were usually shorter, coarser, and not so regular
or finely spiral. They were definitely motile, but had
not the rapid spiral movement of S. pallida. In a
Giemsa preparation they were not demonstrable; with
the Fontana a small number were found to take the
silver impregnation readily. The results of animal in-
oculation have thus far been negative, but the essayists
think this may be due to the fact that they have re-
ceived all their cases late in the disease.
6. A Crossed Hip Reflex in Enteric Fever. — E. B.
Gunson writes that the crossed hip reflex has been
noted in cerebral tumor, various cerebrospinal condi-
tions, and in diphtheria. When the quadriceps femoris
muscle is firmly grasped just above the knee between
the thumb and fingers, the patient experiences consider-
able pain referred to the site of stimulation and there
occur flexion at the hip joint and extension of the great
toe of the opposite limb. The reflex may be incomplete
and consist of flexion at the hip only or of flexion at
the hip and contraction of the tensor fascia? femoris
muscle without actual contraction of the great toe;
crossed extension of the great toe without flexion at
he hip occurs in some cases. Pain on stimulation is a
marked feature, and usually persists for several days
after the reflex movements can no longer be elicited.
This reflex has been studied by the author in thirty-
seven cases admitted to the General Hospital, Alexan-
dria, from Gallipoli. The reflex appeared as early as
the second day of the disease, and in one case persisted
into the eighth week; the time, onset, and duration
were vary variable. The reflex bore no absolute rela-
tion to the severity of the disease, but tended to be
more complete and persisted for a longer time in severe
types. The presence of the reflex in enteric fever is
held to signify a temporary perturbation of the spinal
cord, the result of a toxic or inflammatory process, on
which some of the other reflex changes observed in en-
teric fever may also depend, and to which the extreme
weakness of the back and limb muscles may in part be
attributed. The reflex was found to be of some diag-
nostic value, as it was never present in doubtful cases.
British Medical Journal.
September 16, 1916
1. Gas Gangren. as Seen at the Casualty Clearing Stations.
Cuthbert Wallace
2. The Direct Transfusion of Blood: Its Value In Hemorrhage
ana Shock and in the I of the Wounded in
., ™ W,ari, A' Pr"nrose and E. S. Ryerson.
3. Trench Fever : Th- Field Vole a Possible Origin W J
Rutherlord. "
4. A Case of Ulcerating Granuloma Successfully Treated by
Intravenous Injections of Antimony. George C I ow
and H B Newham
it. Lamblia Infections in Alen "Who Have Never Been Out of
England. A. .Malms Smith and J. R. Matthews.
6. A Case of Intrauterine Scarlet Fever. R. M. Liddell and
C. E. Tanyge.
1. Gas Gangrene as Seen at the Casualty Clearing
Stations. — Cuthbert Wallace says that gas gangrene is
still a very striking feature in the surgery of the pres-
ent war. Two very interesting papers have recently
appeared by d'Este Emery and Kenneth Taylor, and if
the two theories of the disease as given by these men
are compared it will be found that they differ mainly
in the part played by the gas. Taylor thinks that it
plays an important part; d'Este Emery denies this,
and believes that the bacteria toxins are the important
factor. Taylor believes that the disease is mainly one
of the muscles; d'Este Emery thinks that this is a mis-
take, and that it is only the fact of the bacteria being
able to produce gas by the aid of the muscle sugar that
leads to this assumption. These two views reflect some-
what different conceptions of the disease, but it seems
probable that both observers have some right on their
sides. The author's own impressions of the disease as
seen at the front and gathered elsewhere may be briefly
stated as follows: (1) It is rare to meet gas gangrene
without a muscle injury. (2) It is chiefly a disease of
the muscles, and is rarely dangerous unless muscle is
involved. (3) The lesion in its early stages may be de-
scribed as a longitudinal one. (4) It is rare to find
all the muscles of a segment of a limb involved, save in
a segment distal to one in which the main blood supply
has been cut off. (5) The muscles affected are in the
first instance the wounded ones. (6) Muscles contained
in rigid compartments, such as the anterior tibial group,
are especially prone to die if wounded. (7) There is
but little tendency for the infection to pass from one
muscle to another. (8) The infection is further ad-
vanced in the muscles than in the intermuscular areo-
lar planes. (9) The muscles become resonant from the
presence of gas long before they become prepitant to
the finger. (10) The presence of gaseous crepitation
does not necessarily mean microbic infection. (11)
Crepitation is usually a comparatively late phenomenon,
and is due to the escape of gas into the areolar and sub-
cutaneous tissue. (12) In an infected limb a vascular
lesion will be followed by the death of the muscle or
muscle group, which death would not have followed in
an uninfected limb. (13) In an infected limb there
are several conditions of the muscles. (14) The micro-
scopical appearances of muscle dead from cutting off
its blood supply are different from those of a muscle
dead from infection. The striation is present in the
former and absent in the latter. (15) The bacteria are
between the muscle fibers and not in them. (16) Micro-
scopical examination suggests that the gas may find its
way between the muscle fibers in front of the bacterial
invasion. (17) In dead infected muscles the fibers are
separated from one another. In the treatment of gas
gangrene the circulation should be helped in every way.
The bad effects of tight bandages must be insisted upon.
In cases in which hemorrhage into a limb is continuing
there is no doubt as to the advisability of finding the
bleeding point. If the artery is a main one an attempt
should be made to suture instead of ligate the vessel.
Suture is worth while trying in a vessel locally throm-
bosed from the effect of trauma. In dealing with gas
gangrene in a wounded segment of a limb and deciding
on the advisability of amputation, it should be borne in
mind that it is usually only the wounded muscles that
become gaseous and that incision or ablation of such
muscles is often sufficient to arrest the disease.
1. A Case of Ulcerating Granuloma Successfully
Treated by Intravenous Injections of Antimony. — George
C. I-ow and H. B. Newman describe this lisease, which
Oct. 21, 1916J
MEDICAL RECORD.
735
they state is a true venereal disease but has nothing to
do with syphilis or the usual venereal diseases. It is
very common in British Guiana, Brazil, and other parts
of South America, and resembles in some ways the
type of change seen in lupus or rodent ulcer. It is be-
lieved to be of protozoal origin. The case which the
authors report was cured by the intravenous injection
of antimony. The first injection consisted in 1 grain
of antimony dissolved in 2 ounces of normal saline in-
jected directly into the vein, the same vein being used
time after time for the different injections. In all,
fifty-three injections were given at intervals of three
or four days. The dose was raised from 1 to 2Vz grains
after the first three weeks. It is suggested that a judi-
cious combination of antimony and the .r-ray would be
worthy of trial and might shorten the length of the
treatment.
5. Lamblia Infections in Men Who Have Never Been
Out of England. — A. Malins Smith and J. R. Matthews
report three cases of Lamblia infection, two of which
certainly and the third almost certainly were contracted
in England. These cases are recorded in view of the
prevalent idea that infections of Lamblia intestinalis
are associated with residence abroad. They were dis-
covered in the routine examination of stools conducted
at the Liverpool School of Tropical Medicine. In com-
menting on these cases the authors observe that it is
almost impossible now and will shortly become quite
impossible to offer any evidence as to whether Lamblia
is indigenous in England. The presence of the very
numerous cases of returned soldiers carrying Lamblia
will make it impossible to state whether any future
case is of native origin.
6. A Case of Intrauterine Scarlet Fever. — R. M. Lid-
dell and C. E. Tangye report the following case as be-
ing unusual. Four of five children in a family, during
a recent outbreak of scarlet fever in a small village,
were removed to an isolation hospital on May 26. On
June 6 the mother was delivered of a child which was
found to be desquammating freely over the whole of
the trunk and limbs, and the urine showed distinct
traces of albumin. These features were so typical that
it was decided to report the case as one of scarlet fever.
The mother is positive that she had a severe attack of
scarlet fever when 10 years of age. It would seem that
the fetus was infected some time prior to May 26, and
that the mother escaped infection through the protec-
tion of her previous attack. Presuming the fetus to
have been infected from the children in the family, the
period elapsing between the infection and the peeling
stage must have been only a fortnight. The writers
quote authorities who raise the question of the possi-
bility of such an occurrence, but hold that while the
rarity of the condition may be somewhat against the
diagnosis, the clinical facts were so striking as to make
them worthy of note.
Le Bulletin Medical.
Septembrr 21, 1916.
Decalcification Consecutive to the Traumatisms of
War. — "J. J." states that while the osteotrophy of acci-
dents to workingmen has been well studied by radiogra-
phy, the forms due to projectile traumatisms have
hardly fixed the attention. However, Surgeon-General
Delorme has just caused to be published a memoire on
this subject. The characteristics of this calcification
are connected solely with the radiograph examination.
This characteristic is the great translucency of the
bones. The articular lines are well preserved, which
evidence is valuable for the exclusion of ostertis. The
short bones are much more prone to suffer than the long
ones. These osteotrophies are of great frequency, but
at present but little is known of the date of superven-
tion, duration, pathogeny, and respective influence of
defective nutrition and innervation. Between ostertis
and ordinary osteoporosis or decalcification there are
these differences: The latter is uniform, while in os-
tertis the changes are irregular. The suppression of
the articular line in ostertis has already been mentioned.
In osteoporosis the trabecular architecture of the bone
is preserved, while in ostertis the reverse is true. For
the treatment of decalcification as a result of firearms,
there are as yet no strict indications. Electricity used
with the»aim of stimulating nervous influence is with-
out benefit. Antisyphilitic remedies given to syphilitic
subjects are also without effect. Recalcification is the
theoretic remedy, and lime salts are being given in-
wardly. Good results are not yet forthcoming.
On the Control of Medical Thermometers. — According
to "J," who is giving a synopsis of a meeting of the
Academy of Medicine, the accuracy of the clinical ther-
mometer leaves much to be desired. The French for-
merly obtained all their supplies from Germany, because
in the latter country they can be made at a price which
defies all competition (they sold at from 0.4 to 0.66
francs a piece). At present the old German supply
has been superseded by goods from Switzerland, Eng-
land, and the United States, sold at a much higher fig-
ure. A committee of the Academy, having been ap-
pointed to investigate this subject, reports that the new
thermometers often lack a guarantee of exactitude,
which makes possible grave errors of diagnosis. There
should be some authorization for official control, so that
the instruments cannot be used unless tested carefully
beforehand. This could be effected completely by en-
couraging a national industry* made possible only by a
special tax which should be lowered to such a degree
that the present selling price should be but slightly ad-
vanced. The control should be carried out through ac-
tivities of the Conservatoire des Arts et Metiers.
La Presse Medicale.
S( i'i: mhi r 14, 1916.
Wide Primary Subperiosteal "Esquillectomie" in the
Treatment of Fractures by Artillery Projectiles. — The
word esquillectomie, which has come into extensive use
during the present war, has no exact equivalent in Eng-
lish. In the older treatment of splintered fractures
every effort was made to save fragments of bone and
allow them to heal in, even often to nail or wire them
in. While the word "esquille" is equivalent in English
to splinter, the latter suggests a small, pointed frag-
ment, while in "esquille" in the present sense there is
no limit as to size. Since in military injuries detached
fragments of bone may soon become necrotic, the opera-
tion of removing them might be regarded as akin to
sequestrotomy. Leriche writes at length on the evil
influence exerted by small splinters of bone revealed
only by radiography. These are very irritating and
may arouse a latent infection. To remove them is
therefore a step in prophylaxis. The author reports
fourteen fractures of the diaphyses of the bones of the
forearm and leg. The radiograph revealed the pres-
ence of detached fragments which would surely have
become necrotic. In a number of cases these pieces of
bone were removed as foreign bodies, covered with dirt
or shreds of clothing. In the main, however, under local
anesthesia (ethyl chloride) suppuration had begun and
the author, with much pains, removed all detached
fragments. The suppuration could have been prevented
had the fragments been removed at the first dressing.
The removal of large fragments, as in the tibia and
736
MEDICAL RECORD.
[Oct. 21, 191G
femur, was effected by the subperiosteal route. In-
stead of becoming infected the broken bones under ra-
diographic control could be seen to unite tolerably well
under callus formation. Conservative surgeons fear va-
rious kinds of mischief, and especially pseudarthrosis,
but the author's results show that this fear is unfound-
ed. The same is true of the dangers of ostertis. The
residual periosteum does much to enhance union. Le-
riche would establish a rule to use this operation in all
fractures of artillery origin, in the interest of normal,
aseptic healing.
Dysentery and Dysenteriform Diarrhea. — Gh-oux
states that of 150 cases of diarrhea treated by him, 40
were of the familiar type, 117 were examples of so-
called dysenteriform diarrhea, while 3 were choleri-
form. But 5 cases ended fatally. In the dysenteri-
form column, convalescence was always announced by
a urinary crisis — a profuse diuresis after a period of
scanty prine. An associated phenomenon was brady-
cardia. In 3 patients the dysenteriform type was asso-
ciated with paratyphoid. Both kinds of bacilli
were present (dysentery, paratyphoid B.) In the
other cases the B. dysenterix could not be detected.
The first case ended fatally. In regard to treatment,
serum is given only when the dysentery bacillus is
present or the clinical syndrome perfect. But this
serum often seems defective in the most typical cases
of dysentery. Under such circumstances we can only
give emetine, which, generally speaking, gives prompt
and good results. In other words, the dysentery is
essentially anieboid, with occasional coincidence of the
bacillus of bacillary dysentery.
Journal de Medecine de Bordeaux.
September, 1916.
Iodine and Gas Asphyxiation. — Boudreau is a partisan
of iodine in the treatment of many infections — fevers,
infectious enterities, etc. He has been testing it with
truly remarkable results on victims of gas asphyxiation
He had long regarded the drug as the heroic remedy
for pulmonary affections, including tuberculosis.
Lesions from gases comprise bronchitis, congestion of
the lungs and bronchopneumonia, in association with'
failure of the general health. Iodine exerts a salutary
action on all these lesions, and the sequela; which they
furnish, and tends to prevent the evolution of tubercu-
losis. The author believes that iodine can to a certain
extent conserve some of the living tissues which would
otherwise soon be sacrificed to disease. The drug also
possesses antitoxic powers which combat the toxic
blood states induced by these gases. Thus it can prevent
the secondary eye changes. The author would treat a case
of gas poisoning just as he would a case of pulmonary
tuberculosis; and such treatment should be both pro-
gressive and intensive. The tincture should be given in
any fluid vehicle — milk, for example. It may even be
placed in any drink which the patient uses — even beer.
The initial dose is very small — a drop or two in each
glass or cup of fluid taken. The dose on the second
day should not exceed 2 drops, the next day 3, and so
on. The number of doses should reach 6 to S daily.
There is no maximum. Some of the author's consump-
tives have consumed as much as 600 drops of the tinc-
ture in 24 hours, and over 60 drops may be taken as
a dose. This medication may be maintained for months.
Hemoptysis is no contraindication. The main aim of
the author appears to be to secure a general trial of
iodine therapy in victims of gas poisoning, based on
his personal experience. Results of others are not
mentioned.
Cancer of the Vertebra.— "J. R." gives an abstract of
a valuable study on this subject by Montanaro of
Argentina. Three cases are reported in great detail
with superb illustrations. In all cases the growths
were intrinsic. The first symptons were very painful
radicular neuralgia. These were aggravated by heat
or cold, were boring or lancinating, and were worse
at night; often they were so severe as to prevent walk-
ing. Radiography revealed nothing precise. Study of
lumbal punctates had indicated hyperalbuminosis and
hyperleucocytosis. Other symptoms were those common
to cord compression (paraplegia, atrophy, abolition of
reflexes, troubles of urination).
Thymic Disturbance in the Adult. — George H. Hoxie
relates the history of a number of cases in which
the condition had been diagnosed as neurasthenia or
myasthenia. This group of cases has in common en-
largement of the thymus, shortness of breath and ex-
treme weakness, but shows no gross pathological
changes. Variability of the pulse and blood pressure,
subnormal temperature, and atony of the gastroin-
testinal tract, in patients showing no evidence of or-
ganic disease, are additional symptoms pointing to the
endocrine disfunction. The dulness is usually noticed
when percussing the manubrium sterni. If the dull
area extends out a half inch or more on either side of
the manubrium, and if the manubrium is duller than
the corpus, one should proceed with differential tests.
Gentle percussion rather than the stronger type is nec-
essary to bring out a body so closely adherent to the
posterior surface of the bone. Under such ordinary
percussion the dull area is that of a triangle with its
base just below the interclavicular notch and its apex
between the junctions with the sternum of the second
and third ribs. The aortic dulness does not reach as
high as the center of this area and does not lie as
symmetrically under the sternum. An intrathoracic
thyroid might give a similar dull area, but this could
usually be found to extend above the interclavicular
notch and move with the act of swallowing. Aneurysms
of a size sufficient to cause substernal dulness would
give also a thrill of pulsation. The fluoroscope should
be used to verify all cases in which the percussion
would indicate thymic enlargement. In making this
examination, when one sees a mass in the sternum,
one should keep in mind the questions: "Does it have
a movement of its own? Does it have a definite form
through which the bones are seen more indistinctly?"
The treatment of the condition demands rest and forced
feeding, with attention to the emunctories and the en-
vironment. The medical treatment calls first for the
use of arsenic in heavy doses. It would seem as if the
thyroid gland furnished the best material to permit the
thymus to sink back into quiet. This the author has
worked out by trying the various glandular extracts.
He says one would suppose that the adrenal extracts
were of particular value, but thus far this has not been
clinically verified. — N< w 1 ork Medical Journal.
Acute Abdomen Following Trauma. — G. B. Kunkel
summarizes his article as follows: Do not hold lightly
any trauma of the abdomen, but watch carefully and
treat expectantly. Do not wait for a patient to bleed
to death. If a hollow organ is suspected to be per-
forated, operate at once. Operation delayed over
eighteen hours in a case of perforation gives a very
grave prognosis. Purgatives have no place in an acute
abdomen. Let the severe pain, tenderness and rigidity
be the red flags to place you on guard and guide you
to a happy issue in the recovery of the case. Do not
forget that a delay of twelve hours in perforation can
place the balance against vour patient. Do not mask
symptoms by morphine. Diagnose speedily. — Tnterna-
' !,->mial of Surgery.
Oct. 21, 1916J
MEDICAL RECORD.
737
3Jnstirattr? JHtfiiriu*.
Association of Life Insurance Medical Directors.
— The twenty-seventh annual meeting of this As-
sociation will be held in New York on Wednesday
and Thursday, October 25 and 26, 1916. The fol-
lowing papers will be presented: Address by the
president, Dr. Franklin C. Wells, on "The Func-
tions and Scope of the Medical Department"; "Con-
servation Work and Life Insurance," by Dr. Thom-
as H. Willard; "Life Expectancy Following Opera-
tion on the Gail-Bladder," by Dr. Charles H. Mayo;
"The Need in Medical Selection of Standards by
which to Measure Borderline Risks," by Arthur
Hunter, Esq., and Dr. Oscar H. Rogers; "The Best
Way to Obtain Better and More Careful Medical
Selection from the Examiner in the Field," by Dr.
William R. Ward; "The Best Way to Get an Ex-
aminer to Use the Sphygmomanometer," by Dr.
P. E. Tiemann; "Urine Examinations," by Dr.
David N. Blakely; "The Importance of Glycosuria
in Life Insurance," by Dr. J. Allen Patton ; "Se-
lection of Women," by Dr. T. H. Rockwell; "The
Heart Beat and Its Irregularities," by Dr. Laurence
D. Chapin.
Relative Frequency with Which Obesity Is
Found Associated with Different Diseases. — In a
paper read before the Assurance Medical Society
in London Dr. F. Parkes Webber discussed this
question. Among the most recent statistical data
bearing on the point are the following:
During the years 1913 and 1914 an Italian as-
surance company, Istituto Nazionale delle Assi-
curazioni, rejected 308 obese candidates. In 36.38
per cent, the obesity was apparently without com-
plications; in 21.75 per cent, it was associated
with glycosuria; in 10.38 per cent, it was asso-
ciated with nephritis; in 7.18 per cent, it was as-
sociated with albuminuria; in 5.84 per cent, it was
associated with heart trouble; in 5.19 per cent it
was associated with arteriosclerosis; in the re-
maining cases there were various complications,
such as syphilis, alcoholism, bronchial catarrh,
etc. (I. Romanelli, II Policlinico, August 8, 1915.)
The following statistical table was obtained from
the Life Assurance Data of the "Viktoria" office in
Berlin: (Bruno Moses, "Die Fettleibigkeit in ihrer
Beziehung sur Lebensdauer und Todesursache,"
Berlin, 1906, p. 23.)
In All Assured Per-
sons, Per Cen-t.
Cause of Death.
During the
Three Years
1900-1902.
During the
Three Years
1903-190.5.
Corpulent,
Per Cent.
Acvite diseases of the respiratory organs. . . .
Chronic diseases of the respiratory organs
(pulmonary tuberculosis |
Diseases of the heart
Diseases of the kidneys . . .
Apoplexy ....
Diseases of the liver . .
Diseases of the blood .
Alcoholism
:-es (erysipelas^
11
17
13
'9"
Not given
Not given
0.8
1.5
5
12
14
14
•
9
8.3
2 1
1
1
1
11 1
5.4
18.9
-
9 8
4.4
1.5
(i 2
3 9
The following table shows the percentage of
deaths among 26,222 dying from all causes, classed
as overweights and underweights (i. e. 20 per
cent, variation from normal). It is from the ex-
perience of the Connecticut Mutual Life Insurance
Company, 1846 to 1895, inclusive, quoted from
Shepherd in Green's "Medical Examiner."
Cause of Death.
Underweight ' Per
Cent, of Deaths).
Overweight (Per
Cent, of Deaths.)
22.0
1 1
0 0
14 0
6.0
7.8
1 9
2.2
3.5
23.0
15.5
17 9
12.0 fi 5
16 4
7 5
5.2
9.0
8.5
9.7
G. M. Low, in an article on "Extra Rating as a
Statistical Problem," quoted by Greene, gives the
following table showing the number of actual and
expected deaths among obese persons :
Cause of Death.
Actual
Deaths
(Stout
Persons).
Expected
(Healthy
Males).
Percentage
of Actual
to
Expected.
0
14
10
12
16
1
8
3
0
4
3
S
7
9
14
3
10
4
8
2
200
175
143
133
Diseases of the brain and nervous Bya I em
114
33
80
75
0
200
The following table of causes of death in regard to
fatness or leanness of the assured is from Arthur
Hesse, "7066 Todesfalle der Basler Lebens-
Versicherungs-Gesellschaft," Leipzig, 1899:
General Nutrition When Accepteo for Life Assurance
Cause of Death.
Lean.
Mkdium.
CoRPfLENT.
Total.
Per
Cent.
Total.
Per
Cent.
Total.
Per
Cent.
48
106
389
82
57
17
69
66
46
43
33
13
6
3
9
22
46
43
15.64
16.56
23.61
17.71
17.33
18.77
11.79
11 05
12.07
8.81
12.36
11 93
\l N'.l
2.03
7.09
14.3S
19.49
11.20
179
391
1,077
291
201
52
322
246
217
249
136
61
24
40
57
104
131
186
58.31
61.10
65.35
62.85
61.09
60.46
55.05
57.61
56.96
51.03
50.94
55.96
36 36
27 ns
44 ss
67.97
55.51
48.44
80
1.43
182
90
71
17
194
121
118
196
98
35
36
105
61
27
59
S3
26 05
22.34
11 04
19.44
21.58
19.77
Diseases of the circulatory organs
Diseases of the digestive organs . .
Diseases of the nervous Bysted
33.16
28.34
30.97
40.16
36.70
32.11
54.55
70.94
48 03
17 65
Miscellaneous and uncertain
25 00
21.61
Total ...
1.092
16.13
3,964
58.53
1,716
25 34
E. H. Kisch, writing on "Fettsucht," in "Eulen-
burg's Real-Encyclopadie der gesammten Heilkunde,"
Vienna, 1895, says that in 19 necropsies on corpulent
persons who had died suddenly the causes of death
were found to be acute edema of the lungs in 12
cases, cerebral hemorrhage in 6 cases, and rupture
of the heart in 1 case. In autopsies on corpulent per-
sons whose death was not sudden, Kisch found that
in nearly two-thirds of the cases of fatty heart,
cardiac hypertrophy and dilatation were likewise
present; in many cases, sometimes in relatively
young individuals, arteriosclerosis was associated
with fatty heart. One-third of the subjects died
from cerebral hemorrhage. In nearly all the cases
there was some pathological change in the kid-
neys, varying from passive congestion to granular
atrophy. In half the cases there was fatty liver.
738
MEDICAL RECORD.
[Oct. 21, 1916
Hook j&tvievaB.
Muscle Training in the Treatment of Infantile
Paralysis. By Wilhelmine G. Wright, Boston
Normal School of Gymnastics, 1905; Chirurg.-ortho-
pad. Klinik of Prof. Dr. A. Hoffa, Berlin, 1908; As-
sistant to Robert W. Lovett, M.D., Boston. Second
edition. Price, 25 cents. Boston : Ernest Gregory.
1916.
This is a very practical and timely treatise on the
reconstructive treatment of the paralysis following
poliomyelitis. Dr. Lovett is one of the recognized
authorities on the after treatment of this malady, and
Miss Wright's methods have been developed in accord-
ance with his teachings and are the result of her ex-
perience during many years of association with him in
orthopedic work. The little book cannot fail to be help-
ful to every physician who is called upon to advise in
the case of a victim of this crippling disease.
Surgical Nursing and Technique. A Book for
Nurses, Dressers, House Surgeons, etc. By Charles
P. Childe, B.A., F.R.C.S. Eng. Lieut-Col. Royal
Army Medical Corps (Territorial), Senior Surgeon,
Royal Portsmouth Hospital, Medical Officers in
Charge of the Surgical Division, 5th Southern Gen-
eral Hospital, Portsmouth. Price, $2.00 net. New
York: William Wood and Company, 1916.
In Surgical Nursing Mr. Childe has produced an ex-
tremely useful manual. The first edition was issued
under the title of "Operative Nursing and Technique"
and proved very popular. It deals wholly with operative
nursing and is mainly intended for the large class of
Sisters and nurses who find themselves saddled with
the great and interesting responsibilities of modern
operative nursing, either in hospitals or private homes
or houses. The second edition has been brought thor-
oughly up to date and contains a chapter on nursing in
military hospitals. The book may be strongly recom-
mended to nurses as a practical and clear exposition of
their surgical duties.
On Modern Methods of Treating Fractures. By
Ernest W. Hey Groves, M.S., M.D., B.Sc. (Lond.),
F.R.C.S. (Eng.); Surgeon to the Bristol General
Hospital ; Consulting Surgeon to the Cossham Hos-
pital; Late Hunterian Professor of the Royal Col-
lege of Surgeons of England; Major R.A.M.C. in
charge of the Surgical Division of the 21st General
Hospital, British Expeditionary Force. Octavo of 286
pages with 136 illustrations. Price, $2.75 net. New
York: William Wood and Company, 1916.
This is a book of much scientific interest. The handling
of the subject is for the most part along general lines
and about one-third of the text is concerned with the
description of the author's experimental work on
animals and the deductions, comments and conclusions
based thereon. The author has aimed "to show that the
various methods of treatment should all be brought into
our service as occasion requires, instead of being re-
garded as independent, rival, or mutually destructive
systems; and, secondly, to emphasize the necessity for
mechanical accuracy and efficiency in dealing with what
after all is largely a mechanical problem."
In the introductory chapter entitled : "The myths of
yesterday and the problems of today," Groves suggests
that in comparison with the development in other fields
of surgery the treatment of fractures has lagged be-
hind; and that the common practice of today is prob-
ably more like that of a thousand years ago in this de-
partment than in any other. He pays a tribute to
Bardenhcuer, Lucas-Championniere, and Lane, who
have been pioneers in getting us away from what he
calls the methods of medieval surgery in the case of
broken bones. Among the myths is the idea that the
average fracture is "set" in the sense that the frag-
ments are placed in accurate apposition and alignment
when we speak of "setting" the bone. The x-ray has
shown that old ideas on this point needed to be revised.
Other so-called "principles" in the classical treatment
of fractures by immobilization come in for ridicule or
caustic criticism.
After discussing the relation of the .r-ray to the
treatment of fractures, the relation between form and
function, and other matters, he proceeds to the discus-
sion of fracture treatment under present day conditions.
The new methods are grouped under three main
divisions and several sub-divisions. The main divisions
are; I. Methods of Massage and Mobilization; II. Ex-
tension Methods; III. Operation Methods. These latter
involve the exposure of the seat of fracture, the direct
reduction of the deformity, and fixation by wire, plates,
screws, pegs, or grafts. Each method is discussed in
detail and one gets a good general idea of their uses
and limitations, the one remarkable exception being
that almost no space is devoted to the consideration of
the value and technique of applying the bone graft, a
method that, in this country at least, has been used
extensively and bids fair to supersede many of the oper-
ative methods to whose consideration Groves devotes
a considerable portion of his book. There are many
suggestions of great value to the skilled surgeon and
many of the devices which Groves has originated or
adapted are worthy of general adoption in properly
selected cases and should be beter known.
While, as we have intimated, this is a book that will
appeal especially to the operating surgeon who is inter-
ested in the scientific aspects of the subject, there is
much that will also appeal to the general practitioner;
and none can fail to have a better appreciation of the
problems of fracture treatment after reading it.
Gynecology. By William P. Graves, A.B., M.D.,
F.A.C.S., Professor of Gynecology at Harvard Medi-
cal School; Surgeon-in-chief to the Free Hospital
for Women, Brookline; Consulting Physician to the
Boston Lyin-in Hospital. Large octavo of 770
pages, with 303 half-tone and pen drawings by the
author and 122 microscopic drawings by Margaret
Concree and Ruth Huestis, with 66 of the illustra-
tions in colors. Price, cloth, $7.00 net. Philadelphia
and London: W. B. Saunders Company, 1916.
In writing the work the author had in view its use
both as a text-book and as a work of reference. This is
not always a happy combination because the needs of
the undergraduate and the practitioner are generally
so dissimilar; but because of the division of the work
into three parts, each more or less independent of the
others, the reader of one class who is looking up a sub-
ject is not obliged to read what is intended for the
other. This will be better understood when we state
that Part I, of 135 pages, deals with the physiology of '
the pelvic organs and the relationship of gynecology
to the general organism; Part II, of 375 pages, "is
designated primarily for the undergraduate student who
is taking his initial course in gynecology," and includes
a description of those diseases that are essentially
gynecological; while Part III, of 225 pages, is devoted
exclusively to the technique of gynecological surgery.
In each section the subject matter is taken up in
logical fashion and the various subdivisions in the dis-
cussion of any particular subject are made at once ap-
parent to the reader by the judicious employment of
various sizes of heavy-faced type. As far as possible
the author has omitted extended textual descriptions
when the points in question could be as well or better
shown by illustrations with appropriate legends. This
applies especially to the microscopic appearances of
normal and pathological tissues and to the section de-
voted To operative technique.
The Dream Problem, by Dr. A. E. Maeder, of Zurich.
Authorized translation by Drs. Frank Mead Hal-
lock and Smith Ely' Jelliffe, of New York. Price,
80 cents net. New York: The Nervous and Mental
Disease Publishing Co., 1916.
This little book presents another view-point of the
dream problem. Freud looks upon the dream as the
representation of an unfulfilled wish and lays stress
upon the activities of the repressing mechanism which
he calls the endo-psychic censor. Stekel sees bisexuality
in every dream and also thinks that the thought of
death appears somewhere in it. Adler sees in the
dream an abstracting, simplifying endeavor to find a
protective way for the ego-consciousness out of a situ-
ation which thi^atcns a defeat. Dr. Maeder, however,
sees in the dream a possible solution of the problem con-
fronting the individual and therefore ascribes a con-
structive role to it. He attaches a greater importance
to the manifest dream content than Freud does. The
dream, he says, is perhaps the primitive work of art.
It is prospective as well as retrospective and points the
road for the patient to follow. It has a preparatory
arranging function belonging to the work of adjust-
ment. This preparing function is Maeder's contribu-
tion to the study of dreams and has been severely criti-
cized, especially by the Vienna school. The transla-
tion reads very smoothly which is always a triumph in
an English rendition of German psychoanalytic mate-
rial. Like all the works in this monograph series, this
book is published with paper covers which makes it
necessary to rebind if it is to see much use.
Oct. 21, 1916]
MEDICAL RECORD.
739
j^nmtij Exports.
NEW YORK ACADEMY OF MEDICINE.
Stated Meeting, Held October 5, 1916.
THE PRESIDENT, DR. WALTER B. JAMES, IN THE CHAIR.
The Management of Poliomyelitis with a View to Min-
imizing the Ultimate Disability. — Dr. Robert W. Lovett
of Boston presented this paper. (See page 705.)
Dr. Simon Flexner said that the subject of Dr.
Lovett's most excellent paper was one that should
properly be discussed not by a pathologist, but by an
orthopedic surgeon, from the point of view presented,
though it was a pleasure to him to be asked to
open the discussion because he had followed with
interest the work of Dr. Lovett in Boston and in Ver-
mont in which he had carried into effect principles and
methods of after-care of the paralyzed which appeared
to be an improvement over older methods of treatment.
Dr. Lovett had based his views on the pathology of the
disease which was the logical way to approach the sub-
ject; and he had done the speaker the honor to employ
in his description conceptions and explanations which
the latter's studies had been responsible for. The basis
of the modern conception of poliomyelitis was that it
was an infectious disease in which the paralysis was
merely an incident and an accident and by no means a
necessary part. The percentage of cases in which
paralysis occurred was not yet established, but it was
probably much lower than had been previously believed.
Had the pathology of the disease been worked out origi-
nally in artificially infected animals, this confusion
would never have occurred. Nevertheless, Wickman
had discovered clinical types of the affection in which
paralysis never occurred. But experiments on animals
and the employment of lumbar puncture both showed
that, whether or not paralysis occurred, changes took
place in the cerebrospinal membranes and fluid which
indicated implication of the meninges in the patholog-
ical process. In many cases no invasion of the sub-
stance of the brain and spinal cord occurred. When
invasion did take place, it was through the lymphatic
structures about the blood-vessels which became in-
filtrated with cells — usually of lymphoid type. In a
proportion of cases the process went on further than
this; but it was common that when so much involvement
had arisen, actual infiltrations occurred in the nervous
tissues — the grey matter of the cord especially but also
the white matter in far less degree and not only the
anterior grey matter of the cord, but the posterior also
and the intervertebral ganglia which were among the
earliest structures to show lesions. The infiltrative
process damaged the nervous tissues and thus interfered
with function in two main ways: the cellular invasion
of the sheath of the blood-vessels obstructed the lumen
and reduced the flow of blood; the cellular and fluid
exudate pressed on the nerve cells and fibers. In this
way alone disturbance of function leading to paralysis
of muscle groups might be produced. This class of
pathological changes was subject to complete reversion.
Once the infectious process was arrested, as it was by
the developing immunity principles, resolution of the
exudate occurred and function was restored. This
change was noted clinically quite frequently in cases in
which paralysis of members disappeared in a few days
or weeks. But another severer lesion might occur.
The virus of the disease might attack and severelv in-
jure or actually destroy nerve cells. When the cells of
the anterior horn were thus injured and became neu-
ritic, they were quickly invaded by phagocytes which
brought about their disintegration. This process was
not reversible; its effects were therefore permanent.
Commonly the two classes of changes were united in
one person, so that partial, but not complete recovery
of function took place. The muscles presided over by
the lost nerve cells were, of course, for the time being
paralyzed. The theory on which Dr. Lovett was pro-
ceeding in this instance was to reeducate the nervous
system in such a manner as to open new paths along
which impulses might pass from the brain to the
muscles. On account of the many connections between
neurons, there would not seem to be anything anatom-
ically impossible involved in the concept. The proof
must lie in the results achieved by the educative meth-
ods which he described. In concluding, Dr. Flexner
called attention to the fact that the pathological
processes, being what they were, tended to reversion.
Hence recovery was the outcome to be looked for and
expected, its extent being determined by the degree of
the reversionary process to which the paralysis was
due. Hence any form of treatment not distinctly pre-
judicial would be followed inevitably by some improve-
• ment. This improvement tended to occur during the
early weeks or months following the attack; the para-
lytic residue, after this process was exhausted, was
that attributable to severer injury or destruction of
nerve cells. The restoration of this further loss of
function, when it was accomplished, might be the re-
sult of the reeducative methods which had been de-
scribed.
Dr. Edward C. Rosenow said that Drs. E. B. Towns,
G. W. Wheeler, and himself had studied the present epi-
demic, both in Rochester, Minn., and here in New York
at the New York Hospital, from the standpoint of the
elective localization of bacteria from the tonsils and
throat and from lesions in the central nervous system.
The technique used was similar to that employed by him
in studies on the elective localization of bacteria in vari-
ous other diseases, including diseases of the nervous sys-
tem. They had found in the tonsils, especially in pa-
tients over three or four years of age, a surprisingly
large amount of infective material, though these pa-
tients showed none of the subjective or objective signs
of tonsillitis. In all of seventeen cases in which the ton-
sils were removed after death and carefully sectioned
there were found from one to fifteen abscesses, usually
at the base along the capsule, but not communicating
with the surface. They contained a peculiar opalescent
material containing large and small mononuclear cells,
polymorphonuclear leucocytes, and often large numbers
of diploeocci of the usual size; occasionally there were
some small forms, fusiform bacilli and micrococci. Ade-
noids removed from four patients at autopsy showed
similar abscesses. The ages of these patients ranged
from seven months to twenty-four years. Owing to the
presence of large numbers, and often in almost pure
form, of a streptococcus which produced paralysis in an-
imals, rabbits, guinea-pigs, dogs, cats, and monkeys,
and to the low virulence of the bacterial flora in these
patients, they felt with Dr. Roper that tonsillectomy was
justified in those patients in whom there was persistence
of fever, irritability, lack of appetite, and little or no
improvement in the paralysis, or those in whom the pa-
ralysis was slowly extending. This had been done under
light anesthesia in eleven cases, and in no instance was
there any sign of acute tonsillitis. In most of them a
large amount of pus and cryptic material was found dut-
ing the tonsillectomy. Numerous cross-sections of the
extirpated tonsils revealed pockets similar to those
found in the tonsils in the fatal cases, but which were
smaller and fewer in number. None of the patients were
made worse by the operation; indeed, most of them
showed improvement soon after the tonsillectomy, and
in several instances the results were strikingly favor-
able. In the light of these facts it was possible that un-
recognized foci in the lymphoid tissue of the throat were
an important factor in determining the severity of the
initial paralysis and especially in preventing the usual
early improvement. The localized foci probably afford-
ed the entrance way of the organisms having an elective
affinity for the central nervous system. The number of
cases in which tonsillectomy was performed were, of
course, too few to warrant the drawing of positive con-
clusions, but they were highly suggestive. The experi-
ment had proved, however, the presence in the throat,
in the tonsils, and in the central nervous system, in epi-
demic poliomyelitis of a peculiar streptococcus which
produced in animals a flaccid paralysis similar to that
observed in patients afflicted with poliomyelitis.
Dr. Frederick Tilney said they were greatly in-
debted to Dr. Lovett for showing them what could be
done in the after-care of this disease. There were cer-
tain details which interested him particularly. It was
well known that there was a focus of intensity of inflam-
matory activity in the central nervous system, and that
this determined the degree of paralysis. They had no
means at the present time of combating the inflamma-
tory process in this focus in the acute stage of the dis-
ease. It might be that serum did some good, and expe-
rience seemed to show that it was of some benefit in the
preparalytic stage and in the ascending, bulbar, and
meningitic types of the disease. The first thing was to
determine where the focus of inflammation had been in
order that the muscles most affected might receive at-
tention. With electric reactions this might be shown
best, and the electric reaction should be taken at the out-
set in every case since it was not only important in di-
740
MEDICAL RECORD.
[Oct. 21, 1916
agnosis and prognosis but equally so in treatment. Some
said that active treatment should begin when acute
symptoms disappeared; others that it should begin six
or eight weeks after the onset. The disappearance of
tenderness was the best guide as to the time when it was
advisable to institute treatment. This might occur by
the end of the fourth week, but if tenderness still per-
sisted treatment should be deferred. The usual forms
of treatment (immediate after-care, not surgical treat-
ment) were exercise, electricity, massage, and support.
Electricity seemed to have fallen into disrepute because
some had obtained poor results, but it should be remem-
bered that in many instances electricity had been applied
unscientifically; sometimes but one battery had been
used at home by the patient. The faradic current should
not be used, for it was absolutely of no use in the case of
profoundly paralyzed muscles and it partially tetanized
paralyzed muscles, which was exceedingly fatiguing.
The most beneficial type of current was the sinusoidal,
and this could be used to advantage provided certain de-
tails were observed. It should not be applied unless the
limb was first massaged and heated by means either of
a hot pack or the calorescent lamp; otherwise the con-
traction of the muscles caused by the electricity was
painful. At the end of three or four weeks one could
begin to give warm baths to which a considerable
amount of salt had been added. While the patient was
in the bath voluntary movements might be attempted
which would be assisted by the buoyancy of the salt wa-
ter. Efforts directed toward the reeducation of the
muscles might be begun as soon as the patient could get
up and about; this was usually about the fifth week.
There should be individualization in the muscle reeduca-
tion and the treatment should be carried out at stated
intervals every day for a long time. Braces, splints,
plaster casts, etc., carefully and properly applied, were
indicated when a limb was in malposition or when a pa-
ralyzed muscle was unduly stretched, and this treatment
should in every instance be combined with the use of
electricity, massage, etc. These various means consti-
tuted the type of treatment that every case was entitled
to, and without such a combination of treatment and its
persistent application for a long period of time no child
could be said to have had a full opportunity for com-
pletely normal restoration.
Dr. Charlton Wallace said the medical profession
owed much to Dr. Flexner and his associates for what
had been taught them regarding poliomyelitis. All who
had children had been afflicted during the past few
rnonths with hysteria because of this disease which they
did not know how to control. He had nothing to say
about the pathology and histology of the disease, but
would confine his remarks to the treatment. Each case
of poliomyelitis presented its own problem and was an
individual study. A prerequisite for the proper care of
these cases was a knowledge of muscular anatomy and
mechanism. It was well to beware of those who were
not properly trained in anatomy and the mechanism of
the muscles. Treatment was to be considered when the
acute stage stopped, but there was no telling how long
the acute stage might last; it lasted as long as the acute
inflammatory process in the spinal canal continued, and
this was as long as there existed any tenderness in the
joints. There should be no treatment during the acute
stage, unless to prevent toe drop, except the serum
treatment. After the acute stage orthopedic treatment
should be instituted. Dr. Wallace said that some cases
had come under his observation in which the tenderness
persisted for three or four months, and in these cases
the patient should be kept in bed. A bed suitable for a
patient with paralysis of the shoulders and back muscles
should have no springs, but should consist of a mattress
on a wooden platform, so that there should be no sag-
ging, the aim being to keep the body as well as the ex-
t remit ies in a horizontal plane. It was important that or-
thopedic treatment be supplemented bv general hygienic
care, and this was the duty of the "family physician.
If anything was to be said about braces it would be to
disagree with what had been said, for in his opinion no
patient having had poliomyelitis should be allowed to go
about without braces. The brace was to prevent deform-
ity and to avoid the stretching of weak muscles and so
that the pull of strong muscles would not produce con-
tractures. Walking should be encouraged as soon as the
patient could stand and get about, as it trained the
muscles to functionate again. Dr. Wallace said thev
owed something to Dr. Teschner for an article published
in the Annala of Surgery of November, 1899, in which
he advised muscle training, but warned that it would
not cure a patient, but was simply an aid toward resto-
ration of power. In some cases coming under his expe-
rience in which muscle training had been employed and
parents had been led to believe it would do all the work,
the deformity which resulted had been the greatest he
had ever seen; there had been the most severe lateral
curvature after this treatment. Therefore if one used
muscle training it must be done with the greatest care
and caution and support should be used where it was
needed. One should take advantage of every aid that
could be used in treating these patients without permit-
ting oneself to be misled in regard to anything. Opera-
tive treatment should not be undertaken until four or
five years had passed except to correct contractures and
deformities. Where there was a dangling foot it might
perhaps be operated on in from two to two and one-half
years after the onset of the disease. The removal of the
astralagus and the displacement backward of the foot,
combined with the transplantation of active tendons,
was the procedure used in this condition. Several cases
coming under his observation had been helped by com-
paratively early operation; they were less troubled by
cold and frostbite in the winter. Frostbite which had
occurred before the operation did not recur the winter
following the operation. In patients who seemed to have
no calf muscle at all he had seen the calf muscle develop
under treatment. With proper braces, proper care, and
persistent treatment one might get improvement if one
was patient and could control the parents and persuade
them to wait and watch.
Dr. Godfrey R. Pisek said he begged to disagree.
with Dr. Lovett in his statement that he was presenting
nothing new this evening. We must acknowledge that
his scientific method of muscle testing would add valu-
able facts to our conceptions of poliomyelitis and place
the treatment on a more rational basis. Dr. Lovett
brought a glad note of optimism — an optimism based on
results obtained and recorded. As one of the jury listen-
ing to his statistics Dr. Pisek said he would vote that
Dr. Lovett had proved his ease. Dr. Wallace had dis-
cussed this paper from the orthopedic standpoint; he
wished to take this opportunity to say a few words on the
duty of the pediatrist. The pediatrist was mainly con-
cerned with the acute and convalescent stages, and it
would seem that upon him devolved the task of sifting
out the large mass of data gathered during this epi-
demic, particularly from the clinical standpoint; estab-
lishing, if possible, a symptomatology for the acute
stage. Seventy per cent, of the cases were easy to diag-
nose; the other 30 per cent, were not so readily diagnos-
ticated, while the so-called abortive or nonparalytic
types were baffling in the extreme. Another duty that
was before thern was the analysis of the great number
of cases observed in the city, so that they might have a
rational basis for their treatment. The laboratories
were at work and some were offering new etiological
factors that certainly opened up new avenues of thought.
The serum treatment, except in the very early hours of
the disease, had lost the support of those who used it
with great hope and who had the largest opportunity to
watch its effects. Dr. Roper reported for the New York
Hospital Annex that there were no drugs whatever used,
nursing care only being employed (except in one case of
serum treatment), and yet in this hospital the mortality
was lower than that reported for the city. The specific
treatment must wait upon the pathologists and epidemi-
ologists, but meanwhile the management must be worked
out in relation to the pathological processes of repair
and absorption which took place even after the infection
had occurred. Emphasis should be placed upon the coun-
sel of the essayist- — precision, efficiency, and persistence
in the treatment. The public, owing to the courageous
stand of the Health Commissioner, had been awakened
to their responsibilities. The orthopedic institutions of
the city would not have room efficiently to care for the
large number of cases discharged from the hospitals.
The ordinary dispensary was not fitted or qualified to do
so. There was need for immediate action on the part of
the Association of Outdoor Clinics to the end that a uni-
form standard of equipment might be established, that
follow-up work be enforced so that the patient might be
constantly encouraged, and the necessarily long course
of treatment, as Dr. Lovett had so admirably shown,
might be persisted in, restoring to usefulness many who
would otherwise remain crippled for life.
Dr. Foster Kennedy said that there was nothing
that had not been said better than he could say it. Dr.
Lovett spoke of the attitude of the neurologist and of
balancing the advantages of the brace and electricity.
There could never be an even balance, because elec-
tricity at its worst was not much more harmful than an
Oct. 21, 1916]
MHDICAL RECORD.
741
incantation while braces could be destructive. Neurol-
ogists for years had striven against the splinting of
palsied legs. If a rigid apparatus was placed on a
muscle that already had a damaged innervation it made
that muscle more atrophic and recovery more difficult.
Passive movements and massage constituted proper
treatment, but when given only two or three times a
week they were useless. It was only reasonable to give
them for five or ten minutes five or six times a day. If
the mothers were taught in the dispensaries how to give
this treatment better results would be obtained among
the children of the poor than among the children of the
rich who received treatment at less frequent intervals.
Dr. Kennedy said he spoke only to emphasize the con-
victions of most neurologists as to the best means of
getting results in these cases and to urge the necessity
of continued massage and passive movements for a long
period of time and many times a day. If this was
carried out there would be less deformity and fewer
braces, and still fewer operative procedures would be
required.
Dr. Abraham Jacobi said that he had seen this dis-
ease occasionally for the past sixty years and what he
had heard about it to-night had not been at all uniform.
He had not seen any cases during the epidemic this
summer, but had seen a number of cases in the epidemic
of 1907. He thought the disease as it appeared in
sporadic cases was about the same years ago as at the
present time. The cases usually had the following de-
scription : A baby was put to bed apparenty well and
was taken up in the morning paralyzed, with from two
to four sets of anterior spinal nerves involved. The
course of the disease, as a rule, was as follows: The
child was badly paralyzed at first; it was better in five
or six days. The improvement during these first days
was rapid, then less rapid for five or six weeks, and
that was the end of the improvement. One case coming
under his observation was an exception to this; in this
case the child was treated by the galvanic current, some
(500 or 800 applications having been made over a period
of years. This child finally got well. Dr. Jacobi said
that if he had anything to say about the treatment of
this disease it was that one should not undertake any
form of treatment unless it could be extended over a
number of years.
Dr. Herman C. Frauenthal said that in the ap-
plication of electricity, the massage oil or talcum must
be removed before the electricity was applied. To be
successful with electricity the galvanic current must
be used. The faradic current was not definitely stand-
ardized and the sinusoidal was not to be depended upon.
The galvanic current always gave contraction in an
increasing or decreasing amount and it was the only
current that could move muscles that were partially
paralyzed. All currents had a value in the hands of the
man who understood their effects. Muscle training
could not be applied until the child was about three
years of age. A good way to reeducate muscles was to
have the child make a movement with the normal limb
and then to endeavor to imitate it with the affected
limb.
Dr. Lovett, in closing the discussion, said he had
been much interested in the free discussion and in the
different opinions expressed. He felt, however, that
at the present time the situation was such that it was
better to emphasize the matters upon which they could
agree than those upon which they differed.
THE AMERICAN ASSOCIATION OF
IMMUNOLOGISTS.
Third Annual Meeting, Held in Washington, D. C,
May 11 and 12, 1916.
(Concluded from page 657.)
Immunity Results Obtained from the Use of Diphthe-
ria Toxin-Antitoxin Mixtures and the Use of the Schick
Test.— Drs. William H. Park and A. Zingher of New
York City presented this paper, based upon a series of
over one thousand cases, that had been actively im-
munized with diphtheria toxin-antitoxin. These sus-
ceptible individuals were selected by means of the
Schick test out of a total of about 10",000 children and
adults in 10 different institutions. The mixtures of
toxin-antitoxin that were used for immunization were
either neutral (66-70 per cent. L + to each unit of
antitoxin) or slightly toxic (80-90 per cent. L + to
each unit of antitoxin) to the guinea-pig. The dose
was varied from 0.5 c.c.-l.O c.c, and the number of in-
jections from one to three. The injections were made
subcutaneously at intervals of 7 days. The local re-
actions at the site of injection were generally mild ;
in the older children and adults, the redness and swell-
ing were more marked. General symptoms, like malaise,
and temperature of 100°-102° F. were noted in 10 to
20 per cent, of the cases; in a few the temperature
reached 104° F. The symptoms lasted 24 to 48 hours,
and then rapidly subsided. Both local and general
symptoms were especially evident in those who showed
a susceptibility to the protein by giving a combined
pseudo and true Schick reaction. No harmful after
effects were noted in several thousand injections. The
retests with the Schick reaction showed that only 30-40
per cent, became immune 3 weeks after the first in-
jection, about 50 per cent, at 4 weeks, 70-80 per cent,
at 6 weeks, and 90-95 per cent, at 8 to 12 weeks. The
best results were obtained with the full immunization,
consisting of 3 injections of 1.0 c.c. each, given at
weekly intervals. The duration of the active immunity
was studied in a group of children that were followed
up for over 1% years; these cases showed that the
active immunity persisted for at least that length of
time. It is possible, that the immunity induced by the
injections of toxin-antitoxin started a continued cellular
production of antitoxin, which would have otherwise
appeared much later in life. From their results Park
and Zingher concluded that it was advisable to im-
munize children soon after the first year of life, so as
to afford them a protection against diphtheria at a
time when the disease was most dangerous. In addi-
tion such young children, by not having any hyper-
sensitiveness to the bacillus protein, showed very mild
local and constitutional symptoms after the injections.
An immune child population could thus be developed
with the result that fresh clinical cases would be pre-
vented and the bacillus carrier would probably soon
disappear as a hygienic factor in our communities.
Interesting and parallel results were noted in guinea-
pigs and horses. Guinea-pigs were fairly resistent to
active immunization with diphtheria toxin-antitoxin,
and in that respect they showed an almost complete
parallelism to the positive Schick cases among human
beings. After injections of toxin-antitoxin, an anti-
toxic immunity developed slowly from the 6th to 8th
week. Horses, on the other hand, as a rule corre-
sponded in their behavior toward small doses of toxin-
antitoxin to human beings, who were naturally immune.
They both gave a ready response, even after a single
injection of toxin-antitoxin, and showed a distinct in-
crease in the antitoxin content toward the end of the
first week. Occasionally, a horse was found that had
no antitoxin in the control bleeding; such animals re-
sponded slowly to small doses of toxin-antitoxin. It
was probable that the tissue cells of the naturally im-
mune human beings and the majority of horses had
acquired the property of giving a quick and easy re-
sponse to the stimulation of diphtheria toxin. The use
of the Schick test in the selection of susceptible chil-
dren for immunization and in controlling the results
of the treatment was justified by the great clinical ac-
curacy which the test had shown during a period of
several years in the separation of the susceptible from
the immune individuals. The test should be carried out
properly with a fresh toxin solution, and the results
read daily, for a period of 72-96 hours. The pseudo-
reactions should be controlled with heated toxin, or
recognized by their rapid disappearance after 72 hours.
It was only those individuals who gave the more
marked local reactions after the injections of toxin-
antitoxin. In conclusion Park and Zingher stated that
the Research Laboratory of the New York City De-
partment of Health would supply those who were con-
nected with institutions, and interested in taking up
the work, both the toxin for the Schick test and the
toxin-antitoxin for immunization.
Anaphylactic Food Reactions in Dermatology with
Special Reference to Eczema. — Dr. ALBERT Strickler
of Philadelphia spoke of the relation of diet to various
diseases of the skin. Fourteen food products were
tried out. The method of injection employed was the
endermic one, and the dose used was one-tenth of a
c.c. In all, four diseases were studied — eczema, urti-
caria, acne and psoriasis. In conclusion, he said the
anaphylactic food tests were of value in the etiologic
diagnosis and in the treatment of various di?eises of
the skin. These reactions found their greatest value
in eczema. In chronic urticaria, acne and psoriasis the
tests were disappointing. As yet our experience was
too limited to draw any definite conclusions.
742
MEDICAL RECORD.
[Oct. 21, 1916
Comparative Studies of the Wassermann and Hecht-
Weinberg Reactions in Syphilis, with Special Reference
to Cholesterinized Antigens. — Dr. John A. Kolmer of
Philadelphia stated that the Hecht-Weinberg test
utilized the complement and natural anti-sheep hemo-
lysin of the human serum. The primary object of this
study was to determine if this test was more delicate
than the Wassermann reaction conducted with chol-
esterinized extracts. The Hecht-Weinberg tests were
conducted after the modification of Gradwohl, by which
the hemolytic activity, and accordingly the proper dose
of sheep cells to be used for each serum, was deter-
mined according to the amount "of a 5 per cent,
emulsion of sheep cells hemolyzed by a 0.1 c.c. of serum.
The same three extracts were used in the Hecht-Wein-
berg and Wassermann tests, namely, an alcoholic ex-
tract of human heart reinforced with 0.4 per cent,
cholesterin ; an alcoholic extract of syphilitic liver, and
an extract of acetone insoluble lipoids of beef heart.
All extracts were titrated for the antilytic and anti-
genic units in both systems, respectively. With sera
collected twenty-four to forty-eight hours previously, 93
per cent, were found to contain sufficient complement
and anti-sheep hemolysin to permit the conduct of the
Hecht-Weinberg test. In 82 per cent, of the sera the
results varied and in this manner: in 15 per cent, the
Wassermann was negative and the Hecht-Weinberg test
positive. Of these reactions, the positive Hecht-Wein-
berg tests were largely correct and occurred mostly
with the sera of syhilitic persons under vigorous treat-
ment; in 3 per cent, the Wassermann was positive
and the Hecht-Weinberg was negative, and all of
these occurred with the sera of persons in the latent
and tertiary stages of syphilis. With the sera of per-
sons known not to be syphilitic, the Hecht-Weinberg
test showed about 10 per cent, falsely positive re-
actions; most of these reactions occurred with the
alcholic extract of syphilitic liver, and fewest with
the extract of acetone insoluble lipoids. All of these
sera yielded negative Wassermann reactions with all
antigens. The Hecht-Weinberg test was found unre-
liable in the diagnosis of syphilis on account of the
tendency to yield proteotropic reactions; it was more
delicate, however, than the Wassermann test, and had
its greatest value in a negative reaction as a control
on treatment with the sera of known syphilitics. In
conducting the Hecht-Weinberg test, alcoholic extracts
of syphilitic liver were found least, and extracts of
acetone insoluble lipoids best suited for this technique.
Studies in the Epidemiology of Lobar Pneumonia. —
Dr. A. R. Dochez of New York presented this com-
munication. He said studies had been made of pneu-
mococci isolated from individuals suffering from lobar
pneumonia and had shown that the majority of these
organisms fell into definite biological groups. In view
of these constant differential characters of the pneu-
monococcus, it had been deemed advisable to study the
pneumococci occuring in normal mouths. It had been
commonly assumed that infection in pneumonia was
autogenic, and occurred from invasion of the lungs by
pneumococci habitually carried in the mouth. If this
was so one would find the same types in the normal
mouths that occurred in disease. Examination of a
series of normal individuals showed this not to be the
case. The two types of pneumococci responsible for
the majority of severe cases of lobar pneumonia were
not found in the normal healthy mouth, except in such
instances as where the individual harboring of the
organism had been in intimate association with a case
of lobar pneumonia. When such a condition existed,
the organism found in the normal mouth invariably
corresponded in type to that found in the lung of the
diseased individual. These studies made it probable
that the majority of cases of pneumonia were depen-
dent either on direct or indirect contact with a pre-
vious case.
Captain Edward B. Vedder of Washington, D. C,
said they had thought for a number of years that
they knew all about pneumonia. They had learned a
long time ago that perhaps a large proportion of
normal individuals carried the pneumococeus in the
sputum. Of course, it was plain that if they suddenly
became chilled and their resistance was greatly low-
ered that they would develop pneumonia. This "was a
very comfortable theory. This was nobody's fault and
they did not have to do anything about it except to
die when their turn came without making too much
fuss. Now, Doctor Dochez and his associates came
along and told them that this was like other things
they had learned; it was all wrong. Now, if Doctor
Dochez was right, and the speaker was inclined to
think that he was, the question was "What were they
going to do about it?" Treatment with the anti-
pneumococcic serum seemed to be a little discouraging
in view of the fact that it would be a long time before
the practicing physician would recognize the different
types of pneumococci as he ordinarily met them. This
was a difficulty that could be obviated by co-operation
with the laboratories. But this entailed delay. In
any case, prevention was much more important than
cure, and it was right here that Doctor Dochez's paper
opened up a most hopeful vista. It meant that every
case of pneumonia might be traced directly to a pre-
vious case, either directly or indirectly. It meant that
from a sanitary point of view pneumonia must be
treated just like any other infectious disease in which
the infecting agent was transmitted by the buccal
secretions of those affected, and that the present wide-
spread prevalence of pneumonia was due to the pres-
ent policy of laissez faire. When the various boards
of health finally came to life, as they probably would
in from one to twenty years, they might expect the
following measures: (1) Notification of all cases of
pneumonia. (2) Prompt visitation by a health offi-
cer, collection of specimens, and laboratory diagnosis
of the type of organism present, in the patient and in
the contacts. (3) Isolation of the patient and of any
contacts who harbored the type of pneumococeus found
in the patient. (4) A negative culture requirement
before the patient or carriers were permitted to mingle
with the community.
The Localization of a Streptococcus in Animals from
a Case of Recurring Neuritis and Myositis. — Dr. Ed-
ward C. Rosenow of Rochester, Minn., presented this
contribution which he summarized as follows: A
streptococcus having peculiar properties was isolated
from the dead pulp of the left upper first molar in
the region where the attacks of pain usually began.
The streptococcus was also demonstrated in the sec-
tions isolated from the infiltrated deep fascia and
muscles of the left side of the neck. A similar strepto-
coccus was isolated from the pharynx and stool. This
streptococcus was proved to have elective affinity for
the pulp of teeth, dental nerves and muscles in ani-
mals. It was repeatedly isolated from and demon-
strated in the experimental lesions in animals whose
blood was sterile; the lesions were again produced on
injection and the streptococcus again isolated. Many
animals appeared to be in pain, and one rabbit had
marked swelling and tenderness over the left upper
jaw. This affinity was proved absent in the diph-
theroid and D. fusiformis also isolated from the pulp
of the tooth, and in the streptococcus broth culture
filtrate. Streptococci from other sources rarely caused
lesions in the pulp of teeth and dental nerves. The
phagocytic power of the patient's blood following the
attack over the strain from the tooth was twice that
of comparable normal blood. These results would ap-
pear to warrant drawing the conclusion that the at-
tacks of pain in the face in this patient were due to
a streptococcus infection of the sheaths of the dental
nerves, and that the pain, swelling, tenderness and
spasm of the mucles of the neck were due to myositis
and fibrositis — the result of infection by this strepto-
coccus. The demonstration of living streptococci in
the pulp of the tooth and in the fascia of the muscle
during quiescent intervals was significant, and might
explain the recurrence of the attacks. The cavity in
the tooth containing the dead pulp originally infected
from the mouth, judging by the character of the filling
and the bacterial flora, was quite unable to heal for
mechanical reasons. This appeared to afford a culture
medium for the growth of the streptococcus. From
stimulation of the defensive mechanism in the patient
during the attacks, active growth appeared to be held
in check and the symptoms disappeared in conse-
quence, only to reappear later from recurrence of
active growth and localization of the streptococci
when immunity was low. The improvement in the con-
dition of the patient since the extraction of the tooth
appeared to be due to the removal of this focus and
to prolonged artificial stimulation of the defensive
mechanism by means of the autogenous vaccines, which
it was hoped would lead to the destruction of all the
streptococci in the muscle and dental nerves, and re-
sult in the ultimate recovery of the patient. However,
the isolation of the streptococci from so many places
would probably make recovery difficult.
DR. George W. Wheeler of New York stated that
streptococci were usually classified according to their
Oct. 21, 19161
MEDICAL RECORD.
743
effects in bloodagar plates, as hemolytic or non-hemo-
lytic. The non-hemolytic varieties had been further
classified according to their fermentation reactions
with different sugars, but wide variations were found
by these methods, due to the variations in the organ-
isms themselves and to chemical changes in the sugars
during the process of sterilizing the media. None of
these differential methods gave any clue as to what
the streptococci would do when they were in the ani-
mal body. Doctor Rosenow's work began where these
methods ended. His original idea was that organisms
growing in the human body had certain delicate, tran-
sient, biological activities which were soon lost when
the bacteria were grown on artificial media. In order
to demonstrate these activities, the organism must be
transferred from the human organism to animals,
the original culture from the patient being used for
inoculation, and the lesions in these animals studied.
Animal inoculation with recently isolated brains,
grown under certain definite conditions, showed that
the lesions produced in the animals were very often
similar to those in the patient from whom the organ-
isms were obtained. Whether this was merely a coin-
cidence or a specific affinity which the organisms had
for certain tissues could only be determined when a
great deal of experimental evidence of this kind had
been presented and carefully examined. Control ani-
mals were necessary to rule out the possibility of the
lesions being spontaneous. In work which he had
done according to the methods described by Doctor
Rosenow, with streptococci from nine cases of arthritis
and endocarditis, lesions were found in the joints of
animals in 75 per cent, of the cases; in muscles in 63
per cent.; in the heart in 55 per cent., while in other
organs lesions were relatively infrequent; the appen-
dix, 6 per cent.; the stomach, 11 per cent.; the brain
and cord, 6 per cent.
Dr. E. C. Rosenow of Rochester, Minn., in closing
the discussion, said that he preferred using the terms
"green producing" and "hemolyzing streptococci," in-
stead of streptococcus viridams and hemolytic strepto-
coccus, because there appeared to be numerous vari-
ants of each strain, particularly of the former, and
because one might be transmuted into the other. He
expressed his appreciation of the work done at the
Rockefeller Institute on the classification of the
pneumococci and the observations made on them. In
his hands the pneumococci showed, as in those of Doc-
tor Cole and Doctor Dochez, fixed characters when
grown in the usual way, but when the pneumococci
were placed under special environment they lost their
specific glutinating reactions and took on new features,
and they might be converted even into hemolyzing
streptococci. The demonstration of living streptococci
in the muscles during the quiescent period was of im-
portance and in accord with similar findings in ulcer
of the stomach, chronic rheumatism, eholesystitis, etc.,
because it showed that not too much should be ex-
pected from the removal of the primary focus in these
diseases which were characterized by exacerbations
and quiescent intervals, and served to explain these
exacerbations and remissions.
A Note Concerning the Specificity of Pneumococcus
Types. — Drs. A. P. Hitchens. E. K. Tingley, and
George Hansen of Glenolden, Pa., reported this case.
They stated that the horse in question had been under
treatment for several months with a pneumococcus
corresponding in serological reactions with Neufeld
type 1. The last injection was given about one month
before death, and the bleeding subsequent to this
showed that the potency of the serum of this horse
was such that 1,100,000 c.c. of the serum would pro-
tect a mouse against a fatal dose of pneumococci of
the homologous type. Blood culture three days before
the death of the horse showed the presence of a pneu-
mococcus not corresponding in type with that with
which the animal had been injected. The pneumococcus
recovered was still under examination. It did not
correspond with type and -was not the mucosus. It
did, however, bear strong resemblance to some strains
of pneumococci obtained from equine infections.
Autopsy of the animal showed pulmonary consolida-
tion and inflammation of the mucous membranes lining
the respiratory passaees.
Studies in Typhoid Fever.— Dr. A. L. C.ARBAT of New
York presented this contribution. He first considered
the complement fixation test after prophylactic im-
munization and compared it with the agglutination
test. As a result of these investigations, he makes the
following summary: In contrast to the strong agglu-
tination test a positive complement fixation test after
prophylactic typhoid immunization was not a regular
occurrence, as it was during or after typhoid fever.
This point might be an aid in deciding for or against
the diagnosis of typhoid fever in an inoculated indi-
vidual still having a positive Widal and ill with a sus-
picious typhoid and negative blood culture. A posi-
tive complement fixation test was obtained most often
after three injections with a polyvalent vaccine; two
injections with this same vaccine or three injections
with the single strain (Rawling) gave hardly any com-
plement fixation. He presented a study of duodenal cul-
tures in typhoid fever. He stated that of every 10,-
000 apparently perfectly healthy residents 2.3 per cent.
were typhoid carriers and that 55 per cent, of all
typhoid cases were due to carriers, either directly or
indirectly. Of every 100 typhoid cases three to six be-
came carriers.' This made it evident that the ideal
prophylaxis in typhoid fever was the detection of the
typhoid carrier. A questionnaire sent to various hospi-
tals for the purpose of finding out what and how many
institutions examined the urine and stools of their
typhoid patients before discharging them showed that
of twenty-four institutions nine examined the urine
and stools before discharging patients; eleven insti-
tutions disregarded such examinations entirely. There
were many difficulties which they all had with the
stool examinations. For this reason the writer had
devised a method of collecting bile from the duodenum
by means of the Einhorn duodenal tube. He had
found that this was a simpler and more reliable method
for the detection of typhoid bacilli than stool examina-
tions.
Doctor Garbat presented a third study with ref-
erence to convalescent typhoid serum in the treatment
of typhoid fever, based on his experience with three
cases. All three cases were very acute, and in all
the serum from convalescent typhoid patients had
been employed with distinct benefit. The writer be-
lieved it was worth while to try this form of serum
therapy.
Dr. A. H. Sinclair of Honolulu. Hawaii, said he
was prone to believe that, after the use of typhoid
vaccine, if typhoid fever occurred, there must have
been something wrong either with the vaccine itself
or with the technique of its employment. He did not be-
lieve that any patient who gave a positive Widal after
typhoid fever could again contract the disease. The iso-
lation of the bacilli from the blood or from the stools
showed the applicability of the complement-fixation test.
Dr. George H. Robinson of Glenolden, Pa., related
an experience with a small number of cases of typhoid
fever, in which it seemed that clinically the well-fed
cases gave fewer typhoid carriers than the starved
cases.
Dr. Abraham Zinger of New York said that during
the past eighteen months at the Willard Parker Hospi-
tal he had been giving convalescent fresh whole blood
by means of intramuscular injections in scarlet fever
cases. Distinct benefit was noted in toxic cases after
injections of blood obtained from patients who were
three to four weeks convalescent. If it should be
proved that convalescent blood had therapeutic value
even as late as six months after the disease, then
the opportunity of employing this treatment would be
much greater. Convalescent blood could be used not
only in diseases that resulted in a more or less per-
manent immunity, like scarlet fever, typhoid and
measles, but also in diseases that were followed by
only a short protection, like ervsipelas and pneumonia.
The blood in these cases should be obtained from donors
not more than two to three weeks convalescent. Doc-
tor Zinger said he had used intramuscular injections
of normal blood in late septic cases of scarlet fever,
in which the toxemia was no more in evidence. Such
blood was not given for any specific action, but for
its general stimulating and nutritive value.
Doctor Garbat, in closing the discussion, said that
all the cases at the German Hospital were fed by
the high caloric method; the physicians had practically
abandoned the starvation treatment. Whether typhoid
carriers occurred more frequently in those with high
caloric value or in these under the so-called starvation
treatment he did not know.
Friday. May 12 — Second Day.
The Standardization of Antimeningitis Serum by Ani-
mal Protection Tests. — Dr. George H. Robinson of
744
Ml.DICAL RECORD.
[Oct. 21, 1916
Glenolden, Pa., presented this paper. He stated that
the variable ability to produce agglutinins and com-
plement fixing bodies had been noted among horses
under antimeningococcic treatment. An animal pro-
tection test seemed desirable as a measure of the
potency of the serum. A sixteen-hour old culture of
meningococci on serum dextrose agar was necessary
for the test. Suspended in fresh guinea pig serum
and diluted three times with 0.85 per cent, salt solu-
tion most strains were virulent for white mice. If
antimeningococcic serum was injected two hours pre-
vious to the infection of the cocci, considerable protec-
tive power could be demontrated. The amount of
serum used had been invariably 0.5. Culture was used
in 0.5, 0.25, 0.12, etc., amounts. By this method the
amount of protection afforded by different sera very
closely paralleled the extent of the treatment the
horses had received. Agglutinating and complement
fixing powers showed no correlation with protective
power. The test was specific in that different strains
of meningococci could be distinguished as well as the
gonococcus. As a routine measure all freshly isolated
strains of meningococci were tested with a polyvalent
serum, and those against which the serum did not
protect were incorporated into the treatment of the
horses. The polyvalency of antimeningitis serum was
of extreme importance. If the amount of immune
serum necessary to protect against one minimum lethal
dose of living culture be considered as a unit, a uni-
form standardization of antimeningitis serum was ob-
tained. Such a standard meant more to the physi-
cian, and was a better test of the therapeutic efficiency
of a serum than test in vitro.
An Analysis of a Series of Cases Changing to Wasser-
mann Positive after a Negative Period of Twelve Months
or Over. — Dr. Louis A. Levison of Toledo presented
this report. He said he had collected sixteen cases
fulfilling the conditions mentioned in the title. Six
of these patients had been treated at least in part by
the writer, and of these only one was treatd from
the start. The idea that a single negative Wasser-
mann after treatment meant a cure of syphilis was
entertained by many physicians despite its utter lack
of basis in fact. The cases cited showed that a patient
with syphilis might not be cured or have his disease
process arrested even after the Wassermann had been
negative for twelve months. There was more than
passing significance in the fact that practically all
these cases were late or advanced when they were
competently treated. They received mercury either
in small or inefficient amounts, some not at all, at the
time when treatment could have been of value. The
Wassermann reaction had a definite value as a guide
to treatment, but care should be taken in dismissing a
patient from treatment and observation on the
strength of a Wassermann negative period which had
not lasted longer than from twelve to eighteen months.
A Stable Bacterial Antigen with Special Reference to
the Meningococcus Antigen. — Dr. George Hansen of
Glenolden, Pa., presented this communication. He
stated that various methods had been recommended
for the standardization of antimeningococcus serum.
No method so far devised was considered satisfactory.
There had recently been a return to the complement
fixation, not because it was supposed that complement
fixing antibodies had any exact relationship to the
therapeutic value of the serum, but because the method
was fairly accurate and served to identify the serum
with the various types of meningococci with regard to
polyvalency. An antigen, which might be distributed
to various laboratories, and which would remain un-
changed under the varying conditions therein, would
remove one source of variation in results. Further-
more, such an antigen might have great value in the
case of other bacteria, as for instance, the gonococcus.
Cultures for the preparation of dried meningococcus
antigen were grown on salt free agar. The growth
was collected in distilled water, an equal volume of
alcohol was added and the mixture centrifuged at high
speed. The bacteria was further dehydrated by re-
peated washing with alcohol and finally with ether.
The resultant mass was dried and preserved in ramo
oyer phosphorus pentoxid. For use weighed amounts
of antigen were ground in a mortar and suspended in
physiological saline solution. The usual preliminary
titrations and controls were set up to be certain that
the reactions were specific. The dried antigen had
been checked up against its homologous serum and a
large number of heterologous sera and had been found
to yield specific results.
The Clinical Significance of the Wassermann Test. —
Arthur F. Coca of New York, read this paper. He said
the Wassermann reaction was a biochemical test; that as
it was performed with reagents whose chemical consti-
tution was practically unknown, some of them being
relatively very unstable bodies. The Wassermann "mix-
ture" was subject to considerable variations dependent
upon the particular method or modification of the orig-
inal technic used and also upon the manner of stan-
dardizing the different reagents, as well as upon the
quality of the antigen preparation available. On ac-
count of the above mentioned technical variations as
well as on account of factors heretofore uncontrolled
a considerable want of uniformity in the results of
the Wassermann test existed. There had yet to be
recorded a series of parallel tests carried out by dif-
ferent observers on the same sera in which the re-
sults agreed throughout. As had been pointed out
by Uhle and MacKinney, the disagreements were more
common in just the cases in which the need of reliable
information was greatest. The results of the Wasser-
mann test were further vitiated by the fact that it
was being performed by an ever-widening circle of
superficially informed and uncontrolled "techicians."
It had been clearly demonstrated that the positive
Wassermann reaction was not specific for syphilis.
It occurred not only with some regularity in other
conditions, but also sporadically in many others.
Analysis of its relations to the therapeusis of syphilis
showed that in the great majority of instances the
result of the test did not influence the course of spe-
cific treatment. The use of the Wassermann test as
a legal criterion of eligibility for marriage must be
unconditionally opposed.
Serum Reactions Following Treatment with Sensitized
and Non-Sensitized Bacteria. — Dr. G. H. Smith of Glen-
olden, Pa., presented this contribution. He stated
that work he had been doing toward the determina-
tion of the mode of reaction induced by immunization
with sensitized and non-sensitized typhoid antigens
gave the following results: (1) The agglutinating
titre of the sera obtained indicated that the non-
sensitized antigen was more efficient. The difference,
however, was slight. Agglutinins appeared earlier
in the course of the treatment if a non-sensitized anti-
gen was used. (2) Sera produced by treatment with
non-sensitized antigen were more active in complement
fixation tests. (3) In the case of the opsonic and
bacteriotropic indices the differences in values ob-
tained were not of great significance, either in degree
or in the rate of production. (4) The degree of leu-
cocytosis produced with the two types of antigen in-
dicated an essential difference. The animals receiv-
ing sensitized antigen responded with a greater pro-
duction of leucocytes, the response after each injec-
tion being increasingly greater, and the increase oc-
curring after a shorter interval of time than in the
animals receiving non-sensitized antigen.
Prophylactic and Therapeutic Inoculations in Certain
Affections of the Respiratory Tract. — Drs. George W.
Ross, H. K. Detweiller and J. C. Maynarp of
Toronto presented this communication, in which they
express the opinion that so-called "common colds"
might be due to a variety of microorganisms, such as
the B. rhinitis, B. influenzae of Pfeiffer. M. catar-
rhalis, the pneumococcus and various streptococci.
The question arose as to the likelihood of symbiosis
occurring among these organisms, increasing their
parasitism. There was recently an epidemic of "cold"
in Toronto, during which a whole batallion of soldiers
quartered there were unfitted for duty because of
this epidemic. The writers prepared vaccines from
many strains of different organisms isolated. Sixty-
two soldiers were inoculated with these vaccines, re-
ceiving from one to six inoculations. The results
were very gratifying, and warranted the suggestion
that this method might at least be applied to the
control of such epidemics in institutions where large
numbers of people were in .close contact.
The Diagnosis and Treatment of Septicemia. — Dr.
Oscar Berghausen of Cincinnati read this paper. He
said the essential feature of septicemia was the multi-
plication of infecting organisms within the blood cur-
rent. The termn "bacten'emia" was not descriptive of
any special pathological condition. It would be far
simpler to speak of infections due to ordinary organ-
isms of suppuration, as either "toxemia" or "septi-
cemia," meaning by the latter term that the organ-
isms had begun to multiply in the blood current.
Pyemia was simply a complication of septicemia.
Oct. 21, 1916]
MEDICAL RECORD.
745
They had made blood cultures in fifty cases having
symptoms resembling clinically septicemia. Fifty-
seven per cent, of these cultures were positive, the
streptococcus being the prevailing organism, although
the staphylococcus was occasionally found, or a bacil-
lus of the colon type in terminal infections. Of twen-
ty-three patients with a positive blood culture, 74
per cent, died and 26 per cent, recovered. Of seven-
teen patients with a negative blood culture, 35 per
cent, died and 65 per cent, recovered, showing that
the percentage lacked only nine of being reversible.
This showed the value of blood culture in suspected
septicemia cases, not only in the diagnotic, but also
in the prognostic sense. In the positive cases they
had also the means for preparing an autogenous vac-
cine to assist nature. The total white count varied
from 7100 to 25,000 in the patients who recovered;
from 7000 to 30,000 in those who died. Ordinarily in
this series of cases a low white count indicated a bad
prognosis. However, a low white count might be
found in patients with a severe type of septicemia
and still recovery might quickly follow. The differen-
tial white count, on the other hand, was of the great-
est importance. When the polymorphonuclear count
approaches 90 per cent., particularly when the total
white count was low, the prognosis became grave.
They looked upon such a relationship as due to over-
stimulation of the mechanism of immunity. In only
two of the patients who recovered was the polymor-
phonuclear count above 85 per cent. ; in both of these,
owing to the long continued infection, a severe grade
of secondary anemia had developed. The blood pic-
ture was important because we were enabled thereby
to determine the presence or absence of a severe grade
of anemia or of acute leucemia. In most of these
cases the antistreptococcic serums obtainable on the
market had been employed before the writer saw the
cases ; in none was a cure reported. In several in-
stances a marked drop in the temperature followed
the use of the serum, but this was only a temporary
response. In thirteen of the cases autogenous vaccines
were employed in addition to the regular symptomatic
treatment, and of this number seven recovered. This
series of cases included seven cases of streptococcic
septicemia, twelve cases of puerperal sepsis, six cases
of purpura hemorrhagica and twelve atypical cases,
all due to trivial wounds, surgical procedures, or local-
ized septic processes, and three cases of septicemia
following abdominal operations. In true septicemia
the prognosis depended upon the state of health of
the individual, the length of time the infection had
existed, the type of organism causing the infection
and the complications which might develop. The
longer the course of the disease the more favorable
was the prognosis. A negative blood culture and a
polymorphonuclear count below 85 per cent, spoke for
a favorable outcome. The patient should be treated
as a consumptive, at least he should be given plenty
of fresh air. He should be fed as generously as pos-
sible without deranging the digestion. The hot pack
was indicated in septicemia marked by high tempera-
ture and erythema and in the absence of the more
serious complications with stimulation before or after
the pack. We might employ digitalis in the begin-
ning to enforce the heart's action, though we could
not thereby prevent the onset of endocarditis. Of
the antipyretics quinine was the most important; it
should be used in small doses and often. Bacteriocidal
medication had been, on the whole, practically useless.
Apparently good results had been obtained by hypo-
dermoclysis. Antistreptococcic serum had little anti-
toxic and bacteriocidal value. Their experience had
been limited to the use of autogenous vaccines and
thev believed their continued use was justified. The
indications for surgical intervention when a pyemic
abscess had developed were well known. Spinal punc-
ture was indicated when symptoms of meningismus de-
veloped. The patient should be carefully watched dur-
ing convalescence.
Treatment of Tuberculosis Pulmonalis by Tuberculin.
Dr. A. N. Sinclair of Honolulu, Hawaii, presented
this communication. He related his experience with
tuberculin in the Leahi Home for Consumptives which
had convinced him of the value of this agent. Out of
309 cases treated without the use of tuberculin in the
four years prior to the adoption of the tuberculin
treatment 27.2 per cent, of all cases treated were
either arrested or were able to return to their former
occupations, while out of 506 cases treated during the
next four years with tuberculin 50.1 per cent, were
enabled to resume their former occupation.
He had also found with reference to the efficacy
of the tuberculin that there was an almost constant
rise and fall of the average weight line parallel to
the state of freshness of the diluted tuberculin. He
had used this weight line to check up the potency of
the tuberculin injected from week to week. In dis-
cussing the reasons for the failure of many others to
get satisfactory results with tuberculin, he stated
that he believed this was entirely due to lack of atten-
tion to details, to the omission or commission of some
vital factor that appeared of minor importance. The
essayist stated that he never had occasion to go above
1/300 mg. and rarely over 1/500 mg., instead of doses
1000 times as large (2 mg.). Next to the opsonic
index the best control for the dosage was that first
suggested by Sutherland; although, without desiring
to detract from him the honor of this discovery, the
writer had used a similar control at the Leahi Home
for a number of years before this was published. This
control was what might be termed the temperature
reaction after injection. The main points to bear in
mind were the day after the injection on which the
highest temperature was reached, and whether or not
normal was reached by crisis within twenty-four hours
or by lysis. There were seven reactions which he rec-
ognized and in accordance with which he regulated
the dosage. If the reaction was highest after 72 hours
and there was no fall to normal after 72 hours tuber-
culin should be discontinued. A delayed reaction or
continued high temperature indicated an inability to
absorb the tuberculin and the dose must be decreased
or halved, if continued. He usually began with 1/3000
mg. given weekly and increased by 1/3000. Another
factor which he had taken into consideration was the
amount of albumin in the sputum. A high albumin
content, or one increased since the last dose of tuber-
culin, threw the decision towards decreasing or dis-
continuing the tuberculin; a low albumin content, or
a decreased one, gave confidence in either repeating or
increasing the dose. Tuberculin should never be given
haphazard or by rule of thumb, experience alone en-
abled one to gauge the amount that should be given.
The Value of Tuberculin in the Treatment of Tuber-
culous Lymphnoditis. — Dr. George P. Sanborn of Bos-
ton presented this paper. He stated that this report
was based on a series of sixty selected cases of lymph-
nodular tuberculosis treated in the Department of
Vaccine and Serum Therapy of the Boston City Hos-
pital, and a few of them in private practice. This
group of cases included such as had developed under
good conditions of hygiene and in which surgery was '
not primarily indicated and they therefore furnished
fairly ideal experimental conditions. The feeding,
housing, and general condition of these patients made
possible the use of tuberculin as the one method of
treatment without injustice to the patient. All cases
received inoculations of bacillus emulsion, the initial
dose in children being 1/50,000 to 1/25,000 mg.; in
adults, 1/20,000 to 1/10,000. Both human and bovine
tuberculin were used. The initial dose was sufficiently
small to produce no subjective symptoms. The inocu-
lations were given immediately beneath the skin so
that the intensity of the reaction could easily be ob-
served. Where the local reaction was considered suit-
able, dosage was usually held the same until its inten-
sity became less. Dosage was then increased. Calci-
fied and caseated glands could not be reduced by tuber-
culin and had been referred to the surgeon after a
course of tuberculin had been given. Long continued
tuberculin treatment might render the surgical prob-
lem of extirpation difficult. The results of tuberculin
treatment in this series of cases might be summarized
by stating that there was diminution in the size of the
nodes in 83 per cent, of the cases; one or more nodes
broke down in 33 1/3 per cent.; one or more lymph
nodes developed during treatment in 20 per cent, of
the cases; surgical procedures were necessary in 11
per cent.; there was a gain in weight in 60 per cent.
In the possibilities of being favorably influenced by
tuberculin, patients under fifteen years of age ap-
peared to have the advantage. A demonstrable im-
provement had been observed in at least 83 1/3 of the
cases treated. Recurrence took place in eight cases
in this series.
Clinical and Pathological Observations on the Dangers
Encountered in Certain Technical Procedures Frequent-
ly Used by Serologists and Clinicians.— Dr. H. S. Mart-
746
MEDICAL RECORD.
[Oct. 21, 1916
land of Newark presented this paper, which gave a
resume of the contraindications, dangers and accidents
met with in lumbar puncture, intraspinous and intra-
cranial injections, intravenous medications, blood trans-
fusions, etc. The observations of the author were based
on clinical and pathological data, from over 1,500
autopsies at the Newark City Hospital. The paper in-
cluded the presentation of pathological specimens.
Intravenous Therapy; The Use of Sensitized Bacterins
Intravenously, Especially in Pneumonia. — Drs. William
Egbert Robertson of Philadelphia, Pa., and Claude
P. Brown and Allen G. Beckley of Glendolen, Pa.,
presented this communication, which was read by Dr.
Robertson. He stated that up to the present time bac-
terins had been given therapeutically most frequently
in chronic, localized infections, less often in general
infections. Treatment had usually been with the non-
sensitized type and the mode of administration had
been subcutaneous. Very little clinical use had been
made of the intravenous administration of sensitized
bacterins. Because sensitized bacterins, from a theo-
retical standpoint, would seem to give a quicker re-
sponse in the production of immune bodies, and be-
cause with the intravenous mode of administration an
immediate action of the bacterin might be secured
with no attendant local reaction, the authors had em-
ployed serobacterins intravenously in a series of cases.
One case of typhoid, treated in this way, gave very
severe reactions after injections of the bacterin. Satis-
factory recovery was made. Severity of reaction after
the intravenous use of sensitized bacterins was typ-
ical in typhoid cases in general and was much more
pronounced than in pneumonia treated in the same
manner. In eleven cases of pneumonia two procedures
were followed, some patients being given a polyvalent
bacterin composed of sensitized pneumococci alone,
others a mixture of sensitized pneumococci, strapto-
cocci, and staphylococci. Those receiving the pneumo-
cocci alone experienced no sharp reaction, while those
reeiving the mixed bacterin reacted with chill and sub-
sequent rise in temperature accompanied by a marked
change in the total white count and polynuclear in-
crease. Of the eleven cases treated ten made a prompt
recovery. The eleventh case, which terminated fatally,
was complicated with nephritis. In the cases treated
no detailed attempt was made to study the type of the
infecting organism, but of seven cases in which this
was done, three were of type I, three of type II, and
one of type III. In preparing the pneumococcus bac-
terins, seven strains, including the three fixed types,
were used. These were sensitized with the serum of
goats and sheep, immunized against the various types.
* Officers Elected for the Ensuing Year. — President,
Dr. Richard Weil, New York City; vice-president, Dr.
John A. Kolmer, M. D., Philadelphia, Pa.; treasurer,
Dr. Willard J. Stone, M. D., Toledo, O.; secretary, Dr.
Martin J. Synnott, M. D., 30 So. Fullerton Avenue,
Montclair, N. J.; council, Dr. Arthur F. Cock and Wil-
liam H. Park, New York City.
IMatp UrMral ICirrttfitng SnarfiH.
STATE BOARD EXAMINATION QUESTIONS.
Kentucky State Medical Board.
June 13, 14, 15, 1916
ANATOMY
1. (a) Describe the spinal cord, and (6) give its
length, weight, points of beginning and ending in the
pinal canal.
2. How many pairs of nerves are given off from the
spinal cord?
3. in) Locate and describe Peyer's glands, and (b)
state where they are largest and" most numerous.
4. What blood-vessels carry blood from the heart to
and from the lungs?
5. (live the origin and distribution of the great
sciatic nerve.
6. Describe the lymphatics of the liver.
7. Locate and describe the small intestine; state
where it begins, where it terminates, and name the
divisions.
8. Describe the esophagus, its structure, length, place
of beginning and termination.
9. Name, locate and describe the bones of the arm
and forearm.
10. (a) What bones form the pelvis, and (b) state
the difference between the false and true pelvis.
PHYSIOLOGY.
1. Describe the medulla oblongata and discuss its
functions.
2. Describe the digestion and assimilation of proteins.
3. Tell what you know of (a) the manufacture,
(b) functions and (c) final disposition of white blood
corpuscles.
4. Give in detail the functions of the kidneys.
5. Give the structure and functions of bone marrow.
6. (a) Discuss the essentials in the ventilation of a
school room, (6) a bed room, and (c) the dangers of,
and (d) tests for impure air.
7. (a) Differentiate between striated and non-stri-
ated muscles. (b) Give examples.
8. (a) Describe the sympathetic nervous system.
(6) Give its functions.
9. (a) Describe the development of the humerus.
(6) Of the temporal bone.
10. (a) Describe the most important vestibule of
the body, and (6) give its functions.
BACTERIOLOGY.
1. (a) Describe in detail the method of immunizing
a person against typhoid fever. (6) What is the dose
for a child weighing 50 pounds?
2. (a) Describe the Widal reaction. (b) Give its
value as a diagnostic symptom in typhoid fever.
3. (a) Describe the diphtheria organism; (6) its
staining characteristics, (c) Give method of detecting
diphtheria carriers.
4. Describe the organism of syphilis.
5. (a) Describe method of securing specimen for ex-
amination for malaria, (b) Differentiate the three va-
rieties of the malarial organism.
6. Differentiate the ova of (a) Ascaris lumbricoides,
(b) hookworm, (c) Oxyuris vermicularis.
7. How would you identify gonococci?
8. Give method of staining sputum for tubercle
bacilli.
9. Describe the tetanus bacillus.
10. Describe the meningococcus.
ANSWERS.
ANATOMY.
1. "The spinal cord is the elongated portion of the
cerebrospinal axis contained in the spinal canal. Its
length is about sixteen to eighteen inches, extending
from the medulla above to the lower border of the first
lumbar vertebra below, where it terminates in the
cauda equina by a slender prolongation of gray sub-
stance, called the conus medullaris. It presents two
enlargements, the upper or cervical, extending from
the third cervical to the second dorsal vertebra, and
the lower about the position of the second or third
dorsal vertebra. It is divided into two lateral halves
by the anterior and posterior median fissures, united
in the center by the commissure. The lateral portions
are again subdivided by the antero-lateral and postero-
lateral fissures into the anterior lateral and posterior
lateral columns, and posteriorly a narrow fissure sep-
arates the posterior median column from the posterior
median fissure. The gray substance occupies the center
of the cord, and is arranged into two crescentic masses
connected together by the gray commissure. The pos-
terior horn forms the apex cornu, from which arises
the posterior root of the spinal nerves. The anterior
horn is thick and short, and affords origin to the an-
terior root of the nerves. The gray commissure con-
tains throughout its whole length a minute canal the
central canal, or ventricle of the cord, continuous above
with the fourth ventricle." (Young's Handbook of
Anatomy.) The spinal cord weighs about one and a
half ounces.
2. Thirty-one pairs of spinal nerves are given off
from the spinal cord.
3. Peyer's patches are aggregations of solitary
glands, measuring from about half an inch to three
inches in length; they are found mainly in the ileum,
but also occur in the duodenum, and jejunum; they are
situated lengthw-ise in the intestine, and are located
opposite to the mesenteric attachment. Each patch is
surrounded by a group of the crypts of Lieberkuhn.
There are said to be from 30 to 50 of these patches
in the human intestine. As a rule, they have no villi
on their surface.
4. The pulmonary artery conveys the venous blood to
the lungs. The pulmonary veins convey oxygenated
blood to the heart. The bronchial arteries supply blood
for the nutrition of the lungs.
Oct. 21, 1916]
MEDICAL RECORD.
747
5. The great sciatic nerve arises from the sacral
plexus, and passes out of the pelvis through the great
sacrosciatic foramen, below the piriformis muscle; it
extends down the back of the thigh, passing between
the great trochanter of the femur and the tuberosity
of the ischium; at the lower third of the thigh it divides
into the internal and external popliteal nerves. It sup-
plies the hip-joint and the biceps, semitendinosus,
semimembranosus, and adductor magnus muscles.
6. "The lymphatics of the liver are numerous, and
-consist of a superficial and a deep set. The former
pass in various directions. Thus a large number go to
the hepatic glands in the lesser omentum; others pierce
the diaphragm and finally end in the right lymphatic
duct; others (a few) go to the lumbar glands. As
regards the deep set, some following the hepatic veins
.and inferior vena cava, end in the thoracic duct; others,
following the portal veins, end in the hepatic glands.
The efferents from the hepatic glands in the lesser
•omentum accompany the hepatic artery, and end in the
celiac glands." (McLachlan and Skirving's Applied
Anatomy.)
7. The small intestine is situated in the abdominal
cavity. It begins at the pyloric end of the stomach, in
the epigastric region and ends at the ileocecal valve in
the lower part of the right lumbar region. Its average
length is about 23 to 25 feet. It is divided into three
portions, the duodenum, the jejunum, and the ileum.
The duodenum is the first part of the small intestine,
it is about ten inches long, and extends from the pylorus
to the left side of the body of the second lumbar ver-
tebra. The jejunum and .ileum form the coils of the
small intestine and are covered by the great omentum;
they form the remainder of the small intestine, the
upper two-fifths being the jejunum and the lower three-
fifths the ileum; there is no line of demarcation between
these two parts. The coils of the jejunum and ileum
are suspended from the posterior abdominal wall by
the mesentery. The wall of the small intestine is com-
posed of four coats, a serous, muscular, submucous, and
mucous.
8. The esophagus is a muscular canal, about nine
or ten inches long, and extending from the lower border
of the pharynx (at the upper border of the cricoid
cartilage) to the stomach. It passes down along the
front of the spine, through the superior and posterior
mediastina, through the esophageal opening in the dia-
phragm, and ends in the cardiac orifice of the stomach
(opposite the tenth dorsal vertebra). It is generally
in the median line, but it curves to the left at the
root of the neck and again at the esophageal opening
in the diaphragm. It is composed of a general fibrous
covering on the outside, then a muscular coat consisting
of two layers, an outer longitudinal layer and an inner
circular layer; inside this is a submucous coat of areolar
tissue; and the esophagus is lined by a mucous coat
which is covered by stratified squamous epithelium.
9. "The humerus, or arm-bone, the largest and long-
est bone of the upper extremity, consists of a shaft,
head, neck, greater and lesser tuberosities, and lower
extremity.
"The shaft, cylindrical above, flattened and prismoid
below, becomes twisted jn the middle, and presents: A
rough triangular surface about the middle of its outer
surface for insertion of the deltoid muscle, and a mus-
culo-spiral groove for the musculo-spiral nerve and su-
perior profunda artery, on each side of which arise the
external and internal heads of the triceps muscle.
"The tipper extremity presents — the head, forming
nearly a sphere, projecting upward, backward, and in-
ward, articulating with the glenoid cavity; the anatom-
ical neck, immediately beneath, is slightly grooved for
the attachment of the capsular ligament; greater tuber-
osity, external to the head and lesser tuberosity, with
three facets from before backward for attachment of
supraspinatus, infraspinatus, and teres minor muscles;
lesser tuberosity, smaller but more prominent than
greater, is anterior to head, for the subscapular muscle ;
biciptal groove, passes downward and inward between
the two tuberosities and lodges the long tendon of bi-
ceps; the anterior biciptal ridge, bounds the groove in
front and receives insertion of pectoralis major muscle;
the posterior biciptal ridge receives the latissimus dorsi
and teres major; the surgical neck, including the head,
neck, and both tuberosities; a rough impression near
the center of the inner border for the coraco-brachialis
muscle; nutrient canal, below and directed toward the
lower extremity.
"The lower extremity presents from within outward
the following: Internal condyloid ridge, extending up-
ward from the condyle; internal condyle, more promi-
nent than external, gives origin to the flexors and pro-
nator radii teres; epitrochlea, an eminence separating
the trochlea from the internal condyle; trochlea, a pul-
ley-like articulating surface for greater sigmoid cavity
of ulna; eoronoid fossa, a small depression bounding the
trochlea in front, and receiving the eoronoid of the ulna
in flexion ; olecranon fossa, a larger depresssion behind,
and receiving the olecranon process of ulna in exten-
sion ; supra-trochlear foramen, sometimes formed by
perforation of one fossa into the other; radial head, or
capitellum, a smooth, rounded eminence articulating
with cup-like depression on head of radius; external
condyle, less prominent, gives origin to the extensors
and supinators; external condyloid ridge, extending up-
ward on the shaft from the condyle.
"It articulates with three bones — scapula, radius, and
ulna. (Young's Handbook of Anatomy.)
"The Radius is a long bone, shorter than the ulna,
situated on the outer side of the forearm, the upper end
small, the shaft slightly curved, and the lower end ex-
panded to form part of the wrist joint. It consist of
shaft, upper and lower extremity. The shaft is pris-
moid, slightly curved, and presents: An internal border,
sharp and prominent, for interosseous membrane; an
anterior border, marked at its upper third by an oblique
line, for attachment of flexor longus pollicis, supinator
brevis, and flexor sublimis digitorum; anterior surface,
affords attachment above for flexor longus pollicis, be-
low for pronator quadratus, and presents at the junc-
tion of middle and upper two-thirds a nutrient foramen
directed upward; posterior surface gives attachment
at upper third to supinator brevis, and at middle third
to extensors of thumb.
"The upper extremity presents: Head — a cup-like
cylindrical cavity, for articulation with capitellum of
humerus, and on its side an articulating surface for
lesser sigmoid cavity of ulna and orbicular ligament,
which nearly surrounds it; neck, the constricted portion
below the head; bicipital tuberosity, below and to inner
side, divided by a vertical line into a rough surface
posteriorly, for attachment of biceps tendon, and smooth
surface anteriorly for bursa.
"The lower extremity, large, expanded, and quadri-
lateral, presents: Carpal articular surface, smooth,
concave, triangular depression divided by an antero-
posterior ridge into an outer facet for scaphoid bone
and inner for semilunar ; sigmoid cavity, a shallow
concavity at inner side of carpal end, for articulation
with ulnar head; styloid process, projects obliquely
downward from the external surface, for attachment
by its apex to external lateral ligament of wrist-joint,
and by its base to insertion of supinator longus muscle.
Its outer surface is marked by two grooves for ex-
tensors of thumb. The posterior surface of the lower
extremity is also marked by three grooves from without
inward for the following: Ext. carpi radialis longior
and brevior in first, ext. secundi internodii in second,
and ext. indicis, ext. communis digitorum, and ext.
minimi digiti in third. This surface has also attach-
ment of posterior ligament of wrist." — (Young's Anat-
omy.)
"The ulna is a long bone to the inner side of the
forearm, and consists of a shaft and an upper and
lower extremity. It forms the greater part of the
articulation with the humerus, but does not enter into
the formation of the wrist-joint, being excluded by the
interarticular fibro-cartilage.
"The shaft is prismatic above, smooth and rounded
below, and presents: Anterior surface, gives attach-
ment to the deep flexors and pronator quadratus;
nutrient foramen on anterior surface, directed upward
toward the elbow-joint; posterior surface marked above
by an oblique line for part of supinator brevis, above
which is smooth triangular surface for anconeus mus-
cle, and the lower third for extensor muscles of the
thumb; external border, sharp in middle two-thirds, for
attachment of interosseous membrane.
"The upper extremity is large and irregular, and
presents: Olecranon process (head of elbow), projects
upward and forward, its apex being received into the
olecranon fossa of the humerus in extension of the fore-
arm; its upper border has rough impression for the
triceps muscle; its lateral borders are grooved for ex-
ternal and internal lateral ligaments; eoronoid process,
smaller than olecranon, projects forward from anterior
surface, being received into eoronoid fossa of humerus
in flexion. Its supper surface forms part of the great
sigmoid cavity. Its under surface has rough impres-
sion for insertion of brachialis anticus, and has, at its
junction with the shaft, the tubercle of the ulna for
the oblique ligament. Its outer surface is the lesser
748
MEDICAL RECORD.
[Oct. 21, 1916
sigmoid cavity. Its inner surface gives attachment to
the internal lateral ligament, and tne flexor digitorum
sublimis, flexor profundus digitorum, and one head of
pronator radii teres. Greater sigmoid cavity is a large,
semi-lunar depression between the olecranon and coro-
noid processes, divided into two unequal lateral parts
by an elevated ridge. It is continuous on the outer side
with the lesser sigmoid cavity and articulates with the
trochlear surface of the humerus. Lesser sigmoid
cavity is an oval, concave, articular depression, external
to the coronoid process, for articulation with the head
of the radius. Its prominent extremities give attach-
ment to the orbicular ligament.
"The lower extremity is small and cylindrical and
presents: Head, an external, rounded, articular process,
for the triangular fibro-cartilage below and the sig-
moid cavity of the radius externally; Styloid process,
projects from the posterior and internal part of the
extremity, its apex gives attachment to the internal
lateral ligament of the wrist, and it is marked at its
root by a depression between it and the head, for at-
tachment of the fibro-cartilage; groove, upon the
posterior surface, for passage of extensor carpi ulnaris
It articulates with two bones — humerus and radius."
(Young's Anatomy.)
10. The pelvis is formed by the two ossa innominata,
the sacrum and the coccyx; each os innominatum is
made up of ilium, ischium, and pubis.
The false pelvis is that expanded portion of the
pelvis above the iliopectinal line and the upper margin
of the symphysis pubis. The true pelvis is the part
beneath this plane. It is smaller, and has more perfect
walls than the false pelvis.
PHYSIOLOGY
1. The medulla oblongata is the lowest part of the
encephalon, and is continuous below with the spinal
cord. It extends from the lower margin of the pons to
the lower margin of the foramen magnum. It lies in
the basilar groove of the occipital bone; its dorsal sur-
face is between the cerebellar hemispheres. It forms the
lower part of the floor of the fourth ventricle. It is
about one inch long, half inch wide, and half inch thick.
It has anterior and posterior median fissures, which are
continuous with those of the spinal cord.
The functions of the medulla oblongata are: (1) It
is a conductor of nervous impulses or impressions from
the cord to the cerebrum, from the brain to the spinal
cord, also of co-ordinating impulses from the cere-
bellum to the cord; (2) it contains collections of gray
matter which serve as special nerve centers for the
following functions or actions; respiration, salivary se-
cretion, mastication, sucking, deglutition, speech pro-
duction, facial expression; it also contains the cardiac
and vasomotor centers.
2. Proteids are digested in the stomach (by the pepsin
of the gastric juice) and in the small intestine (by the
trypsin of the pancreatic juice).
During digestion the proteids are split up into pro-
teoses, peptones, polypeptides and amino-acids. The
amino-acids are believed to be taken as such by the
epithelial cells and carried to the blood of the portal
capillaries. Another view is that in the intestinal
epithelium the amino-acids are built-up again into
proteins such as are found in the blood. There are
three theories of the further history of the proteids.
According to one of them (the theory of Voit), "the
protein of the tissues, living or organized protein, is to
I"' differentiated from the absorbed circulating protein.
It is only in this circulating protein, which is assumed
to be present in the fluids of the body, the blood and
lymph, that catabolic changes take place. These
changes take place under the influence of the living
The more resistant organized protein is not sup-
1 to undergo catabolic changes. If any of it does,
it is cast off into the fluids of the body, and thus be-
comes circulating protein, undergoing catabolic changes
in precisely the same manner. It is obvious that a small
part of the absorbed protein must be utilized to re-
place the waste of the organized protein and to sub-
the process of growth. This portion is termed
tissue protein." (Lyle's Physiology.)
3. fyhiti blood corpuscles are formed in the spleen,
lymph glands, and lymphoid tissue; also from other
white cells by direct cell-division in the blond stream;
the eosinophils may be derived from the bone marrow.
Their fate is uncertain: it has been asserted that they
are converted into red blood cells; they play a part in
the formation of fibrin ferment: they are' sometimes
converted into pus cells. Their functions are (1) to
serve as a protection to the body from the incursions
of pathogenic microrganisms; (2) they take some part
in the process of the coagulation of the blood; (3) they
aid in the absorption of fats and peptones from the
intestine, and (4) they help to maintain the proper
proteid content of the blood plasma.
4. The functions of the kutney are: (1) To secrete
(or excrete) urine; (2) to regulate the reaction of the
urine; (3) the formation of hippuric acid; (4) regu-
lation of the composition of the blood plasma by ex-
cretion of abnormal or toxic substances; and (5) the
production of an internal secretion. The mechanism of
the secretion of urine by tltc kulneys is twofold: (1) By
filtration, most, if not all, of the fluid is eliminated,
and also inorganic salts; this depends upon blood pres-
sure, and takes plaee in the glomeruli. (2) By cell
activity and selection, in the cells of the convoluted
tubules, the urea, and principal solids are eliminated.
5. Bone marrow. "Red marrow is the connective
tissue which occupies the spaces in the cancellous tis-
sue; it is highly vascular, and thus maintains the
nutrition of the spongy bone, the interstices of which
it fills. It contains a few fat-cells and a large number
of marrow-cells. The marrow cells are ameboid, and
resemble large leucocytes; the granules of some of these
cells stain readily with acid and neutral dyes, but a
considerable number have coarse granules which stain
readily with basic dyes like methylene blue. Among
the cells are some smaller nucleated cells of the same
tint as colored blood corpuscles. These are termed
erythroblasts. From them the colored corpuscles of
the blood are developed. There are also a few large
cells with many nuclei, termed giant cells or myelo-
plaxes. Yellow marrow fills the medullary cavity of
long bones and consists chiefly of fat-cells with nu-
merous blood-vessels; many of its cells also are the
colorless marrow-cells just mentioned." (Halliburton's
Physiology.)
6. (a) The essentials in the ventilation of a school-
room are that there must be 1,000 cubic feet of space
for each individual, that the air in this space must be
changed three times in an hour, that the air must be
warmed to 60" to (55 : Fahr., and that it must be mois-
tened and purified (or at least strained to remove ex-
cessive dust. "Theie is considerable difference of opin-
ion as to the best locations for inlets and outlets, and
as the conditions are necessarily different in every case
and so many factors are to be considered, it is difficult
to lay down any general rules. It should be an aim,
however, to have the air well distributed and to have
no direct draughts from the inlets either upon the oc-
cupants or to the outlets. Usually the outlets should be
located near the top of the room, owing to the tendency
of the used air to rise, and because, in unventilated
rooms, the foulest air for some time after its contamina-
tion will be found nearest the ceiling. The products
of combustion from lights, etc., will also practically
all be in the upper strata of air. If, however, pro-
vision is or can be made for a constant and sufficiently
strong aspirating force in the outlet ducts, it may be
advisable to withdraw the used air from near the floor
level and below the inlet openings, though not in too
close proximity to them, since in this way a more
thorough distribution of the incoming air and a greater
dispersion of its contained hea't are secured. The loca-
tion of the inlets should depend on the temperature of
the incoming air; if it is cold it should be admitted near
the ceiling, so that it may diffuse and be partially
warmed before reaching the inmates of the room; if it
is warmed it may come in near the floor or below the
middle level of the room." (Egbert's Hygiene and
Sanitation.)
(b) In a bedroom, for adults, proper ventilation may
be secured by having double windows, or double panes
of glass, with an opening at the bottom of the outer
and at the top of the inner one, so that the fresh air
may enter in an upward current; or by placing a board
under the lower sash so that fresh air can enter in the
middle.
(c) The dangers of impure air are: Drowsiness,
headache, digestive disturbances, mental dullness, and
disease or liability to take disease. The chief danger
to health is in the increase of carbon dioxide, the
presence of crowd-poison, dust, irrespirable gases, and
bacteria.
(d) The relative amount of carbon dioxide in the
air is taken as an indication of its purity; not because
the carbon dioxide is itself harmful in the amounts
generally encountered, but because it is readily esti-
mated and is a fair indicator of the purity of the air.
Pettenkofer's method of determining the percentage-
of carbon dioxide in the air: A large cylindrical con-
Oct. 21, 1916]
MEDICAL RECORD.
749
tainer of known capacity, say, 15 liters, is filled with
the air to be examined; a known volume of barium
hydroxide is then added and shaken up with the air.
'1 ne carbon dioxide combines with the barium hydroxide
to form a barium carbonate, which is insoluble, and
also incapable of acting upon an indicator. The barium
hydroxide employed is of known strength, e.g., it may
be of such strength that 1 c.c. of the solution neutral-
izes 1 c.c. of carbon dioxide at normal temperature and
pressure. If then we find that 10 c.c. of the barium
hydroxide has been neutralized by the carbon dioxide
present in the air, we know that 10 c.c. of carbon di-
oxide is present in 15 liters or 15,000 c.c. of the air
examined.
7. Voluntary muscle is more or less under the control
of the will, does not contract rhythmically, does not
evince peristalsis; involuntary muscle is not under the
control of the will, it is rhythmical in its contractions,
and is also characterized by peristalsis.
Further, voluntary muscle is striated, has long nar-
row fibers with cross striations and many nuclei be-
neath the sarcolemma. Involuntary muscle is non-
striated, has spindle-shaped fibers, one nucleus cen-
trally located, and no sarcolemma. The great excep-
tion is cardiac muscle, which is involuntary and also
striated. Voluntary muscle is found in all the skeletal
muscles, pharynx, diaphragm, larynx, external ear, and
eye. Involuntary muscle is found in the alimentary
tract from the middle third of the esophagus to the
anus, in the ducts of glands, in the trachea and bron-
chial tubes, within the eyeball, the internal urinary and
genital systems, circulatory (except the heart) and
lymphatic systems, and the capsules of some organs.
8. "The sympathetic nervous system consists of (1) a
series of ganglia connected together by a great gan-
glionic cord, the gangliated cord, extending from the
base of the skull to the coccyx, one gangliated cord on
each side of the middle line of the body, partly in front
and partly on each side of the vertebral column; (2) of
three great gangliated plexuses or aggregations of
nerves and ganglia, situated in front of the spine in the
thoracic, abdominal, and pelvic cavities respectively;
(3) of smaller or terminal ganglia, situated in relation
with the abdominal viscera; and (4) of numerous
fibers." — (Gray's Anatomy.)
Function: It has a controlling influence over the se-
cretion of most of the glands, the lacrimal, the salivary,
the sweat glands, the glands of the stomach and intes-
tines, the liver, the kidney, etc.; it presides over the
circulation by regulating the caliber of the blood-vessels
and the action of the heart; it influences respiration;
and, all involuntary muscles, those of the digestive ap-
paratus, of the genitourinary system, of the hair folli-
cles (pilomotor nerves), are under its control to a great
extent.
9. Development of the humerus. "Ossification occurs
from a primary center in the shaft and six or seven
secondary centers in the extremities. In the upper
extremity centers appear in the head, great tuberosity,
and sometimes in the small tuberosity, which, after
fusing together, join the shaft about the twentieth
year. In the lower extremity centers appear in the
trochlea, capitellum, and outer and inner condyles, the
three former of which, after coalescing, unite with the
shaft in the seventeenth year. The inner condyle forms
a distinct epiphysis which unites somewhat later."
(Gerrish's Anatomy.)
Development of the temporal bone. "The squamosal
and tympanic bones ossify in membrane, each from a
single center; the petrous portion and styloid process in
cartilage, the former from four centers, the latter from
two. The fetal tympanic bone forms an incomplete
ring, which incloses the tympanic membrane. It is
open above with its free ends united to the squamosal.
The defect in the ring due to this opening above is
known as the notch of Rivinus. Two tubercles, one
growing from the front and the other from the back
of this ring, meet in the floor of the meatus, enclosing
a foramen, which is gradually (though not always)
closed, and thus the tympanic plate is formed. At
birth the mastoid process, articular eminence, and
tympanic ring are flat, the glenoid fossa is shallow,
and the hiatus Fallopii opens at the genu of the canal."
(Gerrish's Anatomy.)
10. The vestibule of the internal ear. "The vestibule
is situated on the inner side of the tympanum, behind
the cochlea and in front of the semi-circular canals. It
is somewhat ovoid in shape, and measures about one-
fifth of an inch in length. On its outer wall is the
fenestra ovalis, closed by the base of the stapes and
membrane; on its inner wall is the fovea hemispherica,
pierced by minute holes, for the filaments of the audi-
tory nerve and opening of the aqueductus vestibuli; on
its roof is a small depression, the fovea semi-elliptica;
behind are the five openings of the semi-circular canal,
and in front an opening which communicates with the
cochlea." (Ashby's Notes on Physiology.) The func-
tion of the vestibule — It is supposed to be concerned
with equilibrium.
BACTERIOLOGY.
1. Method of immunizing against typhoid. The vac-
cine is administered subcutaneously over the insertion
of the deltoid muscle; the site of the injection should
have been previously painted with tincture of iodine;
intramuscular injections are to be avoided; after the
injection has been given the iodine is wiped off with
a pledget of cotton and alcohol; no dressing is needed;
the syringe and needle must be sterile; three such in-
jections are given at intervals of about ten days; the
dosage for adults (of 150 pounds weight) is 500 million
bacilli for the first injection, and 1000 million bacilli
for the second and third injections; each of these
amounts is contained in about fifteen minims or one
cubic centimeter; for a child weighing fifty pounds the
dosage should be about one-third of the above, or a^
little more, for children take the injections very well.
2. (a) The Widal test for tvphoid fever "depends
upon the fact that serum from the blood of one ill with
typhoid fever, mixed with a recent culture, will cause
the typhoid bacilli to lose their motility and gather in
groups, the whole called 'clumping.' Three drops of
blood are taken from the well-washed aseptic finger tip
or lobe of the ear, and each lies by itself on a sterile
slide, passed through a flame and cooled just before
use; this slide may be wrapped in cotton and trans-
ported for examination at the laboratory. Here one
r',-op is mixed with a large drop of sterile water, to re-
dissolve it. A drop from the summit of this is then
mixed with six drops of fresh broth culture of the
bacillus (not over twenty-four hours old) on a sterile
s'ide. From this a small drop of mingled culture and
blood is placed in the middle of a sterile cover-glass,
and this is inverted over a sterile hollow-ground slide
and examined. ... A positive reaction is obtained
when all the bacilli present gather in one or two masses
or clumps, and cease their rapid movement inside of
twenty minutes." — (From Thayer's Pathology.)
(b) Its diagnostic value is believed by some to be
great; others place little reliance on it. It may be
absent in cases of typhoid fever; it may be present for
several months after an attack of typhoid; the reac-
tion may not be obtained till the third week of the dis-
ease; it may be present in other diseases or in per-
fectly healthy persons. The above have all been urged
as objections; certainly only positive results have any
value at all.
3. The characteristics of the bacillus of diphtheria:
The bacilli are from 2 to 6 mikrons in length and from
0.2 to 1.0 mikron in breadth; are slightly curved, and
often have clubbed and rounded ends; occur either
singly or in pairs, or in irregular groups, but do not
form chains; they have no flagella, are non-motile, and
aerobic; they are noted for their pleomorphism; they
do not stain uniformly, but stain with any aqueous
solution of an anilin dye, they also stain well by Gram's
method and very beautifully with Loeffler's alkaline-
methylene blue; Neisser's stain is also recognized.
Diphtheria carriers can only be detected by the find-
ing of the diphtheria bacilli in the secretions of their
nose and throat. A sterile swab is rubbed over any
visible membrane on the tonsils or throat and is then
immediately passed over the surface of the serum in a
culture tube. The tube of culture, thus inoculated, is
placed in an incubator at 37° C. for about twelve hours,
when it is ready for examination. A sterile platinum
wire is inserted into the culture tube, and a number
of colonies of a whitish color are removed by it and
placed on a clean cover slip and smeared over its sur-
face. The smear is allowed to dry. is passed two or
three times through a flame to fix the bacteria, and is
then covered for about five or six minutes with a
Loeffler's methylene-blue solution. The cover slip is
then rinsed in clean water, dried, and mounted. The
bacilli of diphtheria appear as short, thick rods with
rounded ends; irregular forms are characteristic of this
bacillus, and the staining will appear pronounced in
some parts of the bacilli and deficient in other parts.
Methods of culture: The bacillus of diphtheria grows
upon all the ordinary culture media, and can be readily
750
MEDICAL RECORD.
[Oct. 21, 1916
obtained in pure culture. Loeffler's blood serum, par-
ticularly with the addition of a little glucose, is an
admirable medium for the rapid growth of this bacillus.
The medium should be alkaline and not less than 20° C.
4. Syphilis is due to infection by the Treponema
pallidum, also called the Spirochseta pallida. This is a
slender spirillum, with regular turns, the curves vary-
ing in number from three or four to twelve or even
twenty; it is about 4 to 20 mikrons long, actively motile,
with a fine flagellum at each pole; it is flexible, hard to
stain, and has not been cultivated on artificial media.
How it divides is not known. It stains best with
Giemsa's eosin solution and azur.
5. In examining for malaria: "Prepare some per-
fectly clean and very thin cover slips, and remove all
traces of grease. Cleanse the skirfof the finger-tip or
ear with soap and water, and then with alcohol and
ether. Make a small prick in the skin. Wipe away the
first drop of blood, leaving a perfectly dry surface, so
that subsequent drops will not run. Squeeze out a
tiny drop about the size of a large pin's head. Touch
the apex of this drop with the center of a cover glass,
and immediately drop it, face downward, on a perfectly
clean slide. Make several such preparations, and reject
all those in which rouleaux are present. It is abso-
lutely essential that the red corpuscles should lie flat.
Examine with a 1/12 immersion lens and rather feeble
illumination. Look in the red corpuscles for the pres-
ence of small black specks, often rod-like and showing
slow movements of translation. These are surrounded
by clear areas. One may also see in the center of some
of the red cells clear ameboid areas which show no
pigment. Rosette forms may also be visible. These
forms of the parasite are always present in cases of
malaria which have not had quinine. Other varieties
are only met with in some chronic cases. Of these there
are two chief forms: (1) The crescentic, (2) the flagel-
lated. These are easily recognized. The crescentic
bodies are highly retractile, rather longer than a red
blood corpuscle, and about 2m in diameter. Particles of
pigment may be recognized in the parasite and also in
some of the ordinary leucocytes." — (Hutchinson and
Rainy.)
TERTIAN.
QUARTAN.
Cycle in man 48
hours.
Ameba in red cell
active.
Decolorizes red
cell rapidly.
Causes red cell to
swell.
Outlines not
sharply defined.
Pigment in fine
granules, abun-
dant, in motion.
Spores 15-20, usu-
ally 18, small.
Flagella more
numerous.
Ring forms com-
mon, early,
more distinct
than those of
estivo - autum-
nal.
3 days.
Sluggish.
Slowly.
Size preserved or
diminished.
Sharp.
Coarser, fewer.
ESTIVO-
AUTUMNAL.
6-12, larger.
24-48 hours.
Smaller than ter-
tian.
Hemoglobin deep-
er in tint.
Red cells shrivel.
Pigment in fine
peripheral
granules, not
often in motion.
Small, 6-30, usu-
ally 18.
Less numerous.
Common, ring
and disk form
less distinct.
— (Thayer.)
<;. The ova of Ascaris lumbricoides "are elliptical
with a thick (4m) transparent shell and an external
albuminous coating which forms protuberances; the ova
measure 50m to 70m in length, 40m to 50m in breadth ;
they are deposited before segmentation; the albuminous
coating is stained yellow by the coloring matter of the
feces, but it is sometimes absent. The egg cell is un-
segmented, it almost completely fills the shell, and its
nucleus is concealed by the large amount of coarse yolk
granules."
The ova of Ancylostoma duodenale "appear to have a
single contour. Under high powers this appears double,
but they are the outer and inner surface of the true
(chitinous) egg-shell. Internal to this is the extremely
delicate yolk-envelope, a kind of skin secreted by the
egg cell around itself for protection. The eggs are oval,
with broadly rounded poles, 56m to 61m by 34m to 38m.
In fresh feces they contain four granular nucleated seg-
mentation masses of the ovum separated by a clear
space from the shell."
The ova of Oxyuris vermicularis "are oval, asym-
metrical, with double-contoured shells, and measure 50m
to 55m by 16m to 25m; they are deposited with clear,
non-granular tadpole-like embryos already developed."
(From The Animal Parasites of Man, by Fantham,
Stephens, and Theobald.)
7. Gonococci are recognized by their form (diplo-
cocci), their location (intracellular), and their staining
properties (eosin and methylene blue, and being decolor-
ized by Gram's method) ; they are exceedingly difficult
to cultivate, and this feature renders differentiation
from the Micrococcus catarrhalis easy, inasmuch as the
latter grows readily on simple culture media.
8. To demonstrate the existence of tubercle bacilli
in the sputum : The sputum must be recent, free from
particles of food or other foreign matter; select a
cheesy-looking nodule and smear it on a slide, making
the smear as thin as possible. Then cover it with some
carbolfuchsin, and let it steam over a small flame for
about two minutes, care being taken that it does not
boil. Wash it thoroughly in water and then decolorize
by immersing it in a solution of any dilute mineral acid
for about a minute. Then make a contrast stain with
solution of Loeffler's methylene blue for about a minute;
wash it again and examine with oil immersion lens.
The tubercle bacilli will appear as thin red rods while
all other bacteria will appear blue. The tubercle
bacillus is rod shaped, is from 1% to 3% mikrons in
length and about one-third to one-half a mikron in
breadth, is a strict parasite, is not motile, and has no
flagella. It is slightly curved, does not form spores, is
not liquefying; is nonchromogenic ; is aerobic; it re-
sists acids; it grows well on blood serum; stains well by
Ehrlich's, Ziehl-Neilsen's, or Gabbett's method; it is
Gram-positive.
9. The bacillus of tetanus is characterized by its
peculiar spore, formed at one end of the bacillus and
giving it the appearance of a pin ; it is purely anaerobic,
and cannot be developed at all in the presence of oxygen.
It generally comes from the soil, and is found in pene-
trating wounds. It appears in two forms, the spore-
bearing form, as described above, and the vegetative
form, which is a short bacillus with rounded ends, and
which may occur singly or in pairs, or may form long
filaments. It grows in gelatin stab cultures in the
middle of the medium and the colonies look something
like a fir tree; its growth is slow, and a disagreeable
odor is at the same time emitted. In bouillon, it grows
near the bottom of the tube, and produces gases.
10. The meningococcus is a small, non-motile, non-
flagellate coccus; it does not form spores, does not
liquefy gelatin, is aerobic, and pathogenic; it appears
in diplococcus groups, and may be found within or out-
side the cells; it stains readily with the ordinary anilin
dyes, but is Gram negative. It grows readily upon meat
infusions, and especially so on media to which ascitic
fluid or blood serum has been added.
(To be continued.)
Antirabic Service of the Pasteur Institute in Tunis for
1915. — The total number of cases treated was 443, from
which number must be deducted twenty-three (fifteen
cases in which dog was not shown to be rabid and eight
who abandoned treatment) . There were five deaths of
patients under treatment, due to severity of infection
or late arrival at the institute. The total number thus
far treated at the latter is 5,711, with eighteen deaths.
The animals had homes in about one-half the cases, the
others being strays. The large number of pet animals
is difficult to explain. In only forty cases was diagnosis
made by inoculation. In sixty-two the veterinary diag-
nosis was made, and all other animals were merely sus-
pects.— Archives de I'Institut Pasteur de Tunis.
Pellagra. — Jelks concludes an article on this subject
as follows: "We never saw a pellagrin in this country
until a few years ago, yet there are in the State of
Mississippi alone perhaps 5,000 cases to-day, at least
3,500 of which have been reported this year. Many
cases are not reported as pellagra at all. There are
perhaps 50,000 cases of pellagra in this country to-day
and the disease is increasing at an appalling rate. It
is a fact that usually the skin symptoms, upon which so
many rely for a diagnosis, are late symptoms, or may
escape entirely the casual observer. Certainly we must
learn to make diagnosis of pellagra or rather the con-
dition upon which depends this misnomer, and late
symptom. — Pacific Medical Journal.
Medical Record
A Weekly Jotirnal of Medicine and Surgery
Vol. 90, No. 18.
Whole No. 2399.
New York, October 28, iqi6.
$5.00 Per Annum.
Sin£le Copies, J 5c.
(Original Arttrka.
HYDROLOGY IN MILITARY PRACTICE.*
By GUY HINSDALE, A.M., M.D.,
HOT SPRINGS, VA.
FELLOW OF THE ROYAL SOCIETY OF MEDICINE.
"The old order changeth," and nowhere will the
change be more noteworthy than in the attitude of
travelers and health-seekers toward European spas.
American and English tourists will some day seek
again the Continental watering-places, but it is
safe to predict that a generation will pass before
they flock to Teutonic resorts as in the past. We
shall never hear of a British King visiting Hom-
burg again, and it is doubtful if Americans will
spend their millions annually in Karlsbad, Wies-
baden, and Nauheim for years to come. British
watering-places will undoubtedly have a revival, and
the innumerable French spas will surely gain im-
mensely in popularity with all English-speaking
travelers. This is but natural, and it does not re-
quire a prophet to foretell it.
In England a systematic effort has been made in
the last year to afford wounded and invalid soldiers
and sailors the benefits of spa treatment at home.
A committee of the Royal Society of Medicine has
been charged by the War Office with this service,
and has carefully examined its resources with this
end in view. The peculiar adaptation of each one
of the forty-five different resorts has been stated
in a report recently issued, and consequently their
doors have been opened to thousands of soldiers
and sailors invalided home. No doubt the soldier
who is sent to Buxton, Harrogate, or Bath will be
more fortunate than his comrade who finds himself
in the best of London hospitals unless he needs the
special skill of some metropolitan consultant. Even
the remedial uses of air and water may often over-
balance the skill of the best specialist.
It is the intention to distribute cases wherever
the best treatment can be afforded, and it is found
that the spas and other bathing establishments in
Great Britain afford special advantages for after-
treatment.
The surgical affections which are amenable to
treatment in this manner include contusions and
bruises, sprains and strains of joints, fracture near
joints with immobility, fractures imperfectly healed,
unresolved effusions, fractures with osteitis and
necrosis (obstinate cases), wounds unhealed and
painful scars, cases where arterial circulation is
locally deficient, as from the effects of pressure or
frost-bite, and, finally, cases after operation.
Ills Spas May Heal. — Among the medical affec-
tions appropriate for spa treatment are rheumatic
disorders, fatigue fever and muscular rheumatism,
*Read at the thirty-third annual meeting of the
American Climatological and Clinical Association at
Washington, May 9, 1918.
or subacute fibrositis, all of which are liable to fol-
low fatigue and exposure; sciatica and lumbago,
convalescence from rheumatic fever, chronic ar-
ticular rheumatism, synovitis, and degenerative
arthritis.
Among the circulatory disorders are defective
peripheral circulation, cardiac dilatation, Graves's
disease, and tachycardia.
Nervous diseases form a very important class, in-
cluding the condition of nervous shock resulting
from traumatism, mental shock or operation, neur-
asthenia and psychasthenia, irritative conditions
with excitement and insomnia, and melancholia.
Then, also, the palsies, both central and peripheral,
the atrophies and the terrible cases of peripheral
neuritis and kindred afflictions which Drs. Mitchell,
Morehouse, and Keen cared for during our own
great war. Then comes the long list of digestive,
hepatic, respiratory and cutaneous disorders. The
committee has indicated appropriate climatic and
hydrologic treatment, and the particular places
where these can be afforded.
I have recently received from Dr. Charles W.
Buckley, of Buxton, an account of the treatment
afforded soldiers at that famous spa. In his letter
he says:
It will perhaps be best if I first describe what is
being done here. Buxton, with Bath and Harrogate,
is doing very much the same in the matter, while the
smaller spas, Droitwich, Woodhall Spa, Llandrindod,
Strathpeffer, etc., are using their resources so far as
they go.
In Buxton the large mineral-water hospital known as
the Devonshire Hospital, which has 316 beds and a
complete installation of baths, has placed 200 beds at
the disposal of the military and naval authorities for
the treatment of rheumatic disorders and such other
conditions as are likely to benefit by the Buxton climate
and special forms of treatment. About 1,500 patients
have been treated so far, with a very large proportion
of cures. Very few cases of wounds are received, and
only those in which massage or similar treatment is
required for the treatment of stiffness, nerve injuries,
etc. A fair proportion of cases of nerve shock are sent,
but, except in the milder forms, would be better treated
in institutions more especially devoted to that class of
case. The great bulk of the cases are rheumatism,
articular or fibrous (muscular), sciatica, gonorrheal
and traumatic arthritis, and what is known as "Flanders
foot," a form of frost-bite due to standing in trenche-
up to the knees or higher in cold water.
There is also a Red Cross hospital of fifty beds; the
cases are of similar type, but with a larger proportion
of men sent to convalesce after wounds. They have
their balneological treatment at the municipal bathing
establishment. In both hospitals, while mineral-water
treatment, baths, douches, etc., is the chief therapeutic
measure, massage and electrotherapy, especially ioniza-
tion, are employed.
The Canadian Red Cross Society has just established
a hospital of 300 beds in the town for the treatment of
special cases similar to those dealt with at the hos-
pitals already referred to, but it is expected that case?
of nerve shock will receive special consideration at this
hospital. It will have its own electrotherapeutic es-
tablishment, but will send cases for mineral-water
treatment to the municipal establishment. It will be
staffed by officers of the Canadian Army Medical Corps,
752
MEDICAL RECORD.
[Oct. 28, 1916
but for the special treatment by the mineral water two
local practitioners have been given honorary commis-
sions in order that their special experience may be avail-
able. I have the honor to be one of these.
For officers requiring treatment special arrangements
have been made lor their accommodation at hotels, etc.,
in the town. They receive free treatment at the baths
and free medical attendance.
Both at Harrogate and Bath the mineral-water hos-
pitals have been largely or entirely given over to sol-
diers, but as they are both smaller than the Buxton
hospital they do not accommodate so large a number of
military cases, I believe. In Bath there is also a Red
Cross hospital and a V. A. D. hospital; there is no es-
sential difference, I think, between these two organiza-
tions; there is also a small hospital for officers. Pri-
marily these hospitals are for cases likely to receive
special benefit from the spa in question, but, as in the
case of Buxton, wounded soldiers are received as well.
A large hospital of 500 beds is about to be opened at
Combe Park, near Bath, and staffed by the local doc-
tors, but this will be for wounded soldiers and not for
special bath treatment. At Harrogate the Grand
Duchess George of Russia maintains a private hospital,
and there are also hospitals under the V. A. D. system
on the same lines as those already referred to. In the
smaller spas the mineral-water hospitals are also in use
for soldiers, supplemented by small V. A. D. hospitals.
We have no hydrological institutions in this country
strictly comparable with those in the States. The so-
called hydropathics are often no more than pensions or
hotels with a small equipment of baths and simple
forms of douche; a few of these have taken soldiers
for special treatment, but I cannot give you any de-
tails beyond what you will find in the small book pub-
lished by the Health Resorts Sub-Committee of the
Royal Society of Medicine, which you already have.
Yours sincerely,
Chahles W. Buckley.
France is sending her wounded as far as Biarritz
and Nice and the neighboring Riviera, and we hear
that Vichy and Aix-les-Bains are full of soldiers
"taking the cure" until able to join the ranks again,
if need be. One of the great sources of reputation
of Aix was the remarkably good results achieved
in affections of the joints and in supplementing the
work of the military surgeon. The soldiers of
Napoleon went there, and recovered and fought
again in later campaigns.
I have recently received from Dr. Margnat, of
Vichy, who is now in command of a field ambulance,
a letter in which he describes the efforts which the
sanitary corps is making to afford balneologic
treatment to the troops in the present war. The
spas in France which are receiving sick and
wounded soldiers by direction of the War Office are
Amelie-les-Bains, Bareges, Bourbonne-les-Bains,
Bourbon-PArchambaut, Vichy, and Plombieres. In
Algeria they are utilizing Hammam R'hira, Bains
de la Reine, and in Tunis, Hamman Lif. In cases
where the springs belong to the Government, the
soldiers sent for treatment are under the rules in
force in military hospitals; but in other cases ar-
rangements are made with the private owners for
the use of the establishment as may be required.
Mineral spring hospitals receive, first, soldiers
and sailors on active service; next, soldiers and
sailors on non-active service, either invalided or
retired, and, finally, officials in the Colonial, Custom-
house, or the Forestry Service. Cases sent for
treatment are subject to selection by Army sur-
geons, and are restricted to those in which ordinary
means of treatment have been used during a suffi-
cient length of time without success. They may
therefore be considered chronic cases.
At Vichy the thermal military hospital, which is
assigned to the soldiers' balneologic treatment, has
about 300 beds. It is open from May 1 to Septem-
ber 15. This interval is divided into six seasons:
(1) from May 1 to 21, (2) from May 24 to June
13, (3) from June 16 to July 6, (4) from July 9
to 29, (5) from August 1 to 21, and (6) from
August 24 to September 13.
The military patients are distributed beforehand
between these different seasons ; they must all arrive
on the same day and leave on the same day as well.
The interval of two days between each period is
used for cleaning and disinfecting the hospital.
In the hospital itself there is a bathing establish-
ment where the patients take their cure of baths
and douches. Like the patients in civil life, they
drink at the "buvettes" belonging to the Govern-
ment.
The soldiers' cure is directed by military doctors
specially appointed by the sanitary corps, but gen-
erally not belonging to the station.
With its 300 beds the military hospital in Vichy
provides treatment for thousands of patients.
The other stations capable of receiving soldiers
have less important organizations, and with the ex-
ception of Amelie, which has three, they do not all
possess a special establishment for soldiers. Plom-
bieres, Bourbon l'Archambaut, Bareges use the
civil establishments for treating the military
patients.
The treatment at Vichy is indicated for digestive
troubles, dyspepsia, rheumatic and gouty gastralgia,
enteritis and chronic colitis, liver and spleen en-
gorgements (especially after malaria, hepatic colics,
uricsemia, uric lithiasis, gout, renal colics, arth-
ritism, obesity, and diabetes).
Bareges and Amelie-les-Bains for old painful
wounds, old fistulous wounds, retracted muscles, old
joint diseases, local tuberculosis with no infection
of the lungs, indolent ulcer, cutaneous herpetic
trouble, inveterate syphilides.
Bourbonne-les-Bains and Bourbon-l'Archambaut
for lymphatism and scrofula, chronic rheumatism,
sciatica, muscular atrophy, traumatic arthritis, stiff-
ness of the joints.
Plombieres for visceral rheumatism, gastralgia,
enteric dyspepsia, chronic dysentery, painful en-
gorgement of the liver, painful cystitis, sciatica,
neuralgia, traumatic neuralgias.
In the present war the spas have played a very
important role, but at the same time a very complex
one. They are serving a useful purpose for the
wounded owing to their many hotels, and for their
physiotherapeutic resources in the treatment of
troubles consequent upon wounds. The thermal
military hospitals afford the balneologic treatment
proper to each station, so that now soldiers can fol-
low balneological treatments not only in the above-
mentioned spas, but also at Neris, Aix, Salies-du-
Bearn, le Mont-Dore. Uriage, Luchon, Chatelguyon,
Canterets, Dax, Argeles, etc.
Dr. Margnat says he has no statistics of the re-
sults obtained from balneological methods. But
from a few particulars which have been procured,
balneotherapy, with douche massage and hot baths,
has given excellent results in a series of wounds
and stiffness of the joints, especially in muscular
troubles.
Hypertonic baths, such as those of Salies-du-
Bearn, have been extremely favorable to wounds
slow to heal, and Neris's hyperthermal baths to
acute articular rheumatism.
Vichy, with its extensive bathing establishment
f douches, massage, mineral baths. Zander insti-
tute), has contributed to the recovery of an incal-
culable number of wounded.
Oct. 28, 1916]
MEDICAL RECORD.
753
The role of the balneologic treatment of troops
having taken part in the war will certainly not be
over with the latter. We anticipate an organization
after the war which will utilize all resources to
remedy as much as possible the diseases and in-
firmities of warfare.
I am informed that at Karlsbad there are about
3,000 soldiers sick or wounded. Of the medical
men usually in practice at that spa only two are re-
ported to be left, and these are over 70 years of
age. The use of the baths is probably, therefore,
in the hands of attendants or military surgeons.
Dr. Heinrich Kisch, of Marienbad, is credited
with having proposed fifty years ago that the Bo-
hemian health resorts should be accorded neutrality
in war time. He made this proposal when war be-
tween Austria and Prussia was threatened:
"It was considered at a parliamentary sitting in
Prague, December 7, 1866, and the Government was
asked to further the project. Count Forgach, then Gov-
ernor, lent his aid. In August, 1867, there was an in-
ternational conference in Paris on the aid societies for
wounded soldiers. Dr. Kisch sent a pamphlet to all
who took part to persuade them to use their influence in
favor of the idea and to decide that a supplementary
article should be added to the articles of the Geneva
Convention. Surgeon-General von Langenbeck spoke
in favor of Kisch's proposal in the Paris Conference,
and requested that all health resorts should be regarded
as neutral within the area of war.
"During the long period of peace nothing was done
about it. In 1912, during the Balkan War, Dr. Kisch
took the matter up again. The president of the Austro-
Hungarian Association of Health Resorts addressed a
memorandum to the Foreign Secretary of State and
asked his support in this matter. Meanwhile, in Aug-
ust, 1914, the great European War broke out. The
Foreign Ministry replied that the matter was being
given serious consideration. The law of December 26,
1912, permits the utilization of health resorts for mili-
tary purposes in case of necessity. According to the
Geneva Convention of July 6, 1906, military hospitals
are protected, as are also institutions in health resorts
which are employed for the military health service.
Against declaring health resorts in general as neutral,
said a high official of the Ministry of War, there are
circumstances which must be very thoroughly con-
sidered.
"Dr. Kisch is a man of perseverance, and has not
given up hope of being able to realize his idea after the
war. He thinks that this war has proved the important
role played by the health resorts in curing wounded and
sick soldiers, and that this fact will lead after the termi-
nation of the war to repeated negotiation of his pro-
posal. He believes he will live to see his idea accepted.
In this case he said to an interviewer that Goethe's
words will prove to be true: 'Was man in der Jugend
gewiinscht, bietet das Alter in Fiille' (That which one
has wished for in his youth, age offers in fullness)." —
Journ. turner. Med. Assn., April 29, 1916.
Bath Trains. — It is interesting to note that bath
trains are now used by the armies in the field.
These are in use in Austria and Hungary, and also
in Serbia; doubtless, also, in Germany and France.
They are provided with sterilizing equipment,
usually a refrigerator car into which steam is intro-
duced. When baths are required the hot water is
obtained from the locomotive. One of these trains
has two cars with thirty bath-tubs each, two tank
cars to supply the water, one car for undressing,
four freight cars with clean linen, a sleeping car
for the personnel of the train, and two or three cars
for the disinfection of clothing. This arrangement
permits 1,200 men in the course of ten hours to
take a shower bath and have all their clothing
thoroughly sterilized.
Even in the trenches it is possible to have needle
shower baths. Cablegrams announce that the
Philadelphia Committee of the American Ambulance
has forwarded ten portable needle shower baths
fighting on the Verdun battle front. They are much
in demand, and 150 more are requested. Each bath
outfit costs $120, and the needle spray is operated
by means of pumps.
Combined Methods. — In addition to hydrologic
forms of treatment, well-equipped spas provide mas-
sage, local dry heat by means of special electrically
heated apparatus, and active and passive exercises
by Zander apparatus. Electrotherapy also occupies
an important place in the combined method of treat-
ment.
In some of the larger French hospitals, notably
the Grand Palais in Paris, which has been converted
into a military hospital with 2,400 beds, all these
measures are successfully applied. An experienced
hydrologist from one of the French spas is in charge
of that department. There is also a large out-
patient service, where soldiers, chiefly officers, from
all parts of Paris are treated; but the reports would
indicate that better results are obtained with the
in-patients, probably because daily treatment, some-
times extending over months, is required, just as
we observe it in the case of physical treatment ap-
plied in civil practice.
According to Drs. Fox and McClure, local hydro-
logical treatment is employed in a special manner
for wounded limbs, especially for trophic lesions
resulting from prolonged suppuration, chronic
oedemas, swellings of the peri-articular tissues, and
fractures of the articular ends of bones, and pain-
ful and adherent cicatrices. Such applications pre-
pare the way for massage and movements, and ren-
der them easier and less painful. The arm or leg is
placed in a local bath of running water (balneation
a I'eau courante). The temperature is hyper-
thermal, ranging from 40° C. to 46° C. and gradu-
ally increasing, and the duration from twenty to
thirty minutes. The current is rotatory, of a
strength that can be varied at will, and it can also
be directed to any part of the limb. Such applica-
tions produce extreme vaso-dilatation and increased
arterial circulation. In addition to these familiar
effects, which are well seen in the treatment of
stiffness and fatigue fever by hyperthermal baths,
it is believed that "whirl baths," as they may be
called, have a special action due to the movement
of the water. The hydromassage, added to their
high temperature, appears to have a marked seda-
tive effect in relieving pain, and also promotes the
lymph circulation and diminishes the effusions and
swellings of soft parts. This form of bath there-
fore accelerates the retrogression of sub-inflamma-
tory conditions. The same effects are not observed
from baths of similar temperature in still water.
Whirl baths are now always given before manual
or mechanical treatment, and increasing importance
is attached to them. At the annexe of the Grand
Palais in five months 2,124 preparatory treatments
in eau courante were given.
American Hydrological Resources. — It occurred
to me that we ought to draw some lessons from
European experience and make an inventory of our
own resources, and at least see where we would
stand in case we should be involved in a serious
war. Conditions in the United States are very dif-
ferent from those in Europe, where, for the most
part, the great spas are owned by municipal or
national governments. I asked the Surgeon-General
of the United States Army whether the subject of
the use of spas for soldiers had ever been con-
sidered, and he replied that, as far as he was able to
ascertain, no similar arrangement as, for instance,
754
MEDICAL RECORD.
[Oct. 28, 1916
that organized in England had ever been contem-
plated by the Medical Department.
Aside from the reservation at Hot Springs, Ar-
kansas, which for over eighty years has been owned
by the United States, and the wonderful thermal
springs of the Yellowstone National Park, as yet
unprovided with any medical establishment, the
Government owns no spas. The State of New York,
however, at an expense of over a million dollars, has
acquired valuable springs and surrounding property
in Saratoga, and is engaged in a praiseworthy effort
to equip this spa for the general use of the public.
This valuable property is now under the direction
of the New York State Conservation Commission,
and it is destined, we hope, to have a new era of
usefulness.
We come, then, to the privately owned spring
resorts where balneologic or hydrotherapeutic treat-
ment, or both, is given.
In Maine we have Poland Spring, twenty-five
miles from the sea-board. It has a small hydro-
therapeutic department, and it is the only notable
spring resort in New England. It has a capacity
of about 600. In New York, besides Saratoga, al-
ready referred to, we have Sharon and Richfield
Springs, Glen Springs, with its special treatment
for cardiac cases, and Clifton Springs.
In Pennsylvania, Bedford Springs, about 300
miles from the sea-board; in Virginia, Hot Springs,
Healing Springs, and Warm Springs, with a com-
bined capacity of about 1,000, and an excellent
equipment for balneologic treatment; the hydro-
therapeutic equipment of the Chamberlin at Fort
Monroe on Chesapeake Bay. The capacity of this
resort is about 500, and it is on Government prop-
erty. In West Virginia the White Sulphur Springs,
thoroughly equipped, and with a capacity of about
1,200. This resort is about 250 miles from Wash-
ington and 300 miles from Chesapeake Bay.
In Indiana, French Lick, with a capacity of 1,000,
well equipped with bathing facilities. Distance
600 miles from the sea-board.
In Michigan there is Mount Clemens, with nu-
merous bathing establishments utilizing the saline
sulphur water. Battle Creek Sanatorium, provided
with a complete hydro-therapeutic department.
Distance 628 miles from New York.
In Arkansas there are numerous establishments
utilizing the thermal springs and a Government
hospital for officers and enlisted men. Distance
about 1,000 miles from the Atlantic sea-board.
Still farther west we have Glenwood Surings, in
Colorado, and Arrowhead, Paso Robles, Napa Soda
Springs, Paraiso Hot Springs, Klamath Springs,
and other minor resorts. It is impossible to men-
tion even the names of others, but they are for the
most part open during the summer, and not very
extensively or scientifically equipped. These re-
sorts, however, would prove useful in case of opera-
tions on our Pacific coast.
It would be necessary in case of hostilities in-
volving any considerable number of troops to have
convalescent camps at which soldiers recovering
could remain under military supervision until ready
to rejoin. Because of expense and difficulty of un-
dertaking long railway journeys, it is probable that
the spas near our coasts would play a more promi-
nent part than those far in the interior.
In the United States, as in England to-day, it
would be doubtless possible to arrange for the use
of privately owned spas for military purposes if
that should ever be necessary.
There are some methods employed in European
spas not very extensively used in this country. We
do not make so much use of mud baths, of inhala-
tions, and intestinal irrigations. These methods of
treatment, common in European spas, especially on
the Continent, are used to a very limited extent in
the United States. Such measures require a
special equipment, and probably will come into
greater use in the future.
BIBLIOGRAPHY.
Fox, Fortescue R.: "British Health Resorts in Peace
and War," Brit. Med. J own., July 17, 1915.
— "The Value of Medical Baths for Invalid Soldiers,"
I'roc. Roy. Soc. Med., January, 1915.
Fox, Fortescue R., and J. Campbell McClure:
"Health Resorts for Convalescence and Sick Leave in
the Army," Lancet, April 17, 1915.
— "A New Combined Physical Treatment for Wound-
ed and Disabled Soldiers (Heat, Massage, Electricity,
Movements)," Lancet, February 5, 1915.
"Hydrologic Treatment for Wounded and Invalid
Soldiers and Sailors." London: Adlard & Son, May,
1915.
AGITOPHASIA ASSOCIATED WITH AGITO-
GRAPHIA.
By JAMES SONNETT GREENE, M.D..
NEW YORK.
DIRECTOR, THE NEW YORK INSTITUTE FOR SPEECH DEFECTS ; CON-
SULTING PHYSICIAN TO THE CHRYST1E STREET HOUSE.
Agitophasia is a condition of excessive rapidity
of speech in which sounds or syllables are uncon-
sciously omitted, slurred, mutilated, swallowed, or
in any way imperfectly uttered, causing at the
same time the speech accent to become distorted.
The defect may be apparent or latent; that is, oc-
curring from the first efforts at speech or appear-
ing during the course of the development of speech.
It is due to a pathological condition of the nervous
system, usually the brain, and occurs in children
up to the age of fourteen but occasionally persists
to adult age.
It is of prime importance for normal speech
that there be a coordination between the intended
thought to be uttered and the word to be used.
For conversational speech definite complete thought
is necessary before the speech organs are set in
motion for the desired words or sentences. It is
always essential that there should be a complete
personal supervision so that the desired words and
sentences are correctly used.
In agitophasia, however, the mental action is so
rapid and the desire to speak is so excessive that
the speech organs cannot keep pace, there being a
disproportion or a form of ataxia which is appar-
ent, showing an incoordination between the desire
to talk and the motor skill. In other words, one's
ideas are so profuse and rapid that it is a physical
impossibility for the vocal organs to express them
clearly and distinctly in speech. The normal time
correlation between speech and thought is lost.
There is usually a pronounced lack of concentra-
tion; attention to what is heard is so superficial
that on repetition many words are distorted, swal-
lowed, and mutilated. This condition of agitophasia
is sometimes referred to as spluttering, cluttering,
tumultus sermonis, logorrhea, pararthria, and para-
phasia prseceps.
Pathologically the motor speech area, Broca's
convolution, is involved, so that motor vocal memo-
ries are distorted. There is an involvement of the
nerves of some of the association or, projection
Oct. 28, 1916]
MEDICAL RECORD.
755
tracts running to the nuclei of the nerves govern-
ing the muscular action of the speech mechanism.
Most cases of agitophasia are complicated by agi-
tographia, a defect of writing which is similar to
the speech defect present in the patient; that is,
Fig. 1. — Diagram illustrating the speech zone of the left
hemisphere. This scheme shows the centers involved in the
mechanism of speech anil the interrelationship between speech
and writing.
just as the patient distorts and mutilates letters,
syllables, and words in speech, he does the same
when writing letters, syllables, and words. The rea-
son for the presence of this writing condition is
readily explained. The graphic motor word memo-
ries, being acquired last, are the least deeply im-
printed and most easily disarranged. These memo-
ries are closely associated with the motor vocal
memories, not alone through cerebral location but
through function as well, this being exemplified
when learning to write. On considerable practice
we unconsciously repeat inwardly what we write.
Gutzmann states that there is a defect in the
"ideogenic center," resulting in lingual ataxia. It
is logical to deduce that this same condition exists
in the writing, resulting in graphic ataxia. The
ideation of a written or spoken word is based upon
the association of the component syllables. If silent
thought omits syllables and words in the construc-
tion of sentences they cannot be expressed in writ-
ing; therefore an impairment of this function of
association naturally results in a pathological state,
not only of spoken language but of written language
as well.
Those who are feeble mentally very often show
agitophasia to a marked degree. Mental coordina-
tion is lost, resulting in a torrent of half-articulated
words on attempts at speech with normal tempo, al-
though articulation is perfect when slowly per-
formed.
The condition is either congenital or acquired
(injuries, tumors, etc.). Retarded acquisition of
speech and stuttering may be causative factors,
and, as previously mentioned, according to Gutz-
mann, there is a defect in the "ideogenic center."
The psychic behavior of those suffering from agi-
tophasia is shown in their restlessness and hasty
disposition. They are impulsive, irritable, and sen-
Cx^x^A,
r
/'
FIG. 2. — Specimen ol the patient's handwriting.
sitive, and any disturbing influence is conducive to
an exaggeration of their condition, leading to mo-
roseness, melancholia, etc.
In these cases it is rather interesting to note
that speech in the form of dramatic recitation or
A.
3?
Fig. 3. — Kymographic tracings of the forearm muscles ; A,
specimen of the patient's writing ; B, kymogram of the pa-
tient ; C, kymogram of a normal person.
C.
Fig. 4. — See explanation of Fig. 3.
singing is good, being almost normal. This no
doubt is due to the fact that a new form of thought
is not required, because through former repetitions
correlation between thought and expression
(speech) is almost undisturbed. Reading is more
756
MEDICAL RECORD.
[Oct. 28, 1916
or less disturbed according to the difficulty of the
words.
The peculiarities of writing known as agito-
graphia will be best illustrated through the cita-
yum &
^f^^^j^C
9 ^^£>~-
Fig. "'. — Specimen oi the patient's writing, after oni week of
training.
tion of a case which recently came under my ob-
servation :
A young man, twenty years of age, was referred to
me for treatment by an instructor in writing. This
patient being fairly well educated was able to do gen-
eral clerical work in an office except for one factor — his
writing was barely decipherable. He, therefore, in
order to improve his condition, decided to take a course
in penmanship. Although he faithfully followed in-
structions he did not seem to make much progress. His
instructor was unable to understand why an intelligent
young man, like his pupil, should not show improve-
ment. His writing bore the same characteristics that
he had when he entered his class four months ago.
He came to the conclusion that there must be some
definite reason for the pupil's non-progress and since
his attention was attracted to the fact that the young
man's speech was abnormal, he referred him to me.
I found that he was suffering from the condition sum-
marized above — agitophasia — which was complicated by
agitographia. Just as in speech, he mutilated and swal-
lowed sounds and syllables so he practically did the
same thing in writing by the omission of letters or parts
of the letters comprising the various words. We know
that through the perfection of sensorimotor reflexes
(both cutaneous and muscular) acting through the
spinal cord, writing becomes almost automatic; but in
this case, this perfection was interfered with. The
following is a specimen of writing which was taken at
the patient's first examination:
The patient states that when his father was a young
man he had a habit of talking rapidly, which gradually
disappeared in later life. There was never an ab-
normal writing condition present. His brother, the
only other male member of the family, on the contrary,
always suffered from agitographia, but never from
agitophasia. The mother and three sisters never showed
any signs of either condition. It is rather interesting
to note that the condition affected onlv the male side
&M&' cxjT Z#Cu4 £^r*-* ifir^'
6> >&-« >~>— <£■—■ <
&^y*-a(. &*J i/
Fig. 6. — Handwriting of the same patient as shown in Fig. &
after six weeks of training.*
of the family. The patient does not give a history of
any condition since his childhood that could be con-
nected directly or indirectly with his present state. No
history of convulsions. He is in good health, mentally
alert, but rather nervous and excitable. His speech and
writing difficulties he has had since childhood. In his
speech, when a sentence assumed a complicated form,
his mind sometimes became so confused that he would
offend against the grammatical and syntactical construc-
tion, inasmuch as he would repeat words or exchange
them for others.
In his writing this did not occur, but he would, for
example, disjoint syllables or letters — that is, he would
miss a part of a letter, as the second curve of the letter
N. He would half form letters in his hurry to get to
the next letter and commit a few other vagaries which
can be better understood by examining his style of pen-
manship than by reading the explanation. (See Fig. 2.)
His physical examination reveals no apparent abnor-
malities in development. Eyes — pupils regular, equal,
central, react to light and accommodation, vision normal.
Ears — negative. Mouth — teeth and gums in good con-
dition; teeth in a state of lingual occlusion. Palate —
high-arched and rather narrow. Tongue and throat —
negative. Pharynx and larynx — normal. Laryngeal ex-
amination shows no evidence of spasmodic condition.
Nose — nasal obstruction on right side due to the pres-
ence of a spur on the septum. Breathing — shallow, ir-
regular, and of the costal type. Superficial and deep re-
flexes— normal, no abnormal reflexes elicited. Station
and gait — normal. Slight ataxia of upper extremities.
No tremors.
When writing for an extended period, the patient dis-
played a fatigue neurosis of the hand which was some-
what different from the condition commonly known as
writer's cramp. In writer's cramp we have a spasmodic
and disordered condition of the muscles concerned in
writing, due probably to a functional perverted activity
of the spinal motor centers, leading to disabilities in
connection with the act of writing. In the spastic form
of writer's cramp a spasm sets in in one or several
The improvement in his writing kept pace with the
improvement in his speech.
Oct. 28, 1916J
MEDICAL RECORD.
757
muscles that are being used. In some cases the flexors
are affected; in other cases the extensors. The spasms
may be either tonic or clonic. In the latter case the
fingers, hand, or even the whole arm become affected
with involuntary jerky movements. The arm aches and
is sometimes tender.
In our case of agitographia there was only tension
of the muscles of the forearm, which was due to volun-
tary inhibition in keeping his hand from running away.
To quote the patient: "I must hold my hand back, if
not, it will run away with the pen." He was unable to
write for extended periods of time on account of this ex-
cessive muscular tension.
The kymographic tracings (Figs. 3 and 4) show
the difference between muscular contractions of
this patient's forearm when in the act of writing,
and the muscular contractions of the forearm of a
normal person when writing. The vibrations seen
in the patient's record show definite tension or
spasm irregularities. The vibrations seen in the
normal person's record do not show spasm irregu-
larities.
The diagnosis of this condition is sometimes con-
fused with that of stuttering or lisping, but a com-
plete examination of the patient readily yields a
correct diagnosis.
The fundamental basis of all treatment in cases
of agitophasia with or without agitographia is the
inculcation of a sense of rhythmical slowness, both
in speech and writing. This is best accomplished
through suitable pedagogic exercises. High-fre-
quency treatment, faradism, etc., are very bene-
ficial. Surgical conditions present should be at-
tended to. In the case cited, a right nasal spur was
removed, giving the patient normal breathing.
In conclusion, if these cases are observed and
diagnosed, especially at an early age, they readily
respond to proper treatment; consequently, agito-
phasia, associated with or not associated with agi-
tographia, can be classed under curable conditions.
BIBLIOGRAPHY.
1. Hermann Gutzmann : "Sprachheilkunde," 1912.
2. Coen: "Sprachanomalien," 1886.
3. Wyllie: "Disorders of Speech."
4. Nadoleczny: "Die Sprach und Stimmstoerungen
im Kindesalter, 1912.
5. Bing: "Affections of the Brain and Spinal Cord,"
1909.
6. Liebmann: "Vorlesungen liber Sprachstoerungen,"
1899.
7. Kussmaul: "Disturbances of Speech," 1877.
l'".". West One Hundred and Third Street.
ARTERIAL HYPERTENSION; SYMPTOMS,
SIGNIFICANCE, SEQUELAE AND
MANAGEMENT.41
By HENRY FARNUM STOLI/, M.D..
HARTFORD, CONN.
ASSISTANT PHYSICIAN TO THE HARTFORD HOSPITAL, PHYSICIAN
TO THE HOME FOR CRIPPLED CHILDREN AT NEWINGTON.
The importance of a discussion of cardiovascular
disease will scarcely be questioned. At a time
when we point with pride at the lowering death
rate from diphtheria, meningitis and tuberculosis
the mortality from cardiovascular-renal disease is
steadily, even alarmingly increasing.
All of the time allotted to the discussion of this
topic might with profit be devoted to any one of
the subheads appearing in the title. However, it
will perhaps be of more practical value to consider
rather briefly all aspects of the subject.
We cannot really cope with the problem of hyper-
*Read at the meeting of the Litchfield County Med-
ical Society, held at Winsted, April 25. 191fi.
tension until the underlying or real cause is deter-
mined. Nevertheless, by early detection and intel-
ligent management we can usually prolong life and
relieve more or less completely many distressing
symptoms. We do not know how long hypertension
can exist before symptoms are manifest, but ap-
parently the factors which result in cardiovascular
disease may operate for many years without sign
or symptom.
Symptoms. — There are certain complaints which
should immediately suggest the possibility of
hypertension. These may be referable to the heart
or to the kidneys ; they may be cerebral in type or
general in character. Headache and irritability,
too often in a woman attributed to the "change of
life," may in reality foreshadow a grave calamity,
as a case I recently saw in consultation demon-
strates.
Case I. — The patient, an unmarried woman of forty-
eight, had had a stroke of apoplexy about twelve hours
previously and died shortly after our arrival. She had
always been exceptionally well, except that for several
years she had been subject to severe headaches which
were especially apt to come on in the morning, and for
the past year she had been irritable and hard to get
along with.
While many cases of hypertension are not accom-
panied by headache it is nevertheless a frequent symp-
tom and is very often most marked on awaking.
The irritability of this patient quite naturally had
been attributed to the menopause through which she
was passing. It is worthy of note that both her mother
and maternal grandmother died of shock at about
sixty-five. Moreover the patient's next youngest
brother aged 43, who denies syphilis, had a slight stroke
of apoplexy a year ago.
It has long been known that certain families are
prone to cardiovascular disease, and it is incum-
bent upon the physician to impress upon all
members of such families the importance of hav-
ing their blood pressure taken at least once a
year, as there may be few or no symptoms
though the disease is making steady progress.
While it should be the routine to take the blood
pressure on all patients it is especially important
in that unfortunate group of sufferers we refer to
as neurasthenics. An hemoptysis or an epistaxis
may be the first symptom to send the patient with
hypertensive disease in search of medical advice.
Case II. — A little over a year ago I saw a man aged
forty in consultation who eighteen months previously,
when apparently in good health, began to bleed from
his nose. Notwithstanding that he received the usual
treatment for epistaxis, the hemorrhage persisted for
over two weeks and then, after subsiding for a time,
recurred again. He was finally given injections of
rabbit serum. About this time it was discovered that
his systolic blood pressure varied from 190 to 215, and
that his urine contained considerable albumin.
Case III. — A man of forty-eight was seen with Dr.
Hanley in Stafford Springs. Five months previously
he had had a pulmonary hemorrhage. He had been in
good health previously, except (and please note the ex-
ception), that for the past two years his endurance
has not been as good as formerly, and for several
months he had noticed a tightness across his chest, on
extra exertion. Not alarming symptoms seemingly, but
really of grave import, as four days following the
hemoptysis the left side of his body became paralyzed.
This hemiplegia cleared up completely, but was shortly
followed by several other attacks. His systolic pressure
varied from 190 to 240.
An interesting group are the patients who from
time to time have attacks of spasm of the cerebral
arteries.
Case IV. — For several years I had under my care
an old lady over seventy who had a number of attacks
of convulsions involving one-half of the body which
were followed by more or less complete hemiplegia that
758
MEDICAL RECORD.
[Oct. 28, 1916
usually cleared up within thirty-six to forty-eight
hours. Spirits of Glonoin dropped on her tongue —
5 to 10 drops — would always stop the convulsions.
Another patient of advanced years, a gardener
by occupation, had many attacks of paralysis, but
frequently he would be at his work in the garden a
few days later.
It is of interest that in neither of these cases
was apoplexy the cause of death. The former died
of sepsis from a bed sore following a fractured
hip, and the old gentleman from an acute nephritis
following prostectomy.
Sleeplessness, especially in the early morning
hours, is often dependent upon vascular change and
merits careful investigation. Dyspnea on exertion
or paroxysmal and precordial pain occurring in a
patient of middle age should always suggest cardio-
vascular disease. While directly attributable to
failing cardiac muscle it is as a rule but part of a
widespread vascular pathology.
Of about equal significance, though not so widely
appreciated, are the digestive disturbances develop-
ing in individuals past fifty, often plethoric in type,
who have hitherto enjoyed good digestion. They
complain of a fullness and "pressure" below the
sternum, are usually flatulent and most uncomfort-
able after their heartiest meal.
Nycturia and especially nocturnal polyuria are
strong evidence against the integrity of the kid-
neys. Mention should also be made of visual dis-
turbances and general indefinite wandering pains.
Not infrequetly an oi-thopedist is consulted because
of painful feet and legs.
As my practice does not include obstetrics, I have
had no personal experience with the blood pressure
readings in pregnancy, but their value has been
thoroughly established. It has been demonstrated
that hypertension frequently antedates the symp-
toms of toxemia and the appearance of albumin in
the urine. Accordingly the physician who does not
ascertain the arterial tension of his pregnant pa-
tients is not doing his full duty.
Case V. — A few months ago a young married woman
was referred to me by her physician because of an
annoying cough. No signs of pulmonary disease were
found, but her systolic blood pressure was 280, dias-
tolic 170. She had been pregnant three times. During
the first pregnancy she was in excellent health and
gave birth to a healthy, though not robust child. Dur-
ing the second pregnancy she developed a nephritis,
and was blind for several days. This pregnancy was
interrupted before the eighth month. No blood pres-
sure readings were taken. It was again necessary for
the same reason to interrupt the third pregnancy. Fol-
lowing this pregnancy the urine had cleared up and
for this reason the patient had been assured her kid-
neys were all right.
The woman with hypertension and toxemia dur-
ing pregnancy should be kept under very close ob-
servation for a month or two after confinement.
Frequent blood pressure readings should be made
and when the tension remains high we must con-
clude that a nephritis exists. Such a patient should
not become pregnant again, as it is very probable
that a toxemia will occur with possibly a fatal
outcome.
Hypertension is so predominantly a condition of
middle life and old age that we are not apt to
realize that it is sometimes present in childhood.
During the past year I have had four children
with hypertension under observation. Two com-
plained of morning headaches, but in the other two
there were no symptoms. All were heredosyphi-
litic.
It is important to remember that the symptoms
of an advanced nephritis in an old man may be due
to the back pressure from an enlarged prostate
which will promptly clear up after prostectomy.
Nature and Significance of Hypertension. — The
blood pressure consists of an essential pressure
which is required for life to be maintained and an
incidental pressure which is dependent upon the dif-
ferent physiological processes and the various ac-
tivities of our daily lives. The normal systolic is
the essential plus the incidental, and for men and
women of middle life is 150 and 140 respectively.
Though dependent upon a number of things, the
systolic pressure represents chiefly the cardiac
force. The diastolic pressure is about 80 mm.
lower than the systolic and is a measure of the
peripheral resistance.
We are not yet in a position to say very much
about the pulse pressure, that is the difference be-
tween the systolic and diastolic pressure, but the
determination of the diastolic pressure is of great
importance, as sometimes we find it considerably
raised when the systolic pressure shows but little
variation from normal. It is not so easily affected
by various influences as the systolic pressure and
is, in the absence of an incompetent aortic valve,
a better indication of the condition of the arteries.
When the walls of the arterioles throughout the
body have lost their elasticity and the lumen is
diminished, the essential pressure must rise in
order that the circulation be properly maintained.
In the early days of blood pressure estimation this
fact was lost sight of and attempts were made to
get the pressure "normal" not realizing that the
normal for the man with a granular kidney was
higher than for his more fortunate fellow whose
kidney was healthy.
Over and above this essential pressure is the in-
cidental element that depends upon the normal
functions of the body and the stress of our daily
life. Sudden exertion, great and constant mental
application, fits of anger, straining at stool, run-
ning for street cars, hurrying up stairs, etc., all
raise our systolic pressure and the more or less
constant recurrence of these sudden elevations of
the pressure results in damage to the arteries, es-
pecially if in the past they have been the seat of
an inflammatory process. As sclerosis develops the
essential pressure rises and so a vicious circle is
established.
Before the employment of kidney function tests
many patients were seen in whom the kidneys
could not be indicted from the examination of the
urine, yet at autopsy nephritis would be revealed.
As a result of the development of a number of dif-
ferent methods of investigation it has been shown
that a persistent hypertension is practically al-
ways indicative of change in the kidneys. Even
when the picture is that of diabetes, the hyperten-
sion is due to an accompanying cardiovascular con-
dition rather than to the diabetes. However, the
kidney arterioles are not alone involved, for careful
examination has revealed that the condition is a
widespread disease of all the smaller arterioles.
While definite knowledge is lacking, it seems prob-
able that the pathological process which ultimately
manifests itself as hypertension disease has its in-
ception years before symptoms occur.
Though an immense amount of work has been
done in an endeavor to find the causal factor of
hypertension, there is no definite agreement among
clinicians. Alcohol, tobacco, . lead poisoning, syph-
Oct. 28, 1916]
MEDICAL RECORD.
759
ilis, intestinal autointoxication, the acute infections
of childhood and chronic foci of infection all have
their champions. The first three certainly have no
part in the causation of the cardiovascular disease
so common among women of comfortable circum-
stances. No clear case has been made against in-
testinal autointoxication as the universal cause,
though it is possible that it is sometimes a factor.
It is conceivable that a chronically diseased ton-
sil or an abscess about a tooth of many years' dura-
tion might result in arterial disease. In fact, I
have been told of a case where the extraction of a
tooth and the cure of the abscess was followed by
a fall of pressure. Yet nearly every ward patient
has pus about his teeth, but only a few have hyper-
tension.
There is some evidence, both clinical and experi-
mental, that the acute infections may cause ar-
terial degeneration which may be followed by a
certain degree of sclerosis, yet it has never been
established that the pathology started by scarlet
fever, diphtheria, etc., will continue to advance for
years after the disease has been clinically cured.
We do know, however, that the Treponema pal-
lidum, whose predelection for the arteries has long
been known, quietly and unobtrusively causes wide-
spread destruction of vascular tissue. Markedly
sclerosed, even calcarious arteries have been found
in children with hereditary lues who have had none
of the acute infectious diseases.
However, be the underlying cause what it may,
it is very apparent that the stress of life is un-
questionably the direct or immediate cause. The
death rate from cardiovascular-renal disease is
much higher in large cities where the pace is most
rapid and higher in this country than in England
and Wales, where the life is more tranquil. In
fact, in Great Britain the increase has been practi-
cally negligible.
Sequelse. — The best compilation of what surgeons
call "the end results" have been made by Janeway.
Half of his hypertensive patients had died by the
end of five years, and of those living half died during
the next five years. That is, only a quarter lived
over ten years. Women live on the average longer
than men, notwithstanding that they have pres-
sures fully as high. This is probaly due to the fact
that they are better able to save themselves when
symptoms develop.
Gradual cardiac failure is the cause of death in
about 30 per cent. It is important to recognize this
group because they must be treated as cardiac cases
irrespective of the hypertension.
About 20 per cent, die of uremia, while apoplexy
causes death in 15 per cent. Angina pectoris and
intercurrent infections each cause death in approxi-
mately 7 per cent, of instances. In women death
from angina and from edema of the lungs appears
to be rare. Apoplexy or uremia is the cause of
death in most cases in which pressure is persist-
ently above 200. Angina and, strangely enough,
gradual cardiac failure are not apt to follow these
very high pressures.
Severe morning headaches, nocturnal polyuria
and visual disturbances indicate that death will
probably result from uremia, and in about 75 per
cent, of cases within six years. Cardiac symptoms,
of which dyspnea is the most constant, suggest
death from gradual cardiac failure. Janeway
found that a rapid and continuous loss of flesh was
an unfavorable symptom.
Management. — We may roughly divide our pa-
tients into two classes. The first comprising the
individuals who come to our office, as their symp-
toms are not sufficiently urgent to make them give
up work. The other group comprises those in whom
the disease is further advanced and who are seen
at their homes or in the hospital.
In the first group it is particularly important to
study each case thoroughly in order that we may
ascertain if possible what the incidental factor of
the hypertension is. It may be prolonged mental
application without adequate periods of relaxation;
it may be too many cigars, or it may be too long
hours and a general unhygienic regime under which
the patient lives.
Inquiry as to his habits should always be very
thorough, as a readjustment of his life is necessary,
but it should be brought about with the least pos-
sible violence. To tell an active business man with
moderate hypertension that he must immediately
give up all his business is speaking thoughtlessly
and unwisely. He will not take kindly to crochet-
ing, neither will he sit under a tree and write son-
nets. With care, however, we can usually rearrange
his habits so that a great deal of strain is taken
off of his arteries.
The "noon hour" should be multiplied by two.
After the midday meal, which should be the chief
meal, rest in a recumbent position for an hour is
desirable. If the patient can sleep a part of that
time so much the better.
If the physician explain to an intelligent patient,
that as the arterioles lose their elasticity and their
lumen diminishes, the blood pressure must of neces-
sity rise to maintain the circulatory balance, he
will materially lessen the anxiety that the term
high blood pressure occasions. If the physician
further explain the incidental factor of arterial
tension and enumerate its chief causes he will
readily obtain his patient's cooperation, which is so
essential in the management of these cases.
The hypertensive individual must first of all stop
"hustling." He must school himself to say, "There
will be another car in a few minutes" when he is
late at breakfast. If he must climb stairs, deliber-
ation should characterize the act. If he be a really
remarkable man he may learn to control his tem-
per, for there are few things more injurious to
diseased arteries than bursts of anger.
The individual with but a slight degree of hyper-
tension, free from morning headaches, and who is
eliminating a good amount of phthalein in two
hours (50 per cent, or over) should not be put on a
milk diet nor told to give up all meat. A moderate
amount once a day is desirable.
It has long been known that overeating is dis-
tinctly harmful and it is particularly so in this class
of patients. The heaviest meal had best be taken
at midday and the supper be simple. The impor-
tance of complete relaxation one or two days of
each week cannot be overestimated, as fatigue is
cumulative. It is important that the patient take
several warm baths each week, have a daily evacu-
ation of the bowels and a cathartic once or twice
a week, but too active catharsis will be followed by
faintness and weakness.
One cannot deduce that because the urine con-
tains no albumin the integrity of the kidney has
been preserved. When the amount of urine passed
during the night exceeds the amount voided during
the day and when the gravity is persistently low
or "fixed," one must conclude interstitial changes
have already begun. The phenolphthalein kidney
760
MEDICAL RECORD.
[Oct. 28, 1916
function test is the only one of the function tests
that can be readily performed by the general prac-
titioner and it corresponds quite accurately with
the more complicated estimations of the non-pro-
teid nitrogen in the blood.
It is important, however, to appreciate that the
amount of phthalein eliminated at any time is an
estimate of the kidneys' ability to excrete that drug
only at that particular time and does not per se
warrant an absolutely favorable or unfavorable
prognosis. The kidneys may improve or the
trouble may extend within the next few weeks. It
is desirable in all cases of hypertension to ascer-
tain from time to time how the kidneys are func-
tionating, as occasionally the diminution in func-
tion may precede serious symptoms.
During the winter months hypertension patients
should avoid all unnecessary exposure, as even a
mild infection may result disastrously.
Vasodilating drugs are not usually called for and
are often harmful. In certain cases they will un-
questionably relieve symptoms, but their routine
employment as soon as the patient comes under
observation should be discouraged. When the ten-
sion is very high a prompt venesection may be life-
saving.
I have frequently obtained marked relief from
sleeplessness, nervousness and headaches by the
use of potassium iodide and mercury either by in-
jections or inunctions, though the Wassermann test
was negative.
In the second class of individuals, where the kid-
ney and heart are not longer able to adequately do
their work, the patient must be in bed.
Digitalis is nearly always required irrespective
of the blood pressure and fears of a higher tension
resulting are groundless. Not infrequently a com-
bination of potassium iodide and digitalis will give
results not obtainable with either used alone. A
low phthalein output and an increase in blood nitro-
gen regularly accompany this stage of the disease,
and the diet should be low in protein and sodium
chloride.
If the patient be very edematous only 800 c. c.
of milk in twenty-four hours should be allowed
(Karrel diet). This has the advantage of being
low in protein and sodium chloride.
When compensation is reestablished carefully
regulated exercises are to be instituted.
The distressing dyspnea that so often attends
the final days of hypertensive patients can be con-
trolled only by morphine. The temporary improve-
ment from a good night's sleep following its use
is often very gratifying, and it should not be
withheld when the end is near.
7T. I'lUTT STREET.
MILK AND COMMUNICABLE DISEASES/
BY I.IXSI.Y H WILLIAMS. Mil
ALBANY, \- V
i'v COMMISSIONER OF HEALTH. NEW YORK STATE.
An outbreak of communicable disease was traced
to consumption of raw milk as far back as 1854.
Since that time there has been a large number of
epidemics traced to the consumption of raw milk,
and in each instance it was found that there was.
or had been, a case of specific communicable dis-
ease upon the dairy farm where the milk was pro-
duced or among employees handling the milk.
•Read at the Annual Conference of New York State
Health Officers, Saratoga Springs, June 7, 1916.
There is now a large amount of literature on the
subject of milk-borne diseases and numbers of epi-
demics of septic sore throat, typhoid fever, diph-
theria and scarlet fever have been found to be due
to the use of raw milk which had been infected
with the organisms of these diseases.
The work of the British Royal Commission on
the Study of Bovine Tuberculosis and that of Theo-
bald Smith, Ravenel, and Park, in this country,
have conclusively demonstrated the fact that bov-
ine tuberculosis may be transmitted to man and
that from 5 to 15 per cent of all cases of tubercu-
losis in children are of bovine origin. During the
past year and a half there have been reported to
the State Department of Health at Albany over
800 cases of communicable diseases causing thirty-
seven deaths which were due to outbreaks of scar-
let fever, septic sore throat, diphtheria and typhoid
fever. In each epidemic the cases occurred largely
upon the milk route of one dairy. A careful study
of these epidemics has shown in each instance that
the cause was due to the presence of an individual
affected with one of these diseases upon a dairy
farm supplying the milk to the persons who be-
came ill of the disease.
The use of raw milk has not generally been con-
sidered in this country as a source of danger, but
for many years physicians in Continental Europe
have regularly recommended the use of boiled milk
for the feeding of children and infants. About
twenty-odd years ago there was introduced into
this country a change in infant feeding caused by
the boiling or pasteurization of milk. As time
wore on and the demand for the use of this milk
became more widespread, physicians reported un-
fortunate results and a few cases of scurvy were
described among the many thousands of children
using it.
With the increasing difficulties of introducing
an adequate supply of fresh milk several of the
larger milk dealers in our great cities conceived the
idea of heating their milk in order that they might
keep it for a longer time. These dealers then began
to pasteurize their milk. In the pasteurization of
ten or more years ago it should be remembered that
it was performed by what is known as the "flash
system." The "flash system" consists in rapidly
passing milk over a heated coil raised to a tempera-
ture of 167° or more F. When this system
began to be more generally applied, objection
was made to it by health boards and physi-
cians, for the following reasons: The health boards
objected because they felt that this would enable
unscrupulous milk dealers to sterilize filthy and
disease-infected milk; and that in milk which had
been heated in this manner the lactic acid bacteria
would be destroyed and the milk, instead of souring,
would become putrid and would be consumed without
the consumer knowing that the milk had spoiled, as
it would not have the well-known sour taste. Physi-
cians objected on the ground that the consumption
of this milk by infants and children would result in
large numbers of cases of scurvy. The opposition
was nowhere greater than in the city of New York.
Six years ago the city of New York adopted the
general chlorination of the entire water supply of
the city. This did not produce the expected diminu-
tion in the amount of typhoid fever in the Greater
City and a more thorough study of the cases of
typhoid fever resulted in the discovery of several
widespread epidemics of typhoid fever upon the
routes of one or more milkmen. By tracing this
Oct. 28, 1916|
MEDICAL RECORD.
761
milk to its source, cases of typhoid fever and
typhoid carriers were found upon the dairy farms
which had infected nearly the entire milk supply
of one or more dealers. These and other epidemics
soon convinced the authorities of the city of New
York of the importance of pasteurizing the entire
milk supply of the city.
In making a study of the subject it was found
that milk pasteurized by the flash system had a
certain number of disadvantages. Some of the milk
in passing rapidly over the heated coil soon formed
a film which varied in thickness so that in some
places the stream of milk passing over the coil was
subjected to varying degrees of heat. Careful
examinations made showed that such a method of
pasteurizing did not always destroy the pathogenic
bacteria. Later investigation showed that such a
high amount of heat was unnecessary in order to
destroy all pathogenic bacteria, and it was ulti-
mately found that a temperature of from 142 deg.
to 145° F., if maintained for a period of 30 minutes,
would entirely destroy all pathogenic bacteria.
Certain objections, however, are still made to
pasteurization as follows: (1) Feeding of pas-
teurized milk to infants may cause scurvy; (2) pas-
teurized milk has a stale, flat or boiled taste; (3)
pasteurization of milk diminishes the amount of
cream in a bottle of milk; (4) pasteurization in-
creases the cost of milk; (5) pasteurization devital-
izes the milk and reduces its food value. Each and
every one of these objections can be readily met.
The mortality records of the city of New York,
where over 90 per cent of the milk supply has been
pasteurized by the holding method, show no in-
crease in the number of deaths from scurvy. Even
if there may be a possible increase in the number
of cases of scurvy, it is fairly generally admitted
by children's specialists that the danger from milk-
borne diseases is far greater than the danger of
scurvy, and that by the proper administration of
orange juice to infants beginning at the sixth
month or earlier, the occurrence of scurvy will be
prevented.
The second objection, as to the change in taste
of pasteurized milk, has a certain foundation
because, if milk be heated to above 155° F.,
it will have a somewhat boiled or flat taste, but
if milk be properly pasteurized within the tempera-
ture limits now usually prescribed by cities and
States, there will be no alteration in the taste. Sim-
ple experiments will readily demonstrate this.
Many persons have made the simple test of samp-
ling first raw and then pasteurized milk and have
not been able to distinguish between them. Pas-
teurization properly performed produces absolutely
no change in taste. If there is a change in taste it
is always found that the milk has been heated to a
higher temperature than is necessary.
It has been stated by some observers that there
is a diminution in the amount of cream when milk
is pasteurized. This complaint is made by the con-
sumer. A complete series of experiments carried
out in the laboratory of the New York City Depart-
ment of Health by Kilbourne showed that there was
a diminution in the volume of butter fat, which rose
to the surface in milk which had been heated to a
temperature higher than is necessary through
faulty pasteurization, and that within certain limi-
tations the higher the temperature to which the
milk was heated the smaller the amount of cream
which rose to the surface. But even at the higher
temperature there is a diminution in the amount of
cream which rises of only 10 per cent. It should
be definitely understood, however, that even though
the cream line be diminished there is absolutely no
diminution in the fat content of the milk, and there-
fore no diminution in the nutritive value.
It must be admitted that the cost of machinery
and the cost of operating a pasteurizing plant is
considerable, but the actual cost is far less than one
cent per quart of milk and in some communities in
New York State properly pasteurized milk is now
being sold at the same rate as the raw product, and
the concerns selling this milk are making money
from the sale of their product.
A number of experiments have been made in
feeding pasteurized milk to young, growing ani-
mals. It has been found that calves and other
smaller animals, when fed on pasteurized milk, will
thrive just as well and gain in weight just as stead-
ily as when fed upon the raw product. An experi-
ment carried on some years ago under the direction
of Drs. Park and Holt of New York City in the
feeding of infants, showed that infants fed at the
breast had fewer cases of illness among them and
did better than infants who were fed upon properly
modified milk. In two groups of infants fed on
modified raw milk and modified pasteurized milk
there were fewer cases of diarrhea and fewer
deaths among those fed on pasteurized modified
milk than among those fed on raw modified milk.
Another interesting fact is that the cities of
New York, Boston, and Chicago have for from
three to five years had a large majority of their
milk supply pasteurized, and during this period
there has been a large diminution in infant mor-
tality and in the number of deaths from diarrheal
diseases.
Conclusions. — It would seem, therefore, that the
chief objection to the pasteurization of milk is that
it is a change from the long-continued habit of the
use of raw milk and that, although there may be a
slight increase in the cost of milk that has been
pasteurized, yet the health insurance that is given
in preventing a larger number of epidemics of milk-
borne infectious diseases is far more important
than the small sum paid for this protection.
It must be said, however, that there are still a
number of medical men and health officers who con-
tend that pasteurized milk is nothing more than
cooked filth, but sanitarians and health officers
should insist that pasteurized milk must be pas-
teurized clean milk and that every precaution should
be taken to insure the milk being pasteurized in
clean containers. The method of pasteurization
should be supervised, for if the milk is improperly
pasteurized complaints will come, and they will be
made against the whole process of pasteurization
rather than at the slip in the method. But if pas-
teurization is carried on intelligently and under the
direction of qualified health officers it will give the
quality of milk that the people demand, and will re-
sult in a diminution in the amount of communicable
diseases.
Practical Value of the Schick Reaction. — Arthur
Sprenger concludes that the Schick test is of positive
value in determining the susceptibility of a patient to
diphtheria, and also in differentiating doubtful mem-
branes of the throat. It shows that in some cases pas-
sive immunity is of short duration. The author does
not, like others, find that immunity is a familial char-
acteristic. The test insures a saving of antitoxin, for
it has shown that less than 50 per cent of children are
susceptible to diphtheria. Carriers give a negative
Schick reaction. — Illinois Medical Journal.
762
MKDICAL RECORD.
[Oct. 28, 1916
THE ROLE OF DOCTORS' SONS IN THE
LINCOLN ADMINISTRATION.*
A CONTRIBUTION TO THE PSYCHOLOGY OF GOV-
ERNMENT.
By WILLIAM BROWNING, Ph.B., M.D.,
BROOKLYN, N. Y.
PROFESSOR OF NEUROLOGY, LONG I8LAND MEDICAL COLLEGE.
The important part taken by doctors' sons in the
regime of Lincoln does not appear to be generally
known, if, indeed, it has ever been recognized.
Nor, in the case of most of these participants, do
the customary biographical sketches give any indi-
cation of the medical parentage.
Except as casually included in medical history
and memorials, that side of medical life which may-
be termed the Sociology of the Profession has been
but little studied. Kelly has explored the relation
of physicians to botany, and doubtless there have
been efforts in one or another direction that deserve
mention.
Such a sociology represents a more democratic
phase than does isolated achievement or individual
prowess. And it might naturally be expected that
in America it would have both a larger field and a
sounder appreciation than elsewhere. There is now
an abundance of material on the sociological side
concerning the profession itself. Though in its
entirety a large subject, many parts are sufficiently
complete in themselves to admit of separate presen-
tation.
In the historic interest of our members, to offset
attacks on our calling, and as a genetic study, the
gathering of material of this order has a larger
warrant than merely to gratify curiosity.
Since the days of the Revolution no period in our
country's history has been so stressful, so fraught
with danger, and so seriously in need of wise guid-
ance, as that of the Civil War. The leader of that
time was Lincoln. The superior quality of his wis-
dom in action and in the selection of his immediate
supporters is recognized. It consequently becomes
a matter of deep interest to size up the mental
atmosphere of his surroundings, and to see if any
clear element is recognizable. That he had a true
genius for gathering and utilizing opponents as
well as presumable congenials renders any element
in his make-up and entourage the more striking.
It is easy to pick out the men who officially and
personally stood next to him, distinctly more so
than most others, and this group became more pro-
nounced as his administration progressed. At least
four of these were his own choice; and doubtless
he was consulted about the selection of some of the
others. For the present purpose it is only necessary
to give an outline sketch of each, sufficient to show
his standing, relation and paternity. Most inter-
ested readers can fill in much from memory. The
cases in point are as follows:
1. Judge David Davis, the private adviser and
legal friend of Lincoln, who accompanied him in
both these relations on the momentous iournev in
February, 1861, to Washington, and remained in
that capacity unofficially. He had not acquired at
that time all the national reputation that came later
(U. S. Judge, Senator from Illinois, and in 1881-3
acting Vice-President) ; yet he proved fully worthy
of the confidence placed in him.
*In part from a paper read November 16, 1915 be-
fore The Book and Journal Club at Baltimore.
In the Republican national convention of 1860
Judge Davis (as delegate-at-large from Illinois,)
had secured the nomination of Lincoln, and after
the election "was a chief councillor of the Presi-
dent."
Judge Davis was a son of Dr. David Davis, a
physician of Cecil County, Mo.
2. John Hay, Lincoln's personal private secre-
tary, in later years U. S. Secretary of State. Nico-
lay, a German by birth, was the chief executive
secretary, but Hay was the one in close confidential
relations, perhaps more so than anyone else during
the full period of Lincoln's administration. He was
very young for such a responsible post, only 23
years of age at the start, though admitted to the
bar.
Hay was born in Indiana, the third son of Charles
Hay, M.D. (1801-84), a native of Kentucky and "a
prosperous physician."
3. Then came the Vice-President, Lincoln's run-
ning mate in the campaign of 1860, the Hon. Hanni-
bal Hamlin, ex-officio president of the U. S. Senate.
His term did not expire until March 4, 1865.
Hamlin was a lawyer, had been speaker of the Maine
House, M.C., U. S. Senator, and Governor of Maine.
Subsequently he was our minister to Spain. He
was born at Paris, Me., the son of Dr. Cyrus
Hamlin.
Dr. Hamlin was born in Massachusetts (1770),
was a practising physician, and at times had filled
a number of positions of local responsibility.
4. Solomon Foot (1802-66) ; never much in the
public eye, and now little heard of. Yet as presi-
dent pro tern, of the U. S. Senate (Feb. 16, 1861,
to April 26, 1864), as floor leader of that body,
head of its most important committees, potentially
in line for the Vice-Presidency, and chairman of
arrangements for the Lincoln inauguration in 1861,
he was an invaluable aid at the transition time and
for much of the Lincoln period. He was the most
prominent advance agent who held over to the new
era, a man of mature years and wide training, who
come into his heritage of responsibility on the
withdrawal of part of the members.
Foot had been professor of "natural philosophy
at the Vermont Medical School, Castleton, 1827-31,"
lawyer, Speaker of the Vermont House, State's At-
torney, M.C. (1836-42 and 1843-7), U. S. Senator
(1851-?), and railroad president.
He was a native of Vermont, the son of Dr.
Solomon Foot. His father, a physician, born in
Connecticut, died when the son was barely nine
years old.
The two secretaryships, of State and of War,
were at that time unofficially, if not formally, recog-
nized as the leading two cabinet portfolios. In this
case the long term of service of the occupants show
each to have been persona grata to the President.
Everyone who recalls that period or is familiar with
its history is well aware of the fact that in the
general estimation these two men were Lincoln's
main reliance and his most representative cabinet
heads.
5. William H. Seward, Secretary of State. Seward
had previously served as Governor of New York
and as U. S. Senator. Though he had been the
chief competitor for the Republican Presidential
nomination in 1860, he gracefully accepted and ad-
mirably filled the statesman's position in Linco'n's
cabinet. He was the ranking member of that body,
remained through Lincoln's whole administrative
career, and subsequently engineered the purchase
Oct. 28, 1916]
MEDICAL RECORD.
763
of Alaska. He was born in Orange County, N. Y.,
the son of Dr. Samuel Swezy Seward.
Dr. Seward came from Connecticut. In later
years he "combined medical practice with a large
mercantile business."
6. Owing to the peculiar conditions of the time,
the cabinet officer next in importance was the Sec-
retary of War. From Jan. 15, 1862, on, this post
was filled by Edwin M. Stanton (who had previ-
ously been the U. S. Attorney-General in the cabinet
of President Buchanan). By the necessities of his
very important position, by continuance of service,
and by personal association he was, next to Seward,
the cabinet officer in nearest affiliation with Lin-
coln. Stanton was a lawyer by training, born in
Ohio in 1815, and the son of Dr. David Stanton.
His father, "a prominent physician," was of
Quaker stock, and came from an eastern State. He
died while his son, Edwin, was a child, although
not until he was some years old.
7. On the legislative side highly important for
the administration is the Speaker of the Congres-
sional House. From early 1863 on this position was
filled by the Hon. Schuyler Colfax. He was a mem-
ber of Congress from 1855 to 1869, and subse-
quently (1869-73) Vice-President of the United
States. He was born in New York City, March 23,
1823, the second child of Schuyler Colfax, Sr.
The father was born in New Jersey, Aug. 3, 1792.
He married Hannah D. Stryker, April 25, 1820, and
died of tuberculosis, Oct. 20, 1822, five months be-
fore the son was born. Small wonder that there is
a paucity of details regarding the father. An old
account states that he studied medicine, and then
took a bank position to earn means for starting in
practice. Another biography indicates that he
studied medicine in 1810-12 with Dr. David Marvin
of Hackensack, N. J. Studying medicine with a
preceptor instead of at a medical school was the
more common way at that time. His widow dis-
claimed any knowledge of this, except that he and
the doctor were old friends. But, as she was speak-
ing long afterward, had been married in her six-
teenth year, had but a short married life with him,
and that some time after the date assigned for his
studying, her lack of information on this point
hardly counts. The positive evidence is sufficient
to warrant including the name of the son in the
present list.
Taken together, the seven men named were, next
to Lincoln himself, the leaders in the executive and
even the legislative work of the U. S. Government
during that period. They were closest to him in
official and personal relations, and, with the balance
of the cabinet, constituted his special lieutenants,
advisers, and administrative guard. It is conse-
quently a notable fact that the seven were all sons
of physicians, and this is the more striking as it is
without known precedent. Of course, periods of
such gravity and far-reaching interest are in them-
selves rare.
To read theories into or out of history is known
to be as unprofitable as theorizing in medicine.
Still, we have finally come to the stage in medicine
where it is possible to have profitable theories.
And the more embryotic science of history may yet
find activators.
To offer any generally acceptable explanation of
this peculiar occurrence is hardly possible. To say
that it was a mere coincidence is the simplest and
most customary way. That, however, offers no ex-
planation, and it is against experience and every
theory of probabilities.
To suppose that it was definitely planned, as by
one mind or some coterie, is quite as improbable.
No incentive or reason appears for such a vast
sch.-me. Nor is there any evidence or suggestion
of i.ach an effort. Nor, finally, can we see any way
bj which it would have been practically possible.
A further view comes up that cannot be as read-
ily decided. Everyone is invigorated by a stimulus
Liat appeals to him. Of all the educated and
trained classes and in the community, the medical
Is the only one that in any real analysis stands
heartily and with conservative wisdom by the whole
people. Did, then, the sentiment, the national and
intensely democratic spirit of the time rouse these
men, because of their inherent attitude, more than
it did others of possibly equal ability in the com-
munity?
There is an alternate way of looking at the mat-
ter that is rational and appeals more to med-
ical minds. This grouping of prominent men was
doubtless accidental, in the ordinary acceptance of
that term ; that it was so in the psychological sense
is hardly imaginable. The drift of circumstances
and the compelling necessities of the time had sim-
ply forced the selection of those specially suited to
the extreme demands of the situation. Because it
was involuntary and natural makes the occurrence
the more significant.
We can grant that this combination of talent was"
just a coincidence — and yet draw a long bow. It
affords strong evidence — perhaps- the strongest pos-
sible— of the superior intellectual value of medical
training and heredity. And those who attribute
thereto an educational quality of basic character
may see a direct verification in this development at
a national crisis.
Besides his leading official mainstays it may be
noted that Lincoln's leading competitors in the na-
tional campaigns of the period afford parallel illus-
trations. Seward has been mentioned above.
8. A leading opponent, both before and in the
campaign of 1860, was Stephen A. Douglas, LL.D.,
United States Senator from Illinois. And it waa
with Douglas that Lincoln had just previously held
the series of public debates that so stirred the na-
tion. On the popular vote at the election Douglas
was next to Lincoln, though behind Breckenridge
and Bell on the electoral count. "Socially they were
on friendly terms," and Douglas even held Lincoln's
hat during the inauguration at Washington.
Douglas was born in Vermont, the only son of
Stephen Arnold Douglas. The father, "a native of
New York State and a prominent physician," died
suddenly when his son was two months old.
9. In the campaign of 1864 Lincoln's opponent
was George B. McClellan, General-in-Chief, U. S. A.
General McClellan was a native of Philadelphia, the
son of George McClellan, M.D. Dr. McClellan was
born in Connecticut in 1796 and was widely known
as a surgeon and professor of surgery.
That all talent of this kind was not exhausted in
the first line trenches, to use a phrase of to-day.
might be shown by innumerable examples; that,
however, .would not affect the main "exhibit."
It is natural in this relation to turn back for
comparison to that other time of national tribula-
tion, the Revolution. The surprising number of
medical men who were signers of the Declaration
of Independence has long been a matter of note.
There were at least six with medical training, four
764
MKDICAL RECORD.
[Oct. 28, 1916
of them practitioners. And in close correspond-
ence with this is the fact that the Mecklenburg
declaration in 1775 was written by Dr. Brevard, a
surgeon.
At the Lincoln period, nearly ninety years later,
the mantle of the fathers may be said, profession-
ally speaking, to have descended to the children.
r.4 Lefferts Place.
LESIONS OF THE FRONTAL LOBES.
By EDWARD MERCUR WILLIAMS, M.D.,
SIOUX CITY. IOWA.
Lesions of the frontal lobes, particularly of the
mid and prefrontal zones, are always rather ob-
scure in their symptomatology.
The cases presented here, while allowing very
little doubt as to the diagnoses, show interest-
ing points, as well as demonstrating how easily
one may be misled in considering confusing or ob-
scure signs as due to distal pressure or cutting of
transcortical fibres. In two of these patients (B
and C) symptoms thus attributed to general pres-
sure or invasion were afterward found to have
been caused by an additional growth in one and
by two extra growths in the other.
The rapid but late onset of the symptoms in
case A, four months after an injury which gave
very slight disturbance at the time of the accident,
is rather out of the ordinary, and the later course
of the disease gave several points of interest, such
as voracious appetite, impotence, incontinence of
urine and feces, and a peculiar emotional state
very difficult to describe accurately. The man had
constantly an expression of fear or anxiety and
always spoke as though he looked for something
unexpected to happen. Just before his operation
he was found out on the lawn in his gown and
barefooted, although he had not protested against
the operation at any time. He simply said at this
time that he was afraid, but did not resist further
or refuse to be operated.
The confusing picture in case C can be easily
understood when knowing of the presence of the
two other growths in the prefrontal and opposite
parieto-occipital regions respectively. The vora-
cious appetite was a pronounced symptom in all the
cases of tumor or hemorrhage, whereas in several
cases of frontal lobe abscess, either proven or sus-
pected, but not included in this paper, the loss of
appetite was marked, this being in all probability
due to the profound toxemia.
In case C this excessive appetite and thirst was
so pronounced that the man would cry and scream
as though in pain before a nurse could bring him
a glass of milk after he had asked for it. No doubt
the loss of emotional control had a great deal to do
with these outbursts. I later found out that the
man had "spells or fits of excessive hunger," as the
relatives called it, for a number of years previ-
ously.
Frontal ataxia is not very common, but was pres-
ent in case A and case B, and oddly enough con-
tralateral in one and homolateral in the other, being
so marked in the former as to have previously led
to a diagnosis of probable cerebellar involvement.
In this series, including the two frontal abscesses
and a case of frontal hemorrhage above mentioned,
but not described in detail, the optic atrophy as
*Read by title at the forty-second annual meeting of
the American Neurological Association at Washington,
D. C, May, 1916.
described by Kennedy was not found in any in-
stance. However, there were changes to indicate
an older and more advanced process in the involved
side in a tumor and abscess and a hemorrhage and
a changing of the apparent intensity of involve-
ment in the case with multiple tumors.
Tests of the sense of smell were negative in all
cases but one, where there was a definitely greater
involvment on the affected side.
This brief series has led me to conclude that a
localization as to the side involved in a frontal
lesion can be made only guardedly from such signs
as slight disturbance of mentality, upset of emo-
tional control, intensity of optic neuritis, or dis-
turbance of smell, unless definite motor or speech
disturbances are present. In three instances, not
included here, where in addition to the usual gen-
eral signs of brain tumor and above-mentioned
symptoms of frontal involvement disturbance of
motor speech was present, an operation failed to
reveal any lesion in that locality, unless possibly
too deeply subcortical to be found.
Case A. — Farmer, age 40, a patient of Dr. V. B.
Knott. Four months previously he had been kicked in
the forehead by a horse. He was dazed for a few min-
utes, then went on with his work. He had several at-
tacks of severe headache and some slight general feeling
of weakness, but otherwise no disturbance up to a few
days ago, when he began to suffer intensely from head-
ache and he noticed a great increase in his appetite and
thirst. He rapidly became impotent, and during several
days in the hospital developed incontinence of urine and
feces. When walking the man would wander, or totter
toward the opposite (left) side, and in his attempts to
eat and dress himself and perform finder, nose and heel,
knee and pointing tests, the ataxia in the left was very
pronounced. There was also a certain amount of weak-
ness difficult to differentiate from ataxia. Double neuro-
retinitis, possibly slightly more advanced on the diseased
side.
The deep reflexes were about normal in the contra-
lateral side (left) and less active in the homolateral, or
right side. Plantar reflexes normal. The emotional
state has been described, a peculiar expression of fear
or anxiety and "far away," or vacant, expression. The
patient seemed able to remember and figure well enough,
yet he gave one the impression of a certain degree of
mental impairment, or dullness. Operation and removal
of an old clot from the right, mid and prefrontal region
epidural, with complete recovery.
Case B. — Mrs. K., age 35, patient of Dr. R. Q. Rowse.
Headache, more or less, for a number of years, but dur-
ing the last five weeks more constant and severe. Sight
gradually diminishing in this time, particularly within
the last three weeks. Nausea and vomiting often during
this period. The sexual desire is diminished. For some
weeks she has eaten and drunk a great deal more than
her normal amount. Right ptosis was present for a
couple of weeks, clearing up entirely. There seems to
be a possible history of slight forgetfulness, but this
is very doubtful.
At the time of the examination the patient did
not seem to show any particular mental disturbance,
except some lassitude easily attributable to the headache
and nausea, etc. Left pupil was larger than right and
reacted less to light and accommodation. Ptosis was
present in the left with paralysis of the other oculo-
motor muscles on that side. The right internal rectus
was also slightly involved. Sight was diminished to
almost complete blindness. There seemed to be a
slightly better ability to recognize objects as shadows
with right eye and in right field of right eye and possi-
bly of left eye. Advanced "choked disc" in both eyes
with evidence of an older process of the left. There was
ataxia of the left arm and leg as shown by the usual
tests, the deep reflexes of both arms were absent, also
he knee jerks and the ankle jerks were very weak,
more so on the left. Plantar irritation gave normal
response on left and a very active upward and inward
drawing of the foot on the right. A very slight twitch-
ing of the right wrist extensor muscles occurred at in-
tervals of a few seconds, almost constantly. When
first tested the sense of smell was gone on both sides,
possibly due to acute coryza. Tested two days later.
Oct. 28, 1916 J
MEDICAL RECORD.
765
showed a definite difference of the two sides, diminished
on one side and almost entirely gone on the side of the
tumor (left).
At operation the left prefrontal area was exposed
and a tumor resembling a melanosarcoma, but later
proving to be a sarcoma, was found involving a large
portion of the prefrontal lobe. The patient died in
several weeks and the autopsy disclosed an additional
sarcomatous growth on the under surface of the right
temporal lobe, well back toward the occipital area. This
may have had something to do with the indefinite, but
suggestive, hemianopsia.
Case C. — Farmer, age 47, patient of Dr. V. B. Knott.
About four weeks prior to my examination, patient
found right arm and leg partially paralyzed upon
awakening. As he had suffered a great deal from
rheumatism he attributed it to that and in a few days
the condition improved so that he could go about again.
I was informed later that the patient had really been
more or less handicapped in the use of his right arm
for two years or more. The headache, which was pretty
severe, also cleared up, as did a partial facial paralysis.
He also had a facial paralysis on the left nine years
previously. In the last week or so the headache became
more severe and patient had nausea and vomiting, not
cerebral in type, but increasing in frequencv and sever-
ity.
In the examination I found the pupils equal and
reacting normally. No ocular muscle disturbance. The
examination of the fundi showed a neuroretinitis with
hemorrhagic streaks and spots, resembling very much
albuminuric retinitis more active on the right, veins not
particularly engorged nor arteries changed in caliber,
discs indistinct. Seemed to be some weakness of both
facial nerves in entire distribution, could wrinkle right
brow fairly well, however. The right arm showed im-
paired strength for all the coarser and finer movements,
though they were all possible. The same was true of
the right leg. Left side was normal. Arm reflexes
more active on the right, also the knee jerks. Ankle
clonus and positive Babinski on the right. No sensory
changes either from touch or position anywhere. Heart
sounds feeble and slow, about seventy per minute. Press-
ure right arm 135-90, left 125-82. Diminution in
amount of urine, high colored and loaded with dark
granular casts and albumin. A tentative diagnosis of
nephritis was made at this time with request for fur-
ther information about the case in view of the great
possibility of brain tumor.
Three weeks after this examination I again saw
the patient. He had had a number of unconscious
spells of a few minutes' duration with twitching of both
shoulders and to some extent the right hand. Had
shown lack of emotional control ; as already mentioned,
would grasp a glass of milk, when brought to him, in
both hands and gulp it down greedily. Several times
there were outbursts of foolish laughter with no ap-
parent cause. There had been several motor aphasic at-
tacks lasting only a few minutes. Vomiting and head-
ache had become much worse, almost constant, in fact.
The patient did not seem to have the same degree of
intelligence as formerly, although the rest of the fam-
ily denied this possibility. Paralysis of risrht arm and
leg almost entirely cleared up, particularly the right leg;
plantar reflex on the right and left at this time normal.
No clonus. Knee jerks below normal on both sides. Urine
had shown neither casts nor albumin for a couple of
weeks. Diagnosis of tumor in the mid-frontal or post-
frontal region on left was made. At operation a
tumor the size of a pigeon's egg in post-frontal region
and about an inch and a half below the cortex, about on
a plane with the arm center, was removed. It was a
clearly defined encapsulated growth of carcinomatous
nature.
The man became practically well a couple of weeks
after the operation, then rapidly became worse, and
the old area was opened and no hemorrhage found ;
a decompression was done in the opnosite side and ex-
cessive bulging of the dura found. Patient died several
weeks later and the autopsy revealed two other growths
similar in shape and a little larger than the removed
growth, one further forward in the pre-frontal area on
the same side and on a plane about one-half inch lower.
It was entirely subcortical and clear cut. The cortical
indentations were very poorly developed or atrophied
in the region of the frontal pole. On the opnosite side
(right) a similar growth just back of the occipito pari-
etal juncture and also about an inch subcortical was
found.
443 Davidson Building.
EYE INJURIES AS RELATED TO WORKMEN'S
COMPENSATION.*
By F. D. GULLIVER. M.D.,
NEW YORK.
IN my talk this afternoon I shall endeavor to re-
late some points bearing on eye injuries, which 1
hope will not only be of interest but of assistance
to you in dealing with these cases which come
under the Workmen's Compensation Law.
1. I shall first speak briefly of the function of
the eye and describe how the amount of visual
power is measured and expressed.
2. Of the most common eye injuries showing
part of eye affected, and shall explain certain tech-
nical phrases so that reports on eye injuries can
be more easily interpreted.
3. I shall describe the best means of shortening
the period of disability and of preventing perma-
nent disability after eye injuries have occurred.
4. I shall endeavor to point out that malingerers
and exaggerators exist among eye claimants; the
probable number of the same and the means of de-
tection.
5. I shall draw attention to compensation for
partial defects of vision; how various States re-
gard partial defects of vision, and their basis for
making awards for such defects, and shall make a
comparison of awards in the various States with
those of the New York Industrial Commission.
6. And, finally, I shall deal briefly with the
answers to any questions regarding the eye, and
invite full discussion of my remarks.
The eye is the only organ in the body whose
function can be accurately measured. In cases of
partial loss of function, the remaining amount can
be determined by standard tests and expressed in
fractions of normal vision. Such being the case,
eye injuries should be the simplest of all injuries
from the standpoint of adjusting a fair scale of
indemnity to the injured. For instance, in the case
of a crushed hand or foot, there would naturally
be a considerable diversity of opinion as to what
fractional amount of usefulness still remained.
But, as stated before, in partial impairment of
sight the amount of vision remaining can be ac-
curately determined and definitely stated.
How is the Amount of Visual Power Determined
and How Stated? Visual acuity, amount of vision,
visual power and vision are synonomous terms.
Vision is usually the term employed. Vision is
measured by standard test figures, or test types
of fixed dimensions. These test cards are used
throughout the world and agreed upon by all doc-
tors as the standard and accepted means of de-
termining the amount of vision. And if there is
one point on which doctors would all agree, it is
this point.
The ability of the patient to distinguish the let-
ters on the cards is expressed in fractions — the
distance at which test card is placed being the
numerator, and the distance at which letters dis-
played subtend an angle of five minutes, the de-
nominator. Test cards are always placed at a
distance of twenty feet, and the cards are properly
illuminated either by daylight or artificial reflected
light. Then, with a patient at a distance of twenty
feet who can distinguish only the top letter of card,
vision is stated as 20/200 or 1/10 of normal. If
he reads the second line, 20/100 or 1/5 of normal,
♦Delivered before the New York Claim Association
May 5, 1916.
766
MEDICAL RECORD.
[Oct. 28, 1916
and so on. Of course, it is taken for granted in
persons not seeking remuneration for an alleged
injury that they are using their full visual power.
Cases of suspected malingerers or exaggerators
I will speak of later on.
Now, in a case of eye injury, what you men want
to know is: (1) What is the amount of vision
present? (2) Was defect of vision due to injury as
claimed? (3) Is vision improved by glasses? (4)
Is defect of vision permanent?
Eighty per cent. (80 per cent.) of eye injuries re-
sulting in defects of vision involve the cornea. The
pupil, or pupillary area, is the central portion of
the cornea through which we see. Any injury af-
fecting this part of the cornea naturally results in
loss of vision. Unless injury does affect the pupil-
lary area, there is no impairment of vision. In-
juries to the cornea in most cases leave a portion
of the cornea opaque or cloudy. This condition is
commonly expressed by the following terms, which
all mean the same: scar of cornea, macula of cornea,
nebula of cornea. So that when you get a report
from a doctor on an eye, stating that there is a
scar macula, or opacity of the cornea, and that
vision is 20/50, you will know that there is an
opaque or cloudy condition of the cornea and vision
is 2/5 of normal.
The next most common injury to the eye, im-
pairing vision, is injury to the lens. When the
lens has been injured a cataract develops, which
is also called traumatic cataract. Cataract means
that the lens loses its transparency and becomes
opaque. In all cataract cases there is always al-
most total loss of vision. Now, in many of these
cases, the cataract can be removed, and by putting
a proper lens before the eye the sight is restored
to one-half, or even to normal vision. Such im-
provement in the sight of an eye after the re-
moval of a cataract is usually of no practical ad-
vantage to the injured, for the following reasons:
It is impossible to wear the cataract glass on the
injured eye and still use the other eye at the same
time. This is because the cataract glass over one
eye produces double images and great discomfort.
Of course, in the event the sight of the other eye
becomes impaired, the injured can use the cata-
ract eye alone for visual purposes. Commissions
rule, however, that in a case where cataract has
been removed, although the injured may have good
vision in the eye by using a cataract glass — for
reason already stated, namely that the injured will
have to depend on the uninjured eye for visual
purposes — such a case is entitled to compensation
for total loss of the eye. I believe this ruling a
fair one in a compensation case when viewed from
the standpoint of loss of efficiency to the injured.
In a liability case, I would view the matter quite
differently.
Foreign bodies, especially steel, penetrating the
eye are of rather common occurrence, and are im-
portant injuries. In any case where there is any
possibility of a foreign body in an eye, it should
have an x-ray examination without delay.
The retina is the innermost coat of the eye, and
is very important because it is the part of the
eye by means of which we are able to see. In-
juries and inflammations of the retina are called
retinitis, and are usually associated with marked
impairment of sight. In the retina are often found
evidences of a general syphilitic condition and of
other general diseases, such as Bright's disease,
diabetes, thickening of the arteries, etc.
Now, as to malingerers and exaggerators. — In
my work of examining eyes of persons seeking
compensation, I have found that fully ten per cent,
pretend there is defective sight in one or both eyes
when vision is normal, or exaggerate greatly the
amount of defective sight. Of course, the reason
why persons with eye injuries try to deceive the
physician examining them is that they believe thai
he cannot disprove their statements in regard to
the amount they are capable of reading on the test
cards. Very happily for insurance companies this
is not the case. Very rarely will a claimant simu-
late total blindness of one eye. They always elect
to lessen greatly the amount of vision actually
present. The best means of detecting and expos-
ing exaggerators and malingerers is to fight them
with their own weapons, namely deception. There
are many simple rules and tricks to employ that
expose the cleverest of this class of claimants. All
methods of detection are based on making the
claimant' believe that he is seeing with the good
eye, when in reality he is using the injured eye.
This is accomplished by different arrangements of
glasses and prisms. Examining these cases and
detecting false claims and statements affords one
both diversion and amusement, and the satisfac-
tion of knowing that the individual has not ac-
complished his dishonest aim.
I wish to state in this connection that in all eye
cases with defective vision, I have the injured come
to my office twice before making report as to
amount of vision. It is not fair to the injured or
the insurance carrier to make a statement on such
an important matter as this until I have obtained
complete and conclusive evidence. In cases of
malingerers, I have them report to me three or
even four times in order to use different tests in
different ways and under different conditions be-
fore making a final report on the case.
Furthermore, in this connection, I would say
that when reports of eye specialists do not agree
as to amount of vision in a particular case, it is
not a question of opinion as to amount of vision,
because the same tests are universally used. The
explanation is that the injured on one examination
intenionally or unintentionally did not use the full
visual power of the eye. One can easily under-
stand how a person might be nervous under first
examination by a physician and not need the test
card to an amount equal to the full visual capa-
city.
I have a case in mind where I found vision to
be 2/3 of normal. The medical examiner for the
commission requested an examination by another
specialist. This physician, famous in his profes-
sion, reported the vision as 2/7, and the man was
awarded for total loss of the eye. Subsequently, I
examined the man and found vision to be 2/3.
Now, of course, the physician designated by the
commission stated what he believed to be a fact
in regard to amount of vision; but the claimant
was not using full visual power. I might add that
the above case has been appealed.
What are the best means of lessening duration
of disability and preventing permanent disability
(partial or total) after eye injuries have occurred?
In the first place, you must know that there are
a considerable number of persons awarded com-
pensation for a defect of vision which has existed
previous to the date of the alleged injury. The
only certain way to exclude such cases is to have
;ill applicants for work examined by a physician,
Oct. 28, 1916J
MEDICAL RECORD.
767
and in a case of defective sight not to give employ-
ment to such applicant.
Fully appreciating that it is not practicable to
observe the above measure in all cases, how then
can a person having an existing defect of sight
and receiving an injury to that eye be prevented
from receiving compensation to which he is not en-
titled. The only means I know of are: (1) To get
immediate notification from assured of all eye in-
juries. (2) To make an immediate investigation of
the case. (3) To have injured report at once to an
eye specialist for examination, or, in case where
the injured cannot or will not report for examina-
tion, have an eye specialist visit the injured in his
home or hospital. I cannot emphasize the impor-
tance of above procedure too strongly. It is of the
greatest moment if you would avoid paying false
claims. In many cases I am not asked to examine
a case until several months after the injury. How
am I to tell them whether the injury, as alleged,
caused the loss of sight? Whereas, if I had seen
the case a week, or even two weeks after injury, I
could say whether the injury on the date alleged
caused the condition, or whether some previous in-
jury was responsible for it.
My suggestions as to an immediate examination
apply to the treatment of eye injuries as well. I
know of a large number of cases where sight could
have been saved if properly treated by a physician
skilled in this particular branch of medicine. The
following cases coming under my observation are
only a few examples: A man with a piece of steel
in his eye was treated for two months by an osteo-
path— by rubbing or massaging his back. Another
with the same condition was treated by a doctor for
a month with electricity. One case of cataract was
operated upon and the eye subsequently removed
before the insurance company was notified. An-
other case where the eye was badly injured, the
sight was wholly destroyed and serious inflamma-
tion was present. The treatment indicated was
removal of the diseased eye. This eye was al-
lowed to remain until the good eye became af-
fected by sympathetic inflammation. Result, total
blindness — i.e. total permanent disability.
Aicards in partial defects of vision in one eye.
The law specifies the amount for total loss of one
or both eyes and leaves it to the commission to
fix a lesser amount when the defect is only partial.
The majority of cases by far with which you have
to deal are partial defects of sight of one eye. It
is to these cases that I will devote my closing re-
marks.
From the point of view of an eye specialist, I
have long felt that the awards for partial defects
of one eye by the New York Commission were not
in proportion to the actual loss of function, and
greatly in excess of possible loss of efficiency or
earning power to the injured. In order to learn
how the commissions of Germany, Austria and
States in our country regard these cases, and on
what basis thev make awards, I have addressed a
copy of the following letter to all States and terri-
tories— about thirty in number:
Dear Sir:
For the mirpose of comparison, I am endeavoring to
get from the various States in which Workmen's Com-
pensation is in force, the basis on which their boards or
commissions make awards in cases of defective vision
resulting in partial loss of sight.
In most jurisdictions the law gives the amount of
total loss and leaves it to the Commission to fix a lesser
amount when the loss is only partial. Have you any
fixed rule on which to base the award in partial loss of
sight, or do you estimate the loss on a percentage basis?
In order to simplify the matter and arrive at a basis
for estimating awards in all cases, I think it would be
well to start with award for total loss of sight of one
eye. Then, taking the case of an individual with
normal vision in one eye and a laborer, or of such occu-
pation as does not require good binocular vision to ef-
ficiently perform his woik, would you be kind enough to
inform me on what basis or to what extent you would
consider the above case compensable, when having the
following fi actional amounts of vision in one eye:
20/200 (1/10); 20/100 (1/5); 20/70 (2/7); 20/50
(2/5); 20/40 (1/2); 20/30 (2/3).
1 have received replies from all States and re-
viewed the laws of Germany and Austria. In Ger-
many and Austria, and in all States of our country
where there has been occasion to rule on such cases,
the basis of award is as follows: Individuals with
remaining vision of 1/10 or less of normal in the
injured eye are compensated as for total loss.
Where vision is more than 1/10, awards are made
on a percentage of total loss. The above basis ap-
plies to all occupations.
Let us compare awards of other States with
those of New York. Our commission takes into
consideration the vocation or work of the injured
in considering the amount of award. This is only
just and fair, and in my opinion a commendable
act of that body. But, of course, the question
naturally arises, if one class of workmen is to re-
ceive more for partial loss of vision, why should
he not receive more for total loss?
The New York Commission rules that in a case
where remaining vision of the injured eye is 1/3
or less, the injured is entitled to compensation as
for total loss. Now, with 1/3 of the amount of
average normal vision remaining, an individual
has a considerable amount of sight. For instance,
if a man had only one eye and in that eye had 1/3
the amount of normal vision, such man would be
able to go around the city, recognize different ob-
jects and read medium-sized type in the newspa-
pers. Of course, with two eyes and normal sight
in one, the condition is far different. However,
the New York Commission regards an eye with
1/3 remaining vision as totally lost.
More important still, a person with total loss
of one eye cannot see objects on that side; that is,
he has lost one-half of his binocular field of vision.
A person with 1/3 vision still retains the extent
of his field of vision. Again, with total loss of one
eye, the injured is greatly handicapped by an ab-
sence of the appreciation of the dimension of depth
when looking at objects. This power is accom-
plished by using both eyes in conjunction. With
1/3 vision, one can use the injured eye in conjunc-
tion with the good eye and enjoy the great advan-
tage of stereoscopic vision.
Our commission has ruled in cases where the
injured eye has remaining vision of 2/3 the amount
of normal vision, the claimant is entitled to com-
pensation for 1/2 loss of the eye. In amounts of
vision between 2/3 and 1/3 of normal vision, the
award is determined largely by the vocation or
work of the injured. The above awards apply to
laborers and those not requiring particularly good
visual power. In cases of mechanics and those per-
sons requiring good vision, the award may be in-
creased at the discretion of the commission.
Before establishing a basis on which to make
awards for defects of sight of one eye, a knowl-
edge of the proportion of persons who never ac-
quire normal vision in both eyes should be had.
Without error of refraction corrected, i. e. by
768
MEDICAL RECORD.
[Oct. 28, 1916
glasses, the percentage is from 30 to 40. Again,
acuteness of vision is largely a matter of training,
and laborers whose sight requirements are mod-
erate, and illiterates who never do any reading,
are apt to have subnormal vision when tested on
cards with letters and numbers with which they
are unfamiliar. Now, a person not needing particu-
larly good vision, as obtains in many employments
coming under the act, can perform his work very
efficiently with 2/3 vision in both eyes. Of course,
with normal vision in one eye and 2 3 vision in
the other, there could not possibly be loss of effi-
ciency on account of sight.
I direct especial attention to the ruling of the
Commission of this State where injury to one eye
with remaining vision of 1/3 compensation is
awarded as of total loss. In Germany, Austria and
all other States to which my attention has been
called — and I have made searching inquiries — the
loss must equal or exceed 9/10 to secure compen-
sation for entire loss. It is important and Inter-
esting to consider the basis and merits of the two
rulings.
It is clear that with 1/3 remaining sight the
field of vision is not destroyed, whereas where the
remaining vision is but 1/10, the field of vision is
practically gone. This is equally true of the stereo-
scopic vision. It seems unfair that with the field
of vision and stereoscopic vision practically intact,
compensation for total destruction should be given.
This view is taken in all jurisdictions other than
in this State. It is self-evident that total destruc-
tion is one thing, and 1/3 remaining vision with
a field of vision and stereoscopic vision remaining
is quite another thing, and compensation in the two
cases should not be identical.
My aim is to make clear that the general ruling
giving total compensation where 1/10 of vision re-
mains, with practical loss of both field of vision
and stereoscopic vision, is far more equitable and
should be adopted in this State. Likewise, it is un-
fair to one who has suffered total loss of an eye
to receive no more compensation than one with 1/3
of the sight remaining and with the field of vision
and stereoscopic vision practically unimpaired.
As the percentage of remaining vision can lie
ascertained by measurement, compensation should
be given to the extent of the percentage of loss of
vision. This is the general rule outside of this
State. But in New York, where the remaining
vision is 2 3 of normal, compensation is given for
1 2 of the loss of the eye. Were it impossible to
measure with accuracy the amount of vision de-
stroyed, an arbitrary ruling giving 1 2 compensa-
tion where remaining sight is 2 3 might be justi-
fied. Where the actual percentage of loss is readily
ascertained, equity and justice would indicate that
the compensation be placed at the actual loss.
It is furthermore to be considered that in this
State the financial compensation for total and par-
tial destruction is greater than elsewhere. The
measure of damage is greater, and the basis of
compensation is more favorable to the injured.
There is no pretense that there exists in this State
a greater value in eyesight than elsewhere, or
that the partial or total destruction should be
measured more favorably to the injured, especially
since, as above explained, the extent of loss may be
accurately measured and correspondingly compen-
sated without arbitrary ruling.
Speaking from the standpoint of both the in-
jured and assurer no fair adjustment for partial
loss of sight can be reached without a consideration
of the vocation of the claimant. A study by com-
mission of the visual requirements of each class of
employment coming under the act, and a classifica-
tion formerly made with a percentage of award
for each class, in my judgment, would be the fair-
est to the injured and to the insurance carrier.
!»."» West Seventy-second Street.
PRIMITIVE MEDICINES.
A SHORT SKETCH ON EMETICS AND PURGATIVES.
By .r. BAKKI.KV PERCIVAL, M.D.,
PARAMARIBO, DUTCH GUIANA.
Our cats and dogs pick up carrion now and again
with the consequence that their stomachs get out
of order. Instinct impels them to strain for relief
by vomiting the obnoxious matter. Housewives
hear the hawking and drive them out of doors, if
possible before it comes to the worst! The ani-
mals often get nausea and pain, but cannot get im-
mediate relief until they have taken an emetic of
grass. The discomfort or pain drives them to take
medicine.
Primitive man was like the dog in his habit of
picking up meat wherever he found it and no matter
how tainted it might be. He would also taste
strange fruit, some of which might be poisonous.
When the painful results drove him to do some-
thing he chewed herbs which he had learned by
former experience caused vomiting.
Our children eat unripe and rotten fruit and
come crying to their mothers with their hands
pressed against the painful part. The mother
finds the child retching and gives large draughts
of tepid water, sometimes putting her finger down
the child's throat until the desired result is ob-
tained.
These are examples of the beginnings of medi-
cine; we may call them fancies but they are rea-
sonable. When man first began to take medicine
is a riddle which will probably never be solved, and
yet the problem is worth considering. Pliny, whom
we consider one of the ancients, said he admired
the industry and laborious research of the ancients
in finding out by experiment the medicinal prop-
erties of plants. We also have to thank, not only
the Chaldeans, Egyptians, and Greeks, but the
East Indians and Americans as well. The real
origin of medicine, however, goes back to primitive
man when his impulses were mainly instinctive.
What happens when poisonous crabs or sprawns
are taken? 1 can state from personal experience.
There is retching, colic, cold sweats, and a general
feeling of collapse. Something must be done to
relieve the symptoms and the feelings indicate an
emetic, a purgative, and a warm bath. The mo<t
urgent is the emetic, but vomiting often takes place
without assistance. The principle of all medicine
should be to assist nature and this was acted upon
by the primitive American, who followed the same
course as our cats and dogs by chewing some herb
as an emetic.
There is one herb peculiar to America which must
have been discovered long ages ago, for it is wide-
spread and never truly wild. This is tobacco, which
possibly may have been the primitive emetic. That
it is powerful everyone will admit, especially the
boy who has suffered from his first smoke. To
chew the green leaves is even more likely to cause
vomiting than the smoke. Every smoker knows
i
Oct. 28, 1916 J
MEDICAL RECORD.
769
the effect of a tiny bit of tobacco when accidentally
swallowed.
Those who only know tobacco as smoked, or taken
as snuff, are possibly not aware that it has been
taken internally as a diuretic in dropsy. It is,
however, so very powerful that in many cases it
produces nausea; it is also much used externally
as a sedative for aches and pains as well as swell-
ings. The medicine man generally drinks tobacco
water when he is going through his ordeal. He
also uses it to bring on a trance when carrying on
his work.
Smoking is probably a late development of its
use and a strictly American discovery. Possibly
the sedative effects of tobacco water were agree-
able to those who enjoyed getting drunk, but the
nausea and sickness were too much even for the
Indian. It probably led to smoking, which gave
the pleasant feeling so well known, and no nausea
after the smoker became accustomed to it. The
smoking habit was unknown in the old world until
introduced, but it so quickly spread that some have
doubted whether it did not exist in India before
the discovery of America. The evidence, however,
will not admit of this.
A well-known emetic is the kaka-baballi or buck-
puke, which is much used by the native cross-bred
races in South America. As far as I can gather it
is free from the defects of tobacco. Other emetics
include bullet tree bark, red mora, and others with
only Indian names.
The wild coffee or myamya root is Indian as
well as creole; it seems to be a very violent emetic,
only used in extreme cases of bilious fever. The
so-called white lily bulb is another severe emetic.
The creole emetic most commonly in repute is the
palse ipecacuanha.
It may be stated that most intoxicants are also
emetics. The Indian's piwarri is decidedly so and
beer is not far behind. The most repulsive stage
of drunkenness goes to prove that all intoxicants
are emetics when first taken.
It is a sound principle to take medicine when
there is something which impels us to do so and
this impulse might be given by the spirit drinker
as a reason for taking up the habit. But, as all
medicines are poisons and should be used to assist
nature only when absolutely necessary, there is
no rational excuse for their being taken habitually.
Emetics and purgatives are both indicated when
some poisonous meat or berry has been taken.
There are both retching and colic, indicating plainly
that the somach and bowels must be relieved. This
is provided for by several remedies, especially those
nausious herbs which cannot be retained if chewed
or swallowed without disguise. On this account
most of the nastier purgatives are now; used in
pills. Primitive man did not know how to make a
pill and, therefore, many of his medicines acted
both ways. The negro often asks the druggist
for pills to work both ways; his medicine must
"do him justice." He has not the idea of assist-
ing nature, but desires to take her by storm.
Whether the Indian also likes strong purgatives I
am not quite sure, but we may expect that his
stoicism in pressure of pain means that he is glad
to know that the remedy is fighting the disease.
A gentle laxative would probably be unsatisfactory
to the man who wants to fight a disorder.
Emetics and purgatives are very numerous, espe-
cially among the creole remedies. One of them is
well known in gardens as Allamanda cathartic and
is an Indian medicine of great potency. Acosta
said long ago that there are a thousand simples in
America fit to purge, and though I have not come
across anything near a hundred still the purgatives
are too numerous to deal with in this article. I
think that a mere list would be of little value and
anything more would take up too much space; I
can, therefore, only give a few examples.
The Creoles use carrion-crow bush as a purga-
tive, and like many others of its class it some-
times acts as an emetic. The leaves are used fresh
in decoctions and are more powerful than senna, to
which it is closely allied. Other species of Cassia
have similar properties, and we may safely state
that the genus contains many good purgatives be-
sides the two species known as senna.
An allied plant called "Doctor Doodles" or Bar-
bados Pride is probably a valuable medicine, for
it supplies from its different parts mild and drastic
purgatives to suit young chidren and strong men.
The flower buds may be used as a gentle aperient
for children, the open flowers for adults, the leaves
and pods as stronger purgatives, the bark of the
stems yet stronger; and the root is so drastic as to
be dangerous.
This suggests the fact that we have something
analogous in the Natural order Euphorbiacese, to
which the castor oil plant belongs. We can get milk-
weed as a gentle laxative and go on to belly-ache
bush, castor oil, physic nut, and sand-box, which
last is dangerous. In connection with the reac-
tions of plants we may state that butterflies and
moths appear to feed on a number of allied species
of similar qualities. They choose by the odors
and tend to confirm deductions made from botanical
alliances. In cases just mentioned we have a divi-
sion of the bean family with qualities like senna,
and the Euphorbias more or less resembling castor
oil.
Jalap is represented here by a substitute, the
four-o'clock or marvel of Peru, the roots of which
were once used as an adulterant of the real drug.
It is not quite so strong as jalap, but the roots are
so similar that a novice could hardly tell them apart.
Aloes is grown in boxes by the Creoles and the
juice sometimes used as a purgative; it is, how-
ever, too nasty for general adoption. Its use is
generally limited to external dressings for "rose"
and other swellings.
We have already stated that colic is one of the
symptoms of poisoning; many vegetable poisons
are drastic purgatives, decidedly painful because of
their griping. Among them I may mention the
frangipanni, the mudar or ladies pin-cushion, and
the good-luck. These are very dangerous. We
have also in cultivation some of the cucumber
family, such as Karyla and luffa, the active prin-
ciples of which are similar to that of colocynth ;
these are not worth considering.
The tendency of late years has been to reduce
the heoric doses once so common. We still find,
however, that some of the Creoles must have griping
purgatives, for mild aperients will never "do them
justice." If the women dealt only with themselves
it would not be so bad, but unfortunately their
children are often injured by drastic cathartics.
Even when they use castor oil they often give an
adult's dose to a child. We may safely state that
as a rule too much medicine is taken everywhere.
When the primitive man took an emetic or purga-
tive and got relief he did not go on with the medi-
cine for weeks as some people do nowadays.
770
MEDICAL RECORD.
[Oct. 28, 1916
We may ask whether any of these medicines are
worth retaining. In regard to emetics we may
say that they are hardly needed except in the treat-
ment of poisoning. If a purgative is required it
is generally safe to take a small dose of castor oil ;
this was formerly made in the Colony from seeds
grown here and could be so again. A good sub-
stitute for senna is the Barbados Pride, the leaves
of which can be dried and kept for some time.
The foregoing facts point to certain conclusions
from which we can form a tentative theory of
medicine. It was once supposed that the constitu-
ents of plants were made for the use of man; we
know that they are for the benefit of the plants
themselves. Indian corn and wheat contain what
we may call baby's food, for the starch and other
things support the young plant until it is strong
enough to feed itself. Man has utilized the stores
of plant food for his own purposes, but they were
not secreted for his use.
We can apply the same principle to medicine.
Through the ages there has been a grand struggle
between plant and animal, the results of which we
can see every day. Certain animals feed on cer-
tain plants and the plants resent this by secreting
noxious juices, some of which are poisonous to
most animals. But there are always some that be-
come immune and are able to feed on the poisons.
A certain amount of protection is gained, prob-
ably enough to insure the preservation of the
species, but it is never complete.
Disorders and diseases are common to plants as
well as animals. They are largely due to the won-
derful provisions for eliminating the weak and
unfit. As soon as the plant or animal is injured
there is a grand struggle between the recuperative
powers and those scavengers that are always ready
to dispose of the dying and dead. If there is
enough internal power to heal or overcome the
sickness there is a recovery, otherwise death en-
sues. If the animal or plant can do anything to
help the healing process it is well, but little has
been done by others than man. What we see in
dogs and cats is suggestive, and possibly wild ani-
mals may take similar emetics.
The principle, as we see it in nature, is that an
impulse is given to do something when we suffer
pain. In fact pain is the warning note; like
hunger, it plainly says take what is suitable. Proper
foods were always known, but not proper medi-
cines. There has been more improvement in the
preparation of foods than in that of medicine, but
great progress has been made in both. There is,
however, apparently a fault with the latter; people
take medicine when not really sick. This is not
helping Nature, and in many cases it hampers the
recuperative powers.
On this principle I must condemn tobacco smok-
ing and spirit drinking, even though I condemn my
own pipe. They are medicines and should be used
only when we are sick. However, I suppose people
will go on smoking and drinking, for we are not
always rational.
MsbitaitQui Katea.
Opinion Evidence. — In an action against a railroad
for iniuries in a derailment, where the road eo"tcnded
that the nlaintiff did not receive the injuries through
the derailment, but from disease, it was held that tes-
timony of a physician that in his oninion there was no
injurv to the cartilages of the kneo joint, am! that when
the plaintiff received the injury, of which she to'd h-m
there was a fracture of n-e or more of the synovial
cartilages, was inadmissible — .Tackmann v. St." Louis
& H. R. Co. (Mo.) 187 S. W. 786.
Insufficient Evidence of Malpractice. — Action was
brought against a physician for damages on account of
injuries sustained by the plaintiff wnile a patient at
a maternity hospital for the purpose of confinement, by
reason of the breaking off of the glass tip of a vaginal
douche while it was inserted in the vagina of the plain-
tiff, and permitting the broken fragments to lemain
imbedded in her flesh without informing her
thereof. On appeal from a judgment for the
plaintiff it appeared that the plaintiff was at-
tended by the defendant during her confinement
in a large maternity hospital; that shortly after
her confinement she suffered from the effects of what
was subsequently found to be the presence of frag-
ments of glass in the wall of the vagina; that she was
discharged from the hospital without the discovery of
such condition; that thereafter she consulted the defend-
ant and was treated by him because of her continued
suffering; that the doctor made several examinations,
and attributed the trouble to the failure of the stitches
to heal which were necessarily taken in the person of
the plaintiff after the birth, or to the fact that the gut
used in sewing up the torn parts had not absorbed or
assimilated in the plaintiff, and calcareous matter had
accumulated.
The court said: "It would hardly be profitable to
enter into a discussion of the facts of this case in this
opinion. The plaintiff has completely recovered. The
only negligence claimed against the defendant is for his
delay in making such an examination of the vaginal
cavity as would disclose the foreign substance there-
after found. Two experts of standing have sworn in
behalf of the defendant that it would have been poor
surgery to have made such an examination as would
disclose the existence of foreign substance before the
time that it was actually made by the defendant. One
expert, on behalf of the plaintiff, has sworn that such
an examination ought to have been made three months
before it in fact was made. It is always easy, after
the cause of an injury has been found, to look back and
say that that cause should have been sought for. To
my mind the jury failed to give proper force to the
fact that this defendant had never had the slightest
cause of suspicion that any foreign substance could be
causing this trouble. Every fact surrounding the case
and its treatment would constitute almost proof of its
absence. The breaking of the glass of a vaginal douche
within the vagina is a circumstance so rare as not to
have been reasonably contemplated at any time by the
defendant, and for failure to anticipate this most un-
usual occurrence the defendant has been most unjustly
charged with a substantial money judgment, and, what
is worse, with a stain upon his professional fidelity,
That this verdict is clearly against the weight of evi-
dence I have no doubt whatever."
Judgment for the plaintiff was reversed and a new
trial ordered. — Rogers v. Voorhees, New York Appel-
late Division, 157 N. Y. Supp. 330.
Tuberculosis Hospital a County Purpose. — In an
action to enjoin the erection of a tuberculosis hospital
by a county, the New York Appellate Division holds
that the erection and operation of a hospital is a proper
county purpose, although the hospital takes some pay
patients. It has never been held that the incidental
revenue from board, or from special care, deprives such
an institution of its charitable character. — Smith v.
Smith, 160 N. Y. Supp. 574.
Testimony as to Professional Service Where Patient
Has Died.— Under New York Code Civ. Proc. Sec. 829,
prohibiting testimony of an interested person as to a
transaction with a decedent, in a physician's action for
professional services atrainst executors of a decedent,
testimony of the physician that he attended decedent
professionally was held inadmissib'e. — Kennedy v. Mul-
ligan, ,New York Appellate Division, 160 N. Y. Supp.
105.
Improper Cross-Examination of Medical Witness. —
In an action by a husband for damages for personal
injuries to his wife, one of the elements of damages
was the bill of a nhysician who had had principal
charge of the plaintiff's wife after the accident. He had
testified to the amount of his bill, and was asked on
cross-examination if he exnected to ret it naid out of
the litigation. The nuestion was he'd imnroner. —
.To'man v. Alberts, Michigan Supreme Court. 158 N. W.
886.
Oct. 28, 1916]
MEDICAL RECORD.
771
Medical Record.
A Weekly Journal of Medicine and Surgery.
THOMAS L. STEDMAN, A.M., M.D., Editor,
PUBLISHERS
WM. WOOD & CO.. 51 FIFTH AVENUE.
See fourth page following reading matter for Rates of Subscription
and Information for Contributors and Subscribers.
New York, October 28. 1916.
THE ETIOLOGY OF EPIDEMIC POLIOMY-
ELITIS.
There has been no epidemic of recent times that
has so excited the attention of the whole populace
as that which has prevailed during the past sum-
mer. The youth of the patients affected, the rapid
spread of the disease, the high mortality, and the
mystery which surrounded the methods of trans-
mission, combined to add to it a peculiar terror,
which was not lessened by the rigid and often un-
necessary quarantine regulations which were
adopted by some localities. The causative organ-
ism may be said to have been discovered by Flex-
ner and Noguchi, but the epidemiology of the dis-
ease was certainly not on a satisfactory basis. The
publicity given to the epidemic naturally attracted
many investigators, and the result of their work
has begun to appear in articles which, if the infor-
mation which they contain is correct, have increased
somewhat our information as to the cause and
spread of poliomyelitis.
The work which was done in the New York Hos-
pital Branch had already received a certain amount
of attention, but the first authoritative description
of the results accomplished was given by Dr. Rose-
now at a meeting of the New York Academy of
Medicine on October 5, as reported in the Medical
Record of October 21. In this report, Rosenow
summarized briefly the work done by him and his
associates, Towne of Boston, and Wheeler of New
York. They followed the lead which Rosenow es-
tablished in his work on the elective localization of
streptococci in the study of rheumatism, endocar-
ditis, gastric ulcer, and other conditions, and were
able to isolate a pleomorphic streptococcus which,
as a result of their extensive animal experiments,
they felt justified in regarding as the cause of the
disease. If they are correct in this assumption,
we may perhaps look on the Flexner and Noguchi
organism as a form which this coccus takes when
grown anaerobically. One of the most interesting
statements made by Rosenow is that regarding his
success in isolating this organism from the tonsils
of patients suffering from the disease, an observa-
tion which might have an important bearing upon
the treatment and epidemiology of poliomyelitis.
If, as these authors believe, the tonsil is the focus
in which the streptococcus so develops as to acquire
its elective affinity for the central nervous system,
then the removal of the tonsils should have a
marked influence upon the incidence of the disease.
It is doubtful if any physician at the present time
would have the temerity to advocate wholesale re-
moval of the tonsils of children, but if Rosenow's
hypothesis is established there will doubtless be a
tremendous sacrifice of the tonsils of the young and
helpless when another epidemic appears. The re-
moval of the tonsils even during the course of the
disease is said to have had a favorable influence
upon it in a few cases.
The work is, of course, in the line of confirmation
of Rosenow's theories concerning the streptococcus,
but the problem is far too large for it to be worked
out in so short a period of time; one way is merely
pointed out, and there will probably be no lack of
workers to follow it. The objections to this theory
that will occur to every one are innumerable, and
it will be necessary to reconcile it with many of the
apparent facts of quarantine, immunity, curative
sera, and the like; and then there is the work done
at the Johns Hopkins seeming to point to an intesti-
nal localization, though of that we know little be-
yond what has appeared in newspaper reports. Nev-
ertheless, the investigation by Rosenow and his as-
sociates will stand as a good piece of work, and
even if, eventually, the whole theory is disproved,
the observations are there, and only the interpre-
tation can change.
THE IRRITABLE HEART OF SOLDIERS.
Recently a good deal has been written concerning
the soldier's heart. Sir James Mackenzie has ex-
pressed his views on the subject, while Sir James
Barr has given his somewhat original ideas in a
paper published in American Medicine for Septem-
ber, 1916. In the September issue of the Canadian
Medical Association Journal Dr. Robert Dawson
Rudolf, Professor of Therapeutics in the University
of Toronto and Lieut. -Colonel Canadian Expedi-
tionary Force has contributed a paper dealing with
the question. He does not agree wiith Barr as to
the causation of the so-called soldier's heart but is
in more or less complete agreement with Mackenzie
with regard to the nature of the condition. Rudolf
points out that soldier's heart, as witnessed at the
French front, can hardly be due to strain of the
heart muscle to which it has been largely attrib-
uted for the reason that trench warfare does not
give rise to strain sufficient to damage a previously
healthy heart muscle. On the other hand the strain
to which the nerves are subjected by the mode of
warfare in France no doubt has much influence. All
kinds of functional nerve conditions are encount-
ered, including nervous instabilities of the circula-
tion. The heart and vessels are very largely under
the control of the nervous system and the rate of
the pulse is perhaps a better index of the state of
this system than anything else. Moreover, as
Rudolf points out, when the whole nervous system
is under such tension it will yield, if at all, at its
weakest point, and the weakest point varies in dif-
ferent individuals. If a person's circulation is his
weakest point, then that is where it is most
likely to give way. Rudolf's conclusions are as fol-
772
MEDICAL RECORD.
LOct. 28, 1916
lows: (1) The condition called "soldier's heart"
is not an entity but includes merely the worst ex-
amples of a circulatory instability that grades up
from the nearly normal to a degree so great that it
may completely incapacitate the patient. (2) The
circulatory instability has often been there before
and is merely brought into prominence or exag-
gerated by the unusual physical and mental sur-
roundings of a soldier's life. The very same con-
dition occurs, only more rarely, in civil life. (3)
In many cases the condition appears to be caused
or precipitated by infection with consequent toxe-
mia, also by nerve shock or strain, but in many
instances no such clear origin can be traced. (4)
The condition appears to be essentially one of neur-
asthenia in which the circulatory apparatus hap-
pens to show the most symptoms. (5) The best
test of the degree of the condition is to take the
history in conjunction with the pulse rate when
the patient is standing. (6) The treatment is not
that of ordinary heart disease, but should be di-
rected in every possible way toward increasing the
general tone, including the mental tone of the suf-
ferer. (7) The patient should not be told, or allowed
by our bearing towards him to think that he has
"heart disease" as such is not strictly the case, and
such a belief does much harm. (8) The progress
in well-marked cases must be guarded, but the
great majority of patients bad enough to be inval-
ided home will probably not be fit for "full dutj "'
for a long time, but will eventually be quite capable
of doing light duty. (9) The ultimate fate of the
bad cases (after years) remains to be investigated.
Sir James Barr, to whose views reference has
been made, attributes the condition simply to hyper-
thyroidism, basing his conclusions on the study of
soldiers back from the front. The treatment, there-
lore recommended by Barr is directed to the condi-
tion of the thyroid gland and he claims to have re-
ceived excellent results from it. The weight of evi-
dence as to the causation of "soldier's heart" is.
however, with Sir James Mackenzie and those who
agree with him, albeit Sir James Barr has made out
a plausible case. It is a question of very considera-
ble importance, as the irritable heart occurs more
or less frequently in civil life. It is therefore to be
hoped that the problem will be solved in the near
future.
SHALL WE PUNISH MANIACS?
A situation which constantly confronts the physi-
cian in charge of the insane, and which the general
practitioner occasionally encounters, is the problem
uf the excited patient who, left to himself, would
tear up everything about him, including his own
clothes, soil his surroundings, injure himself and
assault others. To his exasperated guardian he
often seems to be actuated by a malicious spirit,
and this impression is heightened by his conversa-
tion, which is apt to be abusive and allusive to the
highest degree, enumerating his physician's failings
accurately, and indulging in the grossest and most
vulgar personalities. It is but human to want to
tie up a patient who has just slapped one in the
face, and it is easy to be convinced that such a
patient's reasoning powers, being in abeyance, he
should be treated as a child.
Let us not delude ourselves with the idea that
we are engaged in any sort of a therapeutic measure
when we have to resort to tying down such a patient.
In the reports of a hospital for the insane we some-
times find a record of so many "dry-packs" given
in the course of a year. The term "dry-pack" is
a euphemism given to the process of tying an excited
patient hand and foot for a given time. Hot and
cold packs, either of the sheet or blanket variety,
have, of course, their proper therapeutic indications,
and the hot or cold water acts as a sedative or a
stimulant, depending on various things. The "dry-
pack" can, by no stretch of the imagination, be con-
ceived to have any therapeutic value. The officers
of these same hospitals boast that no patient is "re-
strained" in their institutions, and salve their con-
sciences by calling their cases — really the most
severe form of restraint — "dry-packs." Any one
can get an idea of how one feels in a "dry-pack" by
reading the scenes in Charles Reade's "It's Never
Too Late to Mend," where the prison chaplain tests
the form of punishment of lacing a prisoner in a
tightly-strapped jacket; or to allude to actual ex-
periences he can read the description by Clifford W.
Beers in "A Mind That Found Itself," of the night
he spent in a straitjacket.
We are getting gradually away from the old idea
of treating the mentally disordered as if they were
criminals. We no longer think it necessary to put
chains on maniacs or even to stupefy them with
drugs. Psychotherapy between attacks and hydro-
therapy during the attacks are the methods of
choice. Of all forms of hydrotherapy for excited
cases, the continuous bath is the best, and it has the
great merit that it can be administered, in a some-
what modified form perhaps, in nearly every private
home. It is interesting as illustrative of the changed
attitude towards mental cases that at first it was
thought necessary to tie the patient in a continuous
bath, with the result that finding himself restricted
in his movements, he struggled to be free. Now he
is merely put in the bath and watched. He may at
first get out and run about the room, but he is soon
chilly enough to be glad to step back into the warm
tub.
We should conclude, therefore, that everything in
the way of disciplinary measures lor mental cases
is absolutely contradicted both for the sake of
justice and lor therapeutic reasons. The maniac
should be treated, not punished. If it is impossible
for any reason to give him adequate hydrothera-
peutic treatment, or to watch him constantly so as to
prevent him doing damage to life or property, and it
is found necessary to restrain him in some way, let
the physician at least be honest enough to acknowl-
edge that it has been found necessary to restrain
his patient, and not call his bonds a "dry-pack."
FERHAN ON THE BACTERIOLOGY OF
TUBERCULOSIS.
As is generally known, Koch's bacillus does not ex-
plain all the phenomena of tuberculosis, and espe-
cially does it fall short in connection with the prob-
lems of acquired immunization. Some authorities
Oct. 28, 19161
MEDICAL RECORD.
773
go so far as to state that the acid-fast bacillus of
Koch is wholly devoid of either immunizing or
curative powers. If there were not some natural
immunizing forces in the body tuberculosis would
in a short time destroy the race. Koch's bacillus
cannot confer such protection. Ferran, the Spanish
bacteriologist, insists that when tuberculosis arises
de novo in the body, it is not caused by Koch's
bacillus as such, although the power of the latter to
cause inoculation tuberculosis is not called into ques-
tion. According to Ferran, Koch's bacillus makes
up but a small fraction of the complete biology of
spontaneous tuberculosis, being merely the last step.
Ferran says that in human beings conjugal infec-
tion but rarely occurs — the incidence varies from 7
to 22 per cent, according to the material — and he
does not understand how any spouse could escape
infection if Koch's bacillus was the sole or even
the chief agent of transmission.
Ferran holds that Koch's bacillus is naturally
a saprophyte. He finds five varieties of bacteria
present in tuberculosis, one of these representing
the classical acid-fast bacillus of Koch. Literally it
is the fourth term of an ascending mutation, due to
adaptative evolution. A further form is that de-
rived artificially from the tubercle bacillus. The
Koch organism is by no means the same thing as the
virus of tuberculosis. The artificial form is regres-
sive, just as the three ascending forms are progres-
sive, Koch's bacillus standing at the apex. The
natural forms cause spontaneous tuberculosis but
are not infectious from man to man. They are ubiq-
uitous, in the air, soil, and water. If by any chance
they enter the blood they give rise to a form of
septicemia. If they gain access to the tissues, there
is no immediate reaction, but instead a process of
adaptation on the part of both bacterium and host,
the latter obtaining a general immunization from
the formation of antibodies in the blood, while the
former tends to pass through mutations until Koch's
bacillus is formed. If the latter stage is reached
there has been no immunization — the individual is
tuberculous; but in the majority of cases this is a
local process admitting of spontaneous arrest, the
subject is affected, but not infected with the dis-
ease.
Ferran's teachings apply to bacteriology in gen-
eral and go far to fill a number of defects in pres-
ent day teaching. According to Persano (Rwista
critica di clinica medico), these views have excited
much controversy. The opposition is based partly
on the claims that vaccines and sera produced un-
der Ferran's teachings have not yet led to practi-
cal results. Ferran's rejoinder to his critics is that
his methods are in the experimental stage, but show
encouraging results. Evidently several years must
elapse before a final judgment regarding these
claims can be formed.
exposing simulation, but the malingerer soon learns
to show pain under this maneuver and to imitate
the defense exerted by the true subject of the dis-
ease. In La Riforma Medica, for July 10, Neri sug-
gests a substitute procedure as follows: The sub-
ject is asked to stand and make various indifferent
movements, such as elevation of an arm, bending
forward, folding the arms, etc. If he has sciatica
there will be some embarrassment in flexing the
trunk on the lower extremities, flexion is more pro-
nounced on the healthy side, and there is a slight
rotation toward the affected side. Or the affected
member may be flexed on the body, in which case
the heel will be elevated, while the patient, feeling
a severe pain at the sciatic foramen supports himself
on the sound limb. In the simulator these flexions
are produced without reactions, or defence move-
ments, which are wholly instinctive. On the cadaver
the author learned that the flexions cause stretching
of the sciatic nerve. Vigorous active and passive
flexions of the head on the trunk also cause pain in
sciatic nerve of a sciatic victim, this being felt at
the sciatic foramen. If the patient is supine,
flexion of the head may cause a slight flexion of the
hip upon the pelvis and of the leg on the thigh.
This defence reaction is sometimes accompanied by
clonus. This behavior has been explained by the
possibility of a drawing upward of the medulla
oblongata, corresponding to the flexion of the head,
with a resulting traction upon the nerve radicles.
It is evidently, however, not pathognomonic for
sciatica.
Simulation of Sciatica.
Sciatica, having no objective characteristics, is an
affection which invites simulation. Patients who
have recovered from other affections in hospitals
have obtained an extension of their sojourn by this
means. Lasegue's sign — accentuation of pain as a
result of traction on the limb — is of great value in
Hepatic Prophylaxis.
The various manifestations comprised under the
term hepatic insufficiency have been freely dis-
cussed in recent years, and in the more severe types
we see urobilinuria, alimentary glycosuria, amino-
aciduria, and acidosis. There is a form of true
diabetes due to this causation, and functional insuffi-
ciency is a forerunner of cirrhosis of the liver, as
shown by the urobilinuria which precedes that af-
fection. Given a condition of hypohepatism (to
paraphrase the terminology of thyroid pathology)
how is it to be antagonized'.' Regnier (Gazei
Medicale de Paris) states that proper diet is the first
requirement. The subject cannot digest fats and
articles containing fats, and has grayish stools,
diarrhea and constipation alternating. He is drowsy
by day and wakeful at night. He is intolerant to
alcohol and tobacco, has no desire to work, is melan-
cholic. In addition to fats, he must eschew wine,
spices, sauces, excess of meat, fresh bread, pastry",
yolk of eggs, shell fish, and an entire series of dishes
which might disagree. No chemicals should be
given. The author advocates lactic acid ferments,
which may be combined with selected yeasts. To
stimulate the hepatic cells he counsels organotherapy
and gives hepatic and splenic extracts and bile salts.
The latter are especially valuable and may be all that
is necessary. He has great faith in hepatic extract,
which has a beneficent action on the blood in in-
creasing its coagulability, and he regards it as the
logical remedy in impending cirrhosis. According
to him, older as well as more modern clinicians
(Semmola, Joffroy, Millard, et al.) have made thi<
use of organotherapy. The urine which character-
izes hypohepatism is said to return to the normal
under this treatment. Cirrhosis, whatever form it
may take, is always preceded by a certain degree
of hepatic insufficiency.
774
MI-DICAL RECORD.
[Oct. 28, 1916
2faaa of lb? i$w>k
Poliomyelitis Epidemic. — During the week end-
ing October 21 there were reported in New York
41 new cases of poliomyelitis, making a total to that
date of 9,243 cases, of which 2,379 have been fatal.
Cases of the disease have also been reported from
several places in the State. At Ithaca, eleven stu-
dents at the University have been quarantined be-
cause of the occurrence of a case of the disease
in the house in which they roomed. Other cases
have been reported in schools and colleges in New
York, Connecticut, and New Jersey, but no serious
outbreak has occurred. In Westmount, near Mon-
treal, two cases of poliomyelitis developed shortly
after the holding of a dog show, and it has been
suggested that the disease was introduced by dogs
from New York exhibited at that time.
Need for School Physicians. — The New York
Bureau of Welfare of School Children has recently
sent to the Board of Estimate of this city a memo-
randum urging that provision be made for the ap-
pointment of additional inspectors, physicians, and
nurses in the public schools. It is stated that dur-
ing the last school term each school physician had
the care of 9,200 pupils, and each nurse of 4,800.
It is possible, under the present conditions, to ex-
amine each child only once in three years, whereas
an annual examination is essential.
Fire in Hospital. — A blaze in a bathroom and
clothes hamper, in the women's ward of the Lu-
theran Hospital, Brooklyn, on October 21, caused
some alarm among the inmates, but was extin-
guished before serious damage had been done.
Balkan Relief Fund. — For the relief of the peo-
ple of Albania, who, their land devastated by the
opposing armies, are literally starving to death, an
attempt is now being made to raise funds. Appeal
is made for contributions in any amount, and these
may be sent to the Balkan Relief Fund, 70 Fifth
Avenue, New York.
Gifts to Charities.— By the will of the late Dr.
James Y. Shearer of Sinking Springs, Pa., the sum
of $60,000 is bequeathed, following the death of
the wife and daughter of the testator, to Jefferson
Medical College, Philadelphia, to be used for the
endowment of a chair of bacteriology.
To Dedicate Hospital. — The new Lutheran Hos-
pital at the northeast corner of Convent Avenue
and 144th Street, New York, will be dedicated on
October 29, and opened to the public on the fol-
lowing day. The buildings were made possible
largely by the generosity of Dr. Inslee H. Berry, one
of the founders of the hospital, whose entire resid-
uary estate, on his death in 1912, passed to the
institution. With this, and further gifts received
since that time, the directors have erected a hos-
pital and provided an equipment complete in every
detail.
Personals. — Dr. William Seaman Bainbridge of
this city was elected an honorary member of the
Vermont State Medical Society at its annual meet-
ing recently held in St. Johnsbury, and of the
Society of Pennsylvania Railroad Surgeons at the
annual meeting in Philadelphia on Friday of last
week. He delivered the oration at the meeting of
the Pennsylvania Surgeons.
Dr. H. H. M. Lyle of New York spoke before the
Waterbury Medical Society, Waterbury, Conn, on
October 9, describing the results of the Carrel
method of sterilization of wounds as he had ob-
served them during his service in France, and as
detailed in the report of the Surgical Section of
the New York Academy of Medicine, published in
another column of this issue.
Dr. David S. Booth has undertaken the editorial
management of the Alienist and Neurologist of St.
Louis, upon the death of its editor, Dr. C. H.
Hughes, pending the appointment of a permanent
editor.
The Diagnosis of Diphtheria. — Dr. D. L. Gaillard
of Greenville, Tex., writes that for years he has
depended upon swabbing the suspected tonsil with
solutions of the perchloride of iron as a diagnostic
help in diphtheria. In follicular tonsillitis the de-
posit is broken up, in diphtheria the membrane is
stained only. Dr. Gaillard asks that others try
this method and report the results.
Removals. — Dr. William A. Downes has removed
his office to 424 Park Avenue.
Dr. Fellowes Davis, Jr., has also removed to 424
Park Avenue.
Dr. Edward Lindeman announces the removal of
his office to 565 Park Avenue.
Society Elections. — Medical Association of the
Southwest: Annual meeting at Fort Smith, Ark.,
on October 2 to 4. The following officers were
elected: President, Dr. Everett S. Lain, Oklahoma,
Okla. ; Vice-presidents, Dr. H. L. Snyder, Winfield,
Kan.; Dr. J. H. Thompson, Kansas City, Mo.; Dr.
M. M. Smith, Dallas, Tex. ; and Dr. Charles S. Holt,
Fort Smith, Ark.; Secretary-Treasurer, Dr. Fred H.
Clark, El Reno, Okla. The next meeting will be held
in Kansas City, Mo.
Fairfield County (Conn.) Medical Society:
Annual meeting at Noroton on October 10. Officers
elected: President, Dr. Frank H. Barnes, Stam-
ford; Vice-president, Dr. Frank M. Tukey, Bridge-
port; Secretary, Dr. EH B. Ives, Bridgeport; Treas-
urer, Dr. Henry B. Lambert, Bridgepurt.
Vermont Homeopathic Medical Society: An-
nual meeting at Montpelier on October 11. Officers
elected: President, Dr. E. B. Clift, Fair Haven;
Vice-president, Dr. W. G. Hodsdon, Rutland; Sec-
retary, Dr. George I. Forbes, Burlington; Treasurer,
Dr. F. E. Steele, Montpelier.
School of Chiropody. — The faculty of the School
of Chiropody of New York has recently been in-
creased by the addition of the following: Dr. Edwin
C. Adams, professor of surgery ; Dr. Paul Luttinger,
director of laboratories; Dr. Joseph Mark, adjunct
professor of physiology; Dr. E. C. Rice, associate
professor of clinical chiropody; Dr. Harry E. Mere-
ness, Jr., lecturer in pathology; Dr. Carl C. Franken,
lecturer in bacteriology; Dr. S. S. Markell, lecturer
in surgery. The student body of the school now
numbers over one hundred.
Surgery in Moving Pictures. — Vivid pictures of
the wonderful surgery done by Dr. Alexis Carrel
and others on the wounded soldiers in French hos-
pitals have recently been made with a cinema cam-
era and brought to this country by the Clinical Film
Company. The picture will be shown before med-
ical societies, medical students, etc., and, judging
from the reported effects of a private view given to
representatives of some of the New York news-
papers recently, it is hardly probable that they will
appeal to any but technical audiences.
The Late Dr. Marple. — The Board of Surgeons
of the New York Eye and Ear Infirmary record with
deep sorrow and sincere regret the death of the
late Dr. Wilbur Boileau Marple. who died suddenly
at Kennebunkport, Me., September 30. 1916. Dr.
Marple had been connected with the infirmary for
Oct. 28, 1916]
MEDICAL RECORD.
775
twenty-five years, first as assistant surgeon, and
from 1901 to the time of his death as attending sur-
geon. He was also for a number of years one of
the representatives of the Board of Surgeons on
the Board of Directors.
The death of Dr. Marple has removed from among
us a distinguished ophthalmologist, admired col-
league, wise counsellor, and honored friend. His
loss is greatly deplored by all of us. The Board of
Surgeons desire to express their appreciation of
his high professional attainments, and extend to his
bereaved family their profound sympathy. (Signed)
John E. Weeks, M. D., Edward B. Dench, M. D.,
W. E. Lamb***. M. D.
Obituary Notes. — Dr. James Albert Cowan of
New Yoik, a grauuaue of the College of Physicians
and Surgeons, New York, in 1904, died at his home,
from apoplexy, on October 15, aged 43 years.
Dr. Oliver L. Hudson of Princeton, Ind., died at
his home on September 22 after an illness of several
weeks, aged 86 years.
Dr. A. B. Daniel of Claxton, Ga., a graduate of
Jefferson Medical College, Philadelphia, in 1857,
died at his heme after a long illness, on September
30, aged 82 years.
Dr. Lawrence Yancey King of Florence, S. C, a
graduate of Louisville Medical College in 1891, died
suddenly on September 30, at Richmond, Va. Dr.
King was a member of the Kentucky State Medical
Association and the Florence County Medical So-
ciety.
Dr. Henry J. McKenna of Long Island City,
N. Y., a graduate of the University and Bellevue
Hospital Medical College, Nev, York, in 1901. a
member of the Medical Society of the State of New
York, the Queens County Medical Society, and the
Associated Physicians of Long Island, and visiting
surgeon to St. John's and the Long Island College
Hospitals, died in New York on October 17, aged
37 years.
Dr. Nathaniel Matson of Brooklyn, N. Y., a
graduate of the New York University Medical Col-
lege, New York, in 1864, and a member of the Medi-.
cal Society of the State of New York, the Kings
County Medical Society, the Associated Physicians
of Long Island, the Brooklyn Medical Society, and
the Brooklyn Pathological Society, died at his home
on October 14, aged 77 years.
Dr. David F. Lincoln of Boston, a graduate of
the Medical School of Harvard University in 1864,
died at his home on October 17, aged 75 years.
Dr. William Preston Miller of Hagerstown,
Md., a graduate of the University of Pennsylvania,
School of Medicine, Philadelphia, in 1894, and a
member of the American Medical Association, the
Medical and Chirurgical Faculty of Maryland, and
the Washington County Medical Society, died at
his home, from pneumonia, on October 5, aged 46
years.
Dr. William Stiles, Jr., of Philadelphia, a grad-
uate of the Hahnemann Medical College and Hospital
of Philadelphia, in 1875, died at his home on Octo-
ber 7, aged 74 years.
Dr. John Savile Lees of Bridgeport, Pa., a
graduate of the University of Pennsylvania, School
of Medicine, Philadelphia, in 1863, died at his home
on October 9, aged 74 years.
Dr. William Peter Knight of Luverne, Ala., a
graduate of the Southern Medical College, Atlanta,
Ga., in 1892, and a member of the Medical Associa-
tion of the State of Alabama and the Crenshaw
County Medical Society, died suddenly on October 4.
OUR LONDON LETTER.
(From Our Regular Correspondent.)
INJURIES TO GREAT CERVICAL VESSELS — EMBOLISM —
BLOOD PRESSURE — CEREBRAL ANEMIA — SCARLET
FEVEK — TYPHOID FEVER — LONDON'S MEDICAL OFFI-
CER OF HEALTH.
London, September 30. 1916.
Sir G. H. Makins has published a group of cases
illustrating some of the effects of injuries to the
great vessels in the neck. Cerebral embolism is
somewhat frequently the consequence of such in-
juries and the thrombi may be entirely independent
of septic infection. But if the vessel lie exposed in
an infected wound the thrombus is likely to disin-
tegrate and septic emboli may be set free, or sec-
ondary hemorrhage may occur when the damaged
arterial wall is exposed to the full force of the blood
pressure. Such cases show that embolic obstruc-
tion of even minor cerebral vessels may have more
serious effects than the blocking of vessels supply-
ing small areas of a limb where anastomosis is not
much interfered with. Cerebral disturbance due to
such wounds is occasionally met with in civil prac-
tice; in fact, more often than was supposed before
military practice demonstrated its frequency. The
cases are important, the prognosis unfavorable, and
the clinical symptoms so complicated as to obscure
the diagnosis and history. Abolition of pulse,
superficial or temporal, is evidence of obstruction or
complete obliteration of the arterial lumen. But
although a corroborative factor, this is by no means
a necessary sign for diagnosing arterial thrombus,
a lateral mural thrombus projecting into the lumen
of a vessel may grow and quite obstruct the vessel
or it may get detached and be the obstruction; it
may as such prove more dangerous than greater
damage causing more rapid and complete forma-
tion of the occluding thrombus with a firmer attach-
ment to the whole circumference of the vessel, giv-
ing it greater resisting ability to the blood pressure.
In these cases this pressure is a rising one as the
shock of the injury passes off. Arterial lesion is
the more probable when both apertures — entry and
exit — are present. So it is when a retained missile
can be detected by x-rays. The coexistence of signs
of injury in contiguous structures is a further aid
to diagnosis, particularly injury to the sympathetic
chain.
The striking difference of these cases from those
dependent on sudden cerebral anemia, such as fol-
lows ligature of the carotid, is mentioned. Primary
or secondary hemorrhage and complete hemiplegia
leading in many cases to a fatal issue in 24 to 36
hours. In the emboli cases the paresis is more
slowly developed. As to treatment, rest appears to
be the only hope, and that but a feeble one.
The annual report of London's medical officer of
health is on the usual lines and one need not say
that the statistics it contains are as full as ever and
offer a basis for many investigations. Many of the
charts are so good that they seem able to convey
their message almost independently of the text.
Those whose work has any relation to its contents
will need no reference to it — they will already
have been considering it. There was a slight de-
cline in the estimated population for 1914, at-
tributed by many to the difficulty of poor pprsons
with families obtaining the accommodation they re-
quire within the county who are therefore obliged
776
MEDICAL RKCORD.
I Oct. 28, 191fi
to reside at some distance. The expectation of life
in these last returns again shows an increase, and
that for both sexes and for all periods of life. The
marriage rate is higher than in any year since 1874.
But the birth rate has continued its fall, and is now
24.3 per 1,000. It was 25 for the period 1909-13.
The death rate is again very low — 14.4, as against
13.7 — for the whole of England and Wales. The
highest rate is in Shoreditch ; the lowest in Lewis-
ham. The first quarter of the year has the highest
incidence; the second quarter the lowest.
The infant mortality again has a lower rate —
104 per 1,000 births, against 107 in the preceding
five years. Some cases of smallpox were found at
the port and measures promptly enforced to pre-
vent it spreading were successful. A double notifi-
cation of measles and smallpox occurred in some
districts, the schools as well as the sanitary au-
thorities also reporting a similar return of whoop-
ing-cough. Scarlet fever had a slight increase
in the rate. The wave curve of this disease cor-
responds with one showing the prevalence of fleas ;
also with one in inverse relation to rainfall. Ty-
phoid broke out at the turn of the year 1913-14
and was traced to a particular establishment, and
in that to the kitchen. There were 789 cases, and
in 400 the source of infection traced. Trash sold
in the streets, fish and shellfish, are considered to
be sources of danger in London. But the improve-
ments in sanitation have done much to restrict the
growth of the typhoid toxin in the capital, and the
greatest danger is from cases imported from pol-
luted foreshores and distant estuarial waters.
UrogrrBa of fHpfltral §>rtpnrp.
Boston Medical and Surgical Journal.
October 12. 1916.
1. Wert- the Sailors of Columbus the First European Syphil-
itica? Andrew F. Downing.
2. The Massachusetts Tuberculosis I.eagut- Remarks by the
President. Vincent V Bowditch.
3. The Flan of the State Department of Health for Mori
Tuberculosis Hospitals. Eugene R. Kelley.
4. The Relation of the Anti-Tuberculosis Society to the Local
Board of Health. John W. Tapper.
5. The Visiting Tuberculosis Nurse. .Mary Van Zile.
6. Tuberculosis in Rural Communities. Vanderpoel Adriance
7. Some of the Problems of the Trustees of Massachusetts
Hospitals for Consumptives. Arthur K. Stone.
S. The Value of a Program of Work for Anti-Tuberculosis
Societies. Mrs. W. H. I. "thro].
9 Report of the Secretary of the Massachusetts Tubercul*
League. Seymour H. Stone.
2. The Massachusetts Tuberculosis League. — Re-
marks by the President. — Vincent Y. Bowditch, in his
address before the Massachusetts Tuberculosis League
on the occasion of its second annual meeting-, reviewed
the purposes for which the League was established.
These are to keep watch upon the work which is being
done throughout the State, to note and encourage those
communities where work is being actively done, to stim-
ulate to action those in which there possibly has been,
and may still be, indifference as to the importance of
all anti-tuberculosis work. He emphasizes three points
as most important in the anti-tuberculosis campaign:
First, there is need of a more rigid enforcement of
the present law requiring all cases of tuberculosis to
be reported by the attending physician to the proper
authorities. Such an enforcement in the present state
of public opinion may at times be embarrassing to the
physician in attendance, but at the same time the pub-
lic must be taught that registration, not necessarily
meaning discomfort to the patient or friends, is abso-
lutely necessary if the disease is to be brought under
control in the future. Second, a constant endeavor
should be made to induce proprietors of mills, factories,
and shops to watch the health of their employees more
carefully and attend to the hygienic surroundings of
their workers. Much has been done in this direction
but there is still vast room for improvement in the fu-
ture. Third, there is need for the establishment of
open air schools not only for those already ill, but for
those not afflicted but who need to be fortified against
disease. No one familiar with the work of the open-
air schools can fail to be impressed by what can be
done by such measures to restore health to tuberculous
children. Similar methods could be adopted by all
schools with infinite benefit to preventive medicine.
6. Tuberculosis in Rural Communities. — Vanderpoel
Adriance summarizes the situation in respect to rural
tuberculosis by stating that rural communities are very
ignorant of the prevalence of tuberculosis and have
been neglected in the anti-tuberculosis campaign. The
formation of anti-tuberculosis leagues should be en-
couraged in such communities. The State Board of
Health should be encouraged to make a thorough sur-
vey of the prevalence of the disease and should enforce
the law which demands instruction about tuberculosis
in the public schools. The education of the public
school children on the subject of tuberculosis is of
prime importance, not only from the standpoint of the
individual child but because in it lies the main hope of
this campaign, since the children of today will be the
workers of the next generation. Instruction in regard
to bovine tuberculosis is especially needed. Bovine
tuberculosis is commonly conveyed through milk and is
a menace, particularly to children under five years of
age. There should be a state law compelling the pas-
teurization of all milk.
7. Some Problems of the Massachusetts Hospitals for
Consumptives. — Arthur K. Stone mentions as among
the problems confronting the trustees of hospitals, lack
of cooperation on the part of communities and local
health boards and the difficulties of administration.
One of the most difficult problems concerns a class of
patients who, after a period of progress, seem to come
to a standstill, or the progress is very slow indeed.
Some, though the active progress of the disease is ar-
rested, show that they can never become self-support-
ing, active citizens again. They can live, and happily,
under the protecting walls of an institution. Some of
these persistently have bacilli and some never have
bacilli or only at long intervals. The question comes up
as to what shall be the attitude of the State to these
persons. In the course of years groups of such patients
tend to collect at various institutions and the question
is asked, "What is to be done with them?" To this
group must be added a group of patients where, in
spite of marked symptoms and signs in the lungs, there
is nevertheless grave doubt whether the process is that
of real tuberculosis, or rather of so-called chronic bron-
chitis or bronchiectasis. These people are sick and suf-
fering, but they are not, so far as is known, danger-
ous to the public health. It is desirable to know to
what extent the State should make provision for their
care. A difficult therapeutic question to be solved is
how, after the period of rest has passed and the patient
has returned to a normal temperature, and bacilli
have disappeared from the sputum, shall he obtain the
graduated work necessary to put him in the best pos-
sible condition to enable him to return home capable of
being a productive citizen ?
New York Medical Journal.
October 14. 1916.
1. The Postfebrile Treatment of Anterior Poliomyelitis. Dex-
ter l> Ashley.
2. Epidemic Poliomyelitis. W. Sohier Bryant.
3. Intracranial Murmur of Long Duration and Spontaneous
Cessation. Frank K. Hallock.
Oct. 28, 1916|
MEDICAL RECORD.
777
4. Pelvic Inflammation. H. M. Armitage.
r.. Chronic Renal Infarcts. Nathaniel R. Rathbun.
6. Extrauterine Gestation. Earl P. Lothrop.
7. Status Lymphaticus. William Ledlie Culbert.
8. Cystoscopic Rectovesical Transillumination. P. S Pelouze
9. Obstetrical Abdominal Hysterectomy with a Report of
Twelve Cases. Alfred M. Hellman.
2. Epidemic Poliomyelitis. — W. Sohier Bryan dis-
cusses the nasopharyngeal aspects of poliomyelitis. He
believes that the experimental work of the past six
years has given abundant proof that the virus or micro-
organism of poliomyelitis occurs first on the mucous
membrane of the nasopharynx and is given to other
victims through the excretions of the nose and throat.
He points out that abortive cases and carriers are com-
puted to be four or five times as many as are patients
with distinct paralytic symptoms. The infection of the
mucous membrane of the nasopharynx is so general
and so far spread that the quarantine net cannot catch
all the people carrying the infection. In view of the
problems presented he suggests the management of the
nose and throat with the view of making the pharynx
a poor culture surface for the virus. The care of the
nasopharynx should be made a routine matter; the pub-
lic should attend to the conditions of the nose and
throat in the same manner that it attends to the care
of the teeth. Health authorities and family physicians
should urge regular examination of the tonsils, adenoid
and nasal passages for the treatment of infected mu-
cous membrane. The key to the prevention of epi-
demic lies in such care. Those coming into contact with
cases of poliomyelitis should have special naso-
pharyngeal treatment, consisting of sprays, applica-
tions through the nose, and the insufflation of powders
through the nose. Since no specific treatment is known
for poliomyelitis it is necessary to use those agents
which have proven advantageous in nasopharyngeal in-
fection from other organisms, such as silver salts, iron
salts, phenol, corrosive sublimate, essential oils, iodine
solutions, kaolin, calomel, quinine sulphate, charcoal,
etc. The following is a description of the technique of
one of the methods of treatment suitable for prophy-
laxis and for the purpose of lessening the dose after
the infection: Spray the nose with a solution of 1
per cent, cocaine with one in 8,000 adrenalin to shrink
the turbinates and slightly deaden sensibility. With a
small cotton carrier apply hydrogen peroxide through
the inferior meatus of the nose to the back wall. If
there is much effervescence of the hydrogen peroxide,
make several applications until effervescence has sub-
sided and wipe the foam from the mucous membrane.
If incidentally in this application the adenoid tissue
appears to be very thick apply nitrate of silver (10 per
cent., children; 25 per cent., adults) with a small dry
applicator to the region of the adenoid and the
pharyngeal pituitary, being careful not to use enough
to permit its running down into the pharynx. If the
adenoid tissue feels smooth and thin use a saturated
aqueous solution of ferrin alum. For prophylaxis re-
peat the treatment after four days.
3. Intracranial Murmur of Long Duration and Spon-
taneous Cessation. — Frank K. Hallock relates the his-
tory of a patient, forty years of age, who from her
earliest recollection had a pulsating sound in the head,
variously described as "pounding," "whistling," "steam
escaping," etc. When thirty-eight years of age, after
an ocean voyage, she lost this sound, which had not
returned save for a few seconds during a delayed and
disturbed menstrual period. The systolic bruit could be
heard by the stethescope at all points on the cranium,
but was most marked in the left occipital and postauri-
cular regions. On the left side of the head the sound
was loud enough to be heard with the naked ear held
close but not touching the scalp. Its character objec-
tively was that of a steady, pulsating, whirring, rush-
ing sound, synchronous with the pulse. Ordinary exer-
cise and body movements did not modify the sound to
any extent. Turning the head sharply to the right
stopped the murmur both objectively and subjectively,
while rotating the head to the left or flexing it down-
ward did not interfere with the sound. In discussing
the possible diagnosis in this case the writer assumes
that this systolic bruit was due to a structural arterial
abnormality existing from childhood. He says that
this murmur would ordinarily be diagnosed as aneurys-
mal or its equivalent, but in addition to a constricted,
dilated, or sacculated portion of artery, one could also
picture the possibility of a sharply tortuous, angulated,
or kinked section, either free or in relation to some
bony or soft growth or projection. It might be that
in these later years with a more equalized and better
balanced vascular system there was a somewhat les-
sened flow of blood in the cerebral vessels and a slight
diminution of the fluid volume within the cranium.
This would favor the cessation of the murmur.
6. Extrauterine Gestation. — Earl P. Lothrop dis-
cusses the diagnosis and treatment of extrauterine ges-
tation and reports five cases in which the diagnosis was
made before operation. He says that when a correct di-
agnosis was made before operation the operator should
thank his intuition rather than his judgment. The his-
tories of his cases show that most cases present sug-
gestive symptoms at the time of rupture. There is
usually sudden pain followed by flowing, and a feeling
of faintness or collapse may follow these symptoms.
After rupture the history of repeated attacks, together
with the finding of a pelvic tumor, may guide one cor-
rectly. In all cases the possibility of gonorrheal sal-
pingitis should be carefully considered. An analysis
of the writer's series of 83 cases shows that their ages
ranged from 21 to 41 years, 54 occurring between the
ages of 21 and 36 years, 19 between the ages of 36 and
41 years, and in 10 cases the age was not correctly
given. The gestation was going on in the right tube in
43 cases and in the left in 40. The number of tubal
abortions was 15; unruptured, 5. Of the ruptures two
were interstitial. Fifty-nine occurred in the middle of
the tube; two at the fimbriated end. In this series of
83 cases there was only one death from shock a few
hours after the operation. In 15 cases the other tube
was diseased and in 21 there was a chronic appendicitis.
Three cases had been operated on for tubal gestation
on the opposite side. The writer thinks conservative
treatment in cases with mild symptoms and slow bleed-
ing with the development of hematocele, when seen late,
is permissible, but that such cases should be kept under
observation and operation performed later if there is a
recurrence of hemorrhage. He outlines the usual oper-
ative procedures and concludes that every case of sup-
posed pregnancy in which sudden pain develops, flow-
ing or shock should be considered extrauterine until
proven otherwise.
7. Status Lymphaticus. — William Ledlie Culbert re-
ports two cases of what for the want of a more definite
term is usually called status lymphaticus. These cases
serve to draw attention to the importance of a thorough
physical examination of all children who present them-
selves for operation, especially those for removal of
tonsils and adenoids. When a child shows any deviation
from normal we should look all over the body for en-
larged glands, bone deformities characteristic of
rachitis, and areas of sternal dullness. Pribram of
Prag draws special attention to enlarged papillae at
the base of the tongue and an omega shaped epiglottis
as significant of this condition. If any stigmata are
present suggestive of an enlarged thymus, operation
778
MEDICAL RECORD.
[Oct. 28, 1916
should be refused, or at least deferred until a full
laboratory investigation can be made, including skia-
graphs.
8. Cystoscopic Rectovesical Transillumination. — P. S.
Pelouse states that the digital examination of subvesi-
cal structures per rectum is at best uncertain and that
he has made an application of the old method of transil-
lumination to these structures. He inserts the cysto-
scope into the bladder, dilates the viscus with water,
introduces an electric bulb into the rectum, and turns
out the cystoscopic light; this makes it possible to
transilluminate the intervening structures. This can be
done so thoroughly that the tiny blood vessels at the
base of the bladder are distinctly seen, changes in
tissue thickness and density can be accurately deter-
mined, and the ureter followed for a short distance.
The essayist has had made a curved shaft for carrying
a large transillumination lamp which makes it possible
to bring a larger field under observation. The value
of this procedure is in the determination of infiltrations
of tissues from vesical, prostatic, or rectal growths,
and the diagnosis of stones in the lower end of the
ureter.
9. Obstetrical Abdominal Hysterectomy. — Alfred M.
Hellman relates his experience with twelve cases of
abdominal cesarean section. He gives thirteen indica-
tions for cesarean section and states that the abdominal
operation is preferable to the vaginal, because it takes
less time, assures greater cleanliness, the abdominal
incision is wholly under the control of the operator, the
patient can be sterilized if needed, and tumors can be
removed. By the abdominal operation one is more
likely to get a viable fetus. Rupture of the uterus is
more likely to occur if a low incision is used than if a
high one. The bladder and ureters will not be injured
by a high incision. The adbominal cesarean section also
returns the parts much more nearly as they were be-
fore than does the vaginal incision. The convalescence
is less painful and more likely to be smooth. In con-
cluding, Dr. He'.lman says it is time that the general
practitioner learned that there is a safe method of
delivery in complicated but uninfected cases, one that is
free from the multilating effects of forceps, version,
and the like, and it is time that this same truth is
brought home to the laity.
Journal of the American Medical Association.
October 14, 1916.
1. Obstetric Surgery a Modern Science : Its Scope and Limi-
tations. Edward P. Davis.
2. Meddlesome Midwifery in renaissance. Joseph B. DeLee.
3. Obstetrics and Gynecology Under Ideal Conditions in a
General Hospital. Frederick C. Holden.
4. Anesthesia in Human Beings by Intravenous Injections
of Magnesium Sulphate. Charles H. Peck and Samuel
J. Meltzer.
5. Th» Significance of Pulse Form. A. W. Hewlett
6. Some Factors in the Production of Cardiac Dyspnea.
Francis W. I'eabody.
7. Roentgenocardiograms: Tolygraphic Slit Tracings of
Cardiac Pulsations by the Roentgen Ray. A.. W.
Crane.
8. Nail Extension in Fractures of the Lower Extremity.
John C. A. Gerster.
9. Nails and Screws Through Joint Surfaces, in Autografts
and in Fractures Into Joints. Arthur T. Mann
10. A Bacillus Isolated from Epileptics; Preliminary Report.
^ I'liam Barclay Terhune
11. Constipation and Intestinal Infection In Epileptics.
Charles A. L. Reed.
12. Simple Procedure for Nasal Bleeding. William Lapat
1. Obstetric Surgery a Modern Science. — Edward P.
Davis. (See Medical Record, July 8, 1910, page 85.)
2. Meddlesome Midwifery in Renaissance. — Joseph B.
DeLee. (See Medical Record, July 8, 1916, page 86.)
3. Obstetrics and Gynecology Under Ideal Conditions
in a General Hospital. — Frederick C. Holden. (See
Medical Record, June 17, 1916, page 1115.)
4. Anesthesia in Human Beings by Intravenous In-
jection of Magnesium Sulphate. — Charles H. Peck and
Samuel J. Meltzer state that in this preliminary report
they wish to relate briefly the course of anesthesia in
three operations performed on human beings exclu-
sively under the influence of intravenous injection of
magnesium sulphate. In summary they state that the
observations made in these cases prove conclusively
that the state of anesthesia which is produced by in-
jection of magnesium sulphate is actually anesthesia,
that is, that in this state sensation as well as conscious-
ness are temporarily more or less completely abolished.
This central effect may or may not be accompanied by
a pronounced paralysis of the endings of the motor
nerves of a great part of all skeletal muscle?. Evi-
dently the central effect, especially the effect on the
sensation of pain and on consciousness, can be ob-
tained with a smaller dose of the magnesium salt than
that which is required for a paralysis of the motor
nerve endings. The central effect also appears to set
in sooner than the peripheral one. The employment of
intravenous injection of magnesium salt as an anes-
thetic may prove to be indeed a practicable and advan-
tageous method, because, in the first place, it may cause
simultaneously a moderate degree of relaxation of the
muscular mechanism, and, secondly, because the unto-
ward effects can be rapidly reversed by a careful admin-
istration of a solution of calcium chloride. This method,
however, before it can be made practically serviceable,
would require a good deal of careful study. They,
therefore, at least for the present, abstain from a dis-
cussion of the possibility of the practical applicability
of this method.
5. The Significance of Pulse Form. — A. W. Hewlett.
(See Medical Record, July 1, 1916, page 33.)
6. Some Factors in the Production of Cardiac
Dyspnea. — Francis W. Peabody. (See Medical Record,
July 1, 1916, page 33.)
7. Roentgenocardiograms. — A. W. Crane. (See
Medical Record, July 1, 1916, page 33.)
8. Nail Extension in Fractures of the Lower Ex-
tremity.— John C. A. Gerster claims the following ad-
vantages for this method of treating fractures of the
lower extremity: (1) It is a safe measure provided the
proper technique is employed. (2) Because of its small
site of attachment, it is of great value in recent simple
fractures with extensive abrasions, in recent compound
fractures with much destruction of soft parts, and in
multiple fractures of the same limb. (3) Because of
its efficient traction, in conjunction with osteotomy, it
is the only method whereby the shortening present in
certain old malunions can be safely overcome even
months after the original fracture. (4) In relation to
open operative reduction, it may be stated that in cer-
tain cases nail extension will obviate the necessity for
operative intervention, and in other cases it can be em-
ployed to prevent shortening until the suitable time for
plating has arrived.
9. Nails and Screws Through Joint Surfaces, in Au-
tografts, and in Fractures into Joints. — Arthur T. Mann
writes that his experience warrants the conclusions
that: (1) The autografts unite with a line of callus as
fine as those of simple fractures, with a free joint, and
without adhesions. (2) The autografts seem to live,
but in reality the bone trabecular are gradually re-
placed by microscopic bone growing inward from the
vascular spaces between them, while the cartilage con-
tinues to live and to a limited extent aids in the for-
mation of the new bone adjacent to it. (3) The main
replacement of the bone in the trabecular seems to
take place directly from bone cells without the prelimi-
nary formation of cartilage, and the dead portions of
the trabecular seem to be absorbed in a line immediately
adjacent to the new growing bone without the inter-
Oct. 28, 1916J
MEDICAL RECORD.
779
vention of special osteoclasts. (4) Condyles detached
from all tissue save the crucial ligament unite like free
autografts. (5) Condyles, attached more or less to
other tissues as well, continue to live throughout, or
nearly so. (6) Nails and screws are tolerated in the
human being as well as in the experimental cases, and
with surprisingly little reaction. They remain firmly
embedded in every specimen recovered, but the Roent-
gen ray shows a slight thinning of the bone about them.
(7) The surface covers with connective tissue, a rever-
sion of the cartilage from hyaline to fibrocartilage
and then to connective tissue, which overlays connec-
tive tissue derived from the vascular spaces between
the trabecular. (8) The response of the condyles to the
presence of a rigid body projecting above the joint sur-
face is to build up the condyle in its attempt to with-
draw it, and prevent further injury to the opposing joint
surface. This also takes place when the condyle is an
autograft. (9) This growth is a true growth of bone,
and the cartilage tends to retain its normal thickness.
(10) The groove cut by a projecting nail or screw, in
the opposing surface, covers over with hyaline carti-
lage, and the groove tends to fill up with bone as the
projecting body is withdrawn by the growth of the con-
dyle. (11) The line of fracture in the cartilage tends
to cover over with cartilage, largely of the fibrocarti-
lage type if it is narrow, with connective tissue if it is
wide. (12) In autografts, empty drill holes fill with
new bone, growing up from below, only to a very lim-
ited degree from the bone and cartilage in the graft;
in living fragments, from the trabecular of the frag-
ment, very little from the cartilage. The surface covers
with the same kinds of connective tissue as do the nails
and screws.
10. A Bacillus Isolated from Epileptics. — William
Barclay Terhune makes this preliminary report. He
states that feeling a deep interest in epilepsy, he under-
took a study of individuals classified as epileptics in
the East Louisiana Hospital for the Insane. It was
decided that this investigation should be conducted
from every possible angle; accordingly, case histories
were reviewed, relatives questioned with a view if dis-
covering the part played by heredity, personal injuries,
illnesses, and psychic factors recorded. Accurate rec-
ords were kept giving the number and description of
the paroxysms in each patient, the nurses were inter-
rogated regarding the habits and disposition of the
epileptics in their care, and careful mental examina-
tions were made. While he was in the midst of this
work, Reed of Cincinnati published a paper definitely
asserting that epilepsy was caused by a bacillus which
might be isolated from the blood stream, which or-
ganism was found in large numbers in the colon of
epileptics, and was demonstrable in the retroperitoneal
glands. That epilepsy was of toxic origin was not a
new idea, in consequence of the labors of Haig, Weber,
Ferrani and many others. In view of the mass of sta-
tistical evidence pointing to the importance of the
hereditary influences, and the traumatic factor, as well
as the information gleaned from psychanalysis, he
could not do otherwise than view with great skepticism
the assertion that epilepsy was an infective process.
Accordingly, the work embodied in this report was per-
formed with the view of substantiating or disproving
this assertion, and was begun with the preconceived
idea that there was not any such organism as the
Bacillus epileptiais. In summarizing he states that al-
though he began this work profoundly biased in his
opinion, as he believed that epilepsy was not bacterial
in origin, he was forced to the conclusion that the bacil-
lus which he had isolated, which was identical with the
Bacillus epilepticus described by Reed, must be an
etiological factor in epilepsy, in view of the following
facts: A bacillus was isolated from 75 per cent, of the
epileptics examined; it was present during and follow-
ing a seizure but not during the intraconvulsive period,
except in the case of one patient who was debilitated by
ill health; it was not found in non-epileptics; it caused
typical epileptoid convulsions in cats, during which
death occurred, both when they were injected intra-
venously and when they were fed cultures of the or-
ganism; the organism might be recovered from the ani-
mal during the convulsion and after death.
11. Constipation and Intestinal Infection in Epilep-
tics.— Charles A. L. Reed makes a reply to Caro and
Thorn and Wherry and Oliver, who have failed to find
the Bacillus epilepticus in the blood of epileptics ex-
amined by them, and who therefore infer either that
the organism does not exist, or if it does exist it is a
contamination, or, in any event, it has nothing to do
with "idiopathic" epilepsy. Reed states that the fact
of the existence of the organism seems to be fairly
well attested, since it has been isolated by a number of
investigators in a large percentage of epileptics. The
inference that the organism is a contamination is also
unfortunate since it is scarcely likely that the differ-
ent investigators should all have found the same con-
tamination. The reason for the failure to induce con-
vulsions in animals by Wherry and Oliver was due to
the use of a subculture from a subculture which was
probably not sufficiently potent to overcome the natural
immunity of the animal. Reed also discusses the ob-
jections to his classifications of this organism. He pre-
sents the complete bacteriological records of his cases
which Wherry and Oliver report from the standpoint
of their individual observation, and in analyzing them
finds that they show that positive findings were not
made in every specimen taken. He finds several cases
in which positive findings were not made until, in one
instance, after the examination of the sixth specimen.
The ratio of positive to negative findings is as 7 : 13.
He cites one series of five and another of eight in which
the first examinations proved negative. He says it will
be seen from this that in the single examination of four
cases and the three examinations of one case which
Wherry and Oliver report it is not surprising that they
obtained negative findings. Reference is also made to
the work of Marie Bra, who in the early part of this
century found an organism again and again in the
blood of epileptics; other European investigators failed
to find it, and disgusted with the treatment she re-
ceived she for.'ook the scientific world and married.
The Lancet.
September 23, 1916.
1. A Series of Cases of Cerebral Embolism Consequent on the
Reception of Gunshot Injury to the Carotid Arteries.
G. H. Mak:ns.
2. Notes on the Agglutination Reactions with Oxford Stand-
ard Agglutinable Cultures in a Series of Patients, In-
cluding Those Examined in a Recent Civilian Outbreak.
R. Donaldson and Barbara Clark.
3. An Application of Drop Measuring to Widal Technique ;
a Replv to Adverse Criticism. E. W. Ainsley Walker.
4. A New Remedy for Syphilis, Luargol or "102." N. S.
Bonard.
5. A Note on the Use of Perforated Celluloid in the Dressing
of Certain Wounds. S. R. Douglas.
1. A Series of Cases of Cerebral Embolism Conse-
quent on the Reception of Gunshot Injury to the Caro-
tid Arteries. — G. H. Makins bases this communication
on the clinical history of 14 cases. He states that
limited injuries are the most prolific source of origin
of this class of cases. The presence of a definite per-
forating wound of the artery has been assumed from
the existence of obvious signs, such as systolic arterial
bruit, and arteriovenous murmur and purring thrill,
the detection of a pulsating swelling in the course of
780
MEDICAL RECORD.
[Oct. 28, 1916
the vessel, or the occurrence of a secondary hemorrhage
demanding surgical intervention. A non-penetrating
injury has been assumed when none of the above signs
could be detected, while diminution or abolition of the
carotid or superficial temporal pulses has been regarded
as evidence of obstruction or complete obliteration of
the arterial lumen. Obliteration or considerable di-
minution of the distal pulse, although a corroborative
factor, is by no means a necessary sign for the diag-
nosis of the formation of an arterial thrombus. The
determination of the period which has elapsed between
the reception of the injury and the onset of signs of
cerebral lesions, while of prime importance, has proved
of considerable difficulty. Reasoning from analogy,
however, the rapidity with which a clot capable of caus-
ing cessation of hemorrhage from a ruptured artery in
the limbs allows one to conclude with some confidence
that a period of a few minutes would suffice. Hence
very early development of symptoms need not be an oc-
casion of surprise. In five of these 14 cases there were
symptoms of damage to the cervical sympathetic nerve.
Only one of these 14 patients died. Of the remainder,
one was sent home practically recovered from an incom-
plete right brachial monoplegia and aphasia, while
slight improvement had occurred in some of the others.
The general impression, however, was not a favorable
one. As to treatment, rest is the only resort; it might,
however, be remarked as an important fact in support
of the diagnosis (in favor of embolism as opposed to
cerebral softening fqrom anemia) that in two cases in
which subsequent complications necessitated ligature of
the common carotid, neither patient suffered any in-
crease in symptoms; in fact, one man's condition im-
proved at once and the other made a steady improve-
ment.
2. Notes on the Agglutination Reactions with Oxford
Standard Agglutinable Cultures. — R. Donaldson and
Barbara Clark present a study of the serum reactions
of 275 patients, of whom 184 were soldiers. Of these
latter 165 came from the Mediterranean, 18 from
France, and one contracted paratyphoid in Reading.
There were 91 civilians, of whom 53 were cases of
typhoid or paratyphoid occurring during the Reading
outbreak, while the remaining 38 were not suffering
from the typhoid-paratyphoid group of diseases, but
were used as controls. In their examinations they have
used a slightly different technic from that used by
Dreyer and have employed the Oxford standard aggluti-
nable cultures throughout. These they have found thor-
oughly satisfactory. They believe their method the
most accurate and the simplest of all agglutination
methods where routine work is concerned. The great
majority of their cases arrived with the diagnosis "en-
teric," whereas out of 115 cases only 13 per cent, at
the outside could be claimed as true typhoid. The mor-
tality among these typhoid cases was nil, and offers a
marked contrast to the 15 per cent, mortality among
53 uninoculated civilians. Out of the 115 cases exam-
ined twice, 71.6 per cent, contained agglutinins for
paratyphoid bacilli, and out of the whole number of
military eases 60.3 per cent, agglutinated paratyphoid
organisms. The impression that paratyphoid B infec-
tions are more common among these cases is probably
more apparent than real, and is probably not to be ex-
plained merely by saying that one type of case was
more common during certain months. The results ob-
tained by the authors point to an explanation based on
the time elapsing from the onset of the illness till the
first agglutination. The nearer to the onset that the
first agglutination is made the greater will be the num-
ber of positive A agglutinations. The further on one
goes in convalescence before taking a reading the more
likely is it that the less persistent A agglutinin will
have disappeared, and consequently there will be a
greater apparent percentage of B infections. These
examinations did not furnish any clear evidence of
coagglutination of A for B or vice versa, and there was
no evidence of B. typhosus evoking coagglutinins for
paratyphoid organisms in the lowest dilutions employed
(1 in 27). Paratyphoid infections in persons inoculated
against typhoid have acted as a stimulus to the agglu-
tinin-forming mechanisms which had previously been
called into being by a preventive T inoculation. The
need should be emphasized for repeated agglutinations
at intervals in the case, at least, of persons previously
inoculated. It does not seem that any diagnostic infer-
erence can be drawn from a consideration of the titre
in inoculated persons, where only one examination
has been made. This study affords no evidence to sup-
port the view advanced by Tidy that marked pyrexia
for some days is associated with diminution or disap-
pearance of typhoid inoculation agglutinins. The civil-
ian epidemic in Reading was not due to B. typhosus
alone, but was complicated by a paratyphoid infection
in a certain proportion of the cases. The source of in-
fection was probably a military one. None of the 38
uninoculated controls showed any trace of agglutinins
to typhoid, or paratyphoid A or B except four, and in
one of these there was a history of contact.
4. A New Remedy for Syphilis. Luargol or "102". —
N. S. Bonard writes of his experience with this prepara-
tion in Lock Hospital, where about 100 cases of syphilis
at different stages were treated with luargol. All of
these cases without exception have done well and the
results are most satisfactory. The therapeutic effects
have been more rapid than with salvarsan, neosolvar-
san, galyl, novarsenobenzol, or neokharsivan. No seri-
ous complications or reactions have been observed. All
symptoms of the disease have cleared up rapidly. The
injections have been made with concentrated solutions
of "102" by means of a 20 c.c. glass syringe. All out
patients have been treated in the consulting room and
have left immediately after. In the wards of the hos-
pital the patients were not kept in bed after the injec-
tions. Frequent small doses have proved to be of
greater benefit and to give better results than larger
doses at longer intervals. The contraindications for
luargol are the same as for other arsenical compounds.
In acquired syphilis with primary, secondary, or ter-
tiary symptoms without nervous complications, the fol-
lowing doses should be injected in a normal adult pa-
tient: 0.15, 0.20, 0.25, 0.30, 0.30, 0.30 gm., i.e. totally
1.50 gm. in six injections repeated every second, third,
or fourth day. For a female patient in the same con-
dition the following doses: 0.10, 0.15, 0.20, 0.25, 0.25,
0.25 gm., i.e. a total of 1.20 gm. A violent reaction may
occur if the dose is too large, which is regarded as an
anaphylactic crisis caused by the precipitate, which is
the principal agent in the pathological manifestations.
Sufficient alkalinization of the product will obviate the
appearance of these nitroid crises.
5. A Note on the Use of Perforated Celluloid in the
Dressing of Certain Wounds. — S. R. Douglas suggests
for the alleviation of pain caused by the removal of
dressings which have become adherent to the wound
the employment of sheets of perforated celluloid. This
material, which is rather too stiff to be conveniently
applied to the irregular surface of the wound, was
found to become perfectly safe and pliable, and at the
same time somewhat elastic, after it has been soaked in
a five per cent, carbolic solution for a few hours. The
carbolic acid solution having been washed away with
sterile salt solution, the softened celluloid can be ap-
plied to the wound surface and falls at once into all the
Oct. 28, 1916]
MEDICAL RECORD.
781
irregularities; any suitable dressing can be applied over
it. On redressing the wound it is found: (1) That the
celluloid lifts off the surface of the wound without caus-
ing any pain; (2) that all the discharges from the
wound have passed through the perforations, leaving
the surface of the wound quite clean; and (3) that the
celluloid has regained its original stiffness, thus making
an accurately fitting splint, which tends to keep the
wounded tissue in a complete state of rest. After the
celluloid lias been taken off the wound it is cleansed in
tepid water and again softened and sterilized by plac-
ing it in the 5 per cent, carbolic acid solution. Heavier
sheets of celluloid treated in this way have been found
to make excellent splints.
British Medical Journal.
September 23, 1916.
1. A Note on Weil's Disease (Spirochetosis Icterohaemor-
rhagica) as It Has Occurred in the Army in Flanders.
Adrian Stokes and John A. Ryle.
2. A Memorandum Upon Heart Affections in Soldiers, with
Special Reference to Prognosis of "Irritable Heart."
J. C. Meakins, J. Parkinson, E. B. Gunson, T. P. Cotton,
J. G. Slade, A. N. Drury, and Thomas Lewis.
3. Note on the Antenatal or Pregnancy Clinic at the Edin-
burgh Royal Maternity Hospital. J. W. Ballantyne.
4. Some Principles of Investigation in Blood-Pressure Prob-
lems in Health and Disease. James M. McQueen.
5. Septic Endocarditis; Intravenous Injection of Eusol: Re-
covery. J- Allman Powell.
1. Note on Weil's Disease (Spirochetosis Ictero-
lia?morrhagica) as it Has Occurred in the Army in
Flanders.— Adrian Stokes and John A. Ryle state that
about 15 cases of Weil's disease have come under their
observation and they have been able to confirm the find-
ings of the discoverers of the cause of this disease. In
two cases they have succeeded in infecting animals,
and these have shown the characteristic pathological
changes. In each instance the guinea pig was found to
have the spirochetes in large numbers in the liver and
blood. Two of four experiments done on the sixth day
of illness were positive; no positive results were ob-
tained after the sixth day. The infected guinea pigs
became ill on the fifth day after injection, in one case,
and on the seventh day in the other. The lungs of these
animals presented the small hemorrhagic spots, like
the wings of a mottled butterfly, which is one of the
most important changes in the diagnosis of the disease.
The authors think that, while the experimental facts
which they present are meagre, they are sufficient to
show that the cause of epidemic jaundice in Flanders
is identical with that found in Japan, and to emphasize
that it is important that the infective possibilities of
Weil's disease be recognized. The clinical histories of
individual cases are given, from which it appears that
there are both mild and very severe types of the dis-
ease. The jaundice, weakness, and pain in some cases
have been slight and of not long duration. On the other
hand, there were three deaths in this series and two
other patients were very ill.
2. Heart Affections in Soldiers, with Special Refer-
ence to Prognosis of "Irritable Heart." — J. C. Meakins,
J. Parkinson, E. B. Gunson, T. F. Cotton, J. G. Slade,
A. N. Drury, and Thomas Lewis present this memoran-
dum based on observations made at the Military Hos-
pital, Hempstead, where 200 beds have been set aside
for soldiers suffering from heart affections. Of 251
patients, 113 were discharged from the army within a
few weeks of admission. This group contained 31 cases
of mitral stenosis, 7 of mitral stenosis and aortic dis-
ease, 22 of aortic disease, and 53 of myocardial disease
with or without enlargement and with or without
mitral incompetence. The graduated exercises and
marches by which some of the patients are returned
to duty or fitted for civil life are described. With
reference to the prognosis, they state that the pro-
portion of favorable results is highest among men
who have broken down in health on active service.
Men who develop their symptoms while training at
home are distinctly unfavorable subjects. The preva-
lence of rheumatic or choreic history amongst cases
of irritable heart is too high to be a matter of coinci-
dence (19 per cent.); it suggests the presence of early
rheumatic heart lesions in many of these soldiers. Pa-
tients in whom there is such a history rarely reach the
higher grade exercises, though their physical signs do
not differ from the remainder. The majority have to
be discharged as permanently unfit. Of the irritable
heart cases, 46 per cent, gave a history of symptoms
dating back prior to enlistment. The longer the his-
tory the worse the prognosis; patients in whom the his-
tory is of years standing make little progress; those
soldiers are most likely to return to duty in whom the
history is of a few months' duration.
4. Some Principles of Investigation in Blood-Pressure
Problems in Health and Disease. — James M. McQueen
deplores the lack of method shown by some clinicians
in the choice and arrangements of their observations
on blood pressure. He points out that the feature to be
studied in the circulation in health and disease is the
power of the heart in conjunction with changes in the
peripheral blood field to adapt itself quickly and effi-
ciently to extra strain. If a satisfactory knowledge of
the heart and peripheral circulatory system in the
human subject in health and disease is to be gained it
is necessary to examine and record the changes in the
systolic, in diastolic, in pulse pressure range, rate of
heart beat, and rate of respiratory rhythm during the
strain thrown on the heart by exercise, not after it is
over. The systolic pressure can be estimated during
exercise either by the auditory or the tactile index,
but the diastolic index is estimated by the auditory in-
dex alone. Consequently it is best to adhere to the
auditory index for both measurements. In making the
examinations the subject is placed on his back on a
polished table and the exercise consists in rhythmically
drawing up his feet and legs as in swimming on the
back. The mildness of this exercise depends upon the
length of time it is kept up. It is also possible to ex-
amine the circulatory phenomena during exercise in the
erect posture by the auditory method, the exercise em-
ployed being that of working a silent lathe with one
foot. By these methods it is found that the ranges of
blood pressure, both systolic and diastolic, in both
healthy and unhealthy subjects vary greatly. It is ob-
vious that the response to a given amount of work of
normal adults with a blood pressure, say of 130 sys-
tolic and 75 diastolic, and a rate of heart beat, say 78,
should be investigated. The author believes that in
cases with departures from the normal by testing them
against the performance of a given amount of work
we may be able to solve some of the problems as to
how nature adapts both the heart and the peripheral
circulation so as to overcome initial defects. Until we
know the significance of various levels of pressure, sys-
tolic and diastolic, with various rates of heart beat,
and respiratory rhythm, a mere chronicling of measure-
ments in countless clinical lectures is without signifi-
cance.
5. Septic Endocarditis: Intravenous Injection of
Eusol; Recovery. — J. Allman Powell reports the case
of a girl, 13 years of age, in whom an erysipelas of the
right foot and leg was complicated by septic endocar-
ditis. Two injections of antistreptococcal serum were
administered. The first seemed to be followed by some
improvement; after the second the patient became ra-
pidly worse. As a last resort it was decided to give her
eusol [a solution of 12.5 grams each of calcium chloride
782
MEDICAL RECORD.
[Oct. 28, 1916
and boric acid in 1 liter of water] intravenously. Forty
c.c. of eusol was administered, preceded by 300 c.c.
normal saline. At the time of the injection the patient
was apparently dying. After the injection she per-
spired freely and an hour later had another rigor. From
this time she gradually improved, and several months
after was apparently well except for some rapidity of
the pulse and anemia. No blood culture was made so
the diagnosis was not proved, but clinically the case
was typical of acute sepsis of the blood stream.
Journal de Medecine de Paris.
September, 1916.
Treatment of the Carriers of Diphtheritic Bacilli. —
Labbe and Canat cite abundant evidence of the tenacity
of this bacillus to remain in the throat, especially after
proliferation. After an attack of diphtheria, 50 per
cent, of victims are carriers for one month, 40 per cent,
from one to two months, and 10 per cent, from two to
three months. Carriers have remained carriers for
458 days, 669 days, etc. In war times it is a great
burden to keep carriers of any disease isolated for
weeks. The most vigorous and protracted sterilization
may not dislodge all of the bacilli until perhaps three
months have expired. Antisera used in solution or in-
sufflation perhaps represent an advance, but are still
on trial. The authors make use of the following sys-
tem: During the first postdiphtheritic three-month pe-
riod, when bacilli of all lengths may be present, the
throat is irrigated abundantly with Labarraque's solu-
tion 30 per cent, in water, while a 10 per cent, resorcin
ointment is introduced into the nostrils. Both remadies
are exhibited twice daily. The throat is also swabbed
with iodized glycerin 1 per cent. Of twenty-nine pa-
tients thus treated, twenty-four were freed from ba-
cilli in an average of thirty-one days. The extremes
were fifteen and forty-eight days. In the other five the
average persistence was over forty days. (As a matter
of fact, one was discharged still a carrier on the
seventy-fifth day and the other four under the same
conditions on the ninetieth day.) In a second period
the antimicrobic serum was used on all carriers,
thirty-five in number, the powder being insufflated into
the nose and throat. The bacilli disappeared in from
nine to sixty days, save for one case in which they
persisted for ninety-five days. The average was twenty-
four days. Naturally the two methods could not be
applied jointly. We see here a slight advantage of the
serum over the antiseptic treatment.
Specific Treatment of Scarlatina with Sodium Salicy-
late.— Ramond and Schultz refer to the disease as it
occurs among the troops. Originally the treatment
was purely symptomatic, and consisted partly of red
light. It seemed impossible to jugulate a violent at-
tack, and the authors sought a remedy which wouki
exert a quasi-specific action directly upon the disease.
On account of some similarity between this disease and
acute articular rheumatism, the salicylate of sodium
was the first to suggest itself. The so-called rheumatic
manifestations of scarlatina respond readily to this
drug, and this rheumatism is clearly the disease it elf
and not a complication. The drug is indicated in all
types of the disease, and should be given always in
apyretic cases in which dangerous complications may
develop. It should be given from the start to the fin-
ish of the fever and general reaction. Allowing three
days for this, it should be given for two days more.
After the fifth day it should be discontinued, and re-
sumed from the fifteenth to the twentieth day, when
late complications are due. These arise in part from a
reanimation of the scarlatinal virus, which is at once
controlled by the salicylate. K these complications
were really due to the streptococcus the salt would
exert no power over them; however, a simple infection
may readily be grafted upon the primary disease if the
remedy be not promptly given. The dose is about 6
grams per day, increased to 8 grams or more if re-
quired. Scarlatina, like acute rheumatism, is char-
acterized by nocturnal exacerbations; hence the drug
should be followed up during evening and night. When
the treatment" is resumed at the fifteenth day the dosage
need not be as large. As already stated, the fever, un-
der the action of the drug, subsides by the third day.
If defervescence does not occur we may accuse some
secondary infection or a complication like bronchopneu-
monia. The throat lesions rapidly undergo involution,
but, with the recrudescence of the disease, may reappear
in an aggravated form. It is purely a scarlatinous
symptom, and is rapidly controlled by the salicylate.
The early nephritis of scarlatina is not a serious mani
festation, but the later form is always uncertain. The
salicylate may abort it if given in time, but if it have
several days' headway the drug should be given cau-
tiously, in relatively small doses, lest the kidneys be
unable to excrete it. If it can pass the kidneys the
dose may be increased. But the drug evidently has nc
salutary effect on the organ, and is given for the sake
of the disease as a whole. On all other manifestations
of the disease the drug behaves more or less as a spe
cific.
Treatment of Pertussis. — Satre discusses the subject
with candor. He gets a certain amount of relief from
bromoform, which diminishes the intensity of the cough
and vomiting. Relief must not be looked for until two,
three, or four days after the treatment has begun. For
children under 2 years of age he prefers terpene. A
third trustworthy medicament is quinine, pushed in
broken doses. A child of five receives 1 gram ir
twenty-four hours. The drug is given persistently for
several days only. If benefit has been obtained he stops
its use or continues it in much smaller doses. If the
results of the sulphate are negative, he then gives the
chlorhydrate, bromhydrate or carbonate. His reliance
upon it is such that in case of intolerance by the mouth
he injects hypodermically the bichlorhydrate. In sev-
eral days the course and severity of the disease should
be favorably influenced.
La Presse Medicale.
1916.
Clinical Notes on 289 Cases of Icterus ObservtJ in an
Ambulance Service. — Gimbert, at the Medicochirurgical
Reunion of the V Army, stated among the troops all
ages suffered and cases occurred almost equally in all
seasons. Among predisposing causes are previous so-
journ in the colonies, abuse of meat diet, vaccinations
performed at too frequent intervals. Myalgias and
arthralgias are often seen at the onset of jaundice, and
transitory albuminuria is often present. When enlarge-
ment of the liver exceeds 15 or 16 cm., one may think of
destruction of the hepatic cells or intrahepatic dis-
orders of circulation. Bradycardia and low-tension pulse
are often present and dilatation of the heart may be
very frequent. Intense anemia may follow the jaundice,
accompanied by slight enlargement of the spleen, sug-
gesting the possibility cf a critical hemolysis. The
temperature, elevated at first, becomes in turn a per-
manent hypothermia. All the clinical types have been
observed, from simple congestion of the liver to fatal
icterus gravis (two cases). Prolonged icterus and re-
lapsing icterus were also seen. The prognosis may be
grave, ard advanced age and intemperance are largely
Oct. 28, 1916]
MEDICAL RECORD.
783
responsible; these factors always aggravate the dis-
ease. From the therapeutic viewpoint sodium salicylate
is the best cholagogue, while urotropin and calomel are
the best antiseptics. Adrenalized serum has rendered
excellent service. The best regimen has appeared to be
legume broth and low -protein diet. A milk diet
was inferior to the preceding.
Utilization of the Cochleo-Orbicular Reflex in Deaf-
ness.— Gault's material consisted of soldiers who were
completely deaf, partially deaf, suspected of deafness.
These have all been tested in the usual manner, includ--
ir*g search for the nystagmus reflex by excitation of
the labyrinth (vestibular). Can excitation of the coch-
lea also produce this reflex? A cochlea-orbicular reflex
has been known for many years. It may be produced
by certain brusque procedures, such as firing a pistol
close to the ear. The sound is transmitted to the organ
of Corti, reaches the cochlear nucleus in the bulb, is
irradiated by the facial nerve, and causes a contraction
of the superficial facial muscles, and especially of the
orbicularis palpebrarum. This contraction varies much
in degree, but if it is present at all it guarantees that
the organ of Corti and acoustic nerve are intact, so far
as gross lesions are concerned. If, on the contrary, the
reflex is suppressed, the vestibule is destroyed. Marked
reduction in degree of the reflex suggests a minimal
lesion in the vestibule. To practise the test the author
uses the horn of a bicycle, which is not burdensome to
the patient yet well suited to excite the organ of Corti.
The eyelids are watched with a strong lens to discover
the slightest flicker. The horn is blown about 2 meters
from the ear, and must be on a prolongation of the
biauricular line. The meatus must be plugged with
cotton soaked in vaseline, and cardboard or some simi-
lar substance placed in front of the ear. The eye ob-
server gives a signal to the horn blower. At the very
first sound the former notes through his lens perhaps a
minimal contraction of the orbicularis. The subject is
unable to resist this action of the muscle. If total
deafness from organic disease is present, the reflex is
entirely absent. However, in a heredosyphilitic patient
with apparent total deafness, the horn when blown at
the distance of 1 meter elicited a feeble response. In
traumatic total or subtotal deafness listed as due to
shell shock the reflex is not entirely extinguished, and
unconscious simulation is often revealed by the test.
Many of these patients will promptly recover, but it is
best to "let them down easily" and treat them as if
they were actually deaf, promising good results from
certain remedies, which duly appear, to the wonder of
the patient. In some of these subjects with marked
psychic trauma both the cochlear and vestibular reflexes
are normal, but there is a fixed idea of deafness. These
men must not be mistaken for malingerers. A so-
called deafness by inhibition of cortical origin is often
seen and is curable by therapeutic suggestion. Of 500
to 600 cases of "traumatic" deafness of mostly early
appearance, but a single case of total permanent deaf-
ness was noted despite the frequent diagnosis of laby-
rinthitis. In malingerers of total deafness, who are
more rare than is generally believed, the cochleopal-
pebral reflex exposes the deception.
Gazette Hebdomadaire des Sciences Medicales de
Bordeaux.
September 24. 1916.
Treatment of Post Chloroformic Vomiting. — Jeaneney
states that there are two forms of this accident. One
is of psychic origin and is of a benign type — only mucus
or bile being evacuated. The patients may be obssssed
with the idea that they must vomit, or may simply
He influenced by some association of ideas or even be
nauseated by the smell of chloroform. The other type
of vomiting is known as the toxic, and produced by the
action of some poison on the vomiting center, usually
chloroform itself. The patient may be hypersensitive
to such toxic influences. Ranking with this type as a
serious form of vomiting is that produced by acute
postoperative dilatation of the stomach. The toxic
cases may be conservative for when vomiting is checked
by treatment the patient still feels malaise and sense of
weight in the epigastrium relieved only by vomiting
which may supervene about the third day, often when
a purgative is given. In toxic vomiting we see violent
accesses occurring without apparent cause, rebellious,
frequent, with a peculiar odor of the breath. Slight
icterus now appears, with delirium and convulsions
and eventually bradycardia. The syndrome is due to
the great fragility of the hepatic tissues after chloro-
form. The prophylaxis of chloroform vomiting consists
in the milk regimen and the use of a purgative. The
stomach must remain empty for some eight hours.
This precaution works wonders. In veterinary practice
apomorphine is given. The purest and best chloroform
must be used. It must have been recently distilled.
Much must depend on the anesthetist as some of them
hardly ever see vomiting. After the operation noth-
ing is taken into the stomach for ten hours when a
spoonful of water is first given, then liquid diet, semi-
liquid diet, lactovegetarian diet up to full regimen.
When psychic vomiting appears, a combination of euca-
lyptol and menthol is given by the mouth, while oxygen
is inhaled. Any powerful essence or aromatic substance
may be smelled. Spirits of cologne inhaled from a mask
is a favorite remedy in England. If these measures fail
the ordinary substances given to check vomiting may
be tested in succession, as ice, charged water, etc., etc.
The author is not enthusiastic over this class of rem-
edies, considering the psychogenic nature of the vomit-
ing. In toxic vomiting the first indication is gastric
lavage. After a due interval hot drinks are given, sweet-
ened or alkalinized, and later milk. Next day a sodium
sulphate purge is given. If the case is desperate blood
transfusion is practised. It must not be forgotten that
we do not wish to suppress the vomiting entirely, but
to reduce its degree notably.
Reflex Disturbances and Cerebral Insufficiency. —
Mezie like others has noted reflex disorders in a great
variety of wounded soldiers, comprising contractures,
pareses, paralyses, hypotonias. They are accompanied
by troubles of sensibility, trophic disturbances, vaso-
motor and thermic disorders, and alterations in the
blood pressure, as determined by Pachon's oscillometer.
In addition, such conditions as edema, refrigeration,
cyanosis, profuse sweats cause suspicion of reflex dis-
orders. According to Babinski and Froment the wound
of the extremity produces these reflex disturbances
chiefly on the corresponding side through the inter-
mediary of the cells of the cord, some of which are
activated and others muffled. Cerebral fatigue acts as
a contributory cause. The author would make cerebral
insufficiency a most important factor. In these patients
there are numerous evidences of this insufficiency both
physical and mental. The condition may be due to
mental over-activity and fatigue or to commotion. Per-
sistent insomnia and repeated emotions play their part
as does an innate cerebral inferiority. The various
forms of physical therapy give the best results in treat-
ment.
Casualties Among the Canadian Troops. — The total
number of casualties among the members of the Cana-
dian forces up to the middle of October are reported as
52.025. diviHpd as fo"ow: Won~rl°d. 37.939: t-p'ed in
action, 8,133; died of wounds, 3,120; died of sickness,
452; missing, 2,381.
784
MI.DICAL RECORD.
[Oct. 28, 1916
Hook 2&mroi0.
The Art of Anaesthesia. By Paluel J. Flag«, M.D.
Lecturer in Anesthesia, Fordham University Medi-
cal School; Anaesthetist to Roosevelt Hospital; In-
structor in Anaesthesia to Bellevue and Allied Hos-
pitals, Fordham Division; Consulting Anaesthetist
to St. Joseph's Hospital, Yonkers, N. Y.; Formerly
Anaesthetist to the Woman's Hospital, New York
City. Pp. 341 with 1136 illustrates. Price, $3.50.
Philadelphia and London: J. B. Lippincott Company,
1916.
Almost anyone can hold a cone and pour ether on at
the word of command of the operator but, as Flagg says,
the proper administration of an anesthetic is more
than a mere mechanical performance and the art of
anesthesia is acquired by becoming familiar with the
laws which govern its administration and by develop-
ing the ability to properly correlate and apply these
laws. With these facts in mind the author has dis-
cussed the subject most intelligently and has elaborately
presented the fundamentals of correctly administering
anesthetics of various kinds and in various sequences.
After an introductory historical sketch the author
proceeds to the classification of anesthesia, its char-
acteristic signs and its administration by the various
methods and agents ordinarily employed. Each of the
three types of anesthesia — general, local, mixed — is dis-
cussed in detail, often in most exhaustive fashion; and
this applies particularly to the 200 odd pages devoted
to general anesthesia. This is considered from every
angle. The stages of anesthesia — induction, mainte-
nance, and recovery; the signs of anesthesia as shown
by changes in respiration, color, muscle symptoms, the
behavior of the eye reflexes, and the pulse; the methods
of administering ether — oral insufflation, intrapharyn-
geal, intratracheal, oil-ether rectal, intravenous; general
considerations and the technique of administering ethyl
chloride, chloroform, nitrous oxide, and the various
sequences — all these subjects are treated with much de-
tail. Methods of local and mixed anesthesia are then
briefly outlined, this closing Part I of the book. Part
II, "Bearing upon factors incidental to the actual ad-
ministration of the anesthetic," discusses preliminary
medication, post-operative treatment, emergency
anesthesia, etc.
The book's greatest fault lies in its prolixity and we
should say that the text could be condensed at least one-
third without leaving out anything of vital importance.
Circumlocution and redundant words and phrases
abound. Hence, while the embryo anesthetist cannot fail
to profit greatly by reading the book as it stands, it
would be much more valuable as a teaching instrument
after proper condensation and a little friendly editing;
for the English construction is not always what it
should be.
Aseptic Surgical Technique with Especial Refer-
ence to Gynecological Operations, Together with
Notes on the Technique Employed in Certain Supple-
mentary Procedures. By Hunter Robb. M.D.. for-
merly Professor of Gynecology, Western Reserve
University and Gyneeologist-in-chief to the Lakeside
Hospital, C'eve'and, Ohio; Fellow of the American
Gvnecological Society and of the American College
of Surgeons, etc. Fifth edition, revised. Octavo of
292 rages, with -14 text figures and '24 p'ates. Price,
$2.00 net. Phi'adelphia and London: J. B. Lippincott
Company. L916.
Tn the preface to the first edition, which appeared
twenty-two years ago, it is stated that the technique
recommended is in the main that practised in the gyne-
cological and surgical departments of the Johns Hop-
kins Hospital. Certainly many radical changes in
technique have been made at the Johns Hopkins Hos-
pital as well as everywhere else in the past twenty
years; but starting with that excellent model, occa-
sional revisions have made it possible for the author
to follow the same general scheme and still inco ate
new material and alter the old in accordance with the
best teachings of the day.
The author first discourses upon the importance of a
bad il training to the surgeon; and makes the
point that the trained bacteriologist will have exalted
ideas of surgical cleanliness, and cannot fail to see the
many inconsistencies that occur during the majority of
operations. Sepsis and wound infection, the micro-
organisms generally concerned, asepsis, antisepsis, the
principles of sterilization, dry and moist heat, fractional
sterilization and chemical disinfection are taken up in
order. This is preparatory to the actual business of
the book — instruction in the practical application of the
principles of sterilization as concerns gowns, dressings,
instruments, sutures, etc.; the care of instruments, rub-
ber gloves, drainage and other materials; the prepara-
tion of the operative field ; the preparation that must
be made for operations in private houses; the prepara-
tion of the patient for major and minor operations;
postoperative care; and numerous other matters that
must be understood by the nurse, operator, and assist-
ants in order that opeiations may be conducted with
that aseptic technique which is the desired goal of most
competent operators to-day and the despair of many.
In the latter part of the book are found a number of
chapters on examinations of various kinds. Some of
these would be improved by further revision; and this
applies especially to that on the examination of the
bladder and ureteral catheterization, for this chapter is
in many respects far out of date. The final chapter,
on endometritis, has been added in this edition. Why
the author has added twenty-seven pages on this sub-
ject is beyond our comprehension. It seems to us en-
tirely out of place in a work of this sort, especially as
it is the sole representative of the discussion of disease
affecting a particular organ.
For the nurse, for the interne, and, above all, for the
man who is occasionally called upon to operate and who
has not had the advantage of rigid hospital training,
this book should be of great value.
The Clinics of John B. Murphy at Mercy Hospital,
Chicago. Volume V, Number 3, June, 1916. Oc-
tavo of 178 pages, with 44 illustrations. Price per
year, paper, $8.00; cloth, $12.00. Philadelphia and
London: W. B. Saunders Company, 1916.
This is a better issue of the Clinics than has appeared
in many months. With the exception of one case of
infective costal perichondritis, bone and joint cases are
conspicuous by their absence. This is, in itself, cause
for rejoicing; for our appetite for clinical lectures on
hone and joint diagnosis and operative technique was
long ago satiated. In this volume about thirty-five
clinical cases are discussed and every one should be of
interest to the general practitioner, for most of the
cases are such as he is apt to meet any day in his prac-
tice. There are also a number of valuable tables, diag-
nostic and otherwise, in connection with certain of the
subjects.
Modern Medicine and Some Modern Remedies. Prac-
tical Notes for the General Practitioner. By Thomas
Bodley Scott, Author of the Road to a Healthy Old
Age. With a preface bv Sir Lauder Brunton. Bart..
F R.S. Price, $1.50. New York: Paul B. Hoeber,
1916.
This little work consists of four essays, devoted respec-
tively to disorders of the heart, arteriosclerosis, endo-
crinology and chronic bronchitis. The first thing to
attract the reviewer's attention is the fact that the
essays are not reprints of journal articles, but have
been independently composed. The author, a clinician
of wide experience, has endeavored to popularize
among the ranks of the busy practitioner, some of the
latest developments of internal medicine, all of which
have reference directly or indirectly to those disorders
of the circulatory system which continue to be the great
menace to those past middle age. Therefore it is hardly
necessary to dwell on the timeliness of the book. Sir
Lauder Brunton's service as sponsor to the book is
unnecessary, but welcome. In his preface he bitterly
assails the Germans for robbing mankind of the treas-
ures of the University of Louvain.
Ultra-Violet Light Bv Means of the Alpine Sun
Lamp. Treatment and Indications. By Hugo Bach,
M.D., Bad Elster, Saxony, Germany. Authorized
Translation from the German. Price. $1.00. New
York: Paul B. Hoeber. 1916. pp. 114.
Tins little work is properly devoted to the indications
for the use of ultra-violet lighl lamps and the technique
for carrying out the same. Not much space is devoted
to the principles and construction of the apparatus,
with which the physician is presumably sufficiently
familiar. The raison d'etre for the book appears to
be associated with the use of the lump for eeneral dis-
orders, as distinguished from local, superficial ailments.
Here belong tuberculosis, chlorosis and anemia, leu-
keuria, arteriosclerosis, cardiac and renal disease,
obesity, diabetes, furunculosis, gout, chronic rheum-
atism, neurasthenia, etc.. etc. In this class of cases the
lamp is regarded as an understudy of direct solar light
whenever the latter is not fully available.
Oct. 28. 191(5 i
MFDICAL RKCORD.
785
Swrtrtit Reports.
AMERICAN ASSOCIATION OF OBSTETRICIANS
AND GYNECOLOGISTS.
Twenty-Ninth Annual Meeting Held at Indianapolis
September 25, 26, and 27, 1916.
The President, Dr. Hugo O. Pantzer, Indianapolis,
in the Chair.
Appendicular Abscess Complicated by Hemorrhage and
Death. — Dr. Magnus A. Tate of Cincinnati spoke of
this condition as rare. The patient was a young woman
who had her first attack. Her abdomen was opened
through the right rectus, and drainage was profuse
for six days. At the end of the tenth and eleventh
days her condition was good. On the twelfth day she
complained of pain and nausea. On the morning of the
thirteenth day there was hemorrhage from the wound,
and on the fourteenth day her condition was alarming,
death occurring the same evening. Autopsy revealed a
gangrenous sac, the size of a dollar, which was found
in the mesentery, probably the site of hemorrhage.
Dr. Albert Goldspohn of Chicago said that this case
reminded him of an experience he had after a vaginal
hysterectomy in a septic case a number of years ago
where, after a normal course following operation, the
patient began to bleed about two weeks after the wound
had nearly closed. After futile attempts to stop the
hemorrhage by local tamponning and the use of clamps,
he saved the patient's life by doing an abdominal sec-
tion and ligating the internal iliac arteries.
Drainage for Pus Conditions in the Pelvis During
Pregnancy. — Dr. Francis Reder of St. Louis stated that
the most frequent cause of a pus accumulation in the
pelvis during pregnancy must be attributed to a dis-
eased appendix. A pelvic abscess was very insidious,
with the exception, perhaps, of a subphrenic abscess.
The reason for this was that the diagnosis of appen-
dicitis was often obscured by pregnancy. If the pains
and frequent indispositions, which usually accompanied
the pregnant state, were not closely scrutinized and cor-
rectly and promptly interpreted by the physician, the
primary clinical picture of an attack of appendicitis
might be readily overlooked, and only recognized when
the more serious phases of the disease had manifested
themselves. Pregnancy did not in any way predispose
to appendicitis, but on account of the anatomical
changes which took place in the pelvis during preg-
nancy, appendicitis might terminate in a pus formation
more rapidly than in the nonpregnant state. A close
study of the symptoms of an appendix lesion during
pregnancy might bring out some clinical points which
differed from the usual clinical picture as it was found
in women who were not pregnant. For instane, before
any pus formation had taken place, the pulse and tem-
perature might show little or no change. The pain
was usually located in the epigastric region and re-
mained there until the disease had reached the stage
when all pain ceased. The triad of Dieulafoy was often
so obscured by other conditions that it was usually
blurred, and its presence therefore overlooked. Even in
an advanced pregnancy a readily recognizable rigidity
of the right rectus was seldom encountered, and only ex-
ceptionally did palpation reveal a tender spot oyer
McBurney's point. Nausea and vomiting, two alarming
symptoms in an attack of appendicitis, counted for
naught during pregnancy because they were frequently
associated with the toxemia of the latter condition. The
most satisfactory and convincing evidence as to the
presence of pus in the pouch of Douglas could be ob-
tained by a rectal examination. If the accumulation
was considerable, no difficulty should be experienced in
promptly detecting a fluctuating mass, even if the ex-
amining finger was inexperienced. Surgery during the
pregnant state must have its limitations and they
must be more respected in the latter stage of gestation.
An abdominal operation, for example, could be done
with less risk of interrupting pregnancy before the
fourth month than after. Furthermore, the thorough-
ness with which an operative measure during early
.pregnancy could be carried out was fraught with less
danger than in the later stages. Great antipathy still
existed as to attacking a pelvic abscess through the
rectum, largely because of the likelihood of infecting
the abscess cavity. This was doubtful, inasmuch as it
was one of nature's ways in relieving the organism of
a pus accumulation in the pelvis. Patients relieved in
this manner had usually suffered no untoward results
and their recoveries had been satisfactory.
Dr. Herman E. Hayd of Buffalo, N. Y., said that in
cases of appendicitis complicated with pregnancy mis-
carriage was apt to take place. Miscarriage was liable
to occur in typhoid fever complicating pregnancy. Un-
doubtedly a bacteriemia was established, and the fetus
was made ill by reason of the infected blood, and as a
result the woman had a miscarriage. The point the
essayist brought out of opening the abscess through the
rectum was a good one.
Dr. W. A. B. Sellman of Baltimore stated that he
had had experience with two cases of appendical ab-
scess complicating pregnancy. One woman was preg-
nant four months, and the other six months. One
method of dealing with these abscesses was that sug-
gested by the essayist of opening through the vagina
posteriorly into the cul-de-sac and by that means reach-
ing the abscess. The second method was opening the
abscess through the rectum. He selected the abdominal
route, made an incision, drained the cavity, leaving the
drainage tubes in. His experience was that in ap-
pendical abscesses it was necessary to drain the cavity
for a longer period than that suggested by Dr. Reder.
Dr. Roland E. Skeel of Cleveland said that as re-
gards making a puncture through the rectum in these
abscesses he had used that procedure for ten years,
but he would emphasize the fact that there must be an
abscess cavity. If there was no abscess cavity with a
thin wall, it would be dangerous on account of peri-
tonitis or rectal infection. He could recall cases of
appendicular abscess which opened and drained through
the rectum spontaneously.
Dr. Reder, in closing, said that in these cases he con-
tented himself with draining and did not care to use
a split tube for fear some irritation by pressure might
excite infection.
Rupture of the Uterus; Sepsis; Operation; Recovery.
— Dr. Rufus B. Hall of Cincinnati reported a case of
rupture of the uterus, followed by sepsis, with a walled
off abscess, which was operated upon thirty-seven days
after delivery. The patient made a slow but satisfac-
tory convalescence and was now perfectly well. Rup-
ture of the uterus during labor was a rare and danger-
ous accident. It was so fatal that it was our duty to
report every case in detail, whether the patient re-
covered or not, that the profession might profit by the
facts revealed in each individual case. He asked if it
was possible that an unrecognized small rupture, caus-
ing leakage into the abdomen, might not be more fre-
quent than was generally believed. The case reported
would suggest that as a possibility, because there were
no symptoms connected with the case that would sug-
gest rupture of the uterus, and it was not suspected
until revealed at the time of the operation.
Rupture of the Uterus in Cesareani7ed Women. — Dr.
John Norval Bell of Detroit drew the following con-
clusions: (1) A cesareanized woman was always in
danger of uterine rupture in subsequent pregnancies
and should be under careful observation for the last
half of her gestation. (2) In case her puerperium fol-
lowing the first section was afebrile she might be al-
lowed to go to term if she could be in the hospital for
the last month of gestation ; otherwise the labor should
be anticipated and operation done at least two weeks
prior to term. (3) Implantation of the placenta over
the scar area undoubtedly increased the danger of
rupture, as did also an afebrile puerperium following
operation.
Rupture of the Cesarean Scar. — Dr. Abraham J.
Rongy of New York City drew the following conclu-
sions: (1) Spontaneous rupture of the cesarean scar
occurred in about three per cent, of cases. In most in-
stances rupture took place during labor. Not fre-
quently it took place during the latter half of preg-
nancy, especially in the last six weeks. (2) We had
no means by which we could judge the strength of the
scar. Rupture would occure in cases which ran an
afebrile course and in which union of the wound was
apparently by first intention. (3) One-third of all
cases that were operated for reoperated section showed
evidence of inflammatory reaction in and about the
uterine wound. The result in such cases was a weak-
ened scar. (4) Proper suturing of the uterine wound
and exact approximation of the edges would not always
prevent subsequent rupture of the scar. (5) The mor-
tality rate of repeated section was smaller than that
of primary cesarean section, because these patents
were more carefully watched by competent men. (6)
786
MEDICAL RECORD.
[Oct. 28, 1916
A patient who had had a cesarean section should not
be allowed to go through a tedious or severe labor.
If labor did not progress rapidly, repeated section should
be performed. (7) When advising a patient to have a
cesarean section the management of subsequent preg-
nancies should be taken into consideration and dis-
cussed with one of the members of the family. (8)
As a general rule, it might be stated that fully seventy-
five per cent, of women who had had a cesarean sec-
tion were delivered by repeated section during their
subsequent labors. (9) The obstetrician should al-
ways bear in mind that cesarean section created a new
problem for the woman, and therefore he must carefully
weigh the indications before he decided upon the ab-
dominal route. He must remember that the dictum,
once a cesarean section always a cesarean section, held
true in fully seventy-five per cent, of cases.
Dr. Palmer Findley of Omaha said that if ninety-
seven women out of a hundred went through labor with
a cesarean scar successfully without intervention, the
thing to do was to put the woman in a hospital, if pos-
sible, and be ready to interfere, but we should not
adopt the method of performing a cesarean operation
on every woman who had had a previous cesarean scar
in the uterus. He did not think we should be guided
by any three per cent, of chances except this: we should
take every precaution to safeguard the woman in the
event of imminent rupture of the scar.
Dr. J. Henry Carstens of Detroit said he had had
about fifteen patients upon whom he had performed
cesarean section a second time. In all of the cases
there was pelvic deformity. There was not one of
them in whom the operation was performed for pla-
centa previa or eclampsia. He made it a point to
have these patients go to the hospital early, if pos-
sible, and operated on them two weeks before the ex-
pected time of labor. He hesitated twice before he
would sterilize a woman who had had no children.
Dr. Henry Schwarz of St. Louis said that he en-
dorsed every word Dr. Findley had said. Within the
last year he had delivered two women through the nat-
ural passages. One was a woman on whom Dr. Web-
ster of Chicago had performed a cesarean section on
account of obstruction to delivery by an ovarian tumor.
He did a cesarean section on the other patient years
ago. The woman was brought to the hospital with a
temperature of 104° ; she was intensely sapremic, there
was an offensive discharge, with a dead macerated fetus
in the uterus. He removed the fetus. The patient
was a young woman, and this was her first pregnancy.
After emptying the uterus and removing a subserous
fibroid which was situated on the left side of the uterus,
close to the external os and blocking the pelvis, and
after removing a smaller fibroid near the fundus, he
closed the uterus, because the woman was young and
had had no children. He delivered this woman about
seven months ago through natural passages.
Dr. James E. Davis of Detroit said that the problem
from a pathological standpoint was this: First, we
had a reduction of muscle tissue, a degradation of a
normal tissue, then we had a degradation of the con-
nective tissue by the interposition within the connec-
tive tissue cells of syncytial cells. The connective tis-
sue, while it might be in certain instances as strong
as the muscle tissue, yet was not as resistant to the
syncytiolysins which were formed from the syncytial
cells, and wherever we had syncytial cells we had a tis-
sue of very low resistance so far as its ability to with-
stand pressure was concerned.
Dr. Maurice I. Rosenthal of Fort Wayne said that
the important thing was infection, and that infection
was predisposed to by intrauterine pressure. If the
lochia was kept free from the internal surface, the en-
tire suture line closed owing to the absence of the
intrauterine pressure, and that was a point in safe-
guarding against the infection of the wound and in
securing perfect wound healing.
Dr. Irving W. Potter of Buffalo said that he had
done cesarean section on a number of patients a second
time without any trouble. One could not see the scar
in the majority of cases from the outside, but if one
felt from below up one would find a thinning in many
of the cases, although it was not enough to make any
special difference.
Dr. Hkrman E. Hayd of Buffalo said he would like
to ask Dr. Bell why he removed the uterus in this case?
Whv did he not sew it together instead of removing it?
Dr. Bell, in closing, said he must confess he was
afraid the woman might have died. In order to sew
the uterus he would have been obliged to freshen both
edges entirely, because there was a scar, and except
for the fibromuscular bands across, he would have been
obliged to remove the surface of the normal part. He
thought he could do the other operation better.
Dr. Rongy, in closing, said that he never sterilized
a woman unless she had had two children. He did not
do hysterectomy in these cases, but resected the tubes
on either side and then embedded the cut ends of the
tubes in the wall of the uterus. That was a safe pro-
cedure.
Gunshot Wounds of the Abdomen in Pregnant Women.
— Dr. Lewis F. Smead of Toledo, Ohio, reported the
case of a woman shot through the abdomen with the
recovery of both mother and child. The bullet perfor-
ated the colon and the uterus of the mother, the pla-
centa, and the hand of the child. Gunshot wounds of
the abdomen were more dangerous during pregnancy
than at other times. The abdomen should be opened
in all cases, if possible. The uterus at full term should
be emptied by cesarean section and at earlier periods
if the organ was badly injured. A uterus during labor
was likely to spread any infection which was free in
the abdomen and a pregnant uterus was therefore a
menace to the patient if peritonitis developed. The
uterus would usually be emptied by cesarean section or
hysterotomy because the abdomen was open. Hyster-
ectomy was usually not indicated in gunshot wounds
of the abdomen unless the uterus was badly lacerated.
Drainage should always be used in these cases and ir-
rigation very rarely. He gave an abstract of about
thirty cases of gunshot wounds of the abdomen in
pregnant women.
Dr. John D. S. Davis of Birmingham, Ala., said
that he rose to report a case of gunshot injury in a
woman pregnant three and a half months. She was
handling a small rifle when it went off and shot her
through the abdomen, producing twenty-five perfora-
tions, six through the transverse colon and nineteen
through the small intestine. She was brought a dis-
tance of eighty-five miles. He saw her twelve hours
after the reception of the injury. There were five
perforations on the mesenteric border of the small in-
testine, and two perforations on the mesenteric border
of the transverse colon. He closed back the serosa
and turned in the musculature and put the serosa over
that. Instead of doing two resections of the gut, he
took out five feet of the intestine between the nineteen
perforations. She recovered and gave birth to a living
child at the ninth month.
Version with Report of Five Hundred Cases. — Dr.
Irving W. Potter of Buffalo, N. Y., stated that in the
advocacy of all procedures we should have a clear idea
of the results. In these 500 cases there was not a
maternal death, and there were no iniuries to the
mother's soft parts that required repair. In other
words, there were no tears of the cervix or the per-
ineum that necessitated suturing. There were no
alarming hemorrhages, and the period of involution in
these cases was shorter than ordinary with less flow
during the puerperium. The convalescence was more
rapid due to the elimination of the shock that was ex-
perienced by patients going through a long second stage
of labor. There was also apparent greater strength of
the patient at the end of the puerperium. In refer-
ence to the fetus, there were 57 stillbirths, the greatest
cause being prolapsed cord; in 30 cases alone death
was due to this cause. His conclusions were as follows:
"Version should be more often done to shorten the
time of labor, lessen the shock to the mother, and elim-
inate undue pressure to the child's head. That the
majority of occipito-posterior positions were best
treated by version. That version can readily be accom-
plished in primiparae and should be more often done.
That the fetal mortality in version should not be as
great as in prolonged instrumental delivery. That
head iniuries to the child were lessened by a properly
performed version."
Lymph Gland Extract. Its Preparation and Therapeu-
tic Action. — Dr. DAVID HADDEN of Oakland, California,
stated that he had used in several cases of strepto-
coccemia the magnesium sulphate solution advocated
by Harrower. The magnesium sulphate solution alone
produced no leucocytosis, but used in conjunction with
leucocytic extract, a marked leucocytosis resulted of
a more profound character than the extract alone pro-
duced. These patients recovered. Two cases of easy
bleeders, one with hemorrhage from the abdominal in-
cision, the other with free oozing from the mucous
membrane had a complete and permanent cessation of
the bleeding almost immediately following the one dose.
Oct. 28, 1916J
MEDICAL RECORD.
787
His associates had been using this lymph gland extract
in cases of hemophilia, pulmonary hemorrhage and
tonsillar bleeding with very favorable results. He
had used, during the last two years, lymph gland ex-
tract, in all inoperable cases of carcinoma, and discount-
ing fully the possibilities of spontaneous improvement,
he believed he was justified in the conclusion that the
effects had warranted the use of the extract. He prob-
ably would never use body extracts in operable cases
of malignancy as a substitution for operation, but if
proven of value in animal work, they would have their
place as a prophylactic. In inoperable cases, it gave
one method that undoubtedly prolonged the patient's
life and relieved many of the distressing symptoms, so
that the amount of opiates necessary was lessened,
but, above all, it put in our hands an ability to make
the patients really feel something was being done for
them. The present important field for the lymph gland
extract was, however, undoubtedly in cases of hemor-
rhage and especially so in patients whose blood changes
resulted in lowered coaguability. Dr. Archibald and
Dr. Moore were anxious to see the extract tried out
more extensively in tuberculosis and other chronic in-
fections, for they felt that their laboratory experi-
mental work had demonstrated its effect in these cases.
Dr. James E. Davis of Detroit said he would like to
ask Dr. Hadden if in using the lymphocytic extract he
know how the platelets were produced. There were a
number of theories about it. Some believed that the
platelets had nothing whatever to do with the coagula-
tion ; others had raised the question as to just what
the platelets were, whether they were fragmentary
portions of the lymphocytes, and he wondered whether
light had come to Dr. Hadden in this particular in-
stance of the platelet.
Dr. Hadden, in closing, said that, personally, he
could not express any opinion with reference to the
function of the blood platelets. We knew they were
markedly increased, that so much of the spaces in be-
tween cells were filled with blood platelets. After a
series of injections in lower animals Dr. Moore had
proved conclusively, although he was not willing to
give the evidence publicity, that we were dealing with
an enzyme and the presence of the enzyme produced
these changes.
Observations on Blood Pressures During Operations.
— Dr. Charles W. Moots of Toledo, Ohio, said that,
having made observations and records of the pressures
in ninety-eight per cent, of his cases for the past eight
years, he had, as a result of his experience alone, come
to certain conclusions which he wished to offer at this
time. (1) The systolic pressure alone was of very
slight if any value. (2) The diastolic pressure alone
was of much more value than the systolic alone. (3)
The pressure ratio was the essential factor, and offered
the earliest danger signal. (4) There were certain ele-
ments in technique which had marked and constant
effect upon the pressures. These were as follows: (a)
The physical or emotional state of the patient. (6)
The position of the patient upon the table, the extreme
Trendelenberg being the worst, (c) Overdosing by the
anesthetist, (d) The amount of traumatism inflicted
by the actual operation, such as cutting and tearing
the tissues with scissors, the hands and other dull in-
struments; the packing of large gauze packs instead
of rubber tissue into the abdominal cavity, (e) The
preservation of the fluids in the body up to the hour
of the operation, this being absolutely necessary to
maintain the usual pressures.
Dr. R. R. Huggins of Pittsburgh said that when one
was suspicious of any weakness on part of the cir-
culatory apparatus of the patient, if he would take the
pulse pressure with the patient in the lying position
and found that it went down that patient was a bad
risk. A patient with a blood pressure of 170 or 180,
with low diastolic pressure, should always be watched.
The same thing was true of low blood pressure.
Dr. Carstens said that he had for some time insisted
on taking the blood pressure of patients a day or two
before operation, and if we had a patient with a blood
pressure of 170 it was dangerous to operate before
adopting some measures to reduce it.
Points in the Diagnosis of Pelvic Troubles — Dr.
J. Henry Carstens of Detroit said that these patients
had pains when moving the uterus and the pelvic or-
gans in certain directions. If one pulled the uterus to
the right, they complained of severe pain in the left
side, and vice versa. When one pulled the uterus away
from the bladder no complaint seemed to be made, but
when one pulled the uterus forward or away from the
rectum severe pain was complained of, often in the
back. These cases were due to adhesions, and he be-
believed the adhesions were caused by an infection from
the rectum and sigmoid, as these patients were often
suffering from chronic constipation. In many cases it
was difficult to convince the patients that an operation
was necessary when they had always been in perfect
health before. He was convinced that when the history
was perfectly clear of the non-existence of any trouble
previously with a gradual onset of pain and distress, it
was very much increased when moving the uterus and
the pelvic organs.
Care of Patients Before and After Operation. — Dr. H.
Wellington Yates of Detroit stated that every sur-
geon should be a humanitarian. Surgery was a thing of
art as well as science, a thing needing a fine esthetic
sense rather than mere boldness. It was constructive,
not destructive; it was saving life, not taking it, and
likewise a surgeon was not he who had boldness, but
one who had judgment, not alone he who knew how
and when to operate, but also he who knew to refrain
and when to conserve. Surgeons had paid too little at-
tention to the internal secretions. Patients did not
come for operations per se, they came to be cured of a
malady of which they usually knew nothing, and placed
themselves in our hand, because they had been re-
ferred to us by some other physician, who had failed
to cure them. We should be exceedingly careful in the
selection of such cases. As a rule, they were not given
thorough examination — general physical examination.
In general, he had been giving his patients more
preoperative care than formerly. For two or three
days he fed them well on easily digested nutritious
foods; the last day he gave six ounces of water each
hour while awake; this filled the blood-vessels, increased
kidney, liver, and skin excretions and secretions. Ner-
vousness and loss of sleep won exhausting and should
be met by such remedies as the usual sedatives or
opium. He thought it imperative that the patient be
given sufficient quantities of opium to induce sleep. As
regards obdominal surgery, we had learned that the
viscera and their coverings spoke in no uncertain man-
ner, and to some extent we had learned their language
and, therefore, after an operation some of them cried
out by expression of pain ; some by way of abdominal
distention; some by way of vomiting; some by thirst;
some by pallid skin and sunken eyes; but the meaning
of it all was, that we had given insult. One's insides
were never intended to play ball in, but if perchance the
ball had gotten in, our duty was to get it out as quickly
as we could, with gentleness and safety. We had been
taught by this language that we must get in and get
out; that we must do the least handling possible to
accomplish results; that we should avoid forcible re-
tractions, and when we sought to pick up bleeding
points, should pick them up separately, instead of in-
sulting all the adjacent tissues; warm moist gauze,
used gently, was less offensive than dry gauze, used
roughly. The handling of patients should vary in ac-
cordance with their psychology and the nature and
severity of the operation. In all operations of gravity,
he used the Murphy drip, with bicarbonate of soda and
glucose, as soon as the patient was returned to her bed.
The soda would overcome tendency to acidosis, the
glucose furnished an easily absorbable carbohydrate,
and thus supplied energy. In those who through acci-
dent had lost much blood or who sweated profusely,
the giving of two pints or more of this solution re-
lieved the distress of extreme thirst and overcame the
tendency to shock. In closing he wished to leave these
thoughts: (1) Our patients were entitled to more pre-
operative and post-operative care than they had been re-
ceiving. (2) Patients suffered from shock in conse-
quence of long anesthesias, exposures, and rough
handling of tissues. (3) Surgery was a thing of art
and gentleness as well as of knowledge and skill.
Fibromyomata Uteri and Cardiovascular Disease. —
Dr. Ben R. McClellan of Xenia, Ohio, said that since
attention had been directed to this interesting question,
he had had opportunity to study carefully twenty-six
cases of fibromyoma uteri, nine of which had well
marked cardiovascular complications. In each case the
diagnosis of the latter condition was confirmed by a
competent internist. Of the nine, only two gave any
history of other adequate cause than the presence of
the fibroid uterus; these two gave distinct histories
of a previous acute pelvic infection. Two of the nine
patients died, one within a few hours following a diffi-
cult removal of a very large multiple fibroid of many
years' growth, which had undergone cystic degenera-
788
MEDICAL RECORD.
[Oct. 28, 1916
tion, and was complicated by every extensive adhe-
sions to the surrounding viscera. The heart behaved
badly during the operation and death was undoubtedly
due to shock, which in turn was caused by extreme
traumatism in the presence of heart and blood vessels al-
ready handicapped by changes due to the presence of
the chronic uterine disease. The other case, which had
very pronounced cardiac and renal complications, was
carefully prepared for the operation which was not
difficult, although the tumor was of extreme size. The
patient made an exceptionally good recovery up to the
eleventh day, but died without warning while sleeping
after a dinner which she had greatly enjoyed. No
doubt the cause of death was brown atrophy of the
heart. The remaining seven cases had all recovered
with symptomatic relief from cardiac trouble, ana
only three, on careful examination, showed some hyper-
trophy. That a relationship between the two diseases
existed there could scarcely be any doubt, but the
etiology of the cardiovascular changes remained as
yet in the field of theory.
Operative Judgment as a Factor in Surgical Mortality
and Morbidity. — Dr. Roland E. Skeel of Cleveland,
Ohio, said that in the matter of the particular opera-
tion which he performed he would cite two or three
widely separated types of cases as examples. There
might be an honest difference of opinion as to whether
exophthalmic goiter was a medical or surgical condi-
tion, but there could be no honest difference of opinion
as to the outcome of properly applied surgical treat-
ment. Even this rarely gave a complete cure in the
sense that all the symptoms were relieved permanently
and at once, but it did convert the patient from an in-
valid or semi-invalid into one whose condition was such
that self-support was possible and the health nearly
as good as the average, but this result could not be
obtained by slavishly following out one method of pro-
cedure whether that be pole ligation, tying of one or
more vessels, or partial thyroidectomy. The last had
a prohibitive mortality if used in each and every case,
the first two were not efficient in the chronic slow-going
type of cases, especially in women, while they not only
had a very low mortality but a high permanent recov-
ery rate in acute cases in the male, in whom the pelvic
functions did not constantly disturb the nervous
equilibrium. By a proper selection of cases for the
various procedures, by a judicious selection of the
anesthetic for the individual case, and, above all, by
speed in operating, absolute prevention of postopera-
tive bleeding, gentle manipulation of the gland, and
sealing of the relatively large raw area by painting
the wound surface with tannic acid solution combined
with drainage, practically every case could be saved.
In the treatment of intestinal obstruction the slavish
obedience to some precept learned while a student or
swallowed in its entirety because propounded by the
master of a surgical clinic was likely to result in as
serious a disaster as delayed diagnosis. To eventrate
every patient through a huge incision meant that the
operator had utterly overlooked the possibility of death
from shock due to exposure of the peritoneum and much
handling of the gut; to attempt operation through a
wholly inadequate incision meant that an enterostomy
only would be done. Reopening the primary incision in
postoperative obstruction was all that was needed
ordinarily, since the obstruction would be found in or
about the operative site, and under any circumstances
an incision large enough to admit the hand for explor-
ation should be sufficient unless the obstruction was at
a point far remote from the exploratory opening.
(To be continued.)
Insufficient Protection in Radiology. — Nogier ques-
tioned as to whether the customary protection really
protects in deep radiation in which very hard tubes and
very penetrating rays are employed and undertook a
series of researches to decide the question. He found
the apparatus guaranteed by manufacturers does not
protect at all. A lead glass shield was found to be of
unequal thickness and not opaque. Despite this shield
a photographic plate exposed during a session of radio-
theraphy was impressioned in an intense fashion. The
rays which pass through the shield cause secondary
rays when they impinge against the walls or other ob-
jects which also affect photographic plates, even behind
protecting screens. Silk containing lead salts gives but
feeble protection, and eight thicknesses are inferior to
the leaded rubber of Miiller. — Archives d'electriciti
medicate.
NEW YORK ACADEMY OF MEDICINE.
SECTION ON SURGERY.
Stated Meeting, Held October 6, 1916.
Dr. John Douglas in the Chair.
Rupture of the Uterus with Prolapse of Intestines —
Resection. — Dr. Seward Erdman presented this case.
He stated that the patient was an Italian woman, 23
years of age, and married, who was admitted to Dr.
Pool's service at the New York Hospital on June 5,
1916. Three months before admission to the hospital
she became pregnant for the first time. One month
before admission she began to bleed profusely, and had
continued to bleed since that time. For the past two
weeks she had had abdominal cramps. During curette-
ment for incomplete abortion which was being per-
formed under ether anesthesia and with asceptic pre-
cautions, the operator recognized the prolapse of intes-
tine into the vagina and at once sent the patient to the
hospital. The pulse and general condition of the patient
were excellent. Immediate operation was performed.
After iodine preparation, a median suprapubic incision
was made. Upon opening the peritoneum, some four
ounces of free blood were encountered. The soft, boggy
uterus, the size of a three months' pregnancy, showed
a linear tear one and one-half inches long in the fundus
posteriorly, just medial to the right cornu and on a level
with the tube. Firmly wedged into this rent were the
two limbs of the loop of ileum, its mesentery crowding
still more the small tear. With the gentlest traction,
and without difficulty, the loop was drawn up out of
the uterus, when it was found to consist of about fifteen
inches of collapsed and badly traumatized ileum torn
completely from its mesenteric attachment. The torn
edge of the mesentery had been well puckered into the
uterine wound and its vessels thrombosed so that it bled
scarcely at all. Fifteen inches of the ileum were re-
sected, a lateral anastomosis by suture using the Roose-
velt clamp having been done. The wound in the uterus
was closed by two layers of sutures. The abdominal
wound was closed without drainage. With the patient
in the lithotomy position a large blunt curette was
passed lightly, bringing away several small fragments
of membrane. On the third day both breasts became
painfully distended with milk, requiring stuping and a
tight binder. The wound healed by primary union and
the patient went home on the twelfth day. The report
from the Follow-Up System snowed that the patient
developed a slight left saphenous thrombo-phlebitis
soon after leaving the hospital, which troubled her for
four weeks. She had suffered from no further abdom-
inal, intestinal or pelvic symptoms.
Dr. Charles H. Peck said he had had a case similar
to the one reported by Dr. Erdman some fourteen years
ago in which eight and one-half feet of intestine was
drawn through the rent in the uterus. As soon as the
intestine was recognized laparotomy was performed by
another surgeon and it was replaced but not resected.
The intestine was stripped from the mesentery just as
in Dr. Erdman's case. Twenty-four hours later, when
the case came under his care, resection was performed
and the patient recovered in spite of the presence of
well-marked peritonitis. Dr. Peck said he had followed
this case right along until a year or so ago, and she
had remained well. He had been interested in the case
because of the length of intestine removed, and had fol-
lowed it to see what the results might be. No chronic
diarrhea had developed. Some two years after this
operation the patient had undergone an operation for
ventral hernia, and it was interesting to see what was
found at the site of the anastomosis. Everything had
smoothed out and the ileum was practically free from
all traces of operation.
Accidental Scalping United per Primatn. — Dr. George
Sheinberg presented this patient by invitation. He
stated that the woman had been admitted to the Lincoln
Hospital with a complete eversion of the scalp, the en-
tire scalp resting on the occipital bone. She was em-
ployed in a laundry and her hair was caught in a shaft.
She was not unconscious and grasped the scalp, and
did not allow it to be torn off completely. The scalp
was torn through the eyebrows just over the bridge of
the nose and from ear to ear. The wound was full of
i hair and particles of dust. It was cleansed,
sutured with three rows of deep sutures, and drainage
was provided for in the back of the head. After the
operation the patient's temperature never rose above
99.5° F. and she had no pain, headache or dizziness,
Oct. 28, 1916]
MEDICAL RECORD.
789
and she felt well. There were a few adhesions over the
right eye.
Osteomyelitis in Children (Two Cases) with Demon-
stration of Lantern Slides of X-Kay Plates Showing the
Bone Repair Following this Disease. — Dr. Frederic W.
Bancroft presented these patients. The first case
occurred in a boy, 5 years of age, who was seen two
days after having sustained a fall and injury to the
left knee. The child had had chills and fever, but had
not vomited. The knee was red, swollen, and exquisitely
tender. Physical examination was negative save for
enlarged and injected tonsils and a few palpable nodes
in both cervical chains. The child complained of much
pain and the antitibial region was particularly tender.
Active and passive motion were limited. There was
an abrasion one inch in length on the inner aspect
of the knee. During a period of seven weeks the
following operations were performed: (1) An in-
cision carried through the fascia and periosteum
through which four ounces of pus were evacuated.
Counter drainage was established. (2) Incision and
drainage of bilateral suppurative parotitis. (3) In-
cision and drainage of metastatic abscess of the back,
with the evacuation of eleven ounces of pus. (4) As-
piration and irrigation of the knee joint, after which
the knee was put up in entension. (5) Aspiration and
irrigation of knee joint as before. (6) Excision of
sequestrum of the tibia. An incision was made from
the tibial tubercle on the anterior surface of the leg
to about 5 cm. above the lower extremity of the
tibia. A sequestrum about fifteen inches long consist-
ing of the entire circumference of the bone was re-
moved and a smaller sequestrum about 4 cm. in
length was also removed at the lower portion. There
was beginning involucrum at the lower end. The se-
questrum extended up as far as the epiphysis. After re-
moving dead bone and exuberant granulation tissue, a
gauze packing was inserted at both extremities and the
intervening area sutured together with deep silkworm
gut, going through skin, muscles, and periosteum, and
thus largely obliterating dead space. A small area
was left for blood clot to form within the periosteum.
The bacteriological examination showed the staphylo-
coccus albus in cultures from the parititis, from the
leg, and from the blood. In the culture from the leg
there was also a member of the streptococcus group
present. Nearly two months after the last operation
and almost four months after the first, a sequestrec-
tomy for chronic osteomyelitis of the tibia was per-
formed. A cavity in the bone was found, about 1x2%
inches in size. Two sequestra were removed and con-
siderable soft granulation tissue curetted away, care
being taken not to destroy any healthy endosteum or
connective tissue. After hemostasis was established,
the cavity was filled with Mosettig Morehof's bone
wax. Three days later the patient had a temperature
of 103° F., and some of the bone wax was removed.
About six weeks later an operation was performed for
chronic osteomyelitis humerus. The bone was found
diseased from about the middle of the shaft up to a
short distance from the epiphyseal line. The deltoid
fibers were separated; the bone was found not covered
with periosteum, much roughened, and with two cloaca
extending into the medullary cavity and small abscesses
in the fiber of the deltoid. Cultures showed a pure
growth of staphtlococcus aureus. This operation was
performed on November 27, 1915. On June 19, 1916,
another operation was done, consisting of an excision
of a sinus that included a small sequestrum from
osteomyelitis of the humerus. Convalescence was un-
eventful. The second patient was a girl, 8 years of
age, who fell and injured her left knee. Her past his-
tory and physical examination were negative except
for a few palpable lymph nodules in the left cervical
chain. The knee appeared red and swollen and was
extremely tender, active and passive motion at the knee
joint being practically nil. The knee was soft and
edematous, and a patellar click could be made out.
There was likewise a swelling in the popliteal space,
which looked and felt like a popliteal bursa. On May
11, 1915, incision and drainage for suppurative ar-
thritis of the left knee was performed. In this case
also there followed a series of operations including
incision and drainage of the popliteal space, incision
and drainage of a secondary abscess on the outer side
of the thigh about four inches above the knee, drain-
age of an abscess under the extensor femoris on the
outer surface of the femur, operation on the lower end
of the femur at which the periosteum was found to
be infiltrated and the outer side of the femur necrotic;
at operation the wound in the lateral surface of the
thigh was enlarged and about five cm. of the outer
portion of the femur removed. The last operation was
done on June 29. On October 16, a sequestrotomy
for chronic osteomyelitis of the femur was performed.
A cavity 1x2 inches in size was found in the bone, in
the center of which were two sequestra. On December
14, an incision was made and drainage provided for an
alveolar abscess and the right lower canine tooth was
extracted. The patient was discharged on the 21st day
and had since been under observation. Dr. Bancroft
said he presented these cases not because he was at-
tempting to show any originality of treatment, but to
stimulate discussion so that they might derive some
fixed ideas in regard to therapy. He discussed the fol-
lowing disputed points: (1) In the acute stage, how
much drainage was necessary? Should one make a
groove throughout the entire infected area, or was it
sufficient to make numerous drill holes into the medul-
lary canal to allow the pus to escape? (2) How soon
after the acute process was it safe to remove the
sequestrum? This latter question involved two classes
of cases: (a) Those in which there was a second
bone to act as a splint in the forearm or leg. (b)
Where there was no other bone to act as a splint.
After discussing these two classes of cases he con-
cluded that in acute osteomyelitis an attempt should
be made to produce sufficient drainage with the least
possible trauma to the blood supply and tissues of the
medullary canal. This could often be done by making
good-sized perforations into the canal. The sequestrum
should be removed as soon as sufficient involucrum had
been formed to resist the pull of the muscles. In the
tibia and fibula six weeks after the onset of the acute
process might "be sufficient. At this time the a;-ray
showed only a very small shadow of involucrum, about
one-sixteenth of an inch. In the femur or humerus a
longer time was necessary — Nichols thought about six-
teen weeks.
Congenital Goiter. — Dr. Edward W. Peterson pre-
sented a girl, twelve years of age. He stated that on
January 18, 1905, when the patient was five weeks
old, she was admitted to the Babies' Ward of the Post-
Graduate Hospital. Her parents were Hungarians and
both were healthy. There was no syphilis, tuberculosis,
cancer, or goiter in the family. The mother had had
one miscarriage at the second month. This was the
first child. The labor was easy and uneventful. The
infant was normal except for a relatively large tumor
on the right side of the neck. There was some diffi-
culty in breathing for the first two hours after birth,
after which there was neither dyspnea nor dysphagia.
Aside from the deformity, the tumor apparently pro-
duced no symptoms. The physical examination showed
a growth on the right side of the neck, behind and to
the inner side of the sternomastoid muscle, extending
from the level of the jaw downward nearly to the
clavicle. The tumor was made up of two masses, the
larger situated above. It was smooth on the surface,
of firm consistency, and did not fluctuate at any point.
Below and to the side there was distinct palpable nodu-
lation. An incision was made parallel to the border of
the right sternoeleidomastoid muscle. A fibrous cap-
sule which surrounded the growth was opened and the
tumor was dissected out without difficulty. There was
very little hemorrhage. Several times during the oper-
ation artificial respiration had to be resorted to. The
wound was closed without drainage. For twenty-four
hours after the operation the infant had to be prodded
occasionally, as the breathing would stop. A nurse
was in constant attendance and would do artificial res-
piration at such times. The temperature rose to 105°
F. shortly after the operation and then gradually de-
clined. There were no special features until the ninth
day, when there occurred a convulsion lasting for five
minutes. On the thirteenth day there was twitching
of the extremities, and the eyes rolled from side to
side. On the fourteenth day there were almost con-
stant convulsive movements of the hands, arms, and
legs, with twitching of the facial muscles and rolling
of the eyes. It was about this time that the pathologist
reported the specimen to be a "congenital thyroid
tumor" (goiter). Believing from the appearance of
the two lobes making up the growth, that the whole
thyroid gland had been removed, thyroid extract was
started at once, followed by a cessation of the tetany.
At this time palpation of the neck revealed no evidence
of any remaining thyroid tissue. The thyroid feeding
was kept up for the first four years of the patient's life,
and was then discontinued. A close watch was kept for
790
MEDICAL RECORD.
[Oct. 28, 1916
the appearance of any evidence of hypothyroidism, but
the subseqeuent development of the patient mentally
and physically had been normal. This was explained
by the fact that for some time now it had been evident
that all of the thyroid had not been removed at the
operation. Palpation of the neck showed, to the left
and attached to the trachea, what should and did cor-
respond to the left lobe of the thyroid gland. Origin-
ally this could not be felt.
I'ntliological Report. — Dr. Sondern made the follow-
ing report: Macroscopically, the tumor was horseshoe
in shape; one side was composed of a large elongated
tumor mass measuring 6 cm. in length, 4 cm. in width,
3 cm. in thickness. The other side was composed
of a tumor measuring 4 cm. in length, 2% cm. in
width, and 2 cm. at its greatest thickness. These two
tumors were joined at the concavity of the horseshoe
by an isthmus of fibrous tissue. Both of the tumor
masses had a slight irregular lobulated appearance.
Microscopically, sections taken from both tumors
showed the same structure, which was that of the thy-
roid gland. The acini had undergone a slight adenoma-
tous proliferation and were filled with a very dense
colloid material, the greater number of them being dis-
tended by it to the dimensions of small cysts. The
epithelium was very much flattened by the intra-acinus
pressure of the colloid. Nowhere did the epithelium
show any malignant proliferation. The entire growth
was surrounded by a thin fibrous capsule. The diagno-
sis was adenoma and colloid degeneration of the thy-
roid gland (goiter). The points of interest in this
case were (1) the presence of a congenital tumor of
the neck which proved to be a goiter ; (2 ) the abnormal
location of the thyroid gland; (3) the accidental com-
plete thyroidectomy; (4) the development of tetany.
(5) the disappearance of the tetany upon the adminis-
tration of thyroid extract; (6) the subsequent normal
physical and mental development of the patient. The
following questions naturally arose: Was all the thy-
roid tissue removed at the time of the operation? Why
did tetany develop? Would the child continue to de-
velop?
Dr. Peterson also presented a second patient, a boy
10 years of age, from whom the thyroid had been
removed without any great difficulty and who had been
greatly improved since the operation.
Dr. Henry C. Falk presented a patient who had
undergone a bilateral resection of the thyroid by the
method which he described in his paper.
Exophthalmic Goiter. — Dr. John Douglas presented
this case. He stated that he showed this patient not
alone because the exophthalmic goiter was improved
by operation but because of the apparent relation of
hypothyroidism to dispituitarism in this case. The
patient was first seen on November 6, 1915, when she
gave a history of having been ill for six months. She
had tachycardia, a pulse of 140, marked sweating,
flushing on emotional excitement, exophthalmos, tremor,
and attacks of vomiting. She was so sick with the
hypothyroidism that it would have been dangerous to
operate, so she was put to bed and treated for the con-
dition. She had large extremities and the typical
symptoms of dispituitarism. The sella turcica showed
no enlargement by x-ray examination. Pituitary ex-
tract was given and the symptoms immediately became
much worse; when it was discontinued they became
better. In order to make sure that it was the pituitary
extract that aggravated the symptoms, the drug was
administered again, and again the symptoms became
worse. As was well known, it had been proven that
there was a relation between the adrenals and the
thyroid, and indeed between all ductless glands, and a
similar relation seemed to be demonstrated in this case.
This case gave evidence of some slight degree of
acromegaly. As the patient was still too ill to stand a
hemithyroidectomy, an attempt was made to ligate the
thyroid artery under a local anesthetic, but she became
so excited and started vomiting, so the attempt was not
successful. Gas and ether were then administered and
a hemithyroidectomy was performed. Since the opera-
tion there had been a very marked improvement in the
condition of the patient: the pulse was very little more
rapid than normal, being about 80, instead of 110 as
before the operation, and the patient had gained fifty-
pounds in weight.
A Case for Diagnosis. — Dr. Reginald H. Sayre pre-
sented this patient, a young man who had first come
under his observation last June. He gave a history
of having stubbed his toe and fallen down stairs three
years before. A few weeks after this injury a swelling
developed in his knee and the calf of his leg and he
suffered a great deal of pain in the neighborhood of
his knee. The question in this case was whether the
condition was in any way connected with the bones or
not, and whether it was a malignant condition or not.
The mass had grown to its present size within a few
months after the injury and had not enlarged mate-
rially since. He had at first thought that it might be
an osteoma and had applied a bandage, but without
results. There was a little mass in the femur and
what this was he was not prepared to say. The soft
mass seemed to be divided into two or three parts by
trabeculae. Dr. Sayre said he was somewhat at a loss
for a diagnosis and would be glad to receive sug-
gestions.
Dr. Charles H. Peck said that about two years ago
he had had a case with a tumor somewhat like the one
exhibited by Dr. Sayre's patient. It was in the popli-
teal space and he had taken it to be some form of
bursitis. The patient had practically no pain, though
he had had the tumor for two years. He had con-
sulted a number of surgeons during this time, who
expressed different opinions regarding it. Dr. Peck
said he thought it was a non-malignant condition and
attempted to excise it. He found that it was a sarcoma
and very difficult to remove. He dissected it out as
best he could, but it returned later in a much more
malignant form than the original growth. The growth
in Dr. Sayre's case was in almost the identical locality,
but in this case he did not believe it was a sarcoma.
Dr. George H. Semken said he had had a patient
with a condition somewhat similar to that presented
by Dr. Sayre. There was a mass in the gastrocnemius
which was diagnosed as a chronic bursitis. It was
removed and sent to the laboratory and the report
stated that the growth was largely cartilaginous. This
growth extended up to the popliteal muscle where it
was attacked. Dr. Semken said it wras not uncommon
to get such cartilaginous growths in old injuries and
he offered this as a possibility in the present case.
Dr. Robert T. Morris said he did not see why Dr.
Sayre hesitated to do an exploratory operation. The
growth might be a myoma and it might respond to
a--ray treatment. He knew of two cases in which there
was sarcoma in this region in which the growth had
been kept under control by the .T-ray. In this case he
would suggest getting a specimen.
Dr. Alfred Stillman said that he had had a case
with a somewhat similar tumor, which was soft and
nodular. He was doubtful as to the diagnosis, but
took it out and found it was a myxoma ; he was in-
clined to think that this was a myxoma.
Dr. W. S. Schley thought the growth might be a
fibromyoma.
Dr. Sayre said he was much obliged for the sugges-
tions and possibly the patient might decide to be oper-
ated on, but thus far he had refused.
Resection of the Thyroid. — Dr. Eugene H. Pool pre-
sented this paper, which was read by Dr. Henry C.
Falk. He stated that partial thyroidectomy as usually
practised consisted in extirpation of one lobe and isth-
mus, sometimes supplemented by resection of part of
the second lobe. In the removal of the lobe the technique
generally followed was an intracapsular extirpation.
In order to afford a greater degree of protection to the
recurrent laryngeal nerve and to the parathyroids
some surgeons advocated leaving a layer of thyroid
tissue in this region; but this procedure resulted in
more hemorrhage, prolonged the operation, sometimes
difficult to control, and led to greater postoperative
exudate. In a former article Dr. Pool had presented
an anatomical study to determine whether the theo-
retical advantages of leaving a portion of the posterior
part of the lobe had sufficient anatomical basis to out-
weigh the practical disadvantages. From this study
he concluded that for the prevention of tetany the
posterior part of one lateral lobe must always be left.
Even if one lobe only was operated upon, permanent
safety was best insured by leaving in sttu the posterior
part of that lobe. Then, if s a subsequent operation
with complete removal of the second lobe became neces-
sary, the operation might be performed with relative
safety. He found that the recurrent nerve was rela-
tively immune from injury when a true intracapsular
extirpation of the lobe as made, yet there was some
danger of injuring it which might be avoided by leav-
ing a portion of the posterior part of the lobe. He
found further that it was an advantage to leave mi situ
the posterior part of both lateral lobes, in relation with
each of which a recurrent laryngeal nerve and two
Oct. 28, 1916]
MEDICAL RECORD.
791
parathyroids usually lay. The amount of thyroid that
must be left in a thyroidectomy to avoid myxodema was
variously estimated as from one-sixth to one-fourth of
the gland. The case sto which this operation were
applicable were in general the diffuse colloid goiters;
it was not necessary, of course, in the single cystic
thyroid or adenoma. It had a very limited field in the
exophthalmic group where symmetry was a secondary
consideration and the patient was operated upon for
symptoms only. In regard to the theoretical objections
to resection, it might be stated that hemorrhage could
be controlled either by Balfour's technic or by use of
the clamp described in this paper. After describing
Balfour's method of bilateral resection employed at the
Mayo Clinic, Dr. Falk presented the clamps, similar
to a Scudder gastric clamp, which facilitated the
technic of resection by lifting and steadying the lobe
and controlling hemorrhage. The lobe was freed with
or without ligation and section of the superior vessels
as the case demanded; the isthmus was cut across and
its stump separated from the trachea ; the lobe was then
grapsed well back by the clamp, which was placed
vertically with one blade on each side of the lobe. The
clamp had long, delicate blades so as to grip but not
crush the thyroid; it had a broad clutch by means of
which it might be locked while the blades were com-
paratively far apart as in grasping a broad lobe; the
bayonet shape allowed the blades to be introduced more
readily into the wound. The technic of the operation
was described in detail and illustrated by lantern-slides.
With the patient in the oblique position, the head
higher than the feet, a sand bag under the shoulders
to extend the neck, and the goiter frame in place, intra-
tracheal anesthesia was administered with the Janewey
apparatus. A curved incision was made corresponding
to the crease of the neck from the external jugular
of one side to that of the other side. The anterior
jugular was clamped, cut, and ligated. The deep fascia
cut through to the infrahyoid and sternomastoid
muscles. The flap of skin, platysma, and deep fascia
were freed with the knife and lifted as far as the
incisure of the thyroid cartilage. The separation of
such a flap was easy because of the natural cleavage
plane. The point to be emphasized was that at the
anterior edge of the sternomastoid the division of the
fascia which pasesd behind this muscle must be cut as
the flap was lifted. The depressors of the hyoid were
separated vertically with the scissors passed between
the sternohyoid muscles. In general the sternohyoid,
sternothyroid, and omohyoid should be cut across and
reflected on one or both sides. The line of division of
the muscles should be high so as to avoid their nerve
supply. Straight clamps of the Pean variety were
placed transversely across the muscles which were to
be severed. The cutting of the muscles involved a con-
fusing detail in that the sternothyroid was extremely
thin and it might be left undivided. With care, how-
ever, all the muscles might be severed together. The
handle of the lower clamp was slowly rotated and the
muscles as a sheet were easily stripped free. The lobe,
with the large veins and capsule, now presented, and
by passing the finger gently into the plane mesial to the
carotid and keeping away from the capsule, this tissue
plane was opened up. The left index finger was intro-
duced behind the upper pole of the lobe, making the
superior vessels accessible for ligation. These were
ligated high up. The lobe was then lifted forward and
mesially and separated from the posterior tissues until
the inferior thyroid branches were reached. It was
then allowed to drop back. The pyramidal lobe was
dissected free and two clamps were placed across the
isthmus and the isthmus cut across between. The
right portion of the isthmus was freed from the tra-
chea. The lobe, with the pyramidal lobe and stump of
the isthmus, was then lifted and the goiter clamp placed
from above downward and closed so as to grasp gently
the posterior part of the lobe anterior to the recurrent
laryngeal nerve and the parathyroids. The lobe was
thus steadied and sufficient pressure was exerted to
control hemorrhage. Large vessels on the surface were
clamped behind the proposed line of resection and the
anterior part of the lobe excised. After ligating bleed-
ing vessels the sides of the lobe were then approximated
with mattress sutures and the edge overhanded with a
continuous catgut stitch. A small lobe was thus con-
structed without injury to the recurrent laryngeal
nerve, the parathyroids, or the inferior thyroid artery
before its entrance to the gland. The left side was
treated in the same manner, two small lateral lobes
being thus substituted for the enlarged thyroid. A
puncture wound for drainage was made about an inch
below the skin incision. After removing the sand bags
so as to relax the muscles, the depressor muscles were
approximated by a stitch which overhanded the two
clamps holding their cut edges. The clamps were then
removed and the stitches drawn tight and tied. This
operation relieved pressure, minimized danger to para-
thyroids and recurrent laryngeal nerve, provided a
sufficiency of thyroid tissue, and insured symmetry.
Double resection might be carried out readily either
by Balfour's method or by the use of the clamp de-
scribed, or by a combination of the two methods.
Dr. Charles H. Peck said that the technique which
Dr. Falk had described was a very rational one and
had distinct advantages over hemithyroidectomy in
simple colloid goiter. It was necessary to leave some
tissue, and if one left it all on one side he was likely
to have disappointing results. If this plan was carried
out and a fair amount of tissue was left there would
not be so many cases that would require a second
operation. Dr. Peck said he had been doing bilateral
resection for some time, which he preferred to a hemi-
thyroidectomy, but he thought the method just de-
scribed was the best he had seen; he had not as yet
used these clamps, but intended to do so.
Dr. JOHN Douglas said that he had done the bi-
lateral wedge-shaped resection and the hemorrhage had
been considerably less than he had expected. There
had not been a great deal of bleeding from the thyroid
itself, but he had found it necessary to drain his wounds,
as they bleed freely afterward, and unless the drainage
was very efficient one might have had bad results.
Dr. Horace M. Hicks of Amsterdam, N. Y., said that
he had been interested in Dr. Pool's paper and his very
clear and able description of his technique. He himself
had operated on over 200 goiters, and though this was
few in comparison with the number removed by Kocher
or Charles Mayo, still it had been quite an experience,
an experience that had been sometimes tragic, often-
times commonplace. In most instances he had been
able to remove the gland without trouble. He had used
the "bow" or "half moon" incision. The lowest point
in this incision was carried within three-quarters of
an inch of the clavicle. The skin was then dissected
as high as the upper extremities of the incision would
permit. At a point corresponding to about the middle
of the gland, the external jugulars were located and
each tied twice at an interval of about one-half an inch.
The muscles were then divided, without clamping, be-
tween the ligatures before mentioned, from one sterno-
mastoid to the other, clean through to the capsule of
the gland. He had next endeavored to reach the upper
end of either side, which was most desirable, though
not always practical; if unable to do this easily, he
had tied the superior thyroidal artery as high as
possible and cut clean through the gland at this point,
suturing or clamping bleeding points. From this stage
a fairly rapid gauze dissection carried one to the tra-
chea, being careful to keep next to the capsule but not
tearing or wounding it. The method was much like
the removal of the sac of a hydrocele. After very care-
fully securing the superior thyroid arteries by liga-
tures, a scissor dissection was used to complete the
removal of the gland from the trachea. No clamps
were used for fear they might include within the grasp
the recurrent laryngeal nerve.
Disinfection of War Wounds by the Carrel Method
as Carried Out in an Ambulance at the Front. — Dr.
H. H. M. Lyle read this paper which was illustrated
by colored photographs (Lumiere) showing the wounds
and their progress. The Carrel method of disinfect-
ing wounds was based on the following conception: To
render an infected wound sterile it was necessary to em-
ploy a suitable antiseptic in such a manner that the
chosen antiseptic came in contact with every portion of
the wound; that the antiseptic be maintained in a suit-
able concentration throughout the entire wound, and
that this constant strength be maintained for a pro-
longed period. If these conditions were fulfilled every
wound would show its response to the treatment by the
diminution and disappearance of its microorganisms.
The antiseptic employed was Dakin's hypochlorite of
soda, 0.5 per cent. This was an ideal wound anti-
septic of high bacterial activity and low toxic or irri-
tating quality. In addition to being a strong wound
bactericide, Dakin's solution had, due to its pyo-cyto-
hemolytic powers, the great clinical advantage of being
able to dissolve pus, old blood clots, tissue debris, etc.
The living tissues resisted this dissolution, due to the
protection afforded them by the sodium chloride of the
792
MEDICAL RECORD.
[Oct. 28, 1916
serum. The course of the wound was directly depend-
ent on the thoroughness of the first surgical act and
this should be carried out under the strictest aseptic
precautions and at the earliest possible moment. This
consisted of a thorough, methodical, mechanical disin-
fection of the wound with the extraction of all shell
fragments; particles of clothing, dirt, etc. The opera-
tive field was painted with the tincture of iodine, the
bruised and necrotic edges of the skin were trimmed
away with a sharp knife, and everything that could
have been infected by the traumatism, or could have be-
come the source of infection, was removed. Gentle-
ness of manipulation was the keystone of the technique.
In many of the cases it would be found that fibers of
clothing, grass, dirt, etc., were encrusted in the mus-
cular surfaces of the wounds. To avoid overlooking
this blood-stained debris the tract of the projectile
must be lightly but methodically resected. Dakin's
solution had, due to its hemolytic properties, the power
of dissolving recent blood clots. A poor hemostasis in-
vited the danger of a secondary hemorrhage. In the
introduction of the instillation tubes, the guiding prin-
ciple was to place them so that the liquid would come
in contact with every portion of the wound. Instilla-
tions of the fluid were made every two hours by re-
leasing the adjustable clamp controlling the flow. This
interrupted instillation was kept up until the wound
was proven st^'ii. ■ Khe tubes were then removed and a
compress moistened with Dakin's solution was applied.
The Carrel method was not a continuous irrigation but
a mechanical attempt to deliver an antiseptic of a defi-
nite chemical concentration to every portion of a sur-
gically prepared wound and to insure its constant con-
tact for a prolonged period. When on three successive
days, the bacteriological control showed the wound to
be sterile, it was closed by careful layer sutures. The
wounds treated by the Carrel technique were entirely
different in appearance from those treated by the ordin-
ary methods. The Carrel wounds had strikingly bright
red, vivacious granulations, a minimum amount of
mucoid-looking secretion, and no odor. There was no
redness, no tenderness, no induration of the skin edges.
Under the light of the results obtained, many of the
phenomena which they had been taught to consider as
normal processes of wound healing must now be con-
sidered abnormal. The results obtained by the Carrel
method in their ambulance were truly remarkable, and
had to be seen in order to be appreciated. No sec-
ondary abscesses developed on the surface and there
was only one case of osteomyelitis and this responded
readily to treatment. The average stay for wounds
of the soft parts was 14 days, for compound fracture
28 to 36 days. The transformation which was estab-
lished in their results was startling, the immediate
complications became more and more rare, and suppu-
ration disappeared from their services almost com-
pletely.
Dr. Fred Albee said that while in France he had
had a rather exceptional opportunity of observing the
treatment of war wounds and could confirm every-
thing that Dr. Lyle had said. Certainly the manage-
ment of fractures and wounds in Dr. Lyle's hospital
was excellent. Dr. Carrel's management of fractures
was not up to Dr. Lyle's. The pictures had shown the
condition of the wounds and he had never seen any-
thing like the way in which wounds healed when steri-
lized by the Carrel-Dakin method. They were re-
markable because of their lack of discharge and lack
of sensitiveness, and because of their redness and sup-
pleness and the ease with which they could be closed
up. This bleaching powder had sometimes been wrongly
used and a few hospitals had objected to it on the
ground that it caused bleeding of the granulations. It
must be remembered that the commercial bleaching
powder was not pure and if it contained sodium
hydroxide it would then cause bleeding. This difficulty
was being remedied. At Dr. Rlake's hospital they
had carried out experiments in the laboratory to de-
termine the potency of this antiseptic and the results
of these experiments had been misleading. If the re-
sults of test tube experiments were not in harmony
with practical results in this matter, then in this in-
stance the test tube was not reliable. It had been ob-
jected that in wounds treated in this way pus organi
grew more luxuriantly in the lesions." It was found
that if with a platinum loop some secretion was taken
from a lesion and smeared on a slide, then dried and
stained, manv bacteria could be counted in an oil
immersion. The wound should not be closed while one
found bacteria in this way, but when the number of
bacteria had diminished to one or two on a slide the
wound might be closed with safety. It was generally
recognized that mere observation of a wound was not
a safe criterion by which to be guided in reference to
the time when a wound might be closed witih safety.
tiljerojiiuittr Bjinta.
Treatment of Furunculosis. — This is both opera-
tive and medical and is followed according to the
method of Unna: The operator first notes the set
of the hair around which the boil is situated; then
the skin covering the boil is gently squeezed until
a bloodless white area is presented, which is the
bacterial focus. With a darning needle sterilized
to dull red heat this central white area is punc-
tured to 3 or 4 m.m. in depth, care being taken to
follow the direction of the hair. This plan of pro-
cedure immediately removes the focal area and gives
instant relief of tension and pain. If such is not
the result the operation has not been performed
correctly. Any one of the following pastes may be
used as a dressing:
K Kaolin (Fuller's earth), 20
Glycerin, 10
Ichthyol, 5
After, this has been applied the surface should be
covered with some impervious material such as
guttapercha paper. Another paste which hastens
healing is:
j3 Sulphur, 10
Oxide of zinc, 10
Chalk, 10
Glycerin, 30.
When no inflammation or irritation of skin is
present the formula may be changed to: 10 parts
each of sulphur, oxide of zinc, chalk, oil of turpen-
tine, and vaseline. Axillary boils, while not as
painful as those around the back of the neck, are
more troublesome on account of the tendency to
return. Unna states that in the beginning stages
these abscesses may be opened with a small cautery,
but that later the skin in the axillary region should
be shaved and each small abscess opened by tiny
incisions, after which the armpit should be dressed
with
I£ Mercurial ointment, 25
Oil of turpentine, 5
Lead plaster, 20
This again should be covered with guttapercha
paper, which remains in situ without any bandage.
— Berliner klinische Wochenschrift.
Chronic Granular Pharyngitis. — Coble uses in
this condition, especially when there is much irri-
tation of the membrane, compound tincture of ben-
zoin, full strength, applied to the membrane. Com-
pound tincture of benzoin may be used effectively
on gauze where a packing that will prevent foul
odors is needed for the nose. Tincture of iodine,
one drachm, glycerin one ounce, may also be applied
to the nose and pharynx. The weaker solution
should be used first, but if a stronger one be re-
quired the following prescription covers the need:
TS Iodine crystals., grs. ijss-x
Potassium iodide, grs. vijss-xxx
Glycerin, §j
These iodine solutions are very efficacious when
used after tonsillectomy and do not produce the
pain caused by the application of some other solu-
tions, such as silver nitrate, etc. — Indianapolis
Medical Journal.
Medical Record
A Weekly Journal of Medicine and Surgery
Vol. 90, No. 19.
Whole No. 2400.
New York, November 4, 1916.
$5.00 Per Annum.
Single Copies, 15c-.
(Original Artirlra.
ACUTE POLIOMYELITIS.
By H. L. ABRAMSON, M.D.,
NEW YORK,
BUREAU OF LABORATORIES, DEPARTMENT OF HEALTH.
Acute poliomyelitis, or infantile paralysis, as it is
more commonly known, was first mentioned by
Underwood at the end of the eighteenth century,
but it was not clearly differentiated from other
cerebrospinal disorders until 1840 by Heine. It was
not until Medin reported his observations on the
Stockholm epidemic of 1887 that the haze which
enveloped the clinical aspects of this disease was
somewhat lifted. He recognized and described in
addition to the already familiar spinal form, from
which it received its name, bulbar, polyneuritic,
ataxic, and encephalitic types.
To the Scandinavian physicians belongs the large
credit for the intensive study of the clinical, path-
ological, and epidemiological sides of the problem
of poliomyelitis. Ample opportunity for such study
was presented by the recurrence of epidemics in
that country every six to eight years. The first to
have been described was by Bergenholtz in 1881.
Then Medin reported the epidemics of 1887 and
1895. Wickman,1 also a Scandinavian, has contrib-
uted more clinical, pathological and epidemicological
facts to the solution of the problem than any other
man of recent years. He studied and reported the
Swedish epidemic of 1905. It was he who first
called attention to the abortive and meningitic types
and a type resembling a Landry's paralysis. It was
Wickman who first proved that the disease spreads
from person to person.
The New York epidemic of 1907 to 1909 stim-
ulated study of this disease. Very little, however,
was added to the clinical side as a result of such
study. The research turned to the rather mys-
terious questions of specific cause, problems of
natural and artificial immunity, serum treatment.
These studies which had their inception in the epi-
demic of 1907-1909 have received a tremendous
stimulus by the epidemic now raging throughout
the Middle Atlantic States. Scientific men of the
big laboratories throughout the country are con-
centrating on the problems of detection of carriers;
the recognition of the mild atypical cases; the pro-
duction of a curative serum; problems of transmis-
sion, and most important of all, a protective vaccine.
With the glorious record of past achievements in
preventive medicine to encourage, I feel that the
many minds now at work on these problems are sure
to produce something that will prevent the recur-
rence of the dread scourge and render it as infre-
quent as smallpox is to-day.
Acute poliomyelitis has been conceded by all
modern workers on the subject to be an acute gen-
eral infection with apparently a special predilection
for the central nervous system. It can be compared
to measles or scarlet fever, each of which is an
acute general infection with skin manifestations.
The virus of poliomyelitis has a special affinity for
nerve tissue in much the same way as the virus of
rabies, the characteristics of which it greatly re-
sembles. That this virus does attach itself to the
central nervous system has been proven many hun-
dreds of times in experimental work. The brain
and cord of fatal human cases when injected sub-
durally into monkeys will produce after an incuba-
tion period of from 2 to 19 days a type of paralysis
closely resembling the human type. This virus can
be transmitted from monkey to monkey for many
generations and this method of passage tends to fix
the incubation period of monkey poliomyelitis, so
that after a number of passages, the incubation
period will be from 9 to 14 days.
The virus of poliomyelitis has been found else-
where in the body. It has been demonstrated in
the nose, mouth, and throat, and also in the mucous
membranes of the intestines. It has been recov-
ered from the blood in monkey poliomyelitis. The
mucous membranes may be the points of entry for
the virus, but it has been definitely proved that the
virus is also excreted onto these membranes.
How the virus reaches the central nervous system
is a much mooted question. Some believe that it
is a blood infection and the virus gains entrance by
that route. Others think that it makes its way into
the brain and cord along the lymphatics of the nerve
trunks. Against the former hypothesis stands the
fact that the virus has not been demonstrated in
the blood of human cases even in the earliest stages,
though it has been found in the blood of one monkey
that had been infected by the intracerebral route
by Clark, Fraser and Amoss.3 This last fact does
not prove that it is a blood borne infection as it is
possible to conceive of the virus being eliminated
in that way and so reaching the mucous membranes.
That the virus gains access to the central nervous
system by way of the perineural lymph channels is
indicated by a rather conclusive experiment. Active
virus was injected into the sheath of the sciatic
nerve. Proximal to the site of injection, the nerve
was ligated. This monkey did not come down with
the disease, whereas the control animal whose nerve
was not ligated showed typical symptoms in the
usual period of time.
Other evidence which lends belief to this method
of invasion of the central nervous system lies in
the fact that that limb which receives an intra-
muscular injection of active virus is invariably the
first to show symptoms, indicating that the virus
is conveyed by the nerve of that limb. If it were
primarily a blood invasion, it would be expected
that occasionally another limb or limbs would show
signs first.
794
MEDICAL RECORD.
LNov. 4, 1916
Further, the perineural lymphatic route in polio-
myelitis would fall into line with the already defin-
itely established paths of infection of nerve-cell
poisons, such as rabies and tetanus. So in view of
the preponderating mass of evidence, it has become
generally accepted that the virus gains access to
the central nervous system by the perineural lymph
channels.
As stated above, the virus of poliomyelitis re-
sembles very much that of rabies. It is a nerve-
cell poison; is filterable, that is, when an emulsion
of the infected brain and cord is pushed through
the finest grained porcelain filter, the filtrate retains
the ability to produce infection in monkeys. This
is unlike the common bacteria which are easily
strained out by even coarser grained filters, the
filtrate of which will contain no bacteria.
It is very resistant. It can stand a freezing
temperature for at least 50 days ; but is killed at 50°
C. in V-2. hour. It withstands the immersion in 50
per cent glycerin for long periods of time. It with-
stands drying much longer than fixed rabies virus.
It is resistant to 0.5 per cent carbolic acid for 3
days. It is killed by ll> per cent carbolic acid in
24 hours.
Pathology. — The pathologic changes produced
by this virus are not striking when viewed with
naked eye. The changes, such as they are, are to
be found principally in the central nervous system
as is to be expected when one considers the symp-
tomatology of the disease.
The gross changes in the brain, basal ganglia,
and pons consist principally of marked engorgement
of the pial and parenchymatous vessels; an accu-
mulation of an excess of serous fluid in and beneath
the pia; edema of nerve tissue itself. In a rare
case, where the involvement of the brain has been
marked, as in the cerebral spastic types, one may
find areas of softening of the cortex. I found one
such case in an autopsy on a young man of 27 years,
who presented what appeared to be a left sided
spastic ehmiplegia. In this case a large area of the
central and parietal portion of the cortex of the
right side was softened into a mass of mushy con-
sistency. There were signs of capillary hemorrhage,
but no gross hemorrhage.
The changes in the spinal cords of most of the
35 post mortems done by the writer at the Willard-
Parker Hospital in New York were those already
described by Wickman, Harbitz and Scheel,' and
many other students of the pathology of this dis-
ease. They consist chiefly of a marked hyperemia
and swelling of the gray matter. Whereas in a
healthy cord of an infant, the gray matter is only
slightly differentiated from the enveloping white
matter, in the polio-infected cord, one finds the gray
columns very distinctly marked off from the sur-
rounding white matter. There is swelling in most
cases of the anterior horns, though in some the
posterior horns share in the process to an equal
degree. The gray matter presents in the acute
stage a distinct reddish tinge, in most cases, indi-
cating increased vascularity. In some instances
there are what appear to be minute circumscribed
hemorrhages.
The white matter also shows congestion of its
vessels, and in some cases marked edema, so marked
at times as to produce a distinct softening of the
cord. The posterior root ganglia show changes
similar to that of the gray matter of the cord.
The remaining organs, as a rule, show little of
import. Practically all cases terminating with
respiratory paralysis show edema and congestion of
lower lobes of lungs. The liver and kidneys often
show marked congestion and frequently some acute
parenchymatous degeneration. The spleen in a
number of cases shows enlargement, congestion and
a marked hyperplasia of the lymphoid follicles. The
Peyer's patches in a few cases appear somewhat
raised and reddened and the corresponding mesen-
teric lymph nodes slightly enlarged and congested.
Otherwise there is nothing worthy of remark.
The microscope shows, in the affected portions of
the central nervous system, marked congestion of
the blood-vessels, with great accumulations of small
round cells about them. Nerve cells can be seen in
all stages of degeneration and in the process of
being taken up by the phagacytic cells. There is
an accumulation of excess of fluid which tends to
separate the interstitial tissues. This is the micro-
scopic picture of the stage of destruction. That of
the period of reparation consists in the replacing of
the destroyed nerve tissue by young connective tis-
sue. This, as it grows older, contracts into firm
fibrous tissue and produces the scarring of the gray
matter, which is characteristic of the cords of
recovered cases of poliomyelitis, in which there are
residual paralyses.
The pathogenesis of this disease is still an open
question among pathologists. Some think that the
virus has a direct destructive effect on the nerve
cell and that the vascularity, edema, and round cell
infiltration are only the evidences of the body re-
action to the presence of the virus. Another school
of workers consider the nerve cell degeneration
secondary to the marked inflammatory reaction; in
other words, that the nerve cell is destroyed in a
mechanical way by the effect of pressure of the
engorged vessels, edema, and cellular infiltration.
The opinion of the writer coincides with those
who consider the virus a specific nerve cell poison
in a manner analogous to the virus of rabies,
tetanus, and diphtheria. If one concedes that polio-
infection is principally manifested by disease of the
central nervous system, and there is no divided
opinion on that score, then one must also concede
that it is the active elements of the brain and cord,
namely, the nerve cells, which have special affinity
for the virus of poliomyelitis.
The epidemiology of poliomyelitis has not as yet
been completely worked out. Much remains to be
accomplished in this field of work. Wickman, how-
ever, by his celebrated work in the Swedish epi-
demic of 1905, has definitely proved that the disease
is transmitted from person to person. He was able
to trace units from one focus to another, and of the
formation of foci from these single units along the
paths of most frequent human travel, so that on
the completion of his study, he was able to present
a map showing the main central focus, with arms
radiating along the most commonly used roads to
other foci and these in turn exhibited similar arms
extending into smaller groups of cases along the
roads leading from this focus. It was, therefore,
clearly demonstrated that one must watch the
human animal in order to elucidate the finer point
in the transmission of the disease. The question of
how it is transmitted from one to another is as yet
not solved.
Dr. M. J. Rosenau,* of Harvard, a few years ago
thought he demonstrated that the virus was carried
from one to another through the biting stable fly,
much after the manner of malaria and yellow fever
transmission by the mosquito. This work gained
Nov. 4, 1916J
MEDICAL RECORD.
795
considerable credence until it was definitely proved
by Dr. Edw. Francis,' of the U. S. P. H., by a series
of conclusive experiments that the biting fly was
unable to convey polio-infection from one to an-
other. That work has apparently settled the theory
of transmission by that route.
The theory of transmission by dirt and dust ob-
tained some basis through the work of Neustadter
and 'Ihro," who demonstrated the presence of the
virus in the dust of a room in which was isolated a
case of poliomyelitis. Up to the present time this
work has not been confirmed. While it is true that
the disease is very prevalent in our congested East
Side and South Brooklyn, it is also found in the out-
lying districts, where there is anything but conges-
tion. It is found in the most sanitary homes as well
as the filthy ones. So it seems to the writer that if
dirt and dust were among the chief means of con-
veyance of the disease, it would be found almost
exclusively in the very poor districts. That the
virus may be demonstrated in the dust of rooms in
which poliomyelitis cases have been cared for is no
real argument for the transmission of the disease
by that method.
The idea as to the causation of epidemics, preva-
lent in New York and shared by the writer, is as
follows: The virus of a previous epidemic, having
lost its virulence by means of burning itself out,
has become quite widely disseminated onto persons
who are or have become immune. This virus in the
course of eight or ten years, through some unknown
agency, receives an intensification of its virulence.
In the meanwhile a crop of non-immunes has devel-
oped. Increased virulence of virus plus numbers of
non-immune children equals an outbreak. This, to
my mind, will explain the peculiar recurrence of the
disease at intervals of eight or ten years, and will
explain the almost simultaneous development of
groups of cases at widely separated localities, as
New York and Minnesota. It will also explain why
in some epidemics there is a mortality of only 5 per
cent, and in others of over 20 per cent. It is simply
a matter of virulence. In one the virulence jumped
four times as high as in the other. That the virus
is present between epidemics is evidenced by the
presence of sporadic cases. Twenty to thirty cases
every year are seen by the Meningitis Division of
the New York Board of Health. The mortality
among these is very low, probably not more than 1
or 2 per cent.
Now that we have our outbreak started, how
does it spread ? It spreads despite all the efforts of
modern hygiene and sanitation. There must be a
reason, and that reason in our opinion is the fact
that there is a form of the disease so mild that it is
not recognizable by the rank and file of physicians.
This type of case after a day or two of indisposi-
tion, with perhaps a little vomiting and fever, is up
and about and playing with the neighboring chil-
dren. This is one of the chief, if not the chief,
means of the rapid spread of epidemics. Another
means which will be difficult to rule out — and, in
fact, observations in the present make it seem likely
— is the carrying of infection into the homes by
healthy adults.
To summarize our ideas of the building up of
epidemics, we have, first, the man-to-man convey-
ance, the presence of a virus of increased virulence,
the existence of a crop of non-immunes, the exist-
ence of a very mild type of the disease difficult of
recognition and therefore not quarantined, and,
lastly, the transmission bv healthy adults.
Clinical Viewpoint. — From the clinical viewpoint,
acute poliomyelitis is often simple, many times diffi-
cult, and nearly always terrible. In the present epi-
demic our mortality is about 22 per cent, of those
cases recognized as poliomyelitis. If all the cases
that were not diagnosed were included, it is felt
that this percentage would suffer quite a loss. Pre-
vious epidemics in this country and abroad had a
mortality figure of about 5 to 10 per cent. Seventy
to eighty per cent, of those paralyzed have some
residual paralysis.
The age incidence in some 2700 cases collected by
Wickman is as follows : Up to 3 years, 39 per cent. ;
3-6 years, 24; 6-9 years, 13; 9-12 years, 7; 12-15
years, 6; over 15 years, 11 per cent.
Leegaard presents the following figures in 788
cases : Up to 4 years, 28 per cent. ; 5-9 years, 27 ;
10-14 years, 19; over 15 years, 26 per cent.
The age incidence in the mortality figures of the
present epidemic in New York City up to and in-
cluding July 31, 1916, in a total of 848 cases, is as
follows: Under 1 year, 15 per cent.; 1 year, 23;
2 years, 20 ; 3 years, 14 ; 4 years, 8 ; total under 5
years, 80 per cent.; 5-9 years, 16.5; 10-14 years, 2;
14-35 years, 1.5 per cent.
From Wickman and Leegaard's7 figures it is read-
ily seen that while acute poliomyelitis is preferably
a disease of early childhood, it will also attack young
adults in considerable numbers. In my series of
thirty-five post-mortems in the present epidemic
there is included a case of 15 years of age, one 22
years, one 27 years, one 34 years, and one 58 years.
When the figures on the age incidence are collated
it would not be surprising if there were from 3 to 5
per cent, of cases over 15 years of age. The mor-
tality figures of the New York Department of
Health show a great preponderance of fatalities in
children under 5 years of age.
Age appears to be the chief predisposing cause.
Physical condition and character of surroundings
play little part, if any, except such condition as con-
gestion, which will, of course, permit more intimate
contact of carrier of contagion, and the non-im-
mune. The meteorological conditions cannot be
blamed. The 1907 epidemic raged in a dry, hot
summer. This epidemic holds forth in a rather
moist, moderate summer. One of the worst epi-
demics in Sweden occurred in the midst of one of
their very severe winters.
The clinical picture of acute poliomyelitis is that
of an acute infection plus such manifestations of
disturbance of the central nervous system as may
have been attacked by the disease process. Thus
we usually have a sudden onset, with fever of, say,
102° to 105°. headache, drowsiness, or irritability.
The skin may be hypersensitive to touch so that the
patient will cry out with pain on being handled;
he prefers to be let alone. He may perspire ex-
cessively. Then he will complain of pain in the back
of the neck, especially if moved. If an attempt is
made to manipulate his legs, after the manner of
Kernig, he will complain bitterly of pain along the
spine and resist the efforts to straighten out his leg
when it is flexed at the thigh. His knee jerks may
be present, sluggish, or completely absent. The next
day the neck may be more rigid, the Kernig sign
more marked ; if the knee jerks had been present
they may have disappeared, with perhaps evidences
of weakness in one leg or perhaps both legs.
If there is further progress of the disease up the
cord, the next center struck after the arm center is
that of respiration. That, in the great majority of
796
MEDICAL RECORD.
[Nov. 4, 1916
the cases, proves fatal, though there have been a
number of instances in this epidemic where children
have recovered alter the respiratory center has been
involved.
The description above presented is that of the
common spinal type, and it is from this that the
disease receives its name. It is the rapidly ascend-
ing form with respiratory involvement, the Landry
type, which swells our mortality lists. If poliomye-
litis were as simple as above described, the disease
would present no difficulties to the physician. When
one considers the multiplicity of physiological func-
tions of the central nervous system, then, and then
only, can 0113 gain a true conception of possibilities
of clinical manifestation of the disturbance of these
functions. The virus may attack any portion of the
central nervous system or several widely different
portions at the same time. This fact gives rise to
most bizarre forms of paralysis. It is this fact,
too, which contributes so greatly to difficulty of an
adequate classification of types.
Wickman classifies the types as follows: (1) The
spinal poliomyelitis form, (2) the form resembling
Landry's paralysis, (3) the bulbopontine, (4) the
encephalitic, (5) the ataxic, (.6) the polyneuritic,
(7) the meningitic, (8) the abortive.
Other authors, as Zappert and P. Krause, give
equally cumbersome classification. It is really very
difficult to arrive at a compact yet comprehensive
ossification.
We prefer to classify the various types according
to a classification already existing for separation of
various chronic forms of nervous disease:
1. Cortical, where the upper motor neuron only is
involved.
2. Spinal, where the lower motor neuron is in-
volved; this is to include the bulbar paralysis as
well as that of the cranial nerves.
3. Corticospinal, where both upper and lower mo-
tor neurons are involved.
4. Ataxic, when any of the systems which have
to do with maintenance of a state of equilibrium are
attacked, such as the cerebellum, posterior root gan-
glia, the vestibular nerve.
5. The meningitic form.
6. The abortive or non-paralytic form.
The clinical manifestation of the cortical type
may be paralysis of spastic type; some present
clonic convulsions on one or both sides, continuing
in some instances as long as forty-eight hours. This
type has not been a frequent find in this epidemic.
The spinal form is the most common type, and
presents the flaccid type of paralysis with loss of
reflexes. The corticospinal form will present a com-
bination of both spastic and flaccid paralyses. It
has not been my fortune to see any of this type.
The ataxic type will present nystagmus and dis-
turbances of equilibrium, and is usually present
along with manifestation of lower motor neuron in-
jury.
The meningitic form is an extremely interesting
tvpe. The picture resembles so closely that of an
acute purulent meningitis that one would almost in-
variably call it that until the spinal fluid gives one
the hint that one is dealing with the meningitic
form of poliomyelitis. The first case of the epidemic
was one of this type. This form may also present
evidence of cranial nerve paralysis, but the menin-
geal symptoms dominate the clinical picture.
The abortive form will prove, in our opinion, to
be the most common of all the types mentioned
above. Most students of the subject consider that
there are at least as many of this type as of the
sum total of the other forms. It manifests itself in
a manner similar to that of the paralytic type, ex-
cept that it presents no paralysis. The knee jerks
may disappear and there may be a very transient
paresis, but there is no actual paralysis. These are
the cases that may be diagnosed as influenza or
gastrointestinal disease, and it is this form which
renders the proper quarantine control inadequate.
Diag?iosis. — The diagnosis of poliomyelitis is both
easy and difficult. It requires no great diagnostic
ability to recognize the frankly paralytic forms,
such as the cortical and the spinal forms, especially
in the presence of an epidemic. The diagnoses ot
the ataxic and meningitic forms are confirmed by
the examination of the cerebrospinal fluid.
The abortive form, especially where knee jerks
are present, can be diagnosed with any degree of
certainty only by lumbar puncture and examination
of the fluid. The Meningitis Division of the New
York Department of Health advises physicians who
have patients that present vague meningeal symp-
toms without any adequate explanation of their cau-
sation to perform lumbar puncture and have the
spinal fluid examined. It is through this agency
that we shall be able to obtain a more adequate idea
of the relative number of abortive cases, and also
it is by the extension of this laboratory aid that we
shall be able to more effectively prevent the spread
of the disease.
The spinal fluid in poliomyelitis presents changes
which deviate in practically all cases from the nor-
mal. While the changes are definite, they are in no
sense specific. In other words, given a spinal fluid
for examination- without any further information
added, one could not say that it is a poliomyelitis
fluid. One must needs have an adequate clinical
history in conjunction with knowledge of abnormal
changes in the spinal fluid. The reason for this is
apparent. There is no specific organism as yet that
can be demonstrated in the spinal fluid of poliomye-
litis. Other diseases, as tuberculous meningitis,
lues of the central nervous system, typhus, and
some cases of whooping cough in the convulsive
stage, present changes in the spinal fluid in many
instances strikingly similar to those of poliomye-
litis. The finding of the tubercle bacillus will at
once establish a diagnosis of tuberculous menin-
gitis. But we find the bacillus in smear in only
about 50 to 60 per cent, of known tuberculous fluids.
That leaves about 40 to 50 per cent, of tuberculous
fluids against which to strike a differential diag-
nosis. This would seem to present an insurmount-
able difficulty, but it is fortunate for the clinicians
that the diseases which present changes in the
spinal fluid so much like that of poliomyelitis are
clinically easily distinguishable. Whooping cough
and typhus have characteristics which separate
them easily. Lues can be put aside by history and
Wassermann reaction. That leaves tuberculous
meningitis in 40 to 50 per cent, of cases. In the
great majority of cases a differential between tu-
berculous meningitis and poliomyelitis presents no
difficulty. In the former there is a slow, gradual
subfebrile onset, cold in type, with meningeal symp-
toms developing after a week or two. In the latter
there is most commonly an abrupt onset, with high
fever, florid in type, with meningeal svmptoms ap-
pearing very early in the disease. This method of
diagnosis serves in the great maiority of cases.
There are cases of acute onset with high fever in
tuberculous meningitis, but they are, fortunately.
Nov. 4, 1916J
MEDICAL RECORD.
797
rare. This type, too, is more apt to present the ba-
cillus in smear. Then difficulty may arise when an
accurate history is not obtainable. Some rare forms
of epidemic meningitis may present a fluid not un-
like some that we find in poliomyelitis.
The spinal fluid in poliomyelitis is, as a rule,
clear by reflected light. By transmitted light can
be seen a suspension of material in a good many
instances. Occasionally the fluid is opalescent and
even slightly turbid.
Chemical examination shows it to contain albu-
min, globulin, and a copper-reducing substance,
probably dextrose. Albumin and globulin are ab-
normal constituents, and indicate inflammatory
change. The presence of reducing substance is nor-
mal, and absence of the same is abnormal. The
absence of the reducing substance is very uncom-
mon, and when it is met with it is in the severest
cases of the meningitic form. The diminution or
absence of the reducing substance indicates that the
pathological process has involved the choroid plexus,
which is the mechanism that secretes this substance
into the spinal canal. The quantity of these con-
stituents is graded from 1+ up to 4+, depending
upon the intensity of the reaction.
The cytology of poliomyelitis fluids is character-
ized in the great majority of instances by a great
preponderance of small mononuclear cells with a fair
sprinkling of large mononuclears, or perhaps they
may be called endothelioid cells. This latter cell is
not commonly found in the fluid of tuberculous men-
ingitis, and therefore may give us a hint as to
whether or not the fluid under examination is a
poliomyelitis fluid. When this type of cell is found
in sufficient numbers, we suspect the possibility of
poliomyelitis. It is, however, by no means pathog-
nomonic of this disease.
Another cell which the writer has noted with suf-
ficient frequency to attract attention is a glia-like
cell. This cell looks strikingly like the glia cells of
the central nervous system, from which, in my opin-
ion, they migrate into the cerebrospinal fluid. The
writer has not up to the present time encountered a
cell of this type in the fluid of tuberculous menin-
gitis, and when found has considerable diagnostic
weight, especially when the clinical history of the
case is not very definite. It is a well-known fact
that the glia cell of the central nervous system can
assume phagocytic properties, and that, in my opin-
ion, is how they find their way into the spinal fluid.
The glia cell, as well as both the large and small
mononuclear cells, may contain very small, deep-
staining granules and rod-like bodies, the signifi-
cance of which is at the present time unknown.
As to microorganisms in the spinal fluid, none
have up to the present time been found. While the
spinal fluid presents no specific characteristics per
se, yet it presents, in the great majority of cases,
definite changes, without the knowledge of which
great numbers of abortive and atypical cases would
go begging for a diagnosis. To summarize, the
changes in the spinal fluid of poliomyelitis are as
follows :
1. The fluid is increased and many times under
pressure.
2. It is in nearly all cases clear to the naked eye.
but occasionally it may be opalescent or even slight-
ly turbid.
3. Albumin and globulin are increased as a rule
to 1-K and not infreouently to 3+ and rarely to 4+-
4. Fehling's solution is in the great majority of
cases promptly reduced.
5. The cells are definitely increased at some stage
of the disease, usually in the early stage.
6. The predominating cell type is the small mono-
nuclear up to 90 per cent, of the total. There are a
number of fluids, particularly those which are opa-
lescent or slightly turbid, in which there is a pre-
ponderance of the polynuclear ceil up to as high as
75 per cent.
The fluid that offers the greatest difficulty of dif-
ferentiation is that of tuberculous meningitis. Nor-
mal fluids, while impossible of differentiation macro-
scopically, show no abnormal constituents from
either the chemical or the cytological aspect.
Lumbar puncture is a simple and safe procedure,
and resort to it should be had whenever there is
question of diagnosis of a condition which presents
evidences of meningeal and brain or cord disease.
Many an obscure condition may be rendered simple
by the thorough examination of the spinal fluid.
Prognosis in poliomyelitis is at best a hazardous
venture. Cases which the clinician considers very
grave may clear up within 24 to 48 hours and pre-
sent the most astonishing improvement. On the
other hand, there are cases which, apparently mild,
will rapidly develop fulminating symptoms and pass
out in a few hours. In most of the rapidly fatal
cases death occurs within the first six or seven days
from the onset; usually it is three to four days.
Therefore, if a case lives for one week, the chances
of preservation of life are much improved. This is
true particularly of the spinal form. The cortical
and meningitic types, however, may go on to two or
three weeks before passing out. There are some
unusual cases of the disease which present symp-
toms of the abortive type. These clear up rapidly
in a day or two and one will consider the danger
past. Four or five days later the child will be seized
with an acute onset, high fever, and paralysis which
may prove to be of the Landry type. This form is
sometimes called the relapsing form. There is an-
other type of the mild case in which there are all
the initial symptoms of a true case, a subsidence of
these symptoms followed by an interval as great as
two weeks before the typical flaccid paralysis ap-
pears, the paralysis in these cases not being ushered
in by stormy symptoms. Of all the types classified
above, the spinal form leads in the production of
mortality. This is due without a doubt to the great
preponderance in numbers of this type over the
other. The meningitic and encephalitic forms are
just as serious or more so perhaps than the spinal
form. When the figures in this epidemic are col-
lected there will be found a higher relative mor-
tality in these types than in the spinal form.
As to the age, the mortality figures cited above
indicate that the disease is particularly fatal to
children under five years of age. This figure is
perhaps misleading inasmuch as the great prepon-
derance of cases occur among children under five
years of age. The writer's observations in this epi-
demic lead him to believe that poliomyelitis in the
adult is a very grave disease. The mortality per-
centage in cases above 16 years of age will exceed
the mortality figures of the epidemic at large. It
is interesting to note at this juncture that the adult
only rarely presents the spinal form, the more com-
mon types at this age being the meningitic or en-
cephalitic varieties.
The prognosis as to the residual paralysis is
guess work. Some of the rapidly ascending types
even with involvement of respiratory center have
recovered without a sign of residual paralysis.
798
MEDICAL RECORD.
[Nov. 4, 1916
This, however, is not common ; whereas, cases in
which there is only one limb involved may present a
permanent paralysis in that limb; 70 to 80 per cent,
of cases presenting paralysis have residuals. It is
the way of wisdom, especially in the present epi-
demic, with a mortality of 22 per cent., and the
manifestation of marked eccentricities in the course
of the disease, to be ultra-conservative. It will pre-
vent many embarrassing situations and preserve
brilliant reputations.
Prophylaxis. — The demonstration of the fact that
poliomyelitis is transmitted from one human being
to another furnishes a rational basis for the prose-
cution of prophylaxis. However adequate, prophy-
laxis in the matter of isolation of disease carriers
is rendered most difficult by the existence of the
very mild cases that go undiagnosed. Until this
type of case is taken more seriously by the general
profession and unremitting efforts are made to
prove whether or not it is poliomyelitis, then and
then only shall we approach a more perfect isolation
of the virus.
The question of transmission of the disease by
healthy adults or other immunes deserves much se-
rious study. This method of transmission will be
proved to have had a large share in the rapid dis-
semination of the disease. In view of these facts,
personal contact of all kinds should be reduced to
the possible minimum; such as the prevention of
gatherings of children and adults, and even of
adults. Osculation in time of an epidemic of polio-
myelitis is the height of folly. Wherever possible,
persons should occupy beds singly.
In view of the finding of the virus in dust, though
this work has not been confirmed, it would be no
great wrong to advise absolute cleanliness in the
home. The possibility of transmission by food has
not received serious consideration thus far. It
would be well that foods, wherever possible, be
boiled or subjected to heat before consumption. The
slogan especially in time of epidemic should be a
clean body, a clean home, and a clean city.
When diagnosed, all cases should receive strict
isolation, preferably in a hospital. Suspicious cases
should be strictly quarantined in their homes until
diagnosis is confirmed or negatived by examination
of spinal fluid.
As to the use of gargles and sprays in the nose
and throat, one cannot place too much dependence
on them. Contact is the method of transmission.
Prevent that and there will be no need of gargles
and sprays. If one puts too much credence in the
efficiency of solutions in the nose and throat one
is apt to be careless in the prevention of that most
important element in transmission of disease — con-
tact.
There is no method of specific prevention by such
means as the Pasteur treatment or vaccination
against smallpox. Experimental work on monkeys
by Landsteiner and Levaditi," Romer and Joseph,1'
Krause" in Germany, and by Flexner" and cowork-
ers in this country is decidedly encouraging.
Stimulation of search for a method of specific pre-
vention is bound to result from the intense interest
aroused in the subject by the present epidemic.
When a satisfactory method is evolved, poliomyelitis
will have been robbed of its terrors. Epidemics of
poliomyelitis will be as rare as those of smallpox
are to-day.
Treatment. — Treatment of the acute stage con-
sists chiefly in isolation; absolute rest and good
nursing night and day. Urotropin is advised in
good sized doses, about five grains every four hours
for a child of three to five years of age and graded
up and down according to age. When using this
drug, keep a sharp watch for bladder irritability.
If it appears, diminish the dose or discontinue en-
tirely, preferably the latter. This drug is recom-
mended by Flexner on the basis of some experi-
mental work, in which the incubation period of the
disease in a monkey was retarded for a period of
forty days through the use of this drug.
Lumbar puncture may prove of great help in the
meningeal and cortical types, and in any case which
presents marked meningeal symptoms.
Specific therapy by the use of serum derived from
persons who have passed through an attack has
been tried by the Scandinavian physicians and by
Netter11 of France, with inconclusive results. The
rationale of the treatment is as follows: Serum
from a recovered case exerts upon active polio-
myelitis virus a neutralizing effect when the two
are kept in contact for a period of 24 hours, so that
when this neutralized virus is inoculated into the
brain of a monkey, it no longer produces the symp-
toms of poliomyelitis; whereas, the control monkey
inoculated in a similar manner but with virus not
previously acted upon by the immune serum comes
down in the usual time and manner. This experi-
ment demonstrates conclusively the presence of anti-
bodies in the blood of persons who have recovered
from poliomyelitis. These antibodies have been
demonstrated in the blood of persons as long as 30
years after the attack. Flexner" has shown in a
rather small number of experiments on monkeys
that when serum from such' persons is adminis-
tered intraspinally within 24 hours after the active
virus is introduced into the brain and when the ad-
ministration of the serum is continued for several
days after the infective virus has been so intro-
duced, such animals fail to come down with polio-
myelitis. Experiments in treatment of actual mon-
key poliomyelitis by immune serum has to the
writer's knowledge not yet been recorded. These
facts, then, offer the basis for treatment with im-
mune serum.
As to the possibilities of harm from the intra-
spinal administration of this serum, the practice is
too recent and too limited to afford adequate ob-
servations on that point. From personal experience
in a very few cases and from theoretical considera-
tions, I fear that in some cases it is not without
harm.
The introduction of a therapeutic serum into the
subdural space of a case in which there is no evi-
dence of meningeal inflammation as determined by
the examination of the spinal fluid is followed in
many instances by a marked meningeal reaction.
Subsequent fluids withdrawn after the introduction
of serum reveal evidences of meningeal inflamma-
tion. The fluid is usually turbid, due to great in-
crease of cells; there is a 3 -f- to -f- 4 albumin and
globulin, and there may be a diminution of the re-
ducing substance. In other words, there are all the
evidences of a purulent meningitis without the pres-
ence of microorganisms, an aseptic meningitis.
An aseptic meningitis in some cases is likewise
set up in poliomyelitis upon the introduction of im-
mune serum into the spinal canal. The writer feels
that the superimposing of this condition upon an
already existing edema and congestion of such a
delicate and vital structure as the gray matter of
the spinal cord may have, in some cases, a power
for harm. Personally, I feel that it ought not to be
Nov. 4, 1916]
MKDICAL RECORD.
799
used in the spinal form for fear of stimulating the
attack by the virus of the vital center of respira-
tion. It is too delicate a mechanism to tamper
with. Perhaps in the meningitic variety with no
involvement of the cord it may prove of value. A
study of this method of treatment is now under
way at the Willard-Parker Hospital under super-
vision of the New York Department of Health Lab-
oratories. When the figures are collated and as-
sorted perhaps then we shall gain a true idea of the
value of this method of therapy.
REFERENCES.
1. Wickman, Ivan: Nervous and Mental Disease
Monographs, No. 16.
2. Clark, Fraser and Amoss: Jr. Exp, Med., Vol.
XIX, No. 3, March 1, 1914.
3. Harbitz and Scheel: Jr. A. M. A., Vol. L, No. 4,
1908.
4. Rosenau, M. J.: Jr. A. M. A., Vol. LX, No. 21, May
24, 1913.
5. Francis, Edw.: Jr. Infect. Dis., Vol. XV, No. 1,
July, 1914.
(i. Neustadter and Thro; N. V. Medical Jour., No. 21,
October, 1911.
7. Leegaard : See Ivan Wickman.'
8. Landsteiner and Levaditi : La Poliomyelite Ex-
perimental, Soc. de Biol. 19, II. 10.
9. Romer and Joseph: Die Epidemische Kinderlah-
mung. Berlin.
10. Kraus. Wiener klin. Wochensehr. 1910, No. 7.
11. Flexner and Lewis: Jr. A. M. A., Vol. LV, 1910,
p. 662.
12. Netter, A.: Serotherapie de la poliomyelite, Bull,
de l'Acad. de Med., Oct. 12, 1915.
13. Flexner, Simon: Jr. A. M. A., Vol. LXVII, No. 8,
Aug. 19, 1916.
216 Kast Fifteenth Street.
DREAMS AND DREAMERS.
By ISRAEL BRAM, M.D.,
PHILADELPHIA. PA.
INSTRUCTOR IN THE MEDICO-CH1RURGICAL COLLEGE.
"And Dreams in their development have breath,
And tears and tortures, and the touch of joy;
They have a weight upon our waking thoughts,
They take a weight from off our waking toils,
They do divide our being."
— Byron.
Dreams! What a wonderful, lace-like network of
varied images the mere word suggests. What mys-
terious vistas of boundless mansions with sky-high
ceilings and bottomless staircases — what terrible
experiences o'er fearful precipices and blood-cur-
dling encounters with ferocious beasts — what fabu-
lous fortunes gained and spent — what grotesque
combinations of numerous, widely varied images
into wonderful, mysterious phantasies are exhibited
to us by the evanescent pictures called dreams. How
often does it seem a pity that these gloriously beau-
tiful soap bubbles are doomed to vanish to eternity
on awaking! Almost as mysterious a question as
that of the hereafter, the subject of dreams con-
fronts us as a silent sphynx ; and though it has at-
tracted the attention of man from the dawn of his-
tory, the sifting of the vast amount of material
written on the subject reveals nothing but a few
vague ideas of but relative rather than absolute
practical value. The study of some of the phases
and plausible theories of this peculiar state of man-
kind constitutes one of the most fascinating forms
of mental recreation.
The literature of man is rich in dream fancies,
and because of its very intangibleness and vague-
ness the dream has inspired facts to sweet songs,
and has often even furnished the plot of a successful
drama. Shakespeare found that "We are such stuff
as dreams are made of, and our little life is rounded
with a sleep." Novalis, the German poet, has written
so beautifully of dreams that we cannot help quot-
ing : "The dream is a barrier against the regularity
and commonness of life — a free recreation of fet-
tered fantasy, in which the pictures of life are united
together, interrupting the seriousness of grown-up
men with joyous children's play. Without the dream
we should surely age earlier, and thus the dreams
may be considered, perhaps, not a gift directly from
above, but a delightful task — a friendly companion
through life's toils."
It is said that Alexander's army would have been
annihilated were it not for a dream in which Dion-
ysius directed the means of safety.
In the Bible, dreams are considered the chosen
method of the supernatural power to manifest it-
self. It was in a dream that Abraham was made
the founder of nations by the Lord, who appointed
him to teach the pagan world the errors of poly-
theism.
When Jacob was on his way to seek a wife
among the daughters of Laban, he dreamt that he
beheld a ladder extending from earth to Heaven,
on which the Angels of God were ascending and
descending, and he was promised that his seed should
be as the dust of the earth. Subsequently the Angel
of God spoke unto Jacob in a dream, saying : "Lift
up now thine eyes, and see that all the rams which
leap upon the cattle are speckled, ring-streaked, and
grizzled; for I have seen all that Laban doeth unto
thee. Now arise, get thee out from this land, and
return unto the land of thy kindred." Thereupon
Jacob, with Rachel, his wife, and Leah, stole away
with their children, their cattle, and their goods,
unawares to Laban, the Syrian. The third day after
Jacob's flight Laban first heard of it, and after a
seven days' journey overtook him in the Mount
Gilead. Meantime, God came to Laban, the Syrian,
in a dream by night, and said unto him: "Take
heed that thou speak not to Jacob either good or
bad." When Laban met Jacob he chided him for
going away secretly and said: "It is in the power
of my hand to do you hurt, but the God of your
father spake unto me yesternight, saying, 'Take thou
heed that thou speak not to Jacob, either good or
bad.' "
It was the recital of one of his dreams that insti-
gated Joseph's brethren to sell him into Egypt.
Having correctly interpreted the dreams of the
King's chief butler and chief baker (who were his
fellow-prisoners) his fame spread through the land,
so that when the King himself had a perplexing
dream, Joseph was sent for; and so impressed was
the king by his ability that Joseph became very
powerful, and virtually ruler over all the land of
Egypt, and was thus enabled subsequently to save
his brethren and prepare the way for the escape of
the Children of Israel from bondage to a land flow-
ing with milk and honey.
While Daniel and his three comrades were living
at the court of Nebuchadnezzar — "God gave them
knowledge and skill in all learning and wisdom,"
and Daniel became proficient in the interpretation
of all visions and dreams. "When two years later
Nebuchadnezzar had a dream which he had forgot-
ten, he issued a decree for the slaughter of all his
wise men and magicians, because they could not
make known to him the dream and its interpreta-
tion." Daniel saved their lives and his own by
revealing to the king "the visions of his head upon
800
MKDICAL RECORD.
[Nov. 4, 1916
his bed," and their interpretation. One of the mem-
orable results of this dream was that Nebuchad-
nezzar at last confessed to Daniel that his God was
the God of gods and the Lord of kings, and he made
Daniel himself to rule over the whole province of
Babylon and to be chief governor over all the wise
men thereof. Nebuchadnezzar in due time had an-
other dream, which Daniel was called upon to inter-
pret. It was of painful import. The king was to
be driven from men; his dwelling was to be with
the beasts of the field, he was to be made to eat
grass as oxen, and to be wet with the dew of Heaven,
and seven times were to pass over him until he
should know "the Most High ruleth in the kingdom
of men and giveth it to whomsoever he will." "At
the end of these days," said Nebuchadnezzar in his
official proclamation of this experience, "I lifted up
mine eyes unto heaven, and at the same time mine
understanding returned unto me; and for the glory
of my kingdom excellent greatness was added unto
me."
The definition of the term "dream," as of other
mysterious natural states and forces, is practically
impossible. We are able usually to distinguish be-
tween the shock produced by electricity and the heat
experienced when a boiling kettle is touched, but
neither the term "dream" nor "electricity" is capable
of a concrete, lucid definition.
We are possessed of two mind mechanisms, con-
sisting of a consciousness which predominates our
thoughts and actions when awake, and a "dream
consciousness" or "subconsciousness" which rules,
because of sleep or some other reasons, when the
usual or "day" consciousness is dormant. The dream
consciousness is usually present also in the waking
state, the degree depending chiefly on the mental or
psychological make-up of the individual. We all do
a certain amount of dreaming during the perform-
ance of our daily duties. In the midst of any mental
or physical application, the trained observer will
easily catch himself in moments of dream conscious-
ness, to find that he made brief mental excursions to
some distant lands. On the perusal of this article,
the reader may at the same time recall that he
dreams often or rarely; and perhaps, from time to
time images of people met or thoughts of duties
performed or to be performed will flit through his
mind. The vividness of these day-dream images
and their individual duration will, of course, be in
inverse proportion to the degree of the concentra-
tion of attention to the article before the reader.
This other self, acting independently, may conjure
up thought upon thought, despite the fact that the
reader is interested in this paper and assimilating
its essential points. These subconscious impressions
»f the waking hours closely resemble dreams; indeed,
it is impossible to strictly separate them from the
dreams of the night, excepting that in the latter
the images are often exaggerated, often confused
into a chaotic jumble, frequently presenting condi-
tions physically impossible; while in the former,
though fleeting, the images do not crowd, are more
orderly, and actions are physically possible. There
is in our conscious life a luxuriant halo of these
subconscious associations; but the normal person's
mind is developed and trained to keep them where
they belong — in the background, a condition con-
sistent with sanity and mental efficiency. The ability
to suppress these subconscious impressions consti-
tutes the essence of mental attention and concen-
tration. The more absent-minded we are the more
vivid, coherent and prolonged these subconscious as-
sociations become, the next step being light sleep,
then sound sleep. The chronically absent-minded
person, therefore, rightly deserves to be considered
in a degree asleep and a dreamer.
Active attention and sound sleep hold the sub-
stratum of mental activity or dream consciousness
in obeyance; the most favorable conditions for
dreaming being light sleep and absent-mindedness.
The gradations of frequency and vividness of
dreams, in ratio to the degree of waking con-
sciousness, may be thus diagramatically illustrated :
Absent
Mindedness
ound
Attention
However sound a sleep may be, dreams probably
occur, though one may not be able to recall them
on awaking. The mind is never entirely asleep; all
experimental evidences seem to confirm this opinion.
The mere imperfect the sleep, however, the greater
the vividness of dreams and the more likely of recall
to memory in awaking. The occurrence of sensory
stimulation determines the reduction in the sound-
ness of sleep and is in direct ratio with the occur-
ence of "recallable" dreams, varying from the dream
image of an orchestra concert in the presence of the
buzzing sound of a mosquito close to the sleeper, to
the nightmare of being stabbed by a band of ruf-
fians, as a consequence of the gastric insult from the
indigestion of a modern banquet the night before,
in which perhaps several forms of meat, fish, and
lobster were prominent constituents.
Freud, the eminent psychologist, remarks, "Every
distinctly perceived noise or other sense impression
gives rise to a corresponding dream picture. The
rolling of thunder takes us into the thick of a battle;
the crcwing of a cock may be transformed into
human shrieks of terror; the creaking of a door
may conjure up dreams of burglars breaking into
the house. When one of our blankets slips off at
night, we may dream that we are walking about
naked or that we are falling into water. If we lie
diagonally across the bed with the feet extending
beyond the edge, we may dream of standing on the
edge of a terrifying precipice or falling from a great
height. Should our head accidentally get under the
pillow, we may imagine a big rock hanging over us
and about to crush us under its weight."
There are certain provisions of nature which may
be justly regarded as auxiliaries to sleep and uni-
versal in their operation, and which seem to have
for their purpose the removal of sources of stimuli.
At uniform intervals in every twenty-four hours of
our life the sun withdraws its light and covers us
with a mantle of darkness. This not only invites
sleep by withholding a stimulus which discourages
it, but practically interrupts or modifies all form-;
of industrial activity; it interferes seriously with
locomotion ; it suspends most of the plans and occu-
pations which engage our attention during the sun-
lit hours of every day, and emancipates us for a
few hours from the dominion of our natural pro-
pensities and passions, which engross so much of our
time and thought by day. Nor is it only by the set-
ting of the sun that we are invited daily to give
Nov. 4, 1916]
MEDICAL RECORD.
801
pause for a few hours to our worldly strifes. In
sleep all the sensorial and other functions dependent
upon or under the government of the will are re-
laxed. To secure this relaxation we seek positions,
places and all other conditions best calculated to
shelter us from light, noise and all other awakening
influences. Like man, the lower animals at such
times choose a retired place, assume postures which
demand no voluntary effort and which expose them
least to external forces which may chance to disturb
them. The serpent coils itself up so as to expose
as little of its superficial surface as possible to dis-
turbance; the bird conceals his head under his wing;
the porcupine covers his eyes with his tail ; the skunk
rolls himself into a ball; the dog covers his face with
his paw. Why should the ploughman leave his plough
in its furrow when the sun ceases to light its way?
Can any o'.her satisfactory reason be suggested than
that he may for a few hours be as one dead to the
concerns of his farm and plough, and his soul for
a time be freed from their distractions? Whatever
else may be the final purpose of sleep, that purpose
also obviously must be among the contributory pur-
poses of nocturnal darkness, for that is one of its in-
evitable and periodical consequences. The subcon-
scious element of our waking state consists of memo-
ries which appear and disappear, occupying our mind
in turn. But they differ from memories of our dream
state in that they are always memories which are
closely connected with our present situation, our
present action. I recall at this moment the remarks
of Herbert Spencer on sleep, because I am
discussing the subject of dreams ; and this act
orients in a certain particular direction the activity
of my memory. The memories that we meet while
waking, however distant they may at first appear
to be from the present action, are always connected
with it in some way.
Our memories, at any given moment, form a solid
whole, a pyramid, so to speak, whose point is in-
serted precisely into our present action. But behind
the memories which are concerned in our occupations
and are revealed by means of it, there are others,
thousands of others, stored below the scene illumin-
ated by consciousness. Indeed, it is even said that
all our past life is there, preserved even to the most
infinitestimal details, and that we forget nothing,
and that all that we have felt, perceived, thought,
willed, from the first awakening of our conscious-
ness, survives indestructibly. But the memories
which are preserved in these obscure depths, are
there in the state of invisible phantoms. They
aspire, perhaps, to the light, but they do not even
try to rise to it; they know that it is impossible
and that I, as a living and acting being have some-
thing else to do than to occupy myself with them.
But suppose that, at a given moment, I became dis-
interested in the present situation, in the present
action — in short, in all which previously has fixed
and guided my memory; suppose, in other words,
that I am asleep. Then these memories, perceiving
that I have taken away the obstacle, have raised the
trap door which has kept them beneath the floor of
consciousness, and arise from the depths. They rise,
they move, they perform in the night of uncon-
sciousness. They rush together to the door which
has been left ajar. They all want to get through.
But they cannot, there are too many of them. From
the multitudes which are called, which will be
chosen? Thus arises the apparent inconsistency of
dream images.
During a brief period of a few minutes dream
pictures corresponding to hours of time may be
enacted. Thus, a dreamer fell asleep while listen-
ing to some one who was reading to him and awoke
again toward the termination of a sentence that
had been begun when he dozed off. The actual dura-
tion of sleep was about ten seconds or less, yet he
dreamt of a storm, shipwreck, and heroic rescue
which would occupy at least three hours of time in
real life. There is no conception of time or space in
dreams; we live in an ideal world. These peculiar
characteristics of dreams are due to the fact that
volition and attention are absent; the mind has no
control over the objects that crowd upon it. There
is no concentration or fixity of thought necessary
for memory. In other words, in the dream state
there is a decentralization of the mind. Ideas, gro-
tesque, often confused, arise spontaneously, crowd
upon the mind, become vivid and vanish. Dreams
usually leave only a faint impression on the mem-
ory, so that on waking, what was at first vivid and
distinct, fades rapidly and insensibly away.
There is a peculiar tendency to exaggeration dur-
ing dreams. A homely person or object becomes
ugly, a beautiful being becomes the most handsome
in the universe. A tall person is a giant, a short
individual a midget. If we trip and fall down a
flight of stairs, the flight is never ending, and we
never reach the bottom, but continue on our journey
until we awake. An important event relating to
ourselves or those near to us may never be dreamed
about, but a wart or mole on the forehead of a
stranger may be dreamed of repeatedly.
In a dream we become no doubt indifferent to
logic, but not incapable of logic. There are dreams
when we reason with correctness and even with
subtlety. I might almost say at the risk of seeming
paradoxical, that the mistake of the dreamer is often
in reasoning too much. He would avoid the ab-
surdity if he would remain a simple spectator of the
procession of images which compose his dream. But
when he strangely desires to explain it, his ex-
planation, intended to bind together incoherent im-
ages, can be nothing more than a bizarre reasoning
which merges upon absurdity. The dream is the
state into which you naturally fall when you no
longer have the power to concentrate yourself upon
a single point, when you have ceased to will.
In the dream the same faculties are exercised as
during waking, but they are in a state of tension
in the one case, and of relaxation in the other. The
dream consists of the entire mental life minus the
tension, the effort, and the bodily movement.
From this essential difference can be drawn a
great many others. We can come to understand the
chief characteristics of the dream. But I can only
outline the scheme of this study. It depends es-
pecially upon three points: the incoherence of
dreams, the abolition of the sense of duration that
often appears to be manifested in dreams, and final-
ly, the order in which the memories present them-
selves to the dreamer, contending for the sensations
present where they are to be embodied.
The incoherence of the dream seems easy enough
to explain. As it is the characteristic of the dream
not to demand a complete adjustment between the
memory image and the sensation, but, on the con-
trary, to allow some play between them, very differ-
ent memories can suit the same sensation. For ex-
ample there may be in the field of vision a green
spot with white points. This might be a lawn
spangled with white flowers. It might be a billiard
table with its balls. It might be a host of other
802
MEDICAL RECORD.
[Nov. 4, 1916
things besides. These different memory images, all
capable of utilizing the same sensation chase after
it. Sometimes they attain it, one after the other.
And so the lawn becomes the billiard-table, and we
watch these extraordinary transformations. Often
it is at the same time, and altogether, that these
memory images join the sensation, and then the
lawn will be a billiard-table. From this comes those
absurd dreams where an object remains as it is and
at the same time becomes something else. As I have
just said, the mind, confronted by these absurd
visions, seeks an explanation and often thereby ag-
gravates the incoherence.
As for the abolition of the sense of time in many
dreams, that is another effect of the same cause. In
a few seconds a dream can present to us a series of
events which will occupy, in the waking state, en-
tire days. When we are awake we live a life in
common with our fellows. Our attention to this ex-
ternal and social life is the great regulator of the
succession of our internal states. It is like the bal-
ance wheel of a watch, which moderates and cuts
into regular sections the undivided, almost instan-
taneous tension of the spring. It is this balance
wheel which is lacking in the dream. Acceleration
is no more than abundance a sign of force in the
domain of the mind. It is, I repeat, the precision
of adjustment that requires effort, and that is ex-
actly what the dreamer lacks. He is no longer
capable of that attention to life which is necessary
in order that the inner may be regulated by the
outer, and that the internal duration fit exactly into
the general duration of things.
It remains now to explain how the peculiar relaxa-
tion of the mind in the dream accounts for the pref-
erence given by the dreamer to one memory image
rather than others, equally capable of being inserted
into the actual sensations. There is a current
prejudice to the effect that we dream mostly about
the events which have especially preoccupied us dur-
ing the day. This is sometimes true. But when
the psychological life of the waking state thus pro-
longs itself into sleep it is because we hardly sleep.
A sleep filled with dreams of this kind would be a
sleep from which we came out quite fatigued. In
normal sleep our dreams usually concern themselves
rather with the thoughts which we have passed
through rapidly, or upon objects which we have per-
ceived almost without paying attention to them. If
we dream about events of the same day, it is the
most insignificant facts, and not the most important
which have the best chance of reappearing.
In accepting the definition that a dream is a con-
dition of physiological delirium we approach a very
plausible explanation of dreams. An eminent ob-
server has said: "Find out all about dreams, and
you find out all about insanity." While this may
appear a trifle exaggerated, yet most alienists agree
that dreams and many forms of mental aberration
have a great deal in common. Is it not possible,
let us ask, for the substratum of mental activities
known as dream consciousness, which lacks so much
in logic and reasoning, and is totally devoid of will,
to gain the ascendency under certain adverse condi-
tions, thus to constitute a form of mental aberration
classified under insanity? From the summing up
of such evidence as he collected, Ellis concludes: "If
we pierce beneath the surface we seem to reach a
psychic stage in which the dreamer, the madman,
the child, and the savage alike have their starting
point. It thus happens that the way of thinking
and feeling of the child, the savage and the lunatic
each furnish a road by which we may reach a
psychic which is essentially that of the dreamer."
Charles Lamb tells us that during the early part
of his life he was constrained to retire to a lunatic-
asylum, where he was detained for several months.
In a letter to his friend, Coleridge, written a few
years after his recovery, he said: "At some future
time I will amuse you with an account, as full as
my memory will permit, of the strange turn my
frenzy took. I look back upon it at times with a
gloomy kind of envy ; for while it lasted I had many,
many hours of pure happiness. Dream not, Cole-
ridge, of having tasted all the grandeur and wild-
ness of fancy till you have gone mad."
The so-called "nightmare," the terrifying dream,
is usually the result of an unpleasant sensory stim-
ulus, often of pathological origin. Dr. Franklin, in
a letter once written to a Miss on the act of encour-
aging pleasant dreams, said: "In general, man,
since the improvement of cooking, eats about twice
as much as Nature requires. Suppers are not bad
if we have not dined, but restless nights naturally
follow hearty suppers after full dinners. Indeed, as
there is a difference in constitutions, some rest well
after these meals ; it costs them only a frightful
dream, and an apoplexy, after which they sleep till
doomsday."
In some dreamers the activity of the cerebrum is
such that the train of thought leads to movement,
and the sleeper may be heard muttering, tossing
about, or making gestures. The extreme cerebral
activity in sleep is seen in somnambulism, which is
arbitrarily divided into four types: (1) Those who
speak without acting (a common variety, often ob-
served in children, and not usually considered som-
nambulistic) ; (2) Those who act without speaking
(the most common variety) ; (3) Those who act and
speak; (4) Those who not only act and speak but
who also have an active sense of touch, sight, and
hearing. This fourth class is most rare, and merges
into the condition of mesmerism or hypnotism.
Sometimes the actions performed by a subject of
somnambulism are of complicated character, and
bear some relation to the daily life of the sleeper.
Thus a cook has been known to rise out of bed,
carry a pitcher to a well in the garden, fill it, go
back to the house, fill various vessels carefully with-
out spilling a drop, then return to bed and have no
recollection on awaking of what had transpired.
Again, somnambulists have been known to write
letters and reports, execute drawings, and play upon
musical instruments. Frequently they have gone
along dangerous paths, executing delicate move-
ments with precision; indeed, the somnambulist
seems to have perceptions supernaturally acute,
walking with confidence and safety along roofs of
houses, on the banks of rivers, and other perilous
places where nothing could have tempted him to go
when awake. The following is another interesting
example of somnambulism: "A girl of twenty-four,
a hospital patient, went to the staircase leading to
the nurses' quarters, suddenly turned around, and
went to the wash house. The door being closed, she
groped for a time and went toward the women's
dormitory, in which she formerly slept. She went
up to the top of the house where this dormitory was,
opened a window leading to the roof, went out of
the window, walked along the gutter ( under the
horrified eyes of the nurse who followed her, and
who did not dare speak to her), went in again by
another window, and proceded downstairs."
The beloved French literary genius, Voltaire, in
Nov. 4, 19161
MEDICAL RECORD.
803
his "Philosophical Dictionary," thus presents his
views and experiences on dreams and dreamers :
"I have known advocates who have pleaded in
dreams, mathematicians who have solved problems,
and poets who have composed verses. I have made
some myself, which are very passable. ... It
is, therefore, incontestable that consecutive ideas
occur in dreams, as well as when we are awake,
which ideas as certainly occur in spite of us. We
think while sleeping, as we move in our beds, with-
out our will having anything to do either in the
motive or in the thought. ... A man pro-
foundly afflicted at the death of his wife or his son
sees them in his sleep; he speaks to them, they reply
to him, and to him they have certainly appeared.
It is, therefore, impossible to deny that the dead
may return; but it is certain, at the same time,
that these deceased, whether inhumed, reduced to
ashes, or buried in the abyss of the sea, have not
been able to reserve their bodies; it is, therefore,
the soul which we have seen. This soul must there-
fore be extended, light, and impalpable, because in
speaking to it we have not been able to embrace it.
"Dreams also appear to me to have been the sensi-
ble origin of primitive prophecy or prediction.
What more natural or common than to dream that
a person dear to us is in danger of dying, or that we
see him expiring? What more natural than that
such a person may really die soon after this omin-
ous dream ? Dreams which have come to pass are
always predictions which no one can doubt, no ac-
count being taken of dreams which are never ful-
filled; a single dream accomplished has more effect
than a hundred which fail. Antiquity abounds with
such examples. How constructed are we for the
reception of error! Day and night unite to deceive
us! . . .
"But how, all the senses being defunct in sleep,
does there remain an internal one which retains con-
sciousness? How is it, that while the eyes see not,
the ears hear not, we, notwithstanding, understand
in our dreams? The hound renews his chase in a
dream ; he barks, follows his prey, and is present at
the death. The poet composes verse in his sleep;
the mathematician examines his diagram, and the
metaphysician reasons well or ill ; all of which there
are striking examples.
"In one of my dreams I supped with Mr. Tourdn,
who appeared to compose verses and music, which
he sang to us. I addressed these four lines to him
in my dream:
Thy gentle accents, Touron dear,
Sound most delightful to my ear!
With how much ease the verses roll,
Which flow, while singing, from thy soul!
"In another dream, I recited the first canto of
the 'Henriade' quite different from what it is. Yes-
terday I dreamed that verses were recited at supper,
and that some one pretended they were too witty.
I replied that verses were entertainments given to
the soul, and that ornaments are necessary in enter-
tainments. I have, therefore, said things in my
sleep which I should have some difficulty to say when
awake; I have had thoughts and reflections, in spite
of myself and without the least voluntary operation
on my own part, and nevertheless combined my ideas
with sagacity, and even with genius. We should
never be good philosophers except when dreaming !"
Dreams are not always a confused chaos of events.
There are instances in which dreams were charac-
terized not only by the most sane concentration and
continuity of thought, but also in which the images
were of considerable use to the dreams. Often what
appears to be beyond human ability is accomplished
through dream ideas and inspirations. There are
on record numerous instances of writers who for
want of further ideas became discouraged and put
aside a work to which they had been devoting a
vast amount of energy and time. Suddenly they
would awake some morning to find themselves pos-
sessed of the key to the successful issue of their
toil. The same has been observed of many prom-
inent inventors.
Paganini, the great violinist, once dreamt that
the devil was pacing up and down his room playing
his violin. The music played by his diabolic majesty
was so weirdly mysterious, entrancing, and wonder-
ful, that he was awakened with a start. He looked
about, rubbed his eyes, and realizing that it was but
a dream, rushed to his work desk to jot down the
composition as he remembered it. The result is the
wonderful composition known as "The Devil's
Trill," recognized to-day as one of the most diffi-
cult, beautiful, and wonderful works ever composed
for the violin, and is a constituent of the reper-
toire of every violin virtuoso.
It seems that in the "useful" dreams, occurring at
times in inventors, writers, composers, and others,
there is the possession in the subconscious mind of
the knowledge yearned for, but because of the ex-
treme anxiety of the individual, and also the rush
of daily ideas and thoughts upon the mind during
the waking hours, the subconscious ideas are
crowded out. During sleep those ideas or images
are released, coming forward with a sudden bound,
like caged birds suddenly freed. The suddenness
of this release of the novel idea or image may be
great enough to awaken the dreamer with a start.
In conclusion, we cannot help feeling, as intelli-
gent mortals, that dreams are a godsend, and that
pleasant dreams should be encouraged. The way to
court pleasant dreams is to avoid the causal factors
of unpleasant ones. The proper care of the diges-
tive and other functions, the avoidance of emotional
excitement, and the maintenance of a cheerful,
kindly spirit toward all the world are conducive to
the avoidance of nightmares, and the occurrence of
sound, healthful, rejuvenating sleep; and if dreams
occur they are as a gift of Heaven, or a taste of
Paradise. The blissful dream of the man or woman
of good habits and clear conscience carries body
and soul in a fairy bark away from this vale of toil
and tears to lands of joy, of nectar and ambrosia,
to return at purple daybreak.
"Sweet sleep be with us, one and all!
And if upon its stillness fall
The visions of a busy brain,
We'll have our pleasure o'er again,
To warm the heart, to charm the sight,
Gay dreams to all ! Good-night, Good-night."
1714 North Seventh Street.
Pancreatic Function in Alcoholic Venous Cirrhosis
of the Liver. — Udaondo and two others have studied
five cases of hepatic cirrhosis with autopsy control.
In every case the pancreas was the seat of lesions cor-
responding to the type of interstitial sclerosis. These
undoubtedly aggravated the course of the hepatic dis-
ease and hastened death. Pancreatic perturbation
was shown clinically by the characteristic diarrhea,
precocious cachexia, and sensory syndrome. An exact
diagnosis was made by clinical methods in each case.
All essential details were present including results of
histological examination. Little or no improvement
was obtained from treatment. The cachexia was pro-
gressive and soon ended fatally. — Revista de la Asocia-
cion Medico. Argentina.
804
MEDICAL RECORD.
[Nov. 4, 1916
TUBERCULOSIS AND CANCER.
A POSSIBLE EXPLANATION OF THE LONG-DISCUSSED
QUESTION OF THEIR MUTUAL ANTAGONISM WITH
THE SUGGESTION OF THE USE OF TUBERCU-
LIN FOR THE PREVENTION OF RE-
CURRENCE OF CANCER.
BY WILLIAM M. DABNEY, M.D..
BALTIMORE. MD.
The question of antagonism between diseases has
long occupied the attention of physicians and that
apparent clinically between cancer and tuberculosis
has, as is well known, been the subject of a great
deal of discussion in the past. The literature on
the subject is voluminous, but as the object of this
article is to bring to notice certain particular fea-
tures only it has seemed unnecessary to go
into a prolonged discussion of the reasons which
finally led the majority of medical men to con-
clude that this supposed antagonism was appar-
ent rather than real. Suffice it to say that ex-
haustive and critical autopsy findings finally
brought this about, and in fact led some authors
to assert that not only was there no antagonism
between these diseases, but that tuberculosis in
some cases played a definite causative role in the
subsequent development of cancer, this being es-
pecially true of so-called skin cancer.
That this supposed antagonism is apparent rather
than real is probably true as regards tuberculosis
in general, but to the writer it has appeared ques-
tionable as regards active tuberculosis, and one of
the objects of this article is to present the reasons
which have led him to adopt this attitude at vari-
ance with the trend of opinion of to-day.
When one considers the widespread dissemina-
tion of tuberculosis, so widespread, in fact, that it
has been stated that practically no individual who
has reached the age of 40 years has escaped it, it
is evident that autopsy records leading to a verifi-
cation of the question of the antagonism between
these two diseases could reach but one conclusion,
especially when one considers the additional fact
that cancer may be said to be rare under 40.
Modern physicians and surgeons, being well
aware that pathology is to medicine the court
of last resort, have naturally accepted their ex-
haustive and accurate autopsy findings as conclu-
sive and as deciding in the negative the question
of antagonism between these two diseases. As
showing, however, how firmly rooted the idea has
become it is only necessary to state that since the
question has been generally accepted as settled,
some exponent of the positive side has occasionally
arisen, only to be downed by the weight of evidence
:ts presented by an exponent of the negative. Among
those in comparatively recent years holding the posi-
tive view is G. W. McCaskey, who in an article pub-
lished in the American Journal of the Medical
Sciences, July, 1902, stated that he found cancer
present in 1.4 per cent, of cases of active tubercu-
losis, and noted in addition that there had been a
retrogression of the cancer after the injection of
tuberculin, the use of which he suggested in his
article. In spite of all this, however, almost any
physician or surgeon of large experience, if asked
whether he has ever seen active tuberculosis and
cancer combined, will reply either in the negative
or that he has seen such a combination very in-
frequently.
Such being the case, the question arises how can
these divergent opinions be reconciled? The writer
believes this possible and suggests the following
explanation: Pathologists in making complete and
careful autopsies would naturally find evidences of
tuberculosis which to the physician would be un-
known. These tuberculous lesions, although prop-
erly classified as such in autopsy reports, are
clinically unrecognizable, and as a consequence it
is only the active tuberculous lesion which is
likely to come to the notice of the examining phy-
sician or surgeon. Their conclusions, therefore,
as to the supposed antagonism between these two
diseases would be largely confined to such cases as
presented both diseases in a more or less active
state at the same time, whereas the pathologist at
the autopsy table must draw his conclusions from
the actual anatomic findings. To the writer, con-
sequently, it would seem that an actual antagonism
exists between active tuberculosis and cancer, and
he offers the following in support of his belief:
Tuberculosis has a tendency to produce a lympho-
cytosis, and as Murphy and Morton of the Rockefel-
ler Institute have shown in an article published in
the Journal of Experimental Medicine for August,
1915, lymphoid activity is an essential factor in the
immunity process of artificially engrafted cancer, it
would seem that those cases of tuberculosis which
brought about a condition of lymphoid activity
would exert an inhibitory influence on cancer.
Accepting these deductions as facts, the question
arises, of what use can they be made clinically?
It would seem to the writer that tuberculin which,
according to some authors, certainly stimulates
lymphoid activity, would meet the requirements.
Theoretically, a preparation derived from a case or
group of cases of proven lymphoid activity would
seem preferable.
Furthermore, although lymphoid activity, as
Murphy and Morton have shown, may be a neces-
sary factor in the process of cancer immunity, it
is by no means certain that it is the only one, or
even the most essential one, and it is possible that
tuberculosis may exert other and unknown inhibit-
ing influences on cancer. Should this be true a
proper preparation of tuberculin might in all like-
lihood have the same effect.
There are other and weighty advantages in the
use of tuberculin for this disease, should it prove
of use at all, and these are (1) its harmless-
ness properly given, and (2) that it would be ap-
plicable to practically all cases of cancer in view
of the usual incidence of this disease after the age
of 40 and the fact, as before stated, that almost
every individual who has reached this age has had
tuberculosis, and consequently, in some degree,
would be sensitive to the action of tuberculin.
Following out the foregoing trains of thought,
the writer has put them to the practical test. He
has personally administered tuberculin to two pa-
tients suffering from cancer, and through the kind-
ness of his friend. Dr. Hugh H. Young, head of the
Department of Urology at the Johns Hopkins Hos-
pital, it has been administered under the super-
vision of Dr. Norman B. Keith to three patients at
the James Buchanan Brady clinic. A sixth case
was at the writer's suggestion similarly treated by
his friend, Dr. William A. Fisher, at the Union
Protestant Infirmary, and a seventh by Dr. Charles
W. Larned of this city.
The method of practical procedure varied some-
what as to type of tuberculin, dosage, freouency of
administration. Careful differential counts of the
Nov. 4, 1916]
MEDICAL RECORD.
805
blood, however, both before and after administra-
tion of the vaccine, were made in all cases except
in the last case, and these counts served as a prac-
tical guide.
A few remarks about this case, in which it was
impossible to get differential blood counts, would
seem proper. Miss X. Inoperable cancer of the
esophagus. According to Dr. Larned the improve-
ment in this patient's general condition was so no-
ticeable following the use of tuberculin that mem-
bers of the family remarked on it and asked what
was being used to bring about this change. Her
condition after three months or more of tuberculin
therapy still continues improved. The treatment is
being continued.
The work is as yet in a most unfinished state and
naturally few, if any, correct conclusions can be
drawn from so few cases, particularly in view of the
fact that these cases were all inoperable and pre-
sented conditions anything but ideal for putting the
foregoing ideas to the practical test. It is inter-
esting, however, to note that of the six cases in
which careful blood tests were made, four showed
a change in the lymphocyte count following the ad-
ministration of 'tuberculin, and from a clinical
standpoint two, at least, of the seven showed an en-
tirely unexpected improvement.
This being only a preliminary report, naturally
but few cases have so far been tested. It would
appear, however, that the results in these few cases
would justify the statement that, given the proper
preparation, dosage, etc., tuberculin will bring about
a lymphocytosis in practically all cases.
There are several additional questions in connec-
tion with this subject which it would seem proper
to present now. First: The statement has been
made that cancer is occurring now at an earlier age
than formerly, and that this is true even though
one takes into consideration the greater diagnostic
skill of the present-day medical man. Granted the
truth of this, to what is it due? Is it due to the
widespread crusade against tuberculosis and the
consequent diminution in the comparative number
of cases of what was formerly called consumption?
Has the partial elimination of this phase of the
tuberculous infection taken away to some extent
one of nature's bulwarks, the lymphocyte, and ren-
dered the individual more liable to cancer at an
earlier age?
Furthermore, if it be true that cancer does de-
velop now at an earlier age than formerly, would
not this fact negative the following criticism which
might be leveled against the foregoing ideas,
namely, that active tuberculosis and cancer are
rarely combined for the reason that the sufferer
from active tuberculosis usually dies before reach-
ing the so-called cancer age.
Second : Of what use, if any, would tuberculin be
in those inoperable cases treated by radium and
allied substances? So far as the writes knows,
actual proof of the effect of radium on the blood is
not available, but in two at least of the cases which
have been cited the lymphocyte count was low. In
one of these cases there was a dictinct drop in the
lymphocyte count immediately following the first
radium treatment, and on this account the low
lymphocyte count in the other case was considered
to have been the result of several radium treatments
given some time previously.
Naturally, no positive conclusions can be drawn
from two cases, but these facts, taken in conjunc-
tion with the statement made by Murphy and
Morton that the x-ray exerts a markedly deleterious
influence on lymphoid activity, would seem to indi-
cate that the same was probably true of radium.
Such being the case, the use of tuberculin to stimu-
late lymphoid activity during the course ef radium
treatment would seem indicated.
Third: Granted the use of tuberculin to be indi-
cated in cancer, what form of tuberculin shall be
used? Human or bovine? From the fact that
bovine tuberculosis usually affects the glands and
cancer is primarily disseminated by the lymphatics,
would not the bovine appear to be the preparation
of choice?
Would it not be possible to solve this question
for each individual case by the use of the von
Pirquet skin test, with vaccines obtained from both
human and bovine bacilli? The preliminary dose
to be given each case might also be estimated by the
adoption of this method if one used two or more
dilutions of each preparation and noted the result-
ing reactions.
It has been stated that von Pirquet's skin reac-
tion produces a local lymphocytosis, which fact
could likewise be made use of in the adoption of
this method as a preliminary step in tuberculin
therapy, especially in the case of superficial cancer.
It should not be understood that in presenting
this article the writer makes any claim for it other
than that above stated, namely, that, granted
the necessity for lymphoid activity in the produc-
tion of cancer immunity, any harmless substance
which will bring this about would seem theoretically
to be of use, and furthermore, it would appear that
until the cause of cancer is discovered, any harm-
less procedure which has a certain amount of back-
ing as the result of both clinical and experimental
experience might have its possibilities for good if
used in conjunction with surgery and in the in-
operable cases with radium and allied substances.
The stimulation of further interest in the princi-
ples underlying the supposed antagonism between
these two diseases, as well as others, would seem
a result well worth the effort, even though the
method advocated in the foregoing should prove of
no value.
211 Professional Building.
ANAPHYLAXIS TO MERCURY— WITH
REPORT OF A CASE.
By M. ZIGLER, M.D.,
NEW YORK.
INSTRUCTOR, GENITOURINARY AND VENEREAL DISEASES, POST-
GRADUATE MEDICAL SCHOOL AND HOSPITAL, CHIEF OF CLINIC
GENITOURINARY DEPARTMENT, LEBANON HOSPITAL.
During ten years' experience in the treatment of
syphilis with mercury, none of my patients have
shown the unusual phenomena which occurred in
the case about to be reported.
My usual experience with the intramuscular in-
jections of mercury for syphilis is that at the out-
set of the treatment the most marked reactions
occur, but that after the patient has had a num-
ber of injections, about a dozen, these reaction-
ary symptoms gradually diminish in intensity and
number and finally disappear entirely. By reaction-
ary symptoms I mean rise of temperature, pulse
acceleration, increased headache, backache, and bone
pains, occasionally restlessness, even delirium, etc.,
and do not refer to the ordinary symptoms of mer-
curialism, to wit, salivation, spongy gums, metallic
odor, abdominal pain, gastroenteritis, etc.
806
MEDICAL RECORD.
[Nov. 4, 1916
The reactionary symptoms present after mer-
curial intramuscular injections, I have usually
ascribed to two causes. First, to the presence in
the patient's blood stream of myriads of dead
spirochetes and their endotoxins; second, the pres-
ence in the patient's body of a foreign chemical,
namely mercury.
If this drug (Hg) is continued over a very long
period of time, then not only are there no reaction-
ary symptoms, but a great number of patients fail
to respond to the drug. That is, syphilitic mani-
festations which formerly cleared up readily with
mercury fail to do so. In other words, for the time
being the patient has developed mercury-fast
spirochetes similar to the arsenic-fast organisms, as
described by Ehrlich.
Under these circumstances it is advisable to dis-
continue the mercury for a time and administer
arsenic in the form of salvarsan or neosalvarsan.
This arsenical preparation will kill off many
spirochetes that the mercury no longer could affect.
It is probable that those remaining that are not
killed by this new drug are so damaged and changed
in their chemical affinity that on the readministra-
tion of mercury the original resistant strain of
spirochete will then respond to mercurial treatment,
with the result that syphilitic manifestations will
again be dissipated.
In starting the patient with mercurial medication,
it is advisable to commence with the minimum dose,
increasing the same at each injection until the pa-
tient develops signs of mercurialism, then continue
the treatment with a slightly smaller dose. This dose,
of course, varies with different patients, depending
on the weight, sex, age, and general robustness. The
lower the weight the less dosage, unless the individ-
ual has a special idiosyncrasy to this drug, in which
case one should give less than the average minimum
dose. One usually gives a smaller dose to females,
to the aged, and to the alcoholic. If an alcoholic is
given a large dose at the outset of his treatment,
it may put him into such a state of shock that he
may develop delirium tremens. However, if in the
alcoholic it becomes necessary to give a large dose
of mercury, it is advisable to put him to bed and
have him watched by a trained attendent for 24 to
48 hours. This may be necessary only for the first
two or three injections. In addition this type of
case should receive large doses of bromides.
The dose of salicylate of mercury is one-half to
three grains given every fourth to seventh day. The
details as to dosage for different patients have been
gone into in order to bring out the marked excep-
tion in the case here reported. The following is the
history of this unusual case:
H. R., as:e 27 years, single, male, commenced to have
intercourse at 16 years, since which time has had inter-
course weekly. Denies ever having had either gonor-
rhea or a chancre..
About one and one-half years ago he noticed a scaly
eruption on his testicles and on right palm. This has
persisted ever since. In addition he says that he feels
"down and out." He tires very easily. Complains of
anorexia. Has no bone pains or headache. At present
the chief complaint is the palmar and testicular erup-
tion and a feeling of general weakness.
Examination (Sept. 15, 1913) shows a papulosqua-
mous circinate lesion in the center of the right palm,
also a number of similar lesions on the scrotum, a few-
mucous patches on the lateral edge of the tongue, also
one on the lower lip and scattered erythematous areas
on the soles of both feet. No glandular involvement
oresent. The diagnosis of secondary syphilis was made.
Blood was drawn for a Wassermann test, and treatment
was withheld until next visit.
Sept. 29. Wassermann of the blood was strongly
positive. Some new papulosquamous lesions appeared
on the penis. The patient received on this date salicy-
ate of mercury, 4/5 grain, intramuscularly, with ung.
hg. ammoniatum 5 per cent, to be rubbed into palms
and scrotum.
Oct. 6. The patient feels stronger and much better
generally; is not so easily fatigued. Lesions on the
scrotum somewhat improved. Received salicylate of
mercury, 1 1/5 grains, intramuscularly. Still continued
the use of the white precipitate.
Oct. 20. — Says that for the past week the eruption
on his testicles has disappeared. Feels stronger and
more like working. Missed his treatment last week
because he was too busy to call at the office. Is con-
tinuing the use of the white precipitate ointment. Re-
ceived salicylate of mercury, one grain this day.
Oct. 27. A few new lesions have appeared on the
penis and testicles. Complains of pain in the right
ankle. On this date received 1% grains of salicylate
of mercury, intramuscularly, in addition to white pre-
cipitate ointment.
Nov. 5. — General feeling of well being. Salicylate
of mercury, 1% grains intramuscularly.
Nov. 10. Feels stronger than ever. The lesion on
his lower lip is still present but improved. Injection
given of 1% grains salicylate of mercury.
Nov. 7. Some improvement in the lesions on the soles
of the feet. The tongue and lower lip show additional
improvement. Injection of 134 grains salicylate of
mercury.
Nov. 24. Within an hour of his last injection he
developed cold sweats and felt generally tired. This
continued the entire night. The next day and during
the entire week he felt all right. Received injection of
1 grain salicylate of mercury this day.
Nov. 24, Dec. 1, 8, 15, 22, 29. Received 1 grain
salicylate of mercury each of these days without any
reaction following.
On Jan. 5 and 16, 1914, he received IY2 grains each
day, no reaction following.
Jan. 19. Received neosalvarsan 0.3 gram intraven-
ously. Felt a little drowsy for one hour after the ad-
ministration, otherwise there were no reactionary
symptoms.
Jan. 26. Reports that no reaction occurred after
reaching home. Gained 2 pounds during the week.
All the lesions on the tongue, lips, and foot have dis-
appeared. Feels very well.
Jan. 26, Feb. 2 and 9, 1914, he received an injection
on each date of 1% grains salicylate of mercury with-
out any reaction following.
Before going into further details as to the sub-
sequent history of this case, it would be advisable
to give a summary of the salient features of the
action of mercury up to this point. At the very
first treatment, this patient received four-fifths of
a grain intramuscularly and in addition mercury in
the form of ammoniated mercury ointment, 5 per
cent., the latter rubbed into the palms and scrotum
twice a day. Yet no reaction followed. From that
time on received weekly injections, varying from
1 to 1% grains. In spite of this dosage, he had but
one reaction, and that was after a dose of 1%
grains. In many instances he received weekly in-
jections of V/z grains, for three successive weeks,
without any reactionary symptoms. I will now con-
tinue with the further progress of this case and
we shall see what a marked change took place in
the patient's tolerance for this drug. He stopped
treatment for a period of eight months because he
was obliged to leave town.
Oct. 6, 1914. The patient has returned because of
recurrence of all of his symptoms, having had no treat-
ment from Feb. 9 to Oct. 6, 1914, a period of about
8 months. Received a salicylate of mercury injection,
3/5 grain, this day.
Oct. 14. Had a well-marked reaction after the pre-
vious injection, manifesting itself by extreme degree
of tiredness and weakness. This lasted 24 hours, after
which he felt stronger than he did prior to his injec-
tion. Received an injection of 1V4 grains this evening.
Had a marked reaction within one hour after this
injection. Manifested by cold sweats, vomiting,
diarrhea, terrific headache, marked prostration, and
Nov. 4, 1916 J
MEDICAL RECORD.
807
weakness. In fact, his symptoms were so severe that
his family thought he would die. I saw him about 5
hours after his injection, and found him in a condition
of extreme shock, with general pallor and a weak and
rapid pulse. He remained in bed 24 hours. After
which time he felt considerably improved, except that
he complained of headache and dizziness, which per-
sisted for an additional 24 hours. He was able to
return to work on the third day.
Oct. 26. Because of the above-mentioned symptoms
I reduced his injection to 1 grain on this date. In spite
of this reduction, and in spite of the fact that he had
received no injection for a period of twelve days, in-
stead of his usual weekly injection, he again had severe
symptoms, manifesting themselves within a few hours
by frequent vomiting and a very severe headache.
Nov. 11. Because of previous symptoms from one
grain dosage, I reduced his injection on this date to
three-quarters of a grain. Within four hours he de-
veloped severe occipital headache, with constant "ham-
mering in the head." He was unable to sleep all night.
A dull headache continued all the week, in spite of the
fact that there was a marked improvement in his speci-
fic lesions.
Nov. 18. For experimental purposes I again gave
him three-quarters of a grain of salicylate of mercury.
He again developed severe headache within three hours,
but immediately took bromides and slept all night. Had
no reactionary symptoms during the rest of the week.
Nov. 25. Since he complained comparatively little of
his last injection, I thought I would try and see what
symptoms would occur if I should slightly increase the
dose. This day I gave him four-fifths of a grain in-
stead of three-quarters.
Dec. 7. The patient returned to the office and re-
ported that within four hours after the last injection
he again developed so severe a headache that he was
obliged to remain in bed. The pain this time not re-
lieved by bromides, in fact, it continued without cessa-
tion for 36 hours. He also suffered with abdominal
cramps, but no diarrhea. The note on my index card
for this date was "This patient apparently has be-
come most susceptible to mercury, and I am accordingly
obliged to diminish his dose to one-half a grain." This
I accordingly did.
During this entire period, from Oct. 6 to Dec. 7, 1914,
while he was having such a hard time with his reac-
tionary symptoms from mercury, he nevertheless
showed a very remarkable diminution in his manifesta-
tions of syphilis.
Dec. 14. Reported that there was no reaction after
the last injection of half a grain of salicylate of mer-
cury. The patient's lesions have all disappeared. He
again received but half a grain of the drug on this
date.
Jan. 2 and Jan. 8, 1915. He developed no reaction
from the previous half grain injections. So thereafter
I decided to keep him on that dose, which he has been
able to stand without any symptoms following.
Summary. — In studying this case carefully one
sees that at the outset the patient was well able to
take between one and one and one-half grains of
salicylate of mercury without any symptoms. Not
until one and three-quarters grains were given were
there any signs of reaction. In other words, during
the entire first period of treatment, that is from
September 15, 1913, to February 9, 1914, the pa-
tient had absolutely no reactionary symptoms with
a dosage varying from one grain to one and one-
half grains.
Then came the second or middle period, a period
of about eight months, during which the patient
had no treatment. It was during this rest from
treatment that the patient had a change to develop
anaphylaxis. The pathologists have proved that cer-
tain foreign material injected into the body can, as
a rule, be gradually increased in dosage up to a cer-
tain point and the animal or patient can remain at
that dosage almost indefinitely ; but cease the treat-
ment (injection) for a period beyond three weeks
and then recommence the injection and one will
find that the body has developed hypersensitiveness
to this foreign material. In the human body this
may show itself by marked symptoms of anaphylac-
tic shock, occasionally even death. In the lower ani-
mals with less resistance death is not at all infre-
quent.
After the eight-month period of rest, the patient
returned for treatment. Immediately upon receiv-
ing his treatment he developed symptoms of hyper-
sensitiveness to mercury. On his return I started
him on three-fifths of a grain ; this was followed by
a marked reaction. I increased the drug at the fol-
lowing visit to one and one-half grains, and the
patient went into extreme shock, although, as pre-
viously mentioned, the patient took this dosage
eight months before without any symptoms follow-
ing. I then cut down the dose to one grain and he
still showed marked symptoms. I then diminished
the dose to three-quarters of a grain, and within
four hours the same manifestations occurred. I
repeated the three-quarter of a grain dosage at the
next visit with an identical result, showing beyond
any doubt that this patient's tolerance for mercury
had diminished more than 50 per cent, within eight
months. Finally, seeing that even three-quarters
of a grain could not be tolerated, I was obliged to
cut down to half a grain, which was the only dosage
he could take without a reaction.
Conclusions.— 1. This case is reported because it
is the only one I have ever had in which after a pe-
riod of cessation of mercurial treatment an intoler-
ance to the drug developed.
2. In spite of his intolerance to mercury he re-
sponded in a remarkable manner to the treatment.
3. My usual experience is that after a time the
patient's tolerance for mercury is increased, while
his response to treatment is diminished.
4. I do not know of a similar case reported in the
literature, but in view of the fact that anaphylaxis
to mercury may occur after the cessation and re-
commencement of treatment it behooves one to re-
commence with small doses, even if the patient has
previously taken large doses without any reactions.
40 East Forty-first Street.
INDUCED PARANOIAC CONDITIONS.
Br ARTHUR K. PETERY, M.D.,
NORRISTOWN, pa.
first assistant physician, state hospital for the insane.
In reviewing the various paranoiac conditions that
frequently come to our attention, that type which
might be called Induced Paranoia, that is, paranoid
ideas induced by environment, seems to be of par-
ticular interest from the fact that it is being sepa-
rated more carefully and the chances for recovery
are much more favorable than were previously
thought to be.
Formerly such cases were usually brought to-
gether under the general grouping of Dementia
Prsecox and the prognosis was rated as decidedly
unfavorable, but the adoption of some of the later
theories regarding the causation of these conditions
has led us to look at these cases in a somewhat
different manner and to be more optimistic as to
their outlook for recovery.
Real paranoia is a form of psychopathic personal-
ity, and is a product of necessity arising from the
irritations of life, and during the life of the indi-
vidual these conflict with the other elements of their
existence. These people are not in accord with
their environment or fellow beings and are continu-
ally meeting with difficulties in maintaining their
ideas. There is little or no effort on their part to
adjust themselves to their surroundings, but there
808
MEDICAL RECORD.
[Nov. 4, 1916
is often a great tendency to bring other people to
accommodate themselves to their views and opin-
ions, and meeting the proper individual this effort
is not difficult. An occasional example is seen in
the originators of certain religious movements.
The true paranoiacs are the incentives; they come
in contact with persons of psychopathic natures,
force their opinions on them, and are accepted by
them as facts, thus bringing them into the fold of
the type termed "induced paranoia." The origina-
tors are usually strong and active, while the in-
duced are weak and hysterically inclined.
These patients, so long as the stimulus is present,
retain these abnormal ideas, and their life and ac-
tions are practically under the control of the orig-
inator; but remove the stimulus or the originator
and those induced can discard the ideas either to ac-
cept new ones or not, although during the activity
of these induced ideas they are entirely irresponsi-
ble for their acts and frequently commit crimes,
even murder as a religious sacrifice. These patients
often need only such an impetus to make them start
to misinterpret things and to carry them out ac-
cording to their own ideas or the ideas of the origi-
nator. If these persons are placed under favorable
environment, free from conflicting stimuli, and are
given a little assistance along the proper channels
they frequently discard the ideas and return to their
usual or normal condition.
The following case was one of particular in-
terest :
Family History. — The father was of temperate
habits ; had been active in church work at one time, but
for the past fifteen years took no special interest in
religious matters. The mother showed no unusual
mental or religious tendencies. No history of any
mental diseases elicited.
Personal History. — Was the sixth child in a family
of seven; attended school during the winter months
from six to fourteen years; learned poorly and had to
study hard to gain what the other pupils acquired
easily; he often cheated and copied from others. Never
received any serious injuries. Had hay fever at in-
tervals since sixteen years of age; used alcoholics and
on several occasions to excess. Married at the age
of twenty-eight years; domestic life was happy.
Worked as a farmer until eight years before his ad-
mission, when he began working in the cement mills,
gradually advancing to the position of master mechanic
and earning about $125.00 per month. Was confirmed
in church at the age of sixteen and at twenty-four years
was a teacher in the Sunday School and took a very
active interest in church work. Later he became less
attentive and attended irregularly. Was always in-
clined to go to extremes in everything.
At the time of his trouble he was about thirty-five
years of age and was admitted to the State Hospital at
Norristown, June 5, 1908, from a county prison, where
he had been held on the charge of murder of his niece.
The records state that in January, 1908, he was out
with some friends when one of them mentioned that a
common friend had been converted and had "changed
greatly for the good." After thinking about it he
became dissatisfied with his own spiritual condition.
sought out the converted one, talked it over with him
and was advised to read his Bible; this he proceeded
to do at every opportunity and to the extent that in
March, 1908, he obtained two weeks' leave from his
work to continue his reading.
About the middle of February, 1908, he received
what he thought was his first sign from God and about
March 15, while reading his Bible he looked out of the
window and saw the "Angels of Light." which he de-
scribed as "balls of fire" moving about and passing in
various directions; also during the day the evil spirit
appeared to him three times and tried to tempt him.
He then interested his wife, as well as his brother-
in-law, in these new found ideas and during April
they frequently held religious meetings, but without
any violent outbreaks. However, during the latter
part of April the brother-inlaw, his wife, and child
came to spend several days at the patient's home,
which time they devoted to religion, and each had
frequent visions, in fact, was seemingly trying to out
do the others. They dined irregularly, the spirit telling
them when to eat, etc. During this time the child
played about the room and occasionally brought leaves
and other trifles to them. They developed the idea
that the child was possessed of a devil and that these
offerings were temptations from the devil to attract
them from their religion. The child continued to annoy
them until finally the patient pushed the child to the
floor, holding it by the neck to drive out the devil, and
in a short time the child was strangled to death. The
impulse came to kill, drive out the devil, and thus
send the child to Heaven instead of Hell. The next
day, when arrested, the patient was still having visions,
but was much quieter generally. In prison he showed
little of his former excitement.
The hospital records state that on admission the
patient talked readily and was mildly exalted spiritu-
ally; was positive that he had done no wrong and
maintained this attitude until the latter part of De-
cember, 1908, when in conversation he stated he had
begun to realize that he had "allowed his ideas to take
too deep a hold on him" and that he had gone entirely
too far. Where the impulse came to kill came from, he
did not know, but was willing to admit that it might
have been due to the fact that he was temporarily un-
balanced mentally.
From this time on a marked improvement was
noticed. He worked about the wards and also took
charge of some incubators, being successful in the rais-
ing of chickens. In January, 1911, when before the
staff, he said that when admitted he felt he could not
criticise himself for his actions and that he felt justi-
fied in doing what he had done, but that about a year
after his admission he began to have some doubt as
to his actions being proper, but was not sure and would
not admit it for' that reason; he was unable to tell what
changed his opinion, except that since being here and
seeing insanity, he felt he might have been insane.
He was discharged February 1, 1911, into the custody
of the sheriff, who returned him to the Courts, and
who eventually discharged him. He is now living out-
side, making a fair living, but is rather erratic.
During this writing it has been noticed in the
newspaper that a brother of this patient committed
suicide by inhaling gas, while out on bail. He had
been arrested on charges of conspiracy to kidnap
a four-year-old son of his wife's niece, with whom
he had eloped, while his own family were in Cali-
fornia. It is probable that there was also an ab-
normal element in this brother.
Another type of induced paranoiac conditions is
found in the Imprisonment Psychosis. This occurs
in persons of psychopathic natures who are con-
fined or prevented from leading the lives to which
they are accustomed ; they find they are unable to
accommodate themselves to this state of affairs
and finally to recompense themselves, develop a
psychosis of degrees varying from depressions to
active hallucinations. These conditions usually dis-
appear quite promptly when the person is placed
under more favorable circumstances either by re-
moval to a hospital or by allowing them more privi-
leges in the prison.
The following case is a clean-cut example of this
type :
In the family history, the father at the age of
seventy-two years is an excessive user of alcoholics;
the mother has a harelip and is "tongue-tied." No
definite history of any mental disease can be found.
The patient, a white male, now about forty-one
years of age, attended school from his sixth to eleventh
year, but never got along well. Worked in a rolling
mill up to his thirtieth year, after which he became
a telephone lineman. At the age of twenty-one years
had a severe attack of pneumonia and typhoid fever;
was confined to bed for twenty-two weeks, following
which his mother thought he was not as keen mentally
as prior to his illness. At the age of thirty years he
married and five children resulted from this union.
Nov. 4, 1916|
MEDICAL RECORD.
809
One child died during infancy, another of convulsions
and a third at the age of one week from a "brain
abscess." He used alcoholics and at times to excess.
Wassermann reaction of blood positive.
Nine years prior to admission he was arrested for
striking an officer while intoxicated and served a
sentence of one year. Fourteen months before his ad-
mission he was arrested for stealing coal, tried, and
sentenced to two years. After serving fourteen months
he developed mental symptoms and was committed to
this hospital, May 28, 1913.
On admission he was depressed and extremely ap-
prehensive; believed that he was going to die and that
he was brought here for that purpose. His attention
was held with difficulty; admitted the presence of
hallucinations of hearing; stated that frequently he
heard the warden at the prison talking about him ; that
he also heard other voices speaking ill of him; de-
clared that the warden and keepers placed poison in
his food and abused him without cause; that they re-
fused to obtain a lawyer for him when he was un-
justly convicted of stealing coal; also he thought his
wife was untrue to him while he was confined in jail.
Under hospital treatment and routine he showed a
progressive improvement both physically and mentally.
In five months he made a gain of thirty-four pounds
in weight. His hallucinations disappeared, but he was
suspicious and retained ideas of poisoning. While he
denied these, still he was frequently seen picking his
food apart and carefully examining it before eating.
On October 25, 1913, he obtained a key and made his
escape from the hospital. On January 2, 1915, he was
located and returned. While away from the hospital
and leading the life to which he was accustomed he
regained his normal mental status and on his return
talked well, realized his condition, and said that on his
first admission he was "pretty sick" and that "his
voices and ideas" were the result of his illness; no
hallucinations or delusions could be elicited.
January 13, 1915, he was returned from the hospital
to the prison to serve out his unexpired sentence. How-
ever, when seen a month or so later in the prison he
was again becoming apprehensive and developing
mental symptoms. The keepers expressed the fear
that they would have to return him "to the hospital,
for he was "getting off again." However, on advice
and by a special effort on their part they were able
to tide him over to the completion of his sentence.
Another class of cases very closely allied to this
type of psychosis is the Psychosis of the Deaf and
one which seems to be becoming more prominent;
at any rate we are seeing more of these cases at
this time. These people are really isolated or im-
prisoned to a certain extent from their surround-
ings and being of a psychopathic makeup, with a
sense of embarrassment from their affliction, find
satisfaction by making explanations to themselves
which they magnify until they have developed a
psychosis.
Very frequently there is some pathological condi-
tion of the ear present that causes a roaring or
buzzing and which these cases are prone to inter-
pret as "voices"; they become suspicious, people
talking together are surely discussing them, and
they feel that they are always the object of con-
versations. This usually leads to a depression; they
think they are being watched; that derogatory re-
marks are being made about them until finally in
order to escape these torments they attempt vio-
lence or self-destruction. The following case is
rather typical:
Family History.- — The father was shot in the head
during the Civil War and died at the age of fifty-one
years in an insane asylum. A maternal nephew is now
in this hospital suffering from paresis.
Personal History. — Patient is a white male about
forty-six years of age; his early life was uneventful;
attended school from his sixth to twelfth year and
learned well. Was a leather finisher by occupation and
worked steadily up to several months before his ad-
mission.
At the age of seventeen years had typhoid fever,
suffering three relapses, and was confined to bed for
four months. During his convalescence he became
totally deaf and remained so. Two months prior to his
admission he first complained that he heard voices
which told him people were trying to "put up a job
on him," and that his fellow workmen talked about
him ; he then attempted suicide by drinking iodine, but
prompt treatment frustrated his attempt. Several
days later he twice attempted to throw himself before
moving trolley cars; was picked up by the police and
taken home. The next day on the advice of these
voices he attempted suicide by cutting his throat with
a razor; he was immediately taken to a general hospital
and as soon as he had recovered sufficiently he was com-
mitted to this institution.
On admission he was depressed; answered questions
slowly; his orientation and memory showed no im-
pairment. He admitted the presence of hallucinations,
and these hallucinations and the resulting depression
were his chief mental characteristics. These voices
threaten, call him vile names, and abuse him no mat-
ter whether he is playing cards or working. When they
are annoying him more than usual he will complain to
the physician ; occasionally he can be partly convinced
that these "voices" are due to his diseased ear con-
dition. This will seem at times to satisfy him, but
again this argument will have no effect against his
statement that "they are so real to me." He has been
in the hospital since 1912 and shows no definite mental
deterioration at this time. His memory is good; is
well versed in current events; is a good worker and
careful in his habits.
This case is interesting from the fact that the
patient is able to be convinced up to a certain point,
but is then overwhelmed by his hallucinations and
lapses back into his former condition.
If the physical condition of these cases is such
that it can be cured or even improved by treatment
the mental outlook for the patient is good, but if
the hearing is completely destroyed the outlook is
bad. Occasionally such a patient might be benefited
by analysis or by education to the fact that his
ideas are developed as a result of his physical dis-
ability.
The above cases have been selected from the rec-
ords of this hospital as typical of the various phases
of induced paranoia. Of course, the symptoms may
vary in intensity from a few vague persecutory
ideas to an elaborate system of delusions and active
hallucinations, but the taking into consideration of
the entire history of the case and the underlying
causes may help to reduce the number of unfavor-
able prognoses.
DEVELOPMENT OF LITHOLAPAXY DURING
SIXTY-TWO YEARS FROM CIVIALE
TO BIGELOW.
By CHARLES AUBREY BUCKLIN, M.A., UD.,
GLASGOW. SCOTLAND.
The first step in the establishment of this opera-
tion was made by Civiale of Paris in 1817, who
commenced to experiment on lithotrites during
that year. His first publication regarding a suc-
cessful result with the operation of lithotripsy was
in 1824, and it produced a great sensation among
the surgeons of the world. The second step regard-
ing this operation was the publication of Civiale's
ideas among English surgeons who took kindly to
them.
Civiale's publication of his successful case of
treatment by crushing the stone in the bladder
incited John Weiss, a skilled instrument maker,
to invent and manufacture in London during the
year 1824 a lithotrite, which for large instruments
is, in the author's opinion, superior to the one of
Civiale's construction. Thanks to Weiss' instru-
ment, members of the English profession were led
810
.MEDICAL RECORD.
[Nov. 4, 1916
to consider lithotripsy with favor; although French
surgeons still consider Civiale's construction the
best for light instruments, while recognizing the
Weiss-Thompson construction as the best for heavy
instruments.
Brodie used the Weiss lithotrite in cases that
were reported in "Lectures on Diseases of the Uri-
nary Organs" in 1833, Second Edition, page 318.
In the spring of 1825 the spring saw was used in
the bladder for the reduction of stones to frag-
ments, but without any decided success.
In 1830 the Weiss screw lithotrite was shown to
Heurteloup, who within a few months brought out
his instrument, in which a hammer was substituted
for the screw of the Weiss instrument. In 1833
Brodie reported in the London Medical and Surgical
Journal cases in which he had used the Weiss litho-
trite successfully. In 1833 the Weiss lithotrite was
modified so as to act with the screw or the hammer.
In 1834 Fergusson published a description of his
lithotrite, which was simply that of Weiss, save that
it worked with a rack and pinion instead of a screw
and was less efficient from a mechanical point of
view.
In 1834, on October 7, Brodie wrote to John
Weiss the following: "It must be between nine and
ten years since you first showed me a lithotrite
that you made for the purpose of crushing calculi
in the cavity of the bladder by means of a screw.
I have not the slightest doubt but the credit of hav-
ing contrived a lithotrite for crushing calculi in the
bladder by means of a screw belongs to you."
In 1834 Anthony White of the Westminster Hos-
pital stated in a letter to John Weiss that "the first
of your lithotrites shown to the surgeons of London
was in the year 1824." Thompson became intensely
interested in lithotripsy in 1863, and, after inspect-
ing Civiale's, Weiss', and all the lithotrites then in
the market, he made certain suggestions regarding
what it was necessary for lithotrites to possess in
order that they might become popular. Thereafter
the Weiss lithotrite was called the Thompson in-
strument, not because of any original suggestions
made by Thompson but because it was considered
politic to change the name.
The third step was the invention by Bigelow of
litholapaxy at Boston in 1879; his first publication
appeared in that year. Two lithotrites purchased
at Paris in the spring of 1878 were laid away be-
cause the author became disgusted with the lack
of success attending lithotripsy in relieving the
irritation of the bladder which was due to the frag-
ments of calculi remaining within its cavity. One'
of these lithotrites was Civiale's and the larger one
was Thompson's instrument. They were not
brought out again until 1882, when the author com-
menced to practise the operation of litholapaxy by
Bigelow, which he has followed since this last date,
usually relieving the patient of every trace of an
irritable bladder by one operation.
The evacuating apparatus purchased by the au-
thor in 1882 is known as Bigelow's first evacuating
apparatus; there are now a second and a third
evacuating apparatus by this author for evacuating
(he fragments of crushed stone from the bladder,
also several unimportant imitations of Bigelow's
instruments, all of which the author has seen used
in the hands of other men. The first instrument
of Bigelow's is the most perfect instrument ever
devised for removing the crushed fragments of
stone from the bladder. There are not any breaks
in this bag which exhausts this instrument except-
ing at the two extremes, where there is little or no
motion produced by closing the bag. In this in-
strument it is much easier to produce a bag that
will not continually leak than in any of the newer
forms of this instrument. There is not a cock or
valve attached to the apparatus, as there is in some
of the newer forms of evacuating instruments. Its
extreme simplicity is its merit. The separation ox
the fragments of stone from the bladder is more
rapidly accomplished by the first instrument recom-
mended by Bigelow than by any other differently
constructed instrument.
The special advantage of the first instrument of
Bigelow's is a lengthy piece of tubing which con-
nects the bag with the proximal end of the urethral
tube, which enables the operator to appropriate the
fullest effects of gravitation in separating the frag-
ments of stone from the urine or fluid in the blad-
der by lowering the bag to the lowest possible po-
sition while the instrument is being used for the
above purposes. It certainly has advantages over
all other forms of evacuators in this separation act.
Browne of London, in his eulogy of the late
Clover published in the Lancet on May 12, 1866,
attempts to place his name first regarding the as-
piration of foreign pieces of calculi from the blad-
der. Dr. Flemming of Dublin published in the
Dublin Journal of Medical Science in February.
1866, a device similar to Clover's for evacuating
fragments from the bladder after lithotripsy, the
only difference being that in Clover's instrument
the catheter projected into the cylinder that was
intended to collect the fragments, which Clover
claimed was the only difference between his satis-
factory instrument and Flemming's unsatisfactory
instrument. It will be observed that in both of
these instruments there was an uninterrupted wash
through the receiving chamber every time that the
pumping bag was squeezed, and that neither of
these instruments could have been satisfactory for
the purpose it was intended to fill.
The perfection of the operation of litholapaxy
was published by Bigelow of Boston in his meth-
ods of operation. His work is now known all over
the world and is generally appreciated. His first
instrument was perfect, as is confirmed through
the removal, by a man of Browne's experience, of
the valves within his evacuators, and thus reducing
them to the simple first instrument of Bigelow.
The mechanical instincts of every practitioner of
surgery should condemn Clover's apparatus as not
being of any practical value in removing the frag-
ments of stone from the bladder after a crushing
operation. Thompson used Clover's device long be-
fore the apparatus of Bigelow was published, and
abandoned it; suffice it to say that he never aban-
doned Bigelow's device.
After the two lithotrites described in this paper
Bigelow's device is necessary to complete the op-
eration.
It may be interesting to compare the operation
as performed with Bigelow's device with Civiale's
and Thompson's attempts to rid the suffering pa-
tients of the annoying bladder irritations occa-
sioned by the presence of fragments of stones
within this organ.
It is a common experience to see the patient en-
tirely relieved of his irritable bladder by a single
operation of litholapaxy. a result never obtained
from the operation lithotripsy in the practice of
Civiale or Thompson.
One-fifth of a grain of morphine is given to the
Nov. 4, 1916]
MEDICAL RECORD.
811
patient every twelve hours for the first four days
after the operation, and this is followed by a table-
spoonful of heavy magnesia at the close of the fifth
day. No unpleasant symptoms accompany this op-
eration if the above instructions are strictly fol-
lowed.
Stricture of the male urethra is a frequent com-
plication which has to be obviated before the pa-
tient submits to an operation for stone in the blad-
der by litholapaxy.
The male urethra should always be examined for
determining the normal caliber of this canal. The
Otis or Kollmann urethrometer has invariably been
used by the author for the above purpose. The dis-
tended portions of these instruments should always
be covered by a rubber cap for the purpose of pre-
venting the mucous membrane of the urethra from
falling between the distended springs of the instru-
ment. Both the instrument and the cap should be
sterilized every time before being used. Should a
stricture be encountered, the author's portable
quadruple-action crutch for exposing the perineum
should be used and the structured portions divided
by external urethrotomy (Medical Record, Janu-
ary 4, 1913), so that a tube of the normal caliber
of the urethra may be readily introduced after the
meatus has been properly stretched to receive this
urethral tube.
The unscrewing of a lithotrite the bill of which
has been hooked into the meatus is the handiest
way of stretching the meatus to receive this prop-
erly sized urethral tube for performing litholapaxy.
When the crutch is used while treating a stricture
of the urethra it is desirable that it be retained in
position during treatment for the stone.
23 Mansion House Road.
ANOMALOUS CASES OF MASTOIDITIS.
By CHARLES B. BRODER, A.B., M.D..
NEW YORK.
INSTRUCTOR IN LARTNGOLOGY, POLYCLINIC MEDICAL SCHOOL AND
HOSPITAL : ADJUNCT LARYNGOLOGIST AND OTOLOGIST. CITY
HOSPITAL ; VISITING OPHTHALMOLOGIST AND LARYN-
GOLOGIST, PEOPLES' HOSPITAL.
The difficulties that beset the surgeon in a mastoid
operation depend a great deal on the anatomical
configuration of the mastoid process and the rela-
tionship of the structures in intimate contact with
it. In the average temporal bone the mastoid
process is cellular in character, of pneumatic,
diploic, or mixed type, and the position of the sig-
moid sinus and of the floor of the middle fossa to
the mastoid process is more or less definite.
The following cases of mastoiditis show anomalies
in the anatomical structure of the bone, abnormality
in the position of the sigmoid sinus and an atypical
character of osseous involvement.
Case I. — H. W., age 21 years, was admitted to
Peoples Hospital March 29, 1916. Patient complained
of a continuous discharge from the left ear for last
six months following a severe attack of influenza. For
a few weeks previous to admission, the discharge was
more profuse, and he had severe pains on the left side
of the head. Physical examination showed abundant
pus in the external canal, and a large perforation in
the anterior inferior quadrant with prolapse of the
posterior canal wall. The functional test revealed
diminished hearing for voice and whisper in the left
ear, the other ear being occluded by the Barany noise
apparatus. Marked tenderness over the antrum was
elicited on pressure. Diagnosis: Subacute purulent
otitis media with complicating mastoiditis.
A simple mastoid operation was performed, with
curettage of the Eustachian tube through the perfora-
tion in the drum membrane. On removing the cortical
layers of bone the sinus was found to lie well forward
and superficial, the knee impinging on the supromeatal
triangle area, and coming in contact with the posterior
canal wall. In fact, the sinus completely filled the mas-
toid process. This position of the sinus rendered the
exposure of the antrum difficult and tedious. No other
mastoid cells were found. The necrosis had involved
the tegmen antri with exposure of the dura, which
was found covered with granulations.
The point of interest in this case was the extreme
forward position of the sigmoid sinus, with the
rudimentary development of the mastoid, and the
absence of all cellular structure. The mastoid pro-
cess was of the kind commonly seen in infants.
Case II. — E. H., age 20, gave a history of a persistent
discharge from the left ear, with deficient hearing for
the past five years. At the time of admission to the
hospital, January 23, 1916, an otoscopic examination
showed a chronic purulent otitis media, associated with
all the symptoms of an acute mastoiditis. The lower
half of the drum was gone, the discharge was profuse,
and there was marked tenderness especially over the
upper part of the mastoid.
On account of the long and narrow condition of the
process, with the possibility of a forward sinus, chisel-
ing was begun from the suprameatal spine downward,
along the anterior border and continued in a groove
until the antrum was reached. Further curettement re-
vealed the sinus well forward and the middle fossa
plate unusually low; in fact, it was considerably below
the linea temporalis. No necrosis was found any-
where except in the zygomatic region, where the cells
were completely broken down. The bridge between the
tympanum and antrum was removed and the posterior
canal wall lowered on a level with the external semi-
circular canal. The incus and malleus were found
intact and were left in. The attic was cleaned out,
and the Eustachian tube curetted through the posterior
opening. The retroauricular incision was sewed up
almost completely, a small opening being left at the
lower end for packing and drainage.
The interesting points in this case were the lo-
calization of the infection to the zygomatic cells,
the rest of the process being free from inflammatory
changes, and the unusually low position of the dura
which called for exceptional care to avoid injur-
ing it.
Case III. — J. W., 21 years old, was admitted to
Peoples Hospital December 10, 1915, with a history of a
discharging left ear for the last three months. Exami-
nation showed a subacute exudative otitis media asso-
ciated with a purulent condition of the mastoid cells.
A mastoid operation was performed. A perpendicular
incision was made through the soft tissues down to the
bone and the flaps retracted. Directly underneath the
periosteum the bony wall of the sigmoid sinus came to
view. This extreme superficial position of the sinus
rendered it liable to injury if a secondary horizontal
incision would have been made. An anatomical anomaly
of this kind contributes greatly to the accidents of mas-
toid surgery. The cells were found filled with detritus
and granulations, necessitating a thorough exenteration.
Healing was uneventful and rapid.
Case IV.— P. G., age 70. Operated upon October 29,
1915.
This case was fully reported in a previous publi-
cation, the case history showing a chronic purulent
otitis media with a latent suppurative labyrinthitis
and a complicating mastoiditis. It is mentioned in
the present instance as illustrating the extreme de-
velopment of cells in the temporal bone. The cells
were widely distributed, surrounding the sigmoid
sinus and extending far back into the occipital bone,
high above the linea temporalis into the squamous
portion, deep down around the pyramid of the
petrous portion, and showing marked development
at the zygomatic region extending upward and for-
ward as far as the apex of the glenoid fossa.
This case together with the one with the rudi-
mentary mastoid shows the two extremes in the cel-
lular development of the adult temporal bone. Com-
812
MEDICAL RECORD.
[Nov. 4, 1916
plete removal of all the cellular structure exposed a
very extensive area.
Case V. — M. S., 40 years old, was admitted to my
service at the Peoples Hospital May 26, 1916, with the
history of a discharging ear for the past three weeks.
Careful inquiry failed to show any previous ear trouble.
Examination gave all the signs of an acute purulent
otitis media and mastoiditis. The mastoid process was
exceptional large size, broad and flat. Tenderness
elicited only over the emissary vein. The main sub-
jective symptom was a severe headache, especially at
night.
On operating, the mastoid process was found dense
and compact, showing complete sclerosis such as often
occurs in a chronic purulent otitis with involvement
of the mastoid cells. In this case, previous aural infec-
tion was ruled out by the history. With the exception
of the antrum there was complete absence of cellular
tissue, the mastoid space being occupied by massive
bone. The sigmoid sinus was situated deep, and far
back from the external meatus. On exposing the antrum
a slight trace of muco-pus was found, but elsewhere
there was no visible inflammatory involvement. The
region at the posterior root of the zygoma, and the
tip, also the space around the knee of the sinus, were
cleaned out and searched for necrosis, without any trace
being found. It was finally decided to close the wound,
when on further curettement free pus oozed out from
the space between the upper surface of the bend of the
sigmoid sinus and the floor of the middle fossa. This
area was now thoroughly cleaned out, leading to a
denuded dura and sinus, the two surfaces almost com-
ing in contact. A smear of the pus on examination
showed the pneumococcus.
The points of value in this case were the com-
pact character of the interior of the mastoid process,
in an acute otitis media, with the absence of any
cellular structure, also the localized point of de-
generation, far removed from the source of infec-
tion. Except for the completeness of the operation,
this localized area would have been overlooked and
might have caused serious consequences.
The anomalous conditions enumerated in the above
cases show the necessity of preparation and care
in mastoid surgery. The examination of the mas-
toid process as to its shape and size will often give
an indication of the location of the sigmoid sinus.
Skiagraphy offers valuable information as to the
site of the sinus and of the floor of the middle fossa
and may locate deep and hidden points of infection.
The case of P. M. shows the necessity of the com-
plete operation in mastoiditis and every otologist is
acquainted with numerous instances where exente-
ration of apparently normal cells led to and revealed
unsuspected areas of necrosis.
22] SECOND AVENUE.
A CASE OF GASTRIC ULCER.
BT J. RUSSELL VERBRYCKE, JR., M.D..
WASHINGTON. D. C.
ATTENDING GASTROENTEROLOGIST TO THE WASHINGTON ASYLUM
HOSPITAL.
The following case is one of a very common dis-
ease, but with a number of unusual and most in-
structive features:
Mrs. J. R., set., 47, consulted me in March, 1914, com-
plaining of epigastric pain running around the abdomen
to the back, heartburn, and constipation. She was
afraid to eat. The symptoms used to come on two hours
after meals, but of late have appeared at various times
and were relieved only partially by alkalies. Her
symptoms had started fifteen years before. Twelve
years before she had two profuse hemorrhages and
was treated for ulcer, remaining in bed some weeks.
Abdominal examination showed the stomach to be
hypertonic. There was slight general tenderness with
a point of greater tenderness localized midway between
the naval and gall-bladder region. Examination of the
stomach contents showed free HC1 60, and a total
acidity of 74. There was faint occult blood in the stool.
She was put on an ambulatory treatment for several
days without improvement. She was then radiographed
and a marked spasmodic incisura was seen extending
half way across the stomach and opposite a tender spot
on the lesser curvature, half the distance from the
cardia to the pylorus. Physical examination at this
time showed marked tenderness and irritability of the
stomach and she was advised to have an operation
without delay.
She determined to await advice from her son who
was an intern in a Western hospital and just one week
later she was seized at four in the afternoon with
terrific pains in the abdomen, chills, and fever. I saw
her at 10 o'clock the next morning at which time there
was great general abdominal tenderness but no rigidity.
There was slight fever, a pulse of 90, nausea, but no
vomiting. A subacute perforation was suspected.
Morphine, gr. Vi, was given and everything stopped
by mouth.
At 1 P. M. her condition was about the same except
that the pulse had gone to 100. Leucocyte count at
this time was 4,400. She was taken to the hospital
and Dr. L. H. Reichelderfer saw her with me at 5 P.M.
Her temperature on admission was 99.8° and was
steadily rising, while her leucocyte count had fallen
to 3,200. We decided to watch her carefully and try to
hold off operation until the arrival of her son, but at
10 P. M. her condition seemed worse with temperature
of 101.8°, pulse of 110, and a white blood count of
2,850 with 73 per cent, polymorphonuclears, so that we
were afraid to delay further in spite of the absence
of much rigidity.
Operation by Dr. Reichelderfer revealed a mass of
fresh adhesions on the lesser curvature about two inches
from the pylorus and beneath these a blood red, con-
gested area. The peritoneal covering of the whole
stomach was somewhat congested but this spot was fiery
in color. Careful palpation showed that there was no
thickening to indicate induration and palpation alone
would not have located the ulcer. It had progressed
partly through the peritoneal coat and there was prob-
ably a pin hole perforation, as the gross appearance
was such, although the opening could not be found.
The ulcer area was turned in and a gastroenterostomy
performed. The whole stomach was carefully examined
for other ulcers or scars and none were found. The
temperature dropped at once to normal and the
leucocyte count rose, showing plainly cause and effect.
Recovery from the operation was uneventful.
This is one of the most instructive cases of ulcer
I have ever had, and I will emphasize several points.
There is such a thing as a chronic non-indurated
ulcer or a non-indurated surgical ulcer, some
writers to the contrary notwithstanding. This
same ulcer had undoubtedly existed for fifteen
years, as periods of remission were comparatively
short during that time and no scars of other ulcers
could be found. Such a non-indurated ulcer may
progress to hemorrhage (three years) and to per-
foration (fifteen years).
It is often difficult and at times impossible for
the surgeon to find a known ulcer. Touch is usually
depended upon. No thickening could be felt in this
case and had it not been for the unusual reddening
it would not have been possible to have found it.
In view of the foregoing, a medical diagnosis
based on signs and symptoms, but not symptoms
alone, is of greater value than a surgical diagnosis
made at the time of an exploratory incision. There-
fore, every patient should have a complete examina-
tion and localization of the ulcer before operation,
when conditions permit, in order that the surgeon's
task may be easier. The ulcer is not always under
the tender spot. No ulcer is safe from dangerous
complications. There may be trouble in a month or
not for many years.
Although perforation often develops without
warning it is occasionally possible, as in this case,
to determine that the ulcer is in a very irritated
condition a week before perforation.
Nov. 4, 19161
MEDICAL RECORD.
813
The rising temperature and falling leucocyte
count in this case indicated very poor resistance.
One of the counts of 4,400, 3,200, and 2,850 was the
lowest that I have ever encountered. It was cor-
roborated by several counts. That the low count
was directly due to the patient's condition is evi-
denced by the fact that it arose immediately after
operation.
I have maintained several of the views empha-
sized above for some time and have a number of
cases illustrating each, but it has never been my
good fortune before to have one patient presenting
proof of so many of them.
The Rochambeau.
Privileged Communication Statute Docs Not Apply to
Will Contests.— The South Dakota statute, Code Civ.
Proc, Sec. 538, declares that a physician or surgeon
cannot without the consent of his patient, be examined
in any civil action as to any information acquired in
attending the patient, which was necessary to enable
him to prescribe or act for the patient. Section 12 de-
fines an action as an ordinary proceeding in the court
of a justice, by which a party prosecutes another party
for the enforcement or protection of a right, the redress
or prevention of a wrong, or the punishment of a pub-
lic offense. The South Dakota Supreme Court holds
that, in view of Section 486, excluding testimony as to
transactions with deceased persons in both civil actions
or proceedings by or against executors, etc., and th°
limitation in Section 538 to civil action, a will contest is
a proceeding and not a civil action, and a physician of
the testator may testify as to the latter's incompetency;
for the statute making physicians incompetent, being
in derogation of the common law, should be strictly con-
strued.—In re Golder's Estate (S. Dak.) 158 N. W. 734.
"Practice of Medicine" — Wisconsin Law. — In pro-
ceedings for practising medicine without a license it
was contended that the provisions of the Wisconsin
statute, Section 1435, Stats. 1913, arbitrarily attempt to
define what is to constitute the practice of medicine
and surgery, and condemns practices which do not, in
substance, constitute the practice of medicine and sur-
gery, and hence deprive persons of rights guaranteed
them by the State and Federal Constitutions. The de-
fendant claimed that the provision of the section penal-
izing all persons who shall append to their names the
words or letters, "Doctor, Dr., Specialist, M. D., D. O.,
or any other title, letters, combination of letters or
designation which in any way represents him or her,
or may tend to represent him or her, as engaged in the
practice of medicine, surgery, or osteopathy in any of
its branches, or who shall for a fee or for any compen-
sation of any kind or nature whatsoever prescribe or
recommend for like use any drugs or other medical or
surgical treatment or osteopathic manipulation, for the
cure or relief of any wound, fracture, bodily injury, in-
firmity or disease," is an arbitrary classification as
medical and surgical practitioners of persons who are
not necessarily engaged as such practitioners, and thus
deprives them of the liberty to do these things, contrary
to their constitutional rights. The court said the con-
tention overlooked the fact that the use of the words
or titles so appended to a name is denounced by the law
whenever they represent, or tend to represent, the per-
son as a practitioner of medicine, surgery, or oste-
opathy, or if he as such a practitioner does anything by
way of treatment or gives a prescription for a fee. All
the prohibited acts are limited to persons who in fact
do these things as practitioners of medicine, surgery, or
osteopathy.— Piper v. State (Wis.), 158 N. W. 319.
Injury as Cause of Typhoid. — In an action for per-
sonal injuries by being run down by an automobile, the
Wisconsin Supreme Court holds that testimony of a
physician that typhoid fever may be caused by polluted
water or food, but that in his opinion there was a con-
nection between the plaintiff's injury and his contract-
ing typhoid, is insufficient to warrant a finding that
the illness was caused by or had any connection with
the injury.— Slack v. Joyce (Wis.) 158 N. W. 310.
X-Ray-Picture Evidence. — The Michigan Supreme
Court holds, in an action for personal injuries, that an
expert witness will not be allowed to testify as to what
an .r-ray picture showed, in the absence of the picture.
The picture is the best and only evidence of what it
did or did not reveal, and while it is matter of com-
mon knowledge that the correct reading of such a pic-
ture is a thing for experts, there can be no proper cross-
examination of an expert interpreter in the absence of
the thing interpreted. — Jolman v. Alberts (Mich.) 158
N. W. 170.
Practising Without License Not a Joint Offense. — Sec-
tion 8315 of Missouri Revised Statutes, 1909, makes it
an offence to practise medicine without a license, and
under Section 8313 the license to practise medicine must
be procured by individuals. The Kansas City Court of
Appeals holds that the joint participation in an act of
treatment constitutes no joint offence, but may consti-
tute one or two offences according to whether one or both
of the parties is without a license. The failure to pro-
cure a license is necessarily an individual and not a joint
matter, so that a conviction of two jointly indicted for
practising medicine without a license when the jury
fixed the punishment at $50 for both defendants, and the
court entered judgment for $5 against each, was re-
versed.— State vs. Hendricks (Mo.), 187 S. W. 272.
Revocation of Licenses — Advertising Cure of Incur-
able Diseases. — In a prosecution for revocation of a
practitioner's license for wrongful advertising it ap-
peared that the defendant advertised his ability to cure
many diseases either wholly incurable or nearly so. The
Washington Supreme Court held that to prove the of-
fence of wrongful advertising denounced by the statute
moral turpitude need not be shown. But it was also held
that it is not merely unethical but immoral to get money
from the poor, the simple, or the ignorant by advertis-
ing the cure of what is incurable, and the courts will call
that incurable which the present stage of knowledge so
pronounces. Nor is it incumbent on the State to show
whether there was any actual harm done to any one
through the defendant. The statute aims to protect the
purse as_ well as the health from quacks, and the other
burden, if cast on the board, would, through the many
conflicting and contributing influences on the health of
patients, make proof exceptionally difficult. — State
Board vs. Jordan (Wash.), 158 Pac. 982.
Practising Without License. — The Washington Su-
preme Court holds that a system of "Suggestive Thera-
peutics," in which the defendant indulged in prayers,
laying his hands on the patient, manipulating the mus-
cles and nerve controls, and claimed cures, is "practising
medicine," and the name and method a mere subterfuge
to escape the requirement of license. — State vs. Pratt
(Wash.), 158 Pac. 981.
Expert Testimony as to Malpractice in Adjustment of
Splints. — In a malpractice action it appeared that the
injury to the plaintiff, a child, was due to undue pres-
sure caused by adjustment of splints on a broken arm by
the defendant not allowing for the usual swelling accom-
panying such cases. It was held that the question as to
whether the omission to properly adjust the solints con-
stituted negligence was one for expert testimony. —
Priestley vs. Stafford (Cal.), 158 Pac. 776.
Chiropractors Require Certificates in California.— A
person who was a teacher and demonstrator of a chiro-
practic system in a ehropractic school and treated afflict-
ed subjects who sought and received treatment at his
hands free of charge was held guilty nevertheless of
practising a system and mode of treating the sick and
afflicted without possessing a certificate of the Califor-
nia State Board of Medical Examiners. — People vs. Oak-
ley (Cal.), 158 Pac. 505.
Practising Without Certificate— Gratuitous and Emer-
gency Services. — In an action for practising a system of
chiropractics without a certificate it is held that the Cal-
ifornia statute covers such practice whether the service
is compensated or gratuitous. Where persons had pre-
viously had the attention of physicians, their ailments
being more or less chronic, and the defendant's services
being sought to some extent as a last resort, and after
other practitioners had failed to afford relief, the treat-
ment rendered by him could not be classed as emergency
services not prohibited by the medical act. — People vs.
Vermillion (Cal.), 158 Pac. 504.
Users of Narcotics as Witnesses. — The habitual use
of opium, morphine, cocaine, or other like narcotics, as
it tends to impair the mind, destroy the memory, and
pervert the moral character of a witness, may be shown
for the purpose of affecting his credibility or "the weight
that should be given to his testimony, but is not ground
for the exclusion of his testimony unless it satisfactorily
appears that he was under the influence of the drug to
such an extent that he was unbalanced when a witness.
State vs. Fong Loon, Idaho Supreme Court, 158 Pac. 233.
814
MEDICAL RECORD.
[Nov. 4, 1916
Medical Record.
A Weekly Journal of Medicine and Surgery.
THOMAS L. STEDMAN, A.M., M.D., Editor.
PUBLISHERS
WM. WOOD A CO., 51 FIFTH AVENUE.
See fourth page following reading matter for Rates of Subscription
and Information for Contributors and Subscribers.
New York, November 4, 1916.
CAROTID TUMORS.
The first exhaustive American paper upon this sub-
ject was contributed in 1906 by Keen and Funke
(Journal of the American Medical Association, 1906,
XLVII). By including all cases found by a careful
search of the literature, they were able to present
reports of 29 cases — 27 in the living, and two that
had been discovered at autopsy. After this time
sporadic case reports appeared in medical journals
in various parts of the world so that seven years
later, when Callison and MacKenty (Annals of Sur-
gery, December, 1913) had occasion to report a
case and reviewed the literature, it was found that
theirs was the thirty-first case that had been re-
ported since Keen and Funke published their ar-
ticle, thus making a total of sixty. The latest addi-
tion to the literature of this subject is contributed
by Randolph Winslow (Annals of Surgery, Septem-
ber, 1916), who brings the number up to 72 by
reporting in detail two cases (one of which was
operated upon by himself, the other by his col-
league, Dr. A. M. Shipley) and adding brief refer-
ences to ten other cases, reports of which he had
found in the literature since the publication of
Callison and MacKenty's article. We may add that
the list is still incomplete since we know of at least
one case (F. S. Mathews, A)inals of Surgery, May.
1914, page 752) that is not included in Winslow's
references. It is thus seen that more cases have
been reported in the last decade than Keen and
Funke were able to collate in 1906 from all previous
literature. Whether this should be accredited to
the greater skill of the present generation of sur-
geons or to the more general study of pathological
specimens in recent years is a question; for cer-
tainly there seems to be no good reason why there
should be an actual increase in the percentage of
individuals having carotid tumors, as the above sta-
tistics would seem to indicate.
The carotid body is briefly described by Winslow
as a small structure situated at, or just posterior
to, the bifurcation of the common carotid artery.
It is not a gland in the usual acceptation of the
term, but appears to belong to the sympathetic
nervous system and to the chromaffin group. It is
best developed in early fetal life and gradually dis-
appears in later life. If it remains it is liable to
change into a tumor presenting evidences of ma-
lignancy. The function of this ganglionic mass is
not known. Winslow also says: "That this struc-
ture is prone to evil is shown by the ever-increas-
ing number of 'carotid tumors' that are being re-
ported. These cases occur with practically equal
frequency in males and females and are found in
almost the same ratio in the decades from 20 to 60.
A few cases have been reported under 20 years of
age and about an equal number above 60. The
youngest case reported was 7 and the oldest 74.
The type of tumor is usually endothelioma or peri-
thelioma, which is generally benign or but slightly
malignant at first, but if not removed tends to be-
come cancerous."
The symptoms seem to be quite indefinite. Wins-
low finds that generally there are no distinctive
subjective symptoms, though there may be altera-
tion of the voice from pressure on the recurrent
laryngeal nerve, cough, slight dysphagia, radiat-
ing pains, or a sense of discomfort or tenderness.
Sometimes there is an irregularity of the pupils
from pressure on the cervical sympathetic ganglia.
"Usually the patient seeks advice on account of a
slow-growing lump in the upper part of the neck,
which has either taken on a more rapid growth or
has increased gradually to such an extent as to
produce deformity and to cause embarrassment."
The growth is occasionally rapid, but there is gen-
erally a history of a lump that has been present for
several years, and when advice is sought it may be
as large as a pigeon's egg or a hen's egg. The
tumor is single, egg-shaped, and usually unilateral;
but at least three cases of bilateral carotid tumor
have been reported. The location of the tumor is
opposite the thyroid cartilage and may extend up-
ward to the base of the skull or downward toward
the clavicle. The tumor is smooth, firm, movable
laterally but not vertically, and sometimes there
is an upheaval pulsation with bruit and thrill, from
its relation to the carotid arteries. The growth is
originally encapsulated and does not infiltrate the
surrounding tissues until malignancy is well ad-
vanced. Sometimes, as in Mathews' case, these
growths are extremely vascular.
Positive diagnosis has seldom been made before
operation; but Winslow finds that the condition is
being recognized more frequently as its clinical fea-
tures are becoming better known. He made a ten-
tative diagnosis of carotid tumor before operation
in the case he reports, though he admits that he
was not sure of the diagnosis until the tumor had
been exposed and he saw its relation to the carotid
artery. Carotid tumor has been most frequently
mistaken for a tuberculous lymph-node, aberrant
thyroid, carcinoma, or sarcoma of glands. In Wins-
1 w's opinion, "a single, slow-growing, firm, smooth,
discrete, usually painless oval lump, more or less
fixed, situated in the superior carotid triangle op-
posite the thyroid cartilage and anterior to or
under the sternomastoid muscle, should always
cause us to suspect a neoplasm of the carotid body."
The treatment is operative; but operation should
be undertaken only by the expert since there is
danger of wounding the hypoglossal, recurrent
laryngeal, or pneumogastric nerves, and since liga-
tion of the common carotid and internal jugular,
with its attendant dangers, cerebral and otherwise,
i.i
Nov. 4, 1916J
MEDICAL RECORD.
815
may be necessary. In some cases the growth may
be shelled off the vessels, though danger of recur-
rence is much greater than when the vessels and
tumor are removed en masse. Keen's statistics
showed a mortality of 27 per cent.; but Winslow
found that in the entire 59 cases in which the
tumor has been reported extirpated there have been
12 deaths, a mortality of about 20 per cent. Since
the only hope of removing these growths without
ligation of the carotid and without danger of re-
currence is in the early period of their develop-
ment, while they are firmly encapsulated and loosely
attached to the vessels, general practitioners as
well as surgeons should bear them in mind when
consulted by one having a deep, fixed tumor in the
carotid region and promptly refer the patient to a
surgeon competent to deal with it.
IS LAUDABLE PUS LAUDABLE?
It is not so long ago that we used to speak much of
laudable pus, not so long ago in the history of medi-
cine, that is. Those of us who are young in years —
we are all young in spirit — remember our professor
of surgery saying during one of his first lectures
something like this, "Formerly it was not believed
that a wound was healing properly unless a quantity
of typical creamy pus was present. This was called
'laudable pus,' because it was thought that it was
really beneficial. Now we know that for a wound to
heal in an ideal manner there should be no pus what-
ever." As a matter of fact, the old-time doctors
were not so far off after all. This kind of pus to
which they referred was usually a staphylococcus in-
fection, had little tendency to spread, and showed
an active resistance of the tissues to the infective
organism. So that while as a purely academic
proposition it may be conceded that the ideal wound
is a pusless wound, still in actual practice it is some-
times better to let the pus alone.
Of this opinion are Drs. Donaldson, Alment, and
Wright, who published a report in the British Med-
ical Journal for August 26. These doctors entered
upon their military practice firm in the belief that
pus has no place in the modern surgeon's scheme of
things; experience taught them that in many cases
the pus should be left alone, and the patient would
get along the better for it. There did not seem to
be any delay in healing, the patient's general condi-
tion remained good, and his pulse and temperature
stayed down. The patients themselves were put in
a more cheerful frame of mind by doing away with
frequent, painful dressings, and the tissues were al-
lowed to remain in a state of rest, most favorable
for healing. There is, to be sure, an esthetic ob-
jection in the odor arising from the seldom-dressed
septic-case, but this would seem to yield in im-
portance to other considerations.
The writers quote a number of cases illustrating
the success of their method, which is, briefly, as fol-
lows: The wound is thoroughly opened up, irri-
gated, then packed with gauze containing saline tab-
lets and covered with a moist dressing. About a
week intervenes before redressing. Sometimes sym-
toms arise which appear alarming, and self-restraint
and confidence are necessary. Unless increased
swelling, a persistently rising pulse, tenderness, and
edema arise, the policy of non-interference should
be maintained. Many objections to this method
have, of course, been made, say its advocates, but the
only one which does not apply equally to the other
methods is the one based on smell, and this may be
partially invalidated in various ways. Concluding,
the writers say that they are aware that a method
so diametrically opposed to current practice will
meet with harsh criticism, chiefly on theoretical
grounds, but they urge, and with a show of reason,
that their method is not founded on theory, but on
practice, and should be given a thorough practical
trial by any sceptics before being discarded.
It is just such methods as these that American
physicians can learn with benefit. In the event of
war, which recent history has taught us is by no
means impossible, we should have large numbers of
wounds to attend to, most of them being frankly
septic. We should be confronted with the problem
of curing these cases as completely and as quickly
as possible, and at the same time the procedure which
would require the least work on the surgeon's part
would be the method of choice, for there is no doubt
that such an eventuality would find our profession
fearfully overworked.
EARLY DIAGNOSIS OF PULMONARY
TUBERCULOSIS.
The subject of early diagnosis of pulmonary con-
sumption is becoming more and more complex. One
sanatorium expert regards it as almost fatal to wait
for bacteriological and stethoscopic signs and lays
stress solely on the pulse, evening fever, cough, and
slight wasting, this syndrome often antedating the
resources of physical diagnosis. A second expert
takes the view that in many so-called incipient cases
in which recovery occurs the patients never had
tuberculosis, but have become objects of suspicion
by sojourn in the sanatoria. There appears to be
warrant for almost any extreme of opinion because
of lack of standardization of diagnostic criteria.
The discovery of bacilli in the sputum is still the
only criterion, but since it is of limited prognostic
value it must have backing of some sort. At pres-
ent the Schron-Much granules are the object of
search of the bacteriologist, and if these are absent
tuberculosis is regarded in some quarters as prac-
tically excluded. A great advance was made in this
field when very small quantities of sputum were
made to yield positive finds. The chance of finding
bacilli varies directly with the amount of sputum
available for repeated tests, and with the amount of
time at the bacteriologist's disposal. From the lat-
ter viewpoint any method which can cut short the
time without prejudice to thoroughness should be
welcome to the clinician.
In II Policlinico for July 9, Martelli publishes the
following method for early recognition of bacilli in
the sputum when expectoration is almost absent:
1. Give the patient up to one gram of iodide of
potassium daily, with expectorants (senega, ipecac)
for two or three days. 2. Collect from 100 to 200
c.c. of sputum and treat it in the usual manner with
antiformin in equal parts, leaving it from 2 to 4
816
MEDICAL RECORD.
[Nov. 4, 1916
hours in the thermostat. 3. Centrifugalize with
high velocity, decant, and wash with saline solution,
repeating this several times. 4. Make three very
thin smears on slides, fix, and color with Giemsa
stain in order to reveal ordinary bacteria, cell
residues, etc. 5. Stain a slide with Ziehl's car-
bol-fuchsin with consecutive decoloration with acid
and alcohol; another slide may be treated by Much'?
method, reserving a third one in case of failure of
one or the other method, or of a double negative re-
sult. This technique may reveal the presence of a
few isolated bacilli and of a few clusters of Schron-
Much granules and thus establish a diagnosis of
incipient pulmonary tuberculosis. The author has
been able to make this diagnosis in cases which
clinically were regarded as examples of pretubercu-
lous fever, Addison's disease, febrile anemia, chlo-
rosis, etc.
Precisely the same technique may be used suc-
cessfully in glandular tuberculosis by substituting
borings from the glands for sputum.
Operative Treatment of Chronic Obstructive
Jaundice.
There is little doubt that in cases of obstructive
jaundice operation is generally if not always called
for. Drs. Erdmann and Heyd, writing in the Amer-
ican Journal of the Medical Sciences for August,
1916, say that in most circumstances any operative
intervention will be in the nature of a palliative
procedure to provide drainage for the biliary secre-
tion or excretion. Given an obstruction in the
common duct or its terminus, the ampulla of Vater,
there is the choice of a variety of operations. The
simplest is external drainage by means of a cho-
lecystostomy. Such an operation entails a rapid
loss of bile salts and body fluids and should not be
the procedure of choice, but an anastomosis between
the gall bladder and some nearly approximate por-
tion of the intestine is physiologically and anatom-
ically correct. However, the choice of a particular
operation will depend upon a number of factors
such as (1) the physiological efficiency of the pro-
cedure; (2) the ease of technical accomplishment;
(3) the relative immunity from ascending infec-
tion; and (4) the immediate and remote effect upon
the. patient's metabolism. The following are the
conclusions reached by the author of the article
referred to: (1) All cases of obstructive jaundice
are entitled to operative consideration. There is
a certain definite percentage of cases that are cured
because there has been a mistake in the diagnosis.
(2) Any of the above operations are not prohibitive,
considering the severity of the disease and its hope-
less outlook. (3) The immediate relief from itch-
ing, in addition to the prolongation of life, is an
exceptionally strong argument for operation. (4)
Operation obviates the development of "pressure
pain" from increasing distention of the biliary ap-
paratus. (5) These operations are advised solely
as palliative procedures, and as such their purpose
must be clearly understood.
The Scrotal Sign in Pellagra.
The commonly held impression of the onset of pel-
lagra is that it begins with erythema of some ex-
posed part of the skin, usually the backs of the
hands. Some recent investigations* seem to dis-
prove this theory and call attention to a new sign
which in all the cases studied appeared first and
would have been overlooked had it not been for the
peculiar circumstances of the investigation. These
were the production of pellagra experimentally in
previously healthy adult males. As a means of
checking up the conclusion that a restricted diet,
chiefly of carbohydrates, is responsible for pellagra,
a record of the experimental production of this con-
dition in healthy persons by such a diet is ex-
tremely valuable. Such an experiment is recorded
in a recent Public Health Report. At the farm of
the Mississippi State Penitentiary, about 8 miles
east of Jackson, Miss., about seventy to eighty con-
victs were stationed. Twelve of these volunteered
for experiment and were put on a restricted diet.
This consisted of biscuits, mush, grits, gravy, syrup,
sweet potatoes, and collards. The twelve volun-
teers and twenty "controls" were kept under con-
stant observation, their entire skin surface being
examined every day. About five months after the
beginning of the experiment the first symptoms ap-
peared. In every case the first appearance of the
lesion was on the skin of the scrotum. Later
lesions appeared on the backs of the hands and in
one case on the back of the neck. In view of the
fact that these experiments afforded, probably for
the first time, an opportunity to observe cases of
pellagra from the beginning and that in all these
cases the scrotal sign was the first one, it would
naturally suggest the examination of the scrotum
as a routine measure in physical examinations made
in the districts where pellagra is rife. It will next
be necessary to perform the same experiment on
a group of women to determine the corresponding
initial lesion in that sex.
Nma of tip? Wttk.
Centralization of Red Cross. — The demand for
the courses of instruction conducted under the di-
rection of the National Committee on Red Cross
Nursing Service has developed so rapidly that
some of the Red Cross chapters in the larger cities
have organized teaching centers. This centraliza-
tion of instruction has been found to result in
greater economy, more uniform teaching, better
control, and better classification of those who com-
plete the courses. Centers have already been es-
tablished in Cincinnati, Chicago, Los Angeles, and
New York. To facilitate the dissemination of infor-
mation about the needs of European war sufferers
among its chapters, the American Red Cross has
established a special bureau in the Metropolitan
Tower, New York.
Status of Red Cross Base Hospital Units. — The
American Red Cross has recently issued a circular
defining the status of the base hospitals which
have been or are being organized under the De-
partment of Military Relief, and pointing out that
these have a strictly war-time purpose, and are
not available for civilian relief after disasters
other than war. The statement says: Base hos-
pitals are purely military units, organized at the
request of the Medical Departments of the Army
and Navy, and equipped with a view to the needs
of the military service only. In both organization
and equipment they are too massive and too iramo-
* "Experimental Pellagra in the Human Subject
Brought About by a Restricted Diet," By Joseph Gold-
berg and G. A. Wheeler, U. S. Public Health Service.
Nov. 4, 1916J
MEDICAL RECORD.
817
bile for civilian relief work. The muster-in pledge
contemplates only national service, when called
into the military service of the United States; and
it has been decided by the Judge Advocate General
of the Army that the law does not authorize the
calling out of these units by the President except
in time of war or when war is imminent.
Health Insurance. — A public meeting on Com-
pulsory Health Insurance will be held under the
auspices of the Committee on Medical Economics of
the Medical Society of the State of New York at
the Academy of Medicine, 17 West Forty-third
Street, New York City, on Thursday evening, No-
vember 23. The speakers will include men of na-
tional reputation and experts on Health Insurance.
Health Insurance in Canada. — The Weekly Bul-
letin of the Department of Health, New York,
states that the plank for the compulsory health
insurance of wage earners has been adopted by
the National Liberal Party of Canada as a part of
its platform for the election following the con-
clusion of the war. It is anticipated that the
Conservative party will adopt a similar progres-
sive program, and that health insurance laws will
be enacted in Canada in the early days of recon-
struction. "Compulsory health insurance of wage
earners, based on joint contributions from the
State, employers, and employees, has been estab-
lished in Germany, Austria-Hungary, Russia, Great
Britain, Holland, Norway, Roumania, and Serbia.
In most of these countries both cash and medical
benefits are provided for the insured workers, and
effective campaigns for the prevention of sickness
have become general," says the Bulletin. In this
country a bill has been drafted by the American
Association for Labor Legislation, and will be
introduced next year in more than twenty State
legislatures.
Harvey Society. — The second lecture of the
present series of the Harvey Society will be given
at the New York Academy of Medicine, 17 West
Forty-third Street, on Saturday evening, Novem-
ber 4, at eight-thirty, by Dr. F. M. Allen of the
Hospital of the Rockefeller Institute. The sub-
ject of the lecture will be, "The Role of Fat in Dia-
betes."
Personals. — Dr. Charles Lincoln Furbush of
Philadelphia has been appointed special assistant
to the American Embassy at Berlin, as medical in-
spector of prison camps in Germany.
Dr. Fernando Cakleron y Roca. a Filipino, has
been named to succeed Dr. William E. Musgrave
as medical director of the Philippine General Hos-
pital. Dr. Musgrave's resignation was recently
accepted by the Governor-General.
Dr. Harry Vaughan of Morristown, N. J., is a
candidate for the governorship, standing as the
joint nominee of the National Prohibition and the
Local Option parties.
Dr. Walter H. Brown has resigned as State epi-
demiologist of Massachusetts, and will preside as
executive officer of the Board of Health of Bridge-
port. Conn. It is planned to establish in Bridge-
port a series of clinics modeled after the out-
patient department of the Massachusetts General
Hospital.
Prof. John Scott Haldane of the University of
Oxford, who came to this country last month, and
has delivered several lectures here, sailed from
New York on October 27 for London.
Gifts to Charities.— By the will of the late Mrs.
Emily Lavanburg of New York, bequests of $10,000
each are made to Mt. Sinai Hospital, the Home for
Aged and Infirm Hebrews and the Montefiore
Home, New York.
A Public Clinic in Genito-urinary Diseases will
be held every Thursday evening at 8.30 o'clock by
Dr. Abr. L. Wolbarst, at the West Side German
Dispensary and Hospital, 328 West Forty-second
Street, New York. The clinics will begin on Novem-
ber first, and will end in April. Physicians and
medical students are cordially invited.
Clinical Society of the New York Polyclinic
Medical School and Hospital. — A regular meeting
of this society will be held in the surgical amphi-
theater of the Polyclinic, 341 West Fiftieth Street,
on Monday evening, November 6, at 8.30 P. M. The
discussion will be on goiter and the thyroid gland.
Maine Medical School.— The Medical School of
Bowdoin University, Brunswick, Me., began its
ninety-seventh annual course of instruction on
October 16, with a registration of 55. The require-
ments for admission were raised this Fall to two
years of college work, including physics, chem-
istry, biology, and either French or German. A
number of changes have been made in the fac-
ulty.
Emmanuel Movement. — The status of what is
known as the Emmanuel Movement, an employment
of the principles of psychotherapy by the clergy-
men of the Episcopal Church, may shortly be de-
termined before the Supreme Court of the State
of California. The Rev. Parker Boyd of San Fran-
cisco, said to be head of the Emmanuel Health
Institute of that city, was recently arrested on a
charge of diagnosing without a medical license,
and the case will probably be taken before the
highest court. The health institute is described
as part of the Emmanuel Movement, devoted to
suggestive therapeutic treatment.
Ambulance Work on Film. — A private view of
the film of the American Ambulance Field Service,
"Our American Boys in the European War," was
recently given in New ork. The picture shows
every detail of the work of the young American
college boys in caring for the wounded.
Hospital Destroyed. — A fire in the Roman Cath-
olic Hospital at Farnham, Quebec, on October 26,
completely destroyed the building and resulted in
a serious loss of life, the estimate being that five
children, eight women, and six men had per-
ished.
Healthy Jersey. — During the month of Septem-
ber there were reported in New Jersey 2,139 cases
of communicable diseases, as compared with 3,558
during August, a decrease of 1,419. Cases of in-
fantile paralysis dropped from 2,114 in August to
957 in September; typhoid fever showed a slight
increase, 331 cases as against 287, but both scarlet
fever and diphtheria declined.
Medical Relief for Palestine.— The Zionist Com-
mittee, New York, has secured permission from
the Department of State for the sending of a medi-
cal unit and a large quantity of drugs to Palestine,
the drugs to be shipped on the Syrian relief ship
which is to sail shortly under the joint auspices
of the Syrian Committee and the American Red
Cross. The medical unit, which will be sent as
soon as sufficient funds are collected, will consist
of ten doctors and five nurses, and will deal with
the epidemics of typhus and cholera now raging
in Palestine.
Birth Control Clinic. — After spending several
days in a still hunt, the New York police succeeded
818
MEDICAL RECORD.
[Nov. 4, 1916
on October 26 in locating and raiding the birth
control clinic established by Mrs. Margaret Sanger
in the Brownsville section of Brooklyn. Mrs. San-
ger and her assistant were arrested and held in
$500 bail each.
Death of Centenarian. — Mrs. Mary Simpson
Clingman of Cedarville, 111., died at her home on
October 23, within two months of her 107th birth-
day. She leaves four children, the oldest 74 and
the youngest 65.
Barnert Hospital Dedicated. — The new Nathan
and Miriam Barnert Memorial Hospital, erected at
a cost of $150,000, and presented to the city of
Paterson, N. J., by Mr. Nathan Barnert, as a
memorial to his wife, was dedicated on October 24.
The hospital covers an entire city block at Broad-
way and East Thirtieth Street.
Beriberi Case. — The Board of Health of New
Bedford, Mass., announced on October 24 that a
case of beriberi had been discovered in the city.
The patient arrived in this country recently on a
packet from Cape Verde.
Civil Service Examinations. — Open competitive
examinations will be held in various places in New
York State on December 2, 1916, for the purpose
of filling vacancies in the positions listed below.
Full particulars may be obtained by application
to the State Civil Service Commission, Albany,
N. Y.
Women physician, regular or homeopathic, State
hospitals and institutions. Salary, $1,000 to $1,500
and maintenance. Candidates must be licensed
medical practitioners of the State of New York,
and must have had at least one year's experience
on the medical staff of a hospital or three years'
experience in the general practice of medicine.
Physician, State prisons and reformatories. Sal-
ary, $2,000 without maintenance. Examination
open only to men who are licensed medical practi-
tioners in this State, who are not less than 25
years of age, and who have had at least three
years' practice. It is expected that one appoint-
ment will be made at Sing Sing in the near future.
Deputy medical examiner, Bureau of Deporta-
tion, State Hospital Commission. Salary, $3,500.
Applicants must be physicians licensed to practice
in New York State, and with not less than five
years' experience in the practice of Medicine.
Minimum age limit, 30 years. Applicants will be
expected to have a knowledge of the Insanity
Law and experience in the care and treatment of
the committed or alleged insane in the New York
State Hospitals, or elsewhere, or knowledge and
experience of the problem of the alien insane and
their deportation.
Dentist, Monroe County service. Open to men
only. Candidates must be graduates of a recog-
nized dental college, and eligible to enter the State
licensing examination. A vacancy exists at the
Iola Sanatorium at $60 per month.
American Medical Editors' Association. — The
Forty-seventh Annual Meeting of this Association
was held at the Hotel McAlpin, New York City,
October 25 and 26, under the presidency of Dr.
Edward C. Register of Charlotte, N. C. The report
<>f the secretary shows the affairs of this organiza-
tion in a thriving condition both financially and
as regards membership. Twenty-five applications
for membership wore received during the past
year. In his presidential address, Dr. Register
spoke on "The Freedom of the Medical Press,"
making a strong plea for the independently owned
and edited medical journal, and sounding a word
of warning against the tendency to put medical
journals officially and irrevocably under the con-
trol of medical organizations. An entire session
was devoted to a symposium on "The Duty of the
Medical Editor in Harmonizing the Doctor with
Medical Legislation and Its Administration, and
in Securing His Aid, Cooperation, and Support in
Framing and Enforcing Proper Laws, with Spe-
cial Reference to Antinarcotic Legislation." Dr.
C. F. Taylor of Philadelphia gave a resume of the
antinarcotic laws in the various States, which
showed that in a number of States the law forbids
the dispensing of narcotics by the physician. He
said : "Medical editors do not seem to have grasped
the idea now being fought out in regard to the
dispensing of remedies by physicians. One of
the errors they have fallen into is to regard dis-
pensing as a method of selling drugs. That is
totally wrong. It is simply the idea of preserving
to the doctor his right to dispense remedies to his
patients as he desires to do so. The question is
whether the doctor shall be allowed to carry a
medicine case and have the customary supply of
medicines in his office, or whether his armamenta-
rium shall be reduced to a prescription pad. Many
times the doctor must be prepared to do something
for his patient immediately. To go empty-handed,
and write a prescription for the patient to get the
medicine when the druggist pleases, will leave
many a patient in a bad situation." A dramatic
feature of this discussion was the plea of an aged
physician, who had for thirty-five years been a
morphine habitue, and who had taken thirteen
cures, without avail, for mercy and justice for
others in a like plight. He said that society con-
doned the weakness of a man who was a slave to
whiskey, while it made of the man who was ad-
dicted to the use of a drug a social outcast, without
ever attempting to understand his disease. What
was now needed was a better understanding of the
evil and a wiser course of dealing with it than by
the passage of unreasonable laws. Judge C. M.
Collins of the Court of Special Sessions told the
story of the criminal and the underworld, as he
saw it from the court room, and said that drastic
laws were needed and had come to stay. The judge,
however, could interpret the law with discretion,
and the legitimate practitioner of medicine had
little to fear. As for those who used their pro-
fession as a cloak under which to carry on illicit
traffic in drugs, the medical profession should de-
vise some way of dealing with them by which their
licenses would be revoked. He suggested an or-
ganized method, such as the legal profession now
had, for dealing with offenders against the rules
and regulations governing the practice of law.
Mr. B. C. Keith, representing the Department of
Internal Revenue, explained that the Bureau which
he represented was engaged simply in enforcing
the Harrison law, and that they needed the sup-
port of all physicians. He stated that a conserva-
tive estimate placed the number of drug habitues
in the United States at 1,000,000. Dr. Ernest F.
Bishop of New York City urged the study of the
problem of drug addiction from the clinical side.
His experience showed that the solution of the
problem rested with the medical profession and
the medical journals, who must teach that drug
addiction is a disease which belongs to the prov-
ince of internal medicine, and can be dealt with
successfully from this standpoint.
Nov. 4, 1916]
MEDICAL RECORD.
819
Among other papers read and discussed were
the following: "Latin and Greek as Prerequisites
of the Study of Medicine," by Dr. Abraham Jacobi
of New York; "The Responsibility of American
Journalism," by Dr. George M. Piersol of Phila-
delphia; "Book Reviews in Medical Journals," by
Dr. H. S. Baketel of New York; "Editorial Individ-
uality," by Ira S. Wile of New York; "The Editor's
Prerogative in Editing Original Contributions," by
Dr. H. Edwin Lewis of New York; "The Medical
Journal and Its Sphere in Medical Progress," by
Dr. A. S. Burdick of Chicago; "Independence in
Medical Journalism," by Dr. Llewellyn Eliot of
Washington, D. C. ; "The Function of a State Medi-
cal Association Journal," by Dr. George W. Kos-
mak of New York; and "The Editorial Collabo-
rator," by Dr. Samuel F. Brothers of Brooklyn.
The following officers were elected: President,
Dr. George M. Piersol of Philadelphia; First Vice-
president, Dr. Charles Wood Fassett of St. Louis;
Second Vice-president, Dr. Robert M. Green of Bos-
ton; Secretary and Treasurer, Dr. Joseph Mac-
Donald, Jr., of New York.
The annual banquet of the Association was held
at the Hotel McAlpin on the evening of October
26.
Medical Society Elections.— Vermont State
Medical Society: Annual meeting at St. Johns-
bury on Oct. 12 and 13. Officers elected: Presi-
dent, Dr. Clarence H. Beecher, Burlington; Vice-
president, Dr. Charles W. Howland, Shoreham;
Secretary, Dr. William G. Ricker, St. Johnsbury;
Treasurer, Dr. E. H. Martin, Middlebury.
New Mexico Medical Society: Annual meeting
at Albuquerque on October 13 and 14. Officers
elected: President, Dr. C. S. Losey, East Las Ve-
gas; President-elect, Dr. John W. Kensinger, Ros-
well; Vice-presidents, Dr. Charles A. Frank, Al-
buquerque; Dr. F. H. Crail, East Las Vegas; and
Dr. Hugh V. Fall, Roswell; Treasurer, Dr. Frank
E. Tull, Albuquerque; Secretary, Dr. R. E. McBride,
Las Cruces.
Henderson County (Tenn.) Medical Society:
Annual meeting at Lexington on October 11. Offi-
cers elected: President, Dr. William I. Howard,
Wildersville; Vice-presidents, Dr. J. P. Joyce and
Dr. J. B. England; Secretary, Dr. Samuel T. Par-
ker, Lexington.
St. Luke's Guild of Catholic Physicians (Bos-
ton) : Annal meeting at the Carney Hospital, Bos-
ton, on October 18. Officers elected : President, Dr.
John T. Bottomley; Vice-president, Dr. John R.
Slattery; Secretary-Treasurer, Dr. John J. Sullivan.
Relation of the Chemist to the Public Welfare. —
A meeting of the New York Section of the Ameri-
can Chemical Society will be held at the Chemists'
Club, 50 East Forty-first Street, New York City.
at which the following papers will be read: "The
General Problem of Public Service Training." by
Prof. Charles A. Beard of Columbia University and
of the Training School for Public Service; "The
Status and Compensation of the Chemist in Public
Service," by Prof. Frederick E. Breithut of the Col-
lege of the City of New York; "The Chemist in Pub-
lic Service," by Dr. Harvey W. Wiley ; "The Chemist
in the Service of New York City," by Dr. Otto H.
Klein, director Central Testing Laboratory.
New Societies Formed. — The New England Sur-
gical Society, which was organized early this year
with a membership of 75 representative surgeons
from the six New England States, held its inaugural
and first annual meeting in Boston on October 5.
6 and 7. The sessions were held at the Harvard
Medical School, at several of the Boston hospitals,
and at the Copley-Plaza. During its first year the
officers of the society have been as follows: Presi-
dent, Dr. Samuel J. Mixter, Boston ; Vice-president,
Dr. John B. Wheeler, Burlington, Vt. ; Secretary-
Treasurer, Dr. Philemon E. Truesdale, Fall River,
Mass.; Executive Committee, Dr. John W. Keefe,
Providence, R. I.; Dr. Joseph M. Flin, New Haven,
Conn.; Dr. Lyman Allen, Burlington, Vt. ; Dr. Her-
bert L. Smith, Nashua, N. H.; and Dr. William L.
Cousins, Portland, Me. The society will meet once
a year in various cities in New England.
The alumni of the College of Medicine of Ford-
ham University, New York, at a meeting held in
this city on October 27, formed an association. The
following officers were elected: President, Dr.
James McSweeney; Vice-president, Dr. John J.
Sheridan; Secretary-Treasurer, Dr. Francis Mc-
Govern. Father J. Tiernan addressed the members
of the association on "The Menace of Birth Con-
trol."
Obituary Notes.— Dr. Louis McLane Tiffany of
Mount Custis, Va., a graduate of the University of
Maryland, School of Medicine, Baltimore, in 1868,
and a member of the Medical Society of Virginia,
the Medical and Chirurgical Faculty of Maryland,
the Baltimore City Medical Society, and the Ameri-
can Surgical Association, professor emeritus of
medicine at the University of Maryland, and con-
sulting surgeon of Johns Hopkins Hospital, St. Jo-
seph's German Hospital and the Church Home and
Infirmary, died from heart disease at his home, on
October 23, aged 73 years.
Dr. David Braden Kyle of Philadelphia, a grad-
uate of Jefferson Medical College of Philadelphia in
1891, and a member of the American Medical Asso-
ciation, the Medical Society of the State of Pennsyl-
vania and the Philadelphia County Medical Society,
died at his home on October 23 from pneumonia,
after a short illness, aged 53 years. Dr. Kyle was
professor of laryngology at the Jefferson Medical
College, and a member of the American Laryngolog-
ical Association, the American Laryngological,
Rhinological and Otological Society, the American
Otological Society, the College of Physicians of
Philadelphia, the Puget Sound Academy of Ophthal-
mology and Oto-Laryngology, the Philadelphia
Pediatric Society, the Pathological Society of Phila-
delphia, the Philadelphia County Medical Society,
and the Medical Society of the State of Pennsyl-
vania, and also a fellow of the American Medical
Association.
Dr. Alexander A. Uhle of Philadelphia, a grad-
uate of the University of Pennsylvania, School of
Medicine, Philadelphia, in 1898, died suddenly fol-
lowing an injection of cocaine preliminary to an
operation on the tonsils on October 21, aged 42
years. Dr. Uhle was a member of the College of
Physicians of Philadelphia, the American Medical
Association, the Medical Society of the State of
Pennsylvania, the Philadelphia County Medical So-
ciety, the Philadelphia Academy of Surgery, the
American College of Surgeons, the American Asso-
ciation of Genito-Urinary Surgeons, the American
Urological Association, the Philadelphia Genito-
Urinary Society, and the Pathological Society of
Philadelphia. He was assistant instructor in geni-
to-urinary diseases in the University of Pennsyl-
vania, assistant surgeon to the dispensary for
genito-urinary diseases of the University Hospital,
assistant genito-urinary surgeon to the Philadelphia
General Hospital, assistant surgeon to the dispen-
sary of the German Hospital.
820
MEDICAL RECORD.
[Nov. 4, 1916
PRONUNCIATION OF POLIOMYELITIS.
To the Editor of the Medical Record :
Sir: — Here in New York somebody imagined that
euphonies would be mollycoddled by pronouncing
"poliomyelitis" as though it were spelled "pohlio-
myeleetis"; "pohlio" as in "folio," "eetis" as in
"Musketeer." This pronunciation appears to be
contagious, and it may give some young phonetist
a bad spell. The difference between doctors and
educated people is this: erudite folks were spanked
in school days if they did not know that in the
poliomyelitis question they were dealing with omi-
cron, and not with omega; consequently they now
pronounce the first part of the word as it is pro-
nounced in the first part of the line ending with
"wants a cracker." The last part of the word when
leaving Athens for New York becomes pronounced
"itis" with an eye upon the first "i" in sturdy Eng-
lish, although there is equally good authority for
pronouncing this "i" like "ee" in "teeth." One may
follow his mentor so far as this particular point is
concerned.
The public will lose that confidence in doctors
which it should not have had in the first place, if
we take liberties with the property of the English
language. In professional circles we know that not
one gynecologist in five can pronounce the name of
his specialty correctly. We may understand that
to mean that the other four are equally careless in
their diagnoses, and likely enough to treat a flexion
of the uterus by mechanical means when the auto-
nomic ganglia of a susceptible patient responding
to distant peripheral irritation are in need of bella-
donna only. That is a trade secret, and the public
willingly goes on paying bills for work that should
not be done. When it comes to a matter of pro-
nunciation of a word that is in everybody's mouth,
however, a sapient public will feel that doctors are
not to be trusted with the care of an infection if
they cannot be trusted with a word which enters
at the very threshold of a case.
Robert T. Morris, M.D., F.A.C.S.
616 Madison- Avf.ni'e, Xew York.
OUR LONDON LETTER.
(From Our Regular Correspondent.)
THE PROPOSED NEW CENTRAL MEDICAL BOARD — PRO-
TEST BY DUKE OF BEDFORD — DIFFERENCE BETWEEN
"MEDICALLY UNFIT" AND "NOT LIKELY TO BECOME
AN EFFICIENT SOLDIER" — DUTIES OF RECRUITING
AND APPROVING OFFICERS — SELECTION OF MEN
FOR R. A. M. C. — HEALTH OF LONDON FOR 1915.
London, October 7, 1916.
The Duke of Bedford has made a vigorous protest
against the government's proposal to set up a new
Central Medical Board, and he gives an illustration
of the way in which recent alterations in the re-
cruiting forms permitted an epileptic to be enlisted
and posted to a battalion; he served with the
colors for 158 days, spent about 00 days in hospital,
and on one occasion had an epileptic fit at physical
drill. He was discharged from the army as "not
likely to become an efficient soldier" — his character
marked "good." Since his discharge his general
health has further declined, his fits increasing in
frequency so that he cannot resume his former oc-
cupation. If he had been discharged as "medically
unfit" he would have been entitled to a pension, but
not as it is. The duke remarks that it is the duty
of medical boards, recruiting officers, and approv-
ing officers to guard taxpayers from financial lia-
bility arising from the enlistment of men whose
health shows that in a few months they will be dis-
charged in a worse state than on entrance. Un-
sound men on discharge have a claim for compensa-
tion for injury to their health and wage-earning
capacity while in the service. These unsound men
who are sure to have spent part of their time in
hospital are a dead loss to the State for they de-
prive sound men of training and armament, or oc-
cupy beds wanted for men invalided from the front.
The duke objects that this will only be a source of
expense and give no relief to taxpayers for past
failures of the existing system, and further he
adds that these boards and officers are paid to pre-
vent men who can only become a burden on the pub-
lic purse from being compelled to serve in the army.
He asks why when such officers fail in their duty
should the whole cost be thrown on the taxpayers
and says it is a sound principle that those who run
up the bill should contribute toward its payment.
They can easily be identified, as the names of the
officers responsible for their enlistment appear on
different army forms. The local committee should
have the power of compelling the attendance of
approving officers to explain the circumstances un-
der which unfit men were enlisted, and, if no satis-
factory explanation is given, of recommending that
the offending officers should contribute from their
pension, pay, or allowances to the compensation
that may be awarded.
It is suggested that the position of the central
medical war committee should be defined in the
military service bill now before Parliament and
in any other measure by which it is affected. At
present doctors who enroll do so through the com-
mittee which selects out of the whole number men
as required by the R. A. M. C. It seems of the
first importance that under compulsory service the
same arrangement should continue and that the
selection of unenr oiled medical men should be en-
trusted to the central medical war committee, and
this in justice both to the profession and to the
civil population.
The medical officer of the London County Council
reports that the health of the metropolis for 1915
does not compare favorably with recent years, not
so much on account of any influence of the war, as
owing to increase of deaths at relatively high ages,
attributable no doubt to a prevalence of influenza
and of other respiratory diseases during the winter
months.
The marriage rate of London for 1915, assuming
the population to be four and one-half millions,
works out at 25.9 per 1,000 living — higher than any
previous year. This rate has been slowly increasing
annually since 1908, but the bulk of the increase
last year must be attributed to the war. It is prob-
able, however, that many marriages registered in
London were not residents here. The birth-rate
which has been falling for a number of years past
was 23.6 in 1915 as compared with 24.3 in 1914
and 25 in the period 1909-13. Discussing the con-
tinuous fall in the birth-rate for the past 40 years.
the medical officer says that a theory which ascribes
it to a "change in the moral tone of the community
and to the artificial limitation of families has met
with some acceptance." Against this one of the
most cogent arguments is the fact that the fall is
widespread throughout Europe and affects certain
other civilized communities.
Nov. 4, 19 16 J
.MEDICAL RECORD.
821
Unmreaa of fHeforal fcrfenr*.
Boston Medical and Surgical Journal.
October 19, 1916.
1. Surgery of the Thyroid Gland. C. A. Porter.
2. Recent Advances in Our Knowledge of the Active Constitu-
ent of the Thyroid. Edward C. Kendall.
3. Conditions Affecting Secretion of the Thyroid Gland. W.
B. Cannon.
4. The Clinical Value of Metabolic Studies of Thyroid C
Walter M. Boothby.
5. Partial Thyroidectomy with Local Anesthesia. Scopolamine
and Morphia. Frank H. Lahey.
6. The Treatment of Graves' Disease by the Roentgen Ray.
Malcolm Seymour.
7. The Excretion of Hexamethylenamine by Damaged Kid-
neys. George Gilbert Smith.
S. The Ileocecal Valve and the Chronic Intestinal Invalid.
John Bryant.
1. Surgery of the Thyroid Gland. — C. A. Porter ana-
lyzes 185 cases of goiter in hospital and private prac-
tice of which 85, showing definite Graves's disease or
hyperthyroidism present, or very definite in the imme-
diate past, were subjected to operation. In these 85
cases there were 31 ligations and 19 hemithyroidec-
tomies; in 17 the right lobe was removed with ligation
of the vessels on the left; in 18 the major portion of
both lobes, leaving a bit of the upper or lower poles,
and a posterior strip of the gland. In the writer's
opinion partial lobectomy is a more severe and bloody
operation than hemithyroidectomy, but he feels that it
is followed by more immediate improvement and that
the danger of recurrence is less. Of these 85 cases
operated upon 20 are absolutely cured, 18 much im-
proved, 4 not improved, and requiring further operation;
16 have not reported. Medical treatment of the cases
not subjected to operation is discussed and the conclu-
sion reached that if, after a patient has had a reason-
able course of rest, medical treatment, and x-ray treat-
ment, the symptoms persist, operation should be ad-
vised. Among wage-earners, who cannot give up the
time, and in the chronic cases, in which the disease
has advanced too far to allow of delay after a pre-
liminary rest, operation should be performed. Whether
this be a preliminary ligation, or lobectomy under local
or general anesthesia, must be determined in each case.
Finally, in chronic cases, in which there is doubt as to
whether the patient is suffering from existing toxemia
or has been poisoned irreparably by the disease, modern
tests, of which basal metabolism is probably the most
important, will aid the surgeon much in deciding for or
against operation.
2. Recent Advances in the Knowledge of the Active
Constituent in the Thyroid; Its Chemical Nature and
Function. — Edward C. Kendall recalls that about eight-
een months ago he reported the isolation from the thy-
roid of a crystaline compound containing GO per cent,
iodine. Since that time he has perfected the method
for its isolation and has studied its chemical property
and functions. He has experimented on animals and
obtained a large number of results from clinical obser-
vations from which it appears that the entire activity
of the gland is manifested by the administration of this
crystaline compound alone. There appears to be no
other substance in the thyroid secretion which acts di-
rectly. After the administration of the compound there
is no apparent effect for many hours. There is no in-
creased pulse rate or drop in blood pressure. However,
if the thyroid hormone and amino acids are injected
simultaneously, the pulse rate is enormously affected,
and even death may result, due to the apparently great
increase in metabolism going on in the animal. It
appears very probable that the thyroid hormone mani-
fests its activity by reacting in some way with amino
acids.
4. The Clinical Value of Metabolic Studies of Thyroid
Cases. — Walter M. Boothby states that disease? of the
thyroid gland, with their extreme variations in basal
metabolism, afford a most striking example of the sig-
nificance of metabolic studies. Basal metabolism for
clinical purposes can be obtained with a high degree of
accuracy by collecting, measuring, and analyzing the
expired air. In normal persons the basal metabolism
rarely varies more than 10 per cent, from a normal
figure, depending upon age and sex, when compared by
surface area determined by DuBois height-weight
curve. Several cases of thyroid dystrophies, in which
the basal metabolism was determined, are cited, and
these show that in conditions of thyroid overactivity
the metabolism may increase to over 100 per cent, above
normal, and in conditions of underactivity it may be
decreased to 50 per cent, below normal. They have
found that the patient's condition, judging from the
sum total of the objective and subjective symptoms,
correspond very strikingly to the numerical expression
of the basal metabolism.
G. The Treatment of Graves' Disease by the Roent-
gen Ray. — Malcolm Seymour writes that they have had
under Roentgen ray treatment at the Massachusetts
General Hospital 144 cases of Graves' disease, the
treatment of most of these having been carried on since
August 1, 1915. Of these 144, eighty have been given at
least two treatments and all of these have shown im-
provement, with the exception of seven cases. Nearly
all have gained in weight, the average gain having been
seven pounds. The pulse rate has been lowered in all
but a few cases, the average being twelve beats. The
writer outlines his method of treatment and concludes
that the advantages of the Roentgen ray treatment are
that there are no fatalities; there is no resulting scare,
as after operations; it is painless and, if unsuccessful,
an operation may be done with less risk, because of
the favorable action of the x-ray on the thymus gland.
7. The Excretion of Hexamethylenamine by Dam-
aged Kidneys. — George Gilbert Smith has been investi-
gating the statement made by Falk and Sugiura that
in a number of pathological cases involving the impair-
ment of kidney function, abnormally small amounts of
hexamethylene tetramine were excreted. The cases
studied, fourteen in number, fell into two groups: (1)
the surgical kidneys resulting from renal calculus ob-
obstructing prostate, etc., and (2) the medical nephriti?
of chronic interstitial or glomerular type. As positive
evidence on the question of the output of urotropin by
infected kidneys, facts are presented drawn from a
study of ten cases of undoubted renal disease of this
type. In every case urotropin was excreted; in three
cases, in a strength of 1 to 10,000; in two, 1 to 30,000;
in one 1 to 40,000. It was weaker in the other fou'-
although strong enough to give a definite test with
Burnam's method. In chronic nephritis of advanced
degree, in three cases a diminution in the output of
urotropin which would be a serious factor in its employ-
ment as a therapeutic agent. Fortunately, in such
cases it need seldom be employed. In kidneys damaged
by infection, even to a very marked degree, the drug
may be excreted in a strength as high as 1 to 10,000.
The fact must be borne in mind that, no matter how
much urotropin is excreted, it will be useless as a bac-
tericide unless it is broken up into formaldehyde by
urine, which is definitely acid.
8. The Ileocecal Valve and the Chronic Intestinal In-
valid.— John Bryant presents a preliminary note on val-
vular incompetence, together with a number of case
reports demonstrating successful non-surgical therapy
in this condition. He states that his personal experi-
ence seems to justify the following assertions:
(1) In the mild or ambulent group of chronic intestinal
cases, the frequency of incompetence may be distinctly
822
MEDICAL RECORD.
[Nov. 4, 1916
in excess even of the accepted ratio of one to five. (2)
When present, incompetence should be treated as an un-
desirable pathological entity; an entity, however, usu-
ally responsive to intelligent treatment. (3) Under ade-
quate medical treatment the patient may be assured at
least some degree of improvement, with corresponding
alleviation of symptoms; surgery is only secondarily
indicated. (4) Medical treatment may even restore
the valve to complete competence. (5) The progress and
results of treatment are under absolute control through
the agency of the bismuth-Roentgen meal and enema.
Given a case with a chronic intestinal history, with local
pain, coarse crepitation on pressure over the right iliac
fossa, excessive gas formation not easily relieved, con-
stipation, stasis, and evidences of toxic absorption and
a presumption of valvular incompetence is created,
which should be subjected to proof by the x-ray.
New York Medical Journal.
October 21, 191G.
1. Considerations in the Medical Treatment of Goiter.. J.
M. Anders.
2. The Early Diagnosis of Tuberculosis. Edward O. Otis.
3. Removal of a Third Lobe of a Cystic Goiter. A. Ernest
Gallant.
4. Focal Points of Infection. Noble P. Barnes.
5. Laryngeal Abscess. Milton J. Ballin.
6. Leiomyoma of the Pylorus. Joseph R. Eastman and
Harry K. Bonn.
7. Gravid Uterus Duplex. W. R. Jackson.
8. Tuberculosis of the Bronchial Glands. Marv E. Lapham
9. Pyorrhea Alveolaris. R. G. Hutchinson, Jr.
10. Chauffeur's Fracture of the Radius. A. C. Burnham.
11. Pseudoscarletina. Bernard Frankel.
1. Considerations in the Medical Treatment of Goiter.
J. M. Anders says that the medical treatment of goiter
must have special reference primarily to the particular
clinical variety. For example, if the given case in hand
is of the non-toxic form, then iodine and thyroid ex-
tract are indicated; if of the toxic type, or exophthalmic
goiter, then these medicaments would be for the most
part pernicious in their nature. It has always seemed
to him to be the part of wisdom to discontinue the iodine
in cases in which the thyroid extract is exhibited, on ac-
count of failure of the former remedy to bring about a
cure. If, however, the dessicated thyroid extract, like
the iodine, fails when employed alone, then these reme-
dies should be given simultaneously, their action being
almost identical, notwithstanding. Should untoward re-
sults follow the thyroid medication, they may be suc-
cessfully combated by two or three minim doses, thrice
daily, after food, of Fowler's solution. Disappearance of
goiter should be the signal for the discontinuance of
the remedy but a recurrence, however slight, should
lead promptly to its readministration. An ointment of
biniodide of mercury with massage over the gland
favors absorption of the hyperplasia. The treatment
of this type of goiter is entirely satisfactory, provided
that the condition is recognized early enough, and iodine
and other agents recommended are judiciously and
promptly employed. Amonc the prominent causative
factors of Graves's disease are emotional excitement,
shocks, tuberculosis, rheumatism, syphilis, and intoxi-
cation from the. intestinal canal, and each of these
should receive proper and careful attention. Of the
numerous available remedies which have been advo-
cated, two are worthy of mention, quinine hydrobromide
and antithyroids Mobius.
2. The Early Diagnosis of Tuberculosis. — Edward 0.
Otis treats of this subject and concludes that the diag-
nosis of early clinical tuberculosis depends upon the
careful and painstaking assembling, correlation, and
study of the symptoms, together with the evidence of
the temperature and pulse and such definite physical
signs as can be clearly discerned. The main reliance
must be upon the symptoms, the pulse and the tempera-
ture. If the physician spent the major part of his
time and efforts in studying the symptoms and less upon
the attempt to determine uncertain physical signs, fewer
cases would slip through his hands unrecognized.
3. Removal of the Third Lobe of a Cystic Goiter. — A.
Ernest Gallant reports this operation upon a woman
with exophthalmos and the points of interest which led
to a report of this case were as follows: (1) The
mother and five sisters had goiter and were said to
have been cured by medicine; (2) the successive en-
largement of the right and left lobes after removal of
the middle lobe, with intervals of fourteen and four
years, respectively; (3) the aphonia following the sec-
ond operation, and restoration of the voice after the
third operation; (4) the very disagreeable effects when
thyroid gland or potassium iodide was administered;
(5) the almost uninterrupted discharge from the sinus,
and the serious discomfort and "queer feelings" when-
ever the sinus closed temporarily and the secretion
could not escape; (6) the marked diminution of the
exophthalmos; (7) the return of a considerable growth
of hair in a woman of her age (fifty odd years).
5. Laryngeal Abscess. — Milton J. Ballin reports three
cases which he believes are clear examples of laryngeal
abscess in which the localized suppuration was situated,
as in the majority of instances, on the left side, and in
which complete recovery ensued after timely intralaryn-
geal measures. The main purpose in presenting this
subject is to call attention to the infrequency of this
laryngeal infection and to emphasize the fact that if it
is recognized in time and urgent intralaryngeal
measures are adopted, alarming complications can be
prevented, and a satisfactory outcome can be ob-
tained in the majority of the cases.
6. Leiomyoma of the Pylorus. — Joseph R. Eastman
and Harry K. Bonn state that since the stomach is the
primary seat of approximately two-thirds of all gastro-
intestinal earcinomata, it follows that the diagnosis of
any tumor of the stomach is especially important in
patients at the cancer age. For this reason they deemed
this case of leimyoma of the pylorus, occurring in a
man fifty-eight years of age, of sufficient interest to
justify its report. It serves to emphasize the follow-
ing points: (1) Benign neoplasm of the pylorus, es-
pecially the myomata, may simulate early carcinoma.
(2) Even though the patient has reached the cancer
age, benign neoplasm cannot be excluded. (3) Care-
ful sectioning and study of benign neoplasms is nec-
essary for correct diagnosis. (4) The frozen section
method cannot be considered an infallible method of
diagnosis in this type of neoplasm.
8. Tuberculosis of the Bronchial Glands. — Mary E.
Lapham says that the symptoms of tuberculosis of the
bronchial glands are caused by the absorption of toxins
and by pressure on adjacent structures. The syndrome
of tuberculous toxemia is the same as that from the
lungs; it is the pressure symptoms that are of partic-
ular interest in this form of tuberculosis. Compression
of the great vessels may cause cyanosis and edema of
the face or even edema of, and hemorrhages into the
meninges. It is possible that compression of the supe-
rior vena cava may have something to do with the rap-
idly fatal cases of cynosis, dyspmea, unconsciousness
and death, so typically fatal in the bronchial gland tu-
berculosis of infants. It is also possible that the stasis
in the mcningal circulation explains the association of
tuberculosis meningitis with that of the bronchial
glands. As a rule, the meningitis attacks children in
apparently good health, and without the knowledge ac-
quired at autopsy there would be no reason for sus-
pecting that meningitis may be secondary to absolutely
concealed tuberculous processes in the bronchial glands.
Autopsies teach that this association always exists, and
,
Nov. 4, 1916 J
MEDICAL RECORD.
823
it is inferred that the rapidity of meningeal processes
leaves no time for slower developments. Pressure upon
the sympathetic may cause irritability of the vasal
motors, evidenced by rapid changes from palor to
blushes; unequal or unilateral flushing of the cheeks;
circumscribed reddening of the second intercostal space,
associated with menstrual rises in temperature, a con-
sciousness of unstable heart action, of fiutterings and
palpitations and quickened pulse; unequal pupils and
protrusion of the eyeballs. It is probable that a cer-
tain class of gastrointestinal disturbances, character-
ized by lack or suppression of functional activities, may
be due to pressure upon the sympathetic nerves, because
these disturbances are present in tuberculosis of the
bronchial glands when pulmonary tuberculosis cannot
be proved. It is possible that the rhachialgias and in-
tercostal neuralgias preceding the discovery of tubercu-
losis of the spine may also be caused by enlarged bron-
chial glands and the infection of the spine may prove
to be a secondary condition. Pain in the region of the
trapezius is one of the earliest symptoms of tubercu-
losis of the bronchial glands, as is also pain over the
root of the lung. Pressure upon the fibers of the re-
current laryngeal may cause pain in the larynx, laryn-
gospasm, and paralysis of the vocal cord. Changes in
the quality of the voice may be one of the very early
manifestations of enlarged bronchial glands.
Journal of the American Medical Association.
October 21, 1916.
1. Fertility and Sterility: A Histological Study of the Sper-
matozoa, the Ovaries, and the Uterine and Vaginal Se-
cretions in Their Relation to This Question. Edward
Reynolds.
2. Experimentally Transplanted and Transposed Whole
Metatarsal Bones. W. L,. Brown and C. P. Brown
3. The Etiology of Epidemic Poliomyelitis: Preliminary
Note. E. C. Rosenow. E. B. Towne" and G. W. Wheeler.
4. Experimental Studies in the Etiology of Acute Epidemic
Poliomyelitis John W. Xuzum and Maximilian
Herzog.
5. A New Instrument for the Clinical Measurement of Dark
Adaptation. Harry S. Gradle.
f>. Immune Human Serum in the Treatment of Acute Polio-
myelitis. C. W. Wells.
7. A Report of One Hundred Consecutive Cases of Fibro-
myomata Uteri Subjected to Operation. Stephen E.
Tracy.
S. Operative Treatment of Fibromyomatous Uterine Tumors.
John B. Deaver.
9. Recent Progress in the Treatment of Uterine Cancer. J.
H. Jacobson.
10. Bacterial Vaccines in Treatment of Pulmonary Tubercu-
losis. Impressions as to Clinical Value. S. G. Bonney.
1. Fertility and Sterility: A Histological> Study of
the Spermatozoa, the Ovaries, and the Uterine and Vagi-
nal Secretions in Their Relation to This Question. — Ed-
ward Reynolds. See Medical Record, June 17, 1916,
page 1113.)
2. Experimentally Transplanted and Transposed
Whole Metatarsal Bones. — W. L. Brown and C. P. Brown
relate the experiments they have made on dogs and
present a number of .v-ray photographs showing the
results obtained. In describing their technique they state
that all the dogs' feet and sides for the transplants
were prepared after the dog was anesthetized with
ether by shaving and painting with full strength tinc-
ture of iodine. Following the operation, all wounds on
the feet were dressed with a liberal quantity of pheno-
lated gauze and adhesive plaster. The wounds of the
thighs and backs were always dressed with collodion
and cotton. There were no infections. They state in
conclusion that: 1. True transplantation of a part or
whole bone into the tissue, where it has no function
to perform, is a very different matter from transposing
an entire bone into the bed of its fellow of the op-
posite side. 2. Whole metatarsal bones covered with
periosteum, their articular ends included, and trans-
posed into the position occupied by their fellow of the
opposite side will live, functionate, and grow, but when
truly transplanted under like circumstances into the
tissues, where they do not act as an integral part of
the bony framework and have no function to perform,
they are invariably absorbed, as are all other trans-
plants under like circumstances.
3. The Etiology of Epidemic Poliomyelitis; Prelimi-
nary Note. — E. C. Rosenow, E. B. Towne, and G. W.
Wheeler. (See Medical Record, October 21, page
7739.)
4. Experimental Studies in the Etiology of Acute
Epidemic Poliomyelitis. — John W. Nuzum and Maximil-
ian Herzog state that they have obtained from the
postmortem material in typical cases of poliomyelitis,
from tissues of the central nervous system, tonsils and
mesenteric glands, and from the cerebrospinal fluid
obtained by lumbar puncture during life, a grampositive
micrococcus which grows well on dextrose ascites broth
to which a sterile piece of rabbit's kidney has been
added — but always better aerobically than anaerobi-
cally. Cultures of this organism, when injected into
monkeys, produced the typical clinical and pathologic
picture of acute poliomyelitis. Definite flaccid paraly-
sis has been produced in dogs and in many young rab-
bits. In rabbits, however, as others have pointed out
before us, there is a variation in the microscopic
picture, although many of the changes attendant on the
disease in man and monkeys are present in the central
nervous system of the rabbit following paralysis.
Anaerobic cultures in fluid mediums were passed
through Berkefeld filters V, and inoculations of the
filtrate into suitable mediums produced a growth of
the larger form of the organism seen in aerobic cul-
tures. This would seem to indicate that the organism
under anaerobic conditions assumes a form so small
that it may pass through the Berkefeld filter. The
virus of rabies, as is well known, presents itself in a
large form, the Negri bodies, and in the small puncti-
form granules which can evidently pass the filter. In
considering the gram-positive coccus in its etiologic
relation to acute poliomyelitis, we must remember that
it may act as a carrier of a real ultramicroscopic in-
visible virus which, together with this micrococcus,
might still be transferred in the cultures and passed
along in the inoculations. In tissues from the central
nervous system of poliomyelitic material preserved in
50 per cent, sterile glycerin, this same micrococcus was
alive after a period of thirty-five days, and could be
cultivated in pure culture on suitable mediums.
6. Immune Human Serum in the Treatment of Acute
Poliomyelitis. — C. W. Wells reports a series of fifteen
cases of acute poliomyelitis treated by the administra-
tion of immune human serum. He says the adminis-
tration of immune human serum in acute poliomyelitis is
lia?ed on the recognized principles of immunity. Be-
cause the lesions are not confined to the nervous system,
and because the lesions therein consist essentially of
perivascular infiltration, intravenous injection of serum
appears to be rational procedure, either alone or in
combination with intraspinal injection. The intra-
venous injections of serum should, if possible, consist
of doses of from 50 to 100 c.c. or more daily. Follow-
ing the intravenous or intramuscular injections of
serum, spinal fluid should be withdrawn. The intra-
spinal injection of the serum usually produces an in-
crease in the number of leucocytes with increase in the
proportion of polymorphonuclear cells in the spinal
fluid. No ill effects have followed the use of serum in
this series, either by intravenous or intraspinal injec-
tion. In all cases after the intravenous injection, and
to a less degree after intraspinal injection, a noticeable
improvement usually occurred, which unfortunately in
some cases was only transient. The early administra-
824
MEDICAL RECORD.
[Nov. 4, 1916
tion of the serum is urged, necessitating therefore an
early diagnosis of the disease. In severe cases late
administration of the serum has produced little if any
noticeable influence on the course.
7. Report of 100 Consecutive Cases of Fibromyomata
Uteri Subjected to Operation. — Stephen E. Tracy. (See
Medical Record, July 8, page 87.)
8. Operative Treatment for Fibromyomatous Uterine
Tumors. — John B. Deaver. (See Medical Record, July
8, page 87.)
9. Recent Progress in the Treatment of Uterine Can-
cer.— J. H. Jacobson. (See Medical Record, July 8,
page 87.)
10. Bacterial Vaccines in the Treatment of Pulmo-
nary Tuberculosis — Impressions as to Clinical Value. —
S. G. Bonney writes that from the data so far obtained
his position is that vaccine therapy should by no means
be permitted as a routine measure in the treatment of
tuberculosis. It has a place as a tentative procedure in
a class of cases subject to certain modifying limitations.
The careful adjustment of the dosage is vitally impor-
tant. The results obtained are very uncertain. The
gain established in a few cases is, however, impressive.
The proportion of cases exhibiting improvement is
disappointing. Vaccines not infrequently are shown to
possess vast possibilities of injury. In the use of vac-
cines the attitude of the profession should be one of
the utmost conservatism. The cautious employment of
baterial vaccines would seem to be appropriate chiefly
for persons who fail to show gratifying improvement
under conservative management and should be restricted
largely to this class of patients. It does not from this
follow that vaccines are indicated for all patients
who are doing poorly. It may, however, be granted
that a demonstrated inability to respond favorably to
an intelligent regimen suggests the expediency of
specific therapy. On the whole the writer's experience
with vaccines in far advanced cases have been disap-
pointing, though he has had one or two instances in
which the clinical picture was unexpectedly trans-
formed. The results obtained in a fair proportion of
cases in which there was moderate fever have been
such as to encourage the further cautious employment
of vaccine therapy. This is also true to a large ex-
tent in afebrile cases. The greater proportion of such
invalids may be expected to make fairly satisfactory
progress under proper supervision without recourse
to vaccine therapy, but occasional indications for its
administration may be found in patients with distress-
ing cough and abundant expectoration. In this class of
patients the application of vaccine therapy is some-
times gratifying.
The Lancet.
September 30, 1916.
1. An Inquiry into the Natural History ot Septic Wounds.
Kenneth Goadby.
2. The After-care of Persons Suffering from Fulmonary
Tuberculosis, P. C. Varrier-Jones.
3. An Enquiry into the Clinical and Radiological Diagnosis
of Intrathoracic Tuberculosis in Children of School
Age. Walker Overend and Clive Riviere.
4. Enucleation of the Tonsils. Walter W. Howarth.
5. Treatment of Cloth by Antiseptic Substances in Relation
to Wound Infections. Mary Da^
1. An Inquiry into the Natural History of Septic-
Wounds. — Kenneth Goadby presents the second section
of this report which was prepared for the Medical Re-
search Committee. In the first section, published in
The Lancet, July 15, sinus formation and the bacteria
present in sinuses and sequestra were considered. This
section of the report deals more particularly with vac-
cine therapy. The incidence of organisms found in
the examination of 200 cases of septic wounds, accord-
ing to the day of examination after wounding, is pre-
sented and detailed data with reference to the vaccine
treatment given. Out of the total of 200 cases, the
malignant edema group of organisms was found in 38
per cent.; the B. perfringens in 75 per cent.; B. hibler
closely follows malignant edema; B. proteus and B. coli
occur in 47 per cent, and 40 per cent, respectively;
streptococci in 81 per cent., and staphylococci in 86 per
cent. Or it might be stated that anaerobic bacteria
were present in some 50 per cent, of badly wounded
cases and about 20 per cent, of simple flesh wounds,
but the incidence of aerobic bacteria is more common,
being met with in about the same relative proportion in
all the wounds examined. These wounds were exam-
ined at least two days after the injury. The investiga-
tion warrants the conclusion that anaerobic bacteria
present in a large proportion of the wounds owe their
infectivity to the association with anaerobic species,
and that among these species the proteus and coli
groups and streptococci, some of the latter being facul-
tative anaerobic, are to be regarded as largely con-
cerned in the development of acute septic processes
within and around the wounds. Two series of cases
were treated, one with vaccine and one without, the
treatment being exactly parallel in other respects. The
comparison of these series was based on the determina-
tion of the duration of the febrile period as deter-
mined by temperature charts and by the period during
which the patient remained in the hospital. Examin-
ing the two series critically, the evidence is overwhelm-
ing that the protection afforded by the vaccines was
responsible for the absence of secondary hemorrhage
in the vaccine cases. No vaccine case developed acute
gas gangrene, although the bacterial flora and the phys-
ical condition of the wounds were certainly highly
potential. There is a difference of ten days in the
duration of the fever in favor of the vaccine cases and
a difference of 27 days in the hospital. As a result
of this investigation the author recommends the fol-
lowing routine treatment: Polyvalent vaccines should
be prepared from strains of organisms isolated from
the infected wounds, consisting of (1) streptococci
(aerobic and anaerobic varieties), sensitized with anti-
streptococcal serum; (2) B. proteus; (3). B. lactis
aerogenes, and (4) B. coli. A mixed vaccine of sensi-
tized polyvalent streptococcus 5,000,000, with B. proteus
10,000,000, should be given to all septic cases when ad-
mitted, pending the bacteriological report. In cases of
gas gangrene streptococcal vaccine combined with
B. proteus and B. lactis aerogenes should be used in
strengths of 10,000,000 each. The inoculations as in-
dicated by the bacteriological examination should be
repeated on the third day, and the dose raised to 10,-
000,000 streptococci with 20,000,000 of the appropri-
ate bacilli. Meanwhile, autogenous vaccine may, if
necessary, be prepared for special cases when desira-
ble. The author also discusses plating and wiring in
septic fractures and states that in severely septic
wounds it is not invariably followed by the disastrous
results sometimes attributed to this method. When
plating and wiring are carried out in immunized sub-
jects the results seem highly satisfactory.
3. Inquiry into the Clinical and Radiological Diag-
nosis of Intrathoracic Tuberculosis in Children of School
Age. — Walker Overend and Clive Riviere give this re-
sume of an investigation undertaken for the Local Gov-
ernment Board of London. The material of inquiry
was formed by 61 children between the ages of five
and ten, being resident in the district of Bethnal Green.
They belonged to three classes, the first containing
children with no known source of tuberculous infection
in the house, the second exposed to infection of slight
or limited extent, and the third to severe infection, one
or both parents having in many cases died of the dis-
ease. Of 23 children from healthy households, 12
Nov. 4, 191 6 J
MEDICAL RECORD.
825
showed abnormal physical signs in the chest; of 19
cases with a limited household infection only four were
free from signs of the disease, while of 19 cases with
a severe household infection five were free from phys-
ical signs of the disease. It was found that the reflex
bands of impairment suggestive of active lung involve-
ment showed a notably higher incidence in the first
two classes than in the last, suggesting that with longer
exposure the active processes have time to die down.
Enlarged supraclavicular glands were found in a few
cases and appeared to be of some value where found.
Radiographical examination for the most part accorded
with the clinical findings in this series. Wherever clin-
ical evidence of the involvement of the tracheo-bron-
chial glands existed this was confirmed by the x-ray.
In a few cases radiograms showed tracheo-bronchial
opacity unnoted at the clinical examination. Bifur-
cation glands were visible in nearly all cases on the
oblique radiogram; evidently a definite degree of en-
largement is necessary to produce the characteristic
right paravertebral dullness observed on clinical ex-
amination. The relation of hilum opacities to pul-
monary glands could not be clearly established. In
commenting on his observations in this series of cases
the author expresses the opinion that it serves to in-
crease our sense of the artificiality of the distinction
between tuberculous "infection" and tuberculous "dis-
ease," and that it not only appears that tuberculous in-
fection is widespread, as has long been known, but also
actual tuberculous disease of a degree that can be de-
tected clinically. These facts would seem to call for a
readjustment of our clinical concepts.
5. Treatment of Cloth by Antiseptic Substances in
Relation to Wound Infections. — Mary Davies, in collab-
oration with Kenneth Taylor, has made an investiga-
tion to ascertain whether antiseptic substances incor-
porated with cloth will have any power to inhibit the
growth of bacteria after the cloth so treated has been
exposed to the open air for some time before being
heavily infected. A variety of antiseptics were tested,
the one finally chosen for further experimentation be-
ing pyxol, a compound of cresols and soft soap. This
compound has the advantages of being easily procurable,
fairly inexpensive, and inoffensive as regards color.
Garments are saturated with a 5 per cent, solution and
worn before the antiseptic has thoroughly dried on
them. Experimentally it has been possible to prevent
cloth from becoming a focus of infection in the test
tube and in wounds by treating it with an antiseptic
before it is contaminated with infected material. Some
degree of bactericidal value is retained even after a
month's constant exposure to hot sun and storms of
rain. An open wound coming into contact with anti-
septic clothing would be less likely to become badly in-
fected, even if both clothes and skin were extremely
dirty at the time, than is the case where neither clothes
nor skin have any property of inhibiting the growth of
bacteria with which they become saturated during
trench fighting. If these deductions prove correct the
practice of periodically impregnating the clothing of
armies upon active service with an antiseptic would
fully repay its cost in reducing the proportion of highly
septic wounds. Antiseptics of the cresol type seem to
be most useful and practical.
British Medical Journal.
September 30, 1916.
1. Radical Abdominal Operation for Carcinoma of the Cervix
Uteri : Result of One Hundred Cases Reckoned on an
Absolute Cure Basis. C'omyns Berkeley and Victor
Bonney.
2. The Use of Insecticides Against Uice. A. Bacot.
3. A Fatal C'ise of Gastroenteritis Due to Bacillus Aertrycke
vet Suipestifer. E. J. McWeeney.
1. Perchloride of Mercury Poisoning by Absorption from the
Vagina. A. F. Wilkie Millar.
... Case of Puerperal Septicemia Treated by Autogenous Vac-
cine, with Recovery. William Grier.
6. A New Solid Medium for the Isolation of the Cholera
Vibrio. H. Graeme Gibson.
7. Note on the Value of Hexamine In Aural Suppuration and
in Meningitis. Douglas Guthrie.
1. The Radical Abdominal Operation for Carcinoma
of the Cervix Uteri.— Comyns Berkeley and Victor Bon-
ney report their experience with a series of 100 cases
of carconoma of the cervic uteri operated on between
April, 1907, and September, 1911, by the radical ab-
dominal method, using a very thorough operation con-
sisting of the removal of the uterus with its cervix
contained in a bag formed of the upper half or two-
thirds of the vagina, closed by a clamp, designed for this
purpose. The ovaries are removed with the uterus and
upper portion of the vagina, also the Fallopian tubes,
broad ligaments, parametric and paravaginal tissue
down to the upper surface of the levator ani, and the
glands and cellular tissue occupying the obturator
fossae and investing the external and internal iliac
arteries and veins. In cases in which the glands about
the external iliac artery and vein are obviously carci-
nomatous, the dissection is carried up to the bifurcation
of the aorta. The results of the operation in this 100
cases, among which were many who had been dismissed
from other hospitals as inoperable, were as follows:
Died of the operation, 20; died of recurrent growth, 32;
died of other diseases, 2; lost sight of, 7; cured, 39. In
every case the regional glands removed at operation
were microscopically examined, and in thirty-five were
found to be malignant. Of the thirty-nine cured cases
all were known to be well at the present time. These
writers report an operability rate of 62.5 per cent, and
have found from the large number of cases they have
dealt with that patients suitable for operation pre-
senting themselves to the surgeon for the first time
have, on an average, had symptoms for six months.
The life expectation of these women is, therefore, on an
average one year and three months. It may, therefore,
be stated with confidence that where the patient sur-
vives the operation for three years or over, her life
has been prolonged by the operation. On this basis
the present series showed that out of eighty cases that
survived the operation, forty-nine, or 61.2 per cent., had
their lives prolonged.
2. The Use of Insecticides Against Lice. — A. Bacot
describes the various experiments that he has made
to determine the insecticidal effect when substances
were used in diluted condition to impregnate cloth.
Cytisine was found satisfactory from an experimental
point of view, but offered the objections that in the con-
centration in which it was effective it might have a
toxic effect and the cost of production would make it
an expensive remedy. Further experiments suggest that
a practical remedy may be found for preventing the
spread of lice among troops by the use of a crude liquid
carbolic acid and soft soap emulsion for the impregna-
tion of shirts and underclothing. The emulsion should
consist of 45 to 50 per cent, of soft soap, combined by
heating with 50 to 55 per cent, of the crude carbolic. A
5 per cent, solution in warm water should be used to
impregnate the garments. To determine the practica-
bility of this suggestion tests should be made to ascer-
tain the percentage of men likely to have irritable skins
which might be susceptible to this percentage of cresol
and the efficacy of the remedy to keep the men free from
lice in the field.
4. Perchloride of Mercury Poisoning by Absorption
from the Vagina. — A. F. Wilkie Millar reports a case of
perchloride of mercury poisoning which occurred as the
result of placing a tablet in the vagina under the im-
pression that it would serve the same surpose as when
826
MEDICAL RECORD.
[Nov. 4, 1916
dissolved and used as a douche. Twelve hours later
the symptoms of poisoning- appeared and progressed
rapidly to a fatal termination. Particular interest
attaches to the typical nature of the symptoms pro-
duced and the manner in which mercury picks out the
lower end of the small intestine, the cecum, and the as-
cending colon as its selective site. The changes found in
the kidneys showed the marked action of the mercury on
this organ. This case is also interesting from its
medicolegal aspect.
6. A New Solid Medium for the Isolation of the Chol-
era Vibrio. — H. Graeme Gibson describes his method of
preparing an alkaline medium, which possesses differ-
entiating properties which should be especially useful
in the detection of cholera carriers, as the feces emul-
sified in broth can be plated directly on it. The method
is based on the fact the cholera vibrio alone of all the
intestinal organisms acidifies starch. In the case of
water examination, after enrichment in peptone water
for a few hours, a drop or two of the peptone water
is plated and a tentative diagnosis can then be arrived
at in eighteen hours owing to the allied vibrios taking
a longer time than the true cholera vibrio to bring
about acid production. After forty-eight hours, if the
cholera colonies are in excess and the plate spread
somewhat thickly, the medium itself becomes distinctly
acid, and colonies other than those of cholera take on
a distinctly pink tinge; the cholera colonies, however,
can still be distinguished by their deeper red center
which other colonies lack.
7. Note on the Value of Hexamine in Aural Suppu-
ration and in Meningitis. — Douglas Guthrie has made a
number of experiments to determine the correctness of
the findings reported by Crowe that hexamine given by
the mouth could be detected in the cerebrospinal fluid
withdrawn by lumbar puncture one hour later, and that
after the subdural inoculation of dogs and rabbits with
streptococci the administration of hexamine appeared
in many cases to avert the onset of meningitis. Bar-
ton, following up these observations, suggested that
the drug might be useful in middle ear suppuration as
he had been able to recover it from aural discharges.
The writer finds two sources of fallacy in the results
and deduction of these workers. First they employed
Hener's sulphuric acid test, which does not differentiate
between the drug hexamine and its decomposition prod-
uct formaldehyde. Secondly, hexamine is not split up
and hence can be of no antiseptic value in any but an
acid medium. Ear discharges and cerebrospinal fluid
are alkaline. His experiments show that after the
administration of hexamine it appeared in the urine in
all cases, but in no instance could it be detected in the
aural discharge even when the most delicate test, the
Rimini-Burnam reaction, was employed. The drug was
given in large doses and symptoms of intolerance ap-
peared in two cases. With regard to the cerebrospinal
fluid, results seem to point to a similar conclusion, either
that the drug does not make its way into the fluid at
all or appears in such small quantities as to be of no
therapeutic value. Intradural injections of hexamine
may conceivably have some effect on the meninges near
the site of injection, but oral administration is useless.
Revue Medicale de la Suisse Romande.
S( /-'■ mbi i- 20, 1916.
The Von Pirquct Reaction in the Schools of Lausanne.
Wi'ith. after a general outline of the results of this
t ion and of the incidence of tuberculosis, states that
Lausanne has a comparatively low death rate for this
affection, one, moreover, which is virtually stationary.
In comparison with other Swiss cities, however, it is
high, and it has been proposed to use the von Pirquet in
the schools. Is it wise to test thousands of children with
the result that a few more lives may be saved? Ac-
cording to authorities 95 per cent, of all children are tu-
berculous, i.e. have the condition in a latent form. What
would be the good if all were "pirquetized?" By rights,
according to theoretic conditions, one would need to be
"pirquetized" weekly, for those not infected could read-
ily become so. Would a negative reaction guarantee
that a child was not tuberculous ? The advocates of the
test admit that such children as are candidates for tu-
berculosis betray this lack of resistance in many ways.
These are the real suspects. Nevertheless should uni-
versal tests be practised? To cause a reduction in the
incidence of tuberculosis prophylaxis seems the logical
course. This means general sanitation, rigidly carried
out, plus school hygiene. The author and other oppo-
nents of "pirquetization" are not opposed to the test
per se, i.e. they have no fear of complications, nor do
they shrink from the physical effort, nor are they old
fogies. The task, however, increases with each year be-
cause both positives and negatives must be followed up,
along with all new pupils. There can be no common
ground between "pirquetization" and vaccination for
smallpox, for the latter is meant to protect directly the
individual and the public.
Progressive Lipodystrophy in a Child. — Boissonnas
relates the case of a boy of six years, of good antece-
dents, and normal in appearance until three and one-half
years of age, when he developed whooping-cough, with
sequential emaciation of the face. Later he was at-
tacked by influenza, as a consequence, perhaps, of which
he developed a nephritis. The lipodystrophy may or
may not have been determined or aggravated by some
of these illnesses, but only the pertussis seemed respon-
sible for its onset. Examined he showed normal growth,
skeletal configuration, etc., but the face showed a re-
markable contrast to the rest of the physique, which in
general was in a flourishing state. The face was thin
and pinched, the cheeks furrowed, the eyes sunken. The
skin of the face was supple and normal, but contained no
subcutaneous fat. The muscles of the face were all in-
tact as were those of the tongue. The neck was thin,
and one did not encounter a panniculus until the level of
the clavicles and upper border of the scapula?. The pan-
niculus of the trunk was normal. There was an accumu-
lation of adipose on the buttocks and upper portion of
the thighs. The genitals were well developed. The legs
were plump, but there was no obliteration of the knees
and malleoli or dorsum of the foot. Of the cases of this
malady on record the majority have been in females.
Thus far treatment is without influence on the progress
of this dystrophy.
Hydrophobia in the Foxes of Alaska. — Captain Feren-
baugh, U. S. Army, mentions the fact that so-called
crazy foxes were seen in the Yukon Delta region in the
spring of 1915. With mouths hanging open and drip-
ping with foam they would approach settlements and
try to bite the dogs. Demented, stiff, and emaciated,
they were easily killed. Nevertheless five dogs were
bitten and succumbed to rabies. In the interior of
Alaska the disease seems to have been unknown until
1914, when a man died of the disease three weeks after
the bite of an Esquimaux dog. During the crazy fox
episode a soldier was bitten by one of the infected dogs.
He was hurried to San Francisco, took a Pasteur cure
and has since remained well. The Esquimaux have in
general regarded the craziness of the fox as the result
of starvation. But any naturally shy animal which
unprovoked attacks men and dogs is best regarded as
rabid. — The Military Surgeon.
Nov. 4, 1916]
MKDICAL RECORD.
827
Sunk iRfutauH.
The Influence of Jov. By George Van Ness Dear-
born, Instructor in Psychology and in Education,
Sargent Normal School, Cambridge, Mass., etc.
(Mind and Health Series. Edited by H. Addington
Bruce, A.M.) Price, $1 net. Boston: Little, Brown
& Co., 1916.
Several books have already appeared in this series,
which might be called one of popular psychology. This
volume is based chiefly on certain experiments made by
the author and others demonstrating the physiological
effect of certain emotions, particularly the benign one
of joy, on bodily systems. The whole theory is, of
course, a further application of the conditioned reflex
as discovered by Pavlov in the last decade of the Nine-
teenth century. It is, in fact, a scientific support of
the "New Thought" doctrines formulated for popular
reading. The only defect is that while admittedly a
book primarily for popular consumption, the writer
finds difficulty in reaching the level of his audience.
Thus we have such statements as "Kinesthesia may be
considered the dynamic index of organism always in
motion in relation to mind, and in emotion this principle
is more obvious than elsewhere" (p. 21). And again,
"Suggestion then is the more or less impulsive deter-
mination of a motive through influence exerted on the
associative 'resultants' of the cortex, and implies a les-
sened control from the more purely voluntary and per-
sonal correlations as well usually as a narrowing of the
field of consciousness" (p. 139).
Dr. Dearborn in the first part of his book describes
the action of joy in stimulating secretions in the gastro-
intestinal tract, its influence on the circulation; he de-
scribes the effect of good humor and enthusiasm on the
nervous system, and finally its beneficent effects on the
love-life. In the second part he lays down a philoso-
phy of life something after the style of the Cheeryble
brothers. He indicts in somewhat familiar phraseology
the fiends of indolence and worry and praises work and
play, both to be done of course with an ostentatious
joyousness. Finally he alludes to the pragmatic side
and points out the economic value of joy to the world.
The latter part of the book has a much wider appeal
than the earlier part and is much easier for the lav
reader to understand. The book as a whole should find
its audience chiefly among physicians, educators, nurses,
and employers of labor.
Diet for Children, A Complete System of Nursery Diet
with Numerous Recipes; Also Many Menus for
Young and Older School Children; A Home and
School Guide for Mothers, Teachers, Nurses and
Physicians. By Louise E. Hogan (Mrs. John L.
Hogan). Author of "How to Feed Children," "A
Study of a Child," "The Introduction of Domestic
Science in the Schools of New York City," U. S.
Government Bulletin No. 56. etc. Price $.75. In-
dianapolis: The Bobbs-Merrill Company, 1916.
One of the most hopeful signs in these times of restless
feminine activity is the awakening to the needs of ra-
tional and thoroughly intelligent feeding not only of
bab'es but of children and older bovs and girls, by the
mothers and other women engaged in caring for the
young of the race. Louise Hogan has made a success-
ful attempt to meet this demand. She quotes the great
Abernathy in saying that one-fourth of what we eat
keens us and the other three-fourths we keen at the
pe'il of our lives. This book is a wise endeavor to
reduce this peril.
Obstetrics Normal and Operative. By George Peas-
lee Shears, B.S., M.D. Professor of Obstetrics and
Attending Obstetrician at the New York Polyclinic
Medical School and Hospital; formerly Instructor in
Obstetrics, Cornell University Medical College: At-
tending Obstetrician at the New York Citv Hosnital:
Senior Attending Obstetrician at the Miserie^rdia
Hosuital. With 419 illustrations. Price. $6.00.
Philadelphia and London : J. B. Lippincott Co., 191fi.
Through the irony of circumstances, the author of this
work died suddenly while the result of his labors was
going through the press. His aim, although he was of
scholarly cast of mind, was to produce a purely prac-
tical book and in this he has succeeded well, although
not a few treatises on obstetrics are written with this
very aim. The more practical a book the more individ-
ualized it must be, for it is certainly not altogether
practical to cite the teachings of other men save when
the latter are endorsed fully by the author from his
own experience; and the author has certainly written
a personal book. In turning over the pages we see
relatively few citations. As a test, under obstetric
surgery, we do not find mention of a single contempo-
rary author in forty consecutive pages of text, and this
is not an isolated instance. On the other hand he has
borrowed illustrations very freely, with due credit to
the source. In regard to the burning questions of the
day he advocates a partial substitute for twilight sleep
— two small injections of morphin-hyoscin in the first
stage. He does not even mention nitrous oxide under
anesthesia, save that in obstetric operations "it should
never be given until after delivery." In puerperal
sepsis he is a strong advocate of the serum treatment.
He prefers Dew's method in asphyxia neonatorum and
of mechanical methods Holden's apparatus. The gen-
eral attitude of the author is conservative, which is no
doubt wise from the teaching standpoint. Still the
public is entitled to a full mention of recent matter of
importance, which might be given in fine print, or in
some other way which would not interfere with a con-
servative attitude in the principal text. There is a
very large per cent, of students who wish to lean, and
rather heavily, upon a one-man text-book while others
differently constituted, find the study of such a work a
useful discipline, for they too must in time depend
chiefly upon the results of their own experience for
practice and teaching. Hence Dr. Shear's book should
meet with a ready sale.
Operative Midwifery. A Guide to the Difficulties and
Complications of Midwifery Practice. By J. M.
Munro Kerr, M.D., CM., Glas. Fellow of the
Royal Faculty of Physicians and Surgeons, Glas-
gow; Hon. Fellow, American Gynecological Society;
Professor of Obstetrics and Gynecology, Glasgow
University (Muirhead Chair) ; Obstetric Physician,
Glasgow Maternity Hospital; Gynecologist, Royal In-
firmary, etc. Third edition. Price, $6. New York:
William Wood & Company, 1916.
The first edition of this work appeared in 1908 as a
successor to the volumes on the same subject by Barnes
and Herman. The present edition contains twenty
more pages of text and fourteen more cuts than the
original book. When we bear in mind that the work is
for all practical purposes a manual of operations and
that only accredited procedures can be recommended,
and also that it is very largely a personal book, we can
understand why numerous remedies are omitted, such
as mechanical methods of reanimating the newly born,
lumbar puncture in eclampsia, etc. On the other hand,
the new edition is particularly full on cesarean section,
the number of indications for the latter being now very
large. The book is a worthy successor of Barnes's
"Obstetric Operations" and Herman's "Difficult Labor."
Abnormal Children (Nervous, Mischievous, Pre-
cocious, and Backward). A book for Parents, Teach-
ers, and Medical Officers of Schools. By BERNARD
Hollander, M. D., Author of "The Mental Functions
of the Brain." Price, $1.25 net. London: Kegan
Paul, French, Trubner & Co., Ltd. New York: E. P.
Dutton & Co., 1916.
As noted on the title page, this book is addressed to an
audience chiefly lay in character, and is subject to the
implied limitations. It is, as a matter of fact, a brief
description of feeblemindedness, precocity, and neurotic
manifestations in children, with some glittering gen-
eralities offered in the way of treatment. As often
happens to the writer who attempts to present medical
matters in a popular vein, the author is obliged to be
superficial and dogmatic, at times even to the verge of
misrepresentation. Thus he says, "Heredity is by far
the most frequent and the most potent predisposing
cause of nervous and mental disease." And again, "A
man who can drink continually for a number of years
and keep out of a lunatic asylum, a prison, or a hos-
pital, must possess an inherently stable physical and
mental organization." Like most English writers, he
uses the unfortunate terms "lunatic" and "insane"
freely. He also speaks of sexual immorality as if it
were peculiar to urban life, says that somnambulists
can read, and after alluding to the Binet-Simon tests
in a paragraph, makes the interesting observation that
they have been criticized as not being individual
enough, and concludes by saying, "Anyhow, the prin-
ciple is right, and it should be easy to improve upon
the details." Goddard, Yerkes, Bridges, Healy, et al.,
take notice! But aside from these statements, to which
the hvnp'Tn'tjeal might take exception, as they might
to his individual phrenology, the book is quite readable,
and we should imaeine could not be read by the parent
or teacher without benefit.
828
MEDICAL RECORD.
LNov. 4, 1916
&flrt?ty Squirts.
MEDICAL SOCIETY OF THE STATE OF PENN-
SYLVANIA.
Sixty-sixth Annual Session, Held at Scranton, Sep-
tember 18, 1<J, 20, and 21, 1916.
(Special Report to the Medical Record.)
(Continued from page 701.)
SECTION ON MEDICINE.
Chairman's Address. — Dr. J. Wesley Ellenbekger of
Hariisbuig referred to the average increase of human
life fiom uventy-nve years in the sixteenth century to
forty-seven years at the piesent time, which increase
he aitiibuted to the work of the medical profession. He
suggested as possibly an ideal system for the better
service of the many the grouping in one building of an
internist, a surgeon, a laboratory man, and other
specialists with individual offices; the fees to be divided
according to the amount of service given and in harmony
with established prices. Attention was called to the
prospective health insurance bill and the co-operation
of physicians urged that a satisfactory bill might be
presented to the Legislature.
Types of Pneumococci in Infants and Children. — Dr.
A. Graeme Mitchell of Philadelphia said the present
study was undertaken to ascertain whether the same
types of pneumococci were present in infants and
children with pneumonia as in adults. He found that
the so-called fixed types of pneumococci were of infre-
quent occurrence in infants and children as compared
with adults; that the pneumococci without definite ag-
glutination reactions and classed as Type IV were of
more frequent occurrence in infants and children than
in adults; that the mortality of infants and children
infected with the fixed types (I, II, III) seemed to be
lower than in adults. The fixed type occurred at all
ages from six months to eleven years. Type IV was
found often to cause as severe an infection as the fixed
types. Type I seemed to cause a mild infection. Type
IV was found to be the most frequent infecting organ-
ism in bronchopneumonia, although the fixed types
might be found. Complications were found more fre-
quently with Type IV.
The Specific Treatment of Acute Lobar Pneumonia. —
Dr. Rufus Cole of New York stated that the specific
treatment of a disease consisted in treatment directed
toward the destruction or inhibition of the growth of
the etiological agent in the body, or neutralization of
the injurious substances produced by this agent. With
present knowledge, specific treatment might consist in
the employment of drugs having a specific action
(chemotherapy) or the use of measures based on es-
tablished principles of immunity (immunotherapy). In
the latter case, at least, exact knowledge of the etio-
logic agent in each individual case must be obtained.
This, he said, was especially important in pneumonia,
for different races of pneumococci showed well-marked
immunological differences, there being at least four
different types of pneumococci. Methods were now
known for determining quickly in each individual case
the type of pneumococci concerned. To increase the
patient's resistance, it was observed that he might be
stimulated to produce immune bodies himself (bv the
employment of vaccines) or immune bodies might be
administered to him by giving him immune serum. At
present the author stated that there was no experi-
mental evidence and no conclusive clinical evidence in-
dicating that the first method was effective. There was
reason for believing, however, that the use of imnr.ine
serum would be of value. Clinical experience indi-
cated that an immune serum effective against Type I
pneumococci had great clinical value. Immune sera
again: t the other types, however, wore at present not
of therapeutic importance. The onlv specific ehemo-
theraneutic agent against pneumococci now known was
ethylhydroeuprein (optochin.) In the emnlovment of
this drug proper dosage was said to be of fundamental
importance. The proper dosage had been determined
through experimental and clinical studies. Clinical
studies, employing this proper dosage, suggested that
this drug might be of considerable therapeutic value.
The Treatment of Pneumonia bv Other Than Specific
Methods— Dr. M. HOWARD Fussell of Philadelphia re-
garded fresh air, rest and most vigilant watchfulness
as the princinal factors in the care of croupous pneu-
monia. Cardiac weakness demanded digitalis, caffeine.
camphor. Food should be nourishing and of moderate
amount. Alcohol was of use when there had been ad-
diction during health. It was useful as a food in small
quantities, not more than 2 or 3 ounces in twenty-
four hours. Strychnine might be given fairly con-
tinuously.
Dr. Lawrence Litchfield of Pittsburgh, discussing
Dr. Mitchell's paper, referred to Type IV being the
infection most fiequently found in children, and sug-
gested in this type the term "Group" rather than Type,
since this group was made up of different types. Re-
garding Dr. Fussell's paper he emphasized especially
the importance of keeping the patient warm when he
was being cared for in a cold room or on the porch.
There should be plenty of woolen blankets under the
patient as well as sufficient covering over him, and if
the weather were very cold he would put the patient
between blankets. He also emphasized the value of
using abundance of water. If not readily taken by
the mouth it should be used intravenously and with
dextrose rather than sodium chloride.
Osteomalacia. — Dr. Lawrence Litchfield of Pitts-
burgh gave a brief consideration of skeletal disorders
more or less closely related to osteomalacia; different
theories as to etiology- — disorders of the ductless glands,
acidosis, calcium metabolism and infection, with report
of a case. In conclusion the author said that it would
seem that at the present time the rational procedure
is a ease of osteomalacia should be an attempt to secure
the best possible hygienic environment, a generous diet,
rich in phosphorus and calcium, the avoidance of termi-
nation of lactation, the avoidance of pregnancy,
adrenalin therapy, and if no improvement were noted,
sterilization of the patient by the a;-ray; if then no im-
provement, ovariectomy, possibly followed by a return
to the administration of phosphorus and the hypo
dermic use of adrenalin.
Acidosis. — Dr. J. Harold Austin of Philadelphia de-
fined acidosis as an abnormal diminution in the amount
of carbonates and phosphates of the blood. To the
severe grades of acidosis having the peculiar hyperpnea
without cyanosis he applied the term acid intoxication.
For determining the mild forms of acidosis and the
more accurate diagnosis of all forms mention was made
of several of the newer laboratory methods. The de-
pleted base in the blood should be replaced and this was
best accomplished by the administration of bicarbonate
of soda. Alkali might bring about a cessation of the
hyperpnea of acid intoxication and diminish the labora-
tory evidence of acidosis. In the severest cases of acid
intoxication, however, death occurred even when the
urine had been rendered alkaline.
Dr. Alfred Stencel of Philadelphia called attention
to the tendency of overlooking subsidiary conditions of
greater importance perhaps than the definite ascer-
tained disease under treatment. This tendency was
particularly to be remembered in the treatment of aci-
dosis so frequently associated with other diseases. For
example, a patient might be more seriouslv threatened
by an accompanying cardiac decompensation than the
acidosis. Similarly in renal disease the accompanying
acidosis might be the more serious condition. He felt
that the general impression that cases of acid intoxi
cation were necessarily fatal was not correct. He, per-
sonally, had seen two cases recover.
The Failing Heart; Recognition and Care of Certain
Types. — Dr. Howard S. Anders of Philadelphia re-
garded the relation of the failing heart to heart failure
as that of incipient tuberculosis to the advanced stact
of the disease. He believed the failing heart to be
almost invariably curable. One of the best danger
sienals of the condition was a ventricular flatter, pal-
pable and audible near the apex beat and limited to the
aren bounded above bv the third interspace and within
by the left parasternal line. Intestinal autotoxemia he
regarded as one of the most palpable causes of a heart
that is failing functionally. Digestive disturbances
with gastric and co'onic distention and acidosis were
also frequent elements in failing heart.
Dr. James D. Heard of Pittsburgh cited two cases
demonstrating the inability at times to discover the
underlying pathology in cardiac failur<\ The first case
was an instance of auricular fibrillation in which
autopsy showed a lesion of the sino-auricular node: the
second, one of complete heart block without demon-
strable causative organic lesion. Emnhasis was rriven
to the great prognostic va'ue of early recognition of
alternation of the pulse. The longest survival of any
pntient recorded was in a patient of Tabora who was
alive six years after the arrhythmia was noted. Dr.
Nov. 4, 1916]
MEDICAL RECORD.
829
Heard regarded it as improbable that the majority of
such natients would live more than a year.
The Curability of Certain Cases of Chronic Nephritis.
— Dr. Alfred Stengel of Philadelphia discussed the
question of chronic nephritis as a chronic condition,
offering the proposition which he believed to be in keep-
ing with the teaching of most pathologists, that chronic
nephritis, like some other so-called chronic diseases, is
not at ail a chronic disease in the sense that it is a
process which once initiated through the impetus origi-
nally given goes on and on as a progressive malady.
Chronic arthritis, chronic myocarditis, and sclerosis of
the liver were cited as not being in a strict sense chronic
diseases in that they had inherent tendency to pro-
gressive deterioration as a result of the original im-
petus. They required for their increase a repetition of
stimuli or of assault similar to the original one or the
same as the original one. This he regarded as an im-
portant fundamental principle and defensible in regard
to chronic nephritis. Evidence was submitted to show
the relation of nephritis to infections and the prob-
ability that repeated reinfections occasion a gradually
increasing involvement of the kidneys. Clinical evi-
dence was cited as showing that removal of foci of
infections is sometimes followed by an arrest of ths
disease, or, if not too far advanced, by complete dis-
appearance of the evidences.
Dr. Davis Riesman of Philadelphia suggested the
possibility of the over-emphasis at present of the sub-
ject of foca! infection. This, however, was not entirely
without merit, since subsequent to the over-emphasis,
the little that was useful would remain. He believed
that heredity was an etiological factor in nephritis and
cited the case of a child dying from chronic parenchyma-
ous nephritis. The father of the child had had chronic
interstitial nephritis. He believed that the mistaken
diagnosis of nephritis is sometimes given upon the dis-
covery of albumen. A stone, while giving no classical
symptoms, might be the focal cause of albumen and
casts. Such had been proved to be the condition in a
man who had been refused life insurance because of the
urinary findings. In a boy of eight years of age re-
garded as a case of hopeless chronic nephritis perfect
recovery followed removal of the tonsils, which appar-
ently were the site of focal infection.
Dr. James D. Heard expressed his belief that the
question of focal infection was not sufficiently consid-
ered in connection with the so-called degenerative con-
ditions of kidney, heart, and blood vessels. Removal
of sources of infection from the cardiac mechanism of-
fered corroborative evidence of the influence of focal
infection; a case in point was one of temporary fibril-
lary auricle in a diabetic patient in which upon the
Allen treatment the urine became sugar frse and the
blood picture returned to normal.
Dr. George E. Holtzapple of York regarded the
relationship between focal infection and chronic ne-
phritis and other degenerative diseases so important
and yet so apt to be overlooked that it should be con-
tinually emphasized. Carefully taken histories would
frequently reveal evidence of chronic interstitial ne-
phritis with but little to account for it beyond the pres-
ence of some infection, such as scarlet fever, in child-
hood. He emphasized the fact that focal infection
might exist without local manifestation at the portal
of entry and was discoverable only by the rr-ray. Even
when not found he was not unmindful that focal infec-
tion might exist.
Dr. Harry M. Keller of Hazleton agreed with Dr.
Stengel concerning the relationship of focal infection
of the teeth and tonsils to disease of the kidneys and
other degenerative affections. The point confronting
the general practitioner, however, was that of deciding
when to pull out all the teeth of his patients, which
decision might be rendered increasingly difficult by the
opposing views of two or more a>ray specialists.
Dr. Stengel, in closing, observed that nephritic pa-
tients were liable to local diseases, secondary to the
nephritis and that a discovered focus might be the
result of an existing nephritis rather than the cause
of it. No haim could be- done, however, in treating the
lesion known to exist. Replying to Dr. Keller, it was
obvious that sundry healthy teeth would have to seek
that Valhalla where some of the appendices of surgical
patients had found their place. Mistakes would be
made bv the over-enthusiastic and uninformed. He was
not, however, addressing himself to that sort of prac-
titioner, but calling attention rather to the importance
of the proper investigation in all chronic diseases in
wnic.i ij.uu.o be included nephritis.
Typhoid and Typhophors. — Dr. Samuel G. Dixon,
Commissioner of Health of Pennsylvania, reviewed the
work of the Bureau of Health in the prevention of
typhoid fever and quoted its statistics of 3917 deaths
from typhoid fever in 1906 and 1025 in 1915. There
were reported in 1906 sick of typhoid fever 24,471 ; in
1915, the number was 8048. The name of typhophor
was suggested as brief and distinctive for the "carrier"
of typhoid fever. The history of a "carrier" was given
who had been traced in an outbreak of typhoid fever
in Perry County in the spring of last year. Under
treatment with kaolin and autogenous vac. in the
Hospital of the University of Pennsylvania in the serv-
ice of Dr. Alfred Stengel the patient had regained her
normal health. Emphasis was given to the importance
of the protection of watersheds against pollution and
possible carriers among construction and repair
workers.
Dr. Alfred Stengel referred to the use of kaolin in
the case under discussion as a beautiful illustration of
the introduction of physical chemistry into medicine and
surgery, the credit of which was due to the bacteri-
ologists. After six negative cultures had been secured
he had regarded the patient as probably cured. Three
negative cultures required by some health boards he did
not believe were adequate.
The Attitude of the Department of Labor and Indus-
try Toward the Problem of Occupational Diseases. —
Mr. John Price Jackson of the Department of Labor
and Industry of Pennsylvania reviewed the results of
the Workmen's Compensation Act since its inaugura-
tion on Jan. 1, and called attention to the proposed
amendments of the law, notable the problem of what
should constitute an occupational disease. He urged
the importance of reports upon occupational diseases
being forwarded to the department and of the holding
of clinics of such diseases that the question might be
adequately considered in the preparation of the pro-
posed amendments. The profession was urged also to
give thoughtful consideration to the proposed compul-
sory health insurance, and to its corrollary, old age
insurance. Were such attention not given the possi-
bility was mentioned of a resultant paternalistic and
injurious governmental system.
Dr. J. W. Schereschewsky of the United States
Public Health Service called attention to inconsistencies
arising in the general ob'ection to industry bearing the
economic loss due to certain forms of occupational dis-
ease. Such an instance was to be observed in the case
of a man being suddenly overcome by benzol fumes
while waterproofing a tank; in contrast to which a
girl working in a cannery might become chronically poi-
soned by benzol fumes and death result. The only
difference in the two cases would be the period of time
in which death ensued. The inference was logical that
if compensation were due in the first instance it was
equally so in the second. Social insurance was to be
regarded as the next most important social advance.
Were the cost of such social insurance conditioned in a
special locality or industry by the general prevalence of
disease, obviously it would create a strong financial
stimulus to preventive measures.
Dr. H. F. Smyth of Philadelphia said that in defining
an occupational disease there must be considered the
patient's previous occupation, general health and
physique, personal habits and home hygiene as well as
the general hygiene of the plant where he was em-
ployed and precautions taken to minimize the particular
hazard. To increase the number of compensable dis-
eases full reports upon all occupational diseases he felt
should be compulsory, such tabulation showing also
the proportion of diseased to healthy individuals in the
industry. He had had occasion to note the entire lack
of such statistics throughout the United States.
Dr. James I. Johnston of Pittsburgh cited as illus-
trating complexities arising under the administration of
the act the case of a coal miner who had had a fracture
of the rib and in whom tuberculosis had become estab-
lished. It was suggested as not improbable that the
man had had tuberculosis and that his resistance to the
disease had been lowered by the accident. How to
settle the question equitably to all concerned offered
some difficulties.
Dr. Francis D. Patterson of the Department of
Labor and Industry, in closing the discussion for Com-
missioner Jackson, urged that the medical profession
of Pennsylvania formulate a definition of occupational
disease which would stand an "acid test."
Some Phases of Chronic Colitis.— Dr. Edwin Zug-
smith of Pittsburgh considered the more common forms
830
MEDICAL RECORD.
[Nov. 4, 1916
of mucous and membranous colitis. Usually the dis-
covery of mucus in the stools would establish the diag-
nosis. The amount of mucus varied from microscopic
quantities to great masses constituting the entire dis-
charge. Record had been made of a single evacuation
of several pounds. The anemia and nervous irritability
often present in colitis, the author stated, were fre-
quently responsible for the diagnosis of neurasthenia.
Pain, fatigue and meager endurance were mentioned as
prominent features of the disease. Colitis was said to
be often a secondary process resulting from infectious
states of the gums and teeth and other focal infection.
The relief of the bowel condition subsequent to the cure
of pus was mentioned as an indication of the septic
origin of colitis. In the absence of the pancreatic
juice and bile or their diminution or alteration colitis
was practically certain to follow. Ptosis, said by some
to be invariably present in colitis, was considered a pre-
disposing cause. The relationship of colitis and ap-
pendicitis was said to be very close, and special atten-
tion to the colon following appendectomy was advised.
Colitis, while often a secondary process, might give
rise to other conditions, such as neurasthenic symptoms
and joint affections. Severe inflammatory rheumatism
was considered as a frequent resultant of a diseased
colon. Confusion in diagnosis was said to occur from
absence of examination of the stools. The proximity
of the hepatic flexure also caused confusion in diagnosis.
Because of the widespread teaching that pain after eat-
ing indicated ulcer colitis was sometimes mistaken for
ulcer of the stomach or duodenum. Such teaching Dr.
Zugsmith regarded as fallacious. With proper food and
under hygiene and medication many cases of colitis were
cured, while most of the cases were helped to the point
of complete comfort.
Dr. Samuel G. Gant of New York regarded colitis
and constipation as much more frequently of rectal than
of abdominal origin. He believed that such patients were
often over-treated. Local treatment should be given
in chronic ulcerative colitis, catarrhal or specific. The
x-ray and the microscope he believed to be overrated,
since in chronic ulceration and diarrhea diagnosis could
be made by the symptoms, proctoscopic inspection of the
rectum and microscopic examination of the stools. Care
should be taken to see during irrigation that the medica-
ment came in contact with all sides of the bowel. He ad-
vised as the best non-operative treatment the placing of
the patient in the inverted position and filling the colon
with about a quart of coal oil. Flushing of the colon
with a solution of 20 grains of nitrate of silver and a
quart of water would reduce the number of stools. Re-
sultant pain was to be treated by washing out the colon
with a saline solution. Such a patient should be placed
upon a diet of baked potatoes and unsalted butter.
Dr. Lawrence Litchfield of Pittsburgh regarded the
giving of too many enemas one of the commonest causes
in the mild type of chronic colitis. He had found one
of the heavier forms of liquid paraffin useful in the
constipation, and has been particularly impressed with
the association of chronic colitis and neurasthenia and
hysterical conditions. In cases enteroptotic, congenital
or acquired, he had seen the greatest benefit from a
course of rest and feeding as suggested by William
Gerry Morgan in Washington.
Dr. Zugsmith, in closing, said that the association
of colitis with ptosis was so frequent that it was of
necessity found in many patients who were nervous.
This nervousness was increased by the absorption from
the bowel with the consequent irritation; as these con-
ditions improved the nervousness disappeared to a very
great degree.
The Chemical Diagnosis of (Jail-Bladder Disease. —
Dr. Martin E. Rehfuss considered the diagnosis of
gall-bladder disease, and particularly stone, from the
standpoint of the examination of the blood serum for
the cholesterol content, examination of the bile obtained
by mean- of duodenal intubation, and the microchemical
studies of the feces. Attention was directed to the im-
portance of a definite increase of serum cholesterol in
the causation of calculi. He had found in thirty cases
of various conditions, sixteen being stone, a positive
increase of serum cholesterol in every one. In the ma-
jority of another series of forty cases hypercho-
lesteolemia was found. The importance of the micro-
chemical examination of the feces was emphasized, in-
asmuch as gall-bladder and hepatic disturbances were,
as a rule, accompanied by disturbances in fat digestion
and in bile elimination
The Diagnosis and Treatment of Chronic Intestinal
Indigestion in Children. — Dr. Robert K. Rewalt of
Williamsport emphasized the importance of recognition
and treatment of this most frequent condition found
in children to which too little attention was paid. The
diagnosis was to be based upon the symptomatology
which was rather comprehensive, and included irrita-
bility, capricious appetite, coated tongue, irregular
fever, abdominal pain, tympanites and flatulence, con-
stipation, poor physical condition, secondary anemia, in-
dicanuria, and peculiar nervous phenomena. Treatment
was to be based upon general management, strict diet
with intelligent co-operation of mother and nurse, and
drugs.
Dr. Harry Lowenburg of Philadelphia said it was
not always possible to determine whether the digestive
features present in these cases were primary, or the
secondary effects of an underlying etiological factor.
Such factor might be assumed to be a biochemical toxin
which, interfering with the nervous mechanism of the
gut prevented digestion and assimilation of food. It
was also true that this toxin might be secondary to a
disturbance of the digestive function as the result of
prolonged injudicious feeding or of psychic shock inci-
dent to vicious environment. The non-digestion and
subsequent fermentation, however, were dependent upon
the character of food and the intestinal bacterial flora,
and not upon the inherent defect in the gut. The term
toxic diathesis in Dr. Lowenburg's opinion would better
describe the condition discussed than chronic intestinal
indigestion. Cases exhibiting irregular temperature ex-
tending over some time Dr. Lowenburg would attribute
in all probability to chronically diseased caseous ton-
sils or to some other focus of suppuration in which case
the digestive symptoms would be secondary. He would
urge a systematic examination of the urine and of the
stools in all of these cases. Diet was to be considered
individually. In his experience the elimination of milk
for a month or so was beneficial. Milk and scraped
beef he believed to be incompatible, and he would sub-
stitute the term pancreatization for peptonization, being
more comprehensive and self-explanatory. Evacuation
of the bowels was better secured by the use of general
measures, the local use of suppositories, glycerin and
water enemas and the administration of toxic laxatives,
than by purgation.
The Value of Roentgen Rays in the Diagnosis of
Pulmonary Tuberculosis. — Dr. Willis F. Manges of
Philadelphia presented this paper, and among the con-
clusions from his study the following are noted: That
tubercles of macroscopic size, miliary or conglomerate,
cast recognizable shadows on the sensitive plate; that
the presence of tubercle shadows was essential to defi-
nite x-ray diagnosis, regardless of the variety, stage
or extent of the lesion ; that the lesion in the depth
of the lung was as easily recognized as one at the sur-
face; that in the acute exudative stage of bronchopneu-
monic phthisis the tubercle shadows might be obscured
by the exudate shadows, and that there might be other
cause of localized exudate than tuberculosis; that the
roentgenogram frequently revealed tuberculosis over-
looked clinically, and that in the Roentgen rays there
was at hand a means of diagnosis as positive as the
findings of tubercle bacilli in the sputum and available
at a much earlier period in the disease.
Dr. George E. Pfahler of Philadelphia said that by
means of well prepared stereoscopic plates the skilled
roentgenologist could detect tubercles in the lungs when
no larger than a pin head. In every case, however,
there should be careful physical diagnosis as well as
Roentgen study. The old idea that tuberculosis could
not be definitely diagnosed until tubercle bacilli were
found in the sputum must be abandoned in the interest
of this class of patients. While a Roentgen study was
valuable in all cases it was especially so in early and
recurrent cases and in the chests of children. The diffi-
culty in .r-ray diagnosis of pulmonary disease, he said,
was not so much in not detecting the disease as in de-
termining its nature when recorded upon the photo-
graphic plate. Here even the most expert must still be
in doubt upon certain points. By co-operation of phy-
sician and Roentgenologist, however, these points would
be illuminated and a decided advance made in the diag-
nosis and treatment of pulmonary tuberculosis.
Dr. James I. Johnston of Pittsburgh emphasized the
importance of supplementing the physical study of sus-
pected tuberculosis with the x-ray plate. In the very
early cases and in the determination of the activity of
the lesion it would seem to an internist that the oppor-
tunity of the medical man were greater than that of
the Roentgenologist.
Epidemiology and Clinical Features of Infantile
Nov. 4, 1916]
MEDICAL RECORD.
831
Paralysis. — Dr. Charles A. Fife of Philadelphia said
that the epidemicity of infantile paralysis was first
recognized in 1890. The disease had evidently been ob-
served, however, by Underwood in 1774 and by Jork
in 1816. While the theory of contagion by personal
contact he said was supported by more evidence than
any other he thought it probable that a specific carrier
would be found. He regarded infantile paralysis as es-
sentially a general infection in which the organisms and
possibly toxins had a special affinity for the nervous
system. Such a disease might cause innumerable com-
binations of signs and symptoms. The importance of
the so-called abortive type and the preparalytic stage
of the other types were emphasized in connection with
public health considerations. Many children, he said,
had developed paralysis some days after "an attack of
indigestion" which might have been prevented by rest.
Dr. Alfred Hand, Jr., of Philadelphia described sev-
eral widely varying cases of infantile paralysis which
had been under his care. One was that of a man aged
48 who had sore throat, restlessness, inability to
sleep, loss of appetite, with twitching of the muscles
of the left side of the face. Bell's palsy of the left side
of the face developed, and two days later paralysis
of the right shoulder spreading to the leg. Uncon-
sciousness and paralysis of the bladder and rectum fol-
lowed, and death occurred in nine days. Sections of
the medulla studied by Dr. Spiller showed lesions of
acute anterior poliomyelitis.
Dr. Theodore H. Weisenburg of Philadelphia re-
ferred to his study of infantile paralysis from the neu-
rological standpoint. Practically all deaths had been
due to respiratory paralysis. The meningeal cases had
been very numerous. In the meningeal cases there was
in most instances marked increase of cerebrospinal
fluid, although in one or two cases a dry tap had been
obtained. He had seen a large number of bulbar cases;
blindness, but once. He regarded lumbar puncture the
best treatment, to be repeated as frequently as indi-
cated. He was not enthusiastic concerning serum
treatment; he believed that adrenalin offered a little
more hope. He placed much emphasis upon the im-
portance of rest.
Dr. Theodore LeBoutillier of Philadelphia believed
the number of abortive cases of infantile paralysis in
the present epidemic to be quite large. While he be-
lieved that the abortive type would give acquired im-
munity to a child for life, the case of one child had
been observed who had an apparently authentic history
of a second attack of the disease. In the transmission
of the disease he was inclined to believe that dirt and
dust, especially the latter, might be as great a carrier
as direct or indirect contact. This was particularly
emphasized to him in recalling that the rainfall during
August in Philadelphia was .84 of an inch rather than
the usual amount of 4% inches. The mortality per-
centage also had been highest during August. In treat-
ment lumbar puncture had been more effective than
any other agent.
Some Phases of the Drug Habit Problem, Especially
in Relation to the Harrison Act. — Dr. John H. W.
Rhein of Philadelphia urged the enforcement of legis-
lation in the control of the use of opium as a drug habit.
The sale also of the hypodermic syringe should, in his
opinion, be legally forbidden. The ill effects of the
drug habit were said to be more apparent in character
and psychic decline than in the physical deterioration.
Treatment relative to the removal of the drug was
given. A cold pack was of value for the nervous mani-
festations. The need of special wards in which these
patients might be treated was emphasized. He believed
it the duty of the State to care for drug addicts as for
the insane, epileptic and feeble-minded. He believed
that the distribution of habit forming drugs should be
legally prohibited except legitimately by physicians.
(To be continued.)
A Certain Immunity of Arabs to Syphilis. — Sicard
and Levy have noted the fact that wounded interned
Arabs very often give positive seroreactions of syphilis,
and especially the cerebrospinal-fluid reactions which
point to localization in the nerve centers. The ma-
jority of those tested are by these criteria latent syph-
ilitica. On the other hand, there is not the slightest
clinical evidence of the disease. The nervous paren-
chyma, like the other tissues, is thus enabled to protect
itself from the syphilitic virus, as are also the
meninges. The only explanation of this phenomenon is
racial immunity. — Gaceta Midica Catalana.
AMERICAN ASSOCIATION OF OBSTETRICIANS
AND GYNECOLOGISTS.
Twenty-Ninth Annual Meeting, Held at Indianapolis
September 25, 26 and 27, 1916.
The President, Dr. Hugo O. Pantzer, Indianapolis,
in the Chair.
(Continued from page 788.)
Prolapse of the Uterus in Nulliparous Women. — Dr.
Palmer Findley of Omaha said that in several of the
reported cases the procidentia occurred about the time
of puberty and in these cases it was recorded that the
girls were poorly nourished; some with tuberculosis of
the lungs associated with persistent coughing, others
who were compelled to do hard labor. A suggestion of
the rarity of the lesion in the nulliparous women was
found in the excellent contribution of Kepler, who col-
lected 70 cases in the literature up to 1911. To this
number he added one of his own and 80 from personal '
correspondence, making in all 151 cases of procidentia
uteri in nulliparous women. He classified these cases
as follows: (1) Cases due to congenital defects which
occurred in the new born or at the time of puberty.
(2) Cases not due to congenital defects, occurring later
in life. In his judgment there was an element of in-
fantilism in most if not all the cases of procidentia in
nulliparous women. The fact that these women were
sterile was highly suggestive. In support of the theory
of infantilism as an underlying factor in the develop-
ment of procidentia, he had two cases on record. The
relation of mental defects to prolapsus uteri was forci-
bly illustrated by the observations of Kepler, who
found 38 mental defectives in 80 cases of procidentia
in nulliparous women. In this group were dementia
precox, imbecility, idiocy, chronic mania, hysterical in-
sanity, cretinism, and nervousness of high degree. It
had long been recognized that defective mental and
physical development went hand in hand and the casual
relation of mental defects or prolapsus uteri was read-
ily conceived.
Radium, a Palliative. — Dr. Douglas C. Moriarta of
Saratoga Springs said that radium possessed a power
to con-ect the disagreeable odor which accompanied the
breaking down of cancerous tissue. This was a very
great boon to the patient as well as to the household.
Further, radium controlled hemorrhage. In six cases
in which he used radium pain was relieved, the odoi
was markedly controlled, hemorrhage ceased, and there
was a change in or a disappearance of the local path-
ological tissues. Two patients died in coma two months
after the treatment; four were alive and hopeful. In
one case the uterine hemorrhage was not of cancerous
origin, but the condition was a terminal one. He was
sure the patient would have died had it not been for
radium. In using radium in these cases he believed
it was possible to produce a toxemia which might
prove fatal, and he was sure he had seen the end
hastened in this way. He would suggest two precau-
tions when applying radium locally ; first, a patient
with a low leucocyte count should not be given pro-
longed applications of radium and, second, when radium
was used it should be accompanied by the liberal ad-
ministration of alkalies. He wished to emphasize his
conviction that no case of this type -was so desperate,
and no postoperative condition so hopeless that radium
should not be used with an expectation of the allevia-
tion of the distressing symptoms.
A Modified Gillian Operation and Its Ultimate Results.
— Dr. Albert Goldspohn of Chicago said those who
denied the pathological nature of retroversio-flexion
affirmed it by their acts when they corrected it in con-
nection with operations for its complications. The harm
of retroversion was mostly brought about through em-
barrassment of the venous circulation by torsion of the
broad ligaments and by traction in descent of the
uterus. Clinical observation and experience indicated
that the competency of the veins becomes impaired.
Admitting this as a probable factor in the pathology,
an effective and lasting as well as innocent cure was
best obtained through an overcorrection, by suspending
the uterus at a higher plane than it naturally or nor-
mally occupied, by a substantial implantation of round
ligament loops, reinforced by their peritoneal covering,
into the recti muscles and their aponeurosis, best after
the Gillian technique, in addition to correction of the
version. To secure the desirable degree of anteversion,
and also to avoid intestinal complications, the implanta-
832
MEDICAL RECORD.
:Nov. 4, 1916
tion should not be more than 3 to 4 cm. from the edge
of the symphysis pubis, and it should bring the distal
unused segment of the ligament and its uterine origin
both in contact with the abdominal wall. The efficiency
of this modification of the Gillian operation was shown
in the 127 examined cases, including the double test
of pregnancy of 21, nearly all natural and mature
births, with a return of displacement of only 1 3/5 per
cent.; with both pelvic and general health "good" or
"excellent" in 88 per cent.; improved in 10 1/5 per cent.,
and unimproved in only 1 3/5 per cent, in a total num-
ber of 164 cases observed from 2 to 7 years or over
SY2 years on the average. Its harmlessness was shown
by the utter absence of any deleterious effects at all
traceable to it in the 21 births noted; likewise from
the absence of intestinal complications and of discom-
fort to the patients.
Pathology of the Vulvovaginal Ducts and Glands. —
Dr. James E. Davis of Detroit gave the history of the
literature of the vulvovaginal glands, with a short out-
line of the physiology, gross and microscopical anat-
omy. The special pathology as reviewed in the litera-
ture was at many points incomplete. The abundance
of material for exhaustive study of these parts had
been limited by clinical inattention to the details of the
external genitalia examinations. A better definition
of the gross pathology and frequent correlation with
the microscopic changes in the ducts and glands was
desired. The vulvovaginitis of school-girls, w,hen of
gonococcal origin, might exhibit remarkable chronicity.
The unhealed lesions during puberty and adult life
exhibited marked infectious potentialities with a much
wider range of pathological changes than was com-
monly observed in cysts and abscesses. Primary ma-
lignancy, while not at all frequent, was significant and
offered an unusual fatality when not recognized early.
The Standardization of Definite Procedures During
Gynecological Operations. — Dr. E. A. Weiss of Pitts-
burgh said that his own deductions were that: (1)
Many mistakes that were made during gynecological
operations were preventable. (2) While the operator
was legally responsible for every action in the oper-
ating room, the average surgeon did not take ade-
quate measures to safeguard the patient and himself.
(3) By adopting a definite routine or standardized
method both for himself and his assistants, better
team-work was accomplished, and consequently les-
sened mortality and morbidity.
The Surgical Treatment of Uterine Cancer. — Dr. J.
H. Jacobson of Toledo, Ohio, summarized as follows:
The prophylaxis and especially the early diagnosis pre-
sented the greatest problem in dealing with uterine
cancer. The radical abdominal operation thus far had
given the highest percentage of cures in operable cases.
Until radium, x-ray, and Percy's method shall have
proved their superiority to operation, their use should
be limited to the inoperable cases. There was abundant
clinical evidence at hand to prove the value of radio-
therapy; it therefore seemed logical to follow every
palliative or radical operation with radiotherapy.
Practical Consideration of Surgery of the Stomach —
Dr. George W. Crile of Cleveland said that despite
the mechanical perfection of operative technique, the
first contact with the bad risk patient with gastric
cancer was still menacing because of the narrow margin
of safety due to starvation. In these cases the reserve
alkalinity of the body had been reduced, nutrition was
impaired and the reserve stores of water and of poten-
tial energy had been diminished. The purpose of his
paper was to describe a plan of surgical treatment by
which these dangerous factors might be obviated or
diminished. As a result of these procedures in his
clinic the mortality rate of operations upon the stomach,
including explorations in cases of inoperable cancer,
resections, and gastroenterostomies had been reduced
approximately two-thirds.
The Mechanics of the Stomach After Gastroenter-
ostomy.— Drs. J. H. Jacobson and John T. Mippiiv
of Toledo drew the following conclusions: "(1) That
all patients examined in this series were uniformly
well. (2) That gastroenterostomy openings properlv
made and placed do not obliterate. (3) That the gas-
troenterostomy openings functionate equally as well in
the presence of cither an open or c'osed plyorus. (1)
That it is not necessary to artificially occlude the
pylorus in gastroenterostomy. (5) That the gastro-
enterostomy opening to secure the maximum amount
of drainage must be of ample size and placed as near
the pylorus as possible, preferably in the antrum
pylori. Such openings must not be made on the fundus
of the stomach nor on the lesser curvature. (6) That
gastroenterostomy is essentially a drainage operation.
(7) That serious distention in the jejenum does not
occur after gastroenterostomy; the food is seen to
pass rapidly through the many loops of the small in-
testine before it finally stops. Even in those patients
who are entirely relieved of their former symptoms
food can be forced backward into the stomach from the
jejenum and, although this can be done easily, such
regurgitations do not seem to make any difference."
Value of Pain, Jaundice, and Tumor Mass in the Dif-
ferential Diagnosis of Diseases of the Right Upper
Quadrant of the Abdomen — Dr. J. D. S. Davis of Bir-
mingham, Alabama, stated that the usual symptoms of
peptic ulcer were pain, vomiting, and hemorrhage; the
most important of which was pain. Pain was the
earliest definite symptom. It was usually aggravated
by large amounts of food and often relieved by small
amounts. Pain might come on during ingestion of
food, but more frequently came on a few hours after
meals and at night. Gastric ulcers were often char-
acterized by periods of long remission, intermittency
taking place for long periods of time, during which
the patient often believed himself well. The .x-ray
examination would often be helpful in determining the
presence of peptic ulcer. Much valuable information
might be secured by the roentgenologist, many of whom
claimed to diagnose seventy-five per cent, of ulcers.
In appendicitis the pain in a large number of cases oc-
curred at the epigastrium and then was diffused over
the abdomen and generally localized at or near Mc-
Burney's point. If the appendix was long enough to
extend into the region of the gall-bladder and ducta
its inflammation might excite symptoms of cholecysti-
tis or choleodochitis and the pain might be at the rib
border. If located behind the cecum pain might be
referred to the loin or to the right rib margin. Jaun-
dice was a valuable diagnostic sign. It appeared in
appendicitis and renal disease only as a result of sepsis.
Obstructive edema due to a duodenal ulcer near the
ampulla of Vater sometimes resulted in a closure of the
common bile duct and might cause pancreatitis and
jaundice. Choledochitis and cholelithiasis was accom-
panied with slight or marked jaundice which might
be of an intermittent or transient type. It might be
so slight that an examination of the conjunctiva or a
chemical examination of the urine was necessary to
detect it. Appendical tumors might be located any-
where in the abdomen. It was sometimes six or more
inches long and might become attached to any other
abdominal organ. When inflamed it might become fixed
by adhesions to some surrounding tissue. Floating
kidney tumors were usually marked by smooth, sharp
outlines and mobility. They were usually free from,
pain and tenderness unless obstruction resulted from
ureteral pressure. A hydronephritic or pyonephritic
kidney was usually stationary or fixed well back into
the loin and did not move with the diaphragm. The
hydronephritic kidney usually presented no urinary
findings, while the pyonephritic kidney was usually
accompanied by septic symptoms — the urine showing
blood, pus, albumin, and casts. Pain was the most
prominent symptom in all conditions of the right upper
quadrant, and was of great value in a differential diag-
nosis, if the peculiarities and characteristics of pain
common to each condition were kept in mind. Regard-
less of every aid in diagnosis, it was often d'fficult to
differentiate and, instead of waiting months or years
for the trouble to clear up, an exploratory diagnosis
under nitrous oxide, gas-oxygen, or novocaine should
be made.
Excessive Drainage Complicating Surgery Upon the
Common Bile Duct. — Dr. J. E. Sadlier of Poughkeep-
sie, N. Y., said that in analyzing the histories of the
two cases herewith reported, he noted certain points
of similarity, namely, they both were long standing
cases of common duct infection and incomplete ob-
struction ; the latter was a result of the ducts being
filled with gallstones to such a degree that they must
have constituted an impediment to the normal and
u^ral outflow of bile resulting from the obstruction,
he had in each case well marked dilatation of the com-
mon duct. In only one case was there an alcoholic
history and likewise in but one case was theie in-
volvement of the pancreas. Hence, these two condi-
tions could be eliminated as complete causative factors.
Thev could not be disregarded as partiallv influencing
conditions in provoking the excessive drainage. He
was unab'e to state the positive cause for this peculiar
and serious complication, but he was disposed to be-
Nov. 4, 1916J
MEDICAL RECORD.
833
lieve that we had a condition somewhat analogous to
that seen in the surgery of the hypertrophied prostate
gland, where as a result of incomplete emptying of the
urinary bladder, we got back pressure upon the ureters
and kidneys, which, when suddenly relieved through
operative intervention, resulted in an excess outflow
of urine of low specific gravity, which was a well
known source of danger in a person debilitated by long
continuation of the pre-existing disease. Was it not
quite probable that in partial obstruction to the outflow
of the bile, by reason of the common duct obstruction
from stone, we had a dilatation of the smaller
biliary radicles in the liver? Increased back pressure,
which, when suddenly relieved by operative removal
of the obstruction, produced a condition of venous en-
gorgement of the liver with resulting outflow of fluid
which was more in the nature of a transudation than
an actual biliary secretion, and tnis coupied witn a
back flow of pancreatic fluid through the dilated duct,
would account for the excessive drainage. Yet he
would not presume to definitely determine the causa-
tive factor, for the object of this paper was not to
analyze the condition, but to suggest that in our oper-
ative work upon the common bile duct we must con-
sider the possibility of excessive drainage and be pie-
pared to combat it before the patient became de-
hydrated to the danger point.
Diverticulitis of the Descending and Pelvic Colon. —
Dr. John W. Keefe of Providence, R. I., after report-
ing two cases in detail, emphasized the following points
in connection with them: The symptoms found re-
sembled those of appendicitis, but with the local man-
ifestations on the left side. He pointed out the value
of roentgenological examination, and also laid stress
on the importance of differentiating diverticulitis of the
colon from carcinoma, tuberculous or luetic growths. One
should not attempt too much at the primary operation.
The two-stage operation was often preferable. Tem-
porary co'.ostomy might be desirable. Conservative sur-
gery was of the greatest value in this disease.
Appendicular Abscess, Complicated by Hemorrhage
and Death. — Dr. Magnus A. Tate of Cincinnati spoKe
of this condition as rare. The patient was a young
woman who had her first attack. Her abdomen was
opened through the right rectus, and drainage was
profuse for six days. At the end of the tenth and elev-
enth days her condition was good. On the twelfth day
she complained of pain and nausea. On the morning
of the thirteenth day there was hemorrhage from the
wound, and on the fourteenth day her condition was
alarming, death occurring the same evening. Autopsy
revealed a gangienous sac, the size of a dollar, which
was found in the mesentery, probably the site of hem-
orrhage.
Inguinal Hernia Attached to the Cord, Undescended
Testicle, Uterus, Tubes, and Broad Ligament. — Dr.
Edmund D. Clark of Indianapolis reported a case
which was a very good example of hermaphroditism in
a man. The external conformation of the patient was
that of a normal male. The hernial sac contained a
uterus, broad ligament, and Fallopian tubes. Although
married to an apoarently normal woman for six years,
no pregnancy had resulted.
Absence of Muscular Tone an Important Factor in
the Etiology of Postoperative Paralvtic Ileus — Dr. R.
R. Huggins of Pittsburgh stated that distention and
stasis, varying in degree, followed most laparotomies.
This was usually a temporary paralysis, a reflex ac-
tion through the plexuses of Auerbach and Meissner,
the result of manipulation and trauma. There were
cases where infection could be excluded and patients
died of paralytic ileus. The comparative frequencv in
vaginal hysterectomy was significant. There was little
exposure and handling of intestines. Careful pre-
operative, operative and postoperative treatment was
important in lessening postoperative paresis, but we
were occasionally confronted with an aggravated form
of this condition and death ensued. He believed that
in certain instances, where death occurred from so-
called paralytic ileus, it was primarily due to lack of
muscular strength in the walls of the stomach and in-
testines. This depended largely upon the general
muscular tone in the individual previous to operation,
the amount of exhaustion incident to the operative pro-
cedure, and the effects of the anesthetic. Keith had
called attention to the presence of nodal tissue, neuro-
muscular in character, in the bowels, which was simi-
lar to that in the heart. This was located at various
points in the intestinal tract and acted as a local pace-
maker. A block might occur, as in the heart, at any
point where one rhythmical zone passed into another.
Magnus demonstrated that the strips beat more actively
when removed from a normally fed animal than from
one that was not digesting. The intestinal tract had
an intrinsic tone, which was regulated by extrinsic
nerves. Tonic contraction and rhythmical peristalsis
disappeared when there was general bodily weakness,
and when the depleted central nervous system failed
to deliver the necessary tonic impulses. Postoperative
distention varied in direct proportion to the strength
and tone of the general muscular system. Patients
with poor general muscular tone requhed more careful
preparation, and greater efforts to minimize exhaustion
from anesthetic and operative effects.
(To be continued.)
NEW YORK ACADEMY OF MEDICINE.
Stated Meeting, Held October 19, 1916.
The President, Dr. Walter B. James, in the Chair.
This meeting was devoted to the Wesley M. Carpen-
ter Lecture and an appreciation of Dr. John B. Murphy.
Dr. Walter a. James, in opening the meeting, stated
that the rust Wesley M. Carpenter Lectuie was de-
livered in 1892 and one had been delivered annually
ever since. The lectureis had all been men who stood
in the foremost rank of physicians and surgeons in the
Uniied States. In considering who should be selected
to deliver the lecture this year Dr. Murphy had been
chosen. He had accepted the invitation last spring and
had intimated along what lines his Daper would be. Dr.
James said he heard nothing more from Dr. Murphy
until August 9 when he received a letter telling him
how much he had looked forward to coming, but stating
that he had been ovei taken by the disease to which he
had devoted so much study, an acute metastatic aortitis.
He died suddenly on August 11. On the forenoon of the
day of his death, while suffering intensely and unable
to speak, he wiote that he had placques in the aorta
and requested that an autopsy be done to verify his
diagnosis. This diagnosis was fully verified; it was
found that he had acute, ulcerating placques in the
aorta. He died as he had lived trying to help the medi-
cal profession in its task.
An appreciation of Dr. John B. Murphy. — Dr. George
E. Brewer made this address. He said in part that on
the 11th of last August the medical profession of
America had been shocked by the sudden and unex-
pected news of Dr. Murphy's death. This news brought
to all of them a sense of deep personal grief. It was
fitting before listening to his last piece of scientific
work that they should pay tribute to the memory of this
remarkable man. Dr. Brewer then briefly reviewed the
life and woik of Dr. Murphy and enumerated the many
honors that had been conferred upon him. He stated
that early in his career Dr. Murphy had gone abroad
to study and had been greatly impressed by the work
of Bilhoth. Albert, and von Bergmann. At that time
the scientific spirit in America had not been aroused.
Dr. Murphy returned fired with enthusiasm and did
much to give an impetus to scientific work in medicine
and surgery in this country. He possessed all the ele-
ments of the successful surgeon, knowledge, originality,
imagination, admirable technique, sober judgment untir-
ing enery, and optimistic enthusiasm. He attacked by
nrefe'ence the great problem in surgery. By unweary-
ing industry he opened the path and blazed the trail fmrn
one achievement to another. Among the first of his
discoveries and one of the greatest contributions to
modern surgery was the Murphy button. This was fol-
lowed by his work on the problems of thoracic surgery
in the broader sense; he saw conditions that had not
come under the observation of other surgeons. In 1898.
he gave the results of his observations in this field of
surgery and to-day they still stood as surgical gospel
on this subject. He then became interested in neurologi-
cal surgery. It mifrht be remembered th"t at this time
a great deal of futi'e neuro'ogical surgical work was
being done, because the anatomy and pViysio'ngy of the
nervous system we-e not understood. Dr. Murnhv de-
voted two vears to the study of the anatomy and physi-
ology of the nervous system. The work that he did in
this field was not appreciated at that time, but it was
to-day. He next atta^'-ed the problem of ankvlosed
joints. Up to this time, as a rule, these patients
passed from 0"e surceon to pnother without receiving
any benefit. When Dr. Murphy announced the results
that he had obtained in apparently hopelessly ankylosed
834
MEDICAL RECORD.
[Nov. 4, 1916
joints and showed that these joints could be leturned to
normai tunc Lion tne protession was astounded. Follow-
ing tins came nis familiar work in bone grafting and
now, to-night, his work on septic arthritis. Those were
but a few or the contributions Dr. Murphy gave to
surgery which marked distinct advances. In all of
these ne departed far from the beaten track. He
valued the advantages of animal experimentation and
of laboratory investigation. Every operative procedure
was tirst tried on animals; he never experimented on
hi.-- patients, but always kept uppermost in his mind
the welfare of those who entrusted their lives to his
care. As a teacher he was no less great than as a sur-
geon. His pupils looked upon him as a gieat master of
surgery. In teaching the profession at large he was
equally as successful as in undergraduate work. He
was not only a master in surgical technique, but a clear
and logical thinker, and a powerful and interesting de-
bater on medical subjects. He was quick and alert
physically and even more so in his mental processes.
He despised sham hypocrisy, indolence, and all low
standards of living. He lived his religion in his daily
life. He was a fair man aliKe to friend and enemy. In
closing, Dr. Brewer said it might be well to ask what
lessons might be learned from the contemplation of this
singularly gifted man. His life work refuted what was
held by many in the profession, that was, that if one
wanted to succeed in his profession in the community in
which he lived and to become a great surgeon, he should
not waste too much time in purely scientific or 'labora-
tory work. Dr. Murphy made his great contributions
to surgery because he was willing to devote a large
measure of time to laborious, painstaking work in the
laboratory. Dr. Murphy was revered for his qualities
of mind and heart and his devotion to duty, and also for
the results of his achievements that made it possible to
give relief to suffering humanity.
Wesley M. Carpenler Lecture — A Clinical and Exper-
imental Study of the .Metastatic Arthntides. — Dr.
Philip H. Kreuscher of Chicago delivered this lecture
which was based on the study of over 800 clinical eases
and was illustrated with lantern slides. He stated that
on the last page of his day book Dr. Murphy had writ-
ten the following quotation: "He went away as he had
come, nobly careless of himself, thinking only of the
things he had tried to do." Dr. Murphy's work had
been splendidly conceived and it was with reluctance
and a recognition of his great responsibility as well as
his great privilege that the speaker brought the mes-
sage committed to him.
Coming to the subject of the paper, he said that by
metastatic infection was meant an infection in or about
joints due to the invasion of pathogenic organisms
which had been harbored and were capable of multiply-
ing in the tissues of the host. They were classified as
acute, subacute, and chronic; as uniarticular, biarticu-
lar, and multiarticular. Etiologically they were classi-
fied as those due to a known organism and those in
which the origin could not be found. Pathologically
they recognized acute or chronic serous, chronic sup-
purative, and fibrinous or plastic arthritis. They did
not include those due to tuberculosis or the bone in-
volvements of syphilis. Particular stress was laid on
the following points: "(1) Every case of acute general
infection is surgical and must be treated surgically.
(2) Those lesions thought to be infections in the joint
cavities are in reality infections about the joints, out-
side of the joint cavity. (3) There is a definite in-
cubation period for every metastatic arthritis. (4)
The joint fluid does not contain bacteria in a large per-
centage of the cases. (5) Metastases to the ioints
occur because of a definite logical reason." To ap-
preciate the many problems, mechanical and patho-
logical and the management of infection, one should
atomy of the synovial membrane with its
layers, pockets, and diverticula, and the blood supply
of 'he ioints. One must consider the specific, exciting,
and predisposing causes as well as the atria of infec-
tion. An analysis of 849 cases showed that the source
had occurred in the following sites and with the fre-
quency designated: In the tonsils in '25 5 tier cent, of
the cases; the teeth, 18 per cent.: urethra. 17 per cent.;
sinuses. 17 per cent.; lungs and bronchi, 5 pit cent.:
b'adder, 4 per cent.: kidney pelvis. 4 per cent.; appen-
dix. L> pc cent.; gall-bladder. 2 per cent.; furucu'osis,
typhoid fever, scarlet fever, tetanus, and dysentery,
each »i per cent. The following organisms were found:
The streptococcus in 31 per cent, of the cases, gono-
coccus. 14 per cent.: staphylococcus. 8 per ent. ; colon
bacillus, 4 per cent , and a combination of two or more
organisms in 38 per cent, of the cases. The infection
was uniarticular in 9 per cent, of the cases; biarticular
in 13 per cent., and multiarticular in 78 per cent. It
was acute in la per cent., subacute m 21 per cent., and
ehionic in bti per cent, uoth extiemities and the spine
were involved in i3 per cent, of the cases. Seventy-five
per cent, of the general infections occurred between the
ages of 10 and 40 years, and 11 per cent, from 50 to 80
yeais. the gieatest susceptibility was between the
ages of 30 anu 40 years. In this series approximately
l>o per cent, were females. Three-fourths of the in-
lecLions occuried during the late fall, winter, and early
spung. iheie was a aetinite history of trauma in 90
per cent, of the cases. Ankylosis occurred in prac-
tically 4 per cent, of the cases. Tne total of those who
were partially incapacitated was 85 per cent., and there
were oniy 15 per cent, that could continue to do their
customary woi k without any interference with func-
tion, iheie was a definite period of incubation for
every infection. For the Neisserian infection it was
18 to 24 days after the primary infection; for the
staphy.ococcus 8 to 14 days, while a streptococcus in-
fection might occur within 48 hours. In typhoid fever
the secondary infection might occur four, six, or eight
weeks after the beginning of the typhoid. The diag-
nosis was not complete until one had determined the
atrium of the infection. This was sometimes easy, as
when there was a definite history of tonsilitis, but in
other cases it might be very difficult to trace a con-
nection between a metastatic infection and the original
infection. One could not make a diagnosis from the
fluid taken from a joint. In the last 37 consecutive
cases which they had examined only one showed a posi-
tive bacterial growth on the cover; this was in a series
of untreated cases and included every kind of infection;
several were uniarticular and several multiarticular.
Dr. Kreutscher said he could not understand why cer-
tain authors reported positive cultures from the joint
fluids in from 5 to 87 per cent, of their cases. Dr.
Murphy and he believed that the infection was peri-
articular and that only in rare instances did bacteria
pass directly into the joint cavity. Three cases of
hypertrophic villous synovitis all gave negative bac-
terial findings. The reason for the absence of bacteria
from the fluid of the joints was explained by assuming
that the bacteria were carried by the blood stream and
lymph channels. There were important arterial anasto-
moses surrounding the large articulations. The dia-
physis and epiphysis were supplied by the larger ves-
sels, branches of which passed around these structures,
passing inward to the ends of the bones, to the peri-
chondrium, and the synovial membrane. The synovial
membrane and fringes were supplied with a rich net-
work of capillaries fiom smaller synovial branches. Dr.
.Murphy, in 1912, expressed the opinion that the infect-
ing microorganisms found lodgment in the terminal
loops of these synovial branches, but did not ordinarily
penetrate to the synovial fluid.
The treatment of metastatic arthritis was surgical.
Arthritis no more belonged to the domain of internal
medicine than did acute fulminating appendicitis.
Treatment by internal medication and external appli-
cations was as irrational as the same treatment applied
to a perforating gastric ulcer. One must put into
effect masterly, preconceived, accurately directed and
timely activity. Such treatment consisted first in aspi-
ration. Drainage tubes were to be condemned. They
were the cause of ankylosis in !>(! per cent, of the cases
in which they were employed. Second, a Buck's exten-
sion must be applied the first day in every case of acute
arthritis. The patients found this apparatus com-
fortable and wore it at night. It gave relief by remov-
ing the intraarticular pressure. Third, cofferdamming
of the infiltration of the lymph spaces must be accom-
plished by injecting an antiseptic solution into the joint.
Fourth, the primary focus of infection must be removed
if it could be found, whether it was in the tonsils, the
teeth, the nasal sinuses, or the gastrointestinal tract.
Fifth, deformities should be treated by extension, the
Travois splint, plaster casts, and other appliances.
Sixth, autogenous vaccines were of great value if used
for the lesions for which they were intended. They
should be made from 'he bacteria grown from the
patient's b'ood in accordance with recognized and ap-
proved methods Seventh, in the way of prevention, it
was the duty of every physician to advise his patients
in resrard to the danger arising from a focus of infec-
tion in the teeth, the tonsils, or elsewhere in the body.
Dr. Kreuscher said that during the course of this
study many problems had come up and five of these had
Nov. 4, 1916]
MEDICAL RECORD.
835
been the subject of investigation. These were as fol-
lows: (1) Experiments to determine the intraarticular
pressure resistance of human joints. (2) Experiments
to find a suitable antiseptic for joint injections. (3)
Investigations to determine the localization of patho-
genic organisms following the injection of bacteria into
the blood stream of rabbits, and to find out why they
did not pass directly into the joint fluid. (4) An
endeavor to find out why metastases occurred. (5) An
investigation to find out whether the rapidity of
metastasis depended upon the type of organism or upon
the variety and virulence of the mixed infection. It
was shown that the capsule of the adult hip would
withstand a pressure of from 35 to 50 pounds per
square inch; the capsular ligament of the adult knee
in the cadaver would withstand 60 to 120 pounds
pressure per square inch before rupturing. It was
noted that when an inactive joint was subjected to
severe internal pressure, the leg tended to become
slightly rotated inward, and adducted and flexed, as in
acute infection with effusion. A large number of ex-
periments were made with a variety of antiseptics
from which it was found that a solution of 2 per cent,
formalin in glycerin, which had been made twenty-four
hours before using, was most effective. From their
experiments to determine the localization of pathogenic
organisms following their injection into the free blood
stream, they had concluded that the bacteria localized
in the terminal loops of the synovial branches and did
not enter the joint fluid. Among experiments made
along this line, B. pyocyaneus from postoperative
wounds were injected into rabbits, the dose being two
billion bacteria. All of these rabbits died at the end of
four days without joint manifestations. Cultures were
taken from the heart blood of these animals and the
B. pyocyaneus was present in pure culture. Two billion
bacteria were then taken from the cultures of the heart
blood of these rabbits and injected into the ear veins
of a new series of rabbits and these died in eighteen
hours. A third series of rabbits were injected with a
smaller dose of the bacteria, and some of these were
sick for several days and recovered; others showed no
illness at all. They had concluded from this that the
B. pyocyaneus, usually considered a low-grade patho-
genic organism, might cause death quite as quickly as
the streptococcus and occasionally might cause joint
involvement. Experiments were made with hemolytic
streptococci by injecting two billion bacteria in the ear
veins of rabbits. Some of the rabbits died in twenty-
four hours, others recovered after twenty-seven days,
having shown positive joint manifestations on the
fourth and fifth days. Sixty-five per cent, of the ani-
mals showed involvement of one or more ioints; 4
per cent, showed suspicious joint lesions, and 30.5 per
cent, showed no involvement up to date. In 4 per cent,
of the animals the ioint localization did not take place
until the fifteenth day after the injection. At autopsy
a smaller percentage of joints than was expected were
found free from pus containing bacteria. In a larger
percentage than was expected abscesses occurred around
the ioints and along the shafts of the bones in the soft
tissues. They therefore concluded that a metastatic in-
fection in a large percentage of the cases occurred
outside the joint, a conclusion Dr. Murphy reached a
number of years ago. There was a definite reason for
the occurrence of metastases. A metastasis did not
usually take place unless there was a mixed infection
or a secondary infection was superimposed on a pri-
mary one. A metastasis from a strepococcic pyorrhea
alveolaris did not usually take place until a foreign
streptococcus was superimposed on the primary infec-
tion. Experimentally they had found that a guinea
pig did not ordinarily show metastases in the distal
organs even after large quantities of microorganisms
had been injected directly into the heart, but if these
injections were preceded or followed by an injection
of oreanisms of another strain, metastases occurred in
the liver, kidneys, endocardium and ioints. Rabhits
injected with streptococci and then with a quantity of
staphylococci, or other pathogenic organisms, showed
a rapid and multiple joint infection in 90 per cent, of
the cases. The lesson to be learned from this was
that if they were going to prevent metastases it would
have to be done bv the early removal of the focus of
infection. The laitv would have to be taught that if
this were not done the condition might become chronic
and metastases and deformity might follow. When this
occurred thev would have to resort to arthroplastic
treatment of the kind Dr. Murnhy had devised and
carried out with such success. The fifth problem pro-
posed, namely, did the rapidity of metastases depend
upon the specific infectious organism, or did it depend
upon the variety and virulence of the mixed infection,
they were still working upon, but as yet had not reached
definite conclusions.
B»tate JHrfoiral ICtrpttsmg fBoarite.
STATE BOARD EXAMINATION QUESTIONS.
Kentucky State Medical Board.
June 13, 14, 15, 1916.
(Continued from page 750.)
1. (a) Differentiate between hydrocele, scrotal
hernia, and varicocele. (6) What treatment would you
advise in each?
2. How would you treat a compound, comminuted
fracture of the olecranon process?
3. (a.) Differentiate between fracture of the vault
and base of the skull. (6) What treatment would you
advise in each?
4. (a) How would you diagnose an hypertrophied
prostate gland? (b) What treatment would you advise?
5. Differentiate between intestinal obstruction, acute
appendicitis and tubercular peritonitis.
PATHOLOGY.
1. (a) Describe healing by granulation. (6) To
what conditions does it lead?
2. Give the pathology of a gangrenous, perforated
gall-bladder.
3. (a) Describe the gross appearance in pyosalpinx,
and (6) what is the usual infecting organism?
4. Name and describe three varieties of malignant
tumors.
5. (a) Describe bone necrosis. (6) What is a se-
questrum, (c) An involucrum?
SKIN, HYGIENE, MEDICAL JURISPRUDENCE, MENTAL AND
NERVOUS DISEASES.
1. Discuss and diagnose lupus vulgaris.
2. Discuss and diagnose psoriasis.
3. Name the varieties of eczema.
4. What are the conditions necessary for a model
sleeping room?
5. Give special hygienic conditions required for fac-
tories in which women and children are employed.
6. What would you say as to the fitness of water
for drinking purposes which contains nitrites and
nitrates?
7. (a) Name as many nuisances dangerous to health
as you can which are frequently found about cities.
(6) About country homes.
8. What principal measure would you use to prevent
the spread of the infectious diseases?
9. (a) What medico-legal complications might arise
due to an erroneous diagnosis of pregnancy? (6) How
would you avoid them?
10. Give the etiology of multiple neuritis.
OPHTHALMOLOGY, OTOLOGY, AND LARYNGOLOGY.
1. Give some of the conditions that would cause you
to advise iridectomy.
2. (a) What is a staphyloma? (6) Give cause.
3. Give cause and symptoms of chronic dacryocystitis.
4. (a) Diagnose a case of empyema of frontal sinus.
(6) How would you manage it?
5. (a) Define aphonia. (6) Give some of its causes.
6. Give etiology and symptoms of hyperemia of the
labyrinth.
7. (a) What are the usual causes of rupture of the
mcmbrana tvmpani? (6) What symptoms would you
expect to follow?
8. What symptoms would lead you to make a diag-
nosis of acute circumscribed otitis?
9. What are the symptoms of postnasal adenoids?
(6) What means would you employ for relief?
i0. (a) Under what conditions would you intubate?
(6) Give detailed technique.
ANSWERS.
SURGERY.
1. In hydrocele the tumor begins in the scrotum and
may ascend to the inguinal region ; does not vary very
836
MEDICAL RECORD.
[Nov. 4, 1916
much in size, except to steadily increase; is translucent;
is dull on percussion; gives no impulse on coughing.
In hernia the tumor begins in the inguinal region and
may descend to the scrotum; is very variable in size,
and may be reducible, or disappear on lying down; is
not translucent; is not dull on percussion; gives an
impulse on coughing as a rule.
in varicocele tne swelling feels like a bag of worms;
it may empty when the patient lies down ; there is an
impulse on coughing or straining, but no translucency.
Treatment of hydrocele. — The fluid may be withdrawn
with trocar and cannula; this will have to be repeated.
Tapping, fol.owed by injection of strong antiseptics,
such as carbolic acid, or iodine. The sac may be ex-
cised either wholly or partiallv.
For hernia, Bassini's operation (or some modification
of it) is recommended.
For varicocele the best treatment is to remove th»
varicose veins between double ligatures.
2. In compound comminuted fracture of the olecranon
process "the wound should be irrigated with a few
gallons of physiological sterile salt solution, and the
edges of the wound trimmed of devitalized tissue. In-
ternal fixation of the fragments should not be per-
formed at the initial operation in compound cases,
though it may be possible to retain the fragments in
position by suturing the fascia covering the posterior
surface of the process in closing the wound. A sec-
ondary operation may be done after the wound (ren-
dering the condition compound) has healed, and the
danger of infection has passed. Following a firm in-
ternal fixation of the fragments the upper extremity
may be immobilized with an internal right angle splint."
(Preston's Fractures and Dislocations.)
3. Fracture of base of the skull. The Signs are
those of (1) injury to the brain, (2) escape of cranial
contents, (3) injury of cranial nerves. (1) Injury to
the brain may be of the nature of concussion, compres-
sion, or laceration. (2) Escape of cranial contents,
which may be blood, cerebrospinal fluid, or rarely brain
itse1^ 1. Hemorrhage manifests itself in various situ-
ations, according to the position of the fracture. In the
anterior fossa the bleeding may be from the nose or
into the orbit, or may pass back into the pharynx, be
swallowed, and subsequently vomited. The eye may be
pushed forward and pulsate if the cavernous sinus be
ruptured. In the middle fossa blood usually runs from
the ears ; but slight bleeding from the ear may be caused
by minor injuries, such as rupture of the membrana
tympani, tearing of the lining of the auditory canal,
and fracture of the tympanic bone. In the posterior
fossa a hematoma may form behind the mastoid process.
2. The escape of cerebrospinal fluid is a certain sien
that a fracture communicates with the subdural space.
It may appear in the same situations as hemorrhage,
but is usually found escaping from the ear owing to
fracture of the petrous bone. The fluid is limpid, spe-
cific gravity 1005, with no albumin, but containing pyro-
catechin, which gives the same reaction as sugar with
Fehling's solution. The amount which escapes may be
small or very large, but as a rule it soon ceases. (3)
Injuries to the cranial nerves vary according to the site
of fracture. That most commonlv involved is the facial,
in the aqueductus Fallopii, and the paralysis may come
on immediately from rupture, or after two or three
weeks from the pressure of callus.
Treatment: The chief aim of treatment is to prevent
sepsis. The ear must be mopped out with an antiseptic,
and then kept covered with an antiseptic dressing, as if
it were a wound. The patient must then be kept quiet,
the bowels opened with a purge, and an icebag applied
to the head. The diet should be low, and a return to
active life not permitted for six weeks. If septic menin-
gitis occurs the patient is bound to die. (From Aids to
Suraery.)
Fissured fractures of the vault are due to direct in-
juries, such a^ blows, or hi indirect injury, such as com-
pi-pssion, which hursts the sk'iH. If s:mnle there are no
definite si^ns; if compound the fissure can be seen and
felt. The prevention of sepsis forms the main line of
treatment. Callus mav form at the site of fracture and
produce traumatic epilepsy.
Depressed end punctured fractures are due to direct
violence; usually affect the vault; may be simple, com-
pound, or comminuted. The outer table mav be de-
pressed without the inner heine; broken, in such places
as the frontal sinus. Rarely the inner table is broken
and denressed without fracture of the outer. As a rule
both tables are broken. The inner suffers most damage,
as it is less supported; the force of the blow is more
diffused by the time it reaches the inner; also the
momentum of the striking body is less, and the debris
of the outer table increases the size of the penetrating
body.
Symptoms: If there is a wound, the fracture and de-
pression may be seen, and blood, cerebrospinal fluid, or
brain, may be escaping. If there is no wound a care-
ful examination is necessary, as a hematoma may form
and obscuie the depression. In cases of doubt an in-
cision should be made.
In a simple depressed fracture there is usually some
concussion, which is followed by compression from
hemorrhage in the neighborhood. The depressed bone
also causes compression later by the spreading edema it
sets up in the brain. Death may result quickly, or the
patient may recover and then become the subject of
traumatic epilepsy from irritation of the cortex. If the
depression is over the motor area convulsions or
paralysis are quickly induced.
In a compound depressed fracture the blood escapes
and does not produce compression. Concussion may or
may not be present. The advent of sepsis produces in-
flammation of the bone, membranes, and brain, which
may be limited if the drainage is free; but if not death
soon follows from compression by the inflammatory
exudation. During the stage of compression a hernia
cerebri is formed. If the depressed fragments are early
removed and asepsis is maintained the patient has a
good chance, unless the brain itself is severely injured
Treatment. — In all cases, except the saucer-like de-
pressions which occur in young infants, it is necessary
to elevate or remove the depressed fragments, stop all
bleeding, and disinfect the wound. Symptoms should
never be waited for, because, although the patient may
recover without operation, the depressed bone may caus?
traumatic epilepsy or insanity. The skin is shaved and
purified, and a large flap is turned down to expose the
fractured area, or if a wound is present it is enlarged.
Comminuted fragments are removed, and sharp edges
which press on the dura mater are clipped away with
Hoffmann's forceps. If an elevator cannot be introduced
under the depressed bone a trephine hole is mad?
through the nearest sound bone, the elevator intro-
duced, and the bone prised up. The piece of bone
removed with the trephine should be replaced. If the
dura mater is torn it should be stitched up and then the
scalp flap is sutured without a drain, unless oozing is
still going on. If the fracture has been compound it is
better to drain it for twenty-four hours. In punctured
fractures the hole must be enlarged by trephining, so
as to remove the depressed spicules. After operation
the patient must be kept quiet in a darkened room on
fiquid diet for a few days. — (Aide to Surgery.)
4. Prostatic hypertrophy is characterized by: Slow-
ness in starting urination; difficult micturition; fre-
quency of micturition, particularly at night; the pres-
ence of residual urine, as mav be demonstrated by cathe-
terizing the patient just after he has urinated; dull.
aching pain in the perineum and above the pubes: en-
largement of the lateral lobes of the prostate; there
may be cystitis and retention of urine. Palliative treat-
ment consists in: Mild and unirritating diet, avoidance
of alcohol, taking plenty of milk or water, or other
diluent. Alkalies and sedatives should be taken, also
urotropin or other antiseptic so as to prevent cvstitis.
Regular catheterization, at least once a day. preferably
in the evening, and with due aseptic precautions. Oper-
ative treatmt ni is excision of the prostate gland.
5. Acute appendicitis. — The vecocrnition of a tvpjrn'
case depends upon a few cardinal svmptoms — viz . the
acute development of severe pain in the risht iliac fossa,
coming on in a person previously healthy and usuallv
under forty years of age; appendicular tenderness,
unilateral induration, fever, vomiting and constipation,
or, more rarely, diarrhea.
Acute tuberculous peritonitis. — As in appendicitis, so
in tuberculous peritonitis, pain, tenderness, and fever
are present, but in the latter the onset, is more gradual,
and the sifrns of tumor and increased resistance in the
ileocecal region are absent. Movable dulness mav be
present in the tuberculous affection, but not in appen-
dicitis until the peritonitis is eeneral. The lungs gen-
erally show lesions in tuberculous neritonitis.
Acute intestinal obstruction. — When this is due t|p
int'isi'scention there mav be si"ns of a tumor. b''t not
at McBurnev's point; the tenderness over the site of
the mass is less intense, wbile the frequent, b'oodv dis-
charges that are seen in this condition, accomn^nied by
tenesmus, do not characterize appendicitis. When ob-
struction is caused by strangulation stercoraceous vom-
Nov. 4, 1916J
MEDICAL RECORD.
837
iting is apt to occur; pain, local tenderness, and signs of
a tumor appear, but not at McBurney's point. (Anders'
Practice of Medicine.)
PATHOLOGY.
1. (a) Healing by granulation occurs (1) when the
edges of the wound nave not been brought together, (2)
when the edges have been so damaged that sloughing
occurs, (3) when sepsis has prevented healing by tirst
intention. Exudation of piasma and leucocytes occurs,
followed by fibroblasts and budding from the capillaries,
thus forming granulation tissue. The dead tissues or
sloughs aie separated, and a red area of granulation is
then exposed. The deeper layer of granulation tissue is
converted into tibrocicatricial tissue, which contracts,
and so the wound gradually lessens in size. In the
meantime epithelium spreads in from the edge over the
surface, and so the scar is completed. — (Aids to Sur-
gery.)
(0) It leads to cicatrization.
2. Pathology of gangrenous perforated gall-bladder. —
Should the gall-bladder have been previously normal
or only slightly diseased and non-adherent it may be-
come consideiably, sometimes very much, enlarged; but
if previously the seat of cicatrization from chronic in-
flammation no enlargement may occur; in this case it
is usually united to adjacent tissues and organs by
adhesions. The wall of the gall-bladder is softened,
swollen, edematous, congested, and usually very dark
reddish, greenish, or blackish in color. The mucosa is
congested and desquamated and covered with a fibrino-
purulent, sometimes also hemorrhagic, exudation. In
many cases there is more or less ulceration, especially
toward the fundus in consequence of the relatively
poorer vascular supply of the fundus and the gravita-
tion of gallstones. The ulceration may proceed through
the wall and lead to perforation. The cystic duct is
usually occluded even in the absence of gallstones. The
contents consist of turbid, bile-stained, fibrinopurulent,
sometimes sanguinolent fluid; gallstones are present in
about 80 per cent. . . . The infiltration of the gall-
bladder is widespread and may lead to extensive dissec-
tion of the different coats, the separation, for instance,
of the mucosa from the underlying coats or extensive
sloughing. . . . When a large section of the gall-
bladder becomes necrotic the term gangrenous cholecys-
titis is not inaptly applied. The lesions resemble those
just described, with the addition of complete necrosis or
gangiene of a variable portion of the gall-bladder; the
gangrene usually begins at or near the fundus and
spreads toward the neck; in some cases it begins about
a gallstone more or less firmly embedded in the wall of
the erall-bladder. — (From Modern Medicine, by Osier
and McCrae.)
3. Pyosalpinx. — "The dilation of the tube into a cyst
is the final stage of salpingitis. The tumor formed bv a
dilated tube is seldom larger than a pear, although a
pyosalpinx may reach to the umbilicus. The tube is
commonly contorted, winding round the upper and back
part of the ovary, the outer part of the tube being the
more dilated. The wall is generally thickened, but at
one or more spots it may be thinned. The thinning is
not due to tension, but to ulceration, and this ulceration
may take place at a part where the tube is not dilated,
and may perforate and cause death. The mucous mem-
brane is ovorerown. thickened, edematous, injected so as
to be purple in color, and ecchymosed, or if may be
<-'Iatr> co'ored : there may be cnlcareous nlat^s and nodules
in the mucous membrane. In some cases there has been
overgrowth of gland tissue. The ovary is generally
en'.T-eed." — (Herman's Handbook nf Gvnecoloay.)
The usual infecting organism is the gonococcus.
4. A sarcoma is a malignant connective tissue tumor;
the others a~e all innocent. A sarcoma consists of cells,
between each of which a minute ouantitv of intereel'u-
lar tissue can be demonstrated. The cells differ in size
and shane in different growths. Bone and cartilage
may be developed in any of them. It is always devel-
oped from mesoblastic tissue; it may be at first defined
or encap=u!ed. but always in its later staees infiltrates
the surrounding tissues. The blood supply is ahvivs
abundant, even to producing a nulsating tumor. The
vessels are on'v clefts between the cells of the prowth,
so that inte'stitinl hemorrhage is frequent, and dissemi-
nation bv the veins is rendered easv. It follows from
this that secondary growths occur first in the lungs un-
less the primary growth is in the portal area. Other
orws mav be affected affer the lungs. Occasionally
Ivmphatic glands are implicated. esDecial'v in melon-
otic sarcoma, lympho-sarcoma, sarcoma of tonsil, testis.
and thyroid. Secondary changes, such as myxomatous,
fatty and hemorrhagic, may occur. A sarcoma when
cut appears homogeneous and varies according to its
vascularity from tne grayish-white of a fibrosarcoma
to the deep maioon of a myeloid sarcoma. Sarcoma
may be congenital or appear at any age. The species
are determined according to the prevailing type of cell.
Roaent utcer is a carcinoma beginning in sebaceous
glands. It generally occurs in patients over forty and
is of very slow growth. It begins as a smooth, rounded
knob in the skin about the nose, eyelids, orbital angles or
cheeks, slowly increasing in size. In time ulceration
occurs. The ulcer has a smooth, depressed base covered
with ill-formed granulations and bounded by a slightly
raised, indurated, rolled over edge. There is little dis-
charge if sepsis is prevented and little or no pain. The
lymphatic vessels and glands are not affected, and dis-
semination does not occur. The ulcer spreads and de-
stroys surrounding structures; even bone is not spared,
so that the brain may ultimately be exposed.
Epithelioma, or squamous-celled carcinoma, may arise
on any surface covered with stratified epithelium. It
usually arises in the middle aged or elderly, but may
also occur in the young. It often results from long con-
tinued irritation and may arise in old scars or ulcers.
It may appear in one of three forms: (1) A wartlike
growth with an indurated base; (2) a small circular
ulcer with raised, rampartlike edges; (3) an indurated
fissure. The growth extends to the deeper structures;
the surface ulcerates and becomes foul from contamina-
tion with putrefactive organisms. The nearest lym-
phatic glands always become infected sooner or later,
and a fatal termination occurs rapidly unless treatment
is early and thorough. Secondary deposits, except in
the glands, are rarer than in glandular carcinoma. The
glands sometimes undergo cystic change, invade the
skin, ulcerate, become foul, and may cause death by
scondary hemorrhage from ulceration into large blood
vessels. — (Aids to Surgery.)
5. "Necrosis, or gangrene of bone, is death of a portion
of bone en masse. The dead portion (sequestrum) varies
in size from a small superficial flake, such as follows
suppurative periostitis, to a mass representing the en-
tire shaft of the bone, such as not infrequently follows
acute osteomyelitis. The causes are acute and chronic
inflammations of the periosteum, bone and medulla. The
sequestru7n separates from the living bone by a line of
ulceration or demarcation much the same as in gan-
grene of soft parts. The surrounding living bone
usually undergoes a condensing ostitis and becomes
much harder than normal. Small and superficial se-
questra may be discharged spontaneously through a
sinus, which inevitably exists in all but very small
aseptic sequestra, in which complete absorption without
suppuration is possible. If the necrotic mass is large
or centrally located spontaneous discharge is impossible
and suppurative inflammation may continue for years.
The dense bone which surrounds the sequestrum in
these cases is called the invohierum, and the sinus lead-
ing from the surface down to the cavity in whieh the
seanestrum lies is called the cloaca." — (Stewart's Sur-
gery.)
SKIN, HYGIENE, MEDICAL JURISPRUDENCE, MENTAL AND
NERVOUS DISEASES.
1. Lupus vulgaris is a tuberculous ce'lular new
growth, characterized by reddish or brownish patches
consisting of panules, nodules, and flat infiltrations,
usually terminating in ulceration and scarring. The
affection occurs most often upon the face and is due to
local infection bv the tubercle bacillus. It is distin-
guished from syphilis and epithelioma by its occurrence
before puberty, slow course, history and concomitant
signs of the tuberculous diathesis, soft nodules, multinle
and superficial ulcers, absence of pain, yellowish,
shrunken and hard scars and slight discharge. Ths
condition is chronic and in small patches may be en-
tirely cured. — (Pocket Cyclopedia.)
2. Pnorias's is a common chronic inflammatory dis-
ease of the skin, characterized by variously sized lesions,
having red bases, covered with white scales resemb-ing
mother of pearl. It affects by preference the extensor
surface of the bodv. The lesions are infiltrated, ele-
vated. clearly defined, covered with white, shining, easily
detachable sca'es which, upon removal, revepl a red,
punctate, bleeding surface. The eruntion is absolutely
drv. and itching is usually absent. — (Pocket Cyclo-
pedia.)
The snecial points of value in reference to diagnosis
are the lesions of variable dimensions, all being capped
838
MEDICAL RECORD.
[Nov. 4, 1916
with pearly white scales; borders severely outlined; ten-
dency to convalescence, with the presentation of bleed-
ing points upon removal of scale.
3. Varieties of eczema. — Eczema erythematosum, E.
papulosum, E. vesiculosum, E. pustulosum, E. rubrum,
E. squamosum, E. nssum, E. sclerosum, E. verrucosum,
E. papillomatosum.
4. The sleeping room should be as large as possible,
with the maximum of sunshine and fresh air; it should
face the south, or east, or southeast, and should contain
no hangings and have as few "dust catching" contri-
vances as possible; it should not lead into a bathroom.
There should be a separate bed for each person, and,
preferably, each person should have his own room.
There should be provision for moderate heating of the
bedroom and a warm dressing loom may be necessary
in cold weather.
5. "In addition to the ordinary hygiene of factories
and workshops, such as proper space, air, ventilation,
water supply, lighting, healing, drainage and plumb-
ing, ordinary cleanliness and absence of dust care
should be taken that women and children do not work
too long at a time or at occupations involving the use
of poisonous or deleterious materials; that there are
ample toilet and lavatory accommodations, and that
these are separate and away from those used by men ;
there should also be opportunity to sit, and women
should not be expected to remain standing for long
periods of time." — (Scott's State Board of Physiology
and Hygiene.)
6. "Nitrates may be found in pure water from deep
wells in the chalk, but as a rule are due to oxidation of
organic matter of animal origin. Even if accompanied
by only a small proportion of organic matter nitrates
in water from a source open to suspicion must be re-
garded as oxidized filth, which may at any time be fol-
lowed by unoxidized filth. A trace of nitrates not ex-
ceeding N = 0.35 per 100,000 would not suffice to con-
demn a water otherwise pure.
"Nitrites must be considered as pointing to sewage
contamination, and their presence should condemn the
water. They indicate more recent and therefore more
dangerous contamination than nitrates." — (Aids to
Sanita ry Science. )
7. The chief city nuisances are: Noise, smoke, dust,
waste matters, gases and fumes, odors and various of-
fensive trades (such as the keeping of live animals, the
killing of animals, the sale of animals, the manufac-
ture of animal products, carpet beating, smelting and
chemical manufactures). About country homes the
nuisances which are the most in evidence are the im-
proper disposal of waste or refuse material and the
keeping of live animals.
8. To prevent the spread of infectious diseases: They
should be reported to the health authorities; adequate
isolation and quarantine (when necessary) should be
enforced; proper prophylactic measures (as vaccina-
tion) should be ordered; children, from houses where
there is such disease, should not be allowed to mingle
with other children; proper disposal should be made of
sputum and excreta; details bearing upon the preven-
tion of each disease can be learned from special man-
uals on the subject.
9. (a) Medicolegal complications which may arise
from an erroneous diagnosis of pregnancy: The char-
acter of the woman may be involved; the legal rights
of the child may be involved; the paternity of the child
and the mother's right to demand from the father sup-
port for the child are also involved; inheritance of
titles and property are also to be considered.
(6) The practitioner should be very careful in mak-
ing a diagnosis of pregnancy; he should remember that
the positive signs of pregnancy are not present during
the first few months; in doubtful cases he should main-
tain a strict silence, remembering that time will aid in
making the diagnosis sure.
10. Etiology of multiple neuritis: The disease is said
to be due to the action of poisons (in the blood) on
ihe peripheral nerves. These poisons may be: Alcohol,
lead, arsenic; diseased conditions as gout or syphilis;
and bacterial toxins, such as are found in specific fevers,
sepsis, etc.
OPHTHALMOLOGY, OTOLOGY, AND LARYNGOLOGY.
1. Indications for iridectomy: (1) Glaucoma; (2)
some cases of chronic and recurrent iritis and irido-
cyclitis; (3) complete circular synechia; (4) partial
corneal staphyloma; (5) tumors and foreign bodies in
the iris; (6) recent prolapse of the iris. (From May's
Diseases of the Eye.)
2. Staphyloma is a bulging of the cornea or sclera.
It is due to inflammation.
3. Uturonic dacryocystitis is caused by obstruction of
the nasal auct. Ihe symptoms are: Epiphora, fulness
in the region of the lacrymal sac and the escape of a
viscid tluid when pressure is made on the distended
lacrymal sac.
4. "Suppuration in the frontal sinus is attended with
frontal headache, vertigo, especially on stooping, and
tenderness on pressure, particularly over the internal
orbital angle, or on percussion over the frontal region.
Pus escapes into the middle meatus of the nose, and if
wiped away will reappear if the head is bent forward
for a few minutes. After removal of the anterior end
of the middle turbinated bone it may be possible to
catheterize the sinus and wash out pus from its interior.
The diseased sinus may present a darker shadow than
the healthy one on transillumination or in an x-ray
photograph. The treatment consists in exposing the
anterior wall of the sinus by an incision in the line of
the eyebrow, chiseling away sufficient bone to admit of
free removal of all infected tissue and establishing ef-
ficient drainage through the infundibulum into the
nose." — (Thomson and Miles' Manual of Surgery.)
5. Aphonia is loss of voice due to some interference
with the vocal cords. Causes : Laryngitis, edema of the
glottis, retropharyngeal abscess, excessive use of the
voice, tumors of the larynx, foreign bodies in larynx,
inflammation of the laryngeal nerves, paralysis of the
laryngeal muscles, and hysteria.
6. "Hyperemia of the labyrinth may result from middle
ear inflammation, exanthematous diseases, mumps, some
intracranial disease, cessation of menstruation, disease
of the heart, excessive use of alcoholic liquors, quinine,
amyl nitrite, prolonged irritation from the use of the
telephone receiver and vasomotor disturbances. Symp-
toms: There is present a sense of fullness in the ear,
with ringing and roaring sensations and sometimes
giddiness, nausea and vomiting. The symptoms are
somewhat intensified by the horizontal position." —
(Kyle's Diseases of Ear, Nose and Throat.)
7. Rupture of the membrana tympaui may be caused
by direct violence, such as blows or by instruments in-
troduced into the meatus; or by indirect violence, such
as the sudden condensation of air in the meatus, which
may be produced by an explosion or the firing of a
heavy gun in the immediate neighborhood; traction on
the auricle, inflammation, irritating substances, and
vegetable growths may also cause rupture of the mem-
brane. Symptoms: Sudden and severe pain, impaired
hearing, hearing subjective noises, vertigo, a watery
discharge in the meatus, a whistling sound in the ear
when the patient blows his nose.
8. Acute circumscribed otitis. — The symptoms are a
feeling of fullness in the ear, a slight itching sensation,
pain in the ear with tenderness on pressure, swelling in
the auditory meatus which causes stenosis and slight
deafness, tinnitus, pain on mastication, and increase of
the pain and discomfort; the neighboring lymphatics
may become involved, in which case the'e v'll be ris?
of temperature to about 100° to 101° F. There may
be slight constitutional symptoms.
9. Postnatal adenoids. Symptoms: Mouth breath-
ing; snoring; open mouth; a vacant, dull expression of
the face; modification of the voice (nasal twang), with
inability to pronounce certain letters.
Treatment consists in early and complete removal by
curette or forceps.
10. Intubation. Indications. Dyspnea from diph-
theria or membranous laryngitis, stenosis, tumors, and
some forms of paralysis of the larynx, and edema of
the larynx.
Method: The child is wrapped in a blanket to control
the arms and legs and is held upright by a nurse seated
in a chair, while an assistant holds the head upon the
nurse's left shoulder and prevents the mouth gag from
slipping. A long piece of silk is passed through the
small opening in the upper part of the tube, the tube
fastened to the introducer, and the silk looped around
the little finger. The left index finger is passed into
the throat and lifts the epiglottis while the tube is
passed along it into the glottis. The left index finger is
then made to press upon the head of the tube, which is
released by pulling the trigger on the introducer, which
is then withdrawn. When one is assured that the tube
is in the right place and that the symptoms are re-
lieved, the silk loop may be cut and withdrawn while
the finger is again made to press down on the tube. —
(Stewart's Surgery.)
I To be concluded.)
Medical Record
A Weekly Journal of Medicine and Surgery
Vol. 90, No. 20.
Whole No. 2401.
New York, Noveimber ii, iqi6.
$5.00 Per Annum.
Single Copies, 15c.
©rtgtnal Arttrkfi.
ACHYLIA GASTRICA;
A STUDY OF SIXTY-FIVE CASES
By ALBERT F. R. ANDRESEN, M.D.,
BROOKLYN, N. Y.
In medical literature of recent years there has been
a decided scarcity of articles relating to achylia gas-
trica. This is unfortunate, because, while by no
means an uncommon condition, it is probably less
frequently correctly diagnosed by the average prac-
titioner than any other stomach condition. In a
critical study of between six and seven hundred
cases of all kinds in the gastrointestinal clinic of
the Brooklyn Hospital Dispensary, sixty-five, or
about ten per cent., were found to be suffering from
achylia. In private practice the percentage would
undoubtedly be lower, because among the better
classes we do not see the neglect and abuse of the
body which play such an important role in the eti-
ology of this condition. Nevertheless probably five
per cent, of all patients with gastric disturbances
would be found to have achylia gastrica if properly
examined. The present paper is based upon a study
of the sixty-five cases referred to above.
Strictly speaking, achylia gastrica is the name
given to a condition characterized by an entire ab-
sence of gastric secretion, i.e. an absence of hydro-
chloric acid as well as of the enzymes, pepsin and
rennin. By common consent, however, it is now
understood that the term includes all cases in which
there is an absence of free hydrochloric acid in the
gastric contents, although enzymes and some com-
bined acid may be present.
Concerning the etiology of achylia there has been
considerable discussion and doubt. Some authors
have attempted to show that a large proportion of
cases is of functional origin, others, that it is always
of organic origin. While it must be admitted that
there may be a congenital weakness or anomaly of
the gastric mucosa, accompanied by achylia, in
adults it is always well to look for some organic
cause for this condition, either within or without the
stomach. To better understand the generally ac-
cepted theories concerning the etiology of achylia,
it is well to consider briefly the three factors neces-
sary to the production of normal gastric secretion,
viz., (1) normal gastric glands, (2) the presence
of HC1 producers or enzyme activators in the blood,
and (3) a normal central and peripheral nerve-
supply to the gastric glands. Abnormal conditions
affecting any of these three factors may produce
achylia gastrica. Therefore, in considering the gen-
erally accepted theories regarding the etiology of
achylia, we can take up abnormalities of each of
these three groups separately.
I, Abnormalities of the gastric glands, producing
achylia, may be of three kinds, viz. : (1) Functional,
i.e. a condition in which normal glands do not pro-
duce normal secretion. I do not feel that this con-
dition is often met with, except possibly as a develop-
mental anomaly. (2) Inflammatory conditions of
the gastric mucosa, either (a) catarrhal, as a result
of chronic irritation from the ingestion of alcohol
or nicotine to excess, or improper or insufficient
masticated food, or (b) infective, as a result of
primary foci of infection elsewhere causing a gen-
eral inflammatory condition of the gastric mucosa
(.89 per cent, of my cases showed infections of the
mouth, nose or throat). (3) Atrophy of the gas-
tric mucosa, as a result of (a) chronic inflamma-
tion as above; (b) arteriosclerosis with attendant
sclerosis of the mucosa; (c) new-growth pressing
upon or destroying the secreting cells, such as car-
cinoma, sarcoma, fibroma, gumma, or extensive
scar tissue from chronic ulcer; (d) distant wasting
diseases, such as tuberculosis, intestinal parasites,
chronic malaria, diabetes, plumbism, sprue, pel-
lagra, etc.
II. Diseases of the blood, which might be a factor
in causing achylia by impairing the bodily nutrition-
or by interfering with the carrying of HC1 produc-
ers or enzyme activators, include: (1) Anemias and
leucemias. Pernicious anemia, long recognized as
an accompaniment of achylia, has been attributed by
some to be the cause, by others the result, of achylia.
Chronic gas poisoning may cause achylia by virtue
of the destruction of blood which it causes, or by
direct poisoning of the glands. (2) So-called gouty
conditions and intestinal or other toxemias. (3)
Syphilis, tuberculosis, or any form of septicemia.
(4) Diseases of the glands of internal secretion,
about the function of which, especially in regard to
digestion, there is still considerable doubt, but
which undoubtedly play an important part in pro-
ducing or activating gastric secretion.
III. Abnormalities of the nervous system, which
might interfere with the normal innervation of the
gastric glands, producing achylia. These are exem-
plified in tabes, during the crises of which there is
as a rule an achylia, and by the still largely theoret-
ical states known as vagotonia and sympathetico-
tonia. Under this heading might also be classed
chronic infections or other abnormal conditions
outside the stomach, such as pelvic disease, gall-
stones, appendicitis cases, especially postoperative,
and extensive ptoses, which are supposed to act
reflexly through the nervous system in producing
achylia.
The contention that achylia gastrica is essentially
a disease of those past middle life is borne out by
our series, the average age of our patients being
43.9 years, and 23, or 35 per cent, being fiftv years
of age or older. Of 65 patients, 29, or 44.6 per
cent., were males, 36, or 55.4 per cent., females, the
apparent disagreement with the usual belief that
840
MKDICAL RFXORD.
[Nov. 11, 1916
more males are affected being probably due to the
fact that the total number of female patients in the
clinic far exceeds that of the male. Bad teeth, that
is, gross evidences of decay and infection, were
found in 58, or 89 per cent., of our cases. Other
conditions which might have played an important
part in causing the achylia, arranged in the order
of the frequency of their occurrence, are shown in
Table A.
Disease.
Number.
Per Cent.
11
10
10
8
6
3
3
3
2
2
2
6
17
15
15
11
9
4.5
4.5
4.5
3
3
3
9
65
100
A simple explanation of the cause of achylia
which has not before been suggested, and substan-
tiation of which does not as yet exist, would be
that, except possibly in congenital cases or in those
due to tumor or disease of the glands of internal
secretion, it is always due to a chronic generalized
hematogenous infection of the gastric mucosa,
probably by the Streptococcus viridans, as a result
of a primary focus of infection elsewhere. The
stomach would be made a locus minoris resistentiae
by abuses such as the excessive ingestion of alcohol,
nicotine, insufficiently masticated food, or other irri-
tants, or by sclerosis from arteriosclerosis. Neglect
of the teeth is usually an accompaniment of chronic
alcoholism, and is also common in older persons.
In our series, the large percentage of infections of
the mouth, nose, and throat (over 90 per cent.)
would account for the primary focus of infection
in these cases, as would pelvic infections, tubercu-
losis, syphilis, septicemia, etc. The explanation of
the occurrence of achylia after operations for infec-
tions of the appendix, gall-bladder, and pelvis would
be that the manipulations at operation threw into
the circulation infective material which localized
in the already reflexly irritated stomach wall. The
finding of streptococci in the blood of the patients
with achylia and pernicious anemia would also be
explained. The anemia might even be explained by
■the presence of a coincident infection of the hema-
topoietic organs. This theory would also explain
the periods of exacerbation and remission of symp-
toms in pernicious anemia, so much resembling
those of chronic arthritis or appendicitis. In this
connection, the frequent association of achylia with
chronic joint troubles is suggestive. Even in carci-
noma cases the achylia might be due to a compli-
cating infection of the mucosa, it being usually
true that carcinoma does not cause achylia until
ulceration occurs, and this ulceration is probably an
infective process. This infective theory is one
which might well be investigated.
The symptoms of achylia gastrica may often be
very indefinite, and there may even be nn symptoms
for a considerable length of time, as long as pan-
creatic and intestinal digestion remain normal. In
our 65 cases the average duration of the symptoms
before the patient applied to us for treatment was
two and one-half years. Pain or distress at vari-
able times after eating, often relieved by food or
alkalies or by lying down, occurred in 57, or 87 per
cent, of our cases. Sour regurgitation occurred in
29, or 44 per cent., vomiting in 23, or 35 per cent.,
of which two, or 3 per cent., had hematemesis. The
bowels were regular in only nine, or 15 per cent., of
the cases, constipation occurred in 36, or 55 per
cent., and chronic diarrheas in 20, or 30 per cent.
In the diarrheal cases the average duration of
symptoms had been three and one-half years, as
against two and one-half years for the whole series,
suggesting the idea that the diarrhea is due to the
long continuance of the achylia. Anorexia, muscu-
lar weakness, insomnia, and nervous irritability
were usually complained of. Loss of weight usually
occurred, but was not excessive.
The explanation of these symptoms lies in a
study of the physiological effect of gastric juice
containing the normal amount of hydrochloric acid.
These effects are as follows:
1. Proteins are peptonized.
2. Connective tissue is changed so as to be di-
gestible by the digestive ferments in the intestine.
3. The pylorus is closed through irritation.
4. The secretions of the pancreas and intestinal
glands are stimulated.
5. The stomach and intestines are disinfected.
Insufficient disinfection allows free growth of
bacteria, with acid fermentation, and the resultant
organic fatty acids cause pain and distress, belch-
ing, and sour regurgitation. The fermenting, in-
sufficiently prepared food is hastened into the duo-
denum through the relaxed pylorus, and the in-
sufficiently stimulated pancreatic and intestinal se-
cretions, sadly overtaxed, eventually fail properly
to complete digestion. This results in irritation
of the intestinal mucosa, causing a hurrying along
of the intestinal contents, with resultant diarrhea,
and, eventually, a catarrhal enterocolitis. The
diarrheal movements, often enormous in size, usu-
ally occur after eating, the peristalsis and sphinc-
teric relaxation excited in the stomach by the food
extending rapidly along the entire intestinal tract.
The diagnosis of achylia gastrica depends upon
gastric analysis. The only suggestive symptom is
the diarrhea, although the history of chronic alco-
holism, tuberculosis, and various other of the more
common causes of achylia, associated with gastric
symptoms, should make one suspicious of this con-
dition.
The gastric contents, removed with the ordinary
stomach tube one hour after an Ewald test meal,
show an absence of chymification and an increased
motility, the mass extracted being thick, moist, and
sausage-like. There is also an absence of free
hydrochloric acid, a total acidity usually under
twenty, absence or great reduction in proteolytic
and milk-curdling enzymes, and the presence of
more or less mucus. Increased peristalsis is shown
by the small amount of residue obtainable. In our
forty-six cases examined in this manner, the total
acidity averaged eleven. In the diarrheal cases,
twenty in number, the total acidity averaged thir-
teen, so that the degree of acidity would not seem
to be a determining factor in causing the diarrhea.
The stools usually contain mucus and connective-
tissue fibers, and. occasionally, occult blood.
For the past ten months we have been using the
Rehfuss fractional method of test-meal examination
in our clinic. By this method a fine tube with a
fenestrated metal tip is left in the stomach through-
out gastric digestion, and 6 or 8 c.c. of the contents
after an Ewald test meal are removed at fifteen-
Nov. 11, 1916]
MEDICAL RECORD.
841
minute intervals until the stomach is empty. We
have been able to confirm Rehfuss's contention that
many cases called achylia because of the findings
at the one-hour point after the ingestion of the
test meal were really cases of delayed digestion,
the acidity, as shown by the Rehfuss method, reach-
ing normal, or even becoming higher than normal,
after one and one-half or two hours. A true achylia
must show absence of free hydrochloric acid in all
specimens removed. Out of 190 cases of all kinds
examined by the Rehfuss method, 19, or 10 per
cent., showed a true achylia, the percentage agree-
ing, strange to say, almost exactly with the per-
centage of achylia cases previously found. In
these cases the average highest total acidity
was fourteen. Emptying of the stomach was very
rapid in the simple cases, all residue being gone by
the end of from one and one-quarter to two hours
after the test meal was given. In pyloric carcinoma
cases, and in a case of chronic ulcer at the pylorus,
stasis was shown by a greatly delayed emptying
and the presence of lactic acid and lactic acid
bacilli. In the simple cases, bile regurgitated early,
often by the end of one-half hour, due to the re-
laxed pylorus. Mucus was usually present to excess,
and microscopically large numbers of bacteria,
leucocytes, blood, and epithelial cells were found.
An interesting finding was the invariable presence
of blood in the contents. Visible blood was always
found at some time during the procedure, but fre-
quently occult blood would be found in the begin-
ning and visible later. This finding is, of course,
explained by the congested or atrophic and friable
condition of the mucosa, and seems to obviate the
necessity of describing as an entity an achlorhydria
gastrica hemorrhagica, as has been suggested. In
1G of our 19 cases, or 84 per cent., occult blood was
found in the stool after three days' meat-free diet.
The finding of blood was not, however, constant,
only occurring at irregular intervals.
Differential diagnosis, after an examination of
the gastric contents has established the presence of
an achylia, is practically confined to the determina-
tion whether or not carcinoma of the stomach is the
cause of this achylia. The occasional occurrence of
gumma, of other neoplasms than carcinoma, or of
indurated gastric ulcer with achylia, should be
borne in mind, although their differentiation from
carcinoma, except possibly in the case of gumma, is
not usually made before microscopical examination
of sections of the tumor establishes the diagnosis.
Aside from the finding of a gastric tumor, associ-
ated with symptoms of achylia, the following find-
ings are suggestive of carcinoma as a cause of the
achylia :
1. The constant finding of occult blood in the
stools.
2. The presence of lactic acid, lactic acid bacilli,
and infusoria in the gastric contents removed from
a fasting stomach.
3. The finding of a considerable amount of al-
bumin in the stomach washings — an index of 200
to 400 by the Wolff-Junghans method.
4. A Wolff-Junghans curve, in the fractional
cases, rising rapidly and out of all proportion to the
curve of acidity.
5. Excessive loss of weight and strength, even
when the diet is sufficient, under normal circum-
stances, to cause a gain in weight.
The finding of fragments of carcinomatous tissue
or of carcinoma cells in the gastric contents is, of
course, diagnostic, but, like the finding of a palpable
tumor, is too late to be of value to the patient. The
most valuable aid in differentiating carcinoma in
doubtful cases is undoubtedly the Roentgen ray.
By means of serial Roentgenography, even the pres-
ence of early carcinoma of the^body of the stomach,
which it is practically impossible to recognize by
any other means, can often be ascertained with a
considerable degree of accuracy. The Abderhalden
test for carcinoma, even if reliable as indicating the
presence of a carcinoma, would not, in the absence
of confirmatory evidence, be of any help in locating
the carcinoma in the stomach, as simple achylia
may occur as a result of carcinoma in a distant part
of the body.
The prognosis in achylia gastrica depends upon
its cause. In carcinoma the prognosis is bad, as
carcinoma cases which are sufficiently advanced to
show a total absence of free hydrochloric acid in
the gastric contents are usually beyond hope of cure
by operative procedures. In the presence of per-
nicious anemia, the outlook is decidedly unfavor-
able, although these cases will frequently have
periods of entire absence of all symptoms, followed
by acute exacerbations, as mentioned above. In
other cases the prognosis as to life depends upon
the prognosis of the coexistent disease. In the so-
called cases of simple achylia, the prognosis as to
life is good, the disease itself, under proper treat-
ment, not being fatal, and not tending to the de-
velopment of carcinoma or other serious complica-
tions. The chances of complete recovery of normal
gastric function are not favorable, although we
have seen many cases in which, after a course of
treatment such as described in this article, the test
meal showed normal findings in a few months.
Treatment. — The indications for treatment in
achylia gastrica group themselves under the follow-
ing general heads:
1. The removal of any infective foci, which, in
addition to being a probable etiologic factor in the
disease, tend to weaken the patient's reconstructive
powers, so necessary to effect a cure. Operative
treatment of such infective foci in the mouth, nose
and throat and accessory sinuses, abdomen, pelvis
or any other part of the body, should be preceded, if
possible, by a course of dietetic and tonic treat-
ment, and the use of autogenous vaccines of the
streptococcus viridans, obtained from these foci of
infection. This procedure would tend to prevent
complications when operation would throw into the
circulation large amounts of infective material. If
the infective theory is correct, the use of the vac-
cines might also be of some theoretical value in
hastening improvement in the condition of the gas-
tric glands. In the few cases in which we have
tried this method, improvement in the patient's
condition seemed more rapid and more complete
than in those where it was not used.
2. The treatment of any constiutional abnor-
mality complicating or possibly acting as a causa-
tive factor in the achylia. This would include treat-
ment of the anemias, leucemias, malaria, syphilis,
tuberculosis, cardiovascular-renal diseases, rheu-
matic conditions, alcoholism, etc. In addition to
treatment specific for any of these conditions,
tonics would be indicated. I have been in the habit
of combining ferric chloride and calcium chloride
with the hydrochloric acid usually given in this
disease. The use of the so-called bitter tonics
before meals may in some people have some effect
842
MEDICAL RECORD.
[Nov. 11, 1916
in stimulating the appetite, but no effect on the
gastric secretion may be expected, as shown by the
recent researches of Carlson and others. The best
tonic after all is a proper diet, and this will be dis-
cussed in detail later on. Exercise, especially in
the fresh air, gynrhastics, baths and change of
scene are of value. Abdominal massage and elec-
tricity may be used.
3. The treatment of the diseased stomach must
have as its keynote the conservation of its motor
function. With the secretory function impaired,
the motor function is of the utmost importance, and
any measures such as over-feeding, or over-disten-
tion by careless lavage, should be avoided. Lavage
was formerly a very popular procedure, but has
more recently been practically abandoned. The
amount of mucus removed by this method is prob-
ably more than compensated for by the subsequent
increased secretion of mucus by the irritated
stomach. A tumblerful of hot water given one-half
hour before meals has a cleansing effect, besides
being a valuable addition to the diet. Mineral
waters are not necessary, but where given should
be those which contain sodium chloride as a prin-
cipal constituent. Mineral oil, given in tablespoon-
ful doses, morning and evening, is soothing to the
irritated gastrointestinal mucosa, and, besides
being of value in relieving constipation, is not con-
traindicated in diarrhea.
4. Dietetic Treatment: The diet should be con-
centrated, and should consist of small amounts of
food frequently repeated, preferably every two and
one-half or three hours. The food should be in
such form as to cause the least possible irritation
to the diseased mucosa, and to require little or no
alteration to make it digestible by the intestinal
secretions. To prevent putrefaction it is best at
first not to allow any kind of meat. For the same
reason eggs should not be allowed unless soft-
boiled, and then only in moderation, not more than
one or two a day. It is better to derive the neces-
sary protein of the diet from vegetables, or from
nuts in moderation. Gelatin is also valuable as a
protein sparer. Milk should be an important part
of the diet, and it is well borne except in some
diarrheal cases, where it seems to cause more irri-
tation of the bowel. Frequently, however, this tend-
ency to irritation can be overcome by having the
milk peptonized, or acidulated with dilute hydro-
chloric acid, one dram to a glass of milk, added
just before the milk is taken. It has been our
experience that buttermilk and artificially soured
milk are not well borne.
Carbohydrates form a valuable part of the diet
in these cases. Starches are best given in such a
form that the protein envelope, which requires di-
gestion by the gastric juice, shall have been broken.
For this reason strained vegetable soups, or purees,
of potatoes, peas, beans, lentils, spinach, or carrots,
are valuable. Thoroughly cooked cereals and pud-
dings, served with cream or with stewed fruits or
fruit juices, are tasty and easily digested. Flaked
or shredded cereals are also good, as are bread,
toast, and simple crackers. The so-called "vegetable
meat" preparations, made of vegetables and nuts,
provide an agreeable variation to the diet. Sugars
are of value, but must be taken in moderation to
avoid acid fermentation in the bowel, as evidenced
by sour stools. The less fermentable sugars, such
as lactose or maltose, may be added to the diet to
increase its fuel value.
Fats and oils, in the form of butter, cream, olive
oil or yolk of egg, are good to add to the caloric
value of the diet, and also tend to soothe the irri-
tated gastric mucosa. Taken to excess they are bad,
especially in the presence of diarrhea.
Beverages, besides milk, which may be allowed,
include cocoa, weak tea or coffee, or, better, cereal
coffee substitutes, and fruit juices. The use of
alcohol in any form should be interdicted, as should
be the use of tobacco.
In a general way, the diet should consist of be-
tween two and three thousand calories, a little more
than the amount required in the average normal
person. The best index of a proper diet is the
patient's weight. In a debilitated, undernourished
patient, an increase in weight is necessary ; in no
patient is loss of weight during treatment admis-
sible. A good sample diet for a single day, con-
sisting of 2,515 calories, is shown in Table B. By
varying the nature and quantity of the different
constituents, such a diet can be made acceptable, or
even agreeable, to the patient.
Table B.
Food.
BREAKFAST.
Apple sauce
Milk
With cocoa or lactose
Cereal
With sugar
With cream
Egg. poached, on toast
Bread and butter
10.:i0 a.m.
Milk
With Lactose
Graham crackers
LCNCH.
Cream vegetable soup or puree
Milk and lactose, as above
Bread and butter
Bread or chocolate pudding- .
4 P.M.
Milk, lactose and graham crackers .
SlFPER.
Potato or tomato bisque soup .
Fresh asparagus
Raw cabbage salad
Bread and butter
Milk and cocoa or lactose. . . .
Gelatin with cream
ON RETIRING.
Milk, lactose and crackers
Olive oil
AFTER EACH MEAL.
Total number of calories: 2, 515
Quantity.
4 ounces
6 ounces
1-2 ounce
4 ounces
1 dram
1 ounce
1 egg, 1 slice
1 slice
t> ounces
1 2 ounce
2 small
0 ounces
r> ounces
1 slice
4 ounces
As above
4 ounces
1 ounce
2 ounces
1 slice
As above
4 ounces
\- :ih,.v.'
1 :. ounce
Calories.
75
125
40 +
75
25
50
150
65 605
125
40
10 175
125
165
65
200
75
25
50
65
165
50
5. The use of hydrochloric acid and enzymes is
a subject about which there is still considerable
controversy. Probably the most valuable aid in re-
lieving the symptoms of achylia gastrica is the use
of hydrochloric acid. While this acid cannot of
necessity be given in such quantities as to insure a
concentration in the gastric contents even approach-
ing the normal, its effect, even in small doses, is re-
markable. The distress and sour regurgitation
after eating are quickly relieved. Vomiting usually
ceases at once, and diarrhea, in my experience, has
been always controlled within a few days, being
often followed by obstinate constipation. The bene-
ficial effects following the use of hydrochloric acid
can be ascribed to the fact that its ingestion pro-
duces effects similar to those produced by the nor-
mal acid in the stomach, viz., a stimulation of
gastric, intestinal, and pancreatic secretion, a
Nov. 11, 1916]
MEDICAL RECORD.
843
changing of pro-enzymes into active enzymes, an
improvement of amylorrhexis by aiding in the di-
gestion of the starch envelopes, and an antiseptic
action. The dose of the acid should vary from
fifteen drops to one teaspoonful or more of the
dilute hydrochloric acid, preferably beginning with
larger doses and reducing their size as symptoms
are ameliorated. It should be given one-half hour
after eating, well diluted with water, and swallowed
through a tube to avoid burning the teeth. By dis-
solving one teaspoonful of cane sugar in the wine-
glassful of water, etching of the oral mucosa can
be further avoided. A substitute for the acid, sup-
posed to be less disagreeable to the patient, is
acidol, a hydrochloride of betain, which is said
to form nascent hydrochloric acid on reaching the
stomach. The dose is from 10 to 30 gr., each
grain representing one minim of hydrochloric acid.
It is expensive, and not much better liked by pa-
tients than the very cheap acid, given as above
described.
The use of enzymes and activators, at one time
very fashionable, has now largely fallen into disuse.
Pepsin is usually being excreted by the gastric
mucosa long after the hydrochloric acid has disap-
peared, and needs only the acid to activate it. An-
other fact to be borne in mind is that enough dilute
hydrochloric acid could not be given by mouth to
produce the hydrochloric acid concentration neces-
sary for pepsin action. The use of preparations of
pancreatic glandular extracts, such as pancreon,
pancreatin, and other similar preparations, is not
of much value, especially where hydrochloric acid
is given, as this destroys their activity. The use
of secretins has not proved clinically to be of any
value.
Conclusions 1. The usually indefinite symptoms
of achylia gastrica warrant careful search for this
condition in all cases of gastric disorder.
2. Its diagnosis depends upon gastric analysis,
and the Rehfuss fractional method of test meal
examination is the most satisfactoiy to use.
3. Knowledge of its etiology is still uncertain,
but the infective theory should be investigated.
4. If an infection, the term gastritis, or better,
endogastritis, would not be a misnomer for this
disease.
5. Acceptance of the infective theory demands
the removal of infective foci as a part of the treat-
ment, and points the way to efficient prophylaxis.
6. Diet and the use of dilute hydrochloric acid
are the other important items in the treatment.
BIBLIOGRAPHY.
Andresen, A. F. R. : L. I. Med. Journ., April, 1916;
and The Proctol. and Gastroenterol., June, 1916.
Borries, G. V. T.: Hospitalstidende, Copenhagen,
Oct. 6, 1915.
Brown, T. R.: Bull. Johns Hop. Hosp., July, 1914.
Disque, L. : Archiv v. Verdaungskr., Berlin, June 18,
1915.
Einhorn, Max: Medical Record, June 11, 1892.
Eisner, Hans: Lehrb. d. Magenkrankh., 1909.
Pilcher, Jas. T.: Amer. Journ. Med. Sc, August,
1913.
Rehfuss, M. E.: Amer. Journ. Med. Sc., July, 1915.
SS9 Union Street.
Arthritism. — Bazin and Bouchard described under
the names "arthritism" and "slackening of nutrition"
a group of conditions, including gout, asthma, rheu-
matism, gravel, gall stones, obesity and diabetes, which
are frequently met with in the same individual or the
same family, and which are transmissible by heredity
and are interchangeable: a gouty subject who has or
has not diabetes may have a child who develops diabetes,
asthma, or gravel, etc. — Cornwall in the Medical Times.
THE HORMONE EQUATION OF THE PSY-
CHOSES.
By C. R. CARPENTER, M.D..
EAST SAN DIEGO. CAX..
IN the recent work of Harrower, entitled "Practical
Hormone Therapy," Bayle is quoted as saying, with
reference to his extensive use of the spleen, that it
is "perfectly innocuous." The writer has used the
spleen therapeutically quite extensively in many
conditions, notably in malarial infections ; and while
in the main, owing to the marvelous power of the
endocrine organs to adapt themselves to circum-
stances, the observation of Bayle is correct, experi-
ence has shown that in a certain number of cases
this power of adaption fails, and symptoms of a
grave and alarming character supervene.
If this happens only once in a thousand times,
and there is little doubt that it happens much
oftener, its character of being "perfectly innocu-
ous" is no longer sustained. Indeed, we are at once
placed under the imperative obligation to study the
conditions under which this happens, and if possible
to find the remedy. For hormone remedies are being
used more and more widely all the time, and are
destined to take a commanding place in the field
of medicine.
For this reason it is considered of the highest
importance right at this point to make a somewhat
sweeping statement, of far-reaching significance,
which the present paper will endeavor to substan-
tiate.
That statement is this: In the treatment of any
disease by the administration of the spleen, it is not
safe to give it alone; and it should never be done.
The mere fact that it has been given for long
periods of time, in large numbers of cases, ap-
parently without bad effects, simply renders those
effects, when they do appear, more difficult to
understand. It is more than probable that they
have occurred frequently without a suspicion of the
real cause. After many years of observation, the
conviction has been formed in the mind of the
writer, that the spleen is a remedy of remarkable
power in the treatment of many diseases, especially
those of an infectious character.
It is more than a remedy. The evidence is con-
tinually growing that it forms the center of a group
of organs, which constitutes what is now known as
the "defensive mechanism of the body." It is the
functioning of this group of organs, modified by
numerous accessory glands to meet the special re-
quirements of different infections, that has been
known in past years as the vis medicatrix naturse,
the healing power of nature, the natural resistance
of the body, and by many other like terms.
It is upon this force that physicians in all ages
have relied for their curative effects. No physi-
cian worthy of the name expects to accomplish any-
thing for his patient without it. The most modern
physicians with the most modern methods rely upon
it the most. Whether they use antitoxins, bac-
terins or what not, nobody claims that they have any
direct curative power. It is freely admitted that
they depend for their action upon calling forth an
expression from the defensive mechanism of the
body.
But no force of great power can exist in nature
without the possibility of doing harm. It must be
controlled, and its power limited to doing good and
not evil. So it is with the spleen. Nature does not
contemplate its acting to the detriment of the in-
844
MEDICAL RECORD.
[Nov. 11, 1916
dividual. And so this strange and powerful organ
is hedged about in its functions, and controlled in
the exercise of its power by the other glands and
organs with which it is associated, so that it may
not become a Frankenstein in the physiological and
pathological world of its operations.
But, as has been said, there are times when these
endocrine restraints fail ; and when they do, results
follow that are sometimes of the direst character.
It is earnestly hoped that the sidelight thrown by
this little study upon a long darkened subject, may
result in giving to the world an adequate knowledge
of the true cause of mental alienation, and a
rational treatment for the condition.
When the spleen was first used in the treatment
of malarial infections, its effects were so marvelous
that it was thought the fundamental basis of all
natural immunity had been discovered. When an
effort was made, however, to use the same remedy
in other infections, no such brilliant effects were pro-
duced; and in most cases it failed utterly. Even
in the treatment of malarial infections it was found
that notwithstanding its brilliant effects in the large
majority of cases, there were also cases in which it
failed to a greater or lesser degree; and some in
which it failed entirely. It was found that these
patients were uniformly anemic, from blood lysis.
Naturally, a hematinic was given; and when this
was done the effect was quite as satisfactory as in
other cases.
It just happened, however, that the hematinic
used was one which contained a considerable con-
tent of pepsin; and it was found that when other
preparations of iron or manganese were used, the
effects were not so good. But still deeming the
raising of the hemoglobin the necessary point, the
red bone marrow was used, as being theoretically
the ideal hematinic to use in this connection. This
also failed completely, notwithstanding it had been
used with great confidence. By the process of ex-
clusion, then, the conclusion was inevitable that the
pepsin content had more than the significance of
a digestive substance. Its effect was too spectacu-
lar to be due merely to the improvement of diges-
tion, which, in many cases, needed no special im-
provement.
Evidently the combination of the pepsin with the
spleen supplied some need on the part of the spleen,
which enabled its hormone to activate the exhausted
phagocytes, and give them power to cope with the
invading army of Plasmodia.
With apologies to Sir Almroth Wright, if a
phagocyte is quiescent in the presence of a disease
germ, it is not wholly because it feels the lack of a
condiment to tickle its appetite, but because it lacks
the power of aggressive action. And it lacks the
power because the spleen and its complementary
organs have been so weakened by the infection that
they fail to supply to the circulation the necessary
hormones either in quantity or quality.
About ten or twelve years ago a colleague who
had been interested in the use of the spleen by
papers on the subject, presented by the writer in the
local society, announced that he was "Done with
using the spleen!" Upon being asked why he ex-
pressed himself in such an emphatic manner, he
said, "Because it made by patient crazy!" The
writer being at that time quite as certain as Dr.
Bayle that the spleen was "perfectly innocuous," as-
sured him that such a thing was quite impossible.
And the intimation was dropped that his patient
was probably crazy before he took the spleen.
"No, sir," said the doctor emphatically, "I knew
my patient very well, and he was never crazy till
he took that spleen. He is a raving maniac now."
The termination of this case is unknown, but,
needless to say, it was at this time like an ex-
plosive bomb thrown into the camp. A great fear
came into the writer's heart when he recalled the
free and almost unlimited use that had been made
of this remedy. Unlimited, that is, so far as was
at that time known. But the overruling power
which guides children and those who invade the
dark secrets of nature without the lamp of knowl-
edge, had guided better than he knew. Upon re-
flecting that the free use of the remedy had been
uniformly without bad effects, however, the con-
clusion was reached that the case related had been
a post hoc and not a propter hoc; and the work was
continued.
Case I. — A year or so after this, however, a case
of estivoautumnal fever came under treatment. This
form of infection is much harder to control with spleen,
as well as with quinine, than the tertian form. Indeed,
the limitations of the spleen in the treatment of
malarial infections, as has been remarked before,* par-
allel very closely the limitations of quinine. So much
so that the question is very naturally suggested: Are
not the effects of quinine in the treatment of malarial
infections largely due to a stimulation of the spleen,
causing it to throw off into the circulation the hormone,
which undoubtedly produces the curative effect when it
is given internally in those infections?
In the case cited, therefore, the remedy was being
pushed; and as the patient did not show marked
anemia the pepsin hematinic had not been given, when
the patient began to show aberrations of the mind. De-
lirium, however, is not uncommon in such cases; and
the family said of this patient that he always became
delirious when he had fever, so nothing was thought of
it. He did not improve, however, but grew steadily
worse. Quinine was substituted for the spleen, but al-
though the temperature came down the patient was no
better. It was noticeable that when his temperature
came down his mind did not clear. He grew steadily
weaker, failing to respond to any means of stimulation,
and died without recovering his mind at all.
Whether this patient would have died anyhow it
is, of course, impossible to say, but in the light of
subsequent studies, it is now believed that the men-
tal symptoms were produced by the spleen. Whether
it contributed to his death is to be doubted, but
certainly it did nothing to prevent it.
One other case was necessary in order to educate
the writer to the point where it was recognized
that beyond a doubt the spleen under certain con-
ditions was capable of producing grave mental symp-
toms, if not indeed contributing at least to a fatal
issue. The effect of the spleen in the treatment of
cancer had been under observation for some time.
Several cases had been treated by local application
with gratifying results, and it was thought that
better results might be produced by using it sub-
cutaneously.
Case II. — A case soon presented itself in a lady whose
husband said she was dying of a cancer of the neck.
He had heard of the experiments cited, and was willing
to try anything that offered the slightest hope of bene-
fit. The patient was about 40 years of age, fairly
well nourished, and not especially cachectic in appear-
ance. The growth was a lobulated carcinoma of the
right side of the neck, fulminating in the rapidity of
its growth. She was rapidly losing strength, and be-
lieved she was going to die. She was very calm and
collected about the matter, however, even cheerful, and
was much interested in the philosophy of the glandular
treatment so far as it was explained to her. She was
an unusually intelligent patient, and cooperated in
carrying out the details of her treatment as far as
possible.
After some days' treatment, ten minims of the solu-
*Medical Record, 190(5, LXX, 165.
Nov. 11, 1916]
MEDICAL RECORD.
845
tion being injected subcutaneously every third day, the
fulminating growth seemed to be somewhat checked,
and there seemed to be room for encouragement. But
just as it was beginning to appear that there might
be some diminution in the size of the tumor, the hus-
band telephoned one day that the treatment might as
well be discontinued as his wife had lost her mind and
was sinking rapidly. She died shortly afterwards with-
out regaining her mind.
At first, grief and disappointment at the apparent
failure of the treatment to give the relief it had
seemed to promise, obscured a critical judgment of
the circumstances of this case. But more and more
as the facts were dwelt upon the question obtruded
itself : did the administration of the spleen here pro-
duce the unbalancing of a mind that had seemed to
be more than usually well balanced? The more
they were dwelt upon, the more unavoidable seemed
the conclusion that the breaking down of the mind
had not been a merely natural step in the process of
dissolution. And finally the conviction was reached
that the spleen had been the direct cause of the
mental alienation.
But if the spleen was capable of producing mental
alienation in one case, why not in all cases? Evi-
dently because the tendency to do so was held in
check by some other organ or organs. What then
were the conditions under which mental symptoms
were possible? The memory of the other two cases
recurred, and a careful scrutiny of the conditions
was made. It was a long time before any compre-
hension of the circumstances came. But finally the
fact was noticed that a least one condition was
common to all three cases.
They all, for one reason or another, were defi-
cient in sexual power. Not, of course, that they
were sexually impotent; but the last case, for in-
stance, was approaching the climacteric. The other
two, though younger, presented conditions which
suggested unmistakably a reduction in the power of
hormone production by the sex glands.
What if the sexual hormone was deficient? What
would it mean?
Clearly if a diminution of the sexual hormone
caused the administration of the spleen to produce
mental alienation, two very important deductions
must be made. First, there is a possibility that aH
mental alienation, at least of a functional character,
may be due to a coincident hypersecretion of the
spleen and a hyposecretion of the sex glands.
Second, if this deduction be correct, the administra-
tion of the sex glands in functional cases ought to
restore the hormone balance, and hence restore nor-
mal mentality. Combined also with the spleen
whenever it is administered, the sex gland should
also prevent the production of mental symptoms
in any case.
But what of the vast number of so-called cases
of organic mental alienation? Would the adminis-
tration of the sex glands alone correct them also?
This seemed improbable. The intimate connection
of diseased kidneys with many forms of insanity is
well known, and it would seem that these organs
must have an important influence on the spleen also.
Again, long previous experience with the admin-
istration of the spleen combined with digestive sub-
stances suggested that many more cases of mental
symptoms might have been seen had not this pre-
caution been taken, and that the digestive hor-
mones must have also some restraining power over
the spleen. This indeed was found to be the case,
not only with the peptic hormone, but the pancreas
and parotid.
The mammary glands also, except during preg-
nancy and lactation, stimulate the production of the
sexual hormone, and hence assist in the restrain-
ing influence on the spleen.
Gradually by some such course of reasoning the
elements of the following equation were brought
together, with the determination that whenever an
opportunity presented it would be tried out:
2G + P + Pr + R + M=HB.
Where G is the sex gland, P the pancreas, Pr
the parotid, R the renal gland, M the mammary
gland, and HB the hormone balance.
This presupposes that careful distinction is made
between the sexes, which requires two different
equations, one male and the other female. It is not
best to combine the testes and ovary in one equa-
tion, as experiment has shown that the administra-
tion of such a combination may produce intense eye
strain with painful ocular symptoms. This, by the
way, is an important lead for further investiga-
tion.
A long time elapsed before an opportunity finally
presented to make use of this theory. The case
which first called for the administration of hormone
equation No. 45, as it has been called, occurred at
a time when the full hormone equation was not
available. But as it was a purely functional case
of puerperal mania, it was just as well, as it en-
abled the working out of the main point of the
theory.
Case III. — The patient was a young woman 22 years
of age, primipara. Labor was normal in every way
except that as soon as chloroform was given she began
to show aberrations of the mind whenever the anes-
thetic wore off. The aberrations took the form of vio-
lent abuse of the attending physician. The family was
assui-ed that she would be all right in the morning
when the anesthetic had worn off completely. But the
next morning she was as bad as ever, and it was quite
evident that a genuine case of puerperal mania was
in hand. Instantly the determination was reached to
put to the test the theory that had so long been in
mind. Some small powders of ovary were prescribed
containing about two grains each, with instructions to
give one every two hours. Before the second powder
was given the mind cleared perfectly. The rest of the
powders were given but only to make assurance doubly
sure. There has been no recurrence of the symptoms
since.
Case IV. — The next case was that of a woman about
46 years of age, who had a cancer of the thyroid which
was pressing on the laryngeal nerves so that it had
threatened asphyxia from spasm of the glottis and
tracheotomy had been performed. She had been under
treatment for some time with the subcutaneous use of
spleen and lymph glands. The ovarian solution had
been combined with them with the idea of preventing
any mental symptoms, and although considerable doses
had been given no trouble had been experienced. As
the tumor reduced rather slowly, however, it was
thought to hasten matters by increasing the dose. Hav-
ing, however, by this time a somewhat unwarranted
confidence in the controlling power of the sex gland the
dose of ovary was not increased. Not long afterwards
the nurse rushed into the office with the information
that the patient was out of her mind. That she would
not speak, but just stared straight before her without
giving any sign.
On going to the patient she was found in a state of
profound typical dementia. The jaw dropped, the
mouth open, the eyes leaden and staring, the face ashen
and expressionless. A more perfect picture of com-
plete dementia could not be imagined. Although a
totally uneducated woman she had an unusually quick
and keen mentality; so that the change in her appear-
ance and manner was the more extreme, not to say
appalling. But even in the excitement of the moment
it was impossible not to note the radical difference be-
tween this type of psychosis and that of the former
case, and to note also the probable cause of that dif-
ference. Instantly the ovarian solution was produced,
but with fear and trembling; for who could tell
846
MEDICAL RECORD.
[Nov. 11, 1916
whether it would have the same happy effect in this
new type of psychosis. A full dose was given sub-
cutaneously, however, and the result awaited in painful
suspense. In a few moments expression began to come
back into the blank face. The still eyes began to move
about from face to face, and in not more than thirty
minutes the mind was entirely restored.
This patient finally died from a spasm of the
glottis, before the tracheotomy tube could be rein-
troduced; but the importance of the lesson it teaches
in the study of the influence of hormone secretions
in the production of the two great types of mental
disease, can hardly be overestimated.
It has been found in a study of the previous cases
that a hypersecretion, or experimentally, an over-
does of the spleen alone, with a coincident hyposecre-
tion or diminution of the sexual hormone, precipi-
tates mental symptoms of a maniacal type.
In this case, however, we had mental symptoms
of the second great type of psychoses, dementia,
produced by an overdose of the spleen plus an over-
dose of the lymph glands, with also a coincident
diminution of the sexual hormone. The woman was
46 years old.
So far as known, the lymph glands alone have
never produced mental symptoms of any character;
but, as will be shown by the next case, when com-
bined with spleen they readily produce mental
symptoms of a demential type, provided the sexual
hormone is diminished.
Case V was that of an old gentleman 78 years old,
with pyelitis and cystitis, in which there w^as profound
constitutional sepsis. Wishing to diminish constitu-
tional sepsis, the lymph glands and the spleen were
used. Hexamethylenamin and other measures were
used, of course, but they are of no importance in this
connection, while surgical interference was positively
refused. As long as the lymph glands alone were used
no trouble was experienced, but wishing to intensify the
effect, the spleen also was added to the treatment,
guarding it with a small amount of testicle and the
other elements of equation 45.
But evidently this patient, probably on account of his
advanced age and his depressed condition, was par-
ticularly sensitive to the effects of the spleen and lymph
glands, and the preventive measures proved to be in-
sufficient. The next morning, on entering the sick
room, the same picture described in the last case was
presented. The dropped jaw, the open mouth, the
ashen face and dead staring eyes of complete dementia.
This patient was a man of unusual character, and a
mentality above the average. As in the last case, the
change was little short of appalling. But fortunately
having the benefit of previous experience the emergency
was met with greater confidence. The proportion of
the sex gland was adequately increased, and be-
fore the writer left the house the symptoms had dis-
appeared.
At least twice before the close of this case by his de-
mise— his case had been hopeless from the start in the
absence of surgical measures — he again exhibited these
mental symptoms, when the preventive measures were
inadvertently relaxed. Each time the symptoms were
promptly removed by increasing to the proper point the
proportion of preventive hormones.
This case, therefore, shows beyond a doubt that
it is perfectly possible in susceptible individuals to
produce the symptoms of dementia at will, and re-
move them with the same facility.
Case VI was different from the three preceding cases
in that it was precipitated by what might be called
natural causes. Mrs. McC. was a lady about 48 years
of age, mother of a large family, several sons and
daughters being grown. The family had suffered many
reverses of such a severe nature that it was the sub-
ject of remark by all who knew them. Mrs. McC.'s
general health, however, was good, and she was physi-
cally strong. She bore up admirably through all these
trials until her eldest son, perhaps 25 years old. died
suddenly one night in a terrific hemorrhage, under most
distressing circumstances, after being bedridden for
a year or more with tuberculosis.
The day after the funeral Mrs. McC. lost her mind,
and was found wandering in a vacant lot, muttering
incoherently, and aimlessly picking wild flowers and
weeds. When she was found by friends, and they tried
to take her home, she suddenly collapsed, and they had
to carry her in.
When the writer reached her she was still in bed,
muttering and talking incoherently. She was in just
the state mentally that one would expect to lead to an
ordinary case of melancholia. Indeed, if her condition
were to be characterized by a name it would be most
correctly described as melancholja, which is classified
by some alienists as demential in type.
Is it not perfectly logical then to believe that in this
case we had a hypersecretion of the spleen caused by
grief and the accompanying powerful emotions plus a
hypersecretion of the lymph glands, with a coincident
hyposecretion of the sex glands?
And is it not logical to suppose that the difference
between the symptoms of this case and those of the other
two cases of typical complete dementia was caused by
some difference in the relative secretions of the other
glands which are known to exercise a restraining in-
fluence over the spleen?
Just what these differences are will have to remain
for future investigation. But the significant thing
about the case was that the hormone equation No. 45-P
restored the mind quickly and perfectly. The next day
the lady got up and went about her usual duties. A
few days later she transacted most of the business
necessary to collect the life insurance on her son, and
has had not a sign of aberration since.
It is not too much to say that if this patient had
been treated by the usual methods she would have
found a place in the state insane asylum; and
probably would have died miserably, or lived a liv-
ing death.
This is a short case record, as the writer not being
an alienist has taken the cases just as they have
come to him in a general practice. But so illuminat-
ing is their character that it seems difficult to
escape from the following conclusions:
1. The administration of the spleen is capable
of producing insanity of either an active or a
maniacal type.
2. Hence, insanity of this character is probably
caused by a hypersecretion of the splenic hormone,
either actual or relative.
3. In functional cases the hormone of the sex
glands absolutely controls this condition, and pre-
vents or removes mental symptoms.
4. The administration of the spleen and lymph
glands may produce insanity of a demential type,
and hence insanity of that type probably is pro-
duced by a hypersecretion of both the spleen and
lymph glands, actual or relative.
5. The essential condition for the production of
any of these effects is a diminution below the nor-
mal of the sexual hormone in the circulation.
6. The male hormone will not protect the fe-
male, nor will the female hormone protect the
male, from mental symptoms.
7. The hormones of the kidneys, the digestive
organs, and the mammary glands are important in
their restraining effects upon the spleen and lymph
glands, so far as their influence upon mental func-
tions is concerned.
8. It is possible by combining these restraining
hormones to develop a practical specific therapy for
mental alienation.
9. By applying such a treatment early in the
disease the old chronic incurable cases of organic
insanity would be prevented, as the longer the con-
dition exists the more extensive become the struc-
tural changes in the brain.
10. The division of psychoses into at least two
main types, mania and dementia, is based upon
etiology and is therefore scientific.
Nov. 11, 1916]
MEDICAL RECORD.
847
INFANT MALNUTRITION.
Br WILLIAM HENRY PORTER, M.D.,
NEW YORK.
PROFESSOR EMERITUS IN PATHOLOGY AND GENERAL MEDICINE IN
THE NEW YORK POST-GRADUATE MEDICAL SCHOOL
AND HOSPITAL. ETC.
The study of metabolism and its disturbances is
the one great and unsolved problem in medicine.
It begins with conception, so far as the individual
is concerned, and ends only in death. In so far as
the coming generations are concerned, it should be-
gin in a careful selection of life partners and be
continued throughout life. For unless the fathers
and mothers are anatomically and physiologically at
their best during the child-bearing period, they
cannot acquire the best possible progeny, and with-
out the best, succeeding generations must retro-
grade. The nearer these ideals are approached, the
more nearly will we come to practical eugenics. The
following interesting case illustrates some of these
points :
A healthy young woman was married at twenty
to a healthy, robust man a few years her senior,
Owing to the fact that her mother's kidneys were
seriously involved during pregnancy, and she died
of nephritis shortly after the young lady was born,
it naturally made her somewhat fearful as to the
outcome in h6r own case. She placed herself under
my care shortly after she became pregnant. The
diet and hygienic conditions were carefully and
scientifically regulated, and the bowels were kept
moving freely during the whole course of the preg-
nancy. The result was that the kidneys performed
their function perfectly both during and following
the pregnant state. The patient had a perfectly
normal confinement and a strong and vigorous
baby, one that has continued to grow strong and
healthy in every respect, even though it was bottle
fed. Some two or more years later she again be-
came pregnant. In the meantime, however, she
moved to another city and passed from under my
direct care. For some reason or other during the
second pregnancy, the diet and hygienic conditions
were not as carefully regulated as in the former
pregnancy. While the second confinement was per-
fectly normal and without any kidney complica-
tions, the baby was not nearly so strong and robust
as the preceding one. The second baby had icterus
neonatorum quite badly and it was with consider-
able difficulty that it was made to thrive at all. It
also was a bottle fed baby. After several months,
however, the baby apparently was doing pretty
well, but never advanced in the regular and vig-
orous manner that a baby should. At about the
end of six months, while the child looked fairly well,
it was not gaining. It seemed to have little strength
for its age, was but little inclined to do the things
common to its age, and would lie upon its back by
the hour, making no effort to roll over or sit up in
a changed position. The baby was hardly able to
sit up in the mother's lap unless the back was well
supported. Doubt was expressed by some as to the
power of vision, and to some it seemed mentally
defective. There was no sign of any teeth. In
the next four months the baby made no progress in
weight or any other respect. Toward the end of
this period the baby began to show signs of abso-
lute retrogression, but without any positive signs of
disease. There appeared to be nothing wrong other
than faulty assimilation, and an arrest of nutritive
activity. At the end of ten months there was no
sign of any teeth, the baby could hardly sit up, and
made no effort to creep or get upon its feet. There
was no evidence, apparently, of any suffering of
any kind on the part of the baby. Several experi-
ments were made in the changing of food, but all
to no avail. At this point the case was referred
back to me for an opinion and advice as. to what
might be done for the child.
Just about this time a carbonated aqueous solu-
tion attracted my attention, one of high alkaline
bases, and in which there was a high percentage of
calcium carbonate with the CO,. It was claimed
that in consequence of these facts its use would
speedily overcome the so-called "superacid condi-
tions" of the animal economy. As a matter of fact
these so-called "superacid" conditions are only
diminished alkaline ones, for nature never allows
the system as a whole to become acid. Some of the
secretions may be rendered unduly acid, but nature
always prevents absolute acidity, a state which is
incompatible with the maintenance of animal life,
and which is overcome by the withdrawal of the
more fixed alkaline bases from the various struc-
tures of the body. This withdrawal naturally dis-
turbs the alkaline balance of the animal economy
which is absolutely essential for perfect metabo-
lism, and various grades of disturbed metabolism
ensue. Therefore, from a practical standpoint it
becomes just as essential to overcome lowered alka-
linity as it would be were it within the range of
possibility to have an absolutely acid state of the
system. On the other hand great care must be ex-
ercised not to overalkalinize the animal economy,
for both extremes tend to disturb metabolism, the
former, however, more than the latter. This solu-
tion has the following composition per hundred
parts of water: Sodium carbonate (Na.C03),
00.404; sodium phosphate (NaJHPO,), 00.023;
sodium chloride (NaCl), 00.080; calcium carbonate
(CaC03), 00.057; magnesium carbonate (MgC03),
00.004; potassium chloride (KC1), 00.004.
The one ingredient in this solution which ap-
pealed most of all to me was the sodium phosphate
(Na.HPOJ a salt which is usually formed from
the trisodic phosphate (Na.(PO,) in the process of
digestion when the hydrochloric acid is formed into
sodium chloride (Na3PO, + HC1 = NaCl +
Na2HPO,). This latter salt, the disodic phosphate,
is quite abundant, relatively speaking, in the blood.
It is also very essential for perfect metabolism, the
maintenance of the normal acidity of the urine, and
for the transformation of uric acid into sodium
urate. In view of the above it occurred to me
that this was a case in which to try the use of these
alkaline salts. Hence, my suggestion to the mother
was to make no change in the composition of the
baby's food, but in its preparation I recommended
the substitution of water containing the salts in the
above proportions, for the water she had been
using in preparing the milk, allowing time for
most of the carbonic acid gas to escape before pre-
paring the milk. Also to give a little of this water,
decarbonated, between feedings. Very shortly after
this change was made (about two weeks) there
was marked evidence of improvement in the child's
condition. At the end of four months the baby
had regained all of the natural activities of a child
of its age. During these four months the baby
gained nearly four pounds, cut six teeth, and was
able to stand on its own feet unassisted. A month
later it gained more in weight, cut more teeth, and
became very bright and lively in all respects.
848
MEDICAL RECORD.
[Nov. 11, 1916
While fully realizing that this is but one case,
and covers only a short period of time, it seems
worthy of reporting, especially in view of the fact
that no further change was made in the diet and no
medicine was given. Also, because the case ap-
peared to be one of true and simple malassimila-
tion, due to the lack of some essential element to
maintain perfect metabolism. The results certainly
point very strongly toward the elements given as
the factors necessary for the reestablishment of
took quinine during the day. That evening he
began to cough. He appreciated at this time that
he was feverish. He continued to be up and about
for an entire week, treating himself with drug-
store "cough mixtures" and being attended by a
"doctor" who worked in the drug store. Finally he
was told that he should see a physician. He came
to me on the eighth day of his illness. A relevant
point in his previous personal history is that the
patient had pneumonia seven years ago.
I'i,;. l. — Sphygmogrmn madi with Dudgeon's sphygmograph, Feb. 20, 1014, at 1.30 p. m. Right radial artery.
normal metabolism within the system of this un-
fortunate child, though one would, of course, have
to see a large number of cases before it would be
possible to affirm with absolute certainty that, the
good results obtained were directly due to the action
of the salts.
One of the chief purposes of this paper is to
bring to light another etiological factor in dis-
turbed metabolism, to wit: the lack of alkaline
balance, a very common cause and one not often
recognized, and one which if neglected in the man-
agement of these cases prevents recovery in many
instances. It has long been known that in many
forms of malnutritive diseases of infants and young
children, it often is not so much a lack of the min-
eral salts as it is a failure properly to utilize and
assimilate them. On the other hand, if the proper
physiological balance can be established in relation
to these saline bases, they will normally stimulate
sluggish and inactive protoplasm into more normal
activity and finally bring about normal metabolism.
It is a known fact that most of our modern methods
of cooking usually deprive our vegetable food prod-
ucts of their natural salts so essential to perfect
metabolism. Hence the brilliant results obtained
by some physicians who prescribe for their patients
the eating of uncooked or raw vegetables. Atten-
tion is again drawn to the fact that most of our
disturbances of metabolism are due in part to a loss
of this alkaline balance, which in its most pro-
nounced form is at the present moment attracting
much attention under the name of "acidosis," a
condition in which there is a lack of these salts, or
an inability to utilize them perfectly, with a vain
effort on the part of the animal economy to draw
these fixed alkalies from the structures of the body,
with consequent increased acidity of many of the
secretions, until we pass from a simple disturbed
chemical function to one that brings about true
pathological changes.
46 West Eighty-third Sn-. I
A CASE OF AURICULAR FIBRILLATION.
By .1. WHEELER SMITH, JR., Ml).,
BROOKLYN, NEW XOBK.
W. W. came to me on February 16. He is a
native of Ireland, is forty-seven years old and is
unmarried. His occupation is that of grocery clerk.
He complained of "a heavy cold" and presented
cough, fever, and dyspnea. He stated that he awoke
early on the morning of the ninth with a chill. He
His temperature was 103°. I instructed him
to go to his bed at once. At 8 P.M. of the same day
I made the following observations of his physical
condition : Patient in the dorsal recumbent posi-
tion, apparently comfortable; quite lucid and cheer-
ful. His skin was white, dry and hot. The con-
junctiva were congested; the scleras injected. The
pupils were of moderate size, equal and regular,
and reacted well to light and accommodation. There
was marked movement of the ate nasi in inspira-
tion and the lips were thin, pale and slightly
cyanotic. No herpes labialis was seen. The tongue
was soft, pale, indented by the teeth, and coated
all over with a light white fur. The throat was
uniformly reddened. The neck was symmetrical.
There were marked arterial and slight venous pul-
sations. The thorax was of moderate size, fairly
well nourished and symmetrical. The respiratory
movements of the thorax were distinctly diminished
all over the left side, over which side, also, tactile
fremitus was increased. Both apices were dull.
The right front, however, was resonant; but the
left front was dull, merging below into a flatness
which extended over the left axilla and base. Aus-
cultation elicited harsh bronchial breathing over
the entire left side, with many small moist rales
and a few large ones. The cardiac apex was felt
faintly and irregularly in the fifth space in the
midclavicular line. The area of cardiac dullness
was somewhat increased both to the right and to
the left. The heart sounds were very weak and
muffled and were markedly irregular both as to
time and intensity. The rate was very rapid. Some
of the sounds heard at the apex apparently repre-
sented contractions on insufficient blood to send
a wave to the radial, hence the radial rate was
considerably slower than the apex rate. The abdo-
men was slightly tympanitic. The extremities pre-
sented nothing worthy of note. I made a diagnosis
of lobar pneumonia, involving both lobes of the
left lung and of cardiac irregularity.
On the following day, the ninth day of his ill-
ness, dating from his chill, the patient was mark-
edly cyanotic but quiet. The apex rate was 172
and the rhythm was still very irregular. The type
of the irregularity was not yet determined, but
it was quite definitely not a respiratory irregu-
larity. Physical signs showed the entire left lung
to be consolidated ; there were numerous large moist
rales over the upper lobe anteriorly. The back was
not examined. Great difficulty attended the deter-
mination of the blood pressure because of the
Nov. 11, 1916]
MEDICAL RECORD.
849
marked irregularity of that factor. At times no
pulse wave came through to the radial under pres-
sure of 70 mm. Hg. ; at times a pressure of 110
mm. Hg. was necessary to keep all back; some-
times even more. At 6.45 P.M. on the seventeenth
the apex rate was 176. At 7 P.M. phlebotomy was
done and sixteen ounces of blood drawn off. At
7.15 P.M. l-200th grain of strophanthin was given
intravenously in 10 c.c. of physiological salt solu-
tion. The apex rate was not appreciably affected,
but the patient felt very much more comfortable.
Leucocyte count at this time showed 30,000 white
blood cells per cu. mm.
At 11.45 A.M. of the next day, the eighteenth, the
patient was comfortable. The entire left side
showed small and medium-sized crackling rales on
inspiration, and harsh tubular breathing in front.
The cardiac rate was 142 and the rhythm was still
very irregular. The irregularity was certainly not
a respiratory irregularity and did not sound like
extra systole. There was no evidence of peri-
cardial involvement. At 4 P.M. the apex rate was
• 156, the radial rate 98. The patient was breathing
quietly and sweating profusely. At 8.30 P.M. the
patient was still very comfortable. The apex rate
was 160; the radial, 135. The breath sounds low
in the axilla were more quiet, and were accompanied
by large numbers of moist rales, both inspiratory
and expiratory. Over the upper part of the left
00
170
|«1
1-JTl
|
n
".,■
/'. i
>
SO, 7 6 9
120
%
\
r
^~
C H
/■
\
\
_-■•
■-.
/
X-
\
.
"\
\
70
Fig. 2. — Tracing showing improvement under treatment.
front the sounds were very rasping and there were
large numbers of inspiratory rales. There was no
involvement of the right side.
On February 19, the eleventh day of the illness,
the patient's temperature dropped rapidly from
103° to 98.4°. Resolution took place very slowly.
Marked impairment of resonance, increased tactile
fremitus and voice sounds and roughened breath
sounds, with rales, persisted for ten days after the
crisis.
Fig. 1 is a pulse tracing made on the twentieth,
the day after the crisis. On the twenty-third the
cardiac condition was diagnosed auricular fibril-
lation, the diagnosis resting upon the very marked
irregular irregularity in the ventricular contrac-
tions, as appreciated both by auscultation at the
apex and by palpable demonstration of irregularity
in rhythm, force and volume of the pulse at the
wrist. A second diagnostic point was the marked
and constant pulse deficit. It was determined to
put the patient upon digitalis. Digipuratum was
employed in tablet form. Fig. 2 is a graphic
record of the patient's improvement. It is drawn
according to the plan of James and Hart (Amer.
J<n,r. Med, Sci., CLXVII, 1, Jan. 1914.) The car-
diac rate, as auscultated at the apex, is represented
by the upper line; the radial rate, as palpated, is
represented by the lower line; the pulse deficit is
represented by the shaded area between the two
lines; the average systolic blood pressure is repre-
sented by the dotted line. Determinations were
made daily at 9.30 A.M. and at 7 P.M. Observa-
tions were begun on February 24 "at 4 P.M. No
medication was given on the twenty-fourth, twenty-
fifth and twenty-sixth, but was begun on the twen-
ty-seventh ; on that day and thereafter one tablet of
digipuratum was given at 9 A.M. and another at 4
P.M. Each tablet is equivalent to IV2 grains of
the leaves of digitalis. It will be seen that on
March 1 the cardiac rate rose to 172 and the radial
rate to 156. This rise in rate was concomitant
with an elevation of temperature to 103.3°. At
the same time the patient complained of great
soreness in his right arm. Examination revealed
large, inflamed, indurated areas in the subcutan-
eous tissue, which were acutely tender. It de-
veloped that the nurse, being unfamiliar with the
method of administration of the tablets, had dis-
solved the tablet each time and injected the solu-
tion hypodermatically. In consequence, great irri-
tation of the tissues was induced and a general
response effected. Thereafter the tablets were
given as intended, by mouth, and great improve-
ment was had almost instantly.
Observations were discontinued on March 9. The
medication, however, was continued. The patient
was out of bed on the twelfth and paid me his last
visit on the sixteenth, feeling, at that time, so he
said, better than he had felt for a great many
years.
1249 St John's Place.
PERSONAL EXPERIENCES IN CONTRACT
PRACTICE.
BY LUCIUS F. HERZ, PH.B., M.D.,
NEW YORK.
ASSISTANT SURGEON NEW YORK POST-GRADUATE HOSPITAL
DISPENSARY.
Toward the end of my House-Surgeonship at the
Post-Graduate, I was shown an advertisement in
one of the prominent medical journals, which called
for a surgeon for a large corporation in a town of
65,000. I wrote to the number given in lieu of
definite address, and inquired for full particulars
in regard to the position offered, and received the
following letter in reply. For obvious reasons,
names have been suppressed or changed.
Blankville, March 15, 1916.
Lucius Herz, M.D., New York City.
Dear Doctor: — I am in receipt of your letter of date
March 12, concerning position at the plant of the Blank-
ville Steel Company.
The Blankville Steel Company is a subsidiary of the
United States Steel Corporation and have just estab-
lished a plant in this city that has cost $20,000,000. The
future of the steel business is very bright in this locality
and I have no doubt that this plant eventually will be
among the largest in this country, and for the right
man there will be a chance to grow with the industry.
We now are just finishing a new surgical hospital at
the plant, which will be modern in every way. We have
a hospital right at the works where all minor work is
done, also first aid.
I now have two men at this place, but have one who
is unsatisfactory and will discharge him soon. The
salary of $100 per month does not include board, but it
does include room at the hospital. There is a good
opportunity to build up a private practice that will
eventually amount to many times this salary.
I am also looking for an assistant at my office, as my
laboratory man and pathologist is going to leave me
next month. There may be a chance for you to take
his place, if you should prove the right man. I may
give you a chance in my office and hospital work.
I demand the best credentials as to your moral char-
acter as well as your professional character.
850
MEDICAL RECORD.
[Nov. 11, 1916
This place is not filled yet as I am considering several
applications, being anxious to get the very best man
possible and one who is willing to work and grow up
with the business^
Let me hear from you soon, as I am anxious to fill
this place as soon as possible.
Very truly yours,
As I cared more for clinical than for laboratory
work, I made a formal application for the position
at the steel plant, and after some more correspond-
ence, and investigating the references that I gave,
I was accepted. Judging from the small salary
named, and the statement regarding outside prac-
tice, I assumed that the position was a half-time
position, similar to the New York City positions, re-
quiring routine work for a few hours per day, and
then being on call for serious emergencies only. The
reader will shortly see, that in contract work, it is
unwise to assume anything, and the only proper
way to engage in it, if there is any proper way, is
to have a signed statement specifying what one's
exact duties consist of.
After a journey of 1,600 miles, I found myself in
Blankville, and proceeded at once to the office of the
writer of the letter. There I met Dr. — , a
shrewd and prosperous looking man of about sixty.
After exchanging a few commonplaces, we "got
down to business," and then, and not until then, I
was given a true inkling as to what my duties would
consist of. He broached the matter delicately by
inquiring whether I had much night work at the
Post-Graduate, to which I replied that I did early
in my service, but toward the end, most of the night
work was done by my juniors. He then announced
that my work would consist chiefly of night work. I
was, of course disappointed, but decided to face the
proposition bravely, and if the chances for outside
work were so wonderfully good, would gladly sac-
rifice an occasional hour's sleep. I did not even
then surmise what my duties would be, as I as-
sumed that only serious night cases would require
my attention. Dr. then took me out to the
plant, introduced me to the superintendent, and
showed me the new hospital, and then we returned
to town. The plant was twelve miles from the cen-
ter, and was reached by trains which were few and
far between, but this additional disappointment did
not fease me either. Then, Dr. did the one
act in all our dealings that I can feel grateful for;
namely, he took me to the best hotel in town, reg-
istered me as his guest, engaged a parlor and bed-
room for me, and told me to stay there over night,
take my meals there, and charge it to him, remain-
ing until the following morning. I thus had a re-
freshing night's sleep, the last for some time to
come.
Dr. informed me that I was to treat the
employees for actual injuries under the Working-
men's Compensation Act, and that medical and
other cases not resulting from injuries ranked as
private practice, and that I would be permitted to
charge for them. My hours were to be arranged by
the senior surgeon at the plant. Dr. X.
The next morning, bright and early, I arrived at
the plant, and met Dr. X, a man of about thirty-
five, of the classical stage doctor type, goatee, very
professional manner, etc. He informed me that I
was to assist on the day dressings, from 9 to 12
A. M., could have the afternoons off, then come back
at 7 p. m., do the routine night dressings until 9
P. M., and then sleep at the infirmary, and remain
on call all night. The laborers were to knock at
my door to arouse me. I was soon to learn that
they were not at all reticent about disturbing my
sleep.
My first night, I was aroused by feeling some-
body rudely pulling at my foot. I awoke with a
start, and found an ignorant, grimy, laborer at the
foot of my bed. I thought an unusually serious ac-
cident made him dispense with formality, and asked
what the trouble was, and was told "head cut." I
made him wait outside, donned my bathrobe, and
stitched up a slight scalp wound. Thus it went,
several times each night, sometimes eight to ten
times. Some few had courtesy enough to knock at
my door, but the majority walked in and sat down,
but were promptly informed that this was my bed-
room, and that they were not permitted in there
except at my invitation. I soon found out how
people abused the privilege of free medical atten-
tion. Infinitesimally small scratches, tiny abra-
sions, "barked knuckles," slight bruises, cinders in
the eye, slivers under the nail, etc. A long array
of tedious, uninteresting cases, not nearly so in-
teresting as the average dispensary clinic, because
the motto of "Safety First" adopted by the Steel
Trust, made the foreman send the laborers to me
for ridiculous trifles. I soon realized that I had
been tricked. I first vented my indignation upon
X, and told him that if I had to work so hard
nights, it was unreasonable to make me work days,
and I refused to work longer at that schedule even
for twice my salary. (Inquiry had revealed to me
the fact that my predecessors worked nights only,
and that X. was imposing upon me so that he could
attend to his private practice.) X. agreed that it
was pretty strenuous but thought that I should
stand it. I was firm in my resolve, however, so he
gave in, and said that I should work nights only.
I found also that I was expected to work seven
nights per week, and that it was utterly impossible
to obtain a night off, as X. would not take my place
evenings. I surely expected one night per week
off, but was merely told, "You can't have everything
you want." On the other hand, he never hesitated
to ask me to take his place mornings or afternoons,
when he was busy with a private case, and I was
foolish enough invariably to consent.
Finally, loss of sleep began to tell upon me. The
cases were rarely of any interest, and half the time
could have been handled by a nurse or orderly. I
became more and more tired. Five hours sleep out
of the twenty-four was doing exceedingly well for
me. I could fall asleep the first time I retired
readily enough ; the second time, perhaps after an
hour's wait, and the third time not at all. To-
ward the last of my work there, however, I could
not sleep at all, as I was completely worn out, and
finally obtained forced sleep by taking trional.
All this for what? For nothing! For a concern
that worked constantly, day and night, day after
day, an iron monster without heart or soul. My
strenuous and conscientious work was paid for at
the rate of $10 per month more than the lowest
paid common labor! A fine recompense for seven
years in college and two and a half in hospitals.
The strenuousness of the work was unbelievable.
Sometimes for two successive night I was aroused
eight times. On every case, no matter how ab-
surdly simple, in addition to treatment, I had to
make out a detailed report in triplicate, giving the
man's name, age, department, number, address
nationality, cause of accident, party blamed, prob-
able length of disability, description of injury.
Nov. 11, 1916]
MEDICAL RECORD.
851
treatment given, etc., etc. This generally required
more work than the treatment of the case, and was
-absolutely useless, for the clerical part was dupli-
cated by the casualty clerk.
To add to the joys of this position, I was both-
ered night after night by the telephone ringing, and
asking for the wrong department. Also, it would
frequently ring, and announce the fact that a man
was coming over, and three-quarters of an hour
later a man would leisurely arrive, with a sprained
ankle. I would treat him, make out my report, and
retire, when an hour or two later the phone would
ring again, and the foreman would ask me what
the nature of the injury was; I would answer, and
then after an hour or so finally obtain sleep again.
Over two hours of sleep lost for a sprained ankle!
These unnecessary and false alarm calls became so
frequent that I had to resort to the device of plug-
ging the instrument. I understand that I was re-
ported for this, and that the powers that be did not
approve of it; however, my health was worth more
to me than their opinion, and if a trifle like this
should outweigh my hard and faithful work in their
estimation it made little difference to me. My con-
science is clear.
Of all the cases that I treated there was only
one of unusual interest. This was a man who was
caught in a crane, causing a simple fracture of
the femur, and a punctured wound involving the
popliteal artery, which was pumping away like the
much-quoted fire hose. In spite of the fact that
every department was provided with a tourniquet,
there was nobody with sense enough to apply it,
and the man was brought to me pretty well exsan-
guinated, and the stretcher that he was lying on
was literally saturated with blood. I immediately
applied a tourniquet, stimulated him with a hypo-
dermic of strychnine, gr. 1/15, also gave morphine,
gr. 1/6, combined with atropine, gr. 1/150, and
clamped and ligated the artery through the original
wound, assisted only by the laborers, who manipu-
lated the leg, and compressed the artery at my
direction. The man was then transferred to the
hospital, 12 miles away, by ambulance, where he
was infused. He was too exsanguinated, however,
to establish a collateral circulation. Gangrene
arose, requiring amputation of the extremity, and
death occurred from his original shock two days
later.
In regard to outside practice, there was some, of
course, among the 5,000 people living in the tiny
villages near the steel plant. There were three
villages, the most modern being made up of new
concrete houses with all modern conveniences.
In this village X had his office. The other
two villages were a town of about 1500, mostly
made up of the older families of American
people, and a town of about 2500, made up chiefly
of the foreign element. Both towns were quite
primitive. The people had electricity, but not gas,
in the more modern of the houses. The foreigners
burned oil or candles in their one-story or even two-
story shacks. Pigs, cows, and geese shared the
paths known as sidewalks with the humans in the
foreign town. The one paved street in this town
stood out in marked contrast to the cross streets,
where the mud often came half-way to one's knees.
As to practice, one had to build it up gradually
here, as elsewhere. There was little competition,
but much self-doctoring. However, I had no diffi-
culty in obtaining a case per day during my first
month of practice. For one who could live under
primitive conditions, a fairly good opportunity was
present here, not so good, however, as Dr. 's
alluring letter would imply. After much looking
around for an office, I finally selected the least of
the evils offered, and took one in which I could at
least have room enough. It was in an old building
of barn-like splendor, but much needed improve-
ments were promised by the owner in the way of
running water, painting, varnishing, etc. Some of
these promises were kept, such as the painting, but
were considerably delayed, and the running water
was not even begun two weeks after its promised
completion. However, I made the best of things,
and moved in just as soon as the place was at all
habitable. After occupying the place for four days,
I was about to enter my office, on a day when the
wind was blowing a stiff gale, when the entire tin
roof was blown off, landing within a few feet of
me. This was too much for me, so I promptly moved
out and took an office in Blankville itself.
The night work was becoming more and more
strenuous as they increased the night shifts and
opened new departments. Besides being aroused
numerous times per night for new injuries, fre-
quently an old routine dressing case would appear
at 2 or even 5 A. M. and expect to be dressed. Of
course, I refused to be imposed upon, these patients
having been repeatedly told that dressing hours
were from 7 to 9, but they continued to show up at
these unearthly hours, and often became quite nasty
when I refused to treat them. It was told to me
that certain men had reported me for refusing to
treat them when injured. In other words, when I
refused to treat an old routine case it was reported
in such a way as to appear like a new injury, and
I was reported for neglect of duty. Nothing was
said to me directly, but indirectly this was carried
back to me. Evidently one false accusation carries
more weight with people of narrow caliber than
dozens of exasperatingly trying cases faithfully
treated. Finally, when the strenuousness of the
company work and the loss of sleep began to tell
upon my health more than I cared to have it, I
gave Dr. ■ a month's notice, and the only com-
ment that he made was, "Well, you are not much of
a sticker!" Much of a sticker indeed! I wish that
he would try it for just one week. I had made the
statement to friends that no human mind ever made
such a position possible. It must have been the devil
himself who devised it. I also found that I had re-
mained longer than any of my predecessors, one of
whom left after about three nights of it.
I would bear Dr. no resentment if he had
made it plain to me in his letter that the position
was a night job. Of course, I would never have
considered it then. Peruse his letter once more.
It reads like a description of wonderful opportuni-
ties of the Golden West as found in popular novels.
There are no sins of commission present, but cer-
tainly one glaring one of omission. Talk about
medical ethics when one doctor thus deliberately
tricks another! I wonder if Dr. 's conscience
is clear.
In regard to charging patients who were not
injured while at work, for instance, men coming in
with furuncles, stomach trouble, etc. According to
Dr. 's instructions, we were permitted to charge
them. However, if the complaint was very trivial,
like a headache, etc., we dispensed a few migraine
tablets and did not charge. If a thorough physical
examination were required, or prescriptions indi-
cated, we would charge $1, which was fair enough.
852
MEDICAL RECORD.
[Nov. 11, 1916
one will agree. However, both X. and I were re-
ported for charging for treatment, and he received
a letter mentioning an instance in which I had
asked for a fee and was refused, the foreman re-
porting me for this! We were informed that all
cases must hereafter be treated free of charge. I
had found that cases were too apt to be treated by
the pill doctor style, tablets for every ailment
known, and dispensed without either a careful his-
tory or any physical examination. For instance,
abdominal pain would be treated by chlorodyne
tablets, which contain morphine, gr. 1/6, and cana-
bis indica, gr. V2. Is this up-to-date medicine? I
refused to practice this sort of medicine, and studied
each case carefully. However, this is a rather
thankless job, when one is paid about $0.25 per
case.
Before I finally left the company, X. suddenly left
without notice. The details never were made clear,
but as his successor was hired upon a full-time
basis, it is quite evident that the superintendent
objected to his spending so much time with his
lucrative private practice and so little for the com-
pany, and attempted to compel him to remain at
the plant all day, which he refused to do. , Hereto-
fore he had come and gone as he pleased, and left
the janitor in charge, the latter being quite a skill-
ful dresser. As X.'s private practice amounted to
about double his salary, at a conservative estimate,
and as his salary was only slightly larger than mine,
I cannot blame him for leaving.
Lastly, a word in regard to contract practice.
It might be all right when the physician is hired
directly by the company, but where one man is chief
surgeon and hires his own assistants out of his
contract it is usually unsatisfactory. Does it seem
fair that a concern as wealthy as the United States
Steel Co. should pay its surgeons less than half what
the United States government pays hers? Does
it seem fair that a subsidiary of the Steel Trust
should pay a man with two college degrees, obtained
from one of the leading universities of this country,
but 30 cents a day more than its lowest paid com-
mon laborers, most of whom can neither read nor
write English? Perhaps other concerns are more
generous, but my advice would be, do not accept
contract practice unless you can conduct it from
your own private office, or unless it pays sufficiently
well to consider it as a full-time proposition. The
lowest pay that any concern should offer its sur-
geons on full time should be $200 per month, as
the work is very strenuous, monotonous, and unin-
structive, and the social opportunities are usually
nil.
i"ii Rast Seventy-ninth Stre
THE MILITARY QUARANTINE STATIONS OF
BUNGARY.
i. Ml IRi IWITZ, Ml>,
NEW YORK.
FORMERLY MILITARY SURGEON IN THE AUSTRO-HL'NG Al'.l AN AND
■ . ARMIES.
On my return from the European battlefields in
after being away from the United
States for more than eighteen months, I was not
only surprised but agreeably concerned by the many
preparations being made for national defense, and
as a physician the medical aspect of these appears
to me as one of the most important issues. 1 wish,
therefore, to describe as briefly as possible the sys-
tem of the military observation or quarantine sta-
tions employed in Hungary along its threatened
borders, for the prevention of the spread of infec-
tious and contagious diseases into the interior of
the country, trusting the idea will come under the
attention of our military hygienists along the Mex-
ican border.
Several months after the outbreak of war in
Europe, the Minister of the Interior, in connection
with the Ministers of War and Home Defense, or-
dered the construction of fourteen observation or
quarantine stations in as many Hungarian towns
near the Carpathian Mountains, as listed in the ac-
companying table.
■
Area
Number
Barracks
Number
Beds
Number
Physicians
Numl er
Nurses
96,000
144.000
135,000
72.000
34, )
192,000
75,000
150,000
93,000
75.000
141,000
30, i
26
25
69
46
26
63
17
28
47
4.'
17
26
31
23
2930
2975
4500
2720
4500
1880
3050
3100
3200
■
3000
3900
1741
30
20
47
24
14
26
15
20
21
22
10
19
22
16
140
120
135
128
116
241
173
210
75
130
214
75
These towns are situated along the railroads
running from various points on the battlefronts,
and are connected with one another and with Buda-
pest, the capital. They are of a fair size so that
food material and other necessities can be obtained
at any time.
The hospital itself is situated on the outskirts of
the town, just alongside of the railroad track, and
where possible adjacent to a river or stream below
the town. From the main track is switched off an-
other track to carry the Red Cross train immedi-
ately in front of the receiving barrack.
The hospital consists of a group of from twenty-
five to forty-seven barracks each approximately 50
feet by 225 feet in size, or even larger, placed con-
veniently apart to allow for proper roadways, drain-
age trenches, or small tracks running between the
barracks for carrying materials on small cars or
hand cars. They are built of wood with cement
foundations, and covered externally with rain-proof,
whitewashed asbestos. In addition to the barracks
holding the sick and wounded, there are barracks
set aside for receiving patients, bath, kitchen,
Fig. 1 — Map of Hungary showing the locations of the mili-
tary quarantine stations.
power house, laundry, doctors', nurses', and em-
ployees' dormitories, general administration offices,
storage, carpenter, morgue, laboratories, etc.
Each ordinary barrack, or barrack containing
wounded or non-infectious sick, contains from 50
Nov. 11, 1916]
MEDICAL RECORD.
853
to 120 beds, one bandage room, one dining room,
two diet kitchens, four toilets, two bath rooms, and
two bedrooms for nurses (see diagram).
All soldiers, civilians, correspondents, etc., leav-
ing the front for the interior must pass through
or revolver, knapsack, uniform, boots, etc. These
are placed in a bundle to which is attached the num-
ber of the admission card given to the patient. This
admission card is attached around the patient's neck
and later to his assigned bed.
Fig. 2. — Munkacs barracks
ctober 2, 1915.
the required quarantine period at one of these ob-
servation stations. The object of this is the sepa-
ration of all those afflicted with contagious, infec-
tious, and even venereal diseases, with a resultant
isolation strictly carried out. An exception is neces-
sarily made in the case of troops being transported
from one front to another.
The routine employed by most of the quarantine
stations is as follows:
Fig. 3. — Munkacs barracks on November 20, 1915.
1. The trains are brought up to the receiving
barrack and immediately emptied and disinfected.
2. The patient goes or is carried from the wait-
ing room to the receiving room, where he gives up
his military equipment such as rifle, bayonet, sword.
Fig. 4. — A ward in the Munkacs barracks,
3. Then small valuables are given up, such as
money, watch, medals, pocket knife, etc., which are
placed in a small bag, numbered, and immediately
disinfected by passing through steam, and returned
to the patient when he gets through with the bath.
4. The patient is then stripped, the undercloth-
ing turned in, and is taken to the barber's room,
where the hair of his head, arm pits, and pubes is
clipped away with electric shears.
5. Next comes the bath, a thorough scrubbing
with soap, hot water, and brush, and in some sta-
tions with lysoform. After this, fresh underwear
is given, with a hospital coat and cap.
6. The "inspection" doctor then examines the
soldier, who is classified according to what the con-
dition may be, and assigns him to the proper bar-
rack.
The patients are classified in the following way:
(1) Those having contagious or infectious dis-
eases; (2) those suspected of having a communica-
ble disease; (3) disease carriers; (4) those suffer-
ing from non-infectious diseases; (5) the wounded.
This results in the quarantine stations being di-
vided into two great divisions, a regular hospital
and an epidemic diseases hospital. The latter is
separated from the former by space, and a high
fence at the gate of which is placed an armed guard.
The barracks of the epidemic division differ from
the others, in that each one is divided into forty or
fifty rooms, so that better isolation of each individ-
ual case can be carried out, no matter what the in-
fection may be, and they are so arranged that the
doctors, nurses, and orderlies coming from a pa-
tient must pass through special private bathroom
K O
WDTDWDWDW,
MM
01]
Dnannna
OoOoOoQoOlOoOoOoOmOoD
DWD°D[
nonnnnnnr
onDnnnonDrpnarpnnrpi
OWCTO
OoDoDoO,
DTD
'oDlQoOoDlDoOoDJoDoOoD
J H
Fig. 5. — Diagram of two wards (A and B) for non-infectious cases. C, bandaging room; D. kitchen or diet room;
E. F, nurses' sleeping rooms; < ;. H. patients' toilets; I, J. nurses' toilets; K, bathroom; L, kitchen and dining room for
orderlies and servants.
854
MEDICAL RECORD.
[Nov. 11, 1916
before they can reach their own individual quar-
ters. The patients in these barracks stay until
cured. Iincluded in this group are the barracks
containing the suspected cases. If after a period
of fourteen consecutive days there occurs no de-
velopment of any contagious or infectious disease,
the barrack is cleared, fumigated and scrubbed with
a solution of mercuric bichloride, the patients be-
ing transported to the hospital division as conval-
escent.
The suspected and known disease carriers are
given a thorough treatment with antiseptics and
diet, and after five days are allowed to leave for the
interior with proper instructions as to cleanliness
and personal habits.
In all other barracks, or what I have classified
as the hospital division, patients who are free from
fever after five days quarantine from the time of
their admission, are transported toward the interior
and distributed in the various base hospitals for
further treatment.
In this way Hungary fights the more important
enemy, Disease. It is indeed rare to find a case of
typhus or cholera in Budapest, while in yienna
many of the hospitals were ofttimes full of con-
tagious and infectious diseases, owing to the fact
that Austria proper had no such system of quar-
antine.
By no means is the Carpathian front the only
border protected with these observation stations, as
there are very many of them along the southern
frontier, while many are being built now along the
Roumanian side. How much safer would we not
be, here in New York, if our soldiers, instead of
being quarantined for ten days in this city, would
spend their observation period, say, at Dallas, Tex.?
ECONOMICAL, EFFICIENT, AND SPEEDY
METHOD OF ADMINISTERING SALVAR-
SAN AND SIMILAR PREPARATIONS.
By GEORGE NOBLE KREIDER, A.M., M.D., F.A.C.S.,
SPRINGFIELD, ILLINOIS.
Very few there are who now will deny the great
value of Salvarsan or its substitutes in the treat-
ment of specific disease. This, of course, when ad-
ministered intravenously in proper doses and in
conjunction with the deep injection of a mercury
salt in the buttocks.
Taking this for granted, it is proposed to show
how the preparation may be given most effectively,
safely, and economically in appropriate cases.
Preliminary Precautions Quite Necessary. — No
treatment should be given without a thorough ex-
amination, and before each treatment the urine
should be tested for albumin. Each patient should
bring a specimen of urine in a clean bottle, which
is examined in the laboratory before the treatment.
Especial attention should be devoted to the examin-
ation of the heart and aorta, as lesions of these
parts are frequently found in syphilitics.
Attention to Details Injures Safety. — The treat-
ments are given once a week to a number of pa-
tients rendezvoused at the hospital. The patient is
directed to come at a certain hour. An effort is
made to keep the patients separated so that they
may not meet each other and discuss the treatment.
The hospital offers the advantage of having rooms
where patients may be quickly treated should com-
plications arise. Adjoining rooms are available,
where the patient rests before leaving for home.
The hospital pathologist, Dr. W. G. Bain, prepares
the solution for all the cases at one time, and fills
the syringe with the dose which has been decided
on by me. Each dose is poured out of the entire
solution into a small sterile beaker, thus avoiding
any danger of commingling the doses. Practical
experience proves this necessary. He sterilizes the
needle after each injection. The arm, at a right
angle to the body, is extended on a small sterile
dressing table placed by the side of the operating
table. The operator sits on a chair, with one foot
resting on a footstool, and thus works easily and
comfortably. The attending nurse (sister) intro-
duces the patient to the operating room and reports
on the urine test. She prepares the table for each
patient, sterilizes the arm, and applies the sterile
towels. She tightens the tourniquet and releases
it gently when the vein is safely punctured. She
takes charge of the patient after the treatment and
provides a room and bed should it be found desir-
able. She bandages the arm after the treatment if
necessary. A solution of adrenalin is kept prepared
for hypodermic use in case of emergency.
Directions for Patients Taking Special Treat-
ments.— The patients are given the following type-
written directions when they arrange to take the
treatments. They serve to impress on the patient's
mind the importance of the transaction and the
necessity of carrying out the details:
Mr Date 1916.
The treatments are given at the laboratory at St.
John's Hospital each Tuesday morning between 9
a.m. and noon.
The number of treatments at the hospital will
be at least six. The dates of your treatment will
be
The day before ( that is, Monday) you should take
a glass of water every two hours and a teaspoon-
ful of Epson salts at bedtime. You should eat a
very light breakfast before the treatment, and
lunch and dinner after treatment. A clean bottle
containing urine wrapped in paper, bearing your
name, should be brought to the hospital each Tues-
day and given to the sister.
Soon after your treatment you should go home
and rest the remainder of the day; at least sit
down. Let me know of any particular bad feeling.
An effort is made so to regulate the treatment that
there will be no bad feeling. Sometimes it is neces-
sary for the patient to stay in the hospital Tuesday
afternoon and night.
Some member of the family should usually come
with you, at least the first time.
The treatments at the office number twelve and
are given Thursday, Friday or Saturday afternoon,
as per arrangement. The dates of your treatments
will be
You should take a short rest after this treatment.
No need to fast before or after office treatment.
A hot bath is to be taken each day. Be careful
to keep teeth and mouth clean. Let the doctor
know if there is any tenderness or bleeding of gums.
The cost of the hospital treatment varies with the
amount of medicine given. This fee covers the
amount of medicine given, the use of room, the as-
sistance of Dr. Bain, and my services. This should
be paid each Tuesday.
The Gentile Instrument Used Shortens Time of
Treatment. — I believe I introduced to America the
syringe made by Gentile of Paris. This I obtained
in August, 1914. It revolutionized the treatment
in my hands. A fairly good imitation of the Gen-
tile syringe is made by the Becton Dickinson Com-
pany. It is made entirely of glass. The nozzle of
Nov. 11, 1916]
MEDICAL RECORD.
855
the syringe is placed at the lower pole, and there-
fore the force is applied to the piston in a direct
line instead of at an angle. The needle is finished
with a thumb hold and its insertion thus made
much easier. I am using this syringe and with it
the time of treatment is much shortened.
Economy in Numbers. — By administering the
preparation to a number in one day we may use
one or more of the large ampoules containing two
or three grams of the drug at a saving of at least
40 per cent, in the cost of the single dose. This,
of course, is a desideratum to the patient, and the
surgeon, especially if he is called on to treat some
charity cases.
A Schedule of Treatments Prevents Confusion. —
A schedule is prepared the day before. A sample
schedule for one day is given below and explains
itself. It will be noticed that the initial dose is 0.2.
Usually no dose of more than 0.3 is given. The
exception in this table was No. 9, a husky negro,
and No. 11, who received the first dose of the second
series.
Intravenous Injections of Diarsenol (C nadian)
March 21. 1916 — Sen-ice of Dr. G. N. Kreider
Pay-
Name
Address
No.
Amt.
"Urine
ment
Symptoms
1— A.B.
City
3
.3
N.
Cash
Slight symptoms
2— J. 0.
City
3
.3
N.
Cash
No symptoms
3— M. F.
New Berlin
1
2
N.
Later
Pain in arm
4— W. D.
City
5
!3
N.
Later
No symptoms
5— E. D.
City
5
.3
N.
In full
No symptoms
6— L. A.'
City
5
.3
alb.
In full
No symptoms
7— M. L.
Waverly
3
.3
N.
Pd.
Some nausea
8— B.L.
City
3
.3
N.
9— C. M.
City
1
.3
N.
Guarnt.
No symptoms
10— M. H.
Mechanicsburg
2
.3
N.
Pd.
No symptoms
11— W. B.f
City
IB
.3
N.
Pd.
No symptoms
12— C. N.
Edinburg
3
.3
N.
Pd.
No symptoms
13— M. H.
City
2
.3
N
Pd.
High fever
14— M. W.
City
1
.3
N.
Pd.
No symptoms
15— M. P.
Chicago
5
.3
N.
Pd.
No symptoms
16— A. C.
HiUsboro
4
.3
N.
Pd.
No symptoms
4.6
' This patient was given 12 intravenous injections notwithstanding the presence of
albumen in the urine. There were no disagreeable symptoms.
tThis second series of treatments is indicated by the letter B .
Time Required. — We estimate that the time re-
quired for each treatment averages fifteen minutes.
Of course, the actual time required for injecting
the 60 to 90 c.c. in the vein after it is safely punc-
tured is very short, but there is always some time
required for getting the patient into the room, ar-
ranging the table, preparing the arm, and caring
for the patient after the treatment.
Concentrated Solution Always Used. — The prepar-
ation has been given by me for two years in con-
centrated solution. In all this time, embracing
more than 600 injections, there has been no symp-
tom that could be attributed to this method. This
plan, therefore, is safe for the patient and enables
the surgeon to treat cases much more rapidly than
when 300 c.c. of solution is used according to the
old method advocated when the remedy was first
introduced. I used the old plan for three years, but
would not return to it.
Modern Methods Eliminate Disagreeable Symp-
toms.— When the intravenous injection of salvarsan
was first introduced, nausea, vomiting, diarrhea,
and more or less fever was the rule, but with such
a plan as is above outlined it is the exception. Since
using the Gentile syringe and needle the difficulty
of puncturing the vein and injection of the solution
has been nearly abolished. I have had but two
bad arms in two years.
522 Capitol Avenue.
A STUDY OF THE NEWER PHYSICAL SIGNS
IN THE DIAGNOSIS OF EARLY
PULMONARY TUBERCULOSIS.
By MAX GROSSMAN, M.D.,
BROOK-LYN. NEW YORK.
While different observers' * ' * have been busy in
research work in the laboratory studying pul-
monary tuberculosis from every possible angle in
the endeavor to facilitate early diagnosis and thus
render possible early treatment, clinicians have not
been idle, and have faithfully done their share in
the studying of physical signs and phenomena, en-
larging our scientific knowledge and proving of
service to humanity.
As shown by previous articles of the writer,"'
one of the earliest effects of the tubercle bacillua
is its effect on the heart. No sooner does the tuber-
culous process become active than the heart dilates,
manifesting itself in a rapid pulse of weakened
quality.
At the same time a phenomenon takes place in
the heart which cannot be overestimated as to the
value of its recognition; the writer refers to pul-
monary accentuation."
Pulmonary accentuation means that the pulmonic
second sound is louder at the second left pulmonic
interspace than at the second right aortic inter-
space. This is abnormal in adults and when ob-
tained is of value in connection with other signs.
An interesting point about this and one which the
writer has not seen emphasized before is the fact
that pulmonary accentuation may persist for a long
time even after the tuberculous process has healed
or become arrested, and may be the only physical
sign remaining of a previous tuberculous pulmonary
infection.
It is well to remember, and this is a fact not men-
tioned by the writer in his previous articles on the
subject, every once in a while dilatation of the
heart may persist even after the case has become
arrested. The value of these points cannot be over-
estimated. It has been shown, time and again, that
what appears to be an early pulmonary tuberculosis
is really an old process showing an exacerbation
and simply, as it were, breaking out again. If this
last statement be borne in mind, it can be readily
appreciated that any sign or group of signs which
is helpful and assists us in coming to a conclusion
regarding the existence of a previous tuberculous
infection is of great aid in guiding us as to the
possibility of present infection.
Now, let us go to the pulmonary apices, the head-
quarters as it were, and see what information new
in character has been learned in the study of diag-
nosing early pulmonary tuberculosis.
First in its great clinical importance let us take
up the sign popularized by Dr. Robert Abrahams*
and now known to clinicians generally as "Abra-
hams' Acromion Auscultation." This exceedingly
valuable sign, which was later additionally studied
by Nathan Magida,' Frank A. Bryant.10 and others,
is of the greatest help in detecting the earliest man-
ifestations of tuberculosis in the apices. Acromion
auscultation may persist for some time, even after
the process is no longer active, and in such cases
it would tend to show the existence of a previous
infection. In this connection the writer has noticed
the following, which he has not heard mentioned
before and which he believes is of great value in
many cases in distinguishing a recent infection
from a previous one: When rales are heard on aus-
cultating the acromion process this would most
856
MEDICAL RECORD.
[Nov. 11, 1916
likely show recent infection, certainly an active con-
dition. When rales are not heard, simply a pro-
longed expiration or abnormal whispered sound,
this would most likely indicate a chronic condition
— that is an old tuberculous process.
Surface temperature mentioned years ago in von
Ziemssen's "Cyclopedia of Medicine" in relation to
scrofulosis was adopted and elaborated by Abra-
hams" in the detection of incipient pulmonary
lesions. The writer has noticed the following in-
teresting phenomenon in connection with the same:
While a higher temperature than normal at an apex
is followed by acromion auscultation, the opposite
proposition does not hold good; that is to say an
apex showing abnormal acromial breathing may
not show any abnormal surface temperature. It is
well to remember, moreover, that both abnormal
acromial breathing and surface temperature are
rarely present in advanced pulmonary tuberculosis.
The reason for this being no doubt the ulcerative
changes taking place, when the destruction of lung
tissue gives the acromion process no opportunity
to transmit the atypical respiratory sounds, and
probably results in there being little or no hypere-
mia present at the apex in this unfortunate stage.
In conclusion the writer would state that since
the finding of the tubercle bacilli in the sputum no
longer shows an early lesion it behooves the con-
scientious diagnostician to master the other meth-
ods of diagnosis so that he may be able with rea-
sonable certainty to tell when an incipient lesion is
present. Aside from the scientific interest attached
to the study of new phenomena which are now
gradually becoming better understood, the writer
believes time spent on the comparatively newer
signs enumerated in this article will repay the care-
ful student and open up a field which offers many
possibilities in its scope and further elaboration.
In this connection much credit is due Dr. Robert
Abrahams, who by his teachings and writings has
helped to place the subject of diagnosis of incipient
pulmonary lesions on a basis which affords oppor-
tunity for earlier recognition and hence greater
benefit to the afflicted patients.
REFERENCES.
1. Czaplewski: Lehrbuch der klin. Untersuchungs-
methoden, 1904, p. 384.
2. Uhlenhuth: Med. Klinik, 1909, V. P. 1296.
3. I.oeffler: Deutsch. med. Wchnschr., 1910, Vol.
XXXVI, p. 1987.
4. Kawai: Med. Klinik. 1911, Vol. VII, p. 142.
5. Max Grossman: "Dilated Heart as a Sign of Early
Apical Pulmonary Tuberculosis," Medical Record,
April 15, 1916.
6. Max Grossman: "Interesting Observation in Diag-
nosis of Incipient Apical Pulmonary Tuberculosis,"
American Medicine, April, 1916.
7. Max Grossman: "Cardiac Dilatation," Netv York
Medical Journal, June 17, 1916.
8. Robert Abrahams: "Auscultation at the Acromion
Process," Archives of Diagnosis. April. 1913.
9. Nathan Magida: "Acromial Breathing as an Aid
in the Diagnosis of Apical Pulmonary Tuberculosis,"
.V. w York Medical .Journal. December 27, 1913.
10. Frank A. Bryant: "Acromial Auscultation,"
Journal of the American Medical Association. May 23,
1914.
11. Robert Abrahams: "Early Pulmonary Tubercu-
losis," New York Medico! Journal, July 29. 1916.
124 Lee Avent
Simulation of Albuminuria. — One of the ingenious
methods employed by malingerers in the present war
is the simulation of albuminuria by the injection of
white of egg into the bladder. The detection of this is
difficult, although it is asserted that a mixture of acetic
acid and formo] will precipitate the egg albumin; the
urine is then filtered and tested for pathological albu-
min.— Lyon Medical.
Prescriptions for Intoxicating Liquors. — The Missouri
statute, Revised Statutes, 1909, Section 5784, declares
that any physician who shall make any prescription to
any person other than for medicinal purposes shall be
deemed guilty of a misdemeanor. Section 5781 provides
the character of prescription which will protect a drug-
gist in making sales of intoxicants in quantities of less
than four gallons. A physician who unlawfully issued a
prescription for intoxicating liquor wrote it in such a
manner that the druggist who filled it was not protect-
ed; it was not dated, and it did not state that the intox-
icating liquor was prescribed as a necessary remedy,
though it stated it was "prescribed for medical purpose
only." The Springfield Court of Appeals, State vs. Nic-
olay, 184 S. W. 1183, held that the "physician was nev-
ertheless guilty of a violation of Section 5784; the word
"prescription" as used in the statute meaning a direc-
tion of remedy or remedies for a disease and the manner
of using them, and not necessarily a valid prescription
which would protect the druggest who filled it.
Evidence in Poisoning Case. — On the trial of a man
for the murder of his wife by poison with morphine or
laudanum it was held proper to admit evidence (1) of
a physician who made the postmortem examination that
the condition of the brain and blood led him to suspect
poison; (2) of a chemist, that a jar handed him con-
tained a liquid "said to be the stomach contents" of
one whose death was attributed to poison, where the
liquid was proved by witnesses from whom the chemist
received his information to be what it was said to be;
(3) of a chemist who had examined the contents of the
deceased's stomach, as to the quantity of morphine or
laudanum that was likely in the system of the deceased
or in the stomach prior to death; (4) to show the de-
fendant's relations with another woman and his effort
to resume sexual relations with her after his wife's
death; (5) that there was a lack of any appearance of
grief on his part at his wife's death; (6) of an expert
witness as to what portion of 4 grains of morphine or
opium would likely be absorbed through the system. —
State vs. Crivelli, New Jersey Court of Errors and Ap-
peals, 98 Atl. 250.
Concealment of Nature of Malady. — The fact that a
physician concealed from a parent that a child had diph-
theria which resulted in death does not tend to show
lack of skill or reasonable care in treatment. — Hoover
vs. Buckman, 194 111. App. 308.
False Answer in Insurance .Medical Examination. —
The false answer in an application for life insurance as
to having consulted a physician within a specified time
before the date of the medical examination, the appli-
cant having warranted that his answers were true and
having agreed that if the answers were untrue all
rights to himself or to his beneficiary should be for-
feited, is a bar to recovery on the benefit certificate
issued. — French vs. Modern Woodmen of America, 194
111. App. 438.
Medical Evidence of Misbranding. — In a proceeding
to forfeit drugs as being misbranded under the Food
and Drugs Act there was evidence that the drugs were
stated to benefit locomotor ataxia. In support of its
case the Government called several witnesses, physi-
cians of proven ability, knowledge, and experience, who
testified that the pill would not, and why it could not,
have any beneficial effects in locomotor ataxia and the
other diseases named, partial paralysis, sciatica, etc.
They also testified that medical opinion was unanimous
in so saying. It was also shown, and all of this without
contradiction, that the pill was practically the well-
known Blaud pill, used generally in medical practice.
It was complained, however, that the testimony of these
witnesses was not competent, being a mere expression
of their personal opinions or views. But the Circuit
Court of Appeals. Third Circuit, held that the case was
wholly different from one where witnesses were testify-
ing to their personal views upon a controverted ques-
tion of oninion. The testimony here was of fact, name-
ly, that there was general, uncontroverted consensus of
opinion. For example, referring to the effect of the
pills, the proofs were that they were utterlv useless for
locomotor ataxia; that, so far as the witness knew,
there was no difference in medical opinion on that point.
nor on the point that there is no combination of drugs
known to medicine, which can he compressed into one
pill, that could possibly exert a beneficial effect on all
the various troubles named.--Eleven Gross Packages,
Etc., vs. United States, 233 Fed. 71.
Nov. 11, 1916]
MEDICAL RECORD.
857
Medical Record.
A Weekly Journal of Medicine and Surgery.
THOMAS L. STEDMAN, A.M., M.D., Editor.
PUBLISHERS
WM. WOOD A CO., 51 FIFTH AVENUE.
See fourth page following reading matter for Rates of Subscription
and Information for Contributors and Subscribers.
New York, November 11, 1916.
ANTIDOTES IN MERCURIC CHLORIDE
POISONING.
The popularity of mercuric chloride as a means of
suicide has led to the proposal of a large number of
substances as antidotes to its poisonous action.
Many of them have been tried from time to time
but generally without much effective result. The
desirability of determining the relative value of
these substances led Fantus to undertake an ex-
perimental study of their effectiveness on animals
which had received a fatal dose of the drug. His
report (Jour. Lab. and Clin. Med., 1916, i. 879),
makes very interesting reading. He first estab-
lished the fatal dose of the drug for rabbits and
determined the average length of life of the ani-
mals after they had been poisoned. He then de-
termined the influence of the various antidotal
measures when applied at the time the poison was
administered or subsequently. He was able to show
that dilution had no effect aside from a mitigation
of the local lesions and that albumin, the standard
antidote, was unable to prolong the life of the
poisoned animal except when given at the same time
as the bichloride. Sodium bicarbonate, sodium
acetate, and stannous chloride each had a certain
amount of antidotal effect and might be expected
to be of some use, though not very reliable. He was
able to obtain much more favorable results with the
use of Carter's antidote which consists of three
parts of sodium phosphite and two of sodium ace-
tate. This was efficacious in greatly prolonging the
life of the poisoned animals even when it was given
after the administration of the sublimate. A sub-
stitution of sodium hypophosphite for the phos-
phite gave results that were quite similar though
perhaps more uniform. His best results were ob-
tained with an antidote composed of one part of
sodium hypophosphite and five parts of hydrogen
peroxide. This combination of a reducing and an
oxidizing agent has no chemical justification but his
results were uniform and he suggests the explana-
tion that the peroxide acts as a catalyzer.
Fantus is careful to say that the eliminative
treatment which has met with such success at the
hands of Lambert and Patterson should not be
neglected merely because an apparently efficient an-
tidote has been found. The excellent results were
obtained by those investigators without any such
antidote but it is reasonable to believe that such
chemical treatment might at least hasten the time
of recovery. The author advises that if the amount
of poison taken is known, the amount of hypophos-
phite used shall be ten times the amount of bichlo-
ride taken. As this dose might itself be poisonous
it would be wise to wash the stomach thoroughly,
after giving it, with a very dilute solution of the
antidote and a safe dose could be left in the stomach.
It is very gratifying that such information is now
at our command and the mortality from sublimate
poisoning should be much lower in the future than
it has been in the past.
THE GASOLENE TROUBLES OF ENGLISH
PHYSICIANS.
We who grumble at the soaring price of gasolene
little realize what real trouble is. Across the sea
our English cousins are not only obliged to pay a
greatly increased price for gasolene, or petrol as
it is usually called there, but they have difficulty in
getting enough for the legitimate needs of their
practice and its sale is hedged about with so
many restrictions that a British doctor never
knows when he will break the law. Several fac-
tors, all due to the war, are responsible for the
dearth of gasolene in England. One is the fact
that a large quantity is required for the troops, —
for their motor ambulances, motorcycles, aero-
planes, etc. Another is the actual decrease in the
importation of petroleum due of course to the di-
version of oil shipped to safer waters. A third
factor is the shortage of metal containers, metal
being in great demand for military purposes.
In view of these facts the English authorities
have placed the supply of gasolene under their
control and have definitely restricted the amount
which may be issued, these restrictions being most
stringent on cars used merely for pleasure and
growing less so as the use of these cars is more and
more necessary, the most deserving car user being
justly considered the physiciain. A committee was
accordingly appointed by the President of the
Board of Trade early in the spring to control the
supply and distribution of gasolene and to consider
what measures are necessary to the national in-
terest "(1) to ensure that adequate supplies of
gasolene shall be available for the purpose of war
and for other essential needs, and (2) with the
above object to regulate the use of gasolene for
other purposes in the United Kingdom during the
period of war; and subject to the direction of the
Board of Trade, to give executive effect to the meas-
ures decided on." This committee divided gasolene
users roughly into three classes: The first class
included doctors and government officials engaged
in business such as that of police, the second class
embraced all other consumers including those who
maintained cars or motorcycles for pleasure.
It was not thought at first that it would be neces-
sary to restrict any reasonable demands of the first
two classes, but this view had to be modified later.
The amount of gasolene used by the troops in the
field at first equaled and later exceeded the amount
used by the entire United Kingdom before the war.
Upon representation of the British Medical Asso-
858
MEDICAL RECORD.
[Nov. 11, 1916
ciation the committee made arrangements so that
the wants of physicians should be supplied in pri-
ority to nearly all other users. The n.oderate re-
strictions at first placed upon the use of gasolene
were soon found inadequate, and on August 1 it was
made impossible to purchase gasolene without a
permit from the Petrol Committee of the Board of
Trade. Permits were issued for not more than six
months' supply, the duty (six cents a gallon) had to
be paid at the time of issuance of the permit. In
some cases medical men for some unknown reason
were not allowed as much for the six months to
come as it was shown they had actually used in
their practice for the six months just passed. This
was taken of course with bad grace by the doctors
and the British Medical Association was stirred to
action. The Petrol Committee finally decided to
grant them the amount requested up to the maxi-
mum of fifty gallons per month; as this is only one
and two-thirds gallons per day, or an amount suffi-
cient to run a car from fifteen to thirty-five miles,
it can readily be seen that it must fall short in
many cases of heavy practice, especially in view of
the shortage of physicians and the extra work im-
posed on the remaining ones.
The English medical periodicals have accordingly
been full of letters from subscribers protesting
about this situation and grumbling in true British
style. It appears, however, in cases which the Brit-
ish Medical Association has investigated, that fail-
ure of a medical man to be supplied with sufficient
gasolene has nearly always been due to some neglect
on his part, — delay in presenting his demand, or
failure to notify his local garage in time of the
amount that he required. As the Board of Trade
has adopted the policy of giving the medical profes-
sion the gas over all other users it would seem that
with reasonable care it should not suffer greatly
unless indeed the entire supply of the country is cut
off.
MULTIPLE TYPHOID.
That a number of different bacteria may give rise
to the same symptom has long been recognized, and
typhoid fever is known as a plurispecific disease of
this character. It is much less understood that
several infections may coexist, and that one kind
may succeed another, thus simulating a relapse or
reinfection. Many striking facts have recently been
made public showing that a simultaneous infection
with two or more specific germs is very seldom suc-
ceeded by a relapse or new infection. Typhoid fever
from a single germ naturally exhibits a typical
course and temperature curve, and gives positive
agglutinative and blood-culture tests. Multiple ty-
phoid is not more severe than single typhoid. Atyp-
ical typhoid must often be due to double or multiple
infection. When true relapse follows a pure typhoid
it means that the original infection has been ar-
rested temporarily, only to break out anew. But
in many cases the relapse means that a patient
convalescing from simple typhoid has become in-
fected by a second form of the disease; that is,
the condition of the intestine after simple typhoid
makes it fall a ready prey to one of the paraty-
phoids.
Double or multiple typhoids show an atypical and
intricate course, but agglutination and blood-culture
tests supply the positive evidence. When a subject
develops typhoid some months or years after a first
attack, it may mean that the immunity is lost, or
that the patient falls a victim to a second form of
the disease. Especially significant are all of these
facts for the efficacy of protective vaccination. In
theory at least, the serum used should be polyvalent
to the extent of comprising the products of all
three of the causes of typhoid. This was first pro-
posed by Castellani, and the plan has been tested
widely in several countries, notably by Chantemesse
of France, who began its systematic use in 1915
among soldiers and marines.
Very recently, Grimberg has published (under
the auspices of Chantemesse) a study of 160 cases
of typhoid in various Paris hospitals, in a pamphlet
entitled "Les Typhoides Intriquees." The work is
extremely technical, devoted almost wholly to agglu-
tination and other serum tests and blood-culture
finds in the various single and multiple infections
and the pseudorelapses and pseudoreinfections, in
both vaccinated and non-vaccinated subjects. The
chief point upheld throughout is that mixed or
polyvalent vaccine is a completely scientific as well
as practicable idea. The author believes that pro-
gressive infection is more common than unique in-
fection, because one attack, even if it furnish im-
munity to a second infection of the same sort, almost
necessarily furnishes the occasion for infection by
one of the other diseases. This preponderance of
mixed or progressive infection makes necessary the
routine use of a triple vaccine.
COLLECTION AND DISPOSAL OF DOMESTIC
WASTES.
There is little doubt, in fact, it is not even a mat-
ter for argument that the proper disposal of sew-
age of every description bears a very definite rela-
tionship to disease and mortality. Unsanitary con-
ditions and ill health and high death rates are
synonymous terms. Where sewage is got rid of in
such a way that the germs of disease are not spread
broadcast, there good health prevails and obviously
the reverse is the case. No more conspicuous ex-
amples of the influence upon health of good sanitary
conditions have ever been afforded than the result
of effective sanitation in the European war. It
has now been going on for longer than two years
under conditions seemingly most prone to spread
disease yet there has been no widespread epidemic
on any front, with the exception of typhus fever in
Serbia. But there is no need to elaborate the argu-
ment that thorough sanitation is essential to good
health and the point which it is desired to empha-
size is that domestic sanitation is often very de-
fective and is a fertile means of disseminating in-
fection. The proper disposal of domestic wastes is
a problem which has not yet been solved, or rather
it might be said that it is very frequently neglected.
In th<T Canadian Practitioner and Revieic Septem-
ber, 1916, F. A. Dallyn writes on the subject and
draws attention in particular to the menace of the
privies and especially of the unscreened privies.
He shows that in the better educated parts of
Nov. 11, 19161
MEDICAL RECORD.
859
Canada statistics prove that the infant death rate is
very considerably less than in some of the other
centers and that where there are a good water sup-
ply and sewerage system both the infantile mortal-
ity and the death rate from typhoid fever are low.
It is not only in the country districts that the
menace of the unscreened outside closet exists; in
the suburban parts of many American cities it
is present and even the environs of New York are
not free from the opprobrium of allowing such a
survival of the dark ages to continue. Where there
is a privy it should, at least, be screened so that
flies cannot gain access to it and carry the germs
of disease far and wide. It is a scandal of the
first degree that outside closets should be permitted
in the neighborhood of large modern cities. Up to
date sewerage plants should be established wher-
ever possible and in any event, as Dallyn points
out, proper means should be instituted for the col-
lection of domestic wastes. By so doing the inter-
ests of public health and particularly of infants'
health will be best served. Ignorance as to the
means of preventing many diseases can no longer
be pleaded.
than the choice of a surgeon. The clumsy knife
may maim or slay the body; injury to the soul
is of infinitely greater moment."
Psychoanalysis.
Although Freud has not a few followers among
the English-speaking members of the medical pro-
fession, speaking generally his theories have ex-
cited a considerable amount of repulsion in Great
Britain. Granted that many of his conclusions are
based on a sound foundation and that the sexual
element does enter largely into the question of
neurosis, yet the manner in which Freud and his
disciples introduce sexuality into all the acts and
pleasures of life and claim that analysis will bring
forth the fact that repressed sexual desire is re-
sponsible for the neurotic tendencies exhibited by
so many civilized persons has aroused repugnance
and some disgust. Dr. Agnes Savill, in the Medical
Press, May 17, 1916, voices the opinion of a large
proportion of the medical profession when she says,
"So unanimous a repugnance has in all probability
a healthy cause, and points to a deep-rooted confi-
dence in the innate righteousness of human nature
which seems assailed by this recent school of
psychologists. The common sense of the common
man rises against the conclusions of Freud, which
strip humanity of dignity and beauty." Savill
draws attention to the fact that there is another
school of practitioners of the new psychology
whose home is in Zurich and whose high priest is
Dr. C. G. Jung. This school is not so well known
as that of Freud, owing partly to the fact that its
publications have not been translated so freely, and
partly, no doubt, because the very boldness and
novelty of Freud's view have brought worldwide
publicity. Jung is not blind to the sexual origin
of many neuroses, but the place he attributes to it
is very different from that of the Viennese school.
According to Savill the Viennese school seeks the
meaning of man in his primitive sexual roots;
the Zurich school looks at the flowering branches of
man's social activities and aspirations. Savill ends
a strong article with a warning to employ the
greatest care in the choice of an operator employ-
ing psychoanalysis, saying that "no protest that
influence is not consciously used will convince us
that the choice of the analyst is not more important
Gunshot Wounds of the Rectum.
As a rule, the injuries received during the present
war have been wounds of the upper extremities,
and especially of the head. These results have
been due, of course, to the trench warfare, the
head and upper parts of the body being less well
protected than the lower parts. However, injuries
of the lower extremities are by no means infre-
quent, and in a paper read recently before the
Royal Society of Medicine of London, P. Lockhart
Mummery discussed gunshot injuries of the rectum.
In the first instance, it is the experience of sur-
geons at the front that in wounds of the rectum
there is a considerable amount of suppuration, and
that it always is difficult to control sepsis in these
cases. In fact, such wounds are generally of a
serious nature. Mummery, who is at a hospital in
London, does not treat these cases until it is no
longer a question of saving life or controlling
sepsis but of dealing with the deformity pro-
duced by the healing or part healing of the
wounds. It is pointed out that no attempt should be
made to close wounds of the rectum while there
is sepsis. One should wait until healing has oc-
curred before doing any operation to close the
opening. Mummery believes that all such open-
ings into the rectum can be closed successfully if
sufficient care be taken, always providing that
enough of the anal musculature has been left to
secure a functional result. A very striking fact
in connection with these wounds is that the re-
sults are in many cases extremely crippling. The
size of the wounds, particularly where some por-
tion of the bony pelvis has been struck, coupled
with the fact that almost without exception the
wounds have suppurated violently, results in fear-
ful cicatrization which causes serious stricture
and contraction of the parts, more particularly if
the anus is involved. As a rule, bullet wounds of
the rectum cause serious injury to the bladder or
other structures in the pelvis, and sepsis in the
surrounding tissues with frequent abscesses gives
trouble for months after the rectal wound has
healed.
£foros of tip Wte k.
Report on Poliomyelitis Epidemic. — An inter-
esting summary of the recent poliomyelitis epi-
demic in New York has just been issued by the
Department of Health. The total number of cases
placed under quarantine by the department up to
and including October 11 was 9,177; of these, how-
ever, 250 cases were found, after careful clinical
study, not to be poliomyelitis, so that the total of
true cases was 8,927. The total number of deaths
recorded by the department was 2,343, giving a case
fatality of 26.24 per cent. The department divides
these cases into three classes, the first consisting of
those treated in the hospitals of the department, the
total number of these being 4,474, with 653 deaths,
a case fatality of 14.59. The second group consists
of 2,663 cases admitted to twenty-seven other hos-
pitals in the city; among these there occurred 387
deaths, a case fatality of 14.53. The third group
includes those cases treated in the home, because
(a) home conditions were adequate for isolation
SCO
MEDICAL RECORD.
[Nov. 11, 1916
or (b) the patients were too ill to be removed, or
(c) because the cases were not reported to the
department until the death certificate was pre-
sented. This group numbered 2,040 cases and the
deaths totaled 1,303, giving a case fatality of 63.87.
The high percentage of fatality in this group is
largely due to the fact that the major portion of
the cases comprised in it were of the severest type.
The department reports that up to September 30 a
total of 16,267 cases of supposed poliomyelitis were
reported by physicians, nurses, and members of
various households, and that of these only 8,630
proved to be true cases. From August 21 to Octo-
ber 13 there were discharged from the hospitals of
the Department of Health, 2,053 cases; of these 66
per cent, showed paralysis of some degree; in 18
per cent, the paralysis had wholly disappeared, and
15 per cent, had not shown any paralysis at any
time during the course of the disease. The after-
care work in the homes has shown that of 2,715
cases, 1,865 show a severe paralysis of one or both
legs, so that the children are unable to walk; 530
more were partially paralyzed in the legs, but were
still able to walk, and 273 had one or both arms
totally paralyzed. The department estimates that
between 75 and 80 per cent, of the cases with per-
sistent paralysis will fall in the class of persons
usually obtaining medical services free through dis-
pensaries or hospitals.
Report on Poliomyelitis. — The Committee of the
American Public Health Association, appointed to
report upon the subject of poliomyelitis, has sub-
mitted its findings, of which the following is an
abstract: The specific cause of poliomyelitis is a
microorganism, a so-called virus, which can be posi-
tively identified at present only by its production
of poliomyelitis in monkeys experimentally inocu-
lated. This virus is present in the nerve tissues
and certain other organs of persons dying from the
disease, and in the nose, mouth, and bowel dis-
charges of patients suffering from the disease. It
has also been shown that healthy associates of
poliomyelitis patients may carry the virus in their
noses and throats. These findings, together with
the fact that monkeys have been infected by direct
application of the virus to the mucous membrane
of the nose and by feeding of the virus, and strong
evidence that infection may be directly spread from
person to person. The fact that contact between
recognized cases can seldom be traced may be ex-
plained by the lack of means for detecting mild,
non-paralytic cases and by the belief that healthy
carriers of the virus and undetected cases are con-
siderably more numerous than the frankly para-
lyzed cases. Many facts, such as the seasonal in-
cidence and rural prevalence of the disease, have
seemed to indicate that some insect or animal host,
as yet unrecognized, may be a necessary factor, but
specific evidence is lacking, and the weight of pres-
ent opinion inclines to the view that poliomyelitis
is exclusively a human disease and is spread by per-
sonal contact, whatever other causes may be found
to be contributory. Personal contact includes the
possibility of infection by the transference of body
discharges from one person to another and of in-
fection through contaminated food. The incuba-
tion period, though not definitely established, is be-
lieved to be less than two weeks and probably in
the great majority of cases from three to eight
days. For the control of the disease, the employ-
ment of the following administrative procedures
is demanded. (1) The requirement that all recog-
nized and suspected cases be promptly reported. (2)
The isolation of patients in screened premises. The
duration of infectivity being unknown, the period
of isolation must necessarily be arbitrary, and six
weeks has been recommended and generally ac-
cepted. (3) Disinfection of all body discharges.
(4) Restriction of the movements of intimate as-
sociates of the patient as far as possible, including
at least exclusion of the children of the family from
school and other gatherings. (5) Protection of
children as far as possible from contact with other
children or with the general public during epi-
demics. (6) Observation of contacts for two weeks
after the last exposure. There is no specific treat-
ment of established value in poliomyelitis, but dur-
ing the persistence of the acute symptoms, rest in
bed, symptomatic relief, and passive support for
the prevention of deformities are necessary. Active
measures during this stage may cause serious and
often permanent injury. Hospitalization of pa-
tients where possible is to be encouraged. The best
chances of recovery from residual paralysis demand
skillful after-care, often long continued, and al-
ways under the direction of a physician familiar
with neurological and orthopedic principles of
treatment.
Caring for Paralysis Victims. — The Post-Grad-
uate Hospital, New York, has recently opened a de-
partment for the care of children on the lower
East Side who have recovered from infantile paraly-
sis. The latest appliances used in the after-treat-
ment of the disease are being installed, and four
masseurs and two nurses have been assigned to the
work. The New York Committee on After-Care of
Infantile Paralysis Cases is forming plans for the
centralization of all this after-care work into one
organization to look after all the children dis-
charged from hospitals, and to provide for the
training of nurses especially for this work and the
laying out of the city in districts in order that the
work may be carried on systematically. Dr. Holt,
it is reported, has estimated that there are be-
tween 4,000 and 5,000 children in the city who be-
cause of paralysis will have to be cared for this
winter and through the next year ; in many cases
provision will have to be made for the child's future,
as very few of those seriously crippled recover per-
manently. The New York Association for Improv-
ing the Condition of the Poor has formed a special
committee on after-care of infantile paralysis in
New York State, outside of New York City. The
association will cooperate in this work with the
State Department of Health. Under the auspices of
the latter a series of clinics is being held in various
places throughout the State.
Health Supervision of School Children. — In sup-
port of the 1917 budget estimate of the Bureau of
Child Hygiene of the New York City Department
of Health, the Bureau of Welfare of School Chil-
dren has issued a memorandum in regard to the
proposed expenditures. The appropriation asked
for is $17,240 in excess of that received last year,
and it is explained that the additional money is
needed for the enlargement of the staff of medical
inspectors and nurses and the employment in addi-
tion of six dental hygienists. If the money is avail-
able it is proposed to employ 125 medical inspectors
instead of 100 as at present, and 252 school nurses
instead of 200. The reports on medical inspection
during 1915 show that out of 925,000 pupils en-
rolled in the public and parochial schools, only 305,-
665 or 33 per cent, were examined for physical
Nov. 11, 1916]
MEDICAL RECORD.
861
defects, and that of those so examined 222,072 or
72.6 per cent, had physical defects requiring treat-
ment. It may be assumed that an equally large
percentage of the children not examined were suf-
fering from various defects which were a handicap
in their school work. Under the Education Law
of the State of New York the employment of physi-
cians to examine each public school child each year
is made mandatory outside of New York City; in
the city, under the present system, each child is
examined but once in three years, and this is due
to the fact that with the existing staff of physicians
9,200 pupils are assigned to each, while each nurse
is supposed to care for 4,800 pupils. As a result
not only is the medical inspection inadequate, but
the follow-up work of those cases found to need
attention in the homes is ineffective. For the first
time an appropriation has been asked to provide
for the employment in the schools of dental hy-
gienists, the value of whose services has already
been demonstrated in several cities outside of New
York. The large percentage (63.9) of children
with defective teeth in the public schools, and the
fact that more than half of these children are prob-
ably too poor to patronize private dentists, offer
the most convincing proofs of the need for such
prophylactic treatment as the dental hygienists are
fitted to give.
Proposed Abolition of Heroine. — A meeting of
the Committee on Drug Addiction of the National
Committee on Prisons was held at the Hotel Van-
derbilt, at which, besides the chairman, Dr. Simon
Baruch, were present Drs. Samuel W. Lambert,
Frederick Peterson, Frederick Tilney, ex-Surgeon-
General Charles F. Stokes, Mrs. Helen Hartley Jen-
kins, chairman of the Committee on Social Hygiene,
and Mr. Joseph D. Sears, secretary, ex officio. Dis-
cussion revealed a consensus of opinion that heroine
is, among drug addicts, most prevalent among boys
and in the early decades of adult life, and therefore
the chief promoter of vice and crime. In view of
this fact resolutions were adopted stating that since
heroine is not so indispensable a drug that its place
cannot be easily taken by other drugs and measures
that do not menace public welfare, the committee
recommended federal legislation to prevent the im-
portation, manufacture, and sale of heroine.
Montefiore Home. — The new private pavilion of
the Montefiore Home was opened for inspection on
November 6, at which time the annual meeting of
contributors was held. The funds for the pavilion
were obtained entirely by private subscription and
no expense has been spared to make the hospital
one of the most complete of its kind in the world.
Street Accidents. — The National Highways Pro-
tective Society reports that during the month of
October, 54 persons were killed by vehicles in the
streets of New York City; for the same period the
Police Commissioner reports a total of 59 deaths
from the same cause. In the State outside of New
York City, 38 persons were killed by vehicles dur-
ing the month, while in New Jersey 27 met death
in the same way.
New Public Health Association. — The commit-
tee appointed at a recent conference of the health
officers of Connecticut to consider the plan of form-
ing a public health organization in the State, has
reported favorably, and the preparation of a con-
stitution is now under way. Dr. C. J. Bartlett of
New Haven, has been put in charge of the arrange-
ments for organization, and the first meeting will
be held in that city on December 6. The society
will be called the Connecticut Public Health Asso-
ciation, and will work along the general lines of the
American Public Health Association.
Personals. — Dr. William Sharpe, professor of
neurologic surgery in the New York Polyclinic Med-
ical School, spoke on "Recent Advances in Brain
Surgery," before the College of Physicians of Pitts-
burgh, Pa., at a dinner at the University Club on
October 27. The talk was illustrated by moving
pictures.
Gifts to Charities.— The White Plains Hospital
Association is the residuary legatee under the will
of the late Mrs. A. C. Foulds of White Plains, who
died recently.
Mr. William Bell Wait of New York, widely
known as an educator of the blind, who died re-
cently, left an important valuable bequest to the
public. Mr. Wait's will provides for the free use
of his several inventions, thirteen in number, made
for the purpose of reducing the cost, increasing the
durability, and enlarging the amount and scope of
literature for the blind in the New York point sys-
tem. The decedent gave all his books relating to
the blind to the New York Institute for the Educa-
tion of the Blind, of which he was principal for
many years.
Discussion on Poliomyelitis. — At a meeting of
the New York Neurological Society to be held at
the Academy of Medicine, Tuesday, November 14,
at 8.30 p. M., the subject for discussion will be
"Poliomyelitis: Its Diagnosis and Treatment, and
the Management of the Recent Epidemic." Papers
will be read by Drs. W. M. Leszynsky, Frederick
Tilney, B. Sachs, and C. L. Dana.
Gifts for Dental School. — Columbia University,
New York, has announced the receipt of two gifts,
amounting to $125,000, from anonymous donors, to
be used toward the establishment and endowment
of the new dental school. Officially the dental
school has opened at the University, but the actual
dental courses will not begin for two years. Stu-
dents entering upon the study of dentistry at the
University must first spend two years at the Col-
lege of Physicians and Surgeons, specializing in
dentistry for the next two. The dental school is
thus really a graduate school, the only one of its
kind in the country.
Ambulances for Paralysis Victims. — Three am-
bulances, one each to be used in Manhattan, Brook-
lyn, and Boston, in transporting children recover-
ing from infantile paralysis between their homes
and surgical clinics, were assembled in City Hall
Park, New York, on October 31, to be dedicated and
to receive the good wishes of the Mayor. The am-
bulances were purchased and will be maintained by
the Militia of Mercy.
New Medical Library. — The New York Medical
College and Hospital for Women, New York, has re-
ceived a gift from Mr. M. W. Dominick of a medi-
cal library, which will be endowed by Mr. Dom-
inick as a memorial to his son, Dr. George Carleton
Dominick, who died recently.
Obituary Notes. — Dr. Emory G. Drake of Brook-
lyn, N. Y., a graduate of Long Island College Hos-
pital, Brooklyn, in 1874, died at his home on Oc-
tober 29, aged 64 years.
Dr. Thomas J. Morton of Philadelphia, a grad-
uate of the Jefferson Medical College, Philadelphia,
in 1885, for twenty-five years physician to the coro-
ner's office, and for many years a member of the
Common and Select Council, died at his home on
October 12, aged 52 years.
862
MEDICAL RECORD.
[Nov. 11, 1916
Dr. Daniel Newton Mason of Suison City, Cal.,
a graduate of the National University of Arts and
Sciences, Medical Department, St. Louis, in 1879,
died at his home on October 4, aged 73 years.
Dr. Hawley Nathan Barney of Richmond, Cal.,
a graduate of the University and Bellevue Hospital
Medical College, New York, in 1900, and a member
of the American Medical Association, the Medical
Society of the State of California, and the Contra
Costa County Medical Society, died at the Napa
State Hospital, Napa, Cal., on October 7, aged 39
years.
Dr. Harry C. Weber of Louisville, Ky., a grad-
uate of the Kentucky School of Medicine, in 1898,
and a member of the Kentucky State Medical Asso-
ciation, the Jefferson County Medical Society, and
the American Urological Association, died at his
home, from uremic poisoning, on October 6, aged
46 years.
Dr. Stockbridge P. Graves of Saco, Me., a grad-
uate of the New York Homeopathic Medical College
and Flower Hospital, New York, in 1861, died at
his home on October 12, aged 90 years.
Dr. William S. Allee of Olean, Mo., 'a graduate
of the Missouri Medical College, St. Louis, in 1875,
and a member of the American Medical Associa-
tion, the Missouri State Medical Association, and
the Miller County Medical Society, died at the Wes-
ley Hospital, Kansas City, on October 9, aged 64
years.
Dr. L. Dann of New York, a graduate of the New
York University Medical College, New York, in 1885,
died suddenly at his home on October 20.
Dr. William G. Dubois died of uremia at Cam-
den, N. J., on October 28 at the age of 59 years. He
was graduated from Hahnemann Medican College
and Hospital in the class of 1880.
Dr. Peter J. McCahey died at Philadelphia on
October 22 at the age of 60 years. He was gradu-
ated from Jefferson Medical College in the class of
1885.
Dr. George Lesser of New York and Brooklyn,
a graduate of New York University Medical Col-
lege in 1897, died at his home on October 22, aged
46 years.
Dr. William J. Coppernoll of Newark, N. Y.,
a graduate of the University of Michigan Medical
School, Ann Arbor, in 1887, and a member of the
Medical Society of the State of New York and the
Wayne County Medical Society, died in Laconia, N.
Y., on October 14, after a long illness.
Dr. Clarence A. Rogers of Cordova, Tenn., a
graduate of the Memphis Hospital Medical College.
.Memphis, in 1903, of the Medical Department of
the University of the South, Sewanee, in 1906, and
of the Vanderbilt University, Medical Department,
Nashville, in 1907, died suddenly at his home on
October 10, aged 38 years.
Dr. HAYDEN Austin West of Sewanee, Tenn., a
graduate of the University of Tennessee, College
of Medicine, Memphis, in 1899. and a member of
the Tennessee State Medical Association and the
Franklin County Medical Society, died on October 8,
aged 38 years.
Dr. Joseph IT. BREWER of Salem, Ore., a gradu-
ate of the Northwestern Medical College, St. Jo-
seph, in 1881, died recently at his home, after a
year's illness, aged 69 years.
Dr. Benjamin F. O'Daniel of Denver, Colo., a
graduate of the University of Louisville, Medical
Department, in 1874, died at his home, from
Blight's disease, on October 16, aged 66 years. Dr.
O'Daniel had served as chief surgeon of the Mis-
souri Pacific Railroad for seventeen years.
Dr. Percy Guy Davis of Deerfield, Mass., a grad-
uate of Baltimore Medical College in 1896, died sud-
denly at his home on October 20, aged 49 years.
LIEUTENANT-COLONEL EDGAR ALEX-
ANDER MEARNS,
United States Army.
Dr. Edgar Alexander Mearns, Lieutenant-
Colonel, United States Army, retired, died at the
Walter Reed General Hospital, Washington, D. C,
on November 3, aged 59 years. Dr. Mearns was
born in Highland Falls, N. Y., and in 1881 was
graduated from the College of Physicians and Sur-
geons, New York. Two years later he was ap-
pointed assistant surgeon in the medical corps of the
United States Army, and rose steadily in the service
until on January 1, 1909, he was retired for phys-
ical disability with the rank of lieutenant-colonel.
During all this time he devoted himself to the study
of natural history, and wrote largely on the sub-
ject, his published works numbering, it is said, one
hundred and twenty-two. Of the whole collection of
birds in the Smithsonian Institution, one-tenth are
credited to his efforts, and the Institution is also
the richer as the result of his two trips to Africa,
the first in 1909-10 as the Smithsonian representa-
tive on the Roosevelt trip, and the second a year
later with the Childs-Frick expedition. His last
work was the report of these two expeditions.
(Snrrrapimftrtir?.
SAMUEL COOPER'S TEACHING ON PUS.
To the Editor of the Medical Record:
Sir: — Dr. John W. Wainwright found an old book
in a garret in Cherry Valley and kindly sent it to
me. This volume proves to be "First Lines on the
Practice of Surgery," by Samuel Cooper, first edi-
tion, London, April 30, 1807. The time corresponds
with Napoleon's invasion of Spain, and Cooper was
surgeon "To the Forces" (British). In view of a
recent editorial article in the Medical Record
about "Laudable Pus," possibly this abstract from
a work more than a century old may prove of some
interest :
"The sympathetic fever attendant on inflamma-
tion has been considered an essential step to suppu-
ration; but with little foundation. Is there not a
regular secretion of pus from the most indolent ul-
cers? Is there not the same process on every blis-
tered surface? In such cases is there not often-
times a total absence of fever?
"That dead animal matter cannot be converted
into pus is proved by sloughs of the cellular mem-
brane, tendons, fasciae, etc., remaining unchanged in
abscesses a considerable time and by dead bone ly-
ing unaltered in pus for many months. Whatever
diminution of these substances may, under such cir-
cumstances, happen, occurs only on that side which
is next to the living solids and can be satisfactorily
accounted for on the principle of absorption.
"Pus always partakes of the nature of the sore
which produces it. To the surface secreting it pus
is quite unirritating though it may greatly irritate
any other. Hence, it is useless to wipe matter so
Nov. 11, 1916]
MEDICAL RECORD.
863
completely from the surface of granulations as some
are wont to do; but it is highly proper to keep the
surrounding skin free from it.
"Stimulating antiseptics such as spir, vini camph.,
olterebinth, etc., may diminish fetid effluvia; but
they are apt to create a renewal of sloughing when
they extend their action to living parts."
It may not be amiss to say that Cooper treated
contused wounds with solutions of alum and of
"acetite of lead." Probably every surgical clinic in
our city if not in our country is using, to-day,
R . Alum .Iss., Plumbi acet. 3i., Aq. §iv. It is termed
"alum acetate solution."
Douglas H. Stewart, M.D.
OUR LONDON LETTER.
(From Our lingular Correspondent.)
WOMEN'S WORK AT THE FRONT — DR. ELSIE INGLIS IN
SERBIA — ROYAUMONT VISITED BY PRESIDENT
FRENCH SOLDIERS AT ROYAUMONT — THE LATE T.
J. WALKER — SOCIETY OF CHEMICAL INDUSTRY —
BRITISH DYES.
London. October 14, 1916.
Women's work at the front appears to be a great
success and owes much to Dr. Elsie Inglis, whose de-
voted service with the Scottish women's hospital
units in Serbia has elicited admiration in all direc-
tions. Since the first efforts in this direction the
work has grown steadily and the example of the
pioneers has been followed by English, Irish, and
Welsh women, though the organization still retains
the name of Scottish Women's Hospitals and its
headquarters are in Edinburgh, and the wounded of
our French, Belgian, and Serbian allies have reaped
the benefit of services which were at first offered to
but declined by the British government. Dr. E.
Inglis is now at the head of seventy-five British
women, forming the staff of two field hospitals, a
large motor transport section — serving with the
Serbian army in the Dobrudja. The units are lit-
erally women's units, for not only are the medical
officers all women, but the transport, the sanitary
work, the motor repairs, and all work in connection
with the hospitals is done by women. The French
and Serbian authorities have often given expression
to their gratitude for the splendid achievements of
the Scottish Women's Hospitals. One of the places
giving most fruitful results is Royaumont, where
our ancient abbey has been transformed into a well-
equipped institution for the treatment of French
wounded. This was begun with one hundred beds,
but these have now been increased to four hundred.
At a meeting in London lately Miss Cicely Hamil-
ton, who has devoted much time and work for the
past two years to this hospital, gave an account of
its doings and spoke with enthusiasm of the reputa-
tion which British nurses and hospitals have ac-
quired in France and of the abounding gratitude of
the French people. Between 3,000 and 4,000 French
soldiers have already been treated at the Royau-
mont Hospital, which was recently visited by Presi-
dent Poincare, who expressed admiration of all he
saw there. An appeal on behalf of the London
Committee was made by Miss Mary Lowndes and
supported by Lady Emmott.
You will probably remember the name of Dr.
Thomas James Walker, a foremost physician in the
provinces, local secretary to the Archaeological Con-
gress in 1862, and author of the "History of the
French Prisoners at Norman Cross" (1913). Last
year the honorary freedom of the city of Peterbor-
ough was conferred on him on his eightieth birth-
day. He was an original member of the North-
amptonshire Volunteer Corps and held the rank of
Lieutenant-Colonel. Of his family of thirteen chil-
dren, six sons are now serving in the navy or army.
The recent meeting of the Society of Chemical In-
dustry took into consideration the position and
prospects of the dye and fine chemical industries,
which seem to have suffered from lack of coopera-
tion. From their proceedings it seems that if we
are to recapture the color and fine chemical trade
we must give more scientific attention to the tar in-
dustry and we need a central research laboratory.
Protection for British dyes was brought up, but
the idea obtained very little support. It was stated
that Germany would flood the market with fine
chemicals at a loss, if allowed, rather than not hold
monopolies. It was said that we are now self-sup-
porting as to the salicyls, and it was hoped we should
not let them again become a German monopoly. It
was argued that some degree of protection for the
next ten years was needed by the manufacturers
of organic synthetic drugs, as without it what had
been achieved would be lost by Germany's state
aided and organized opposition.
$rai3Vt8B of Mthuni ^>t\tnti.
Boston Medical and Surgical Journal.
October 26, 1916.
1. Anterior Poliomyelitis. A. J. McLaughlin.
2. The Occurrence and Diagnosis of Pericarditis. Edwin A.
Locke.
3. A Second Note on the Frequency of Epilepsy in the Off-
spring of Epileptics. D. A. Thorn.
4. Artificial Heliotherapy : The Mercury Vapor-Quartz Light
a Valuable Therapeutic Agent. John Bryant.
5. The Treatment of Obesity by a Rational Diet. Edward E.
Cornwall.
6. The Streptococcus Mucosas Capsulatus as a Cause of Mas-
toid Disease. Gorham Bacon.
7. A Case of Double Empyema Successfully Operated Upon.
with Remarks Upon Localization. F. B. Lund and II.
Morrison.
8. A Case of Bloody Tears. M. J. Konikow.
1. Anterior Poliomyelitis. — A. J. McLaughlin, who
has made observations with reference to poliomyelitis
in Massachusetts during the recent epidemic, agrees
with other writers as to the source of infection of this
disease and reviews some of its epidemiological pecu-
liarities. He states that most diseases spread in a
regular progression along the lines of travel. This
applies even to those diseases which are spread by
insects, but is not true of poliomyelitis, which fre-
quently skips an intervening city between two badly
infected cities. He finds that it frequently attacks less
than one person per thousand population. Two ex-
planations of this have been advanced, either that the
amount of susceptible material is limited by some
immunizing influence or that its transmission is devious
and selective, involving possibly an animal reservoir
and an insect transmitter. The prevalence of the dis-
ease seems to be greater in rural and suburban districts
than in cities. The most consistent epidemiological
character of poliomyelitis is its age incidence. The
writer has made an effort to determine whether the
age limit of those attacked was the same in rural and
urban outbreaks. The prevalence of the disease in 15
towns, ranging in population from 427 to 2,213, was com-
pared with that in the worst stricken of the smaller
cities, North Adams. The total population of the rural
groups was 23,361; that of North Adams 22,939. The
attack rate was nearly the same in the two. In the
rural group there were 37 under five years of age, 26
between the ages of five and ten, and seven over ten
years; in the North Adams group there were 76 under
five years of age, 24 between five and ten years of age,
864
MEDICAL RECORD.
[Nov. 11, 1916
and none over ten. This is suggestive that the age limit
of susceptible age groups may be higher in rural and
suburban life. The writer thinks it not improbable
that an active immunizing influence is going on con-
stantly, constituting an endemic prevalence of this dis-
ease, with relatively few paralyzed cases. This hypoth-
esis would best explain the age incidence of the disease,
for with a widespread infection opportunity is afforded
for obtaining immunity in the first years of life.
Theoretically, such a process of immunization would be
most active where opportunities for contact were
greater, that is, in the city. If this reasoning is sound
we should not only have a lesser number of immune
persons in the country but the susceptible groups
would have a higher age limit.
2. The Occurrence and Diagnosis of Pericarditis. —
Edwin A. Locke comments on the relative infrequency
with which pericarditis is seen clinically in comparison
with its relative frequency at the autopsy table. He
has made a careful study of the autopsy reports of the
Boston City Hospital for the past nineteen years to-
gether with the clinical records of the same cases. The
total number of post-mortem sections was 3683. In
this series acute lesions of the pericardium were de-
scribed in 150, and chronic lesions in 209 instances.
Exclusive of these 359 cases of true pericarditis, 88
showed milk patches in the pericardium. These figures
show that acute pericarditis was found in 4 per cent, of
all autopsies. In this series of autopsies acute endo-
carditis was described in 5 per cent, and chronic endo-
carditis in 12.6 per cent. In only 27 instances among
the 150 cases of acute pericarditis was there any clear
evidence in the clinical notes of the presence of disease
of the pericardium. A detailed study of the various
types of pericarditis found reveals an even greater
deficiency in the clinical work. The most glaring errors
are in the cases of pericarditis with effusion of various
forms. The writer believes that in at least 50 per cent.
of these cases it should be possible to diagnose this
condition with reasonable certainty. Rheumatism is
the commonest cause, and in adults pneumonia and
pleurisy probably conies next. A less common cause
is tuberculosis of the thoracic organs or acute miliary
tuberculosis. The clinical picture is difficult to give.
In not a few instances the onset is more or less well
marked. The patient becomes restless, breathes with
a shallow, rapid respiration, looks distressed and
anxious, the face has a dusky pallor, and the patient
complains of pain or oppression in the region of the
precordia. Later symptoms depend largely on the
degree of cardiac embarrassment and pressure from
the distended pericardial sac. In the early stage tha
first and most important sign is the friction fremitus.
As a rule this is double, though fairly commonly it
occurs as a single sound, or rarely triple. The peri-
cardial sounds never begin or end with a shock and are
characterized by the same intensity throughout. The
commonest areas where they are heard are at the base
and over the middle portion of the heart. It seems not
improbable that in a not insignificant percentage of
the cases the rub is heard over a relatively wide area
of the thorax and in the lower left back also. The
physical signs of adherent pericardium are described
together with the characteristics of adherent pericar-
dium in roentgenograms, and the opinion is expressed
that, considering the relative frequency of pericarditis
and its favorable course with spontaneous recovery in
many instances, paracentesis is rarely necessary.
3. A Second Note on the Frequency of Epilepsy in
the Offspring of Epileptics. — D. A. Thorn has made an
intensive study of cases already reviewed in a previous
article to determine to what extent epilepsy is trans-
mitted directly from parent to offspring. Thirty-three
matings are considered which resulted in 133 offspring.
Of these 86 are living and 47 dead. Of the total 133
offspring there is a history of convulsions in 10, five
having died in infancy, during seizures, two becoming
arrested cases, and three confirmed epileptics. The
group of living offspring contains 46 cases still under
20 years of age. The writer thinks it is not probable
that 50 per cent, of these will develop epilepsy, while
in the cases over 20 years of age heredity will play a
much less important part. The results of his earlier
work have been to a large degree substantiated and
his conclusion that epilepsy is less often transmitted
directly from parent to offspring than we have here-
tofore been led to believe seems to be justified.
6. The Streptococcus Mueosus Capsulatus as a Cause
of Mastoid Disease. — Gorham Bacon states that accord-
ing to his experience the Streptococcus 7nucosus capsu-
latus is the most destructive germ with which the
otologist had to contend, and the question of an opera-
tion when the mastoid cells are involved is a most
important one. He cites a number of cases which serve
to emphasize the following points: 1. The patient may
have very severe pain, or the pain may be slight, and
the temperature is seldom much above normal. 2. Ten-
derness on pressure over the mastoid process may be
well marked, or there may be none, especially where
the outer cortex is thick. 3. The discharge in some
cases is very profuse, while in others it is slight, and
there may or may not be sagging of the posterior and
upper canal wall. 4. The x-ray is a most valuable aid,
as the cells on the affected side will be cloudy, and in
some instances it is possible to detect an epidural or
perisinous abscess. 5. We should err on the safe side
and operate when in doubt, for we often find a great
destruction of bone, even in cases that present few
symptoms. It is only in a few cases, which yield
readily to treatment, that an operation can be avoided.
New York Medical Journal.
October 28, 1916.
1. Anesthesia Reviewed. James T. Gwathmey.
_. The Sources of Error in Diagnosis. Edward C. Hill.
3. An Accessory Ovary. Allen J. Smith and Alfred C. Wood.
4. The Therapeutics of Cerium. Reynolds Webb Wilcox,
5. The Treatment of Bladder Tumors. J. T. Geraghty.
6. Tumors of the Bladder. Leo Buerger.
7. Intestinal Stasis. Eliza M. Mosher.
8. Rectal Anesthesia. William M. Johnson.
9. Anesthesia. P. J. Flagg.
10. Rabies. Miley B. Wesson.
11. The Clinical Thermometer as a Carrier of Infection. L.
Martocci-Piseulli.
12. Some Notes and a Prophecy. G. Arbour Stephens.
2. Sources of Error in Diagnosis. — Edward C. Hill
discusses the principal causes of diagnostic error under
some dozen different headings, such as mistaking
symptoms for diseases, effects for causes, overlooking
the focus of infection, disregarding diet and habits,
neglecting the mechanical factor, slighting the reflexes,
ignoring the psychic factor, diagnosis by proxy, diag-
nosis by predilection, the pathognomonic delusion, the
using of names without sense, and sheer ignorance. He
has differentiated some one hundred and seventy-five
causes of headache, scarcely any two of which should
be treated just alike. A cough may arise all the way
from wax in the ear to an incompetent heart, as well as
from any affection of the respiratory tract. Albumi-
nuria accompanies a hundred different conditions besides
organic affections of the kidneys. Iron and arsenic
may be of great service in treating anemia, but the
cure must be sought further back than in the blood.
Pleurisy is practically always a complication of pneu-
monia, tuberculosis, or some other general infection.
Most cases of so-called ptomaine poisoning are either
acute indigestion from excess of food or an incom-
Nov. 11, 1916]
MEDICAL RECORD.
865
patible combination of foods, or else some more or less
obscure surgical condition, such as perforating duodenal
ulcer or mesenteric thrombosis. In discussing the
mistakes made by slighting the reflexes, the writer
considers the reflexes in angina pectoris, and points out
that he has met cases in which pain was referred to
the left arm, and a case of pneumonia of the right
lower lobe, with marked diaphragmatic pleurisy, in-
volving the phrenic nerve, which was apparently re-
sponsible for pain in the right side of the neck as the
chief subjective symptom. Mackenzie calls attention
to cases of gallstone disease that have been treated
for years for neuritis. A considerable number of
physicians have mistaken a basal pneumonia of the
right side for acute appendicitis. Of all origins of
referred and reflex sensory symptoms probably the
prostate gland is the most prolific source of diagnostic
error. No more frequent error is made than to base a
diagnosis upon a single symptom or sign. If a patient
shows loss of knee jerks he is liable to be set down at
once as syphilitic, whereas there are at least thirty con-
ditions in which knee jerks are absent and of these
hysteria and multiple neuritis are probably the most
important. The practical utility of a study of the
cytology of the stomach washings in demonstrating the
presence of cancer cells is emphasized, and also that
slight degrees of excess of deficiency of the ductless
glands are especially liable to escape detection in the
present state of general ignorance of this province,
although such changes may easily account for other-
wise obscure symptoms. It may be possible that the
control of cell anarchy called cancer lies in the study
of these glands.
5. Treatment of Bladder Tumors. — J. T. Geraghty
relates his experience with 180 cases of bladder tumors
from which he concludes that benign and malignant
papillomata should be treated by fulguration; excision
or resection should not be practised except in cases in
which intravesical treatment is impossible or very
difficult. Radium he has found a great aid in the
treatment, particularly of the malignant papillomata,
and the best results were obtained when the radium
was placed directly against the tumor. When the
tumor is a papillary carcinoma, resection should be
practised by a technique which will reduce to a minimum
the dangers of implantation or recurrence. Radium as
yet has not given results in this type of tumor suffi-
ciently encouraging to warrant its employment in
preference to resection in cases which are considered
operable. Following resection, cystoscopy should be
performed at an early date, and at frequent intervals,
especially for the first year, and if recurrences are
noted, they can occasionally be successfully treated by
a combination of fulguration and radium. Unfortun-
ately a large percentage of cases are first seen when
the disease is so extensive that nothing more than
palliative measures can be adopted. In 69 of the 180
cases in this series the tumors were so extensive and
so hopelessly inoperable that nothing more than palli-
ative measures were adopted.
6. Tumors of the Bladder. — Leo Buerger writes that
from a study of 113 tumors of the bladder, among
which were 55 papillomata, 45 papillary carcinomata,
five squamous carcinomata, two metastatic carcinomata,
and six sarcomata, he concludes that a differential diag-
nosis between papillomata and carcinomata can be
made in almost all cases on a pathological basi. Cer-
tain morphological criteria were accepted as indicating
the existence or the acquisition of malignant traits in
any given tumor. These criteria were found to be
present in parts of the tumor that were accessible, so
far as they could be reached by cystoscopic instru-
ments, and so far as adequate portions could be re-
moved for histological examination. The changes
indicative of malignancy occur, not as heretofore as-
sumed, in the "depth" where they may escape our
diagnostic methods, but first, in the epithelium, not
far from the surface, either with or without areas of
infiltration. A test of the morphological criteria proved
conclusively that they were trustworthy and, if adopted,
led to correct diagnosis. Many of the other loosely
accepted notions regarding the malignancy of papil-
loma per se were found to be fallacious. Only in one
tumor out of 113 was a papilloma found to infiltrate
and still retain "normal" cellular characteristics. A
trustworthy pathological diagnosis and the possibility
of differentiating between carcinoma and papilloma de-
pend upon our opportunities of obtaining material and
upon our ability to recognize the criteria laid down as
indicative of malignancy; that the latter are present
this series of tumors has definitely shown.
11. The Clinical Thermometer as a Carrier of In-
fection.— L. Martocci-Pisculli calls attention to the
danger of conveying infection from one patient to
another by means of the clinical thermometer. Many
physicians content themselves with rinsing their ther-
mometers in cold water and then using them on one
patient after another. A number of thermometers were
taken from various physicians in order to determine
whether germs were actually carried in this way and
whether they could be recovered and grown in culture
media. Several dozen thermometers were examined
by competent bacteriologists in the research laboratory
of the New York City Department of Health. It was
found that all thermometers taken from patients carry
live pathogenic germs and are therefore disease car-
riers. Washing them in water and wiping them dry
in no way destroys the germs or even reduces the
danger of carrying infection. Cool water hardens and
so fixes the mucus with the containing bacteria on the
thermometers. It is absolutely imperative to disinfect
the thermometer after using it on a patient. Physicians
must either devise some method of disinfecting the
thermometer while carrying it in its case, or spend a
few minutes in each patient's house to disinfect it.
Journal of the American Medical Association.
October 2S. 1916.
1. The Infectious Diseases as a Field of Investigation in
Pathology. Frederick P. Gay.
2. Grip in Children. Lawrence T. Royster.
o. Til-- Ultimate Results in the Treatment by Artificial
Pneumothorax. A. G. Shortle.
4. Duodenal Ulcer : Report of a Case in Which Operation
Was Followed by Improvement. H. M. McClanahan.
5. Death Rate in Acute Infections: A Study of the Mor-
tality in Philadelphia During 1911-1915 from
Measles, Pertussis, Diphtheria. Scarlet Fever, and
Typhoid Fever. Edwin E. Graham.
6. Fractional Determination of Gastric Secretions. Ernest
C. Fishbaugh.
T. Radical ' tperation for the Cure of Cancer of the Sec-
ond Half of the Large Intestine. Not Including the
Rectum. William .T. Mayo.
S. The Corpus Luteum : Its Life Cycle and Its Role in Men-
strual Disorders. Emil Novak.
9. Lepra Mutilans. Melvin S. Rosenthal.
10. An Unusual Fracture of Both Bones of the Leg. Charles
Ryttenberg.
11. Traumatic Rupture of the Stomach, with Recovery.
Alanson Weeks.
12. Stricture of the Esophagus: Report of a Case. Walter
M. Brunet.^
13. Report of a*Case of Acquired Hemolytic Jaundice with
Splenectomy. G. A. Friedman and Elihu Katz.
14. Tests by Bar&ny Methods, Demonstrating Neuraxial Dif-
ferentiation of the Fibers from the Horizontal and the
Fibers from the Vertical Semicircular Canals. Charles
K. Mills and Isaac H. .Tones.
15. Thrombosis of Brachial Artery Relieved by Incision and
Massage of the Artery. John A. Caldwell.
16. The Comparative Resistance of Bacteria and Human
Tissues to Certain Germicidal Substances. Robert A.
Lambert.
2. Grip in Children. — Lawrence T. Royster. (See
Medical Record, June 17 1916, page 1117.)
3. The Ultimate Results in the Treatment by Artifi-
cial Pneumothorax. — A. G. Shortle says that during the
866
MEDICAL RECORD.
[Nov. 11, 1916
past four years there have been published in America
numerous reports on the treatment of lung tuberculosis
by artificial pneumothorax, and these have proved be-
yond doubt the value of this procedure so far as the
early symptomatic results are concerned, provided
properly selected patients are operated on. After briefly
summarizing the little that is to be found in the litera-
ture, he deals with only 104 cases, twenty-five of which
are to be eliminated as they proved inoperable, and were
of interest only in showing that almost one case out of
four had such extensive adhesion that operation was
impossible. This left seventy-nine cases that allowed of
sufficient collapse to produce therapeutic results. Of
the seventy-nine patients, thirty-five are dead, two were
apparently made worse, eighteen were improved, and
twenty-one were discharged and treatment stopped
{leaving those cases unaccounted for]. Out of seventy-
nine patients receiving lung collapse, nineteen are to-
day working and in good shape physically; a number
of these are symptom free. Three others discharged
as improved are working but show marked involvement
of the lung. A good proof of the class of patients oper-
ated on is afforded by the fact that of the twenty-five
patients who proved to be inoperable on 'account of
adhesions, sixteen are dead, and seven are living, but in
bad shape physically. Of the inoperable patients only
two, or 8 per cent., are working, and only one, or 4 per
cent., is improved; while of the patients operated on,
twenty-two, or about 28 per cent., are working, and
nineteen, or 25 per cent., are in good shape physically.
Their results appear to be much better than those of
other operators. He ascribes this only to the following
factors: (1) Most of their patients have been treated
in their sanatorium, where the complete rest so essen-
tial to good results can be enforced. He often felt with
Saugman that the procedure should not be undertaken
outside an institution. (2) Their patients have been
largely of the more intelligent middle class, with suffi-
cient funds to afford proper living conditions and with
sufficient brains to lend intelligent cooperation. (3)
They were all treated in a very favorable year-round
climate. (4) This he considered important: They re-
ceived small insufflation of gas, never exceeding 500
c.c, and as a rule 250 to 350 c.c. The habit of intro-
ducing 800 to 1000 c.c. at one operation is always suffi-
cient explanation to me why a given operator has not
had success with artificial pneumothorax.
4. Duodenal Ulcer. — H. M. McClanahan. (See Med-
ical Record, June 24, page 1158.)
5. Death Rate in Acute Infections. — Edwin E.
Graham. (See Medical Record, June 24, page 1160.)
6. Fractional Determination of Gastric Secretions. —
Ernest C. Fishbaugh reviews this subject, aiming to
avoid a consideration of the diagnostic, prognostic, and
therapeutic possibilities suggested by the various curves
presented, and simply points out the value of interval
examination of gastric secretions, and emphasizes the
valuelessness of the ordinary one hour examination.
The association of the various types of curves with
symptomatology and therapeutic management have been
purposely reserved until more extensive data arc al
hand. It seems from an analysis of the fractional study
of gastric secretions in this group of cases, that the
following conclusions are justifiable: (1) One hour
stomach examinations afford insufficient and often mis-
leading information concerning the acidity and enzyme
secretion. It gives no evidence of the secretory curve.
(2) The fractional method of stomach examination fol-
lows the entire cycle of digestion, and supplies reliable
information concerning the type of secretory curve, the
degree of acidity, the ferment content, and an accurate
estimation of the emptying time. (3) By fraction
study, stomach secretions fall into three groups: (a)
stomach secretions whose curves fall toward the end of
gastric digestion; (b) stomach secretions whose curves
rise to the end of gastric digestion, and (c) stomach
secretions delayed or absent.
7. Radical Operation for the Cure of Cancer of the
Second Half of the Large Intestine, Not Including the
Rectum. — William J. Mayo. (See Medical Record, July
8, 1916, page 82.)
8. The Corpus Luteum. — Emil Novak. (See Med-
ical Record, June 17, 1916, page 1113.)
9. Lepra Mutilans.— Melvin S. Rosenthal reports a
case presenting the syndrome of the clawlike contrac-
tion of the fingers, followed by painless and gradual loss
of the digits, complete anesthesia, mutilation and
thickening of the face, ulceration around the mouth and
nose, and leucodermic spots on the hands and feet; this
should identify the case as one of leprosy without the
refinement of differential diagnosis. The patient was a
well nourished black negro, apparently about 40 years
of age, and had been able to follow his occupation as a
bootblack continuously until the diagnosis was made.
By means of leather bands into which his hands were
fitted he was able to hold his brushes and shine shoes.
His patrons were largely medical students, and it was
through the curiosity of one of these that he was in-
duced to visit the hospital, where the diagnosis was
made. The horror with which the public views leprosy
makes the disposition of these cases a difficult problem.
While direct evidence is lacking as to the communieabil-
ity of the disease in this climate, it is assuredly hazard-
ous and undesirable to allow absolute freedom to a
poverty-stricken individual lacking all the facilities for
ordinary cleanliness, living in filth and squalor, and in-
capacitated by his deformity from caring for himself.
The man roams at freedom, using the street cars and
telephones, handling money as he sees fit, and living in
the same sordid, unhealthy surroundings in which he
was originally found. This case well illustrates the
urgent need of a national leprosarium where these un-
fortunates can find a permanent refuge and the com-
munity be spared the presence of an unsightly, mutil-
ated and incurable human being awaiting the final call.
16. The Comparative Resistance of Bacteria and
Human Tissues to Certain Germicidal Substances. —
Robert A. Lambert says that it is recognized that an
ideal germicide for use on infected tissues of the body
is one that will kill the pathogenic microorganism
present without at the same time injuring the tissues.
From experiments made it has been concluded that the
method of tissue cultures affords a simple, direct, and
easily controlled method of determining, under condi-
tions analogous to those in the body, the relative re-
sistance of tissues and bacteria to various chemical
agents, including the common germicides. Of the germ-
icides tested, iodine is the only one which will kill sta-
phylococci in strengths which do not seriously injure
tissue cells. It is possible, however, that on account of
the fibrin-dissolving property of iodine, causing cone
inhibition of wound healing, some other substance
may be found approaching more closely the ideal tissue
disinfectant.
The Lancet.
October 7, 1916.
1. Tlie Future of the Crippled Sailor and Soldier. C. W.
Hutt.
2. The Relation of the Enterococeus to "Trench Fever" and
Allied Conditions. Thomas Houston and John M.
McCloy.
3. The Diagnosis of Tuberculosis by Tuberculin. A Study in
Technique 11. A Ellis.
4. A Note on the Use of Celluloid in Plastic Surgery. Charles
Higglns
5. A Case of Chorion-Epithelioma. H. Neville Taylor.
''.. Spinal Anesthesia with Special Reference to the Acute
Abdomen. Percival P. Cole.
Nov. 11, 1916]
MEDICAL RECORD.
867
2. The Relation of the Enterococcus to "Trench
Fever" and Allied Conditions. — Thomas Houston and
John M. McCloy present the results of investigations
carried out in the St. John's Ambulance Brigade Hos-
pital which have revealed the presence of the enterococ-
cus in numerous diseased conditions. In the course of
routine work evidence has accumulated which indicates
that this coccus is an infective agent in many of the
cases admitted to the medical and surgical wards. The
cases in which infection with the enterococcus was
found do not conform to a disease of special type, having
characteristic clinical features. Most of the cases, how-
ever, have certain symptoms in common, notably sudden
onset with fever, headache, often orbital, loss of appe-
tite, furred tongue, and pains in the back and lower
limbs, especially the shins. For purposes of description
these cases are classified in the following groups: (1)
Septicemic, (2) "trench fever," and (3) myalgic. The
latter group contains the largest number of cases of
enterococcal infection which have been investigated.
The bacteriological methods employed in isolating the
organism from various sources are described. They
have found the blood culture a very valuable method of
diagnosis when positive results are obtained, but dis-
appointing in that in many cases of apparent septicemia
no organism is found. In the enteric group of diseases
the infecting bacillus is rarely found in the blood after
the first week of illness. A bacteriological examina-
tion of the wounds in 110 instances revealed the presence
of the enterococcus in 41 per cent, of the cases. An
examination was made of 543 urines, which showed the
presence of the enterococcus in 18 per cent, of the cases.
It seems that when this organism is found in the urine
it is frequently an infecting agent. It may be, how-
ever, that its presence in the urine is not always of
pathological significance. In the examination of twenty-
eight sputa from cases of several different diseases, the
organism was found in eight, and in these cases there
was other evidence of infection with this coccus. In a
number of cases opsonic index determinations were
made, and evidence of infection with the enterococcus
found. In many of these cases the vaccine treatment
appeared to be of decided value.
3. The Diagnosis of Tuberculosis by Tuberculin. — A
Study in Technique. — H. A. Ellis reviews the Calmette,
Moro, and von Pirquet tests, and points out the objec-
tions to their general use. The failure of these methods
to give entire satisfaction has led him to the adoption
of a method which he describes and calls the papillary
cutaneous method and the multi-papillary cutaneous
method. This is done to distinguish it from von Pir-
quet's, or the mucous cutaneous method. The test is
based on the fact that the papillary layer of the skin
is the one influenced by tuberculin, and that it reacts
to graduated doses, in definite proportions to the doses
employed, with mathematical accuracy consistent Wich
the character of the case. Usually six scarifications are
made to which are applied graduated doses of tuber-
culin; there is also a control scarification. It has been
found that the results are definitely proportional to the
dose and the final reaction. There is a distinct connec-
tion between the multi-papillary cutaneous reaction and
the class in which the case is, and this relation is suffi-
ciently definite to be of great aid in diagnosis and
prognosis. When the reactions do not agree, further
investigation usually demonstrates the cause, for in-
stance the lowering of the reaction by a previous course
of tuberculin treatment. The results also indicate that
the highest multi-papillary cutaneous reaction occurs
comparatively early in the case; a greater subsequent
extension of the disease gives a lower reaction. The
writer believes he has sufficient evidence to justify the
statement that the multi-papillary cutaneous test
properly carried out materially facilitates the early
recognition of the condition of active tuberculosis, is a
material aid toward a general prognosis and a valuable
indication in tuberculin treatment.
4. A Note on the Use of Celluloid in Plastic Surgery.
— Charles Higgins states that during the past six
months he has had the opportunity of doing from 80 to
100 plastic operations on the face, the greater part of
them being for scarred or lacerated eyelids and
shrunken sockets, though there were a number of deeply
scarred faces and noses smashed flat. He found that
paraffin when used to fill up a scar generally found a
way to get out of position, and was anything but satis-
factory. It then occurred to him to try culluloid. He
has since used celluloid for replacing bone, and solu-
tions for filling cavities and raising deep cicatrices. He
uses two solutions, one celluloid dissolved in acetone, the
other a secret preparation, made originally for trade
purposes, its use being to make bad corks watertight
and airtight. In all cases he has covered the celluloid
over with skin taken from the remains of the part to be
reconstructed, or by a flap removed from the immediate
vicinity and attached by a pedicle. The only precaution
he has found necessary to adopt is to take care that the
celluloid plate, which is rather sharp, should not coin-
cide with the line of suture after the wound is closed.
This is easily obviated by undercutting the outer edges
of the wound to be filled in, and pushing the edges of
the plate beneath the skin so raised that its margin is
external to the line of suture. In operations for the re-
moval of cicatrices the fluid preparation is more satis-
factory than the plates. This is introduced by making
a tunnel under the scar and then injecting the fluid by
means of a syringe until the scar rises a little above
the level of the surrounding tissue. The writer enter-
tains the hope that celluloid fracture plates may take
the place of the steel plates now in use.
5. A Case of Chorion-Epithelioma. — H. Neville
Taylor reports the case of a woman who had undergone
a curettage for irregular hemorrhage, and a month
afterward began to suffer from metrorrhagia and vomit-
ing. It was thought that probably she had had an early
abortion and that there might still be something re-
tained. The vomiting and hemorrhage subsided under
medical treatment. About three weeks later the bleed-
ing recurred, and the patient was anemic with a very
"malignant" look. A specimen was removed for ex-
amination. This was followed by further bleeding and
the death of the patient from syncope. The specimen
removed belonged to the second variety of chorion-epi-
thelioma, as described by Galabin. In this case there
had been no amenorrhea since the last pregnancy, two
and one-half years previous, and no other suggestion
of pregnancy. If deciduoma malignum is always the
result of conception, and there was no conception in this
case, then it is necessary to go back to the last preg-
nancy, over two years previous, to account for the
chorion-epithelioma. Other cases have been reported
which give ground for believing that in exceptional in-
stances there is the possibility of such a latent period.
British Medical Journal.
October!, 1916.
1. Remarks on Emergencv Amputations in Military Surgery.
— 1. A Simple Modification of the Guillotine to Flap-
less Method of Amputation. 2. The Forceps Tourni-
quet. J. Lvnn Thomas.
2. The Intraspinal Treatment of Syphilis of the Central
Nervous System ; with the Report of Cases. A. Rocke
Robertson.
3. Notes on a New Ulcerative Dermatomycosis. Aldo Cas-
tellani ; with Report on the Causative Fungus. E.
Pinoy.
4. Further Experiments on Ascaris Infection. F. H. Stew-
art.
868
MEDICAL RECORD.
[Nov. 11, 1916
5. Vaccine in Mediastinal Actinomycosis. W. S. Malcolm.
6. Post-mortem Findings in a Case of Exophthalmos of
Long Standing Originally Due to Graves' Disease.
Ronald Mackinnon.
7. A Universal Leg Frame. Splint, and Cradle Combined.
Martin J. Chevers.
1. Remarks on Emergency Amputations in Military
Surgery. — J. Lynn Thomas states that the following are
the essential points in carrying out the circular amputa-
tion with lateral incisions: (1) The level at which the
section of the bone is to be made must first be de-
termined. (2) The proximal ends of the lateral incis-
ions begin at this determined point, and are carried
down to the bone and continued toward, or into, the
damaged tissues. (3) A clean knife must be used for
each lateral incision if available; if not, the knife should
be thoroughly wiped and sterilized with flame. (4)
The soft tissues are then divided by one clean sweep
down to the bone after the manner of the old circular
method. (5) The two flaps thus produced by the com-
bination of the circular and the lateral incisions are re-
tracted and the bone is sawn through at the level
previously determined. (6) The vessels are ligatured
with silkworm gut or catgut, not thread or silk, for
fear of sepsis in the wound. (7) The flap's are then
forcibly pulled down, forming a funnel-shaped cavity,
in which the muscles are not in apposition. (8) This
cavity is firmly packed with sufficient gauze wrung out
of Wright's hypertonic salt solution or Dakin's fluid,
so as just to allow the flaps to meet firmly over the
packings. The flaps are secured in position by three
strips of self-adhesive strapping and the ends of the
gauze are allowed to project at each corner through the
lateral incisions so as to insure efficient drainage. The
ordinary rubber drainage tubes, Thomas says, must
not be used at all.
2. The Intraspinal Treatment of Syphilis of the
Central Nervous System. — A. Rocke Robertson reports
eight cases, two of which showed early, and one a slight,
involvement of the central nervous system within a
year of the primary infection. Each had received dur-
ing the secondary period a single injection of salvarsan,
followed by maximal doses of mercury by mouth with-
out, however, preventing the onset and progressive in-
volvement of the central nervous system. It may be
presumed, therefore, that this treatment was inade-
quate. A single combined treatment by intravenous
salvarsan and intraspinal salvarsanized serum in one
case sufficed to clear up the leucoplakia on the tongue
and convert the pathological spinal fluid into a normal
fluid. The other six cases were of long duration, and
showed various manifestations of the disease. The con-
sideration of these eight cases from both a clinical and
laboratory standpoint shows that we have a powerful
form of therapy in the combined intravenous and intra-
spinal treatment.
4. Further Experiments on Ascaris Infection. — F.
H. Stewart records some experiments made since the
paper published in the British Medical ./"" rnal of July
1 was written, and offers the following conclusions:
If ripe eggs of Ascaris lumbricoides are swallowed by
rats or mice they hatch. The larvae enter the bodies of
the rodents either by boring into venules of the portal
system or by ascending the bile duct. They are found
in the dilated blood capillaries of the liver, between the
second and fifth days. The larva is in diameter three
times the diameter of a red blood corpuscle of the mouse.
It cannot, therefore, pass through a normal capillary.
The liver cells in the neighborhood of the larvae undergo
rapid degeneration. The larvae are thus enabled to
work their way into the hepatic venules and pass by
the hepatic vein and vena cava to the heart and by the
pulmonary artery to the lungs. In the lungs they are
filtered off at the entrance to the capillary field. Em-
bolism of the arterioles takes place, and the larva? pass
with the effused blood into the air vesicles. They are
found in the air vesicles on the sixth day, in the bronchi
on the seventh day, and in the trachea and mouth on the
eighth day after infection. It is probable that they
emigrate in the saliva of the rodent on to food sub-
stances, such as bread. It has been shown that they can
live for twenty-four hours on damp bread. The experi-
ments which have been conducted so far tend to prove
that the larvae from the lungs of rodents can infect the
pig, and it is probable that in nature infection of man
and the pig takes place by food contaminated by rats or
mice.
7. A Universal Leg Frame, Splint, and Cradle Com-
bined.— Martin J. Chevers described this splint which
consists of a galvanized metal frame, thirty-two inches
long, seven inches deep, and nine inches wide; along the
top on each side is fixed a row of brass studs, which
serve to secure a series of ten straps. These straps,
each three inches wide, are eyeletted, so as to be ad-
justable to half an inch; they are made of waterproof
material, and may be sterilized by boiling. The ad-
vantages he claims for the splint are: (1) It is
adaptable to any size, shape, or length of limb or ampu-
tation stump, and removal of one or more straps when
being used on either the anterior or posterior aspect
of the limb allows of easy access to a wound wherever it
is placed without disturbing the limb. (2) By remov-
ing a strap, heel pressure can be relieved. (3) Eleva-
tion of the limb can be attained by steady graduated
support to the whole under-surface. (4) It can be
used as a double inclined plane by regulating the straps.
(5) One or more straps can be used over instead of
under the limb or amputation stump in order to steady
it. (6) If alternate straps are lowered nearly to the
bed, but so that the leg still swings, and the others but-
toned tense across the top of the splint, the latter act
as a bed cradle or as a rest for lotion trays or irrigation
solution. (7) If any portion of the foot should project
above the splint, an adjustable and detachable guard
ifl shaped) can be used; its legs fix firmly in holes
placed at intervals in the upper parallel bars of the
splint to remove the weight of the bed clothes at any
required spot; this guard has a notch at the top, so that
if the leg has been placed in another splint it can be
suspended from the notch. (8) The waterproof straps
are specially useful for keeping an ice-bag or dress-
ings in place when the constriction of bandages is not
advisable, or when excessively moist dressings are neces-
sary, or where continuous irrigation is required (the
receptacle being placed within the splint, underneath
the suspended leg.) (9) The splint, when the limb is
suspended in it, is almost immovable by the patient on
any ordinary mattress and covering. (10) The foot
may be kept at right angles to the leg or valgus pre-
vented by wrapping two or three turns of a bandage
round the foot and making the ends fast at each side
to the perpendicular or parallel bars. (11) For frac-
tured patella the splint acts better than a Thomas
knee splint on account of the steadiness of the side bars,
over or round which the bandages are passed, and across
the front of the leg, keeping a firmer pressure on the
pads placed above the upper fragment and below the
lower fragment. (12) In cases of severe infection,
where flush amputation has been necessary, skin trac-
tion in after-treatment is facilitated. (13) The water-
proof straps can be made use of for a Thomas knee
splint. (14) The disturbance caused by putting on
and taking off bandages, the heating and constriction
of the limb which may be the result of bandaging can
all be entirely done away with, the straps being used
instead.
Nov. 11, 1916]
MEDICAL RECORD.
869
he Bulletin Medical.
October 7, 1916.
Troubles of Growth in Early Childhood. — Lesage re-
fers to the period between the first and fifth years.
There may be an arrest of growth in the first child-
hood, producing dwarfism in comparison with the stat-
ure of other children of the same age. This, a transi-
tory condition, has nothing in common with nanism or
true dwarfism, although there is often a close parallel-
ism between the two. In some of the cases the stunted
growth is due to defect in one of the glands of internal
secretion, usually the thyroid or hypophysis. In the
simpler forms the giving of one extract alone is suffi-
cient to restore the ability to grow; but cases occur in
which one has to experiment with various glands and
combinations of the same. In certain cases they are all
given in concert and good results follow. In an entire
series of cases, however, the total failure to respond to
opotherapy makes us think the other causative factors
are concerned. The author accuses here a certain "di-
gestive debility" noted even in the first year of life, and
often inherited. The children and the stock from which
they spring are arthritic. The child never has much
appetite and seems to live on nothing. The trouble
usually begins with attempts to wean. Nothing can
overcome the anorexia, save when at rare intervals
something pleases its palate. It has a marked intoler-
ance toward milk, and often toward eggs. From lack
of eating the tongue is always coated. Hence the
parents are led to give purgatives. When these are not
indicated, the stomach is atonic and secretes but little;
it is often distended with gas. The production of bile is
feeble. The bowels are never regular and constipation
is the rule. There is much more fecal matter than
could be expected under the circumstances, and its odor
is very fetid. On physical exploration one is impressed
by the small size of the liver under fasting conditions.
If now the child partake of food of poor quality the
torpid or quiescent state of the liver is at once suc-
ceeded by a congestion which is accompanied by great
pain. Such children are sometimes operated on for
appendicitis, but the surgeon finds only a distended
cecum and colon. The appendix is removed but no
benefit results. The torpid and shrunken liver should
warn against abuse of anesthetics. Insomnia is com-
mon. As for the mental state, it goes to extremes — the
child may be excitable or apathetic. Crises of vomiting
occur, not due to acetone. The condition becomes fixed
and chronic until it is termed a digestive cachexia. Its
appearance is signaled by notable arrest of growth. In
such cases the author believes that we have to do with
a pure deficiency disease — a liver too small and weak
for the economy to thrive. The indication is for hepatic
extract, given either as a press juice or in powdered
form. The dose should be very small — two or 3 grams
daily of the latter, and in combination at times with
thyroid extract, calomel, or ipecac.
La Presse Medicale.
Sept' mbi r 28, 1916.
Hereditary Syphilis in the Third Generation. — Gautier
described the following at a very recent meeting of the
Academie de Medicine. The great grandfather died
young of syphilitic paraplegia. The grandfather never
contracted syphilis, and this is true of the father. Of
three children born to the latter, one was backward,
almost an idiot. The others presented no stigmata of
congenital syphilis, but both had to be operated for
adenoids, and one had skeletal and dental peculiarities.
The Wassermann was positive in the father and all the
children, and negative in the mother. The author re-
gards the various ailments of the three children as all
due to ancestral syphilis. These comprised cerebral
dystrophy (idiocy), dental dystrophies (gap between
central incisors) , high palate, scoliosis, adenoid vegeta-
tions, strabismus, enterocolitis.
Icterus from Picric Acid Poisoning. — Brule, Javillier
and Baeckeroot, out of a large material of jaundice, dis-
covered that ten cases were due to ingestion of picric
acid, and hence were supposed examples of "false jaun-
dice." The diagnosis should be simple, because there
should be no bile pigments in the urine. Experiment,
however, appears to show that picric acid causes a lesion
of the liver, and therewith sets up true jaundice. The
problem is one of chemistry alone, and the conclusions
are as follows: icterus which follows ingestion of pic-
ric acid is an example of true icterus which cannot in
any respect be distinguished from other forms of the
latter. The chemical diagnosis is alone sufficient.
Should the ingestion have been considerable and recent,
picric acid should be present in the urine and recover-
able therefrom, otherwise one should seek the presence
of picramic acid, which may be present in traces long
after the entrance of the drug into the body. If bile
coloring matters alone are present, the reactions will
be different. The presence of these substances never
excludes that of picramic acid; but when, as is usually
the case, the icterus is of the mild type, not biliary
coloring matter but urobilin should be present.
Cure of Tetanus by Serum Despite Violent Reactions.
— Nobecourt and Peyre related this case to the Medico-
Chirurgical Reunion of the Fifth Army. A boy of 8
had received a slight wound on the thumb, already cic-
atrized. He was first seen on the fourth day of a
severe tetanus. No serum was injected until seven days
later, when 280 cm. of an American antitoxin was in-
jected into the veins, with 40 cm. under the skin and
20 cm. into the cord. For the first six days no im-
provement was noted. On the sixth day of treatment
an urticaria appeared, with fever, tachycardia and
meningism. On the ninth day a second intravenous
injection of 20 cm. was practised. A violent anaphy-
laxis at once developed. At the end of three-quarters of
an hour there appeared a crisis of contractures, respira-
tory pauses, cyanosis, pallor, small pulse, etc. This
state lasted half an hour. Despite these untoward
phenomena, more serum was thrown into the veins. All
this while the tetanus was improving rapidly, and at
the end of three weeks the child was discharged cured.
La Presse Medicale.
October 5, 1916.
Colloidal Gold in Typhoid Fever. — Salomon first re-
fers to the introduction in 1902 of colloidal silver by
Netter, who studied especially its value in infectious
diseases. It was noted later that typhoid patients did
not very well tolerate the intravenous injection of this
substance. In 1914 Letulle and Mage began to use
colloidal gold in this manner for the same infection,
and during the war it has been tried out on the troops,
and its value has been pronounced incontestable. But
it has never come into extended use because of its
burdensome reactions, which can neither be foreseen
nor prevented. Half an hour after an injection the pa-
tient experiences a chill and buries himself in the bed
clothing; his condition closely resembles an ague, his
extremities shake violently with extremely troublesome
shocks. There may be vomiting or relaxation of the
sphincters. The access lasts an hour or more, until the
patient is dyspneic and cyanotic, with rapid, small
thready pulse. The physician who is unprepared for
such a sequence is in a painful state of mind. The
condition slowly passes off, aided by hot drinks and
heart stimulants such as adrenalin and camphor. Cya-
870
MEDICAL RECORD.
[Nov. 11, 1916
nosis may persist for several hours. The chill period
is succeeded by one of heat and sweating, the tempera-
ture rising to 40° C, or in persons already in a grave,
toxic, infectious condition to 42° C; but after eight to
twelve hours it drops to normal and subnormal. Dur-
ing defervescence perspiration is profuse. In certain
fortunate cases the temperature does not again rise, but
as a rule it soon regains its former level or higher, and
further injections must be used. The polyuria which
follows defervescence is often extreme. We see after
each new injection the same temperature cycle, but the
course of the disease does not seem modified; the pa-
tient gets well or dies, as under other conditions, but
with a better chance for survival. The cardiac crises
which require active treatment form the great disad-
vantage and the injections seem to favor intestinal
hemorrhage. Doubtless they have caused death from
collapse. The individual reaction shows great varia-
tion. A point in favor of the injections is that they
become less intense with repetition. The author then
gave the subcutaneous method a thorough try out, and
found it harmless but inefficacious. He then turned to
the intramuscular route and found this method a com-
promise— decidedly efficacious and free from grave
dangers. Much depends on a good technique, which is
fully described. Injections should be painless and cause
no inflammatory reaction. They should be followed by
an abortive chill and slight rise of temperature, suc-
ceeded by a fall, during which the patient feels better.
The fever returns and the injections may be repeated
several times. The intramuscular injections may well
be used as a synergist to cool baths and permanent
refrigeration of the abdomen — until the value of a spe-
cific (vaccination) therapy has been proved beyond
doubt.
Reflex Manifestations Following Disarticulations of
the Fingers. — Porot refers to motor, vasomotor, and
trophic manifestations caused by traumatism of the
peripheral nerves. These, in many ways, resemble those
due to hysterical and organic disease. Under the term
motor he includes the special attitudes assumed by the
extremities (overlapping or rigid fingers), the pareses,
with modifications of tonicity, and the so-called para-
tonias. Under trophic manifestations belong muscular
atrophies, thinning of the integument and hypertri-
choses. Vasomotor manifestations include cold hands,
cyanosis, hyperidrosis. In all of these stigmata there is
no sign of organic disease, and the neuromuscular re-
actions are all normal. A study of these phenomena
which may be present under a variety of traumatic con-
ditions shows that they are especially common after
disarticulations and amputations of the fingers. The
wound itself may be trivial. After disarticulation or
amputation there is more or less scar formation, but it
is impossible to determine the rationale of the mani-
festations which are seen to follow. To cite an illustra-
tive case, a soldier was wounded in the left index finger
by a piece of shrapnel. A few days later disarticula-
tion was performed and the wound healed well. A flac-
cid paralysis of the arm supervened with segmental
anesthesia (suggesting hysteria). Upon examination a
reflex hypotonia could readily be demonstrated. There
was marked reflex activity; if the injured finger of the
paralyzed arm was elevated, an inexhaustible clonus
resulted. Idiomuscular contractions were more marked
in the affected limb, as was faradic excitability. There
developed slight muscular atrophy in the forearm, while
the skin was dry. scaly, and odoriferous. The author ad-
mits that it is difficult to exclude a hysterical com-
ponent. Other cases cited do not suggest the latter.
Mental tests show a normal psychical coefficient. One
patient had developed tetanus from his wound, which
complication must be reckoned with as a possible factor
in the contractures which followed.
El Siglo Medico.
Septeinber 30, 1916.
A Medical Martyr to Infantile Paralysis. — In the med-
ical news column is found an article taken apparently
from a lay periodical, which regards the contraction by
a physician of this disease as something sensational.
In the Spring of 1913, Dr. Mulero Grijalbo, while treat-
ing a patient with poliomyelitis, contracted the malady
and the resulting paralysis of his extremities has pre-
vented him from following his profession. Technically
he was the victim of a professional accident. There
is no relief provided in law for such cases and the
victim, deprived of his income, was forced to live in a
small mining settlement. For twelve years (he is now
35) he had worked with ceaseless enthusiasm and zeal
during epidemics of measles, scarlet fever, diphtheria
and typhus, only to contract poliomyelitis from a spo-
radic case. Three children are mentioned as sharing
his fate. With a view of making provision for such
unfortunate victims the lay journal suggests legisla-
tion for the erection of a building for the maimed and
crippled in the Department of Viscaya which would
provide automatically for a case like that of Dr.
Grijalbo. In addition to the Government benevolent
societies, private philanthropy and the College of Phys-
icians of Spain should be active in such a movement.
A memorial should be presented at once to the law-
making body. At present a wounded bull seems to be
of more importance to the community than the afflicted
physician.
Cocainomaniacs. — Sanchez-Herrero asks, "Why are
there seekers for an artificial paradise?" Because de-
generates are increasing in numbers, and such men are
quite indifferent to their own health and to the perpetu-
ation of the species. What does cocaine do? It prevents
the transmission of impressions by paralyzing both cen-
tripetal and centrifugal waves for the time being. The
addict has a sort of honeymoon period at the beginning
of his addiction, or rather before he has become a true
addict. As far as cocaine is taken to relieve suffering,
the victim of nasal troubles is the most exposed to the
cocaine peril. The world of cocainomaniacs is made up
of what Gorki terms submen, who are denatured, de-
humanized; all drug addicts, including alcoholics, tend
to flock together. The drug evil has been caricatured
as a spider's web with a woman's head in the center.
About the web we find degenerates, the unoccupied,
neuropathicsr weak wills, prostitutes and their sou-
teneurs. The drug evil degrades woman; the prosti-
tute takes it to forget or to feel a spark of energy. A
special class of addicts is found among writers. No
amount of education or wealth can avert this peril.
All who fall are alike in becoming antisocial, and those
originally antisocial are naturally the easiest victims.
Hereditary Syphilis in the Second Generation. — At a
session of the Zurich Medical Society an infant of 8hi
months was shown. It was born healthy like the elder
children, but in the sixth month hydrocephalus was in
evidence, and a month later strabismus. Positive Was-
sermann in blood and cerebrospinal fluid. No spiro-
chetes. The r-ray showed pronounced broadening' of the
epiphyseal line in the radius and ulna. After five intra-
venous injections of salvarsan the symptoms all van-
ished. The child's father was apparently normal. The
mother gave a negative Wassermann reaction, but
had sensitive pressure points in the tibia; and
fibulae while the x-ray showed typical gummous peri-
ostitis. She had been deaf and dumb since her sixth
year (labyrinthitis?) The case seemed to throw doubt
on the value of positive Wassermann in infants. — Cor-
responden~-Blatt fur Srhirei:er Aerzte.
Nov. 11, 1916]
MEDICAL RECORD.
871
The American Year-Book of Anesthesia and Anal-
gesia. By Various Contributors. F. H. McMechan,
A.M., M.D., Editor. Quarto; art buckram; India tint
paper; 420 pages and 250 illustrations. Price, $4.
New York: Surgery Publishing Company. 1916.
Anesthesia is coming into its own. Satisfaction
merely with the practice of the art without refinement
of method and without investigation of the science of
anesthesia is passing, thanks to some, an increasing
number, of research workers and the devoted efforts of
skilled anesthetists, all of which puts Anesthesia as a
profession on the high plane where it belongs. The
newest advance is this fine volume of over 400 pages,
which collects the work of about thirty investigators
in the science or art of anesthesia. The topics include
the Theories of Anesthesia; Blood Changes; Peripheral
Origin of Shock; Effect of Posture; Anemia and Re-
suscitation; Blood Pressure; Respiration in Relation to
Acapnia, Apnea, and Anoxemia; Mortality Statistics;
Cardiac Fibrillation under Chloroform ; Delayed Chlor-
oform Poisoning; Kidney Function; Hospital Manufac-
ture of Nitrous Oxide; Newest Methods, as Rectal
Ether and Oil, Pharyngeal Insufflation; Obstetric Am-
nesia, Nitrous Oxide and Oxygen, Novocaine-Suprarenin;
Local Anesthesia and Various Aspects and Uses;
Gasserian Ganglion Injections. These subjects, treated
by such men as Lillie, Casto, Mann, Gatch, Crile, Mc-
Kesson, Henderson, Miller, Levy, Gwathmey, Polak,
Rice, McMechan, and Hertzler, point out the importance
and excellence of the articles, each an original mono-
graph, and the whole constituting a veritable summary
of recent advances. When the Anesthetists' Societies
founded a Journal of Anesthesia, in the supplement to
the American Journal of Surgery there was produced
the long-needed medium of exchange, but until now no
concise year-book has appeared and it will find, no
doubt, a welcome among those who want to keep at
hand the information contained. It is a well printed
quarto volume of impressive appearance and the able
editor, Dr. F. H. McMechan, deserves great credit for
his enterprise. The admission of advertisements may
seem to some quite a departure, but the helpfulness of
reference to apparatus mentioned is among the rea-
sons assigned.
A Manual of Surgical Anatomy. By Lewis Beesly,
F.R.C.S. Edin., Assistant Surgeon, Chalmers' Hos-
pital, Edinburgh; Lecturer on Surgery and Opera-
tive Surgery, Edinburgh School of Medicine for
Women ; Lecturer on Surgical Applied Anatomy,
Edinburgh Postgraduate Courses; Examiner in An-
atomy, Royal College of Surgeons, Edinburgh; Lately
Demonstrator of Anatomy, Edinburgh University;
and T. B. Johnston, M.B., Ch.B., Lecturer and
Demonstrator of Anatomy, University College, Lon-
don; Lately Lecturer and Demonstrator of Anatomy,
Edinburgh University, and Lecturer on Medical Ap-
plied Anatomy, Edinburgh Postgraduate Courses.
Price, $3.75. New York: William Wood & Company,
1916.
This volume gives the main facts of anatomy as viewed
from their practical application in surgery. Surgical
operations are described from the standpoint of an-
atomy rather than technique, and in order to keep the
volume within reasonable bounds the descriptions of
amputations have been omitted. The authors have
given special attention to the anatomical relations of
the joints, and the bearings of their various structures
with regard to the spread of tuberculous disease. An-
other important feature is the inclusion of brief para-
graphs on the development of the different parts. The
volume is well printed and illustrated, and is of very
convenient size; and it should prove a useful addition
to the working library of every practitioner.
Collected Papers of the Mayo Clinic, Rochester,
Minnesota. Edited bv Mrs. M. H. Mellish. Volume
VII, 1915. Octavo of 983 pages, with 286 illustra-
tions. Price, cloth, $6 net; half morocco, S7.50 net.
Philadelphia and London: W. B. Saunders Company,
1916.
The constant increase in the amount of material con-
tributed by the staff of the Mayo Clinic made it neces-
sary to abstract in the 1914 volume some of the articles
the material of which had been partially covered in
that or in former volumes. In the present (1915) vol-
ume still further condensation has been necessary m
order to keep the size of the book within reasonable
limits. As in former volumes, the material is grouped
under six headings. These, with the number of papers
in each division, are as follows: Alimentary Canal,
26; Urogenital Organs, 10; Ductless Glands, 12; Head,
Trunk, and Extremities, 16; Technique, 5, and General
Papers, 15. A wide range of subjects is covered, and
not only the continued studies but many of the articles
on special topics are of even more than usual im-
portance. For the progressive practitioner or surgeon,
who wishes to keep in touch with the latest researches
in surgery and allied branches, these papers of the
Mayo Clinic are of considerable value.
Practical Physiological Chemistry. A Book De-
signed for Use in Courses in Practical Physiological
Chemistry in Schools of Medicine and of Science
By Philip B. Hawk, M.S., Ph.D., Professor of
Physiological Chemistry and Toxicology in the Jef-
ferson Medical College of Philadelphia. Fifth Edi-
tion. Price $2.50 net. Philadelphia: P. Blakiston's
Son & Co., 316.
To those who lave had the privilege of following the
growth of this work through succeeding and successful
editions, the appearance of this fifth revised and en-
larged edition will be a welcome sight. Developed far
beyond its predecessors in size, it has come to be a
complete physiological chemistry and clinical pathology
combined, though of course the microscopical side of
the latter subject is hardly touched upon. It is. a well-
planned textbook for students, and also almost indis-
pensable for the laboratory worker. The omissions are
exceedingly few, the most important being the failure
to include Vogel's method for the detection of mercury
m the excretions. New chapters are those on Nucleic
Acids and Nucleoproteins, Gastric Analysis, Intesti-
nal Digestion, Blood Analysis, and Metabolism. That
on Blood Analysis is a striking bit of evidence of the
way in which methods have developed in that one field
during the past few years.
Rules for Recovery from Pulmonary Tuberculosis
A Layman's Handbook of Treatment. Bv Lawrason
Brown, M. D. Second edition, thoroughly revised
Price, $1.25. Philadelphia and New York: Lea &
Febiger, 1916.
This little book is a valuable one to put into the hands
°f a"y patient, and a revised edition is welcome. The
old days of mystery surrounding the knowledge of the
physician, and of blind obedience on the part of the
patient are past. This type of book is one of the last
steps in the campaign of education which is being so
vigorously waged. Even the most intelligent patient
is going to make mistakes during the earlier part of
his cure, and it is "to help the patient avoid blunders"
that Dr. Brown's book was written. "It is not the
author's intention that the book should be hastily read
and laid aside, like the modern novel, but he believes
that it should be read slowly, chapter by chapter, day
by day." And taken in this dosage, it will give many
a patient the needed stimulation to permanent cure
In the earlier days of cure it will help him to know
why he is following certain orders, and later will be a
reminder that repair is slow and cannot stand added
strain. The n0i=e with which the book is written and
the absolute lack of exaggeration command respect and
the work should for that reason carry more weight with
those who have a long battle ahead.
Sex Problems of Man in Health and Disease A
Popular Study in Sex Knowledge. By Moses
Scholtz, M.D., Chief of Clinic and Clinical Instructor
in Dermatology and Syphilology, Medical Department,
University of Cincinnati; Fellow of American Medical
Association, Ohio State Medical Society. Medical
Academy of Cincinnati, Society of Moral arid Sanitary
Prophylaxis etc. Price, $1. Cincinnati: Stewart &
Kidd Co., 1916.
This is a conventional work, presenting the moral
aspect of the problems involved in an attractive stvle
In a book intended for parents, teachers, and clergymen
any other treatment of his subject would have been im-
practicable. But why push too far the analogv between
male pollutions and menstruation? The former are
almost always traceable to preventable causes. And
why state that a youth feels better after a pollution?
Not only does he suffer physical and mental depression
but a deep sense of humiliation, because of the publicity
so to speak, which invariably follows such events the
wrong interpretations and the comments based thereon
It is often the dread of pollution which drives otherwise
moral youths to acts of onanism and sexual intercourse
Jt would have been a simple matter to have suggested
measures of cleanliness in such contingencies
872
MEDICAL RECORD.
[Nov. 11, 1916
jiwirtij Sfcjwrtfl.
AMERICAN ASSOCIATION OF OBSTETRICIANS
AND GYNECOLOGISTS.
Twenty-ninth Annual Meeting, Held at Indianapolis,
September 25, 26 and 27, 1916.
The President, Dr. Hugo O. Pantzer, of Indianapolis,
in the Chair.
(Concluded from page 833.)
Heat as a Method of Treatment in Some Forms of
Cavity Carcinoma. — Dr. James F. Percy, of Galesburg,
Illinois, referred to some of the historical probabilities
of the use of heat in cancer, and gave briefly a resume
of his own work. In addition, he sug; sted the possi-
bility of destroying cancer in the vag la, rectum and
bladder by the* continuous applicatio of a bearable
or a supportable degree of heat without the use of a
general anesthetic. He gave this degree of heat as
from 49° C. to 60° C. (120° F. to 140° F.) The
author described the instrument by which the con-
tinuous heat was applied. He pointed out the difficulty
of treating cavity carcinoma, especially that of the
vagina, because of its usual lack of bulk or mass, as
there was not enough tissue through which heat could
be disseminated. If the ordinary pasteurizing tempera-
ture, delivered through the Percy cautery, was used,
too much destruction of normal tissue cells might re-
sult from the treatment. If the parts were thin and
the cancer disseminated, and not in mass, the author
had found in two cases that the continuous application
of the above mentioned degree of heat caused in one
case a local disappearance of the growth, and in the
other, also a vaginal case, a clearing up of the local
symptoms, but not the entire disappearance of the
growth which had invaded the cervix and base of the
bladder. In both of these cases the continuous heat
was applied, averaging eighteen hours a day in each
case for six weeks. The work of the author was an
effort to bring to the human sufferer from cancer the
known facts in the destruction of cancer in the labora-
tory animal by the continuous application of heat.
Chronic Intestinal Stasis.— Dr. William Seaman
Bainbridge of New York City said that chronic in-
testinal stasis, or what he had often termed defective
human plumbing, was increasingly being accepted as
one of the fundamental causes of disease. Gradually
the profession was coming to consider the condition as
an entity, with far-reaching results. Many of those
to whom stasis and constipation were at one time synon-
ymous were broadening their viewpoint and learning
that there might be residual intestinal content doing
damage to the entire organism, regardless of whether
there were activity of the lower bowel or not. This was
evidenced by the fact that some of the worst cases
of stasis occurred in those with diarrhea. Unfortun-
ately, in the minds of many of the profession (hap-
pily their number seemed rapidly diminishing) in-
testinal stasis had been thouglht to indicate only one
kind of treatment — the removal of a large portion of
the intestine with its consequent extreme surgical risk.
Those who had given thoughtful attention to the teach-
ings of Lane and others were recognizing the truth of
the oft-repeated statement that the vast majority of
all cases of chronic intestinal stasis belonged to the
physician, through whose prompt and proper care the
necessity of seeking ultimate relief at the hands of the
surgeon would be obviated. Between this overwhelm-
ingly large group and the relatively small number of
neglected patients (those late in the disease, or previ-
ously treated by improper or inadequate surgery) who
must have part of their plumbing removed in order to
attain comparative health and not drift into chronic
invalidism with attendant complications which might
terminate life, there remained a mid-group. In these
cases a careful application of conservative surgery to
the abdomen, according to the principles of the me-
chanics of the intestinal canal, returned the patient
to the first group, where with medical care and reason-
able attention to hygiene and dietetics, he could be
restored to health and strength. The writer, who had
been for many years a close student of body plumbing,
had published from time to time articles covering
various phases of the subject of chronic intestinal stasis.
It was his purpose in this and a number of subsequent
papers to report succinctly a series of case histories
illustrative of various types of stasis treated surgically
and, though brief, it was hoped these would comprise
the essentials in such manner as to present a suffi-
cient ground work upon which to base conclusions.
"Evidence was and must be the test of truth"; as it
was only by weighing the evidence in relation to methods
of treatment that medical progress was possible, it was
hoped that case reports which gave actual results —
good, bad and indifferent — might serve to facilitate this
end.
Tuberculous Glands of the Mesentery. — Dr. Arthur
T. Jones of Providence, R. I., drew these conclusions:
" i 1 ) Tuberculosis mesenteric glands are often a primary
disease of the true tuberculous type. The bovine type
was undoubtedly present in many children and without
producing symptoms, the glands remaining quiescent,
or having a tendency to subside. (2) It is impossible
to make a correct diagnosis before operation, as a rule,
unless there are palpable glands which may be felt
through the abdominal wall, or by the finger in the
rectum. (3) Tuberculous mesenteric glands may be
present without giving symptoms. (4) There are two
clinical types: (a) A slightly progressing one gener-
ally with palpable glands; (b) An acute fulminating
type most often stimulating and impossible generally to
differentiate from appendicitis. (5) Prognosis in the
subacute stage is good without operation. In the acute
stage exploratory laparotomy should be done, but the
glands should not be removed unless there are definite
indications either from adhesions, ulceration, or size of
mass producing pain or much obstruction. (6) Tuber-
culous glands of the mesentery may not present any
symptoms until breaking down begins in the glands,
after which we get our symptoms of tuberculous peri-
tonitis, intestinal obstruction, or symptoms simulating
acute appendicitis. (7) In children and young adults
with history of righ-sided abdominal pain, with or with-
out palpable masses, tabes mesenterica should always
be considered as a possibility."
The Relation of So-Called Ether Pneumonia to Pelvic
and Abdominal Surgery. — Dr. William Edgar Darnell
of Atlantic City stated that for many years it was com-
monly taught that ether irritated the bronchi and was
largely the cause of what was known as post-operative
pneumonia. Such pneumonia was spoken of, and still
was in most hospitals, as "ether pneumonia." Yet any
surgeon in reviewing his experience might find many
facts to disprove, and few or no reasons to prove that
ether was the cause of pneumonia after an operation.
Ether was administered in most hospitals many times
every day, yet the condition known as ether pneumonia
was a rare occurrence compared with the number of
ether administrations given. If the pneumonia were
the result of the ether, we ought to expect to have
many cases every week. Again, if ether produced all
the havoc it had been credited with, the administration
of it by the intratracheal method might almost come
under the classification of criminal malpractice. Yet we
knew that this was done safely every day. Rovsing had
proved experimentally that although ether did occasion
increased secretion of the salivary glands of the mouth,
that the larynx and trachea and the bronchi were not
irritated at all, even when the animals were killed by
administering ether through a tracheotomy tube until
they were dead. The only way, therefore, that ether
could produce pneumonia was by the aspiration of the
accumulated saliva in the throat, usually the result of
technical error on the part of the anesthetist, who
should not allow the secretion to accumulate in the
throat. Such secretions might, of course, be easily in-
fected from the buccal cavity. It was quite possible
under such circumstances that tonsillar infections, in-
volvement of the nasal accessory sinuses or the teeth
might be one of the causes of post-operative pneumonia
which had been attributed to ether. Attention had fre-
quently been called to the importance of the sanitation
of the nose, throat, and mouth before all operations. If
we looked on pneumonia after an abdominal operation
just in the same light as we did the development of a
subphrenic abscess after an appendectomy, they bore the
same analogy to the point of original infection. The
only difference was that in the one case the new focus
of infection landed above the diaphragm, and in the
other beneath it, but both were brought about by the
carrying of infection from the original source in the
abdomen up through the lymphatics and veins by the
retroperitoneal route. The idea was further strength-
ened by the fact that most post-operative pneumonias
would show a mixed infection containing streptococci,
colon bacilli, or other organisms in addition to pneu-
Nov. 11, 1916]
MEDICAL RECORD.
873
moeocci. On the other hand, it was often true that the
appendix, the gall-bladder, the Fallopian tubes and the
ovaries might be the seat of a pneumococcus infection.
It would seem proper to conclude, therefore, that
cases of pneumonia following operations were not due
to the ether. The term "ether pneumonia" should be
discarded and forgotten Post-operative pneumonia oc-
curred with great rarity except after abdominal opera-
tions, and was then probably due to an infection already
existing in the bronchi or lungs at the time of opera-
tion, or to imperfect aeration and ventilation of the
lungs by reason of the fear of taking deep breaths after
a laparotomy, but most often such pneumonia was a
secondary infection of the lung following a septic ab-
dominal condition.
Hospital Management and Mismanagement. — Dr.
Gordon K. Dickinson of Jersey City discussed the
fundamental origin of all hospitals. There was no
proper definition of the term. There were three essen-
tial factors: Patients; attendance by physicians and
nurses; superintendent and the board of managers.
From the viewpoint of the first he discussed therapy,
diagnosis, and education ; from that of the second came
system, red tape, economics, and autocracy. From the
third, the board of managers, made up entirely of the lay
public, came ignorance of the needs and the ideals of
the institution, often working solely through the su-
perintendent, who had made a home of the hospital for
himself. We looked for finances and encouragement,
but the results were disheartening.
The Surgeon's Responsibility to the Economics of the
Hospital. — Dr. Emery Marvel of Atlantic City said that
a mutual dependence existed between the hospital and
the surgeon. This relation imposed upon the surgeon
the duty of guardianship for, and a responsible duty to
the institution. He became, in part, responsible for
the waste and abuse of its resources. He was directly
responsible for loss of service and embarrassment to
the organization when late for operation, dressings, or
other appointments ; the waste in using unnecessary or
unduly expensive supplies, and for misuse of funds oc-
casioned by encouraging expenditures for construction
and equipment which did not give commensurate bene-
ficial returns. A staff surgeon must share responsi-
bility for the neglect to utilize opportunities which, if
taken advantage of, would benefit the hospital. It was
his duty to inspire enthusiasm in attendants, maintain
a congenial atmosphere for the patients and to teach im-
provements in service. It was the surgeon's oppor-
tunity to teach the patient better care for self and give
him knowledge to prevent recurrence of disease or in-
jury. His opportunities for service to conserve the in-
stitution's interest were many, and his responsibility
proportionate.
Removal of the Appendix for the Cure of Trifacial
Neuralgia and Other Nerve Pain About the Head and
Face. — Dr. Maurice I. Rosenthal of Fort Wayne said
that the apology which he had to offer for presenting
this very brief report of only seven cases was the
startling results obtained. He did not claim in this
small experience that he had established a new pathol-
ogy for trifacial tic and kindred affections, but he did
claim that in these seven cases he had fixed the pathol-
ogy in the vermiform appendix, even though the phys-
ical and subjective evidence of appendicitis was so ob-
scure as to be entirely overlooked. In all but one case
there was present almost symptomless chronic appendi-
citis of the obliterating type; the other a symptomless
pus case. It was very probable that a report of 100
cases might reveal some further startling results in re-
currence and might explain the unsatisfactory results
from resection or revulsion of the nerve as well as from
injections used with a view to chemical nerve destruc-
tion. Case No. 7 of this series was more on the order
of migraine or so-called sick headache. It had not been
uncommon in his experience to note the cure of migraine
and so-called sick headache after removal of a diseased
appendix. It was quite possible that many of these
cases came under the same pathology as did tic dolour-
eux and other nerve pains about the face and head.
From the prompt cessation of the pain in six of these
cases we might conclude that the disturbance was a
toxemia with selective action. If the tonsils, the teeth,
the hollow bone cavities gave rise to toxemias and bac-
teriemias of such far-reaching effect, we need not be
surprised if the appendix, a hollow abdominal organ
with its possibilities of aerobic and anaerobic bacterial
development, should also give rise to a toxemia which
might readily be the basis of a selective neuritis or nerve
irritation.
.MEDICAL SOCIETY OF THE STATE OF PENN-
SYLVANIA.
Sixty-sixth Annual Session, Held at Scranton, Septem-
ber 18, 19, 20, and 21, 1916.
(Special Report to the Medical Record.)
{Concluded from page 831.)
section of surgery.
Chairman's Address. — The Chairman, Dr. Levi J.
Hammond of Philadelphia, stated that he hoped that he
should have met in some sense his obligation, when he
had reminded the members of the Surgical Section, for
he was sure he was doing nothing more, of the great
principles which this Section stood to promote. He said
that we were in a time of unusual stress and test. There
never had been a time, therefore, when we needed more
clearly to conserve the principles for which this Section
stood than the present time. That part of the world
from which our inspirations, if not our methods, had in
the past been drawn seemed for the present in the caul-
dron. Just what the outcome of this gigantic ebullition
was to be no one dared at present even prophesy. We
stood apart, as yet, unembroiled, conscious of nothing so
much as our own powers, resources, and possibilities.
There must be no difficulty so great, no truth so obscure,
no problem so involved that the American surgical mind
could and did not solve.
Symposium on First Aid — The Railroad Phase. — Dr.
J. B. Hileman of Harrisburg read this paper in which
he stated that the problem of first aid on the Penn-
sylvania Railroad has been to provide a simple dressing
applicable to railroad conditions and to instruct the
employees in its use. The first aid packet was air and
moisture-proof, and was distributed in tin boxes which
held six. On the outside were printed instructions for
its use and a tag bearing an order for a fresh box as
soon as the seal was broken. These packets were put
wherever they might be of use. Stretchers and blank-
ets were supplied to all baggage, mail, express and work
cars, stations and shops. Employees were taught to
confine themselves strictly to first aid, and in severe
cases to send for the nearest physician. The dangers
of infection and hemorrhage were pointed out. No
drugs or whiskey were to be given. Employees were
taught to effect resuscitation from electric shock by
means of the Schaffer method. His rather extensive
experience in first aid taught him that employees were
keen in appreciation of this subject and did their best
to put into practice the instruction they got. The re-
sults had been most satisfactory.
Injuries Common to Policemen and Firemen and Their
First Aid Treatment. — Dr. Hubley R. Owen of Phila-
delphia read this paper, saying that the common in-
juries to firemen were punctured and lacerated wounds,
due to falling glass, treading on pointed objects, kicks
and bites of horses, falling bodjes, blows by harnessing
apparatus; scalds and burns "by hot water, steam or
acid; asphyxiation by the great variety of smokes and
fumes met with fractures and sprains; traumatic
hernia. Injuries common to policemen were those due
to being struck by prisoners, wounds of the fingers from
striking prisoners; gunshot wounds, fractures, espe-
cially of the jaw from being struck; dog bites. The
principles of first aid treatment of injuries were to
stop hemorrhage, keep the wound clean and put the
part at rest. The army tourniquet was used; wounds
were swabbed with iodine. An immunizing dose of an-
titoxin was given in all punctured wounds; only one
case of tetanus had developed in the first department
since 1871. In shock morphine was used freely. Whisky
was not a good remedy for smoke cases. Six pulmotors
were in use in the first department.
Dr. J. B. Carnett of Philadelphia said that unfortu-
nately it was not often possible to have at the scene
of accident the surgeons, ambulances, pulmotors,
stretchers and the various other equipment described by
Dr. Owen, as being sent out with the Philadelphia fire
fighters. The fact that more than a million serious
accidents occurred each year in the United States
urgently demanded more widespread knowledge of first
aid. A great many lives had been saved each year by
the prompt application of first aid, and many more
could have been saved had the principles of intelligent
first aid been more generally known. It had been urged
against the universal teaching of first aid that "a little
knowledge is a dangerous thing." It was no doubt true
that in exceptional instances first aid teaching, when
874
MEDICAL RECORD.
[Nov. 11, 1916
perversely applied, might lead to meddlesome surgery
or even to disastrous results. Such deplorable in-
stances, due to deficient knowledge, fortunately were
rare and were overwhelmingly counterbalanced by the
great number of lives that were saved by intelligent
first aid attention. First aid, which thus far had been
taught chiefly by the National Red Cross, military and
municipal organizations, Boy Scouts and various cor-
porations, had proven of such vital and practical value
that it should henceforth be included among the sub-
jects taught in the public schools.
Dr. W. F. Skinner of Chambersburg said that one
of the first principles in applying treatment to wounds
was that Nature was the best healer, and, if not in-
terfered with too much, she would bring about a rea-
sonably good result in her own way and in her own
time. He felt that it was as important to know what
not to do for wounds as it was to know what to do.
With reference to burns generally, he felt that a good
rule to follow was the washing of the parts with castile
soap and warm water, using pledgets of cotton for the
removal of foreign matter and then applying the nor-
mal salt solution, heavy dressings of gauze and parch-
ment paper.
Dr. A. W. Colcord of Clairton said that he wanted
to say a word on applying the tourniquet. He always
emphasized that there were three methods of applying
the tourniquet: on the artery, the vein and the capillary.
The tourniquet must never be made tight enough to stop
hemorrhage, only the spurting from the \vound, and,
when spurting was stopped, they must stop tightening
the tourniquet. The remaining hemorrhages must be
stopped by direct pressure on the wound. He placed
the iodine treatment for wounds as the best for appli-
cation at the roadside, the private home, hotel, or any-
where outside of the hospital. In emergency hospital
work he did not believe the iodine treatment was best.
He believed the constant wet dressing was the best.
This was made of saturated solution of boric acid one-
fourth and alcohol three-fourths. They put it directly
to the wound and applied plenty of cotton. In several
thousand cases they had not had a primary infection.
Dr. Edward Martin of Philadelphia said that the
emergency which was commonest was not the fatal
hemorrhage, or the discrimination between uremia, apo-
plexy, heat exhaustion or sunstroke which was to be
done so surely in the books for the laity and which we
ourselves so often failed to make, but infection, and to
the credit or discredit of the profession, which ever one
might choose to regard it, there was no concerted view
as to how infection should be treated in emergency.
There was no concerted view as to emergency dressing.
It was time to formulate our knowledge.
Dr. H. R. Owen of Philadelphia said that they tried
to teach firemen and policemen to do as little as they
could. They carried first aid packages, and the police-
men were taught to place a compress on the wound and
tie a two-tailed bandage around. They had a very com-
plete system of having wounds treated, using an am-
poule of iodine. In regard to punctured wounds the
firemen practically felt their jaws begin to tighten as
soon as they received a punctured wound, and they re-
ported at once for antitetanus serum.
Modern Hospital Organization in Rural Pennsylvania.
— Dr. H. L. Foss of Danville presented this paper, in
which he : tated that Pennsylvania, with a population
of about six million outside of the large cities, had about
150 hospitals good, bad and indifferent. Fully 90 per
cent, of these had no trained laboratory workers; not
over 20 per cent, of them were prepared for r-ray ther-
apy or fluoroscopy. Whenever a young member of the
staff attempted to develop a laboratory he received such
poor co-operation that he soon became discouraged. The
recent requirement of an interneship of one year on the
part of those applying for license to practice medicine
had led to great improvement in these conditions. Cer-
tain positions in order to get the best service required
the incumbent be on a fixed salary. Staff appoint-
ments should be only on merit. The success of the
rural hospital would depend largely upon the education
of the people and to a great extent upon the training
of the general practitioner on whom rested the initial
responsibility in making the diagnosis and recognizing
the need of hospital care. In addition to this the prin-
cipal factors in success were dependent upon a clearly
defined need for a hospital in the community; the con-
struction of an adequate and well-equipped institui
a sound financial basis; a competent and efficient ad-
ministrator who would see to the maintenance of high
standards in the staff; a broad sensible policy, giving
the hospital executive full authoritv and responsibility
in which he would have the complete support of the
trustees; thorough and scientific care of the sick; indi-
vidual investigation of the financial resources of all
patients and discouragement of indiscriminating chari-
ties; an efficient system of purchasing, so arranged
under the direction of the institution's superintendent
that he might be free to take advantage of all changes
in price.
Dr. T. B. Appel of Lancaster said that in opening the
discussion of the very important question of a hospital
for the rural districts he wished to emphasize the fact
that we should all agree on the importance of the de-
velopment of the laboratories. He wished to say per-
sonally in relation to the hospital with which he had
connection that the inspection there had made the
efforts of the staff to increase the efficiency of that
hospital so very much easier than before they had been
told where they were deficient. The modern hospital,
particularly in a small town, was in a sense an educa-
tional institution for the profession. These institutions
should become centers of education for the profession in
that neighborhood, that they might have an opportunity
to see the advantages or to use the advantages of mod-
ern hospital care for patients.
Dr. A. R. Allen of Carlisle said that the present
Board of Medical Examiners had done more to elevate
the medical profession and bring the hospitals up to
the standard than all the work done heretofore in
Pennsylvania or in any other State. He wanted to com-
pliment the chairman and the members of the Board
for the great work which they had done in efficiency
and increasing the good instruction the young medical
men get before they were licensed to practice medicine.
Dr. William H. Walsh of Philadelphia said that he
wished to express his appreciation of Dr. Foss's paper.
He also felt that Dr. Baldy had done a great deal for
the hospitals of Pennsylvania. A great deal of the
opposition he had came from members of the staff of
the hospitals. The improvements he recommended
should have been realized years ago. In reference to
the appointment of staff officers, that was a vital matter.
Dr. Frederick L. Van Sickle of Olyphant said that
he thought a rural hospital to-day was confronted with
a question which had not appealed to it so strongly in
the past in relation to the newer developments of
surgery and medicine which were to come under the
head of sociologic or workmen's insurance. Employers
were trying to get men and women cured in medical
cases, and it appealed to the sense of the manufacturer,
the mine and mill owner, when he was willing to pay
somebody well to get the sick man cured. Therefore,
the efficiency of the smaller rural hospital must be in-
creased and the men doing the work must be up to the
standard.
Dr. John B. Roberts of Philadelphia said that some
things must be obtained for efficiency. First, a per-
manent medical dictator. Somebody must be on duty
as a medical men and have control from the 1st of Janu-
ary to the 31st of December at 12 o'clock at night.
The damnation of small and large hospitals was the
fact that nobody was boss, and every man who came on
duty every six weeks ordered something different. The
form of treatment must be a standard which everybody
must obey.
Dr. J. M. Baldy of Philadelphia said that the matter
rested with the staff of the hospital. If they arose to
the opportunities that had now come to them for the
standardization of their institutions the State board
would be patient. As medical men they had a unique
opportunity to awaken interest, and he felt that if they
did not measure up to these responsibilities eventually
that the shame of it should come on our own heads.
The unequal development was one of the crying evils of
this State. They found in their inspection that from
75 to 80 per cent, of the work done in the rural dis-
tricts was surgical, and that of that about 75 to 80 per
cent, was emergency. He would like to know how the
Bureau of Medical Education and Licensure could send
an interne into such a hospital for his fifth year. If
this condition was altered such institutions would sim-
ply get a credit for second or third year interneship
and be classified as special hospitals.
The Treatment of Deformed Union and Non-union of
Fractures. — Dr. John B. Roberts of Philadelphia read
this paper, saying that deformed union of bone was
usually due to lack of knowledge of efficient treatment
of the fracture or to neglect in applying well-known
mechanical or physical principles to the problem of
treatment. Operative exposure for remedying de-
Nov. 11, 1916]
MEDICAL RECORD.
875
formed union of bone was demanded in only a limited
number of cases, subcutaneous refracture tor the cor-
rection of angular aeformity was comparatively easy.
'Inis proceouie was available and successful for a long
periou after the fragments had been firmly united.
After-treatment was on tne same lines as in accidental
iractuie. Kepair in delayed union snouid be nascened
by massage, good food, air, and surroundings, and the
interrupted use of constriction with a rubber band at
the proximal side of the fracture. There should not be
too hasty resort to operation in non-union. Using the
limb and rubbing the ends together by manipulation,
also injection of blood hypodermically into the tissues
around the fracture, was helpful. When these meas-
ures failed operative treatment was demanded.
The Treatment of Compound Fractures. — Dr. Jona-
than M. Wainwright of Scranton read this paper, in
which he stated that the main problems presented by
compound fractures were to prevent or cure infection
and to procure and maintain satisfactory reduction.
The more important of these was infection; indeed, it
would be better if we substituted for open and closed
fractures the terms infected and uninfected fractures.
Very few infected fractures were restored to even a
near approach to normal. Researches in the armies in
Europe had shown that Dakin's hyperchlorous acid so-
lution was most effective in the treatment of infected
fractures. These studies had also shown that the re-
tentive fracture dressings must be such as to permit
access to the wounds for the purpose of dressing. As
regards drainage, we must accept the teaching of
Moynihan, namely, that there "never yet was such a
thing as a gauze drain." He believed that the fixation
methods would narrow down to three: open operation
and suture of the fragments by kangaroo tendon, the
Albee sliding graft, or extension by the Steinman pin.
Dr. John B. Lowman of Johnstown said that he
thought the. treatment of fractures was a very serious
proposition. Very many angles should be considered
before doing operation, and before doing it you should
be perfectly satisfied in your own mind that you should
do it. He had not been so successful as Dr. Roberts
with these old fractures of four or five months by
breaking them. He thought the success of the treat-
ment of compound fracture lay in the primary dress-
ing. In compound fracture too much was done in the
way of first aid. You ought to let them alone. In their
mills at home in a fracture nothing was done at the
time except to put on a clean piece of gauze and the
patient sent to the hospital immediately. Their men
were instructed never to pull a fracture. He thought
the thing to do was to convert the compound ino a sim-
ple fracture before attempting any method of operation.
The thing to do was to wipe all the foreign material off
you could and paint with iodine and put on a dressing.
Their success with compound fractures by practically
letting alone had been that their percentage of infec-
tions had become very low. He did not think any plate
should be put on a compound fracture.
Dr. William L. Estes of South Bethlehem said that
he was beginning to be in the position in which he
dreaded to see a fracture. He believed that the indica-
tion in the compound fracture was, first, as the reader
of the paper had said, to provide for as nearly absolute
drainage as possible. He thought they might all con-
clude that a compound fracture was an infected wound
when it came in. If these fluids which develop were
dammed up they would inevitably press on the blood-
vessels and a thrombus develop, and, if it continued, a
necrosis. The indication then was to relieve that pres-
sure as soon as possible and to prevent it. As absolute
drainage as could be should be used. The great prin-
ciple enunciated by the reader should be remembered,
namely, that gauze was not a drain. One must pro-
vide tubular rubber, bone, or what not. He thought,
too, that he was not quite in accord with the dictum
that metallic plates should not be used. He persisted in
using metallic plates with the greatest satisfaction.
Speaking of rest, he thought we sometimes carried that
principle too far. He did not believe that absolute im-
mobilization was necessary for the union in fracture.
He thought he had seen delayed union caused from im-
mobilization. Certainly cases of delayed union had
seemed to yield to use.
Dr. Edward Martin of Philadelphia said that, as a
rule, a fracture united in proportion to the traumatism
which had been inflicted. The greater the traumatism
and larger the exudate, the slower the union. There
seemed to be almost no constitutional condition which
would either delay or interfere with the union of frac-
ture. They had had the best results in those eases of
delayed union by the Bier condenser and by the simple
common-sense expedient of changing the treatment.
Excepting in the operative cases, tney were not greatly
troubled with non-union or greatly delayed union. In
contravention of what had been said, it seemed to them
that every case of fracture operated on whether by
kangaroo tendon, bone plates, pins, pegs, staples, screws,
unless there was some delay in union and the delay was
proportionate to the traumatism inflicted on the end of
the bone, they were to some extent led from the ideal
of opposition.
Dr. Charles E. Thomson of Scranton said that 50
per cent, of their compound fractures healed without
marked infection with ordinary first dressings, or, if
infected at all, the infection was negligible.
Dr. G. F. Bell of Williamsport said that in the large
majority of cases that were infected it was due to the
fact that the surgeon went into the operative field be-
fore proper aseptic preparations had been made. In the
simple operation of necessity in these compound frac-
tures one had to open up the field to see what blood
vessels and muscles were torn, what fragments of bone
were comminuted, or to see what muscles were between
the fragments, which no surgeon could see and which no
.r-ray would show.
Ligation of the Superior Pole of the Thymus in Oper-
ating for Goiter. — Dr. Lever F. Stewart of Clearfield
read this paper, in which he said that about 30 per
cent, of the cases of toxic goiter operated upon were
either not cured or were not helped in any way. There
were cases of Basedow's disease in which the thyroid
alone was responsible, and others in which both the
thyroid and the thymus were responsible. In dissec-
tions which he had made, in the majority of cases the
inferior thyroid arteries gave branches to the superior
pole of the thymus. In some instances this branch was
given on only one side. In one out of ten cases no such
branch was given off. Ligation of the inferior thyroid
artery close to the gland did not touch its branch to the
thymus. As a result the thymus might become con-
gested and enlarged. Ligation of the superior pole of
the thymus would circumvent this and in addition have
a favorable influence upon the thyroid participating in
the disease.
Dr. Donald Guthrie of Sayre said this paper of Dr.
Stewart's opened up a new line of reasoning. He
thought, aftgr all, that those who had done thyroidec-
tomy in which either one lobe or part of one lobe had
been taken out and where the inferior arteries had been
taken out had been worried for the first or second day
by a lot of pressure symptoms, and it was his belief
that some of these cases might be suffering from an
engorged thymus.
Dr. G. T.Matlack of Wilkes-Barre said that in his
experience in doing thyroidectomy it was very rarely
he saw the enlarged thymus glands. He had removed
three enlarged thymus glands, but not in exophthalmic
goiter. It was a very hard thing to find an enlarged
thymus gland when operating: for goiter. He was look-
ing for it all the time and did not find it. He believed
we would have to give the thyroid credit for most of
the evils.
Dr. Charles H. Frazier of Philadelphia said that he
felt disposed to take the view that Dr. Matlack had
taken as to the importance of the thymus gland in the
intoxication we saw associated with the enlarged thy-
roid. He knew in the literature we found cases which
were extraordinarily imnortant in pointing in the other
direction. He personally had not found them in his
clinic and he had been lookng for them, having most of
the patients fluoroscoped, but had not found as yet any
coincident enlargement of the thymus gland in thyro-
toxicosis.
Dr. George C. Johnston of Pittsburgh said that the
relation between the thymus and thyroid in cases of
thyrotoxicosis was a very doubtful one. Practically
he believed there was little connection. Lots of these
cases of undoubted thymus were diagnosed as aneurism
or mediastinal tumor, but if you put the patient in the
recumbent posture you would find the thvmus drop over
and give the shadow of a doe's ear. It was such an
unusual thing that it was absolutely diagnostic.
Support of the Stomach After the Beyea Gastropexy.
— Dr. T. Turner Thomas of Philadelphia presented this
paper, in which he said that Dr. Beyea's operation was
the only one which hune the stomach in its normal,
physiological position. All others attached the stomach
to the anterior abdominal wall, so that it then hung in
an abnormal position. Full credit had not been given to
876
MEDICAL RECORD.
[Nov. 11, 1916
the reported success of the Beyea operation, because it
had always been claimed that the stomach afterward
hung by the shortened gastrohepatic omentum, which
was obviously too weak a structure to support such a
weight. The His models, patterned after frozen bodies
with tne organs in their normal positions and formalin
hardened bodies, proved that in life the anterior and
upper surface of the stomach and the under surface of
the liver were in close, intimate contact over a wide
area. The effect of the Beyea operation, therefore, was
to cause the development of strong, supporting adhe-
sions in this area of close contact. Such close, strong
adhesions were found in a patient reoperated on after
a preceding Beyea operation. Therefore, the support
of the stomach after the Beyea operation was ample for
all needs and the stomach was in the best possible situa-
tion.
Dr. H. D. Beyea of Philadelphia said that while Dr.
Thomas sought to form adhesions between the stomach
and liver, he tried to avoid them. He scarcely retracted
the liver to any great extent. The operation he did
originally was the suture of the gastrohepatic omentum.
He didn't think he ever got the stomach sufficiently high
in the original operation. He now placed four sutures
through the hepatic omentum and tied them, and this
brought this in contact with the lesser curvature of the
liver. Then inflammatory reaction took place with the
formation of further adhesions. He had operated upon
more than fifty cases. He had made no statistical study
for the last two or three years as to the results. Up to
that time 90 per cent, had gained in weight.
Dr. G. M. Dorrance of Philadelphia said that this
tissue which Dr. Beyea spoke of was on the under sur-
face of the liver and was very strong. It runs from the
transverse fissure to the oesophagus. In thirty-four
fresh cadavers they had found this band, and by sutur-
ing the stomach in the method he described and fasten-
ing scales to the bottom the stomach would stay up with
14 to 16 pounds' downward pull. Dr. Thomas did not
take up the indications. There was practically only one
indication, acute wrinkling of the duodenum, for this
operation. If motility was good the stomach might be
down in the pelvis and still empty itself.
Dr. T. T. Thomas of Philadelphia said that he be-
lieved strongly in the Beyea operation. There must be
shown some other method than that conceded by Dr.
Beyea by which the stomach was held up or the Beyea
was not a rational operation. He thought he had shown
clearly from the normal anatomy of the part that that
operation cannot be done in any without the develop-
ment of a considerable area of adhesions between the
stomach and liver, which would be very much stronger
than the gastrohepatic omentum ever was.
Obstruction of the Common Bile Duct. — Dr. C. D.
Schaeffer of Allentown read this paper, in which he
said stone was the usual cause of obstruction in the com-
mon bile duct. Stones were seldom found in the com-
mon duct, but came down into it from the gallbladder.
They seldom caused complete obstruction ; when the ob-
struction was incomplete there was a ball-valve action,
as described by Fenger, which was attended by pain,
irregular chills, followed by high fever and sweats, and
later on by intensified jaundice. If the obstruction was
in the ampulla of Vater or at the orifice of the papilla,
bile might be retrojected into the pancreas, an occur-
rence which was followed by acute hemorrhagic necrosis
of the pancreas. If the obstruction was due to a polyp,
the health became impaired insidiously and there was
progressive jaundice, persistent intestinal indigestion,
and emaciation. The earlier the operation was done the
more favorable the outcome. In cancer the operation
must be done so early as to permit complete excision of
the growth ; if this could not he done, cholecystenteros-
tomy might prolong life. Resection of the bile duct
most suitable in the structural type of obstruction was
attended by a mortality of 50 per cent.
Cholecystectomy the Operation of Choice. — Dr. A. R.
Matheny of Pittsburgh read this paper, in which he
said that as the work of Rosenow showed gallstones
was not a disease per se but always a sien of a previ-
ously diseased gallbladder which, once diseased, either
remained a nidus of infection or, as a result of inflam-
mation, lost its function, it was probable that the gall-
bladder was simply a pressure chamber; hut, even ad-
mitting that it was a storage reservoir, this function
was nullified in cholecystitis. Therefore, given an or-
gan whose function was impaired or destroyed and
whoso presence was a source of infection, it was reason-
able to remove it if the risk was no preater than drain-
age would be. The mortality in the experience of sev-
eral good surgeons in the past two years had been no
greater from cholecystectomy than from cholecystos-
tomy. From the point of view of end results, there
could be no question that removal of the gallbladder
showed less morbidity than did drainage. If we would
remove the gallbladder, except where it was necessary
for drainage, we would avoid the unpleasant experience
of an unimproved patient and removal of the gall-
bladder by another surgeon.
Dr. J. A. Lichty of Pittsburgh said that Dr. Matheny
had brought out a very interesting point in gallbladder
disease which was not thought of when he began to
compile his statistics upon gallbladder work. Several
years ago he collected statistics covering twenty or
twenty-two years. In the early part of that time,
when the gallbladder was removed there was very little
thought of it and he made no effort to compare cholecy-
stectomy and cholecystostomy. At that time he pub-
lished some 614 cases, and 193 of these were operated
upon; 174 were gallstone cases, and drainage was done
in most of these. Two of these had to be operated on
on account of failure of the operation. Cholecystectomy
had to be done. He recalled in his early cases one very
satisfactory cholecystectomy. The question was whether
the results would be comparatively good. He would
rather have a live patient with the gallbladder in than
a dead patient with the gallbladder out.
Dr. Ernest Laplace of Philadelphia said that only-
one reason stood in the way of removing the gall-
bladder, the supposititious one that it was a necessity to
functionating of proper digestion. It had been proved
that it was not. Therefore, why preserve an organ that
was not of essential use to the system? He removed all
gallbladders, every one and without exception, and only
hesitated when the necessary time required for proper
work might jeopardize the life of the patient. Not that
he feared the after results, but that the doing of this
operation in the correct way at the time did not seem
possible.
Dr. J. H. Jopson of Philadelphia said that he found
himself very much in accord with Dr. Matheny's views
in the indications for the removal of the gallbladder.
When he began to remove gallbladders the mortality of
cholecystectomy was higher than cholecystostomy.
With the improvement of technique he found the mor-
tality was no more than in cholecystostomy and end re-
sults were very much better. He was still taking out
gallbladders which he formerly drained. He thought
when a gallbladder was acutely inflamed and patchy
with gangrene, as in some cases of acute pancreatitis,
or in occasional cases of infection of the gallbladder,
we had better let it alone.
Dr. H. L. Foss of Danville said that there was no
question about the value of cholecystectomy, as there
were cases where there was a history of recurrence of
stone. He recently performed a cholecystectomy on a
patient operated on three times before for gallstones.
When the gallbladder was removed he counted over 500
shotlike stones. That patient had been drained three
times before.
Gastric and Duodenal Ulcer from the Study of
Twenty-five Operative Cases. — Dr. H. B. Gibby of
Wilkes-Barre read this paper, in which he said that
the most common evidences of ulcer in his cases were
pain coming on one-half to three hours after meals and
progressive emaciation. The painful attacks were re-
current and sometimes morphia was needed for relief.
Basing his opinion upon the etiology and pathology of
ulcer, he would say that an ulcer cannot be permanently
cured by medical treatment. Surgery met the require-
ments of a cure. The proper method of operation in
gastric ulcer was either excision, if the ulcer was large,
or destruction with the Paquelin cautery, if small, com-
bined with gastroenterostomy. For duodenal ulcer his
results had been pood from folding in the hardened area
with matt ress sutures and doing posterior gastroenter-
ostomy. In his series 88 per cent, had been relieved of
soureructations and a like number of abdominal dis-
tension. In view of the results obtained, operative
treatment seemed logical and justifiable.
Dr. H. D. Gardner of Scranton said that three or
four times as many ulcers of the duodenum would be
found as ulcers of the stomach. In operating: make your
incision under local anesthesia. In favorable cases you
could do all your work in this way. In the more diffi-
cult ones you could make your diagnosis and plan your
work, which often took half the time.
Dr. F. P. Ball of Lock Haven said that he was more
and more convinced that erastric ulcer was much more
common than was formerlv supposed. If one looked for
it he was much more likely to find it. More than four
times as many cases of ulcer were found at autopsy as
Nov. 11, 1916]
MEDICAL RECORD.
877
were diagnosed before death. This would indicate that
we were missing the diagnosis in a great many of these
cases. The history in a good many cases was so indefi-
nite and the symptoms so obscure that we could not
make a positive diagnosis.
Dr. J. A. Lichty of Pittsburgh said that when it came
to chronic peptic ulcer he had the opinion that it was a
surgical condition. That would mean that every pa-
tient with a chronic peptic ulcer should be operated
forthwith. That was not altogether in the interest of
the internist. But the patient was one party in the
procedure, and it was not always possible to bring pa-
tients to operation. The indications for operation in
peptic ulcer were very definite. For the last two years
it had occurred to him that he was seeing quite a num-
ber of patients who had been operated, and it was a
most discouraging thing when you took a history of
chronic appendicitis and thought you would take the pa-
tient to the hospital, and before you got through he
would say: "Two years ago I was operated upon and
had my appendix taken out." Among 1400 patients of
all kinds he had seen 126 cases who had beautiful ulcer
histories and good operation, beautiful appendix his-
tories and careful operations, and yet their symptoms
continued; so surgery did not appeal to us so tremen-
dously in these doubtful cases when we had experience
of that kind.
The Value and Limitation of Radiotherapy in Gyne-
cology.— Dr. F. E. Keene of Philadelphia read this
paper in which he said that his report comprised an
analysis of 116 cases treated in the gynecological de-
partment of the University Hospital; 69 cases were of
malignant growths of the vagina, cervix or urethra, and
47 cases of benign hemorrhage of myomatous or myo-
pathic origin. The majority of cases received 85-110
mgms. for 24 hours. In one case of cauliflower growth
in a woman of 28 who was six months pregnant 210
mgms. were applied with complete cure. The only im-
mediate effects were nausea and vomiting which usually
ceased 24 to 36 hours after removal of the radium. In
44 per cent, of cases of cancer there was complete heal-
ing and in only 2 cases was there no benefit. In not
a single instance had there been a failure to check
bleeding in the cases of benign hemorrhage. Mild
symptoms of menopause were developed in 10 cases. In
cancer of the fundus, operation was preferable to
radium; this was also true of early cervical cancer. In
cases of small myoma whose only symptom was hemor-
rhage 100 per cent, of cures might be expected. This
work was still on probation.
Dr. H. K. Pancoast of Philadelphia said that he had
kept in touch fairly well with this work and could in-
dorse all that Dr. Keene had said. The gynecologist had
the advantage over the Roentgenologist in that he was
able to use this agent himself; whereas the Roentgen-
ologist was usually not a gynecologist. There were
undoubtedly some advantages in radium over Roentgen
rays in this one feature. The results of radium therapy
in carcinoma of the cervix could not be classified as
cures as yet because the longest cases had yet almost
three years to run before they came within the five year
period. There were cases in which a combination of
radium and .r-rays might do good, the radium not being
quite strong enough to reach the outer border of the
growth.
Dr. George C. Johnston of Pittsburgh said that the
disadvantage of this treatment was that it required the
physician to have anywhere from $10,000 to $25,000
worth of radium. Also this work required considerable
experience and a careful technique and the results which
these gentlemen had so beautifully described might not
be expected to follow the application of radium without
regard to the case. Where simple hemorrhage was en-
countered aside from malignancy, these cases were con-
trolled with mathematical exactitude by deep Roentgen
therapy. He made that statement without any qualifi-
cation whatever.
Advantages of Local Anesthesia. — Dr. Harvey F.
Smith of Harrisburg read this paper in which he stated
that patient and persistent use alone could train a judg-
ment as to the limitations of local anesthesia and the
type of cases in which it was indicated in preference to
general anesthesia. The possible disadvantage might
be noted as follows: The operative field could always
be completely anesthetized or the mental attitude of the
patient might not be right. However, the fact that
painless surgery could be done without ether was be-
coming more widely known by the laity and converts to
this method were usually easily made. Too much en-
thusiasm with too little judgment might lead to inexact
or incomplete surgery. The question of additional time
required for operations under local anesthesia was re-
garded by some as an objection. This was only relative
and should hardly be considered valid. The advantages
might be briefly summed up as follows: The novocain
and adrenalin combination when injected in proper so-
lution and with correct technique was absolutely safe.
This was his personal judgment as well as the judgment
of all users. There was a minimum of surgical shock
and encroachment upon the patient's margin of safety;
rarely was there vomiting, neither was there ether
toxemia to overcome. Because of these facts the pa-
tient entered promptly upon a smooth and comfortable
convalescence. There was prompt and, he believed, bet-
ter wound healing due to the sharp dissection and gen-
tle handling of the tissues. Moderate toxemia might
occur, but no serious heart, lung, gastro-intestinal or
kidney disturbance seemed to follow the use of novo-
cain. Office and ambulatory surgery was simplified.
Postoperative pain was less in abdominal cases if a 1/6
per cent, solution of quinine and urea was injected
around the field of operation. This caused an edema of
the tissues which was not serious if the suturing was
not too tight. Weighing these limitations against the
advantages and possibilities he felt that we could fairly
say that novocaine anesthesia, plain or with one of the
possible combinations, should be used when the opera-
tive field could be completely anesthetized and the men-
tal attitude of the patient was right or when the vitality
of the patient was low and the margin of safety was
narrow and a minimum post-operative shock was re-
garded as a factor necessary for recovery.
Dr. J. Torrance Rugh of Philadelphia said that he
wanted to mention a little point in the matter of the
toxemia which resulted from the use of these local
anesthetics. Very early in the discussion of the use of
cocaine toxic effects were extremely common and all
manner of stimulants, such as strychnine, whiskey, and
so on were used to counteract the effect. In a case on
which he was operating he had had no strychnine or
any of those substances present and he used nitro-
glycerin with the happiest effects and it suddenly
dawned on him that nitroglycerin was the physiological
antidote of cocaine and of these anesthetic agents.
Since then he had not seen any cases of toxic effect
from the local anesthetic drugs. He used with the in-
jection a small amount of the nitroglycerin and it physi-
ologically controlled the toxic condition.
Dr. C. F. Nassau of Philadelphia said that if the
surgeon's enthusiasm led him to believe that he could
stick in a few syringefuls of a local anesthetic and then
go ahead and do his operation, he was going to be
bitterly disappointed. The statements to be made to
the patient had a great deal to do with the success.
There was a certain psychological element that must be
judged. One must not operate on every patient under
local anesthesia even if he would like to. If one were
in the habit of doing it and had in the ward of a hos-
pital a patient who had successfully come through an
operation conducted in this way, he had no difficulty
in getting the next patient to be done in the same way.
A local anesthetic sometimes meant the difference be-
tween life and death. He did not believe anybody had
any business to give a general anesthetic for strangu-
lated hernias.
Dr. Ernest Laplace of Philadelphia said that he
wished to express his conviction that infiltrating an-
esthesia was a superior mode of anesthesia. In his
mind it was superior to lumbar, intravenous or rectal
anesthesia, all of which were local methods. In in-
filtration anesthesia, you could direct, you could inject
what you pleased. You knew when you were at the
beginning and the end. You did just what you wanted
to do.
Dr. S. G. Gant of New York stated that personally
he had used eucaine in V» of 1 per cent, solution for
the last few years. He used it in all operations.
Quinine-urea solution had proven satisfactory. When
one did not get anesthesia it was because one did not
understand the technique. If we gave an elaborate
technique the measure was voted a success. Those who
gave local anesthesia would have many patients and
increase their reputation.
Dr. Kate Baldwin of Philadelphia said that she
simply wished to add her approval of using local an-
esthesia for operations more than had been done. She
had done almost everything with it. She was very sure
that she saw others using general anesthesia where they
just as well use the local.
Conservative Treatment of Puerperal Sepsis. — Dr. E.
878
MEDICAL RECORD.
[Nov. 11, 1916
E. Montgomery of Philadelphia read this paper in
which he stated that in his early experience 40 years
ago puerperal sepsis was regarded as a specific con-
dition; now it was recognized as being due to the same
causes as general surgical sepsis. Then mortality in
hospitals was much greater than in private practice
and these patients were not admitted to hospitals if it
could be avoided. His experience led him to condemn
the resort to operative interference in cases of infection
as being prejudicial to the patient. It was better to
keep the patient clean and trust to nature rather than
to interfere surgically. The objection to early surgical
interference was that the organs had already passed
beyond the reach of surgical measures and these only
break down barriers which nature had instituted. He
would advocate the use of autogenous vaccines prepared
from the blood of the patient, and in cases where these
could not be obtained the employment of prepared
serums, even horse serum. Measures that should be in-
stituted were those to promote effective elimination and
immunity. He would not hesitate to employ surgical
measures, even sacrificial surgery, in those cases in
which the organs were destroyed and were simply foci
for further extension of disease.
Dr. G. E. Shoemaker of Philadelphia said that the
word conservative treatment must not be misunderstood
as opposed to radical measures, if necessary, but he for
one would like to join with those who believed that radi-
cal measures as usually understood were not required
in the management of puerperal sepsis. He would say
at once that his hospital experience was peculiar in this
respect. The maternity infections which came were not
those which they had themselves delivered. They were,
therefore, without a history which was reliable as to
the absence of retained pieces of placenta. There were
other cases which came as the result of criminal inter-
ference and there they had no history. There were
other cases which had been hastily examined and recog-
nized and unloaded on the hospital. In these cases one
must change his attitude as to noninterference. He
must never forget that these cases tended to get well of
themselves. In regard to an active interference by a
cutting operation, he hesitated to do it above the pubis
unless absolutely obliged to do so.
Influence of Lesions of the Rectum on Various Ab-
dominal Conditions. — Dr. Ernest Laplace of Philadel-
phia read this paper in which he said that abdominal
symptoms unaccompanied by any subjective rectal
symptoms might be due to a rectal condition whose
presence was unsuspected. The lymphatics and venous
circulation of the rectum accounted for the ease with
which toxins were absorbed and found their way into
the general circulation, while the complex innervation
of the rectum might account for many reflex symptoms
so misleading as not to suggest their possible origin in
the rectum. The cardiac, the pyloric, the ileocecal and
the anal sphincter being in nervous communication with
each other it was no wonder that the irritation of
the one might result in reflex spasms of one of the
others. His experience impressed him with the neces-
sity of making a thorough examination of the rectum
in every abdominal case which came for operation.
Dr. Reed Burns of Scranton said that the fact that
cardiospasm could come from an obscure rectal trouble
was new to him. He was glad to know it. Whenever
one examined a patient for gastrointestinal disturb-
ances he ought to begin at the mouth and end at the
anus. There might be pyorrhea, diseased tonsils, or at
the bottom of it chronic renal trouble, and gallstone
trouble. It might be that the early symptoms of loco-
motor ataxia were making us think that we had gall-
stone trouble. So there was no end to it. Microscopical
and chemical examination of the contents of the stom-
ach and feces was necessary. A thorough examination
of the patient all over was equally necessary and when
we had excluded certain things then we figured the
diaenosis so that it could be made out.
Closure of Fecal Fistula by Extraperitoneal Method.
—Dr. C. F. Nassau of Philadelphia read this paper in
which he said that in suppurative or gangrenous con-
ditions of the appendix, two methods of closure were
indicated, depending upon whether it was of the large
or of the small intestine. For the method described
the best condition was when the bowel was adherent to
the abdominal wall without interposition of a small coil
of intestine. With free exposure of Deritoneal cavity, a
small drain made hernia possible. Wound infection "did
not cause a breaking down. The skin scar was excised,
cut away and the tract disinfected with phenol and
alcohol, the top of the tract closed by sutures, the
aponeurosis of the external oblique was cleaned and
circular incision made around the tract. The abdominal
wall was dissected away close to the fistula. After
getting through the edges of the muscular layer, one
came upon a layer of transversealis fascia, parietal
peritoneum, and peritoneal covering of the bowel. The
fistula was amputated, the tract was crushed and tied
off close to the bowel wall and the wall of the bowel
folded in by row after row of chromic catgut. After
the fecal wall was folded out of sight the deepest layer
was picked up and a continuous suture of the depth of
the wound was made. The internal oblique and trans-
versalis muscles were freed and brought together.
Dr. Ernest Laplace of Philadelphia said that the
question Dr. Nassau brought up was most interesting.
It was well that he had brought this one point out
forcibly. That was the differentiation of these various
fistula; and suggested a method which in itself was
bound to be a very successful method, although limited
to a very small number of cases.
Habitual Dislocation of the Ulna, Report of a New
Operation. — Dr. M. Behrend of Philadelphia read this
paper saying that there were two kinds of habitual dis-
location of the ulna, traumatic and pathological. Trau-
matic occur in conjunction with fractures of the radius
and ulna. Pathological follow infection usually of the
soft parts. His case followed severance of all the
flexor tendons at the wrist. Infection followed. After
a tedious convalescence it had been found that the ulna
remained habitually dislocated. A review of the litera-
ture revealed 19 cases reported of habitual dislocation
of the pathological variety. This included the writer's
case. A new operation was performed which consisted
in driving a nail transversely through the ulna and
radius. Great care had to be exercised in avoiding the
joint. Function was perfect except for a slightly lim-
ited supination of the hand. Pronation, flexion, and
extension were normal. The patient had returned to
his occupation of chauffeur.
The Value of Animal Experimentation. — Dr. Walter
B. Cannon of Boston delivered an address on this
subject before a general meeting of the Society on
Thursday evening, Sept. 21. Dr. Cannon compared
the two methods of learning about natural objects,
that of observation and that of experimentation
under which conditions were controlled, and showed
how great had been the increase of our knowledge in
physical realms through the application of the experi-
mental method. Precisely similar had been the increase
of our knowledge of medical facts through the applica-
tion of the experimental method to the study of disease.
Continuing this idea he showed that a sound basis of
acquaintance with tuberculosis came through animal
experimentation and that our present effective and
hopeful fight against the disease was due directly to this
knowledge. The same condition had proved true of
bubonic plague; whereas formerly people placed their
faith in anti-pestilential pills and royal antidotes, they
now trapped the rats whose fleas conveyed the disease.
Diphtheria, likewise, had had its mysteries revealed
through experimental procedures; and antitoxin, which
had very greatly reduced the death rate and suffering
from the disease, had not only been discovered through
animal experimentation, but was produced through the
use of animals. Another disease of similar fearfulness
was epidemic cerebrospinal meningitis. Through ani-
mal experimentation a method of treatment had been
discovered which had reduced the death rate from ap-
proximately 75 per cent to about 25 per cent, and
greatly lessened the defectiveness of those who sur-
vived. The development of surgical asepsis and with
it the treatment of childbed fever had likewise been the
outcome of experiments on animals. The saving of life
from this knowledge alone had been immeasurable. An-
other way in which animals had been useful to man
had been that of serving as means for the discovery of
useful drugs, such as the sleep-producing drugs and the
local anesthetics. Animals had been directlv service-
able in the discovery of salvarsan as a means of treat-
ing syphilis. In public health laboratories and in the
laboratories of hospitals, animals were used also for
diagnosis of obscure diseases. In spite of the enor-
mously valuable benefits which had come to mankind
from animal experimentation, there were persons, the
antivivisectionists, who had objected to the use of ani-
mals for this purpose. The antivivisectionists mainly
based their claim on ethical grounds, but when we con-
sidered that we permitted the dehorning and branding
of cattle, unspeakable barnyard operations, the slaugh-
tering of myriads of birds and beasts for sport — all
Nov. 11, 1916]
MEDICAL RECORD.
879
without any anesthesia — it seemed ridiculous to select
as an object for attack the methods employed in operat-
ing on relatively few animals in the laboratories with
the hope of reducing pain and suffering in the world.
Dr. Cannon then explained that throughout this country
regulations had been adopted in all the laboratories
where experimental methods were being employed in
the study of medicine, which provided for the bodily
comfort and the sanitary treatment of the animals, and
required all the operations to be sanctioned by the di-
rector of the laboratory. Furthermore, that these regu-
lations required all operations likely to cause greater
discomfort than anesthetization itself, to be done under
anesthesia and to be followed by painless death. The
question then was whether in the presence of our igno-
rance of many diseases, such as measles, scarlet fever
and infantile paralysis, we were to bow before the
antivivisectionists and do nothing to increase out knowl-
edge of these diseases, or whether we were to make
use of the methods which had given us knowledge and
consequently greater power in the cure or prevention
of the diseases which had been mentioned. The phy-
sicians perceiving that more power to fight disease
could come only from more knowledge, trust the deeper
humanity of the investigators who were seeking that
knowledge. In the end society must determine which of
these contending parties should prevail.
Philadelphia Neurological Society.
At a stated meeting held October 27, Dr. Alfred
Gordon presented "A Case of Astasia-Abasia in a
Syphilitic." The patient was a colored man, 46 years
old, an insurance agent, who ra.ther suddenly found
difficulty in walking, although he could execute all move-
ments with the lower extremities while in bed. The
gait was ataxic and station swaying, but the knee-
jerks were exaggerated. There were no ocular changes,
no sensory disturbances, and no derangement of the
sphincters. Examination of the spinal fluid disclosed
a strongly positive Wassermann reaction, and the case
was looked upon as one of spinal syphilis, involving
especially the white substance of the cord. Marked im-
provement ensued on antisyphilitic treatment.
Dr. George E. Price exhibited "A Case of Paralysis
Following Inoculation Against Rabies." The patient
was a barber, fifty-three years old, who, while under the
influence of alcohol, annoyed a pet dog, by whom he
was bitten. The animal was killed without examination
of his nervous system, and with a view of averting pos-
sible rabies the man was treated with specific virus. As
a result there developed paralysis in the lower ex-
tremities of progressive character, with exaggerated
reflexes and impairment of sensibility, indicative of a
lesion of the spinal cord.
Dr. James Hendrie Lloyd exhibited "A Patient with
Syringomyelia and Arthropathy of the Shoulder-joint."
The patient was a woman, about fifty-eight years old,
who presented rigidity of the right shoulder-joint, to-
gether with wasting of the intrinsic muscles of the
hands and partial main en griff e, with preserved tactile
sensibility and impaired temperature sense.
Dr. Francis X. Dercum exhibited "A Case of Tor-
sion Neurosis." The patient was a man, about thirty
years old, who for a dozen years or more exhibited
torsion of the neck and varus of the right foot, without
hysterical stigmata.
Dr. Charles W. Burr exhibited "A Boy Presenting
Mobile Spasms." The patient was about ten years old,
and he at one time presented atonic muscular weakness
with flaccidity, and at a later period a tendency to
muscular overaction on slight provocation, without
actual spasticity. The knee-jerks were increased, the
ocular conditions were normal, the electrical reactions
were not changed, the mental state was good, and sensi-
bility was preserved.
Dr. William G. Spiller presented a communication
entitled "Newer Views Regarding the Pyramidal
Tracts, Corroborated by Syringoencephalia."
Ambard's Constant in the Clinic. — Leza concludes
that the "constant of Ambard" is the most rational
method for exploring the functional capacitv of the
kidneys. Prostatics are almost always nephritics, which
explains the operative non-successes in prostatic sub-
jects. Prostatectomy is advisable when the constant is
below 0.07 or between 0.07 and 0.15, but is eontraindi-
cated when above 0.15. The constant is of value in
the prognosis of nephritis. — Revista Medica Cubana.
The Medical Record is pleased to receive all new
publications which may be sent to it, and an acknowledg-
ment tvill promptly be made of their receipt under this
heading; but this is tvith the distinct understanding that
it is under no obligation to notice or review any publica-
tion received by it which in the judgment of its editor will
not be of interest to its readers.
The Dietetic Treatment of Diabetes. By B. D.
Basu, Major, I. M.S. (retired). Published by The Panini
Office, Bhuvaneshbari Ashram, Bahadurganj, Allah-
abad. 1916. Seventh Edition. Revised and enlarged.
105 pages. Price Re. 1-8.
I. K. Therapy in Pulmonary Tuberculosis, with a
Summary of Cases and Forty-two Illustrative Charts.
By William Barr, M.D., D.Sc, D.P.H. Published by
William Wood & Company, New York. 1916. 82
pages. Price, $1.25 net.
Pye's Surgical Handicraft: A Manual of Surgical
Manipulations, Minor Surgery, and Other Matters Con-
nected with the Work of House Surgeons and Surgical
Dressers. Edited and largerlv rewritten by W. H.
Clayton-Greene, B.A., M.B., B.S., F.R.C.S. Seventh
edition. Fully revised with some additional matter and
illustrations. Published by William Wood & Company,
New York. 1916. 614 pages. Price, $4.50 net.
A Text-book of Pathology. By W. G. MacCallum,
Professor of Pathology in the College of Physicians and
Surgeons, Columbia University, New York. Published
by W. B. Saunders Company, Philadelphia and London.
1916. Illustrated. Drawings by Alfred Feinberg.
1085 pages. Price, $7.50, cloth.
Facts for Freshmen Concerning the University
of Illinois, Intended for Young Men About to Enter
College. By Thomas Arkle Clark, Dean of Men, and
Arthur Ray Warnock, Assistant Dean of Men. 102
pages. Published by The University. 1916.
Medical and Surgical Reports of the Episcopal
Hospital of Philadelphia. Vol. III. 356 pages. Illus-
trated. Published by Press of Win. J. Dornan, Phila-
delphia. 1915.
Traumatic Pneumonia and Traumatic Tubercu-
losis. By F. Parkes Weber, M.A., M.D., F.R.C.P.,
London. Published by Adland & Son and West New-
man, London. Price, sixpence.
Universal Military Education and Service. The
Swiss System for the United States. By Lucien Howe,
Fellow of the Royal Society of Medicine; Member of
the Royal College of Surgeons; Professor Emeritus of
Ophthalmology. Published by G. P. Putnam's Sons,
New York and London. The Knickerbocker Press.
1916. 138 pages.
The Healthy Girl. By Mrs. Joseph Cunning,
M.B. (Lond.) Hon. Med. Director to the Open-Air
School in the London Botanical Gardens and A. Camp-
bell, B.A., Lecturer in Biology and Hygiene, Technical
Institution, Swindon. Published by Henry Frowde,
and Hodder & Stoughton, London. The Oxford Press,
American Branch, New York. 1916. Illustrated. 191
pages. Price, $1.75.
Diseases of Children. By Edwin E. Graham, A.B.,
M.D.. Professor of Diseases of Children in the Jeffer-
son Medical College. Published by Lea & Febiger, Phil-
adelphia and New York. 1916. Illustrated with 89
engravings and 4 plates. 902 pages. Price, $6.00.
A Purin Free Dietary: Sample Menus and Recipes.
By Edna Alice Waite and Robert Ellsworth Peck,
M.D. Published by Elm City Private Hospital, New
Haven, Conn. Paper, 24 pages. Price, 25 cents.
The American Year-Book of Anesthesia and
Analgesia. By Various Contributors. F. H.
McMechan, A.M., M.D., Editor. Quarto; art buckram;
India tint paper; 420 pages and 250 illustrations. Pub-
lished by Surgery Publishing Company, 92 William St.,
New York City, 1916. Price, $4.00.
A Practical Treatise on Disorders of the Sexual
Function in the Male and Female. By Max
Huhner, M.D. Published bv F. A. Davis Company,
Philadelphia, Pa. 318 Pages. Price, $3.00 net.
Charity Inspector and Social Investigator, Ex-
amination Instruction — A Course of Instruction for
Candidates for Institutional Inspector, Social Inves-
tigator, Inspector State Board of Charities, Charity
Application Investigator, etc. By SOLOMON Heckt,
Associate Editor, Civil Service Chronicle, and Julius
Hochfelder, LL.M. Published bv Civil Service
Chronicle. 23 Duane St., New York City. 148 pages.
Price, $3.00.
880
MEDICAL RECORD.
[Nov. 11, 1916
A Text-Book of Human Physiology, Including A
Section on Physiologic Apparatus. By Albert P.
Brubaker, A.M., M.D. Published by P. Blakiston's
Son & Co., 1012 Walnut St., Philadelphia, Pa., Fifth
Edition. Revised and Enlarged with 1 Colored Plate
and 359 Illustrations. 776 Pages, Price, $3.00 net.
Lippincott's Nursing Manuals — Care and Feed-
ing op Infants and Children, A Text-Book for
Trained Nurses. By Walter Reeve Ramsey, M.D., In-
cluding Suggestions on Nursing by Margaret B.
Lettice and Nann Gossman. Published by J. B. Lip-
pincott Company, Philadelphia & London. 123 Illustra-
tions. 290 Pages. Price, $3.00 net.
The Problems of Physiological and Pathological
Chemistry of Metabolism, For Students, Physicians,
Biologists and Chemists. By Dr. Otto Furth, Au-
thorized Translation by Allen J. Smith. Published by
J. B. Lippincott Company, Philadelphia & London, 667
Pages. Price, $6.00.
Physiological Chemistry — A Text-Book and Man-
ual for Students. By Albert P. Mathews, Ph.D., Pro-
fessor of Physiological Chemistry, The University of
Chicago. Published by William Wood & Co., New York,
1916. Second edition. Illustrated. 1037 pages. Price,
$4.25 net.
A System of Mature Medicine as Taught in Mc-
Cormick Medical College, Chicago, 111., founded 1893,
chartered in Illinois. By Charles McCormick, M.D.
Published by McCormick Medical College, Chicago, 111.
1916. Vol. I, Optics and Ophthalmology. Illustrated.
319 pages. Price, $20.
Precis-Resume de Chirugie de Guerre. Par Jean
Fiolle, Chirurgien des Hopitaux, Professeur suppleant
a l'Ecole de Medecine de Marseille, Aide-major a l'am-
bulance chirurgicale automobile 21; et Paul Fiolle,
Ancien interne des hopitaux et de la clinique urologique
de Marseille, Aide-major du Ier corps colonial. Preface
de M. le Professeur Jacob du Val de Grace. Librairie
Felix Alcan, Paris. 148 pages. Price, 2 francs.
Vaccine Therapy in General Practice. Third
edition. By G. H. Sherman, M.D. Published bv G. H.
Sherman, M.D., Detroit, Mich. 1916. 523 pages.
Practical Bacteriology, Blood Work, and Animal
Parasitology, including Bacteriological Keys, Zoolog-
ical Tables, and Explanatory Clinical Notes. By E. R.
Stitt, A.B., Ph.G., M.D. Published by P. Blakiston's
Son & Co., Philadelphia, Pa. Fourth edition, revised
and enlarged with four plates and 115 other illustra-
tions containing 505 figures. 497 pages. Price, $2 net.
Principles of Diagnosis and Treatment in Heart
Affections. By Sir James Mackenzie, M.D., F.R.S.,
F.R.C.P., LL.D. Ab. & Ed., F.R.C.P.I. (Hon.). Pub-
lished by Henry Frowde & Hodder & Stoughton, Lon-
don. Oxford University Press, American Branch, New
York. 1916. 264 pages. Price, $2.50.
International Clinics, A Quarterly of Illustrated
Clinical Lectures and Especially Prepared Original
Articles. By Leading Members of the Medical Profes-
sion Throughout the World. Edited by H. R. M.
Landis, M.D. Vol. III. Twenty-sixth "series, 1916.
Published by J. B. Lippincott Company. Illustrated.
309 pages. Price, $2.
Syphilis and the Nervous System for Practitioners,
Neurologists and Syphilologists. By Dr. Max Nonne,
Chief of the Nervous Department in the General Hos-
pital, Hamburg, Eppendorf. Authorized translation
from the second revised and enlarged German edition
by Charles R. Ball, B.A., M.D. Published bv J. B.
Lippincott Company, Philadelphia & London. 98 illus-
trations in Text. Second American edition revised.
450 pages. Price, $4.
Manual of Psychiatry. Bv J. Rogues de Fursac,
M.D., Formerly Chief of Clinic at the Medical Faculty
of Paris, Physician in chief of the Public Insane
Asylums of the Seine Department, and A. J. Rosanoff,
M.D., First Assistant Physician, Kings Park State
Hospital, N. Y. Published bv John Wiley & Sons,
Inc., New York 1916. Fourth edition. Revised and
enlarged. 522 pages.
The Rockefeller Foundation International
Health Commission. Second Annual Report January
a 191'5— De«ember 31, 1915. Published bv the Offices of
the Commission, 61 Broadway, New York, N Y
U. S. A., January, 1916; 185 pages.
Seventeenth Annual Report of the State Board
of Insanity of the Commonwealth of Massa-
chusetts, for the Year Ending November 30, 1915.
Published by Wright & Potter Printing Co., State
Printers, 32 Derne Street, 1916. Public Document No.
63; 383 pages.
uJJjprapFutir Otitis.
War Treatment for the Eczemas. — While no new
drugs are being used for the treatment of these
conditions, it is interesting to note the test the old
ones are standing. For moist eczema the following
paste should be applied liberally and often. As
there is a tendency for this paste to dry in the jar,
a small amount of water may be added to it upon
application:
1{ Sulphur, 10
Chalk, 10
Oxide of zinc ointment, 80
After the death of the cocci and consequent re-
duction of inflammation and itching, the application
of a simple paste containing 1 per cent, carbolic
acid or creosote, or 10 or 12 per cent, tar will be
found very efficacious.
For the callous or horny variety of dry eczema,
Hebra's lead ointment ( unguentum diachylon), with
the addition of 10 to 12 per cent, tar, or 2 per cent,
salicylic acid, or 1 per cent, carbolic acid, or balsam
of Peru may be applied. These drugs relieve the
intense itching. Soap and water should be avoided
in cases of eczema and a mild oil used to cleanse the
parts. In the seborrhoic cases, which occur more
often in summer, the chalk-sulphur-zinc paste al-
ready given is a specific. The dry papular eczemas
may be treated by applying chrysarobin 1, collodion
20, to the affected area with a pledget of cotton
wool or sterile gauze, and while it is drying Hebra's
ointment may be rubbed in thoroughly with the
hand. The application of the ointment upon the
collodion removes irritation and spreading of the
eczema. The dressing must be repeated when the
crust comes off. — Berliner klinische Woehensehrift.
General Treatment of Chronic Nephritis. — Boyd
follows this regime in these cases: Nitrogen re-
tention must be reduced or eliminated principally
through the diet. When the patient is able to stand
it, all nourishment must be withdrawn for twenty-
four hours and thirst satisfied with distilled water.
Purgatives should be administered, as much nitro-
genous waste can be carried off through the intes-
tines. Hot air baths or hot packs may also be
employed. After this rest period a non-protein diet
is begun, consisting of arrowroot cooked with water,
cream, sugar, and such stewed fruits that do not
contain benzoic acid, such as apples, prunes, and
figs. This plan may be continued for one or two
weeks without any deleterious effect upon the pa-
tient's strength, and may produce a definite fall in
blood nitrogen. Milk may now be given and
stronger and more palatable farinaceous foods than
water-arrowroot added to the diet. This rest treat-
ment answers as well in the early stages of acute
nephritis, as it allows complete, or nearly so, rest
for the kidneys. — Edinburgh Medical Journal.
Sodium Hypochlorite as a Wound Dressing. —
This drug possesses a high germicidal action even
in the presence of serum, and is harmless also where
surgical instruments and cotton materials, both
colored and white, are concerned. It is used in the
following proportions: Sodium carbonate, 550 gm.,
is mixed with bleaching powder, 800 gm. ; this mix-
ture is dissolved in half a carboy of water, the
solution thoroughly shaken and made up to 40 litres,
the clear fluid poured off and 150 gm. boric acid
added. This is a concentrated form of the solution
(4 per cent.) ; it must be diluted with six parts
of water before use, and will keep for a month. —
Brit. Med. Jour. Prescriber.
Medical Record
A Weekly Journal of Medicine and Surgery
Vol. 90, No. 21.
Whole No. 2402.
New York, November i8, 1916.
$5.00 Per Annum.
Single Copies, 15c.
Original Arttrks.
THE CRUCIAL AGE OF MAN.*
By W. STANTON GLEASON, M.D..
NEWBDRGH, N. Y.
The crucial age of man is practically that period
of his existence ranging between the ages of forty-
five and fifty-five. It is the age when the majority
of active energetic men drop away or are seriously
incapacitated by degenerative processes undermin-
ing their inherent vitality. Influences of birth,
environment, education, etc., all have an effect to
advance or lower the dial point of their existence.
But from any point of view it is generally recog-
nized that at man's crucial age the death rate is
steadily increasing, especially among those who are
the mental and physical brawn of professional and
mercantile life. Their loss is preeminently a dis-
tinct one, for they drop out before their allotted
cycle is complete or their work accomplished.
Under this consideration as a profession we per-
force ask ourselves the question. Is there not more
active means whereby we may in a partial sense
at least solve this medical problem? We realize
that acute disease and so-called accidents of life
may cause many fatalities at the crucial age. Then
again many frail beings who through modern
methods of treatment weathered the stormy con-
ditions of childhood are wrecked on the rocks of
middle life, their vitality exhausted and their span
of life run out. But it is the average man under
average conditions and modern environment who
presents himself for our study and aid, and it is
for us to carry him through if possible.
Amid the clouds of theory as to the incipient
underlying forces that bear heavily upon this
period of the active man's existence, basic causes
are gradually being evolved which are weathering
the test of experiment and we hope for increasing
results.
The primary efforts in the solution of this ques-
tion have been advanced through the effective con-
joined work of the clinician and laboratory inves-
tigator. And in order to familiarize ourselves with
those deductions which have passed beyond the
theoretical test, it is well for us first to recapitu-
late the normal chemical changes and control in
the human body. For it is not possible to ap-
preciate the abnormal unless we have an absolute
picture of the normal. That there are chemical
and nervous causes for physical retrogression at
the crucial age is well established, and it is uni-
versally recognized that the chemical changes in
protoplasm which constitute its metabolism are
the basis of all the phenomena of life. Sherring-
*Read at a meeting- of the First District Branch of the
Medical Society of the State of New York, at Pough-
keepsie. Oct. 14, 1916.
ton shows us that all activities of the body, mus-
cular, glandular, somatic, and visceral, are con-
trolled and regulated by the nervous system.
Herbst drawing his deductions from experiments
upon lower animals, states that at some stage of
development the nervous system has an important
action upon growth and development. Bayless and
Starling proves that an autonomic or self-acting
system exists at different points in the human body
apart from the central nervous system, and that
the plexus of Auerbach, a self-acting point, pre-
sides over peristaltic movements of the intestines.
Magnus indicates that even the swaying move-
ments in the intestines formerly regarded as purely
muscular are dependent upon the plexus of Auer-
bach. The existence of peripheral plexuses in the
walls of blood vessels has been demonstrated by
Dogiel, and their presence explains many of the
phenomena of local control after nerve section.
The further investigation by Langley Anderson and
Gaskell indicates with emphasis the important in-
fluences of the nervous system upon development,
growth and nutrition. Therefore the prime factor
in the control of the human body in all its various
functions is the nervous system.
The Chemical Aspect. — Under normal chemical
conditions it is generally appreciated that the
ductless glands and their internal secretions play
an important part in sustaining the equilibrium of
metabolisms. Paton holds that perfect metabolism
of advanced life is governed largely by the internal
secretions of the ductless glands. Mental emotions,
especially care, grief, etc., powerfully influence the
ductless glands with the secondary effect of slow
degeneration.
Strauss, Adami and Watson deduced the conclu-
sion that the liver and kidneys are closely allied to
the thyroid, and when this gland degenerates the
other organs are seriously affected. Eppinger and
Falsa divide the ductless or endocrinous glands into
two groups according to the action of their inter-
nal secretions.
1. The "accelerator" group, including the supra-
renals, or adrenals, and the thyroid gland. All
three increase protein metabolism. The adrenals
cause mobilization of carbohydrates in liver. The
thyroid causes increased fat absorption.
2. To the "inhibitory" group belong the pancreas
and parathyroids; both retard protein metabolism
and restrain sugar mobilization in the liver. Ac-
cording to this grouping and action, increased
sugar production depends upon influences that
stimulates the accelerator secretion of the supra-
renals or lessen the restraining of the pancreatic
secretions.
The gonads, or sexual glands, also have an internal
secretion which acts upon the metabolism of the
body to stimulate it in each sex in a specific man-
ner. It has been shown that the interrelationship
882
MEDICAL RECORD.
[Nov. 18, 1916
of the internal secretion and the nervous system
seems to indicate a dominance of the nervous sys-
tem over the internal secretion. The question is
raised how far the body, mental development, and
character of the individual are influenced by the
condition of the endocrinous glands. The supposi-
tion in the light of present investigation is that the
influence is an important one. Any disturbance of
this perfectly controlled cycle brings lowered nutri-
tion, diminished metabolism, and incipient degenera-
tive processes.
Toxins. — The agents of unrest in this complete
control are the toxins the insidious rust in the nor-
mally perfect mechanism. The initial step in toxic
disturbances is based on our knowledge of protein
digestion. Through the investigations of Kutscher
and Abderhalden, and the epoch making split-pro-
tein announcement of Vaughan, much of the mist of
the past has faded away as regards the ultimate of
protein digestion. Vaughan holds that "the body to
be in perfect health must have all the cells function-
ate in harmony, and as these cells are made up of
protein to a large extent they must have protein
food. The proteins entering the human system
through the intestines are split into amino acids
and synthesized into specific proteins. The cells
of each organ have their own ferments peculiar to
that organ and these ferments act to defend the
cells against foreign proteins." If, however, the
foreign split-proteins overwhelm these ferments the
possibility of ultimate cell degeneration is immi-
nent. The toxic products of the anaerobic bacteria
of the intestines acting on protein bodies produce
as we know, indol, phenol, etc. These compounds
experimentally fed to animal.-, bring about changes
that are strikingly similar to those pathological
processes common to the aged.
Lane has emphasized that in health maintenance
the question of prime importance is body drainage,
the non-absorption of poisons, and the elimination
of whatever poisonous matters may be found in the
intestinal canal. It is reasonably well proven by
Armstrong and others that toward middle life the
proximal end of the large intestine favors only the
digestion of vegetable substances and the condi-
tions are especially favorable to decomposition of
protein products and the formation of bacterial
toxins. The deductions of Fisher and MacFadyen
after a series of test meals with subjects at the
turn of active life, bring out clearly the fact that
if food residues are abundant, intestinal stasis is
prolonged, and the antiseptic natural power of the
intestinal wall is weakened, then the putrefactive
flora reaches its maximum development. Barger
and Dale further argue that "we have not isolated
all the active principles as products of bacteria]
action in the intestine, and these poisons have no
doubt a powerful influence in disturbing enzyme
activity. And as the enzymes are the foundation
of cellular activity, any disturbance in their action
would lead to abnormal phases of metabolism."
Eastman points out that toxemia from the colon
can come from colitis, adhesions, colon dilatations,
viscerptosis, and stasis. Bassler, Adami, and oth-
ers hue shown that various forms of anaerobic
bacteria are the evident causes in the formation of
adhesions.
Lane and his school hold that the human race
would be better off without a colon because it is
the seal of 30 much misery. The originality of
Lane's idea, and the energy with which he followed
his theory excited the admiration of the medical
profession. But the vista of health and relief for
victims of intestinal stasis and chronic arthritis
through ileosigmoidostomy has yet to be more fully
verified.
Air. Arthur Keith of London, according to the
British Journal of Surgery, believes that neither
position of the intestines nor peritoneal bands play
an important part in the causation of intestinal
stasis, deducing his conclusions from a long list of
.r-ray pictures of Jordan.
Bottomley points out that in all his cases of sus-
pected intestinal stasis the a;-ray always reported
positive, which report was not always demonstrated
by operation. It is evident the final swing of the
surgical pendulum tends gradually toward conser-
vatism, and it becomes more and more evident that
the long suffering colon is less the happy hunting
ground surgically for the operative cure of most of
man's woes. However, deducting an overenthusi-
asm in the original Metchnikoff idea, there still re-
mains the broad ground of established fact deduced
from unbiased souixes and experience that the in-
testines are the seat of far-reaching insidious pois-
ons, especially evident at the crucial age of man.
Through the intestinal and metabolic poisons dem-
• rated and undemonstrated, which are potently
active at the turn of life's activity, we find at least
an argumentative cause for disturbance of the nerv-
ous systemic control and the foundation laid in
metabolic changes for arteriosclerosis, uric acid
excess, arthritic complications, and possibly dia-
betes mellitus.
Ai'teriosclerosis.- — We know that arteriosclero-
sis is a low grade inflammation of the coats of the
arteries, usually with progressive degeneration.
We also know that these undermining processes,
when they exist, are usually found after the age of
forty. How well do we know the causes? The
clinician and the laboratory worker urge that ar-
teriosclerosis is probably evolved from a toxic ori-
gin, not the accepted toxic effect of syphilis and
lead, but toxemias generated in the human body
through lowered defense. Wheeler thinks that the
usual, but not the only cause of this poisoning is a
special animal protein to which the particular bodb
cells have become sensitive. Vaughan also cites in-
stances of this sensitive state being produced in
animals by injecting them with the serum of the
susceptible individual. If we knew the particular
protein which is poisoning our patient, we could ap-
ply the "few protein" diet, and in theory at least
work out his salvation.
Heredity no doubt is a factor in arteriosclerosis.
The legacy of lowered resistance makes for the sec-
ond generation a special susceptibility for the in-
sidious advances of the gouty or uric-acid diathesis,
with the complicating arteriosclerosis. This type
seems to be unusually prone to meat-protein pois-
oning, and it is for them to be well advised as to
dietetics. Then again there are types primarily
normal in every physical sense, who unguided carve
nut their own cycle of existence. Their years are
punctuated with a history all their own. a history of
overindulgence in eating and drinking. They burn
more than their quota of midnight oil in satisfying
their mental and physical sense. And finally hav-
ing fulfilled all the elements in the formula for
producing arteriosclerosis, with high blood pres-
sure and casts in the urine, they drop out in cross-
ing the crucial bridge. As another example we
have the earnest strenuous workers in both busi-
ness and professional lines, whose brains acting in
Nov. 18, 1916J
MEDICAL RECORD.
883
close concentration keep the mental and physical
forces at extreme high tension. With them the day
of rest is ever an advancing point, an anticipated
goal, evanescent as the will-o'-the wisp. There is
no doubt, especially in this class, that certain
poisons are developed probably from intestinal
sources which have not yet been identified, which
are produced by lowered resistance through high
systemic tension. The toxins acting slowly and in-
sidiously gradually undermine the vitality, causing
increased blood pressure, cardiovascular changes
and finally apoplexy or invalidism.
Uric Acid. — In gout there is always an excess of
uric acid in the blood, and the prime lesion of gout
is the deposition of uric acid in the form of sodium
biurate at the points of least resistance. Although
uric acid is always found in excess in the blood in
even incipient gout, there is a growing conviction
that it plays a secondary part in the symptom com-
plex. Futcher emphasizes this in stating that uric
acid is a mere weapon of greater forces compara-
tively unknown. There is no experimental proof
that an excess of uric acid causes special toxic
symptoms. The summary of the uric acid argument
is that uric acid, or irregular gout, is a disease of
intermediary purin metabolism, in which certain
tissue ferments play an important role, and some
unknown toxic agent or throw down of purin
metabolism is the controlling force in the insidious
terminal results.
Chronic arthritis may have an indirect affinity
with the gouty diathesis; or again chronic arthritis
may be acquired from a focal source due to a
chronic confined infection or possibly some form
of intestinal toxin. An examination of 498 cases
of chronic arthritis in the service of Dr. Frank
Billings furnished valuable information on the inci-
dence of mouth infections, 76 per cent, of these
showed well defined pyorrhea after a--ray examina-
tion. Focal sources of infection are usually found
in the head in the form of alveolar abscess, tonsillar
abscess, and various chronic sinus conditions. Bill-
ings considers focal infection as largely responsible
for arthritis, chronic appendicitis, cholecystitis,
pancreatitis, etc. In focal infection extreme diffi-
culty has been experienced by observers in isolat-
ing the specific germ or germs. It is not found
in the joint cavities, the place usually examined,
but it is found in the areolar tissue about the joint.
This definite organism has been isolated from the
human subject afflicted with rheumatic fever in-
jected into rabbits producing a disease identical
with that in man — this has been confirmed by
Tuboulet and Wassermann.
Rosenow emphasizes the fact that focal sites of
infection furnish a place where bacteria may ac-
quire new properties. These properties are brought
about by a mutation or change of bacteria from one
type into another type of radically different toxic
effect.
Elliott also writes that in the treatment of our
patients from focal infections the autogenous vac-
cines in order to be of any avail must be obtained
from closed cayities under proper antiseptic pre-
cautions. These cavities are practically human test-
tubes, and the streptococci in these concealed cavities
under low oxygen pressure and in the presence of
other bacteria lose their virulence and acquire a
special affinity for joints or the endocardium.
Raines' theory that the organism causing the
arthritis may also attack the nervous system is
generally accepted. Any break in the normal must
be met by prompt action especially at the crucial
age when the defenses are weakening.
Diabetes Mellitus. — According to the United
States mortality Statistics of 1909, diabetes mel-
litus is most common after forty, and therefore is
a distinct menace to mankind at the vulnerable age.
It is the belief of some authors that diabetes is be-
coming more frequent, the assigned cause being
increasing wealth and consequent indulgence. Fos-
ter, however, asserts that better evidence is re-
quired to establish the fact. No theory has been
advanced which explains to us all the insidious in-
fluences of this disease; the hypotheses brought
forward evidently move us nearer a final solution,
but in the meantime the general practitioner awaits
the final verdict of the laboratory. Palacios con-
siders diabetes a disturbance of metabolism from
intestinal toxins. Allen holds that an amboceptor
normally supplied by the pancreas is lacking in the
disease state, and in default of amboceptor the cells
are unable to fix and utilize the sugar.
Warthim and Wilson very recently showed his-
tological syphilitic changes in six autopsies on dia-
betics, four showing the Spirocheta pallida in the
myocardium; they deduce the conclusion that "it
is very probable that latent syphilis is the chief
factor in the production of this form of pancreatitis
most frequently associated with diabetes, but dia-
betes is not always coincident with severe degrees
of pancreatitis." Our present precise methods of
treatment of diabetes mellitus are due to the well
conceived idea of Dr. Frederick Allen, and through
this impetus medicine has made a great stride
forward in the management of this disease. Due
credit should also be given to Nellis Foster, Joslin,
and others, who have sustained this work in the
study of human chemistry. Allen's methods are
too well known to you for repetition, but I would
emphasize that to be distinctly true to his plan,
two weeks' initial treatment at least should be given
your patient in a hospital, in close proximity to
the laboratory. For it is only keen observation
of the daily urinary changes and the physical con-
dition of our patient' that makes for ultimate suc-
cess in true diabetes. Consider, however, your
diabetic at the crucial age also afflicted with
arteriosclerosis, traces of albumin in the urine and
casts. This picture presents to you a problem de-
manding special skill to pilot your patient safely
between the frowning rocks of dietetic possibilities.
It has been well said that under such a cloud we
must treat the man, not the disease, for the latter
is incurable. We must rely on the proteins of milk,
cream and cheese, and establish an index of toler-
ance toward certain foods as oatmeal and various
starches. In order to keep our patient up to the
highest possible point of physical energy, the caloric
estimate of daily food consumption must be care-
fully made. Watch carefully heart and kidney func-
tion, being always alert to counterbalance an in-
tensification of symptoms toward either disease.
Summary. — In this general review of real and
theoretical data of possible causes of degenerative
changes, we appreciate full well that the laboratory
worker and clinician only partially answer the ques-
tion of the possibility of conserving and prolonging
life at the crucial age. In the face of this obscurity
it behooves us to take the fragments of established
fact and weave them into rules and methods and
apply them with energy. In estimating the known
processes of degeneration at middle life, there is
but slight variance of opinion in the deduction that
884
MEDICAL RECORD.
[Nov. 18, 1916
toxins and acids are the insidious factors in grad-
ually disturbing the balance and control of the
human organism. These toxins, known and un-
known as far as science has determined, are those
generated in the intestines, those generated through
faulty metabolism, and also those generated from
infective or focal sources. Imbued with this present
day enlightenment, we should advise our patients
along a broad common-sense line of procedure. Indi-
vidualize every case, appreciating that ancestry,
mode of life, environment, and hygienic conditions
are as important in the final estimate as the chemi-
cal and physical findings.
A full synopsis of causes bearing upon the integ-
rity of individual welfare must be made with all
the mechanical and laboratory aid within our scope.
For this type of manhood relegate medicines to an
accessible port, for refuge only in case of storm.
Treat toxemia largely as a dietetic error, and regu-
late your individual diet lists accordingly. Food de-
mands must be met by careful caloric estimates. As
meat protein is especially susceptible to putrefactive
changes in the intestines its use should be strictly
limited. Substitute to an extent cheese for meat
protein unless cheese indigestion forbids. Use vege-
tables and greens and the carbohydrates generally
with milk and milk products. The use of fruits
is largely a matter of individual estimate. If uric
acid with gouty conditions prevail, acid fruits are
forbidden, and the same argument holds true in a
rheumatic diathesis. The use of tobacco and alco-
holic beverages should be regulated through care-
ful judgment as to individual temperament. My
experience proves that a starvation day at stated
intervals enables nature's defenses to reestablish
their functions. Daily bowel actions are imperative,
and this must be largely brought about with a ratio
of coarse-grained food in conjunction with exercise
and abdominal massage. Avoid cathartics as far
as possible, but if laxatives are required high grade
mineral oils hold the preference. A fortnightly
dose of castor oil lowers decidedly toxic absorption.
For the extreme nervous tension of business and
professional life, exercise in the open air is ideal.
But exercise must always be tempered with caution,
holding in mind that the rust of age is slightly in
evidence. Walking either on the golf field, street,
or country road, meets every requirement for re-
laxation of mind and body. The strong argument,
however, leading to prolongation of life, is the con-
sistent and judicious arrangement of periods of rest
be it either in hours, days, or months. Nature de-
mands recuperation and the penalty will be paid
unless due heed is paid to her demands.
These brief deductions drawn from theory and
practical fact, point out to us clearly, that with all
our science, Humboldt was about right when he
said, "Health is the most admirable manifestation
of right living."
Pelvic Lavage. — H. L. Kretsehmer and F. W. Gaarde
publish their results with the treatment of colon bacillus
pyelitis by this procedure. Acute cases are not included.
They say that from their results they believe that pelvic
lavage gives a greater number of bacteriologic cures in
a less space of time than any other form of treatment,
but it is important to insure a sterile urine in order to
prevent recurrences. The number of injections required
varies from one to eight. In several instances they ob-
tained sterile mine after one or two treatments in
patients who had been on internal treatment for many
months without results. In patients failing to respond
to this form of treatment there may be conditions other
than simple pyelitis, such as tuberculosis, calculus, or
ureteral stricture. — Journal Am. Med. Association,
.MENTAL HYGIENE.
Br HENRY M. FRIEDMAN, M.D., LL.M.,
NEW YORK.
M TING ASSISTANT SURGEON, UNITED STATES PUBLIC HEALTH
SERVICE.
No one can long be in contact with the mentally
ill, any more than he can be in contact with the
physically ill, without being brought face to face
with the questions of causation, of prevention, and,
m a lesser degree, of cure. In view of the number
of the afflicted, of the universality of their dis-
tribution, the physician is in constant touch with
them and with the hereditary, social, environmen-
tal, as well as medical conditions which must be
at their base. He has the opportunity of seeing
the cases in embryo as well as when fully devel-
oped. Unfortunately, he does not often recognize
the relation between early symptoms and fully de-
veloped cases. Those especially interested in men-
tal conditions usually see only the fully developed
cases — and in the hopeless stages. But for the
physician to be able to help in preventive work he
must be well orientated on this widely distributed
malady. Often, however, even though he sees the
causes that operate, and recognizes their signifi-
cance in the development of these conditions, he is
yet unable to prevent their coming into being or
to encompass their removal, because the causes are
so general, so basic, that they are quite beyond
the individual to influence. Yet, unless he is well
informed, he cannot be in position to urge on the
public the necessary remedial measures. The phy-
sician can arouse the public to demand the pro-
tection of the mental health of the public, to pro-
mote the study of diseases of the mind, and to
ameliorate the condition of the afflicted. These
are, in a broad way, the elements of mental hy-
giene.
Mental hygiene is a medical problem, not a lay
one, except possibly in the field work. Even there
the medical man is of infinitely more value. The
nature of mental conditions is not nearly so myste-
rious as the nature of many physical conditions. It
is perhaps not too radical to say that mental con-
ditions are as easily diagnosed as the physical, and
that the first steps in evolving therapeutic, but
especially prophylactic measures, have long since
passed. General knowledge can be further encour-
aged by opening the psychopathic wards to the
profession, by lectures, and by clinics. The idea
that insanity and other mental conditions are, so
to say, ultra-pathological, and not possible of com-
prehension or of attack except by the specially
qualified or "anointed" specialist, must be cleared
away here, as elsewhere, before much progress can
be made in the movement for mental hygiene. They
are as amenable to the ordinary medical mind as
other pathological conditions. They are neither
vague nor mysterious.
In speaking of mental hygiene, it is hard for
many to conceive of the applicability of so definite
;i term as hygiene to the heretofore vague and
nebulous conceptions of the mind. We usually think
of hygiene in terms of the bath, the antiseptic, sew-
age, food, and the like. Yet whether metaphori-
cally "i- actually, these factors all have their ana-
logues with respect to the mind. Mental hygiene
is, in fact, the basis of all hygiene, since right
thinking includes the observance of all hygienic
considerations and of all health regulations. At any
rate, whether figuratively or not, there are certain
Nov. 18, 1916]
MEDICAL RECORD.
885
definite matters the institution of which, or the
correction of others, lend themselves to the con-
servation of the mind. The field is wide and va-
ried. It embraces hygienic breeding, actual hy-
giene of the body, prevention of disease and cor-
rection of defects, moderation in the use of food,
drugs, and alcohol, abstenance from excesses of all
kinds, general improvement of social conditions,
proper mental, physical, and vocational training.
It also embraces the segregation of the mentally
defective and the mentally disordered in proper
institutions or hospitals for observation, diagnosis,
and treatment, so that they may not be in position
to exert a deleterious influence on others. It in-
cludes, further, the teaching of right and proper
methods of thinking, the training of even tempera-
ments, the encouragement of healthful interests,
proper introspection, and the discouragement of
improper, artificial, or masturbatory mental habits.
Neither school training alone nor home training
alone is sufficient to carry out this aim; but both
must work in intelligent co-operation.
Heredity plays an important part in mental
states but usually only as the foundation for a su-
perimposed abnormal structure built thereon by
adverse conditions. There would otherwise be a
foundation but no structure. Indeed, it is the
aim of mental hygiene to prevent the building of
such a structure over an hereditarily defective
foundation. On the other hand, many of the men-
tal conditions are not entirely preventable because
they seem to be handed down as such from ancestor
to progeny, as is so well illustrated in the profound
mental deficiencies. There are less profound con-
ditions which are handed down as weakened or
inferior constitutions, which, however, requires
some environmental adversity to activate. In the
matter of prevention, or of hygiene, the only thing
that can be done with them is early apprehension
and segregation so that they may not come in con-
tact with adverse conditions, and especially so that
these stocks may be prevented from passing their
defective strains to others. The epileptic, the fee-
bleminded, and the insane are really subjects of
notifiable disease conditions. There is as much
contagion in them as in infectious diseases — either
through improper example or the development or
propagation of inferior strains. The clearing-house
idea and compulsory central notification of all cases
will do much to eradicate tfiem. There are too
many illustrations of the hereditary factor in re-
spect to the central nervous system to warrant
overlooking or underestimating it in the slightest
degree.
The best method of keeping down the defective
population has not yet been determined. Marriage
laws are unsatisfactory because of the very nature
of laws which are capable of combat, varied inter-
pretation and nullification because of the reading
into the law of so many exceptions. Although the
requirement of health certificates, based on exami-
nation before marriage, is a step in the right direc-
tion, practically, it has not been found to *vork
out satisfactorily because of the ease with which,
for example, syphilitic reactions can be masked, or
the difficulty of recognizing incipient conditions,
and the injustice of refusing permission to marry
to those of defective stock, although they may be
greater factors in the transmission of this strain
than even those with acquired disease conditions.
From 50 to 70 per centum of the mental cases are
hereditary. Defectives seem to be especially pro-
lific, probably because they are really lower forms
of beings. For institution defectives, criminals,
etc., sterilization would seem to be the method of
election to destroy the strain. There is, however,,
a great deal of opposition to this procedure be-
cause it is considered cruel, a deprivation of the
human right of procreation, and on the ground
that the laws of heredity are not yet clear enough
on which to found so radical a departure. The
study of the laws of heredity promises to be one
of the most fruitful fields of human endeavor. At
any rate, it is even now obvious that the mental
hygiene of the individual must be enforced in the
ancestor to be of value to the offspring.
Perhaps one of the largest contributions to the
defective element of this country comes through
immigration. This is quite natural, for immigra-
tion no longer demands the facing of hardships
such as was encountered in pioneer days. On the
contrary, it is often the path of least resistance for
those who are unable to make a place for them-
selves among their own. Not only is there the
likelihood of mass admixtures of defective individ-
uals or of defective stocks but of whole atavistic
or aboriginal races. Unless this source is strictly
censored, not only with relation to the actual de-
fectives but with relation to the potentially defec-
tive or constitutionally inferior, the more domestic
or local measures will be continually bowled over
by the influx of great numbers of these sources of
contamination. Even the keeping out of such
stocks en masse is not too radical a measure to
prevent contamination. The prevention of the mar-
riage of defectives, or other means of inhibiting
their further propagation, the exclusion of alien
foci of "infection' are hygienic measures of su-
preme importance.
While the hereditary cases may be considered in
the light of damage already done and in so far
irremediable, the great mass of acquired disease,
which is causative of much of the mental disease
incidence, and against which mental hygiene must
be especially aimed, is almost entirely preventable.
These acquired genetic factors include syphilis, al-
coholism, tuberculosis, arterial degeneration, etc.
Alcohol alone causes about 20 per centum of the in-
sanities, while the so-called parasyphilitic nervous
and mental diseases are almost entirely, if not
entirely, syphilitic in origin. Even the many ap-
parently innocent neuroses are of immediate luetic
origin or are more indirectly the last shoots of a
luetic ancestry. With alcohol may be included the
excessive use of drugs. The increase of that part
of the incidence of insanity caused by the increased
consumption of alcohol and drugs, and against
which the campaign for mental hygiene is especially
directed. is made clear when one considers that in
the last 20 years there has been an increase of 750
per centum in the use of drugs with an expenditure
of over 150 million dollars per annum. Even if
toxic, somatic, or other pathological conditions are
not directly causative they are at least provocative.
They are still, without doubt, intangible psycho-
genic bases combined with the acquired — both must
be read together, too much importance placed on
neither.
Among acquired conditions predisposing to, or
causing insanity, and in the nature of intoxica-
tions, are the various infectious diseases, parasitic
diseases, nutritional diseases, and internal gland
diseases. There is a biochemical relation between
mind and body; their greatest forces for good must
886
MEDICAL RECORD.
[Nov. 18, 1916
go together. Before attempting either to prevent
or to treat mental conditions the physical condition
must be inquired into. The part played by the
hormones, the secretions of the ductless glands, in
the causation of mental deficiency and mental dis-
turbances has recently gained much prominence. It
is a mooted question whether or not in mental con-
ditions, where hereditary and somatic factors are
not evident, the cause cannot be found in the in-
ternal secretions, as is illustrated in the mental
states in thyroid disease, acromegaly, Addison's
disease, etc. The prevention of all these must be
left to preventive medicine. Their eradication will
in so much reduce the field of the psychiatrist or of
the mental hygienist.
Generally poor environmental and unhygienic
conditions resulting from congestion, poverty, and
ignorance are not, however, individually preventi-
ve factors. The hygienist must call the attention
of the public to the significance of these conditions
in the perpetuation of mental conditions and in
arousing the public conscience to the improvement
of general and social conditions. The movement
of mental hygiene is broad enough to call for a
social organization to combat this malady. Social
medicine has now a definite place in the medical
sciences. The improvement of conditions among
the sick as well as among the well is quite within
the sphere of social medicine. It already has an
established place in many large medical institu-
tions— with follow-up work, help, and advice sub-
sequent to hospital or clinic treatment. This sort
of work is even more necessary in psychopathic
conditions. Pernicious social influences often acti-
vate the constitutionally inferior. For these a de-
sirable environment must be created to keep them
from changing from latent to active. Adverse
environment acts badly on an already prepared
mind — a mind prepared by heredity, by acquired
disease, by vices, or by excesses.
Overspeed, highpressure, and overwork in the
strenuous life of modern times are large contribu-
tors toward mental and physical degeneration.
There is a tendency to overspeed for long periods
without much rest, which soon breaks the worker
down — a tendency to product-efficiency without in-
dividual physical efficiency. There seems to be,
moreover, also an individual desire to work for a
short period of life, at great speed, to acquire suffi-
cient money to live a life of prolonged ease there-
after. It so often culminates, however, in mental
and physical breakdown, and is, altogether, very
poor economy. Likewise, speedy maturity, forced
by improper methods of education, especially in the
precocious, encourages early decline, decay, and
mental deterioration. In these endeavors we take
a great deal of stimulation of all kinds — with dire
results to the nervous system. Such stimulants as
alcohol, drugs, and pernicious sexual habits all help
to hasten one to this end. Alcohol, syphilis, and
speed are a trinity that causes much insanity.
Moreover, there are many congenital and ac-
quired physical and sensory conditions which either
retard mental development or irritate the nervous
system and cause respectively deficiency or dis-
order. The correction of eye, ear, and nervous con-
ditions is often preventive and curative of some
very profound mental states. The correction of de-
fects in early life goes a long way to prevent the
development of disorder and disease especially in
those with poor constitutions.
Of prime importance in all hygiene, as well in
mental hygiene, and in the correction of ills, mal-
developments, etc., is physical training. Logically,
physical training is the first step in mental train-
ing. A mind devoting itself to physical hygiene is
devoting itself at the same time to mental hygiene.
Mems sana in corpore sano is more true than ever
before. Physical training, unlike education, must
be begun early. It must be maintained through-
out life. It is a habit that does away with many
of the postural and sedentary ills of life. It sup-
plies the strength and endurance needed in so many
occupations and from which the weak are barred.
Physical weakness causes economic weakness, dis-
turbances, and poverty — all inevitable forerunners
of disease and disorder.
Sedentary persons have whole systems of unused
muscles, and in them corresponding brain areas are
rendered useless. It is to this class that the neu-
ropaths especially belong. Motor energy stored up
by proper muscular energy can be used or con-
verted into mental energy. The one is really re-
serve force for the other. The development of
one goes hand in hand with the other. Neither can
very well get along without the other. Muscular co-
ordination and muscular action are the first things
taught the mentally defective. It is through mus-
cular activity that it is hoped to arouse the neigh-
boring and bordering mental centers. Physical
training must be selective — to bring out retarded
muscle groups. The same physical education can-
not be given to every person. In physical as well
as in mental training each individual is a case by
himself. Muscular development and physical train-
ing develop useful central activities, purposeful ac-
tion, and do not encourage aimless, tiresome, fa-
tiguing, and exhaustive activities. The strongest
mind is the one with the least peripheral — useless —
activity. It is the one in which most of the unused
energy can be converted into mental energy, or
used elsewhere in an emergency.
Mental training, while it includes, docs not mean
entirely educative training. In the last analysis,
education is really only a training of the memory
— to be sure, the most important faculty. Educa-
tion lays up information that can be drawn from
when needed. But perhaps more important than
training the memory and laying up information,
at least in the interest of mental stability, is the
training of the disposition, the temperament, the
general character, of proper methods of thinking.
of control of the passions, of introspection, of an
understanding of the proper proportion of things,
of altruistic and of sympathetic traits, of rapid
decision, etc. Indecision is the result of improper
training. It is almost worse than too hasty and
too superficial decision. Whether by religious
methods or otherwise the cultivation of an altruis-
tic sense is a help in maintaining mental equilib-
rium. Individual faculties which are found re-
tarded must receive special training. It is only in
this way that failures and disappointments can be
prevented. These are themselves very severe men-
tal traumata, conducive to the development of mor-
bid mental states.
Insanity is rarely of sudden onset; it is the
result usually of long standing and continued abuse
of the mind, of the body, or of both. Besides, there
are premonitory symptoms, often subtle, more often
well marked. They may manifest themselves in
changes of temperament, of disposition, of char-
acter, etc. Personal characteristics are usually very
much an organic part of an individual and, normal-
Nov. 18, 1916]
MEDICAL RECORD.
887
ly, do not undergo sudden changes. It is difficult
enough to train them purposely, and then only, if
at all, after constant and studied effort. A change
in personal character is always significant. For-
tunately, in most individuals such a change does
not go beyond this stage and does not degenerate
into a definite psychosis, especially if there has
been early mental training, or if the abuse of the
mind has not been too severe. On the other hand,
if the significance of the mere change is not recog-
nized and the abuse, overspeed, or excitement, con-
tinues, the change turns into a distinct abnormality.
And it is thus far the sad experience that when
once the boundary lines of change have been over-
stepped return to the normal is not usual. It may
be that the environment that provoked the original
condition is still operating and keeps the patient
under, or especially because facilities for early indi-
vidual treatment are not yet afforded; besides, fa-
vorable environment is not an element easy to pro-
cure. Cures are not nearly such hopeful outcomes
as prophylactic measures. Many of the cures are
not really cures of the insane but of the pre-insane;
and it is in these pre-insane especially that the
greatest good can come from mental hygiene, and
from voluntary admission into psychopathic hos-
pitals.
Mental hygiene is as broad and comprehensive
as preventive medicine, perhaps broader; it is too
comprehensive to be definite. The prevention of
every abuse comes within its folds. Mental stress
and lack of adequate rest from fatigue are two
cardinal causes of insanity. They may be classed
among the toxic causes because the accumulation
of the fatigue products acts as an organic poison.
High pressure requirements can in a measure be
overcome by periodic rests, changes, or vacations.
Change is particularly a great regenerator and re-
juvenator. Change of scene and recreation will very
often anticipate a mental breakdown. Even the
change of scene given in an asylum or hospital is
of such benefit; and it is for this reason that it is
now universally advocated that persons threatened
with mental disturbances apply for voluntary ad-
mission to a psychopathic hospital long before the
actual break has taken place.
While heretofore the operation of prophylactic
measures did not seem as plain where the mind was
concerned as in the more tangible somatic condi-
tions, thanks to the mental hygiene movement it is
becoming more apparent each day. The develop-
ment and the conservation of the mental faculties
are as important to mental health as the develop-
ment of the muscles to bodily health. An empty
and untrained mind is not a healthy mind. Atrophy
is not health. Work and exercise are as necessary
to mind as to body — but not overwork. The at-
tempt to educate a nervous or feeble mind under
the same conditions of speed and pressure as the
normal child is as bad as requiring all children, no
matter what their muscular capacity, to undergo
the same amount and the same kind of physical
training. Exhaustion must follow in both in-
stances. The separation of children into appropri-
ate groups for education and for physical develop-
ment is a measure of highest prophylactic and
hygienic importance. The school competitive sys-
tem is not desirable for the rapidly growing child.
It is perhaps that from the realization of this factor
that the various new methods of individual teach-
ing for children have sprung up. The competitive
system is the cause of a great deal of menstrual re-
tardation, hysterical manifestations, and psycho-
pathic symptoms in girls about the period of
pubercy. An average minimum need for a school
class should be the only one established and main-
tained. Native ability will come out in due time
without competitive stimulation. Competition is
best left for later life, and there is already too
much of it even there.
Academic education for those who have ability
or inclination only for vocational work causes many
failures and disappointments, and acts as a direct
injury to the nervous system which is so often
permanent. It is highly fatiguing to these motor-
minded individuals and its continuance is unhy-
gienic. The teacher should be able to recognize
mental fatigue and to provide against it. Fatigue,
rest, habit, etc., are elements in the child with
which the teacher should be convei-sant. The
teacher can carry out her part in the movement for
mental hygiene by being familiar with the physio-
logical and psychological needs of her pupil. Fa-
tigue is often a matter of bad training. It is just
as necessary to build up a mental reserve force as
it is a physical reserve force, for use in emergen-
cies. Without proper drill aimed at individual
needs, capabilities, and possibilities the school be-
comes merely a forcing or cramming medium.
School inspection and child surveys are the means
of bringing to light the defective, and the nature
of their deficiencies. Coupled with investigation,
entire defective family strains can be detected.
Proper follow-up work with the defective families
can do much to reduce "return" or new cases, as it
has done in such diseases as tuberculosis.
Mental retardation and mental defect are not,
however, synonymous. Retardation is due to dis-
use and to neglect; defect is due to inherent brain
defect. The apparent results may, however, be the
same if care is not taken to differentiate them.
Every mental faculty, memory, attention, will, etc.,
may be retarded through neglect in training and
through disuse. The lack of discipline of home or
of school permits the mind to lag and allows out-
side pernicious influences the easier to take hold.
Lack of interest follows lack of understanding. It
is the discipline of effort, of work, of interest, that
trains the mental faculties into habits of work and
habits of right thinking. It takes the mind away
from the many pernicious extrinsic psychological
processes, so conducive to mental disturbances. In
the better classes especially are nervous disorders
the result of idleness, sedentary life, and a lack of
proper mental interests. The ordinary forms of
amusement are no longer satisfying to them, and
excesses of various kinds are the natural results
They become blase, introspective, self-centered, they
suffer from functional nervous disorders, and then,
lastly, actual psychoses. An unproductive life, no
matter in what sphere of society, as well as all
forms of overstimulation are factors in the develop-
ment of mental disturbances. Mental and physical
activity are hygienic and therapeutic measures,
when properly selected and not overdone.
Mental training must include a training of self-
reliance, else there will ensue a sort of negativism,
indecision, apathy, and lack of mental energy.
While these may be due to fatigue they are more
often due to neglect. The acquirement of desirable
mental habits is, likewise, a matter of training.
Distinct effort will cure the tendency to trivial
anxieties and worries. Perhaps encouragement to
unburden themselves of their worries and anxieties
888
MEDICAL RECORD.
[Nov. 18, 1916
immediately as they occur to some one who is sym-
pathetic, perhaps to counsellors and confessors, will
be helpful. This may be the human origin of the
confessional — and the calm and ease it affords those
who can take advantage of it justifies its use.
Habits of exaggerating, of looking for slight
personal affronts to brood over must be discour-
aged during the developmental period. The ten-
dency can in a measure be overcome by teaching
a philosophic analysis of things — a better under-
standing of real proportions in life. A relentless
hunt for the good in the bad — for the sunny side
of life, is a great help in overcoming such baneful
mental habits as suspiciousness, supersensitive-
ness, seclusiveness, anxiety, fear, despondency, un-
due excitement, idleness, day dreaming, and the
like.
The neuropathic, nervous children must be ex-
posed to some adversity — to the elements, so to say
— and not coddled too much ; they must be encour-
aged to learn their own legs; they must be "hard-
ened." Children who rarely display any emotion,
and are of the "shut-in" type, must even be goaded
to the display of emotion, almost by any method,
in order that they may have an opportunity to in-
dulge in the "gymnastics of emotion." Environment
has a great deal to do with the development of de-
sirable mental habits, and unless the desirable ones
are knowingly developed and the undesirable ones
knowingly eradicated the mind will founder with
the first ill wind. Favorable external influences
such as are furnished by settlements, recreation
and community centers are hygienic measures social
in nature and of very first importance. It is with
this sort of therapeutics and prophylaxis that social
medicine is concerned. For the very weakest men-
tally, occupations must be furnished that keep the
mind pleasurably occupied, so that they may have
no time to exercise their morbid mental habits.
Perhaps the acquirements of hobbies is a valuable
preventive measure.
Intense emotion is just as fatiguing as mental
or motor effort. In early life, at least, and in the
neuropathic, it must be studiously avoided. Those
who are temperamentally thus inclined should be
urged to keep away from displays, exhibitions, or
anything which they know from experience has a
tendency to arouse intense emotion — at least until
they have trained themselves against it. To be of
value to the organism emotion must be followed by
action; much emotion should not be allowed to ac-
cumulate without some commensurate action. Dis-
tinct vital energies, without any adequate return.
are consumed by such displays of emotion as anger,
jealousy, etc. The telling of fear stories to chil-
dren arouses emotion which often remains as a dis-
tinct psychic injury. For the same reason children
should never be led into experiences that do not
perfectly belong to their years.
Thus far the treatment of mental conditions has
been almost entirely custodial. There were main-
tained asylums or retreats from which few returned.
Yet even with the mere improvement of the custo-
dial care given these patients the number of cures
have increased. Further improvement with respect
to facilities, space, etc.. coupled with a rational
search for the genetic factors will return many
more to society. For incipient cases, for the so-
called psychoneurosis, psychasthenics, voluntary ad-
mission to hospitals are recognized to be prominent
factors in prophylaxis. Even mere residence in a
nital i= of benefit because it takes these patients
away from the noise and turmoil of life, from which
they are really suffering and from which they seek
to escape and submerge in the form of their delu-
sions. The opportunity given for observation, diag-
nosis, and the correction of somatic difficulties must
prove helpful. If indicated, psychoanalytic treat-
ment can be given under the very best conditions.
Hospital care can be combined with rest, work,
exercise, and occupation.
On the other hand, definite therapeutic measures
in the treatment of the insane has practically not
yet been developed, except in the more recent meth-
ods of psychoanalysis. It is plain that the mentally
ill must be taught to find themselves. And what-
ever may be said in criticism of the methods, prin-
ciples, or possibilities of psychoanalysis this has
been the means of opening the field of active treat-
ment in cases heretofore closed to any but passive
measures. Time and study will reveal how much
actual merit there is in the method. It is intended
by this to teach patients to find themselves by hav-
ing them abandon their own aimless introspection
and substituting instead a more methodical and
rational introspection — an analytical and not a path-
ological introspection. Eventually, psychoanalysis
must have its place taken by a sort of autopsychoan-
alysis — if the benefits are to be very broad. Ra-
tional psychoanalysis contemplates teaching the pa-
tient to become a "more rational, thoughtful, and
mature individual." Here lies its place in mental
hygiene. Psychoanalysis searches for the truth be-
hind any impression, in order that the impression
may not soar into the mysterious, beyond control,
where it becomes a fascination from which it is
hard to withdraw; not to allow impressions to be-
come exaggerated, not to allow them to grow need-
lessly, but to analyze, interpret and separate all
thoughts that obscess the patient into their com-
ponent or genetic factors. In order to be in a posi-
tion at any time to offer mental aid to a patient
it is necessary to make complete analyses of the
personality with respect to traits, habits, work, etc.,
so that any breach may be found and filled in. In
all forms of mental treatment or of mental work a
degree of intimacy, sympathy, and confidence must
lie maintained, much beyond that required in ordi-
nary medical work.
Ordinary psychological investigations deal with
motor, sensory, and purely intellectual elements;
but these are difficult to interpret in terms of their
dynamic relation to the personality of the individual
— which is disordered in the insane. These latter
may be called the intrinsic psychologic elements as
against the former or extrinsic which deal with the
external dynamic manifestations of the mind. It
is with the intrinsic elements that psychotherapeu-
tics is concerned. Therapeutic measures attempt to
create order out of disorder, comprehension out of
misapprehension — to clear away the psychic debris
whose presence lends to unhygienic conditions in
the mind.
One is said to be well balanced mentally who is
able to hold and does hold a proper relation to his
environment; he is unbalanced when in a dynamic
sense be is disturbed by such psychogenic factors
as conflicts, tansrles. day dreams, etc. There is,
then, no sharp line of demarcation between sanity
and insanity. It is the ability to adjust or to read-
just oneself under adversitv which determines
sanity or insanity. To cure means to help to read-
just. Mental hygiene mav mean a general readjust-
ment of environment to the many of a class against
Nov. 18, 1916]
MEDICAL RECORD.
X.VJ
mere individual adjustment. During the period of
maladjustment, there are manifestations of temper,
fads, fancies, seclusiveness, etc. Normal persons
may have these same symptoms after stress, but
they are the normal ones because they are able to
overcome them, and to readjust themselves, while
the abnormal cannot — at least not without help.
In the body, fever, pain, and other reactions are
Nature's efforts at protection; in the mind, such
manifestations as delusions, illusions, etc., are ef-
forts of the mind at readjustment, or attempts in
this way to get away from sources of irritation.
These are attempts to become readjusted to an en-
vironment of difficulty. There is an attempt to re-
establish an equilibrium. We usually see only those
who fail in these attempts. Those who have suc-
ceeded do not come under observation. As in other
conditions a great many get well without observa-
tion, and, of course, without treatment. More of
this type can get well, or, better, can avoid becom-
ing ill, by conforming to general and mental hy-
gienic measures. In respect to the mind, then, we
are concerned mainly with the failures at readjust-
ment, but we must also make it easier for the suc-
cessful to determine a successful issue.
On the other hand, psychoanalysis has its limita-
tions. By its very nature it is a therapeutic meas-
ure of refinement in language taking place between
patient and physician. The best results can occur
only in those who by nature or through education
have acquired sufficient refinement of language so
that many of the subtle variations of expressing
mental processes can be conveyed to them. To the
crude, whose range of language is restricted to the
lower degrees of expressions — expressions even
much lower than the sum of their very few experi-
ences— in whom there is not even language for the
grossest of their experiences, analysis cannot be
made. Besides, of course, it cannot be applied to
the excited or to the deeply depressed. It is limited
in its action to the pre-insane, as a prophylactic
measure, and is in no wise a panacea for all mental
ills. Psychoanalysis is a therapeutic measure rich
in language, in terms, and in expressions. The ex-
periences of the ignorant are more often bodily than
psychic. The range within which there can be in-
jury of their minds is very small. A wealth of
psychic experiences and actions in a constitution-
ally inferior mind are the most prolific causes of
mental injuries.
Undue repression of desires, emotions, and senti-
ments are psychogenic factors, and while normally a
certain amount of repression is necessary for social
order, the weak can stand little of it. and perhaps
even the strong not too much of it without harm.
Society demands a certain amount of repression.
It is the cognizance of the need for this demand and
the ability to live up to it that makes for the
normal. The tendency in the young to undue re-
pression, dissociation of the personality into the
unreal and the imaginative, to indulgence in emo-
tional excesses and the like must be overcome by
substituting appropriate action and healthful rec-
reation. A little self-scrutiny does no harm, if it
becomes the means of knowing onself, and provided
it does not degenerate into too great an introspec-
tion: psvchoanalysis is the giving of therapeutic in-
trospection. The insane complex, in which there is
a submersion out of harm's way, is a medium of
protection. Psychotherapeutics must discover the
conditions from which the patient finds himself
forced to escape, and the removal of these condi-
tions is the goal of treatment. Many of us normal
beings submerge into minor depressions, the blues,
self-pity, self-engrossment, fantasy, etc., in order
to escape some unhappy or unpleasant condition;
we are normal, however, according to our ability to
rise again and stay on the surface. The abnormal
cannot, at least not without help, and even then some
not at all, because they have sunk for the third and
last time, so to say. Perhaps the ability to supply
them with a more fruitful, different, or less harm-
ful medium in which to submerge would not be so
fatal.
The elements in mental hygiene are, then, the
eradication of the hereditary element by restricting
propagation by known defectives, by eliminating
the disease, the drug, the alcoholic and the excess
factor in acquired mental conditions, by the ex-
clusion of alien foci of "infection," by the improve-
ment of general hygienic and social conditions, by
proper physical, mental, and vocational training, by
voluntary admission of the pre-insane into psycho-
pathic hospitals and the subsequent follow-up work,
by psychotherapeutics wherever possible, and lastly
by a better understanding by the profession at large
of the various phases of mental disorders and their
early recognition.
351 East Fiftieth Street.
THE TREATMENT OF MERCURIAL
STOMATITIS.*
Bt DOUGLASS W. MONTGOMERY. M.D..
SAN FRANCISCO. CAL.
Some years ago, in conversing with a friend on
the effect salvarsan would have on the treatment
of syphilis, he remarked that it would certainly
make us more strenuous in our employment of mer-
cury. That we have become more exact in our
dosage, and more methodical and more energetic in
the administration of mercury is most true. Pos-
sibly the reasons for this change are not so much
the introduction of salvarsan, however, as the dis-
covery of the spirochete and of the Wassermann
reaction. The first gives definiteness to our thera-
peutic thought, and the second impels us to secure
a negative result. In the endeavor to obtain a
negative result, however, we run the risk of causing
inconvenient or distressing symptoms from the drug
itself, and in giving mercury prolongedly, as must
be done in syphilis, one of the chief incidental acci-
dents is stomatitis.
Mercurial stomatitis is caused by the mercury
administered, but in many of its manifestations is
far from being directly due to it. The state of the
mouth and very especially the sanitary condition
of the teeth are of great importance in rendering
the patient susceptible to mercury. The mere pres-
ence of the teeth is important, as shown by the in-
frequency of stomatitis in infancy and in toothless
old age.
The Normal Mucous Membrane of the Mouth. —
The mucous membrane of the mouth should be pink
and smooth, and the normal gums should be firm
and should hug the teeth tightly. The interdental
pyramids of the gums should not be prominent but
should sit in between the teeth, so closing the space
around the neck. No matter how close the apposi-
tion may be, it nevertheless constitutes a weak joint
receptive to bacterial attack. An ideally perfect
mouth is, however, seldom seen except in infancy.
*Read before the Sonoma County Medical Society,
June 8, 1916.
890
MEDICAL RECORD.
[Nov. 18, 1916
The modern civilized man always has a gastro-
enteritis, the condition of which is reflected in his
oral cavity. In many people with a dirty mouth, a
coated tongue, and a foul alimentary canal, the gums
become spongy and redundant and fall away from
the teeth, leaving a more or less deep open groove
between the gum and the tooth, and besides this
the gum pyramids elongate and tend to flap out-
wards, leaving still larger pockets between the teeth.
Food is forced into these grooves and pockets, and
when the particles are protein they are attacked by
the anaerobic putrefactive bacteria, the deleterious
influence of which in combination with mercury,
will be taken up later.
The formation about the teeth of phosphate of
lime deposits, commonly called tartar, also throws
the gums away from their natural close apposition
to the teeth. After these inflammatory changes
have lasted sometime the gums shrink, exposing the
teeth still further to deleterious influences. Al-
though these conditions are not normal, yet their
presence in a more or less marked degree is so usual
as not to excite comment.
Effect of Mercury on the Mouth and Alimentary
Canal. — Mercury, no matter how given, excites the
alimentary canal throughout, and the larger the
dose the greater the effect. It causes redness and
tenderness of the mucous membrane of the mouth,
swelling of the gums and of the tongue, a disagree-
able metallic taste, a characteristic nauseating fetor
of the breath and salivation. The teeth become sen-
sitive in chewing, or when smartly clamped together,
or to acids or to heat, and especially to cold, such
as ice water, and they get a curious feeling of being
too long; in some cases they may loosen and even
fall out.
In considering the condition of the mouth the
state of the rest of the alimentary canal is of in-
terest, as any disturbance along it reflects itself in
the mouth. There may be redness and soreness of
the throat, with an abundant accumulation of frothy
mucus, such as is so graphically described by
Rabelais.1 Mercury may also cause icterus, vomit-
ing of glairy mucus, and painful diarrhea with
watery, mucous stools stained with blood, simulat-
ing dysentery.
The local trouble may give rise to severe neural-
gia of the fifth nerve. I well remember one of those
stubborn, elderly men with fixed habits of thought,
who consulted me on account of what he insisted
was a neuralgia due to syphilis. I found that be-
sides the neuralgia, he had tender, swollen gum-, a
wet mouth, and the familiar fetor, and he had been
receiving mercurial injections. The pain was so
intense that he felt overwhelmed by it, and was
bent on having me give him more mercury, although
evidently he already had had too much. With the
utmost difficulty I persuaded him to defer the mer-
curial treatment.
Mercury, therefore, when given to a man with a
normal mouth may, through its own physiological
action, cause highly disagreeable symptoms of a
ngestive nature, and when the oral cavity is illy
kept and irritable, mercury is especially adapted to
add seriously to his troubles.
The Interaction Between the Putrefactive Bac-
t, ria and Mercury. — Almkvist has worked out this
subject in a most fascinating way.1 As before men-
tioned, when the proteid foods are pressed into the
pockets about the teeth, or into the recesses of the
mouth, they are attacked by the anaerobic putre-
factive bacteria, principally the fusiform bacillus
of Plaut-Vincent and the Spirochseta dentium.
Among other iniquities perpetrated, these bacteria
form H2S gas.
When mercury is given, either by the mouth, by
inunctions, or subcutaneously, it is principally taken
up by the blood, and so circulates in the capillary
loops of the papillae of the mucous membrane of the
mouth. Here it comes in contact in the capillary
wall with the above-mentioned sulphureted hydro-
gen produced by the putrefactive bacteria, causing
a precipitate in these capillary walls of the black
sulphide of mercury. This black sulphide, H„S,
although usually estimated as being insoluble, is
only relatively so, as it exerts a detrimental action
upon the capillary loops, and interferes with the
function of the vessels in transmitting nourish-
ment, which in its turn, brings about degeneration
and molecular death of the superimposed epithe-
lium. This affected epithelium constitutes, there-
fore, additional dead proteid matter, furnishing
still more nutriment to the anaerobic putrefactive
bacteria, and so on progressively leading to erosions
and to ulcerations of greater or less extent and
depth, abscess formation, periostitis, necrosis, for
instance of the lower jaw, and even the death of
the patient.
Further investigations may either substantiate
or invalidate Almkvist's views of the sequence of
events constituted by the anaerobic bacteria, H.S,
H„S, and lesion of the capillary walls, but it is un-
likely that anything will be found to diminish the
etiological importance of the anaerobic bacteria
themselves as a cause of inflammation and ulcera-
tion in mercurial stomatitis. The weighty influence
of this knowledge in our estimation of this condi-
tion will be appreciated when treatment is consid-
ered.
Sensibility of Certain Locations in the Mouth. —
The gums just behind the lower last molars have
long been recognized as being particularly sensitive.
This seems partly due to the narrow angle between
the tooth and the ascending ramus of the lower jaw.
If the gum here becomes swollen it is apt to be
crowded and irritated in the angle. This irritation
is increased if the treatment falls at a time when
the wisdom tooth is breaking through the gum,
which is not such an unusual coincidence, as I have
two such cases in the office at present. Because
of the remoteness of this position also, it is difficult
to reach it with a tooth-brush, and therefore food
frequently lodges, ferments, and irritates. The
mucous membrane in this situation often rises into
a tender, easily bleeding point, which Almkvist says
is nothing more than an interdental pyramid. The
gums behind the upper front teeth are also, in my
experience, often sensitive, which may be also partly
due to the difficulty of getting a tooth brush into
this region, and the consequent accumulation of
tartar. In a patient under treatment now, this is
the only situation that is sensitive, but the sensi-
tiveness in him is not near the teeth, but a little
farther back on the riffles.
Almkvist says that he finds the gums behind the
upper last molars to be as sensitive as those behind
the lower last molars. He ascribes the sensitiveness
to the existence of a natural pocket, called the
pterygo-gingival angle. There is a fold of the mu-
cosa that extends downwards and outwards from
the palate to the gum. called the pterygo-gingival
fold. The above-mentioned pocket lies between this
fold, the tooth and the cheek, and is therefore called
the pterygogingival angle. It is my impression.
Nov. 18, 1916J
MEDICAL RECORD.
891
however, that the gums about the lower molars give
more trouble than those about the upper ones.
The cavities of a carious tooth may also form a
focus for troubles, which cause irritation and in-
fection of its gum. A woman at present taking
inunctions under my charge has had this trouble
adjoining a cavity in which the filling is broken. A
portion of the edge of a soft tongue projecting into
such a cavity may also become infected. Almkvist
gives a striking instance of this.
As before mentioned, one of the specific effects
of mercury is to cause dilatation of the blood vessels
in the tongue. This and the sympathy that natur-
ally exists between the tongue and the rest of the
alimentary tract cause the tongue to become heavily
coated, flabby, and swollen. Its edges and the
under surface of its tip, lie in contact with the
affected gums, and therefore become infected by
them. The softness of the edges of the tongue make
them take the impression of the teeth against which
they lie, giving rise to saucer-shaped facets with
yellow purulent borders, the well-known "orchestra
chair" tongue.
The very same thing that occurs on the edges of
the tongue, occurs also in the cheeks. The soft
mucous membrane of the cheek pouches takes the
impression of the teeth, and extends as a ridge be-
tween the upper and lower sets, forming what is
called the interdental line. The tonsils too, when
they are hypertrophic and full of cavities in which
food may lodge, may form a starting point for
ulcerations.
The Complicated Etiology of Mercurial Stoma~
titis. — The upshot of the matter is that there are
many etiologic components entering into the inci-
dence of stomatitis and its gravity, besides the
direct action of the mercury itself. There is the
previous state of the mouth, the stomach, and the
alimentary canal, the presence of the anaerobic bac-
teria and the susceptibility of the patient to their
deleterious action, and the sensitiveness of the indi-
vidual patient to the drug mercury itself. Intricate
as the disease, hydrargyrism, is, there is a distinct
advantage in appreciating these different etiologic
factors and in knowing where trouble is likely to
break out, as giving a greater objectivity and intel-
ligence to therapeutic measures. The other danger
of being so cautious as to render the treatment of
syphilis ineffective out of fear for the remedy
must also be avoided.
The severer forms of stomatitis are rarely now
seen, but the milder grades are frequent, and should
receive attention as indicating that the limit of tol-
erance for the drug is being reached, and also be-
cause intelligent treatment may add much to the
patient's comfort.
Grippe as a Complication in Treatment With
Mercury. — One of the accidents that may befall in
giving a course of mercury is a grippe infection.
The patient becomes constipated, and develops a
metallic taste, and gingivitis and ptyalism super-
vene. The conjunctiva? may become yellow, and bile
may appear in the urine. The patient feels utterly
miserable. If the mercury is not stopped, severe
mercurialism will almost certainly develop. In or-
dinary grippe a dose of calomel is given as being
the best intestinal antiseptic and aperient. When
this disease supervenes during a mercurial treat-
ment, this remedy, of course, is to be avoided.
The chemical changes in our body are unbeliev-
ably swift, and the corporeal structure is held to-
gether and the initial energy is furnished by what
is hypothetically called vital energy.* Some men
have much of this vital force, others have very little,
but whether much or little of this driving energy
is present as a natural endowment of the individual,
there is no common disease that will so suddenly
lower it as "grippe."
When the functions of the organs work perfectly
and the food is duly transmuted into energy, and
the waste is cleared away steadily by the emunc-
tories, the stream of mercury given for the cure of
syphilis flows along and is uninterruptedly dis-
charged. Let, however, the vital energies decrease,
and the chemical activities of the body slow down,
and the emunctories slacken in their discharges,
then the mercury will accumulate and begin to act
detrimentally. All these misfortunes and more too
may happen as a consequence of a "grippe" infec-
tion, and time and again I have had to interrupt
a mercurial treatment on account of this interloper.
Prophylaxis. — As before mentioned, mercury
causes very little trouble in the mouth in infancy,
but in the adult the susceptibility is so marked that
the laity is well aware of it, and patients fre-
quently ask for directions regarding the care of the
teeth and mouth. In almost every case, at some
time during the treatment, there will arise some
irritation, generally controllable by quite simple
means. In fact no one thinks of interrupting treat-
ment because of these slight symptoms, which are
regarded as signs that the patient is well under the
influence of the drug. When the symptoms become
more serious, however, the mercury is stopped im-
mediately, and means are taken to facilitate its elim-
ination and to control the oral trouble.
As a preliminary, at the very outset of treatment,
the patient is requested to brush the teeth after
each meal three times a day, using any of the good
tooth powders or pastes, of which there are some on
the market, containing chlorate of potassium, that
are excellent for this purpose. As for chlorate of
potassium, many men have adopted the routine of
prescribing a tooth paste containing it, for no other
reason than that it acts well. As we shall see later,
this is a sufficiently interesting circumstance.
The brushing, however, is essential, and the clear-
ing away of the food from between the teeth, and
the depression of the gums with silk floss or a
handkerchief wrapped around the finger or a point-
ed orange woodstick. Indeed as brushing is some-
times very painful, the orange wood stick, the finger,
and the silk floss may be the only means of cleaning
tolerated. Tartar should be removed and decayed
teeth filled or evulsed. In florid syphilis the dentist,
of course, should be warned for fear of infection.
The patients frequently become very sensitive to
acids that set their teeth on edge, such as those of
the citrus fruits and vinegar. This often leads them
to blame the acids for the salivation, and inciden-
tally, the physician, if he had not warned them of
this contingency. It is rare, however, for a little
dash of lemon or vinegar to act either disagreeably
or detrimentally — when the teeth become very sen-
sitive, of course, it is a different matter.
Moderate smoking may be allowed except when
the mouth is very irritable. There is no question
that alcohol is injurious. Mouth washes or drinks
that are too hot or too cold should be avoided ; ice
water seems to be particularly harmful.
*This is also called by Prof. Benjamin Moore, biotic
energy. "The Breath of Life," by John Burrows, 1915,
p. 107. This change of name was introduced because
the phrase "vital energy" had fallen into such ill repute.
892
MEDICAL RECORD.
[Nov. 18, 1916
Peroxide of hydrogen is now regarded as almost
a specific in mercurial stomatitis. Nicholas men-
tions that it will often prevent its development, and
frequently will cure one already under way. Scholtz
says that as soon as the gums begin to swell and a
purulent film appears, a very dilute perhydrol solu-
tion (1:500 or even 1:1000) constitutes the best
mouth wash. The question as between peroxide of
hydrogen and perhydrol is an interesting one. Per-
hydrol is a 30 per cent, solution of peroxide of
hydrogen, H.,0,, and is free of acid. It, therefore,
differs from the peroxide of hydrogen solution of
the pharmacopoeia in being acid free, and in being
ten times stronger. The addition, however, of a very
small quantity of acetanalide stabilizes the H:Oa and
enables it to be made so slightly acid as not to be
hurtful, so that the difference between the two prep-
arations, when carefully made, is reduced to a mat-
ter of strength, and as they are almost always em-
ployed highly diluted in stomatitis mercurialis
this difference may also be equalized. Perhydrol
has the disadvantages of being expensive, and being
liable to explode. Expense under the circumstances
is a matter of importance, as the free use of the
mouth wash is essential.
Scholtz employs the following prescription :
K Sol. perhydroli, 5.00.
Aq. ad., 200.00.
M. Sig. : A teaspoonful in a half or a full glass of
.vater as a mouth wash, several times a day.
As peroxide of hydrogen is one-tenth the strength
of perhydrol an equivalent prescription would be:
1> Peroxide of hvdrogen, 50.00.
Aq., ad, 200.00.
M. Sig.: A teaspoonful in a half or a full glass of
water.
This is slightly astringent and antiseptic, it cleans
the mouth and gums, and dissolves and scatters the
mucopurulent coating, and therefore deprives the
anaerobic bacteria of their food. As occasion re-
quires, this solution may be employed stronger.
In cases in which the margin of the gums is still
more strongly affected, as in pyorrhea alveolaris,
undiluted peroxide of hydrogen may be directly ap-
plied, or a mixture of equal parts of peroxide and a
20 per cent solution of nitrate of silver:
T? Peroxide of hydrogen.
Argent, nitric. (20 per cent, sol.) aa, 10.00.
M. Sig.: Apply with a cotton swab.
Both chlorate of potassium and peroxide of hydro-
gen, the two remedies found so excellent in mer-
curial stomatitis, give off their oxygen very readily,
and it may be presumed that it is to this circum-
stance that they, in a great measure, owe their effect
in interfering with the activity of the anaerobic
bacteria.
Liq. alumini acetatis, a teaspoonful or less in a
glass of water, makes an excellent mouth wash and
gargle.
There are several good mouth washes on the mar-
ket of the same general formula as the liquor alka-
linis antisepticus. A principal ingredient of these
is borax, a mild antiseptic of an unctious, soothing
nature. Boric acid may be used advantageously
alone, dissolved in water, a heaping teaspoonful in
a glass. Years ago I ran across a recommendation
by Louis Brocq of adding boric acid powder to slip-
pery elm bark tea, which makes a particularly
smooth, simple, mildly antiseptic preparation in irri-
tative lesions of the mouth. First the infusion is
made by putting a handful of the bark in a moder-
ate sized pitcher and adding hot water. After
standing for some time the tea may be poured out
through gauze. A heaping tablespoonful of boric
acid powder may be added to a quart bottle of this
infusion. If this is more than sufficient to dissolve,
the residium sinks to the bottom of the bottle, and
in any case can do no harm. The patient may carry
a quantity of this in a flat bottle in his hip pocket
for frequent use. Every author insists on the fre-
quent employment of these mouth washes as being
of the utmost comfort to the patient, and it is one
of the chief advantages of the acetate of aluminium,
boric acid, and of the very dilute peroxide of hydro-
gen mouth washes that they can be so employed,
without either inconvenience or financial embarrass-
ment.
Chromic acid, in 10 per cent, solution, is the
best application for erosions. It must, however, not
be used too frequently, as in that case it will irri-
tate an already irritable condition. A swabbing
every two or three days is usually much better than
a daily application. Nitrate of silver, in 10 per
cent, solution or as the stick, may also be used in
the same way, but usually does not act so kindly.
When the gums are very soft and swollen, it is best
to brush them with a 10 per cent, or 20 per cent,
solution of nitrate of silver followed immediately
by a 10 per cent, solution of chromic acid (Scholtz).
Chromic acid may be used in yet another way
when ulceration occurs. A 25 per cent, solution is
brushed over the surface, followed by the applica-
tion of nitrate of silver stick (Boeck). A combi-
nation of red chrome silver is formed as a crust,
under which healing takes place. In larger ulcera-
tions iodoform gauze may have to be laid between
the gums and the cheeks. I have never had to em-
ploy either of these expedients, but no man can say
when he will have to do so, as in giving mercury
hypodermieally the dose is irretrievable, and the
patient may be hypersensitive to the drug. Fur-
thermore it is well known that the most severe cases
of stomatitis may occur with the inunction treat-
ment. The two effective ways of administering
mercury, therefore, are intimately linked with a pos-
sible severe stomatitis.
Tincture of rhatania, tincture of nut-galls (gal-
larum), and tincture of myrrh are employed for
their astringent effect. They are, however, of lesser
value than those previously mentioned, but may be
very useful when the gums are in good order.
R Tr. rhatania?.
Tr. gallarum, aa 15.00.
M. Sig.: Fifteen to twenty drops in a half glass
of water as a mouth wash.
Eliminator:/ Treatment. — The elimination of an
offending substance must be fundamentally more
important than the control of the symptoms it pro-
duces. This axiom holds as good for mercury, caus- '
ing a severe stomatitis, as for any other foreign
body. The first step to be taken, therefore, is to
stop the drug, and if inunctions have been employed,
to give a hot bath with plenty of soap to free the
skin of the mercurial ointment. Some would add
Vleminckx' solution to this bath in order that the
inert black sulphide of mercury may be formed.
The essential, however, is the water, the soap and
the scrubbing to free the skin of the mercury, and
so to stop absorption and inhalation.
Formerly the impure sulphuret of potassium,
called "liver of sulphur." was much used for sulphur
baths, but now Vleminckx" solution is generally pre-
ferred. This solution is made by adding quick lime
to sulphur and boiling it down :
Nov. 18, 1916J
MEDICAL RECORD.
89*
IJ Sulphuris sublimati, gv.
Calcis viva, .">xx.
Aq.,,51.
Boil together with constant stirring until the mix-
ture measures gxxx. This is sufficient for about
five baths.
One hundred and fifty to two hundred gi'ams, or
five or six ounces, are added to a bath. The two
disagreeable features of this bath are its evil odor
and the way it blackens a metal bath tub. The
advantage to be reaped in fixing the metal mercury
as the black sulphide is very small, as all the metal
attainable on the surface can be removed by a bath
of soap and hot water.
The rate of the elimination of mercury varies
greatly in different cases, and the reasons for the
variability are usually unascertainable — one of
them, however, an attack of la grippe, has been
previously discussed. There seems to be no doubt
that the chief emunctory is the intestinal canal.
Vogel, and Lee, for instance, recently have found
that, in cases of bichloride of mercury poisoning,
the mercury persisted longer in the feces than in
either the stomach washings or in the urine."
The next measure, therefore, after stopping the
drug, is to see that the bowels are acting properly.
A dose of castor oil may be given as the best
cleanser of the alimentary tract, and this should
be followed by a steadily acting laxative, such as
senna or rhubarb, which may be advantageously
combined with a diuretic:
R Pot. acetatis, 5v.
Ext. sennse fl., §ii.
Aq. gaultherias ad., Jiv.
M. Sig. :A teaspoonful in a little water p.c.tid.
To give a diuretic and not to give abundance of
water is like putting a mill wheel in a dry mill race.
The patient, therefore, should be advised to take
warm drinks in plenty. The value of the various
teas rests probably in the fact that many people
cannot take plain warm water without nauseation.
These teas set the skin as well as the kidneys in
action, and if to this ingestion of hot water there
is added a hot bath with a subsequent rest in bed
of two hours to encourage perspiration, much will
be accomplished.
Here may be mentioned the administration of
atropine as a hypocrinic. A hypocrinic is a drug
that lowers the secretory activity of a gland, and
for this purpose the use of belladonna and atropin
have been advised to control the tormenting saliva-
tion. If, however, these drugs are given to lower
the activity of one set of glands, they just as surely
lower activity in others, and therefore interfere
with the intestinal, renal and cutaneous elimination
of mercury. Furthermore the effect of these drugs
on the salivary glands is apt to be very little, where-
as their general effect on the entire secretory sys-
tem may be quite pronounced, and therefore more
harm than good may easily be accomplished by their
employment. All the other hypocrinic or inhibitory
drugs are in the same catagory. Many men, for
instance, prescribe opium with mercury as a routine
practice in giving mercury by the mouth, with the
double purpose of preventing a diarrhea and of
allowing the mercury to accumulate in the body. It
is not, however, the mercury that accumulates in
the body that does the good, it is that that actively
changes into a form noxious to the spirochete and
then passes through, carrying with it the peccant
materials. The action is, therefore, spirocheticidal
and eliminatory, and any interference with elimi-
nation is detrimental both in the treatment of syph-
ilis, and in any of the accidents produced by
mercury.
In reflecting on the phenomena of mercurial
stomatitis one cannot fail to be struck with their
intimate connection with the teeth. Sensitiveness
of the teeth is one of the first symptoms ; the trouble
is most apt to begin in the neighborhood of the
teeth; the condition of the teeth is of the first im-
portance in the incidence of the symptoms, absence
of the teeth secures a comparative immunity, and
the treatment is largely directed toward the care
of the teeth and gums.
REFERENCES.
1. Rabelais: Pantagruel, Prologue to Book II.
Writen, 1533.
2. Almkvist, Johan: Ueber die primaren Ursprungs-
stellen und die sekundare Ausbreitung der merkuriellan
ulzerosen Stomatitis, und ueber die Entstehung der
Salivation bie Quecksilberbehandlung. Dermatologische
Zeitschrift, Jan., Feb., 1916.
3. Vogel and Lee: "Mercury Elimination in Bichlor-
ide Poisoning," Medical Record, January 8, 1916.
323 Geary Street.
THE CARE OF DIGESTION.*
BY MAX E1NHORN, M.D_
NEW YORK.
PROFESSOR OP MEDICINE AT THE NEW YORK POSTORADUATB
MKDICAX, SCHOOL..
Digestion deals with the processes of food inges-
tion, assimilation, and ultimate waste elimination.
Health and life are dependent upon the harmonious
working of the digestive apparatus. Its disturbed
function creates disease; its interruption for a
longer time carries death with it.
It appears worth while to consider here some of
the points which serve to keep the digestion in good
shape, in order thereby to preserve health.
For this purpose we may divide our subject mat-
ter into the following items: (1) Food intake:
quantity required in growth, manhood, old age; (2)
State of the body for this act; (3) Period of assimi-
lation; (4) The final act of waste elimination (def-
ecation).
The quantity of food required is very definite and
is greater in the period of development and man-
hood than in middle age or old age. During the
time of growth a large quantity of the nourishment
is utilized for the upbuilding of the body. In man-
hood the greatest activity is manifested, and this
again requires additional nutritive material. In
middle and advanced age the activities are grad-
ually reduced and the food requirements are ac-
cordingly lessened. With the beginning of middle
age there is often a tendency to corpulence; for oc-
casionally at this period with the reduction of work
there is no decrease in the quantity of food intake.
The surplus of nutritive material is then stored up
in the body in the form of fat.
The diet should be watched and arranged some-
what differently for these different periods of life.
In most instances in health our instinct guides
us correctly and the appetite is a sufficient monitor
to go by. Transgressions may, however, occur in
both directions by faulty habits (overeating on the
one hand and too scanty nutrition on the other) .
Thus opulence and high living give rise to an over-
abundance of the food intake, while poverty and
avarice in the parent's house or in the boarding
*An address delivered before the employees of New
York City, October 11, 1916, at the Municipal Building,
New York.
894
MEDICAL RECORD.
[Nov. 18, 1916
establishment may lead to subnutrition. Both
hypernutrition and subnutrition practised for a
longer time may become established as a habit, i.e.
the appetite here becomes deranged and is no more
a fit guide for the best purposes of the organism.
In order to look for good health we must guard
against either of these faults.
How shall we know whether we eat just right?
The quantity of food physiologically required is
known, and for the physician it is a simple matter
to make a computation and to state whether some-
body eats enough, too much, or too little.
The layman, however, can likewise easily find the
right measure. First, his appetite may be used as
a guide; second, everybody should eat about as
much and as often as his neighbors and associates;
third, everybody can see whether his body and
strength are in good condition. If everything is
harmonious and goes on smoothly, this alone is suf-
ficient. If not the scale may be utilized and weigh-
ing yourself once a week or so will soon show
whether there be too much or too little food taken.
What kinds of foods should be taken? Here,
again, the answer is: look at your neighbors, do the
same, and you will not go wrong.
The following rules may, however, be given in a
general way. Arrange for a great variety of food,
which should embrace most nutritive substances
easily digestible and also difficult of digestion. To
select a diet in health consisting merely of easily
assimilable foods would be a great mistake as it
would serve to decrease the efficiency of our diges-
tive apparatus.
Eating being one of the most important functions
of the organism should not be done haphazard, but
performed with care. A moderate amount of
work preceding the meal increases the appetite and
enhances the digestive function.
A few more rules regarding diet in health may
here be added. There is a tendency in this country
toward eating too much meat, which often leads to
constitutional disturbances. Some people here take
meat regularly at each meal. As a rule meat should
be partaken of once or twice daily in quantities of
about one-quarter of a pound for an adult, but not
much above this. Plenty of vegetables should be
served with it. Bread and butter, fruits, and salads
should be used liberally. Water should be taken
with each meal, and if thirst be present also in be-
tween. Its importance cannot be too much appre-
ciated.
Water itself is one of the principal ingredients of
the organism. It contains, besides, in small quanti-
ties, mineral salts of different kinds which are uti-
lized in the body economy. Food digestion, assimi-
lation, and elimination require for these processes
water as an intermediary, without which life is im-
possible. Fresh cool spring water at meal time in-
creases the appetite and augments the pleasure of
eating.
Too great fatigue destroys the appetite and ban-
ishes the joy of eating. The latter is then done
mechanically, almost with disgust, and the process
of digestion is thus disturbed right from the start.
I 'ining meal time rest of the mind and body is essen-
tial. A comfortable scat, a nicely set table, pleasant
company, wholesome food and drink (fresh spring
water) are important factors in increasing the
worth of the meal. General conversation not re-
quiring much concentration of mind is rather use-
ful. Direct business talk should be avoided. The
meal should be ingested leisurely and time given to
the enjoyment of the different courses (food ar-
ticles). The eating should be performed neither too
quickly nor too slowly. Both deviations lead to
manifold digestive disturbances. A short period
of rest following the meal is advantageous. A mild
cigar and pleasant conversation contribute toward
the enjoyment of this after-table act.
The real act of digestion begins after the inges-
tion of food. The alimentary canal may be likened
to a factory in which all the material brought in is
sorted and changed in such a manner that it can
enter the circulation and by means of that stream
of communication reach all the body tissues.
Assimilation of Food. — Unfit substances or the
remnants of food which cannot be utilized any more
are carried along the digestive canal to be elimi-
nated at the end. The tissues of the body likewise
throw off dead or waste material. They accomplish
this through the eliminative systems (lungs, kid-
neys, skin, and alimentary tract, including the
liver) reached by all the tissues through the blood
stream. The digestive canal is thus one of the
principal avenues for the traffic also of waste prod-
ucts of the body itself.
The assimilation is greatly favored by keeping
the body in good trim. For this the organism must
be in a state of contentment, which can be reached
by satisfactory mental and bodily work. Every oc-
cupation should be performed with a good will and
pleasure, and should not be carried on to over-
fatigue and annoyance. Thus assimilation will be
helped and good health made possible. Plenty of
fresh air and a certain amount of muscular exer-
cise (walking, horseback riding, rowing, gymnas-
tics) are of importance. In the same way after the
working hours rest and a sufficient amount of sleep
(eight hours daily) are essential for good digestion
and perfect health. Both exercise and rest, proper-
ly apportioned, enhance assimilation as well as elim-
ination.
The final act of digestion consists in the expul-
sion of all the remaining unutilizable food sub-
stances and some waste products from the alimen-
tary tract (defecation). This usually occurs once
daily in normal individuals. Regular attendance to
this natural event is likewise important for the
well-being of the organism. With regard to this
act the call of nature should be obeyed at the right
time. Frequent neglect to perform this duty as well
as too much devotion to it lead to irregularities of
the bowel and ultimately to ill health. In health
the best principle is to let things take their natural
course. Too much interference with it often leads
to abnormal conditions and disease.
To sum up, the care of good digestion embraces
the following items: simple life, in which work and
rest for mind and body are harmoniously divided;
regularity of meals, frugality, great diversity of
wholesome foods taken, in just the right proportion;
an abundance of water; proper attention to the call
of nature. Good digestion is also the best promoter
of good health and a long life. There is no elixir of
youth for old age, or a rejuvenation remedy. In
keeping our organism, however, in good trim, in
looking out for its steady and harmonious ac-
tivity, we succeed in delaying and perhaps also
shortening the advancing state of invalidism and the
dissolution period, with death at its end.
Life is not complete without death. The latter is
a natural event at some time for each living being
and its advent should not be begrudged.
20 Kast Sixtt-third Street.
Nov. 18, 1916]
MEDICAL RECORD.
895
AMBULATORY TYPES OF THYROID
DISEASE.*
By ELEANOR BERTINE, M.D.,
NEW YORK.
SHELDON FELLOW IN MEDICINE, CORNELL UNIVERSITY MEDICAL
COLLEGE.
In the last eleven months 134 cases of thyroid dis-
ease have passed through the Cornell Medical Clinic.
As in dispensary practise in general, they have been,
for the most part, patients with the less serious
manifestations of the trouble, the large majority
belonging to that most obscure class, the formes
frustes. However meager our knowledge of real
Graves' disease may be, it is a flood of light com-
pared with our understanding of the processes tak-
ing place in the organism to produce these aberrant
conditions. While the laboratory attacks the sub-
ject of their cause from the experimental point of
view, some light may be shed upon the problem by
a more careful observation of the demonstrable re-
sults as shown in the clinical pictures presented.
With this end in view a study has been made of the
material seen in the Cornell Thyroid Clinic.
For every new admission during the year a chart,
such as here shown, was filled in. and at each sub-
sequent visit a careful record has been kept of the
progress in respect to pulse, weight, circumference
of the neck, blood pressure, tremor, and the patient's
own statement of how she feels, with, of course, the
treatment. For this purpose the second blank was
used.
First, a word about the patients. A small ma-
jority were American-born; of the rest Russian-
Jews and Austro-Germans were numerous, with only
an occasional representative of the Irish, Italian,
and other nationalities. Practically all were women,
half the number being single and half married.
Most of the married women kept house and had
children. The single patients were about equally di-
vided between school-girls, girls engaged in some
semi-domestic occupation, as sewing or domestic
service, and workers in miscellaneous industries.
Though all were poor, there was comparatively little
destitution among them.
Clinically, there was found the greatest variety
of combinations of signs and symptoms. An at-
tempt to classify some order into this confusion re-
vealed a serious difficulty, namely, the inadequacy
of our ordinary classifications. There were a few-
cases of real Graves' disease, many cases of partial
Graves' disease, no cases of true myxedema, some
cases vaguely suggestive of myxedema, though dif-
fering from it in many essentials, and a large num-
ber combining the elements of a partial Graves' with
a suggestion of myxedema in a way that no mere
variation in the quantity of thyroid active princi-
ple could account for. An attempt to classify our
cases as vagotonic or sympathicotonic according to
the work of Eppinger and Hessf gave no more il-
luminating results. There is still much doubt as
to which division of the vegetative nervous system
is responsible for many prominent symptoms. Then,
too, even accepting the conclusions of these workers
in this regard, very few of our patients fell wholly
or even predominantly, in one class or the other, but
combined symptoms and signs of both to such a de-
gree that the picture was more confused than sim-
plified.
*From the Medical Clinic of the Cornell University
Medical College in New York City.
tEppinger and Hess: Vagotonia, Nervous and
Mental Disease Monograph, Series No. 20.
So discarding all preconceived ideas and focussing
attention only on the patients, an attempt was made,
finally, to see some principle on which a sound di-
vision could be made, a principle that should not pre-
tend to explain or assign causes, but which should
be so true to facts that it could be used when the
time comes to help test explanations and theories of
causes. Aside from nine simple goiters without
symptoms, the patients fell clinically in to (.1) those
in whom stimulation was the chief factor, stimula-
tion of metabolic processes, of the nervous system
and heart, and (.2) those in which functional depres-
sion was the outstanding feature. In addition there
were all intermediate gradations and combinations
of the two conditions.
The first group, or nearly half the total number,
can be quickly dealt with because it 'presents the
well-known syndrome of hyperthyroidism. All these
patients had a goiter, usually small or moderate in
size, tremor and nervousness. The increased metab-
olism was shown by loss of weight, tendency to ele-
vation of temperature, and the compensatory mech-
anism of sweating. One-half were poorly nourished
and nearly two-thirds complained of sweats. Three
per cent., however, were over-stout, but these were
all middle-aged women who had had the disease in
a mild form for years. More or less exophthalmos
occurred in 70 per cent, of the cases. All the pulses
were irritable, running up abruptly with the slight-
est exercise or excitement, and in addition most of
them were rapid, 72 per cent, being over 100. There
were a large number of young girls in this class,
37 per cent being between 10 and 20 years of
age, with the number in each succeeding decade pro-
gressively falling. Menstrual disturbance though
occurring in some slight degree in 45 per cent.,
consisted in half the number of only a reduced or
retarded flow, and hence was not prominent as a
complaint.
The second group contained those characterized
chiefly by depression of function. There were 27 of
them, well-nourished, a majority in fact over-stout,
usually with good color, yet complaining bitterly
of weakness. This symptom stood out above all the
rest, and was the thing for which 90 per cent,
primarily sought relief. This is in marked con-
trast to the hyperthyroid group, in which, though it
included two bad cardiacs, two recent operative
cases, and all the very sick people, only 26 per cent,
complained of weakness. Though largely subjective,
expressing itself in easy fatiguability, disinclina-
tion for mental or physical exertion, loss of con-
centration, and emotional depression, there was also
definite muscular relaxation that was evidenced by
posture and abdominal flabbiness, often with viscero-
ptosis. With this were associated frequent head-
aches in 85 per cent, of cases, constipation in 71 per
cent., and in 78 per cent, a distressing sense of pres-
sure in the neck or choking sensations, which had
no apparent relation to the size of the goiter or the
probability of its interfering mechanically with
surrounding structures. Menstrual disturbances
were the rule, and were very troublesome. There
were more large goiters among these patients than
among the previous group, the age tended to be
older, and the duration longer. This, with the
tremor so frequently present, suggested the possi-
bility that the depression phase might be a late
sequel to that of stimulation. In a few cases this
appeared to be true, notably in two in whom a
slight exophthalmos occurred, but the great ma-
jority gave a history that could not fairly be so in-
898
MEDICAL RECORD.
[Nov. 18, 1916
Department No.
Cornell Univ. Medical College
Medical Clinic
OUT-PATIENT DEPARTMENT
M. P.
Occupation,
Chief Complaint
Diagnosis
Date,
8. M. W.
Nation,
Race,
SUUUART
»noi.ouiCAL Factors
Onset
Past History
Family History
Puuurr Condition
Etiology-Predisposing Exciting
Signs and Symptoms in Order of Appearance
Type of Case — acute, chronic, mild, severe, hyper-, hypo-, mixed
Probable cause — Exhausting or infectious diseases (Tonsillitis) Pregnancy Sudden shock or prolonged straio
Gradual or Sudden
Approximate date
Subsequent developments (see outline below)
Prev. Simple goitre (duration and how caused)
First symptom
Childhood — BCarlatina, diphtheria, rheumat, chorea, rickets
General health ( ) acute rheumat, typhoid, malaria, pneumonia, pleurisy, tonsillitis, colds, winter cough. »om
throat headache, indigestion, gonorrhea, syphilis alcohol tobacco, drugs
Habits Sleep Bowels Food
Menstruation — age at start accomp. by goitre or nerv. regularity duration pain
Miscarriage — no. loss of blood Pregnancies — no. and character
Insanitv, Neroses, Thyroid disturbances, Epilepsy. Cancer, Diabetes
THYROID — Enlgm'nt Rate of growth Effect of excitemen
Consistence Pulsation Thrill Bruit
Pressure sympt. (dyspnoea, hoarseness, dry throat, choking sensation
EYES — Exophthalmos (degree, uni-or bilateral) Injection of conjunctivae
HEART — Rate Force Area of impulse Additional pulsations
Qualitv of sounds
ARTERIES— Pulse (rate and character)
NERVOUS— Tremor, parts affected
Twitchinga and spasms
Restlessness (mental and physical)
CUTANEOUS— Sweating
Rashes (Erythema, Urticaria, Papules)
DIGESTIVE— Diarrhoea
NATIVE— Menses
Lobes affected
Dilated vein*
{Von Graafe's
Stellwag's
Mocbius
Size
Irritability
Murmurs Palpitation
Pulsating vessels Murmurs BLOOD PRESSURE
character Weakness of muscles (where and how manifested)
Pains and Neuralgias
Apprehensiveness Irritability Defective memory Sleep
Pigmentation (location, character) Edema
Hair
Vomiting Appetite Thirst
Effect of pregnancy WEIGHT TEMP.
Department No.
Seen by Dr.
Cornell University
Medical College
MEDICAL CLINIC
Chief Complaint
Diagnosis
Name,
Address,
Age,
M. F.
Occupation,
Date.
S. M. W.
Nation
Race,
Date
Pulse
Weight
Neck
1 Bl. Pres.
Tremor
Treatment
terpreted. However, some of our own hyperthyroid
cases appear to be going through this transition
while under observation, so it probably does occur.
Thus far the cardinal symptoms, asthenia, phys-
ical and mental fatiguability, headache, intestinal
sluggishness, and choking sensations, might be at-
tributed to a hypothyroid condition, and doubtless
this plays a part in producing the picture. How-
ever, there are some important differences. The pa-
tients do not look myxedematous ; they lack the pal-
lor, the apathy, the somnolence, the falling hair and
thinning eyebrows.* They are alert enough, gen-
erally have normally moist skins, pulses that aver-
age about 82, and not one had the slightest sign of
the characteristic infiltration of the skin.
Perhaps the most conclusive evidence that the
condition is not so simple as a mere thyroid defici-
ency is the combination of the symptoms of the
latter group with those of hyperthyroidism in every
conceivable arrangement. Thirty-three cases of the
series were thus classed as intermediate, each pa-
tient having symptoms belonging to both types.
For instance, nervousness, tremor, more or less
emaciation, and irritability of pulse may be asso-
ciated with lassitude, inertia, emotional depression,
and headaches. Or again, there may be on the one
hand, tachycardia (120 or more) and sweating, and
on the other, obesity, constipation, and asthenia. A
case history will illustrate the combination.
Mrs. M. Atre 2G, a Roumanian Jewess, married but
with no children, has had, for nearly two years, a
*Hertoghe, E.: Thvroid Insufficienev. Medical
Record. Sept. 19, 1914: Practitioner, Jan. 1915.
small goiter, some exophthalmos, and a marked
tremor. She is very nervous, poorly nourished, and is
slowly but constantly losing weight. Her pulse is
moderately accelerated, 108, and she sweats consider-
ably, though able to do light housekeeping. So far, a
pretty straight case of mild Graves' disease. But in
addition, she complains of great weakness, headaches,
constipation, almost constant choking sensations, and
dysmenorrhea, except for the poor nutrition, an
equally complete picture of the opposite type.
A few cases have come to the clinic after hav-
ing a partial thyroid lobectomy. The tachycardia,
tremor, and exophthalmos remain, but the oper-
ation has been followed by a marked gain in weight,
even to the point of obesity, headaches, choking sen-
sations, asthenia, and constipation. There is here
an extrathyroid element, probably adrenal or pitui-
tary. Somehow the balance between the thyroid and
the other endocrine glands has been upset.
Summary and Conclusion. — 1. Of 134 cases of
thyroid disease, there were: (a) Nine simple goi-
ters; (6) sixty-five cases in which stimulation
from excessive thyroid activity was clinically the
chief feature; (c) twenty-seven cases in which de-
pression, physical and mental, was the chief fea-
ture; (d) thirty-three cases in which there was a
mixture of stimulation and depression.
2. Simple quantitative change in thyroid secre-
tion is inadequate to explain groups o and c, but
the cause must be sought in some at present ill-
understood incoordination between several endo-
crine glands. Hence of 134 cases of thyroid dis-
ease, at least 60 present features of a complex endo-
crine disturbance.
103 East Twf.ntt-mnth Ptv:
Nov. 18. 1916J
MKDICAL RECORD.
897
CONGENITAL CLUB-FOOT.
CLINICAL STUDY OF A SERIES OF 21 CASES WITH
REMARKS ON TREATMENT.
By I. REITZFELD, M.D.,
NEW YORK.
ASSISTANT SURGEON.
HOSPITAL FOB DEFORMITIES AND JOINT
DISEASES.
This report is based on a study of 21 cases, seen at
the clinic of the Hospital for Deformities and Joint
Diseases and from the services of Drs. H. C. and
H. W. Frauenthal, whom I want to thank for the
privilege of reporting same. This study must be
considered purely preliminary in character. For
the purpose of simplicity and aid in reaching con-
clusions, a history form was gotten up, presenting a
number of important data.
Each case on the first visit to the clinic was made
the subject of the following inquiries: The name
and age, the character of labor, the question of
hereditary taint, the time when the deformity was
first noticed, the presence of associated congenital
abnormalities, the type of deformity, whether single
or double, etc., were all noted. Later on the method
of treatment, and the complications, if any, were
also considered. Each patient was photographed,
and where absence or deficiency of bone elements
was suspected radiographs were taken. In this se-
ries there were 21 cases, taken as they came and un-
selected. Of this number 12 were males and 9 fe-
males. The ages of the deformed ranged from 10
hours to five years.
To enable us to consider the question of trauma-
tism during birth, the character of the labor was
carefully gone into. Of the series 19 of the cases
had perfectly normal births and in the remaining
2 the delivery was instrumental. So that it is fair
to assume that trauma plays a small role, if any, in
the production of this condition. The question of
heredity is a rather interesting one. In the series
only one case gave a definite history of a familial
tendency. In the case of M. G., an older child of
10, was afflicted with a similar deformity. This
case is rather of unusual interest and will be re-
ported in detail further on. Personally, I feel that
hereditary predisposition is a factor, a contributing
one, perhaps, and not a direct cause.
In all but two of the series the deformity was
noticed soon after birth ; in one case it was not ob-
served until the third day and in the other one week
following birth. It may be safely said, however,
that the deformity in both cases was undoubtedly
congenital, for all other etiological factors can be
excluded. It was interesting to note that in this se-
ries 5 cases presented associated abnormalities. In
case of M. L. there was a fusion of the third and
fourth toes on both sides. Case of T. B. presented
an anomalous condition of the small toes of both
feet. The metatarsophalangeal articulations of
these toes were perhaps one-half inch posterior to
the normal situation. Case of M. L. revealed a con-
genital constriction about the second finger of the
right hand (amniotic adhesions). Case of M. G.
showed congenital malformation of the left car. and
case of H. Z. presented congenital dislocations of the
fourth toes of both feet, at the metatarsophalangeal
joint line.
A rather frequent condition that I noticed in a
number of the cases was the relative smallness in
size of the big toe in the affected foot. Whether
this is to be considered an abnormality or not I am
unable to state.
The types of talipes as seen were as follows:
Equinovarus numbered 15, ten of which were bi-
lateral. Of the five single deformities three in-
volved the right foot and two the left one. Three
of the cases in the series were pure varoid in char-
acter. All were bilateral. There was one case of
calcaneus affecting the left foot and two cases of
valgus. Of the latter one was double and the other
single, involving the right foot.
Anatomical Observations. — Inspection of the af-
flicted members presented a number of points. In
all of the cases seen the heels were found small and
when there coexisted a contracted tendo Achillis a
fold just above the heel was always encountered.
These folds were also observed about the ankle, on
either side, depending on whether a varus or valgus
deformity existed. In talipes varus the folds were
found on the inner side of the foot, and in valgus on
the opposite side. As correction of the condition
progresses one notes the appearance of the folds of
the skin onto the opposite side of the joint, and at
the same time an associated stretching of the origi-
nal folds.
In talipes equinovarus the outer border of the
foot assumes a curve with its concavity facing the
median line. A few cases in the series presented
marked displacement of the astragalus. This is of
great importance. Until this displacement is cor-
rected, no true and stable cure is obtainable— at
least that has been my experience. Indentations or
dimplings were encountered a number of times.
These have been seen on the soles and inner border
of the feet. They are supposed to be due to am-
niotic adhesions.
Treatment. — The treatment to be described is
according to the method in use at the clinic of the
Hospital for Deformities and Joint Diseases. No
claim for originality is made. It consists of three
fundamental principles — correction, retention, and
supervision.
Correction is obtained by manipulation, with es-
pecial effort toward replacement of any existing
faulty position of small bones of the foot, especially
the astragalus and cuboid. The earlier treatment is
begun the better the prognosis as to a cure. Each
foot is manipulated for a period of about five to ten
minutes, following which the limb is fixed in the
corrected position. For the purpose of retention we
use first adhesive straps, followed by plaster of
paris. The patients are instructed to return at
least once a week, the dressings, howTever, are
changed about once in two or three weeks, when the
same process is gone through. This in brief is an
outline of the treatment for talipes in general. The
different types, however, require special considera-
tions.
Talipes Equinovarus. — After manipulation a pri-
mary roller of gauze (one inch bandage) is applied
from the toes to the knee. This is to fit snugly, each
turn overlapping the previous one. Care is exer-
cised not to leave any exposed and uncovered areas,
as these make fruitful soil for ulcerations. With
the deformity corrected as much as possible, and the
gauze roller applied, the next step consists in hold-
ing the acquired position by use of adhesive straps,
usually one or two in number, rarely three. These
straps are about one-half inch wide and from 4 to 7
inches long, depending on the size of the leg. They
are applied from within outward and should partly
overlap. They should be long enough to go beyond
the knee. A second roller bandage is now applied
in a similar fashion as the first. Tbis helps to
398
MEDICAL RECORD.
[Nov. 18, 1916
maintain the adhesive straps in the desired position.
When the knee is reached the adhesive straps, which
extend beyond the joint, are then reflected and kept
there by a few turns of bandage. Over this a thin
light cast of plaster of paris is applied. A one-inch
bandage is usually found sufficient.
Recently we have modified the above to the extent
of adding and incorporating in the bandage or
dressing a thin wooden splint, measured to the size
of the sole of the foot and so applied. The object
of this is to prevent a narrowing of the forepart of
the foot. Before applying the splint it should be
well padded.
After correction of the deformity is obtained the
feet are placed in very light metal braces which are
easily removed, so as to allow for massage. This is
applied especially to the peroneal group of muscles.
At this time the patients are instructed to return
three times a week for massage treatments. When
the child has reached the walking stage, proper
shoes are ordered and so constructed as to force the
feet somewhat into valgus position (elevation of
the soles on the outer side with a small pad under
the arch to prevent breaking down completely. In
other words, to prevent flat foot). From now on
the case is supervised to prevent relapse.
In those cases where manipulation is not sufficient
to overcome the equinus position, the patient is re-
ferred to the hospital for surgical relief (tenotomy.
tendon lengthening, etc.) But this takes the pa-
tient from the clinic and I shall not describe these
measures.
Talipes Varus. — Treatment consists in the same
measures as used in overcoming the varus deform-
ity in equinovarus, and as this has been described
no further mention is necessary.
Talipes Valgus. — In this condition manipulations
to be used are the reverse of those in varus deform-
ity. It is a good plan to apply any bandage that
may be necessary from without inward. This aids
in overcoming the valgus. The same holds true to
the application of adhesive straps. They should be
started on the dorsum of the foot, running outward
over the external border of the foot, across the sole
and then up alongside the inner margin of foot and
leg. When the stage of correction has been reached
and massage is indicated, this is to be directed
mainly toward muscles of the legs, which, when
active, produce inversion of the foot. Shoes, when
ready to be worn, should be constructed so as to
throw the foot into a slight varus position (inner
side of sole raised).
Talipes Calcaneus. — In this form, the foot is
dorsiflexed on the leg at an acute angle. On the
dorsum one may see folds of skin. The dorsiflexor
muscles are found shortened and the extensors
lengthened — notably the tendo achilles group. In
the one case of calcaneus in the series, it is possible
with just the merest use of force to dorsiflex the
foot so that the toes actually touch the front of the
leg.
For the relief of this type we use a malleable
metal splint, well padded. This splint is applied so
as to increase the angle of dorsiflexion. It is ap-
plied posteriorly, extending from a distance a little
above the knee to the toe line margin. The part is
first manipulated in such fashion as to stretch the
contracted or shortened anterior group muscles and
to shorten the calf muscles, then a gauze roller is
applied. The splint is then fitted to the limb, bent
at the knee, and at the ankle. In the latter position
il is bent so as to keep the foot in equinus. The
knee is taken in so as to allow for greater correc-
tion of the deformity. The splint is held in position
by another gauze roller and this is followed by the
application of a plaster case.
When correction has been obtained massage, espe-
cially directed to the calf muscles, is instituted. The
part is then redressed as above described with a
plaster of paris splint (removable). This is done to
enable one to remove the dressing easily. When the
child begins to walk, it may be advisable to elevate
the heels of the shoes somewhat. This has a tend-
ency to maintain the equinus position.
For the correction of different types of club foot
I have found that the average time is about four
months. Occasionally delay in cure is caused by
intercurrent infantile diseases and complications
due to the correction of deformity. In one of the
cases (equinovarus), as a result of faulty applica-
tion of corrective dressings, pressure sores de-
veloped on the anterior surfaces of both ankles. It
took ten weeks to cure these, leaving ugly scars.
The results obtained at present writing may be
spoken of as cured, improved, and unimproved. By
cured, it is to be understood that stable correction
of deformity has been obtained. By the term im-
proved, some correcting has been obtained, but not
entirely so. The designation unimproved refers to
those in which no change for the better has resulted.
In this latter class I have included those cases in
which treatment has been given for a short time and
in which no change is yet to be expected. Among
the cured there were five cases of equinovarus and
one of calcaneus. Two cases of equinovarus, one of
valgus, and one of varus were improved. Seven
cases were unimproved, of these two were equino-
varus deformities, one valgus, and four were of
varus type.
After all is said and done, the correction of de-
formity is accomplished in a comparatively short
time, a few weeks or months, but the result can be
determined only after constant and active super-
vision for two or three years following so as to
guard against relapse.
."7 East Ninety-sixth Street.
A FOUR YEARS' STUDY OF THE KELLING
HEMOLYTIC TEST.
Bv B. G. P.. WILLIAMS. M.D.,
PARIS. ILLINOIS.
About four years ago I became sufficiently inter-
ested in the promise of Kelling's hemolytic reaction
to undertake tests with a view to diagnosis. The
first of these was set up on September 18, 1912.
This test was positive. At the time I warned the
people that the reaction was still in the experi-
mental stage and could not be regarded as specific.
The patient was alive nine or twelve months after
that date and consultants were of an opinion that
the growth was after all a benign one. The patient
agreed to an operation. Exploration, however,
revealed an inoperable tumor mass and the patient
died within a short time.
Meanwhile I had refused to undertake further
tests until convinced that the results of this first
one had not been misleading. Led to believe that
the test might have a clinical value, I then adopted
it as a laboratory procedure of probable worth and
have applied it, not routinely, but in cases selected
according to the conditions noted below.
The number of tests made under these conditions
Nov. 18, 1916]
MEDICAL RECORD.
899
is 90. About 100 other tests might be added were
I to count controls and reactions used for study,
mainly in normal cases. I have no apology to offer
for a report on so apparently small a number for
the reason that the selection of sera was not hap-
hazard from hospital wards and so on, but in every
case there was some good reason to regard malig-
nant neoplasm of the abdominal viscera as a possi-
bility. I might say, however, that this reason was
sometimes merely the fact that some physician had
suggested cancer, although we saw no real clinical
signs or symptoms confirming such a diagnosis.
According to available reports one or more of the
"positives" are still alive since tests set up sev-
eral months ago, but in general the results have
been so convincing as to prompt me to make at
least the following brief conclusions as to the value
of the test.
Probable Value of the Kelling Test. — My experi-
ence seems to prove that when properly applied
and interpreted the Kelling test is of value in the
diagnosis of cancer and especially in the differ-
ential diagnosis of benign and malignant abdominal
neoplasms. As a routine procedure for the diag-
nosis of all cancers in all stages it is practically
valueless and misleading.
The value of the hemolytic reaction in my hands
may best be expressed in the words ventured by
me about four years ago:' The so-called "explora-
tory operation" is becoming altogether too fre-
quently applied in cases which are probably fatal
and inoperable. The chief promise of the hemolytic
test is that of preventing hopelessly developed,
necrotic, and metastatized abdominal tumors com-
ing to the operating table. On numerous occasions
I have witnessed these cases, and no pen can paint
the horrible picture of the ubiquitous, rotting
masses of daughter tumors revealed. It seems to
me that in such surgery there is little actual re-
ward, and any test which promises to illuminate
will be most acceptable to a conscientious surgeon.
Any abdominal malignant tumor of several months'
growth or one which is palpable is invariably
inoperable, and if the malignant nature is known
it requires not even a glance into the belly to prove
that it is too late for the knife. As a matter of
fact, the exploratory operation is not ordinarily
attempted to determine whether or not it is too late
to operate, but whether or not the growth chances
to be benign and can be removed by virtue of thiy
fact. The case is altered, of course, when certain
indications suggest (regardless of malignancy)
that a gastroenterostomy is to be done to relieve
the patient.
Workers apparently agree that the sera of pa-
tients with late malignant neoplasms of the viscera
invariably cause hemolysis of alien corpuscles, and
that this hemolysis is usually prompt and marked.
More interesting and valuable than this is the fact
that the sera of patients with benign operable
tumors do not cause hemolysis unless the test be
applied very late indeed. It has been claimed that
when certain techniques are used (not that of Kel-
ling) the sera of patients with advanced tubercu-
losis, syphilis, and so on, bring about these reac-
tions; but such conditions are likewise not oper-
able, and the value of the test, even though judged
by an incorrect application, is not limited by these
possibilities. So also pernicious anemia and ne-
phritis (easily differentiated by blood and urine
examinations) may, according to some techniques,
cause hemolysis, and these conditions are likewise
inoperable. Suppurations, it is claimed, may also
produce positive sera, but such conditions do not
usually enter into the differential study of benign
and malignant tumors and may be regarded as no
greater source of error than a positive Wasser-
mann in a case of scarlet fever. Moreover, if Kel-
ling is right the hemolytic properties of the sera of
pus cases are lost by raising the temperature to a
certain degree, while those of the cancer sera are
retained, and we have thus a very accurate method
of differentiation.
It would not, perhaps, be just to ignore all of
these claimed exceptions. But keeping in mind the
countless variations (most of them uncalled for) in
technique which have characterized the work of
our American investigators, and the constant re-
sults noted above, certainly the future promises
much for the reaction, at least in those circum-
scriptions of diagnosis which I have indicated.
In brief, therefore, I suggest that the questioned
positive reactions given by other sera include
chiefly the nonoperative conditions, and these are
usually diagnosticated by other methods and do
not enter into the special differential question.
They should not detract from the main proposition
that if the serum of a person (who has been af-
fected for several months with a condition which
may be malignant, and if so is certainly by this
time inoperable, but even at this late hour the pos-
sibility that it is benign still exists) invariably
brings about a prompt and marked hemolysis of
standard suspensions of alien corpuscles we should
not hope to find at operation benign fibroids, simple
peptic ulcer, or other condition easily remedied by
the knife, and we should hesitate to approach sur-
gery which promises so little. We do a great in-
justice to the patient when we recommend such
surgery.
Selection of Cases. — I would hesitate to propose
binding rules for the selection of cases. Now and
then with our greatest care we will deny the test
to the patient who would be served the best by its
application. I have touched upon some of the main
points when considering the value of the reaction.
The following suggestions may be added:
1. There must be some reason to suspect ab-
dominal neoplasm — a palpable tumor, cachexia in
a good subject for cancer, an unexplained and sus-
picious stomach history, a suggestive gastric
analysis, a diagnosis of malignancy proposed by
another clinician, and so on.
2. Essential anemia, nephritis and so on should
be ruled out by proper laboratory examinations be-
fore undertaking and interpreting a hemolytic
test. Rule out tuberculosis if possible, although
some cases of abdominal tuberculosis may be re-
garded in a class with cancer so far as surgical
treatment and prognosis are concerned.
3. The hemolytic test should be preceded by the
use of a--ray and gastric analysis in questioned
stomach cases and by a diagnostic examination of
curettings in uterine cases.
4. It is not necessary to be able to palpate the
abdominal tumor, though it is much better and
usually possible to do so by the time the advisa-
bility of the test is considered.
5. Do not hesitate until the tumor is very large,
for it is conceivable that hemolysins may arise by
virtue of retrograde changes in enormous benign
growths denied proper pabulum. This introduces
a very dangerous source of error.
What Is the Hemolytic Test ?— Kelling found
900
MEDICAL RECORD.
[Nov. 18, 1916
that there exist in the blood sera of patients af-
fected with malignant disease certain substances
or a substance innately capable of destroying the
red blood cells of organisms not cancerous, but only
to a limited extent the red cells of the cancerous
patient, the latter appearing to be immunized (if
such a term is proper) to these bodies.
Furthermore, these cancer sera rapidly hemolyze
erythrocytes of chickens and other aliens, whereas
normal sera have but little effect. The precise
nature of the cancer hemolysin has not to my
knowledge been accurately determined. Wade has
shown that it is poisonous. It is especially plenti-
ful in cancers of the mucous surfaces- — stomach,
intestine, etc. It may be a toxic protein remnant.
Again it may be a salt or salts of certain fatty
acids (cholesterin or sodium salts of oleic acid)
which have been shown to have hemolytic prop-
erties.'
Claims of Kelling. — The first communication of
Kelling appeared about nine years ago,3 and sub-
sequent reports by him concerned mainly case re-
ports and technical modifications rather than any
change in opinion regarding the value of the reac-
tion. He claims that when the test is properly ap-
plied it is specific for internal cancer even in its
incipiency, and that the reaction depends upon the
presence of antibodies in the serum capable of
causing hemolysis of the corpuscles of the hen ir-
respective of the location of the growth, its struc-
ture, or any retrograde changes which may be tak-
ing place in its cells. I am unable to verify or re-
fute this broad claim, being denied the use of ma-
terial in a charitable institution or an endowment
to make possible such an undertaking in my labora-
tory. The claim of the originator of the hemolytic
test should not be lost sight of, but cannot be con-
sidered in this paper.
Choice of Technique. — Instead of adhering to an
original technique long enough to prove the value
of a reaction, laboratory workers (and especially
those of this country) begin at once to modify
and "improve" upon it, with the result that many
good tests are "botched up" and dropped in dis-
gust. This has been the case with the Kelling
test. It is to the shame of our workers that there
is today no standard or universal technique for the
hemolytic test. Four years ago I made a plea for
such, and so far as I know I am the only man in
this country who still adheres to the technique as
proposed by Kelling. Modifications have been em-
pirical, uncalled for, and entirely stupid, and it is
not difficult to understand why the reaction has
never gained a place in the average diagnostic
laboratory. Parenthetically, I might say that Kel-
ling has modified the technique somewhat, but the
changes are not sufficient to subtract from the
value of the original method nor the cases he ex-
amined by that method.
Preparation of Serum. — All operations should be
carried out under aseptic conditions, not because
the reaction depends upon the isolation of micro-
organisms in pure culture, but because a number of
hours are necessary and some of the materials
(citrate, etc.) may spoil. Secure blood from the
patient in a sterile test-tube. Fifty drops are suffi-
cient in a possible case of cancer, where we do not
wish to deplete the circulation. Where a normal
individual must supply serum for several controls
the blood may be secured from a vein by a needle.
For a single control the finger is cleaned with al-
cohol and pierced with a Moore spring lancet. I
do not usually separate the serum by mechanical
methods as by centrifugalization, but merely slant
the tube and place upon ice. Keep it there for
twelve hours. Then draw off the serum carefully
with a sterile pipet and dilute 1:10 with physio-
logical salt solution (formerly we did not dilute, but
used practically the same amount of the serum in
the end as contrasted to the corpuscle suspension).
Empirically we now incubate for 24 hours at 37°
C. This is claimed to render inactive certain
lysins and inhibiting substances which might be
present in noncancerous sera and yet not affect the
cancer-produced hemolytic substances. In most of
my work I have used also nonincubated serum, and
the results have been about the same. Personally,
I have seen no advantages thus far in incubation
before mixing with corpuscles. The serum is now
ready for use and should not be set aside, but the
corpuscle suspension should also be ready at this
point for making the test.
Preparation of Corpuscles. — With a pair of
small, sharp-pointed shears open a blood-vessel on
the under side of a hen's wing. The hen should be
healthy, and it is best to pick a fowl known to
have been healthy for several months. I select a
good laying hen, and by keeping my own stock am
assured that it is healthy. In case the hen is pur-
chased just before doing the work it is best to kill
it and be assured that the viscera are free from
sarcoma. Receive the fresh blood directly into a
vessel containing 2 per cent, sodium citrate solu-
tion. This prevents coagulation and is preferable
to defibrinating with glass beads, because the latter
method injures the red cells and thus favor*
hemolysis. Centrifugalize. Draw off citrate and
substitute physiological salt solution. Repeat this
process several times until the corpuscles are en-
tirely washed. It is best to centrifugalize slowly,
which avoids adhering of corpuscles into a mass,
for the breaking up of such a mass injures the cells
and favors hemolysis. Finally add enough or sub-
tract enough supernatant salt solution to approxi-
mate a 5 per cent, suspension, again mix by invert-
ing the tube, and this second component is ready
for use.
Technique. — Slender serum tubes are used. In
each place 10 drops of the corpuscle suspension. To
one or more add equal part of the iced, diluted,
incubated, unknown serum. To others add equal
part of the iced, diluted, incubated, normal serum.
To still others add equal part of physiological salt
solution, and yet others equal part of distilled
water. If at hand, serum from a cancer patient
may likewise be used to control. Place tubes in
rack and incubate from 24 to 48 hours at 37° C.
Each tube should be tightly corked and inverted
hourly, providing for thorough mixing.
Readings. — Hemolysis is most marked in the
tube containing distilled water. It is marked in
the sera of patients with late growths. We have
found it most marked in cancers of stomach, intes-
tine, and uterus. There should be absolutely no
hemolysis in the controls with healthy sera or phy-
siological salt solution, or else an error must be
-uspected. Following is the proper positive test: —
Suspected serum, marked hemolysis.
Normal serum, no hemolysis.
Physiological salt solution, no hemolysis.
Distilled water, very marked hemolysis.
Known cancer serum, marked hemolysis.
Conclusions. — Several American workers have
tried out this reaction upon a series of cases from
Nov. 18, 1916]
MEDICAL RECORD.
901
hospital wards with a view of verifying the claims
of Kelling in regard to the reaction being specific.
I am perhaps the only laboratory worker in the
country who has put the method to use for the pur-
pose of diagnosticating and differentiating inoper-
able abdominal tumors.
This communication has been prepared to answer
a large number of inquiries from laboratory diag-
nosticians and other physicians concerning the
technique and interpretation I have used. It seems
to me that the method is a promising one and de-
serves further study, not so much by the research
worker as by the diagnostician.
REFERENCES.
1. Williams, B. G. R.: Archives of Diagnosis, October,
1912.
2. Vetlesen: Norsk Magazin for Laegenvidenskaben.
3. Kelling: Berliner klin. Wochensehr., 1907, p. 1355.
Kelling: Wien. klin. Wchnschr., 1914, XXVII, 927.
J. A. M. A., Editorial, Sept. 5, 1914.
Crile: J. A. M. A., Vol. L, p. 1883.
Blumgarten: Medical Record, April, 1909.
109 EAST COURT.
AUTOINTOXICATION FROM CHRONIC IN-
TESTINAL STASIS, DUE TO HYPERTRO-
PHY OF THE SPHINCTER ANI, SIMU-
LATING APPENDICULAR COLIC*
By ARTHUR A. LANDSMAN, M.D.,
NEW YORK.
CLINICAL ASSISTANT DEPARTMENT RECTAL SURGERY, N. Y. POST
GRADUATE MEDICAL SCHOOL AND HOSPITAL ; DEPUTY SUR-
GEON, RECTAL DISEASES, O.P.D., N. Y. HOSPITAL ; AT-
TENDING PHYSICIAN, HOME DAUGHTERS OF JACOB.
This case derives its interest from the circum-
stance that the patient was ill for four weeks with
subacute abdominal symptoms, which were attri-
buted to appendicitis, for which operation was
advised.
The patient, a woman, is 20 years old, married,
has one child of 2 years; her family history need not
detain us. Menstruation and urination normal, habits
good, appetite poor, bowels regular up to one year ago.
Since then it has become increasingly difficult for her
to have a normal movement; the stools being small,
hard, dry, and lumpy, accompanied by straining, ne-
cessitating enemata and physic, even then productive
of but poor results at the expense of much abdominal
distress. She has been accustomed to only one move-
ment in nine days for the past year.
Four weeks before she presented herself for exam-
ination, her condition became markedly worse, with pain
in the right lower abdominal quadrant, cramps oc-
curring at frequent intervals, obstinate constipation,
nausea, headache, dizziness, backache, radiating pains
in the legs, cardiac palpitation, but no fever, chills, or
vomiting. Examination of the abdomen showed some
distention, diffuse tenderness on deep pressure over the
right iliac fossa, and hyperesthesia of the skin over
the right lower abdomen; there was no pain on the
right side when pressure was made over the left, no
pain when the fingers were suddenly withdrawn after
deep palpation, no subjective disturbance in the ab-
domen when the thigh was flexed on the pelvis. Tem-
perature 99°, pulse 76. Vaginal examination showed
no evidence of tubal or ovarian disease. Digital ex-
ploration of the rectum disclosed a small, tightly-
contracted, irritable anus, with a hard, thickened mus-
cular band surrounding the anal canal, which per-
mitted only with difficulty the introduction of the little
finger. The rectum was distended with feces.
The signs elicited by abdominal palpation were sug-
gestive of subacute appendicitis, but the previous his-
tory of the patient, the function of the bowel, and the
condition of the stools, together with the physical find-
ings obtained on examination of the anal canal, pointed
* Reported before the New York Physicians Associa-
tion, May 25, 1916.
to partial intestinal obstruction due to hypertrophy of
the sphincter ani, with secondary toxemic manifesta-
tions. Hence it was thought advisable to relieve the
condition at this point, by division of the sphincter
muscle. Ths was done under quinine and urea hydro-
chloride anesthesia, the wound was drained, and the
anal canal dilated with a No. 10 Wales bougie daily.
The patient had a satisfactory movement on the day
following her operation, unassisted, and a normal defe-
cation every twenty-four hours since; her abdominal
cramps and tenderness in the right iliac fossa disap-
peared with the establishment of normal bowel function,
all subjective gastric disturbances ceased, and she feels
better than she felt in a year.
No attempt is made to draw any general con-
clusions from one case, and it is simply reported
as an interesting instance in which symptoms in-
dicating a grave intra-abdominal condition were
apparently due to an obstruction in the anal canal,
and were promptly relieved when the obstruction
was removed. The writer is well aware that this
patient may quite possibly harbor an appendix in
a latent state of inflammation, which may light up
at some future time — that is a negative proposi-
tion which he is not disposed to argue; neverthe-
less, it will be admitted that there appears to be a
significant relation of cause and effect in the con-
dition of this patient before and after the opera-
tion.
Two points deserve attention: (1) That toxemia
from absorption of intestinal contents may produce
symptoms which simulate appendicular colic; (2)
That the cause of chronic constipation may be
found in mechanical conditions of the rectum and
anal canal, which are aggravated by physics and
enemata, but yield at once to simple operative
measures, which may be undertaken under local
anesthesia.
74 s Fifth Street.
X-ray Photographs as Evidence. — In an action for
alleged malpractice in the treatment of a fractured
wrist, expert medical witnesses called by the defendant
testified that x-ray plates of the wrist offered in evi-
dence for the plaintiff as showing an indentation showed
the epiphyseal line. In rebuttal the plaintiff showed by
a medical witness that on the preceding day the latter
was requested by the plaintiff's attorneys to take an
x-ray photograph of a pair of normal wrists and that he
had done so. The plaintiff then offered the x-ray photo-
graph so taken for the purpose: (1) Of rebutting the
defendant's evidence that the radii shown by the x-ray
plates in evidence were normal; (2) of rebutting the
testimony given in defense that the epiphyseal line ap-
peared on the x-ray plates (in the case) of the radii,
and (3) of showing normal radii, the condition and ap-
pearance of normal radii, to rebut the testimony of the
defendant's witnesses that the radii shown by the x-ray
plates in evidence showed normal conditions. It was
held that this evidence was properly excluded for two
reasons, if not more: (a) The receipt of the photo-
graph offered would have raised many collateral and
immaterial issues, such as whether the wrists there
represented were in fact normal, whether the age of the
person whose wrists were shown was such as to make
his or her wrists fairly and reasonably similar to the
normal wrists of the plaintiff, whether the photograph
was taken in a manner fairly to represent the wrists of
the person in all respects material to the purpose for
which it was offered, etc. On all the questions so raised
evidence would have been admissible, and thereby nu-
merous immaterial collateral issues would follow bear-
ing no relevancy to any question before the trial court,
(b) The .r-ray photograph offered was the result of an
experiment entirely outside the case. The photograph
was held to be admissible only in the discretion of the
trial court, and the wisdom of its exclusion was ob-
vious from the immaterial and collateral issues likely
to arise if it were admitted. — Davis vs. Dunn, Vermont
Supreme Court, 98 Atl. 81.
902
MEDICAL RECORD.
[Nov. 18, 1916
Medical Record.
A Weekly Journal of Medicine and Surgery.
THOMAS L. STEDMAN, A.M., M.D., Editor.
PUBLISHERS
WM. WOOD A. CO., 51 FIFTH AVENUE.
See fourth page following reading matter for Rates of Subscription
and Information for Contributors and Subscribers.
New York, November 18, 1916.
THE MEDICAL ASPECT OF UNIVERSAL
MILITARY EDUCATION.
In all the great amount of discussion which has been
going on about "preparedness" and compulsory mili-
tary service or education, the arguments have largely
centered around the legality of the procedure, its
military necessity or advisability, and the possibility
of the development of a militaristic party which
would endeavor to force the country into war. Ad-
vantages which would accrue to the individual in
the way of physical and mental development have
been mentioned but not, we think, with sufficient
emphasis.
While this country may excel in a competition
of trained athletes or in certain kinds of mental
ingenuity or shrewdness it is certain that the
average man is far from being a picture of per-
fect physical development, and the lack of self-con-
trol and the extreme contempt for the law of the
American have become proverbial. A casual inspec-
tion of the crowds on the streets of any one of our
large cities will reveal pale, undernourished, and
poorly developed youths and pasty, flabby men in
large numbers, and will convince the open-minded
observer of the desirability for the individual of
some form of regular physical training. That the
country-bred, moreover, are not greatly superior to
those brought up in the city has been the experience
of most military men who have had occasion to han-
dle large numbers of troops.
In addition to this physical handicap the country
is cursed with the presence of a very large group
who, confusing liberty and license, confess allegiance
to no constituted authority. These individuals de-
mand from society every protection and the oppor-
tunity for material gain but deny the right of that
society to exact any return. It is particularly in
respect to these points that Dr. Lucien Howe de-
velops his discussion in his recent book on Uni-
versal Military Education and Service.* He points
out the position of the United States in world poli-
tics and our need for adequate preparation, and
outlines briefly the Swiss and Australian systems
and their applicability to this country.
The many advantages of universal military edu-
cation to the nation are so evident as to need
♦Universal Military Education and Service; the
Swiss System for the United States, bv Lucien Howe,
F.R.S.M. Price, $1 net. G. P. Putnam's Sons. New
York and London. 191G.
little discussion and he devotes most of his at-
tention to the development of his chief argument,
the advantages of such education to the individual.
Education should include the development of the
pupil in at least four different directions — health,
knowledge, character, and efficiency. He points out
that of twenty million pupils in this country about
three-fourths have physical defects sufficiently grave
to require attention and seriously to threaten
health. Partly as a result of this poor start the
standard of health of the average American is so
low that over 50 per cent, of the applicants for the
Army and Navy were rejected for physical disabili-
ties in 1914 and in the following year less than 10
per cent, of the applicants for the Marine Corps
were found to be physically fit.
Most certainly any system of military training
would necessarily include gymnastic exercises and
these regularly performed and accompanied by
the regular routine physical examinations would
inevitably rapidly raise the standard of physical
health of our youth. In the matter of knowledge
America does not rank so low as she does in military
strength yet there is still room for improvement. In
all countries the percentage of illiterates is much
less in the army than in the civilian population and
in Germany, the most militaristic nation of our
time, there is but one illiterate for every 385 in the
continental United States.
In its effects on character and efficiency a mili-
tary training would have no less striking and im-
portant results. The lack of deference shown by
the American boy to his elders is notorious and
parallels his lack of self-restraint and self-sacrifice,
qualities out of which character is developed. As
logical consequences of our slackness in early train-
ing America stands high among the nations in in-
temperance, divorce, disobedience to law, and crime.
The most sure way of correcting these fundamental
faults in our youth is shown to be some form of
military discipline. Universal military training
would also provide trade instruction for the youth
and thus increase his efficiency as a unit in the coun-
try's productive strength. The girl also would re-
ceive her share in instruction and would be better
prepared to share in governmental responsibilities
and in the education of the young. The attitude of
the so-called "pacifists" and their apparent number
afford strong support to the disgraceful accusation
that many Americans rank low in loyalty and in
readiness to sacrifice personal interest to the good
of the country.
The one great lesson taught by military service is
the one great lesson most needed by the citizens of
this country : obedience. The attitude of the "anti-
preparedness" adherents is strongly remindful of
that of the antivivisectionists who are always per-
fectly ready to receive the benefit of any medical
progress which is founded directly on animal experi-
mentation but who, from either a silly sentimental-
ity or dense ignorance, deny the right of the profes-
sion to use the means by which such knowledge is
obtained. It is a sad commentary on the condition
of things in the United States that such a book as
that of Howe's should be necessary. It is a hopeful
sign for the future that such a book has been pro-
duced.
Nov. 18, 1916]
MEDICAL RECORD.
933
THE CARE OF RURAL SCHOOL CHILDREN.
There is little doubt that in every country physical
efficiency is rare, this is to say, that in the large
majority of individuals there exist defects which
subtract considerably from the ideal of perfection.
Of course, no one is physically perfect and most of
us are far from that state. That physical imper-
fections abound is continually being demonstrated
by the rejections for army service in all countries.
Before the outbreak of war in Europe the rejections
in Great Britain were numerous and in this coun-
try a similar state of affairs prevails. Dr. Tali-
aferro Clark, surgeon, U. S. Public Health Service,
writing in Public Health Reports, Oct. 6, 1916,
states that an officer connected with the recruiting
station of the U. S. Marine Corps, New York City,
has been quoted by George J. Fisher in "Physical
Preparedness" to the effect that only 316 of 11,012
applicants for enlistment in this branch of the pub-
lic service were up to the required physical stand-
ard.
The particular point, however, that Clark makes,
is that it has been noted by observers in other
countries that, in the case of volunteers for military
service, rejections because of physical unfitness are
in direct relation to the number of years spent in
the school. The writer therefore, seems inclined to
think that there may be some truth in the hypothesis
that the schools may be responsible in a measure for
such lack of development. He further holds that
this view is all the more evident when it is recalled
that the greatest number of rejections for enlist-
ment on account of physical defects were due to
abnormalities of physical development, defective
vision and hearing, heart disease, faulty teeth, and
postural defects. These defects are to a great ex-
tent preventable, or at least controllable, depend-
ing upon their prompt recognition during childhood,
the period in which so many of them have their
origin.
In discussing the condition of school children in
one county in Indiana, in which investigations were
undertaken by the Public Health Service with re-
gard to physical averages, it is pointed out that,
compared with the records of children in most urban
centers as tabulated in "A Manual of Diseases of
Infants and Children," by John Ruhrah, the boys
of this county were below the average height from
the age of 6 to 17. The girls were under mean
height from the age of 12 to 17. The deficiency
ranged from 0.7 to 2.3 per cent, among boys and
from 0.2 to 2.8 per cent, among girls. The deficiency
of weight from the age of 7 to 15 varied from 0.2
to 5.9 per cent, in boys, and from the age of 7 to 16
in girls 0.6 to 8.9 per cent. Unsuitable food was
found to be the chief cause of this backward physi-
cal development. Moreover, no adequate facilities
for play were provided and no systematic physical
exercises were practised in any of the rural schools
of this county.
Ear troubles, impaired vision, and defective teeth
were found to be very prevalent. With regard to im-
paired vision faulty illumination is held to be large-
ly responsible for the condition and in addition to
this, a number of rural school children were badly in
need of glasses and had never been refracted. It
goes without saying, that the rural school child is
greatly in need of instruction in the care of the
teeth and in need of adequate dental service. It
was shown that no fewer than 49.3 per cent, of
the children of this county had defective teeth and
only 16.9 per cent, had dental care. Furthermore,
14.4 per cent, of these children never used a tooth-
brush, 58.2 per cent, used one occasionally and only
27.4 per cent, used one daily.
Sufficient evidence has been already gathered to
indicate that the school is a factor in the spread of
communicable diseases in rural communities, due
largely to the fact that the children of different
families are rarely in intimate contact except at
school. The question then arises how are all these
conditions to be remedied and according to Clark
the answer is: (1) By abolishing school dis-
tricts and establishing a country unit of school ad-
ministration; (2) by establishing an efficient system
of health supervision of school children; (3) by con-
solidating rural schools.
When it is borne in mind that rural school chil-
dren in this country constitute 60.7 per cent, of the
total school enrollment of the country, the vast im-
portance of properly caring for their health and of
endeavoring so to bring them up that both men-
tally and physically they may be able thoroughly to
fulfill their duties and responsibilities is too obvious
to require elaboration. In order to attain this ob-
ject their health supervision should be more strict
by far than it is at present. This Indiana county
presumably offers a fair example of what school chil-
dren are in an agricultural district and the inves-
tigations of the Public Health Service plainly show
that reforms should be promptly introduced if a de-
cent standard of health among the school children
of the country is to be hoped for. Children of a
school age spend more of their waking day at school
than at home and it behooves the authorities to in-
sist that every effort should be made to establish and
maintain their physical and mental health.
THE DIAGNOSIS OF RENAL TUBERCULOSIS.
Guinea-pig inoculation has long been accepted as
the most reliable method for the diagnosis of tu-
berculosis, not only of the kidney, but also in other
parts of the body, such as the pleura, peritoneum,
etc. The method has the great advantage of being
almost absolutely sure in its results, but has the
disadvantage of requiring a long time before the re-
sults of the test can be obtained. Several attempts
have been made to shorten this time without weak-
ening the value of the test. The French advocated
injecting the material into the lactating breast,
which was said to be especially susceptible to in-
fection with the tubercle bacillus. Three years ago
Keene and Laird injected the material into the
thigh and traumatised the inguinal glands, both be-
fore and after the injection. They claimed to be
able to recognize tuberculosis of the traumatized
glands on microscopical examination ten days after
the injection. But lactating pigs are not always at
hand, and traumatising inguinal nodes of thirty or
forty pigs every day, as would be demanded in a
large hospital laboratory, would use up a deal of
time.
904
MEDICAL RECORD.
[Nov. 18, 1916
To shorten time and assure results, Morton has
recommended the use of the x-ray. He bases his
work on the demonstration by Murphy and Ellis
that white mice which have been exposed to x-rays
are made markedly more susceptible to bovine tu-
berculosis than normal animals. This increased
susceptibility was apparently related to a destruc-
tion of the lymphoid tissue. Morton first ascertained
(Jour. Exper. Med., 1916, xxiv, 419) that guinea-
pigs could tolerate a large amount of x-rays with-
out apparent injury to their health, and that one
massive dose would reduce the total white cell count
by about one-half. This reduction affected mainly
the lymphoid cells and was apparent for a period
of more than one week. His method was to radiate
the animal, at the time of the inoculation, for ten
minutes with a Coolidge tube at 12 inches, with 5
milliamperes and 8*2 inches of spark. From one to
two cubic centimeters of urine was injected intra-
peritoneally and the animals were killed and ex-
amined after ten days. His results were excellent in
a small series of animals. He lost but one out of
ten from a mixed streptococcus infection, and all
the control animals gave negative results.
The only objection to the method is that suscepti-
bility is increased to other infections beside the tu-
berculous, and in those cases in which a mixed in-
fection is present it would probably be advisable to
inoculate two animals, one treated and one not, so
as to avoid the loss of the animal. The method
could, of course, be extended for use with fluid from
the chest, abdomen, and spinal canal, and if con-
tinued favorable results were obtained, would effect
great saving, not only in the feeding of animals, but
also in the stay of the patients in the hospital.
Intraspinal Injections of Tuberculin in
Meningeal Tuberculosis.
The high mortality of tuberculous meningitis is
warrant enough for any effort to reduce it. The
number of recoveries from this affection is very
small; some years ago the few alleged recoveries
were discredited, the diagnoses having been purely
clinical, but with the introduction of lumbar punc-
ture the possibility of cure was demonstrated. The
intraspinal injection of tuberculin as a form of
local therapy is of quite recent date, Bacigalupo,
one of the first to test the remedy, having cured
two patients, one with three and the other with
two injections. Laforo, in La Pediatria Espanola,
says he failed to cure two cases treated, but ob-
tained in one a markedly favorable response to the
remedy. A girl aged 9, with evidences of the dis-
ease, received lumbar puncture without incidental
relief. The fluid was clear, and came out without
much pressure. There was an intense lymphocy-
tosis. An injection of tuberculin (Koch's old tuber-
culin) was made. The symptoms remained severe
for some hours. A second puncture gave exit to
much fluid, under high pressure, with prompt im-
provement throughout, the temperature becoming
normal. The following day another decompressive
puncture relieved the symptoms, which had reap-
peared. The child, however, slowly succumbed to
the disease. The second child was 18 months old,
and had been ill 20 days when the first puncture
was made. Withdrawal of 10 c.c. of fluid gave
some relief. An injection of tuberculin caused a
slight reaction and was followed by striking ameli-
oration. For two days recovery seemed to be
taking place, the child beginning to take nourish-
ment with avidity. It was thought best to make
another puncture and mix the fluid with tuberculin.
An intense reaction followed, with headache, vom-
iting, strabismus, convulsions, and death two days
later. The treatment went wrong because the punc-
ture was mixed with blood, which clotted, and pre-
vented admixture with tuberculin. In his next at-
tempt the author, if he can obtain a clear punctate,
will proceed to mix it with tuberculin, thereby
securing a physiological serum in imitation of the
Swift-Ellis salvarsanized serum. A solution of tu-
berculin in physiological serum, 1 to 100, is used,
and from this is formed another of 1 to 10,000. Of
this 1 c.c. is mixed with the punctate (10 or 15
c.c), and the whole is slowly thrown into the spinal
canal. In the favorable results on record, headache,
vomiting, etc., disappear.
The Fourth Disease in Italy.
The Italian literature of the so-called Filatow-
Dukes disease appears to be very light, for in a
representative bibliography of important refer-
ence works we see nothing in that language. In
fact, we obtain the impression that the disease is
not cumulative in southern Europe. However,
Donetti of Lucca reports 15 cases in La Riforma
Medica for August 21, and his conclusions evidently
concur with those of the classic writers on the
subject. It is a clinical entity, a children's disease
of the general infectious type, with an incubation
period of from two to eight days in most cases. It
begins as an angina, simple or follicular, with reac-
tion in the proper lymphnodes. Fever is due to the
anginous component. The eruption comes out dur-
ing a period of four or five days, beginning about
forty-eight hours after the first evidence of disease.
At first there is a general rash, but small papules
soon replace it, and appear to characterize the
disease. The fever subsides long before the com-
pletion of the outbreak. There is a rapid period
of desquamation, the epidermis of the digits com-
ing away in flakes. Itching is usually present.
Complications may be renal or pulmonary. En-
larged cervical and submaxillary lymphnodes may
persist for a long time. Not infrequently the gen-
eral health suffers. The incidence is epidemic
throughout.
A Cynic's View of Syphilis.
Nothing is safe from the ridicule of a witty
Frenchman, and Voltaire was the wittiest of them
all. Naturally, the great problems of life, death,
and disease were, with him, the material from
which epigrams could be made. In those days,
syphilis held sway untroubled by premonitions of
the days of salvarsan. and its ravages were fright-
ful. Thus, in Candidc. the author tells of the
horrible havoc played with the features of Pangloss
by the disease, and its failure to cure his optimism.
He makes his characters tell of the prevalence of
lues among the soldiers, two-thirds of whom, he
says, were affected. By means of the military this
affliction was carried into country villages where,
hitherto, love-making had been as free and unre-
strained as among the birds of the air. To combat
its encroachments, mercury was used lavishly, until
the treatment became only the exchange of one form
of poisoning for another. The experience of the
Nov. 18, 1916]
MKDICAL RECORD.
905
present war is again illustrative of the way in
which the disease is spread by soldiers, showing that
often the life of the soldier, whatever may be its
value in inculcating habits of discipline while he is
on duty, tends to relaxation and license in his leisure
moments.
A Discussion on Health Insurance.
In writing on health insurance a few weeks ago, we
expressed the hope that every medical society in the
State would set aside at least one evening for the
discussion of this important subject, so that when
the Legislature takes up the matter, as it must at
the coming session, the medical profession may be
informed regarding it and be able to cooperate in-
telligently with the lawmakers in formulating a fair
and workable measure. We are therefore glad to
learn that a public meeting has been called by the
Committee on Medical Economics of the Medical So-
ciety of the State of New York, to be held at the
Academy of Medicine on Thursday evening, Novem-
ber 23, to discuss the entire subject of compulsory
health insurance. The topics announced are the
following: "Introductory Remarks," by the Chair-
man, Dr. Samuel J. Kopetzky; "Relations to Pre-
ventive Medicine," by B. S. Warren, M.D., U. S.
Public Health Service; "The Labor Man's Point of
View," by Mr. Hugh Frayne, American Federation
of Labor, National Civic Federation; "The General
Medical Practitioner's Point of View," by Eden V.
Delphey, M.D.; and "The Advantages of Compul-
sory Health Insurance," by Mr. Miles M. Dawson,
Insurance Expert. Now that the State Society has
set the example, doubtless the county societies will
follow suit, and then when the measure is introduced
at Albany it will more likely be in the form of a
wise and just law and one that will be acceptable to
physicians and the public alike.
SfrlttB Of tljF WtBk
Foundation of a Medical School in the Uni-
versity of Chicago. — The General Education Board
and the Rockefeller Foundation have announced the
appropriation of $2,000,000 for the establishment
of a medical department in the University of Chi-
cago. It is understood that the university will set
aside at least an equal sum for the same purpose,
will give a site on the Midway, valued at $500,000,
and will raise a further sum of $3,300,000, and that,
in addition, the present plant and equipment of the
Presbyterian Hospital, Chicago, valued at $3,000,-
000, will be placed under the control of the medical
department of the university. At present, the Uni-
versity of Chicago has no medical school of its own,
though it has an agreement with the Rush Medical
College. The new school, however, will be entirely
independent of the latter, which it is expected will
go out of existence as soon as the new department
is ready. It will thus be possible to organize the
medical school from the beginning along the most
recent developments in medical education, and it is
planned to include in the Faculty and teaching force
only full time men, as regards both laboratory work-
ers and clinical teachers. Laboratory buildings
will be provided and also a university hospital. The
latter, under complete control of the university, with
laboratories and an out-patient department, will offer
ample facilities for clinical teaching. The restric-
tion of the members of the teaching force to full-
time workers is in line with action already taken at
Johns Hopkins Medical School and at the Medical
Department of Washington University, St. Louis.
The new school is expected to provide accommoda-
tions for 300 students, all of whom will be required
to have an academic degree before entering, and it
will also have facilities for postgraduate work.
Prevention and Relief of Heart Disease. — The
Board of Governors of the Committee for the Pre-
vention and Relief of Heart Disease has developed
plans for an active campaign to arouse public inter-
est in the important problems with which it is deal-
ing, and has placed the work in the hands of spe-
cial committees dealing with various phases of the
problem. The Committee on Relief has outlined a
program which covers, first, occupation for cardiacs,
both children and adults; second, the establishment
of classes for cardiacs, when possible in connection
with hospitals, with duties divided into medical and
social; third, the obtaining of more opportunities
for cardiac patients in convalescent institutions;
and, fourth, provision for permanent institutional
care. The committee's program is of especial inter-
est in connection with the plans now being laid for
the after care of poliomyelitis patients, the two
problems presenting many of the same aspects,
though the care of cardiac patients is really the
more important of the two. It is estimated that
there are in the city about 20,000 children alone
suffering from heart disease and requiring syste-
matic care. In a number of ways the two groups
need similar provision for relief; both should be
under constant social and medical supervision; the
members of both should be fitted for occupations
suited to their infirmity; some of the children in
both groups need to be taken to school in convey-
ances. It would seem, therefore, that a way might
be found to coordinate the work of existing agencies
to the fullest extent. The committee on relief ap-
peals for funds to carry on its work.
Gifts to Charities. — By the will of the late Mrs.
Caroline A. Wilson of New York, the Presbyterian
Hospital of this city receives a bequest of $25,000.
New York Physicians' Association. — At a meet-
ing of this Association to be held Thursday, Nov.
23, 1916, at 8.30 P. M., Prof. Alfred Stengel of the
University of Pennsylvania will present a communi-
cation on "Practical Differentiation Between the
Various Types of Chronic Nephritis."
St. Joseph's Hospital, St. Francis' Hospital, the
Home for the Blind, and St. Rose's Home for In-
curable Cancer, New York, receive bequests of $500
each by the will of the late Catherine E. Brown of
Brooklyn.
A bequest of $15,000 is made to the House of
Mercy Hospital, Pittsfield, Mass., by the will of the
late Mrs. Louise F. Crane of Lenox, Mass.
Personals. — Dr. William T. Councilman of
Harvard University and Dr. Robert A. Lambert of
Columbia University will accompany the expedition
headed by Dr. Alexander Hamilton Rice, which will
sail shortly for South America. The members of
the expedition will make a topographical survey of
portions of the Amazon Valley and a study of the
diseases of natives in those regions.
New Medical Society. — At a convention held in
Pensacola, Fla., on October 27, the West Florida and
South Alabama Medical Society was formed, the
following officers being elected: President, Dr.
Louis de M. Blocker, Pensacola; First Vice-Presi-
dent, Dr. M. S. Davie, Dothan, Ala. ; Second Vice-
President, Dr. E. Porter Webb, Laurelhill, Fla. ;
Secretary-Treasurer, Dr. Fritz A. Brink. Pensacola.
906
MEDICAL RECORD.
[Nov. 18, 1916
Obituary Notes. — Dr. William Judkins Conk-
LIN of Dayton, Ohio, a graduate of the Medical
College of Ohio, Cincinnati, in 1868, and a member
of the Ohio State Medical Association and the
Montgomery County Medical Society, died at his
home on October 31, after an illness of several
months, aged 72 years. Dr. Conklin was formerly a
member of the Starling Medical College, Columbus,
Ohio, and since his removal to Dayton had been
active in many ways in the city's life, serving in
the Board of Education and in the Library Board,
of which he was for eighteen years president.
Dr. Frank S. Stirling of Lewiston, Idaho, a
graduate of Cooper Medical College, San Francisco,
in 1864, and a member of the Medical Society of
the State of California and the Nez Perce County
Medical Society, died on October 15. Dr. Stirling
was formerly physician and surgeon for the Pacific
Mail Company, and served as surgeon in the United
States Army during the Modoc war.
Dr. Clinton E. Sapp of South Omaha, Neb., a
graduate of the Medical College of Ohio, Cincin-
nati, in 1875, died at the south Omaha Hospital on
October 12, aged 64 years.
Dr. James Bennett Gould of Minneapolis,
Minn., a graduate of Jefferson Medical College of
Philadelphia, in 1886, and a member of the Amer-
ican Medical Association, the Minnesota State Med-
ical Association and the Hennepin County Medical
Society, died from apoplexy on October 17, aged
56 years.
Dr. John P. Moore of Astoria, L. I., a graduate
of the University of Vermont, College of Medicine,
Burlington, in 1894, physician to St. John's Hos-
pital, Brooklyn, and a member of the Associated
Physicians of Long Island, and the Greater New
York Medical Association, died on October 24, aged
50 years.
Dr. Frank Duane Maine of Springfield, Mass.,
a graduate of New York Homeopathic Medical Col-
lege and Flower Hospital, New York, in 1872, died
suddenly on October 29, aged 77 years. Dr. Maine
was a veteran of the Civil War.
Dr. Franklin S. Jewett of Providence, R. I.,
a graduate of Hahnemann Medical College and Hos-
pital of Philadelphia in 1894, died at his home on
October 24, after a long illness, aged 59 years.
Dr. Edward Sydney McKee of Cincinnati, Ohio,
a graduate of the Medical College of Ohio, Cincin-
nati, in 1881, and a member of the Ohio State Medi-
cal Association, the Hamilton County Medical So-
ciety, and the Cincinnati Obstetrical Society, died
from malarial fever at Quito, Ecuador, on October
20, aged 58 years.
Dr. JACOB M. Dennis of Hopkinsville, Ky.. a
graduate of Jefferson Medical College of Philadel-
phia in 1860, died from paralysis recently, at the
home of his son, aged 82 years. -
Dr. Charles William Penn Brock of Rich-
mond, Va., a graduate of the Medical College of
Virginia, Richmond, in 1859. and a member of the
Medical Society of Virginia and the Henrico County
Medical Society, died at his home on October 19.
aged 80 years. Dr. Brock was a veteran of the Con-
federate Army.
Dr. D. L. Howell of Big Rock, Va., a graduate
of the Medical Department of Vanderbilt Uni-
versity, Nashville, in 1877, died at his home recent-
ly, aged 59 years.
Dr. JAMES M. COYLE of Nashville, Tenn., a grad-
uate of the Medical Department of the University
of Nashville, died at his home on October 21, aged
66 vears.
UIxirrrspmtflntrF.
CALCIUM DEFICIENCY IN NEPHRITIS.
To the Editor of the Medical Record:
Sir: — To the question, "Is calcium deficiency in-
cidental or an essential factor in nephritis?" I can
now answer positively in the affirmative. The proof
is to be found in an examination of the blood, and.
of course, this puts the treatment of the disease
upon an entirely new basis. Thus, it will now be
possible to determine with exactness the defective
metabolism in this disorder, since it is not a diffi-
cult task for a chemist to make this test. This in-
formation was brought to my attention by Dr. P. B.
Hawk, professor of physiological chemistry in Jef-
ferson Medical College, who has been studying cal-
cium metabolism during the past few years, and he
has advised me that the same holds true in respect
to diabetes mellitus. Such being the case, it fol-
lows that rheumatism, so-called neurasthenia, and a
long list of chronic ailments fall into the same
category, confirming my clinical evidence relating
to the deleterious effects of acid excess.
John Aulde, M.D.
1305 Arch Street, Philadelphia.
A DISCLAIMER.
To the Editor ok the Medical Record:
Sir: — During the progress of the Anderson trial
in Brooklyn I was reported in the newspapers as
having said that the case was not one of anterior
poliomyelitis. I endeavored in vain to obtain a
retraction of this statement both from the report-
ers and the editors responsible for it. I would like
to have published the statement that at no time did
I give to anyone, not even to counsel, my opinion of
the case until it was given to the court while I was
on the stand. John P. Davin. M.D.
117 West Si sixth Street, New York.
OUR LONDON LETTER
i From Our Regular Correspondent.)
ROYAL COLLEGE OF PHYSICIANS — HARVEIAN ORATION
— DONATION OF £10,000 FOR RESEARCH CAN
VENEREAL DISEASES BE STAMPED OUT?
London, October 21.
The Harveian oration at the Royal College of
Physicians was delivered on Wednesday by Sir
Thomas Barlow. The chair was occupied by Dr.
Frederic Taylor, president, and there was a good at-
tendance of the Fellows. Among the guests was
the Archbishop of Canterbury. The orator gave a
summary of the life of Harvey and pointed out
that he was carrying on a tradition that had arisen
from that great physician, who was one of the prin-
cipal benefactors as well as ornaments of the col-
lege. Harvey's discovery of the circulation of the
blood was made during a period of great revival of
learning, when the creation and dissemination of
England's finest literature was in progress. As-
trology was as widely accepted for science as as-
tronomy, but physics was not then a science at all.
Chemistry was dominated by unreliable hypotheses
or mere guesses. Harvey's magnum opus was for
a long while during his lifetime linked with the
College of Physicians. For 12 years he expounded
his doctrine and met with only one adverse critic
among the Fellows. He was not only a doctor
Nov. 18, 19161
MEDICAL RECORD.
907
medicines but a doctor me.dicorum, and in paying
homage to him to-day the Fellows were only reviv-
ing the great respect and homage that had been
paid to him by the college during his lifetime. He
several times gave expression to his belief in God
and the Christian faith. He displayed intense love
for his family and friends, and willingness to take
trouble on behalf of the students of his time. It
behooved Fellows to seek out the secrets of nature
as he had done and to continue in mutual love and
admiration among themselves.
The orator announced that in June last the sum
of £10,000 in 21- per cent, annuities had been
offered by Mrs. Eliza Streatfield for the purposes
of endowment, and research. The gift had been
gratefully accepted by the college.
A morning paper has been discussing the possi-
bility of stamping out venereal diseases, thinking
that the record of the president of the local Gov-
ernment Board in respect to rabies a reason for
expecting from him that active administrative
action and dogged perseverance which he displayed
in that case. As hydrophobia is produced in man
only by direct contagion from animals — most fre-
quently from the bite of a rabid dog, though occa-
sionally by handling contaminated material — so
syphilis and gonorrhea are spread only by inocula-
tion of their specific poisons from person to person.
That is the rule, but exceptionally the infection may
be carried by contaminated articles, as, for instance,
a pipe or a towel. Hydrophobia is not a common
disease in England — never has been. The highest
number of deaths from it in any one year since
1880 was 60— in 1885. Since 1902 no death has
been recorded from this disease, if we except two
doubtfully ascribed to it in 1910 and 1911. This
result has been attained by means of the regula-
tions enforced by Mr. Walter Long, who prevented
the landing in this country of dogs from othe'
countries until after a period of quarantine exceed-
ing the period of incubation of rabies, and who in
spite of the opposition of many dog owners, espe-
cially women, insisted on the continuance of his
muzzling order until not a single case of rabies re-
mained in the country. This remarkable success
may encourage the hope of similar results in othei
directions. But the detention of travelers until
they can prove themselves free from venereal dis-
ease is obviously not practicable. Yet if all the
forces of prevention and treatment can be brought
to bear, some success in controlling the spread may
be attained. Among the chief measures requiring
attention are those for securing the early recogni-
tion of these diseases and their treatment under
the best modern conditions. It has been suggested
that confidential notification to the medical officer
of health might be tried, but even if possible the
practical drawbacks to this would prevent its suc-
cess and the attempt to introduce it would drive
many patients into the arms of the quacks. Early
treatment is so important that it is of the first im-
portance to get patients to submit themselves to
their attendant on the first symptom, and to carry
on his treatment until he pronounces them recov-
ered, and still further to watch for and refer to
him every suspicious appearance of a return. It is
by persons who have neglected treatment that these
diseases are chiefly spread, and it is persons who
do not recognize the significance of early and mild
symptoms who later fall victims to urinary dis-
eases, or to paralysis, or insanity, or who are respon-
sible for bringing into the world infected children.
CANADIAN LETTER.
i From our Special Correspondent)
CANADIAN HOSPITALS COMMISSION — THE CONVALES-
CENT ARMY HOSPITAL IN COLLEGE STREET, TO-
RONTO OPENING OF A MILITARY HOSPITAL IN
TORONTO — REORGANIZATION OF CANADIAN ARMY
MEDICAL SERVICE — PROHIBITION IN ONTARIO —
ANNUAL MEETING OF THE CANADIAN ASSOCIATION
FOR THE PREVENTION OF TUBERCULOSIS — ABSENCE
OF SMALLPOX IN ONTARIO AND INCREASE OF
POLIOMYELITIS — DR. JOHN FERGUSON MADE PRESI-
DENT OF TORONTO ACADEMY OF MEDICINE —
OBITUARY.
Toronto. Oct. 18, l'Jlfi.
The Canadian Hospitals Commission was formed
by order-in-C'ouncil, dated June 30, 1915, for the
purpose of providing convalescent homes and medi-
cal treatment for returned invalided and wounded
members of the Canadian Expeditionary Force. It
was decided later that the powers of the commission
should be extended to cover the matter of the vo-
cational re-education of those who through their
disability might be unable to follow their previous
occupations; also that the necessary machinery in
the form of Provincial Commissions and local com-
mittees should be installed in order to provide em-
ployment, not only for disabled men, but at the
close of the war, for the able-bodied men as well.
As mentioned in a previous letter there is a large
number of these convalescent hospitals and homes in
various parts of Canada and the large one on Col-
lege Street, Toronto, was referred to particularly
and it was stated that further details would be
given concerning it. The hospital is situated in a
large old-fashioned roomy building in a central
part of the city, placed in spacious grounds. It will
accommodate more than one hundred inmates and
when I paid a visit the other day appeared to be
filled almost to its capacity.
The majority of the men were suffering from in-
juries of different kinds received at the front. A
few were recovering or partially recovering from
the effects of gas poisoning. A goodly proportion
were suffering from shock to the nervous system
in addition to injuries. The most depressed men
among the inmates (as a rule, they were in excellent
spirits) were those who had been poisoned by gas.
It appears to have a peculiarly lowering effect and,
of course, exerts the greater part of its evil effects
upon the respiratory organs.
The equipment of this hospital for providing the
patients with the means of mechanical treatment
is singularly complete. All the apparatus was given
privately and it is largely due to the efforts of Mr.
F. Davies that so splendid an equipment was got
together. Hydrotherapy is practised considerably
by the agency of circular douches, needle douches,
and rain douches for the relief of nerve troubles
and rheumatism. Continuous leg baths are em-
ployed for treatment of stiffness of the joints
and similar methods are used for the treatment of
stiffness of the arms. Full bath bodily treatment
is utilized for nervous cases and light mental cases.
There is an electrical limb baker for joint stiffness;
also an electric cabinet for the treatment of neural-
gia, rheumatism, and neuritis ; an electrical cradle
for applying heat locally to feet, hands, or, in fact,
to any part of the body where such treatment is
thought to be required; an electrical wall plate by
which faradic and galvanic currents in all forms
can be applied ; high frequency cabinet with full
electrodes ; a lamp to be used for the sun ray treat-
908
MEDICAL RECORD.
[Nov. 18, i916
ment, and lastly a complete equipment of Zander
apparatus for rotation and resistant movements. It
goes without saying that massage is largely used in
connection with one or another of the hydrothera-
peutic electrical or mechanical modes of treatment.
It remains to be said that the results, on the whole,
have been eminently satisfactory and that many men
who without these forms of therapeutic aid might
have been seriously crippled are relatively sound
and supple in limb.
Another military hospital was opened in Toronto
a few days ago. The old Knox College, a fine
spacious building on College Street, has been pro-
vided by the Ontario Provincial Government for the
treatment and care of returned wounded Canadian
soldiers. Numerous organizations, including the
Ladies' Voluntary Aid Society of Toronto, the
Masonic Order, the Orange Order, the St. Andrew's
Society, the Daughters of the Empire, provided fur-
nishings and comforts for the soldiers. At the
opening ceremony Sir James Longheed, chairman
of the Military Hospitals Commission, in his speech
gave a detailed account of what the Government
was doing and prepared to do for the returned sol-
dier. He pointed out that in Canada 6000 men had
already passed through the convalescent homes.
These figures give some idea of the work being
carried on and also of the work which would have
to be done before the war is over.
In my former letter I called attention to the fact
that Col. Herbert Bruce of Toronto, who has been
appointed Inspector General of the Oversea Cana-
dian hospitals, had criticised some features of the
existing system of the Canadian Hospitals in Great
Britain. The main stumbling block to Colonel
Bruce and to the committee composed of several of
the leading army medical corps officers from Canada
to assist him in his investigations, was the mixing
of the Canadian wounded and the other British
wounded. Colonel Bruce and the committee have
given it as their opinion that the Canadian wounded
should be segregated in Canadian hospitals. Sir
Sam Hughes, the Canadian Minister of Militia, is
said to be in accord with these views. It is stated
that in the report submitted by Colonel Bruce a
complete reorganization of the Canadian Medical
Service is recommended, with the suggestion that
the medical arrangements in Canada, in Great
Britain and overseas be co-ordinated. Among other
recommendations are that Canadian casualties be
as far as is possible treated in Canadian hospitals
and that the care of Canadian sick and wounded
be the first duty of the Canadian Army Medical
Corps, that the Canadian hospitals be concentrated
and voluntary hospitals for Canadians be abolished,
hospitals now conducted or equipped by the Red
Cross being taken over by the Medical Service for
administration, that incapacitated Canadian soldiers
be returned to Canada as soon as they are fit to
travel, for further medical treatment and that the
three Canadian hospitals now at Salonica be re-
turned to England immediately if they can be spared
by the Imperial authorities. Other recommenda-
tions affecting arrangements in Canada are made.
Among these are, that immediate steps be-taken to
provide hospitals with 1000 beds each in Halifax.
Montreal, Winnipeg, and Vancouver, with a smaller
one in Ottawa, and that these provide accommoda-
tion for a limited number of officers; that for the
purpose of assisting in the organization of these
hospitals a number of Canadian medical officers who
have had experience at the front be detailed for dutv
in Canada; that all ranks before leaving Canada be
examined by an independent medical board, a num-
ber of these boards to be established in various
parts of Canada, this to be done for the weeding
■ nit of the unfit; that no medical units be organ-
ized in Canada in future for oversea duties; that
the officers of the Canadian Army Medical Corps
in future be thoroughly trained at well-equipped
depots to be established in Canada. It is under-
stood that Colonel Bruce makes the statement that
both in France and in England Canadian soldiers
have been begging to be taken to Canadian hos-
pitals and that no effective measures have been
taken to bring this about, while Canadian medical
officers who have gone to England at the sacrifice
of their practise in order to care for Canadian
soldiers, rarely have the opportunity for treating
a Canadian patient. It is chiefly for this reason
that the concentration of Canadian hospitals is
suggested. It is believed that Colonel Bruce has
been authorized by Sir Sam Hughes to carry out
the reorganization of the Medical Service imme-
diately according to the plan which he has proposed
in his report.
It would be ill-becoming in a letter to a medical
journal not to refer to prohibition in Ontario. It
is now impossible to obtain alcohol in saloons or
stores anywhere in this large province. The re-
sults of the enforced abstinence are good. The
step is a radical one but is decidedly in the interests
of health.
The fifteenth annual meeting of the Canadian
Association for the Prevention of Tuberculosis was
held in the Parliament Buildings, Quebec City, on
Sept. 12 and 13. The meeting was successful from
all points of view. Dr. Peter Bryce of Ottawa read
an excellent paper entitled "Why Notification of
Tuberculosis is Necessary." The following officers
were elected: Lieutenant-Governor of Quebec, Sir
Evariste Leblanc was elected as honorary vice-
president. Hon. J. W. Daniels, M.D., of St. John,
N. B., was re-elected president. Dr. Alfred Thomp-
son of Yukon and Hon. R. Turner of Quebec were
also made vice-presidents. Dr. George Porter of
Toronto was re-elected secretary treasurer.
For the first time in more than twenty years the
monthly health returns to the Ontario Board of
Health contained not a single case of smallpox. A
good deal of the credit for this very satisfactory
state of affairs must be given to Dr. J. McCullough,
the chief of the Provincial Board of Health, who has
been ably assisted in his campaign against the dis-
ease by the health officers in all parts of the Prov-
ince. But a few years ago the malady was one of
the most serious as regards both virulence and
prevalence in Ontario and it says much for the
work of public health medical men that they have
been able practically to extinguish the disease. Po
liomyelitis, however, shows few signs of decreas-
ing, the September returns reading 76 cases and 7
deaths or 32 cases more than in August. The rec-
ords point to the fact that the cases are rather
sporadic than epidemic in character, the 76 cases
being scattered over eighteen counties.
Col. H. A. Bruce, who was president of the
Toronto Academy of Medicine, has resigned, owing
to the likelihood that he will be in Europe for a
prolonged period. Dr. John Ferguson, vice-presi-
dent and editor of the Canada Lancet, has been
elected president, and Dr. D. J. Gibb Wishart, vice-
president.
Capt. W. O. McCarthy. M.D., of the Second
Nov. 18, 1916]
MEDICAL RECORD.
909
Rhodesian Regiment, son of the late Dr. McCarthy
of Barrie, Ontario, was killed in action on Aug. 22,
in German East Africa, in his thirty-seventh year.
Drs. A. A. Macdonald, H. T. Machell and C. R.
Sneath, all of Toronto, have each had a son killed
recently In action.
Capt. Dougald B. Maclean, M.D., R.A.M.C, a
graduate of University of Winnipeg of 1911, has
been killed in action.
Boston Medical and Surgical Journal.
November 2, 1916.
1. Relation of the Deep Cul-De-Sac to Prolapse of the Rec-
tum and Uterus, and to Reetocele. Daniel Fiske Jones.
2. The Effect of Alcohol on the Rate of Discharge from the
Stomach. L. T. Wright.
8. Blood Transfusion in the Great War. William Reid Mor-
rison.
4. Undescended Testicle in Children. C. G. Mixter.
6 The Mechanism of the Protection Afforded by the Drain-
age of Prostatics as a Preliminary to Operation. Hugh
Cabot and E. Granville Crabtree.
2. The Effect of Alcohol on the Rate of Discharge
from the Stomach. — L. T. Wright has used the method
first devised by Cannon in conducting these experi-
ments. The work was done in the Laboratory of Physi-
ology in the Harvard Medical School and the procedure
in part was as follows: Medium sized cats, deprived
of food for twenty-four hours, were fastened to a holder
and fed through a stomach tube attached to a syringe,
25 cc. of mushy potato to which had been added 5 grams
of bismuth subcarbonate. This amount of food causes
the stomach in most cats to cast about the same shadow.
Peristalsis and the rate of discharge in these animals
were normal. The consistency of the food was uniform
— the potato was mashed fine and softened by water and
also alcohol. After being fed the animal was immedi-
ately released. X-ray observations of the gastric and
intestinal shadows were made at the end of a half hour,
an hour, and thereafter hourly until four hours after
the feeding, and aggregate lengths of the shadows in
the successive records were utilized to indicate the rate
of gastric discharge. Wright divided his experiments,
feeding six cats with potato-bismuth mixture without
the alcohol, and another set of cats with the potato-
bismuth-alcohol mixture. In the experiments with
alcohol the commercial 95 per cent, alcohol was
employed, and also a 37 per cent, alcohol
diluted with distilled water. This gave two seta
of experiments with the alcohol mixtures — 6 cc. of 37
per cent, and 5 cc. of 95 per cent. The weaker mixture
produced no striking symptoms, while the stronger mix-
ture rapidly produced extreme intoxication. In the
three sets of observations made the results obtained,
representing in centimeters the aggregate length of the
food-masses in the small intestine at the times above
indicated, were as follows: In the first or normal set
without alcohol the average amount at the end of a
half-hour was 14 cm., at the end of two hours 39.5 cm.,
and at the end of four hours 20 cm.; in the second set
in which the weaker dilution of alcohol was used the
average at the end of a half-hour was 21 cm., at the end
of two hours 52.5 cm., and at the end of four hours
36 cm. ; in the third set in which the 95 per cent, alco-
hol was used the average at the end of a half-hour was
2 cm., at the end of two hours 24 cm., and at the end
of four hours 39.5 cm. The first two sets of experi-
ments, including the normal feeding of potato-bismuth
mixture, and the same mixture containing the weaker
alcohol dilution show an increase of the food in the in-
testines at the end of a half-hour, and a maximal num-
ber of centimeters of food at the end of two hours; but
the increase at the end of a half-hour is 50 per cent.
higher in the second set where the weaker alcohol dilu-
tion was used than the average figure for normal con-
ditions, and the percentage obtained was higher at the
end of an hour. This relatively small amount of al-
cohol, therefore, has distinctly an accelerating effect on
the rate of gastric discharge and produces a higher
maximum than the normal. The gastric peristaltic
waves were deep and vigorous, and in most cases at
the end of three hours- no residue remained in the stom-
ach. Contrary to these results in the third set of ex-
periments where the 95 per cent, alcohol was used there
was a slow initial discharge and a gradual rise to a
maximum at the end of three or four hours. When evi-
dent the peristaltic waves were shallow and feeble and
in some of the animals there was present at the end of
four hours a considerable amount of food. The more
rapid expulsion of gastric contents when the weaker
alcohol was used may have been due to both a more
vigorous peristalsis and a more prompt acidulation of
the contents produced by a stimulation of the secretion
of gastric juice by the weaker alcohol; while the re-
tardation of the output when the stronger alcohol was
employed was due probably to effects on both peristalsis
and secretion. The profound influence of the stronger
alcohol on the central nervous system indicates that the
nerves of the gastric wall and possibly the muscle
fibres were similarly affected. On the basis of an acid
control of the pylorus as well as on the assumption of
an intoxication of the gastric neuromusculature Wright
states that it is easy to understand how the stronger
alcohol mixed with the food produced so marked a slow-
ing of gastric discharge as shown by these experiments
4. Undescended Testicle in Children. — C. G. Mixter
states that in the past three years thirty operations have
been performed for the relief of this malformation at
the Children's Hospital, Boston. In seven cases the con-
dition was bilateral, in nine the right, and in seven the
left side was affected. In nineteen it lay within the
inguinal canal, and in eight cases it was just outside
the external inguinal ring. In two cases atrophy was
noticed at the time of operation. In one the testicle was
enlarged and thought to be tuberculous with an accom-
panying tuberculous peritonitis. The age at operation
ranged from twenty months to twelve years. The late
result of operation was ascertained in twenty-six cases
— four cases failed to report. The two cases in which
atrophy was noted at operation showed no improvement
in the development of the testicle, although the organ
remained in the scrotum. Atrophy occurred in eight
cases following operation. The acre at operation had no
bearing on the occurrence of atrophy. The one factor
present in every instance where atrophy occurred was
an interference with the spermatic circulation at opera-
tion. Mixter outlines his technique of operation in
which he endeavors as often as possible to avoid sacri-
ficing the spermatic vessels. He supplies statistics and
concludes that a plastic operation by which the unde-
scended testicle is placed in the scrotum without impair-
ment to the circulation will be followed by normal
growth. Where partial resection of the spermatic ves-
sels is necessary atrophy may or may not ensue, while
complete section of the spermatic vessels has been in-
variably followed by atrophy in a given series of cases,
the blood supply from the artery of the vas being insuffi-
cient to nourish the developing testicle; this operation
should be resorted to in children only under exceptional
circumstances.
5. The Mechanism of the Protection Afforded by the
Drainage of Prostatics as a Preliminary to Operation.
— Hugh Cabot and E. Granville Crabtree present a
consideration of the production of immunity in these
cases in which drainage before operation has been an
910
MEDICAL RECORD.
[Nov. 18, 1916
important factor in reducing the mortality. Drainage
as a preliminary treatment is most essential in the
class of cases with the largely over-distended bladder,
sometimes stretched to the point of overflow, but in
whom infection has not yet occurred. The extremes
are represented by the over-distended uninfected blad-
der and the thoroughly infected but regularly emptied
bladder enjoying a catheter life. The benefits accruing
from drainage in these cases appear to be the result
of two factors: 1. Relief of the so-called "back-
pressure," with the equalization of the kidney circula-
tion, and 2. Infection which is now generally regarded
as a pyelonephritis. Phthalein test was employed for the
purpose of studying the changes in kidney function.
Three conditions in these cases operate to depress kid-
ney function at substantially the same time, namely,
decompression congestion, operation, and pyelonephritis.
Drainage has had the effect in point of time of placing
pyelonephritis second, and operation, if necessary, third.
Cabot and Crabtree have especially studied the nature
of the pyelonephritis — commonly called pyelitis — and its
effect on function, and from their studies have con-
cluded that this condition is practically always produced
by the colon bacillus, and that it is an excretory type
of infection in that the lesion occurs in the attempt by
the kidney to get rid of colon bacilli circulating in the
blood. Blood cultures in these patients with prostatic
obstruction on constant drainage are positive for colon
bacillus in a proportion of cases about equal to that
occurring in typhoid fever, and positive cultures are
much more likely to be obtained when the blood is taken
at the onset of the attack, and negative when taken at
a subsequent period. Both the bladder and the urethra
may be sources of infection, and irritability of the pros-
tate is often observed at the onset of kidney infection.
Pyelonephritis in their opinion is the most important
avoidable incident of the preliminary drainage in cases
of prostatic obstruction, and decompression is rarely of
first importance in its effect upon the kidney; but tin.-
infection deserves the most weighty consideration and
the chief benefit resulting from preliminary drainage
is the immunity to pyelonephritis as a complication of
the operation, which immunity is conveyed by this con-
dition resulting from drainage, giving the patient a
security which it has not been possible to obtain in an-
other way. For the past six months Cabot and Crab-
tree have been endeavoring to produce an artificial im-
munity in these cases by means of vaccination with the
colon bacillus, and they have been able in so far as
agglutination can be regarded as a measure of im-
munity to produce it in their patients. If this infec-
tion can be established by the production of artificial
immunity, a considerable advance will have been made
toward eliminating an important factor in the mortality
of operative procedures for the relief of prostatic
obstruction.
New York Medical Journal.
November i, L916.
1. And the Patient Is Left Out. Robert T. Morris.
'_'. [mpotence In the Mule. Thomas C. Stellwagen.
3. Chronic Appendicitis and Chronic Intestinal Toxemia. G.
Rei e s.i i ; erlee.
4. Chronic Gonorrhea In the Male. Joseph Kaufman.
5. The Physics of the High Frequency Current. Albert C.
('■ >ysi i
i Primary Syphilis of the Rectum, \v E. Jost and R. B. n
Gradwohl.
7. The Oral Administration ol Adrenalin, Henry i: nar-
rower.
8. Anesthe is Reviewed (Concluded). James T. Gwathmey.
9. Tracheobronchitis Due to Nitric Arid Fumes. Chevalier
■
in. M:i ol the reeth. Henry C. Ferris.
M. Autotherapy in ivy 1'" Charle: H Dune:
7. The Oral Administration of Adrenalin. — Henry
R. Harrower has collected in one paper the opinions of
various medical men as to the efficacy of adrenalin
when administered by mouth together with his own
views, the consensus of opinion being that in suitable
dosage of 1,000 solution a speedy and favorable action
is obtained. If adrenalin is given by mouth and the
stomach is evacuated ten minutes later, it is usually
impossible to detect this substance by colorimetric chem-
ical measures. According to the specified authorities
it may be used as an analgesic remedy for gallstone
and renal colic, as part of the treatment of severe in-
fectious diseases in children producing increased blood
pressure and an immediate response in the general
mental and physical condition, while the pulse rate is
reduced and diuresis favored ; acute and chronic
nephritis is benefited most decidedly in many cases by
the administi-ation of adrenalin by mouth. The active
principle of the desiccated gland is naturally similar
to that which is available in a pure state, and the favor-
able experiences with total adrenal gland therapy, by
mouth, is additional proof that the position of those
who have contended that the oral administration of
adrenalin is useless, is fallacious.
9. Tracheobronchitis Due to Nitric Acid Fumes. —
Chevalier Jackson reports a case of a pipe-fitter, pre-
viously in good health, who complained of burning in
the throat following a two hours' exposure to nitric
acid fumes. Half an hour after exposure his lips be-
came blue and five hours later he fell, becoming un-
conscious for a few minutes. Then cough, difficulty in
breathing, and blueness of lips and face were noticed.
Fine rales were found all over both lungs anteriorly
and posteriorly, while showers of fine crepitant rales
were audible at end of inspiration. In left axilla and
in front inspiration markedly increased. Whispered
voice plus. By indirect laryngoscopy frothy mucopus
could be seen bubbling up and down in the trachea, but
there was no coughing effort to expel same and no glot-
tic bechic placement. Bronchoscopy showed intense
acute tracheitis and bronchitis; the trachea and bronchi
showed frothy mucopurulent secretion, and on remov-
ing this patches of grayish furred mucosa with a sur-
rounding areola of intensely engorged cyanotic mucosa
were found. The patient was choked with his own se-
cretions until he was apparently drowning. Trache-
otomy was performed, and large quantities of the muco-
pus were continuo'usly removed. The temperature on
admission was 101.3° F., but never rose above 102% and
subsided to normal at the end of a week. Gentle swab-
bing was done through the wound, and at the end of
the fourth day the patient could cough out the secre-
tions through the cannula. Compound tincture of ben-
zoin was vaporized from a croup kettle close to the can-
nula. Atropine and stimulants were given as needed
The patient was discharged well at the end of three
weeks.
11. Autotherapy in Ivy Poisoning. — Charles H.
Duncan quotes from an article of his published in the
New York Medical Journal for Dec. 14 and 21, 1912,
under the title of Autotherapy, in which he says that
disease may be said to be the proving of one or more
toxins. Symptoms are the expression, or the language,
of toxins. The cure of disease is brought about by
placing the exact toxins that cause the symptoms in
healthy tissues. He then goes on to state that this
method of treating ivy poison is nothing more or
than treating the symptoms with the substance that
caused them or an autotherapeutie procedure, a method
long known and employed by the writer, as in other
forms of anaphylaxis. In Fairmount Park, Philadel-
phia, a few years ago, and also in Bronx Park, it was
the custom upon hiring park hands to instruct them to
chew a few leaves of the poison ivy plant when clearing
away the vines, as a preventive to the well known
Nov. 18, 19161
Ml DICAI. RECORD.
911
cutaneous eruption. Homeopathic physicians have long
employed this method of treating ivy poison, and con-
sidered the cures as homeopathic cures till the writer
pointed out that it was not a similar remedy, but the
exact or autotherapeutic remedy, for it treats the symp-
toms with the exact unmodified substance that caused
them and not a substance that causes a similar set of
symptoms. Their occasional failures may result from
the use of the tincture of Rhus other than the one with
which the patient was poisoned. The exact unmodified
substance that caused the symptoms is employed as the
curative remedy. This is the principle upon which
autotherapy rests.
Journal of the American Medical Association.
November 4. 1910.
1. The Duty of the Medical Profession Toward the Council
on Pharmacy and Chemistry. Robert A. Hatcher.
■>. A Study of Two Hundred and Twenty-Six Cases of
Chorea. Isaac Arthur Abt and A. Levinson.
3. Fever of Obscure Causation in Infancy and Early Child-
hood. Edgar P. Copeland.
4. The Recent Epidemic of Grip. Joseph A. Capps and A.
M. Moody.
5. Acidosis of Gastrointestinal Origin : A Preliminary Study-
Based on Thirty-four Cases. Henry Dwight Chapin
and Marshall C'arleton Pease.
6. Myasthenia Gravis, with Thymoma. W. A. Jones.
7. Experimental Studies of Injection of the Gasserian Gan-
glion, Controlled bv Fluoroscopy. Lewis J. Pollack
and Hollis E. Potter.
S. A Further Note on the Diagnostic Value of Retrobulbar
Neuritis in Expanding Lesions of the Frontal Lobes,
with a Report of This Syndrome in a Case of Aneurysm
of the Right Internal Carotid Artery. Foster Kennedy.
9. Appendicitis in Children. J. Coleman Motley.
10. Some Practical Aspects of Schistosomiasis as Found in
the Orient : Preliminary Report. William L. Mann.
11. The Intestinal Parasites of Twenty Foreign Students in
the University of Wisconsin. Edward J. Van Liere.
12. Studies of the Spinal Fluid During Iodide Medication by
Mouth. Joseph H. Catton.
2. A Study of Two Hundred and Twenty-six Cases
of Chorea. — Isaac Arthur Abt and A. Levinson. (See
Medical Record, June 24, 1916, page 1161.)
3. Fever of Obscure Causation in Infancy and Early
Childhood. — Edgar P. Copeland. (See Medical Record,
June 24, 1916, page 1161.)
4. The Recent Epidemic of Grip. — Joseph A. Capps
and A. M. Moody made a study of the epidemic of grip
which swept over the United States last winter. Their
observations were carried on in Chicago, but in close
touch with the laboratories of the Departments of Health
in all of the important cities. The epidemic began early
in December, and while it had spent its force by the
latter part of January, many cases developed long after.
The chief complications were inflammation of the ac-
cessory sinuses of the head and bronchopneumonia, the
latter being responsible for most of the fatalities.
Capps and Moody found from a study of the blood that
in the majority of patients leucocytosis was absent, al-
though a temperature of from 1° to 3° above normal
was the rule at the time of examination. They state
that while physicians may agree on the existence of a
grip epidemic, it is equally true that bacteriologists
have failed to agree on the causative organism. The
results of analyses made in the public laboratories in
various cities of throat cultures showed the presence of
the Streptococcus viridans and pneumococcus together
with the hemolytic streptococcus in all cases tested in
Chicago, while the influenza bacillus was found only
twice. In New York streptococcus was found most fre-
quently, accompanied by Micrococcus catarrhalis, with
the influenza bacillus in nine cases. From a cultural
standpoint the streptococcus deserves more serious con-
sideration as the causative organism than the influenza
bacillus. The work of Kruse, and more recently Fos-
ter, suggests the possibility of some ultramicroscopic
germ as the cause of the disease. Capps and Moody
ask if the influenza bacillus was responsible for earlier
grip epidemics, and note that the streptococcus and
pneumococcus were the two organisms most constantly
described in the pandemic grip of 1889-1890, and that
it was not until 1892 that Pfeiffer published his discov-
ery of the influenza bacillus, and it is still unproved that
this organism was a factor in the earlier pandemic.
The theory that grip is contracted through personal
contact seems to be borne out by practical evidence, and
at present there is no evidence that food may be a
medium of transmission. The writers suggest that, as
we look back on this epidemic, it may well be asked
what has been done to prevent its inception and its dis-
semination. Have any measures of defense been de-
veloped against this ancient foe? Not in any adequate
measure. Nor is it possible to make any headway along
preventive lines until the laboratory workers go out
into the community and there obtain their material for
study. Furthermore, there should be a better organi-
zation of team work, so that a group of men can attack
the problem simultaneously from several directions and
correlate their efforts.
5. Acidosis of Gastrointestinal Origin: A Prelimi-
nary Study Based on Thirty-four Cases. — Henry Dwight
Chapin and Marshall Carleton Pease. (See Medical
Record, June 17, 1916, page 1117.)
8. A Further Note on the Diagnostic Value of Retro-
bulbar Neuritis in Expanding Lesions of the Frontal
Lobes. — Foster Kennedy states that in the recognition
of disease affecting the frontal lobes there is apt to be
a misinterpretation of symptoms by even the most alert
observers. He calls attention to a syndrome referable
to the inferior frontal sinuses, the occurrence of a true
retrobulbar neuritis, with the formation of a central
scotoma and primary optic atrophy on the side of the
lesion together with ipsolateral anosmia and papille-
dema in the opposite eye. He cites the case of a woman
presenting all these conditions, who had undergone a
decompression operation from which she recovered, but
who a little later died. An examination of the brain
revealed a ruptured aneurysm of the right internal
carotid artery about the size of a small walnut and of
a solid consistency, owing to contained fibrinous matter.
This aneurysm caused marked pressure on the right
optic nerve, just in front of the chiasma, and, to a les >er
degree, on the left optic nerve also. Upward and to
the right it had succeeded in compressing descending
fibers from the right motor area with some deformation
of the anterior part of the right caudate nucleus. The
anterior horn of the right lateral ventricle was consid-
erably larger than its fellow. The case presents two
features: first, the remarkable rarity of aneurysms
of a right internal carotid artery; and second, its symp-
tomatology offers a very important clue to the diagnosis
of expanding lesions in the subfrontal area. The diag-
nosis of aneurysm in this case cited was quite unsus-
pected during the patient's lifetime. Syphilis was en-
tirely excluded, the cerebrospinal fluid was normal with
the exception of an increased globulin content, which
but tended to confirm belief in the presence of new
growth. The signs given here were sufficient to indi-
cate the exact situation of an expanding lesion within
the skull cavity, and the recognition of this syndrome
may elucidate diagnosis in certain obscure cases of
frontal neoplasm and to separate a group of cases from
the great generic class of toxic amblyopias.
9. Appendicitis in Children. — J. Coleman Motley as a
result of his operative work during the last five years
says that his chief object is to appeal to the general
practitioner and through him to the parent, for a closer
cooperation with the surgeons in an effort to give
the child with a "belly ache" a better chance to live.
Of 404 cases, 37 were in children with an operative
mortality of 5.4 per cent. Of the 367 adult cases of
appendicitis, there was also an operative mortality of
two, or 0.54 per cent. The most constant symptom of
912
MEDICAL RECORD.
[Nov. 18, 1916
acute appendicitis in children is leucocytosis, which
ranges between 9,000 to 34,000, with the polymorpho-
nuclears between 72 and 92 per cent. The high mor-
tality among children seems to be due to the fact that
the early symptoms are not clear-cut and denned a9 in
adults, and are to be considered atypical. This leads
to a confusion in diagnosis and also to the association
of dietary indiscretions as the chief cause of all abdom-
inal pains in children. Early diagnosis and early
operation are indicated. Motley considers purgation
in cases of appendicitis in children as one of the chief
causes of the frequency of perforative appendicitis, but
he does approve of an enema of soapsuds for relief of
either an overloaded bowel or the pain in appendicitis.
He again begs for early diagnosis and operation as the
only sure means of saving life.
12. Studies of the Spinal Fluid During Iodide Medi-
cation by Mouth. — Joseph H. Catton conducted examina-
tions of the spinal fluid of persons under iodide medica-
tion to determine the presence of organic or inorganic
compounds, of iodine. Study 1 included observations on
five patients on routine iodide medication, and Study 2
observations on one person to whom very large doses
of iodides were given. Two tappings were made, and at
the first one as much fluid as possible was withdrawn;
the second tapping being made some time later to ascer-
tain whether or not the newly secreted fluid contained
a greater amount of iodine, if any. As a result of the
observations made Catton draws the following conclu-
sions: 1. In the series of cases examined, regardless of
the amount of iodine administered by mouth, no iodine
or compounds of iodine were found in the spinal fluid.
2. Either iodine compounds do not pass the ependymal
cells of the choroid plexus in any measurable quantity,
or such iodine as does reach the spinal fluid is very rap-
idly fixed in the tissues.
The Lancet.
October 14, 1916.
1. An Address on John Ward and His Diary. D'Arcy Power.
2. Trench Fever : A Relapsing Fever Occurring Among the
British Troops in France and Salonica. Arthur F.
Hurst.
3. The Operation of Laryngo-Fissure. Irwin Moore.
4. The Late SequeUe of F'*rambresia. I'hilip Harper.
5. Wound of the Portal Vein ; Operation ; Death Nine Days
Later. W. H. C. Romanis.
6. Case of Tonsillitis with Hemorrhagic Adenitis. C. Freder-
ick Strange.
2. Trench Fever. — Arthur F. Hurst gives a report of
"Trench Fever" as he found it while working among
the British troops in France and Salonica. In France
the disease was only observed among officers and men
living near the trenches and in the personnel of hos-
pitals in which there were patients suffering from the
disease. No cases occurred among ammunition col-
umns, ordnance and headquarters' troops. For this
reason the condition received its name, though actual
residence in the trenches was not an essential factor.
The writer's attention was first drawn to the disease
in Salonica, where it became extremely common. It
was found that trench fever could be transmitted to
healthy soldiers by the intramuscular or intravenous
injection of the blood of men suffering from the dis-
ease. Injection of the washed red corpuscles had the
same effect, but the plasma and serum were not in-
fective. One attack does not seem to protect against
reinfection. As yet no infective organisms have been
found, but the evidence pointing to an intracorpuscular
infection suggests a protozoal rather than a bacterial
origin. Since the disease produces no nasal, pharyn-
geal, or bronchial catarrh, and seldom any gastro-
intestinal symptoms, it is probable that it is conveyed
through the intermediation of some insect, and the most
common one at all seasons is the louse. Cold, wet and
fatigue appear ^citing causes in a man who has
become infected. Hurst observed that the incubation
period is between fifteen and twenty-five days. The
symptoms resemble somewhat those of influenza, but
without the nasal or bronchial catarrh. The onset is
abrupt, and there is marked tenderness over the shins
—one of the diagnostic features — with marked fever
ranging from 102° to 104°. There are two forms of the
disease, the short form, which lasts from five days to a
week, and the long form, in which there is a periodic
return of symptoms, and the temperature falls more
gradually. In this last form the total duration of
trench fever is generally between four and six weeks.
Men suffering from this condition should be kept to-
gether when sleeping, but could work with other soldiers
when able. The treatment is not extensive, acetyl-
salicylic acid being the most effective analgesic drug.
The bihydrochloride of quinine given subcutaneously
when the temperature rises above 99° appears to put
an end to relapses in prolonged cases.
4. The Late Sequelae of Framboesia. — Philip Harper
states that locomotor ataxy, general paralysis of the
insane, and aneurysm, well recognized as sequelae of
syphilis, seem to have been generally overlooked as re-
mote results of framboesia. This disease is common
among Fijians, while syphilis does not exist. We can
be sure that the disease which is universal to Fijians is
yaws, or framboesia, and not syphilis, because (1) of
its symptomatology and physical signs, which are dif-
ferent from syphilis; (2) the fact that the disease is
not hereditary; (3) the therapeutic tests; and (4) that
there is not a single absolutely certain case of primary
syphilis in a Fijian nor of any hereditary syphilitic
manifestations in Fijian infants. Harper cites a few
cases of tabes and general paralysis of the insane oc-
curring in one district medical officer's routine practice
in a district of 6000 Fijians. Aneurysm is exceedingly
common among these people. The cases given show in
a small measure the high rate of such nervous disease
among the Fijians, but since the entire Fijian popula-
tion has been infected with yaws, probably the case-rate
following this condition might not differ greatly from
the same following syphilis.
5. Wound of the Portal Vein. — W. H. C. Romanis
reports a case of shell wound of the abdomen, in which
the fragment of shell passed through the abdomen from
front to back without injuring any portion of the in-
testinal canal. An Australian soldier was wounded by
high-explosive shell at 4 a.m. on July 5, the fragment
entering just below the left costal margin, one inch to
the left of the ensiform cartilage. Seen late the same
evening, patient's condition was bad; vomiting, with
rigid abdomen, tenderness marked over the epigastric
region, pulse 120 and thready. Laparotomy performed
under chloroform through the left rectus twenty-three
hours after the wound, and the abdomen found to con-
tain a large quantity of fresh blood. A track was
traced to the right, through the left lobe of the liver,
emerging on its under surface, through the lesser
omentum and tearing a lateral hole about half an inch
long in the portal vein from which blood was freely
gushing. A plug was placed in the liver wound and
two artery forceps were clamped on the side of the
vein in a longitudinal direction, controlling the hemor-
rhage. The track of the missile passed on just to the
outer side of the second part of the duodenum and
pierced the peritoneum of the posterior abdominal wall
here. The fragment was followed no farther on ac-
count of patient's condition. Stomach, small intestine
and transverse colon showed no perforation. Wound
was closed after mopping out blood from abdomen, with
plug and forceps left in situ with handles emergent;
from upper end of the incision. Patient improved, and
Nov. 18, 1916]
MEDICAL RECORD.
918
plug removed on second, and forceps on third day. Im-
provement continued until eighth day, when patient
was taking solid food. On evening of eighth day, he
complained of severe hypogastric pain, vomited twice,
and passed some urine containing much blood. His ab-
domen remained soft and mobile, but his pulse failed
and he died in an hour. Postmortem showed good con-
dition of tissues along the path already investigated,
but a large retroperitoneal hemorrhage was present
around the right kidney, and an ulcerated hole was
found in the right renal artery on its posterior aspect,
close to which lay a small jagged piece of shell-case, a
little larger than a green pea. Death was apparently
caused from secondary hemorrhage from the renal ar-
tery on the eighth day.
British Medical Journal.
October 14, 1916.
1. The Morphine-Hyoscine Method of Painless Childbirth, or
So-called "Twilight Sleep." F. W. N. Haultain and
Brian H. Swift.
2. Retraction of the Uterine Muscle Associated with Ob-
structed Labor. H. T. Hicks.
3. Breathlessness in Soldiers Suffering from Irritable Heart.
The mas Lewis, Captain Cotton, J. Barcroft, T. R. Mil-
roy, D. Dufton, and T. R. Parsons.
4. The Estimation of Myocardial Efficiency. J. Strickland
Goodall.
5. Bock's Stethoscope as an Aid to Determining the Efficiency
of the Myocardium. Jeffrey Ramsay.
6. Epidemic Cerebrospinal Fever : the Place of the Meningo-
coccus in its Etiology. Edward C. Hort and Captain
Alfred H. Caulfeild.
7. On the Life-History of the Meningococcus and of Other
Bacteria. J. G. Adami.
2. Retraction of the Uterine Muscle Associated with
Obstructed Labor. — H. T. Hicks says that his reason for
again bringing this subject forward — he first referred
to it in 1906 — is because he knows that this condition is
not often recognized and that he has altered his views
in the light of further experience. The patients are
all primiparae and with some pelvic bone deformity, such
as rickets, etc. The patient has come to term and
labor has just begun and the fetal head is felt just
above the brim. The uterine contractions continue, but
there is no attempt at bearing down, and patient com-
plains of a continuous uneasiness about the abdomen.
The fetal head is still above the brim and with the ex-
amining hand the retracting ring will be found just
above the head. Caesarean section is the only safe
means of delivery. Hicks makes the following con-
clusions: 1. Be on your guard when dealing
with a short, thick-set woman with a square head and
short long bones. 2. A high position of the fetal head,
occurring in a primipara, should at once denote serious
trouble. 3. Measure the diameters of the pelvis, but
do not place too much store upon your estimate. The
brim may be obliquely distorted, and this will prevent
the head from entering the brim and at the same time
will not show up in your calculations. 4. Cut-and-dried
rules on pelvimetry are useful only in severe contrac-
tions of the pelvis. 5. Remember that to apply forceps
to a fetal head which is movable and high above the
brim is an obstetric operation requiring the most care-
ful consideration, and should only be undertaken after
careful examination of the condition of the uterine
muscle around the neck of the fetus. If the examining
hand can he passed easily beyond the shoulders of the
fetus, an attempt at delivery with instruments may be
made. If there is the least evidence that the uterine
muscle is retracting round the neck of the fetus,
Caesarean section should at once be performed. When
once the retraction ring has formed around the neck of
the fetus, it will grip it firmly until the patient is al-
most at the point of death.
3. Breathlessness in Soldiers Suffering from Irrita-
ble Heart. — Thomas Lewis, Captain Cotton, J. Barcroft,
T. R. Milroy, D. Dufton, and T. R. Parsons contribute
a full report to the Medical Research Committee in
which they wish to call attention to another and more
subtle cause of breathlessness than the ordinary causes.
The cause of breathlessness to which they refer is the
absence of an adequate supply of "buffer" salts in the
blood; this condition is found among patients who are
diagnosed as having "irritable hearts," or "trench
hearts," that is, among soldiers invalided. They have
no contant physical signs, but upon moderate exertion
there are excessive fatigue, faintness, giddiness, in-
creased pulse rate, and even while at rest, high respi-
ratory rate. Now the blood is at all times receiving
and parting with acid and alkali; buffer salts, Na,HPO«,
and NaHiPO,, in the presence of C02 produce an in-
crease in the acid reaction of the blood, and ease the
shock to the reaction of the blood by the addition of
acid or alkali. These observations seem to the writers
important because they demonstrate an altered state of
the blood which goes far to explain the otherwise in-
explicable breathlessness in certain patients who suffer
from the condition described as irritable heart.
4. The Estimation of Myocardial Efficiency. — J.
Strickland Goodall bases his conclusions on the study of
2,000 observations made on healthy and diseased hearts
during the past five years. The measure of a heart's
efficiency is its capacity for doing work, whether one is
dealing with a healthy or diseased heart. The physi-
ological heart of a healthy young adult responds to in-
creased work by increased contraction — increased rate,
blood pressure, and respirations. In the diseased heart
in which the myocardium is at all impaired the re-
sponse to work is not by increased contraction, but by
dilatation, so that, although the frequency is increased
(often out of all proportion to the amount of exercise
taken) the blood pressure fails to rise or actually falls,
according to the amount of damage present in the heart
and the amount of work done. The writer tested these
statements by the following methods: the simple stair
test, the exerciser test, the inclined plane test, and
the progressive exercise reaction. These various ex-
ercises have all been found beneficial in many cases of
myocardial disease and when carried out quietly,
systematically, and over sufficient length of time pro-
tects the sick heart by estimating its limitation of
power to work.
6. Epidemic Cerebrospinal Fever: The Place of the
Meningococcus in Its Etiology. — Edward C. Hort and
Alfred H. Caulfeild have devoted much time to the
work, and Hort has shown that the cerebrospinal fluid
in acute cases of this disease in man sometimes con-
tains a filter-passing virus which is not the meningo-
coccus, but which is nevertheless capable of producing
continued fever and death when injected into monkeys.
They draw the following conclusions based on intra-
peritoneal and subcutaneous injection 1. The patho-
genicity to monkeys of cerebrospinal fluid from acute
cases of cerebrospinal fever appears to tend to vary
inversely as its meningococcal content. 2. The cerebro-
spinal fluid in this disease sometimes contains a filter-
passing agent which is not the meningococcus, but
which is nevertheless capable of producing in monkeys
continued fever or death. 3. This filter-passing agent
appears to be a living virus capable of cultivation in the
laboratory, and of passage through monkeys. 4. None
of the pathogenic results here recorded can be reason-
ably attributed to the action of living meningococci as
such, or to the direct or indirect action of a meningo-
coccal toxin. 5. The pathogenicity of cultures of the
meningococcus appears to be due to the concomitant
presence of the filter-passing virus described. 6. The
pathogenic effects observed in the monkeys injected,
whether with cultures of meningococci, with filtered or
914
MEDICAL RECORD.
[Nov. 18, 1916
unfiltered cerebrospinal fluid, or with cultures of X, did
not include gross pathological changes in the cerebro-
spinal system.
Berliner k'inische Wochenschrift.
October 2, 1916.
Diabetes Innocuus. — Rosenfeld delivered a lecture on
on this subject as far back as May 15, 1914, yet it has
just arrived at publication. The term was originally
proposed as a substitute for diabetes innocuus, the
latter being too ambiguous. These cases bear a certain
relationship to renal diabetes, in which condition it had
been shown that the amount of sugar excreted was not
beyond the capacity of normal kidneys under functional
testing, as indicated especially by blood tests for sugar.
In all such cases carbohydrate tolerance could be ex-
cluded as a factor. Porges showed that the diabetes
of pregnancy was as a rule of renal origin. It was
shown that this so-called type of innocuous diabetes
might have a familial incidence. Familial diabetes (ex-
cluding the pancreatic type which may also be familial)
was especially studied by Solomon, who showed that
while blood analyses in these cases were chiefly nega-
tive, exceptions occurred in which the normal sugar
content of the blood was increased. The balance of
Rosenfeld's article is devoted to a concurrence of twelve
cases of diabetes in several families, increased con-
siderably by including relatives not actually seen in
person. In the older generations diabetes was present
as a spontaneous phenomenon, lasting in certain cases
for decades. In certain of the descendants the gly-
cosuria was manifested only under a diet rich in carbo-
hydrates. The patients were often relatively young
when the disease first appeared, as is often the case
with malignant (pancreatic) diabetes. But while in
the latter malady the patients quickly succumb, in these
so-called innocuous cases they may, as already stated,
live for decades, while presenting at times clinical
evidences of mild diabetes (furunculosis, etc.). How-
ever, these familial cases appear to have nothing in
common with the renal form, aside from the fact that
both are harmless. Renal diabetes may be due to in-
creased permeability of the kidneys, while in the famil-
ial type the converse may be true, as is the case in ad-
renalin glycosuria. In fact, there is much to suggest
that the diabetes innocuus of the author has a supra-
renal origin (such as the relatively constant value of
blood sugar). In this type carbohydrate tolerance is
extreme. Women in these families may be allowed to
marry. But great pains must be taken to exclude cases
of pancreatic diabetes.
Therapy of So-called Acetone Vomiting. — Janssen
cites Hecker's opinion that acetonuria is the result of
certain metabolic crises in children, in which acetone
is expelled by the stomach, lungs, and kidneys. In
milder cases vomiting may be absent, the patient suf-
fering from digestive disturbances, constipation, nausea,
prostration and acetonuria. The affection attacks
by preference children of the well-to-do and may be
familial and hereditary. The first crisis of vomiting
usually comes on suddenly and without prodromes, and
the child seems very ill. It continues to vomit at
intervals, and the slightest morsel of food is rejected.
Thirst soon appears as a result of the dehydration, and
constipation is another obvious consequence. The urine
and breath are loaded with acetone. The attacks last
for two or three days and are followed by complete re-
covery. In the opinion of the author a nervous com-
ponent is present. Spasmophilia often coexists. A
survey of case histories shows great diversity in type,
the presence of acetonuria being the most constant
phenomenon. Thus a child aged four had been
nourished largely on milk and butter. A crisis of
vomiting attacks suddenly appeared. The treatment
consisted of an enema of warm tea, to be retained. The
patient slept all night, waking in good condition. There
was no second crisis. A nervous breast-fed child, aged
nine months, had a brief attack of acetone vomiting
and was given a little soup and warm mineral water.
Other cases cited included infants and children with
history of overeating of fat, or presence of spasmo-
philia or with no evident antecedents. Nearly all
showed the presence of acute pharyngitis. The author
does not seek to explain this phenomenon, and does not
appear to connect it with irritation by the vomitus.
The ideal treatment appears to be to distend the
stomach mechanically by water or tea taken per os, or
to fill the colon by enemas of the same. This fluid per-
haps causes the poisonous material to escape by the
kidneys. There seems no doubt that it can cut short
the crisis. The article of food best tolerated is potato
soup or mashed potato. The kind of water taken is im-
material, but it must be taken hot and sweetened with
saccharin. There is further a psychic factor in the
successful treatment of these cases — the personality of
the medical man.
Persistent Lanugo as a Sign of Constitutional Infe-
riority.— Paulsen states that Freund and Hegar upheld
this view twenty years ago. Sellheim believed per-
sistent lanugo an indication of future tuberculosis. The
contention of Paulsen is best shown in the numerous
case histories appended. The first case cited in a girl
of 6Vz years is one of bronchial gland tuberculosis as-
sociated with lanugo on the trunk, running from head
to sacrum on either side of the spine; also over the
shoulder blades and upper arms. In a similar case a
girl of 13 showed also defective dentition and hyper-
idrosis. There were several other cases of bronchial
tuberculosis. Other patients showed actual or latent
pulmonary tuberculosis, the phthisical thorax, visceral
tuberculosis, etc. There was as a rule a bad family
history suggesting hereditary inferiority, and various
somatic stigmata were present aside from those already
mentioned. The presence of lanugo in unaccustomed
localities was sometimes associated with scantiness of
hair in normal regions. This irregularity agrees well
with defective development of the teeth as pointing to
an aberrant development of the ectoderm. This associ-
ation was seen in but one patient of the series and re-
calls the "dog faced" type of hypertrichosis in which
dental defects are uniformly present. Thoracic anom-
alies of development are common - — thorax asthenicus,
funnel breast, etc. Persistent lanugo also suggests a
form of infantilism, and the notable lack of pigment
in some of the patients points in the same direction.
Such problems must be left to the future for solution.
Munchenor medizinische Wochenschrift.
September 19, 1916.
Etiology of Five-Day Fever. — Werner, Benzler, and
Wiese add to an earlier communication the proof that
five-day fever can be transmitted from man to man,
thus showing that the causative agent is present in the
blood. Werner sought to infect himself with the blood
of a patient injected subcutaneously. The results were
negative. Next both Werner and Benzler had them-
selves injected by the intramuscular route, and in both
men the disease developed. The incubation period was
twenty and twenty-three days respectively and the dis-
ease set in with general pains and fever. The curve
of the latter was characteristic. Attempts were now
made to grow anaerobes from the blood. After some
Nov. 18, 1916]
MEDICAL RECORD.
915
negative results they succeeded, with a culture of
anaerobes one month old from the blood of infected
men, in causing an infection in dogs and cats which in
a high degree resembled five-day fever in man. It is
not claimed that anaerobic bacteria are themselves the
cause of the disease but cultures of the latter contain
certain peculiar granules which may be pathogenic or
not, according to circumstances. The real cause of the
disease is probably an ultra visible virus.
Acne Necrotica and the Use of Tobacco. — Weinbren-
ner saw several years ago a patient with acne necrotica
on the forehead and hairy scalp who gave a history of a
stomach disturbance, as a result of which he abandoned
smoking for the time being. During the period of five
or six weeks his skin disease which had been refrac-
tory to treatment disappeared spontaneously, but re-
turned promptly when smoking was resumed. Since
this episode he has treated seven other cases of acne
necrotica in patients who were all smokers save one
who chewed tobacco, and who was the most seriously
afflicted. But two of the seven had stomach disorder,
which, as one knows, is very apt to be present in this
disease. The author has searched literature in the vain
hope of finding mention of some connection between the
eruption and the tobacco habit. In every one of his
patients the disease healed spontaneously when tobacco
was given up, although the tobacco chewer who also
suffered from gastric disorder proved to be far more
refractory than any of the others. Trial breakfast in
this case showed no disturbance of normal acidity.
Acne necrotica seldom or never occurs in women (the
author has never seen a case). In case reports by
others there is no allusion whatever to the use or abuse
of tobacco. That the amount of tobacco used plays a
very small role is shown by the fact that one patient
smoked but two or three very small and mild cigars
daily.
Treatment of Furuncles in the Troops. — Kastan states
in regard to furunculosis that efforts are devoted chiefly
toward local extension and recurrent attacks. A boil
or carbuncle is treated as follows: the surrounding skin
is carefully shaved and ordinary grey ointment thinly
but evenly applied. The lesion must not be covered and
at the proper time should be lanced and allowed to dis-
charge pus. A small, moist wick drain is then inserted
with a moist dressing over all. This dressing may be
medicated with very dilute solution of acetate of alumin-
ium. The most that such treatment can do is to hasten
the expulsion of the core. The author has tested many
local applications and combinations of the same upon
the troops and has arrived at certain conclusions, thus
ointments should never be removed before adding others,
since it is best to continue to add new ointment above
the old. The moist dressings are changed daily at
first, but in order not to interfere with the ointment, the
interval is soon lengthened to three or four days. In
order to explain the efficacy of grey ointment the author
assumes that the metallic mercury is volatilized and
diffused so that it thereby becomes able to destroy the
pyogenic cocci of the lesions.
Le Progres .Medical.
September 20, 1916.
Recrudescence of Malaria in Ancient Foci in France.
— Etienne refers first to the reappearance of malaria
in certain small foci in Flanders, and then mentions
that in Paris conditions are not only favorable for such
an awakening, but that cases have occurred in small
areas both within and without the city. In Paris are
numerous sufferers from chronic malarial infection,
while a form of anopheles mosquito is quite common
in the city. Already numerous reports have been re-
ceived of small group infections in various localities.
The author has had personal knowledge since 1915 of
paludism in the Seille valley, where the disease has pre-
vailed in the past. The Anopheles maculipennis is
known to inhabit this locality. The author, who has
known this region since 1888, has never observed an
inoculated case of paludism, although some of his col-
leagues have made positive claims which may perhaps
have referred to cases of grippe. However this may be,
the author in 1915 encountered a group of six cases of
undoubted malaria, in three of which the hematozoon
was found in the blood. Certain prodromes of the
disease suggested rheumatism. As the cases progressed
diagnosis became assured, the disease developing in
typical fashion. In one patient only there was a
marked history of mosquito biting. To explain the
group of cases it is easiest to assume that the old infec-
tion had never died out. It had persisted for decades
in a larvated form, having been screened by the occur-
rence of other infectious diseases like influenza and
rheumatism. The recrudescence of the disease must
have been due to the upturning of the soil in connection
with trench work. Those with latent malaria now ex-
hibited an active type which could readily be spread
by the anopheles.
The Contractures of Late. Prolonged Tetanus in Com-
parison with Those of Organic Disease and Hysteria. —
Claude and Lhormitte refer to the very great number
of contractures in wounded soldiers. One muscle or a
group may be attacked. The exact relationship be-
tween injury and contracture has from the first been
obscure. In some cases a reflex mechanism, in others
a neuritis has been invoked, while the neurologists be-
lieve in a reflex in association with hysterical fixation.
Recently it has become apparent that another type of
contracture exists which has little in common with the
others, although there could be an association between
them. In tetanus cases contractures supervene soon
after injury, and the muscles affected show a peculiar
rigidity before becoming contractural. Naturally the
major manifestations of tetanus are not in evidence.
The fingers may be flexed to the utmost and completely
immobilized to the strongest attempts at reposition. A
reflex component may be demonstrated. The central
nervous system appears intact. Generally speaking,
the mechanical and electrical excitability is greatly in-
creased. The facial muscles show a sort of mask-like
rigidity, and the masseters and nuchal muscles appear
to be in a state of tonic contracture in but few cases.
No real trismus is present, although the mouth cannot
be fully opened. In a similar fashion one limb or only
a segment of a limb may become contractured perhaps
several months after the injury. In some of these late
chronic cases of tetanus the symptoms persisting long-
est are trismus and rigid abdominal muscles. As a rule
there should be no diagnostic confusion between these
cases and contractures due to organic disease of the
pyramidal tracts. The authors speak as if this abortive
form of tetanus is quite common, but differentiation
between it and functional types is often most difficult.
Its relationship to typical tetanus is not made clear, for
example, in reference to previous attempts at immuni-
zation. It is extremely persistent, but has thus far, in
the author's experience, been without mortality.
Resistance of Spirochetal Foci to Salvarsan. — Wech-
selmann and Arnheim refer to foci of spirochetes in the
region of chancres clinically cured by salvarsan. This
can only mean that treatment was not intensive at the
outset. Whenever the Wassermann reaction has become
negative, the chancre should be completely cicatrized,
free from spirochetes, and non-inoculable. — Deutsche
medizinische Wochensch rift.
916
MEDICAL RECORD.
(Nov. 18, 1916
gmrteig Imports.
Profilaxis del Tifus Exantematico. Por ei Dr. b.
Manuel Martin Salazar, Inspector-General tie
Sanidad. Madrid: Enrique Teodoro, 1916.
This pamphlet is issued by the National Department of
Health, and is naturally a sound, conservative presen-
tation of what we really know of the disease in ques-
tion. The author appears to follow quite closely the
teachings of Nicolle, director of the Tunis Pasteur In-
stitute, who has had extensive experience with the dis-
ease at first hand. Of much interest is the apparently
well-founded claim of Cortezo for priority in antilouse
campaigns against the disease. Such a campaign was
waged in Madrid in March, 1903, and was promptly
reported to the International Conference for Public
Health in Paris. Cortezo's measures are said to differ
in no wise from those in use at present, although no
mention is made of the great advance of such sanita-
tion among the warring armies during the past two
years. About 2,000 cases have been reported in Spain
6ince 1911, with deaths amounting to 311.
Infections of the Hand. A Guide to the Surgical
Treatment of Acute and Chronic Suppurative Proc-
esses in the Fingers, Hand, and Forearm. By Allen
B. Kanavel, M.D., Assistant Professor of Surgery,
Northwestern University Medical School; Attending
Surgeon, Wesley and Cook County Hospitals, Chicago.
Third edition. Thoroughly revised. Illustrated with
161 engravings. Price, $3.75. Philadelphia and
New York: Lea & Febiger, 1916.
This work has passed so rapidly through two editions,
that there is little more to be said in commendation of
it than has been said already. The present edition has
been thoroughly revised and two chapters have been
added, one dealing with the "Relation of Acute Infective
Processes to Industrial Pursuits," and the other with
"Plastic Procedures Instituted for the Correction of
Deformities." The work is valuable mainly, perhaps,
on account of its practical character, and for this reason
in particular, should prove of great use to the practi-
tioner.
Clinical Disorders of the Heart Beat. A Handbook
for Practitioners and Students. By Thomas Lewis.
M.D., D.Sc, F.R.C.P., Assistant Physician and Lec-
turer in Cardiac Pathology, University College Hos-
pital; Physician to Out-Patients, City of London
Hospital for Diseases of the Chest. Third edition.
Price, $2. New York: Paul H. Hoeber, 1916.
This is a thoroughly revised edition, to which, although
a few additions have been made, the teachings of the
earlier editions are preserved in their original form. In
order to keep in touch with the most recent advances in
the study of the heart beat it is almost essential to pos-
sess Lewis's Handbook for reference.
The Catarrhal and Suppurative Diseases of the
Accessory Sinuses of the Nose. By Ross Hall
Skillern, M.D., Professor of Laryngology, Medico-
Chirurgical College; Laryngologist to the Rush Hos-
pital; Fellow of the American Laryngological, Rhino-
logical and Otological Society; Fellow of the New
York Academy of Medicine; Member of the Society of
German Laryngologists, etc., etc. 287 illustrations.
Second edition, thoroughly revised. Price, $5. Phil-
adelphia and London: J. B. Lippincott Company,
1916.
Dr. Skillern made a somewhat new departure when he
wrote in English a work treating in minute detail of
nasal accessory sinus diseases and their treatment.
The only work in the English language in which an at-
tempt has been made to do this is that of Logan Turner,
the Edinburgh specialist, and his work is hardly adapt-
able as a general text book. Consequently the only
available sources of information in the direction are
German and French books. However, Dr. Skillern has
removed the cause of reproach from English nose and
throat specialists, as the work which he has produced
and which has quickly run into a second edition, equals
in all essential features any work of a similar nature.
The present edition has been amplified, and these ampli-
fications include the treatment of sinus disease in chil-
dren; the use of the nasopharyngoscope in diagnoses of
obscure conditions in the posterior ethmoid and sphe-
noid region, Canfield's operation on the maxillary sinus
compared with the preturbinal method with instructions
for and illustrations of both the immediate and ulti-
mate effects of operation on the sinuses. The work has
undergone a complete and systematic revision. A
hitherto almost neglected subject, that of the after
treatment of sinuses upon which an operation has been
performed, is thoroughly discussed and, indeed, the
whole work provides an exhaustive and analytical re-
sume of the matter in question. The illustrations are
excellent.
Burdett's Hospitals and Charities, 1916, being the
Year Book of Philanthropy and the Hospital Annual,
Containing a Review of the Position and Require-
ments and Chapters on the Management, Revenue
and Cost of the Charities, an Exhaustive Record of
Hospital Work for the Year. By Sir Henry Bur-
dett, R.C.B., K.C.U.O. Author of "Hospitals and
Asylums of the World," "Hospitals and the State,"
"Pay Hospitals of the World," "Cottage Hospitals,"
etc. Editor of the Hospital. Twenty-seventh Year.
Price, 10 shillings. London : The Scientific Press,
Limited, 1916.
Burdett's is so well known that it would be superfluous
to review it at length. It may be said, however, that
the present issue reaches the high standard of former
ones, and the result has been attained in the face of the
difficulties created for the printers and editorial staff
by the war. A new feature of the book is a complete
list of the whole of the territorial hospitals, their
exact locality, and the name of the principal nation in
each case. It may be mentioned that Sir Henry Bur-
dett initiated the work of which he has been editor
since its introduction; that he is now seventy years of
age, fifty of which have been spent in laboring con-
tinuously for the voluntary hospitals of Great Britain.
He has raised to himself monumentum mre perennins.
and has earned the lasting gratitude of his fellow
countrymen.
Diseases of the Skin. By Richard L. Sutton, M.D.,
Professor of Diseases of the Skin, University of
Kansas School of Medicine; Former Chairman of
the Dermatological Section of the American Medi-
cal Association; Member American Dermatological
Association, etc. With six hundred and ninety-three
illustrations and eight colored plates. Price, $6.50,
St. Louis: C. V. Mosby Company, 1916.
It requires courage, optimism, and enthusiasm to
write a new book on the skin when twenty competi-
tors, including late editions, are accessible in the Eng-
lish language alone. The work comprises about 900
pages and is hence a treatise. It seems in no sense a
personal book and the author has derived much of his
material on rare and exotic diseases from the best
authorities. He has surprisingly little to say of physi-
cal measures of treatment, and is by no means up to
date in this province. We do not find in his index any
reference to the Kromayer lamp, to ionization, to the
electrotherapy of skin diseases or to the new gasless
x-ray tubes. There is not much over a page of text
on the body louse, despite all that we have learned
about the parasite during the war. The discovery
that the Ducrey bacillus may act as a saprophyte in
the female genitals without infecting the host is not
mentioned. We see nothing of the salvarsan substi-
tutes made necessary by the war, nor of substitutes
for certain other German drugs, the price of which is
now prohibitive. Any author who writes a treatise
owes it to his patronage to make a final attempt to
incorporate all very recent discoveries, even if he has
to use foot-notes. The excellencies of the book are
many, and since nearly all good text-books on derma-
tology have later editions, the author will have plenty
of opportunity to rectify the omissions in the present
work.
Roentgenographs Diagnosis of Dental Infection
in Systemic Diseases. By Sinclair Tousey. A.M,
M.D., Consulting Surgeon, St. Bartholomew's Clinic.
New York. Price, $1.50. New York: Paul B.
Hoeber, 1916.
The relative importance of dental infection will grad
ually be established. At present almost every disease
is being laid to an alveolar abscess. The necessity of
investigating the teeth and sinuses cannot be too
strongly emphasized, but an alveolar abscess may exist
and yet not be the cause of the disease which is beincr
studied. Dr. Tousey himself quotes two estimates that
"10 and 60 per cent, of all artificially filled roots are
abscessed," as shown by .r-ray. The .r-ray must for
some time to come be one of the later aids in most
diagnoses, because of its expense. It is, however, a
recognized and important adjunct. Dr. Tousey's book
will be suggestive to many.
Nov. 18, 1916]
MEDICAL RECORD.
917
§>orirty imports.
FIRST DISTRICT BRANCH OF THE MEDICAL
SOCIETY OF THE STATE OF NEW YORK.
Tenth Annual Meeting, Held in Pouylikeepsie,
October 14, 1916.
The President, Dr. James E. Sadlierof Poughkeepsie,
in the Chair.
Election of Officers. — The following officers were elected
to serve for two years: President, Dr. Richard A. Giles
of Cold Spring; First Vice-President, Dr. Joseph B.
Hulett of Middletown; Second Vice-president, Dr.
George A. Leitner of Piermont; Secretary, Dr. Charles
Ellcry Denison of New York City; Treasurer, Dr. John
A. McCord of Poughkeepsie.
President's Address. — Dr. James E. Sadlier of
Poughkeepsie said that in view of the excellent program
that had been provided he had considered it advisable
to dispense with a formal address. However, there
were a few matters worthy of attention. The First
District Branch had been supposed to include eight
counties; only seven of these had been active hitherto,
owing to the fact that Putnam County had no county
society. This was because of the geography of Putnam
County and lack of transportation facilities making it
inconvenient for physicians from the different sections
of the county to find an easily accessible and central
meeting place. This difficulty had not been overcome
by the organization of the Dutchess and Putnam County
physicians into one society; this would prove a distinct
acquisition, not only to the First District Branch but
to the State Society. Another point of importance
which should be mentioned was that it was imperative
that the county societies should be careful in the selec-
tion of their legislative committees. Legislation of
significance to the medical profession would be brought
up at the approaching session of the Legislature, par-
ticularly in reference to Workingmen's Compensation;
it was highly important that physicians should acquaint
themselves with such legislation before it came before
the Legislature. The medical profession had always
stood ready to do its part to further any cause for the
betterment of humanity, and they should be prepared
to do their part intelligently in respect to Working-
men's Compensation legislation, so that justice might
be done both to the public and to the medical profes-
sion.
The Crucial Age of Man. — Dr. W. Stanton Gleason
of Newburgh presented this communication. (See page
881.)
Dr. Henry Lyle Winter of Cornwall related his own
experience with the crucial age. He said the excellent
paper which Dr. Gleason had presented opened up a
wide field to their view. In a general way, it might
be said that the several clinical pictures of decline of
power which one saw between the ages of forty-five
and fifty-five years were the result of autointoxication.
He said this bearing in mind that the definition of
autointoxication was a very loose one. He supposed
autointoxication meant self-intoxication. There were
four very distinct varieties of intoxication which were
often wrongly classed together, only one of which was
a true autointoxication. The other three were (1)
toxemia by infection, (2) toxemia by absorption, and
(3) toxemia by alimentary intoxication. The first
group, which might be called autointoxication by mi-
crobes, because they are due to the toxins formed in
the organism through microbes which have entered
accidentally; they were not produced under the influ-
ence of a vital process. This condition was found in
any of the acute fevers or chronic germ diseases. These
were not forms of autointoxication, but were poisoning
by specific toxins. The second group of toxemias by
absorption were just as distinct. These occurred, for
example, from any chronic suppurative process. Re-
cently they had been hearing a great deal about the
disorders arising from the teeth and gums. Any of
these might give rise to toxic products accompanied
by indols and phenols. Their absorption gave rise to
more or less accentuated symptoms. The decomposition
of retained urine in the bladder, for example, might
give rise to symptoms of autointoxication by absorp-
tion. A third group which must be excluded from
a definition of autointoxication were the alimentary
intoxications. These arose from the ingestion of foods,
tainted meat, fish, canned goods, etc. In this same
group one must place the milk intoxications seen in in-
fants. This group showed itself in three classical
forms: First, the pseudotyphoid form, with scarla-
tinal or rubriform eruption ; the botulic form, a true
ptomaine toxemia with negligible intestinal symptoms,
but with grave nervous manifestations, such as nuclear
paralysis with dystrophy, strabismus, or peripheral
paralysis with aphonia, etc.; and a mucodysenteric
form, which was the most common form, and with
which all were familiar. In the fourth group were the
true intoxications. These were caused by the toxins
produced under the influence of the vital processes
of the organs. These were the factors that were most
likely to be at work during what Dr. Gleason had aptly
called the crucial age. These toxins were derived from
two sources, from the disturbance of the functions of
the tissues and organs of the body, or from a disturb-
ance of the function of digestion. For practical pur-
poses, Combe had divided the latter into two groups:
(1) The dycrasic autointoxications. (2) The gastroin-
testinal autointoxications. The toxic substances pro-
duced by the functions of the different organs of the
body were not found at their points of origin; they
were either diffused through the blood or appeared
only in the different secretions or excretions, and it
was often difficult to trace them to their source. A
certain number of these substances were not, strictly
speaking, toxic. Instead of producing true qualitative
changes in the blood they produced quantitative changes
affecting the isotonicity, but these changes might be
severe enough to even produce death. There were two
varieties of these changes, a histogenic and an organ-
opathic. The histogenic variety occurred under vary-
ing conditions. When the nucleins were destroyed and
transformed into uric acid, purin bodies, xanthin, hypo-
xanthin, and pxalic acid, and these substances were
formed in excess into the blood, one found the uric-acid
diathesis. The same state of the blood might be found
in leucemia from destruction of the nuclei of the leuco-
cytes. This group was known as the nucleolytic auto-
intoxications. Whenever the albumin was destroyed
too rapidly fatty volatile acids and large quantities
of ammonia were formed and acetone was also pro-
duced. This form of intoxication was the one that oc-
curred in the condition known as acidosis, and was
known as the hypotrophic autointoxication. It was
essentially the condition which the writer had seen
repeatedly in nervous exhaustion. The organopathic
intoxications were numerous, and varied greatly. The
first group dealt with the glands of external secre-
tion. When these glands were not equal to the task
imposed upon them, one had, for instance, in the case
of the kidneys, uremia ; when it was the liver, cholemia.
The glands of internal secretion might also be respon-
sible for autointoxication, as mylodema due to insuf-
ficiency of the thyroid, acromegaly from insufficiency
of the pituitary body, etc. Then, again, there was
gastrointestinal autointoxication, which must not be
confounded with alimentary intoxication. There were
true autointoxications caused by quantitative or quali-
tative alterations in a normal digestion. These were
too numerous to discuss. It was obvious that the
crucial age of man began at a time when, by reason
of changes in his metabolic activity, his powers of
resistance began to diminish and these autointoxica-
tions appeared. The practical clinical application of
all this was that every man who reached the age of
forty-five years should place himself under the observa-
tion of a competent physician, and should report for
examination from two to four times a year. In making
an examination of the urine, one should be particularly
careful to look after the nitrogen output, not only the
total nitrogens, but the nitrogen of urea, of ammonia,
of the purin bodies, and of the extractives. These
bore a reasonably fixed quantitative relation to each
other in the normal individual. A disturbance of this
relation meant trouble. This information would also
assist them in regulating dietary errors with reason-
able accuracy.
Dr. William Seaman Bainbridge, New York City,
said if true autointoxication were limited, as had been
suggested, to disturbances of the endocrine organs, and
self-poisoning as the result of lack of elimination, ex-
cluding all absorption from the respiratory, the gastro-
intestinal, and the urinary tracts, the vital question
still remained, "What causes these disturbances?"
Dr. Gleason, in closing the discussion, said that in
reply to Dr. Bainbridge he would say that as a gen-
eral practitioner he felt that he was on the border line.
He used, as far as possible, the knowledge furnished
by laboratory investigators, but in their reports from
the laboratory they were so enthusiastic that the labo-
918
MI DICAL RECORD.
[Nov. 18, 1916
ratory did not always convince the clinician; and when
it came to a break, as it were, the clinician had to use
his judgment. As to the production of the conditions
which they were discussing, his deductions had come
to about this point: The toxins came from the intes-
tines, or from a focus of infection, and induced changes
in the metabolism and in elimination. Then there were
toxins about which they knew nothing. Again, they
knew that some toxins came from a focus, and that
often such a focus was a closed test tube. The action
of such a toxin might be different in a closed focus
from what it would be if exposed to the air. This fact
might have its effect on a vaccine made from a culture
taken from such a closed cavity. Furthermore, a vac-
cine must be prepared under strict antiseptic precau-
tions. As to the toxins, there were toxins that were
not known clinically that were at work, especially in
gouty conditions, as it was well known that the blood
was rilled with uric acid in this condition. While they
had gotten as far as the uric acid in the blood, there
was evidently a vista lying beyond of which they knew
nothing. The laboratory had thus far touched only on
the outer edge.
Address by President of the Medical Society of the
State of New York. — Dr. Martin B. Tinker of Ithaca
made a brief addiess, in which he spoke of his visit
to the various district meetings. He said that on the
whole they were very interesting and a credit to the
State Society. He said he would only speak informally
as to the ideals and what he wished to accomplish in
the State Society. In order to do this he would take
as his text the Articles of the Constitution of the State
Society and would preach from them. He said the
first purpose of the State Society, as set forth in these
articles, was "to bring into compact organization the
medical profession of the State." The membership of
the Society now numbered about 8,000, and there were
in the State about 15,000 physicians. Allowing for
those who were irregular practitioners, there were left
several thousand who were not members of the State
Society. This was doing about as well as the other
State societies in the United States, but not as well
as they would like to do. Every qualified practitioner
should be made welcome in the Society and persona!
likes and dislikes should have no influence. The second
ideal of the Society, as expressed in the Constitution,
was the "extension of medical science." Undoubtedly,
every doctor had cases that would be of value if he
would report them to his local society. With this idea
in view, and for his own advance in knowledge, he
should take careful histories and keep accurate records
of his cases. The third purpose of the Society was to
"secure the enactment of just medical laws." There
were a number of medical societies whose only purpose
was the advancement of scientific knowledge, but which
had no concern with medical legislation, so that it i-e-
mained to the National and State Societies to secure
the enactment of proper medical laws. They would
have to keep an eye on the laws affecting medical prac-
tice, and they should be familiar with medical com-
pensation laws in connection with the Workingmen's
Compensation. If physicians did not protect their own
interests in these matters no one else was going to do
so. The physician who had among his patients the
family of a member of a legislative committee could
exert more influence with such a man than some official
of the State Society with whom the man was not ac-
quainted. Here was a great opportunity for the country
practitioner to show what he could do, for the time to
stop objectionable legislation was not after it had
reached a legislative committee ; such legislation should
be killed, before it reached any committee, by the local
medical societies. These results could not be attained
without personal sacrifice, but it was the plain duty of
all to take up their responsibilities in this matter and
not to leave everything to their officials. The fourth
purpose, as expressed in the Constitution, was to "pro-
mote friendly intercourse among physicians." There
was a tendency to pettiness and jealousy in small com-
munities; the best way out of this was for physicians
to get together and all take an active interest in the
local and State societies. The fifth purpose of the
Society was "to guard the material interests of its
members, and this was especially a question of medical
defense against malpractice suits. There seemed to
be a large number of unscrupulous people who thought
they saw an easy way of getting money by suing the
doctor, and the best assurance against this danger
was to be found in membership in the Medical Society
of the State of New York, whose attorney had been
more successful protecting its members against mal-
practice suits than any other in this country. The
sixth purpose of the Society was the "enlightenment
of the public as to the state of medical science." The
medical profession had always been a great deal in
advance of actual practice in its scientific knowledge.
For instance, twenty years ago physicians knew the
cause of typhoid fever and how to prevent it, yet it
was only five or six years ago that a city like Phila-
delphia could be made to see the necessity of pure
water supply. The public has found considerable fault
with the profession because they did not know the
cause of poliomyelitis, and when any one assumed this
attitude it was well to call his attention to the fact
that the public did not to-day take advantage of one-
half the knowledge that the medical profession had
given it in regard to sanitation and preventive medicine.
Individually, and as a profession, our support should be
given to public health work.
Experiences in Serbia During the War. — Dr. Ethan
Flagg Butler of Yonkers presented this paper, in
which, in order that the factors involved in the out-
break of the epidemic of typhus might be understood,
he described the nature of the country, its peoples, and
the progress of the war up to that time. He said the
country was essentially agricultural, and facilities for
transportation were very limited, it being necessary
in order to reach certain places to travel by oxcart or
to walk. The climate approximated that of northern
New York or New Jersey. There were few towns of
appreciable size, and but one city worthy of the name —
Belgrade. With the exception of Belgrade, all the
towns, in their architecture and lack of sanitation,
showed the Turkish influence. The people, as a whole,
were ignorant, slow to learn, and wholly devoid of the
least conception of hygiene or sanitation. Their sense
of honor was not overkeen, but they were brave and
patriotic. Every physician was a medical officer in the
army or on the reserve list. However, the organization
and efficiency of the medical department of their army
could not be rated very high. The strong offensive
launched against Serbia by the Austrians in the early
part had the effect of driving a large proportion of
the noncombatant population to the central and south-
ern part of the country. Overcrowding resulted, and
the increasing number of wounded made the establish-
ment of reserve hospital points necessary here and
there throughout the land, and patients were rushed to
these points even before staffs had been secured to
take charge of the hospitals. The American Red Cross
responded to the call for doctors and nurses, and sent
out three units, the second of which was in charge of
the writer. When their party reached Serbia I
found themselves cut off from the other units, one of
which had fallen into the hands of the enemy. They
were sent to a primitive little village on the Greek
border to take charge of the Reserve Hospital there
located. This hospital proved to be a large warehouse
with great bare lofts and unpartitioned spaces, with
no running water, and no provision for the disposal of
sewage or waste. Bedding of all kinds was insufficiini .
and laundry facilities nil. There were 850 filthy pa-
tients, most of them with infected compound fractures,
and within twenty-four hours 450 were added. They
had come primarily to render surgical assistance, but
there was greater need of sanitation. It was under
such conditions as these that typhus, which was always
endemic in the Balkans, broke out. The method of
handling the soldiers was largely responsible for the
rapid spread of the disease at this time. In January.
1915, it became apparent that a serious epidemic ex-
isted, and from that time until the middle of April, 1915,
there was a very rapid increase in the number of cases
and the virulence of the disease. After that it gradually
declined. While their party was in no position to inves-
tigate scientifically the etiology of the disease, there
was nothing in their experience that would tend to
contradict the theory that it was louse borne, and only-
louse borne, and particularly borne by the body or
clothing louse. Lire were everywhere, and no one es-
caped them, but those having found few lice seemed
to have been the ones to escape the disease. There
was no evidence to show that infection occurred through
handling the skin lesions, by dust, droplet, or from
excreta. In support of the louse theory it might be
stated that delousing of the patients prevented the
spread of the disease, no case occurring in louse-free
wards, unless they were being incubated at the time
of admission. One small pavilion was kept entirely
free from typhus for two months while the epidemic
Nov. 18, 1916J
MEDICAL RECORD.
919
was at its height solely by insisting that no patient
should be admitted unless he were thoroughly deloused
to the satisfaction of the authorities in charge of the
hospital. At Belgrade the same thing was demon-
strated. Constant vigilance was assential at all times,
and none but Americans could be trusted with the
important features of this work. They had had the
opportunity of observing a large number of cases of
typhus fever, there being 1)22 cases within the military
hospital at Belgrade, whither they were sent after
completing their service on the Greek frontier. That
was the high figure for one day. The total number of
cases seen was well into the thousands. There was
also a series of cases occurring among Americans, Serbs,
British, Italians, and other nationalities, which came
under their care. A small group of patients, compris-
ing their own staff invalids and persons of authority
brought to them that they might secure the advantages
of their nursing staff, afforded an opportunity to keep
records and to follow the course of the disease minutely.
The incubation period was from seven to fourteen days.
In the majority of cases the onset was sudden, charac-
terized by high fever and headache. The temperature
remained high and the pulse rapid throughout the acute
course. On the fourth or fifth day the typical skin rash
appeared, petechiae, 2 mm. in diameter, increasing in
number from day to day, and not fading on pressure.
Throughout the course of the disease there was much
headache, and pain in the extremities. A profound
toxemia occurred, affecting the central nervous system,
heart, and blood vessels. During the acute course there
was tremor, incoordination, involuntary passages of
urine and feces, and delirium. The pulse became irregu-
lar in rate and force, and diminished in volume. The
acute cases lasted from three to seventeen days, and
were terminated by lysis. As the epidemic progressed
the cases became more virulent and the mortality in-
creased. Convalescence was slow, and complicated by
peripheral neuritis, psychoses, gangrene of the extremi-
ties, and abscesses in most any part of the body. The
true mortality would never be known. The primary
rate approximated 50 per cent, and with the secondary
rate, from complications and sequelae, brought the
total mortality to about 65 per cent. With good nurs-
ing and special care the mortality of the cases re-
ceived into the series receiving special care was 10.7
per cent. Preventive measures consisted in the thor-
ough delousing of all patients within the hospital and
prior to admission. Where there were no lice there
could be no typhus. The acute cases were treated
much the same as typhoid fever was treated in this
country, the bulk of reliance being placed on good nurs-
ing, keeping the patient quiet and free from worry. A
fairly liberal soft diet was allowed, and fluids were
forced upon the patient. Toward the end of the second
week, when the heart muscle began to weaken, various
preparations of digitalis were used, most frequently
digalen, hypodermically. In closing, Dr. Butler spoke
of the lessons of the war, and commented more par-
ticularly on medical preparedness, stating that pre-
paredness meant not only the accumulation of arms
and munitions, but chiefly in the thorough training of
the maximum number of able-bodied males in the mili-
tary duties that they were logically qualified to perform
in times of war. this applied with peculiar force t<>
the doctors. From personal experience at home and
abroad it was evident that it was no more feasible to
take doctors from civil life and place them on active
duty as medical officers of the army than it \va< to
recruit a regiment and then send it, without further
training, to the front. It rested with each member
of the medical profession to decide how far he was
willing to devote himself to his country and to secure
the necessary training for a medical officer's duties.
Experiments in the Use of Moving Pictures in Teach-
ing the Technique of Surgery. — Dr. John A. Wyeth of
New York presented this communication. He said that
in the teaching of clinical surgery some general idea of
the technic might be obtained by observation from
points more or less removed in the amphitheatre, the
practical knowledge which was absolutely essential could
only be acquired by immediate personal contact with
the operator. With the advent of motion picture pho-
tography they began and were still carrying on experi-
ments in order to satisfy themselves of the value of
this means of demonstrating onerative technic to their
classes. Operations on the cadaver and on the liying
subiect had proved fairly satisfactory, and they inclined
strongly to the opinion that with improved apparatus
and wider experience on their part and on the part of
the mechanician, still better results might be obtained.
A gratifying feature of this work was that it was pos-
sible to send these films to medical societies all over
the country, thus enabling many practitioners who
could not find time to visit central clinics to protit by
these demonstrations. Dr. Wyeth gave an exhibition
of these pictures, showing a bloodless amputation at the
hip joint, a ligation of the external carotid, operation
for an inguinal hernia, and his method of injecting
boiling water in exophthalmic goitre. In describing the
ligation of the external carotid, Dr. Wyeth said thai
until 1878 this procedure was forbidden by the text-
books on the ground that the external carotid was an
exception to the general rule in that it did not give
off its branches in a regular manner. He felt convinced
that this statement was not true and in order to prove
his contention made 121 dissections and careful measure-
ments which demonstrated that the external carotid was
no exception to the laws of development. In 1878 he
read a paper before the American Medical Association
in Buffalo setting forth these facts and describing his
method of ligating the external carotid. This procedure
bore his name for a time, but the fact that he had
originated it seemed to have been forgotten.
Early Diagnosis of Cancer. — Dr. PARKER Syms of New
York made this presentation, giving a lantern slide
demonstration of the microscopical changes that had
been observed in the precancerous stage and the early
stages of cancer. He confined himself to facts con-
cerning cancer as distinctive from epitheliomata. He
emphasized the fact that cancer in its eai'ly stage was
a purely local disease. The first change which mani-
fested itself microscopically was in the nuclei of the
cells; these became hyperchromatic. The next step
was a slight fibrosis; then an increasing fibrosis, plug-
ging of the acini, and infiltration and cell prolifera-
tion. Dr. Park spoke somewhat at length of the diffi-
culties surrounding the early diagnosis of cancer and
emphasized the fact that it was only the early recogni-
tion of the condition and early operation that offered
any hope for the cancer patient. He reviewed the
symptoms of cancer of the breast, laying stress on the
fact that pain was not a prominent symptom, but the
"non-restful" breast was likely to be an indication of
the precancerous stage. Dr. Syms also spoke some-
what at length of the significance of gastric ulcer as
a precursor of cancer.
Dr. S. W. S. Toms of Nyack said he felt that Dr.
Syms had covered the subject very thoroughly so he
would only emphasize a few points. The first of these
was that we should not look for physical signs of
cancer as much as we did for a disturbance of func-
tion. A disturbance of function that did not. clear up
in a reasonable time should be regarded with suspi-
cion. A cancer had practically the same relation to the
body of the individual as a case of contagious disease
had to the community. In order to protect the com-
munity the case of contagious disease must be isolated;
in order to protect the individual the cancer must be
extirpated in its early stage. The fact that cancer
occurred in both husband and wife in a number of
instances might only be a coincidence; however, it was
a rather striking fact that merited consideration. Sta-
tistics seemed to reveal the rather disquieting fact that
cancer was on the increase in all parts of the civilized
world; the census of 1900 showed an incidence of 63
deaths from cancer per 1000 population while that of
1013 gave 75 per 1000 population. The records of
RIoodgood showed that 60 per cent, of the cases could
be saved by early operation. An important point which
we should recognize and which we should do our part
to correct was that among the laiety there was a mis-
conception in regard to the early signs of cancer. They
looked for pain, and did not recognize the fact that
pain was practically a svmptom of the last stages of
cancer. The correction of this misconception was a mis-
sionary work which should be undertaken by the physi-
cian. Our patient should be taught that every lump
was suspicious and that irritation and misplaced organs
provided a basis for cancer. They had no specific rules
for the early diagnosis of cancer.
Dr. William Seaman Bainhridge said he wished to
take exception to the last statement. They had one
cardinal rule and that was that they should never
manipulate a tumor. He cited authoritative evidence
showing that the handling of a tumor reduced the pa-
tient's chances of life 40 per cent. Many a patient
who had a good chance for life lost it either before or
at the time of operation through disregard of this
cardinal principle.
920
MEDICAL RECORD.
LNov. 18, 1916
Dr. Edward C. Thompson of New-burgh called atten-
tion to the fact that the Mayos had followed up a
large series of cases in which the pathological findings
had been negative and cancer developed later.
Dr. Eliza M. Mosher of Brooklyn said she wanted
to make a plea for the women themselves. When a
woman came to a doctor thinking she had a condition
that was perhaps suspicious of cancer, she was fre-
quently dismissed with the statement that she was only
nervous and there was nothing wrong with her. This
made her feel foolish, and she would decide never to
consult a doctor again unless she was absolutely cer-
tain there was something wrong. When a woman came
to consult a physician because her fears have been
aroused that she might have a malignant condition she
should be made to feel that she had done the right
thing and that it was much wiser than to have neg-
lected a suspicious condition.
Chronic Intestinal Stasis. — Dr. William Seaman
Bainbridge of New York City presented this communi-
cation, which was liberally illustrated by lantern-slide
pictures showing different types of stasis and methods
of treatment. In a preliminary historical sketch of
man's efforts to find the causes and the cure of disease,
Dr. Bainbridge recalled some of the theories which,
from time to time, had held sway. Among the present-
day theories might be mentioned, along with the germ
theory, the view that disturbances of the internal secre-
tions bore a causal relation to disease; also that disease
was dependent upon the nutrition of the fissures and
the tissue-cells. The treatment of disease, therefore,
was not only a question of the elimination of the toxic
products of bacterial activity, but of the toxins elab-
orated by the tissues themselves. This had been
abundantly proved by Carrel's experiments with the
maintenance of life, in vitro, of tissue removed from
the body of which it had formed a part. Failure to
remove the toxins which resulted from cellular ac-
tivity, invariably resulted in the death of the tissue. It
was evident, then, that the faulty elimination of the
products of physiological activity was a fundamental
factor in the production of disease. Just what part the
internal secretions played in this connection had not as
yet been definitely determined, but the importance of
the gastrointestinal tract in the general maintenance of
proper elimination and the preservation of health, was
a matter of common knowledge. The question of the
prevention of disease was largely a matter of body-
plumbing, which might involve any part of the human
house. Dr. Bainbridge here briefly described the chief
types of defective body-plumbing which lead to the con-
dition now generally known as chronic intestinal stasis.
This condition was a persistent retention or retarda-
tion of the contents in some part of the gastrointestinal
canal, at certain points of predilection, where kinks or
angulations of the canal resulted from undue pull or
constriction by bands of adhesion or resistance. The
fixation of any point in the length of the tube, with a
dropping of the tube on either side of this fixed point,
produced a kink or an angulation, and this, in turn, inter-
fered with the onflow of the contents of the canal. This
stasis of effete material was followed by absorption,
autointoxication, and a long chain of symptoms vary-
ing in degree with the degree of interference with drain-
age. The toxic symptoms were thus secondary to the
mechanical changes. Chronic intestinal stasis was to
be differentiated from chronic constipation, which was
confined to the lower bowel. Either constipation or
diarrhea might accompany stasis. Cases of stasis were
classified, according to the degree of stasis and the se-
verity of the symptoms, into: (1) Beginning cases, in
which a definite condition of stasis might be prevented
by proper dietary and hygienic conditions; (2) mild
cases, in which, in addition to the preventive measures,
it might be necessary to resort to moderate surgical in-
terventions, such as the cutting of bands, replacing hol-
low organs, changing angles, and otherwise restoring
normal relations; i .". ) advanced cases, in which radical
surgical measures were demanded, such as ilco-colostomy
it-circuiting), or ileocolostomy with colectomy.
After surgical treatment, by conservative or radical
measures, the cases were then replaced in the first
group, and were to be kept under the surveillance of tin-
family physician or gastroenterologist, for the purpose
of continuing, as long as necessary, the prophylactic
measures employed in the beginning cases. If this post-
operative treatment were neglected, recurrence of the
severer condition would be imminent. Dr. Bainbridge
emphasized the fact that the first and second groups
were by far the larger, and that the radical measures
employed in the third group should be resorted to only
when absolutely obligatory, and after the simpler meas-
ures had been ineffectually utilized, or had been ruled
out by careful examination by the various diagnostic
measures now available.
Dr. Eliza M. Mosher of Brooklyn said that there
were many of these cases that should not reach the
surgeon, and it behooved medical men to ask them-
selves what they were going to do about these patients.
The first thing to do was to make a correct diagnosis.
They could not hope to gain the dexterity and acute
sense of touch that Dr. Bainbridge and Dr. Lane had
attained, that was beyond the average man, but they
could be a little more careful in their observations.
When a patient came into the office with bad posture,
stooping shoulders, narrow chest, and the symptoms
that went with enteroptosis, he should be able to recog-
nize the fundamental cause of that patient's ill health.
A great deal could be learned in these cases by the use
of the stethoscope, applying it successively over the
different parts of the stomach and abdomen. The pa-
tients which Dr. Bainbridge had designated as belong-
ing to the first group could be cured or greatly improved
by proper treatment. In addition to the regulation of
the dietetic and hygienic habits of these patients a
properly fitting abdominal belt would do much toward
the restoration of the viscera to their normal position.
Dr. Mosher showed the belt which she had devised and
which she had employed in some 324 cases during the
past few years. The belt was so constructed that it held
up the recti muscles, and if these were held up the side
muscles would stay in their proper position. Yawning
and deep breathing were to be recommended, as they
restored the viscera to their normal positions. During
a yawn the abdominal muscles were flattened and drawn
up, and throwing back the head raised the diaphragm
and restored the viscera to a more normal position. Dr.
Mosher cited an instance in which a subsequent opera-
tion showed a most remarkable development of the
abdominal muscles which had been secured by these
exercises, and in closing emphasized the fact that many
physicians were culpable of allowing enteroptosis to
pass unrecognized and not properly treated.
Dr. Edward C. Thompson of Newburgh said what
they had just listened to was valuable not only in that
it pointed the surgeon to big endeavor, but because of
the fact that it pointed the general practitioner to
the need of more careful diagnosis. It brought out
the idea that the ability to make a careful diagnosis
was of as much or more importance than the mechanics
of surgery. The ideas which Lane had brought out
really meant fewer operations, fewer sewings up of
kidneys, fewer appendectomies, and fewer major opera
tions, and it was to be hoped that when the surgeon
did operate he would have the intelligence to lift up
the ileum.
Dr. James E. Sadlier of Poughkeepsie said he ex-
pressed his appreciation of what Dr. Bainbridge and
Sir Arbuthnot Lane had done for the profession in
bringing out the importance of the condition which they
had designated colonic stasis. He also accentuated the
importance of post-operative care. Proper post-opera-
tive care was a most important factor; many of these
cases returned to a sedentary life, and unless their diet
and hygiene was properly regulated they could not be
put back into the well class.
Diagnosis and Treatment of Acute Infections of the
Nasal Accessory Sinuses. — Dr. Milton A. McQuade of
Poughkeepsie read this paper. He said he had chosen
this subject because these infections in the great ma-
jority of cases followed influenza and acute coryza, or
occurred as a complication or sequela of some infectious
disease, and it was the family physician whose advice
and treatment were sought. He outlined the anatomical
and physiological points which helped to an understand-
ing of the process of acute infection, calling special
attention to the fact that the nasal accessory sinuses
were rudimentary in childhood and not fully developed
until the age of fifteen to eighteen years. This ac-
counted for the fact that there was little sinus involve-
ment in the acute coryzas and infectious fevers of early
years. Lindenthal had shown that the influenza bacillus
was the most common cause of acute sinus involvement.
Diphtheria and croupous pneumonia were frequently
complicated by acute sinusitis due to direct invasion.
The other infectious fevers might be an etiological
factor from lowered vitality. Dental caries was re-
sponsible for about 20 per cent, of antrum suppuration.
Tuberculosis, syphilis, malignancy, and osteomyelitis
were infrequent causative factors. The primary infec-
Nov. 18, 1916]
MEDICAL RECORD.
921
tive organism might disappear, allowing the germ of
secondary infection to continue the disease; these were
most frequently members of the streptococcic and
staphylococcic groups. The symptoms of infection of
the nasal accessory sinuses were fever and circulatory
disturbance, usually facial congestion, occluded nares,
nasal discharge, general irritability, depression, rest-
less sleep, and often visual disturbances. Headache was
nearly always present, but very variable as to location,
duration, and intensity. As a rule there was more or
less neuralgic pain in and about the affected cavity ;
referred pain might occur along the branches of the
trigeminus. Yankhaner had noted that if steam inhala-
tions relieved the headache, one could believe the cause
to be in the nasal chambers or sinuses. Tenderness
under the floor of the frontal sinus, directly above the
inner canthus was pathognomonic of inflammation of
this sinus. Antral tenderness was occasionally present
but was variable. Purulent secretion from the nasal
chambers to be pathognomonic of sinus disease must
constantly reappear in the vicinity of the sinus open-
ing. Cacosmia, or an offensive odor in the nose, was
most pathognomonic of sinus disease. Transillumina-
tion as an aid to diagnosis was of comparative value
only, due to irregularities in the thickness of th^e bony
walls and septa, and the difference in the size of sinuses.
The .T-ray was also of little value in the early stage
of the inflammation, but later it might enable one to
determine the condition of the sinus and its size and
position in case operative interference became neces-
sary. Suction was occasionally of value in purulent
cases. In the antrum, puncture and washing was the
surest way to demonstrate secretion. When the maxil-
lary antrum was involved pain was usually referred
over the orbit and around the upper teeth and jaw.
There was a feeling of distention and pressure, which
might not necessarily be due to pent-up secretion but
might be due to swelling of the mucosa. The anterior
antrum wall might be sensitive to pressure. Transil-
lumination might show a darkened area as compared
with the opposite side. This might be confirmed by
a>ray, by suction, and by washing. In involvement of
the frontal sinus there was referred pain along the
supra- and infra-orbital branches of the fifth cranial
nerve and pain referred directly to the sinus dull, ex-
panding, and throbbing rather than neuralgic. The
morning exacerbation was common and often precipi-
tated by some slight exertion, such as stooping, cough-
ing, etc. Ethmoid involvement occurred to a greater or
lesser degree with every acute coryza. The symptoms
were those of a severe cold in the head, with neuralgic
outshoot to the deeper structures of the eye, resulting
in ocular symptoms. The diagnosis of acute spenoidal
involvement was seldom made on account of the diffi-
culty attending the examination. Hei-e the headache
was often localized in the parietal or temporal regions,
radiating to one or both ears. There was a feeling as
though the eustacian tubes were closed. Ocular symp-
toms were more marked and there was more fever and
general prostration than in ethmoid involvement alone.
The complications that might occur were better under-
stood by keeping in mind the anatomy of the parts and
their close interrelation. One could then understand
why one might expect to find among the complication
such conditions as inflammation of the retina and optic
nerve, muscular esthenopia and loss of accommodation,
the various forms of meningitis, and thrombosis of the
venous sinuses. In the treatment of nasal accessory
sinus conditions the patient should be put to bed, given
a purge, mustard foot baths, and Dover's powder. Local
depletion should be effected by cocaine or adrenalin only
if necessary, as frequently they were inefficient and had
a tendency to aggravate the symptoms. Hot alcoholic
drinks should be avoided. Ice bags over the forehead
and eyes were indicated if the headache was severe.
After purgation had been established, aromatic spirits
of ammonia should be administered, half a drachm
everv hour for eight to ten hours. A formula which
had been used with satisfaction for years consisted of
sodium salicylate and quinine, each two grains, and
Dover's powder, one grain, giving a capsule every two
hours. About 95 per cent, of acute inflammations would
respond favorably to this treatment. In acute fulminat-
ing forms of sinus involvement operative measures
might be necessary to provide drainage.
Some Clinical Experiences in Heart Disease. — Dr. J.
H. M. A. von Tiling of Poughkeepsie reviewed some
personal experiences with patients suffering from heart
disease and allied affections and presented deductions
from these. He said they should not forget that the
heart was not simply a mechanism which acted accord-
ing to certain definite inflexible rules, but was a very
delicately adjusted living organism with great indi-
vidual differences in different people. It seemed abso-
lutely wrong to approach a patient with any precon-
ceived fixed idea as to how high the blood pressure
should be, what his heart sounds should be, etc. There
was no such thing as an absolutely normal blood pres-
sure, nor an absolute normal heart. The all-important
question rather was whether that heart was able to ful-
fill its function satisfactorily — could the circulation be
properly maintained? This question obviously resolved
itself into the question, "Was the reserve force of the
heart muscle intact, or was it failing?" They must re-
alize that it was in the last instance not a defective valve
nor a contracted artery which caused the failure to
maintain an efficient circulation but the heart muscle
which was unable to overcome the obstacles, and they
must judge the strength of the heart muscle and its
ability to promptly and sufficiently answer to all rea-
sonable demands if they wished to come to a clear un-
derstanding of their patients. In that respect it did
not help merely to find that the patient had a certain
kind of heart murmur or a certain pulse rate while he
was at rest, but it was more important to know if the
patient was becoming breathless after slight exertion
and it was also very important to learn how often the
heart acted when called upon to perform different kinds
of extra work, such as at the time of extra-physical
exertion, at the time of pregnancy and parturition, dur-
ing times of sickness, or times of mental strain, worry,
or sorrow. The proper adjustment of heart valves and
the whole mechanism of the arteries and veins made it
easier for the heart muscle to maintain the circulation,
and, if anything went wrong with this adjustment, the
heart muscle was called upon to do more work; as long
as the reserve force of the heart muscle was intact it
could perform this extra work. A heart with damaged
valves meant that the heart muscle had to do more
work than if the valves were perfect; such a heart
muscle would fail easier than if the valves were in-
tact; but that same fact was true in different people
with healthy hearts. The heart of a man weighing
300 pounds had always more work to do than the heart
of a man who weighed only 150 pounds, and it seemed
wrong to subject a patient to treatment, or to consider
him as ineligible for life insurance just because he had
a heart murmur, as long as the reserve force of his
heart muscle was sufficient for ordinary circumstances.
The first symptoms of a gradually beginning failure of
the heart muscle were not definite dilatation of the
heart, enlarged liver, ascites, or general edema ; if they
waited for these symptoms before beginning treatment
they would not do justice to their patients. The first
symptoms were rather often quite insignificant and they
were almost always subjective and with no physical
signs. There might be palpitation, breathlessness, dis-
tress, feeling of weakness, etc. Therefore, it seemed
of the utmost importance to take painstaking histories
of these patients; a good history was often of more
importance and value than the physical examination to
determine the condition of the heart muscle. He be-
lieved that even the electrocardiograph was of less
value than an exact history with proper valuation of
the subjective symptoms. Besides, he did not believe
a general practitioner would ever carry an electro-
cardiograph in his pocket — certainly not in their life-
time. It was often very difficult to place the proper
valuation on the subjective symptoms complained of
by the patient. Many patients would become quite
angry and perhaps leave you if you wanted straight
answers to the questions; for instance, if you did not
allow them to state that they had a pain iii the
heart, or in the kidneys, when they did not know
where their heart or kidneys were, and when the pain
was simply somewhere in the left side or somewhere
in the back — or if you did not let the patient get by
with the statement that he was unable to walk because
he was paralyzed, wihout making him state definitely
if it was merely a weakness of the muscles or stiff-
ness of the joints, or pain, or breathlessness, or dizzi-
ness, etc., which prevented him from walking. Very
often they would find that the patient had forgotten,
or did not notice, that the first slight symptoms of the
failing heart until his attention was drawn to it; for
instance, he might not have noticed that his heart
beat much faster when he walked up a slight hill, or
that he had to open his mouth to get sufficient air
as soon as he walked a little faster than usual, yet
those slight symptoms were of great importance and
922
MEDICAL RECORD.
[Nov. 18, 1916
the earlier the weakened heart could be placed under
a proper regime the more chance for a cure. The
heart might be only secondarily affected and the case
for the apparent heart symptoms might be somewhere
else or, on the other hand, one might get complaints
attributed by the patient to other organs which really
were caused by a deficient circulation in those organs
for which again the heart muscle was responsible.
One of the first subjective signs of a failing heart that
many patients complained of was a general feeling of
weakness or exhaustion; but this was by means al-
ways of cardiac origin; it was often of a vasomotor
origin. The extreme of this same condition might be
fainting spells, which meant, of course, a temporary
failure of the heart to sustain a sufficient circulation
in the brain, but they should not forget that some
fainting spells might be of purely mental origin.
Mental exertion certainly had an influence on the
heart, and it was true that the weakened heart could
cause mental and general nervous symptoms before
there was any physical evidence of organic heart le-
sion. It would be of extreme value if they had a defi-
nite method of measuring the reserve force and getting
a definite idea of the functional capacity of the heart
muscle. Unfortunately they had no absolute standard
for this reserve force of the heart muscle. Each per-
son had his own personal standard and test for the
functional capacity of his heart. The object of all
treatment was to prevent the exhaustion of the reserve
force and to restore the more or less exhausted reserve
force of the heart muscle. Rest, of course, was of the
utmost importance in those cases in which the heart
muscle had been weakened by overwork, but one should
not forget that rest for these patients meant mental
rest as well as physical rest. It was well known that
many poisons would cause degeneraive changes in the
heart muscle.
Dr. S. Neuhof of New York said that aside from
Dr. von Tiling's remarks regarding the assumed value
of laxatives in reducing cardiac dilatations, he agreed
in the main with the many excellent points that he
has made. He has, for example, emphasized the great
importance of careful history taking, an almost lost
art. He has correctly stated that cardiac murmurs
did not necessarily spell heart disease. He has quite
properly remarked that most cases of so-called weak
hearts were due not to organic disease but to vaso-
motor instability. Though it was quite true, as Dr.
von Tiling stated, that an electrocardiographic appar-
atus could not be "carried around in one's pocket," he
possibly had forgotten that the lessons to be learned
from it should be carried around in one's mind and
thus if not otherwise available it was of use at the
bedside. By just this process of translating instru-
mental into clinical knowledge they have learned to
readily recognize such arrythmias as auricular fibrilla-
tion and extrasystoles at the bedside. Speaking broad-
ly, in decompensated cardiovascular cases in whom the
factor of infection was either quiescent or non-existent,
he attempted for therapeutic and prognostic purposes,
to group the patients as follows: (1) Mitral lesions
with rhythmic heart. These patients improved only
slowly or sometimes not at all upon digitalis. Rest
with them was an extremely important factor. (2)
Mitral lesions with auricular fibrillation. Unless de-
compensation was extreme or long continued, these
patients improved very rapidly under digitalis. The
irregular cardiac activity was quickly controlled. The
digitalis acted here apparently by blocking many of
the discordant auricular impulses passing through the
conduction system. (3) Aortic lesions with slight or
moderate ventricular hypertrophy. These cases usu-
ally reacted well to rest. Digitalis was not of much
value. The bromides were occasionally followed by
good results. (4) Aortic lesions with extreme ven-
tricular hypertrophy. These patients did not react
well to digitalis possibly because there was not suffi-
cient healthy cardiac muscle unon which the medica-
might act. Even if auricular fibrillation were
present, digitalis medication was not apt to be fol-
lowed by beneficial results. (5) Cardiosclerosis with
decompensation. By the term cardiosclerosis, the
speaker said he meant a pathological condition in which
there was a varying mixture of aortic, coronary, valvu-
lar, and myocardial disease. Those with cardiac fail-
ure and with edema, with or without hypertension, were
apt to react well to the Karrel diet, and digitalis and
theobromine sodium salicylate on alternate days. lie
had modified the Karrel 1,000 c c. milk day by giving
only 500 c.c. of water, tea or coffee on the theobromine
days with excellent results, especially upon the diuresis
and the disappearance of dropsical effusions. In
cardiosclerosis, hypertension, and uremia, without
myocardial insufficiency, the symptoms were mainly
uremic. The therapy lay chiefly in the administration
of alkaloids and the giving of purely carbohydrate diet
or one low in protein and rich in carbohydrates.
Report of a Possibly Milk-Borne Epidemic of Infan-
tile Paralysis. — Dr. John C. Dingman of Spring Valley
presented this report in which he related the circum-
stances in connection with a series of cases of polio-
myelitis that directed attention to a small milk dairy
as the source of infection. On July 23 Dr. Dingman
said he had been called to attend sick children in three
different and widely separated summer boarding
houses. In one, called the Levine House, he found
four children ill with what had been diagnosed and
treated by another physician as malarial fever. They
all became ill on July 20 and 22 and all presented the
same clinical picture, namely, fever, vomiting, obsti-
nate constipation, and a drowsy, soporous mental con-
dition. Two of these cases went on to frank paralysis
of the lower extremities, while the other two recovered
without showing muscular weakness or paralysis.
These four children had all used raw milk from a
dairyman, whom he would refer to as X. Three other
children in the same house who used milk from an-
other source all remained well. The diagnosis of polio-
myelitis in these children was verified by Dr. Le Grand
Kerr of Brooklyn. In another boarding house called
"Locust Court" was a 3%-year-old girl suffering with
a similar illness, although more severe. She developed
paralysis of the muscles of deglutition and speech with
a slight affection of the muscles on one side of the face.
She also showed meningeal symptoms. The diagnosis
in this instance was confirmed by Dr. Koplik of New
York. The rest of the children in this boarding house,
four or five in number, escaped. Upon learning that
this child also had used milk from dairyman X, Dr.
Dingman said he became suspicious and on July 27
visited the premises of this man. Only two cows were
kept in a very filthy barn which had never been in-
spected by the health authorities and the proprietor
had no permit to sell milk. The house occupied by a
tenant was very dirty, unscreened, and swarming with
flies. All sanitary arrangements were primitive and
unclean. A four-year-old boy had been ill five days
and showed a beginning paralysis of the right leg. By
patient questioning of the tenants it was discovered
that a four-year-old son of the Russian landlord had
been acutely ill wdth fever and vomiting on July 4, and
had been in bed and unable to walk for some time.
The parents had not called a doctor and the child was
up and about. This boy on inspection was found to
walk with some difficulty and to drag one foot. On the
same day, July 23, on which the writer was called to
the Levine house, he had been called to another board-
ing house, High View House. Here he saw a four-
year-old boy who had become ill the day before with
fever and vomiting. This case ran a moderate course
with only slight paralysis of the right leg. The diag-
nosis of poliomyelitis was confirmed at the Willard
Parker Hospital. This boy also had been using X's
milk. There were no other cases at High View House
and had been none all season and this house had its
own dairy. In addition to the houses already men-
tioned three others were supplied by this same dairy.
In one of these there were no children and the milk
was not used raw. In a second house there were two
families who had used X's milk but boiled it before
giving it to the children. In the third house there
were three children who had used this milk but the
parents were emphatic in the statement that the milk
had been boiled before being given to the children.
The eight cases here described were the only cases
which developed in or about Spring Valley up to this
time and for some time afterward. The few scatter-
ing cases which did occur later in the summer ap-
parently had no connection with this group of cases.
In order to determine whether these children, all of
whom came from Brooklyn, might have received the
infection before coming to Spring Valley, the writer
reviewed the cases more thoroughly and stated that
they had been followed up at their homes in Brooklyn,
and so far as a thorough investigation showed tlyat
they had not been exposed to the disease before com-
ing to Spring Valley. Three of these children began
using the milk on July 10 and in ten or twelve days
showed the first symptoms of the disease. It was clear
that all the children coming down with the disease were
Nov. 18, 1916 1
MEDICAL RECORD.
923
using the milk from July 6 to 16, at the time that the
Russian boy, the son of the dairyman, was in bed with
the disease. Under the conditions of gross filth exist-
ing on the premises of the dairyman it seemed reason-
able to believe that one or more messes of milk had
become contaminated by the discharges or vomitus of
the Russian boy, who became ill on July 4. The infec-
tive material was probably conveyed by flies, which
had access to the sick boy and to the milk, and thus
the disease was carried to the other seven cases.
Strong corroborative evidence of this might be found
in the following facts: (1) All of the cases had their
onset either on July 20 or 22. (2) They all used the
raw milk, while the families that used the same milk
during the same period boiled it. (3) The milk was
not chilled but delivered warm, which made it an ex-
cellent culture medium for the virus. (4) At that
time all the cases of this disease reported within four
or five miles of Spring Valley were among the cus-
tomers of this dairyman.
ii>tate iflpdtrai Hirntsing IBtmvba.
STATE BOARD EXAMINATION QUESTIONS.
Kentucky State Medical Board.
June 13, 14, and 15, 1916.
i Concluded from pa* • -■'■- \
ETIOLOGY AND PHYSICAL DIAGNOSIS.
1. Give the etiology of vertigo.
2. What are most common causes of varicose ulcers
of the leg?
3. Give the etiology of rachitis.
4. Give the etiology of lung abscess.
5. Give the most probable etiological factors in the
causation of cholelithiasis.
6. Give the diagnosis of Grave's disease.
7. Give the diagnosis of psoriasis.
8. Give the diagnosis of spontaneous intracerebral
hemorrhage (apoplexy).
9. Describe the various kinds of pulmonary rales and
give the significance of each.
10. Give diagnosis of aortic regurgitation.
PRACTICE AND MATERIA MEDICA.
1. (a) Give etiology of acute lobar pneumonia in the
adult, with physical signs of the different stages, (6)
How many stages of the disease, in order of occurrence?
(c) Give treatment for all. (d) What remedy is con-
sidered a specific by some authors?
2. (a) Name different kinds of pneumonia in chil-
dren. (6) Give diagnosis and treatment of each kind.
3. (a) Define hookworm disease. (6) Give causa-
tion, (c) Mode of infection. (d) Treatment. (c)
What new remedy have we, and how is it used?
(/) Does hookworm ever simulate other diseases, and
of so, what?
4. («) Diagnose and treat acute indigestion. (6) If
at all, when would you administer opiates? (c) By
what method would you use them?
5. (a) Differentiate between acute and chronic ne-
phritis. (6) Differentiate between chronic interstitial
and parenchymatous nephritis, (c) Give treatment for
acute and chronic nephritis, both medical and dietetic.
6. (a) Discuss the use of radium as a therapeutic
agent, (b) In what diseases would you prescribe digi-
talis, and what precautions, if any, would you take in
its use?
7. (a-) Do you know of any specifics in medicine?
(6) If any, name three of them, giving dose and indi-
cations for their use.
8. (a) How would you avoid salivation after giving
calomel? (b) What is the usual dose of calomel?
(c) Would you give the entire dose at once or divide it?
9. (a) How would you prepare a tasteless dose of
castor oil? (b) How best give turpentine in typhoid
fever, if used for some time?
10. Would you recommend any drug or drugs to dif-
ferentiate between typhoid and malarial fever? If
so, name them, and how would you use them?
OBSTETRICS AND GENECOLOGY.
1. Name (a) the female internal organs of genera-
tion, (b) giving function of each.
2. (a) What is podalic version? (6) Cephalic
version?
3. (a) Give etiology of adherent placenta. (6) What
precautions would you use in delivering one?
4. Give symptoms of pregnancy at fifth month.
5. What changes take place in the female economy
at puberty?
6. How would you manage a case of antepartum
hemorrhage?
7. (a) Give symptoms of ovarian cyst. (6) What
treatment would you advise and (c) why?
8. (a) What is the most frequent cause of cervical
ulceration? (o) What are the symptoms?
9. Define (a.) menopause, (6) metritis, (c) salpin-
gitis, (d) mastitis and (e) menstrual cycle.
10. (a) What antiseptic precaution would you use in
the eyes of the new born, and (fa) why?
ANSWERS.
ETIOLOGY AND PHYSICAL DIAGNOSIS.
1. Etiology oj vertigo. — Eyestrain or paresis of one
or moie of the muscle.; of the eye, disease of the semi-
circular canals, dyspepsia, constipation, disordered
hepatic function, migraine, excesses (in the way of
exercise, alcohol, tobacco, tea, coflee), organic diseases
of the brain and disturbances of the cerebral circula-
tion.
2. Varicose ulcers of the leg are caused by some in-
jury to a varicose vein; the tissues are edematous,
poorly nourished, and have diminished resisting power.
The injury may be very slight, but the poorly nourished
tissues bieak down and an ulcer results. Bad hygienic
surroundings and neglect are predisposing factors.
3. Etiology of rachitis. — Improper food, want of sun-
light, impioper hygienic conditions; generally, insuffi-
cient food, with the diet deficient in fats and proteins;
rece;, . I il constituents and vitamines has
been advocated as a cause of rickets.
4. Etiology of lung abscess. — Lobar pneumonia; lobu-
lar pneumonia; pyemia; trauma; rupture into the lung
of suppuration in neighboring tissues, such as em-
pyema, subphrenic acid, gastric ulcer, cancer of eso-
phagus.
5. The most probable factors in the causation of gall-
stones are: Bacteria; inflammation of gall-bladder and
ducts; stagnation of bile. The predisposing factors are
age, sedentary occupations, and some specific fevers,
such as typhoid.
6. The diagnosis of Graves' disease is made by the
tachycardia, exophthalmos, goiter, and intentional
tremor; in addition there may be widening of the pal-
pebral fissure and failure of the upper lid to follow the
eyeball when it is rolled downward.
7. Diagnosis of psoriasis. — The patches are chiefly on
the extensor aspect of the limbs, especially on the elbows
and knees; the borders of the patches are well defined;
the scales are white and adherent to the crusts ; there is
no inflammatory exudation ; on removal of the crusts
red, bleeding points are visible.
8. In spontaneous intracerebral hemorrhage (apo-
plexy). — "Usually the onset is sudden, the patient be-
coming unconscious and deeply cyanosed. After the
irritation stage, which occurs during the bleeding, has
subsided paralysis of the opposite side of the body sets
in with conjugate deviation, and often hemianesthesia.
The muscles of the affected side lose tone, as is shown
by raising the limbs. The reflexes are lost, but return
with consciousness; Babinski's sign is present. The
pupils vary; they may be contracted, dilated, or unequal,
in which case the larger pupil is on the affected side.
Various localizing signs may be present, according to
the position of the hemorrhage. The temperature is
normal or subnormal. Urine and feces are passed in-
voluntarily. The pulse is full and slow and the breath-
ing is stertorous. A lumbar puncture yields a fluid
containing blood or altered blood. Within forty-eight
hours of the onset the stage of reaction sets in. The
temperature rises, the sphincters become normal and
the reflexes return. Early rigidity, in which the
muscles resist flexion and extension, may sometimes de-
velop."— (Woodwark's Manual of Medicine.)
9. Rales may be dry or moist. Dry rales occur in
bronchitis and asthma and may be low pitched snoring
sounds (sonorous rales) or high pitched whistling
sounds (sibilant rales). Moist rales are produced by
the passage of the air through liquid and may be crepi-
tant, subcrepitant, or gurgling in character. Crepitant
rales are extremely fine and occur at the end of inspira-
tion: they are heard in the first stage of pneumonia
and in engorgement and edema of the lungs. Subcrepi-
924
MEDICAL RECORD.
LNov. 18, 1916
tant rales are comparatively few in number and are
heard during inspiration and expiration, in capillary
bronchitis, pulmonary edema, hypostatic pulmonary
congestion and incipient phthisis. Gurgling rales may
be large or small and are heard during inspiration and
expiration in phthisical cavities, bronchial hemorrhage,
in the stage of secretion in bronchitis and over the
trachea.
10. Aortic regurgitation is diagnosed by: A diastolic
murmur heard best over the aortic area; the pulse is
peculiar, being the Corrigan or water hammer pulse;
the heart beat is strong and the precordium may bulge;
the carotid, bronchial, and femoral arteries may pulsate
violently; the apex beat is displaced outward, owing to
the hypertrophy of the left ventricle.
PRACTICE AND MATERIA MEDICA.
1. (a) Lobar pneumonia is caused by the Micrococcus
laneeolatus (or Diplococcus pneumonias) ; Friedlander's
pneumobacillus is often found. Predisposing causes are
exposure to draughts or inclement weather, intemper-
ance and winter weather.
Physical signs of lobar pneumonia. — "Inspection re-
veals during the first stage deficient movement of the
affected side, due to pain. The apex beat is normal in
situation and the interspaces do not bulge. In the sec-
ond stage the healthy side rises normally, the affected
side lagging behind. If both lower lobes are impervious
to air, the diaphragm cannot descend and the epigas-
trium does not project during inspiration, the breath-
ing being conducted by the upper part of the chest
(superior costal respiration). Palpation during the
first stage shows the vocal fremitus to be more distinct
than normal, especially over the diseased portions. In
the second stage, the vocal fremitus is markedly exag-
gerated, except in those rare instances of occlusion of
the bronchi by secretion. The cardiac impulse is felt in
the normal position. Percussion: In the first stage, the
percussion note is slightly impaired at times, having a
hollow or tympanitic quality. In the second stage there
is dullness over the affected parts, with an increased
sense of resistance. Over unaffected adjoining areas
the resonance is increased (Skoda's resonance). Auscul-
tation: In the first stage there is heard over the af-
fected part a feeble vesicular murmur, associated with
the true vesicular or crepitant (crackling) rale, heard
at the end of inspiration only. In the second stage
there is harsh, high pitched, bronchial respiration, at
times resembling a to-and-fro metallic sound, except in
those rare instances in which the bronchi are more or
less filled with secretion. Bronchophony, or distinctly
transmitted voice, is present and at times pectoriloquy,
or distinct transmission of articulated sounds, may be
heard. In the third stage, the breathing changes from
bronchial to bronchovesicular and the crepitant rale
(crepitatio redux) returns. As resolution proceeds the
breath sounds are associated with large and small moist
and bubbling rales. — (Hughes' Practice, of Medicine.)
(b) There are three stages: (1) Hyperenia or en-
gorgement; (2) red hepatization or exudation; and (3)
resolution or gray hepatization.
(c) Treatment. — Consists in rest in bed, milk diet and
the administration of fractional doses of calomel fol-
lowed by a saline in the early stage. The nervous
symptoms and temperature may be controlled by apply-
ing ice bags or compresses wrung out of cold water
(60°-70° F.) to the chest or by the use of the warm
or cold wet pack. The heart and pulse should be sus-
tained by the administration of alcohol, strychnine (gr.
1/60-1 '20). atropine, caffeine, strophanthus, and nitro-
glycerin. Digitalis may also be employed. Inhalations
of oxygen afford temporary relief when the dyspnea
and cyanosis are extreme. In young, vigorous and ple-
thoric adults, with hyperpyrexia and a high tension
pulse, bleeding- may be beneficial in the first 48 hours.
Convalescence should be guarded, and tonics, stimulants,
etc., will be found very useful in this period of the dis-
ease.— (Pocket Cyclopedia.)
(d) Serum or vaccine treatment is considered a
specific by some authors.
2. (a) Children may suffer from lobar pneumonia,
lobular or bronchopneumonia and hypostatic pneumonia.
LOBAR PNEUMONIA.
Sudden onset.
Fever is high and regular.
Ends by crisis between
sixth and tenth day.
Generally only one lung
affected.
The physical signs are
distinct, and there is a
large area of consolida-
tion.
Sputum is rusty.
BRONCHOPNEUMONIA.
Gradual onset.
Fever is not so high, and
is irregular.
Ends by lysis, at no par-
ticular date.
Generally both lungs af-
fected.
Physical signs indistinct,
and the evidences of
consolidation are in-
definite.
Sputum is rather streaked
with blood.
LR PNEl MUM \.
Generally a primary dis-
ease.
Age has little influence.
BRONCHOPNEUMONIA.
Generally secondary (to
bronchitis or an infec-
tious disease).
Generally found in very
young or very old.
The symptoms of hypostatic pneumonia are those of
a low grade lobar pneumonia.
For treatment of lobar pneumonia see question 1.
Treatment of bronchopneumonia. — Absolute rest in
bed and a nutritious diet; the chest should be enveloped
in a thick cotton jacket; the temperature of the room
should be equable — about 65° or 70° F. If the bowels
are inclined to be constipated, fractional doses (gr. 1/6)
of calomel are advisable every hour until six or seven
doses have been taken. In the earliest stages the tinc-
ture of aconite is of service. Its action should be cau-
tiously watched, and as soon as the pulse becomes soft
the drug may be omitted. Usually six or seven doses
are sufficient. After the second or third day its action
is too depressing and is not recommended. If the tem-
perature rises above 102.4° F. it should be reduced by
means of a cold bath. Phenacetin may be given to con-
trol the temperature, but should not be used routinely.
After the third or fourth day a flaxseed poultice con-
taining mustard (o 1%) may be applied to the chest
and renewed every hour. After the poultice has re-
mained on the chest about two hours give the syrup of
ipecacuanha (HE 15) every ten minutes until emesis is
produced. Both these procedures should be repeated
on the following day. When the poultice is removed
replace it by a cotton jacket. If the heart is weak give
cardiac stimulants. — (Pocket Cyclopedia.)
The treatment of hypostatic pneumonia is that of the
original condition, with the addition of stimulants (such
as nitroglycerin or strychnine) ; their position in bed is
to be frequently changed.
3. (a) Hookworm disease is a severe malady in the
South, characterized by profound anemia, protruding
abdomen, dropsy, weakness, lack of energy, shortness of
breath, and maldevelopment.
(6) It is caused by the Ankylostoma duodenale or the
Necator Americanus.
(c) The ova arc voided in the feces; the latter are
scattered on the ground, and the ova then come in con-
tact with the feet and hands of the poorer inhabitants,
and are then conveyed to the month.
(d) and (e) Thymol is the new remedy. Treatment
(Prophylactic) — Shoes should be worn, and proper toilet
facilities should be provided. Indiscriminate scattering
of fecal matter is responsible for the prevalence of the
disease, and the most stringent rules should be adopted
to correct this unhygienic nuisance. Flies should be ex-
cluded. Treatment (Active) — On the day before the
treatment is to be begun the patient is advised to eat
little dinner and no supper at all. Late in the afternoon
he is given a full dose of calomel (2 to 10 grains, de-
pending upon the age and strength of the patient) . If
the calomel does not act freely during the night a full
dose of Epsom salt in hot water should be given as soon
as the patient wakes up the next morning. After the
bowels have thoroughly acted, finely powdered thymol
in capsule is given. The dose of thymol should be di-
vided into two equal parts, the first half being given at
once and the second at the expiration of an hour. Fol-
lowing the administration of the medicine the patient
should be instructed to remain in bed. Harris suggests
that the drug should be given in the following quan-
tities:
Up to 5 years of age,
From 5 to 10 years,
Ten to 15 years,
Fifteen and over,
In advanced age the quantity should be somewhat less
than during middle life. The patient should be allowed
no breakfast and no dinner on the day of treatment, a
cup of coffee once or more during the day is permissible,
but nothing in the nature of food. If the patient ex-
periences no ill effects from the thymol, it is well to put
off the administration of a laxative until four or five
10 to 15 grains.
15 to 30 grains.
30 to 60 grains.
60 to 120 grains.
Nov. 18, 1916]
MEDICAL RECORD.
925
o'clock in the afternoon, at which time some saline
should be administered in hot water. After the bowels
have acted well the patient may be allowed to have food.
When the treatment is carried out faithfully it is rarely
necessary to repeat it. It is well after a couple of
weeks to again make a thorough examination of the
feces, and should the microscope reveal the presence of
eggs the treatment should be repeated, and this should
be done over and over again until exhaustive examina-
tions of the feces show by absence of the eggs of the
parasite that all have been expelled. The public should
be especially warned against patent and proprietary
medicines for hookworm disease, as they all have as a
basis thymol, or some other poisonous drug, and are
therefore unsafe in the hands of those unacquainted
with their proper use. — (Pocket Cyclopedia.)
(/) Hookworm may simulate pernicious anemia.
4. (a) Acute indigestion is characterized by : Nausea;
vomiting of undigested, or partly digested, sour-smell-
ing matter, which later assumes a bilious character;
pain and tenderness in epigastrium ; anorexia ; some-
times severe cramps or burning pain in abdomen; tem-
perature normal; pulse accelerated; sometimes prostra-
tion and cold perspiration. It is to be differentiated
from Apperidicitis, in which the greatest tenderness
is in the right iliac fossa, and right-rectus muscle is
often rigid, and a leucocytosis may be present.
Cholelithiasis, in which the pain is paroxysmal, and is
referred to the region of the right shoulder, emaciation
and jaundice may be present, and there may be a his-
tory of such attacks. Intestinal obstruction, in which
the prostration is more marked, there is absolute
obstipation, tympanites, and uncontrollable vomitnr.
which becomes stercoraceous. Uremia, in which a
uranalysis shows albumin, and diminished urea, and the
blood pressure is high.
Treatment — Evacuate stomach and bowels; give an
emetic (a hypodermic of apomorphine hydrochloride)
or use a stomach tube. Then give divided doses of
calomel followed by castor oil or a saline. Apply heat
externally to the abdomen. The stomach must be kept
at rest and no food given for from 12 to 24 hours;
during this time small sips of very hot water may be
allowed. Later, light diet for a few days. For the
vomiting, bismuth subnitrate, or creosote, or phenol
may be administered.
(6) Opiates may be administered for severe pain
which is uncontrolled by the foregoing remedies; but
one must be sure that the case is not one of appendi-
citis, intestinal obstruction, or uremia. Codeine sulphate,
or morphine sulphate with atropine sulphate may be
give,, (c) B hypodermic injection.
5.
ACUTE PAREN-
CHYMATOUS
NEPHRITIS.
1. Most common
in children, from
exposure or in-
fectious fevers.
2. Edema of low-
er eyelids; then
of upper ex-
tremities, trunk,
and, lastly, low-
er extremities.
3. Urine scanty,
dark or smoky
color, high
specific gravity,
1025 or over.
4. Large amount
of albumin.
6. Variety of
casts, such as
hyaline, blood,
epithelial, and
waxy casts, also
free red blood
globules, and
epithelial cells.
6. Urea dimin-
ished.
7. Recoveries fre-
quent.
CHRONIC PAREN-
CHYMATOUS
NEPHRITIS
1. Later life ;
often the conse-
quence of acute
attack.
2. In early stage
same as acute
form ; later-
dropsy may di-
minish.
3. Urine normal
or increased
amount; specific
gravity may fa'l
to 1010; urine
pale.
4. Late in attack,
greatly dimin-
ished; occasion-
ally absent.
5. Large and
small granular
casts; compound
granule cells,
and fatty epi-
thelium.
•5. Urea dimin-
ished.
7. Recoveries
rare.
CHRONIC INTER-
STITIAL.
NEPHRITIS.
1. Late life; of-
ten results from
alcoholism, gout,
lead-poisoning.
2. Dropsy slight
or entirely ab-
sent.
3. Urine greatly
increased; spe-
cific gravity low,
1005; urine pale
in color.
4. Albumin great-
ly diminished,
often absent.
5. Hyaline or
finely granular
casts, occasion-
ally dark in
color: infre-
quently blood
casts and oil
droplets.
6. Urea dimin-
ished.
7. Indefinite dur-
ation, but never
cured.
The treatment of acute nephritis consists largely in rest
in bed, warmth, milk diet, and attempts at elimination of
waste products. Free purgation should be secured by
means of the salines, calomel, or compound jalap pow-
der. Diaphoresis may be favored by the administration
of sweet spirits of niter, and in severe cases, pilocarpine,
and by the use of warm baths, warm applications, or
the vapor bath. Tincture of digitalis (tie 5-20 every
4 hours), tincture of strophanthus, or sparteine (gr. Vt-
¥2) may be given as diuretics. Infusion of cream of
tartar and juniper berries may be employed. The oc-
currence of uremia will require prompt and energetic
measures.
The treatment of chronic parenchymatous nephritis
consists in rest, regulated diet, and the administration
of tonics. The diet should be made up of milk, vege-
tables, rice, and a small amount of meat, fish, and eggs.
Iron, quinine, and strychnine are indicated. Constipa-
tion should be avoided by the administration of the
salines. Bathing and massage are important items in
the treatment. Uremia may occur in this affection.
The treatment of chronic interstitial nephritis should
be directed to the cause, and in addition the diet and
hygiene should receive attention. The food should be
largely of milk, vegetables, and fruit. High arterial
tension should be controlled by nitroglycerin and
aconite. The bowels should be always kept free.
Diuretics are not indicated so long as secretion is free.
The recurrence of uremia will require special treat-
ment. (Pocket Cyclopedia.)
6. (a) Whatever therapeutic value radium may pos-
sess is due to its radioactivity. It has been claimed
that radium emanation is of value in all kinds of non-
suppurative arthritis (except luetic and tuberculous),
in chronic muscular and joint rheumatism, in arthritis
deformans, in acute and chronic gout, in neuralgia,
sciatica, lumbago, and in tabes dorsalis for the relief
of pain. Its chief value is in the relief of pain. In
certain new growths, both benign and malignant, a
favorable influence is exerted; so, too, in epithelioma,
birthmarks, and scars. (From New and Nonofficial
Remedies.)
(b) Digitalis is indicated in diseases of the heart:
(1) When the heart action is rapid and feeble, with
low arterial tension; (2) in mitral lesions when com-
pensation has begun to fail; (3) in nonvalvular cardiac
affections; (4) in irritable heart, due to nerve exhaus-
tion. Digitalis is contraindicated in diseases of the
heart: (1) in aortic lesions when uncombined with
mitral lesions; (2) when the heart action is strong, and
arterial tension high. Digitalis is also a diuretic; and
it is also used in some forms of nephritis, exophthalmic
goiter, pneumonia, chronic bronchitis, etc. Dangers:
Overdose or constant use will cause irregularity of the
heart, headache, vomiting; and hobbling dicrotic pulse,
particularly when the patient changes from the recum-
bent to a sitting posture.
7. Specifics: (1) Mercury is said to be specific for
syphilis; it is said to exterminate the treponema; the
administration of mercury should begin early in the
disease and be continued for two or three years. It
may be administered by intramuscular^ injection, by
inunction, or in combination with potassium iodide.
(2) Quinine is specific for malaria; a ten grain dose
of sulphate of quinine should be given in the sweating
stage, and again five hours before the next paroxysm
is expected.
(3) Diphtheria antitoxin is specific for diphtheria;
the prophylactic dose for children is 500 to 1,000 units,
by hypodermic injection; the therapeutic dose is 2,000
to 4,000 units.
8. (a) To avoid salivation, give small doses of
calomel, carefully watch the effect, and let the patient
use a mouth-v.-ash of a saturated solution of potassium
chlorate with a little tincture of myrrh.
(6) The usual dose of calomel is about one grain as
an alterative, or two grains as a laxative.
(c) Divided doses are recommended.
9. (a) Castor oil may be rendered tasteless by being
administered in capsules; or by being floated on orange
juice or strong coffee, and covered with the same
vehicle.
(b) In typhoid, turpentine stupes may be placed on
the abdomen, or a few drops may be given on a lump
of sugar, or it may be given by enema, in emulsion.
10. The administration of quinine would differentiate
typhoid from malaria. See question 7, above.
OBSTETRICS AND GYNECOLOGY.
1. (a) The female internal organs of generation are:
The ovaries, Fallopian tubes, uterus, and vagina.
926
MEDICAL RECORD.
[Nov. 18, 1916
(0) Function uj ovaries: To develop ova, and an
internal secretion.
Function of Fallopian tubes: To carry ova to the
uterine cavity.
Function o] uterus: To receive and lodge the fe-
cundated ovum; to retain the fetus till it is mature,
then to expel it.
Function of vagina: During coitus it receives the
penis; during parturition it becomes part of the birth
canal; it also serves as a channel for the escape of the
menstrual and other uterine secretions.
2. (a) Fodulic version is that form of version in
which the breech or foot of the fetus is made to pre-
sent.
(6) Cephalic version is that form of version in which
the head of the fetus is made to present.
3. (a) Adherent placenta is probably due to some
diseased condition of the endometrium, resulting in in-
flammation of the decidua or placenta. The diseased
condition probably antedates pregnancy. There may
be partial absence of the decidua serotina, so that the
chorionic villi are in direct contact with the uterine
muscle.
(6) Treatment of adherent placenta : "A finger — one
or two — must be insinuated between the uterus and
placenta at some point already partially separated, or,
if no partial separation exist, at a point where the pla-
cental border is thick, and then passed to and fro trans-
versely through the uteroplacental junction, acting like
a sort of blunt paper knife, until separation be com-
plete. Another mode is to find or make a margin of
separation as before, and then peel up the placenta
with the finger-ends, rolling the separated portion
toward the palm of the hand upon the surface of the
still adherent part. Great care is necessary to avoid
peeling up an oblique layer of uterine muscular fiber,
which might split deeper and deeper until leading the
finger-ends through the uterine wall into the peritoneal
cavity. Should such a splitting begin, leave it alone
and recommence the separation at some other point on
the placental margin. It is sometimes only possible to
get the placenta away in pieces. These should be after-
ward put together and examined to indicate what rem-
nants are left behind. It may be quite impracticable to
get out every bit, but small remnants or thin layers too
firmly adherent for removal do not distend the womb
enough to create hemorrhage from their bulk, and the
subsequent danger of septicemia from their decomposi-
tion may be obviated by injecting warm (2 per cent.)
creolin water into the uterus twice daily until every-
thing has come away." (King's Obstetrics.)
4. Symptoms of pregnancy at the fifth month : Ces-
sation of menstruation, quickening, mammary signs
with secondary areote, enlarged and pigmented abdo-
men, intermittent uterine contractions, active fetal
movements, uterine souffle, and (possibly) the fetal
heart sound.
5. Chayiges that take place in the female at puberty:
Development of the reproductive organs, enlargement
of the breasts, hair on pubis and axilla; the form be-
comes rounded, the hips widen, menstruation occurs;
there are certain mental and emotional changes; and
"the development of those womanly beauties physiolog-
ically designed to attract the male."
6. Severe ante partum hemorrhage is most likely to
be due to (1) accidental hemorrhage, due to premature
separation of the placenta; (2) to placenta praevia.
The treatment is practically the same in each case,
namely, (o check the hemorrhage and promote delivery.
In accidental hemorrhage the membranes should be rup-
tured and the vagina packed, or accouchement force
performed; vaginal cesarean section has been employed.
In placenta prsevia: (1) Introduce one or two fintrers
within the os (the hand being in the vagina) and dis-
sect the placenta from the uterine wall for about 3
inches from the os uteri in all directions, pushing it to
one side if necessary. (2) Rupture the memhranes, and
if there is an unfavorable presentation turn the child
and make the breech engage in the os; or if the head
presents, forceps may bo used if speedy delivery is nec-
iry. The strength of the woman is then the main
point to be cared for, and if in a reasonable time the
uterus seems to be incompetent, the child may be de-
livered by art. In some cases of central placenta
pr.ev:a. where rapid deliverv is renuired. cesarean sec-
tion may give good results for mother and child.
7. (n) An ovarian cyst is generally accompanied by
monorrhagia or metrorrhagia, sterility, bearing down
pain in the pelvis, which may radiate to the b;ick or
thighs, hemorrhoids or constipation, frequent micturi-
tion, and various other pressure symptoms of the di-
gestive or respiratory apparatus if the cyst becomes
sufficiently large. Later on there may be the fades
ovariana, general impairment of health, and ascites.
There are no pathognomonic symptoms. The diagnosis
is made by bimanual palpation and (sometimes) ex-
ploratory incision. The condition is to be particularly
differentiated from pregnancy and ascites.
(6) The treatment is ovariotomy.
(c) No other method of treatment produces any
beneficial effect.
8. An ulcer of the cervix presents a clear-cut border,
sometimes raised and indurated, and the base of the
ulcer is formed by granulation tissue; the cervix has
lost some of its epithelial covering. It may be caused
irritation from pessary or discharge, chancroid in-
fection, syphilis, tuberculosis, or malignant disease.
The chief symptoms are pain, discharge, and hemor-
rhage. By many ulcer of the cervix is regarded as the
precursor of epithelioma or carcinoma.
9. (a) Menopause is the period of a woman's life
when menstrual activity ceases.
(6) Metritis is inflammation of the uterus.
(e) Salpingitis is inflammation of the oviduct, or
Fallopian tube.
(d) Mastitis is inflammation of the mammary gland.
(e) Menstrual cycle is the series of changes occur-
ring in the uterus during the interval between the com-
mencement of one menstrual period and that of the
next following.
10. (n) Immediately after birth the eyelids of the
newborn child should be washed with clean warm water
and onto the cornea of each eye should be dropped one
or two drops of a 1 or 2 per cent, solution of nitrate
of silver.
(0) This procedure will prevent ophthalmia neona-
torum in doubtful cases; it will do no harm in inno-
cent cases; and it is the first stage in treatment if gon-
orrheal infection is present.
BULLETIN OF APPROACHING EXAMINA 1 I
NAME AND ADDRESS OF PLACE \ND D\TR OF
6TATE SECRETARY NEXT E XAMINATIONf
Alabama* W. H. Sanders, Montgomery. . . .Montgomery ... Jan. 9
Arizona* J. W. Thomas. Phoenix Phoenix Oct. 3
Arkansas T. J. Stout, Briukley Little Rock ....
California C. B. Pinkham, Sacramento Los Angeles ....
Colorado David A. Strickler, Empire
Building, Denver .Denver Jan. 2
Connecticut* .... Chas. A. Tuttle, New Haven .... New Haven ....
Delaware J. H. Wilson, Dover Dover Dec. 12
Dist. of Col'ba.. .E. P. Copeland, Washington Washington.. . .Jan. 0
Florida* E. W. Warren, Palatka Palatka Dec. 5
Georgia C. T. Nolan, Marietta Atlanta
Idaho* Charles A. Dettman, Burke
Illinois C. S. Drake, Springfield Chicago Jan —
Indiana W. T. Gott, Crawfordsville Indianapolis. . .Jan. 9
Iowa G. H. Sumner, Des Moines Des Moines. . . . t >c t . 17
Kansas H. A. Dykes, Lebanon Lebanon Feb. 13
Kentucky J. N. MeCormack, Bowling
Green Louisville Dec. 11
Louisiana E. I.. Leckert, New Orleans New Orleans. . .Nov. 30
Maine F. W. Searle, Portland Portland
Maryland I. McP. Scotot, Haeerstown Baltimore Dec. 12
Massachusetts*. W. P. Bowers, 1 Beacon St., Bos-
ton Boston Nov. 1
Michigan B. D. Harison, 205 Whitney
Building, Detroit Ann Arbor. . . .June 12
Minnesota T. McDavitt, St. Paul Minneapolis. . .Jan. 2
Mississippi J. D. Gilleylen, Jackson Jackson
Missouri J. A. B. Adcock, Jefferson Citv St. Louis Dec. 11
Montana* Wm. C. Riddell, Helena Helena April 3
Nebraska 11 B. Cummins, Seward Lincoln
Nevada S. L. Lee, Carson City CarsonCity
N. Hampshire . . . Walter T. Crosby, Manchester . . .Concord Dec. 18
NewJersey *. MacAlister, Trenton Trenton June 19
New Mexico , . . W. E. Kaser, East Las Vegas . . . Santa Fe Oct. 9
New York )
New York H. H. Horner, Univ. of State of I Albany (Jan. 30
New York, Mbany [Syracuse f
[Buffalo
N. Carolina II. A Rovster, Raleigh Raleigh June
N. Dakota G. M. \\ illiamson. Grand Forks. .Grand Forks. . Jan. 1
Ohio < '■* ■•• 11 Matson. Columbus Columbus Dec.
Oklahoma R. V. Smith, Tulsa Oklahoma City. . .Jan. 9
Oregon B. E. Miller, Portland Portland . Ian. 2
Pennsylvania.... N.C. Schaeffer.Harrisburg. . . . {Kt'slmrgh'.0 '.'. !Jan-
Rhode Island. . ,.G. T. Swans, Providence Providence. . .
S. Carolina H. E. Booser, Columbia Columbia.
S. Dakota P. B. Jenkins, Waubay Pierre Fan. 9
{Memphis. . .
Nashville ^.Tune —
Knoxville.
Texas M. P. McElhannon, Belton Fort Worth. . . Nov.
Utah G. F. Harding, Salt Lake City . Salt Lake Cit} ..Ian. 1
Vermont W. Scott Nay, Underbill Burlington Feb. 13
Virginia .I.N. Barney, Fredericksburg ... Richmond Dec. 12
Washington* C. N.Suttner. Walla Walla Spokane Jan. 2
W. Virginia S. L. Jepson, Charleston Clarksburg. . . . Nov.
Wisconsin J. M. Dodd, Vshland Madison Jan. 9
Wyoming H. E. McCollum, Laramie Laramie
•No reciprocity recognized by these States.
t Applicants should in every ease write to the secretary for all the details
regarding the examination in any particular State.
Medical Record
.n
A Weekly Journal of Medicine and Surgery
Vol. 90, No. 22.
Whole No. 2403.
New York, November 25, 1916.
$5.00 Per Annum.
Single Copies, 15c.
©rtgtnai Arttrtefi.
LATIN AND ANCIENT GREEK FOR MODERN
DOCTORS."
By A. JACOB1. M.D.,
NEW TORK.
Complete education means different things in dif-
ferent periods of history. The instruction of the
Hellenic youth meant reading, writing and the
acquaintance with the poets, also gymnastics, sing-
ing, music and swimming. The teaching of the
sophists, such as Protagoras, Hippias and Prodikas
added the necessity of the acquaintance with sub-
jects required in daily life. That is why many
teachers taught dialectics and rhetoric. Indeed, that
proves that individualism is no modern innovation.
It is true Isokrates preached general culture both
theoretical and practical. But the knowledge of
facts was limited. That is why Lucius Ampelius,
when in the fourth century, A. D., he wrote his
"liber memorialis," required 31 pages only for his-
tory, geography, mythology, and astronomy.
Between the accomplishments mentioned above
there was no connection such as we should call scien-
tific. That is why writings on Greek antiquities are
fascinating like the best children's books, but not
scientific. The only author of those times whose
history is full of philosophic thought is Thukydides,
the historian of the Peloponnesian war. The only
real scientist is Aristotle. Plato, charming and
thoughtful, does not belong to that class. His in-
dividualism which was combated by Sokrates (as
represented in Gorgias by Kallickles and in thejfe-
public by Thrasymachos) explains the absence of
intellectual and moral force required by a state
which wants nerve and energy to resist the frequent
invasion of enemies. In modern times the spirit of
poor Nietzsche, the idol of the hysterical of both
sexes in America and Europe, who was unbalanced
all his life-time and finished his vacillating mind in
a lunatic asylum, has often been compared with the
powerless philosophy of the ancients who shone like
meteors, and like meteors proved evanescent.
The scantiness of subjects taught in ancient
times corresponds with the lack of connection be-
tween them. The greatest thinkers do not impress
us with any multitude of known facts. Like the
pupils of our own Latin schools, or the monks of
our mediaeval times, they were strangers in the
world they inhabited. Even the great historian
Herodotus whom we all love and admire for his
honesty, observation, industry, and also credulity,
traced in the naivete of his talks no philosophic
connection between the stories he tells. There was
no scientific link, nor a scientific plan. That is what
*Read at a meeting of the American Medical Editors'
Association, New York, October 26, 1916.
surely and almost abruptly aided in destroying both
ancient culture and political existence.
Aristotle and Galen, with a few successors, con-
trolled the practice of doctors more than fifteen cen-
turies. Their language either in translation or in
original, was Latin. Even Bacon said he translated
his essays into Latin to have them read and under-
stood. German, English and French books written
in the language of their own countries were ex-
ceptions. That is why students and scientists were
drilled in Latin to be acceptable and intelligible to
their peers. Particularly was that so in Germany,
which at an early time controlled the opinions and
teachings of scientific men. It has impressed other
nations to such an extent as gradually to enforce
the imitation of whatever methods were followed
or said to be followed in that country. In more than
its last half century that country has created the
actual progress of medicine. The recognition of
that fact has been the cause of our not only accept-
ing the genuine blessings of German medicine, but
also the methods of inculcating it into the schools
and the preparation for them of the young men in-
tended for its study. That has been so in America
more than anywhere else. For a long time in our
country learning was not common. Until late years
the study in our medical schools was imperfect. We
acknowledged that fact, and felt we might improve
both matter and methods. The question I want you
to consider is whether all our methods as long as
they have been foreign imitations, are praiseworthy,
and worthy, or practical.
Many of us see no progress except in the adoption
of what is "made in Germany." Meanwhile, the
very Germans have long become dissatisfied with
what we envy them, while they acknowledge the
necessity of changing or developing it. The German
schools of learning had for centuries a single method
of pi'eparing the boy for the university and its pro-
fessional studies. He had to run the full course of
their gymnasium and its humanization preparation.
Humanistic was Latin and Greek. It was impos-
sible to be deemed a cultured German adolescent
without them. With them, and almost exclusively
with them, he was declared mature. That was done
when he had passed his nine classes and his exam-
inations, about the age of 18 or 20 years. My pass-
ing them when I was much younger, was by acci-
dent, and deemed abnormal. The worst feature of
that kind of instruction was the frequent absence
of enthusiasm in most young men. It looks almost
impossible for a dry-as-dust soul to rise to a feel-
ing like enthusiasm for a uniform diet on Latin and
Greek grammars. Of living languages nothing was
taught but French, and that scantily, nothing but
grammar again. Of sciences I obtained a fair
amount of mathematics. Of nature history I learned
by heart a few Latin names of plants, and the num-
ber of upper and lower teeth of monkeys. I hated
928
MKDICAL RECORD.
[Nov. 25, 1916
monkeys and nature history. About 1870 when
after a successful war the German military robbed
France of 5,000 million francs, the German people
threw off their agricultural habits and poverty, and
delved into industry, speculation, invention, and
commerce. Then lo and behold, it took only 40
years to make of Germany that wonderfully com-
pact country of systematic progress and resource-
ful aggressiveness which in our era is equaled by
the Japanese only, or not at all. And what has been
the change on the educational fields? There is no
other country but Germany in which the invasion of
practical tendencies has been immediately followed
by the founding of institutions of practical and
useful learning. In this country of ours we are full
of pride, however, with our Massachusetts, Stevens,
Pittsburgh, and Chicago technical schools. Ger-
many has scores of them. Their pupils always in-
vaded this country of ours and our Schenectadys
are glad to employ them. These young men know
more engineering than Latin and Greek. Nor have
the Germans, and it seems we do not appreciate
that, been slow in applying their experience in other
fields. While no boy of 20 could be matriculated in
a university without his fill of ancient languages, in
the revision of the university regulations of the 2nd
of June, 1883, after the 28th of May, 1901, and the
31st of January, 1907, the Realistic Gymnasium
("real gymnasium"), with no Greek and very little
Latin, but more French and English, and some
knowledge of physics and chemistry, became suffi-
cient for a young man — and lately woman also — for
the matriculation amongst medical faculties.
The Secretary of the University of Rostock (Otto
Schroeder) has published a book on the study of
medicine in German universities, and the rules con-
cerning examinations. On page 7 there is one, ac-
cording to which a young man who has passed the
upper realistic school ("ober real schule"), may be-
gin the study of medicine without Latin on condi-
tion of his preparing during the next 21/2 years a
very modest knowledge of that language.
These Germans have had their eyes open for a
long time and adapted themselves to their present
necessities and future advantages. That makes
them so efficient and preposterously successful.
Other nations are slow and sluggish. We Ameri-
cans have been negligent because we have been
spoiled by self-esteem and by luck. The English
are beginning to learn by their present ill luck.
That is why at the annual meeting of the Court of
Governors of Sheffield University, it was agreed in
view of the great demand for physicians to give
effect at once to a resolution that a knowledge of
Latin should be no longer required as a condition of
admission to the medical faculty. (Journal A. M.
A., Jan. 1, 1916, p. 47.)
Great German teachers, such as Friedrich
Mueller, are not even satisfied with the sufficiency
of this modification of ancient requirements, which
has been acknowledged to be a progress. It is time
for us that our legitimate gratitude for our old
German teaching may not render us laudatores tem-
■poris acti, the medieval past.
Still there has been no conformity for some time
in the valuation of Latin and Greek. Latin has no
longer been utilized as the language of scientific
writing and of clinical lecturing in England since
1765, and in German universities these 75 or 80
years. Christian Thomasius, 1655, praised French
and British as a model for his German countrymen,
but he dared to write in German and had the cour-
age in 1688 of announcing a German lecture. That
was in Leipzig a crimen laesae majestatis and
became a source of much annoyance. That is why
when Halle was founded, he emigrated to Halle. It
was one of their greatest physicians who abolished
Latin in his clinical and other lectures. That was
in 1840, and the reformer was Johann Lucas Schoen-
lein. Still Latin and Greek were long considered the
ne plus ultra means of methodical mind culture.
An entertaining bit of history referring to that
belief you may find in the January number, 1914, of
the Bulletin of the Johns Hopkins University, in
which Dr. C. W. G. Rohrer, of Baltimore, published
a sketch of the life and work of John Hunter. He
never was a zealous student at any of his schools.
His brother William wanted him to study medicine
and give up surgery, that is why he wanted him to
have a sound knowledge of Greek and Latin, which
were considered positively required for a complete
medical education, but not for surgery, which was
considered handicraft, and with the exception of
superior minds is at present nothing else. When I
mean to flatter a mere operator I call him a doctor.
At that time John Hunter was 25 years old. He
refused to give up the idea of becoming a great sur-
geon and, as he expressed himself to Sir Anthony
Carlisle, "to be made an old woman of and to stuff
Latin and Greek at the university."
It is true, however, Dr. Rohrer ventures the opin-
ion, that "such stuffing would have been of vast
benefit to him, in preventing those errors of style
and literary composition which so greatly disfigure
and obscure his writings." To a great extent, how-
ever, we have changed all that. Most of us are of
the opinion that with every decade there are com-
ing to the fore additional mind sharpeners and style
improvers which render Latin and Greek rather
back numbers, or surely not first and only teachers
of culture.
That general culture is what you look for, or
should look for in a physician. No general prac-
titioner should be without it. In our time the doc-
tor has no need to be a prescription peddler or a
handy mechanic ; the claims of public sanitation and
preventive medicine are of universal importance. I
wish everybody could have listened to this year's
presidential address of Dr. Vaughan and be taught
or converted.
New there are some of us, and mainly also the
Council of Education of the A. M. A , who study the
best methods of preparing the student of medicine
for his task. In our admiration for German erudi-
tion, such as it was, we still see many of us leaning
towards older German methods. To-day I meant to
do nothing but to express my own doubts and hesi-
tations. They are mine. Perhaps they are those
of the young men who are preparing for their
future. Perhaps the most conservative, that means
reactionary, are converted. Aye, even the English!
For in this society of superior physicians and teach-
ers I felt I should meet with those whose privilege
and duty it would be to pay close attention to the
demands of practical medicine and the considera-
tion of the best intellectual food for those who
mean to prepare for the study of medicine.
The New York Times of August 3rd has the fol-
lowing headlines: "Education Reform Urged in
England, more chemistry and engineering, besides
Latin and Greek, wanted after the war. Lords
consider problem. Swiss and American systems
better than British, Haldane believes; German de-
fects pointed out." If Haldane, at whom they per-
Nov. 25, 1916]
MEDICAL RECORD.
929
sistently sneer because he once called Germany
his spiritual home, had not sneered at German de-
fects, he would have been hissed from the stage,
though he be a "member of the house of lords,"
which as Galton and Karl Pearson mean to prove
would, if not relieved by some intermarriage, be
hopelessly idiotic, at least inferior. And it is these
lords who are urging reform in education. Those of
us who know English history, understand perfectly
why the few names of those who speak of education,
are Haldane, Cromer and Bryce, just as we appre-
ciate the persistent enmity of British politics
against America from 1812 to 1861, and 1916. As
usual we repay it with Wilsonian patience if not
anglomania. Our present record tells us "the Ox-
ford and Cambridge tradition of instilling a little
old school learning in the way of Latin and Greek,
hand in hand with a really expert knowledge of
cricket and judgment of the vintage of port, are to
be scrapped to make room for chemists and engi-
neers, if the reformers have their way!" Now Latin
and Greek have always been the mainstay of the
education of the British who, as Haldane says, have
never been ready to take up new ideas. That is why
in Great Britain there are only 1,500 trained chem-
ists, while four German chemical firms employ as
many as full 1,000.
Cromer has evidently tried to console himself by
pointing to the moral collapse of Germany which
he says is one of the most extraordinary and most
tragic events recorded in history, and to the appar-
ent materialization of the whole national mind of
Germany! He also fears lest the same deteriora-
tion would take place in England, unless sufficient
attention were paid to humanistic, particularly
classical, education. I may say what Cromer does
not know, that this was in part the very feature of
the one-sided education which was the destruction
a hundred years ago of Germany which led to Jena
and Austerlitz, and finally the origin of the German
revolution in 1848 which was controlled by German
professors. Unfortunately German evolution of the
last few decades, both civic and military, which has
replaced ancient by modern languages and meta-
physics by chemistry, has succeeded in making a
desert of Europe. Cromer adds, which is doubtful,
that he learned in America that our American uni-
versities are year by year turning out an increasing
store of invaluable works on classical literature. If
such were true we should perhaps not be obliged to
write long semi-apologetic epistles to the semi-
Indian "first-chief" of Mexico.
Bryce points to the German habit of obedience
as the cause of their efficiency. Let him say the
English and American lack of citizenship which has
cost the English hundreds of hecatombs of human
victims during two years and many billions of
pounds sterling, and the lack of application of
science to business both in England and America.
We have no particular reason to boast of ours.
The haphazardness of our politics and diplomacy
and our wastefulness has not improved our people
and politics. Meanwhile, Latin and Greek, little as
there was, have not helped us, the absence amongst
us of modern languages has been an obstacle to our
American commerce, and benefited the industry and
greed of Germany. We have been slow. Columbia
University is slowly coming to her senses.
The Columbia Alumni News of May 5, 1916, con-
firms the filching of required Latin and Greek, as a
blow to individualism, from the old Degree of Bach-
elor of Arts. It is spoken of as an incident in a
large policy, and should not be mentioned in an apol-
ogetic vein, but as a matter of course and a proof
of progressive policy.
According to R. S. Woodworth, of Columbia, in
Science of August 28, 1914, "while discussion has
been raging over the relative values of natural
sciences and the classics, the student body, where
free, has attached itself to modern literature, and
especially to the humanistic sciences. In Harvard,
according to Dean Ferry of Amherst, 3 per cent of
the student registration goes to the ancient lan-
guages, 25 per cent to mathematics and science, 28
per cent to modern literature, and 44 per cent to
other subjects." And Professor Hervey has found
almost exactly the same proportions among elective
subjects in Columbia College! It is not probable
that the annual report of 1914 published by the
President of Columbia University is entirely cor-
rect when he says : "The asphyxiation of Greek and
Latin as school and college subjects which began a
generation ago was in no small degree due to the
industrious but misguided efforts of school and col-
lege teachers of these subjects." It is not the teach-
ers and their individual influence that make history
but their system. He is more correct when he
adds: "It would be in the highest degree deplor-
able if the modern European languages were to suf-
fer a similar fate and for a like reason."
I do not intend to make you believe that I know
everything better than my peers, but I began to
teach medicine in American schools much more than
half a century ago and believe I know both the de-
mands of the better part of our public and the re-
sponsibilities of those who are to be taught to
prevent or to cure the ailments of the individuals
and of the communities. Maybe some of you
are also acquainted with my share in trying to im-
prove our methods of medical teaching in different
schools with which I have been connected. In my
own time I have also participated in our many en-
deavors to lengthen and deepen the medical curric-
ula, and to add to the requirements for the matric-
ulation and the enforcement of state examinations,
and whatever has added to the opportunities of giv-
ing the public such medical advisers as benefit the
commonwealth, and enhancing the standard and
utility of the medical profession. That is what has
stimulated me to study the ways in which these two
aims might best be reached. Now, I have met with
very incompetent doctors who knew Latin and
Greek, and superior practitioners without them.
That, however, is no sound way of comparing. You
do not measure the profession by individuals. The
question is not one of individual superiorities, but
of the influence preliminary studies may exert on
the average of a useful and eminent profession.
Our physicians must be better than individual pre-
scribes or diagnosticians.
You are asked for the best method of preparing
for their work all the men in the best and most
efficient and most altruistic of all professions, and
the questions which I hesitate to answer but propose
for your consideration is whether the study of
ancient languages is a conditio sine qua non for the
study of medicine, or whether there are other means
of equal or superior value in both the acquisition
of a general culture and superior professional ac-
complishments. In spite of the routine instruction
in high schools, lyceums, gymnasiums, or colleges,
which was rarely interfered with, there have always
been in all countries men whose opinions differed
greatly from the habits of centuries.
930
MEDICAL RECORD.
[Nov. 25, 1916
As early as 1580 Michael de Montaigne insisted
upon the use of the vernacular language as the prin-
cipal study of the young student. He states in the
preface to his book (March 1, 1580), that if Greek
and Roman culture are the objects of the study of
ancient languages they cannot be reached on ac-
count of the difficulties connected with the learning
of them. For that reason, appreciating that diffi-
culty, his father did not permit him the use of his
own French language before the boy was six years
old. His only language was Latin. He was taught
by that experience, and also by his books, that a
child may learn his mother tongue and at the same
time the language or languages of his neighboring
countries. In that way it would not be deemed dif-
ficult to finish one's education with the twentieth
year. Montaigne is very emphatic about that. To
him the time from the twentieth to the thirtieth
year is the period of intellectual and moral initia-
tive and the creative time in a man's life. It is true
that the short duration of human life three cen-
turies ago may have influenced his opinions. But
in our own time a great educator, Huxley, in his
lectures delivered at the Johns Hopkins University
30 years ago expressed his views as to the subjects
and methods of a young student's education from a
similar point of view. He complained bitterly of
the inefficiency of the education of a boy in the
usual curriculum of the medical schools. He was to
be prepared up to his 15th or 16th year for his
university courses. These ought to be the direct
continuation of his previous teaching. His own
language, the history of his own country and its
social life, natural history, including the main
types of animals and plants, and the groundwork
of biology, some arithmetic and geometry would
be an ample preparation for university life. In
that way the medical student will save time which
now has been spent on laboriously learning how to
learn, and on the temptations to which the young
man is exposed in his attempt at searching for a
method of study.
Maybe you remember a paper of Councilman's
which he published a few months ago in the Journal
of the A. M. A. in which he compared the results of
the present German w'th our own American method
of education of the school boy; the former being
more active and time saving and vastly more suc-
cessful than the latter.
In this, our own country, there is a tendency to
add to the subjects to be examined on and to teach
in every kind of school. It is always the pupil who
is examined, or to be examined, never the teacher.
The system remains the same. In college, beginning
courses are found in French Greek, German, and
Latin, elementary courses in every science; mathe-
matics one-half the course offered in every first-
class high school; and in history a repetition of
most all the work of the high school. The prac-
tice of admitting to college with conditions which
enforce the delay necessitated by working up dur-
ing a vear or more, and losing time and systematic
endeavor is bad. The Popular Science Monthly
admits all of that in an article which emphasized
the waste of time acknowledged by all the partici-
pants in a symposium quoted, viz., Harper, West,
Brown. Eliot, Baker, etc. There is very little in
which these experts agree. They prove their ex
pertness to be very one-sided. A four years' course
of college is claimed too long by most of them in
the case of students who mean to prepare for a pro-
fession. Some, like Harper, insist upon four years,
some on two before matriculating for a profession.
Harper at the same time proposes the age of 16 or
17 as proper for entering college. That gives you
20 or 21 to begin a professional study which will be
finished at 25 or 26 for medicine. Butler says:
"Pedagogs suppose that the more time a boy spends
in school and college the better. Educators know
the contrary."
As I said, Huxley proposed to crowd physics and
physiological chemistry into the ordinary schools.
He wants the study of medicine to begin at the
age of sixteen. That is the time in which memory
is very active, and reflection active enough. After
the thirtieth year knowledge may grow and experi-
ence increase, but the quickness of learning and
imagination does not grow. Unless the principles
of biology be acquired at these early years, the first
university year is mostly spent in learning how to
learn.
In this our country the best part of his young
years is spent on preparing a young man for his
life work. The very exertions of the A. M. A. are
directed to prevent a medical student from enter-
ing upon practice before his twenty-seventh year.
I know of no greater mistake, no graver waste of
one-half of a man's life. In grafting politics we
are in the habit of searching for the man higher up.
Pity it should be so. But a greater pity is that we
must necessarily look for the system lower down.
It is the faulty system of our children's education
by incompetent teachers and methods in our pri-
mary and high schools that throws away time, op-
portunity, and results. They do better, with all
their faults, in the other hemisphere. At all events
a young man with avei-age gifts should not spend
one-half of his life, the rising and ambitious and
energetic half, in preparing for its second half,
even if he lives up to and through it, with its duties
and difficulties and obstacles.
A few historical examples of great medical or
other educators may be briefly mentioned. The
recommendations of their methods are not uniform
or equivalent. What I am interested in is their
relation to the ancient languages as part of medi-
cal education.
A few years after the Huxley lectures in Balti-
more, Billroth wrote a book in 1886 on the teach-
ing and learning of medicine. In his opinion the
knowledge of Greek and Latin is indispensable, but
he speaks of the grammars only. He advises the
reading of Nepos, Ovid, Csesar and Cicero, Xeno-
phon and Homer. These are sufficient. It is re-
markable to find this highly cultured man and
teacher emphasizing grammar and grammar only,
that time killer and a possible gate only of culture,
surely not its essence.
S. Squire Sprigge (Medicine and the Public, 1905,
p. 170), refers to the schedule of preliminary educa-
tion as provided for by the English General Medi-
cal Council as follows:
1. English language, including grammar and com-
position.
2. Latin, inclusive of grammar, translation from
undescribed Latin books, and translation of Eng-
lish passages into Latin.
3. Mathematics, comprising arithmetic, algebra,
Greek or a modern language be, as advised con-
Euclid, books 1, 2, 3, with easy deductions.
4. Greek, or a modern language.
I beg to suggest that in all probability that if
Greek or a modern language be, as suggested, con-
sidered equivalent in their influence or general cul-
Nov. 25, 1916]
MEDICAL RECORD.
931
ture, the modern language should be preferred on
account of its practical v<*iue. Moreover, every new
language, ancient or modern, adds to the intel-
lectual possession of the boy who knows it. The
refinement afforded by its acquisition, though he
forget it, remains a central fund with which he
may work in his future life.
Now listen to Charles Darwin. He says of him-
self: "Nothing could be worse for the development
of my mind than Dr. Butler's school which was
exclusively classical and taught nothing else, be-
sides a little ancient geography and history." Else-
where he says : "Nobody can despise more than I
do the former stereotype silly classical training."
Wilhelm Ostwald emphasized the fact that our ex-
clusively classical training takes it for granted
that those so trained are taught the superiority of
the culture which moved within the narrowness of
the ancient languages. That culture, however, was
uniform and non-progressive. That is why it
reached its acme speedily and degenerated rapidly
without establishing any persistent vigor in the
nation so educated and trained. Natural science
and the knowledge of the progress of mankind —
that means history — is often liable to cause im-
mobility.
Ostwald (Grosse Maenner, 1900, p. 88) quotes
Humphrey Davey as a boy who learned little Latin,
and expressed gratitude to his teachers who did
not push him; and Faraday who knew no Latin at
all; Robert Mayer, who was a good swimmer and
runner, but one of the worst Latinists at school;
Justus Liebig, who was the lowest in his class and
had to be expelled; and Helmholtz who, though the
son of a teacher of philology, reports that because
Cicero and Virgil tired him, he clandestinely
worked at optical problems during the Latin les-
sons. Besides he had no social gifts, was rather
slow and clumsy in society, worked slowly and only
while writing, his ideas came to him rather slug-
gishly, and frequently in sudden starts only. And
still they lived to be Humphrey Davy, Faraday,
Robert Mayer, Justus Liebig, and Helmholtz. On
the 2d of November, 1891, his seventieth birthday
was celebrated at Berlin. On that occasion he
spoke of a peculiar lack of his intellect which con-
sisted, according to his report, of an insufficient
memory for unconnected subjects. This defect
caused singular results which made him appear of
limited comprehension in his younger years. On
page 59 of Adolf Kussmaul's book of "Aus meiner
Dozenten Zeit in Heidelberg," 2d Ed., 1908, the
report of one of Helmholtz's lectures which proved
a failure is one of the proofs of that peculiar short-
coming.
Berzelius, who was credited by his teachers with
a good mind, bad behavior, and no interest in an-
cient languages, was the one who discovered cerium,
thorium, and selenium, and found the elemental
nature of calcium, barium, strontium, tantalium,
silicium, and circonium.
I venture to ask: Is it advisable to believe that
the scholastic narrowness of classrooms directed by
teachers with narrow minds is a cause, or frequent
accompaniment of genius?
One of the great financial and judicial minds of
Germany about the end of the last century, Johan-
nes Miquel, my roommate during my Goettingen
year in 1849 and 1850, was as he told me the lowest
boy in his class until he was 11 years old, and re-
puted and called an idiot, was intellectually su-
perior to such an extent as to tempt me to tell him
"you will be either hung or a minister." Forty
years after, in 1890, during the Medical Congress
week of Berlin, he reminded me of my own
prophecies. He was then Prussian Minister of
Finance. It is true, he replied at that early time:
"You will finish in a state prison." He was correct ;
I had been in a Prussian state prison.
Alexander von Humboldt was a slow learner un-
til he advanced to late years of boyhood.
Woehler, the first chemist to change into organic
matter an inorganic substance (ammonium car-
bonate into urea), was a poor pupil except in
chemistry. When I worked in his laboratory in
1849 he tempted me to stop medicine and continue
in chemistry.
Carl Vogt, the zoologist and anthropologist, and
in 1849 one of the three temporary regents of rev-
olutionary Germany, was a bad boy and no Latinist.
Werner Siemens (Lebenserinnerungen, 9 Aufl.,
1912, p. 13), the great electrician, dropped Greek
and took to mathematics.
Alfred Krupp was unusually advanced in age be-
fore he scaled beyond the lowest classes of a gym-
nasium.
Herbert Spencer was considered bright but
hated authority and rules and had no love for Latin.
Bismarck was by no means advanced in ancient
studies.
Adolph Kussmaul ("Aus meiner Dozenten Zeit
in Heidelberg," 2 ed. Stuttgart, 1908, by Czerny,
p. 88) reports of himself: "In my worst dreams
I again sit at the school desk and perspire in my
vain efforts to conjugate Greek verbs."
Andrew D. White, who was educated in a classi-
cal college, when he governed his own Cornell,
treated his scientific department on an equal foot-
ing with the classical. Thus there are many ex-
amples which demonstrate that ancient languages
are losing their absolute predominance in the evolu-
tion of greac minds.
It is characteristic of this tendency that in the
University of Illinois the movement to suppress
the Latin names on prescriptions is gaining ground.
In the first volume, p. 76, of the new Scientific
Monthly, the history of Edward Jenner, by Pro-
fessor D. Fraser, Harris, Ind., M.D., D.Sc, Dal-
housie University, Halifax, N. S., you find the
following lines: "Addresses and diplomas were
showered on him, and in 1813 the University of
Oxford conferred on him the degree of M.D., honoris
causa. As he refused point-blank to pass the ex-
aminations in Latin and Greek required by the
Royal College of Physicians of London, he could
never obtain admission into that learned body.
When someone recommended him to revise his
classics so that he might become an F.R.C.P. he
replied: "I would not do it for a diadem;" and
then, thinking of a far better reward, added: "I
would not do it for John Hunter's museum."*
W. A. Freund, as great a linguist, ancient and
modern, who in his eightieth year returned to the
*When I read that I was reminded of the occurrence
in the life of a smaller man. It is about thirty years
ago when I was requested to apply in writing for ad-
mission to the Academy of Medicine of Paris. I re-
plied I never applied for an honor of the kind. The
answer was that Dr. M. M. of New York had done
so and was a member, and my reply was that the
homeopathic gentleman had no other membership or
honor in America. Perhaps he was known to be seen
in the waiting rooms of French colleagues of Paris; that
I, however, had a great many memberships in Europe
— aye, in America — but was never known to have ap-
plied for any. That is, perhaps, why I never was a
member of the Academy of Paris.
932
MEDICAL RECORD.
[Nov. 25, 1916
anatomical studies of the upper aperture of the
thorax in its relation to tuberculosis and emphy-
sema which he had dropped on account of his pro-
fessional special obligations in a German univer-
sity fifty-three years before, is of the same opinion.
The study of sciences, according to him, must be
commenced in the high schools, so that medicine
may be begun to advantage at an early age. One
or more modern languages must be known, Latin
and Greek swallow up time which should be spent
on studies more useful which are connected with
the duties of human endeavors, and furnish the
same opportunities, perhaps more so, for the train-
ing of the general faculties of the brain.
Now, gentlemen, let me say, if that be necessary,
why I discussed with you one of the subjects con-
nected with the preliminary education of medical
students. Fifty-six years ago, when I began my
career as a teacher, the demands asked from the
young man who meant to become a doctor were
very few, if any. Two years were sufficient to en-
able him to receive his diploma and license. Be-
fore my time, the two years' curriculum was only a
repetition of one, that means, in the second year
the medical lectures of the first were merely re-
peated.
We are now taught and told that 27 years at
least must be passed before the young doctor can
be declared mature. A great many subjects are
taught the existence of which we did not even
know, and the conditions of admission to the study
of medicine are more numerous and various.
Whether Latin and Greek must be counted amongst
them is for you to decide. For you? Surely.
You represent for me the profession of the United
States. The profession has manfully fought for the
progress of medical study, the improvement of the
medical schools in opposition to the alleged — mostly
financial — interests and ambitions of the schools,
and the interests of the public at large that either
suffers or is benefited by the standards of medical
practice, low or high. While so doing you have not
earned thanks from your beneficiaries, it is true,
but are honored by the enmities of every quack and
hysterical woman of both sexes and still rendered
dutiful service to the sick, no matter whether it was
appreciated or not. In all these matters our con-
science was clear, our eyes wide open and learning
expanding. That is what they are to continue.
You must have noticed the tendency in the coun-
cils of the A. M. A. to purify and elevate our medi-
cal schools in that line, but it has appeared to me
that the methods are not all correct. For scores
of years we have learned medicine from the Ger-
mans, but we are not bound to follow the road
every German student had to follow in bygone
*>mes.
You heard my statement according to which the
roads that lead into the gates of medicine have
been widened by the very Germans whom we are
called upon by our own teachers to follow. We
had better follow their afterthoughts, not the
•uethods they have themselves given up.
The question of Latin and Greek is finally not
all. As professional citizens the other question is
before us all, whether we are not wasteful with our
time. Huxley and Freund tell us we are. If we
shall continue to waste two years or three of even-
studying child's life, we owe, it appears, a better
system of training to our population and every
profession, and every medical man and teacher such
as you should enlist with those who know that
easier and better and more profitable schooling will
make more efficient physicians and American citi-
NOTES ON THE DIAGNOSIS OF ABDOMINAL
DISTENTION IN CHILDREN.*
Br LOUIS FISCHER. M.D.,
NEW YORK.
Abdominal distention as met with in infancy and
childhood is not always of grave concern. In many
cases, however, the underlying causes are so varied
that great skill will be required in making a clear
diagnosis.
Abdominal distention is met with in chronic con-
ditions, such, for example, as is seen in Hirsch-
sprung's disease (the chronic megacolon) ; in tuber-
culous peritonitis; in malignant neoplasms involv-
ing the kidney (chiefly sarcomata), or in hepatic
cirrhosis. Abdominal distention due to cirrhosis of
the liver is usually accompanied by serous effusion.
The distention is uniform and not localized. Large
superficial tortuous veins, due to the internal ab-
dominal pressure, are visible. The abdomen is so
tense that it is next to impossible to palpate the
viscera.
Occasionally an abdominal distention due to an
enlarged spleen, in which there is also enlargement
of the liver and profound anemia with ascites, is
noted in Banti's disease. In tuberculosis involving
the mesenteric glands, the child may suffer a slight
rise in temperature, in addition to faulty metabo-
lism, and still show but slight disturbance in the
abdomen. It is in this class of obscure cases that
the von Pirquet skin-test may aid in solving the
problem, and when in doubt I always employ the
test.
When digestive disturbance exists in spite of the
fact that the food requirements have been care-
fully prescribed, and there are no dietetic errors,
such as overfeeding, other causes must be looked
for. If the child does not gain in weight the stool
should be examined for the presence of tubercle
bacilli.
In severe rickets, where marked lordosis exists,
the usual pendulous belly will be noted. It is ob-
vious, therefore, that the spine should always be
carefully examined. In Pott's disease, where there
is an enlargment of the liver and spleen, marked
abdominal distention will be noted.
Other manifestations of abdominal distention, of
a mild or severe form, are seen in conjunction with
hydronephrosis. During inflammatory conditions
of the kidney we do not encounter marked abdomi-
nal distention, but later in the disease when we
have ascites, the diagnosis may be more difficult.
Sometimes disease of the ovaries and the uterine
adnexa may be the cause of abdominal distention.
But, all of these conditions are not of an imme-
diate fatal termination.
What concerns us mostly is the distention asso-
ciated with acute abdominal conditions, or with
diseases adjacent to the abdomen, in which disten-
tion is a very prominent as well as a very serious
symptom.
The theme for this paper has been suggested by
a consideration of the following cases:
Case I. — A female child, six years old, had a sudden
attack of fever and vomiting. The temperature rose to
105°, pulse 140, and respirations 60; there was no
♦Read before the Medical Society of the County of
New York, October 23, 1916.
Nov. 25, 1916]
MEDICAL RECORD.
933
cough. There was marked abdominal distention. The
attending physician diagnosed appendicitis. The marked
dyspnea was attributed to pressure on the diaphgram.
When seen by me there was distinct evidence of lobar
pneumonia of the lower lobe. Later, on the same day, a
surgeon called in consultation corroborated the diag-
nosis of appendicitis. An operation was performed, and
a normal appendix removed. No inflammatory lesions
or adhesions were found in the abdomen. The consoli-
dation of the lower lobe continued for five days. The
child passed through the crisis, had a slow convalescence
and recovered. In this case the abdominal symptom of
distention was so misleading that attention was directed
to the abdomen and nothing else was suspected.
Among the obscurer conditions met in children
with abdominal distention is typhoid fever. We do
not have the classic symptoms so well noted in the
adult, but we must watch for the eruption (roseola)
and the enlarged spleen. We can frequently rely on
the blood count as a diagnostic aid. A marked leu-
copenia of 4,000, 5,000, or 6,000, with a distended
abdomen and swollen spleen, should be looked upon
as suspicious of typhoid fever, even though we do
not have a positive Widal, or a positive diazo re-
action in the urine.
Swelling of the mesenteric glands is occasionally
noted with distention of the abdomen. Such gland-
ular swelling is usually caused by serous or sero-
purulent effusion. A case of this kind was seen by
me sometime ago, in a child three years old.
In all cases of abdominal distention a rectal ex-
amination is imperative. By means of this bi-
manual examination we can determine many, if not
all, abdominal lesions in children. Recurring vomit-
ing, with visible antiperistaltic waves, after the in-
gestion of food or liquids, and irregular or deficient
evacuation of the bowels, should always be a warn-
ing of an overaction of the pyloric sphincter due to
hypertrophy, or it may also be the symptom of a
pyloric stenosis. When suspicion points to the pres-
ence of a pyloric obstruction, an a;-ray examination
should be made. For this purpose the usual bis-
muth meal should be given and the case carefully
studied from a radiographic point of view.
It is a difficult matter to differentiate mild or be-
nign symptoms from those that are serious. This
is so because we cannot always trust to subjective
symptoms in children, and are, therefore, forced to
depend on objective manifestations. The clinical
expert must rally to his assistance all diagnostic
aids, clinical and pathological, remembering that
the prognosis is always endangered by delay.
Abdominal pains resembling colic are met with
daily. If they are due to an acute intestinal indi-
gestion the child is not in danger. This is not the
class of cases that I desire to discuss with you to-
night, but the "acute abdomen" with its very sig-
nificant symptoms in which "watchful waiting" fre-
quently results in death.
An occasional cause of abdominal distention, and
one ending fatally unless surgical relief is afforded,
is intussusception. The diagnosis is not difficult to
make, but if one is in doubt the surgeon should be
called in consultation. Intussusception is by no
means confined to children. I have met it in early
infancy, in breast-fed as well as in bottle-fed in-
fants. Trie following case is instructive:
Case II. — An infant, four months old, was seen with
Dr. Levinson. It had been breast-fed, but received sev-
eral feedings of modified cows' milk each day. The in-
fant seemed to thrive until it had a 9udden attack of
vomiting, marked abdominal distention, and a glairy,
mucous discharge from the bowel. This discharge was
slightly tinged with bright scarlet blood. No feces
were passed for fifteen hours. Temperature was 101°,
pulse 120. On rectal examination an obstruction, which
was diagnosed as an intussusception, was felt. An im-
mediate operation was advised. The family was greatly
alarmed and begged to have the operation postponed
until the following day. Sixteen hours later I again
saw the infant and found the symptoms more pro-
nounced. Vomiting, distended abdomen and a tumor
still palpable. I again advised operation. The child
was taken to the Mt. Sinai Hospital and operated upon
by Dr. A. A. Berg. In this case "the watchful waiting"
proved fatal for the child. I warned the parents as to
the gravity of the prognosis, but they did not realize
the true condition.
Tympany is found in both inflammatory and ob-
structed conditions. In children it appears earlier,
and is much more marked than in the adult. Dis-
tention is usually absent in intussusception, but
there are exceptional instances in which distention
does exist. There are several symptoms which have
an important bearing on the diagnosis. One should
not be misguided by the statement of the mother
or nurse that a distended abdomen with fever is
due to a simple colic. Many a case erroneously
diagnosed as simple colic has proven to be one of a
strangulated gut. A thorough examination is im-
perative in each and every case in which vomiting,
abdominal distention, and especially pain are noted.
In the early stages of acute abdominal inflammatory
conditions fever may or may not be present. The
presence or absence of stool during the preceding
twenty-four hours will aid in determining the exist-
ence of an obstructed gut. Colicky pains with
tenesmus, without expelling flatus or stool, but with
a jelly-like blood-tinged mucous evacuation, should
always arouse the suspicion of an intussusception.
Moribund patients will sometimes recover, as the
following case will prove:
Case III. — Dorothy R., seven and one-half months old,
was seen by me Jan. 17, 1916, in consultation with Dr.
S. Hermann. The child had received mixed feeding,
breast and bottle. She was a well-nourished infant and
had good hygienic care. When seen by me the infant
had been ill several days, had vomiting, tenesmus and
evacuations of bloody, glairy mucus without faecal par-
ticles. There was marked abdominal distention. A
horseshoe-shaped tumor, extending from the cecum to
the colon, was palpable. Tympanites was present, the
pulse was barely perceptible, and cyanosis extreme.
The child was moribund. I concurred in the diagnosis
of intussusception made by Dr. Hermann. The prog-
nosis was grave. The child was sent to the Mt. Sinai
Hospital for immediate operation. The following sur-
gical history was given to me by Dr. A. A. Berg, who
performed the operation: "Abdomen opened in upper
median. Exploration revealed an intussuscepted mass
extending from cecum to splenic curvature of colon,
which was easily reduced. The gut was entirely visible;
cecum somewhat thickened and congested." The child
made a complete recovery.
Case IV. — L. M., fourteen weeks old, was seen with
Dr. Weinstein of this city. The infant had been breast
fed for three months and was suddenly weaned. He
was given a bottle of the following formula: fat, 3:50,
sugar, 6:50; protein, 1:75. After the second feeding
the infant showed distinct signs of colic; screamed, drew
up his legs, vomited and seemed to vomit more food
than he had taken. There was slight distention of the
abdomen, and very active peristaltic waves were visible.
Diagnosis: Pyloric spasm, possibly pyloric stenosis. No
stool passed. It was decided to wash the stomach with
an alkaline solution of warm water and bicarbonate of
soda. The stomach was given absolute rest for one day.
Later maternal feeding was resorted to. In this case
the sudden change from the maternal feeding to the
cows' milk feeding seemed to offend the stomach and
pylorus, for the symptoms appeared after the second
bottle was taken. The symptoms gradually improved
and disappeared in three days. The child recovered.
Blood Examination. — Unless we are dealing with
a positive condition, such as an acute intussuscep-
tion, in which time should not be lost, we can always
profit by having the blood examined with especial
reference to its leucocyte count. A leucocytosis of
934
MEDICAL RECORD.
[Nov. 25, 1916
20,000 or more is always indicative of good resist-
ance. We, therefore, gain the knowledge of the
prognosis as the following case will illustrate:
Case V. — I was called to see a child, M. W., seven
years old, with a history of having been perfectly well
the previous day, but complained of abdominal pains
during the night. The mother took the temperature
and found it normal. The child had vomited — a yellow-
ish fluid. When seen by me the abdomen was dis-
tended, there was marked tympanites, a slight discharge
of mucus from the bowel and continued nausea and vom-
iting. The temperature was normal, the pulse 108. The
diet was restricted, the colon flushed, and warmth ap-
plied to the abdomen. In the evening the child was
comfortable, the temperature and pulse did not vary,
the blood count showed 32,000 leucocytes, and a poly-
nuclear percentage of 85 per cent. The absence of
stool, the persistent vomiting, abdominal distention, and
the discharge of glairy mucus from the bowel, although
not bloody mucus, lead to a suspicion of intestinal ob-
struction or intussusception. The high leucocyte count,
however, suggested an appendicitis. On the second day,
after a history of colicky pains during the night, I de-
cided to have the child operated. She was removed to
the Mt. Sinai Hospital and operated on by Dr. A. A.
Berg. A gangrenous appendix, with a large perforated
abscess, was found.
A similar case, in a child seven years old, is re-
ported by Elliott. The blood count showed 22,600
white cells, with 91 per cent, polynuclears.
The Pulse. — An accelerated pulse should be re-
garded as an indication of a progressive poison
emanating from some inflamed or septic focus. Thus
a pulse of 100, steadily rising to 120 or 130 while
the child is asleep, should be regarded as a grave
prognostic symptom. A pulse rate of 100 rising
progressively, in from six to twelve hours to 110
or 120, will indicate a progressive septic infection.
It is safer not to rely on the pulse and tempera-
ture alone but to have a blood examination made.
If a leucocytosis is noted, then an increasing leu-
cocytosis with an increasing pulse rate is an indi-
cation that the inflammation is spreading, or that it
is more intensified, and regardless of the tempera-
ture we have an indication for an immediate oper-
ation.
The temperature is an important aid in making
a diagnosis. There are many instances, however,
in which a severe inflammatory condition exists
and still the temperature be found normal. This is
especially true in many septic conditions.
It is hardly possible to cover all the conditions,
such as subphrenic abscess, hernia, affections of
the bladder, ureters, kidney, liver, and peritoneum
in the short space of time allotted to a paper, so I
beg your indulgence if we consider only the most
usual and frequent causes of abdominal distention
as met with in children.
In every case of abdominal distention clinical ob-
servations must be carefully made. An acute ab-
dominal inflammation in a child runs a very rapid
course. An inflammation running a course of a
few days in adults may spread as rapidly in a few
hours in children. Many cases have few promoni-
tory symptoms. We are usually told that the child
had been in good health the day before, and took
sick suddenly. A sudden illness, therefore, in which
abdominal symptoms appear should always be
looked upon with gravity. Careful consideration
should be given to such symptoms as persistent
vomiting, singultus, and abdominal distention. The
presence or absence of stool is very important in
arriving at a diagnosis.
Although we have marked abdominal distention
with symptoms pointing to an acute abdominal in-
flammation we should always inspect the lungs,
more especially the lower lobe on both sides, not
only for consolidation but also for effusion. Ab-
dominal distention very frequently accompanies
lobar pneumonia, also pleuropneumonia. The dis-
tention disappears with the subsidence of the acute
pulmonary infection. It is quite possible to have
both conditions at one and the same time.
155 West Eighty-fifth Street.
THE MANAGEMENT OF THE RECENT EPI-
DEMIC OF POLIOMYELITIS IN NEW
YORK CITY, FROM THE NEUROLO-
GIST'S VIEWPOINT.*
Br WILLIAM M. LESZYNSKY, M.D.,
NEW YORK.
PRESIDENT OF THE NEW YORK NEUROLOGICAL SOCIETY.
A MEETING of the Council of the New York Neuro-
logical Society was held on October 12, 1916, for the
purpose of discussing the management of the recent
epidemic of poliomyelitis. Subsequently, a commit-
tee consisting of Drs. F. Tilney, B. Sachs, C. L.
Dana, W. Timme, and W. M. Leszynsky was ap-
pointed to make a general survey of the field. The
various clinics at which these patients are receiv-
ing treatment were visited in order to ascertain the
general plan and scope of the work.
At the three large orthopedic institutions condi-
tions varied. One, receiving over 200 patients, had a
special department. But the facilities and equip-
ment were absolutely inadequate. This was said
to be due to insufficient funds. The physician in
charge had few if any medical assistants, and the
large number of poliomyelitis cases interfered with
the customary routine. The treatment was appar-
ently limited to braces and massage and no neu-
rological observations were made. At another,
where over 300 patients were recorded, there was
no special equipment and no separate department.
All were treated in the general clinic. The treat-
ment was Social Service, braces, and massage. Al-
though it was considered a surgical disease, the aid
of neurologists was welcomed. At another over 200
children were treated daily. A special department
had been organized with elaborate equipment. All
received electrical examination, baking, massage,
electrical treatment, and braces when required. In
the older children muscle training. With all of
these facilities there was no neurological super-
vision.
At Bellevue Hospital and Cornell Medical School
they were under the cooperative care of the neu-
rologist and orthopedic surgeon.
At Mt. Sinai Hospital and the Neurological Insti-
tute they were under the direct supervision of the
neurologist.
At all of the other dispensaries where these pa-
tients are received they were sent to the orthopedic
department.
As a result of these inquiries, and for the pur-
pose of expressing our views as to the best manage-
ment, observation, and treatment of this type of dis-
ease affecting the nervous system, the meeting this
evening will be devoted to the subject as announced.
Let me add that there should be no misconception
as to its object, for it has been conceived and de-
veloped in a purely scientific and philanthropic
spirit.
It is interesting to note that the poliomyelitis epi-
*Introductory remarks at a meeting of the New York
Neurological Society, Nov. 14, 1916.
Nov. 25, 1916]
MEDICAL RECORD.
935
demic of 1907 in New York City numbering about
2,500 cases, ran its course without being discov-
ered, until an unusual number of children with
paralyzed extremities appearing at the various dis-
pensaries occasioned sufficient comment to excite
investigation. At that time the New York City
Health Department being unaware of its prevalence,
no official measures were instituted.
Recognizing the importance of the subject, the
New York Neurological Society appointed in Octo-
ber, 1907, a committee to study the epidemic of that
year. Its membership consisted of seven members
of the New York Neurological Society, Dr. B. Sachs,
chairman; Drs. L. P. Clark, J. F. Terriberry, J. R.
Hunt, S. E. Jelliffe, I. Strauss, and E. G. Zabriskie,
secretary; in association with Drs. L. E. La Fetra,
H. Schwarz, and L. C. Ager, for the Pediatric Sec-
tion of the New York Academy of Medicine; Dr.
Simon Flexner for the Rockefeller Institute of
Medical Research ; Dr. Charles Bolduan for the De-
partment of Health of the City of New York, and
Dr. H. L. Taylor as a representative of orthopedic
surgery.
Seven hundred and fifty-two cases were carefully
analyzed. Their results and conclusions are em-
bodied in a volume of 120 pages entitled "Epidemic
Poliomyelitis; Report of the Collective Investiga-
tion Committee on the New York Epidemic of
1907."
This was published only six years ago and should
still be fresh in the minds of the profession. It is
quite evident, therefore, that the neurologist has
manifested more than a passing interest in this
topic.
Since then the New York City Health Department
has been on the alert, and the affection was promptly
classed among the "Reportable Infectious Diseases,"
thus resulting in widespread publicity during the
epidemic of 1916, and the quarantining and control
up to October 11, 1916, of 8,927 cases. It is indeed
remarkable that since the advent of the recent epi-
demic no reference has been made to the above-
mentioned elaborate report. This valuable work of
the poliomyelitis committee of the New York Neu-
rological Society seems to have been utterly disre-
garded or forgotten by the medical profession, and
also, curiously enough, by the New York City
Health Department, who materially aided in the in-
vestigation and whose representative was an active
member of the committee.
Through the lack of foresight in the management
of the recent epidemic an unprecedented opportunity
for clinical nuerological observation has been irre-
trievably lost. This was, of course, a deplorable in-
cident, for in the excitement and public hysteria
during its prevalence, through the unaccountable
neglect of those in official medical control of these
patients, the value of cooperative neurological study
was entirely forgotten or ignored. This has been
shown unquestionably by the absence of any official
invitation by the New York City Health Depart-
ment suggesting or requesting the cooperation of
neurologists, and by the omission of the names of
neurologists from the lists of committees appointed
either by the city administration or among those
announced as the "Committee on the After-Care of
Infantile Paralysis Cases."
On this "After-Care Committee," which was
formed last August and is composed of 53 members,
there are 25 physicians. The names of three neu-
rologists recently appeared on the list. One, now a
member of the executive committee of 15 members
(seven of whom are physicians), was appointed
within the last four weeks. Of the two others, one
is not aware of his membership, while the other
merely has the privilege of attending its meetings.
Furthermore, the New York City Health Depart-
ment has given printed instructions, with lists of
hospitals and dispensaries where orthopedic treat-
ment may be obtained, to the parents of children
with poliomyelitis upon their discharge from the
hospitals, probably under the influence of the pre-
vailing idea that their only requirement is the ad-
justment of braces. Hence, the entire medical su-
pervision and control of these patients have been
officially relegated to the orthopedic institutions,
thus establishing a precedent which must not be left
unchallenged. For, if the promulgation of such a
doctrine be tacitly accepted without qualification or
modification by the medical profession, it must in-
evitably lead to confusion. These remarks, however,
are not made in any spirit of rivalry, nor do I wish
to attempt to belittle or discredit the value of ortho-
pedic methods in suitable cases.
It is universally admitted that poliomyelitis is a
disease practically confined to the central nervous
system, and that its symptomatology, such as paral-
ysis, atrophy, and trophic changes are due to a
spinal cord lesion and that its infectious origin has
no direct bearing upon the subsequent developments.
Therefore, in consideration of the fact that in the
modern classification of diseases, poliomyelitis has
heretofore been assigned to the province of neurol-
ogy, such an anomalous state of affairs as above de-
scribed, is indeed surprising. To say the least, it
is an extraordinary procedure. But the scientific
interest of neurologists in this disease of the nerv-
ous system has not abated and cannot be so easily
eliminated.
In thus pointing out certain sins of omission and
the unwise encouragement of a popular fallacy, it
is not my purpose to assume an antagonistic atti-
tude. That the orthopedic institutions have been
placed in exclusive charge of the "after care" of
these patients, seems to have been more a matter of
expediency, perhaps, than of medical selection or
preference. But, as this plan of organization is
now well under way, there should be no serious ob-
jection to this arrangement, if it can be satisfac-
torily shown that these children are adequately cared
for, and that their condition will be properly studied
through suitable scientific observation and medical
cooperation. Unfortunately, at the present time,
our hospital facilities for the special care of patients
with nervous disease is extremely limited. We fully
realize the importance of preventive measures, im-
munization, and the value of laboratory research in
this emergency.
In the solution of a therapeutic proposition of this
magnitude, a standardization of treatment should
be instituted adapted to individual requirements,
and the best interests of these patients will be con-
served and scientific progress be promoted by the
harmonious cooperation of the orthopedic surgeon
with the neurologist and pediatrist. I shall not
attempt to define their respective duties in this
field as that matter no doubt will be mentioned by
the readers of the papers.
These disabled children should not be deprived of
any advantages that may be developed from such
associated service, and all available means should
be utilized for their benefit.
As a sociological problem, this may be safely left
to the various social service organizations whose
work is recognized as of the greatest value and is
admittedly indispensable.
936
MEDICAL RECORD.
[Nov. 25, 1916
For the last forty-four years the New York Neu-
rological Society has stood for the advancement of
the science and art of medicine in all its relations to
the nervous system. To-day it is still on the active
list.
The subject of "poliomyelitis" having appeared
during the past month on the program of many
other medical societies in this city, an expression of
our views is now in order.
145 West Seventy-seventh Street.
A THEORY AS TO THE CAUSATION OF
POLIOMYELITIS.
By D. W. WYNKOOP. M.D.,
HEALTH OFFICER.
BABYLON, N. Y.
Has the medical profession measured up to stan-
dard during the epidemic of poliomyelitis recently
passed? How many doctors have been asked by
their patients as to the causation and mode of
infection of this fearsome disease, and have but
shrugged their shoulders in reply?
From my experience as health officer in a com-
munity which had one of the severest attacks of
poliomyelitis for the size of its population, I have
formulated a theory of the disease that I believe
can be accepted.
The Theory. — We know that our bodies are given
immunity to certain diseases if sufficient time is
allowed for the manufacture of the antibody to
combat the disease. In pneumonia the crisis comes
only when this has been formed. In diphtheria
immunity is furnished by the antitoxin serum. In
typhoid fever artificial immunity is also rendered
by serum. In yellow fever there are those who
enjoy natural immunity to the disease. The reason
why many diseases never occur a second time is
that the antibody once established for this particu-
lar disease does not wear out.
In anterior poliomyelitis our own bodies furnish
this immunity if sufficient time is allowed for the
manufacture of its immune body. As proof of
this contention, I offer the age statistics of the
State of New York (exclusive of the city) for
the recent epidemic. Most of the cases have oc-
curred in children under five years of age. The
average was two years. Why should not the rest
of the children of a family come down with the
same disease if it is contagious (as the word is
ordinarily understood) unless they have already
manufactured their antibodies for immunity? We
know that they are not made immune from any
outside source. If immunity is manufactured
within our bodies at an early age of youth where
is its manufacturing plant? Poliomyelitis attacks
only the spinal cord and brings about pathological
changes in the anterior horns. The spinal cord is
nourished entirely by the spinal fluid that sur-
rounds it, and it should be a study from this
source on which the theory of the disease must be
founded.
The Cerebrospinal Fluid.— The secretion of this
fluid is by the choroid plexus in the ventricles or
inner cavities of the brain. The inside lining of
the ventricles is composed of ciliated cells of epithe-
lium. They help secret the fluid that is present
in the ventricles and also surrounds the spinal cord
in its sheath. All the lymph glands in the body
undoubtedly aid in augmenting this fluid. Accord-
ing to the side chain theory of Ehrlich, i.e. that
living protoplasm can be regarded as a central atom
group related to which are secondary groups or
'side chains' which have unsatisfied chemical af-
finities, and that toxic molecules attached to these
side chains produce antitoxin in the central atom
group, it is quite conceivable that these ciliated
cells often in youth have not developed to a
point where they can make their antibody against
poliomyelitis or else the lymph secretion is deficient
in certain qualities. It is conceivable and likely
that some will never make this immunity, and
may be stricken with the disease even in advanced
age.
In natural immunity against disease we have
the vivid picture of phagocytosis, the lymph cells
surrounding the enemy and devouring him, chemi-
cally accompanied by the alexin (undoubtedly a
product of glandular secretion) or fluid which
renders germ life impossible when surrounded in
this medium.
At best, our knowledge of glands and their secre-
tion is most imperfect. Certain diseases are strong-
ly connected with the absence of certain glands; e.g.
the thyroid in cretinism and the absence of certain
properties of this gland in myxedema. A certain
part of the seminal fluid of the tests is for home
consumption and certain closely allied symptoms of
brain and spinal cord disorder are noted when
this required amount is taken away from the
body by excess. It is probable that all immune
substances of the body are made in the glands of
the body. It is in the glands that the fluid lymph
is made. It is from this lymph that we have the
pointing finger of poliomyelitis. This brings us to
this statement: Poliomyelitis is a disease caused
by a negation of glandular efficiency.
Under normal conditions the cerebrospinal fluid
looks like water. In composition it resembles blood
minus its corpuscles and albuminous qualities.
There is no protein matter found and the count of
lymph cells is small.
All nerve cells are bathed in lymph. They take
from the lymph what they need as nourishment
and give back to it the excretions they wish re-
moved. The lymph becomes the middleman con-
necting the nerve cells with the arterial blood be-
yond.
In poliomyelitis this function is disturbed. This
is shown under the microscope by a vastly increased
number of lymphocytes. There is increased pres-
sure in the cerebrospinal fluid which is noted on
lumbar puncture. The increased number of lympho-
cytes is accounted for by the presence of toxic
germs in the secretion it is fighting against.
There are two abnormal conditions that affect
the cerebrospinal fluid in a pathological way. The
first is the quantity of the blood supply and the
second is the quality. Our interest is only in the
latter in arriving at conclusions in connection with
poliomyelitis.
We find that the quality of the blood supply is
altered by insufficiency of oxygen. As examples
of this condition we have anemia, cretinism and
myxedema ( diseases that affect growth to a greater
or lesser extent).
Another feature which affects the cerebrospinal
fluid is an excess of normal constituents. As an
example of this we have the excess of carbonic
acid found in asphyxia, uremia and Graves' disease,
conditions that profoundly affect the cord and
brain.
As a third and most important change in the
Nov. 25, 1916]
MKDICAL RECORD.
937
quality of the cerebrospinal fluid we have the
presence of abnormal constituents. This should be
our working point in finding the causation of
poliomyelitis. There are three things to be con-
sidered under this head: (a) Poisons produced
within the body by perverted functions of organs
or tissues; {b) Action of bacteria upon living fluids
and tissue; (c) Poisons introduced within the
body from without by food, drink or inhalation.
As examples of (a) we have autointoxication by
albumoses, fatigue produced by muscular over-ex-
ertion producing an excess of sarcolactic acid, ex-
cess of uric acid, cholemia shown by bile in blood,
phosphoruria, glycosuria, yellow atrophy of liver,
and oxaluria.
As examples of (b) we have the infectious dis-
eases typhoid, typhus, smallpox, measles, scarlet
fever, influenza and poliomyelitis. I have grouped
the last two together, as I believe it will be shown
they are closely related in both mode of infection
and epidemic tendency. In all the above infectious
diseases the central nervous changes, such as coma,
delirium, stupor and motor irritations, may be
brought about by high fever stimulated by toxic
conditions in the blood or lymph. All tissues of
the body depend upon each other for health. If
one suffers they all suffer.
In only one of the above infectious diseases is
there a definite selective influence shown in attack-
ing a definite site of the nervous system ; this is
in poliomyelitis. In this disease the cord alone
is attacked and yet the site may vary, only affect-
ing a small group of muscles of the foot or a large
group of muscles higher up. Why should the
toxic germ of poliomyelitis find suitable media to
grow in certain interstitial spaces of the cord and
not in others? According to the clinical aspect of
the disease the period from real onset to symptoms
of paralysis supervening is from five to seven days.
This means that by the seventh day the ordinary
patient has finished making his own immunity
and any further extension of the toxic degeneration
of nerve cells ceases altogether. Those rapid cases,
in which paralysis intervenes within forty-eight
hours from the presumable onset, are nearly always
fatal and the groups of muscles involved most ex-
tensive. In these cases the self-immunity manufac-
ture of alexin was absolutely overwhelmed.
Agreeing upon the selective influence found in
poliomyelitis, let us consider the other known dis-
eases that attack the spinal cord or other special-
ized parts of the nervous system. They are:
Syphilis, i.e. locomotor ataxia ; rabies, in the
medulla oblongata; tetanus, in the fifth motor
nucleus; sleeping sickness, i.e. stupor and paraly-
sis; cerebrospinal meningitis; pellagra, and beri-
beri.
Some of these move slowly and others with in-
credible swiftness. In rabies, a protozoon is sup-
posed to be the cause of the disease, and in the
earliest period of its development it is so infinites-
imal in size that it can go through a Berkefeldt
filter. The failure to isolate the germ of polio-
myelitis or have it clearly demonstrated to all under
the microscope is probably due to its infinitesimal
size. Its very method of infection, being borne
along the highways of travel by the gentlest winds,
should prepare one for what to expect in size.
In likening an epidemic of poliomyelitis to in-
fluenza, the history of the latter in 1889-1890 should
be remembered. It sprang up in one of the dis-
tant provinces of Russia in October. In November
it had reached Moscow. In two weeks Berlin was
attacked. Paris and London had it in the middle
of December and by the end of this month it was
present in New York and was spreading through-
out the country. Osier, writing on the types of
this disease, mentions the nervous forms: "With-
out any catarrhal symptoms there may be severe
headache, pain in back and joints, with profound
prostration. Many remarkable nervous manifesta-
tions were noted during the last epidemic. Among
the more serious may be mentioned meningitis and
encephalitis, the latter leading to hemiplegia and
monoplegia. Abscess of the brain has followed in
acute cases. All forms of neuritis are not uncom-
mon, and in some cases are characterized by marked
disturbance of motion and sensation. Judging from
the accounts in the literature almost every form
of disease of the nervous system may follow in-
fluenza. . . . Gastrointestinal form: With the
outset of the fever there may be nausea and vomit-
ing or the attack may set in with abdominal pain,
profuse diarrhea, and collapse." These symptoms
are not so very unlike those of poliomyelitis.
So often have the questions been asked "Does the
disease travel by air, and have climatic conditions
anything to do with its spread?"
In its non-epidemic stage the germ of polio-
myelitis is undoubtedly very resistant to ordi-
nary conditions of temperature; it is perfectly will-
ing to stay in its envelope for any number of years
or seasons. To break from its shell membrane it
needs continued humidity and heat. The early part
of this summer was an ideal occasion for it to
explode from its chrysalis and go forth on its
rounds of destruction among those infants not
already immune.
The summary of the theory I advance is that
antitoxin molecules do exist as part of the nerve
cells and glands which make the majority of chil-
dren immune to poliomyelitis. Serum may carry
its antitoxin molecules but to a far lesser extent.
Poliomyelitis is not contagious, except to those
who are not immune to the disease — to such it is
both highly contagious and infectious. In epi-
demics of this disease the atmosphere is surcharged
with invisible clouds of these germs fresh from
sporadic form or a recent case. The remedy for
poliomyelitis will probably be found in a non-toxic
fluid that will be injected into the spinal cord by
lumbar puncture at the onset of the disease or
as a preventive measure during epidemics. The
nature of this fluid will probably be an extract
made from a mixture of healthy glands (including
thymus) till the one definitely required is found.
In conclusion, I would like to state that, con-
trary to what I have seen in the medical press in
connection with experiments on animals, it is im-
possible to inoculate the guinea pig with poliomyeli-
tis. I have made exhaustive experiments to this
end with the most virulent virus, injecting directly
in the spinal sheath and have been unable to pro-
duce the disease. The guinea pig, as well as most
other animals, is immune, and we should sooner or
later be able to find from what their immunity
comes.
Encephalitis Following Salvarsan Injection. — Kohrs
relates the case of a man of twenty-six with secondary
syphilis, who was given one injection of salvarsan and
who developed no bad symptoms for two days when a
chill set in. Next day he seemed in fair condition, but
one day later there were clinical evidences of apoplexy,
ending promptly in death. Autopsy revealed hemor-
rhagic encephalitis. — Miienchener mcd. Woche7isch>-ift.
938
MEDICAL RECORD.
[Nov. 25, 1916
MEDICINE IN NEW YORK CITY IN THE 60'S.
"THERE WERE GIANTS IN THOSE DAYS."
By A. L. SWEET, M.D.,
GENEVA, N. Y.
At the time of which I am writing the old Uni-
versity Medical College building stood, according to
my recollection, in Fourteenth Street not far from
Union Square. It has since burned down, and I
think that Tammany Hall stands upon its site. I
use this institution as a nucleus around which to
arrange these sketches because I was there at
the time and it was the oldest medical school in the
city, and also in its halls were gathered some of the
great ones of our profession. This building, if it
were to be described, would be characterized as
absolutely without any modern improvements.
There was a tradition that there was a furnace
somewhere in the subterranean regions, but no one
believed it, for there were never any indications
of its existence. During lectures we who were there
as students were obliged to wear our overcoats and
arctics, and during the intervals box and jump
about to keep the circulation going. One would
laugh now to see such an amphitheater as we had
in those days, and in the center a little old black-
board which revolved on a peg on a short post, upon
which Van Buren used to write "prostrate" and
tell us that that was not the name of the gland.
This building contained among other things the
museum of Dr. Valentine Mott, the destruction of
which was an irreparable loss to the medical pro-
fession. In the front of the building on the front
floor was a sort of reception room, where prospec-
tive students were received, and where they pro-
cured the tickets of the different professors and
were registered. I may say in passing, though not
in its proper place, that on the tickets of Dr. Mott
there were engraved a hand with the index finger
extended, and in the end of the finger an eye, a
very striking and significant device. In this room
frequently some of the professors would foregather
before the time for lectures to begin. One morn-
ing in particular I recall that Professors Draper
and Paine were present, and perhaps others I do
not recall. A young lad from a small country vil-
lage was there and was suffering from a bad attack
of homesickness (a malady, by the way, that none
of the great ones could cure — the only known cure
being a railroad ticket) . The racket and confusion
of the city had got on his nerves and he had passed
a sleepless night. He wished the college to give him
back his money and allow him to go home. Pro-
fessor Draper took it upon himself to calm and
comfort the young man, and among other things
told him that "probably God had sent him there for
some good purpose." As a result the young man
stayed and finished his course and graduated with
as high honors as anyone in the school. The remi-
niscences in this article are my own as I recall
them — some of the biographical and other facts
taken from different sources. It is fitting that we
begin these sketches with the name of John W.
Draper, as he was one of the senior professors, and
also because he was a very distinguished man, and
known as well in Europe as in this country. He
was born in England in 1811. and came to this
country in 1830. After finishing his preparatory
studies he took his degree of M.D. at the University
of Pennsylvania in 1836. He took a prominent
position as a teacher of medical and scientific sub-
jects almost as soon as he graduated, and in 1839
was called to the chair of natural history and
chemistry in the academic department of the Uni-
versity of the City of New York. He also lectured
on physiology at that institution. In 1841 he was
appointed professor of chemistry in the University
Medical College, and in 1850 the chair of physiology-
was also added to his duties. In a few years he
became the president of both the medical and
scientific departments of that institution. His con-
nection with the college continued until his death,
but the time of that event I am not able to ascer-
tain. In appearance he was not an imposing man.
He was very short and rather stoutly built, and his
head was so large that it gave him the appearance
of being cut out of one piece. I have a good picture
of him before me now, and his massive and strik-
ingly intellectual face is as vivid in my memory
almost as if I had only seen him a short time ago.
He was a "shaggy" man and evidently did not spend
much time before his mirror, his beard on the
side of his face starting down in his neck and
going up to join his hair. A little tilt to his nose
gave one the impression that he might have a large
sense of humor, and perhaps he had, but the nu-
merous duties which pressed down upon him, and
his constant consideration of great subjects, made
him perforce a serious man. He had the leonine
type of face, and looking upon it one had an im-
pressive sense of the massive mind and soul behind
it. He was a man of immense and varied activities.
He not only lectured constantly and contributed to
many foreign and domestic scientific journals, but
at the same time was pursuing original research
work in many directions. It is impossible to speak
in detail of all he did, but it was said that he was
of great assistance to Morse in his invention of the
telegraph, and one of his discoveries led to the
invention of the incandescent light. His crowning
glory, perhaps, was the discovery of the process by
which the human face could be photographed.
Daguerre, who had the credit of inventing the pic-
ture which bears his name — although he was not
the inventor, only one of those who perfected it,
tried to do it, but gave it up and said it could not
be done, but Professor Draper, who knew more
about the chemical action of light than any other
man, attacked the problem and solved it success-
fully. The first photograph of the human face was
that of his sister, Dorothy Catherine Draper. One
can imagine the feelings of Dr. Draper when that
face looked out upon him from the sensitized paper.
Dr. Draper was one of the most modest and un-
assuming of men. He would come into the lecture-
room with a quiet, almost deprecating air, and
when he came to his experiments would probably
say, "Now, gentlemen, if I have combined these
chemicals properly the result will be of a certain
character," and there were never any failures.
There was only one request that he ever made of
the students, and that was that they would not
smoke in his lecture-room. Owing to some idiosyn-
crasy, tobacco positively unfitted him for his duties.
To be obliged to refrain from smoking was a great
hardship for some of the students, but they all
cheerfully complied with his request. Some of his
important works should be mentioned here: His
"History of the Intellectual Development of Europe"
made a profound impression upon the thinking
classes of the world and was translated into a dozen
or more different languages. In 1865 four lectures
which he delivered before the U. S. Historical So-
Nov. 25, 1916]
MEDICAL RECORD.
939
ciety were published in a volume entitled "Thoughts
on the Civil Policy of America." I suppose that it
is out of print by this time, but if our present-day
statesmen could have access to that volume, they
might gain some ideas which would be of immense
value to them in shaping the political policy of the
nation. Another volume which aroused a great deal
of criticism at the time was his "Conflict between
Religion and Science." I have not the space to go
into anything like a review of this book. Of course
there were many things in it disturbing to the
orthodox Christian, but in my opinion the criticism
grew out of the title more than anything else. It
should have been called the conflict between certain
churches and religion, or better still, between cer-
tain ecclesiastics who were hostile toward anything
in the form of science. I have no positive knowl-
edge in regard to the religious convictions of Dr.
Draper, but the episode of the student which I re-
lated above would indicate that he had a reverent
spirit and that he believed in the divine ordering
of things. It is surprising in the brief time allotted
to us here how much some men can accomplsh;
thus Dr. Draper was distinguished as a scientist,
historian, philosopher, physician.
In this connection I wish to speaK Driefly of the
sons of Dr. Draper. There were two: John and
Henry. Both were exceptionally gifted men, but
I came more in contact with John and remember
him better. He was altogether different in appear-
ance from his father. He was a very handsome
man with absolutely black hair and full beard. He
would stroll into the lecture-room behind the old
table which was covered with all sorts of chemical
apparatus, with his hands in his pockets and a
smile upon his face, which might express the fact
that he had just heard a good story and dropped
in to tell it to the "boys," and very likely he had,
for the sense of humor was very largely developed
in him. He would then take a drink from a tumbler
which by some means always stood there, and draw-
ing his mustache into his mouth to get rid of the
surplus water, would begin his lecture with an air
that seemed to say, "Well, gentlemen, this is all a
joke, but we will have to go through with it, I
suppose." But his lectures, as I recall them, were
brilliant and fascinating, and unlike some in the
building, were all too short. One day he was exam-
ining a student in chemistry for his graduation.
The subject was one of the arsenical tests. At one
stage of the process he asked the prospective M.D.
what would be the result if we placed the glass
capsule over the flame of the spirit lamp? "It
would break the glass," was the naive reply. This
was too much for the risibles of the professor; he
threw his head back and laughed heartily. As I
recall the matter he took the place of his father
in the chemistry department while he continued to
lecture on physiology. He also published several
works and contributed to English and American
scientific and medical journals. Henry was also a
lecturer in the college on chemistry (analytical)
and physiology. He made at Hastings-on-the-Hud-
son the largest telescope that had ever been con-
structed in the United States up to his time. He
was also the author of some books along his own
line and a contributor to scientific journals. He
was also an authority on the spectroscopic condi-
tions of some of the heavenly bodies. Valentine
Mott, M.D., was also a lecturer in this institution
at the time of which I am writing, but it was the
twilight of his great intellect. I only had the
pleasure of hearing one course of his lectures, as he
died in 1865. He invariably illustrated his lectures
on the cadaver and his demonstrator was F. D.
Weiss, a very brilliant young man who passed all
his examinations several years before he was of
legal age to graduate.
One striking habit of Dr. Mott's I will put down
here lest I forget. One would suppose that a man
who had been operating upon the human body con-
stantly for a great number of years would be so
familiar with regional anatomy that he could al-
most find his way in the dark, and yet Dr. Mott
was so considerate of his patients that he never
performed an operation of any consequence without
first performing it upon the cadaver. Dr. Mott had
the Websterian style of face, and his lectures were
absorbingly interesting, not only because of what
he brought out of the stores of his own great ex-
perience, but he had met most of the great surgeons
of the world and had interesting reminiscences of
them.
Dr. Mott was born at Glen Cove, L. I., in 1785.
He took his degree from Columbia College in 1806,
but also studied in London and Edinburgh. He
held the chair of surgery in Columbia until it was
united with the College of Physicians and Surgeons
in 1813. As I said above, his lectures were in-
tensely interesting, but occasionally the shadows
would gather and he would wander from the sub-
ject in hand. One day he gave us an interesting
talk upon flying-machines, which were just begin-
ning to interest scientific men. One day during his
lecture I happened to look across the amphitheater
(and in those days it was not very far across), and
saw a man who became deathly pale as the lecturer
progressed. I supposed, of course, that he was not
a student, but some man who had dropped in from
curiosity and had seen something which he did not
expect. Finally he started up the stairs, and as
soon as he reached the upper level, fell like a log
to the floor. Dr. Mott thought perhaps that it was
someone who was trying to disturb his lecture, and
he expressed his willingness to go up and thrash
him on the spot. He was then 80 years of age.
There is no question but Valentine Mott was one
of the greatest surgeons that ever lived — taking
into consideration his original work, perhaps the
greatest. Sir Astley Cooper, the great English
surgeon, said in regard to him: "He has performed
more of the great operations than any man living,
or that has ever lived." He performed operations
which no other man had thought of and would not
have dared to perform if he had. The following
is a brief resume of the things that he did: "As
early as 1818 he tied the arteria innominata — only
2 inches from the heart — for aneurysm of the right
subclavian artery, for the first time in the history
of surgery. Although the circulation was suppos-
edly entirely cut off, pulsation could be distinctly
felt in the right radial artery, and the limb pre-
sented no appearance of sphacelation. On the 26th
day, however, secondary hemorrhage set in and
the life of the patient was speedily terminated.
He successfully removed the entire right clavicle
for malignant disease of that bone, when it was
necessary to apply 40 ligatures. He was also the
first to tie the primitive iliac artery for aneurism.
He tied the common carotid 46 times and ampu-
tated nearly 1000 limbs. He early introduced an
operation for immobility of the lower jaw and suc-
ceeded after many eminent physicians had failed.
In 1821 he performed the first operation for osteo-
940
MEDICAL RECORD.
[Nov. 25, 1916
sarcoma of the lower jaw. He was also the first
surgeon who removed the lower jaw for necrosis."
He was also the author of several works pertaining
to his own field. He literally died in the harness —
I heard him lecture in 1863-4, and he must have
been at that time 80 years of age. He was one
of the great Americans and was the first man who
won from Europe any recognition of American sur-
gery. It seems to me that there ought to be some
public recognition of his greatness — he ought at
least to have a niche in the Temple of Fame.
Martyn Paine lectured on Materia Medica and
Therapeutics during my stay at the College. He was
one of the greatest thinkers of his time, but was a
brilliant illustration of the saying that "a prophet
is not without honor save in his own country," and
it might also be said of him that he was without
honor in his own college. He had come down from
a former generation and found that medical thought
had swung far away from him and left him solitary
on a desolate eminence. He still believed in blood-
letting in selected cases, and in the antiphlogistic
treatment of inflammation. At this time all blood-
letting had been consigned to the limbo of unconsid-
ered trifles, and pneumonia, typhoid, and diseases
of that class were being treated with quinine and
whisky. Dr. Paine saw no reason to change his ideas
in regard to the treatment of disease, but was con-
tinued in the college out of regard for his eminent
character and for what he had done for the school
in the past. The younger professors smiled indul-
gently when his name was mentioned, and, of course,
the student body took their cue from them, and they
would lounge into his lectures because they must
come before him for exams, but frankly bored and
would sometimes snap their watches if they thought
the lecture was exceeding the limit. He was a tall,
imposing, cadaverous-looking man, with apparently
not an ounce of adipose tissue on his body. His
face was pale and not mobile, but his brilliant, lum-
inous eyes lent to it expression. Dr. Paine was the
author of "Medical and Physiological Commen-
taries," "Materia Medica," "Institutes of Medicine,"
and perhaps other works. The latter volume I am
most familiar with, and it is a monumental work.
There is no branch or phase of medicine which is
not treated in this volume. He wrote before the
days of germs, but he pursued to their lairs the hid-
den causes of morbific action, and the intelligent
reader has no difficulty in accepting his views. It is
interesting to reflect at this time that he sought the
ultimate causes of disease, applied his remedies, and
cured his patients in utter ignorance of the germ
which had caused all the trouble. After a long and
studious life (he would often meet the servant com-
ing down to light the fires as he retired to rest), he
was gathered to his fathers, and as far as I know
no tribute was paid to his memory.
Alfred C. Loomis began his career as a lecturer
about the time I entered the university. As I re-
call the matter he was the last survivor of a tuber-
culous family, and decided that in self-defence he
would study medicine and find, if possible, some
new tacts in regard to consumption, and in this ef-
fort he took the shortest and most direct method to
ascertain the effect of the malady on the human
body. He studied the cases at the bedside and when
they were fatal followed them to the morgue and
studied them post-mortem. In this way he became
absolutely familiar with the pathological lesions of
this disease (and others) which was the foundation
of his fame as a diagnostician in later years. Pro-
fessor Loomis, as I recall him, was a rather tall,
well-built man, with very dark hair and eyes, and
very white but healthy-looking skin. I am frank
to say that I enjoyed his early lectures more than
those of later years, when he had become a distin-
guished man, and his lecture room was crowded
with professors and students from all the colleges.
At this time the very fullness of his teaching made
it difficult for the average student to appropriate it.
One day he was lecturing on croup and related the
following incident: He was coming through one of
the streets on his way to the college when he saw
a number of children playing on the pavement in
front of a large residence. As he came nearer he
heard one of them cough — that peculiar, croupous
bark that we have all heard and dreaded. His first
impulse was to ring the bell and tell the parents to
care for the child, but professional diffidence re-
strained him and the next time that he came that
way there was crape on the door. After leaving
college I did not see Professor Loomis for several
years. I was practising on Long Island and broke
down from overwork and naturally went down to
see him. After a careful examination he told me
that my liver was badly atrophied and if I had any
business matters to attend to I had better be about
them. That was about forty years ago, and I am
here writing about him, and he has long since gone
to dwell in that "low green tent whose curtain never
outward swings." Dr. Loomis said one day that he
supposed every man must have a hobby and his own
was quinine. At that time it was quite the habit
of some practitioners to treat pneumonia with that
drug, which was certainly contrary to all pathologi-
cal teaching, and the effects of the remedy. The
wife of Dr. Loomis, who died of pneumonia, was
presumably treated in the same way. A few years
after, by a strange coincidence, the professor him-
self died of the same disease. Two things impress
me in this connection — before the gathering
shadows shut out the light from that great brain
did he congratulate himself that at least he had not
died of tuberculosis, and did he order for his own
treatment that which had doubtless wrought many
cures in his hands. Dr. Loomis had an international
reputation and was the author of a work on diag-
nosis, which as far as I know has not been ex-
celled.
Just at this point there flits across my mental
vision a unique figure in the professional world.
Prof. "Jimmy" Wood was not one of the great ones,
but he accomplished a great deal, for he began his
surgical career when a mere youth. He was a
miniature man with hands and feet like a lady and
the habit of blushing like one of that sex. As I re-
member, he was connected with the College of
Physicians and Surgeons. I was present at his
clinic one day when he was operating for hernia.
The room was lull of students and professors. He
explained the different tissues as he came to them
and then said. "Gentlemen! the next fascia is the
cremaster muscle — you will probably never see it.
as it is the creation of the anatomist." He came
down to Long Island to operate upon one of my
patients for cancer of the antrum. After the
growth was all removed he asked us to place our
fingers in the upper part of the cavity. "That, gen-
tlemen," he said, "is the cribriform plate of the
ethmoid bone — I never go beyond that." As I said,
he began as a youth and was operating constantly
until his life went into an eclipse.
William H. Van Buren lectured at the old college
Nov. 25, 1916]
MEDICAL RECORD.
941
during my time. He was the most kingly man that
I ever saw. Over six feet in height and well pro-
portioned, with a fine head and face, he was a figure
never to be forgotten. He lectured an anatomy and
surgery, with special reference to the genitourinary
organs. When he came up into the old amphi-
theater and made his courtly bow, there was always
a burst of applause. He published one book, at least,
along the line of his own specialty and perhaps
more, I do not remember.
But we must stop with only a brief mention of
others who were ornaments to the profession in
those years, and who are worthy of a niche in the
medical Temple of Fame. Charles A. Budd and
Fordyce Barker, both brilliant lecturers on ob-
stetrics; Alfred C. Post, who might be remembered
as the Sir Galahad of the profession — without fear
and without reproach — modest and methodical and
delighting in all of what might be called the orna-
mental phrases of medical terminology. During my
own examination he asked if an injury was on the
right side of the cranium, where would the paraly-
sis be, if any? On the left side, of course, was the
answer to that question. "What is that sometimes
called?" he asked. I happened to remember that it
was sometimes spoken of as contre coup. "Yes, sir,
very good," he replied, "a French term." Another
unique figure in the profession was Prof. G. S. Bed-
ford, whose specialties were diseases of women and
children. In 1850 he established a clinic in the
college for the treatment of those diseases, and from
the time it was established to 1868 there had come
before his classes more than 8,000 patients. His
lectures were sui generis — they were witty, senti-
mental, poetical, and religious, and his cases were
presented in such a graphic manner that one would
never forget them. Many of these cases — perhaps
all of them — were reported and published in a vol-
ume which is as fascinating as a novel. Professor
Markoe was known as the great tenotomist, and his
friends said there was not a tendon in the body
which he had not cut. Professor Sayre was the
great authority on morbus coxarius, and was oper-
ating almost daily.
These reminiscences would not be complete with-
out the name of D. B. St. John Roosa, who was a
contemporary of mine, and who became eminent in
his specialty as an oculist. He was not only dis-
tinguished in his profession, but was a public-spir-
ited and influential citizen and received the degree
of LL.D., I think from his own college.
In looking over my notes, I see I have omitted the
name of Prof. J. C. Dalton. He was not an inspir-
ing lecturer, but he was an authority on physiology
and published a work on the subject, which was used
as a textbook at the college. It may be possible that
there are some inaccuracies in these reminiscences,
as I have written with unassisted memory — and a
half century is a long time.
Case of Lipodystrophy in a Boy.— Boissonnas de-
scribes a case of this relatively new affection which has
hitherto been seen to attack girls only. The patient is
six years old and his trouble appeared two years before,
after pertussis. The face, while its musculature is
normal, is quite free from fat. This lack of fat in-
volves the neck but does not extend further downwards.
Arms and trunk have normal fat, but the notes and
lower extremities show a notable increase of adipose.
On account of this peculiar distribution the dystrophy
is spoken of as "fatleggedness." The absence of fat in
the face and neck gives a peculiar appearance to the
child, whose cheeks are hollow and eyes deeply sunken.
The diameter of the cheek shows that only skin and
mucosa are present. — Correspondenz-Blatt fur Sehwei-
zer Aerzte.
AN IMPROVED INSTRUMENT FOR MAIN-
TAINING AN ORAL AIR-WAY, DURING
GENERAL ANESTHESIA.
By JOSEPH E. LUMBARD, M.D.,
NEW YORK.
INSTRUCTOR IN ANESTHESIA, UNIVERSITY AND BELLEVUE HOS-
PITAL MEDICAL, COLLEGE ; ANESTHETIST TO BELLEVUE AND
ALLIED HOSPITALS, HARLEM DIVISION. LUTHERAN,
KNICKERBOCKER, AND LYING-IN HOSPITALS.
IN previous articles* I mentioned the importance
of keeping a free oral air-way for certain condi-
thesia and described my invention for that purpose.
Since then I have changed the instrument, making
it smaller and stronger. Inasmuch as all anes-
thetists fully agree, which is saying much, that too
great emphasis cannot be placed upon the necessity
of keeping a free oral air-way during general anes-
tions, I feel justified in harping on my hobby and
have succeeded in making a more perfect device.
During the last few years numerous tubes have
appeared for the same purpose made by Hewitt,
Connell, Ferguson. Coburn, Flagg, and Pinneo.
/
•
,
1
• ^
Fig. 1. — Lumbard's air-way ; the lower is the pharyngeal end.
Two-thirds actua] size.
In the second of the articles above mentioned I
call my instrument "A Controller of the Tongue
and Palate During General Anesthesia." While
this is possibly more correct than the new title, it
is lengthy and ambiguous.
My latest instrument (see Fig. 1) for maintain-
ing an artificial oral air-way, is constructed as fol-
lows: a double row of three curved wires running
parallel, about an eighth of an inch apart, are firm-
ly held together by three crossbands. The instru-
ment is 4]2 inches long, V-> inch in width and %
inch in thickness. It contains nine pieces and is
nickel plated. Properly made, it will not rust nor
come apart when sterilized.
No attempt should be made to introduce this in-
strument until the patient is well anesthetized, for
the pharynx is one of the last reflexes to yield to
general anesthesia and the introduction of the in-
strument too soon is apt to cause gagging. The
* Helps in Surgical Anesthesia, Journal A. M. A.,
November 23, 1912, p. 1853. A Controller of the
Tongue and Palate During General Anesthesia, Journal
A. M. A., May 22, 1915, p. 1757.
942
MEDICAL RECORD.
[Nov. 25, 1916
instrument is easily introduced by inserting the
pharyngeal end between the tongue and the soft
palate until it rests in the pharynx (see Fig. 2).
Should the respirations become noisy this annoy-
ance can be overcome by extending the head back-
Fig. 2. — Lumbard's air-way in situ.
ward. Sometimes the noisy breathing, when the
tube is in situ, is indicative of a light anesthesia.
In such cases it is better to take the tube out and
deepen the anesthesia before replacing it. A few
cases will do better if traction on the tongue is
made before the air-way tube is introduced; in
such cases do not use the tongue forceps, but al-
ways make traction with a piece of dry gauze held
between the fingers. A swollen tongue from crude
instrumentation will often cause the patient more
trouble than the operation itself.
The instrument does not interfere with any face
mask nor with any method for administering a
general inhalation anesthetic. Not only does this
air-way obviate the task of holding the jaw for-
ward, but is useful in the aged where the lips ob-
struct the air passage.
I have often noticed when instructing interns
and students that they are quick to see and appre-
ciate the advantages of this instrument. I would
earnestly recommend the use of this tube in all
abdominal operations, especially when in the Tren-
delenburg position; also when there is any obstruc-
tion to free respiration during anesthesia. Keep-
ing the instrument in situ after the operation, un-
til swallowing returns, will greatly hasten the re-
covery from the anesthetic. I consider an instru-
ment for maintaining an artificial oral air-way one
of the most important items of an anesthetist's out-
fit.
A free oral air-way is indicated in the following
conditions: When there is (1) cyanosis due to ob-
structed nasal or oral breathing; (2) unrelaxed
muscular condition, due to faulty breathing; (3)
enlarged tongue or falling back of the tongue, espe-
cially when the patient is in the Trendelenburg
position.
When using the insufflation method or oxygen, a
rubber tube can be easily attached to the side of
the instrument by a rubber band or string. (See
Fig. 3.)
The insufflation method and oxygen can also be
used with Lumbard's vapor mask, with the air-way
tube in situ.
The substitution of free oral respiration for im-
perfect nasal or oral respiration will, in a great
majority of cases, immediately be followed by
slower and quieter breathing, improvement in color,
and greater muscular relaxation; in fact, a much
improved type of anesthesia is the result.
The following are the advantages of this tube,
each of which removes several disadvantages in
similar instruments: (1) It will not clog with mu-
cus, thus eliminating the chief defect of other in-
struments. (2) It is easily and quickly inserted.
(3) It is easily kept in position, whereas the weight
of a solid tube often displaces it. (4) It cannot be
compressed by the teeth and gums. (5) It will not
conduct a fluid anesthetic to the pharynx, an acci-
dent liable to occur with other tubes. (6) It may
also be used on children as well as adults. (7) It
is quickly cleaned and sterilized, because it is open
;|
L
■
-
5^
Fig. 1. — Lumbard's air-way with rubber tube attached for the
insufflation method or oxygen. Two-thirds actual size.
on all sides. This tube has well been called the
"sine qua non" of the anesthetist.
1927 Seventh Avenue.
Action of Salvarsan. — It is certain, according to Elias-
berg, that salvarsan may be toxic and fatal and that we
arc unable either to foresee or prevent this toxicity.
Abortive treatment, so-called, only renders the disease
latent and cannot justify marriage. Salvarsan is only a
treatment of symptoms, while the intermittent and
chronic use of iodine and mercurials should cure the dis-
ease.— Dermatologisches Centralblatt.
Nov. 25, 1916]
MEDICAL RECORD.
943
REPORT OF THE COMMITTEE ON INDUS-
TRIAL HYGIENE OF THE RETAIL DRY
GOODS ASSOCIATION.
By MORRIS H. KAHN. .Ml'.
NEW YORK.
One of the vital desiderata in the maintenance and
progress of an industry is that the health of the
individuals concerned in furthering it shall be at
the highest possible standard.
Some industries and the city departments, and
some members of the Retail Dry Goods Association
(Bloomingdale Brothers, Lord & Taylor) have un-
dertaken a method of medical supervision which
calls for periodic examination of every individual
in their employ. Through routine examination of
the employees of various department stores we have
been able to discover cases of kidney and heart dis-
ease, cancer, diabetes, and quite a number of cases
of pulmonary tuberculosis. These diseases progress
insidiously for a number of years and affect the
efficiency of the worker. By the time the employer
feels obligations to the employee for length of serv-
ice, the disease incapacitates him completely. He is
put on the list of dependents or pensioned, or for
months money is spent vainly to help him when the
entire occasion was avoidable.
About 10 per cent, of the applicants for employ-
ment in one store (John Wanamaker) were affected
by tuberculosis.1 Another store revealed twenty-
four cases of pulmonary tuberculosis with physical
signs in the first thousand consecutive examinations
of its employees, and in another were found four
cases of advanced tuberculosis with positive sputum
in the first 250 examinations made.2
It frequently happens that epidemics in depart-
ment stores are averted by the isolation of a case
of infectious disease, such as diphtheria, scarlet
fever, etc. In one department store (Bloomingdale
Bros.), the incidence of acute infectious diseases
during 1914 and 1915 were as follows:
a
OS
a
s
April
May
£
->
>>
3
>->
to
3
■<
1
CO
i
>
o
I
si
a j
1914
Acute follicular tonsil-
litis
15
3
1
14
4
1
18
2
1
4
7
24
2
1
9
6
1
1
5
12 2
1
3
i
1
1
2
1
1
1
0
1
1
i
i
i
I
in
Acute rheumatic fever
2
-.
1
1
2
Pneumonia
9 5
l
1915
Acute follicular tonsil-
6
Acute rheumatic fever
Diphtheria
Malaria.
1
1
i
1
i«
Each case required at least one week of absence
from work. But for the prompt ise'-ition of the
cases of diphtheria, tonsillitis, etc., as they occurred
an epidemic would have been inevitable. At one
time the shoe department of another store was al-
most entirely depleted by the spread of acute fol-
licular tonsillitis. When the smallpox epidemic was
threatened, those department stores having phys-
icians promptly undertook vaccination, with a con-
sequent security which was comforting and healthy;
and they served as subsidiary health centers for
advocating also vaccination against typhoid fever.
In those stores from which the employees go for
one week during the summer to a cottage provided
and paid for by the employer, physical examinations
were made of each applicant. In one store during
1915, 203 applicants were examined especially for
pediculosis capitis, skin diseases, throat and lung
diseases. Leaflets dealing with the eradication of
pediculosis, "colds," tuberculosis, general hygiene,
etc., were distributed among the applicants.
Prevention by sanitary measures and early recog-
nition of disease are the great aims of medical
supervision. In the several industries employing
a physician, he is on the premises for a varying
number of hours during the day, and examines and
treats the medical and minor surgical cases. When
found ill and with fever the cases are sent home and
instructed to stay in bed. Throat cultures are
taken in all suspicious cases. Exact treatment is
outlined until the following morning and the pa-
tient is advised when able to consult the family
physician. If the patients are better the following
morning and return to work they are seen then.
If still ill, they report the fact, after which they
are visited and advised, according to their need.
When necessary, the patient is referred to the
proper hospital and arrangements are made for
admission. Cases requiring dispensary care, as for
test-meals, .r-ray examinations, etc., are sent to the
proper clinics. One store has granted leaves of
absence for this purpose to employees on pass from
physician, without deducting the time. (Bloom-
ingdale Bros.)
When we live or spend any part of the day
among a community affected by conditions and
diseases which are infectious and communicable,
we are taking the risk of the spread of the infec-
tion to our own selves. It is to the advantage of
the conscientious employer to protect his employees
and the public. We cite this merely because the
danger has called itself to our attention repeatedly.
A nurse recently discovered a girl with syphilis
working among other girls in the office of one store.
She had active signs of the disease with an erup-
tion on her skin and sores in her mouth. It hap-
pened to be an office in which no sanitary drinking
cups are installed, adding to the gravity of the
situation. When such a state of affairs is possible
once, no too great precautions can be taken.
With the rapid and splendid advances made by
the Department of Health in our municipal admin-
istration, there is only one way to keep apace
with them, or our sanitation and scientific
methods of industrial supervision in department
stores will become an anachronism and a menace,
rather than an asset. The Department of Health
some time ago inaugurated physical examination of
cooks and waiters of all the restaurants and public
dining rooms of this city, to establish their free-
dom from an infectious or venereal disease in a
communicable form. When a department store
takes such matters into its own hands, through the
conscientious interest of its own physician, it dem-
onstrates a regard for the public welfare which is
highly commendable, and profitable from a com-
mercial standpoint. In one public dining room a
physician noticed a lesion on the finger of a waiter,
,and, jpon investigation, it proved to be an early
and very contagious stage of syphilis.
A prolonged sickness is often avoided by timely
attention. In one store (Bloomingdale Bros.)
where this is constantly enjoined by the physician
in short daily talks to the employees, there has
been a remarkable reduction in the weekly number
944
MEDICAL RECORD.
[Nov. 25, 1916
on the sick-list. This reduction is, in great part,
attributable to these talks. During 1914 and the
early part of 1915 there was a weekly sick-list of
13 to 28, with an average of 19 each week for the
first four months of 1915. The number on the sick-
list fell to from 2 to 12 each week, with an average
of 5 each week for the last six months of 1915, a
reduction of more than half the number. The
talks were given among a fluctuating audience of
employees during their lunch hour, and the phys-
ician noticed the greater number of early cases of
"colds" and infections seeking his attention, which
previously came when the condition required rest
at home and an absence from work of one to six
weeks. Thus immediately a great deal is saved
by such a provision in the medical administration
of our stores.
It is essential for each department store to have
a physician to advise and direct the sanitary side
of the problems which arise in the course of time.
Having a physician and a graduate nurse in attend-
ance is necessary from the standpoint of custom.
When customers faint or are injured in the store,
the presence of the store physician, or of the store
nurse, gives the customer security of prompt med-
ical attention.
The presence of a nurse among the employees is
an educational advantage as well. Cleanliness and
appearance and personal hygiene are habits which
it needs training to acquire. One amazing fact
alone stands out convincingly in favor of medical
supervision. Of 150 girls examined in one depart-
ment store (in 1915) approximately 75 to 50 per
cent, showed vermin in their hair, visible without
deep scrutiny. A customer buying at a counter
where he or she noticed such a condition would cer-
tainly hesitate to buy there again. But a nurse can
keep insisting all day upon eradication of such a
condition. A crusade is being conducted in one
store by the physician with some success through
the distribution of a circular of instruction with
that regard.
In the same store in 1916, it is noteworthy that
of 220 girls examined, only 32 or 14.5 per cent,
showed pediculosis, in marked contrast with last
year's statistics.
During the winter season in every department
store a number of applications, written or verbal,
are received from employees requesting aid. In-
sufficient food, lack of supply of coal, and sickness
figure as factors in the conditions. The only way
to learn of the exact conditions existing is by sys-
tematic visits made to the home of the employees.
This can best be done by the store nurse. The
nurse can also discover the underlying factors and
causes of these conditions in the families — such as
alcoholism and drug habituation ; large families of
minor dependents, mental deficiency, ignorance, lack
of ambition, disease, etc. The nurse can do the
great part of the welfare work in the store.
A medical department is, therefore, an unques-
tionable necessity for each store. It may be made
practicable even for two stores to divide the serv-
ices of one physician. We therefore recommend
the employment of a nurse or doctor or both as a
part of the running force of every department store
and every factory having more than 250 people in
its employ on stationary premises.'
This would mean the setting apart of a room in
which employees might be treated. On the basis
of the broad experience of its members, the com-
mittee suggests that such a hospital be adapted as
economically as possible to meet the real needs of
the employees, and that the money expended be
put into service first, rather than into over-elabo-
ration of plant.
In machine shops and factories, where heavy ma-
chinery is used, a well fitted up operating room is
an essential part of the factory hospital. One doc-
tor testified at the American Public Health Asso-
ciation that he had amputated a leg in his factory
hospital, and performed many other serious oper-
ations. These conditions, however, do not obtain in
the department stores. According to Dr. Kristine
Mann, who has done such excellent work with the
Department Store Education Association, records
show the percentage of cases to run something as
follows, varying, naturally, with the season of the
year or other changing conditions : Minor surgery,
37 per cent.; indigestion, 7 per cent.; colds, 17 per
cent. ; headache, 9 per cent. ; dysmenorrhea, 6 per
cent.; eyes, ears, throat, 8 per cent.; unclassified, 15
per cent.
An analysis was made of the numerical data of
diseases as they occurred in the Bloomingdale Bros.
Department Store during 1914 and 1915. The cases
were accurately recorded daily and reported every
month.
Classification of Diseases.
1914
1915
Number.
Per Cent.
Number.
Per Cent.
Acute infectious diseases, including
tonsilitis, diphtheria, typhoid
Alimentary tract, including mouth ....
Respiratory tract, bronchitis, etc
134
229
186
4
13
229
69
57
32
71
30
60
269
9.6
16.5
13 7
0.3
1
16.5
5
4
2 2
5
2.3
4 2
19.5
106
187
190
6
4
17.1
62
63
. 29
45
4
38
233
9.3
16.4
17
0.5
0.3
Skin diseases, not including pediculo-
15
5.5
5 5
2 5
Genitourinary and gynecological
General diseases, diabetes, chronic
nephritis, anemia, etc
Diseases of bones, muscles and joints. .
4
0.3
3.3
20.4
1383
mil
The most striking feature of this table is the
remarkable parallelism in the percentage of the
various diseases during both years.
When an employee feels ill during the day, the ad-
ministration of some medicine at the time, or that
combined with rest in bed for half an hour or an
hour enables the employee to continue efficient for
the remainder of the day, whereas otherwise much
time is lost with expense to both employer and em-
ployee.
To care for these cases, the store that can afford
the space should set apart a suite of five rooms :
A waiting room, a small doctor's office, a small
sterile room for dressing slight wounds, and two
"wards," where men and women, respectively, could
lie down or be put to bed. If the store cannot give
up this amount of room, the work could be begun
with a waiting room and hospital, the hospital beds
being properly screened. Such a suite should not
be called a hospital, but better a dispensary, in-
firmary, or rest room. The more informal the
atmosphere of the place can be kept, the less nerv-
ous the employees will be, and the more it will be
used by the people.
In a series of examinations conducted by the
Department Store Education Association on about
200 women, discovery was made of the fact that
department store women are pretty bad physical
Nov. 25, 1916]
MEDICAL RECORD.
945
specimens. Their chief defects of body were found
to be bad posture, functional curvature of the spine,
incoordination of muscle, or body rigidity. If these
conditions were eliminated or decreased, no one
can estimate how great would be the improvement
in feelings and symptoms. The lives of the women
outside the stores showed a great need of free
out-of-door (or in-docr) exercise. What they get
in the store, in badly constructed corsets and high-
heeled shoes, behind the narrow confines of a
counter, is negligible.
The committee, from a knowledge of the lives,
desires, and physical needs of the department store
women, would urge that in planning this health
work emphasis be laid on the constructive side of
it with the possibility of introducing, as part of the
welfare work, as Dr. Kristine Mann has so force-
fully advocated, evening gymnasium classes — partly
recreative, partly for health.
No matter how diligently and conscientiously an
individual applies himself to duty, an added stimu-
lus is rendered by an expression of personal interest
by the employer. And to provide medical atten-
tion for the employees is an incentive which finds
its echo in their gratefulness, appreciation, and
efficiency. The committee feels assured that the
results will be remarkable and progressive, and
will more than justify the slight expense of the
introduction and running of this proposed super-
vising and educational system.
REFERENCES.
1. Spalding: Weekly Bulletin, Dept. of Health, New
York City, 1915.
2. Kahn, M. H.: Medical Record, August 21, 1915.
3. Kahn, M. H.: The Survey, 1916, XXXVI, 434.
165 West Seventy-first Street.
OBSERVATIONS OF TETANUS WITH REPORT
OF A SUCCESSFULLY TREATED CASE.
By L. SEXTON, B.S., M.D.,
NEW ORLEANS. LA.
LECTURER ON MINOR SURGERY, TULANE UNIVERSITY.
Tetanus is an acute infection caused by the tetanus
bacillus of Nicolaier (1884) and Kitasato (1889),
usually following some wound or abrasion. Tetanus
is characterized by tonic and clonic spasms of the
voluntary muscles. While it is usual for some trau-
matism to precede the attack, it is not always pos-
sible to discover such wound or abrasion, but it
should be remembered that the infection may take
place within the alimentary canal (being abraded),
or from some subcutaneous injury becoming infected
through the blood (rarely), or from an undiscovered
wound. Tetanus has at times been almost epidemic
in certain hospital wards and in portions of the
tropics supposed to be due to the action of the warm
climate and manure mixed in the stable and garden
soil, favorable to the development of the virulent
tetanus organism. The bacillus is anaerobic, a
facultate, saphrophyte, capable of continuing its
development outside the body tissue. It is an almost
constant part of the soil of the garden, stable, and
dairy pens, and it is on this account that laborers,
negroes, stable and dairy attendants are the most
often attacked by the disease. It should also be re-
membered that such laborers are least careful about
keeping trivial wounds aseptic. The hygienic sur-
roundings, as well as habits of such people are gen-
erally bad. The reason they suffer from tetanus
more often than other people is explained by the
fact that the tetanus bacillus is normally found in
the dung of cattle and other warm-blooded animals ;
hence their liability to infection through contact.
Before asepsis was thoroughly understood the death
rate among infants in poorer white and colored
families was very large, during the first two weeks
of infant life, from so-called "nine-day fits." The
cord in many cases was severed by the midwife's
rusty septic scissors, tied with a dirty thread,
wrapped with an uncleanly rag, and often greased
with non-sterile applications. Hebrew surgeons say
that the deathrate from trismus was more frequent
than it should be, before the rabbis were taught to
be more aseptic with the Mohel and after-treatment
of circumcision. It is our personal opinion that
all such operations in the interest of child conserva-
tion should be done by doctors and dressed under
the direction of nurses who have been thoroughly
drilled in aseptic surgery.
Many cases of tetanus have been produced in the
present European war by explosives and the contact
with stable and garden soil in the trenches of Bel-
gium, France, and Galicia, and other countries,
especially in the highly cultivated districts of these
countries. Early experimenters found that if gar-
den mould or soil was placed in an abrasion or
under the skin of the animal, tetanus would follow.
Kitasato in his studies could not isolate the germ
until he heated the pus to 80 deg. C. for one hour
to get rid of the other septic microbes, as tetanus
is nearly always a mixed infection. The tetanus,
like the anthrax bacillus, is very resistant to heat.
The tetanus bacillus develops in the wound in long
delicate threads, breaking up into separate bacilli
with spores at one end, resembling the head of a
pin. It is next to impossible to recover the tetanus
bacillus from the original wound of infection,
though the cerebrospinal fluid taken from the pa-
tient and injected into an animal will readily pro-
duce the characteristic tetanus convulsion. The
tetanus bacillus always remains in and around the
original wound, while its toxalbumin are absorbed
into the system through the motor nerve tracts ; so
it is a pure toxemia, not a germ, traveling along
the motor nerve tracts. The tetanus bacilli are in-
dependent of oxygen, of low vitality, and invade
only bruised or septic tissue. As the germ devel-
ops in the septic wound, toxic bodies are produced,
going direct to the spinal cord and brain, resulting
in the tonic spasms which are characteristic of the
disease. The toxin is said to be four hundred times
more poisonous than strychnine, to which it is sim-
ilar in pathological action.
There is no doubt about the fact that prevention
of tetanus by proper disinfection of all wounds and
immunizing closes of antitetanic serum is far better
and safer than the treatment of the disease after
it has developed. Tetanus cases have been reduced
by 75 per cent in the United States since the doctors
and the public have been educated to a saner Fourth
of July and Christmas, and the necessity of proper
disinfecting and sterilizing of all wounds as soon
as received. All punctured and lacerated wounds
should be enlarged and relieved of all foreign bodies
by instruments or by pouring into them a warm
50 per cent, solution of hydrogen peroxide in order
to remove the deeper and smaller particles driven
into the tissue. Equal parts of tincture of iodine
and alcohol are more suitable to these wounds than
are the antiseptic dusting powders, which do not so
thoroughly penetrate the wound. The application of
a 20 per cent, phenol solution followed immediately
946
MEDICAL RECORD.
[Nov. 25, 1916
by alcohol to neutralize it, is an almost sure way
of destroying the bacillus. All lacerated wounds
should be thoroughly cleansed, drained, packed and
allowed to heal by granulation. Out of sixty thou-
sand wounded during the present war in Bavaria,
seven-tenths per cent died, four-tenths per cent of
these died of tetanus, regardless of the prophylactic
injection of serum; hence the necessity of using all
other legitimate preventive measures, including
Bier's hyperaemia. The mistake is in giving just
one dose of antitetanic serum and stopping when
it should usually be repeated within from seven to
ten days in order to make assurance doubly sure.
Removal of all foreign bodies, cleaning, opening,
and draining of all wounds has been a routine meas-
ure at our clinic for the past ten years; the result
has been fewer cases of tetanus to treat in the great
Charity Hospital of New Orleans from the clinic,
though many more wounds have been treated dur-
ing that decade than in previous years.
The later is the development of the disease, the
fewer are the spasms, and the more chronic is the
course, the better is the chance for recovery. When
incubation is under ten days the mortality usually
reaches 60 per cent. When it is over ten days and
the course of the disease runs three weeks, it is
denominated chronic tetanus and the mortality is
from 20 to 40 per cent. If the period of incubation
and the course of the disease are both three weeks
in duration, 70 per cent may recover. Lacerated
and punctured wounds in which foreign bodies have
been driven, furnish the best medium for the devel-
opment of tetanus, for the germs are anaerobic, and
are partial to saphrophytic wounds. Gunshot
wounds, compound fractures, and the puerperal
state are also favorable to the development of teta-
nus. Occasionally hospital wards and neighbor-
hoods seem to be infected, the contagion being
spread by actual contact through contaminated
dressings, instruments, etc. The suspected wound
should be disinfected not once, but twice daily, for
it must be remembered that the germs remain in
and about the wound where it was first received
and that it is only the toxin which is generated sev-
eral days after the wound is made, that is absorbed.
There are no symptoms of tetanus manifested until
the toxins have reached the spinal cord. Irritation
of the motor nerve tracts causes the tonic convul-
sions to begin. Muscle cramps and girdle pains are
due to the irritation of the sensory nerves. The
extensor muscles always overcome the flexors, hence
the head is retracted, feet extended, and back arched
(opisthotonous). Tonic spasms are continuous ex-
cept when relaxed by heroic doses of sedative drugs,
which have to be kept up throughout the attack.
The spinal cord is in such a state of excitability
that any noise, draught, or jarring causes painful
spasms to occur. Asphyxia may be threatened by
tonic convulsions of the chest and throat muscles.
Often the inexperienced surgeon is taken off of his
guard as to the seriousness of the attack on account
of the clear mind to the fatal termination. Other
prominent symptoms of tetanus are retention of the
urine and constipated bowels, rigid muscles, includ-
ing the abdominal ones, with no sleep without heavy
drugging. The first symptoms of tetanus are diffi-
culty in mastication, spasms of the jaw. with rigid
neck and abdominal muscles. When the face mus-
cles are involved, a sardonic grin is produced that
is peculiar to the disease. The violent muscular con-
traction with the absorption of the toxin produces
high fever and sweating, which is usually persistent
to the end of the case. The patients usually suffer
a great deal from girdle pains around the waist
produced by spasms of the diaphragm.
We should endeavor to keep the bowels well open
and the skin and kidneys active in order to eliminate
as much of the poison as possible. The irritability
of the spinal cord should be controlled by large alter-
nating doses of sedative medicines, including chloro-
form, to control the spasms. We prevent the toxins
entering into the system by thorough disinfection of
the original wound. We inject two thousand units
of antitetanic serum in the vicinity of the wound
or between the wound and the spinal cord. If the
wound is upon the hand use the serum in the arm
or near the brachial plexus. If in the foot, use it
near the sciatic nerve. Ashhurst and Johns prefer
chloroform to ether in order to relax the spasms,
as it is more easily administered, but it is five times
more lethal in its effects. Meltzer of New York
recommends twenty minims of a 20 per cent solu-
tion of sulphate of magnesia to be injected into
the spinal cord to relax these spasms. Eighteen
cases so treated resulted in four recoveries; two
were acute and two chronic, showing a death rate
of 70 per cent, which was about the same mortality
as under treatment by other methods. Irons recom-
mends from three to five thousand units of anti-
tetanic serum intraspinally and ten to twenty thou-
sand units intravenously as soon as the disease is
diagnosed. The earlier the treatment is begun the
more favorable the prognosis of the case. After
these heroic dosings on the fourth day, he again
uses ten thousand units subcutaneously. We think
the alternate use of syrup of chloral, bromide of
potassium, morphine, and atropine should be the
way in which sedatives are given to control the con-
vulsions of tetanus. Daumsler of the French Army
used six grams of chloral every six hours until the
spasms were relaxed. Wintraud says that little can
be expected from the serum treatment, that its use
is preventive and not curative. Sainton cured six
patients out of twenty-two by injecting 40 c.c. of
a 2 per cent phenol solution twice daily subcuta-
neously. It has been found that phenol is less toxic
by injection than by the stomach. Johns and Ash-
hurst depress the functions of the spinal cord by
from thirty to sixty grains of chloretone given in
either oil or whiskey. The bowels should be kept
open daily by some mild purgative or enema. You
may expect retention of urine, which is very com-
mon on account of the spasm of the cut-off muscle.
Intraspinal injection of fifteen hundred units of
antitetanic serum is the best and quickest way to
apply the remedy to the over-excited spinal cord.
The same amount of spinal fluid should escape be-
fore the antetanic serum is injected. In the nour-
ishing of a case of tetanus rectal or nasal feeding
may become necessary. When it is impossible to
get the food into the mouth on account of the
spasms of the jaws, a tooth may be extracted to
facilitate the introduction of nourishment.
The following is a report of a case of recovery
following tetanus:
Mrs. C, age thirty-five, mother of two children. She
bad never had any serious sickness before, was at-
tacked by all the classical symptoms of tetanus, and
the diagnosis was made accordingly. The only abrasion
that could be found upon her person was an ulcerated
hemorrhoid from which she had suffered for the past
three weeks with impacted feces. The jaw-closing
tonic and clonic spasms increased daily as did the tem-
perature, when it became necessary on the fourth day
to control the spasms by chloroform and sedatives in
large and increasing doses. We darkened the room by
Nov. 25, 1916]
MEDICAL RECORD.
947
curtains, forbade visitors, ensured quiet, and protected
the patient from draughts. Although we pushed the
sedatives to the limit, the patient would be attacked
by spasms as soon as the doses were reduced or given
at longer intervals. In the early period of the disease
we obtained eight vials of 1,500 units each of anti-
tetanic serum, which we administered in the flank, two
each day until they were all used. We discussed the
use of the serum intraspinally, but on the principle of
"safety first" for the patient, we injected into the
flank and deltoid; this we commend to others in serious
cases as they at least subject the doctor to less criti-
cism if the case should prove fatal, as it is liable to do.
We nourished the patient on milk, broths, soups, and
various liquid foods (she swallowed best when under
the influence of sedatives) . We kept the bowels open
with purgatives or enemas, used milk instead of water
to quench the thirst, as it served the purpose of nourish-
ment at the same time. When the temperature would
reach 104°, she was given one 5-grain dose of acet-
phonetidin or acetanilide compound, not to be repeated
more than twice in twenty-four hours, provided the
temperature again reached 104°. The woman finally
recovered.
As to whether this patient was benefited by the
injection of the antitetanic serum as a cure, or
whether the antiseptic treatment of the hemor-
rhoidal ulcer or unloading the impaction, or the
alternate use of the sedatives, nourishing food,
keeping the bowels open, or whether nature cured
the case in spite of our efforts, I leave to the medical
association to judge.
506 Medical Building.
A GASTRIC ASPIRATOR.
By WILLIAM GERRY MORGAN, M.D..
WASHINGTON. D. C.
I WOULD like to describe here a little apparatus
which I have used for fifteen years, which does all
that any other appliance, such as that described by
The gastric contents evacuator. 1, aspirating bulb ; 2,
glass connecting tube ; 3, perforated rubber stopper ; 4, large
test tube with side spout ; 5, stomach tube.
Dr. P. A. Sheaff in a recent issue of the Journal of
the A. M. A does, costs but a few cents, and can be
carried to the homes of patients ; it may well form a
part of a doctor's emergency outfit for aspirating
the contents of the stomachs of patients who have
swallowed poison. This apparatus consists merely
of a test tube an inch and a half in diameter and
six inches in length. It has the usual round bottom;
an inch below the open end is a glass spout; a rub-
ber bulb aspirator, a perforated rubber stopper,
through which passes a glass connecting tube, and
an ordinary stomach tube complete the apparatus.
The method of use of my aspirator is quite simple.
The bulb aspirator is attached to the glass tube in
the rubber stopper which is in turn inserted into the
test tube. The stomach tube is connected with the
spout of the test tube and is then introduced in the
usual way into the patient's stomach. The aspira-
tor bulb is squeezed and the contents of the stom-
ach at once are drawn into the test tube.
One of the advantages of this apparatus over any
other, aside from the small cost, is the fact that
there is so much elasticity in the degree of vacuum
produced in the glass container as greatly to reduce
the danger of injuring the mucosa. Another ad-
vantage is that the patient is told to himself hold
the container, which in a measure distracts his at-
tention to that phase of a very disagreeable pro-
cedure which, in a nervous individual, is of no
small help.
1C24 1 Street.
JHedirnbral TSuitB.
When Use of Books to Contradict Medical Expert Is
Improper. — In an action for personal injuries sustained
in a panic following a burst of fire from a street-car
controller a medical witness for the defendants, basing
his opinion on his experience, testified that the plaintiff
could not have suffered epilepsy as the result of the ac-
cident in question, saying, "Fright does not produce
epilepsy." The plaintiff's attorney, after having identi-
fied through the witness a book on nervous diseases
written by Professor Stan-, asked whether Professor
Starr did not say in his book that "about one-half of
the cases of epilepsy is caused by fright." Questions to
the same import were repeated and so framed as to ap-
pear to be statements of what was contained in Starr's
book. The plaintiff's counsel then exhibited the book
to the court and jury, and stated that he proposed to
show by it that such contrary opinion was stated. It
was held that the allowance of this constituted reversi-
ble error. — Mann vs. Blair, 195 111. App. 254.
Statements to Physician — Expert Evidence. — The Cir-
cuit Court of Appeals, Seventh Circuit, holds that un-
less it clearly appears that the plaintiff's description to
a physician to whom she had gone of her subjective
symptoms was made solely to aid an expert to give
evidence on the trial in an action for her injury, and not
in good faith to assist him in diagnosing her case for
purpose of treatment, it is admissible, though the
weight to be given it by the jury may be slight. If
there is no conflict in the evidence as to the manner of
a plaintiff's injury, it is not improper to permit a physi-
cian to state that the accident did cause, and not merely
that it might have caused, the injury. — Chicago Rys. Co.
vs. Kramer, 234 Fed. 245.
Fees of Young Practitioners. — In an action by a phy-
sician against an estate for services rendered the testa-
trix for some disease of the brain, the nature of which
even a post mortem examination did not clearly de-
termine, it appeared that the plaintiff was a young
physician who had been an old friend of testatrix. The
trial judge allowed the claim of $1,500 only to the extent
of $262, being of opinion that a young practitioner
has no right to charge, or expect to be paid, the fees
charged by those who are older and whose reputations
have been established. On appeal, the Louisiana Su-
preme Court said that it may happen that the knowl-
edge of the schools goes beyond that upon which repu-
tations have been founded, and that the later gradu-
ate, bringing, with his diploma, the latest discoveries,
is more competent to deal with a particular case than
the earlier, with the experience of a past generation.
However that may be, the court held that any physician
has the right, in the absence of a custom of his own, to
charge for his visits, day or night, at least the fee
sanctioned by the custom of the community in which
he lives; nor is he obliged, in so doing, to rate himself
below the class to which, in his omnion, he properly be-
longs; and in such a case, the burden rests upon the
patient who refuses to pay to show a better reason for
such refusal than that the physician is comparatively
fresh from the seats of learning. The amount to be
allowed was increased to $1,500, the amount claimed. —
Succession of Percival, (La.) 72 So. 467.
948
MEDICAL RECORD.
[Nov. 25, 1916
Medical Record.
A Weekly Journal of Medicine and Surgery.
THOMAS L. STEDMAN, A.M., M.D., Editor.
PUBLISHERS
WM. WOOD A CO., 51 FIFTH AVENUE.
See fourth page following reading matter for Rates of Subscription
and Information for Contributors and Subscribers.
New York, November 25, 1916.
TREATMENT OF SYPHILIS OF THE
NERVOUS SYSTEM.
That small group of disorders formerly known as
the parasyphilitic affections of the central nervous
system, which included tabes dorsalis and paresis,
for a long time offered successful resistance to the
efforts of the therapeutists. Tabes especially was
made the object of numerous methods of treatment
some of which achieved a little brief notoriety, but
all eventually were discarded as valueless. The rec-
ognition of the essentially syphilitic nature of these
conditions and the demonstration of the presence of
the spirochete in the nervous tissue placed their
pathology on a sound basis. The advent of sal-
varsan found the profession beginning to realize
that the cerebrospinal fluid offered a rich field for
investigation, and experience with meningitis had
shown them that intraspinous medication was at
times extremely efficacious. Making use of all
the information which had been yielded by such re-
search, Swift and Ellis developed a technique for
the intraspinous administration of salvarsan and
obtained results in the treatment of tabes and pare-
sis which had not been approached up to that time.
Since the publication of their work there have been
numerous papers written on the subject. The tech-
nique has been modified and adapted and altered and
the method has been praised or condemned, often in
no measured terms. Unfortunately conclusions have
been drawn at times from insufficient data and an
unbiased and critical observer might have some
difficulty in obtaining from the literature a very
clear idea as to the true value of this method of
treating this group of conditions.
It is, therefore, a pleasure to see the report of the
cases which have been treated at the Peter Bent
Brigham Hospital during the past three years, which
is presented by Walker and Haller (Archives of Int.
Med., 1916, xviii, 376). The report concerns forty-
eight cases of tabes dorsalis, six of general paresis,
sixteen of cerebrospinal syphilis, and five of syphi-
litic meningitis. There were given 450 intraspinal
injections of salvarsanized serum and 350 intraven-
ous injections of salvarsan. The authors divide their
cases into three groups. The first group consists
of patients who received salvarsan only by way of
the vein. Of these only those whose infection was
comparatively recent showed any definite improve-
ment. Those patients whose infection was of long
standing showed practically no benefit, so far as
their nervous symptoms were concerned, from in-
travenous injections. In group two are collected
those patients who received salvarsan into their
veins and also salvarsanized serum intraspinously.
In most of these cases the improvement was definite
and steady. The cell count of the spinal fluid ap-
proached or reached normal and the Wassermann
became either negative or less strongly positive.
At the same time there was a marked abatement in
their symptoms. Fifteen of these patients have
been observed for a sufficiently long time to deter-
mine whether the treatment has a permanent effect.
Four have relapsed and four died. The other seven
have remained without symptoms for at least eigh-
teen months. Fifteen other cases in this group have
shown improvement, but the interval since the end
of their treatment has not been sufficiently long to
determine the end result. The third group com-
prises seventeen cases in which the Wassermann in
the blood serum was negative, while that in the
spinal fluid was positive. These cases were treated
only by the intraspinous administration of salvar-
sanized serum. All of these patients improved.
One shows a relapse in ataxia and a second still suf-
fers from headaches. The remainder have been
free from symptoms for periods varying from two to
twenty-four months, seven of them for more than a
year.
Patients are, therefore, treated according to this
rule: If satisfactory results do not follow three or
four intravenous doses of salvarsan, they are given
salvarsanized serum as well. If the serum Wasser-
mann is negative they receive only intraspinous sal-
varsanized serum. Following this rule the results
are seen to be most excellent. There are, of course,
some relapses and a few of the patients react so se-
verely that the treatment may be impossible and it
is not possible to say that any of them are perma-
nently cured. Nevertheless, the majority show
marked improvement and many remain without
symptoms for comparatively long periods of time.
Certainly the disease may be considered as arrested
at least. Equally satisfactory results were ob-
tained by Fordyce in the series of 180 cases of
tabes, paresis, and other forms of cerebrospinal
syphilis, reported in the Medical Record of Sep-
tember 30. In most of these cases the Ogilvie modi-
fication of the Swift-Ellis method was used and
proved itself to be as satisfactory as, and in some
respects superior to, the autosalvarsanized serum
method. The results are noteworthy and deserving
the serious consideration of the whole profession.
Certainly no patient with one of these conditions
should be denied a serious trial of this treatment.
The technique is not essentially extremely difficult,
and while much better carried out in a hospital, can,
if necessary, be done elsewhere.
PHARMACY IN RUSSIA.
The Russian government lately appointed a com-
mittee to inquire what native plants were available
as sources of those medicinal substances of which
the empire stood in need. (Pharmatsevticheski
Journal, p. 76, 1916.) Chemists and pharmacists
have addressed themselves to this problem, and the
Nov. 25, 1916]
MEDICAL RECORD.
949
result is that there are now several published clas-
sifications in the Russian Codex of Russian plants
which may be applied to the practical purpose of
supplying the drugs and galenicals that had previ-
ously been imported. In most cases these drugs
are identical with the foreign, while others are very
good substitutes and imitations. Before the war
Germany was the chief producer of alkaloids and
synthetic compounds, and was able to export its
surplus of coal tar, benzol, and toluol to Russia as
well as the finished products of its coal tar indus-
try, salicylic acid, salol, antipyrin, and the series of
antiseptics which Russian markets took on terms
most favorable to Germans. As a Russian writer in
Industry and Commerce pointed out, it was some-
what difficult for the Russian manufacturer to suc-
ceed under a tariff in which there was a wide dis-
proportion between the duties on raw and on fin-
ished products. Raw materials, as a rule, paid
higher duties, and this is the reason, to a great ex-
tent, why Russia has fallen behind in the more mod-
ern chemical manufactures and industries. In these
circumstances the Russian manufacturer could not
make a new drug sufficiently cheaply to compete
with the German.
Now the Government has taken the matter up,
and during the past six months, the resources of
the country in medicinal plants have been studied
and a useful series of galenicals prepared. Phar-
macists have found out, not only that such plants
as digitalis, Aconitum napellus, A. orientale, Vera-
trum album, rhamnus, are plentiful in the Caucasus,
Bessarabia, and the Crimea, but that they yield, in
many cases, an unusually high proportion of the
substances to which their active properties are due.
From Aconitum orientale for instance, the chemist
Kourrote extracted as much as 2.207 per cent, of
crystallized aconitine. Similarly, from Veratrum
album, growing in Bessarabia, he obtained 0.84 per
cent, of jervine. It is in some of the plants of the
Caucasus that, in Russian opinion, the resources of
the country show their real greatness, the richness
in plants that, for want of a better word, may be
described as truly medicinal, the plants in which
the healing and the chemical properties are in happy
equilibrium, in which the therapeutic compound is
formed on the recipe supplied by Nature herself to
the investigating chemist. Many instances are
given in the report of the government pharmacist,
Mouschinski. Among these plants are Pimpinella
saxifraga, polygonum, Senecio crucifolius, Althaea
officinalis, Fceniculum officinale, digitalis, Rham-
nus frangula, Russian male fern, menyanthes, and
geranium. Preparations of all these are to be found
in the new Pharmacopeia.
It is a different story as regards alkaloids. The
war has greatly increased the demand for these
among all nations and, as a consequence, the output
of the sole country on which Russia could now rely,
England, has nearly all been used for the latter's
own needs. Russia is thus deprived of her source
of supply, and incidentally offers the American
chemist one of his greatest opportunities. He can
profit, if he will, by the exclusion of Germany, the
chief manufacturing source of the rarer alkaloids.
There will be keen competition with England later,
but in the meanwhile, the manufacturer in the
United States should take this chance. Besides
this, America and Russia have natural advantages,
such as climate and soil favorable to growing plants.
England, in spite of every effort, has made no great
progress in the manufacture of alkaloids. With a
reduced staff in her laboratories and a limited sup-
ply of labor, the conditions are decidedly opposed to
the contrivance of new processes. And, as regards
synthetic drugs, the war has nearly exhausted the
supply. Many of these are not manufactured in
England. They are now produced in Russia, but
high prices and the cost of freights and of delivery
hamper Russia. When atropine costs on the Brit-
ish market 170 shillings an ounce, the most inter-
esting commercial facts for pharmacists is how to
profit by such prices, which may be either in find-
ing new processes or in developing the sources of
natural supply.
CARE OF CHILDREN IN THE ELEMENTARY
SCHOOLS OF GREAT BRITAIN.
Owing to the falling birth rate and to the slaughter
of adults in the war, Europe is naturally paying
more and more attention to the preservation of child
life. This is especially the case in Great Britain,
where the birth rate has declined, and is declining,
and where men, on account of the war and of emi-
gration before the war, have been decreasing in
number at a somewhat alarming rate. A report
issued recently by Sir George Newman, president
of the Local Government Board, is, in the circum-
stances, a particularly depressing document, and
will doubtless bestir the British public to efforts
with the object of bettering existing conditions.
The report in question points out that there are
6,000,000 children in the elementary schools of Eng-
land and Wales. Of these, 1,000,000 are in bad
physical condition, and 250,000, or thereabouts, are
really too ill to learn. These are startling figures,
and Newman's analysis of the situation is inter-
esting and valuable, in considering not only English
school children, but the school children of this coun-
try. The U. S. Public Health Service is at the
present time investigating the health of rural school
children in parts of America, and the result of their
investigations so far has been almost as discourag-
ing as the English report. The writer of the report
places the blame for the deterioration of English
children on the rearing of children prior to school
age, but chiefly upon school life itself. For disease
and defects in the child leaving school are some
reflection on the influence exerted upon it during
its nine years or so of school life. As the report
notes, it is not easy to escape the deduction that if
the child, on entering school, is ailing, it is part
of the business of those responsible for its ultimate
equipment to seek to improve its physique both be-
fore it comes to school and during its school life;
and if the leaving child is unfit for employment
and citizenship, the system of its education stands,
in greater or lesser measure, condemned.
It is most assuredly undeniable that education,
while primarily designed to equip the mind, must
provide also for the body's needs. The ill-nourished,
unhealthy child cannot absorb knowledge properly,
and even if it could it would be at the expense of
950
MEDICAL RECORD.
[Nov. 25, 1916
its physical powers. It is a means of draining
vitality which augurs ill for the future of a race
or nation. Child power requires as much attention
as man power, and Newman suggests as the sole
reliable safeguard a complete scheme of education,
physical as well as mental, by the state.
Epileptic Myoclonus.
It has often been stated that one case thoroughly
studied has far more educational value than a di-
gest of a lot of loosely observed material. This is
especially the case with little understood affections.
A case by Wolfer in the Correspondenz-Blatt fiir
Schweizer Aerzte, August 26 is one in point. This
disease appears notably in degenerate stock and
the author is fortunate in being able to record the
family history. As there were several cases in the
family, we are reminded that the familial type is
very common and severe. The father was a strenu-
ous drinker and also had tabes, the mother being
healthy. It is of interest that Biihrer reported the
case of the elder (female) in 1901. The father's
father and mother's mother were both alcoholics in
association with marked psychic degeneration. The
sisters' epilepsy began at 12, myoclonus at 14. In
addition to the brother's case, a sister is known to
have had fits. She died of pneumonia. Two more
brothers, healthy in Biihrer's time, are still living
and well (now aged 25 and 23). A sister living at
20 had a doubtful history of partial epilepsy in
childhood. According to Biihrer the case was one
of partial epilepsy with complete unconsciousness.
Thus of 6 cases, 4 were surely tainted as a result
evidently of crossed inheritance. Study of the au-
thor's patient was negative. A piece of pectoralis
muscle showed no evidence of myopathy. There was
evidently a heightened muscular tonus, a heightened
mechanical excitability of the muscles and complete
absence of sensory disturbances. The nervous sys-
tem was unstable, and the intensity of the contrac-
tions was dependent on the state of the psyche. The
author believes that the inferiority of the patient's
constitution was manifested chiefly in the muscles
and parts of the nervous system, both central and
peripheral. Treatment was of no avail. As Lund-
borg exhausted the subject of familial myoclonus-
epilepsy many years ago, but little can be added
that is new, but 4 cases out of 6 children in a fam-
ily should be almost a record.
Treatment of Whooping Cough by the Krauss
Vaccine.
According to Paranhos, of Sao Paulo, Brazil (Bra-
zil Medico, September 30), an epidemic of pertussis
appeared in that city in the early months of 1915
which attacked children with unprecedented se-
verity. At the University Polyclinic all sorts of
treatment laid down by classical writers were given
a trial. It was learned from an article in the
Semana Medica Argentina that a vaccine was pre-
pared and used in that country with excellent re-
sults. Following the published directions, the
author had the vaccine, designated originally by the
name of Krauss, at once prepared both for private
and clinical work. It was tested on a material of
49 cases, of which 28 were in the early stages, 17
between the second and fourth week of the disease,
and 4 after the fourth week. The technique of
Krauss, which consists essentially in the use of in-
creasing doses, was closely followed. In the early
cases there was marked improvement in respect to
cough and vomiting in the great majority. After
the second inoculation the accesses diminished in
frequency and severity. In the more advanced
cases the response to treatment was less pronounced,
or rather more slow, but benefit was apparent after
repeated inoculations, and the duration of the dis-
ease was cut short. As far as this epidemic is con-
cerned, the vaccine may be regarded as decidedly
the most efficient treatment.
Jfe his of tip Week.
Death Rate in New York. — For the week ending
November 11, 1916, the death rate in New York
City was 12.28, representing a total of 1,315
deaths, as compared with a rate of 12.63 and a
total of 1,324 deaths for the corresponding week
of last year. Seven deaths from poliomyelitis
were reported during the week; and there was a
decrease in the deaths to contagious diseases, diar-
rheal diseases, cancer, tuberculosis, and diseases
of the nervous system, and an increase in the mor-
tality of heart disease, lobar pneumonia, and
Bright's disease. The death rate for the first 46
weeks of 1916 was 13.96, as compared with 13.91
for the corresponding period of last year.
Dinner to Health Official. — Mr. Eugene W.
Scheffer, secretary of the Board of Health, New
York, who retires at the end of this year, was the
guest of honor at a dinner given at the Yale Club
on November 15, about 150 guests participating.
Addresses were made by former Commissioners
Goldwater and Darlington, Dr. William H. Park,
Dr. Robert J. Wilson, and others. Mr. Scheffer
entered the Department of Health as assistant
chief clerk in 1895 and became secretary in 1902.
Resolutions of the New York Neurological So-
ciety.— At a meeting of this society held November
15, the following resolutions were presented by
Dr. Walter Timme and unanimously adopted:
Whereas, Anterior poliomyelitis and its con-
comitant polioencephalitis are intrinsically neuro-
logical diseases, and
Whereas, Anterior poliomyelitis and polioenceph-
alitis have been managed in all stages in the recent
epidemic practically without the supervision and
control of neurologists in the institutions of Greater
New York, and
Whereas, In order to avoid faulty diagnosis, inade-
quate treatment, and poor methods of gathering
important statistics, resulting not only in detri-
ment to the present patients but also in a
final loss to scientific medicine of valuable
data of great service in future epidemics;
be it
Resolved, That it is the sense of the New
York Neurological Society that anterior polio-
myelitis and polioencephalitis being neurologi-
cal diseases, the sufferers from such dis-
eases ought at an early period to come under the
care or supervision of neurologists, with the co-
operation of orthopedists and other specialists as
the cases may require. And, in consideration of the
unprecedented number of cases in the recent epi-
demic, in all public institutions and clinics where
these diseases are treated, there should be a stand-
ardization of equipment and method. And be it
Resolved, That the New York York Neurological
Society petition the Committee on Public Health of
Nov. 25, 1916]
MEDICAL RECORD.
951
the New York Academy of Medicine that it consider
the advisability of appointing at once a commis-
sion on poliomyelitis which shall take into consid-
eration the ways and means best calculated to
meet and combat a future epidemic similar to the
one we have just experienced and make definite
recommendations for same. This commission shall
consist of four subcommittees, as follows: (1) A
committee on communicability and quarantine,
comprised of bacteriologists and epidemiologists.
(2) A committee on the criteria of diagnosis and
clinical management, to consist of neurologists,
pediatrists, and orthopedists. (3) A committee on
pathology and serology, to consist of pathologists
who shall devise the best means of caring for such
pathological material as is obtained as a result of
the epidemic. (4) A committee on treatment and
immunization, to consist of neurologists, orthoped-
ists, pediatrists, and bacteriologists. This com-
mittee shall consider the therapeutic means best
adapted to the acute stage and also to the after
treatment.
Physicians to Germany. — Difficulties in trans-
portation may force the abandonment of the plan
to send six American physicians of German de-
scent to Germany and Austria-Hungary for six
months, to care for civilians in those countries.
The State Department is now endeavoring to ob-
tain guarantees of safe conduct from Great Bri-
tain, but it is doubtful that these will be forth-
coming. It is said that $16,000 has been
raised in Philadelphia to pay the expenses of the
trip and the salaries of the doctors.
Anti-Heart Disease. — The Association for the
Prevention and Relief of Heart Disease was re-
cently incorporated in New York for the purpose
of working for the prevention of heart disease
through the dissemination of information and the
application of recognized preventive means. The
association proposes to gather data, to study and
develop occupations and vocational guidance for car-
diacs, and to assist in the establishment of cardiac
classes. The officers of the association are: Dr.
Lewis A. Conner, President; Dr. T. Stuart Hart,
Vice-President, and Dr. N. L. Deming, Secretary.
Changes at Cornell. — Dr. W. Gilman Thompson,
professor of medicine in Cornell University Medi-
cal College since the founding of the college in 1898,
has resigned his chair in order to devote his time
entirely to his private work, and has been appointed
professor emeritus. The vacancy thus created has
been filled by the appointment of Dr. Lewis Atter-
bury Conner, who, has been connected with the de-
partment of medicine at the college since 1898, and
since 1900 has been professor of clinical medicine
and in charge of the medical instruction at New
York Hospital.
Harvey Lecture. — The third lecture of the pres-
ent series of the Harvey Society will be delivered
at the New York Academy of Medicine, 17 West
Forty-third Street, on November 25, at eight-thirty,
by Dr. Paul A. Lewis of the Henry Phipps Insti-
tute for Tuberculosis. Dr. Lewis will speak on
"Chemotherapy in Tuberculosis."
The Seventh District Medical Society of North
Carolina will convene at Monroe on December 4
and 5. The society has a membership of over two
hundred and it is expected that the majority of
the members, as well as a number of invited guests,
will be in attendance.
The Harvard Hospital Unit. — Six surgeons, a
dentist, and twenty nurses sailed from New York
on the Andania on Tuesday of this week to join the
Harvard Hospital Unit at a British base hospital in
France. They will take the places of an equal num-
ber whose term of service expires on December 9.
Since the organization of the unit in June, 1915,
117 surgeons and dentists and 184 nurses have been
in the service.
Additional Gift to Chicago. — Announcement has
been made of the gift of $500,000 from Mr. Julius
Rosenwald of Chicago to the University of Chicago,
for the proposed new medical school. As previously
announced, the Rockefeller Foundation and the Gen-
eral Education Board have given $2,000,000 for the
same purpose, and the remainder of the money
necessary is to be provided by the University of
Chicago and by private subscription.
London "Times" Red Cross Fund. — The London
Times on November 15 announced that its collec-
tions in behalf of the Red Cross had passed the
$25,000,000 mark.
Blockley Ex-Resident and Resident Physicians.
— The thirtieth annual banquet of past and present
internes of the Philadelphia General Hospital was
held at the Hotel Rittenhouse on November 11. Dr.
B. Franklin Stahl presided, and Dr. Herman B.
Allyn acted as toastmaster. Addresses were made
by Dr. J. Chalmers Da Costa, Dr. Joseph Sailer,
Dr. Charles B. Kendall, Dr. Randle C. Rosenberger,
Dr. D. J. McCarthy, and Dr. Wilmer Krusen.
Association for Advancement of Science. — The
sixty-ninth annual meeting of the American Asso-
ciation for the Advancement of Science, and the
national societies affiliated with it, will be held in
New York during the last week of December. An
attendance of more than 2,000 is expected.
Memorial Tablet. — A bronze tablet in memory
of Dr. Abraham Mayer has been placed in Lebanon
Hospital, New York, the dedication taking place on
November 19.
Removal. — Dr. W. A. Bradley has removed from
55 West Seventy-fifth Street to 127 West Seventy-
fifth Street.
Heroine Addicts Increasing. — At a meeting of a
committee of judges, physicians, and others, organ-
ized to fight the drug habit in New York, recently,
the statements were made that heroine addicts are
becoming so numerous in the city that the city
hospitals and institutions must enlarge their facili-
ties greatly if they are to deal successfully with
the cases turned over to them by the courts; that
ninety per cent, of all drug victims are enslaved
to heroine; and that while the drug-store sales have
been cut 75 per cent., smugglers of the drug still
keep the sidewalk dealers supplied.
Fake Salvarsan. — The recent indictment in New-
ark, N. J., of two men engaged in the traffic has
revealed what appears to be a widespread conspiracy
to defraud the Government by smuggling salvarsan
and neosalvarsan into the United States. Still more
serious is the discovery that these men had also
in their possession a large quantity of spurious sal-
varsan, which, on examination, proved to be either
starch or table salt. These spurious products, it
is believed, have been offered for sale throughout
the country, and, as they are contained in ampoules
closely imitating the real product, many physicians
have been deceived. In order to stop the sale of this
fraudulent salvarsan it becomes incumbent on any
physician having any information on the subject
to communicate with Chief Inspector E. R. Nor-
wood, U. S. Customs House, New York, or, in case
of emergency, with the local police authorities.
952
MEDICAL RECORD.
[Nov. 25, 1916
Health Insurance. — A conference on social insur-
ance, to be held in Washington from December 5
to 9, 1916, has been called by the International As-
sociation of Industrial Accident Boards and Com-
missions, an organization of the official bodies
charged with the duties of administering compen-
sation laws in the United States and Canada. An
interesting program has been arranged under the
four headings of Workmen's Compensation, Sick-
ness Insurance and Benefits, Invalidity and Old Age
Insurance, and Social Insurance Applying Espe-
cially to Women.
Accuracy of Poliomyelitis Diagnoses. — The
Weekly Bulletin of the New York Department of
Health for November 18, 1916, contains an answer
to the assertion that the recent epidemic of polio-
myelitis in the city was largely a creation of the
Department, and that a considerable number of
the cases listed as poliomyelitis did not belong in
this class. Of the 9,418 cases occurring during
the epidemic, 4,474 were treated in the Depart-
ment's hospitals ; of this number, 96, after observa-
tion, were discharged as no illness, and in 49 addi-
tional cases the illness proved to be other than
poliomyelitis. This means that actual mistakes in
diagnosis occurred in only 1 per cent, of the cases.
Again, out of 2,715 cases followed in their homes,
1,885 were found to have a serious paralysis, and
530 a partial paralysis, of one or both legs, and 273
a total paralysis of one or both arms. These fig-
ures, in the opinion of the Department, bear ample
testimony to the high degree of diagnostic accuracy
attained during the epidemic.
Opportunities in Civil Service. — The New York
Municipal Civil Service Commission will shortly
hold an examination to fill vacancies in the position
of junior alienist in Bellevue and Allied Hospitals.
The salary of the position is $1,200 per annum,
with advancement to the position of chief alienist
with a salary range of from $3,780 to $4,680 per an-
num for full-time service.
The Commission also offers an opportunity for a
man desiring to fit himself for industrial corpo-
ration work in the Occupational Clinic recently es-
tablished at 49 Lafayette Street. For this work
the compensation ranges from $300 to $600 per
annum for not less than six hours a week, and
from $900 to $1,140 per annum for not less than
eighteen hours a week. The duties include the ex-
amination of applicants for licenses as food han-
dlers. Clinic physicians for the diagnosis and treat-
ment of patients applying at the Tuberculosis Clin-
ics of the Department of Health are also desired.
Further particulars may be obtained from the Mu-
nicipal Civil Service Commission, Room 400, Mu-
nicipal Building, New York.
The National Board of Medical Examiners held
its first examination from October 16 to 21, in Wash-
ington, D. C. There were thirty-two applicants from
seventeen States, representing twenty-four medi-
cal schools; of these, sixteen were accepted as hav-
ing the necessary preliminary and medical qualifi-
cations, ten took the examination, and five passed.
The following States now have the power, and are
willing to recognize the license of the National
Board: Idaho, Kentucky, Maryland, New Hamp-
shire, North Carolina, North Dakota, and Vermont.
Most of the others have expressed their willingness
to accept the license as soon as the respective legis-
latures give them the power. The second examina-
tion will be held in Washington in June, 1917. Fur-
ther information, may be had by applying to Dr.
J. S. Rodman, secretary, 2106 Walnut Street, Phil-
adelphia, Pa.
Obituary Notes. — Dr. Mathew J. Mangan of
Rutiand, Vt., a graduate of the College of Medicine
of the University of Vermont, Burlington, in 1905,
died at his home on October 7.
The New Rochelle Hospital, New Rochelle, N. Y.,
receives $1,000 under the will of the late Mrs. Lydia
W. Thorne, which provides also for the ultimate
gift of the testator's country estate overlooking the
Sound, to the city of New Rochelle, to be used as a
public park.
Dr. James P. Connell of Fond du Lac, Wis., a
graduate of the Medical School of Northwestern
University, Chicago, in 1887, and a member of the
American Medical Association, the State Medical
Society of Wisconsin and the Fond du Lac County
Medical Society, died suddenly on October 22, at
St. Agnes Hospital, after performing an operation,
aged 54 years.
Dr. William Guy Frierson of Shelbyville, Ky.,
a graduate of the Medical Department of the Uni-
versity of Nashville in 1897, died at his home on
October 21, after a lingering illness, aged 41 years.
Dr. Eugene Alexander Freis of Brooklyn, N. Y.,
a graduate of the College of Physicians and Sur-
geons, Columbia University, New York, in 1885,
died at his home on November 6, aged 56 years.
Dr. Nathaniel McMaster of New York, a grad-
uate of Bellevue Hospital Medical College, New
York, in 1868, a member of the Medical Society of
the State of New York and the New York County
Medical Society, and attending physician to the
Demilt Dispensary, died at his home on November 8.
Dr. William Jack McMahon of Courtland, Ala.,
a graduate of the Long Island College Hospital,
Brooklyn, in 1860, and a member of the Medical
Association of the State of Alabama and the Law-
rence County Medical Society, died at his home re-
centy, aged 76 years. Dr. McMahon was a veteran
of the Confederate Army.
Dr. William C. Irby of Laurens, S. C, a grad-
uate of Jefferson Medical College of Philadelphia in
1870, died on October 26, aged 68 years.
Dr. William Alton Burr of Pasadena, Cal., a
graduate of the Hahnemann Medical College and
Hospital of Chicago in 1869, died recently, aged 76
years.
Dr. Edward William Schauffler of Kansas
City. Mo., a graduate of the College of Physicians
and Surgeons, Columbia University, New York, in
1868, a veteran of the Civil War, and a member of
the American Medical Association, the Missouri
State Medical Association, and the Jackson County
Medical Society, died at his home, from heart dis-
ease, on October 29, aged 77 years.
Dr. Owen J. Evans of Minneapolis. Minn., a
graduate of Albany Medical College, N. Y., in 1862,
died suddenly on October 17, from heart disease,
aged 76 years.
Dr. Eugene Clarence Dunn of Fresno, Cal., a
graduate of New York University Medical College
in 1881. and a member of the Medical Society of
the State of California and the Fresno County
Medical Society, died in a sanatorium in Fresno on
October 14, from nephritis, aged 62 years.
Dr. Frederick C. Weaver of Dayton, Ohio, a
graduate of the Miami Medical College, Cincinnati,
in 1894, and a member of the Ohio State Medical
Association and the Montgomery County Medical
Society, died at his home on October 14, aged 46
years.
Nov. 25, 1916]
MEDICAL RECORD.
953
Dr. Edward H. Grannis of Menomonie, Wis., a
graduate of the Hahnemann Medical College and
Hospital of Chicago, in 1875, and a member of the
State Medical Society of Wisconsin and the Dunn
County Medical Society, died at his home on Octo-
ber 14, from pernicious anemia, aged 62 years.
Dr. Frank C. Ferguson of Baltimore, Md., a
graduate of the School of Medicine of the Univer-
sity of Maryland, Baltimore, in 1901, died at his
home on October 11, from pleurisy, aged 37 years.
Dr. Gilman Corson Dolley, a graduate of the
Medico-Chirurgical College of Philadelphia, in the
class of 1907, died at Manila, P. I., on October 21,
at the age of 37 years. He was resident physician
at the Culion Hospital, Palawan.
Dr. Harry W. Weyant of Philadelphia, died of
pneumonia on November 2, at the age of 47 years.
He was graduated from the medical department of
the University of Pennsylvania, in the class of 1895,
and was for twenty-one years surgeon to the police
department of Philadelphia.
THE STORY OF A WINDOW TENT.
To the Editor of the Medical Record:
Sir: — My attention has been called to an adver-
tisement in the Journal of the American Medical As-
sociation of the so-called Walsh Window Tent, in
which it is stated that "four physicians invented it.
The patents of Dr. W. E. Walsh, Dr. J. H. Williams,
Dr. S. A. Knopf, Dr. W. B. McLaughlin are all
combined and built into the Walsh Window Tent."
That I invented the window tent which bears my
name, I do not deny. Those who saw my first tent,
shown on February 27, 1905, at the meeting of the
Medical Society of the County of New York, and the
illustration of it in the New York Medical Journal
of March 4, of the same year, and have also seen
subsequent pictures of it in various publications
(Neiv York Medical Journal, April 22, 1911, Medi-
cal Record, October 31, 1914, Seventh edition of
"Tuberculosis as a Disease of the Masses and How
to Combat It") will even grant me that the device
has been materially improved since it was first pre-
sented to the profession.
I protest, however, most energetically against the
statement in this advertisement to the effect that I
have taken out a patent on this device which was
worked out particularly for the benefit of the con-
sumptive poor who cannot have the luxury of an
outdoor porch. I feel, however, that I must give
the profession an explanation how this window tent
came to be patented at all.
After having seen Dr. Bull's aerarium, which is
an outdoor window tent, suitable for one or two-
story country houses, but utterly impracticable for
a New York tenement house, I was impressed with
the possibility of devising an indoor window tent
and eagerly began to work on the problem. At the
time when I was experimenting with the device Dr.
W. B. McLaughlin was my resident physician in the
New York Health Department's Riverside Hospital-
Sanatorium on North Brother Island. He claimed
to possess mechanical ingenuity and I gave him my
ideas of an indoor window tent, asking him to make
a model and promising to give him an opportunity
to read, together with myself, a paper on the sub-
ject of aerotherapy before the County Medical So-
ciety, when we would present this new device under
our combined names. He made a model, which un-
fortunately was not satisfactory, and I then gave
the idea of the device to the Kny-Scheerer Company
and they made me another model suitable for pres-
entation. In compliance with my promise, however,
I asked the that-time president of the County Med-
ical Society for a place on the program for the meet-
ing of February 27, 1905, the paper to be entitled
"The Open Air Treatment at Home for Tubercu-
lous Patients, with the Description of a Window
Tent and a Half Tent," to be read by S. A. Knopf,
M.D., and W. B. McLaughlin, M.D. I wrote the
paper and invited McLaughlin to be there to dem-
onstrate the window tent. He promised to be pres-
ent, but did not appear. I did not hear from him
again until I learned to my amazement that he had
taken out a patent for the window tent in his name.
I interviewed patent lawyers to find out what I
could do to contest the patenting of a device which
I had invented for the purpose of giving air and
light to the most unfortunate of the poor — the con-
sumptives in the tenement houses of our large
cities. I received a good deal of sympathy, but was
told that such a suit was likely to cost several thou-
sand dollars, and since Dr. McLaughlin had com-
plied with all the legal requirements prior to taking
out the patent, the outcome would be doubtful. I
did not feel that I could afford to risk such a large
sum, but in my popular writings on tuberculosis,
including my International Prize Essay, I made it a
point thereafter to describe the mechanism of the
tent completely so that any one handy with tools
could make one for himself.
From this little history of my window tent you
will see that I have a very strong reason to protest
against being designated as a patentee of a life-
saving device intended for poor consumptives, to
give them God's fresh air to which they should be
entitled without extra pay to such of the medical
gentlemen who claim to be inventors. I had in-
tended that my indoor window tent should be free
from all patent restrictions, just as the above men-
tioned half tent, sputum flask, and other devices
which I have from time to time designed in my anti-
tuberculosis work, are free to all who care to make
them.
The saddest thing of all in this matter is that the
manufacturers of my window tent, which, accord-
ing to such authorities as Babcock of Chicago and
Bonney of Denver, is ideal in every respect, claim
that they can no longer manufacture the device
without loss, owing to the large royalties they must
pay to the owner of the patent, so that now the poor
people who need it most will not be able to get the
tent at a reasonable rate. I have written to the
editor of the Journal of the American. Medical As-
sociation asking him to refuse to publish the ad-
vertisement with my name, and I have no doubt
that my request will be complied with. But among
the readers of the Medical Record I believe I have
a goodly number of friends who are not readers of
the Jownal of the American Medical Association
and for that reason I ask you, Mr. Editor, to extend
to this letter the hospitality of your columns.
S. A. Knopf, M.D.
Action of Salvarsan. — According to Citron injections
of soluble mercurials cannot cause the disappearance of
the Wassermann. Inunctions of mercury and injections
of insoluble mercurials give much better results. Sal-
varsan has a clean superiority to mercury in any form,
but has elements of danger. The author has seen it
cause death in patients with visceral disease, especially
in nephritis. The author gives both remedies in concert.
— Berliner klinische Wochensclirift.
954
MEDICAL RECORD.
[Nov. 25, 1916
OUR LONDON LETTER.
(From Our Regular Correspondent.)
WOUNDED SOLDIERS ENTERTAINED — OUR DAY — ZEP-
PELIN RELICS — LUSITANIA MEDAL, — OBITUARY.
London, October 23, 1916.
Five thousand wounded colonial soldiers were en-
tertained at a fete in Windsor Great Park last Sat-
urday afternoon. Australians, New Zealanders,
South Africans and Canadians were all present, and
all had had their part in the fighting, and many
had wonderful stories to tell. They were gathered
from about thirty hospitals in and around London.
The king showed his interest by granting the use
of the park for the occasion, and Princess Christian,
the Duchess of Albany, Princess Alexander of Teck
and her little daughter, Princess May, paid a visit
during the afternoon. The gathering originated
with Mrs. R. D. Fiske, who has previously enter-
tained wounded soldiers on a large scale, and was
on this occasion backed by the officials of the Aus-
tralian Commonwealth, the gathering being ar-
ranged to commemorate the departure of the first
Australian contingent to the front, just two years
ago. The weather was October's finest, and this
contributed largely to the success of the entertain-
ment, for it seemed rather risky to hold an outdoor
gathering in the middle of October. It was no
slight undertaking to provide for so many men.
There were 1,250 pounds of meat, 4 tons of flour,
6 hundredweight of sugar, 1,000 pounds each of
currant and plain cake, 12 barrels of grapes, 15
boxes of apples, 150 pounds of tea, £25 worth of
butter, and 20,000 cigarettes. The cavalry exercise
ground was specially laid out by the crown authori-
ties for the occasion, water was laid on, and about
a dozen field ovens installed for the purpose of
boiling it. Two huge marquees were erected, each
capable of accommodating a thousand men, tea be-
ing served in batches. The men came by train,
motor cars, and all sorts of vehicles, some even
on steam launches, by river, a taxicab association
brought 250 bad cases from the London hospitals,
and there were many private cars.
The celebration of "Our Day" on Thursday was
a great success, and the Red Cross Society and the
Order of St. John will benefit accordingly. The
weather was all one could hope for in a London
October, and almost every one you met in the street
wore the flag which betokened some gift to the
cause. Four millions of these flags were offered
for sale in London alone, and nearly all were sold.
For the Empire 35 millions were provided, and
it is said not many were left in the hands of the
ladies who sold. The flags were of paper, silk,
and other materials, and of various handsome de-
signs. There were also real zeppelin relics offered
for sale, which found ready purchasers. Brooches,
bangles, and other ornaments, woven with wire from
the wreck of the Cuffley zeppelin, disappeared as
soon as they were offered, at prices from one shil-
ling to ten, in some cases twenty. Well-known
ladies in large numbers presided over stalls in large
hotels and public places. Society was fully repre-
sented, both in the audience and among the inde-
fatigable sellers of programs.
A medal in commemoration of the Lusitania dis-
aster fetched £300. The king gave to the fund
£5,000 the queen £1,000, the Prince of Wales £1,000,
Queen Alexandra £500, the Australian Branch
£31,000; 30 contributors between them subscribed
£76,184. It was felt that no amount could exceed
the needs of the fund, which in the ordinary course
of a week expends £40,000 on the wounded. Last
year the amount raised on "Our Day" exceeded
£1,000,000, and this year a larger sum is hoped for.
An exhibition of zeppelin relics has been held
in the city for some weeks. It attracted some
20,000 visitors daily, and a collecting box realized
over £1,000, principally in coppers, for the Red
Cross Society and the Lord Kitchener memorial
fund. Later a private view was held in aid of
the Countess of Denbigh's war hospital.
The death has occurred of Mr. R. W. Doyne, the
eminent ophthalmologist of Oxford, of which he
was Hon. M. A. 1902. He was surgeon to the Ox-
ford Eye Hospital for more than 25 years and was
consultant to the Radcliffe Infirmary, and first
reader in ophthalmology to the university. The
congress on this specialty was originated by him,
and he was for many years its leading spirit. He
contributed valuable papers to the journals and
wrote a book on the "More Common Diseases of the
Eye," the value and misuse of spectacles in the
treatment of headache, migraine and other func-
tional troubles of the eyes, and undescribed forms
of iritis, family choroiditis and conjunctivitis were
illustrated by him in ophthalmic transactions.
Dr. G. A. Heberden of Victoria, S. A., great
grandson of the famous Wm. Heberden, has died
at the age of 55. He took the double qualification
in 1888. The next year he went to South Africa,
and practised there throughout his life. As M.
O. H. at the siege of Kimberley, he was awarded
the D. S. O.
Dr. W. Symington, J. P. for Brampton, Cumber-
land, where he practised for 28 years, died there
on the 3d inst., aged 51. He was a surgeon-major
of the Fourth Border Regiment (T. F.). He was
attacked by blood poisoning about four months ago,
which has proved fatal.
Dr. W. A. Haslam, R. M. O. Hull Fever Hospital
and Sanatorium, died September 1 of fever con-
tracted in his occupation. He was a Guy's man,
aged 51, took the double qualification in 1892, was
M. O. H. of Prescot (Lanes) Infirmary, 1898, and
in 1911 entered the service of the Hull Corpora-
tion.
Jlnmrrsa of iHpfctral ^ripnrr.
The Boston Medical and Surgical Journal.
November 9, 1916.
1. Treatment of Weak Labor Pains. Stephen Rushmore.
2. A Study of the Symptoms and Treatment of Congenital
Transduodenal Hands. John Homans.
3. Indications for Wet Packs in Psychiatric Cases; An
Analysis of One Thousand Packs Given at the Psycho-
pathic Hospital, Boston, .Massachusetts. Herman M.
Adler.
I. John Clarence Cutter. Sarah H. Powers.
5. Syphilis of the el K. Wood.
6. Control of Scarlet Fever. D. At Lewis.
2. A Study of the Symptoms and Treatment of Con-
genital Transduodenal Bands. — John Homans, having
met with a number of instances of these bands or ad-
hesions, deemed it worth while to make a study of all
such cases occurring over a period of several years at
the Peter Bent Brigham Hospital. The investigation
was undertaken to thruw light upon the question
whether transduodenal bands of congenital origin give
rise to such symptoms as to cause them to be consid-
ered a pathological entity, having a definite course,
symptomatology, and treatment. Eleven cases were
studied in which definite bands passing from the gall
bladder and liver across the duodenum were found, and
in which gastric or duodenal ulcers or gall-bladder dis-
Nov. 25, 1916J
MEDICAL RECORD.
955
ease had been held to be absent. There were six males
and five females, the average age of both being forty-
four years, the youngest nineteen and the eldest sixty-
seven. The average duration of symptoms was eight
to nine years. The general character of the patient's
complaint tended to resemble that of ulcer or gall-
bladder disease, but gave the impression of a reflex
symptom-complex. In respect to intermittency, the
symptoms resembled gallstones or chronic appendicitis
rather than ulcer; in respect to food relief, those of
gallstones and chronic appendicitis rather than gastric
or duodenal ulcer; but when food was present it simu-
lated duodenal or pyloric ulcer in type. In respect to
vomiting, the disease was rather like gastric ulcer or
gallstones; while in respect to bleeding, band cases
presented negative findings. In Roentgen-ray studies
these cases tended strongly to imitate duodenal ulcer.
Romans, at the same time, made a comparative study
of six cases of duodenal ulcers and six of gastric ulcers.
In the preoperative diagnosis of these cases there was
no mistake, while in the diagnosis of the eleven band
cases much inaccuracy was displayed. In but three of
the cases was the existence of bands suggested, while
ulcers of all types, gallstones, and cancer were consid-
ered as the cause of the condition. The Roentgen ex-
aminations in gastric and duodenal motility and in the
position and outline of the stomach and duodenum
showed abnormalities in all instances of well-developed
transduodenal bands in eight out of the eleven cases.
Three cases were not so studied. Of the eleven cases
operated on, one that of an old lady who died one
month after leaving the hospital, probably of cardiac
condition, ten have been followed for periods of two
and a half years in the first case to four months in the
most recent. Three patients died shortly after opera-
tion of intercurrent diseases. Of the eight living, all
are well or express themselves as satisfied with the
results of the operation. Homan treated these cases
by making a division of the transduodenal bands, and
in two instances opened the duodenum and performed
a Finney pyloroplasty. From the study and operation
upon these cases he draws the following conclusions:
(1) Congenital transduodenal bands may be responsible
for symptoms "reflex" in type which have, in spite of
considerable divergence, a definite family resemblance;
(2) accompanying these symptoms the Roentgen find-
ings very generally indicate duodenal spasm or dilata-
tion of the first, or first and second, portion of the duo-
denum; (3) division of the bands and appropriate treat-
ment of raw surfaces is satisfactorily curative, but
plastic operations to widen the opening into the duo-
denum probably give the best results; (4) congenital
transduodenal bands, judging from the frequency with
which they are reported at autopsy, are not necessarily
pathological, but may be responsible for digestive dis-
turbances having a recognizable symptomatology, a
prolonged course, and appropriate operative treatment.
6. Control of Scarlet Fever. — D. M. Lewis, epidemi-
ologist, Board of Health, New Haven, Conn., states
that, from lack of epidemiological observations on spo-
radic or endemic cases, the control of this disease is as
yet limited to the search for missed cases and the su-
pervision of reported ones. He shows that it is pos-
sible to demonstrate the carriers of this disease, who,
as responsible for the missed as well as the reported
cases, are consequently the basis for the control of
scarlet fever. He cites eight cases, ranging from seven
to twenty years of age, who were carriers of scarlet
fever. One case, a boy aged five, was reported Novem-
ber 2, 1914. Released at expiration of six weeks, with
discharging ears and purulent nasal discharge. During
following two months there were four neighborhood
cases in children of the same age. Almost a year later
Lewis found the same boy being admitted to a day
nursery with his ear filled with cotton, a purulent nasal
discharge, a marked streptococcus sore throat, a straw-
berry tongue, and a temperature of 102°. Without en-
suing rash or desquamation, it was only after six weeks'
treatment that the nasal discharge was cured and the
tongue faded. Carriers may be divided into two groups:
those individuals having ear or gland discharges at the
end of convalescence, and those who have had the dis-
ease previously. The one essential is that both groups
shall show some grade of buccal-pharyngeal inflamma-
tion as shall be characteristic of primary scarlet fever.
With the subsidence of this factor in the first group
and its absence in the second group, Lewis does not
find individuals infective. Lewis not only carries out
strict quarantine measures, but any carrier in the fam-
ily, house, or neighborhood was isolated, though given
rear-yard freedom. Inspection of adults was insisted
on only when there was a history of previous sore
throats or the adult was a raw-food handler. Postal-
card notification of all school absentees, as well as
those who are in school and have nasal or ear discharge,
is the basis for finding carriers. During the last four
months of 1915, with some thirty-nine reported cases,
he has a record of twenty-one carriers found, as well
as three missed cases; for the first five months of 1916,
with some ninety cases of the disease, a record of ten
carriers and two missed cases. He says in conclusion
that he has abolished recurrent cases, made infrequent
secondary cases, and lessened reported cases by dem-
onstration of carriers of convalescence and carriers pre-
viously having had the disease and by isolating these
carriers. Results of so-called grading of quarantine
does not depend on the quarantine, but upon the fact
of the presence of the carrier being within or with-
out the family circle. Full liberty may be safely given
to all contacts who are free from the signs of the dis-
ease at the time of isolation of the one sick and the
carrier. Control of scarlet fever will be found to lie in
the supervision of those who have previously had the
disease, at and during those periods when with inter-
current infections they again show the buccal-pharyn-
geal signs of scarlet fever. Secondarily, missed cases
and the convalescent reported cases are of equal impor-
tance.
New York Medical Journal.
November 11, 1916.
1. The Blood and Its Vessels in Epilepsy, and Their Treat-
ment. Thomas E. Satterthwaite.
2. Strychnine as a Tonic. William Forsyth Milroy.
3. Final Control in Medicine. Beverley Robinson.
4. Epilepsy. T. E. McMurray.
5. Postures and Types of Breathing Exercises. Nathalie
K. Mankell, and Edward C. Koenig.
6. The Relationship Between the Nervous System and
Therapeutics in Pulmonary Tuberculosis. Francis M.
Pottenger.
7. Joint Hypotonia. Harry Finkelstein.
8. Acute Mastoiditis. Harold Hays.
9. Shall We Get Rid of Tuberculosis at Last? Richard Cole
Newton.
10. The Struggle for Binocular Single Vision. Aaron Bray.
11. One Thousand Wassermann Reactions. John M. Ladd.
1. The Blood and Its Vessels in Epilepsy, and Their
Treatment. — Thomas E. Satterthwaite states that
though it has long been known that circulatory de-
rangements are produced by epilepsy, it is only during
recent years that it has been found, conversely, to pro-
duce epileptic attacks. In the three principal varieties
of this disease circulatory disturbances are among the
dominating features. He does not include Jacksonian
epilepsy, because circulatory anomalies are not con-
stant features of the neurosis. He refers to many
authorities on this disease with reference to the circu-
latory conditions found, and quotes Gower as advo-
956
MEDICAL RECORD.
[Nov. 25, 1916
eating many years ago the use of nitroglycerin. Ech-
everra of New York about half a century ago stated
that cardiac diseases might originate epileptiform con-
vulsions from embolism of the cerebral arteries. Sachs
has recently reported one case in which focal epilepsy
was produced by enlarged veins in the pia mater and
another by similar conditions in the dura mater. An-
other case is referred to in which the epileptic attacks
disappeared after the vascular growth at the base of
the brain had been removed by operation. After re-
ferring to the general hygienic and therapeutic man-
agement of epilepsy, Satterthwaite is led to the follow-
ing conclusions: (1) Abnormalities of cardiovascular
phenomena occur in the vast majority of epileptic seiz-
ures. (2) The grosser forms of cardiac disease rarely
occur in epilepsy. In fact, they are present in so small
a proportion as to indicate that they are accidental
rather than determining factors of it. (3) That a
cerebral disease or abnormality may produce epilepsy
is well established. The evidence shows that removal of
enlarged veins or nevoid growths adjacent to the base
of the skull has been followed by cessation of the seiz-
ure. (4) There is therefore a reciprocal relation be-
tween circulatory disorders and epilepsy to this extent;
that epilepsy causes circulatory disturbances and that
abnormalities of blood or vessels cause epilepsy. This
reciprocal relation he believes to have been hitherto
overlooked. (5) In most forms of epilepsy there is
cerebral anemia, and this is relieved effectively by va-
rious heart stimulants, the high-frequency current, and
radiant electric light. The importance of the use of
cardiac stimulants in epilepsy has not been properly
appreciated by the profession.
2. Strychnine as a Tonic. — William F. Milroy puts up
a plea for strychnine, for he believes that the profession
as a whole only half appreciates this old time remedy.
Doctors are afraid of it. Few realize what it can ac-
complish in maximum doses; it is in this phase of the
subject that he is especially interested. He uses it
chiefly in cases of pulmonary tuberculosis, where it can
be tolerated and be made to produce beneficial results
over a period of years; while in nervous disorders rep-
resenting conditions of depression good results are to
be obtained. Also in pneumonia, when edema is form-
ing in the dependent portion of the unaffected lung,
prompt relief can be given in a few hours by the injec-
tion of one-sixth grain of strychnine. Its action is pri-
marily upon the nervous system, including the sympa-
thetic system, producing a stimulation of the physiolog-
ical activity of practically the whole body. Admitting
that cardiac muscular power and blood pressure are not
influenced by strychnine, nevertheless the heart action
is influenced favorably in certain conditions, such as
irregular, intermittent heart. Cellular nutrition is not
a process of passive absorption, but is an active, vital
process under the direct control of the nervous system.
Therefore the profound stimulation of the nervous sys-
tem by full doses of strychnine directly promotes a new
and vigorous cell activity of the whole body, thus tend-
ing to restore the lowered opsonic index. Milroy usu-
ally administers the drug by mouth, four doses daily,
beginning with one-thirtieth grain and adding one-
thirtieth to the daily allowance at the end of each five-
day period until eight-thirtieths are given daily, then
reducing the increase to one-sixtieth until the limit is
reached. The maximum dose is indicated by the oc-
currence of muscular rigidity. Though the drug may
not be wholly eliminated from the body under eight
days, it is practically gone at the end of twelve hours,
and therefore the doses must not be too infrequent.
No tendency to habit formation can be induced, and a
perfectly safe margin exists between the first appear-
ance of muscular spasm and a really poisonous dose.
4. Epilepsy. — T. E. McMurray announces that in his
limited experience with epilepsy the following facts im-
pressed him strongly: Digestive disturbances as mani-
fested by foul breath, coated tongue, constipation, and
intestinal gases; the enormous appetite, especially for
bread and sweets. He reports three cases out of eleven
treated according to his treatment in which improve-
ment has been marked as indicated by an absence over
a continued period of time of the convulsions and im-
proved general health. The diet followed was that out-
lined for diabetes, otherwise starch and sugar free.
He recommends to these patients Hill's book on dia-
betes, thereby giving suggestions for a more liberal
diet. McMurray also included pancreatin and sodium
bicarbonate at meals, a dose of epsom salts every fourth
day, and mineral oil daily if needed to keep the bowels
active. In only two cases was it necessary to give
bromides, and then only for a short time. In two of his
cases convulsions returned after excesses at the table
and disappeared after the diet was restricted again.
The cases all showed gastric hyperacidity, acidosis, but
no glucose in the urine. A blood test for sugar was
not made.
Journal of the American Medical Association.
November 11. 1916.
1. The Health Education of the General Public. W. C.
Rucker.
2. The Nonspecific and the Specific Defense of the Child
Against the Tubercle Bacillus. Francis M. Pottenger.
3. The Use of Boiled Milk in Infant Feeding and Else-
where. Joseph Brennemann.
4. The Use of Malt Soup Extract in Infant Feeding. B.
Raymond Hoobler.
5. Rest of the Individual Lung by Posture. Gerald B.
Webb, Alexius M. Forster, and F. M. Houck.
6. Tumors of the Third and Fourth Ventricles. I'eter
Bassoe.
7. The Progressive Torsion Spasm of Childhood (Dystonia
Musculorum Deformans) : A Consideration of Its
.Nature and Symptomatology. J. Ramsay Hunt.
S. Bacteriological Findings in Cerebrospinal Fluid in Polio-
myelitis : A Preliminary Report of the Examination of
Fifty Cases. John W. Nuzum.
9. The Therapeutic Research Committee of the Council on
Pharmacy and Chemistry of the American Medical
Association. Torald Sollmann.
10. The Treatment by Radium of Carcinoma of the Pros-
tate and Bladder: Preliminary Report. Benjamin S.
Barringer.
11. Separation of Buttocks. John C. Silliman.
1. The Health Education of the General Public—
W. C. Rucker states that in order to accomplish any-
thing in a public health way it is necessary that the
sanitary authorities have the financial and moral sup-
port of the citizenship. As assistant surgeon-general,
United States Public Health Service, he speaks with
authority when he says that if the general public is
not informed as to the need for personal and public
hygiene and sanitation, it is extremely difficult to se-
cure public health. More and more time is being de-
voted in efforts to bring these facts before the public;
but the work has only just begun, and he considers that
there is at least thirty years of hard work ahead before
maximum results will be achieved. If publicity be of
the right sort and carried on with a full understanding
of the mass psychology, it will achieve good results in
the end. While the spoken word, the mass meeting, has
a certain place in public health education, it must not
be forgotten that only those who are interested in the
problem come to the lecture. Too much dependence
has been placed in the spoken word. What the Amer-
ican people want is more demonstration and less talk
in public health work. Demonstration takes many
forms, including stereopticon slides and motion picture
films. In reference to the first method, the pictures
should be good enough to tell their own story without
the aid of the lecture, and the same may be said of the
lecture. Moving picture films have not been absolutely
successful; the sanitary scenario must be sugar-coated
Nov. 25, 1916]
MEDICAL RECORD.
957
in order to live up to the traditions of the motion pic-
ture stage. Printer's ink is the greatest medium of
public health education. Intelligent, well-written news-
paper articles, prepared after due consideration of the
psychology of the average newspaper reader, are of the
greatest benefit. The greatest sanitary hope of the
future lies in the health education of the child. This
must begin with the kindergarten and extend through
to college days. The general public does not know how
much good can be done them. We must create in them
a demand for public and personal hygiene. It would be
well to study the methods which have been used in
popularizing manufactured articles and to change the
plan just enough so that it may better fit this important
work which lies ahead of the medical profession. He
considers that the American Medical Association has
already accomplished much in this field, but there is
much more to be done.
2. The Nonspecific and the Specific Defense of the
Child Against the Tubercle Bacillus. — Francis M. Pot-
tenger. (See Medical Record, June 24, 1916, page
1162.)
3. The Use of Boiled Milk in Infant Feeding and
Elsewhere. — Joseph Brennemann. (See Medical Record,
June 24, 1916, page 1162.)
4. The Use of Malt Soup Extract in Infant Feeding.
— B. Raymond Hoobler. (See Medical Record, June 24,
1916, page 1163.)
5. Rest of the Individual Lung by Posture. — Gerald
B. Webb, Alexius M. Forster, and F. M. Houck state
that respiration in a normal person takes place upward
of 30,000 times in twenty-four hours. When a tubercu-
lous patient rests on one side at night, the dependent
lung is restrained in motion; but the upper lung opens
and closes about 12,000 times in ten hours of sleep.
They have noticed a marked tendency for the consump-
tive to lie on the side of the better lung at night, and
it often happens that the very lung which needs the
most rest is getting the most work. For various rea-
sons it would seem that the majority of normal persons
sleep on their right sides. While Walsh pointed out
that in pulmonary tuberculosis the disease would seem
to begin in most patients at the right apex, the writers
have noted that they have had more patients needing
pneumothorax with extensive left-sided than with ex-
tensive right-sided tuberculosis. From history one
would suppose that the disease would be more wide-
spread in the more exercised lung; but the fact that
the majority of persons sleep on their right sides and
that the majority of advanced tuberculous lesions are
apt to be found in the left lung may not prove to be
entirely coincidental. The experiences noted from suc-
cessful artificial pneumothorax show the great value of
rest of the individual lung. During the past year they
have applied this principle of rest in a large number of
cases, and in addition have placed a small firm pillow
to restrain the motion of the diseased lung to a greater
degree. Some patients so treated have been able to re-
main lying on the side of the diseased lung over twenty
hours a day for months at a time with little effort. This
must be accomplished gradually. The results were en-
couraging, and the writers feel that they have observed
in certain cases a cessation of fever, a diminution of
expectoration, and lessened liability to relapses. In a
tuberculous patient a moderate degree of hyperemia is
thus produced by this rest on the affected side. Rest on
the right side must be done occasionally in order to
afford drainage when needed. It would seem wise, the
authors think, to observe all patients who suffer from
either nocturnal or early morning hemorrhages, with a
view to ascertain, if possible, the side on which they
have slept at night.
8. Bacteriological Findings in Cerebrospinal Fluid in
Poliomyelitis. — John W. Nuzum states that it is the
opinion of those familiar with the bacteriology of polio-
myelitis that the cerebrospinal fluid, whether obtained
by lumbar puncture during life or at necropsy, is ster-
ile. Recently he reported the isolation of a gram-posi-
tive micrococcus from the cerebrospinal fluid during life
in eight out of nine cases of acute poliomyelitis, and a
little later this same peculiar gram-positive micro-
organism has now been isolated from the spinal fluid in
forty-five out of fifty cases studied. It presents the
same cultural and morphologic characteristics as does
the micrococcus isolated from the brains and spinal
cords in fatal human cases at necropsy. Control cul-
tures were made with the cerebrospinal fluid obtained
by lumbar puncture from normal individuals and from
patients afflicted with diseases presenting more or less
clinical symptoms resembling infantile paralysis, such
as brain tumors, tabes, tic, etc. In no case was the
peculiar microorganism characteristic of poliomyelitis
obtained. The cultures were made as follows: From
1 to 2 c.c. of the spinal fluid was regularly inoculated
into a series of four tall tubes containing ascites dex-
trose broth, ascites broth, human ascitic fluid, and as-
cites broth to which a sterile piece of rabbit's kidney
was added. The tubes were inoculated at 35° C. At
the end of twenty-four to thirty-six hours a diffuse tur-
bidity commonly appeared in all four tubes of the posi-
tive cultures. Control tubes remained clear. Smears
made at this time usually revealed a minute organism,
gram-positive and arranged in pairs, clumps, and short
chains. Many were so minute as to be just visible under
the oil immersion lens. They corresponded in every
morphologic detail to the minute globoid bodies de-
scribed by Flexner and Noguchi. A further description
of the tubes containing the cultures at the end of forty-
eight to seventy-two hours was given, and the smears
made then show a larger form of the same organism.
Any routine clinical test would be of inestimable value
in these cases of poliomyelitis, especially the atypical
cases. It was hoped that complement fixation tests
might prove a valuable aid in diagnosis. Bacterial anti-
gens were prepared from the cultures of the bi'ains and
spinal cords at necropsy. With suitable controls hem-
olysis resulted in a large number of cases tested. A
number of cases are reported by the author in order to
illustrate the value of the isolation of the organism as a
routine measure. In the cases reported the disease re-
sembled poliomyelitis, but examination of the fluid
showed none of these organisms. At necropsy the true
cause of each condition was found, and none was a case
of poliomyelitis.
10. The Treatment by Radium of Carcinoma of the
Prostate and Bladder. — Benjamin S. Barringer gives
the results of his experience with this form of treat-
ment, and states that problems presented by bladder
and prostate carcinomas are so entirely different that
they must be considered separately. He gives the tech-
nique of using radium in both conditions and reports of
cases, and offers the following summary: By means of
radium we have caused the rapid and complete disap-
pearance of two bladder carcinomas out of nine treated.
These cases were carcinomatous by cystoscopic appear-
ance and microscopic examination. Time only will tell
whether these patients are cured. In one case of pro-
static carcinoma, treated for six months, the carcinoma
and the symptoms have markedly retrogressed. In an-
other case, treated three months (possibly borderland),
the symptoms have improved. Of three other patients
treated, one is dead, one has only recently been treated,
and one is doing a full day's work but could not be
reached for examination.
958
MEDICAL RECORD.
[Nov. 25, 1916
The Lancet.
October 21, 1916.
1. An Address on the Spirit of Medicine. J. Mitchell Bruce.
2. Some Observations on Dysentery. William Magner.
3. A Series of Military Cases Treated by Hypnotic Sug-
gestion. J. Bennett Tombleson.
4. The Luetin Reaction in Syphilis. William Fletcher.
5. The Surgical Uses of Ozone. George Stoker.
6. Placenta Prasvia and Cesarean Section. A. G. Tresidder.
7. Left Fallopian Tube Found in Femoral Hernia. E. G.
Renny.
2. Some Observations on Dysentery. — William Mag-
ner divides this disease into two more or less distinct
stages, due to the pathological aspect of the large in-
testine. The early stage of this condition is character-
istically apyrexial, but the later stage is pyrexial due
to the bacterial invasion of the intestinal walls. As a
result of his work on a large number of cases of dys-
entery he draws the following conclusions: (1) Both
in amebic and bacillary dysentery secondary invasion
of the ulcerated intestinal wall by organisms from the
intestinal lumen is an important factor aggravating
both the local and general condition. The pyrexia so
frequently observed in the later stages of amebic dys-
entery is a result of this secondary invasion, and,
though usually toxic in origin, may be due to bacterial
invasion of the blood stream. A similar septicemia
may occur in the bacillary type of the disease. (2)
Amebic dysentery may be latent, the ulcers being con-
fined to the cecum and producing no symptoms. Apart
from the danger of the disease becoming active, such
cases may act as foci for the spread of the disease.
(3) Every case of amebic dysentery should be treated
by the administration of at least 10 grains of emetine.
Incomplete treatment may result in the patient becom-
ing a cyst carrier and a danger to the community.
(4) The prevention of amebic dysentery depends upon
the elimination of cyst carriers, rapid and complete
disposal of fecal matter, and protection of food from
dust and flies. (5) In bacillary dysentery the earliest
pathological change in the intestinal wall is dilation of
the vessels and a marked hemorrhagic exudation into
the submucous coat. Leucocytic accumulation is a later
phenomenon resulting in necrosis of tissues. (6) Man-
nite-fermenting dysentery bacilli can exist in the intes-
tine in an avirulent form. The presence of such an or-
ganism in the stools loses much of its significance in
the absence of a positive Widal reaction. (7) The ag-
glutination reaction in dysentery is a valuable means
of differentiating the bacillary type of the disease. In
Shiga infections specific agglutinins are invariably
present after the first week of the disease. Distinct
agglutination with a serum dilution of 1 in 100 is diag-
nostic. (8) Judging from serological tests, it would ap-
pear that certain organisms, normally saprophytic, may
in both types of dysentery stimulate the production of
specific agglutinins as the result of invasion of the ul-
cerated intestinal wall. (9) The toxins of Shiga's bacil-
lus are highly pathogenic to rabbits. Subcutaneous in-
jection with either living or killed cultures results in
the development of paralytic symptoms and death. The
characteristic lesions of the human disease cannot be
readily reproduced.
3. A Scries of Military Cases Treated by Hypnotic
Suggestion. — J. Bennett Tombleson reports the result
of sixty cases which he has treated by this method of
therapeutics. He considers the most successful results
were obtained in cases of shock psychasthenia of all
kinds, while cases of hyperthyroidism and neurasthenia
also showed good results. So far as he has been able
to trace them, the cure has been permanent in these
cases, and he suggests that if the samp standard of
criticism be applied to these rases and to similar cases
treated in other ways the utility of hypnotic suggestion
would be obvious to any fair-minded critic. Among the
cases treated were those of neurasthenia due to shock
but with a history of condition some time before the
war; psychasthenia, due to injuries; trench shins, due
to exposure in Balkans; epilepsy, in which fit had oc-
curred every two months but oftener since enlistment;
hyperthyroidism, and chronic rheumatism.
5. The Surgical Uses of Ozone. — George Stoker con-
siders this method of treatment of wounds satisfactory
from every standpoint. He gives the results of the
first twenty-one cases treated at the Queen Alexandria
Military Hospital, which cases were for the most part
those of cavities and sinuses in the femur and tibia.
The apparatus used is known as an Andriolis ozoniser,
and the treatment consists in the application of ozone
to the affected parts. The properties of ozone, which
have a wonderfully healing effect, are, as far as is
known at present, three: (1) It is a strong stimulant,
and determines an increased flow of blood to the affected
part. (2) It is a germicide which destroys all hostile
mieroorganic growth. (3) As the French chemist Hen-
nocque has shown, it has great powers in the formation
of oxyhemoglobin. The ozone is applied on the wounded
surface or to the cavities and sinuses for a maximum
time of fifteen minutes, or until the surface becomes
glazed. Ozone has the particular power of disclosing
dead bone, foreign bodies, septic deposits, etc. This it
does by destroying the granulations and mieroorganic'
growths (presumably unhealthy) that are found in
close contact with septic deposits, foreign bodies, or
dead bone. Cleansing and Dressing: Wounds and sinu-
ses, etc., are washed twice daily with boiled water and
a dressing of dry gauze is applied. It must be observed
that at first ozone causes an increase of the discharge
of pus; later on the pus is replaced by clear serum,
which at a still later stage becomes colored reddish or
pinkish. In open wounds it is necessary to strip off the
parchment-like film surrounding the edges, which is
composed of oxidized serum. This is easily effected by
applying a hot compress for fifteen or twenty minutes,
after which the film can be easily peeled off with a dis-
secting forceps.
7. Left Fallopian Tube Found in Left Femoral
Hernia. — E. G. Renny presents a report of a case of
this condition, and states that he has found no record
of a similar case. The patient, aged forty-two, mar-
ried, mother of three children, noticed a lump in the
left groin for eighteen months. During the last five
weeks it had become painful, and, thinking it was a
rupture, she bought a truss and wore it. The truss
made the lump very inflamed and painful. She then
consulted Dr. Renny, who found a painful swelling in
the groin which, on account of the inflammation present,
made the diagnosis uncertain. It was dull to percus-
sion, irreducible, with no impulse on coughing and no
strangulation symptoms. The finger could be passed
up the inguinal canal for a short distance. Later, after
rest and a subsiding of the inflammation, an incision
was made over tumor. It proved to be a femoral hernia
with somewhat thickened sac, containing a considerable
quantity of green fluid, under tension. Occupying the
crural canal was a red, soft substance which, when trac-
tion was made on it. proved to be the left Fallopian
tube, with its fimbriated extremity presenting. This
was returned to the abdomen without much difficulty.
British Medical Journal.
October 21. 1916.
1. The Highly Strung Nervous System. Guthrie Rankin.
2. Practical Hints on Functional Disorders. M. Culpin.
Preliminary Note on the Intravenous Injection of Gyno-
cardate of Soda in Leprosy, with Farther Ex;
ence <>f Its Subcutaneous Use. Sir Leonard Rogers.
I The Treatment of Certain Diseases of Protozoal Oripln
by Tartar Emetic Alone and in Combinations. Aldo
Castellani.
Nov. 25, 1916]
MEDICAL RECORD.
959
5. Hydrotherapy as an Agent in the Treatment of Conva-
lescents, frank Radcliffe.
fi. Notes on Blood Culture Technique. R. L. Thornley.
1. Digested and Diluted Serum as a Substitute tor Broth
tor Bacteriological i^ui poses. A. Distaso.
S. Biliary Regurgitation After Gastro-enterostomy. Jas. II
.NlCOll.
2. Practical Hints on Functional Disorders. — M. Cul-
pin says that eighteen months' service has convinced
him that much harm is done by failure to recognize
psychical disabilities which, though sometimes so ex-
traordinary as to deceive the most wary, should gen-
erally be diagnosed by anyone who is awake to their
possibilities. Tests of sensation should be applied where
there are not enough signs fully to account for all dis-
ability present. To differentiate between conscious and
unconscious simulation is necessary but often difficult;
sometimes the hysteric is a good fellow who deserves
sympathy more than is consistent with cure; sometimes
he resists all treatment and may say that he has no
wish to be well. Among the types of cases tested and
treated was one of talipes varus with a decided obses-
sion; tilted pelvis with scoliosis and apparent shorten-
ing of a leg, which condition can be produced at will;
paraplegia after shell-shock, which may, however, be
genuine and needs careful diagnosis; frostbite, rheu-
matism, and abdominal psychoses. Culpin urges that a
careful watch be kept for such cases when they begin.
There is no mystery in the diagnosis; ordinary methods
of examination, supplemented by sensory tests, detect
the majority of them. In every injury the extent of
possible movements should be early ascertained, and if
no contradictions are present these movements should
be strongly encouraged. A man whose functional dis-
order is diagnosed as organic will probably be a cripple
for the rest of his life; the longer he remains under the
shadow of a wrong diagnosis the harder will be the cure
when his true condition is recognized.
3. Preliminary Note on the Intravenous Injection of
Gynocardate of Soda in Leprosy. — Sir Leonard Rogers,
who has had a long experience with this treatment as
well as with the subcutaneous method, and published the
results of the same in a recent paper, gives a further
statement. He gives a detailed description of the
method of preparation of sodium gynocardate and the
technique of intravenous injections. He says that the
two great advantages of the intravenous over the sub-
cutaneous method are its painlessness and greater effi-
ciency. Several months are required to produce an
improvement by the subcutaneous method, while by the
intravenous method the improvement is decidedly rapid.
This is a big factor, since many of the patients refused
to return until any material result could be expected
from the subcutaneous method, while from the shorter
method results are practically sure. The most striking
result is the occurrence of definite local reactions in the
diseased tissues, sometimes accompanied by fever. A
most decided reaction was in the greatly thickened ears
of a tubercular case, in whom fever occurred for three
days, with redness and swelling of the helix, accom-
panied by some serous discharge containing broken-
down leprosy bacilli. After the subsidence of the re-
action at the end of ten days the diseased tissues were
softer and less indurated than before, while nodules on
the face, not showing the local reaction, were also di-
minished in size. In two anesthetic cases, with greatly
thickened ulnar nerves, tenderness and slight swelling
appeared in the affected portions after intravenous in-
jections, which has been followed by some return of
sensations in previous anesthetic areas of the hand. It
is thus clear that intravenous injections of the drug
have produced selective local reactions in the diseased
tissues with the greatest amount of infiltration of the
tissues with leprosy bacilli. While the results obtained
have been decidedly beneficial and no ill effects have
been found to follow these reactions, yet the possibility
of dissemination of the bacilli in the body must not be
lost sight of. Rogers concludes from the 200 intra-
venous injections of gynocardate he has given that he
will substitute that method entirely for the subcutane-
ous method.
4. Treatment of Certain Diseases of Protozoal Ori-
gin by Tartar Emetic. — Aldo Castellani, acknowledging
the work of other men in this direction, states that he
has experimented with it in the tropics in the treatment
of yaws, kala-azar, Oriental sore, and relapsing fever.
The mode of administration varies, depending on the
accessibility of the patient. Tartar emetic, though effi-
cacious in yaws, is far from being speedily curative,
and gives better results when combined with other
drugs, of which potassium iodide is most beneficial;
mercury has practically no action. He uses what is
known as the Castellani mixture, which contains tartar
emetic, sodium salicylate, potassium iodide, sodium bi-
carbonate, and water. The active drugs in the mixture
are the tartar emetic and potassium iodide, while tht
sodium salicylate, though not having any specific effect
on the malady, seems to hasten the disappearance of the
thick, yellow crusts capping the framboeting nodules.
The sodium bicarbonate decreases the emetic effect and
prevents to a certain extent the symptoms of iodism.
Tartar emetic was first used by Castellani for the cure
of kala-azar. He treated children between two and four
years for this disease. One case died, due to the fact
of being in a dying condition when presented for treat-
ment. The others recovered, treatment having been
given to some intravenously, to some intramuscularly,
and others by oral administration. In one both intra-
muscular injections and oral administration of the drug
was used. In the intravenous injections the usual 1
per cent, tartar emetic solution in sterilized normal
saline answers well; tartar emetic in 2 per cent, car-
bolic acid solution is also used, especially in relapsing
fever. Half to 2 c.c. is diluted at the time of injection
with sufficient sterile saline to bring it to 5 c.c. and the
whole injected into a vein, taking the usual precautions.
For intramuscular injection tartar emetic gr. viii, car-
bolic acid ttj x, glycerin 5iij, and distilled water to 3j-
Half to 1 c.c. is given every other day intramuscularly.
The oral administration is given in conjunction with the
two other methods, and tartar emetic gr. v, bicarbonate
of soda gr. xxx, glycerine 5j, chloroform water 5j, and
water to 3iij can be given one to two teaspoonfuls in
water three times a day. This dose can be doubled for
adults. He concludes that tartar emetic is of great effi-
ciency in various protozoal diseases such as already
mentioned, and seems to have a beneficial effect also in
relapsing fever.
7. Digested and Diluted Serum as a Substitute for
Broth for Bacteriological Purposes. — A. Distaso claims
that this substitution allows for a more luxuriant
growth of the B. coli group, the streptococci, the sta-
phylococci, B. subtilis, B. proteiis, and fluorescein, and
that, compared to it, the growth on normal broth seems
scanty. The medium is prepared as follows: (a) One
volume of sheep or ox serum is mixed with one volume
of tap water, and boiled till it becomes milky, (b) A
pancreas of a pig is minced and extracted with 400 c.c.
of distilled water in the presence of chloroform for
twenty-four hours. (The first experiments were per-
formed with 1 per cent, trypsin, but, for the sake of
economy, afterward pancreatic extract was used, which
is equally suitable for the purpose.) (c) A piece of the
upper part of the small intestine is extracted in the
same way in order to activate the pancreatic extract,
(d) To one liter of (a) is added 100 c.c. of (b) and 10 c.c.
of (c), and digested at 60° C. for the night. Next morn-
960
MEDICAL RECORD.
[Nov. 25, 1916
ing the flask contains an amber-colored liquid with fine
flocculi floating in it. Filtered through Chardin paper,
the amber-colored liquid passes through and the floc-
culi remain in the filter. The liquid is collected and
sterilized at 120 C. for fifteen minutes, then tubed and
resterilized.
Berliner klinische Wochenschrift.
September 25, 1916.
Medicine in the University of Warsaw in the Past. —
Brudzinski gives a survey of medical teaching in the
university during the old Polish cycle. Nawrocki, the
physiologist — with particular reference to the nervous
system — was active in the university from 1867 to 1874,
at which period the stifling advent of Russianization
interrupted his career. His was not a strong character.
There remain for consideration Szczucki and Luczkie-
wicz. The former lived during 1786-1832. He joined
the faculty of Warsaw University in 1818 as professor
of medicine and pathology, and in 1825 began to deliver
lectures on the history of medicine. He was a fanatical
advocate of Latin for medical instruction, which inter-
fered with his usefulness. The opposition to the mother
tongue on the part of a Polish teacher shows that the
Russians did not exactly originate this proscription.
Luczkiewicz lived 1826-91. Not until 1862 did he join
the medical faculty, and in 1864 began to teach pathol-
ogy and therapy. His literary activity was marked,
and he founded no less than three prominent journals,
edited a cyclopedia of medical science to which he was
also a contributor, wrote a text-book on diseases of the
nervous system, and was also a prolific translator. No
activities are mentioned after 1876, and his status in
the Russianized university is not given. The credit
awarded to Szczucki and Luczkiewicz is chiefly because
of their broad activities in attempts to fix the status of
medicine as a science and art, to write its history, to
look ahead, to preserve the national traditions, and es-
pecially to determine the preliminary instruction best
adapted to a medical career (propedeutics).
Uric Acid Reaction in the Saliva. — Von Noorden (and
Fischer) reports briefly on this subject, and refers to
the elaboration of Folin's calorimetric method for the
general determination of uric acid. This rests on meas-
urements of the blue color which arises when phospho-
tungstic acid acts upon uric acid in the presence of
soda solution. This method has done well in blood de-
terminations of uric acid, and doubtless our knowledge
of blood urea has been considerably increased by Folin's
method as contrasted with the older procedures for
which large quantities of blood were required. As far
back as 1889 Medicus was speculating as to the prac-
ticability of a test based on the blue color liberated in
phosphotungstic acid precipitates as a means of de-
termining the amount of uric acid and other related sub-
stances, but so far as known he abandoned this lead.
The author and van Ackeren, however, used this prin-
ciple in determining the presence of uric acid in the
perspiration. They found a marked positive result in
gouty and nephritic cases. The author then proceeded
alone in tests of gastric juice and saliva, the former
being invariably positive. With saliva there was a
positive result in chronic nephritis and gout and a faint
reaction in normal men. The announcement of Folin's
special method at once caused the author, in cooperation
with Miss Fischer, to take up again the old line of re-
search. The results are thus far as follows: After the
mouth has been cleansed, saliva is induced to flow by
chewing movements and exercise of the tongue. Most
of the fluid comes from the submaxillary glands. When
to the saliva is added phosphotungstic acid and soda so-
lution a blue color almost always appears. If the re-
agent and saliva are present in equal proportions this
color varies between light sky-blue and deep blue. The
saliva should be diluted with water and acetic acid
added cautiously to get rid of the mucus. Albumin is
now precipitated by boiling and the filtrate tested again
for albumin with negative results. The phosphotung-
stic acid now gives a positive result. Each ingredient
of saliva when individually tested gives a negative re-
sult, showing that some alien substance must be in-
volved. When Folin's technique for blood urea was ap-
plied traces of uric acid were found — up to 10 mg. to
100 c.c. saliva. The highest values were, as already
stated, associated with gout and nephritis. In very
young subjects 1 or 2 mg. appear to be normal. The
authors have as yet a number of problems to work out.
It must be learned whether uric acid can be ranked as
a normal constituent of the saliva.
Munchener medizinische Wochenschrift.
September 26, 1916.
Investigations into Typhus Fever. — H. da Rocha-Lima
in his studies of this subject ignores completely the
claims of Proescher and denies that the Plotz organism
is the cause of the disease. He is concerned chiefly
with the finds in the body louse, rather than with the
various organisms recoverable from the infected blood.
He goes back to 1910, in which year Ricketts and Wilder
announced the discovery of certain polar-staining or-
ganisms in infected lice. Since that period a number
of observers, including the author, have independently-
discovered this organism in the louse, and it has even
been claimed that it has been seen in the normal louse.
The author, at first with Prowazek and later by him-
self, found, as a result of hundreds of experiments, that
certain corpuscles could be recovered only from lice
which had sucked blood from typhus patients. These
he named the Rickettsia Proivazeki. In the absence of
cultures a suspension of the infected portions of the
louse injected into guineapigs not only gave the same
picture as when typhus blood is injected, but also con-
ferred immunity. Suspensions of normal lice were used
as controls, and proved negative. The Rickettsia cannot
be made to grow on Plotz's medium, nor as yet on any
other. Its nature cannot be determined, and morpho-
logically similar formations may be seen in smears, so
that the sole identification at present is the inoculation
test. Since the preceding was written the author has
pursued his researches and has found that when lice
are allowed to feed on a convalescent typhus patient
they never become infected. In other words, there is
no such a person as a healthy typhus carrier. The sec-
ond generation of lice which have been infected very
seldom have the disease (one positive result in thirteen
cases). Immediately after, and even at times during,
defervescence the blood is so nearly sterile that lice are
but seldom infected. At the other extreme the blood
may not infect the louse until the fourth day of the dis-
ease, but this point has not been determined. The au-
thor is still at work on his subject.
Burial Injuries in the Trenches. — Orth speaks of the
comparative frequency of burial by falling earth which
has as results shock and severe internal injuries. The
displacement of earth, masonry, and scaffolding usually
results from shell explosion. Thus a man is suddenly
pinned in a certain posture, in one case with knees
slightly flexed. After four hours patient could no
longer feel his legs and was not dug out until eight
hours had elapsed. As the trench was still under fire,
he could not be moved to the hospital until seventeen
hours after his accident. In this case only the legs suf-
fered, because the man was merely caught in the scaf-
folding. Another soldier was covered as high up as the
Nov. 25, 1916]
MEDICAL RECORD.
961
navel, but retained some leeway of movement in the
trunk and limbs. After extrication he was found to be
intact in the trunk and in the joints of the extremities,
the muscles being the tissues to suffer most (this was
also true of the first patient). These accidents affect
chiefly the calf muscles, and the resulting contractures
leave the patients crippled, with an equinus gait.
Microscopic biopsy shows that the muscle undergoes a
special type of injury in these cases, involving degen-
erative phenomena. The changes have been likened to
those of ischemic contracture produced by tight band-
ages; but the author states that such a condition, which
is due primarily to anemia, cannot explain all the phe-
nomena. In the more severe cases there is more or less
crushing, comminution, laceration, compression at a
single point, with resulting necrosis and efforts at re-
generation.
Le Bulletin Medical.
October 14, 1916.
The Fecal and Urinary Peril at the Front. — Bonnette
states that because of the siege-like character of the
present war, with troops almost stationary, unusual
precautions are required for the disposition of excreta.
Man is a poison to man through the presence of the
latter, and no amount of preventive inoculation can
take the place of sanitation. Among the precautions
included under the latter head is the sterilization of
water in barrels by Javelle's solution ; the drilling of
new wells and their supervision; the incineration or
burial of filth of all kinds; the removal of dunghills; the
whitewashing of habitations; the extirpation of lice
and rats; the daily cleansing and sweeping of trenches
and shelters; the frequent changing of loose straw and
straw-beds in the subterranean posts; the supervision
of privies and urinals, etc., etc. Accumulation of fecal
matters furnishes the greatest peril. Some sanitarians
advocate the use of long, shallow furrows around the
towns, without burial. The feces, exposed to the light
and air as well as to the soil, rapidly disappear through
nitrification. The surface water is not polluted. Ad-
mitted disadvantages are the smell and the likelihood
that torrential rains will flood the environment. Even
worse is the attraction of flies with the possibility of
fly-borne diseases. This disposition of feces is satis-
factory in the case of troops on the march, but not in
trench warfare. Portable receptacles (half-barrels)
covered with wooden seats are recommended by others.
As fast as these are filled they may be dumped in large
pits. This idea is sound in theory but not practicable.
The receptacles are never dumped until they overflow.
They are provided with handles and carried about, so
that they continually slop over. Moreover, should they
come into common use many barrels would be taken
from the regular supplies, and the price would soon go
up. Much more practicable are deep pits boarded over
to serve the purpose of fixed privies. The covers are
perforated with holes, with hermetic lids, which serve
to exclude flies. Such pits must be built far removed
from wells. A shelter is constructed over them, open
only in front. In loose, sliding earth the vaults should
be coffer dammed. There is a great variety of con-
struction described in this connection. Small, portable
cabinet apparatus provided with tin pails may be used.
The permanent vaults may vary in accordance with the
number of people to be accommodated at a time, and
may be constructed with the same care as privies for
barracks, with brick vaults or waste pipes. The troops-
should be compelled to use these privies, and if, under
cover of darkness, they avoid making the necessary
journey must be disciplined. While much urine finds
its way into the privies, separate portable tin cans with
freely moving handles are provided at convenient sta-
tions which are indicated by signs. These are emptied
every morning and then disinfected with cresyl or
other substance. A zinc gutter placed at a slight in-
cline along the side of a wall is also much used, the
urine being carried to a receptacle. There appears to
be nothing new in any of these devices and nothing
peculiar to warfare.
La Presse Medicale.
October 23, 1916.
Modifications of Cardiac Murmurs Under the Influ-
ence of Ocular Compression. — Lauboy and Harvier sum
up an article on the subject as follows: The effects of
ocular compression vary and are at times contradictory,
as far as stethacoustic translation is a guide. Never-
theless, we obtain the impression, even in the absence
of graphic proof, that compression of the eye pro-
foundly modifies the cardiac contractions. Even elec-
trocardiography throws no light on this subject as a
whole. That the reflex arc is complete in the test is
certain. Compression is at once followed by a rhythmic
response, and there are also certain other responses
connected with the contraction of the heart. Neverthe-
less, the finds differ not only in different subjects but
in a single individual. A phenomenon of this sort, in
which every individual test may be peculiar, must, of
course, disconcert the clinician and cause him to re-
nounce it as a practical measure. The valvular lesion
which provokes the murmur does not comprise the total
pathology of the heart, but when due to organic dis-
ease it speaks without uncertainty, even if at times in
a feeble voice. We have only to hear it to know how to
make it speak and to incite it to speak. Hence the
authors' test may prove of value in the individual case.
Anaphylaxis. — Soula endeavors to sum up briefly the
entire doctrine to date of anaphylaxis. As originally
formulated by Richet in 1902 it was a very simple affair.
He was then dealing with a single poisonous substance.
At present, after enormous research which has led to
complicated conclusions, there is a tendency to return
to Richet's primitive hypothesis. Thus the attempt to
extend the production of anaphylaxis to nonproteid sub-
stances has been recalled. Richet would do away with
the belief that anaphylactic reactions are specific and
give rise to the formation of immune bodies. The na-
ture of anaphylatoxin is still obscure. The phenomenon
known as passive anaphylaxis shows that the primary
injection induces some change in the blood. Anaphy-
lactic shock after the second injection shows the great
role of the nervous system in anaphylaxis. Extracts
of degenerated nervous tissue readily sensibilize ani-
mals and anaphylactic shock produces peculiar altera-
tions in the brain which renders the nerve substance
toxic. After an animal has been sensibilized it shows
changes in metabolism along with functional hyper-
activity. A sort of proteolysis results, with increased
elimination of nitrogen, while the brain lipoids are in-
creased as a result of anaphylaxis, save when they are
combined with nitrogen. Phosphorus when not com-
bined with lipoids is increased by anaphylaxis, etc. To
sum up in a few words, anaphylaxis seems to be a gen-
eral reaction of the nervous system. The changes in
the blood and fluids are perhaps secondary, and due to
neurochemical disturbances.
Female Bleeders. — Castex mentions the extreme in-
frequency of hemophilia in the female. In the celebrat-
ed Mampel family, four generations of 212 individuals,
there were thirty-seven bleeders, all males. In certain
individual statistics, however, 10 per cent, and even
more have been of the other sex. The author describes
in detail a case of hemophilia in a girl of sixteen. —
Revista de la Asociacion Medica Argentina.
962
MEDICAL RECORD.
[Nov. 25, 1916
Physiological Chemistry. A Text Book and Manual
for Students. By Albert P. Matthews, Ph.D., Pro-
fessor of Physiological Chemistry in the University of
Chicago. Second Edition. Illustrated. Price, $4.25.
New York: William Wood & Company, 1916.
Further acquaintance with this excellent treatise has
served only to confirm the praise of it expressed in
these columns on the occasion of its first appearance.
The time that has elapsed since that date is so short
that but little modification has been required in the
present edition. The most noteworthy changes appear
to be in the section on colloids, in the discussion of which
their surface properties receive rather more emphasis,
and additional references have been supplied in some
instances through the book. This feature of the work is
an especially useful one, and the extensive bibliogra-
phies appended to each chapter make the volume most
serviceable for reference. The book is an extraordi-
narily complete presentation of physiology from the
chemical standpoint, and cannot fail to win the ap-
proval of every reader.
Venesection. A Brief Summary of the Practical
Value of Venesection in Disease. For Students and
Practitioners of Medicine. By Walter Forest
Sutton, M.D., Fellow of the American Medical Asso-
ciation ; Member Medical Society of the State of
Pennsylvania; Allegheny County Medical Society;
Ex-President, Carnegie Academy of Medicine, etc.
Illustrated with several text engravings and three
full-page plates, one in colors. Price, $2.50. Phila-
delphia: F. A. Davis Company, 1916.
The first impression obtained by the reviewer refers to
the complete omission of any reference to the work on
the same subject by Heinrich Stern which has appeared
within two years. The present book was written be-
cause there appeared to be a demand for it, according
to the author. With Dr. Stern's excellent work on the
market, such a demand was perhaps satisfied. The
author is, however, unusually well qualified to write on
the subject, and the book itself reflects throughout his
great practical experience and general information.
Tratado de Pediatria. Por el Dr. Andres Martinez
Vargas, Catedratico numerario por oposicion de En-
fermedades de la Infancia en la Universidad de Bar-
celona, etc., etc. Tomo I. Fundamentos de la Pedia-
tria, Anatomia, Fisiologia, Hygiene, Patologia y Tera-
peutica de la Infancia. Barcelona: T. Vives, 1915.
Dr. Vargas is an authority on pediatrics of interna-
tional reputation, and a treatise on that subject from
his pen is an event in the world of medicine. This first
volume of 959 pages carries the reader only through
general pediatrics, and if the same thoroughness is to
be maintained in special pediatrics at least two volumes
of like size should be necessary to complete the work,
which represents the fruit of the labors of 33 years in
the chair of pediatrics in Barcelona. Over 500 pages
are devoted to the anatomy, physiology, and hygiene,
and nearly 200 pages to general pathology of infancy.
The section on general therapeutics, 146 pages long,
seems hardly necessary from the American viewpoint, as
most of the material will have to be duplicated else-
where, and is in general inferior to the preceding sec-
tions. But few pages are given on diet, although we
should expect to find in this section the entire subject
of infant feeding. Normal dietetics is found under
physiology, but in practice it is hardly possible to con-
sider diet for the well child apart from that of the
ailing child. The several excellent monographs on child
development have been utilized freely by the author,
and calory feeding in infants and young children re-
ceives much attention. The very bulk and thorough-
ness of the work is evidence enough that the author has
drawn extensively on the labors of all contemporary
authorities. On the other hand, he appears to have
received no assistance from collaborators, so that when
finished it will stand as a monument to his life activity.
Examination of the Urine and Other Clinical Side-
Room Methods (late Husband's). By Andrew
Fergus Hewat, MB, Ch.B., M.R.C.P., Ed. Tutor in
Clinical Medicine, University of Edinburgh; Lecturer,
Edinburgh Post-Graduate Vacation Course. Fifth
edition. New York: Paul B. Hocher.
This little book is of great practical value. It was
written with the view of giving the student a short de-
scription of the methods of examining urine, blood,
stomach contents, sputum, etc., and well fulfills the
purpose. That part of the book dealing solely with the
urine is the result of a very thorough revision of the
fourth edition of Husband's book on "The Urine in
Health and Disease." It is a work that would be of
service to all medical students.
Diagnosis and Treatment of Surgical Diseases of
the Spinal Cord and Its Membranes. By Charles
A. Elsberg, M.D., F.A.C.S., Professor of Clinical
Surgery at the New York University and Bellevue
Hospital Medical College; Attending Surgeon to Mt.
Sinai Hospital and the New York Neurological In-
stitute. Price, $5 net. Philadelphia and London: W.
B. Saunders Co., 1916.
This book is a notable addition to neurology and seems
destined to become a classic in the diseases and surgery
of the spinal cord. Dr. Elsberg has divided his subject
into three parts. He takes up first the anatomy and
physiology of the spinal cord, together with the sympto-
matology of surgical spinal disease. The anatomy and
physiology are necessarily very briefly discussed, but all
the essentials are given. One of his chapter headings
is rather curiously expressed: "The Normal and Patho-
logical Physiology of the Spinal Cord." Why not "The
Physiology and Pathology?" Chapter VII deals with
Roentgenology of the spinal column and contains no
less than 23 plates showing x-ray pictures of various
parts of the spinal column, normal and diseased, most
of them full-page plates. These are excellent examples
of the radiographer's skill. There are some beautiful
pictures of fractures of vertebrae, also spondylitis. One
of the latter bears the remarkable caption : "The x-ray
findings were confusing, but did not cause the patient's
symptoms." This must have been a relief to the radio-
grapher.
The second part of the book deals with operations
upon the spinal cord and nerve roots. In this part the
general practitioner will find what is probably the best
description of lumbar puncture in the literature. This
little operation sometimes has to be done by the family
physician, and he is now and then embarrassed by fail-
ure; it seems, moreover, to be a difficult thing to find
discussed adequately in the literature. Dr. Elsberg de-
votes nine pages to it, with seven illustrations, all of
them helpful. His chapter on laminectomy, rhizotomy,
and aspiration of the cord is excellent and, like all the
rest of the book, well illustrated.
The third and largest part of Dr. Elsberg's work is
devoted to surgical diseases of the spinal cord and mem-
branes and is up to the high standard set by the first
part of the book. The chapter on spina bifida is espe-
cially good. Comparatively little space is given to bullet
and stab wounds of the cord and only one picture is
shown, an x-ray of a bullet between the first and second
lumbar vertebrae, and this comes from the European
war. Railway spine is discussed in less than a hundred
words — it had better have been left out altogether.
Mention should be made of the illustrations, which are
superb. There are photographs from life, diagram-
matic studies, x-ray pictures and, best of all, a number
of splendid drawings by Mr. Josef Lenhard from speci-
mens, dissections, and actual operations. In short, all
of the subjects discussed in this volume are illustrated
so thoroughly as to enhance greatly their perspicuity.
The book, aside from its great medical value, is a
notable example of the publisher's art.
The Medical Clinics of Chicago. July 1916. Vol-
ume II — Number 1. Price $8.00 per year. Phila-
delphia and London : W. B. Saunders Company.
In this first number of the second volume there are
presentations from nine clinics and a contribution on
oral infections by T. W. Brophy. A number of cases
of diabetes are presented in a sketchy fashion but are
followed by a fair discussion of the subject. The con-
tribution on oral infection is excellent and is marked
by a sane conservatism. Several of the cases presented
from the clinics also involve the investigation of this
subject so that its importance is well emphasized. In
connection with the presentation of a case of "mul-
tiple tubercular serositis" we wish to protest that ex-
amples of infection with the tubercle bacillus should
be designated "tuberculous" since the term "tubercu-
lar" has no specific application. In this same case the
clinician expresses surprise that the fluid obtained from
the chest should contain an excess of polynuc]ear cells
and thinks there may be some secondary infection.
The French have shown that the tubercle bacillus mav
at times excite a polynuclear reaction and that such
infections are usually comparatively severe. There
is an excellent clinic on the subject of fluoroscopy of
the stomach.
Nov. 25, 1916]
MEDICAL RECORD.
963
S>nmtH Skjrortfi.
MEDICAL SOCIETY
OF THE COUNTY
YORK.
OF NEW
Stated Meeting, Held October 23, 1916.
The President, Dr. Frederick E. Sondern, in the
Chaik.
The Treatment of Contracted Pelves, with Special Ref-
erence to Pubiotomy. — Dr. A. J. Rongy presented this
communication in which he stated that the morbidity
associated with childbirth had not been sufficiently em-
phasized either by teacher or by practitioner. The re-
duction of mortality and morbidity of childbirth de-
pended upon our ability to properly manage the preg-
nant state from the thirty-sixth week of pregnancy on
to the end of labor. This was especially true in primi-
paras. Modern social conditions undoubtedly exerted
a pernicious influence upon childbirth. By forcing a
great number of young women to the industrial field
early in life and compelling them to engage in seden-
tary occupations, their proper physical development
was prevented. Among those of the higher social strata
there was a tendency to overtax the nervous system
either by overstudy or manifold social duties. The re-
sult was a highly sensitive nervous system, incapable of
combatting the emergencies of life. These conditions
had created new problems for the obstetrician, because
of the inability of a large percentage of women to de-
liver themselves. Hitherto too great emphasis had been
laid on the pelvic measurements; it was the relation of
the fetal head to the pelvis that must always be taken
into consideration. This clinical phenomenon must not
be observed at term, when labor had already set in, but
careful examination should be made from the time the
fetal head was supposed to engage itself in the pelvic
basin; this was frequently between the thirty-seventh
and thirty-eighth week of gestation. As the head con-
tinued to grow it might dislodge itself, so that when
labor was about to commence the head would be found
floating above the pelvic brim. Had labor been induced
at the time the first signs of disproportion appeared it
would in all probability have terminated spontaneously.
In the light of our present knowledge induction of labor
at a period of full viability of the child was not asso-
ciated with any danger to mother or child. Hospital
statistics in reference to the induction of labor were
not conclusive and should not be used as a guide. The
average hospital patient was not intelligent, and it was
often impossible to obtain the exact date of the last
menstruation. As a rule, the weight of the child could
be properly estimated and labor could always be in-
duced in cases in which the child apparently weighed six
pounds or more. Dr. Rongy stated that during the past
few years he had induced labor in seventeen such
patients, the smallest child delivered being six pounds,
eight ounces; the largest eight pounds, two ounces.
He felt sure that the morbidity in these cases was
greatly reduced and that the lives of not a few infants
were saved. Recent investigations by a number of
obstetricians proved that the period of gestation varied.
It was shown that only 80 per cent, of women went
into labor between 270 and 280 days from the date of
their last menstruation. A number of women carried
beyond their computed time from one to five weeks.
When this occurred the bones of the head became
harder, the fontanelles diminished in size and moulding
of the head during labor could not take place very read-
ily. Furthermore, these infants did not stand labor
well, between 15 and 20 per cent, dying during labor.
Patients were usually advised to have labor induced
when they went ten days beyond the computed date.
The great problem in obstetrics was not the manage-
ment of those cases in which a correct diagnosis had
been made early, but those that suffered from a relative
disproportion of the fetal head and pelvis in whom
labor had already set in. This class of cases were com-
monly known as the borderline cases. In over 80 per
cent, of these patients delivery by forceps would be
comparatively safe if they were given the test of labor,
but in a small percentage of cases the head failed to
engage, notwithstanding strong uterine contractions
lasting twenty-four hours or longer. Labor in such in-
stances had reached a stage in which cesarean section
as a method of delivery must be eliminated, the mor-
tality of cesarean section in such cases being more than
20 per cent. These patients must be delivered by the
vaginal route, either by high forceps, pubiotomy, or
craniotomy, depending upon the condition of the child
and the parity of the woman. High forceps, except in
rare instances, must be eliminated from the category of
modern obstetrics. This procedure was unsurgical and
its fetal mortality in the hands of the most competent
obstetricians over 50 per cent. The invalidism it in-
duced in the mother was too great. Secondary plastic
operations on the vault in such cases was almost im-
possible, because of the extensive cicatrization of old
lacerations. High forceps might be resorted to in multi-
para, who suffered from simple fiat pelvis in whom the
vaginal vault was relaxed, and in such cases they tried
to engage the head in one of the oblique diameters. The
only indications for craniotomy were in cases in which
the child was dying or dead, and in cases in which at-
tempts at high forceps delivery had failed after a num-
ber of applications. Craniotomy ought never be per-
formed when the child was fully viable. Cases brought
to the hospital after having been in labor from twenty-
four to thirty-six hours, with a history of having been
examined frequently, presupposed infection and one
was compelled to resort to the method which was least
dangerous for the mother, and at the same time offered
the greatest margin of safety to the child. For this
class of patients pubiotomy became the operation of
choice. Pubiotomy should never be performed when the
diagonal conjugate was less than 7.5 cm., or when the
disproportion of the head and pelvis seemed to be too
great. The sacroiliac joint was always injured when
the separation of the cut ends of the bones was too
great. Cesarean section should be made the operation
of election, pubiotomy the operation of emergency.
Pubiotomy had the advantage over any form of
Cesarean section that the patient was not left with a
scar in the uterus, which might permanently weaken the
uterine wall. The writer's experience with pubiotomy
consisted of twenty-eight cases performed at the Jewish
Maternity Hospital during the past seven years. This
was the second largest series in this country. This
operation was never undertaken unless the head was
partially engaged or showed a tendency to engage, the
cervix fully dilated and fetal heart sounds regular and
of good quality. That the field for this operation was
small was demonstrated by the fact that it was only
resorted to eighteen times in over 9,000 indoor cases.
Of the twenty-eight mothers, twenty-seven were dis-
charged from the hospital between the fourteenth and
forty-eighth day, the average stay being twenty-one
days. One mother developed gangrene of the toe on the
tenth day and finally died. All the children were born
alive, but not all survived. Eight died at times varying
from three hours to twenty-four days after birth. The
chief objection to pubiotomy was the complication that
might be encountered during its performance. It should
never be undertaken by one who had not had proper
training in obstetrical surgery. The danger of injury to
the bladder and urethra was very great. In only one
case, however, in this series did sloughing of the bladder
wall occur. Communicating tears of the vagina oc-
curred in six cases, but were readily repaired. Hemor-
rhage and oozing from the cut ends of the bones was
always controlled by pressure and packing. The gait
was somewhat impaired temporarily in six patients.
Injury to the sacroiliac joint could be avoided if the
thighs were properly held by two assistants in order to
prevent too much separation of the cut ends of the
bones. The partly open method of Doderlein was fol-
lowed in twenty-one cases, while in the remaining seven
cases the open method was used. Dr. Rongy presented
a brief history of these cases, from which he said it
might be observed that nearly 60 per cent, of the pa-
tients were multipara?, whose previous labors were com-
plicated and resulted in the death of the children. The
vaginal vault in these cases was lacerated and relaxed.
The Gigli saw might also be used as a prophylactic
measure in cases of breech extraction, in which some
difficulty was expected in the delivery of the head; the
bone could be quickly severed in order to permit the
head to pass through.
Dr. George L. Brodhead said that Dr. Rongy had
brought up many interesting points. He said there was
practically no danger in the induction of labor, and
while he thought that the procedure was comparatively,
free from danger, one might get a prolapsed cord or
malposition. Craniotomy was a comparatively safe
procedure so far as the mother was concerned, but it
had been abandoned in cases in which the child was
viable and in good condition. By a careful examination
964
MEDICAL RECORD.
[Nov. 25, 1916
they could determine the size of the child quite ac-
curately, but in fat women, and where there was hydra-
mion this could not, as a rule, be done. It was undoubt-
edly true that some women did go beyond the normal
period of gestation, and in these patients the advisa-
bility of inducing labor should be considered. They did
not induce labor now as often as they did ten years ago.
They had found that with proper diet the patient might
be able to go to term, but in some instances labor must
be induced at the eighth month. He could not agree
with Dr. Rongy that labor should always be induced
when the patient apparently went ten days beyond term.
The question was simply one of relative proportion be-
tween the head and the pelvis. The high forceps opera-
lion was a dangerous procedure, especially in primi-
parae, and must be undertaken with a great deal of
caution. Craniotomy should not be considered if the
child was in good condition, and one hesitated to do a
Cesarean section in possibly infected cases. Dr. Brod-
head thought that Dr. Rongy was to be congratulated
upon the results in his series of cases and his figures
were in accord with those of Dr. Williams of Baltimore,
but personally he felt that, taking into consideration
both the morbidity and mortality to mother and child,
they would get better results with the extraperitoneal
Cesarean section than with pubiotomy, but at the pres-
ent time they were not in a position to state with au-
thority which of the two operations should be per-
formed.
Dr. George W. Kosmak said that he had performed
pubiotomy in four cases, the last three years ago. Since
that time he had not seen a case that offered the proper
indications for this operation. In three of these cases
they obtained living children; the fourth case was oper-
ated upon after the application of the forceps and there
occurred a submucous rupture of the sphincter ani. This
was not discovered until after the woman got up and
found that she had no control over her bowel move-
ments. One of the great problems in obstetrics was
the borderline case, in which the proper diagnosis had
not been made or where there had been a lack of judg-
ment on the part of the physician. In these cases the
women were formerly allowed to go into labor and to
do the best they could. If the child could not be de-
livered, craniotomy was resorted to, but fortunately that
time was past. Dr. Kosmak was glad that Dr. Rongy
had taken such a conservative view with reference to
the scope of pubiotomy. This was a procedure that
should not be undertaken unless the proper means were
at hand for carrying it out in a correct manner. It was
a good thing to wait until the head became engaged.
As to permanent enlargement of the anterior-posterior
diameter of the pelvis as a result of pubiotomy, he had
made repeated examinations after this operation, and
they failed to show any increase in this diameter. He
had also found that bony union might take place. He
bad come to feel that the vaginal examination played
a small part in infection and he had seen Cesarean sec-
tion done where no vaginal examination had been made,
and the woman became septic. He did not believe that
the infections were due to the vaginal examinations
altogether. If the infecting organisms were in the
vagina then they probably got infection.
Dr. Ralph Waldo said that a few years ago this
operation was quite popular. Dr. Rongy's paper
brought out clearly the indications for pubiotomy. It
was indicated for the emergency type of patients and
was not an operation of preference. When the head
was engaged and there was apparently a slight dispro-
portion between the head of the child and the maternal
parts, it might be advisable to resort to pubiotomy.
Pubiotomy was indicated in a very small percentage of
cases.
Dr. A. J. Rongy, closing the discussion, said that he
did not come to advocate any single method of delivery,
but only to attempt to show how better results might
be obtained in cases of labor if they were properly
watched and if indications and contra-indications for a
given procedure were carefully studied. He wished to
bring to the notice of the medical profession that if a
woman was carefully observed from the thirty-sixth
week of pregnancy to the end of labor, that manv
radical operative procedures would be avoided. It dill
not seem fair and reasonable to the average pregnant
woman to neglect her during the most delicate period
of her life. The usual practice followed by a great
number of physicians to examine the patient once at
the time she called on the doctor to make arrangements
for the delivery could not be too strongly condemned.
In answer to Dr. Kosmak he said that in their cases
I bey had no permanent enlargement of the pelvis after
this operation and that the union was fibrous in two-
thirds of the cases. He did not wish to be misunder-
stood on the question of induction of labor. He did not
perform it unless signs of disproportion of fetal head
and pelvis began to appear. Induction of labor could
be used as a prophylactic measure after the thirty-sixth
week of pregnancy only, otherwise the life of the child
was endangered.
Notes on the Diagnosis of Abdominal Distention in
Children. — Dr. LOUIS Fischer read this paper. (See
page 932.)
Dr. Henry Koplik said that he saw a good many
cases of distension and usually these were referred to
the pediatrist only when the diagnosis was difficult. In
a case of intussusception with distension, it was diffi-
cult to make the diagnosis, because when the disten-
sion developed there was no tumor, or the tumor dis-
appeared, and then they must make the diagnosis not
only on the abdominal but on the general condition.
The cases of distension one met with in connection with
pneumonia were puzzling, and it was sometimes diffi-
cult to say whether the case was one of peritonitis or
of lobar pneumonia. Abdominal distension sometimes
decided the issue of a case of pneumonia and was some-
times the final symptom. The pneumonia might not
be of great extent and the physician thought he was
dealing with a peritonitis; at the same time the" might
have a pneumonia and a peritonitis. The causes of
distension was sometimes very obscure. The diet might
have something to do with it, and also the diaphragm
where there was a local inability of the gut underneath
the diaphragm to expel flatus.
Dr. Max Einhorn said that the most cases that
he saw in children had to do with partial chronic intes-
tinal obstruction. If they saw a stiffening of the bowel
or a peristaltic wave then the diagnosis was easily
made. The distension might be due to a tuberculous
peritonitis and, in some cases, was probably due to in-
testinal fermentation.
Experiences in Bone Surgery in France. — Dr. Fred H.
Albee spoke on this subject, which he illustrated with
lantern slides. He said that at the present time the
chief feature of the war was the surgery of the bones,
tendons and nerves. It took an immense amount of
time for these septic war wounds to clear up under their
older methods of surgery. He hoped to emphasize the
fact that this was not the case with the Carrel-Dakin
method of sterilizing wound. In many of the war
wounds there was a great amount of lost tissue, and
when such wounds were treated by the Carrel-Dakin
method, the results were most remarkable. The granu-
lations were a deep, healthy red, the edges of the wounds
were not inflamed, and the skin was not indurated or
sensitive and would slide about the wound very readily.
These wounds looked different from any he had ever
seen. When a case came from the front the first step
was to look for foreign bodies and to localize them. For
this the fluoroscope was used and the foreign body
charted. The surgeon then went in and took out the
foreign body and all the lacerated tissue was trimmed
away carefully. Then the fenestrated rubber tube,
either covered with gauze or not, was fastened in the
wound, and sutured or not sutured. The tubes were
laid so that the gauze might be kept saturated with the
solution all the time. The reservoir was so arranged
that by turning a stop cock the solution could be fed
into the tubes. Just enough was allowed to flow in to
keep the gauze saturated to the proper degree. A thick
coat of yellow vaseline was applied around the wound.
In some wounds a system of tubes was used. If the
wound was a stump, it was soaked in the solution.
Bacteriological examinations of the wounds were made
every second day. taking a smear from the worst part
of the wound. When only one or two bacteria were
found in the microscopical field, the wound was closed.
The microscopical appearance of a wound was not to be
(rusted as an indication of the time it might be closed.
By this method of treatment the percentage of primary
unions had been over 95 per cent. This method of treat-
ment was applicable to compound and communited
fractures as well as to flesh wounds. Dr. Albee dem-
onstrated with the aid of motion pictures his method of
putting in bone grafts, which was so effective in restor-
ing limbs from which large portions of bone had been
lost. These bone grafts were being used a great deal
in jaw surgery.
Dr. H. H. M. Lyle showed colored photographs of
wounds that were treated by the Carrel-Dakin method
and said the point he wished to make narticularly clear
Nov. 25, 191 6 J
MEDICAL RECORD.
965
was that this treatment was not merely the employment
of a certain antiseptic, but a plan consisting of an im-
mense amount of detail. There was no pus in these
wounds and there were no inflamed edges. By the
older methods it took about three months, sometimes
much longer, to heal up a compound fracture; by this
method most of these wounds were healed in from
twenty-eight days to six weeks. Out of 450 cases
treated by this method and sutured up, there were only
six failures and these were not bullet wounds, but the
more severe war wounds. Depage reported 137 cases
with two failures, eighty compound fractures without a
drop of pus. Pus had been practically abolished in
that ambulance.
Dr. Samuel Lloyd said that they were all learning
and he felt that it was well to have these things brought
home to them, because they might have to use them and
possibly sooner than they expected. They sent nurses
to the Mexican border who wrote that they had 550 pa-
tients in the hospital. Only a very few of them weir
paratyphoids and dysenteries, the rest were gun-shot
wounds and fractures. The fractures were the result
of riding untrained mules and horses, and the gunshot
wounds from trying to learn the use of the new auto-
matic pistols.
NEW YORK ACADEMY OF MEDICINE.
SECTION ON OBSTETRICS AND GYNECOLOGY.
Stated Meeting, Held April 25, 1916.
Dr. George W. Kosmak in the Chair.
Degenerating Fibroid with Marked Toxemic Symptoms.
— Dr. Solomon Wiener reported this case and pre-
sented the specimen, which consisted of the uterus with
adnexa and a large submucous fibroid. In the fresh
state the uterus was the size of a five months gravid
organ and the fibroid was as large as a grape fruit.
The tumor was held under great tension. On cross-
section it showed marked edema with softening. It was
deep purple in color and contrasted strongly with the
pink color of the uterine musculature. It showed ir-
regular areas of deep red, yellowish, and gray discol-
oration. The pathological report was fibromyoma show-
ing edema and beginning degeneration. The patient
from whom this specimen was removed was forty-five
years of age, and had had six children and one mis-
carriage. A year before she had been operated on for
acute appendicitis. For about two months before com-
ing under the writer's care she had been bleeding every
two weeks, the amount of blood lost being about as
much as at the normal menstrual periods. About four
days before her admission to the hospital she had been
seized with severe pain beginning in the left lower
abdomen. This persisted, and later radiated to both
groins and sides. The day before operation the patient
appeared very ill, much more so than was indicated by
her pulse of 120 and temperature of 100.8° F. Physical
examination showed marked tenderness over the lower
abdomen with voluntary rigidity. Bimanually a large
mass could be felt filling the hypogastrium and extend-
ing from the symphysis half way up to the umbilicus.
The mass was firm, tender, and somewhat elastic. The
uterus could not be felt separately from it, and the
cervix apparently moved with the mass. Because of
the thickness of the abdominal wall an absolute diag-
nosis could not be made. However, the indication for
operation was clear. A simple supravaginal hyster-
ectomy was performed. The patient required stimula-
tion while on the table and for twenty-four hours after-
wards. Her subsequent convalescence was uneventful.
The chief point of interest in the case was the marked
toxemia with the relatively slight degenerative changes
in the tumor. The submucous character must have been
the reason for the marked absorptive symptoms and
toxemia. This class of tumors must be regarded as
truly urgent, for the moment that infection of degen-
erative changes occurred the patient's life was endan-
gered.
Examination of Semen with Special Reference to
Minor Defects. — Dr. William H. Cary of Brooklyn read
this paper. He said the frequency with which male
sterility resulted from the lesser degrees of seminal
defect was not realized, nor were the pathological con-
ditions of the semen upon which sterility depended well
understood. Proof of this was found in the literature
which was very scant on this subject, especially in this
country where the examination and study of semen
had been much neglected. This might have been due,
in part, to the unpleasant nature of the work, but
more particularly to the difficulty encountered in secur-
ing properly collected specimens for examination. While
always eager to claim his share of glory in the produc-
tion of his offspring, a man was most reluctant to share
any responsibility for failure. The study of this sub-
ject had been seriously handicapped by the almost uni-
versal assumption on the part of the laity that in the
event of a childless marriage the wife was wholly re-
sponsible. It was not difficult to understand why such
an erroneous impression had prevailed so long. In
the male, ability to copulate and the normal ejaculation
were regarded as sufficient evidence of his power to
procreate; while in the female, the process of ovula-
tion was an obscure one and, therefore, more readily
suspected to be at fault. It was significant that the
more study and observation this subject received, the
higher was placed the percentage of male sterility. In
countries where venereal diseases were more prevalent
than they were here, observers had placed the propor-
tion of cases in which the male was at fault at a sur-
prisingly high figure. Most American writers place the
male responsibility at from 15 to 25 per cent., which
Dr. Cary believed to be a too conservative estimate. In
cases of absolute sterility, the number in which the hus-
band was at fault must be high, at least 1 in 3, for the
sexual hygiene of the woman before marriage was
usually better than that of her mate, and there was no
real evidence to prove that the physiological processes
involved in the production and delivery of the healthy
ovum were more complicated or less often successful
than was the secretion and emission of normal semen.
At the present time it still seemed advisable to seek
first the cause of a sterile marriage in the female. It
must be stated, however, that to conduct long and
exhaustive gynecological treatment and ultimately to
offer a hopeless prognosis without having investigated
the reproductive powers of the husband was neither
fair nor scientific. In general the fertility of the semen
depended upon the presence of (1) mature living sper-
matozoa (normal cells), and (2) a normal secretion to
maintain the vitality of the cells until such time as they
meet the ovum. The opportunity to secure the semen
for examination presented itself oftenest to the gyne-
cologist, and he should be equipped to make the exam-
ination as a routine part of the investigation of ster-
ility. The most satisfactory arrangement for an ex-
amination was made by conveying the necessary im-
plements to the home of the patient and making the
observations immediately after conclusion of inter-
course. The most common cause of sterility in the male
had been formerly attributed to the absence of sper-
matozoa in the semen, the most common cause of which
was gonorrhea. In a very large proportion of the cases
this condition resulted from a unilateral or, more often,
a bilateral epididymitis. Another cause sometimes re-
sponsible for the disappearance of spermatozoa from
the semen was exhaustion due to abnormal demands
upon the sexual organs. The use of the .r-ray had fig-
ured prominently as a cause of azoospermia. The
fecundating power of the semen might be greatly less-
ened by the presence of many malformed spermatozoa.
Such cases were not rare. Inasmuch as it was not de-
termined definitely at what time the ovum was freed
from the ovary, and in view of the physiology of ovula-
tion, it was obvious that the successful completion of
the process of fecundation required that the sperma-
tozoa should not only have the power to migrate to the
interior of the uterus or tube, but that their vitality
must be sustained until the ovum was presented. To
this end Nature produced thousands of fecundating
cells that one might survive to perform its complete
function. Under normal conditions the vitality of the
spermatozoa was remarkable. At the same time they
were extremely sensitive, perishing promptly in tap
water and in faint lactic acid media, or under other
minor changes in their environment. One of the less
common forms of seminal defect was that resulting from
too great density of the semen, in which case their
motion is sluggish and of short duration. Of still rarer
occurrence were those cases in which the fertilizing ele-
ments of the semen were destroyed by the presence of
pus and blood in the semen. The available data justified
the assertion that pus was destructive to the evolution
and life of the sperm cells, and this probably explained
in part t'.ie sterility of women who suffered from endo-
cervicitis and endometritis. There was some difference
of opinion as to the effect of blood upon the seminal
elements, but the writer's observations showed that
spermatozoa would live four or five hours in blood
which corresponded to the observations of Robin, while
966
MEDICAL RECORD.
[Nov. 25, 1916
Dieu had shown that when blood had mixed for some
time with the contents of the seminal vesicles, the sperm
cells were reduced in number or were entirely absent.
The treatment of male sterility had been less studied
and had received less attention than any other part of
the subject. Many of these cases could be helped;
others were hopelessly incurable. If it was suspected
that the cause of sterility was to be found in the hus-
band a detailed history must be secured. And if it
was found that the patient was sterile, his case might
be classified as coming under either one of the two
groups impotcntia cocundi or tia generatidi.
Only the latter group was under consideration. The
treatment of some cases consisted chiefly in regulating
the sexual life, correcting unwholesome habits, or adopt-
ing measures to check involuntary seminal loss. Ster-
ility might be due to defective semen dependent upon a
debilitated condition incident to an overactive business
career, and might be cured by proper regulation of life
and habits of the patient. Sterility due to obesity
might be cured by treatment directed toward lessening
the obesity. Azoospermia resulting from chronic in-
flammations or exudates due to a remote gonorrhea was
very unsatisfactory to treat; these cases would im-
prove and might be cured if placed in the hands of a
genitourinary specialist. Azoospermia, when present
in patients with a negative venereal history, should ex-
cite a suspicion of some chronic constitutional disorder.
It must not be forgotten that absence of spermatozoa
might occur in such rare conditions as cryptorchidism,
congenital absence of the testes, congenital deficiencies
of the excretory passages, and malignant diseases of
the genitals. When dependent upon such conditions the
azoospermia sterility was absolute and permanent.
Tubercular disease of the testes and syphilitic orchitis
rendered the prognosis very unfavorable. Dr. Cary il-
lustrated his paper by lantern slides showing forms of
normal spermatozoa and various types of deformities.
Dr. Max Huhner said he did not sympathize with
the methods of collecting the specimen which Dr. Cary
employed. It meant more work, was rather compli-
cated, and was not as accurate as taking the specimen
from the cervix. The condom specimen might be per-
fectly normal and the sterility due to hypospadias,
epispasias, or the fact that ejaculation occurred before
the penis entered the vagina. He simply had the
woman come to his office after coitus and took a speci-
men from the cervix by means of a platinum loop, and
if live spermatozoa were found one could tell right
away whether the secretions of the vagina were harm-
ful or not, and whether the husband was all right. He
had found that the presence of pus in the semen was
not an absolute test as to its power to fecundate. He
had found that they were not killed in the presence of
gonorrhea, and a man with gonorrhea might impreg-
nate and give gonorrhea at the same time. The test
for viability was not an absolute test either, because
the semen under the microscope was not in its natural
condition, but these same spermatozoa taken from the
vagina after two or three days might still be active,
while they might die in a very short time under the
microscope. Nothing was known about the viability of
the spermatozoa in the Fallopian tubes. In every case
in which the tubes and ovaries were removed, we should
find out when the last coitus had taken place and make
an examination for living or dead spermatozoa. In this
way we might get some information as to how long it
took the spermatozoa to reach the tubes.
Dr. Henry C. Coe expressed the opinion that the pro-
fession had been entirely too ready to resort to curet-
tage in cases of sterility and to make positive prom-
ises as to the success of this procedure, and said that he
was opposed to subjecting a woman to an operation
for sterility until the condition of the husband had been
determined. The suggestion that an examination of
tubes that had been removed should be made in order
to determine the possible presence of spermatozoa and
the length of time during which they retained their
vitality was a very good one, and he did not think this
had been done.
I>r. THOMPSON T. SWEENY said ho was interested in
this subject because he had a large clinic of Jewish
en to whom sterility was a disgrace. In treating
them for sterility he did so only until any pain they
had might be relieved or any tubal condition that was
perceptible to the touch was relieved. It was often diffi-
cult to get a specimen of semen from some husbands, due
to their ignorance in believing that such a request was
a reflection on their manhood. It had been a point of
great interest to him to find that men who appeared
absolutely healthy or powerful or robust and who had
never had gonorrhea, mumps, or any affection, were
sterile. In collecting a specimen of semen he had made
use of the condom tied and dropped into a vaseline bot-
tle containing water at 100 °. In cold weather this bot-
tle was wrapped in flannel and paper to retain the
heat. When the husband was intractable he had the
wife come to his office after coitus and took a specimen
from her vagina. Many women had an occlusion of the
tube sufficient to prevent pregnancy, but too slight to
be detected by digital examination. Such a condition
frequently yielded quickly to local treatment.
Dr. William H. Cary, in closing the discussion, said
he had not considered the subject of impotence except
to refer to it as included in the general subject of ster-
ility. Dr. Huhner, in speaking of methods of examina-
tion, had taken an entirely erroneous viewpoint. In
taking a specimen from the vagina he might find the
spermatozoa dead, having been killed by the hyper-
acidity or other chemical changes in the secretions of
the vagina ; whereas, if he had taken the specimen
directly from the male it might have shown normal
vitality. Therefore, a specimen from the vagina or
cervix was not a fair test of the fertility of the male
element. Dr. Cary said he also had been interested in
finding a condition of sterility in powerful men with
a ziegative venereal history. He had found a condition
of sterility in clergymen, brokers, and lawyers who
were carrying heavy responsibilities, and had found that
sending them away on a prolonged vacation and giving
them a chance to recuperate improved their semen, and
in a number of instances their wives had ultimately
become pregnant.
Congenital and Acquired Retropositions of the Uterus,
Their Differentiation and Relative Significance. — Dr.
Arnold Sturmdorf presented this paper in which he
emphasized the fact that our fundamental conception of
uterine poise, normal and abnormal, had not as yet at-
tained to any concrete finality, and barring the occa-
sional allusion to the existence of congenital retrodis-
placements and their probable dependence upon condi-
tions of general visceroptosis the clinical significance of
such displacements, and their diagnostic etiological and
therapeutic contrast to the acquired form found no
elucidation in the literature of the subject. The
wide diversity in the nature of the two conditions
presenting practically identical symptoms demanded
their clinical differentiation, and such differentiation ne-
cessitated a differentiating factor of pathognomonic con-
stancy. In seeking to establish such a pathognomonic
factor it was necessary to recognize that the malposition
did not represent simply a congenital uterine retrover-
sion but a congenital retroversion of the entire pelvis,
with resultant dystopia of its entire contents. Dicken-
son and Truslow had characterized these cases as the
"gorilla type," in which the pelvis was rotated backward
and downward, the plane of its inlet making with the
horizon an angle more acute than that of the normal
type. This flattening of the sacrovertebral angle was
regularly evidenced by a corresponding obliteration of
the normal lumbar curve, and the measure of its result-
ant approximation to the vertical constituted a patho-
gnomonic index in differentiating congenital from ac-
quired retrodisplacements of the uterus. In order to ob-
tain this measurement the patient, with back exposed,
assumed her natural standing attitude, while the edge of
an ordinary 18-inch desk ruler held vertically in con-
tact with the most prominent spinous processes of the
dorsal and sacral convexities spanned the intervening
lumbar hollow. The distance in millimeters from the
deepest point of this hollow to the edge of the ruler rep-
resented our index. In an extensive series of observa-
tions the index ranged from 12 mm. to 45 mm. An ex-
cess of 45 mm. indicated the pathological lordosis and
was of more obstetrical and less gynecological impor-
tance. An index of 30 mm. made the extreme minimum
compatible with normal anteversion of the uterus; from
25 mm. down, the existence of congenital retroversion
might be positively predicted in nearly every case prior
to its bimanual verification, and this regardless of mul-
tiparity and the other complicating factors that obliter-
ated the differentiating criteria. A uterus congenitally
retroverted before conception would invariably resume
its retroverted position after delivery, when the dem-
onstration of a minus index would reveal the congenital
nature of the displacement and exonerate the accoucheur.
An application of the lumbar index would establish over
one-half of all retroversions, complicated and uncompli-
cated, as congenital, instead of one-fifth as hitherto ac-
cepted. In an abdominal cavity of normal skeletal. con-
Nov. 25, 1916]
MEDICAL RECORD.
967
figuration a true vertical in contact with the sacroverte-
bral promontory would impinge against the inner sur-
face of the symphysis pubis at its lower border; hence,
accepting the principles of deflecting planes which the
writer had previously demonstrated as fundamentally
applicable to this problem, it followed that every devia-
tion from the normal in the angle of the deflecting sur-
faces presented by the sacrum and the symphysis must
induce a corresponding deviation in the direction of the
intraabdominal pressure with resulting visceral displace-
ment, or, in other words, every abnormal pelvic tilt cre-
ated a corresponding uterine tilt. The upward and back-
ward rotation of the pelvis elevated the pubes and low-
ered the sacrum, which latter, thus forming the posterior
instead of the upper wall of the pelvic cavity, necessarily
altered the direction of the sacrouterine ligaments, their
horizontal pull tending to hold the uterus backward
against the depressed sacrum instead of suspending it
from above as in the normal. Furthermore intraabdom-
inal pressure inadequately deflected thrust the loose in-
tesinal coils into the pelvic cavity and against the ante-
rior surface of the uterus, crowding it into the space of
least resistance offered by the sacral hollow. The con-
tinuous attitude was a strain on the sacroiliac joints, the
erector spinas and iliopsoas muscles which induced pel-
vic symptoms that simulated and were generally attrib-
uted to retroversion. Since compensatory retroversion
■jvas a compensatory necessity it followed that any pro-
cedure which converted such a retroversion into an ante-
version converted a compensated into a decompensated
visceral equilibrium within the pelvic cavity. The aim
of the gynecologist in these cases should be to eradicate
all coexisting intrapelvic complications, thus converting
the complicated into an uncomplicated case. Hence these
cases should be treated on purely mechanical and ortho-
pedic principles. During and complementary to such
treatment a properly moulded pessary should be insert-
ed, not with the object of anteverting the uterus but to
act as an artificial ledge at the deficient sacral promon-
tory in the deflection of intraabdominal pressure. This
would afford much relief during the long period of me-
chanical treatment.
Dr. Dougal Bissell said he had never been able to de-
termine just what congenital retrodisplacement was. He
conceived it as dependent upon structural defects as real
as those of congenital prolapse of the entire uterus. As
to the difference between congenital and acquired retro-
version it might be assumed that in the congenital type
the uterus had never assumed the anterior position, while
in the acquired type it might be assumed that the uterus
had occupied the anterior position at some time. Dr. Bis-
sell said he had never recognized such a case as one of
congenital retroversion except in one instance — that
was a case that really fitted in with his idea of congeni-
tal retroversion. This young woman had a backward
displacement of the uterus and a prolapsed double kid-
ney which filled the entire right side of the pelvic cav-
ity to such an extent that it would have been impossible
for the uterus to have assumed the normal position. In
this woman he replaced the kidney but neglected to em-
ploy operative measures to correct the retroflexion. A
pessary was worn for some time but did no good. Later
the woman married, conceived, and was delivered of a
normal child.
Dr. George Gray Ward said he had not been present
to hear the paper, but felt that when one had a case of
retrodisplacement he must not assume that it was neces-
sarily the cause of backache, for backache, as they all
knew, might be associated with faulty posture, irrespec-
tive of the position of the uterus. As to the congenital
type of retroversion he thought that it was not common
and that when one did find it there were not many symp-
toms associated with as a rule as one found in retro-
flexion or retroversion with subinvolution following
abortion or labor. In congenital retroversion one might
find a short anterior vaginal wall and a faulty implanta-
tion of the cervix, and the position of the cervix could
not be corrected without correcting- the short vaginal
wall by an operation such as had been suggested by Dr.
Reynolds of Boston. All of these cases must be studied
individually and the type of operation chosen which met
the requirements of the individual case. Too often a
man had a fad, some particular operation which he ap-
plied to all cases of retrodisplacement. If the uterus
was freely movable and could be replaced the Alexander
operation was suitable, especially if the woman had
borne children and the ligaments were well developed.
The Webster-Baldy operation was suitable where there
was an adherent retrodisplacement with denuded sur-
faces on the posterior wall of the uterus. Here the
round ligaments might be used to cover up the raw sur-
faces. The same might be said of the Coffey operation
when one had a denuded surface on the anterior wall.
When the round ligaments were elongated and in good
condition Dr. Ward said he did a Simpson operation;
this left no loop where the omentum or intestine might
become strangulated. Dr. Ward said he did not believe
in using the round ligaments to support a straight pro-
lapse. Nature did not use muscle for this purpose, and
the round ligaments were muscles. The broad ligaments
and the uterosacrals supported the weight, and the
round ligaments simply limited the backward excursions
of the uterus. It would seem from the anatomical con-
struction of the pelvic organs that woman was never in-
tended to walk upright.
Dr. John Van Doren Young said that a clear concept
of a deformity was the first requisite for its correction.
One did not have to listen long to this discussion to learn
that a clear concept of the displacements under consider-
ation was lacking. Dr. Sturmdorf had cleared the hori-
zon and given some basis for further work along this
line. In a series of 6,224 cases of pelvic conditions
which the speaker had recently reported over 2,300
showed some type of retroposition of the uterus. This
gave one some idea of the importance of this form of
displacement. Dr. Young said he had listened closely to
Dr. Sturmdorf's paper and he did not understand his
statement of congenital versus acquired retroversion.
Each one who discussed this subject should say just
what he meant by the term he used. About 90 per cent,
of our trouble in discussing this subject was due to a
misunderstanding of terms, and the large number of op-
erations were due to the faulty conception of the de-
formity they were trying to correct. From the stand-
point from which Dr. Sturmdorf had presented this sub-
ject it opened up a wide field ; it showed why operations
had so often failed and why the gynecologist needed the
help of the orthopedist in the correction of these dis-
placements; it showed why with the same technique one
operator failed and another succeeded. Dr. Young said
he disagreed with Dr. Sturmdorf on one point, and that
was that a retroposition of the uterus, a mechanical
pathological retroversion with retrocession of the fun-
dus, antrocession of the cervix and descensus of the
whole uterus was cured by a pessary or correction of
body poise; these methods had failed in every patient
he had ever seen. Dr. Young believed we should resort
to operative interference after the pessary had failed.
Twenty-five years ago they talked nothing but pessaries;
within the last five years nothing but operations, and
now the pendulum had swung the other way. Dr. Young
asked whether a mispoised skeleton might not be ac-
quired as the years passed not by evolution but by a
lack of education and development.
Dr. Ijeroy Broun said it was difficult to fully appre-
ciate the various steps in Dr. Sturmdorf's argument
without reading his paper carefully and at leisure. He
wondered whether Dr. Sturmdorf meant to include
among congenital restroversions conditions associated
with a general ptosis of other organs; in the latter
condition it would be useless to operate on a displaced
uterus when there existed a ptosis of other organs, as of
the digestive tract and kidneys. Dr. Broun said he
would not operate for retroversion alone when other pto-
ses were present. When there were symptoms of retro-
version, backache, etc., not dependent upon an ill-fitting
corset, or in cases in which sterility supposedly was due
to retroversion, he obtained successes from operative
procedures oftener than he got failures.
Dr. Samuel Bandler said that if Dr. Sturmdorf's
method of getting this index would in the future show
them the cases of congenital retroflexion without it be-
ing necessary to make a rectal and vaginal examination
he would have added greatly to their gynecological
knowledge. If they had practised gynecology and failed
to recognize a position of the body as typical of malpo-
sition of the uterus, such as that to which their attention
had been called, they had at least now been shown the
A, B, and C of uterine displacement. It did not seem to
him that it had proved any point. Dr. Bandler said that
for a long time he had used the term retrodeviation to
signify a simple retroflexion or retroversion. A retro-
displacement on the other hand was a change from the
normal due to a shortening of the uterosacral ligaments.
Lf Dr. Sturmdorf meant a retroflexion he would discuss
the subject from that standpoint, but what was wanted
was the right name for these conditions. The type of
retrodeviation that took place in a nulliparous woman
was entirely different from that in a woman after her
first labor. This was a reason why the practice of ob-
968
MEDICAL RECORD.
[Nov. 25, 1916
stetrics was of value to the gynecologist, and explained
why a large number of operations for retrodeviation
failed. They all knew that labor was responsible for the
acquired retroflexions. Whether their efforts at correc-
tion of the retroflexion succeeded or not depended on the
ultimate position of the cervix. When the cervix was
low down, it was natural for the fundus to fall back-
ward, and corrective or operative measures must lift up
the cervix and replace the fundus forward. In a large
number of congenital retrodeviations the anterior vagi-
nal wall was extremely short. These were the hardest
cases to replace with a pessary, because the pessary
could not put the cervix high up, and as a consequence
the fundus fell back, because the short vaginal wall
would not permit the uterovesical ligaments to stretch.
The uterosacral ligaments were too loose, and here, if
one did an Alexander-Adams operation and shortened
the round ligaments, the result was that the uterus
simply doubled on itself and would not stay in place.
The proper thing to do in such a congenital case was
to open the abdominal wall and to place the uterus
in such a position that the fundus could be fastened to
the abdominal wall, even three-fourths of the way to
the umbilicus and then the doubling up would not occur
as in the Alexander operation. With so many different
forms and causes of retrodeviation Dr. Bandler doubted
very much if the acceptation of one sign was going to
help them very much in a practical way.
Dr. T. Thompson Sweeny said it was generally con-
ceded that the uterus was supported by the uterosacral
and uteropubic ligaments. It was evident that in the
erect position nature had suspended a body from its
base. On all fours it was inconceivable that a woman
could have a retroversion, since in that position the
uterus was suspended from its apex. Dr. Sturmdorf's
paper explained many of the problems of retroversion.
One woman physician in Chicago, after studying sixty
cases of retroversion without symptoms, concluded that
this was not necessarily an abnormal position. These
were probably congenital cases in which the pelvic cir-
culation adjusted itself to the malposition. Retrover-
sion with inflammation produced symptoms only when
the position interfered with the return of the venous
blood. Dr. Sweeny said he found a large number of
retroversions in young women which produced no symp-
toms, and had made it a practice to let them alone,
making no effort to correct a condition to which the pel-
vic circulation had adjusted itself.
Dr. Sturmdorf, in closing the discussion, said that
the intimation that he advocated the use of the lumbar
index to the exclusion of direct examination in the diag-
nosis of uterine retroversion was an unwarranted per-
version of his position. He had stated distinctly that
"with an index of 25 mm. or less, the existence of con-
genital retroposition might be predicted in nearly every
case, prior to its bimanual verification." The general
trend of this discussion established one fact if nothing
more, that congenital retroversion was known in name
only. It was this fact among others that prompted and
justified his present communication. Dr. Sturmdorf
said he had utilized the general term retropositions
advisedly, dividing the cases into complicated and un-
complicated, because such a division was more con-
ducive to clarify than the textbook classification of
versions, flexions and retropositions, adherent, non-
adherent. He had distinctly stated that the usual oper-
ative measures applied to uterine retroversions and
retroflexions were applicable to the acquired but not
to the congenital form of uterine displacements. He
was not discussing the relative values and indications
for retroposition operations, but the recognition and
differentiation of a class of retropositions in which any
and all operative intervention was imperatively contra-
indicated. The method and means advocated for this
differentiation were so simple that the verification or
refutation of the statements he had made were within
the reach of all.
Radical Extirpation of the Lacrymal Sac. — Carrases
has performed this operation 110 times, using the
Seidel technique. The principal factor in this opera-
tion is the avoidance of hemorrhage, which must be
controlled sufficiently to permit of a deliberate and
lion. The addition of adrenalin to the
novocaine is necessarily of great value, and later
pledgets of gauze soaked in some local hemostatic
may be used as occasion arises. Save when hemophilia
is present a good hemostasis is possible before the
acrnol direction of the sac— Revista de la Asociacion
Medico Argentina.
iilisrrllami.
A Student and Victim of the Plague. — In a re-
cent issue of Health News, published by the U. S.
Public Health Service, an account is given of John
Daniel Major, a seventeenth century student of the
plague. He was born August 16, 1634, in Breslau,
and was a physician and naturalist of no mean
ability. Bitten early by the wanderlust, he stud-
ied at Wittenberg, took courses at many of the
schools in Germany, and finally went to Italy
where he received the degree of doctor of medi-
cine at Padua in 1660. Returning to his own
country, he resided for a short time in Silesia,
and in 1661 married at Wittenberg, Margaret Dor-
othy, a daughter of the celebrated Sennert. The
following year, his young wife was stricken with
plague and died after an illness of eight days.
Distracted by his loss, Major wandered up and
down Europe studying plague wherever he found
it in the hope that he might discover a cure for
the disease which had bereaved him. Spain, Ger-
many, France and Russia were visited by him.
He settled in 1665 in Kiel, where he was made
professor of botany and the director of the bo-
tanical gardens. He made frequent voyages,
however, always in quest of the remedy for
plague. Finally in 1693, he was called to Stock-
holm to treat the queen of Charles the Eleventh,
then ill with plague. But before he could render
her any service, he contracted the disease and
died on the third of August.
Child Labor. — At the request of the Massachu-
setts Board of Labor and Industries, Assistant
Surgeon M. Victor Safford of the U. S. Public
Health Service was detailed by the Federal Gov-
ernment to cooperate with the State authorities
in a study of the effect of employment in various
occupations on the health and physical develop-
ment of children now permitted by law to work
therein. A report of this study with respect to
the cotton manufacturing industry of Massachu-
setts has just been published by the Federal Gov-
ernment as Public Health Bulletin No. 78, en-
titled "Influence of Occupation on Health during
Adolescence." The physical condition of over 600
boys between the ages of 14 and 18 employed in
this industry in different parts of the State re-
ceived careful study.
A considerable proportion of the younger boys
and also of those over sixteen were undersized
and physically undeveloped for their ages while
those between fifteen and sixteen averaged larger
than other classes of boys of their age with which
comparisons were made. This fact is explained
by the accumulation in the mills of strong boys
waiting to reach the age of sixteen to go into
permanent "full time" occupations. The pres-
ence of a noteworthy proportion of undersized
boys is not ascribed to the effects of the occupa-
tion but to the fact that the cotton mill offers
one of the few chances of employment for under-
sized boys. Evidence of injurious effects of their
work or working conditions, even of the tempera-
ture and humidity of the mills, on normal boys
was seldom found. Comparatively few cases of
dangerous diseases were discovered. There was,
however, a wide variety of defective conditions
disclosed by the investigation, many of them of
such a character as to impair seriously the future
health and economic usefulness of the individuals
concerned if not remedied.
Medical Record
A Weekly Jotirnal of Medicine and Surgery
Vol. 90, No. 23.
Whole No. 2404.
New York, December 2, 1916.
$5.00 Per Annum.
Single Copies, 1 5c.
©rigtnal Arttrlw.
A CONSIDERATION OF THE INTESTINAL
TOXEMIAS FROM THE STANDPOINT OF
PHYSIOLOGICAL SURGERY.*
Br JEROME JIuRLEY LYNCH, M.D., F.A.C.S.,
AND
JOHN WILLIAM DRAPER, M.D., F.A.C.S.,
NEW YORK.
(From the Clinic of Surgical Gastro-Enterology, New York
Polyclinic School and Hospital, and from the Laboratory of
Surgical Pathological Physiology, New York University.)
The alimentary canal is the one single system in
the body. All others are bilaterally symmetrical.
Why is this so; are there compensations for the
apparent deficiency, or does it mean that nature has
felt this the oldest of all the systems to be so per-
fect as to be sufficient to the economy as a single
unit? Has this interesting phenomenon any patho-
logical significance? Bichat and others advanced
cognate hypotheses a generation ago. Does the
length of the canal offer any explanation of its effi-
ciency and what bearing, if any, has the fact that
the diameter varies directly with its length? Can
any deductions be drawn from the fact that the
pars pylorica is well developed long before there is
evidence of any fundus? May not priority in origin
point to priority in function? Has not the very
fact of its amazing efficiency a bearing upon the
well-known law that as an organism approaches
perfection it tends to self destruction ?+ In its ex-
treme age, in its refinement of function, we may
perhaps seek for some of the fundamental causes
of its variations from the normal and for the re-
sultant known generally as intestinal toxemia.
Like the many sects in medicine, each one of
which sees truth through its own narrow slit, so
also has the subject of autointoxication been ap-
proached. Some have considered it a mechanical
condition pure and simple; some a neuromuscular
one; some a disturbance of internal secretions;
some as arising from a vagotonic disturbance; some
a psychosis; some, like Adami, consider it a sub-
infection; some, like Combe, a hydrolytic process of
bacterial origin. Non-partisan students are at a
loss in seeking the truth from among this maze of
authoritative statements, for the partisans are
clever and their writings are voluminous.
One thing at least is clear, viz., that the causes
are either exogenous or endogenous. The factors
operating from without, like misplacements, dis-
placements, obstructions, and bacteria which hy-
drolyze proteins within the lumen are totally sep-
arate and distinct from those of a biochemical
nature which probably have their origin in the dis-
turbed conditions in the cells of the intestinal epi-
thelium itself, and are properly endogenous.
*Read before the Jefferson Hospital Medical Society,
Philadelphia. January 28, 1916.
fThe classic example of this is the extinction of the
Irish elk, due to overgrowth of antlers.
What part does the modern surgeon play in this
complex problem? To our mind a very large and
increasingly important one. The physiological sur-
geon is the internist of the future. This view is
not held without dissenting voice for the general
conception of the surgeon's place in the therapeusis
of the canal, aside from the treatment of acute con-
ditions, is that he may occasionally be of use to re-
move mechanical obstructions which cause obstipa-
tion. Popularly this condition is known as stasis.
We hold that this term is an unfortunate one be-
cause it implies mechanical rather than biochemical
or physiological considerations, which seem to the
essayists of far greater importance. This is not a
plea against the mechanistic school which plays its
important part, but fortunately surgery is no
longer divorced from the sciences, having become
an integral part of them." Thus its votaries will
give great help in determining the etiology and
therapeusis of the non-obstructive, non-static in-
toxications, in many of which surgical intervention
alone avails. This means only that the diagnosti-
cian must now think in terms of both medicine and
surgery.
The pathology of adolescence begins in utero, and
this seems to the essayists one the strongest argu-
ments for eugenics. Whether due to ontogeny or
phylogeny needs no further discussion here.
Until birth the child's future is predestined by
the forces of nature. In childhood much can be
done to correct congenital alimentary defects; at
maturity, the individual to a great degree shapes
his own career, quite aside from the limitations of
his environment. Thus there are three periods —
the first, over which we have no control save
through eugenics; the second, over which an in-
creasing control will be gained through increasing
knowledge of child hygiene and therapeusis; the
third, over which control will be gained in direct
proportion to the acquisition and diffusion of the
truth regarding etiology, diagnosis, and thera-
peusis. Out of this vast field we have chosen to
discuss in detail a few factors relating to the third.
For purpose of comparison we may roughly look
upon the stomach as a receptacle which prepares
the food for digestion. In action it is analogous to
a cement mixer — crushed stone, cement, and water
are poured in at one end and without absorption or
loss, chyme is dejected at intervals from the other.
For is it not in the experience of all to have seen
unimpaired digestion proceed in gastrectomized an-
imals or men. It is a specialized morphological
adaptation ; useful but not essential.
Similarly, as regards the ceco-colon which pre-
pares the food for dejection. Who among us has
not seen colectomized men and animals remain in
perfect health, all diarrhea being controlled through
the assumption of colonic function by it embryolog-
ical prototype the terminal ileum? Even more sig-
*Ne\v York University now grants the degree of
Ph.D. in surgery.
970
MEDICAL RECORD.
[Dec. 2, 1916
nificant is the fact that broken health has unques-
tionably been restored in human beings after par-
tial or complete resection of the colon. It is far
from our intent to argue that these organs have no
function, for it is well known that along with all
other groups of specialized cells, those of the
stomach and colon must normally play an important
part in balancing metabolism.
To further complicate the problem of surgical
diagnosis and therapeusis, there are compensatory
properties inherent in the alimentary canal just as
truly as in the heart. A resected stomach may in
part reform in six months; an ileac segment trans-
planted into a colon will shortly assume both the
size and in a measure the function of the colon,
with the exception of anastalsis; a terminal ileum
upon which, by the operation of ileostomy, the
function of a colon is suddenly thrown will vicari-
ously assume colonic function both as regards water
absorption and fecal storage and dejection; an in-
testine will thicken oral to an obstruction and in
proportion to the load, until, as in the heart, over-
load begets atonia and dilatation. Thus it is more
than ever clear that in the alimentary canal we are
dealing with a system which, in part due to asym-
metry, in part to extreme antiquity, and to the per-
sistence in it of primordial zymotic reactions long
dormant and now superseded by the nervous sys-
tem, is endowed with many functions, a few of the
grosser of which are known, but most of which are
utterly unknown. It is a system subject to the
utmost variations of form due both to hereditary
and to environmental conditions, and which, save
the brain, finally is the seat of the most compli-
cated derangements of any part of our bodies. Of
the symptoms traceable to this canal one great sur-
geon has said, "We know so little as to their origin
and treatment that we should consider ourselves
the fools rather than the neurasthenic patients
whom we seek to relieve."
Diagnosis of Adult Com .—After all, the
diagnosis of adult intestinal toxemias has as its
basis the cardinal symptoms diarrhea and constipa-
tion. These conditions have been treated empirically
from time out of mind, so that it is next to im-
possible to get either physician or patient to look
upon them as symptoms rather than as entities.
But progress demands it. As the modern physicist
is showing that the supposed elements are really
manifestations of a single basic ion, and therefore
not in a true sense elemental, so must we modern
physicians realize that the ancient disease entities
which we have been taught to believe in are often
not elements, but are simply symptomatic, superfi-
cial and almost always p • manifestations.
They are far more numerous than the sixty-odd old
chemical ele-i sing the variable outward ex-
ions of a fundamental disturbance of metabolic
librium and of nature's efforts to heal.
It is the oil : the objective method as op-
1 to the subjective; of function vs. form- of
to empiricism. It is signifi-
cant that a true interpretation of symptoms has
been the best means of improving therapeusis. We
are. at best, only beginning to understand that
most symptoms are protective and should be en-
couraged rather than suppressed until the true
cause of the underlying disturbance has been
found. Think of the efforts to treat fever fail
lammatory swellings as though they were
'-lies instead of friends:
There is no field in all medicine more vivid with
the truth of all this than that of the diarrheas. Let
us urge that ali diarrheas and constipations be
looked upon as due to an exogenous cause until
proved to be endogenous. Exogenous causes ai-e
either congenital or acquired. In our experience
failure of fusion and departure from the normal
migration of the cecocolon play a more important
part than the acquired conditions, for they are
transmitted by the same laws of hereditary which
govern transmission or other dominant character-
istics. The common mesentery which results from
non-fusion may permit of 180 degrees mesodorsad
rotation upon adventitious bands which often sup-
port a cecocolon from the parieties constricting
the ascending colon and causing a tadpole-like de-
formity with intermittent partial obstruction, as
occurred in one of our cases recently. Such bands
are doubtless manifestations of nature's efforts to
compensate for the hereditary deficiency. No more
potent argument is at hand in support of extensive
undergraduate study of comparative anatomy and
of research surgery on the lower vertebrates than
this. For every graduate should know that from a
common ancestor we may inherit departures from
our conception of the normal; as, for instance, a
mobile duodenum or mesogastrium, such as are
found in the dog; non-rotation, non-fused mesen-
tery; an herbivorous type of cecum; infantile
cecum; megacecum; absence of sigmoid (quadru-
peds have no sigmoid according to Henscher &
Bergstrand in Ziegler's Beitriige 56, 1913) or of
cecum, and a host of other variants, explicable only
by heredity. The teaching of these fundamentals
seems to us of far greater use than an ingrinding
of the pharmacopoeia or of descriptive anatomy.
Bayliss and Starlings "law of the intestines" or
myenteric reflex is of great importance in the sur-
gical physiology of the alimentary canal. It con-
sists in the production of a relaxation with inhibi-
tion of movements aboral to the spot at which a
mass of food is collected and an increase of tone
together with more powerful contractions oral to
the spot, thus moving the contents onward.
The recent papers by Keith recording the pres-
ence of hitherto unknown intestinal ganglia also
help to explain many things. But there are certain
observations which come to the surgical student of
the alimentary canal, who studies his cases from a
biological standpoint, which seem to us of special in-
terest and which are not as yet widely recorded.
We have for years contended that death from
duodenal or jejunal obstruction is due to an inter-
ference with the internal secretory function of the
epithelial cells of the gut itself rather than to bac-
teriotoxic causes This hypothesis is now accepted
by most invesl Now, if this is true of com-
plete obtructions. what diversity of symptoms may
not be caused by incomplete obstructions occurring
at different levels! Doubtless the complexity of
duodenal enzymes or hormones is much greater
than that of any other part of the canal, though the
subject is far from settled as to details; and this
may explain the relative gradation of symptoms
and the well-known fact that their intensity varies
as the square of the distance from the duodenum
or thereabouts. Moreover, what has been accepted
for the duodenum may be true also of the colon.
This at least affords a working hypothesis to ex-
plain the immediate relief from certain types of
arthritides, as occurred in one case of our series
after developmental reconstruction, and in several
reported by Bottomley. We are not sufficiently ad-
vanced in a knowledge of the internal secretions to
say how important a disturbance of these may be in
Dec. 2, 1916]
MEDICAL RECORD.
971
the colon, nor, indeed whether they exist, but if we
are to believe Pick, even the lowly connective-tissue
cell of the colon secrets an enzyme called tyrosinase,
which has the property of converting aromatic sub-
stances into a pigment closely resembling melanin
in appearance. Thus Pick would account for pig-
mentation of the colon.
Furthermore, this matter of internal secretion of
the gut may have an important bearing upon the
phenomena which we have noted after ileostomy
when there occurs a most marked change in the
physical well-being of the patient as sudden and as
profound as we have noted in the arthritides after
colonic reconstruction.
Previously the clinical changes observed after
this operation have been explained wholly on the
ground that the proteolytic anaerobic bacteria
which Combe and his school have credited with so
prominent a part in intestinal toxemia were unable
to thrive on the acid media of the terminal ileum,
and it is on this assumption that Metchnikoff pop-
ularized the value of the fermented milks. Here
may be another point of similarity between the
physiological mechanism at the beginning and end
of digestion. The acid ileac chyme discharged into
the alkaline cecum may stimulate the outpouring
of enzymes in the lower gut as in the upper. What
has been proved true of one is perhaps true of the
other and there may actually be an internal secre-
tion of the cecocolon which becomes perverted and
autotoxic when motility is disturbed.
Next to be considered is what applied surgery
can do for intestinal toxemia.
It is accepted that a definite number of patients
suffering from the syndrome of intestinal toxemia
have been benefited or cured by operation, after
other methods have been tried. What are the pro-
cedures which have been in general use? First,
ileosigmoidostomy. Second, cecosigmoidestomy.
Third, appendicostomy. Fourth, ileostomy. Fifth,
plication of the cecocolon and repair of the cecal
valve. Sixth, total "Colonic exclusion." Seventh,
colectomy. Eighth, developmental reconstruction
or right ileo-colectomy. The very multiplicity of
procedures is in itself a certain index of our ignor-
ance. What can be said of these operations?
Ileosigmoidostomy has undoubtedly benefited a
goodly number of cases. But what are its draw-
backs and dangers? We have shown in a previous
paper that a dominant anastalsis is often the phys-
iological basis for the symptom constipation. All
operations must be planned so as to minimize the
effects of this symptom of aberrant physiology and
if possible to counteract it. The foremost advo-
cates of this operation admit that because of anas-
talsis in 10 per cent, of cases a subsequent colec-
tomy is a necessary corrective measure. Further,
although we may learn to recognize sigmoidal
anastalsis before operation, who can say that it may
not develop as a result of this operation itself?
The technique, therefore, has a much higher mor-
tality than is usually ascribed to it because of these
secondary complications, and is rightly falling into
disuse.
Cecosigmoidostomy is deficient both theoretically
and in practice. Its employment leaves out of con-
sideration the law to which we have referred, viz.,
that intestinal contents tend to follow the normal
direction of the canal, irrespective of lateral
stomata. We again wish to emphasize the impor-
tance of this law. We have recently demonstrated
a vicious circle in five out of six cases. The follow-
ing case history is illustrative of all :
Patient referred by Dr. Robert M. Brown of Saranac
Lake, New York. Cecosigmoidostomy was performed
for the relief of intestinal toxemia eighteen months ago
by a thoroughly competent surgeon. After the opera-
tion the symptoms were aggravated and x-ray exami-
nation showed that material lay in the distended loops
— for an interminable time. This patient was made
to realize the severity of secondary operation but ex-
pressed the positive conviction that she preferred death
to her existing state, being at the time unable to cor-
relate mentally. Indeed the mental symptoms were
more serious than the physical. Operation revealed an
immensely distended sigmoid and cecocolon, each com-
municating with the other through a stoma which read-
ily admitted four fingers. The technical part of the
previous operation had been perfectly performed, but
the functional result was a failure. In order to restore
normal conditions it was necessary to resect that por-
tion of the sigmoid containing the stoma, to anastomose
the sigmoid, to resect the terminal ileum and the colon
as near to the splenic flexure as could be reached. An
unusual amount of traverse colon had thus to be sacri-
ficed because it was dilated as a result of the previous
operation to the thinness of tissue paper and could
hardly have been expected ever to regain proper tone.
The ileum was then anastomosed to the extreme left
transverse colon in the usual way. Result very satis-
factory.
Appendicostomy is safe though insufficient in
most cases. One important fact in its favor is that
it places the stoma oral to the entire colon. This is
in keeping with our observations, viz., that a stoma
to be effective must be oral to the infected area.
Ileostomy. — This new procedure first intention-
ally employed in this country by us has limited and
definite indications, but is of proven worth. It
was devised and employed by an Italian some
twenty years ago. In connection with our observa-
tions upon severe colonic infections we will deal
with this procedure in a subsequent paper.
Plication of cecocolon may benefit, but it is ques-
tionable whether the results are permanent, and
this coincides with our animal experimental work.
The technical defect may be that the coaptation is
peritoneal rather than muscular. We have now un-
der consideration an adaptation of the autolytic
pentagonal suture which we have long used ex-
perimentally. This introduces the problem of seg-
mental resections, the most important work upon
which has been done by W. Howard Barber.
Plication of the Bauhinian sphincter is said to be
beneficial. We have had no experience with it ; first,
because our z-rays in the healthy humans show
frequent leakage after enema, and, second, because
we have shown experimentally that the mechanical
action of all "valves" is of small value compared
with the neuromuscular forces about them.
What of the cured developmental reconstruction
cases in which the "valve" is excised?
Total colonic exclusion is a new operation, just
described by Strauss. It will afford additional op-
portunities for study and may come to have a place
in the operative therapeusis of the future, but its
principles are quite at variance with the conclu-
sions reached by us experimentally, and upon human
beings twelve years ago.
Colectomy has a place but it is a small one be-
cause of the mortality and of the removal of omen-
tum and the terminal colon which is active in elim-
ination. Lardenois, however, demonstrated to us
in Paris that it is possible to leave the omentum.
Colectomy is indicated in diffuse polyposis, papil-
lomatosis, diverticulitis, and in certain malignant
tumors.
Of the many operations which have been sug-
gested that of developmental reconstruction has
proved very satisfactory in certain carefully se-
lected cases. The writers have applied this term to
972
MEDICAL RECORD.
[Dec. 2, 1916
the ordinary operation of resection of the terminal
ileum, the cecocolon, and the oral part of the trans-
verse colon, because it exactly describes the pro-
cedure. The colon is reconstructed to the primitive
or developmental type seen in the adult dog, or in
the human fetus just following rotation, the great
gut beginning in the right hypogastrium, there be-
ing no true cecum or ascending colon. We have
felt that there may be a definite relationship be-
tween the symptomatic improvement in human be-
ings after developmental reconstruction, and the
fact that more primitive forms, like that of the dog,
are free from colonic disease. We have called at-
tention to the fact that this last formed portion of
the colon is more liable to disease than the older
aboral portion. As in the case of other organs
which have become diseased and dangerous to the
economy this organ, its function destroyed, should
be removed.
One word in regard to colonic vaccines. There
is this to be said in favor of the vaccine treatment:
that it usually helps, it is free from danger, and if
an operation becomes necessary subsequently it
places the patient in the best possible condition to
withstand it. It is valuable postoperatively.
Rectal feeding has long been a satisfying and
comforting necromatic rite. It was ancient his-
tory when Hippocrates was a boy. Of all the de-
lusions of grandeur ever inherited by the profession
this was the most mythical. At last, however, we
have arrived at something definite, viz., the use of
amino acids. Urinary studies prove this. These
final products of protein digestion occur in the
blood, dialyze readily, and are the logical post-
operative sustaining agent of the future.
One cannot consider the field of colonic surgical
therapeusis without being convinced that the future
holds out great things. And perhaps the greatest
of these is the hope that physiological surgery col-
laborating with medicine may help us to find the
true cause of the toxemia, and with it a cure which
will not be operative.
BIBLIOGRAPHY.
Draper-Maury : "Observations Upon a Form of Death
Resulting from Certain Operations on the Duodenum
and Jejunum," Surg. Gynec. and Obstet., May, 1906.
Whipple: "Proteose Intoxication" (Later Studies),
Jour. Experimental Medicine, Jan. 1, 1916.
: Proteose Intoxication, Jour. A. M. A., Aug. 7,
1915.
Barber: "Dilatation of Duodenum," Annals of Sur-
gery, 1915.
: "Dilatation of Stomach," Medical Record,
May, 1915.
: "The Significance of Increased Duodenal Dila-
tability," Medical Record, Oct. 14, 1916.
Sweet: "High Intestinal Stasis," Annals of Surgery,
June, 1916.
Lynch Draper: "The Protective or Esoteric Symp-
toms of the Alimentary Canal," Virginal Medical Semi-
Monthly, March, 1916.
Draper: "Experimental Colonic Stasis," Annals of
Surgery, June, 1916.
: "Intestinal Obstruction," Jour. A. M. A., Oct.
7, 1916.
Lynch-Draper: "Developmental Reconstruction of
Colon Based on Surgical Physiology," Annals of Sur-
gery, Feb., 1915.
: "The Infected Colon and Its Surgery," Medical
Record, June 12, 1915.
: "Contribution to the Surgical Physiology of
the Colon," Annals of Surgery, 1915.
: "Anastalsis and the Surgical Therapy of the
Colon," American Jour. Med. Sciences, Dec, 1914.
: "The Surgical Treatment of Intestinal Tox-
emia," New York State Jour, of Medicine, July, 1916.
Lynch-McFarland-Draper: "Colonic Infections; Some
Early Observed Unclassified Tvpes," Jour. A. M. A.
Sept. 23, 1916.
THE DANGERS AND COMPLICATIONS OF
TONSILLECTOMY.
By S. E. MOORE. M.D., LL.B.,
MINNEAPOLIS. MINN.
MEDICAL SCHOOL, UNIVERSITY OF MINNESOTA.
Speaking of pyelography, Clark says: "When a new
method of diagnosis or treatment is suggested,
there is immediately a wave of enthusiasm, which,
in its intensity, temporarily overlooks the dangers
and disadvantages incident to such a method. For
a time these procedures are applied indiscrimi-
nately to all varieties of cases irrespective of indi-
cations, until the more conservative members of
the profession strenuously object by presenting
concrete examples of mishaps which have occured
due to our inexperience and poor judgment. All
new procedures seem to pass through this stage,
and then finally settle down to their own proper
level." These remarks can be appropriately applied
to the theories of infective foci as causing so-called
sequential constitutional diseases, and also to ton-
sillectomy as a therapeutic measure in the treat-
ment of these systemic diseases, as well as in many
local conditions of the nasopharynx.
The writer has recently observed a case, demon-
strating the dangerous results of ill-advised re-
moval of the tonsils. The medical literature of the
last few years, during the period of the great pop-
ularity of tonsillectomy, is pregnant with untoward
complications following this surgical procedure.
This collection of cases, showing the risks and pos-
sibilities of the promiscuous use of this operation,
is submitted to those who are interested in the sub-
ject.
The history of the case which concerned the
writer is as follows:
In 1910 the patient suffered from an attack of poly-
neuritis, resulting from acute arsenical poisoning. A
complete recovery was the ultimate outcome. In Au-
gust, 1915, a mild recurrence of the neuritis reap-
peared in the posterior tibial regions of both legs. At
that time he had an attack of acute coryza and bron-
chitis. Although by January, 1916, the condition was
much improved, accepting the advice of physicians, he
had the tonsils enucleated. The Slude-Ballenger ton-
sillotome was used and the operation was performed
under local anaesthesia. The tonsils were successfully
and completely removed, but the procedure was of a
painful nature, due no doubt to the great pressure of
the plate of the instrument pressing forcibly on the
posterior pillars of the pharynx. One would presume
that rupture of the fibers of the palato-pharyngeus
muscles frequently accompanies the employment of this
particular tonsillotome. Some non-toxic local anaes-
thetic injected into the posterior pillars would prob-
ably diminish the pain, when the Sluder-Ballenger guil-
lotine is employed. Within four days after the opera-
tion the neuritis became widespread, involving nerves
of the thighs, back, both forearms and arms, neck, feet,
and chest. He was, of course, forced to go to bed,
where he still remains seven months after the ton-
sillectomy. The patient had had one attack of ton-
sillitis in thirty years. The pathological report of the
tonsillar specimens, made by competent bacteriologists
and pathologists of the University Hospital, showed
that a very small amount of tonsillar tissue really ex-
isted, and what was there displayed no areas of ulcer-
ation or suppuration. Streptococci were found in the
culture taken from the tonsils, but this is nothing
unusual, in fact, the rule. The amygdalae, therefore,
showed no areas that could be interpreted as infective
foci, from which so-called sequential disease could arise.
The Wassermann reaction, taken twice, was negative.
Indican was found in the urine.
In the experience of neurologists an individual,
who has once been a victim of polyneuritis, regard-
less of the original cause, will be susceptible to a
Dec. 2, 1916]
MEDICAL RECORD.
973
recurrence at some future time from multifarious
agencies. Sherwood" has written an interesting
article on recurrent multiple neuritis. So far as
the above case is concerned, regardless of the pos-
sibility of contributory factors, as intestional auto-
intoxication, it cannot be reasonably denied, that
the general invasion of the neuritis was the result
of the tonsillectomy.
The amygdalectomy and infective-foci enthusi-
asts will no doubt suggest that the tonsils with in-
carcerated areas of infection, were the original
cause of the neuritis, as following the operation,
they will pertinaciously insist, bacteria and toxins
are poured out from the tonsillar crypts and ad-
joining lymphatics, which being absorbed into the
system, are carried to their destined tissues, thus
justifying the theories of electives localization and
specificity of streptococci, and thereby demon-
strating beyond ai-gument the law of cause and ef-
fect.
As above stated the tonsils pathologically showed
nothing significant. The theory of the flooding of
the body with tonsillar toxins, immediately after
the excision in toto of those organs, is hardly com-
patible with the direction of the blood and lymph
currents following the operative procedure. Hem-
orrhage and venous cozing continue for many
hours, resulting in a thorough and complete auto-
genetic douching of the tonsillar fossse, and it
would appear to be a difficult and supernatural feat
for intangible toxins without any vis a tergo, to
combat with a blood current, which frequently be-
comes alarming in its intensity and occasionally
results in death. Moreover the expert laryngolo-
ist in performing tonsillectomy enucleates the or-
gan and its toxins in toto, at least partially encap-
sulated, a somewhat formidable condition and bar-
rier to ambitious and hostile streptococcic toxins.
In thyroidectomy and breast amputation, the situ-
ation is not parallel; toxins and cancer cells may
be absorbed, for hemostasis is immediate, postop-
erative sloughing is rare, the operation is pro-
longed, manipulation is forcible in areas of freshly
opened blood and lymph channels ; cancer has no
capsule, while in thyroidectomy occasionally the
capsule is incised; and repeatedly portions of both
structures remain to eliminate substances in a
propituous and extensive field for absorption.
Posterior oral surgery is peculiarly handicapped,
because of the inability to render the operative field
sterile of the perennial presence of pathogenic bac-
teria, therefore sloughing occurs in practically all
operative cases and often a severe local and an oc-
casional general sepsis results. The throat is es-
pecially prone to gangrenous and other septic
inflammations. Hence, what happier and more hos-
pitable portal of entry for bacteria and their toxins
could maintain a corporal existence than the slough-
ing postoperative throat bathing the freshly opened
blood vessels and lymph channels, and accompanied
by the sympathetic septic inflammation of the
palate? By tonsillectomy a chronic tonsillitis or
a normal state of that organ is converted into a
condition of marked acuity of a week or longer
duration in most cases. Instead of removing a
focus, a source of infection is created. In many
of these cases if only nature had been left alone
she would have dealt with metabolic problems
through a vis medicatrix naturse.
Therefore, is it unreasonable to entertain the
hypothesis that local reactions in joints, nerves,
and other tissues, following tonsillectomy, result
from a mild general bacteriemia or intoxication
following absorption from the sloughing throat
which invariably appears after amygdalectomy, the
toxins in the blood stream attacking and irritating
an already existing locus minoris resistentixl
Such spot, regardless of its original cause, would
respond to the irritation from the toxins absorbed
from any source. For instance, if any individual
with articular rheumatism, in his convalescence
should be attacked by enteric fever, would not the
joints, their resistance being lowered previously, or
in fact still inflamed, probably manifest their inva-
sion by the typhoid toxin through the clinical evi-
dence of pain, swelling, etc.? A so-called typhoid
rheumatism has been reported many times. Such
a theory denies a specificity of tonsillar toxins for
chronic rheumatic conditions. This hypothesis can
run pari passu with the specific germ origin of
acute rheumatic fever that the tonsil may be the
portal of entry of the streptococcus rheumaticus
or some other microorganism of that affection.
For acute articular rheumatism, evidenced by ra-
pidity of invasion and sthenic phenomena, suggests
an infective bacterial etiology. But with chronic
rheumatism, an indefinite term representing a dis-
ease involving multitudinous tissues, and further-
more characterized by various pathological changes
even in the same structure, a specific bacterial etio-
logical factor, seems, at least in the light of our
present knowledge, not probable; otherwise a cure
of the rheumatic condition, following tonsillectomy
would be the rule, which is decidedly not the case.
Possible neurological reactions in some cases of
the so-called sequential diseases will explain the re-
newed activity of these constitutional diseases after
tonsillectomy. Habit spasm, a pure neurosis, is
practically always made worse after amygdalec-
tomy." Furthermore, chorea, although possibly as-
sociated with rheumatic diseases, occuring in
those with unbalanced nervous systems, is fre-
quently exaggerated after tonsillectomy." ° !5 Fright
in these cases does the same thing.
Perhaps general nerve shock, lowering the vital-
ity of a chronically diseased area, as a joint, or of
normal tissue, as a nerve, and thereby permitting
a toxin already in the blood to act deleteriously
thereon, where under normal conditions no harm
would result, might explain some of these reactions-
Intestinal autointoxication and syphilis might be
such factors.
Therefore, it might be said, that the widespread
general polyneuritic phenomenon following the ton-
sillectomy, in the above case, was possibly due to
either shock alone, or shock increasing the suscep-
tibility of nerve tissue to an already existing toxin
in the blood, or some reaction in metabolism, or a
bacterial toxin elaborated in the throat, perhaps
from the sloughing postoperative areas, but cer-
tainly not from a tonsil free of infective foci.
The extravagant and odd claims of those who be-
lieve in the theories of the specificity and elective
localization of streptococci still remain unconfirmed
by reliable bacteriologists, and wise physicians had
best wait until competent investigators verify these
statements, before the profession in general adopts
them. If the tonsil is proven an excretory organ,
as the work of Henke,"0 Pybus," and Blum" sug-
gests, the partisan of the above theories, however
attractive, might meet with a certain amount of
embarrassment.
Toxins expressed from the tonsils through ma-
nipulation, and thereby producing reactions in
974
AUDI LAI. RECORD.
[Dec. 2, 1916
joints, etc., must be of infrequent occurrence, other-
v - ■ intestinal colic, acting on the wall of the bowel
in cases of enteritis, or the application of Bier's
remia treatment with the use of the Esmarch
roller, or massage of the prostrate gland, would re-
dh, cause such constitutional upheaval-.
[ultifarious complications have followed tonsil-
lectomy, a surgical procedure, which is looked upon
by many physicians as nursery surgery in more
senses than one, but which in truth, as Joseph H.
Bryan, the laryngologist, says, "is always a major
operation."
Hemorrhage. — Many cases of alarming primary
and some cases of secondary hemorrhage have been
reported. A number of fatalities, due to this cause,
are recorded. The writer knows of a case of death
at the University Hospital from hemorrhage fol-
lowing tonsillectomy. The patient had erythremia.
A colleague of Dabney"s reports a fatal case in a
young girl, who swallowed quietly the steady ooze
from the tonsillar cavity till exsanguinated.
Crockett" reports twelve fatal cases and many seri-
ous hemorrhages occurring within a year and a
half in and around Boston. SewelP found reports
of nineteen deaths and fifty severe hemorrhages.
Stucky4 records a death after operation from hem-
orrhage and nine cases of secondary bleeding which
required ligation and suturing of the pillars.
Schuchardt5 reports a case, in which the court found
a verdict, that death was due to hemorrhage, stran-
gulation, or shock. Roe" speaks of a case of fatal
hemorrhage, six hours after operation, the patient
probably being a hemophiliac, the mother having
died of uterine hemorrhage. Brown' reports a case
of severe hemorrhage following tonsillectomy for
chronic rheumatism, the patient nearly dying, the
bleeding being difficult to control on account of
sclerosed arteries. Ballenger" records a number of
cases of hemorrhage. Price11 reports a case of fatal
hemorrhage. Shurley"' records a case of serious
hemorrhage. He was threatened with a suit for
damages. Chenery," Beck." and Iglauer13 report
cases of alarming hemorrhages. Thompson" re-
cords a case of serious hemorrhage in a child, who
swallowed the blood. Still1" speaks of a death from
hemorrhage following removal of the tonsils. Wil-
liams™ has had a case of fatal hemorrhage in a
child six years of age following amygdalectomy.
Dickie" reports nine cases of serious hemorrhage.
Dutrow™ records five severe hemorrhages. Hop-
kins'7 reports two cases of secondary hemorrhage
following tonsillectomy, one occurring on the ninth
day, after operation, and the other on the fifth,
tenth and twelfth days. Burack'" records three dan-
gerous hemorrhages. Agnew" reports a case of
recurrent hemorrhage which lasted for days after
the tonsillectomy. Following an amygdalectomy
upon himself, a medical friend of the writer's had
to summon the operator to check a hemorrhage,
which at least to the patient's mind had the ear-
marks of fatality connected with its continuance.
In Blum's" series there were four deaths and thirty-
cases of hemorrhage.
Nervous ami Muscular Diseases. — Following ton-
sillectomy the neurological complications reported
are usually functional in nature, but not always. A
case of amyotrophic lateral sclerosis in an appar-
ently healthy patient, which manifested itself
shortly after amygdalectomy performed for ar-
thritis, was reported to the writer by a member of
the neurological department of the University Hos-
pital. Pfingst" writes of a case of hemiplegia last-
ing four months resulting from this operation; also
of a patient who had repeated attacks of hysterical
strangulation and spasmodic flexion of the thighs
(Bergh). Dabney reports a case of spasmodic
ngitis following the removal of the tonsils. A
■ of hysterical mutism reported by Hair* was
interesting. This patient, a boy, had been acting
queerly ever since witnessing the bombardment of
Hartlepool. This condition had been accentuated
after viewing a gunpowder explosion to which his
father had been exposed. His symptoms had been
attributed to enlarged tonsils and adenoids, and
tonsillectomy was advised. The question of the cor-
rect diagnosis was disputed by the mother, who re-
marked, without being asked, that "he did not
snore, he did not breathe through the mouth, and
he did not speak thickly." However, medical per-
sistency mastered medical prudence and conserva-
tism and it was decided to operate. When so in-
formed the boy became very much terrified and re-
mained so up to the date of the operation, from
which latter period through the following six
months he was absolutely mute, never uttering a
sound. SewelT reports two cases of tonsillectomy,
where trachectomy was necessitated on account of
prolonged glottic spasm with collapse and cyanosis.
Also one of torticollis following this operation.
Hedges of Plainfield, N. J., records two cases of
torticollis. Chorea resulting from tonsillectomy
has been reported. Layton'7 refers to three cases
of chorea, which began after operations on the
throat. Analyzing observations made in the chil-
dren's medical department of the Massachusetts
General Hospital, Young" says that definite con-
clusions cannot be drawn from few cases; the oc-
currence of chorea after tonsillectomy in twelve out
of twenty-one cases strongly suggests that removal
of the tonsils does not offer the protection against
chorea, and the always present possibility of en-
docarditis, that many have heretofore believed.
Blum" reports three cases of chorea following
amygdalectomy. Under septic complications will be
noted the case of facial paralysis recorded by
Stucky following enucleation of the tonsils. Dun-
bar Roy"5 reports a case of partial paralysis of the
soft palate following the removal of the tonsils and
adenoids. The writer knows of a case of severe
backache accompanied by great weakness, which
lasted several months, after amygdalectomy had
been performed. It was due probably to a neuritis
or myositis. Another case, reported to the writer,
is being treated in a sanatorium for some post-
operative psychical condition resulting from the re-
moval of the tonsils. Still" has known tonsillectomy
in a child subject to habit spasm to markedly ag-
gravate the condition, and in other children follow-
ing amygdalectomy to fall into a state of morbid
nervousness, from which they did not recover for
many weeks. The writer knows of a case in a nor-
mally cheerful and buoyantly spirited woman, where
a prolonged depressed state followed tonsillectomy.
is. — Sontag" reports a case in which deatli
ensued from general infection on the seventh day.
Dean'" records three cases of sepsis; one patient died
on the sixth day; the second recovered, but suffered
from a septic phlebitis involving the internal jug-
ular vein and extended along the cerebral sinuses to
the orbital veins, accompanied by thrombosis of the
latter vessels on the left side and perhaps of the left
trnous sinus. Such was his belief, as there was
exophthalmos with panophthalmitis on the left side
and optic neuritis on the right side. Levy54 says
Dec. 2, 1916]
MEDICAL RECORD.
975
that pyemia and septicemia with exophthalmos may
follow the removal of adenoids, the infection pass-
ing from the pharyngeal plexus to the facial and
ophthalmic veins. The third patient of Dean's also
recovered after an illness due to gangrene of the
muscles of the neck. Ballenger " reports two severe
cases of streptococcic infection, and Pierce:l re-
cords a case of infection resulting in a permanent
torticollis following tonsillectomy. Deane" reports
two cases of severe sepsis following the same surgi-
cal procedure. Bourak33 records a death from gan-
grene reported by Terkenle. Stucky* refers to three
cases of cellulitis, one with facial paralysis of five
weeks' duration. Sewell3 reports two cases of pare-
sis of the soft palate. Bauchacourt3' records a case
of edema of the glottis with death following re-
moval of the tonsils. Koplik" divides septic cases
following tonsillotomy or enucleation into three
classes; first, a form running a fever for several
weeks without endocarditis or other lesion; second,
cases of pyrexia combined with endocarditis, which
may have a fatal issue; third, a form of sepsis in
which infection is severely hemolytic, and causes
destructive blood changes with signs of sepsis, such
as profuse hemorrhagic ecchymotic areas on the
skin, severe hemorrhages from the bowel, and areas
of bronchopneumonia. Koplik must have seen many
cases of postoperative sepsis following amygdalec-
tomy so to classify this condition. Ballengers re-
ports another case, of a physician, from whom he
removed the tonsils, who had general septicemia,
and took six months to recover. Freer37 records
two deaths from pyemia. Martin16 reports two
deaths from septicemia following this popular op-
eration. Still" speaks of a death apparently due to
sepsis following amygdalectomy. Dickie52 reports a
case of retropharyngeal swelling, and Vanderhoof"
records an abscess under the angle of the jaw fol-
lowing tonsillectomies. Blum's" series showed a
death from edema of the glottis.
Endocarditis. — H. L. Ulrich of Minneapolis told
the writer of a case of acute ulcerative endocarditis
which resulted from amygdalectomy. Koplik23 has
published reports of cases of heart disease follow-
ing tonsil operations.
Diphtheria. — Wagner,15 Caille,39 Levenstein,39 and
Kolbrak31 report cases of diphtheria following im-
mediately upon removal of the tonsil ; the patient of
the last-named physician died.
Bronchiectasis. — Lilienthal"' records a case of
bronchiectasis following tonsillectomy.
Pulmonary Abscess. — Wessler53 reports eight
cases of lung suppuration following tonsillectomy
under general anesthesia. Richardson33 records two
cases of pulmonary infarct, one necessitating an
opening to drain a lung abscess. Scudder"5 calls at-
tention to lung abscesses following tonsillectomy.
Beck13 reports a case of pulmonary abscess follow-
ing amygdalectomy. Manges5' records nine cases
of abscess of the lung after tonsillectomy.
Pulmonary Embolism. — LaPlay33 reports a case
of pulmonary embolism following amygdalectomy.
Hyperpyrexia. — Richardson33 and Wishart31 re-
port fatal cases from hyperpyrexia. The latter's
patient's temperature went as high as 107°.
Emphysema. — Richardson records a case of sub-
cutaneous emphysema following amygdalectomy.
Parrish35 reports a case of emphysema on the face,
neck, and chest after removal of the tonsils.
Pneumonia and Pleurisy. — Crockett3 refers to pa-
tient of his own, who died from ether pneumonia,
followed by empyema, acute mastoiditis, and menin-
gitis. A number of other cases are reported, but it
would be difficult to assign the tonsillectomy or
ether as the real cause. Dickie53 records a case of
bronchopneumonia following amygdalectomy. Blum
in his report says that tonsillectomy increases re-
spiratory affections, instead of preventing them.
Particularly severe lesions have supervened in the
cases cited — as mastoid, ear trouble, and asthma.
Rheumatism. — A number of cases have been
ascribed to tonsillectomy. What improvement in
this condition follows the therapeutic removal of
the tonsils for this affection has been assigned to
the abolition of a specific etiological factor. Possi-
bly this can be explained, as suggested above, by
the removal of a general, not specific, irritating in-
fluence. Dickie53 reports a case of acute articular
rheumatism following tonsillectomy. Young'3 re-
cords two cases where immediate recrudescence oc-
curred after amygdalectomy.
Status Lymphaticus. — Packard3" reports a case
of probable death from this cause, although an au-
topsy was performed to confirm the diagnosis. Har-
ris" records a death from status lymphaticus follow-
ing tonsillectomy. The necropsy revealed an enlarged
thymus gland, which weighed eighteen grams.
Dickie"' reports the death of a child, age seven,
probably from status lymphaticus.
Amygdalotomy Rash. — Dickie53 reports scarlati-
form rashes developing after tonsillectomy. Win-
grave37 records thirty-four such cases. Forsyth re-
ports similar results. Richardson33 explains this
phenomena as due to the autointoxication from the
blood, which is swallowed during the operation.
Beck13 records a similar case to the above.
Dryness of the Throat. — Winslow™ reports this
condition as following tonsillectomy. Richardson'8
has many cases who come to him in the hope of be-
ing relieved of the faucial dryness due to amygda-
lectomy. Blum"5 speaks of similar cases.
Appendicitis. — As time goes on, more cases of
this complication of tonsillectomy are being re-
ported. Still, Lockwood, Pavy, and Bramwell men-
tioned the not infrequent association of tonsillitis
with appendicitis during the discussion of Lock-
wood's" paper, entitled "Acute Abdominal Inflam-
mation in Children." Metcalfe" reported two cases
of appendicitis following tonsillectomy. An in-
flamed appendix was removed on the fifth day after
the amygdalectomy in one case, and a gangrenous
appendix was operated upon on the eighth day sub-
sequently to the tonsillectomy in the other case.
Local Results of Tonsillar Operations. — Stucky'3
reports various cases of adhesions of the pillars,
impairment of the voice, difficult swallowing, and
one case where there was matting clown of the an-
terior and posterior pillars, causing traction around
the fossa of Rosenmiiller, resulting in a partial
closure of the Eustachian tube with subsequent
tinnitus. Roe'; refers to two cases of impairment
of the voice following attempts at tonsillectomy by
other operators. Both cases had the tonsils left
behind, but complete adhesions of the soft palate
to the pharynx as result of the mutilation. Sewell3
reports a case of retropharyngeal abscess following
tonsillectomy. Bauchacourt3' and Martin record
three cases of edema of the glottis following
amygdalectomy. Lederman" refers to a hematoma
of the fauces after the same operation. Huber45 re-
ports a lateral pharyngeal abscess due to the same
procedure. Many cases have been recorded of in-
juries to the pillars, accidental removal of the
uvula, cicatrices in the palatine arch, impairment of
976
MEDICAL RECORD.
[Dec. 2, 1916
movement of the vela curtain, and adhesions of the
pillars. Cases of tonsillectomy affecting the sing-
ing voice are reasonably frequent. Balfour" says
that statistics from the New York public schools
show that in 10 per cent, of children operated on
there has been mutilation of the soft parts sur-
rounding the tonsils. Thompson43 reports several
cases of injury to the soft palate and uvula in ton-
sillectomies. Laceration and cicatrization render
the voice nasal; rapid formation of granulations
requires weeks for removal1 Pfingst'1, reports fifteen
cases where the pillars were buttonholed during the
operation. Delavan" has noticed severe inflamma-
tory conditions of the throat and nose following
tonsillectomy, when the operation was performed
during acute inflammation of the throat and even
during convalescence from grippe. Sheedy*7 found
forty deformed throats out of fifty cases operated
upon elsewhere; of these 5 per cent, complained
of difficulty in using certain words, and had nasal
intonation, and two had practically lost the singing
voice. Wishart'" reports three cases of irregularity
in the palate arch resulting from contracture, and
a bad effect on the singing voice in another case.
Dickie" reports cases of scarring of the soft palate
and fusion of the pillars. Stucky* refers to a case
of limitation of tone production after the opera-
tion. Blum* notes injuries to the soft palate and
uvula, impairment of speech, cicatricial bands caus-
ing discomfort, and contraction of the pillars. Roe*
has devised plastic operations for the relief of post-
operative conditions following tonsillectomy.
Infection of the Middle Ear. — Still4* has found
acute otitis media to follow tonsillectomy. Dickie'
reports twelve cases of acute suppurative otitis
media following amygdalectomy. One led to a fatal
meningitis. Blum" reports similar cases.
Cervical Adenitis. — Dickie" reports a case of
cervical adenitis following tonsillectomy. Cervical
adenitis is not cured by amygdalectomy (Blum85)-
Anesthetic Fatalities. — Sheedy™ reports four
deaths following the use of cocaine and adrenalin
solutions in tonsillectomy. Still" speaks of two
cases that died under the anesthetic, and Dickie'
reports a case of death following amygdalectomy,
the probable cause being delayed anesthetic poison-
ing.
Shock. — Still" speaks of another case, in which
death appeared to be due simply to shock, and he
further states, "I could quote other cases from my
own experience in which life was all but lost
through this operation."
Lucemia. — Ireland, Baetzer, and Ruhrah" report
the case of a boy, who following an attack of ton-
sillitis had the tonsils removed. For a month or
more following this, he complained of abdominal
pain, diarrhea, and nosebleed. A diagnosis of lym-
phatic leucemia was made upon the evidence of an
enlarged spleen and lymphatic glands, and the blood
picture.
i: ■ uresis. — Still" has known tonsillectomy to ag-
gravate this condition. Swartz's" series shows no
connection between adenoids and tonsils and
enuresis, where the operation was performed for
the relief of the incontinence.
I.. H. (U. of Minn. Hosp., 8754), female,
admitted May 22, 1916, with the diagnosis of dial
mellitus. The patient complained of pol
eral weakness. Urine showed glycosuria (7 i
and aeetonuria on admission. On treatment the sugar
quickly disappeared, she prac"
any glucosuria up to the date of her tonsillectomy.
which was performed, under local anesthesia, on June
28. The following day a large amount of sugar in
the urine was reported, and, notwithstanding treatment,
the sugar failed to diminish in quantity during the rest
of her stay in the hospital, which she left on July 7.
The patient blamed the tonsillectomy for her post-
operative condition.
Miscellaneous Results. — Specialists reporting to
Blum*"' speak of the following conditions as having
followed tonsillectomy: tendency to become over-
fat, development of signs of hyperthyroidism, re-
currence of adenopathy, nephritis, prolonged de-
pression in adults, increased colds, epileptiform con-
vulsions, failure of relief of secondary infection,
and acidosis. As to the thyroid gland it is inter-
esting to note that Theisen" reports six out of seven
cases in young women of thyroiditis as occurring
with or directly after an attack of tonsillitis. The
glands in all cases were previously healthy and two
developed permanent goiters subsequently.
The above cases have been reported by a few
eminent specialists, who in the main are clever
operators and men of sound judgment. If they
record so many cases as complicating tonsillectomy,
we can only conjecture how many hundred fatali-
ties and sequela? have followed the promiscuous em-
ployment of this surgical procedure by the general
practitioner, the pseudospecialist, the quasispecial-
ist, and specialist. Death and postoperative adhe-
sions probably seal the mouths of their patients.
Canines are muzzled because of their potential
power to transmit rabies; typhoid carriers are
quarantined ; chloroform, because of the fatalities
following its use, has been discarded in many locali-
ties, and "Dammerschlaf" following a very low
fetal mortality ascribed to its employment has been
prohibited by the board of directors in at least one
hospital in the United States; but tonsillectomy,
with its fatalities, dangers, and complications goes
on unmolested.
Amygdalectomy"2 is not a recent addition to our
surgical procedures. Writing in the year 10 A.D.,
Celsus says, "Tonsils which remain indurated after
inflammation if covered by a thin membrane should
be loosened by working the finger around, and then
torn out, but when this is not practicable they
should be seized with a hook and then excised with
a scalpel." We are now reaping the whirlwind, the
result of the momentum of ages, which was sown
centuries ago by the immortal but radical Celsus.
Every intelligent physician recognizes the neces-
sity of the removal of the tonsils and adenoids un-
der certain legitimate and well-recognized condi-
tions. Still," whose views are always sound, recom-
mends tonsillectomy under the following circum-
stances: (1) Recurrent earache, and still more the
slightest degree of deafness. (2) General ill
health ; the child is pale or of pasty complexion,
caused by defective aeration of the blood and in-
somnia due to hypertrophied tonsils and adenoids.
(3) Hypertrophied tonsils with recurrent attacks
of acute tonsillitis, which can be cured only by the
removal of the tonsils. But a slight tendency to
nasopharyngeal catarrh or an occasional attack of
tonsillitis is not per se a sufficient justification for
operative interference. (4) Catarrh starting in
the nasopharynx spreads to the bronchi repeatedly.
so that it may be necessary to remove adenoids.
Asthma and laryngitis stridulosa, only when
there are other reasons for removing accompanied
hypertrophied tonsils and adenoids. (6) Deformity
of the chest resulting from throat obstruction.
Iti rheumatic affections, whether the removal of
the tonsils can prevent this trouble has yet to be
Dec. 2. 1916]
MEDICAL RECORD.
977
determined. (8) Remove the tonsils in cervical
adenitis in a child of a tubercular family or of a
known tubercular tendency, but judgment is to be
used in the tonsillar removal if these glands are in-
flamed or caseous, as irritation of the glands fol-
lowing the tonsillectomy might extinguish the last
chance of the subsidence of the glandular inflamma-
tion. (9) The mere presence of adenoids and ton-
sillar hypertrophy is not sufficient ground for opera-
tive interference. (10) Tonsillectomy does good in
certain cases of epilepsy.
Richardson," speaking of the local indications for
the removal of tonsils suggests operating upon hy-
pertrophied tonsils, or those which are the seat of
chronic lacunar infections, or of follicular tonsil-
litis or abscess formation, or tonsils which are pain-
ful on swallowing or tender on pressure. But he
says33 that "tonsillectomy may be at times attended
by serious, even fatal, complications. With such
knowledge, is it proper or wise to suggest this op-
eration, as is so often done by the internist with
insufficient and inaccurate data from a local stand-
point as a prophylactic measure?" Further on he
states, "I believe that a few general conditions
probably have their portal of entry into the general
system through the tonsil, but I would demand that,
in every individual case, the tonsil be first proved
to be guilty before it is sacrificed. One must hold
steadfastly in mind the fact, when suggesting such
a procedure under such conditions, that we by this
operation are placing the patient in danger of his
life, probably a greater danger to his life than the
probable remote infection."
The fact that certain good results, temporary at
least and perhaps permanent in some cases, have
followed the removal of infective foci for the ben-
efit of certain so-called chronic sequential systemic
diseases is no reason why this procedure should
be employed without reason or limitation. It is
its promiscuous use that is deplorable. To remove
a tonsil, in the light of our meager present knowl-
edge, because no other cause can be found, is both
unsound and unscientific. Wise physicians will not
expect too much from the removal of infective foci.
As a sovereign remedy for many chronic constitu-
tional diseases, its Cheynes-Stokes respirations
will soon be forthcoming, notwithstanding a certain
limited number of apparently beneficial results,
suggesting its reasonable and restricted applica-
tions.
Concerning the function of the tonsil, during the
last two years, Henke'"'" and Lemart have injected
the nasal mucosa with solid particles in suspension,
and have found a direct lymphatic communication
exists between the nose and the tonsils. A similar
communication exists between the mucous mem-
brane covering the alveolus of the upper jaw and
the tonsil. These lymph currents pass through the
tonsils to its free surface and act as a powerful
defensive mechanism. The function of the tonsil is
comparable to an ordinary lymph-gland, and hav-
ing a large free surface, they offer an exceptional
opportunity for the excretion of foreign substances.
It follows that tonsillitis alone or in association
with rheumatism or endocarditis is the result of
lymphatic infection, the portal of entry being in
ps the nose, the accessory sinuses, or the
mucous membrane of the mouth (Fraser') .
loenemann51 regards the tonsil as submucous
lymph glands, and acute tonsillitis as due to infec-
tion reaching the tonsils from the area which it
drain"; that is, the lower part of the nasal cavity.
Pybus'* says, like other lymph glands, the tonsil no
doubt produces lymphocytes; that it receives lymph
from the nasal cavities and acts as a filter in in-
fections of this region; pigment granules injected
into the nasal mucosa may be extruded on to the
free surface of the gland. By a process of absorb-
ing organisms and toxins, the tonsils may act as
immunizing agents to the body as a whole
( Pybus' ) . Blum" injected chemicals and bacteria
into the cervical glands and recovered them in the
tonsil and mouth. He, therefore, contends that the
tonsils are excretory organs. Brieger, Goerke, and
Stohr observed the emigration of lymphocytes from
the center to the periphery of the tonsil, thus sug-
gesting that the tonsils, as modified lymph glands,
may combat infections.*'"' Makuen" considers that
the tonsil is beneficial to voice production, as it im-
proves the resonance of the voice, and by keeping
the pillars apart gives direction to their action in
voice production. This seems a reasonable sugges-
tion as so many singers' voices are injured by ton-
sillectomy. Ashurst, Wright, Swain, and Blum be-
lieve that the tonsils are eliminative organs for
systemic diseases, including scarlet fever and diph-
theria, Ashurst, for the waste products of dentition
(Wright) ; and tubercle bacilli (Swain and Blum85).
As dryness of the throat is a frequent complication
of tonsillectomy, possibly the normal tonsil encour-
ages the accumulation of saliva in that region. The
suggestion that operative injury to the tonsillar
branches of the glossopharyngeal nerve causes dry-
ness and pain is not established (Shambaugh).
The operation of tonsillectomy has become unre-
strained and apparently unlimited in its applica-
tion. A physician in general practice, to the
writer's knowledge, recently recommended within
five minutes amygdalectomy to the first three pa-
tients, whom he had seen in his office that afternoon.
Such rontgenological vision on the part of some
physicians is really remarkable in view of the fact
that the best laryngologists agree that the question
of a diseased tonsil is often a difficult one to decide
from mere inspection.52
The public has been unfortunately educated to
have their tonsils removed. A vicious result of a
promiscuous procedure. Nearly every laryngologist
has patients who have diagnosed their own cases
and come to the physician's office requesting a ton-
sillectomy. Forty boys within one month have had
their adenoids and tonsils removed, and seventy-five
more are scheduled for the same operation at a
training school in Minnesota because the "medical
fraternity finds that these organs are largely re-
sponsible for delinquency in the young." A special-
ist63 at the Massachusetts General Hospital, dis-
cussing the results of tonsillectomy at that institu-
tion, writes as follows: "Of the fifteen cases in
which the reason for removal is not known several
were no doubt operated upon because they were
under an anesthetic for adenoid operation and it
was thought just as well to get the tonsils out, too,
without considering whether there were good rea-
sons for their removal or not." This statement re-
minds the writer of the three indications for cesar-
ean section at a large eastern maternity hospital;
they are, pregnancy, the patient cannot speak Eng-
lish, and is anesthetized. Specialists' replies to
Blum85 questions, resulted in the following con-
clusions : Sixteen laryngologists performed tonsil-
lar enucleation about 10,014 times; 7,486 before,
and 2,528 after fourteen years of age. Among the
indications for tonsillectomy given by these special-
978
MEDICAL RECORD.
[Dec. 2, 1916
ists were malnutrition, systemic poisoning, chronic
hypermeia of fauces, endocarditis, nutritive dis-
turbance, obscure stomach trouble, retarded devel-
opment, anaemia, asthma, focus of infection, foul
breath, anorexia, restless nights, and so-called bili-
ous attacks. Only one specialist objected to the
promiscuity with which tonsillectomy is performed.
One operator showed a baby to Blum in whom he
had removed healthy tonsils "because the baby be-
ing anesthetized for adenectomy, he thought he
might as well remove the tonsils and so avoid future
trouble." Another operator from 1906-1914 had per-
formed 8,000 tonsillar enucleations, equivalent to
nearly three operations per day in one man's prac-
tice.
Barnes7" advocates tonsillectomy for the cure of
quinsy during the acute attack, and Harrison™ favors
amygdalectomy during the acute stage of ulcerative
endocarditis. These physicians apparently prefer
individuality in surgical practice. Another laryn-
gologist,7" in discussing the selection of the period
for tonsillectomy in emergency from danger of suf-
focation, in cases of diphtheria and certain septic
conditions, suggests that amygdalectomy should be
the rule and not the exception. He says that no
harm can possibly be done by removing the local
focus of infection and thoroughly swabbing the
nasopharynx with iodine or peroxide. But why
cause further local reaction and constitutional
shock, when intubation and tracheotomy run on all
fours with experience and common sense? Diph-
theria being an acute septic process, thrombi al-
ready present, may become dislodged from the sur-
rounding inflamed tissue through manipulation.
Rare indeed would occasion arise when indications
would suggest tonsillectomy in preference to intu-
bation or tracheotomy in these cases. Perhaps
where there existed a pharyngeal diphtheria and the
swollen tonsils were actually obstructing respira-
tion, tonsillectomy as a life-saving procedure would
be indicated. The resulting hemorrhage would
probably relieve the local congestion.
In 1912 in Philadelphia there were 37,000 recom-
mendations to parents that their childrens' tonsils
receive immediate attention. In response to let-
ters to several specialists in New York written by
the school department in trying to set some standard
for operative interference, no two laryngologists
agreed." Sanger1* is quite enthusiastic over tonsil-
lectomy, saying that the tonsil operation in a case
in which the removal is indicated is really a life-
saving proposition.
The writer has recently investigated the annual
reports for the last three years of various hospitals
in the large cities of this country concerning the
number of tonsillectomies performed at these insti-
tutions. The examination gave the following re-
sults. The reports of the out-patient departments
are not included.
In 1912 there were 693 tonsillectomies performed
in one hospital.
In 1913 there were 6,441 tonsillectomies per-
formed in nine hospitals; the greatest number for
this year was 3,152, and the smallest number 55,
operated upon in one institution. The average num-
ber in each of the nine institutions for the year was
about 715.
The total number for 1914 was 7,998 in fifteen
hospitals. The maximum number in one hospital
was 3,313, and the minimum number was 59 ton-
sillectomies. The average number for each of these
fifteen hospitals was about 533 operations.
In 1915 there were 11,054 amygdalectomies per-
formed in fourteen hospitals. The maximum num-
ber for this year in one institution was 4,750, the
minimum number being 44 operations. The aver-
age number for each of the fourteen hospitals was
about 789.
All of these institutions over the period of three
years showed a remarkable increase in the number
of tonsils removed except one hospital, a large Phila-
delphia institution, which reported a considerable
decrease in the number of operations.
The writer would not attempt to give even an ap-
proximate number of amygdalectomies performed
in this country based on the foregoing figures.
These hospitals are all large institutions and their
reports are only a suggestive index in regard to the
total number of tonsillectomies performed through-
out the United States.
Considering, however, the fact that there are over
7,000 hospitals in this country, to say nothing of
hundreds of dispensaries, physicians' offices, and
private homes where amygdalectomies are being
performed; also from the consideration that prob-
ably at least one physician in every locality of a pop-
ulation of 1,000 and up is doing amygdalectomies,
it is probably not an extravagant statement to make
that there are several hundred thousand tonsillec-
tomies performed in the United States yearly, with
the number greatly on the increase.
Perhaps it may also be said, compatible with
reason, that the usefulness of this surgical proced-
ure, suggested by indications for its performance,
based on our scientific knowledge of disease and the
proven results of such surgical interference, has
been greatly exaggerated and that therefore the
justification. of the majority of the above tonsillec-
tomies has not and cannot be demonstrated. How-
ever, it is refreshing to note that among eminent
authorities on this subject a decided and happy re-
action has begun to see the light of day. Layton"
of Guy's Hospital in a recent paper registers a plea
for fewer tonsil and adenoid operations. He con-
siders that they form a very important line of re-
sistance to microorganisms, which invade the body
through the nose and mouth. The hypertrophied
tonsils may be the result of a surrounding inflam-
mation. Therefore the original source of inflamma-
tion should be removed. Layton speaks of many
cases of hypertrophied tonsils becoming of normal
size after the teeth had been treated and nasal
breathing exercises were taught (Pybus)." The
late Eustace Smith drew attention to the mucous
disease of the second dentition. Layton holds that
this complaint resembles adenoids, e.g. cough and
enlargement of lymphoid tissue, so by treating the
dyspepsia, operation with its attendant risks of
hemorrhage, choking, and death under an anes-
thetic may be avoided. "The complete removal of
tin' tonsils does nut prt vent further attacks of rlieu-
matism" (Layton).'7 Henke50 claims that the fre-
quency with which the tonsils form the portal of en-
try for many diseases has been much exaggerated.
Still," referring to relationship between tonsillec-
tomy and rheumatism, says that "from clinical notes
kept for some years of cases bearing on this point,
the evidence only proves that the ordinary partial
removal of the tonsils does not prevent the recur-
rence of rheumatism in a child who has previously
had rheumatism." Richardson" states that numer-
ous instances can be given of acute and chronic rheu-
matism and rheumatoid arthritis where tonsillar
enucleation has been followed by total failure to ob-
Dec. 2, 1916]
MEDICAL RECORD.
979
tain relief. The writer knows of a young physician
who was recently carried on a stretcher to the Hot
Springs, Va., suffering from recurrent acute articu-
lar rheumatism. His tonsils had been removed sev-
eral years ago. Comroe™ and Richardson10 agree
that there appears to be a marked reaction in cer-
tain sections against the indiscriminate removal of
tonsils. Comroe hopes that the tonsils will escape
unnecessary and undeserved slaughter, and recalls
the successful escape of a somewhat similar fate of
the ovary, appendix, and the inferior turbinate.
Richardson remarks that it has been stated that no
adult should possess tonsils, nor even the site from
which tonsils had ceased to exist." A prominent
internist in Minneapolis has recently stated "that
the tide has turned against the slaughter of the
tonsils."
Young," at the Massachusetts General Hospital,
referring to the value of tonsillectomy in the rheu-
matic child as a preventive of recurrence of in-
fection, says that his experience has been far from
encouraging since in more than half of the cases re-
lapse has occurred. Fredreich, Layton,17 and Semon
agree that the pendulum has now swung too far in
the direction of operation, and that cases are often
sent to them for tonsillectomy to cure all sorts of
diseases. Balfour" of the Mayo clinic, in a very re-
cent paper, remarks that it is still unsettled to what
extent the tonsils should be held responsible for
various forms of arthritis, lesions of the gastro-
intestinal tract, infections of the gall-bladder, tuber-
culosis, or exopthalmic goiter. Williams,11 deploring
the crippling effects in early childhood of rheuma-
tism, suggests three important points in treatment:
(a) rest, (b) "keep warm and dry," (c) good food.
No mention is made by Williams of tonsillectomy.
Richardson1" objects to the frequent removal of ton-
sils which show no macroscopic evidence of disease,
and the fact that the possessor of this type of tonsil
may be the subject of an infection that cannot be
accounted for, does not justify the removal of the
tonsil. McKisack" does not consider that a con-
vincing case has been made out for the view that a
septic state of the mouth is a common cause of re-
mote disease, although he admits that it is always
a source of danger. He thinks that the extreme
views which have prevailed on the subject are now
becoming moderated. Blum'0 says that no single
case of endocarditis has so far as he is aware been
positively proved as emanating from the tonsil. Mc-
Kenney'0 attacks the enthusiastic tonsilar operator.
G. Hudson-Makuen" sounds a warning to the men
who operate on the tonsil for the most vague rea-
sons imaginable.
It is Hudson-Makuen's firm conviction that the
tonsil rarely is the focus of severe general infec-
tion. He deprecates the wholesale manner in which
patients are "tonsillectomized" in clinics as unsur-
gical in every sense. Blum'' claims that "tonsil-
lectomy" has become more than a therapeutic pro-
cedure; it has become a menace. He further states
that there are too many patients operated on with-
out positive indications and that this operation
should not be performed in infants, and only rarely
up till eight years of life. Laboratory theories are
frequently silenced by the final verdict of clinical
results.
What suggestions does the literature recording
the experience of eminent operators offer in regard
to the indications for tonsillectomy, and the meth-
ods to pursue to reduce as much as possible the un-
happy results? Shurley says "that tonsillectomy
in one case of pernicious anemia or acute leukemia
is sufficient to impress the surgeon with the value
of blood examinations in all suspected cases of
anemia. One case of hemophilia is sufficient to es-
tablish the value of a routine examination to de-
termine the coagulation point. One death from
chloroform is a life-long lesson in the value of
ether."
1. The remarkable number, regardless of its pop-
ularity, of fatalities and complications following
tonsillectomy is astounding.
2. Thousands of unnecessary amydalectomies are
being performed yearly. A great many are being
done on meager theoretical conclusions, the latter
not being borne out by fact.
3. Tonsillectomies, being major operations, should
be done in hospitals and the operator should be a
specialist, experienced in this work. Manges" says
that three days in a hospital should be the shortest
stay demanded of them.
4. Hospital internes should be instructed in the
control of postoperative hemorrhage. The use of
the compressor, cautery, artery forceps, ligature,
suture of the pillars, and the employment of adren-
alin and silver nitrate, should be explained to them.
5. Unless absolutely necessary, operations at the
home, dispensary and the physician's office should be
abandoned. Sepsis and hemorrhage is too frequent
a complication.
6. All patients and parents should be informed
that there are possible dangers and complications
following removal of the tonsils.
7. Levy51 says that in all cases the surgeon should
make sure before operation that there has been no
recent case of illness in the house.
8. Cocaine and adrenalin injections should not be
made into the soft tissue surrounding the tonsils.
Such a procedure is dangerous (Sheedy"").
9. Singers should be informed that tonsillectomy
may injure the voice.
10. When possible, a pathological examination
should be made of all tonsils removed. Many will
probably be found to be normal.
11. Conclusions as to tonsillary hypertrophy
should not be made immediately after an attack of
acute tonsillitis. Inflammatory enlargement may
subside several months later (Still"), and opera-
tive interference may be unnecessary (Layton").
12. The tonsil should be viewed as normal and not
guilty until proved abnormal and guilty. The
standard of surgical interference should be the
avoidance of operation when possible, instead of
razeeing the tonsils out on the slightest pretext.
Intelligent surgeons are now preserving tissue as
much as possible, as the prepuce, ovaries, tubes,
chronically inflamed appendices, gall-bladders, in-
ferior turbinates, and in military surgery, the limbs.
13. The conservative laryngologist should always
be the one to judge of the local condition of the
tonsil. Physicians in general, unless they have
been especially trained in nose and throat work, will
not have had sufficient experience to pass on the
pathology of the tonsil. The laryngologist would be
wise, however, to consult an experienced internist,
who has medical equipose, when the question of
tonsillitis in reference to constitutional diseases
presents itself for decision.
14. Still's" indications for tonsillectomy are
sound. Mere uncomplicated tonsillar hypertrophy
does not call for operation. Practically complete
tonsillar involution takes place in the majority of
children about the age of puberty.
980
MEDICAL RECORD.
[Dec. 2, 1916
15. Take a nose and throat culture in all cases
before operation, as the patient may be a carrier,
as diphtheria has occurred immediately following
tonsillectomy, even in cases where only a throat
culture was taken and found negative, the culture
from the nose being neglected.
16. In all cases test the coagulation time of the
blood. Perform no operation on any one when the
clotting time registers beyond one minute and a
half. Thrombokina.se, as used at the Manhattan
Eye and Ear Hospital, which acts on the fibrin
ferment of the blood and forms a clot, is useful in
controlling oozing. Also in these cases of delayed
clotting time administer caloium lactate for sev-
eral weeks prior to the operation and then test the
clotting time of the blood. Use calcium lactate espe-
cially in cases of the lymphatic type. Wilson" has
proved by the coagulometer that the blood-clotting
time in adults can be reduced from seven minutes to
one minute after the administration of 120 grains
of calcium lactate. Fonio'a" "separierende methode"
determines which of the elements of the blood is
lacking in the individual case. Fonio's "coagulen"
(blood platelets) is a valuable hemostatic. Horse
or rabbit serum can be tried. Hess" uses "tissue
extract" as a hemostatic, applying it locally in cases
of hemophilia. It has been used after tonsillectomy.
The injection of human blood or serum, preferably
familial, or diphtheria antitoxin, can be employed.
Transfusion, by the multiple syringe method, may
be used.
17. It appears to be a good plan to test the bleed-
ing time of blood by the Duke's blotting-paper
method. The bleeding point is independent of the
coagulation time, so that it may be normal in a
case of jaundice in which the coagulation time is
very much delayed, or in a case of hemophilia. If
the platelet count is diminished, then a delayed
bleeding time indicates a hemorrhagic diathesis.
Normally it is 1 to 3 minutes. It is delayed where
the platelet count or the fibrinogen content of the
blood, either occurring separately or at the same
time, are excessively reduced. Constitutional pur-
pura is characterized by prolonged bleeding time
with normal coagulation time.
18. Ligate and stop all bleeding points after ton-
sillectomy, as in all other surgical procedures.
Thompson's" test, keping the child on its side near
the edge of the table, the foot of the latter being
elevated, is a good one. Any bleeding comes out
of the mouth and is discoverable.
19. Avoid shock by using ether in most cases.
The effect of ether is exerted wholly through its
action on the suprarenals." Coagulation processes
are hastened by ether anesthesia."
20. The wisdom of the prophlactic removal of
tonsils appears to be very questionable. Results,
thus far by competent observers, have not justified
the indications in ?nost cases.
21. Operate on no patient with an elevated tem-
perature, as the patient may be in the incubation
stage of measles, scarlet fever, or diphtheria
(Layton,:). Richardson," however, reports a sub-
acute case, which after the patient had been run-
ning an elevated temperature for several months,
the fever disappeared following a tonsillectomy.
22. Operate in no case where the constitutional
or local condition is acute, as in arthritis, neuritis,
coryza, tonsillitis, habit spasm (Still"), or when the
patient is still convalescing from influenza. The
reaction might be worse than the presence of the
tonsils.
23. If avoidable, never operate in the winter
months. Bronchitis is more apt to follow such a
procedure (Still**). Layton" of Guy's Hospital per-
forms no operations on the out-patients during the
winter.
24. Perhaps it would be a good plan for laryn-
gologists to take up the question again of the local
treatment of chronic tonsillitis" and tonsillotomy.
Pybus" says, where the symptoms are only me-
chanical, partial removal may suffice. Comroe" ex-
presses the hope that many tonsils may be rescued
from unnecessary and undeserved slaughter.
25. The snare or dissection method (Balfour*7)
probably surpasses any guillotine method. Finger
dissection helps to avoid severe hemorrhage (Rich-
ardson31) .
26. When the diphtheria bacillus, in carriers, is
once lodged in the tonsillary recesses, causing re-
peated attacks of diphtheria, it is difficult to get rid
of; the tonsils should then be enucleated (Pybus55).
Malignancy is, of course, an indication for their
removal.
27. The "follow-up" system of recording results
should be instituted wherever possible.
28. More attention should be paid to oral asepsis,
before and after tonsillectomy. Treat diseased
gums and carious teeth prior to the operation. No
abdominal surgeon would operate for chronic ap-
pendicitis with a furuncle in his line of incision.
29. Inquire into the history of jaundice, hemo-
philia, purpura, erythremia, the anemias, and dia-
betes before operating. Hemophilia is rarely dan-
gerous after the twenty-fifth year.1" As the skin
and cellular tissue in diabetics are readily invaded
by the microbes of suppuration, and as the multipli-
cation of these microbes is singularly favored by
the presence of sugar in the tissues (Bujvid), it
would appear unwise to perform tonsillectomy upon
a diabetic. Those suffering from diabetes stand all
operative procedures badly.
30. Look for other foci besides the tonsils, and
other etiological factors, and then try generally ac-
cepted treatment for the various chronic systemic
diseases, before attacking the tonsils.
31. Tonsillar inflammation in those subject to
occasional attacks of tonsillitis becomes more in-
frequent and may disappear altogether when middle
age is reached.
32. Tonsillectomy for arteriosclerosis and heart
disease, in the light of our present knowledge, is
absolutely unjustifiiable. Sclerosed arteries retract
and contract with difficulty and severe hemorrhage
is frequent in these cases and difficult to control.
33. Tincture of iodine (Marquis") applied to the
tonsillar fossae after the operation, throat gargles,
and compound tincture of benzoin, when used in
the postoperative period, are useful applications to
be made to help the disagreeable postoperative con-
dition.
34. Perhaps the postoperative sloughing can ac-
count for some of the sequential systemic reactions
in joints and other tissues. Systemic absorptions
of toxins is the rule from acute septic areas.
We offer our argument against promiscuous ton-
sillectomy chiefly to the pliant intellect of youth,
whose minds are not sclerosed, and who are not
beyond the pale of regenerative thought. They are
capable of molding their professional judgment
upon a safe and sane basis, and we therefore pre-
sent our appeal, regardless of the extreme ideas al-
ready inculcated in them, the product of what might
be called bizarre teaching.
Dec. 2, 1916]
MEDICAL RECORD.
981
The tonsil has become the germ of medical hys-
teria, and by the indiscriminating and immoderate
employment of tonsillectomy this operation has
blossomed into the jester of therapeutic measures,
and the clown of surgical procedures — but a prince
of financiers nevertheless.
REFERENCES.
1. Dabney: Transactions of the American Laryngo-
logical Association, 1912.
2. Crockett: Bost. Med. and Surg. Jour., March,
1911.
3. Sewell: Med. Chron., July, 1911.
4. Stuckey: Laryngoscope, October, 1912.
5. Schuchardt: Aertzliche Laehwerstandigen Zei-
tung, 1900, No. 7.
6. Transactions of the American Laryngological As-
sociation, 1912.
7. Brown: Ibid.
8. Ballenger: Ibid.
9. Price: Ibid.
10. Shurley: Ibid.
11. Chenery: Ibid.
12. Beck: Ibid.
13. Iglauer: Ibid.
14. Thompson: Ibid.
15. Pfingst: Laryngoscope, July, 1911.
16. Hall: Lancet, May, 1916.
17. Layton: Ibid., 1914, 1, 1106, Med. Ann., 1915.
18. Son tag: Zeitschrift fuer Laryngologic, Wiirz-
burg, 1908-9, Vol. I.
19. Dean: Laryngoscope, Vol. XX, No. 7.
20. Ballenger: Diseases of the Nose, Throat and Ear.
21. Pierce: Transactions of Sec. of Laryngology and
Otology, A. M. A., 1909.
22. Deane: Cat. State Jour. Med., 1909.
23. Burak: Archiv. fuer Laryngologie and Rhinol-
ogie, B. 22, H. 2.
24.Bauchacourt: Transactions of the American
Laryngological Association, 1913.
25. Koplik: Am. Jour. Med. Sci., 1912, 11, 30, Med.
Ann., 1912.
26. Roy: Laryngoscope, 1915, 361, Med. Ann., 1916.
27. Freer: Transactions of the American Laryngo-
logical Association, 1912.
28. Wagner: Ibid.
29. Caille: Pediatrics, September, 1899.
30. Levenstein: Archives Internat. de Laryngol,
d'Otol. et de Rhinologie, January and February, 1910.
31. Kobrak: Archiv fuer Laryngologic, Berlin, 1906,
Vol. XIX.
32. La Play: Archives gen. de Med., 1905, Vol. II.
33. Richardson: Transactions American Laryngo-
logical Association, 1912.
34. Wishart: Laryngoscope, February, 1909.
35. Parrish: Ibid., November, 1910.
36. Martin : Transactions of the American Laryngo-
logical Association, 1913.
37. Wingrave: N. Y. Med. Jour., 1901.
38. Packard: Am. J. Med. Scie., September, 1910.
39. Harris: Annals of Otology, Rhinology and
Laryngology, 1909.
40. Winslow: Transactions of the American Laryn-
gological Association, 1912.
41. British Medical Journal, November 1, 1913.
42. Stucky: Transactions of the American Laryngo-
logical Association, 1912.
43. Young: Bos. Med. and Surg. Jour., CLXXIII,
356, 1915.
44. Lederman : Kentucky Med. Jour.. December,
1911.
45. Huber: Archived of Pediatrics, 1894.
46. Delavan : Transactions of the American Laryngo-
logical Aassociation, 1912.
47. Sheedy: Medical Record, 1913, 1, 654.
48. Still: Common Disorders and Diseases of Chil-
dren.
49. Richardson: Laryngoscope, 1915, Med. Ann.,
1916.
50. Henke: Arch. Laryngol., XXVIII, 2, Med. Ann.,
1915.
51. Fraser: Med. Ann., 1915.
52. Wishart: Annals of Otology, Rhinology and Lar-
yngology, 1916, Sept.
5:1. Dickie: Jour Laryngol, 1914.
54. Levy: Zeits. f. Laryngol, V, Helf 8.
55. Pybus: Lancet, 1915, 1, 293, Med. Ann., 1916.
56. Dutrow: Laryngoscope, May, 1912.
57. Hopkins: American Otology, Sept., 1911.
58. Burack: Z. Larying. Rhinol.
59. Willard: Jour Ophth., Otol. and Rhin., Feb., 1911,
60. Sheedy: Medical Record, Feb., 1911.
61. Makuen: N. Y. Med. Jour., Aug., 1911.
62. Wood: Progressive Medicine, March, 1916.
63. American Laryngological Ass. Transactions, 1913.
64. Agnew: Amer. Otol., etc., 159, March.
65. Scudder: Bos. Med. and Surg. Jour., 1914, 11.
66. Comroe: J. A. M. A., 1914, 11, Med. Ann., 1916.
67. Balfour: Annals of Surgery, March, 1915;
Archives of Pediatrics, June, 1916.
68. Shurley: HospiiaZ, Dec, 1910.
69. Lilienthal: A nnals of Surgery, July, 1916.
70. Aymard: Lancet, 1915, Vol. 1, p. 1284; Med. Ann.,
1916.
72. JL A. M. A., 1914, 11, 1638.
73. Progressive Med., June, 1916.
74. British Med. Jour., 1915, 1, 453; Med. Ann., 1916.
75. McKenney: Kentucky Med. Journal, June, 1915.
76. Sanger: Southern Med. Jour., Aug., 1915.
77. Makuen: N. Y. Med. Jour., March, 1916.
78. Barnes: Transactions of the American Laryngo-
logical Association, 1915.
79. Harrison: Southern Med. Jour., Jan., 1915.
80. Vanderhoof : Laryngoscope, Jan., 1915.
81. Menges: Am. Journal of Surg., Jan., 1916.
82. Wessler: Interstate Med. Jour., Jan., 1916.
83. Thompson: Lancet-Clinic, Jan., 1916.
84. Marquis: J. A. M. A., Jan., 1915.
85. Blum: Archives of Pediatrics, Nov., 1915.
86. J. A. M. A., 1915, Sept. 11.
87. Schwarts: Bos. Med. and Surg. Jour., 1914, 11,
631. , , . ,
88. Sherwood: Virchow's Archiv. fur pathologtscne
Anatomic, etc., 1891.
89. Frank: Berl. klin. Wochenschr., May 3 and 10,
1915; Prog. Med., June, 1916.
90. DuPan: Rev. med. de la Suisse Romande, Oct.,
1915; Prog. Med., June, 1916.
91. Mendenhall: Am. Jour, of Physiology, July, 1915;
Prog. Med., June, 1916.
92. McKenzie: Med. Ann., 1911.
93. Fonio: Corresp. Blatt f. Schweizer Aerzta, 1915,
XIV, No. 48.
94. Hess: J. A. M. A., April 24, 1915; Progressive
Med., June, 1916. w J
95. Theisen: Ann. Otol, March, 1914; Med. Ann.,
1915.
A number of case reports were obtained from articles
by Dabney and Richardson.
THE SYPHILIS PROBLEM AMONG CONFINED
CRIMINALS.
By EUGENE N. BOUDREAU, M.D..
AUBURN. N. V.
ASSISTANT PRISON PHYSICIAN.
Previous to the introduction of the Wassermann
test in the State Board of Health Laboratory, it was
recognized, in treating inmates of our prison, that
syphilis was very prevalent, but the exact propor-
tion of them affected was unascertained. The ur-
gent need of knowing the ones suffering of the mal-
ady was frequently felt, as when they were admitted
to the hospital for treatment, or when we were
asked to pass upon them before assignment to the
kitchen; so as soon as possible we began sending
the blood of those suspected, either by reason of
their history or clinical picture, to the laboratory
for diagnosis.
Between May 4 and December 1, 1915, one hun-
dred and thirty-five specimens were sent, and of
these sixty-nine showed I +* to 4 + reactions, or
a percentage of 51.11 per cent, positive and 48.85
per cent, negative.
Since December 1, 1915, all admissions have been
subjected to the test unless they had been at Sing
* 1+ cases are included as positive, because after
provocative treatment the larger proportion returned
positive.
982
MEDICAL RECORD.
[Dec. 2, 1916
Sing. During the five months following there were
279 admissions, of which 47, or 16.8 per cent.,
showed positive reactions. During the fiscal year
of 1914-1915, 1,025 new inmates were received in
the prison. The admissions increase each year, but
even at the above rate we can expect at least 173
men (168 per cent.) admitted each year suffering
from syphilis.
In addition, the test has been made on the whole
population of the Women's Prison. One hundred
and twenty-seven specimens were sent from there;
of these, 84 were reported negative, and 43 positive,
or 33.8 per cent, positive. The total population
averages about 110. There are then about 38 of
them in this prison at all times syphilitic. I will
not include this number, however, in this discus-
sion, but give these facts because of their possible
interest. It seems to me that the above facts pre-
sent a moral as well as economical duty for the
State to perform. The moral side I do not wish to
discuss, but the other I do.
Statistics show that n large proportion of those
who have had the infective organisms of syphilis
in their systems for a number of years without
showing frank clinical symptoms, are potential pa-
retics or tabetics. With this in mind, two tables
were prepared which were intended to show con-
cisely the physical findings in the 47 cases above
mentioned showing positive Wassermanns, and also
50 selected indiscriminately that had negative Was-
sermanns. These tables were made up from the
careful routine physical examinations made on ad-
mission by Dr. Frank L. Heacox Prison Physician.
Of the first series, with positive Wassermann :
38, or 80.85 per cent, showed stigmata of degen-
eracy; 27, or 57.44 per cent., presented abnormali-
ties of the alimentary system ; 34, or 70.21 per cent.,
presented abnormalities of the respiratory system,
including the nasal passages; 11, or 23.41 percent.,
presented abnormalities of the circulatory system;
27, or 57.44 per cent., glandular enlargement, in-
cluding 14 with epitrochlear glandular enlarge-
ment; 26, or 55.32 per cent., presented defective
vision; 1 1, or 23.40 per cent., presented neurological
symptoms, dizziness, headaches, convulsions, paraly-
ses, etc.; 20 had chancres over 3 years ago; 11 had
chancres less than 3 years ago; 31 admit chancre,
but only 8 show scars; 16 deny chancre, but 3 show
scars. Of the 50 showing negative Wassermanns: 39,
or 78 per cent., presented abnormalities of the ali-
mentary system; 47, or 94 per cent., presented ab-
normalities of the respiratory system; 47, or 94 per
cent., presented abnormalities of the circulatory sys-
tem; 28, or 56 per cent., presented glandular en-
largement, including 6 with epitrochlear enlarge-
ment; 30, or 60 per cent., presented defective vision;
4, or 8 per cent., presented neurological symptoms ;
7 gave histories of chancre.
Comparison of these groups, because of both the
small number of cases and the little difference in
the clinical findings, gives nothing that is conclu-
sive, but it is rather suggestive that 23 per cent,
show neurological symptoms in the first group and
8 per cent, in the second.
However, from the first group the following con-
clusions can be drawn: 36 per cent, would have
been overlooked if histories alone were considered;
42 per cent, would have been overlooked if glandular
enlargement alone were considered; 76 per cent,
would have been overlooked if scars alone were con-
sidered; 57 per cent, would have been overlooked
if all physical findings alone were considered.
Now, of all of these 47 cases none presented
frank symptoms of tertiary involvement, and 20
have suffered from the disease for over three years.
Then 20, or 7.5 per cent, of all admissions, we may
say are potential paretics, tabetics, etc., or future
wards of the State.
Granted that the State wishes to protect itself
from this future expense, it should furnish, first, the
necessary money for treating these cases; second,
a workable method for treating so many cases for
at least two years; and third, medical men expert
enough to administer the treatment thoroughly.
Let me elaborate slightly on what these items
mean. It is generally accepted that salvarsan or
neosalvarsan is essential to proper treatment. At
least five doses should be given. Salvarsan, when
obtainable, costs $2.50 a dose. In conjunction with
it, mercury should be administered intermittently
until the cure is effected, but the expense of this
is slight, comparatively, unless the bibromate is
used as may be necessary in these cases. Finally,
the iodide of potassium must also be given at inter-
vals to make the mercury effective, and this is at
present $6 a pound. It will require about one pound
per patient a year. Summed up, then, the mini-
mum cost per patient a year would be:
Salvarsan $12.50
Mercury 7.50
Potassium iodide 6.00
$26.00
And for 175 patients $4,550.00
The expense the second year will be nearly dou-
bled, for 175 new sufferers will be added each year.
It is easy to see that the problem of treating so
many patients over a period of at least two years,
many of whom, as shown by past experience, are
delinquent if left to themselves, is a big one. At
the rate of 175 a year there would be an average
of 14 a month to be treated, necessitating the ad-
ministration of 75 doses of salvarsan a month, to
say nothing of the supervision of the iodide treat-
ment and the injections of mercury. This is spe-
cial work in a class with special treatments of the
eye, ear, nose, and throat, or the work of the other
specialties, and cannot be expected of the regular
prison physicians.
Therefore, to fill the third requirement, a trained
syphilologist should be furnished.
Summary. — 1. 16.85 per cent, of the males and
33.85 per cent, of the females of Auburn Prison
are found to have given a positive Wassermann.
2. 7.5 per cent, of all admissions are potential
sufferers from paresis or tabes, or some other form
of nervous syphilis, and, consequently, future wards
of the State.
3. It would cost the State of New York approxi-
mately $9,000 a year to treat properly all the cases
of syphilis at Auburn Prison.
4. History, glandular enlargement, and physical
findings in general, are further proven to be lack-
ing as evidence of the presence of syphilis.
5. Epitrochlear gland enlargement is not path-
ognomonic of syphilis.
Cutireaction in Gonorrhea. — Neisser spares no pains
to obtain cultures of the gonococcus from urethral pus,
but since in certain cases inconclusive results are ob-
tained, he makes use of a vaccine from the doubtful cul-
ture for a scratch test, which he makes also on gon-
orrheal and nongonorrheal controls. Absence of reaction
after forty-eight hours excludes gonorrhea. — Berliner
klinische Wochenschrift.
Dec. 2, 1916]
MEDICAL RECORD.
983
LUPUS ERYTHEMATOSUS AND TUBERCU-
LOSIS:
A SURVEY OF THE LITERATURE.
By LOUIS B. MOUNT, M.D.,
ALBANY. N. Y.
In the following resume of the literature regarding
the relationship of lupus erythematosus to tuber-
culosis, reference is made to the chronic form of
the former disease only. It presents itself clinically
as a patch of dull red color, with a somewhat raised
border, dilated follicles, and tightly adherent
scales. The usual and by far the commonest loca-
tion of the affection is on the nose and the sur-
rounding parts of the cheeks, presenting very often
a butterfly form. Somewhere in the patch atrophy
can be found.
Since the early work of Cazenave and Hebra dis-
tinguishing this disease as an entity, its clinical
picture and histology have been carefully studied,
and as a result many views have been propounded
to explain its origin. Among these views the fol-
lowing might be mentioned: It has been looked
upon as an angioneurosis ; as a disease of the seba-
ceous glands ; as due to a neoplasm ; as an expres-
sion of tuberculosis, due either to the bacillus it-
self or to the toxin. Most of these hypotheses have
been lost by the wayside, but one still is the topic of
lively discussion, dividing dermatologists into two
camps. This one view is the relationship of the
disease in question to tuberculosis. It has its sup-
porters and its opponents.
Jadassohn in his masterly monograph in
Mracek's Handbook covered all the work done up
to the year 1904, and as a result of the study of all
the material arrived at the conclusion that there
was no positive evidence of the tuberculous etiology
of the disease.
Civatte in 1907 published an article in which he
grouped the views of leading dermatologists into
three divisions :
1. Those which held the disease to be of tubercu-
lous origin. There were 17 members of this group,
mostly of the French school, and they gave the fol-
lowing grounds for their belief: (a) There was a
distinct family history of tuberculosis, or there was
a tuberculosis present somewhere in the body; (b)
Tuberculosis of the skin or tuberculides were pres-
ent (c) Cases were seen in which a lupus vulgaris
had become a lupus erythematosus; (d) The com-
bination of glandular tuberculosis and lupus ery-
thematosus was very common, and Darier narrated
a case of lupus erythematosus which had its origin
in the scar following extirpation of tuberculous
glands; (e) Positive local tuberculin reactions were
obtainable in some cases; and (/) It was possible to
show histologically tuberculous tissue in patches of
lupus erythematosus.
2. Those who held the contrary view. There
were 25 members of this group and they claimed
that (a) The occurrence of lupus erythematosus
and tuberculosis in the same individual was not a
common one, and that such a combination with so
common a disease as tuberculosis could very well be
a coincidence; (6) Some cases going to autopsy
showed no focus of tuberculosis in the body; (c) In
most cases a local reaction after tuberculin injection
did not occur; (d) Animal inoculation experiments
gave negative results; (e) The histological picture
was not that of tuberculosis, and the therapeutic
methods were not those of value in tuberculosis.
3. Those who took a middle standpoint, i. e. they
felt that in some cases tuberculosis was present
and that in others it was not. There were 7 in this
group.
This work of Civatte's left the question no nearer
a solution than did the critical review of Lewan-
dowsky made in 1912. And yet in the literature of
the last few years the casual relationship of lupus
erythematosus with tuberculosis has become more
frequent.
There are two main ways by which the relation-
ship between the two diseases could be worked out:
(1) Many cases of lupus erythematosus would have
to be examined in order to find out whether they
show any signs of tuberculosis clinically, by reac-
tion, or by laboratory methods. (2) The attempt
would have to be made to produce experimentally
with the tubercle bacillus a dermatosis which would
be identical both clinically and histologically with
the disease in question. This method was attempted
by Gougerot and Laroche in 1908. They introduced
cultures of the tubercle bacillus into the skin of
guinea-pigs. The result was an eruption which,
the experimenters stated, looked clinically very
much like lupus erythematosus and showed an al-
most identical histological picture.
The following reports of the relationship of lupus
erythematosus to tuberculosis of the internal
organs are of interest: Robbi in Jadassohn's
clinic at Berne reported 87 cases of lupus erythe-
matosus of which 51.6 per cent showed tuberculosis,
the others giving no evidence of the disease. Ull-
man claimed that tuberculosis was demonstrable in
from 80 to 90 per cent of his cases. Among Bern-
hardt's 27 cases only three were free from tuber-
culosis. Bunch, on the other hand, found the opso-
nic index to tubercle bacillus normal in seven of
his ten cases. Only three showed tuberculosis of
some internal organ.
Of greater frequency is the combination of lupus
erythematosus and glandular tuberculosis, espe-
cially of the glands of the neck. The literature has
numerous observations on this point. Of all of
them Delbanco's case is perhaps the most important.
The lupus erythematosus of his patient disappeared
when a tuberculous neck gland was removed, and
reappeared when another became affected.
Among other tuberculous affections with which
lupus erythematosus can be associated, lupus vul-
garis must be mentioned. The association is not
met with often enough to point absolutely to a com-
mon causative factor, and yet is is not exactly un-
common enough not to arouse the suspicion that
they may be related. In this connection Kyrle re-
ported a very interesting case of two symmetrical
patches on the face. These patches were diagnosed
clinically as lupus erythematosus, but the micro-
scope showed one of them to be lupus vulgaris and
the other lupus erythematosus. Ehrman gave a de-
scription of a clinical lupus erythematosus which
microscopically showed typical tubercle formation.
The reverse condition has been described by Hoff-
man.
There have been many reports of the combination
of lupus erythematosus with papulonecrotic tuber-
culide, also with erythema induratum of Bazin.
Much use has been made of the tuberculin re-
action in the attempt to solve the problem. From
figures already given it seems plausible that the
general reaction would be obtained in the majority
of cases. But this would be of no value unless the
local reaction was also obtained. Relative to the
984
MEDICAL RECORD.
[Dec. 2, 1916
latter point Ravogli claims it to be fairly common.
About a half a dozen workers have obtained a local
reaction by rubbing tuberculin ointment and old
tuberculin into the lesions.
Now and then a report has made its appearance
in which lupus erythematosus was said to have been
cured or improved by tuberculin injections. But
since the majority have not been improved, no de-
duction of any value can be drawn from this.
Many have attempted to find the bacillus in the
diseased area by examining stained sections and
macerated tissue, by cultures, and by animal in-
oculation. There has been no success with the
Ziehl method of staining sections, but eight positive
bacillary findings have been reported, all of them
obtained by the antiformin method.
Before taking up the last factor in relating the
disease with tuberculosis, namely, animal inocula-
tion, the main view of the opponents to the tuber-
culous etiology should be spoken of. They claim
that the autopsy of individuals with lupus ery-
thematosus does not always show the presence of a
focus in the body. For this statement to be of value
they must show that the lupus erythematosus area
itself is not tuberculous, for it is possible that the
infection might be exogenous and not endogenous.
They also claim that the histological structure is
not that of tuberculosis. Here again it is possible
that a special soil might react atypically to the ba-
cillus, or that there might be a special variety of
the bacillus producing an atypical reaction.
Up to the time of the experiments of Bloch and
Fuchs there were three positive animal inocula-
tions with pieces of lupus erythematosus tissue.
The first, a case of Gougerot, showed typical patches
on the scalp. Guinea-pigs, inoculated with pieces
of the tissue, were killed after five months and
showed tuberculosis of the liver, spleen, and lungs;
also of the glands nearest the site of inoculation.
The second case, also one of Gougerot, produced in
the guinea-pig tuberculosis of the liver, spleen, and
lungs; also cheesy degenerated lymph glands in
which bacilli were found. Gougerot was thus the
first to show that Koch's bacillus could be the cause
of a typical lupus erythematosus. The third re-
ported case was that of Ehrman and Reines. In-
oculation of a guinea-pig caused miliary tuberculo-
sis of the lungs, liver, and spleen. This case also
gave a general and local reaction after the injection
of one milligram of tuberculin.
The greatest credit is due Bloch and Fuchs for
their epoch-making experiments. According to
their way of thinking there were exactly two meth-
ods by which the relationship of the two diseases
in question could be determined, and these two
methods were: (1) Obtain a corpuscular free ex-
tract of the diseased tissue, and by placing this
extract into the skin of individuals who react to
tuberculin produce changes of a specific nature,
namely, epithelioid and giant cells, and also casea-
tion. (2) Produce positive animal inoculations with
pieces of the tissue.
To avoid all possibilities of error, the experi-
menters first examined in serial section all tissues
used, and made use of such only as showed nothing
histologically that might pass as tuberculosis of the
skin.
In order to test out the first method they pre-
pared an extract as follows: A piece of the tissue.
including the subcutis, was excised, freed of the
upper layers of the epidermis, cut up very finely,
and rubbed up for several hours in a mortar with
sterile quartz sand until a homogeneous mixture re-
sulted. To this mixture eight to ten c.c. of sterile
distilled water was added, and the whole shaken in
a sterile bottle by means of a shake machine for
twenty-four hours and then placed in an ice-chest
over night. The next day the mixture was filtered
through a Chamberland filter and the filtrate evap-
orated in vacuo at a temperature not over 30° C. to
about 0.5 c.c. The result was either a clear or
slightly opalescent yellowish liquid. With this ex-
tract they vaccinated cases of manifest tuberculosis,
such as lupus vulgaris, tuberculides, lichen scrofu-
losorum, etc., using a control extract made from
healthy skin of the same patient from whose skin
the lupus erythematosus extract was made, and suc-
ceeded in every case in obtaining a reaction to both
the Pirquet and the intradermal methods. The
papules resulting from the intradermal method
were examined histologically and showed the tuber-
cle structure.
For their animal inoculation work they used
pieces of lupus erythematosus tissue, placing them,
under aseptic precautions, in the peritoneal cavities
of guinea-pigs. Partial success also crowned these
efforts, positive results being obtained in some of
their inoculations. It was found necessary to carry
the inoculations into the second and third series
before positive findings would result. This might
very easily explain the many failures in this direc-
tion, because in lupus erythematosus we may be
dealing with a bacillus of such low virulence that
its passage through a number of hosts might be
required before enough virulence is attained to pro-
duce characteristic changes in the guinea-pig.
In conclusion, the work of Bloch and Fuchs might
give grounds for their belief that lupus erythemato-
sus of the chronic type may be due to an infection
with the tubercle bacillus, perhaps of lowered viru-
lence or of another variety, upon soil which in the
majority of cases reacts in an atypical manner.
206 State Street.
A NEW SYNDROME.
By SIEGFRIED BLOCK, A.M., M.D.
BROOKLYN', NEW YORK.
SINCE the study of ductless glands has become so
universal many are the therapeutic claims advanced
for their secretions, but few are the real virtues
thus far elicited by the mere doctor. They are often
heralded as the future medicines — the great pana-
ceas for all illnesses, especially those, the cause or
pathology of which is not definitely understood. It
seems that the neurologist has had more dealing
with these glandular extracts than most physicians
because he sees so many cases which all kinds of
specialists have designated as either incurable or
undiagnosable. It is for this reason that the writer
takes the liberty of suggesting an entity which may
be regarded as new in that as a symptom-complex
it is up to the present not described in the medical
literature.
It must not be called "Old Maids' Disease" be-
cause the patients would not return for treatment
so for the present at least, "Block's Syndrome" is
good enough. Before the condition itself is de-
scribed it must be remembered that many cases of
so-called neurasthenia, hysteria, functional neu-
roses, headache, eyestrain, border-line psychoses,
etc., must be included in this description. The re-
port is founded on personal experience and cor-
roborated by a good number of men in several of
the specialties.
Dec. 2, 1916]
MEDICAL RECORD.
985
Definition. — A disease of women ranging in age
from the full development of puberty to the meno-
pause. Most of the cases occur between twenty-
five and thirty-five years. Characterized by sleep-
lessness, a melancholic tendency, peculiar idea of
personality, attacks of crying, general nervous ir-
ritability, sexual hypersensitivity, either loss or
gain in weight, lassitude, and pigmentation of the
skin.
Etiology. — This condition seems to occur mostly
in temperate climate and its manifestations are the
most marked in the transition seasons just after
the hot summer or the cold winter. It seems that
the morning is the worst time for these persons,
although sleepless nights are very common.
The condition seems to be definitely associated
with sexual development and the age of the sufferers
varies just as does the height of sexual life in the
human family. One thing is positive, that is that
the center of sexual activity is the age at which
the symptoms are the most pronounced. The vast
majority of the cases the writer has seen were in
unmarried girls between twenty-four and thirty-
five years of age. Many cases of young widows,
divorcees, or wives of men long away from home, as
seamen, etc., have a similar series of symptoms.
It seems to be either a sexual disorder, causing
an improper functioning of most of the ductless
glands, especially those associated with the adrenal
system ; or, a disorder of these glands causing some
sex aberration. The former seems more rational.
Pathology. — The only pathological changes thus
far noted are pigmentation. This is brown in color
and varies from an almost invisible to a deep, well-
defined, deposit. It may occur in any part of the
body, but is usually found on one or both sides of
the face just back of the malar eminences. The
next most frequent place for this deposit is on the
forehead, more often lateral than central in loca-
tion. This chloasma, as it is termed, is more marked
during the menstrual epochs. It also stands out
quite pronounced after great excitement.
There always seems to be some edema of the feet
and ankles, but the urine is usually normal.
Symptoms. — Those patients claim to be tired,
easily fatigued, and are always impatient and rest-
less. They are very self-centered and easily in-
sulted. They think that others are talking about
them or scheming to take advantage of them in
some way. This they resent and so make their
presence in a family very undesirable. Statements
are misconstrued and cause much worriment to the
patients. Their inability to carry out a prolonged
work completes a picture resembling that of neu-
rasthenia with a mild case of Krapelin's paranoia
combined with a few hysterical symptoms.
As in hysteria we can usually elicit some areas
of either anesthesia or hypesthesia. At times we
get hyperesthesia in some spots, but these do not
occur very often. As in hysteria also the skin over
the ovaries, mamma?, etc., is especially sensitive.
There may be hyposensitivity of the palate.
As in neurasthenia we have the fatigue, the in-
ability for prolonged work, insomnia, lassitude, etc.
Resembling paranoia we have continual doubt as
to what is intended by certain statements, exag-
gerated ego. Self-conceit and the ego are not so
marked as in the psychosis of Krapelin, but this is
distinctly one of the most prominent symptoms.
Memory for insignificant details, with the absence
of thoughts about the important things of life,
make the resemblance to this psychosis quite com-
plete. The arguing, the desire to prove the point
from weak premises, etc., make another parallel
line of thought with the psychosis.
The patient worries greatly over her condition
and tries various remedies for a cure. She is too
stout and tries to get thin, or she is too thin and
tries to get more flesh. She has her superfluous
hair removed, her wrinkles taken out, her tonsils
removed, her turbinates treated; she takes iron for
her blood, she must go on a diet, etc. She becomes
of a very jealous disposition, loses many of her
friends, and her symptoms increase.
The reflexes are all exaggerated. Constipation is
the rule, causing a coated tongue and a foul breath.
Whether the last symptom has any connection is
unknown. There is frequently too much urination,
but this is simply one of the symptoms of the neu-
rotic condition. Various habits, as scratching the
skin on different parts of the body, or even mild
forms of a tic as eye-blinking, or eating manner-
isms may occur. Peculiar tastes as special desire
for pickles, herring, etc., develop.
Sexually these persons seem to be hyperirritable.
Actual consummation of the sexual act does not
bring relief, except in a few cases temporary
amelioration of some of the nervous symptoms may
occur. These soon, however, reappear. Sexual
perversion often is found in such cases. Those per-
sons always wish for something which they cannot
put in words, and the inability to get this something
causes much sorrow. They are very susceptible to
flattery, hence they become good material for all
kinds of sharpers — financial, sexual, or otherwise.
The quack doctor, the religious healer, and all sorts
of faddists are met with open arms.
Treatment. — This disease is primarily a disorder
of the internal secretory glandular system and the
treatment must be divided into two distinct di-
visions; general and specific.
The general treatment which seeks to remove the
cause of a few of the symptoms consists in a change
of surroundings and a modification of the daily
routine from which the patient obtains great but
temporary advantage. Likewise change of diet is
of value. Persons who before were meat eaters
should live on a vegetarian diet while undergoing
the treatment. Friends, especially so-called bosom-
friends, should for a time be kept away. These
persons are inclined to have a rather small circle
of acquaintances and removal from these seems to
work much good. Instead of the regulation three
meals each day a smaller meal every few hours has
its advantages.
A definite time fixed for rising and going to bed
is of value. In fact our "clock-life" is well used
here. By "clock-life" we mean a definite hour for
everything, even for the toilet, using enemas if no
other way will bring about the desired result.
Medication. — The specific medication in these
cases is a combination of extracts of ductless glands.
Just which glands are necessary depend upon the
case. Extract of the whole ovary, together with
some adrenal and thyroid extract, dosage varying
with each case, makes a good general combination
to start with.
It is a curious fact that although many of these
glands act physiologically in opposing ways, when
given in combination the results of the combination
are positive instead of neutralizing, as one might ex-
pect. The cells of Leydig, from the ovary, work
better in a few of the cases than the whole ovary.
In one case, in the sister of a physician, nothing
986
MEDICAL RECORD.
[Dec. 2, 1916
except adrenal cortex, and thyroid extract gave any
result. In another case only a fresh preparation,
in capsules, showed results. Stock tablets were
entirely without value in this case. Once a week we
received fresh pituitary and ovarian extract, but
added strychnine sulphate. Under this treatment
a large chloasma disappeared, there was a gain of
ten pounds in weight and the lady who had been
regarded as an eccentric became normal. Among
some of the changes noted were in one case that a
woman who had been a man-hater changed and
became a wife; her demeanor became quite feminine,
although she had been formerly a very masculine
type. Again a stenographer in a large insurance
company who had been leading a life of immorality
abandoned it for a decent one. The wife of a
physician from another city who had a feeling of
hatred toward her only little daughter was of a pe-
culiarly neurotic disposition; her case had been
diagnosed as dementia precox by several examiners.
She has returned home now and is quite normal in
her affections. This lady had two large pigmented
areas on her right thigh.
In conclusion it may be said that by expert use
of these glands many of our former impossible cases
are relieved of a life of misery not only for them-
selves, but for all with whom they come in daily
contact.
848 Greene Avenue.
ALBINISM, LEUCODERMA, VITILIGO.
BY JOHN E. LANE, M.D.,
NEW HAVEN', CONN.
There is little hope of securing relief from many
of the extravagant absurdities of dermatological
nomenclature and classification. Confusion of new
and rare diseases, such as occurred with pityriasis
rubra pilaris and lichen ruber acuminatus, is of
course unavoidable, when such cases are described
by individual observers in different countries; and
we cannot expect to uproot from a language firmly
implanted names, like anthrax, which have wholly
different meanings in different languages. Per-
haps, too, long names may be temporarily useful
in describing new diseases. "Erythrodermie pity-
riasique en plaques disseminees," and the more
recent "glossite losangique mediane de la face
dorsale de la langue," are excellent examples of
Brocq's admirable powers of description, but they
fall haltingly from any other than a French tongue,
and are a heavy load for any disease to carry
indefinitely.
However, even if these are more or less neces-
sary evils, it seems hardly necessary to perpetuate
a lack of uniformity of names, applied to fairly
well denned conditions, among dermatologists
using the same language. This lack of uniformity
exists to a considerable degree in the application
of the terms albinism, leucoderma, and vitiligo, by
English and American writers. In some cases the
terms are also very loosely defined.
The purpose here is to illustrate the existing
confusion, and to suggest, not a new terminology
(quod di omen avertant!), but the adoption of the
French one, which is definite and consistent. Defi-
nitions have been taken from some of the more
recent books with no attempt at making a com-
plete collection.
Albinism. — All dermatologists define albinism as
a congenital affection, characterized by absence
of cutaneous pigment. Most of them subdivide it
into complete and partial albinism. Some l'mit
the term to "the congenital conditions of achromia
induced by universal absence of cutaneous pig-
ment.'" There seems to be no good reason for
thus limiting it, and for departing from a usage
which is generally accepted.
Leucoderma and Vitiligo. — Leucoderma and vitil-
igo are used as synonymous by most English and
American writers. Here again there are some
exceptions, for leucoderma is occasionally used
"to designate the pigment-atrophy which is partial
and congenital."" This also seems to be an added
confusion and a departure from the generally ac-
cepted terminology. Vitiligo is also sometimes
used exclusively to apply to the conditions for
which most writers use both vitiligo and leuco-
derma.' If these two affections are to continue
to be confounded, there is an advantage in dis-
carding "leucoderma," as it is rarely used in thii
sense except in English, and is much rarer than
vitiligo.
Leucoderma and vitiligo, when used as synony-
mous, are variously defined. "Vitiligo is an ac-
quired pigmentary affection characterized by vari-
ously sized and shaped whitish patches with hyper-
pigmented borders.'" "Leucoderma is a loss of
pigment in the skin, probably due to some toxin."5
"The name leucoderma is given to affections of
the skin characterized by the absence of pigment.
This change in the skin may be primary or second-
ary, and it is to the primary form that the name
leucoderma or vitiligo is given. It is always asso-
ciated with increase of the pigment around the
white spots .... There is a special variety af-
fecting the neck of women suffering from syph-
ilis."0
"An acquired disease of the skin, characterized
by the appearance of white patches with convex
outline extending at the periphery, surrounded
usually by hyperpigmented skin All are
agreed that there is no pigment in the epidermis
of the leucodermic area, but there is a difference
of opinion as to whether the pigment is increased
in the surrounding skin or not. Increased it may
be in some cases, but it certainly is the exception
rather than the rule.'"
German Usage. — By German writers albinism is
used to mean either complete or partial congenital
absence of pigment. Vitiligo is usually employed
to represent the conditions for which both leuco-
derma and vitiligo are used by English writers,
leucoderma being usually reserved for secondary
achromic affections, and being rarely used without
the addition of some qualifying word, as syphili-
ticum or psoriaticum.
French Usage. — In the French terminology al-
binism is used in the same sense as by German
and the majority of English writers, signifying
complete and partial congenital achromia. Leuco-
derma and vitiligo are not used as synonyms, and
the two represent two different conditions, clearly
distinguished from each other.
Leucoderma is an acquired achromia, charac-
terized by a diminution or absence of pigment in
the affected area, without any increase of the
normal pigment in the surrounding skin."
Vitiligo is an acquired achromia, or dyschromia,
characterized by the development of one or more
sharply limited spots of depigmentation surrounded
by a more or less extensive hvperpigmented bor-
der.0
Neither the pigmentary syphilide nor the Ieuco-
Dec. 2, 1916]
MEDICAL RECORD.
987
melanoderma of Fournier is included; nor are any
affections which show other than pigmentary
changes. The simplicity and clearness of this
grouping is apparent.
The confusion of the English terminology will
be made more evident by placing some of the incon-
sistencies side by side.
Albinism is universal or partial congenital
achromia,
is not partial congenital achromia.
Leucoderma is vitiligo.
is not vitiligo.
is partial congenital achromia (Al-
binism),
is not partial congenital achromia.
Leucoderma or Vitiligo (synonyms)
is acquired achromia,
is always associated with increase of
pigment.
is usually associated with increase of
pigment,
may be associated with increase of
pigment, but this is certainly the
exception, not the rule.
is made to include the pigmentary
syphilide of the neck,
is loss of pigment in the skin, prob-
ably due to some toxin.
The differences in spelling may also be noted ;
leucoderma, leukoderma, leucodermia.
The simplicity of the French classification rec-
ommends it, and the clinical difference between
leucoderma and vitiligo is sufficient to make dis-
tinctive names desirable. In addition to this there
is accumulating evidence which seems to be tend-
ing to prove that vitiligo is a syphilitic manifesta-
tion. If this should prove to be the case, it will
furnish a further reason for no longer confusing
the two affections.
Milian asserts that "vitiligo is a purely syphili-
tic manifestation," and that though it is doubtful
whether it can be cured by antisyphilitic treat-
ment there is no doubt that it can be arrested by
such treatment.10
Hudelo says that "the opinion that tends to at-
tach certain cases of vitiligo to syphilis is becom-
ing general."
Joltrain found the Wassermann reaction positive
in eleven out of eighteen cases of vitiligo. Two
of the seven reactions which were negative were
in old syphilitica, who had had the disease more
than fifteen years before.12
Leucoderma is, of course, frequently a syphilitic
manifestation, but it is also frequently due to
other causes.
REFERENCES.
1. Hyde: "Diseases of the Skin," 8th ed., 1909. p.
539; and Ormsby: "Diseases of the Skin," 1915, p 583.
2. Hyde: loc. cit., p. 538; and Ormsby: loc. cit., p.
583.
3. Hvde: loc. cit., p. 540; and Ormsby: loc. cit., p.
584.
4. Shamberg: "Diseases of the Skin," 1910, p. 235;
Sutton: "Diseases of the Skin," 1916, p. 435; Stel-
wagon: "Diseases of the Skin," 7th ed., 1914, p. 610.
5. Hazen: "Diseases of the Skin," 1915, p. 359.
6. Sequeira: "Diseases of the Skin," 1911, pp. 418,
419.
7. Princle and McDonagh, in Allbutt: "Svstem of
Medicine," 2nd ed., 1911, Vol. IX. pp. 560, 561.
8. Brocq: "Dermatologie pratique," 1907, Vol. II,
pp. 50S, 613.
Gaucher: "Maladies de la Peau," 1909, p. 846.
9. Darier, in "Pratique Dermatologique," Vol. IV, p.
846. Brocq: loc. cit.
10. Milian: "Bui. Soc. Franc, de dermat. et de
svph., June, 1914; p. 319.
11. Hudelo: Ibid., p. 318.
12. Joltrain: Ibid., p. 318.
RESEARCHES IN TRICHINOSIS.
By WILLIAM LINTZ, M.D.,
BROOKLYN, NEW YOHK.
PROFESSOR OP BACTERIOLOGY AND PARASITOLOGY, LONG ISLAND
COLLEGE HOSPITAL ; ASSOCIATE VISITING PHYSICIAN,
BROOKLYN JEWISH HOSPITAL.
The following experiments were undertaken par-
ticularly with the idea of ascertaining (1) whether
the isolation of Trichina spiralis in the feces of pa-
tients suffering from trichinosis can be depended
upon in the diagnosis of this disease, as preached
in the textbooks, and whether the views of H. M.
Hayberg,' J. Chathv and others who believe that
the parasites discharged living in the feces consti-
tute a factor in the spread of the disease is correct.
I am indebted to Dr. Edward Buxbaum for the
autopsy material which came from a young woman.
The muscle tissue employed in these experiments
contained numerous living muscle trichinae. This
tissue was cut up in small pieces and fed to albino
rats. The rats as a rule became very sick ten to
twenty minutes after feeding ; they would not move
around, although they were very lively previous to
feeding, their heads would droop, they refused nour-
ishment, the breathing became very rapid, and they
would begin to waste away. These symptoms lasted
about four days, when the rats began to recover,
and in two or three days appeared apparently nor-
mal.
The weight of the rats was between 100 and 150
grams. The amount of muscle tissue fed was be-
tween 4 and 8 grams. The method employed in
searching for trichinae was to make a saline emul-
sion of the fresh feces upon a slide and examine
with the low and high powered lens of the micro-
scope.
Rat I — Feb. 29, 1916. Fed with muscle tissue in-
fected with trichinae. March 2, 1916, again fed with
the tissue. No trichina; found in the feces. March 3,
1916. Made 56 spreads of feces, but was unable to
find trichinae. March 4, 5, and 6, 1916. Feces show
no trichina;. On the last day obtained the following
blood count: Polymorphonuclears, 55 per cent.; eosin-
ophiles, 1 per cent.; small lymphocytes, 40 per cent.;
morphonuelears and transitionals, 4 per cent.; unidenti-
fied cells, 3 per cent. Red cells show metachromato-
philia. Made daily examinations of feces, but found
no trichina;. We finally autopsied the rat on March 9,
1916.
Preparations were made of the skeletal muscles, dia-
phragm, heart, lungs, liver, spleen, kidneys, brain, and
cord, but no trichina; were found. No trichinae were
found in the stomach, but scrapings from the mucous
membrane of the small intestine showed a moderate
number of pregnant worms. Scrapings from various
parts of the large intestine showed the presence of no
trichina;. There were also none in the fecal content of
the large intestine.
Rat II. — Was fed on the very same days and with
the same amounts of infected muscle tissue. Daily
examinations for trichina; were made from the feces,
but none were found.
On March 7, 1916, the following blood count was
obtained: White blood cells, 20,000; polymorphonu-
clears, 80 per cent.; small lymphocytes, 14 per cent.;
large lymphocytes, 3 per cent.; eosinophiles, 3 per cent.;
red blood cells, 9,100,000; hemoglobin, 95 per cent. Rat
was autopsied March 9, 1916. The result of the autopsy
was identical with that of rat No. 1.
Rat III. — Fed with infected muscle March 2, 1916.
Daily examination of feces showed no trichina;. Blood
counts were made on the following dates:
988
MEDICAL RECORD.
[Dec. 2, 1916
Mar. 6,
Mar. 16,
Mar. 18,
1916.
1916
1916.
5er cent
Per cent
Per cent
69
55
57
2
1
1
21
43
1
42
8
5
19
90
100
Polymorphonuclears
Eosinophils
Small lymphocytes
Large mononuclears
Transitionals
Normoblasts
Hemoglobin
Total white, 26,800; total reds, 7,990,000.
Rat autopsied March 20, 1916. Examined pieces of
muscles of all four extremities, diaphragm, liver, spleen,
lungs, heart, heart's blood, brain, cord, kidney, but found
no trichinae. No trichina? in scrapings from gastro-
mucosa or its contents. Found numerous adult preg-
nant trichina; present in scrapings of mucosa of the
entire small intestine. No trichinae was found in scrap-
ings from the large intestine or in the feces.
Rat IV.— Fed infected muscle March 2, 1916. Made
daily examination of feces, but found no trichinae. Blood
examinations were made on the following dates:
Mar. 16, Mar. 18, Mar. 24,
1916. 1916. 1916.
Per cent. Per cent. Per cent.
Polymorphonuclears 55 50 55
Eosinophiles 8 4 4
Lymphocytes (small) 35 46 41
Mononuclears and transitionals 2
Total leucocytes . . 18,400 13,200
Total erythrocytes . . 8,960,000 8,300,000
Normoblasts 4 . . 3
Hemoglobin . . 100
Autopsied rat March 28, 1916. Searched diligently
for trichinae in all organs and tissues, including scrap-
ings from the gastro intestinal mucosa and its contents,
but failed to find parasites anywhere.
Rat V. — Fed with infected muscle March 2. Made
daily examination of feces, but found no trichinae. Blood
examination was made on March 16, showing the fol-
lowing: Polymorphonuclears, 76 per cent.; eosinophiles,
2 per cent.; lymphocytes (small), 21 per cent.; mono-
nuclears and transitionals, 1 per cent.; total reds, 12,-
899,851; normoblasts, 10; hemoglobin, 100 per cent.;
polychromatophilia present.
Conclusions. — At no time were trichinae found in
the feces of rats. Upon autopsy although trichinae
were found in the small intestine none were found
in the large intestine or in the feces. Evidently the
trichinae undergo destruction in the fecal mass.
Therefore, to judge by the experiment on rats, the
finding of trichinae in the feces is a myth and the
feces play no role in the spread of this disease. One
must not confuse the various parasites found in the
feces which bear some resemblance morphologically
to trichinae spiralis.
In view of the fact that in the autopsy material
mentioned above, numerous trichinae were found in
the muscle tissue while none were found in the liver,
it would appear that F. Flury's explanation3 (that
the reason why trichinae seek muscles is because
they need glycogen) is insufficient, because if that
were so one certainly would expect to find numerous
trichinae in the liver.
The cerebrospinal fluid in this case contained a
moderate number of trichinae.
REFERENCES.
1. Hayberg, II. M.: Beitrag zur Biologic der Trichi-
nen, Zeitschrift f. Ticrmed., 1907, ii. 209. Bilden sich
bei der Trichinose toxische Stoffe? ibid., 1907, ii, x 1.
2. Chatin, J.: Contribution a l'etude de la trichinose,
Comptesrend., Med. Acad. d. Sc, 1881.
3. I'lury, F.: Beitriige zur Clinic und Toxicologic der
Trichimen, Archiv f. experiment. Path. u. Pharmakal.,
1913, bcxiii, L64.
1352 Carroll Street.
Sepsis After Gonorrhea. — Pflanz reports a case of
acute anterior gonorrhea of three weeks' duration, ap-
parently cured by a silver salt. Prostatic massage and
irrigation were followed by local abscesses and f;ital
sepsis. Bacillary finds negative. — Medizinische Klinik.
Medical Books as Evidence. — In an action for personal
injuries received in a railroad collision, the North Caro-
lina Supreme Court makes the following rulings with
regard to the use of medical works in evidence. The
opinions of scientists as to producing cause of loco-
motor ataxia, recorded in their works and not intro-
duced under oath, with no opportunity for cross-exami-
nation, are inadmissible in cross-examining a physician
as to such disease. Medical works are not admissible
in evidence, and, when not alluded to in direct examina-
tion cannot be got before the jury, over objection, on
cross-examination, nor can this be done by indirection
in assuming their supposed teachings. The opinion of
an expert witness cannot be contradicted by showing
on cross-examination what some author has said.
When an expert has given an opinion and cited a trea-
tise as his authority, the book cited may be offered in
evidence by the adverse party, as impeaching testi-
mony, but unless the book is referred to in cross-exami-
nation it cannot be used for this purpose. Questioning
a physician on cross-examination who had testified as
to cause of locomotor ataxia, by reference to stated
opinions in medical books being inadmissible as sub-
stantive evidence, cannot be justified on the ground that
it was to test the qualifications of the witness, where it
was not so restricted at the time nor in the charge. —
Tilgham v. Seaboard Air Line Ry. (N. Car.) 89 S. E. 71.
Reference to Medical Authorities Disallowed — Expert
Evidence as to Hysteria. — In an action for damages for
shock from a fallen electric light wire, the plaintiff, on
cross-examination of the defendant's medical witnesses,
elicited testimony that the plaintiff was not suffering
from an organic disease or injury to the nerves or nerve
centers, or any molecular change therein. It was held
as evidence that witness knew it was claimed by some
medical authorities that there might be a molecular
change in the nerves from electricity, and that the con-
trary was also claimed, and that the question was un-
decided, thereby importing into the case the theory of
some authority to refute the testimony of the defend-
ant's witnesses, was reversible error.
It was also held admissible to ask a medical witness
whether or not there was an element of deception and
dissimulation mixed up with their ailments, either
alwavs or some of the time. — Svkes v. Village of Port-
land," Michigan Supreme Court, 159 N. W. 325.
Alcoholic Insanity as a Defense to Homicide. — The
doctrine is almost universal that alcoholic insanity or
mental incapacity produced by voluntary intoxication,
existing only temporarily at the time of the commission
of the homicide, is no excuse or defense in a prosecution
therefor. Drunkeness is one thing, and the disease of
the mind to which drunkenness leads is a different
thing. Temporary insanity occasioned immediately by
drunkenness does not destroy responsibility for crime,
where the defendant, when sane and responsible, volun-
tarily makes himself drunk. To constitute insanity
caused by intoxication a defense to an indictment or
information for murder, it must be insanity caused by
chronic alcoholism, and not a mere temporary mental
condition. — Perrvman v. State, Oklahoma Criminal
Court of Appeals, 159 Pac. 9."7.
Revocation of License for I'nprofessional Conduct. —
The Washington Supreme Court, in proceedings to
revoke a license to practice as an osteopath holds that
the provision stating unprofessional conduct for which
license may be revoked to embrace all advertising of
medical business intended or having tendency to deceive
the public or impose upon credulous or ignorant per-
sons, and so be harmful or iniurious to public morals
or safety, is not unconstitutional, as so vague and un-
certain as to leave the determination to arbitrary ner-
sonal opinion of the medical board; nor is the nrovision
as to advertising medicine to regulate or establish
menses unconstitutional as vague and uncertain. — State
Board v. Macy (Wash.) 159 Pac. 801.
Expert Opinion as to Ptomaine Poisoning. — In an ac-
tion against cafe keepers for serving tainted food it was
held competent for a physician of long experience in
general practice, in reply to a question sufficiently
hypothesizing the plaintiff's evidence to give his opinion
that ptomaine poisoning may be caused by eating im-
pure food or tainted meats, that the eating of tainted
chicken may cause such poisoning to a human being,
and that such taint in meat may be detected by its
odor or bv the microscope. — Glenwood Cafe v. Loving-
good, Alabama Supreme Court, 72 So. 354.
Dec. 2, 1916]
MEDICAL RECORD.
989
Medical Record.
A Weekly Journal of Medicine and Surgery.
THOMAS L. STEDMAN, A.M., M.D., Editor.
PUBLISHERS
WM. WOOD &. CO., 51 FIFTH AVENUE.
See fourth page following reading matter for Rates of Subscription
and Information for Contributors and Subscribers.
New York, December 2, 1916.
POLIOMYELITIS AFTER-CARE.
The aftermath of the poliomyelitis epidemic is re-
plete with important medical and social problems
which the community, as well as the medical pro-
fession, are resolved to meet squarely. Of the total
of over nine thousand cases reported in New York
City about one-fourth died, a considerable percent-
age escaped with light or no consequences, and
about five thousand have come out crippled. Very
many of the children have suffered paralysis of the
lower limbs and approximately 75 per cent, of these
come from families who must depend upon chari-
table medical relief. The factors of age, economic
condition, and inability to walk created the immedi-
ate problem of transportation of patients to dis-
pensaries for treatment. This had become a matter
of first importance and two organizations had made
it their business to attend to it, when recently the
city has taken over the burden. All the other phases
of the problem remain to be dealt with by private
agencies.
The most important agency in the field is the
New York Committee on After-Care of Infantile
Paralysis Cases, which came into existence in Au-
gust at the instance of the Health Commissioner of
the city and with the financial support of the Rocke-
feller Foundation. The committee set itself to work
immediately, but because of the newness of the
problem and its perplexity and for various other
reasons it started with work along the periphery.
It devised a large number of forms for the tabula-
tion of statistical information which will, no doubt,
prove of real value provided medical treatment
given by the dispensaries of the city, which forms
the basis of the statistics, is up to a certain stand-
ard of efficiency.
The main problem, therefore, is the problem of
organizing the medical and dispensary forces in
such a way as to bring the largest results with a
minimum of waste. The After-Care Committee
should take it upon itself to see that the opportuni-
ties of the dispensaries which undertake after-care
work should be of the highest possible order and all
the assistance needed for the equipment and the
necessary corps of workers should be forthcoming.
The necessary funds should be raised by the Com-
mittee and divided among the individual institu-
tions on the basis of quality and quantity of work.
A careful system of supervision should be instituted
and provision should be made for the home treat-
ment of cases which, because of their condition,
cannot be properly designated as ambulatory cases.
It is, moreover, difficult to expect that mothers who
have more than one child and upon whom devolve
all the home duties would be able to give a few
hours several times a week to taking the afflicted
child to a dispensary for treatment and to keep
this up for years. Means should be provided for
taking care of children whose home conditions are
such as to make it impossible for them to be seen
in a clinic as often as is necessary. Visiting
masseurs and nurses may, in a large measure, meet
the situation.
The After-Care Committee has many hard and
complicated problems before it and it is to be hoped
that, with the cooperation of the profession and the
hospitals and dispensaries which should be given
unstintingly, it will be able to solve these problems
to the best interests of the afflicted children and of
the community.
NASCENT OXYGEN IN THE TREATMENT OF
INFECTED WOUNDS.
With regard to the treatment of infected wounds,
and practically all wounds of war are infected to
a lesser or greater extent, there is among those
who have studied the question at first hand a some-
what remarkably wide divergence of views. Some
surgeons, whose reputations are deservedly high,
hold that antiseptics are of little or no use to check
the progress of sepsis, while others whose opinions
are entitled to equal consideration contend that
every infected wound should be treated anti-
septically. Again, there is no unanimity of opinion
as to the kind of antiseptic to be employed, al-
though as the result of clinical experience, one or
two chemical products appear to stand out. How-
ever, the comparative merits of the various anti-
septics in use on the battle fronts and in the mili-
tary hospitals can hardly be brought within the
limits of an editorial article and besides they have
already been adequately dealt with previously in
these pages. The object here is to call attention to
one means of checking the infection of wounds
which has been somewhat largely used and very
well spoken of by many European army surgeons.
Of course, oxygenation, the method to which ref-
erence is made, is by no means a new procedure, but
it has been brought into special prominence during
the war.
The forms of wound infection over which oxy-
genation exerts the greatest effect are those of
the anaerobic type, a type which has been especially
prevalent during the war, owing to the conditions
of warfare and to the nature of the soil in that
part of France in which much of the fighting has
been going on. The land of the north of France
and of Flanders is intensively cultivated and there-
fore thickly manured, and in consequence the
anaerobic spores teem in the soil, and it may be
said that there are few wounds incurred in the lo-
cality which are not more or less infected by them.
The object, then, of effective treatment is to get rid
of these spores or to prevent them from multiplying.
990
MEDICAL RECORD.
[Dec. 2, 1916
Burghard, Leishman, Moynihan and Wright, in
a memorandum published in the Lancet last
spring, stated that the rational line of treatment
of infected wounds consists in checking at the
earliest possible moment the anaerobic infection of
the discharges. The wound should be freely
opened up and then carefully cleansed with an an-
tiseptic solution, all foreign bodies, sloughs, and
blood clots being carefully removed. Kenneth
Goadby in the Practitioner for May, 1916, points
out that free oxygen prevents the development of
the anaerobic germ. Mr. A. G. Foulerton recom-
mends the method of continuous oxygenation in the
treatment of anaerobic infections. The cavity of
the wound or some part of the wound must become
free from oxygen before the spores can become
bacilli and before the bacilli can vegetate. The
wounded tissues must be deprived of oxygenated
blood before their invasion by the bacilli is pos-
sible.
French and German surgeons concur with Brit-
ish surgeons in their views as to the effectiveness
of oxygenation in preventing the spread of anaero-
bic infection. Indeed the fact is too well known to
need emphasis, and the question has been rather
how best to apply the method. It can be applied in
two or three ways, but the easiest and in the opin-
ion of many authorities an effective mode of appli-
cation is by means of frequent or, if possible, con-
tinuous irrigation of the recesses of the wound
with a solution of hydrogen peroxide. Moreover,
such a solution is said to possess the further ad-
vantage of breaking up blood clots and generally
facilitating the disinfection and cleansing of the
wound.
While oxygenation is especially indicated in the
treatment of anaerobic infection, it goes without
saying that it is of value in all wound infections.
Its main value possibly rests in its preventive prop-
erties, that is to say that anaerobic wound infec-
tion will be checked by the early employment of
oxygenation and on the good old principle that "a
stitch in time saves nine" whenever the form of in-
fection is suspected it will be as well, if feasible, to
employ the method. These, at any rate, appear to
be the views of many surgeons of the Allied forces
on the western war front and of the French sur-
geons in particular, who from the first have made
wide use of oxygenation in the treatment of infected
wounds.
RE-EDUCATION OF CRIPPLED SOLDIERS.
One of the most difficult problems presented by the
European war is how to render the numerous
maimed and crippled soldiers more or less inde-
pendent and self-supporting members of the com-
munity. From all points of view a solution or as
good a partial solution as possible of the problem is
not only desirable but essential. The methods of
warfare now in use have crippled, are crippling, and
will cripple a very large body of men, and of men
too who physically and mentally are of the best.
It is necessary for their own well-being and for the
well-being of the nation to which they belong, as
also for the preservation of their own self-respect,
that every effort should be made to re-educate these
men in order that they may be enabled to earn their
living by honest work.
France, as in so many spheres of human en-
deavor, is leading the way in the vocational re-edu-
cation of disabled soldiers. Dr. Bourillon in the
Revue Philanthropique of some months ago dis-
cussed this question at some length. He pointed
out a phase of this matter which is apt to be over-
looked— that it is not only the grave mutilations,
such as the loss of limbs, which disable the soldier,
but other injuries which, while not so arresting,
are equally serious in their results. Such are par-
alysis, joint stiffness, the severing of tendons and
nerves, all of which exert an important influence
on the well-being of the individual in his relation
to society. For instance, a man who has been a
bookkeeper and who loses a leg in the war can earn
his daily bread in the line that he followed formerly.
On the other hand, a professional piano-player or
a typewriter who has lost even a single finger will
be handicapped so far as carrying on the vocation in
which he had become an expert is concerned. Thus
the situation must be considered from the point of
view of the future of the invalided; it is the relation
between his disability and his occupation which is
the essential factor.
First of all, the disabled soldier must be aroused
from the condition of moral inertia which is so
frequently the outcome of the disablement. And
this object can be well accomplished only by teach-
ing him how to use to the best advantage, the phys-
ical qualities and mental abilities which have been
left to him. If these cripples are allowed to lapse
into a state of mental lethargy, it goes without say-
ing that the ultimate consequences will be appall-
ing. Work is the sole means by which they can be
saved from this pit. But in order to be able to work
so as to be of economic service to the State and to
preserve the independence of their families and
themselves, the large majority of disabled soldiers
must undergo a course of re-education. They must
not, however, be practically thrust into the work-
shop. They must be carefully examined so as to be
sure that their physical condition is such as to al-
low of their following the proposed trade. Mind and
body must first be subjected to functional re-
adaptation.
A great deal of this repairing work can be done
by the surgeon and the orthopedist. From the med-
ical point of view, physiotherapy by massage, med-
ical gymnastics, mechanotherapy, baths, douches,
etc., go to cure or ameliorate paralysis, ankylosis,
muscular atrophy, or other injuries caused by or
following wounds received in war. Functional re-
adaptation is of the highest importance from the
moral and economic standpoint. From the moral
aspect, it is of the greatest moment that the crip-
pled soldier shall be self-supporting and self-re-
specting. If he does not work he will be something
of a menace, for the idle man is dangerous to the
nation, to himself, and to his family. From the
economic aspect the idle crippled soldier will be a
burden in place of a source of prosperity to the
State.
Dec. 2, 1016]
MEDICAL RECORD.
991
PRODROMAL SYMPTOMS OF CEREBRAL
HEMORRHAGE.
This subject is of perennial interest because some
of the leading internists and neurologists assert
that there are no prodromes and produce statistical
material to sustain the claim. The great number of
alleged prodromes tends to confuse the subject and
proceeds as a rule from men of limited experience.
Some clinicians believe in the Raymond type of apo-
plexy which is characterized by paresthesia in one
hand but such cases are to say the least extremely
rare. The neurologist lays the chief if not the sole
emphasis on the presence of an increase in intra-
cerebral tension due to a hypertrophic heart, but the
latter cannot produce hemorrhage in the absence of
certain vascular changes. Retinal hemorrhages
occasionally serve as a true prodrome. Apoplexy in
the obese is nearly offset by apoplexy in medium and
thin subjects. It has been stated over and over by
pathologists that there can be no typical apoplexy in
the absence of certain miliary nodular swellings in
the smaller arteries, and that these are practically
congenital. The longer a man lives the greater the
liability of these to rupture. The sudden increase in
tension which causes the hemorrhage cannot be ex-
plained. Other stable factors, as hypertrophy of the
heart, are doubtless present, and the determining
causes show great variation and are often emo-
tional.
"in an article by Kisch cited in // Policlinico Sep-
tember 17, the author enumerates as prodromes of
apoplexy, permanent marked elevation of blood pres-
sure with enlarged heart, beginning changes (sclero-
sis) in the vessels — notably in the brain and kid-
neys— and finally certain associated intestinal dis-
turbances. In the plethoric form of acquired
obesity the gain in weight is closely followed by a
rise in blood pressure. The tendency of the fat is
to accumulate in the abdomen — mesentery, omen-
tum, the perirenal region, etc., with resulting dis-
turbance of the abdominal circulation. If the sub-
jects have indulged freely in tobacco and alcohol the
vessels suffer more in proportion. The enlarged
heart results from increase of blood pressure. Pro-
dromes of apoplexy must therefore be sought in the
loss of arterial elasticity, contractility, and perme-
ability. The author here enumerates the evidences
of cerebral arteriosclerosis as they are described in
standard works of reference. Albuminuria is also
a valuable prodromic indication, along with evi-
dences of sclerotic kidney.
The intestinal disorders which the author has al-
ready termed of prognostic value are of the most
varied kind, and are believed to be due to changes in
the abdominal circulation. Of determining causes
are mentioned excessive physical effort, running,
mountain climbing, over-distention of the stomach,
excesses in beer, sexual excesses, straining at stool,
violent emotions (pleasurable or painful), weather
variations, etc. Immediate prodromes are head-
ache, vertigo, vomiting.
Kisch's views have no bearing on forms of apo-
plexy in the thin subject, the senile subject, and cer-
tain other types. He has done no more than call
attention to the fact that men with cardiorenal dis-
ease, arteriosclerosis, and obesity often owe their
deaths to cerebral hemorrhage. Evidences of these
diseases are not to be construed as prodromes in the
correct sense of the term. Apoplexy of this type is
rather to be regarded as a complication or sequel
of cardiovascular disease, or as a mode of death.
Rhachialbu.minimetry.
The present war has greatly increased the research
of the spinal canal for albumin — in cases of cere-
brospinal commotion, trephining, suspected syphilis,
and metasyphilis, etc. Some advocate lumbar punc-
ture in every case of commotion. Sicard and Can-
talouse, writing in La Presse Medicate, are in fa-
vor of precipitation of the albumin with heat and
trichloracetic acid (1:2). A special graduated tube,
known as the rhachialbuminimeter, is used, and
from 8 to 10 c.c. of cerebrospinal fluid is withdrawn
for a test. Four c.c. of fluid is turned into the
tube (it should be taken from the top) and the
latter should be heated to 80° or 903 C. Then
12 drops of acid are added, the mixture allowed to
cool off, and the tube is occluded with a rubber
stopper. It must now stand perfectly vertical for
five hours, when a reading is taken. (If there is
no haste, it may be allowed to stand 24 hours, when
the precipitate will have settled to a straight line.)
Normal standards must, of course, be known. The
precipitate may be followed up in cerebrospinal
syphilis, tabes, and general paralysis, in order to
mark the evolution of the disease. An increased
amount of albumin, as shown by the tube, is a
hyperalbuminosis which is prominent, for example,
in cerebral syphilis. After 24 hours' standing, an
albuminosis is quickly seen to be pathological, or
the reverse. A residual albuminosis is perceived
in hemiplegic cases after the subsidence of symp-
toms, and may be due to a persistent lymphocytosis.
The authors term this the equivalent of a scar in
solid tissue. As the height of a precipitate in a
tube is only a rough measure of the amount of
albumin present, the authors, by control solutions,
in which albumin is weighed, are able to calculate
values which have the force of actual weight.
Pituitary Extract in Post-Abortion Curettage.
This use of pituitary extract, as suggested by H. D.
Furniss (Surgery, Gynecology, and Obstetrics, Sep-
tember, 1916), seems such a logical procedure that
one wonders at not having seen the suggestion made
in print long before this. Furniss administers one
cubic centimeter of pituitary extract hypodermically
before curetting for incomplete abortion, and has
found that the most favorable time to give the
pituitrin is 15 minutes before the actual curettage
is begun. When the interval between injection and
operation has been less, the resulting contraction
has not been so pronounced. Among the advantages
which accrue from the preliminary injection of
pituitary extract are that it produces firm contrac-
tion of the uterus, so that the curetting is almost
bloodless, and much more easily done; and that
because of the contraction the uterine cavity is
small and the contracted walls present a resistance
to the curette which makes their cleansing less
difficult, and also lessens the risk of uterine perfo-
ration. Furniss states that as yet he has not had
any excessive postoperative bleeding following the
use of pituitrin; but, realizing that such a possi-
bility exists, he advises packing uterus and vagina
with iodoform gauze, which is to be removed at the
992
MEDICAL RECORD.
[Dec. 2, 1916
end of 24 hours. While Furniss' article refers to
the use of pituitrin only before curetting for in-
complete abortion, there seems to be no good reason
why it could not be used to advantage under certain
other conditions ; for example, when curetting forms
part of the operative treatment in those types of
cases in which the uterus is relatively large and
flabby, or when curetting is done in the case of an
individual whose menstrual flow is habitually ex-
cessive. It would seem, therefore, that Furniss has
called attention to a therapeutic resource that will
ultimately be found valuable in a far more extended
field in gynecological surgery than that covered by
the original suggestion.
Sfama of thr Week
Civil Service Examinations. — The United States
Civil Service Commission announces open competi-
tive examinations to be held in various places on
December 13, 1916, for the purpose of filling vacan-
cies in the following positions:
Physician, male, in the Indian and Panama Canal
Services, at salaries in the former from $1000 to
$1200 a year, and in the later, $1800 a year. Ap-
plicants must be graduates of or senior students in
recognized medical schools, between the ages of
twenty-one and forty, and citizens of the United
States.
Dental interne, male; a vacancy now exists in
Saint Elizabeth's Hospital, Washington, at a salary
of $600 a year and maintenance. In addition to the
clinical work, the interne is given an opportunity
for study and for experimental and research work
in the pathological, histological and other labora-
tories of the institution. Applicants must be grad-
uates of or senior students in regularly incorpor-
ated dental colleges, twenty years of age or over,
unmarried, and citizens of the United States.
Further particulars and application blanks may
be obtained from the United States Civil Service
Commission, Washington, D. C, or from local
secretaries of United States Civil Service Boards.
Opportunity for Pathologist. — The New York
Municipal Civil Service Commission will shortly
hold an examination for the purpose of filling a
vacancy in the position of pathologist in the Kings
County Hospital, Brooklyn, at a salary of $1,500
per annum. The examination will be open to citi-
zens of the United States who are graduates of a
reputable medical school. Applications will be re-
ceived up to December 5, at the offices of the
Municipal Civil Service Commission, Room 1400,
Municipal Building, New York.
Diet Experiments. — Twelve employees of the
Chicago Department of Health began on Novem-
ber 22 a two weeks' experiment intended to dem-
onstrate that a person can be suitably and suffi-
ciently fed on an expenditure of forty cents a day.
Throughout the two weeks the diet squad will pur-
sue their ordinary occupations and will endeavor
to keep conditions as nearly normal as possible.
Sydenham Hospital. — The annual report of
Sydenham Hospital for the year ending October 1
shows that during that time 2057 cases were treated
in the hospital and 32,97 1 in the dispensary, of
these 14,186 received free treatment. The deficit
for the year was only $6,680.64, the lowest annual
deficit since the organization of the hospital four-
teen years ago.
Hospital Ships Sunk.— The White Star liner
Britannic, the laigest British ship afloat, which has
been in use as a hospital ship, was sunk by a sub-
marine torpedo or a mine, in the Aegean Sea on
November 21. There were no wounded aboard at
the time, and the loss of life was small. The Brit-
ish hospital ship Braemar Castle, bound from Sa-
lonica to Malta with wounded, also was sunk in the
/Egean on November 23; it is not known whether
the ship was torpedoed or was mined. The loss of
life was slight.
Harvard Doctors Sail. — Another detachment of
the Harvard Medical School unit, consisting of six
surgeons, one dentist and twenty nurses, sailed
from New York on November 20 for Liverpool. The
group will take the place of the doctors and nurses
now on duty at the British base hospital in France.
This makes a total of 117 surgeons and dentists and
184 nurses who have been in the service of the unit
since it was organized in June, 1915.
After-Care of Paralysis Cases. — A campaign
was begun last week to raise $250,000 for a year's
care of the 5600 children who were left paralyzed
as a result of the poliomyelitis epidemic last sum-
mer in New York, and at a meeting held at the
Hotel Manhattan to formulate plans for the work
addresses were made by Dr. John S. Billings, Dr.
John W. Brannan, Dr. Thomas J. Riley and Dr.
Virgil P. Gibney.
Clinics at Lebanon Hospital. — Dr. Parker Syms
and Dr. M. R. Bookman will hold surgical clinics
at Lebanon Hospital, New York, on Wednesdays at
3 o'clock, from November 1 to March 1, to which
the medical profession is invited. The hospital
is most conveniently reached by the subway, West
Farms division, to Jackson Avenue station. A
bulletin of the operations scheduled is posted at
the Academy of Medicine.
United States Census. — The United States Cen-
sus Bureau estimates that on January I, 1917, the
population of the country and its possessions will
have reached 113,309,285, as against 111,579,952 in
1916. The population of the continental United
States at that time is estimated at 102,826,309.
The State of New York leads with an estimated
population of 10,366,778; Pennsylvania is given
8,591,029; Illinois, 6,193,626; Ohio, 5,181,220;
Texas, 4,472,494, and Massachusetts, 3,747,564.
Dr. Charles A. Powers of Denver has returned
after six months of service as surgeon at the Ameri-
can Ambulance Hospital of Paris. He will resume
work there on April first.
Dr. Simon Flexner, director of the Rockefeller
Institute, spoke before the Brooklyn Academy of
Arts and Sciences on November 23, on the recent
epidemic of poliomyelitis, and warned his hearers
that the plague might visit New York again, and
that physicians, unaided by laymen, were power-
less to prevent its vigorous recurrence.
Dr. John Shelton Horsley, surgeon in charge
of St. Elizabeth's Hospital, Richmond, Va., has been
awarded by the Southern Medical Association a
medal for original work in the surgery of blood ves-
sels and intestines.
Fined for Substitution. — For substituting as-
pirin for phenacetin when compounding a prescrip-
tion calling for the latter drug, a druggist of First
Avenue, New York, was recently fined $100 in one
of the city courts.
Medical Society of Virginia. — The forty-seventh
annual meeting of this society was held in Norfolk,
Va., on Oct. 24 to 27. Officers for the ensuing year
were elected as follows: President, Dr. George A.
Stover, South Boston; Vice-Presidents, Dr. Charles
Dec. 2, 1916]
MEDICAL RECORD.
993
S. Webb, Bowling Green ; Achilles L. Tynes, Staun-
ton, and William B. Barham, Newsoms; Secretary,
Dr. Paulus A. Irving, Framville; Treasurer, Dr.
Mark W. Peyser, Richmond. Roanoke was named
as the next place of meeting.
Gifts to Charities. — By the will of the late Mrs.
Wheeler H. Peckham of New York, bequests of $10,-
000 each are made to St. Mary's Free Hospital for
Children, the Sea Breeze Hospital and the Morris-
town Memorial Hospital and All Souls Hospital,
Morristown, N. J.
Deaths Abroad. — Dr. Eugene Louis Doyen of
Paris, whose method of treating cancer by the in-
jection of a serum attracted widespread attention
a few years ago, died at his home after a brief ill-
ness on November 21, aged 57 years.
A recent dispatch from Sir William Osier an-
nounced the death of Miss Louisa Parsons, a
trained nurse who was for many years connected
with the Johns Hopkins Hospital. Miss Parsons
was trained under Florence Nightingale, and had
seen service in Lord Wolseley's Egyptian Expedi-
tion in 1882 and in the Spanish-American and Boer
wars.
Court Reinstates Physician. — By an order of the
District Court of Denver, Col., the name of Dr.
Floyd W. Noble of that city, whose license to prac-
tise was recently withdrawn, has been restored to
the list of practising physicians, and the cancelled
license will be reissued. Dr. Noble was charged
with murder in connection with the death of a
woman in Denver, and was tried and acquitted of
the crime by a jury. While he was still under
charges, however, his license was revoked by the
State Board of Medical Examiners.
Brooklyn Medical Library Association. — The an-
nual meeting of this society will be held on Monday,
December 4, 1916, at the Library Building, Medical
Society of the County of Kings, 1313 Bedford Ave-
nue, at 8.30 P. m. Dr. Edward E. Cornwall will de-
liver an address on "Medical Notes of Early New
England, 1620-1650."
The Private Pavilion of the Montefiore Home
and Hospital was opened with appropriate cere-
mony on November 20, having been in process of
construction for two and a half years. The cost of
construction, with suitable equipment, amounting
to a quarter of a million dollars, was contributed by
four of the directors of the institution. The medi-
cal director of the home was responsible for the
idea of this special hospital for well-to-do chronic
invalids who will there find the comforts of a hotel
in addition to treatments which have proven ef-
fective in chronic cases, such as hydrotherapy, elec-
trotherapy, mechanotherapy, thermotherapy, and
manual massage as well as such medical or surgical
care as the case may require.
Rockingham County (N. H.) Medical Society. —
The annual meeting of the Rockingham County
Medical Society was held in Portsmouth, N. H.,
on November 9, when the following officers were
elected: President, Dr. Herbert C. Day, Exeter;
Vice-president, Dr. George H. Towle, Newmarket;
Secretary, Dr. Ralph S. Perkins, Exeter; Treas-
urer, Dr. Walter Tuttle, Exeter.
Obituary Notes. — Dr. James D. Wagner of
Selma, Cal., a graduate of the medical department
of the University of Nashville, in 1873, died at Long
Beach, Cal., on October 16, from cerebral hemor-
rhage, aged 72 years.
Dr. Carl Buttner of Orange, N. J., a graduate
of the University of Wiirzburg, Germany, in 1867,
and a member of the Medical Society of the State
of New Jersey and the Essex County Medical So-
ciety, died at his home on November 16, aged 67
years. Dr. Buttner had been City Physician in
Orange, was one of the organizers of the first Board
of Health there and was formerly a member of the
staff of the Orange Memorial Hospital.
Dr. Thomas Joseph Dunn of New York, profes-
sor of clinical medicine at Fordham University,
and senior physician to the Fordham Hospital, died
at his home on November 23, aged 52 years. Dr.
Dunn was graduated from New York University
Medical College, New York, in 1888, served for two
years as an interne in Bellevue Hospital and later
studied in Vienna. He was a member of the Ameri-
can Medical Association, the New York State Medi-
cal Society, the Bronx County Medical Society, the
Bronx Medical Association and the Society of the
Alumni of Bellevue Hospital, president of the Bronx
Sanitarium and attending physician to St. Laurence
Hospital.
Dr. Marcus M. Franklin of Philadelphia, a
graduate of the Jefferson Medical College, in the
class of 1870, died on November 6 at the age of 74
years. Dr. Franklin was the first interne appointed
to the German Hospital of Philadelphia, and later
was visiting surgeon to this institution for fourteen
years. He was a member of the Medico-Legal So
ciety of Philadelphia, the Philadelphia Obstetrical
Society, the Philadelphia County Medical Society,
and the Medical Society of the State of Pennsyl-
vania, and a Fellow of the American Medical Asso-
ciation.
Dr. Frederick L. Grander of Scranton, a gradu-
ate of the Jefferson Medical College, in the class
of 1885, died on November 4 at the age of 55 years.
Dr. Milton S. McMurtry, Sr., of Clovis, Cal., a
graduate of the Missouri Medical College, St. Louis,
in 1877, died at his home on October 3, from pneu-
monia, aged 60 years.
Dr. William Lander Settlemyer of Gaffney,
S. C, a graduate of the Kentucky School of Medi-
cine, Louisville, in 1892, died at his home on Octo-
ber 8, aged 49 years.
Dr. William Stiles, Jr., of Philadelphia, Pa.,
a graduate of the Hahnemann Medical College and
Hospital of Philadelphia, in 1875, died at his home
on October 7, from uremia, aged 74 years.
Dr. Isaac D. Jones of Murdock, Neb., a gradu-
ate of the University of Nebraska, College of Medi-
cine, Omaha, in 1895, and a member of the Ne-
braska State Medical Association and the Cass
County Medical Society, died at his home on Octo-
ber 10, of nephritis, aged 52 years.
Dr. John A. Seapy of Geddes, S. D., a graduate
of Bennett Medical College, Chicago, in 1900, and
a member of the American Medical Association, the
South Dakota State Medical Association, and the
Charles Mix County Medical Society, died in St.
Mary's Hospital, Rochester. Minn., recently, aged
42 years.
Dr. Edward O. Plumbe of Chicago, 111., a gradu-
ate of the New Orleans School of Medicine in 1869,
died at his home on October 22, aged 78 years.
Dr. Elijah Smith Ellzey of Blue Mountain,
Miss., a graduate of the Kentucky School of Medi-
cine, Louisville, in 1876, and a member of the Mis-
sissippi State Medical Association and the Tippah
County Medical Society, died in a hospital in Rip-
ley, Miss., on October 13, aged 68 years.
994
MEDICAL RECORD.
[Dec. 2, 191S
Dr. Edwin Elliott of Chesaning, Mich., a gradu-
ate of the Detroit College of Medicine and Surgery
in 1894, and a member of the Michigan State Medi-
cal Society and the Saginaw County Medical So-
ciety, died at his home on September 23, from
angina pectoris, aged 52 years.
Dr. Joseph R. Brown of Seward, N. Y., a gradu-
ate of Albany Medical College in 1868, and a mem-
ber of the American Medical Association, the Medi-
cal Society of the State of New York, and the
Schoharie County Medical Society, died at his home
on October 13, from arteriosclerosis, aged 68 years.
Dr. Charles Westly Lester of Guthrie, Tex., a
graduate of Vanderbilt University Medical Depart-
ment, Nashville, in 1880, and a member of the
American Medical Association, the State Medical
Association of Texas, and the Todd County Medi-
cal Society, died at his home on October 11, from
cerebral hemorrhage, aged 58 years.
Dr. Isaac R. Godwin of Fincastle, Va., a gradu-
ate of the Medical College of Virginia, Richmond,
in 1860, and a member of the Medical Society of
Virginia, and the Botetourt County Medical Society,
died at his home on October 1, aged 79 years.
Dr. John Campbell Spencer of San Francisco,
Cal., a graduate of the College of Physicians and
Surgeons, Columbia University, New York, in 1885,
and a member of the American Medical Association,
the Medical Society of the State of California, the
San Francisco County Medical Society, and the
American Urological Association, died at his home
on October 19, aged 55 years.
Dr. Lee Walton Verdery of Augusta, Ga., a
graduate of the Medical Department of the Uni-
versity of Georgia, Augusta, in 1911, died suddenly
at Fort Sam Houston, Tex., on October 29, aged
28 years. Dr. Verdery was a lieutenant in the hos-
pital corps of the United States Army.
Dr. Charles Edwin Stone of Lynn, Mass., a
graduate of the College of Medicine of the Univer-
' sity of Vermont, Burlington, in 1906, and a mem-
ber of the Massachusetts Medical Society and the
Essex County Medical Society, died at his home
on November 6, after a short illness, aged 48 years.
Dr. Hugh R. Green of Delaplane, Va., a graduate
of the School of Medicine of the University of
Maryland, Baltimore, in 1867, died recently, aged
74 years.
Dr. George D. Stanton of Stonington, Conn., a
graduate of Bellevue Hospital Medical College, New
York, in 1865, and a member of the Connecticut
State Medical Society and the New London County
Medical Society, died on November 4, aged 77 years.
Dr. Emil Hessel Beckman of Minneapolis,
Minn., a graduate of the University of Minnesota
Medical School, Minneapolis, in 1901, and a mem-
ber of the American Medical Association, the Min-
nesota State Medical Association, the Olmsted
County Medical Society, the American Surgical As-
sociation, the Western Surgical Association, and
the American College of Surgeons, died at his home
on November 7, from blood poisoning, aged 44
years.
Dr. Phil C. Naumann of Burlington, Iowa, a
graduate of the State University of Iowa, College of
Medicine, Iowa City, in 1887, died near his office
on October 16, from cerebral hemorrhage, aged 55
years.
Dr. Richard H. Parsons of Mount Holly, N. J.,
a graduate of the department of Medicine of the
University of Pennsylvania, Philadelphia, in 1880,
and a member of the American Medical Association,
the Medical Society of New Jersey, the Burlington
County Medical Society and the American Medico-
Psychological Association, died in the Mercer Hos-
pial, in Trenton, on November 12, from pneumonia,
aged 57 years. Dr. Parsons had been medical
superintendent of the Burlington County Hospital
for thirty years.
Dr. Francis J. Bock of Lancaster, Wis., a grad-
uate of the Hahnemann Medical College and Hos-
pital of Chicago, in 1906, and a member of the
State Medical Society of Wisconsin and the Grant
County Medical Society, died on October 18, aged
41 years.
Dr. Clarius Confucius Birney of Mason City,
Iowa, a graduate of Rush Medical College, Chicago,
in 1874, died at his home on October 21, from
nephritis, aged 69 years.
Dr. Joel V. Sampsell of Elyria, Ohio, a grad-
uate of the Jefferson Medical College of Philadel-
phia, in 1877, died at his home on October 20,
aged 65 years.
Dr. Francis J. Keany of Boston, professor of
dermatology in Tufts College Medical School, and
a trustee of the Boston City Hospital, died at his
home on November 23, aged 48 years. Dr. Keany
was graduated from the Harvard University Medi-
cal School, Boston, in 1892, and was a member of
the Massachusetts Medical Society and the Suffolk
District Medical Society.
Dr. Walter S. Sutton of Kansas City, Mo., a
graduate of Columbia University, College of Physi-
cians and Surgeons, New York, in 1907, and a mem-
ber of the American Medical Association, the Kan-
sas Medical Society, the Missouri State Medical
Association, the Jackson County Medical Society,
American Association of Anesthetists and the
American College of Surgeons, died on November
11, following an operation for appendicitis, aged 39
years. Dr. Sutton was Associated Professor of
Surgery in the University of Kansas, School of
Medicine, Lawrence and Rosedale.
Dr. Charles H. Todd of Owensboro, Ky., a grad-
uate of Tulane University of Louisiana, School of
Medicine, New Orleans, in 1861, and a member of
the American Medical Association, the Louisiana
State Medical Society, and the Daviess County
Medical Society, died suddenly at his home on No-
vember 12, from heart disease, aged 78 years.
Dr. Albert Crandall Way of Perry Center,
N. Y., a graduate of the Department of Medicine
of the University of Buffalo in 1895, and a member
of the American Medical Association, the Medical
Society of the State of New York, and the Wyoming
County Medical Society, died at Evergreen Lodge,
Saranac Lake, on November 5, from tuberculosis,
aged 46 years.
Dr. Guert M. Tinker of Sharon, Pa., a gradu-
ate of the University of Pennsylvania, School of
Medicine, Philadelphia, in 1894, and a member of
the American Medical Association, the Medical So-
ciety of the State of Pennsylvania, and the Mercer
County Medical Society, died at his home on No-
vember 9, from blood poisoning, aged 47 years.
Dr. Arthur S. Townsend of Bennettsville, S. C,
a graduate of the Medical College of the State of
South Carolina. Charleston, in 1887, and a member
of the South Carolina Medical Association and the
Marlboro County Medical Society, died at his home
on November 12, aged 53 years.
Dr. Henry K. Leake of Dallas, Texas, a gradu-
ate of the Kentucky School of Medicine, Louisville,
in 1869, and a member of the State Medical Asso-
ciation of Texas and the Dallas County Medical
Dec. 2, 1916]
MI'.DICAL RECORD.
995
Society, died at his home on October 29, from
nephritis, aged 69 years.
Dr. Julius H. Eichberg of Cincinnati, Ohio, a
graduate of the Miami Medical College, Cincinnati,
in 1889, a member of the American Medical Asso-
ciation, the Ohio State Medical Association, and
the Hamilton County Medical Society, and profes-
sor of materia medica, pharmacy and therapeutics
in the University of Cincinnati, College of Medicine,
died at French Lick Springs, Ind., on November 2,
from heart disease, aged 57 years.
Dr. Henry H. Whitaker of Hilliardston, N. C,
a graduate of the School of Medicine of the Uni-
versity of Maryland, Baltimore, in 1883, and a mem-
ber of the Medical Society of the State of North
Carolina and the Nash County Medical Society, died
at his home on October 12, from cerebral hemor-
rhage, aged 55 years.
Dr. Robert C. Westphal of Yorktown, Texas, a
graduate of the Starling Medical College of Co-
lumbus, Ohio, in 1902, and a member of the Ameri-
can Medical Association, the State Medical Asso-
ciation of Texas, and the Dewitt County Medical
Society, died in Cuero Hospital on October 21, after
an operation, aged 46 years.
Dr. Silas F. Roberts of Glencoe, Ohio, a gradu-
ate of the Hospital College of Medicine, Louisville,
in 1895, was killed by a train at a grade crossing in
Glencoe on October 26, aged 47 years.
Dr. John Saltenberger of Millstadt, 111., a grad-
uate of the Washington University Medical School,
St. Louis, in 1864, died at his home on October 20,
from heart disease, aged 84 years.
Dr. William H. Dukeman of Los Angeles, Cal., a
graduate of New York University Medical College
in 1880, died suddenly on October 22, from heart
disease, aged 61 years.
Dr. William H. Conibear of Lakeland, Fla., a
graduate of Rush Medical College, Chicago, in 1876,
and a member of the Illinois State Medical Society,
the Florida Medical Association, and the Polk
County Medical Society, died at his home on Octo-
ber 25, from carcinoma of the liver, aged 73 years.
Dr. William David Aldrich of Albany, N. Y., a
graduate of the Albany Medical College in 1910, died
on September 28, aged 33 years.
Dr. Neal L. Burgess of Sumner, Texas, a grad-
uate of the Memphis Hospital Medical College,
Memphis, in 1909, and a member of the State Medi-
cal Association of Texas and the Lamar County
Medical Society, died at his home on November 1,
from cerebral hemorrhage, aged 39 years.
Dr. Julius D. Abbott of Bethel, Ohio, a graduate
of the Cincinnati College of Medicine and Surgery in
1874, died in Christ Hospital, Cincinnati, on Octo-
ber 22, aged 71 years.
Dr. Price Patterson of Maysville, Okla.. a grad-
uate of the Memphis Hospital Medical College,
Memphis, in 1901, and a member of the American
Medical Association, the Oklahoma State Medical
Association, and the Garvin County Medical So-
ciety, died suddenly at Maysville on October 28,
aged 53 years.
Dr. John D. McCollum of Alpharetta, Ga., a
graduate of Atlanta Medical College in 1884, died at
his home on October 16, aged 55 years.
Dr. John James Mason of New York, a gradu-
ate of Bellevue Hospital Medical College, New
York, in 1869, died at his home on November 22.
Dr. Marie F. Rose of Harvey, 111., a graduate of
the Hahnemann Medical College and Hospital of
Chicago in 1896, died at her home on October 11.
viuirmijimiDnir*.
HEXAMETHYLENE TETRAMINE AS A FUEL.
To the Editor of the Medical Record:
Sir: — There are many times when the physician
needs a small, hot, sootless flame such as produced
by an alcohol lamp, when he is out of reach of any
such article. It is not generally known, I believe,
that hexamethylene tetramine will give exactly this
kind of flame when ignited. Two five-grain tablets
such as are often carried in the physician's medi-
cine case, will give a clean flame of sufficient heat to
boil 5 c.c. of water in a test-tube within 30 seconds,
and of sufficient duration to keep it boiling for two
minutes. For boiling needles or small instruments,
sterilizing water for hypodermic injections, testing
for albumin by the heat-and-acid method, and many
other similar purposes, this "extemporaneous tech-
nique" may be found useful.
Lowell C. Frost, M.D.
Los Angei.es.
OUR LONDON LETTER.
(From Our Regular Correspondent.)
NOTIFICATION — REPORT OF ROYAL COMMISSION — COM-
PULSION— AUSTRALIAN PLAN — DANGER OF DRIV-
ING MEN TO QUACKS — EFFECTS DISASTROUS — DIF-
FICULTIES OF PREVENTING ILLEGAL PRACTICE —
MEDICAL SOCIETY OF LONDON'S MEETING.
London, October 2S. 1916.
The general subject of notification of venereal dis-
eases is freely discussed in the Report of the Royal
Commission. Among the diseases compulsorily
notifiable by the medical attendant, smallpox, scarlet
fever, typhoid fever, diphtheria, etc., are to be also
reported by the householder. This last duty has not
been strictly enforced — in fact, it hardly can be, for
it can seldom be proved that the householder knew
what the case actually was. If a similar system of
notification were applied to gonorrhea or syphilis, it
seems obvious compulsion to report could scarcely
be enforced against either the patient or the house-
holder; concealment would be so easy and even if
brought to light ignorance of the special character
of the ailment could almost always be successfully
pleaded. If notification is to be enforced it must be
against the doctors who are treating the cases. In
view of the strong motives for concealment and the
relationship of medical men to their patients it is
probable that compulsion would not be really effec-
tive in more than a very small minority of the total
cases. Here the question arises that if all cases
passing through a doctor's hands were reported,
cui bono? The patient is already under medical
care and presumably receiving the treatment best
calculated to render him rapidly free from infec-
tion. In Australia a modified system of notifica-
tion is being tried and the reports of it deserve at-
tention. The doctor is required to notify under a
number and initials only, but if the patient discon-
tinues treatment before he is cured, the doctor must
give his name and address to the medical health
officer of his district. It is hardly likely that this
scheme can be carried out in these islands. If at-
tempted it would probably drive many patients to
irregular practitioners. The chief difficulty in
eradicating venereal diseases and preventing their
consequences, is to overcome the reluctance to con-
sult a doctor. If the patients knew that he was
obliged to report their case to the medical health of-
996
MEDICAL RECORD.
[Dec. 2, 1916
ficer their reluctance would only be increased and
they would resort to quacks in still greater propor-
tion than they now do. It is the great number who
at present do so resort, especially in the early
stages, that defeats the measures of treatment, as
it does those of prevention.
The Royal Commission had before it abundant
evidence of the mischief done by unqualified per-
sons. The earlier symptoms of constitutional in-
fection may be so slight that the patient deludes
himself into the belief that they are not due to
syphilis and only need a little cooling medicine
which he gets from a druggist and fondly thinks
he is well. But later on he is told that he is "as
old as his arteries," he feels himself old, perhaps at
fifty and soon afterwards some constitutional dis-
ease attacks him. His wife, too, gets out of health
and if she becomes pregnant the baby is born dead
or if alive, in such a state that its birth is regarded
as a calamity. To permit the treatment of these
diseases by ignorant persons is to suffer them to
carry disablement and death in various directions.
The Royal Commissioners have no hesitation in
stating that the effects of unqualified practice in
these diseases are disastrous and they add that the
continued existence of this unqualified practice con-
stitutes one of the principal hindrances to the eradi-
cation of those diseases. The medical officer of the
Local Government Board suggested that chemists
and other unqualified persons should be forbidden to
treat these diseases or any disorder of the genito-
urinary organs; and the commission in their report
affirmed that they would have advocated legal means
of preventing it, but for the practical difficulties.
One asks here, should they not have devised the
means of overcoming those difficulties? Surely
they might at least have made some suggestion.
The session of the Medical Society opened on the
9th inst. when the new president, Lt.-Col. D'Arcy
Power, F.R.C.S., delivered an address on "John
Ward and His Diary," opening it with a quotation
from one of the sixteen notebooks in possession of
the society, from which Dr. Severn published ex-
tracts in 1839. Col. Power has examined the earlier
volumes and finds them as it were common place
books of a writer living at Oxjford from 1652 to
1660, a period when nearly all the original members
of the Royal Society were Oxford residents. The
president hopes to return to this subject on another
occasion.
progress at fHrMral l^rmtrp.
Boston .Medical and Surgical Journal.
\ ovember 1C. 1916.
1. Mental Pitfalls of Adolescence. Henrv R. Stedman.
2. The Relation of the State Department of Health to the
Communicable Diseases of Childhood. Allan J Mc-
Laughlin.
3. Measles and the Public Health. Edwin Hi
1 lei Fever. F. B. Mallory.
5 Scarlet Fever. Charles V. Chapin.
port of the Fat Di] ithei i lecurring in the
Connecticut Valle; Health District ol Massachusetts
Ji hn S Hit. hcock.
7 Diphtheria. William II. Park.
8. Whooping Cough: The Measures to be Taken for its i
trol .i John Lovett Mi
1. Mental Pitfalls of Adolescence. — Henry R. Sted-
man gives a clear picture of the most important of
these pitfalls, namely, dementia precox, and considers
that widespread information on the subject is plainly
called for in view of the large number of youths and
girls who are annually admitted to state and private
hospitals for mental disease, and the ignorance of the
general public as regards the special form of the dis-
order which is peculiar to adolescence. The young are
protected by education in physical and moral hygiene,
but against mental deterioration and breakdown little
or no warning or advice is given him or his parents,
until he is placed under care in an institution. Of
the 3,264 new cases of mental disease admitted to the
Massachusetts hospitals in 1915, 804, or over 21 per
cent, were suffering from dementia precox. These
cases represent one-third more admissions than the
combined totals of all patients whose mental condition
is due either to alcohol or syphilis — causes which are
very rarely operative in producing this form of mental
disease. Of all the classified forms of insanity, de-
mentia precox claims by far the greatest number of
victims. This mental condition must not be con-
founded with mental defect or feeble-mindedness proper.
The latter has little or no mind to start with, while the
dementia precox cases enjoy, up to the time of their
breakdown, apparently normal and sound minds. They
most frequently display marked intelligence and prom-
ise. It is during the period or at the end of adoles-
cence, the most critical period of mental life, ranging
in age from 15 to 25, that dementia precox begins. It
may originate a little later, though rarely. The dis-
ease has been divided into several different sub-varie-
ties, but the simpler form is the one most met with out-
side of hospitals. These cases are less striking and
very insidious in their development. The principal
feature is the change in the youth's character, in the
shape of a gradually developing mild apathy and in-
difference. The well-cared-for patient leads a life of
indolence varied by times of aimless activity and tends
to develop obsessions, antagonisms, and anti-social pro-
clivities. The poorer patient develops into either a
tramp, a crank, a criminal, or prostitute in the making.
Wilmans found in 127 vagabonds 66 cases of this con-
dition. The first symptom seems to be lapse in power
of attention, of mental concentration. A very definite
outline of symptoms is given by Stedman and he says
the general appearance of the patient is that of apathy
or mild depression, except at times of unexpected and
transient animation. Lack of energy also is constant,
except at intervals. Their tendency to shrink from
coping with the world, due to a faulty habit of adjust-
ment, resolves itself into the "shut-in" personality
which typifies these cases. Hoch found this type of
personality markedly pronounced in 35 per cent, and
indicated 16 per cent, out of 72 cases of dementia pre-
cox. Another type is the precocious youth who is liable
to mental breakdown in adolescence due to the over-
stimulation of a too active mind. Badly directed edu-
cation, moral and mental, may give a wrong turn to the
tendencies of the nervous child and thus leave him with
little defense against the exciting causes of mental
disease when adolescence is reached. Overstudy, rapid
and excessive growth in height, without corresponding
weight and development, are recognized as abnormal.
There is not sufficient alimentation provided to meet
the demand of the growth of the organism plus ex-
cessive mental and bodily energy. Contrary to popular
opinion, masturbation is almost never the cause of
mental defect or disease. Typhoid and other debili-
tating diseases occasionally leave the patient in a per-
manently weakened mental condition culminating in
dementia precox; also cases of puerperal insanity are
really many times cases of dementia precox superin-
duced by the strain of childbirth. Stedman suggests
that the outlook for recovery in these cases is gloomy,
but that properly instituted preventive measures may
decidedly change the prognosis. Young cases taken at
the beginning of the condition and properly treated
show marked improvement and many have been able
to resume normal life and duties, while others not
reaching the normal have at least been able to lead
Dec. 2, 1916]
MEDICAL RECORD.
997
quiet lives of usefulness. Campbell says that "the re-
searches of Kraepelin, Freud, and Jung of Germany,
and Meyer and Hoch in this country, show that under
proper control many cases of functional disease and
insanity are of such a nature as to be manageable and
preventable." Campbell considers cases of dementia
precox as the most hopeful and classes 39 per cent, as
manageable and preventable. These cases must be
given a congenial environment as to mental and physi-
cal health and kept from over-exertion and fatigue.
Plenty of thoroughly nourishing food and sleep and
the companionship of their fellows will do much to
ward off or overcome this mental condition. Fresh air
should be the breath of life of the young. Sii Thomas
Clouston has said that fatness, self-control, and order-
liness are the three most important qualities for these
patients to aim at. Stedman concludes by stating that
during the period of adolescence all boys and girls
should be carefully guarded and not allowed to under-
take a life beyond their strength and capacity, whether
it be social service work, a life of social gayety, or, as
in the cases among the poorer classes, too hard work
and too little nourishment. Fortunately state preven-
tion and hospitals are doing much to recognize and im-
prove this period of life for the young.
4. The Etiology of Scarlet Fever. — F. B. Mallory
states that the primary lesion of scarlet fever is lo-
cated in the respiratory tract, starting usually in or
round the tonsils. In severe cases it may extend far-
ther down to the bronchi or esophagus. Study of the
lesions of scarlet fever shows the presence in them of
a delicate gram-positive bacillus in large numbers. In
both smears and culture the bacillus is slighly smaller
than the diphtheria bacillus, and varies from coccus-
like to large bacillary forms. The organisms isolated
are facultative aerobes, and grow best anaerobically
upon serum-glycerin (3 per cent.) -dextrose (0.5 per
cent.) -agar. Less abundant growth upon other media
occurs. After further description of the habits of this
bacillus he concludes that it seems reasonable to infer
from these observations that scarlet fever may be due
to a strongly gram-positive bacillus (B. scarlatina;),
which is less virulent than the diphtheria bacillus, but
which infects practically the same localities and in se-
vere cases may extend in the same way to adjoining
tissues, especially the larynx, trachea, and lungs. The
toxin causes necrosis and desquamation of the covering
epithelium and leads to an exudation of serum and
polymorphonuclear leucocytes. Fibrin formation is
usually absent or slight. On this account the primary
gross lesions are inconspicuous and easily overlooked.
There is usually little membrane formation to call at-
tention, as in diphtheria, to the lesions. The bacillus of
scarlet fever usually dies out quickly in the lesions, so
that after the second or third day following the erup-
tion it is often difficult or impossible to demonstrate it;
but it opens the way for streptococcus invasion and
seems to favor its growth.
New York Medical Journal.
November IS, 1916.
1. Birth Control. S. Adolphus Knopf. •
2. Compression Fracture of the Fifth Lumbar Vertebra.
James K. Young.
3. Diagnosis of Duodenal Ulcer. A. Everett .Austin.
4. The Value to the Operating Surgeon of a Thorough Un-
derstanding of Therapeutic Agents. Albert Vandeveer.
r>. Post Partum Sepsis. Albert M. Judd.
6. The Surgical Staff Conference. Frank E. Adair.
T. Testicular Syphilis. M. Zigler.
8. A Female Medical Clinic. Morris H. Kahn.
9. The Spinal Fluid of Normal Children. Orlando H. Petty.
10. Public Health. Harry Greenstein.
3. Diagnosis of Duodenal Ulcer. — A. Everett Austin
refers to the difficulties encountered in the diagnosis of
this condition, as evidenced by the results of autopsies
on cases supposed to have been suffering from duodenal
ulcer when the condition was but rarely found. It is
conceivable, Austin says, that a duodenal ulcer may
spontaneously undergo so complete a cure that the scar
tissue which is left may be fully absorbed and hence
escape the attention of the pathologist. The operation
naturally takes place during the period of activity, and
it is surprising the unerring accuracy with which a com-
petent surgeon, with hands incased in rubber gloves,
can detect indurations in the duodenum resulting from
this form of ulcer. Austin enters minutely into a de-
scription of the symptoms of this condition and the re-
sults in diminution of symptoms on taking food. For
results of his work he refers to thirteen of his own
cases which have furnished the material for his inves-
tigations. From these results he says that it seems
that a diagnosis of duodenal ulcer must be based largely
upon the four factors of periodical and characteristic
fasting discomfort, if not pain, on the presence of hy-
persecretion, particularly of the alimentary variety
rather than the continuous; on the presence of occult
blood in the stool, and on distortions of the first part of
the duodenum, as shown by the radiogram. A short
perusal of any series of cases will soon show that all
of these are never found in any one case. When, how-
ever, any two or three are present, we may well forego
the presence of the fourth factor. The relative value
of the history, of the character of the pain and its in-
termissions, and the detection at some time of occult
blood in the stools, appears to Austin to be of the most
importance. On account of the close similarity of symp-
toms of duodenal ulcer and functional hypersecretion,
the former lose much of their significance, and depend-
ence must be placed more upon physical signs than upon
symptoms; and as hypersecretion is present, both as a
functional disorder and as the outcome of ulcer, the
conclusion must be made that occult blood in the stools
and the distortion of the duodenum as shown by the
a;-ray examination are the positive signs upon which
diagnosis must largely be based. As far as differential
diagnosis is concerned, there is probably no condition
which so closely simulates duodenal ulcer as cholelithi-
asis, but one of the most distinctive points of difference
is the slight trace of bile found in the urine when the
common duct and gallbladder are involved. In typical
gallstone colic the pain reaches a severity which is never
found with duodenal ulcer. Icterus is common with
cholecystitis, while occult blood is more typical of duo-
denal ulcer. The distinction between gastric ulcer and
duodenal ulcer is often impossible, and Austin considers
it a mere refinement of diagnosis at times to reach a
decision. With reference to this condition and appen-
dicitis much may be said, but the writer considers that
the diagnosis of diseased appendix is often made in
error on account of the reflex relations of the plexuses
involved, and that unless undoubted evidence of disease
in the right lower quadrant is present, with other typ-
ical symptoms, it is much wiser to let the surgeon make
the median incision and examine the region of the duo-
denum, at the same time removing the appendix if the
duodenum is found normal. At least, confusion occurs
only with the so-called chronic condition or appendicitis
larvata.
4. The Value to the Operating Surgeon of a Thor-
ough Understanding of Therapeutic Agents. — Albert
Vanderveer, in giving his opinion on this subject before
the American Therapeutic Society, considered that in
general surgery the men of the future who accomplish
success will be those who give the best that is in them
to the study of surgical bacteriology. He expresses
regret for the tendency of some of the younger men in
the profession to lose interest in their cases when once
998
MEDICAL RECORD.
[Dec. 2, 1916
they have touched upon a surgical lesion and consider
the case but fit for the surgeon. In many such in-
stances more persistent investigation would have dem-
onstrated that therapeutic measures following a correct
diagnosis would have obviated the necessity for an op-
eration. A study, complete as possible, of all cases,
employing every means at hand as an aid in diagnosis,
is due the patient from a practitioner. He cites the
thoroughness of the examinations of the Mayo clinic
before operation is decided upon. Cases are given
showing how easily symptoms may be misinterpreted,
and how such cases were cured therapeutically, when
they might have been sent to the surgeon had not care-
ful study of symptoms detected the true causes. He
asks that may it not be said that there will always be a
border-line of cases in which both medical and surgical
diagnosis may be questioned.
9. The Spinal Fluid of Normal Children. — O. H.
Petty, having procured and examined spinal fluids in
nearly fifty cases of infantile paralysis, was impressed
with the fact that the fatal and severer forms of the
disease as a rule showed a lower pressure — that is,
fewer drops a minute from the spinal needle — than the
apparently milder types of the disease. This fact sug-
gested to him the question of the normal fluid; so, find-
ing no detailed records of a large series of normal
fluids, he has begun the study on a series of normal
children, comprising so far a few less than twenty.
The average results are almost startling. They are as
follows: Pressure close to 20 mm. Hg. ; cell count ap-
proximating eleven cells per cubic millimeter, and the
number of drops of spinal fluid a minute usually being
above seventy-five. Up to this time the normal pres-
sure has been considered as from 6 to 8 mm. Hg., the
number of drops a minute as about twenty, and a cell
count above six per cubic centimeter as pathological.
After a sufficient number has been studied to determine
a constant average, they will be reported in detail,
showing pressure as recorded by a mercurial manom-
eter, both with and without general anesthesia, drops
a minute with gage of needle used, and cell count.
Journal of the American Medical Association.
November 1*. 1916.
W. B.
Other
D. A.
M. L.
Results of Recent Studies on Ductless Glands.
( lannon.
Some Clinical studies of the Problems of Cerebral Tone.
Charles K. Mills.
Useful Drugs. Martin I. Wilbert.
Duodenal Cultures in Typhoid Fever as a Means of De-
termining- Complete Convalescence. A. L. Garbat.
The Relation of Diet to Beriberi and the Present Status
of ur Knowledge of the Vitamines. Edward B. Ved-
der.
Syphilis with Neurologic Symptoms Simulating
Conditions : Some Cases and Their Treatment.
Haller and I. C. Walker.
The Etiologic Role of Scar Tissue in Skin Cancer,
Heidingsfeld*.
The Treatment of Malignant Disease About the Month by
Combined Methods. George E. Pfahler.
Radium in the Treatment of Cancer and Various Other
Diseases of the Skin. Frank E. Simpson.
Leukemia Cutis, with Report of a Case. S. E. Sweitzer.
Weakness of the Soft Palate and of the Tongue a I
stant Symptom in Hemiplegia. P. De Long and T. H.
Weisenburg.
Local Reactions of the Pasteur Treatment and Their
Time of Appearance. J. C. Geiger.
The Clinical Value of Complement Fixation in Tubercu-
losis H. R. Miller.
Epidemics of Pemphigus Neonatorum In Chicago: Pre-
i port. Fredei ick Howard Palls,
oform in status Epilepticus, with Report of Cases.
Leigh F. Robinson.
Two I ital Absence of One Kidney. Marcus
\v. Lyon, Jr.
1. Results of Recent Studies on Ductless Glands. —
W. B. Cannon states that the studies which have been
carried on for the past four or five years in the Harvard
Physiological Laboratory with reference to the bodily
changes which accompany strong emotions, such as
fear and rage, have revealed interesting relations be-
tween these emotions and certain glands of internal
10.
ll.
12.
13.
14.
16.
secretion, and have suggested also a way in which emo-
tional excitement may occasion pathological states.
When a cat becomes infuriated the pupils are dilated
and the hair is erect from head to tail; the heart beats
rapidly and the activities of the stomach and intes-
tines are stopped. Both internal and external changes
are due to the passage of nerve impulses to viscera
along the nuerons of the sympathetic division of the
autonomic system. The relation of the fibres connect-
ing the central nervous system with these neurons is
such as to provide fir diffuse action on all the viscera
that are innervated by this division. He explains the
sympathetic control of the suprarenal glands, and that
they have found that these glands secrete epinephrin in
times of great excitement, also that there is an in-
creased liberation of sugar from the liver so that
glycosuria may result, that there is an abolition or
prompt lessening of muscular fatigue, and that there
is much more clotting of blood. Epinephrin also
causes a redistribution of blood in the body, sending it
away from the alimentary canal, whose activities are
inhibited, to the heart, lungs, the central nervous sys-
tem and active skeletal muscles; dilation of the bran-
chioles and increase in the number of red blood cor-
puscles per cubic centimeter are all the result of its
action under emotional excitement. These changes are
the same in man as in the animals and produce rein-
forcement for the great power and endurance which
are exhibited in times of intense excitement. Physiolog-
ical activity is accompanied by the presence of an
electrical difference which may be observed by connect-
ing an active part with an inactive part of the body
through a sensitive galvanometer. Through this method
the glandular secretions have been studied and when
applied to the thyroid, the positive testimony of the
galvanometer is evidence of thyroid secretion, and that
the gland is subject to impulses from a part of the
sympathetic division of the autonomic system, the cer-
vical sympathetic. Experiment further shows that the
thyroid is stimulated by the epinephrin produced by the
suprarenals in times of intense excitement. Experi-
ment also showed that the efficiency of epinephrin is
not produced if the thyroid glands have been previously
removed. Thus a hormone relation between the supra-
renal and the thyroid is clearly demonstrated. Two
questions have arisen in the course of this work: Why
are organs which are disturbed in times of emotional
stress not disturbed at other times? It seemed prob-
able that they were protected from interference by a
high neuron threshold interposed between the central
nervous system and the visceral cells. Consequently
only when great excitement is present in the central
nervous system is this threshold crossed and the
changes in the viscera brought to pass. Why, in cer-
tain pathologic cases is there apparently frequent or
continuous disturbance of the same viscera? Possibly
due to a wearing down of the high threshold here or
there from frequent or great emotional experiences.
Thus dyspepsia, tachycardia and possibly persistent
glycosuria, reported as having an emotional origin,
might be accounted for. Experiments are given by
Cannon and the evidence presented shows that besides
any routine function, the suprarenal gland has an emer-
gency function brought out in times of great excite-
ment. It is not unreasonable to suppose that the
thyroid gland likewise has an emergency function
evoked in critical times, which would serve to increase
the speed of metabolism when the rapidity of bodily
processes might be of the utmost importance and aug-
menting the efficiency of the epinephrin which would
be secreted simultaneously.
5. The Relation of Diet to Beriberi. — Edward B. Ved-
Dec. 2, 1916 1
MEDICAL RECORD.
999
der, in considering this subject and the present status
of our knowledge of the vitamines, says that the con-
sensus of opinion is that beriberi is caused by a dietary
deficiency resulting from faulty metabolism caused by
the lack of certain accessory food substances called
vitamines. He reviews the work of many of the in-
vestigators in this field and credits Funk with the ap-
plication of the name vitamine to the accessory food
substance, the lack of which produces this disease. But
Funk and Drummond did not succeed in isolating the
pure vitamine; but Williams succeeded later by a syn-
thetic method in preparing a pure substance that would
cure polyneuritis in fowls corresponding to the pure
vitamine. Williams and Seidell have found that a sim-
ilar isomerism existing in these substances also exists
in the vitamine of yeast and is primarily responsible
for the instability of these compounds, which has so far
prevented their isolation. Adenin is the purin base in
yeast, which has this property of isomerism. With re-
gard to the antineuritic vitamine Vedder has proposed
the hypothesis that this chemical substance acts as a
building stone of the complex structure of the nervous
tissue, without which it cannot be repaired. When a
deficiency in this vitamine exists the nervous tissue be-
comes first exhausted and then degenerated until finally
the symptoms of polyneuritis appear in fowls or dry
beriberi in man. This theory is based on experimental
observations in man. The antineuritic vitamine is the
only one of the accessory food substances concerning
which there is sufficient evidence to even theorize con-
cerning its action in the body, and more work will be
needed before any adequate conception of the physiologi-
cal action of the vitamines will be known. The study
of beriberi, scurvy, and other deficiencies has given a
working basis that there are a number of different ac-
cessory food substances or vitamines and that each
deficiency disease is caused by the absence of its par-
ticular vitamine. Vedder, from his own experiments
and those of other investigators, considers that we
must assume that there is a whole group of these
vitamines, but that further investigations will be neces-
sary to determine the relation of these various sub-
stances to each other. The study of dietetics from the
point of view of the vitamines has only just begun, and
the exact role they play in metabolism has not yet been
elucidated, but it has been clearly demonstrated that
certain deficiency diseases are due to the lack of cer-
tain accessory foods. Pellagra, beriberi, scurvy, and
other deficiency diseases are to be controlled or pre-
vented through the administration of the proper foods
containing the adequate vitamines. Vedder suggests a
number of foods and dietary rules for use in order to
prevent these deficiency diseases: In any institution
where bread is the staple article of diet, it should be
made from whole wheat flour. Rice used in any quan-
tity should be of the brown undermilled variety. Beans,
peas, or other legumes known to prevent beriberi,
should be served at least once a week. Canned beans
or peas should not be used. Some fresh vegetable or
fruit should be issued at least twice a week, and bar-
ley, a known preventive of beriberi, should be used in
all soups. Cornmeal should be of the yellow or water-
ground variety, that is, made from the whole grain.
White potatoes and fresh meat should be served at least
once a week, preferably once daily, as they prevent
scurvy and beriberi. The too exclusive use of canned
goods must be carefully avoided.
8. The Treatment of Malignant Disease About the
Mouth by Combined Methods. — George E. Pfahler con-
fines his remarks entirely to the therapeutic side of
these conditions, and considers that physicians should
give careful attention to the condition of the mouths of
patients, insuring proper care to any apparent minor
pathological condition from any cause. Syphilitic con-
ditions need special supervision. No single method is
sufficient for the treatment of malignant conditions,
and four methods are available, namely, surgical re-
moval, local destruction by means of electrothermic co-
agulation, deep roentgenotherapy, and the application
of radium in the mouth. Every case of epithelioma
about the mouth should be destroyed locally by electro-
thermic coagulation, or thoroughly excised surgically,
the preference being given to the first method; but
when paipable metastatic glands are present in the
neck they should be excised surgically even though the
disease in the mouth or lips is destroyed electrother-
mically. Then deep roentgenotherapy should be thor-
oughly applied over the wound and over the glandular
area, making use of as much crossfiring as possible.
The surgical procedures are too well known to need
mention here. The electrothermic coagulation differs
from the thermocautery in that the heat is generated
in the tissues and is produced by the resistance offered
to the flow of electricity through the tissues, while the
thermocautery is merely transmitted heat and pro-
duces a more superficial effect. The effect can be thor-
oughly controlled by varying the relative sizes of the
electrodes so that one can make the conductive heat
approximate a cone or cylinder. When one of the
electrodes is a point the greatest amount of destruction
will develop at the point, and then will radiate in a
more or less cone shape toward the opposite electrode,
thereby giving a zone in which the tissues are heated
to the destructive degree for malignancy, but in
which healthy tissues will not be destroyed. Pfahler
gives the technic of the application and the advantages
of the electrothermic coagulation, which are as fol-
lows : The disease is destroyed by conductive heat,
which gives a zone of devitalization without actual de-
struction of healthy tissue, hence saving local tissue
when necessary. There are no raw tissues to permit
the transplantation of malignant cells. There are no
blood or lymphatic vessels opened up through which
the disease can be disseminated during the operation.
There is no hemorrhage to contend with, though, in
tongue cases there is some danger of secondary hemor-
rhage. There are no open wounds and no danger of
infection. The disadvantages of this method of treat-
ment are: There is complete destruction of all the
tissue between the two electrodes ; therefore there is
no chance of saving the blood vessels or nerves which
are in close proximity to the disease. Sloughing and
foul odor are present during the first two or three
weeks. Considerable pain is present during the first
few days after the operation. An open area of tissue
is left which is healed by granulation, but which at
times must be followed by a plastic surgical operation
to close the mouth or correct some deformity. In deep
roentgenotherapy the object is to control or destroy the
out-lying cells or metastases in the coagulation process.
Hence the treatment must be thorough and given with
the understanding that disease may still be present;
for if the disease has been eradicated there is no need
of this method. This treatment must always be given
with the technic used for deep disease. Pfahler be-
lieves that the place of radium in the treatment of ma-
lignant disease about the mouth is within the mouth
and not on the outside. He can see no advantage of
radium over Roentgen rays, and much disadvantage be-
cause so much less in quantity, and so less definitely
controlled when applied externally. When the radium
is applied inside the mouth there is no disadvantage in
its use, for the radium can easily be brought in close
contact with the disease when filtered through at least
1000
MEDICAL RECORD.
[Dec. 2, 1916
0.5 mm. of silver, and when there is applied approxi-
mately 600 milligram hours of radium a decided bene-
ficial effect can be obtained. Many cases of relief and
cure are cited and following conclusions given : The
cases forming the basis of this report, excepting those
involving the lower lip, were almost entirely inoperable,
and therefore every success is a distinct advance and
every failure only a loss of time, energy, and effort.
Combined treatment by surgery, electrothermic coagula-
tion, radium and deep roentgenotherpy will cure some
patients who are otherwise hopeless.
13. Clinical Value of Complement Fixation in Tuber-
culosis.— H. R. Miller says that it is well known that in
most bacterial diseases the body reacts by the forma-
tion of antibodies, and when this takes place the pres-
ence of these antibodies can be detected in vitro by a
number of different methods, and perhaps the most
important of all, the various methods of complement
fixation. He reviews the work already done in this
field, together with his results and concludes that we
have, in the complement fixation reaction, a method
for the detection of active tuberculosis. 1. The re-
action is practically always positive in active tubercu-
losis: 284 pulmonary cases: positive in 275, negative in
nine. 2. Nontuberculous and normal patients react
negatively: 144 cases: all negative. 3. The serums of
syphilitics who have no clinically active tuberculosis are
negative. Two hundred and forty-three positive Was-
sermann cases were all negative except seven, and in
these seven tuberculosis was established in five cases
and was not excluded in the other two. 4. The test is,
as a rule, negative in arrested cases. Of 113 serums
tested, 103 were negative and 10 positive. 5 The von
Pirquet and intradermic tuberculin tests and the com-
plement fixation reaction are not identical or similar
diagnostic procedures, since the former indicates the
existence of a tuberculous lesion whether old and ar-
rested or active, while the latter points clearly to the
presence of some active focus. 6. There is evidence to
believe that there exists a group of tubercle bacillus
carriers who have no manifestations of clinical activity
and whose serums contain no antibodies, and yet dis-
charge tubercle bacilli in their sputum. 7. The pres-
ence of tubercle bacilli in the sputum is not an absolute
guarantee of the activity of the pulmonary tubercu-
losis. We feel reasonably justified, therefore, in as-
suming that the complement fixation test with our
antigen may be of distinct aid in the diagnosis of early
tuberculosis and in the detection of the disease when
the condition is obscure. The test should offer a wide
field of usefulness in prognosis, since the reaction loses
its intensity of fixation as the patient progresses toward
recovery. Lastly, in the fixation test the practitioner
will have at his disposal a measure for the control of
tuberculosis in institutional and private life.
1 I. Epidemics of Pemphigus Neonatorum in Chicago.
— Frederick H. Falls states that there occurred eight
small epidemics of this condition in Chicago last year.
The disease is an epidemic staphylococcic vesicular
dermatitis usually occurring in new-born babies from
the fourth to the fourteenth day, but capable of being
transmitted to older children and adults. The disease
is highly contagious and can be transmitted through
a third party, not infected, but in contact with patients
having the disease. No cases have been reported in
babies who have not been exposed directly or indirectly
to the cases developed in the hospital epidemics. Prompt
isolation with quarantine of the obstetric wards until
the last patient has left the hospital, followed by
fumigation and painting, etc., is necessary. Special
nurses are necessary on these cases. An efficient method
of treating the lesions is to rupture the vesicle as soon
as it forms and to apply 2 per cent, ointment of ammon-
iated mercury to the lesion. Prophylactic and curative
vaccines in doses of 15 millions are being tried, but
their use is too limited to permit of any definite con-
clusions as to their value in preventing or effecting a
cure of the disease.
The Lancet.
October 1!S>. 1916.
1. The Harvein Oration. Thomas Barlow.
2. Penetrating Wounds of the Abdomen. T. Crisp English.
3. The Technique of the Agglutinin Test. P. N. Panton.
4. A Method of Applying the Wassermann Reaction in Large
Numbers. P. Fildes and James Mcintosh.
5. The Occasional Absence of a Rise of Temperature Follow-
ing the Administration of Diagnostic Doses of Tuber-
culin to Tuberculous Persons. Duncan Forbes and
Cecil W. Hutt.
2. Penetrating Wounds of the Abdomen. — T. Crisp
English states that gunshot wounds of the abdomen
form a subject of considerable importance, for there
has been a decided difference of opinion as to the best
line of treatment; some strongly urge operative meas-
ures whenever possible, and others believe that for
most cases expectant treatment offers the best pros-
pects. Extreme views in either direction will prove
to be wrong, but the value of operative treatment under
proper conditions is becoming increasingly obvious.
English writes from Salonika and says that the only
considerable experience of abdominal injuries is that
gained in France, and in framing conclusions we must
draw largely from that experience, remembering that
surgery in France is done under favorable conditions
at the present time. It has been suggested that there
is a tendency to attach undue importance to these in-
juries, considering that they form only a small propor-
tion of the total number of wounds. English says, how-
ever, that anyone who has come into close contact
with numbers of men recently wounded cannot but
recognize the importance of the abdominal group; the
cases owe this importance to their urgency, their high
mortality, and to the fact that many lives may be saved
by appropriate treatment. The multiplicity and severity
of the lesions make a high mortality inevitable, whatever
treatment be adopted; this fact is quickly grasped
when one sees the extent of the injuries as revealed
on the operating table or in the postmortem tent.
Available statistics all emphasize the same fact. From
the army statistics English quotes that in 100 cases
of abdominal wounds, 65 were instances of penetrating
wounds — namely, 30 that died in the field ambulances,
and the 35 diagnosed as penetrating cases in the clear-
ing stations; 11 of these ultimately reached England.
The mortality up to that stage was about 83 per cent.
In civil life operation is the general rule, if conditions
permit it. In the early part of this war surgical work
was influenced by the South African war traditions,
which naturally led surgeons to believe that expectant
treatment would give better results than operative
treatment. War conditions at the beginning were un-
favorable for operative treatment, hence the high mor-
tality discouraged operation. Since the spring of last
year, when siege warefare had become established, oper-
ative treatment was restarted and every facility that
could be devised was supplied. English, from his own
surgical experience, divides these cases that are unfit
for operation into four groups, those moribund on
arrival; in injuries of the liver and kidneys when
there was a certainty that the hollow viscera had
escaped, operation seemed contraindicated; in the dia-
phragmatic group in which the projectile appeared to
have traversed the top of the abdomen, the diaphragm,
and the lower part of the chest, expectant treatment is
usually the wisest plan. Cases now reaching the base
hospitals have been sent there when apparently con-
Dec. 2, 1916]
MEDICAL RECORD.
100i
valescent from operation, or if without operation when
apparently safe from serious trouble. One may as-
sume that the base mortality will be substantially re-
duced and the total improvement in the mortality reach
20 per cent, over the original. English concludes as
follows: 1. Operations for penetrating abdominal
wounds are not advisable unless they can be done in
good surgical surroundings and by an operator with
some knowledge of abdominal surgery; otherwise dis-
asters will be more frequent than successes. 2. Patients
with abdominal wounds should be sent to an operating
station as quickly as possible, provided that they are fit
to travel; their prospects depend mainly on the quick-
ness with which this can be done. 3. Patients who are
not fit to travel should be kept absolutely quiet, warm,
and under the influence of morphia; saline infusion,
hypodermieally or otherwise, is most beneficial. They
are then transported to the operating station as soon
as their condition improves; the question is usually
settled by the character of the pulse. If the pulse-rate
is 130 or over, it is certainly best to keep them in the
place where they are receiving their primary treat-
ment until improvement occurs. 4. On reaching the
place where they can be operated upon patients whose
condition is good should be dealt with at once, other-
wise two to eight hours should be spent in preparative
treatment. Operation is never advisable if the pulse-
rate is 140 or over. 5. The abdominal exploration
must be systematic and quick: the duration of the
operation should rarely exceed 45 minutes. 6. When
good surgical conditions are obtainable operation is the
best treatment in most cases, and must be done as soon
as the patient's condition allows it. Be prepared for a
high mortality, but know that early operative treat-
ment will substantially reduce it.
5. The Occasional Absence of a Rise of Temperature
Following the Administration of Diagnostic Doses of
Tuberculin. — Forbes and Hutt report two cases in tuber-
culous persons where tuberculin was used for diag-
nostic purposes and no rise of temperature occurred.
They say that it is well recognized that a local reaction
and rise of temperature following the administration of
tuberculin does not necessarily indicate the presence
of an active lesion, signs of a focal reaction alone giv-
ing any evidence likely to be of assistance in the diag-
nosis. On the other hand, many believe that active
disease can definitely be excluded if the usual diagnos-
tic doses of tuberculin are not followed by any rise of
temperature. Their reason for this report is to empha-
size the fact that patients suffering from active tuber-
culosis and who have not been previously treated with
tuberculin may have no rise of temperature of even 1°
F. above normal following the administration of diag-
nostic doses of tuberculin. The first was that of a
man 44 years of age, and the second was a boy of 2
years. In the first case there were signs only of im-
paired resonance in the right apex, but history of a
cough off and on for the past ten years. Six gradually
increasing doses of tuberculin were given at intervals
of three or four days. According to four-hourly chart
no rise of temperature occurred, except on the day fol-
lowing the one-half and one milligram doses, when the
mouth temperature rose to 98.6° and 99.2° F. ; but on
two occasions prior to the administration of tuberculin
a temperature of 99.2° had been recorded. The local
reaction was slight. The patient's weight rose steadily
and later he was discharged. Fifteen months later he
was admitted with decided crepitations in the right
apex and tubercle bacilli in the sputum. Again the
test was applied on four successive occasions with
intervals of about seven days, followed by no in-
crease of temperature, except on two occasions, 99°
being recorded on the third day after the one-half
and five milligram doses; but a temperature of 99°
had been recorded a short time prior to the injections.
Case 2. — The patient, a male aged 2, was admitted
suffering from spinal caries and healed tuberculous
abscesses on the foot. He received li, V2, and 1 milli-
gram of tuberculin (T.), the highest subsequent tem-
perature being 98.6 = F. Five months later an abscess
formed on the dorsum of the foot, broke down, and re-
mained open for some time. In this case the maximum
dose administered was 1 milligram, but the child was
only 2 years of age. In this connection it is interesting
to note that of the animals infected with human tubercle
bacilli and tested with homologous tuberculin the fol-
lowing gave a temperature reaction (rises of 0.9° C.
over the normal) ; 107 of 124 calves, or 86.3 per cent.;
6 of 6 goats, or 100 per cent.; 10 of 11 pigs, or 90.9
per cent., and 4 of 4 horses, or 100 per cent. Evident-
ly neither in man nor in animals does the absence of
a temperature reaction following tuberculin exclude
active tuberculosis.
British Medical Journal.
October 2S, 1916.
1. The Harveian Oration. — Harvey, the Man and the Phy-
sician. Thomas Barlow.
2. Meralgia Paraesthetica. W. J. Rutherford.
3. Shell Shock and Its Treatment by Cerebrospinal Galvan-
ism. Wilfrid Garton.
4. Treatment of Meningitis. Walter Broadbent.
5. Collosol Argentum. A. H. Boys.
8. Meralgia Paraesthetica. — W. J. Rutherford de-
scribes this condition as one characterized by mononeu-
ritis of the external cutaneous nerve of the thigh, and
of infrequent occurrence. Rutherford thinks that it is
not so rare as has been previously considered, since he
has seen about a dozen cases in the last ten years, five
cases in soldiers having come under his care within the
last nine months. The condition is of importance from
the military point of view, because it is capable of giv-
ing rise to disability of longer or shorter duration and
may be recurrent. The condition, which may occur in
both sexes, may be of bilateral symmetry, but usually
one limb is affected. Sensation over the area of dis-
tribution of the affected nerve, which as a rule can be
strictly delimited, is lost so far as finer sensibility is
concerned, for slight touch, for perception of points,
for heat and cold, and to a certain extent for pain,
while deep pressure can be perceived and a touch on
the bare skin is felt as though a layer of clothing in-
tervened. In old-standing cases cutaneous thickening
may be made out locally if a fold of skin is pinched
up between finger and thumb, and in some cases the
skin of the affected area begins to grow bald from
atrophy of hair follicles; while cutis anserina is lost
locally, so that no goose-skin appears over the affected
area, even though the other parts show this distinctly.
Perverted sensations are present in the diseased area.
Pain is often present and may be severe. The etiology
seems to be unknown, but the condition may owe its
origin to purely mechanical causes and be dependent on
the local anatomical peculiarities associated with the
course of the external cutaneous nerve. Cutting down
on the nerve has been suggested but as yet not tried.
Treatment seems to be of little avail. During an at-
tack rest and such drugs as phenacetin are indicated,
while purgatives should be given, as a loaded sigmoid
may add pressure in the region of the plexus affecting
the diseased area. Warm underclothing must be worn
on all occasions, as these patients consider climatic con-
ditions can precipitate an attack. The main feature of
the condition is the unreliability of the symptoms and
the likelihood of relapse.
3. Shell Shock and Its Treatment by Cerebrospinal
1002
MEDICAL RECORD.
[Dec. 2, 1916
Galvanism. — Wilfrid Garton says that the term "shell
shock" is made use of to describe two distinct condi-
tions— one a severe type of traumatic neurasthenia,
and the other bearing no resemblance to a neurasthenic
condition but characterized by hysterical manifesta-
tions. It is for shell shock of the neurasthenic type
only that cerebrospinal galvanism is of service as a
treatment, for, its use being based on the assumption
that neurasthenia is an organic disorder, there is no
reason to expect favorable results to follow in a con-
dition of functional disorder. The following symptoms
are usually found in this type: Headache, always ag-
gravated by the advent of thundery weather; insomnia,
mental depression, loss of memory, nervousness, bad
dreams, fatigue without exertion, tremors, wasting, and
loss of appetite. Paralysis of limbs or groups of mus-
cles and localized pains may be present. The resem-
blance between this condition and neurasthenia follow-
ing severe illness is so striking that a similarity of
origin is exceedingly probable. The coexistence of the
majority of these symptoms appearing in a series of
cases admits of but one explanation, and that is that
they are the effect of a common cause — organic dis-
order of the central nervous system; and, as there is
no gross lesion, this is probably a derangement of
metabolism. The character and personality of the pa-
tient are greatly changed by this condition, and it is
inconceivable that such alteration can take place inde-
pendently of any structural damage or metabolic dis-
turbance in the organism. A possible explanation of
the appearance and persistence of the symptoms is
that the violent concussions of the explosion produce a
partial paralysis of the nervi nervorum. The interfer-
ence of nutrition of the whole nervous system would
prevent the restoration of the nervi nervorum to their
normal activity, thus producing a vicious circle. Now,
if there is any probability that shell shock of the neu-
rasthenic type is due to a paralysis of the nerves regu-
lating nutrition or a disorder of metabolism, then the
use of the galvanic current is a treatment from which
one has every reason to expect good results, for the
most powerful agent we have for stimulating the
nerves to activity is electricity. The apparatus used
is a battery of wet Leclanche cells connected to a
switchboard on which there are two other resistances,
each of 1,000 ohms, one in series and one in parallel
with patient and milliamperemeter. The treatment is
commenced with no resistance in parallel and full re-
sistance in series. If this apparatus cannot be obtained
a battery of twelve dry cells, with cell collector and
galvanometer and a resistance of at least 1,500 ohms,
may be used. No current derived from the mains or
any universal apparatus should ever be used for this
treatment. A pad composed of about sixteen layers of
lint, soaked in a solution of sodium salicylate in dis-
tilled water, is applied to the forehead, care being
taken that the pad is evenly wetted and that its cen-
ter coincides with the middle of the forehead. A metal
plate connected with the negative pole is placed over
the center of the pad and the whole bound firmly to the
head. A similar pad soaked in tap water, covered with
a metal plate connected with the positive pole, is firmly
bandaged to the lumbar region. The current is turned
on slowly, and for the first treatment Garton uses only
10 milliamperes for ten minutes, and does not reach the
full strength (20 milliamperes) till the third or fourth
treatment. The patients in the service whom Garton
treated by this method did not remain under his care
sufficiently long enough to effect a cure, but made rapid
progress toward recovery. Several cases with im-
proved results are cited, and Garton concludes that as
a result of this method of treatment nearly all cases
of neurasthenic type of shell shock would derive great
benefit from it and the majority of cases, excepting
those of the most severe type, would be cured in under
three months.
Journal de Medicine de Paris.
Septt mbi. r, tai6.
Indications for Purgatives in Diseases of the Liver. —
Dufourt refers to Louis XIII and his 259 purgations in
one year. This period was the zenith of the cathartic,
for later scepticism became apparent and certain prom-
inent individuals were thought to have purged them-
selves to death. But after a period of reaction the cus-
tom again gained ground, probably because venesection
was being abandoned. Purgatives were believed as a
class to stimulate the hepatic cell, to excite peristalsis,
and, in general, to detoxicate and disinfect the body.
Modern studies have shown that the first stools of pur-
gation abound in microbian intestinal flora, and that on
the next day these were reduced to 10 per cent, of the
normal. Certain nitrogenous substances, however, like
the sulphoethers and indican, have been shown to be
innocent of the accusation of being concerned in intes-
tinal putrefaction. In fact, when these substances have
reached the urine they are in a state of complete oxida-
tion and are not indexes of intestinal toxicity. Purga-
tion is known to produce nervous depression which at
times amounts to syncope; those thus affected may
have not in the least been distressed by their constipa-
tion. Often but small eaters, they have been urged
that there is peril in allowing ingesta to accumulate.
Such patients are left prostrated and dejected. Even a
spontaneous passage has been known to have the same
results. A purge often makes a subject ill all over.
He is thirsty, has no appetite, sometimes has mild
chills, and subfebrile temperature. In any such case
catharsis can hardly have been indicated. The author
next takes up in great detail the view that purgatives
unburden the liver, with the old conclusion that true
cholagogues do not exist beyond all dispute. Not one
has ever been proved to increase the secretion of bile,
although not a few may perhaps promote excretion of
that fluid. In primary icterus due to some deficiency
in the function of the hepatic cell cholagogues are use-
less. On the other hand a flow of bile from the gall
ducts only may be brought about even by milk purga-
tives. Disturbance of the liver is secondarily associated
with digestive disorders and diarrhea may be in evi-
dence as well as constipation. Hence the truth of the
paradox the purgatives are indicated in diarrhea, while
constipation may be overcome in other ways. This doc-
trine emanated originally from Trousseau and has been
upheld by the experience of French colonists. In the
tropics diseases of the liver, of such large incidence,
are associated with diarrhea, which is treated by sul-
phates of soda and magnesia. Not every patient is
benefited thus, and certain women suffer from purga-
tion in the tropics no less than in the North and irre-
spective of the indications. Those who benefit chiefly
are men, great eaters, often gouty, with distress over
the liver, which as a matter of fact is congested or in-
flamed. Calomel relieves them mightily, although it
does not purge them because a small dose is all that is
necessary.
Death of a Sword Swallower. — According to Weinert,
a reservist who could swallow his side-arm was shot
through the chest, the wound healing completely. When
he first resumed his sword swallowing, the point of the
weapon encountered marked resistance, followed by
fatal hemoptysis. The aorta had been perforated as a
result of secondary displacement of the esophagus. —
Munch ener medizinische Wochenschrift .
Dec. 2, 1916]
MEDICAL RECORD.
1003
ilnaitranr? JIUitiriti*.
Medical Selection for Life Insurance. — John L.
Davis, in presenting this subject before the Sec-
tion on Life Insurance, State Medical Association
of Texas, Galveston, said that life insurance com-
panies are paying Texas examiners about a quarter
of a million dollars a year in fees, and that these
fees are always cash and never have to be earned
twice, as often happens in the doctors' ordinary
medical practice; therefore the subject should
interest medical men. Life insurance companies
are great instrumentalities for promoting thrift,
unselfishness, and good citizenship, however, they
are not primarily planned to be humanitarian
institutions, but commercial enterprises. As such
their first purpose is to pay dividends to stock-
holders. Their funds must be securely invested
to earn at least the interest provided by the table
on which premiums are based, and their chief
profits come from savings in mortality, that is,
from having a death loss less than that expected
under the experience table; also from gains in
interest over the 31? per cent usually adopted as
the company's permanent standard or reserve
basis. This savings depends primarily on the care
exercised by the medical examiners in the field.
If this work is carefully and capably done, other
things being equal, the mortality will be well
within the tables, and in the newer companies the
death losses will be far less than the legal amount
set aside for this so that a very substantial balance
will remain at the end of the year to be credited as
surplus.
As is well known the medical examination covers
several general features : the applicant's present
physical condition and record of past illnesses;
his habits, environments, family record, financial
circumstances, etc. Much depends upon the keen
medical insight of the examiner, as a physician
with experience can tell from general observation
of an applicant as to his physical condition.
Habits of mental, moral and physical life are por-
trayed in the countenance and bearing of an indi-
vidual; but in most cases the examination may
proceed along the course provided in the examina-
tion blank. One point Davis emphasized, the
applicant's attitude toward the examiner, which
he states is very different from that of the sick
man consulting his physician for relief. Then all
details as to physical condition are most eagerly
told, while the same individual when examined for
life insurance assumes a different viewpoint, and
compels the examiner to find out all details, past
and present, for himself. The examiner must
always allow for the existence of a duplex per-
sonality like Dr. Jekyl and Mr. Hyde. Davis offers
a few general suggestions as to medical selection:
first, the physical build. The standard man at
35 years of age is about 5 ft. 9 in. and weighs 165
pounds; for every inch above or below there is to
be added or deducted about 5 pounds. As he
grows older the weight slowly increases about half
a pound a year. But actual insurance experience
has shown that mortality among those under 40 is
less among individuals rather heavier than the
standard; after middle life the reverse is true,
"light weight" old folks live longer. When the
abdominal girth is larger than the fully expanded
chest, mortality is noticeably increased. Alcohol
and its use has both a direct and indirect bearing,
for it has exacted a heavv toll from life insurance
companies. Anstie's limit, two ounces of alcohol
daily, seems to be more than can be ingested day
after day without material damage. Reformed
drinkers, like many other reformers, are short
lived ; their mortality is from 50 to 75 per cent, too
high for life insurance. These facts should
emphasize the need of thorough inquiry into the
man's habits, past and present. Another point is
that every illness leaves its impress on the body,
and while most of these impairments and scars
cannot be detected, they are there, nevertheless,
and shorten life. A list of diseases which have
affected life, though recovery at the time and ap-
parent health was attained, is given by Davis. He
includes asthma, albuminuria, bilious colic, gall-
stones, gout, alcoholic habits, pulse, pleurisy, rheu-
matism, and syphilis. Regarding heredity, it is well
recognized that certain families are long lived ;
others lack resistance and die early of ordinary dis-
seases. Family resistance to disease is therefore es-
sential in valuing a risk. The inherited proclivity for
certain diseases as well as inherited individual habits
and traits of temperament are all to be considered
as having a bearing on the applicant in question.
However, in estimating the weight of hereditary
influence one must be broad and equitable, not
confining inquiries exclusively to unfavorable
features transmitted, for ancestors confer on us
not only impairments, but even more positively a
tendency to vitality and health, otherwise nature's
purpose to perpetuate the race would be rendered
futile.
Finally the examiner should have in mind the
differing mortality from a given disease at differ-
ent ages. The serious diseases of young manhood
are those of germ origin — as consumption and
typhoid fever; they are most common and most
disastrous before middle life; after middle age,
the death losses come chiefly from degenerative
diseases. When examination is completed and
careful inspection has been made of the work
done and applicant has been given his rating, the
examiner should put himself in the place of the
medical director and see if all facts are clearly
and fully set forth. Sometimes such a review will
show the need of further explanation on the part
of the examiner. This work is akin to that of a
title examiner in real estate, except that this is an
inquiry into a title of health. On the recommend-
ation of the examiner a deed is given involving
possibly thousands of dollars. Fortunately the
grave responsibility placed upon examiners has
rarely been misplaced. Davis states that after
nearly thirty years of close acquaintance with
medical examiners almost from coast to coast, he
desired to affirm that for dependability under all
circumstances, for efficiency and character, medi-
cal examiners rank among nature's noblemen. —
Texas State Journal of Medicine.
Concealment of Newly Discovered Disease. —
The Arkansas Supreme Court holds that, where an
insured, after applying for life insurance in one
company, but before receiving the policy was told
by another examining physician that he had
Bright's disease, and he told the physician to make
a microscopical examination, which confirmed the
diagnosis, and he then arranged for treatment in
the city to which he was about to go, his failure to
disclose his condition to the first insurer was an
intentional concealment of a material fact, which
voided the policy. — United States Annuity & Life
Ins. Co. v. Peak, 182 S.W. 565.
1004
MEDICAL RECORD.
[Dec. 2, 1916
Honk ifowuia.
Medical Record Visiting List and Physicians' Diary
for 1917. Dated and undated. Newly revised.
Price, $1.25 to $4.00. New York: William Wood and
Company.
This well known visiting list is issued betimes, and, as
heretofore, it is compact and useful. It contains the
customary visiting list, with special blanks for consul-
tation practice, obstetric engagements and practice,
vaccinations, register of deaths, addresses of nurses and
patients, and cash account. There is much miscel-
laneous information at the beginning of the volume.
The visiting list has long enjoyed a well deserved popu-
larity, not only on account of its excellent arrange-
ment, but also because it is of convenient size and is
handsomely bound.
The Practitioner's Visiting List, 1917. For Thirty
Patients per Week. Price, $1.25. Philadelphia and
New York: Lea & Febiger.
This popular visiting list contains the usual blank
pages for noting the daily calls and charges for the
same. The text portion contains a scheme of dentition;
tables of weights and measures and comparative scales;
instructions for examining the urine; diagnostic table
of eruptive fevers; incompatibles, poisons and anti-
dotes; directions for effecting artificial respiration; ex-
tensive table of doses; an alphabetical table of diseases
and their remedies, and directions for ligation of ar-
teries, etc.
The Physician's Visiting List (Lindsay & Blakis-
ton's) for 1917. Price, $1.25. Philadelphia: P. Blak-
iston's Son & Co.
This is the sixty-sixth year of publication of this useful
visiting list. Some new tables have been added, the
most useful of which would have been one of the isola-
tion periods in infectious diseases had it been more com-
plete. The dose list has been revised to conform with
the new edition of the United States Pharmacopoeia.
This table would have been more useful had the official
drugs been designated and had synonyms been noted;
acetanilide, for instance, is given (dose 3 grains), and
also antifebrin (dose 5 grains), with nothing to indicate
that they are the same drug; similarly acetphenetidin
and phenacetin are listed with no hint as to their
identity.
Christianity and Sex Problems. By Hugh North-
cote, M. A. Second edition, revised and enlarged.
Price, $3 net. Philadelphia: F. A. Davis Company,
1916.
This book is obviously a sincere, if somewhat confused
attempt to present sex problems and a solution of them.
In its second edition it is enlarged by many references
to recent literature on the subject, especially to the
writings of Havelock Ellis and Iwan Bloch. The pres-
entation of the problems is as a rule fairly adequate, but
his solutions do not seem so convincing. He offers
nothing new or beyond the usually presented advice and
always emphasizes his belief in the efficacy of religion
as a curative agent. The work is confused and inade-
quate and yet it will serve its purpose to a certain ex-
tent. It has often seemed that much of the difficulty
from sex problems that vexes us at the present time
arises from the fact that we are in a transition period
between prudishness and frankness and that our chief
sin is hypocrisy. If this is true, any sincere publica-
tion aids in the accomplishment of frankness and there-
fore does good service.
Practical Massage and Corrective Exercises. By
HARTVIG Xissf.n, President of Possee Normal School
of Gymnastics; Superintendent of Hospital Clinics in
Massage and Medical Gymnastics; for twenty-four
years Lecturer and Instructor of Massage and Swed-
ish Gymnastics at Harvard University Summer
School, etc. Revised and enlarged edition of the
Author's "Practical Massage in Twenty Lessons,"
with many additions. With 68 original illustrations,
including several full-page half-tone plates. Price,
$1.50 net. Philadelphia: F. A. Davis Company, 1916.
Mr. HARTVIG Nissen has won a well deserved reputa-
tion in this country as an exceptionally able teacher and
exponent of the principles and practice of massage and
corrective exercises. He thoroughly understands the
theory as well as the practice, and is therefore pecu-
liarly competent to write a book on the subject. The
book is well worthy of the author's fame and may be
commended to the attention of all those who desire to
gain a good working knowledge of mechanotherapy.
Diseases of the Digestive Tract and Their Treat-
ment. By A. Everett Austin, A.M., M.D., 1 ormer
Professor of Physiological Chemistry at Tufts Col-
lege, University of Virginia, and University of
Texas; present Assistant Professor of Chemical
Medicine, in charge of Dietetics and Gastrointestinal
Diseases, Tufts College; Member of American Gas-
troenterlogical Association and American Society of
Biological Chemists; Physician to Mt. Sinai Hospi-
tal and Berkeley Infirmary, and Assistant to Boston
Dispensary; Author of "Manual of Clinical Chem-
istry," etc. With eighty-five illustrations, including
ten color plates. Price, $5.50. St. Louis: C. V.
Mosby Company, 1916.
Perhaps 50 per cent of all patients appearing at a
medical clinic complain of "stomach trouble." The
percentage in office practice would at least be high.
"Stomach trouble" may mean any of the "Diseases of
the Digestive Tract" of which Dr. Austin's book treats.
Hence the physician should be well versed in the symp-
toms and methods of diagnosis as well as effective
methods of treatment. Dr. Austin aims to meet this
need in covering carefully, though in not too great
detail, the various diseased conditions which may
arise in the stomach and intestine. The book is rather
conversational in style. In the parts on analysis of
gastric contents and feces this is objectionable as the
descriptions of chemical methods are not given in a
detail or with a clearness which would be necessary
for anyone not already acquainted with the methods
used. It is surprising that there is no discussion of
the fractional study of gastric digestion as worked
out by Rehfuss and his associates. There are two ex-
cellent chapters on dietetics and treatment of diges-
tive disorders. Therapeutic values of various foods
with reasons for such values are given and numerous
suggestions which only a person of wide experience
could offer. A continuous study of the food value and
chemical value for the special condition to be treated
is evident. There is a careful study of those foods
which stimulate gastric secretion and hence should
not be used in hypersecretion. There are satisfactory
discussions of the milk, vegetarian, and salt-free diets
and a good section on hydrotherapy in such simple
forms as may be carried out by any patient at home.
Massage is discussed, but one is surprised to find no
place given to active exercises of the abdominal mus-
cles, from which such excellent results may be ob-
tained.
The Dack Family. A Study in Hereditary Lack of
Emotional Control. By Mrs. Anna Wendt Finlay-
SON, Field Worker of Warren State Hospital, War-
ren, Pa. With Preface by Charles B. Davenport.
Price, 15 cents. Eugenics Record Office. Bulletin
No. 15. Cold Spring Harbor, N. Y., May, 1916.
This is a very excellent report of a very careful study.
The study has been undertaken in a truly scientific
manner and the material handled scientifically. The
difficulties which Mrs. Finlayson has surmounted can
be imagined, for this report involves successful, tact-
ful interviewing of a large number of individuals.
That there are numerous other families of which sim-
ilar studies would be valuable, there can be no doubt,
and it is to be hoped that others doing such work
may be as well fitted for it as Mrs. Finlayson.
The Expectant Mother. By Samuel Wyllis Band-
ler, M.D., Professor of Gynecology in the New York
Post-Graduate Medical School and Hospital. Illus-
trated. Price, $1.25. Philadelphia and London:
W. B. Saunders Company, 1916.
Dr. Bandler's book is a strange mixture of informa-
tion to the mother and information to the physician.
In fact, at the end one is left in doubt whether it is
written for lay readers or for his own profession.
Too dogmatic statements of what should be done dur-
ing delivery are scarcely wise in a book written for the
laity. Many obstetricians would not agree with Dr.
Bandler that repeated vaginal examinations are either
necessary or advisable. And his suggestion of th'
of fituition to establish labor or quicken it during the
dilatation of the cervix, is scarcely the accepted si
On the other hand, the book gives much information
that the intelligent mother would understand. The
discussion of the activities and overactivities of the
ductless glands comes under this head, and also those
on eugenics and puberty.
Dec. 2, 1916]
MEDICAL RECORD.
1005
&amm j&tpatta.
JOINT MEETING OF THE NEW ENGLAND PEDI-
ATRIC SOCIETY, THE PEDIATRIC SECTION OF
THE NEW YORK ACADEMY OF MEDICINE,
THE NEW YORK STATE PEDIATRIC SO-
CIETY, THE NEW JERSEY PEDIATRIC
SOCIETY, AND THE PHILADELPHIA
PEDIATRIC SOCIETY.
Held in Boston, November 4, 1916.
Dr. Alexander C. Eastman, President of the New
England Pediatric Society, in the Chair.
A Clinical Day. — As is usual on these occasions the day
was spent in visiting various institutions and attend-
ing clinics. In the morning members of the societies
met at the Harvard Club, which was the headquarters
for the day, and from here were taken to visit the fol-
lowing institutions: The Massachusetts General Hos-
pital, where Dr. Fritz B. Talbot spoke on "Problems in
Metabolism"; the Boston Dispensary, where Dr. May-
nard Ladd discussed "Clinical Cases with Special Refer-
ence to Feeding"; the New England Home for Little
Wanderers, where Dr. W. R. P. Emerson spoke on the
"Problem of the Delicate Child"; the Children's Hos-
pital, at which Dr. John Lovett Morse gave a clinic;
the Infants' Hospital, where Dr. Charles Hunter Dunn,
Dr. Howell and Dr. Grover demonstrated their method
of giving intrasinus injections, and the Baby Hygiene
Association, which conducts 13 infant welfare stations
and is doing a work entirely preventive and educational.
Luncheon was served at the Harvard Medical School
and in the afternoon a visit was made to the Massa-
chusetts School for the Feeble-minded at Waltham.
Here a clinic was given by Dr. Walter E. Fernald,
superintendent of the school.
Evening Session.
Medico-educational Problems in the Treatment of
Atypical Children. — Dr. G. Hudson Makuen of Phila-
delphia read this paper, in which he said that the phy-
sician was beginning to realize more and more the im-
portance of treating his patients rather than their
diseases, and therefore in his preparation for the prac-
tice of medicine he was finding it necessary to study
psyhcology as well as physiology, anatomy and chem-
istry. This was the result of a fuller realization of
the fact that there was something which distinguished
the human organism from a mere laboratory receptacle
or test tube, and this something was obviously the
mind or personality of the individual. The close rela-
tionship between mind and matter was now generally
recognized and we knew that the physical organism
of man was the basis of his psychical development. It
was well known that the inefficiency of adult life was
largely due to the mistakes of childhood, but it was
not so well known that many of the actual diseases
of later years might be traced to faulty habits acquired
during infancy and adolescence. Children were largely
what we made them, and the factors that determined
their psychophysical condition as well as their person-
ality were heredity and environment. Heredity was an
important factor in the development of children, but
environment was even more important and it was al-
ways subject to change and improvement, and in addi-
tion to this it was probably even more responsible than
heredity for putting the prefix "a" in atypical as it
related to children. Thus the most important feature
in the child's environment was his education and train-
ing, and the most important and neglected period in
the life of any individual was that which came prior
to the so-called school age. Teachers claimed that the
failures of their pupils were due chiefly to faulty habits
formed before their entrance into the schools and col-
leges. The so-called fixed habits were the early ones
formed during the child's physical and mental develop-
ment in the first years of his existence. The Jesuits
had a saying, "Give me the first seven years of a child's
life and I care not who has the rest of it." While the
mind of a child had a physical basis, yet his mental
activities determine to a great extent the character of
this basis by regulating its development, and hence it
was that the general physical condition of the child
might be influenced for good or ill by the character
of his mental and emotional activities. Medico-educa-
tional methods become real measures of prevention only
when they began to be employed during infancy.
Medico-educational methods should aim, not to remane
the child, but to make the "absolute best" of what had
already been made. Nervousness was the most char-
acteristic malady of children and its treatment should
be, first, preventive, and, second, curative. Preventive
treatment was applicable in the earliest infancy and
consisted largely in an attempt to control the child's
physical activities through a careful direction of his
psychical and emotional activities. If the child was
normal physically, this treatment should result in the
development of normal physical and emotional faculties,
but if the child inherited physical abnormalities, such
as cleft palate or other irregularities of structure,
surgery or some form of medication might be indicated
in addition to the psychophysical training. Punishment
should never be necessary except perhaps at the very
beginning and before the child was mentally susceptible
to medico-educational measures. It was estimated that
there were upwards of 300,000 stammerers in the United
States alone and, in the speaker's opinion, if this vast
army of defectives could have had the right kind of
early training there would now be few if any stam-
merers to contend with, and what was true of stam-
mering was true of similar and allied nervous diseases.
The remedial and curative treatment of atypical chil-
dren was an effort to improve their conditions through
their physical activities. The personality of the child
was modified and molded through what had been
called the reflex influences of its own acts and expres-
sions. To make any act or gesture or mode of speech
or motion habitual through deliberate repetition was
to stimulate in the personality the appropriate moral
quality or emotion of which such an act or gesture
was the expression. The Japanese had a theory that
for one to be what he would like to be it was only
necessary for him to persistently act the part. Doing
things with purposeful intent was found to have a
greater educational value than doing them carelessly
or even in play. The play instinct was an important
factor in child development, but it was at the present
time the most overworked of them all both in the homes
and in the primary schools. What might be called
the work instinct was equally important and was now
being greatly neglected in the early training of chil-
dren. The difference between work and play should be
clearly understood by the child, and the greater dig-
nity of the latter should be impressed upon him at
at early age. The child should be taught to do things
not because they were easy, but because they were
right, and the greater the difficulty of doing them the
greater the educational value. Moreover work and play
should not be commingled; they should form two dis-
tinct factors in education. Mr. Roosevelt's advice was
sound; he said, "When you play, play hard, and when
you work, don't play at all." The teaching of correct
postural attitudes and good respiratory, phonatory and
articulatory habits should have a conspicuous place in
all medico-educational methods, both because of their
esthetic value and because they tended to give to the
individual greater self-respect, self-reliance and self-
control.
Intestinal Venous Stasis; Diffusion of Bacteria and
Other Colloids.— Dr. Fenton B. Turck of New York
read this paper and gave an exhibition of lantern slides
showing the diffusion of bacteria through the intestinal
wall. He stated that our ideas of medicine founded
upon a morphological or static conception of the living
body was being shifted more to the consideration of
dynamic properties of life. Synthesis of organic com-
pounds and the role of physics of colloids in biology
had created a new concept of normal and abnormal
conditions of the body. The membrane filter, itself
colloidal in character, determined the rate of diffusion
of the colloidal suspension that filtered through it. Dif-
ferent factors were involved in the permeability of
membranes in the living organism. In the study of
the phenomena the passage of colloids, such as the
white of an egg, unchanged through animal membrane
was surrounded by considerable difficulty because of
the obscurity involved in the identification of colloid
substances after filtration. The writer had found that
emulsion of bacteria, such as the color bacilli, injected
into the intestines of a fetal animal and living animals,
would rapidly diffuse through membranes and tissues.
By appropriate staining methods the rate of diffusion
and the route by which diffusion occurred could easily
be studied. Previous experiments of the author indi-
cated that the intestinal tube was permeable to the
intestinal flora. The degree of this invasion was great-
moo
MEDICAL RECORD.
[Dec. 2, 1916
ly influenced by the splanchnic circulation, which al-
tered the character of the intestinal wall and rendered
it permeable to all forms of bacteria. When bacteria
were injected into the intestines of the fetus distinct
routes were taken from any depot along the entire
tube. Microorganisms injected into the intestines of
a fetal animal rapidly diffused through the mucous wall
of the intestine, between the glands into the areolar
tissue and then coursed along the wall of the intestines
between the muscle coat and the mucous membrane.
At this point many of the microorganisms underwent
bacteriolysis. In the newborn there was no barrier,
no arrest of passage by the mucosa labyrinth; a wall
impervious to bacteria had not yet been sufficiently
formed there, nor apparently were antibodies adequate-
ly generated, since as yet they had not been needed.
As the body grew the tissues became less porous to bac-
teria. When disturbance of the splanchnic circulation
and muscular atony of the wall of the alimentary tract
were produced, then a reversion to the fetal state of
the intestine followed, and then the body needed to be
protected from the "toxins" formed in the "zona trans-
formans" and anti-anaphylaxis was, it might be said,
automatically established. The passage of the bac-
teria took place from the intestinal tract into the in-
testinal wall between epithelial cells and not through
or into the cells and between the muscle cells of the
muscular mucosa. As rapid bacteriolyses were seen
to take place in this submucous zone, Dr. Turck said
he had named it the "zona ti-ansformans." The degree
of permeability of the intestinal wall in a living sub-
ject was increased by a number of factors, namely,
(1) Mechanical obstruction of the intestines; (2) an
interruption of the circulation sufficient to cause atony;
(3) an interference with the nerve supply; (4) a num-
ber of pathological conditions. In order to induce
permeability fundamental changes in the flora of the
individual and in the physiology of the organ must be
induced; among the means of bringing this about were
thirst, hunger, overfeeding, and shock. Dr. Turck de-
scribed his experiments with these various factors
which supported his proposition that bacteria passed
readily through the mucous membrane into the
submucous tissue, where they underwent bacteriolysis
and created lesions of a non-inflammatory character.
Autolysis of the tissues took place following venous
stasis with a resulting asphyxia of the cells. The
muscle cells underwent the characteristic changes of
Zenker's degeneration with atony and dilatation.
Feeding experiments by which various lesions, such as
ulcers of the stomach and duodenum were produced,
were described, and also experiments showing the re-
sults of ligatures applied to the intestines at different
levels. Ligations of the lower portion of the intestinal
tract were not so evident in causing bacterial migra-
tion as in the upper segments. No bacteria seemed
to enter the blood or lymph vessels. The feeding ex-
periments further showed that fat and fatty acid in-
creased the diffusion rate of the intestinal bacteria
through the intestinal wall and hastened the fatal termi-
nation. Six monkeys fed with small squares of bread
fried for thirty minutes in cottonseed oil, in addition
to the usual vegetable feeding, died in from three to
six weeks and showed an increase in the filtration of
bacteria in the tissues. Lesions resulting from disturb-
ances produced in the upper intestinal tract were shown
to be more quickly fatal than those made in the lower
intestinal segments. The passage of the living bac-
teria into the tissues caused a reduction (by absorp-
tion) of the protective bodies (antiferments), and re-
sulted in autolysis. A study of the clinical picture as
seen in the human being paralleled these findings.
Stasis, induced by frequent feeding, causing precipita-
tion and delayed digestion and resulted in fractional
digestion and the production of fatty acids. The
changes produced in the cells were not due to lack of
oxygen or increased carbon dioxide but were due to
acidosis, the result of fatigue to the muscle cells and
asphyxia of those cells from venous stasis. This re-
sulted in atony and permeability of the muscle wall
with diffusion of bacteria and of "the fractional protein
products. Following bacteriolysis and proteolysis, ana-
phylaxis ensued or, in other words, a condition of acido-
sis. The symptoms of this condition in its acute form
were shock, distention, prostration, convulsions, etc.
The symptoms of the chronic condition were wasting,
marasmus, anemia, etc. Treatment must have for its
object the reduction of fatigue of the hollow muscle,
prevention of fatty acid intoxication, intestinal reten-
tion and absorption of intestinal floral; it must also
correct the acidosis, reduce venous stasis, increase im-
munity and maintain nourishment. Thus in the acute
cases, gastric and colonic lavage; lavage with weak
nitrate of silver, followed by sodium bicarbonate; de-
mulcents and venesection, followed by infusion of sodium
carbonate solution, were indicated. In extreme cases
the transfusion of autoserum might be indicated and
also the continuous bath. In the moderate and chronic
cases, gastric lavage and colonic lavage, with gentle
pneumatic gymnastics, were indicated together with
demulcents, oil of cloves, and vaccines. The food should
be reduced to the minimum fineness of particles; the
interval between meals should be prolonged to the
maximum point within the caloric safety, and regular
feeding periods should be established to conform to
the curve of muscle work and relaxation. Foods rich
in mineral salts should be provided, as vegetables
steamed and made into a puree. The intake of fat
should be reduced to a minimum; heated and stale fat
should be prohibited. No extractives were allowed,
though in older children one might give extract-free
meat. For a time the total protein intake might be
reduced. The medication consisted of alkalies by the
stomach and an analgesic mixture. The object of the
demulcent, such as Irish moss or liquid vaseline, was
to prevent the passage of bacteria through the in-
testinal wall. Adsorption of the bacteria might be
favored by the administration of Fuller's earth, char-
coal, or very fine bran. If laxatives were required,
phenolphthalein and calomel might be given.
The Epidemiology of Bacillary Dysentery. — Dr. W.
G. Smillie of Boston presented this paper. He stated
that their study had been made in connection with the
work of the Floating Hospital. The need of such a
study was evident from the fact that the incidence of
bacillary dysentery was greater than that of more
feared and more widely advertised children's disease,
as poliomyelitis, and among children the death rate
was equally high. The methods of treatment of bacil-
lary dysentery had long been known, but the mode of
transmission of the disease had excited only indifferent
or random speculation. The conditions furnished by the
Floating Hospital were most favorable to a study of
the transmission of bacillary dysentery because of the
fact that the victims were usually infants under fifteen
months of age, whose activities were limited and who
therefore came into contact with comparatively few
people and ate but few articles of food. It was com-
paratively easy to trace the source of infection in a
baby under one year of age, but after the child could
walk it became most difficult. Other conditions favor-
ing a study of the epidemiology of bacillary dysentery
were the fact that the diagnosis was clear cut. There
was a definite clinical history; the dysentery bacillus
could be isolated from the stools, and specific aggluti-
nins were developed in the blood of the patient. This
furnished a good working basis for investigation. The
fact that the bacillus was found in the feces only and
not in the other secretions of the body made it evident
that every case represented some short path between
the infected feces of the patient and the mouth of the
victim. The incubation period of adult dysentery was
from three to seven days. The disease in infants was
one with a summer incidence, being most prevalent in
July, August and September, and, finally, bacillary dys-
entery had a preference for the children of the poor.
In addition to the above knowledge they had records of
all cases that occurred and were reported to the city
boards of health, thus bringing out nests of infection
in all parts of the city. A spot map was made of all
the cases of last year for purposes of comparison with
the centers of infection this year. A record was kept
of the daily maximum and mean temperature and of
the relative humidity for the whole summer, of the
nationality of the parents, housing and individual home
conditions with reference to sanitation, together with
careful investigation of all the activities of the case for
a period of two days before symptoms of the disease
developed. In all, 79 cases were studied, 49 being house
cases, and 20 related cases discovered in the course of
the investigation. While 75 cases were obviously insuf-
ficient as a basis for drawing definite conclusions as to
the influence of temperature and humidity there seemed
in this series of cases to be no relation between high
temperature, high relative humidity and the case in-
cidence. The case incidence seemed to be more closely
related to the incidence of flies rather than tempera-
ture, for the hot weather was almost over before there
were many cases of the disease and reports of new
cases continued to come in well through September,
Dec. 2, 1916J
MEDICAL RECORD.
1007
though the humid weather had passed. The families
chietiy afflicted were not the illiterate foreigners, but
the neglectful, poorer class American family. This was
not attributable to the fact that the foreigners were
more cleanly, sanitary or intelligent than American
parents, for in truth they were very much less so. It
seemed to be due to the fact that most foreigners nursed
their infants. Only one of the cases occurred in a
nursing' baby, and this child was nursed only during
the night and was led with condensed milk mixtures
during the day. Though bacillary dysentery was ordi-
narily a disease of poverty and filth, these were not
necessary accompaniments, for the disease might be
found in the better portions of the city. For estimating
the relation between bacillary dysentery and housing
conditions a score card was devised somewhat similar
to that used for scoring dairies. In all forty-one homes
were scored; the highest score was 94 per cent, and the
lowest 15 per cent. The average score for those cases
of bacillary dysentery that were due to direct contact
was only 48 per cent. The average score of those cases
that were a source of infection to others was 41 per
cent. The average score of those cases due to infection
from food was 59 per cent., and the average for those
cases for which no source of infection was found was
71 per cent. The summary of the sources of infection
was as follows: Contact with an acute case, twenty-
one cases; contact with a carrier, two cases; contact
with a house case, four cases; condensed milk epidemic,
fifteen cases; ice cream cones, nine cases; flies, six
cases; source of infection unknown, fifteen cases; milk,
water, and fruit, each one case. An important fact with
reference to the contact cases was that many of these
cases were in the older members of the family, and in
these individuals the disease showed itself in a mild
form. Undoubtedly many cases of summer "ptomaine
poisoning" were truly bacillary dysentery and, though
these sporadic cases were not in themselves serious,
they might become a great menace to the community,
and particularly to the babies of the community; for, as
this investigation showed, a mild adult case might
readily infect a baby, with fatal results. As a general
rule, it might be stated that in every dirty, careless
house which the speaker inspected, and in which the
sick child remained for more than one week, there re-
sulted a contact case. There was evidence to show that
four babies developed bacillary dysentery in the hos-
pital wards, for each child was admitted with quite a
different diagnosis and did not develop the disease until
seven to ten days after admission. These were the
only contact cases that occurred in the hospital, though
virulent bacillary dysentery cases were on board all
summer. Since extraordinary care must be exercised
to prevent cross-infection, no child with bacillary dys-
entery should be admitted to a hospital unless all fa-
cilities for isolating these cases are provided; the most
rigid precautions were necessary, and particularly fly
exclusion. A number of the cases cited showed very
conclusively that the fly was to blame for carrying the
infection. The tenement mother was usually careless
to protect her infant's stools from flies, and the diapers
were seldom boiled; and since flies were so abundant
and screens almost unknown, it was most extraordi-
nary that more cases were not transmitted in this way.
It seemed more than probable that some of the fifteen
cases that had been tabulated as of unknown source
were due to flies. There was a Shiga epidemic last
summer that gave an excellent example of the various
modes of spread of the "casual case" of dysentery. In
this instance the epidemic originated with the two-year-
old son of the dairyman in Haverhill. The source of
this infection was probably an ice cream cone eaten in
Lawrence. The father, mother, and one other child
developed diarrhea; the father, being only moderately
prostrated, kept on with his work in the dairy. The
milk of this dairy was sold almost exclusively to the
Deaconess' Home, a fresh air farm for children between
the ages of seven and fourteen years. In this institu-
tion there developed about twenty cases out of a total
of seventy children. This epidemic began on July 22,
and on July 27 the children were all sent to their homes.
One of these children went to Pine Heights, Dedham,
became seriously ill, and after five days was taken to
the hospital. This child's brother and two sisters also
became ill with the same kind of infection. The dejecta
of these children was thrown into an open privy without
disinfection. A neighbor who came in to assist in the
care of these children carried the infection home to her
husband. Within a few days a child living across the
street developed bloody dysentery and died within a
tew days. About the same time three adult members
of one family living about 1UU yards away developed
severe dysentery, which persisted lor a few days only.
The evidence seemed to point to flies as the carriers in
these last two families. A case developed in the house
adjoining that in which the first child, the one coming
from the Deaconess' Home, lived. The nfteen cases in
which the source of infection was traced to condensed
milk were interesting. They occurred in widely sepa-
rated localities, but in each instance the evidence point-
ed very definitely to a particular batch of a certain
brand of condensed milk.
Dr. Henry I. Ijowditch congratulated Dr. Smillie on
the work he had accomplished and the results he had
attained. He said it might be of interest to hear the
results of their study of the bacillary cases during the
past three summers, since they were especially inter-
ested in dysenteries. In 1914 there were seventy-nine
cases that came under their observation, of which 68
per cent, gave a positive Flexner organism; in 1915
there were seventy-five cases, 85 per cent, of which
showed the Flexner infection; in 1916 there were sixty-
four cases (Dr. Smillie had a few additional ones), and
of these 88 per cent, showed the Flexner infection. In
three-fourths of these cases the bacteria were recovered
from the stools and in others at autopsy, and in a cer-
tain few the diagnosis was made by finding the ag-
glutinins. At the same time they had constantly tried
to see how much of a factor the gas bacillus or the
B. welchii was in these dysenteries. The B. welchii
was found not to play an important part. It disap-
peared quickly in the early course of the illness, and
was frequently seen to appear later when other foods
were given. In 1914 a closer investigation than usual
of the B. welchii was made, which resulted in finding it
in 11 per cent, of infectious conditions, in 27 per cent,
of digestive disturbances, in 28 per cent, of malnutri-
tion cases, and in 28 per cent, of normal cases. The in-
fectious cases were studied closely, while the other
cases were picked at random. They felt at present that
the Flexner organism was the main etiological factor;
that the gas bacillus was a complicating factor, but not
the main etiological factor. This was different from
the stand taken some years ago. On the Floating Hos-
pital, when a case entered with the clinical picture of
dysentery the mode of treatment carried out was to
keep the child on water for the first twelve hours and
then place it on a food with a high percentage of carbo-
hydrate, and moderate protein, as, for instance, fat 0,
sugar 12 per cent., and protein 6 per cent.; this food
was usually given in the form of a fat-free milk with
sugar added. This was continued if the gas bacilli were
not present; but when the gas bacilli did occur the
carbohydrates were diminished.
AMERICAN ELECTRO-THERAPEUTIC
ASSOCIATION.
Twenty-Sixth Annual Meeting — Held in New York
City, September 12, 13, and 14, 1916.
The President, Dr. Jefferson D. Gibson of Denver,
in the Chair.
President's Address: Some Speculations for the Fu-
ture.— Dr. Gibson stated that by the plan of treatment
which he advocated the death rate from tuberculosis
could probably be made in eight years less in the United
States than the present death rate from smallpox. He
outlined his plan as follows: Make use of the health
boards of every city and county. Every child in the
public or other school should be examined for tubercu-
losis and treated, if needed, under the direction of the
board of health. The health board or commissioners
should set aside and maintain a department for this
special school work, known as the Tuberculous Depart-
ment, and the chief or manager of this department and
all assistants needed should devote their entire time to
the care, examination and treatment of the school chil-
dren. Every child that is tuberculous, or shows a re-
action or any sign of tuberculosis, should be treated, in
addition to the ordinary hygienic and dietic measures,
by the x-ray for its direct effect on the bacilli and the
lung tissue by static electricity, for its direct effect upon
the heart, nervous condition, and general metabolism;
and by inhalations of an ozonized oil nebula for its ef-
fect on the cough. By this method during the past
1008
MEDICAL RECORD.
[Dec. 2, 1916
year he had been able to save from death 92 per cent
of all applicants, of all stages and complications of pul-
monary and other forms of tuberculosis. Tuberculo-
sis in young children was usually glandular, and most
latent or incipient tuberculosis in children was in the
bronchial, mediastinal, cervical, abdominal, or inguinal
glands. It was in this stage that the disease should
be detected, because it was well known that the x-rays
would cure a tuberculous gland.
The Treatment of Hypertension and Complicating
Conditions. — Dr. William Benham Snow of New York
said he viewed hypertension as secondary only to a
toxic cause, and as the actual cause of the resulting
arteriosclerosis. If the tension was relieved the labor
of the heart would be relieved and the arterial degen-
eration to a degree arrested. In the treatment the
most important factor was the regulation of the diet.
In advanced cases all proteins should be eliminated
from the diet, and in all cases they should be reduced in
amount. In addition to the regulation of the diet, the
high frequency current should be employed, by the
autocondensation method. The patient was given daily
treatments until the pressure fell to normal or recurred
to the same figure following each daily treatment. This
would be the compensation point for the individual
case. At that point a fixed tension would persist de-
spite the treatment, and beyond that it would be im-
possible to lower the pressure. After finding that point
the treatments were given just often enough to main-
tain the pressure approximately at that lowered point.
Contact in Electrotherapeutic Applications. — Dr.
Fred H. Morse of Boston said this was an important
factor in electrotherapeutics. He considered the shapes
and sizes of electrodes, the best materials to be used,
etc. He described an electrode which had proved very
successful in his hands, made of asbestos combined
with flexible copper gauze, covered with linen and with
a rubber backing.
Roentgenographic Diagnosis of Dental Infections in
Systemic Diseases. — Dr. Sinclair Tousey of New York
read this paper and showed numerous lantern slides.
He drew the following conclusions: A putrescent mass
in the pulp chamber of a tooth might exist for months
or years because the walls of the cavity could not col-
lapse and were incapable of throwing out granulations
and eventually filling the cavity with healthy tissue,
which was the natural process of curing an abscess in
the soft tissues of the body. This putrescent mass
might constantly poison the bony tissue surrounding
the apical foramen sufficient to produce an effect clearly
recognizable in a radiogram. This condition might be
unknown to the patient, and sometimes not reveal it-
self to the usual tests applied by the dentist. From
this long-existing source of infection secondary lesions
and symptoms of the gravest and most diversified char-
acter might arise. The x-ray was to be depended upon
to show whether or not the source of trouble was con-
nected with the teeth or the pneumatic sinuses, and if
so, whether the trouble was due to malposition and un-
natural pressure or to infection. It would be a mistake
to regard every case as due to the teeth.
The Treatment of Inoperable Carcinoma by Bipolar
Ionization. — Dr. G. Betton Massey of Philadelphia said
that in this method the active needles were in-
serted just beyond the periphery of the growth, while
the inactive, negative electrode was inserted in its
center. As no material amount of current traversed
the general body structures, the method could be pushed
to the point of producing a boiling temperature in the
larger growths, thus adding the valuable agency of
heat to the devitalizing chemical action of the dispersed
ions of zinc from the erosion of the zinc electrodes at-
tached to the positive pole. This method was applicable
to large growths when heavy currents were needed. In
small growths the ionization alone was sufficient, ap-
plied in the unipolar method. Illustrative cases were
reported.
Prompt Removal of Exudate from Trauma. — Dr. A.
B. Hirsii of Philadelphia drew the followingconclusions:
Prevailing modes of removing exudate from the tissues
after injury are altogether inefficient, therefore inade-
quate, and lead to needless invalidism through non-
union or deformity after fracture or other interference
with function. Prompt removal of any excess of ef-
fused blood and lymph is necessary for union of broken
bone or lacerated soft structures, leading to resump-
tion of normal function. Mechanical modalities, largely
electrical, alone can supply the deep molecular contrac-
tion of tissue required to force back into torn vessels
their misplaced fluids, and where such extravasated
material has had time to become organized to soften it
sufficiently to bring about its absorption.
Contraindications to the Use of High-Frequency Cur-
rents.— Dr. Frederic de Kraft of New York gave as the
contraindications to the use of the high frequency cur-
rent all conditions where a tendency to hemorrhage ex-
isted, for instance, in cases of pulmonary tuberculosis
with a history of recent hemorrhage or in those where
bleeding had occurred recently in the pelvic organs,
uterus, and ovaries. As it stimulated cell functions it
was contraindicated in hyperthyroidism, Hodgkins' dis-
ease, leucemia, etc. It should not be used in cases of
walled-in pus, tuberculous glands, or acute rheumatism.
It was seldom wise to employ it during menstruation.
In certain cases of obesity it increased the weight.
The Importance of Dieting in Medicine. — Dr. An-
thony Bassler of New York outlined the facts to be
kept in mind in diets for diabetes, cardiac decompensa-
tions, nephritis, polyarthritis, gall-bladder disease, in-
testinal toxemias, and constipation.
The Condenser Discharge; Its Use in Diagnosis and
Treatment. — Dr. Frank B. Granger of Boston said that
in this method of testing muscles a condenser of known
capacity was charged from the main or from a battery
to a constant voltage and was then discharged through
a muscle. For muscle testing this method bade fair to
supplant other methods, as we had an exact numerical
equation, instead of vague terms, and thus the improve-
ment of the patient could be determined readily and
rapidly. In therapeutics more work must be done, more
cases tabulated and compared, before we could assign
it its place in therapeutics.
Uterine Fibroids. — Dr. Mary Arnold Snow of New
York, after discussing the frequency, cause, classifica-
tion, diagnosis, structure, growth, site, and symptoms
of uterine fibroids, advocated their treatment by the
x-ray, preferably by the fractional dose method. The
advantages of the x-ray treatment were: It left the
reproductive system intact, though sterile, whereas the
radical operation meant incalculable reflex shock to the
system mentally and physically. The x-ray treatment
was an ambulatory treatment. There was no danger
from hemorrhage. The patient enjoyed her usual com-
fort. With proper precautions there should be no dis-
turbance of the digestive system, as from the after ef-
fects of an anesthetic, and there should be freedom
from danger to life. The lowest mortality from surgery
was 3 to 5 per cent. There was no period of conva-
lescence, and insanity never occurred. The symptoms
of the induced menopause were less pronounced than
those following an operation. The contraindications
were: Such severe symptoms that the life of the
patient would be endangered by waiting for results
from the x-ray; pedunculated submucous fibroids: in-
fectious gangrene or malignancy, or where the fibroid
was associated with disease of the adnexa.
The Value of the Cooper Hewitt Quartz Lamp in the
Treatment of Alopecia. — Dr. William H. Dieffenbach
of New York in this paper gave a verification of the
claims of Dr. Franz Nagclschmidt of Berlin in the
treatment of alopecia by means of the ultra-violet rays
emitted from the quartz lamp. He showed lantern
slides of numerous cases in his own experience and that
. of Nagelschmidt.
Subacromial Bursitis. — Dr. J. E. DEERING of Worces-
ter, Mass., said the treatment of subacromial bursitis
in the first stage consisted in the use of a rather long
treatment with a high candle power lamp, followed by
twenty minutes to half an hour of diathermy. Often
four or five treatments would relieve and cure a case.
Where there was tension in the bursa static sparks
should be used, preceded by the high candle power lamp.
In the second stage during the formation of adhesions
one should use the high candle power lamp, fifteen or
twenty minutes of diathermy, and fifteen or twenty
minute? of static wave if that be well borne. Where
contraction of adhesions had taken place diathermy
might be omitted from the foregoing treatment.
Some Phases of Intestinal Stasis and Its Treatment
by Physical Measures. — Dr. William Martin of Atlan-
tic City detailed the history of an interesting case of
intestinal stasis treated and cured by a combination of
diathermy, light treatment and vibration of the inter-
vertebral spaces and the static wave and the slow sinu-
soidal currents.
The Treatment of Infantile Paralysis.— Dr. Frank E.
Peckham of Providence, R. I., reported three cases of
infantile paralysis treated in the early stage by the
Dec.
1916]
MEDICAL RECORD.
1009
static wave current over the lumbar region of the
spine, the 500 c.p. lamp over the affected muscles and
over the lumbar spine, and later vibration and gym-
nastic exercises.
The Treatment of Infantile Paralysis Based on the
Present Epidemic. — Dr. H. W. Freuenthal of New
York said that no advance had been made in treatment
in the acute stage further than in the fact that, in cases
where anterior poliomyelitis was detected immediately,
the disease had been checked and paralysis averted by
the use of immunizing serums obtained from persons
who had already had the disease. Treatment should
be begun in the second week. Pain could be relieved by
the warm bath or an electric light bath. The affected
muscles should be treated with the sinusoidal current
alternating with a combined galvanic and faradic cur-
rent. Massage should be instituted the moment the
acute inflammatory symptoms disappeared. Attention
should also be given to a class of active and passive ex-
ercises before a mirror, having the patient concentrate
his mind on the affected muscles.
£>tate fHffciral ICtrnising Hoards.
STATE BOARD EXAMINATION QUESTIONS.
College of Physicians and Surgeons of Ontario.
Final Examination, November, 1915.
medicine.
1. Endocarditis.' Discuss the types, etiology, morbid
anatomy, and clinical manifestations.
2. Cirrhosis of the liver. Enumerate varieties, and
discuss the pathology, symptoms and treatment.
3. Diabetes mellitus. Describe the mode of onset and
urinary findings, and discuss in detail your treatment.
4. Discuss the cause, and describe the prodromal
symptoms, course, and treatment of a case of typhoid
fever.
5. Discuss the etiology, and describe the lesions and
mode of treatment of: Impetigo contagiosa, Herpes
zoster, Alopecia areata.
SURGERY.
1. (o) What symptoms differentiate a malignant
from a non-malignant tumor of the breast? (6) What
course would you adopt in doubtful cases? (c) Describe
the operation for complete removal of the breast.
2. (a) How is intussusception produced? (6) Give
symptoms, (c) Give treatment.
3. (a) Describe a method for amputation in the
middle of the forearm. (6) Enumerate the structures
divided.
4. (a) Give the differential diagnosis between anal
fissure, hemorrhoids and carcinoma of the rectum,
(o) Give the treatment of each.
5. (a) Give the differential diagnosis between
malignant disease of the esophageal and pyloric ends of
the stomach, (b) Give treatment in each case.
OBSTETRICS AND GYNECOLOGY.
1. Give the management of a case of pregnancy up
to the advent of labor, and also from the delivery of
the placenta to the end of the puerperium, in a normal
case.
2. Pains: Define the following: — True, false, weak,
cutting, atonic, expulsive, after.
3. Forceps and pituitrin : What are the indications,
and the contraindications, for the use of each?
4. A woman's abdomen is enlarged from the pelvis to
the level of the umbilicus. Mention the conditions which
may produce such an enlargement. How would you
make a differential diagnosis of them?
5. Prolapsus uteri; give causes, symptoms, and treat-
ment, operative, and non-operative.
ANSWERS.
MEDICINE.
1. Endocarditis.
c. , (Septic
Types:— I. Acutef ,„lmPle . TT, ,- \ Typhoid
Uf x. *"•""= (Malignant or Ulcerative | c^iac
II. Chronic.
The difference between simple and malignant endo-
carditis is probably one of degree rather than of kind.
Etiology: Simple endocarditis is associated with rheu-
matism or scarlet fever. Malignant endocarditis is
also associated with rheumatism, scarlet fever, and also
with pneumonia or septic processes. Micrococci are
often found. Chronic endocarditis may follow an acute
endocarditis, or may be the result of syphilis, old age,
high arterial tension, gout.
Morbid Anatomy: In the simple form there will be
found a cloudiness, followed by edematous thickening
of the valvular endocardium; superficial erosions, and
the formation of small granulations; deposits of layers
of fibrin and corpuscles from the blood, the whole proc-
ess resulting in the formation of small warty vegeta-
tions. These vegetations are most marked at a slight
distance from the free borders of the valves — i.e. those
parts which come into opposition during closure. In
course of time they are transformed into fibrous
tissue. According to Poynton and Paine the infective
organisms are conveyed to the base of the valves by the
capillaries, and thence pass to the subendothelial tis-
sues by the minute nutrient channels in the valvular
substance; others hold that the organisms are derived
from the blood circulating over the surface of the
valves. In the malignant form the initial changes are
similar, but there are some important differences, inas-
much as ulcerations may completely replace the vege-
tations. The differences are: (1) The vegetations when
present are larger and fungating. (2) The underlying
tissues are necrotic and show loss of substance and
round-celled infiltration. (3) They contain masses of
micrococci, while in simple endocarditis the organisms
are scanty. The two forms cannot be distinguished by
the organisms producing them; either simple or malig-
nant endocarditis may arise from a pyogenic infection.
(4) When the vegetations become detached they form
septic emboli, giving rise to metastatic abscesses. (5)
The ulcerative process causes great destruction of the
valves, and may even lead to perforation of the curtains.
(6) The subsequent or permanent changes in the valves,
if the patient survive, are much more marked. (7)
If the vegetation touches the mural endocardium as it
flaps to and fro, the part touched becomes affected by
contact.
As regards the side of the heart most affected — Con-
genital endocarditis attacks the right side of the heart
(but note that many congenital cardiac lesions are due
not to endocarditis, but to developmental faults) ; simple
endocarditis attacks the left only; the malignant at-
tacks both sides, though the left is much more impli-
cated than the right side.
The vegetations are upon that side of the valve op-
posed to the blood-stream — viz., at the aortic valve the
vegetations project into the ventricle, at the mitral valve
into the auricle.
As in pericarditis, the myocardium almost always
shares in the inflammatory affection.
In chronic endocarditis, when not directly due to
acute endocarditis, the changes are: Formation of small
nodular prominences, with thickening of the valve. The
vegetations are much firmer than in the acute disease.
Formation of yellowish, opaque fatty patches. Great
increase of fibrous tissue, which subsequently contracts,
producing much deformity. The cusps become rigid,
curled, and may cause great destruction to the onward
flow of blood, and at the same time fail accurately to
close together when required. Great narrowing of the
valvular orifice. Shortening of the chorda? tendineas
and papillary muscles. Frequently fusion of the chorda
tendineae (adhesions) . Calcification of the fibrosed por-
tion.— (Wheeler and Jack.)
Clinical Manifestations : "Simple Endocarditis. — The
signs are extremely ill marked; possibly increased rap-
idity of pulse, dyspnea, precordial distress, etc., may
attract attention to the heart. On examination some
dilatation of the heart, from the accompanying myo-
carditis, may be found, and a recently developed mur-
mur of a soft blowing or bellows-like character may be
heard in the mitral or aortic areas. The commonest
murmurs are those of mitral regurgitation (systolic),
or mitral stenosis (presystolic).
"It should be remembered, however, that in most
fevers the heart is somewhat dilated, and a murmur,
not due to endocarditis, may be present. We must
therefore be cautious in coming to a too rapid conclu-
sion that a suddenly developed murmur is indicative of
endocarditis. An important distinction is that the on-
set of endocarditis is usually accompanied by a smart
rise in temperature above the previous level, while in
hemic murmurs, or those due to simple dilatation, this
is absent. A diastolic murmur in the aortic area is
likely to be organic (aortic regurgitation).
"Malignant Form. — Three types may be distinguished
— The Septic Type is characterized by the symptoms of
1010
MEDICAL RECORD.
[Dec. 2, 1916
septic infection — viz., rigors, sweats, oscillating tem-
perature, emaciation and metastic abscesses. The symp-
toms may continue for months. Tlie Typhoid Type is
characterized by irregular or intermittent temperature,
looseness of the bowels, petechial rashes, and a rapid
assumption of the typhoid state. Great difficulty may
be experienced in distinguishing this form from typhoid
fever or meningitis. The Cardiac Type is that in which
symptoms of acute endocarditis, with fever of a septic
type, appear in the course of a chronic valvular lesion.
In some of these cases death is rapid; others may re-
cover after a protracted illness.
"Along with these general symptoms there are usual-
ly definite cardiac signs — development of murmur, dila-
tation of the heart, cardiac irregularity, and so on.
But the cardiac symptoms may be altogether latent,
causing difficulty in diagnosis."- — (Wheeler and Jack's
Handbook of Medicine.)
2. Cirrhosis of Liver. Varieties: Portal, or atrophic
or alcoholic; biliary or hypertrophic; also syphilitic or
pericellular.
Pathology. In atrophic cirrhosis the liver may be
very small, but is sometimes enormously enlarged. The
latter condition may be caused by congestion or fatty
changes. Generally, in the atrophic condition, the sur-
face of the liver is rough and nodular. The connective
tissue is increased in quantity, and the liver cells are
destroyed (probably by the poison which causes the
disease). The fibrous tissue in Glisson's capsule is in-
creased, the portal circulation is obstructed, and later
the bile ducts are obstructed and the hepatic cells be-
come obliterated. In the hypertrophic cirrhosis the
liver is always enlarged. The following table (from
Wheeler and Jack) gives the important features of
the morbid anatomy of the two varieties of cirrhosis,
together with the differences:
PORTAL OR MULTILOBULAR
CIRRHOSIS.
1. The bile-ducts are not
involved, and jaundice is a
late sysmptom.
2. The new-formed con-
nective tissue compresses the
branches of the porta! vein.
3 In the earlier stages,
active congestion and pro-
liferation of connective tissue
In the portal spaces may
cause increase in the size of
the liver : later, there is usu-
ally contraction.
4. The capsule is much
thickened, and the surface is
rough and hob-nailed.
5. The masses of liver cells
vary in size, some consisting
of several lobules, others be-
ing smaller than a lobule.
Each mass forms a distinct
area with a rounded outline,
and is enclosed in a fibrous
girdle.
6. On microscopic exam-
ination, the process is seen
to be going on chiefly at the
periphery of the lobules. The
fibrous tissue is very dense.
BILIARY OR UNILOBULAR
CIRRHOSIS.
1. The smaller bile-ducts
are inflamed (cholangitis) ;
Jaundice is early and severe.
2. The portal circulation is
not impeded.
3. The new tissue is dif-
fused throughout the organ,
and causes a great increase
in size.
4. The capsule is not
thickened, and the surface
is smooth (like morocco
leather).
".. The masses of liver cells
consist of isolated lobules.
The cut surface has a uni-
form and finely-granulated
appearance.
6. The fibrous tissue is not
confined to the periphery, but
invades the substance of the
lobules. It is much more
open than that of portal cir-
rhosis.
Symptonis. Atrophic cirrhosis presents gastric
catrrh, with anorexia, dyspepsia, nausea, flatulence,
diarrhea and sometimes hematemesis. The liver is ten-
der and enlarged at the beginning of the disease. As
the disease progresses, and the pressure in the portal
system increases, the liver and spleen enlarge, the
superficial abdominal veins become prominent, ascites
and swelling of the feet are observed, hemorrhoids de-
velop and there may be hemorrhage from the stomach
or bowel. Later, the liver gets smaller, the patient
loses flesh and strength, slight jaundice may be present,
fever, headache, and nervous symptoms (stupor, de-
lirium, convulsions and coma) may appear. In the
hypertrophic cirrhosis the liver is much enlarged, the
spleen enlarged, jaundice is marked, there is pronounced
loss of flesh and strength, hemorrhages into the skin
and from the mucous membrane may occur, pain in the
hepatic region, fever and vomiting are of common oc-
currence. Ascites and dilated abdominal veins are ab-
sent.
Treatment. In atrophic cirrhosis, alcohol must be
forbidden; for the gastric catarrh, bismuth and alkalies
may be adopted; the portal congestion is relieved by
salines and diuretics; Epsom salts, compound jalap
powder, claterium, squill, digitalis and calomel have
been recommended. Paracentesis is indicated for the
ascites; epiplopexy has also been suggested. In the
hypertrophic variety the treatment is symptomatic only,
and follows the lines laid down under atrophic cirrhosis.
The atrophic variety is amenable to treatment in the
early stages.
3. Diabetes Mellitus. The mode of onset is grad-
ual, and generally it is the frequency of urination or
the extreme thirst which attracts the patient's atten-
tion. Occasionally the disease sets in somewhat rapidly,
following injury or a severe chill or intense and sudden
emotion.
The urinary findings are: Increased quantity voided,
from 3 or 4 quarts to 20 quarts or more in a day; the
specific gravity is generally high, 1020 to 1045; the
urine is pale in color and has a sweetish odor and taste;
the reaction is acid; glucose is present in varying
amounts, from 10 to 20 or more ounces being excreted
in a day; the urea is increased, and so is the nitro-
genous output in general; acetone, diacetic acid, beta-
oxybutyric acid are often present; phosphates and
sodium chloride are often present in increased quanti-
ties; fat and gas in the urine are sometimes met with;
albumin may be present.
Treatment. The diet must be carefully regulated,
and explicit written directions must be given to the
patient. The carbohydrates must be limited, the diet
consisting of proteins and fat, the tolerance for carbo-
hydrates must be built up and increased, and a sufficient
number of calories must be supplied. With many pa-
tients the gradual withdrawal of carbohydrates is tol-
erated better than their sudden restriction. The per-
centage of sugar in the urine when the patient is on a
general diet is first to be calculated, then the amount on
a sugar-free diet, and then the quantity of carbohydrate
which can be given without glycosuria appearing. Re-
cently the starvation diet of Allen and Joslin has been
recommended, but the details of this method are too
lengthy for insertion here. Care must be taken lest
a diet which is too exclusively nitrogenous should throw
an excessive strain upon the liver and kidneys. As a
general rule, diabetics must not take: Liver, sugars,
sweets or starches of any kind, wheaten bread or bis-
cuits, corn bread, oatmeal, barley, rice, rye bread, arrow-
root, sago, macaroni, tapioca, vermicelli, potatoes, par-
snips, beets, turnips, peas, carrots, melons, fruits, pud-
dings, pastry, pies, ices, honey, jams, sweet or sparkling
wines, cordials, cider, porter, lager, chestnuts, peanuts.
They may, as a rule, be allowed a diet selected from the
following: Soups or broths of beef, chicken, mutton,
veal, oysters, clams, terrapin or turtle (not thickened
with any farinaceous substances), beef tea, shell fish
and all kinds of fish, fresh, salted, dried, pickled or
otherwise preserved (no dressing containing flour),
eggs, fat beef, mutton, ham or bacon, poultry, sweet-
breads, calf's head, sausage, kidneys, pig's feet, tongue,
tripe, game (all cooked free of flour, potatoes, bread or
crackers), gluten porridge, gluten bread, gluten gems,
gluten biscuits, gluten wafers, gluten griddle cakes,
almond bread or cakes, bran bread or cakes. String
beans, spinach, beet-tops, chicory, kale, lettuce plain or
dressed with oil and vinegar, cucumbers, onions, toma-
toes, mushrooms, asparagus, oyster plant, celery, dande-
lions, cresses, radishes, pickles, olives, custards, jellies,
creams (without sugar) , walnuts, almonds, filberts,
Brazil nuts, cocoanuts, pecans, tea or coffee (without
sugar), pure water, peptonized milk.
In every case the diet list must be prepared for the
individual patient. The general health must also be
attended to. The patient should lead a quiet life, free
from worry, take gentle exercise, bathe daily in warm
water, and only take drugs when indicated. The most
commonly used drugs are codeine, morphine, strychnine,
arsenic and cod liver oil. For the extreme thirst citrate
of potassium or lemon juice with water may be given.
4. Typhoid Fever. Etiology. The exciting cause is
presence of the bacillus typhosus. It may be communi-
cated by contaminated food, milk, water, dust, soiled
hands, clothing, instruments or utensils, flies, "car-
riers," or anything that has become contaminated with
the feces, urine or vomitus of one affected with the
disease.
The prodromal symptoms are vague. There are pain
in the head or back or limbs, general depression, anor-
exia, nausea, chills, headache, epigastric oppression,
diarrhea or constipation, disturbed sleep, cough, nose-
bleed.
Course of the disease. After the prodromal symp-
toms the patient takes to his bed, and from this the
definite onset is generally dated. "During the first
week there is, in some cases (but by no means in all,
Dec. 2, 1916]
MEDICAL RECORD.
1011
as has long been taught) , a steady rise in the fever, the
evening record rising a degree or a degree and a half
higher each day, reaching 103° or 104°. The pulse is
rapid, from 100 to 110, full in volume, but of low ten-
sion and often dicrotic; the tongue is coated and white;
the abdomen is slightly distended and tender. Unless
the fever is high there is no delirium, but the patient
complains of headache, and there may be mental con-
fusion and wandering at night. The bowels may be
constipated, or there may be two or three loose move-
ments daily. Toward the end of the week the spleen
becomes enlarged and the rash appears in the form of
rose-colored spots, seen first on the skin of the abdo-
men. Cough and bronchitic symptoms are not uncom-
mon at the outset. In the second week, in cases of
moderate severity, the symptoms become aggravated;
the fever remains high and the morning remission is
slight. The pulse is rapid and loses its dicrotic character.
There is no longer headache, but there are mental tor-
por and dulness. The face looks heavy; the lips are
dry; the tongue, in severe cases, becomes dry also. The
abdominal symptoms, if present — diarrhea, tympanites,
and tenderness — become aggravated. Death may occur
during this week, with pronounced nervous symptoms,
or, toward the end of it, from hemorrhage or perfora-
tion. In mild cases the temperature declines, and by
the fourteenth day may be normal. In the third week,
in cases of moderate severity, the pulse ranges from
110 to 130; the temperature now shows marked morn-
ing remissions, and there is a gradual decline in the
fever. The loss of flesh is now more noticeable, and
the weakness is pronounced. Diarrhea and meteorism
may now occur for the first time. Unfavorable symp-
toms at this stage are the pulmonary complications, in-
creasing feebleness of the heart, and pronounced de-
lirium with muscular tremor. Special dangers are per-
foration and hemorrhage. With the fourth week, in
a majority of instances, convalescence begins. The tem-
perature gradually reaches the normal point, the diar-
rhea stops, the tongue cleans, and the desire for food
returns. In severe cases the fourth and even the fifth
week may present an aggravated picture of the third ;
the patient grows weaker, the pulse more rapid and
feeble, the tongue dry, and the abdomen distended. He
lies in a condition of profound stupor, with low mut-
tering delirium and subsultus tendinum, and passes the
feces and urine involuntarily. Heartfailure and second-
ary complications are the chief dangers of this period.
In the fifth and sixth weeks protracted cases may still
show irregular fever, and convalescence may not set
in until after the fortieth day. In this period we meet
with relapses in the milder forms or slight recrudescence
of the fever. At this time, too, occur many of the
complications and sequela?. "• — ( Osier's Practice of Medi-
cine.)
Treatment. "This is largely supportive and prophy-
lactic. On account of the wide distribution of the bacilli
in the secretions, it is highly important that the ex-
creta and all substances which come in contact with the
patient should be thoroughly disinfected to prevent dis-
semination of the disease. Corrosive sublimate (1:500),
carbolic acid (1:10), and chlorinated lime are used to
disinfect the stools. Weaker solutions may be em-
ployed for sponging the perineum and anal region of
the patient and for washing the hands of the attend-
ants. The general treatment consists in absolute rest
in bed with the enforced use of the bed-pan. The diet
should be liquid, largely milk, and should be admin-
istered every three hours. The modern tendency is
toward a more liberal diet, and the high calory diet
(as advocated by Coleman) adds to the comfort of the
patient, shortens the convalescence and lowers the death-
rate. Fever should be controlled by sponging, by the
wet pack, and by the full bath. The Brand method
consists in immersion of the body in a tub of water
(70° F.) for 15 or 20 minutes every third hour when the
temperature rises above 102.5° F. The medicinal treat-
ment includes the use of antipyretics, intestinal anti-
septics, and antityphoid serum. Abdominal pain, tym-
panites, and tenderness are best treated with fomenta-
tions and turpentine stupes, while meteorism may be
relieved by the internal administration of turpentine
and by the use of the rectal tube or injections of the
milk of asafetida (j 5-6). Diarrhea, when it exceeds 4
or 5 stools daily, will require the withholding of all food
except milk and the administration of opium, bismuth,
codeine, etc. Constipation should be relieved every 2
days by enemas containing soapsuds. When hem-
orrhage occurs, the foot of the bed should be
elevated, an ice-bag or iced cloth should be applied
to the abdomen, morphine should be given hypodermi-
cally, and opium (gr. 1) should be administered by the
mouth every three hours. Peritonitis usually termi-
nates fatally, and requires the same treatment as hemor-
rhage. Abdominal section should be performed as soon
as the diagnosis is positive. Alcohol, ammonia, strych-
nine, digitalis, etc., should be used if heart-failure
supervenes. Nervous symptoms are greatly lessened
by hydrotherapy, but nerve-sedatives may be necessary.
Sore mouth may be prevented by cleanliness and the
use of ca'rbolized glycerin solution (0.5 per cent.) upon
the gums and teeth." — (Pocket Cyclopedia.)
5. Impetigo contagiosa is an acute, contagious, in-
flammatory disease of the skin, characterized by dis-
crete, flat, superficial vesicles or blebs, which rapidly
become pustular and dry upon the skin as thin crusts.
The eruption is most common upon the face and hands.
The lesions begin as flat vesicles or blebs, which, in the
course of twenty-four hours, become vesiculopustular or
pustular. Rupture soon occurs, the exudate drying
upon the skin as thin, wafer-like crusts, which appear
to be "stuck on." The edges of the crusts become de-
tached, curl up, and the crusts drop off, exposing to
view reddish spots which soon fade. The lesions at
times show a tendency to umbilication. A coalescence
of neighboring pustules may occur, leading to the
formation of patches of considerable size. In pevere
cases there may be slight febrile disturbance. Itching
is slight or absent. Occasionally the eruption takes on
a circinate form. The affection is chiefly seen in poor
children. It is likely to accompany pediculosis capitis,
as the result of scratching. Epidemics of contagious
impetigo are not uncommon in institutions for chi'dren.
The affection is caused by inoculation with the ordinary
pus microorganisms, particularly the staphylococcus
pyogenes aureus. The chief characteristics are the dis-
creteness, superficiality, and autoinoculability oi the
lesions. The affection may be cured in a week or ten
days, or, indeed, may get well spontaneously. The
crusts may be removed with soap and warm water,
after which an ointment of ammoniated mercury (gr.
xxx to 1 ounce of petrolatum) should be applied; mild
antiseptics may be employed, care being taken to avoid
irritation. — (Cyclopedia of Medicine and Surgery.)
Herpes zoster is probably an acute specific disease
of the nervous system, characterized by the formation
of grouped vesicles along the line of a cutaneous nerve,
and accompanied by neuralgic pains. Cold, anemia,
excessive use of arsenic, malaria have been mentioned
as causative factors. There is an irritative or inflam-
matory condition of the central, spinal, or peripheral
nerve apparatus. The process is usually an interstitial
descending neuritis of one of the spinal ganglia. The
parts affected should be protected from injury by a
dusting powder or collodion; the pain may demand mor-
phine. Internally, zinc phosphide, and tonics have
been recommended.
Alopecia areata is a disease of the hairy system
characterized by the more or less sudden occurrence of
round or oval, circumscribed, bald patches, in rare cases
coalescing and producing total baldness. The cause is
usually neurotic in character, although at times the dis-
ease seems to be caused by a parasite. The character-
istics of the disease are the circumscribed areas of
baldness, the pale, smooth skin, the contracted follicles,
and the rapid onset. Internally, arsenic, in addition to
other tonics and stimulants, is of great service. Locally,
stimulation of the scalp is indicated, for which pur-
pose the essential oils, cantharides, capsicum, turpen-
tine, and sulphur are recommended. The faradic cur-
rent applied with a wire-brush electrode is often u;:eful.
In obstinate cases blistering may be resorted to. —
(Pocket Cyclopedia.)
SURGERY.
1. (a) Benign tumors of the breast are generally
found in young women, between the ages of 15 and 30.
They grow very slowly and gradually. As a rule they
are freely movable, are firm, round and oval, and the
nearer they are to the skin the softer they are. They
are not encapsulated, and don't cause retraction of the
nipple or enlargement of the axillary glands. As a
rule they are not painful. Malignant tumors are gen-
erally found in women between 30 and 60 years of age.
Cachexia accompanies them. They grow rapidly. They
are movable in the early stages, later they become
adherent to the skin or pectoralis major muscle, and
are hard and immovable. The nipple is retracted. The
axillary glands are enlarged. Pain is a symptom.
There may be metastatic growths.
1012
MEDICAL RECORD.
[Dec. 2, 1916
(6) In doubtful cases it is well to imagine the growth
to be malignant until it is proved otherwise. If the
breast is removed, and the tumor is proved benign, the
woman has lost a breast; whereas, if it is not re-
moved, and should prove to be malignant, she will lose
her life. The best plan is (with the consent of the
patient) to prepare for a radical operation, excise a
piece of the tumor, have it examined microscopically,
and if it proves to be benign, remove the tumor; if it
is malignant, remove the whole breast and neighboring
lymphatic glands.
(c) "Halsted's operation aims to remove in one piece
the entire breast and overlying skin, the costal portion
of the pectoralis major, the pectoralis minor, and all
the fat and glands of the axilla. The supraclavicular
glands are removed in a second piece. An incision is
carried through the skin and fat, and a triangular flap
turned back. The costal portion of the pectoralis major
is divided close to the ribs and separated from the
clavicular portion, which with the overlying skin is
divided up to the clavicle, exposing the apex of the
axilla; these flaps are drawn upward with a retractor
and separated from the underlying tissues, and the
muscle further split as far as the humerus, where it is
severed close to the bone. The breast, pectoralis major,
and all fat are stripped from the chest wall, including
the pectoralis minor, which is divided at each end, thus
exposing the entire axilla, which is cleansed of fat and
lymphatic glands from above and within, downward
and outward, all small vessels being ligated close to the
axillary vessels, which, with the nerves, should alone
remain. The triangular flap of skin is drawn outward
and the lateral and posterior walls of the axilla like-
wise cleared, the subscapular vessels being ligated, and
the subscapular nerves preserved if possible. The mass
is then turned inward and removed from the chest. A
vertical incision is now made along the posterior mar-
gin of the sternomastoid, and the supra- and infra-
clavicular fat and glands removed by dissecting from
the junction of the internal jugular and subclavian
veins downward and outward. The cervical wound is
sutured, and the edges of the chest wound approxi-
mated by a buried purse-string suture of silk, which
includes the base of the triangular flap, the apex being
spread over the axilla. The rest of the wound is cov-
ered with Thiersch's skin grafts. The axilla is not
drained. The disability resulting after such an exten-
sive operation is surprisingly slight. The entire wound
may be closed in most cases by fashioning two flaps
from the lower lip of the wound. A small gauze drain
should always be placed in the axilla, preferably
through a small incision at its posterior margin, in
order to drain the large quantity of fluid which escapes
from the severed lymph vessels." — (Stewart's Surgei-y.)
2. Intussusception is the telescoping of one part of
the intestine into the part immediately below. It is said
to be due to irregular peristalsis; trauma, diarrhea,
intestinal worms, polypi and new growths in the in-
testinal wall have all been credited with causing the
condition.
(6) Acute intussusception is most common in chil-
dren. It begins suddenly with severe abdominal pain
and vomiting. Blood-stained mucus is passed, perhaps
with tenesmus. Collapse soon comes on, and may be
fatal in twenty-four hours; otherwise death occurs in a
few days from peritonitis. In most cases a "sausage-
shaped" tumor can be felt, usually along the course of
the colon, but lower down, or just above the pubis
The right iliac fossa feels empty. A natural cure may
follow, but rarely, from sloughing of the intussuscep-
tum, whilst the peritoneal cavity is protected by ad-
hesions uniting the entering and ensheathing layers.
(c) Treatment. "The reduction of the intussuscep-
tion at the earliest possible moment is the only treat-
ment admissible, and this can only be clone with cer-
tainty by operation. The abdomen should be opened
over the tumor if it can be felt; if not, in the mid-line
below the umbilicus. The intussusception is then re-
duced by squeezing out the entering portion, beginning
at the lowest part. The intestine should never be pulled
out, for fear of tearing it. If there is any difficulty, the
wound must be enlarged and the lump brought out. If,
owing to adhesions, reduction cannot be done, the intus-
suscepted portion must be excised through an incision
in the ensheathing layer, but the outlook is bad in these
cars. If the bowel is gangrenous, the condition is so
bad that nothing more can be done than to bring out
the coil and establish an artificial anus. If, owing to
any reason, an operation is not possible, nonoperative
procedures must be tried. These consist of attempting
to reduce the invagination by inflation with air or, bet-
ter still, by fluid. A catheter is passed into the rectum
and fluid poured in from a funnel raised not more than
2 feet. A hand is placed over the tumor to feel when
the lump disappears. The objections to this are that
after twelve hours reduction cannot be obtained by this
method; that valuable time is wasted if it fails; that
you cannot tell if the last inch has been reduced (and if
it has not, recurrence is certain) ; that it is no use in
the enteric or ileocolic forms, and that the bowel may
be ruptured." — {Aids to Surgery.)
6. (a) Amputation in the middle of the forearm.
"An anterior and a posterior U-shaped flap are in-
cised on the respective aspects of the forearm, the base
of each flap at the saw-line being equal to a half-
circumference of the limb at that line and the length of
each equal to three-fourths of the diameter — the hand
being supinated in making the anterior flap and the
forearm vertical in making the posterior flap. Having
cut through skin and fascia in outlining the flaps, these
incisions are now deepened upon the line of the re-
tracted skin, beginning at the ulnar side of the anterior
flap, in case of the right arm (and on the radial side
upon the opposite arm). The vertical ulnar incision
will involve the flexor carpi ulnaris and flexor pro-
fundus— the vertical radial incision will involve the two
radial carpal extensors — both vertical incisions passing
directly to the bones. The muscles on the anterior and
posterior aspects of the forearm, at the lower rounded
extremities of the flaps, are cut from without inward in
such a manner as to bevel them slightly. The entire
flaps are now raised from the bones up to a point*suffi-
ciently below the saw-line to furnish a musculoperi-
osteal covering — at which level the periosteum is circu-
larly divided around the bones, the interosseous mem-
brane cut transversely, and the musculoperiosteal cov-
ering freed to the saw-line. The soft parts are then
retracted and the bones sawed. The radial, ulnar, an-
terior and posterior interosseous arteries are tied. The
median, radial, and ulnar nerves should be cut short,
or even dissected from the flap. The musculoperiosteal
covering is sutured and the muscles quilted — and the
integuments sutured in a lateral line." — (Bickham's
Operative Surgery.)
(b) In amputation of forearm at middle third there
will be severed: Skin; fascia; muscles: — supinator lon-
gus, extensor carpi radialis longior and brevior, ex-
tensor communis digitorum, extensor carpi ulnaris,
supinator brevis, anconeus, pronator radii teres, flexor
carpi radialis, palmaris longus, flexor sublimis digi-
torum, flexor carpi ulnaris, flexor profundus digitorum;
arteries: — anterior interosseous, posterior interosseous,
radial, ulnar; veins: — radial, interosseous, ulnar, me-
dian; nerves: — posterior interosseous, radial, median,
ulnar; bones: — radius, ulna.
4. Anal fissure is characterized by the very severe
pain on defecation, and for some time afterward ; con-
stipation and pruritus are commonly present; local ex-
amination shows a "sentinal pile," on the inner side of
which is a very painful ulcer or fissure.
Hemorrhoids. The patient complains of a feeling of
weight, itching, tenesmus. There is but little pain un-
less a fissure or ulcer is also present. Internal hemor-
rhoids, if protruding, are painful; bleeding may be se-
vere. The hemorrhoids are readily seen if external;
internal hemorrhoids may be seen if the patient strains,
or they protrude during defecation.
Carcinoma of the rectum generally attacks persons
past middle age. At first there may be no symptoms
beyond itching and occasional bleeding; then diarrhea,
straining at stool, the discharge of pus or mucus may be
observed ; pain may be present, which radiates to the
back and thighs. Under anesthesia the carcinoma may
be seen by the proctoscope or felt by the examiner's
finger. In the later stages cachexia develops and the
symptoms of stricture are present.
Treatment of anal fissure. The base of the fissure
(including the external sphincter) must be divided: all
piles (including the "sentinal nile") must be removed;
the ulcer must be excised. The wound then heals by
granulation. The bowels must be kept relaxed.
The treatment of external piles when uninflamed con-
sists in preventing constipation, keeping the parts elcan,
and apolying hamamelis ointment. They seldom need
removal e-.:cept when associated with internal piles. In-
flamed piles should be treated by rest, a large warm
enema, and fomentations. If there is much nain the
pile should be incised and the blood-clot turned out.
The treatment of internal piles. Constipation must
be avoided, also excesses in eating and drinking. The
Dec. 2, 1916]
MEDICAL RECORD.
1013
parts must be carefully cleansed and hamamelis oint-
ment applied. Operations include clamp and cautery,
ligature, and Whitehead's operation.
Operation for hemorrhoids. Clamp and cautery. Rad-
ical treatment is advisable when there is much pain and
bleeding. It must be ascertained first that the piles are
not due to disease elsewhere, as cirrhosis or stricture,
or to pregnancy. The bowels are emptied and the pa-
tient is placed in the lithotomy position. The sphincter
is then dilated with two thumbs to expose the piles,
which are caught up with ring forceps. A clamp is ap-
plied to the piles in turn, and they are removed by the
cautery. The bowels are kept confined for five or six
days, when castor oil is given. Very little pain and no
bleeding follow this operation. Removal can be done
by snipping the mucous membrane around the pile and
ligaturing its base. Crushing is also done. — (Aids to
Surgery.)
The treatment of cancer of the rectum \i excision of
the rectum or colostomy. Kraske's operation (excision
of the rectum by the sacral route) : "With the patient
lying on the right side, a median incision is made from
the anus to the middle of the sacrum. The coccyx is
excised. The ligaments and muscles are detached from
the sides of the sacrum as high as a point just below
the third sacral foramina, at which point the sacrum is
sawn across and the lower piece removed. The rectum
is exposed and cut through above and below the growth.
The peritoneum may have to be opened to get above the
tumor. If the sphincter and anus are unaffected they
are left and the bowel is brought down and an end-to-
end anastomosis is made. If the whole rectum has to
be removed the upper end is either brought down and
stitched to the skin around the original anus, or, if this
is not possible, an anus is made just below the divided
sacrum. During the operation the sacral glands must
be searched for and removed if enlarged. Incontinence
usually remains, and is less easy to manage with a truss
than a colotomy." — -(Aids to Surgery.)
5. "If the disease is at the cardiac end of the stomach,
involving the cardiac orifice, the symptoms may resem-
ble those of stricture of the esophagus and be asso-
ciated with dysphagia, ending in an inability to swallow
at first solid and later even fluid nourishment; in such
cases the tumor, being well under cover of the ribs, is
difficult or impossible to palpate, but enlargement of the
supraclavicular glands on the left side is usually pres-
ent.
"If the pylorus be the part involved, dilatation of the
stomach with retention and decomposition of food and
vomiting are pronounced symptoms, the vomiting being
at first irregular, perhaps every second or third day,
soon becoming daily and later occurring after every
meal. Peristalsis may be accompanied by severe pain
of a crampy character which is relieved by vomiting."
— (Keen's Surgery.) There may be felt a tumor a
little above and to the right of the umbilicus, at first
movable but later fixed by adhesions. The pylorus be-
comes stenosed. In the later stages there are pressure
symptoms, such as ascites, jaundice, edema of the legs,
and varicose veins in the abdominal walls.
Treatment. When the cardiac end is involved only
palliative operations are recommended; gastrostomy
may be tried. When the disease is at the pyloric end,
"complete removal of the affected segment of stomach
and of the associated lymphatics is the only means of
curing the disease. In many cases it is only after the
parts have been exposed by laparotomy that it is pos-
sible to say whether or not the radical operation should
be undertaken. If the associated glands are capable of
being removed, and if there is no evidence of metastasis
having occurred, the radical operation should be carried
out. The term pylorectomy is applied when the opera-
tion is performed for malignant disease of the pylorus,
although a considerable portion of the stomach must
also be removed. Adhesion to and infiltration of tin-
transverse colon is not usually a contraindication to the
radical operation, as it is quite feasible to resect the
portion of colon involved. The technique of the opera-
tion has been simplified by the preliminary ligation of
the arteries distributed to the stomach and by the use
of clamps. In the majorty of cases it is best to perform
gastroenterostomy in the first place, choosing a healthy
portion of the stomach; the resection is then carried
out and the cut ends of the stomach and duodenum
closed and invaginated. In weakly patients an interval
may be allowed to elapse between the gastroenterostomy
and the resection. The radical operation is contraindi-
cated when the disease is associated with ascites, when
the tumor has infiltrated the omentum, liver, pancreas,
or abdominal wall, or when metastasis has occurred." —
(Thomson and Miles' Manual of Surgery.)
OBSTETRICS AND GYNECOLOGY.
1. The patient should be instructed fully in the
hygiene of pregnancy, by which is meant the care
which should be observed by the pregnant woman for
the preservation of health and strength both of her-
self and of the fetus. The pregnant woman should take
moderate exercise in the open air; in the last month
massage may take the place of exercise. Daily bath-
ing in tepid water, care of the teeth, regularity of the
bowels, ample sleep in a well-ventilated room, plenty
(but not too much) of simple, nourishing and easily
digested food at regular hours, clothing not too tight,
especially about the abdomen and breast; attention to
the nipples, regular examination of the urine, and the
restriction of marital relations are the main points to
which advice should be directed. In addition certain
measurements are necessary; a pelvimeter will be re-
quired to make these measurements. The interspinal
and intercristal diameters are measured, also the dis-
tance between the ischial tuberosities and the antero-
posterior diameter, as well as the external conjugate.
It is well to notice if the subpubic arch is narrowed; the
diagonal conjugate is also estimated; from the latter
the true conjugate can be obtained.
Care of mother during puerperium. "During the
first iveelt the patient keeps the bed, but after the first
few hours she has considerable license. She may as-
sume the sitting or halfsitting posture to take her
meals and to nurse the baby, and, if necessary, for
evacuation of the bladder and rectum. She should
assume the lateroprone posture both right and left sev-
eral times a day, and lie upon her abdomen for at least
an hour daily. Frequent change of position favors
uterine drainage and massages the uterine supports.
During the second week she has greater liberty, while
the greater part of her time is spent on the bed or
lounge. She may sit up for her meals, to urinate, and
for bowel movements, and she should spend at least
half an hour, twice daily, in abdominal and leg exercises
to keep up her muscular tone. The third week she
may be moved to a chair for a part of the day, having
the liberty of the room. After sitting up for any
length of time she should be instructed to take the
genupectoral position before lying down. Prescribed
exercises for the legs and abdominal muscles are to
be taken daily. The fourth week, if all goes well, she
may leave the room and have the benefits of air and
sun. Physical exercises should be continued. The
duration of the lying-in period and the degree of free-
dom to be given the patient after the second week
must, however, depend on the character and amount
of the lochia, the general progress of her convalescence,
and the rate of the uterine involution." — (Polak's
Obstetrics.)
2. True labor pains are the pains occurring at the
commencement of labor, and which are coincident with
expulsive efforts of the uterus. They begin at the
back, pass to the front, occur at gradually shortening
intervals, are accompanied by uterine contraction and
increased opening of the os externum.
False labor pains occur before labor. They ar« feeble,
do not last long, occur at long intervals, are not ac-
companied by contraction of the abdominal muscles, are
generally felt in front, and do not cause opening of
the os.
Weak pains are such as do not aid much in the ex-
pulsion of the fetus.
Cutting pains are the early pakis experienced by
the woman, and are so called from the "cutting" sensa-
tions experienced by the woman.
Atonic pains are the ineffective pains accompanying
a condition of uterine inertia; the uterus does not
harden to any extent, and contracts feebly and irregu-
larly.
Expulsive pains are such as produce or accompany
the expulsion of the fetus.
After pains are painful contractions of the uterus
which occur after delivery (generally for two or three
days).
3. Indications for the use of forceps are: "1. Forces
at fault: Inertia uteri in the presence of conditions
likely to jeopardize the interests of mother or child.
(a) Impending exhaustion; (6) arrest of head, from
feeble pains. 2. Passages at fault: Moderate narrow-
ing 3*,4 to 3% inches, true conjugate; moderate obstruc-
tion in the soft parts. 3. Passenger at fault: A
1014
MEDICAL RECORD.
[Dec. 2, 1916
Dystocia due to (a) occipitoposterior, (6) mentoan-
terior face, (c) breech arrested in cavity. B. Evidence
of fetal exhaustion (pulse above 160 or below 100 per-
minute). 3. Accidental complications : Hemorrhage;
prolapsus funis; eclampsia. All acute or chronic
diseases of complications in which immediate delivery
is required in the interest of mother or child or both." —
(From Jewett's Practice of Obstetrics.) Contraindica-
tions: Mechanical obstruction in the parturient canal;
incomplete dilatation of the os; non-rupture of mem-
branes; non-engagement of the presenting part; the
fetal head being too large or too small; distended blad-
der or rectum.
Pituitrin may be used in cases of uterine inertia, pro-
vided the os is dilated and there is no obstruction to
delivery.
4. The condition may be anyone of the following:
Pregnancy, uterine fibroid, ascites, ovarian cyst, fat,
pseudocyesis, and subinvolution of the uterus.
Pregnancy: The tumor is hard and does not fluc-
tuate, is situated in the median line, and may give fetal
heart sounds and movements ; the cervix is soft, and
the other signs of pregnancy are present. The rate of
growth of the tumor and the general condition of the
patient's health may also help in arriving at a diag-
nosis.
Uterine fibroid: Menstruation is irregular and some-
times very profuse; absence of the signs of pregnancy;
the tumor is nodular, firm, irregular in outline, and
while generally placed somewhat centrally is not in the
median line, and is not symmetrical; the rate of growth
is irregular, being, as a rule, slow, and sometimes ex-
tending over years.
Ascites: Absence of the signs of pregnancy; the abdo-
men is distended, but the shape varies with the position
of the patient; on lying down there is bulging at the
sides, the tumor fluctuates, and percussion shows dull-
ness in the flanks, with resonance in the median line,
but the dullness varies with the position of the patient.
Ovarian cyst: Absence of the chief signs of preg-
nancy; there may be the characteristic facies, the tumor
is soft, fluctuating, is more to one side, and does not
show fetal signs.
Fat: Absence of signs of pregnancy, also of fibroid,
or ascites.
Pseudocyesis: The uterus is not enlarged, and the
administration of a general anesthetic causes the col-
lapse of the "tumor."
Subinvolution of uterus: The uterus does not increase
in size, there is a leucorrhea, there is generally pain
in the back or ovarian region, there is a history of ir-
regular (and profuse) menstruation, and the signs of
pregnancy are absent.
5. Prolapsus uteri. Etiology: Injury at childbirth,
lacerated perineum, relaxation and elongation of the
ligaments of the uterus, loss of rigidity of the abdominal
walls, increase in the weight of the uterus, subinvolu-
tion, increased intraabdominal pressure. Symptoms:
The patient complains of a feeling of "bearing down";
of trouble with micturition and defecation ; of pain
and fatigue on walking, and of "falling of the womb."
The cervix is low down in the vagina; the sound shows
that the uterine cavity is lengthened. Procidentia is
evident on inspection. Treatment : "A prolapsed uterus
must first be placed in proper position, or a procidentia
reduced. In many cases the introduction of a rubber
ring pessary will then suffice to prevent recurrence.
But it will often be found necessary to repair a torn
perineum, removing at the same time redundant por-
tions of the vaginal walls, before the ring will remain
in the vagina. When such an operation is contraindi-
cated, and the vaginal orifice is so wide that a ring
cannot be kept in, some form of pessary with a vaginal
stem and perineal bands will be required. In cases of
procidentia, where the exposed surface is much ulcer-
ated, the patient should be kept in bed, emollient appli-
cations made to the ulcers, and vaginal douches given.
When the ulcers have healed, a pessary may be intro-
duced. Procidentia due to supravaginal elongation of
die cervix must be differently dealt with. Amputation
I portion of the cervix must therefore form the first
step in the treatment, and it may be required also when
the hyperplasia is secondary to descent. Cases of pro-
lapse and procidentia which resist milder measures re-
quire further operative procedures, such as ventrofixa-
tion of the uterus or the shortening of the round liga-
ments. It is in cases of this kind that hysteropexy has
often given satisfactory results. Total extirpation of
the uterus has been practised for the treatment of
procidentia." — (Sutton and Giles' Diseases <//' I
Hunks Stemtira.
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An Adequate Diet. By Percy G. Stiles, Ph.D.,
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GDrigtnal Arttrka.
THE SCOPE AND TECHNIQUE OF X-RAY
THERAPY.*
By ISAAC LEVIN, M.D.,
NEW YORK.
CLINICAL PROFESSOR OF CANCER RESEARCH, NEW YORK UNIVERSITY
AND BELLEVUE HOSPITAL MEDICAL COLLEGE ; CHIEF OF THE
DEPARTMENT OF CANCER RESEARCH OF THE MONTEFIORE
HOSPITAL AND HOME.
A'-RAYS as will be shown later are in many respects
quite analogous to the rays of light. The spectrum
of the so-called white light may be divided into four
parts. One part situated at about the middle of
the spectrum, consists of the so-called visible rays
of light, i. e. those rays which are so constructed
that they produce a certain impression upon the
retina of the eye, and as a consequence, appear to
our consciousness as rays of light of different color,
varying from red to violet. Below the red rays
there are a number of rays which are invisible, and
when analyzed appear to be the source of heat. At
the other extreme end of the visible rays, i. e. be-
yond the violet, there are a set of rays which are
also invisible, and exert various chemical influences
on the substances which they strike. Still fur-
ther along the spectrum, beyond chemical or ac-
tinic rays, are rays which are known as the z-rays,
and beyond these the gamma rays of the radioactive
substances.
The significance of radiant energy in the main-
tenance of all plant and animal life is very evi-
dent. Let us stop to think for a moment of the
following very simple experiment. If two hen's
eggs are placed in separate small wooden boxes,
the only difference being that one box contains a
small electric light bulb which warms the box to
a certain degree, the other box being cold, it will
be found after the lapse of three weeks that the
egg in the cold box has remained unchanged, while
the egg in the warm box has hatched. Both eggs
contained a fertile germ, and consequently the rays
of heat were indispensable for the development of
the living organism.
The ability of a plant to assimilate the inorganic
substances of the air and soil and change them into
its own organized constituent parts is due to the
chlorophyll, which performs its functions only in
the presence of light. In complete darkness the
plant loses its green color, i. e. the chlorophyll is
unable to assimilate inorganic food, and dies.
Where there is no plant life in existence, animal
life which can feed only on organic substances is
inconceivable ; consequently neither plant nor ani-
mal life can exist in the absence of light.
Every therapeutic measure, in its ultimate
analysis, influences the life and metabolism of the
*Read by invitation at the meeting of the New 5fork
Roentgen Ray Association, March 31, 1916.
cell; and it is evident, therefore, that light, which
is capable of affecting to so great a degree the life
of the cell, plant or animal, must be of great thera-
peutic value. This was appreciated at the very be-
ginning of known civilization, even the old Egyp-
tians, according to the statements of Herodotus,
placing their sick in the hot sand under the direct
rays of the sun.
The discovery of the a-rays by Roentgen and of
the rays of the radioactive substances by Becquerel
was immediately followed by attempts to utilize
these rays for therapeutic purposes. The opinion
still prevails today, however, as it did during the
second half of the Nineteenth Century, that only
organic and inorganic substances which are chem-
ically or rather pharmacologically active when in-
troduced into the organism have any therapeutic
value. Physical methods of treatment are regarded
with distrust and hardly find a place in the curric-
ulum of any medical school or in the text-books
of pharmacology and therapeutics. Until recently
this opinion was in a way natural and in accord
with the conceptions of the relative positions of
physics and chemistry. It has been considered a
scientific axiom that physics dealt only with laws
of energy and with such changes in the constitu-
tion of matter as left each molecule undisturbed,
while chemistry on the other hand, studied the
conditions within each molecule of matter, and
chemical forces were capable of splitting the mole-
cule into its component parts — atoms. It was fur-
ther accepted as an axiom that an atom cannot be
divided any further. Chemistry, then was thought
to be capable of producing the deeper changes
within matter, and consequently within the organ-
ism than physics.
It will be shown later that the hypotheses of
the structure of matter, -the nature of energy, and
the interrelation of the two have radically changed
in the course of the last two decades. If the func-
tions of the science of physics as known during
the last century may be called intermolecular and
the functions of chemistry, interatomic; then the
activities of physics, as they are understood today,
are even more than interatomic; they are intra-
atomic since purely physical agents are capable of
breaking up the presumably indivisible atom into
its component parts.
In view of all this, we must learn to readjust
our therapeutic conceptions as well. The thera-
peutic action of radiant energy must not be con-
fused with the purely mechanical methods of physi-
otherapy. Indeed, if the modern conceptions of the
structure of matter be taken into account, then the
method of radiotherapy is very similar to, if not
identical with the method of chemotherapy. In
both instances, the ultimate effect consists in a dis-
turbance and rearrangement within the atom of
matter. The difference between the two methods
consists in the fact that in chemotherapy a foreign
1016
MEDICAL RECORD.
[Dec. 9, 1916
chemical substance is introduced into the organism,
and influences the electrons within the atoms of
the tissues, while in radiotherapy no foreign sub-
stance is introduced, but the waves of ether con-
stituting the various rays disturb the composition
of the atom.
It is interesting to draw a comparison between
the therapeutic and physiological action of radiant
energy and of the arsenicals, the most potent of the
known chemotherapeutic agents. Both act in a
similar manner, in small quantities they stimulate
cell metabolism, cell growth, and all other cell func-
•
'
V
'
t»
' ' 0 f
I
%
■ *
FlG- 1- — A'-ray photograph of two crystals — nickel sulphate
(below) and beryl (above).
tions. The following excerpt from the most recent
Die experimentelle Pharmakologie" by
Meyer & Gottlieb, describing the pharmacological
action of arsenic illustrates the point: "In a nor-
mal organism there are injured the cells of the
most complex organs, as the liver, kidney, capil-
laries, and the blood, but certain new formations,
as the malignant lymphomata, syphilitic gummata,
etc., seem most easily to undergo destruction under
the influence of arsenic; this phenomenon makes it
possible fur the arsenic to influence abnormal
growth without producing any apparent or perma-
nent change in the normal tissues." The action de-
scribed here is quite analogous to the action of the
radiations.
Radiant energy, then, is capable of inducing
changes in the atomic structure of the constituent
-PrclMT^ X*f\«»}
Hucl.o* ^ Atom
T'V-^: •/?&•
■:■.:■ v..-.-./
*•*
o«*
k-
. >
Fig. 2. — A symbolical drawing of the structure of matter and
the action of x-rays upon it.
parts of the tissues, without the introduction into
the organism of any foreign substance. It is self-
evident that whenever either a chemical substance
or radiant energy may be used with equal effect
in the treatment of a certain disease radiotherapy
ghould be the method of choice.
Like any chemotherapeutic agent, radiant en-
ergy is not a true specific, such as diphtheria an-
Fia. 3. — Radiated and control plants (in text). The
dotted lines show the comparative length of the whole
plant and the intranodular spaces.
titoxin, but none the less, as will be shown later,
its action may be quantitatively selective; i. e. a
certain quantity of radiation which is not suffi-
ciently strong to have a deleterious effect on the
normal tissues of the organism, may influence the
Dec. 9, 1916]
MEDICAL RECORD.
1017
pathological tissues and consequently have a selec-
tive curative effect.
Physics of X-rays. — X-rays are in many respects
analogous to the rays of light. They move in
straight lines, they traverse space without any
Fia. i. — a, Radiated tadpole ; 6, normal control tadpole
obvious transference or intervention of matter,
they act on a photographic plate, excite certain
materials to phosphorescence, and bring about the
ionization of gas. The only characteristic of light
which x-rays do not possess is the deflection by
prisms or lenses. But very recent investigations
have shown that such a deflection may be obtained
when crystals are used instead of mirrors or prisms.
If a pencil of x-rays is made to traverse a crystal,
diffracted pencils are formed, arranged about the
primary beam in a regular pattern, according to
the structure of the crystal. A photographic plate
placed perpendicular to the primary rays and be-
hind the crystal would show a strong central spot
where the primary rays struck it, and other spots
arranged in regular fashion around the central spot
in the places struck by the diffracted pencils. Fig.
1 from W. H. Bragg & W. L. Bragg, "X-ray and
Crystal Structure" shows this.
Thus it seems quite reasonable to suppose that
the rays of light and the x-rays are qualitatively
identical. The difference between the two kinds of
rays consists in the fact that the waves of ether
forming the x-rays are considerably shorter than
the shortest ultraviolet waves of light. The waves
of the so-called soft x-rays are about one thousand
times shorter than those of ultraviolet light, and
the waves of the hard x-rays are still shorter. The
truth of this assumption is further enhanced by
the fact that the photographs shown in Fig. 1 were
calculated mathematically before they were proven
by experiment.
All substances, when exposed to a beam of x-rays,
absorb a part of the rays. The fraction of the rays
thus absorbed depends upon the density, thickness
and the atomic weight of the substance. The re-
maining rays penetrate beyond the interposed sub-
stance. Besides this, the primary x-rays produce
within the substance the formation of secondary
cathode rays: i. e. swiftly moving electrons; and
also secondary x-rays. Fig. 2 gives a rough sym-
bolic sketch of the production of secondary cathode
and x-rays in matter exposes to primary x-rays.
In accordance with Rutherford's conception of the
structure of matter an atom consists of a large
nucleus charged with positive electricity, sur-
rounded like a planet by satellites, by two circles
of negatively charged electrons. One of the circles
of electrons, the so-called "valency" electrons, takes
part in the chemical reactions of the atoms. The
other circle of "emission" electrons gives rise to the
absorption of radiations by the substance. In
metals there are also present "free" electrons be-
tween the atoms, to which the electrical conduc-
tivity of a metal is due. An electron is the small-
est unit of matter known today and is at the same
time presumably an independent unit of electricity;
in other words, it is something which links to-
gether as it were matter and energy. The minute
spaces between the atoms contain the hypothetical
ether which is supposed to penetrate all space in
nature. When a pulse in the ether is short enough
to penetrate between the atoms (»'. e. hard x-rays),
it sets in rapid motion a certain number of the elec-
trons and thus creates secondary cathode rays. The
rapidly moving electrons, on the other hand, create
new pulses in the ether situated between the atoms ;
i. e. create secondary x-rays. Very recently Ruther-
ford showed that the G-rays emitted by radium
may be regarded as secondary x-rays produced in
the radium by the action of B-particles; i. e. elec-
trons, which latter are consequently analogous to
secondary cathode rays. Fig. 2 shows graphically
the relationship in space between the cathode rays
or electrons of the cathode of an x-ray tube, the
primary x-rays, the positively charged nuclei of an
atom, the circles of electrons surrounding the atom
of matter, the free electrons between the atoms
which act as the secondary cathode rays, and the
secondary x-rays. The character of the secondary
x-rays will be the same, for instance whether the
primary x-rays penetrate a certain metal or solu-
tion of a salt of the same metal. This conception
of the structure of matter and the nature of the
x-rays makes clear the importance of the three
main characteristics of the rays; namely, the pene-
tration, the absorption, and the selective action.
Hardest x-rays, i. e. shortest waves of ether, pene-
trate between the atoms of matter without affecting
the substance in any manner. Soft rays, i. e.
longer waves of ether, are unable to penetrate be-
tween the atoms of the substance and are dispersed
over the surface of the substance and again produce
no effect on the latter. Only when the relationship
between the atomic structure of the substance and
the wave length of the x-rays is correct does there
take place a selective absorption of the rays by the
substance, and the latter is then influenced by the
rays.
Jtu'i
■'■•■:.■■■
'.I •
* i *■
V
Fig. 5. — Microphotograph of a piece of carcinomatous
tissue removed from the cervix uteri soon after the begin-
ning of radium and x-ray treatment. It shows degenera-
ated cancer cells surrounded by a round-cell infiltration.
Biological Action of X-rays. — The biological ac-
tion of the x-rays is also analogous to the action of
light. This analogy is very evident in the so-called
x-ray burn of the skin. When a large dose of soft
1018
MEDICAL RECORD.
[Dec. 9, 1916
x-rays is applied to the unprotected skin there takes
place an erythema, blistering, and ultimately the
condition is qualitatively identical with a sunburn
and only differs from it in degree. The browning
of the skin which takes place as a result of an x-
•J
<V*\
♦ * .
'
Fig. 6 i >scopical section of a sarcoma before treat-
ment, showing numerous giant and spindle cells.
ray burn, or occasionally after x-raying of the skin
even without the formation of a burn is identical
with the pigmentation of the skin after a sunburn.
Here again the difference is only in degree.
Fr. Bernig in a recent review states that the
rays of light, or rather of ultraviolet light, which
is biologically the most active part of the spectrum,
produce the following effects on the skin: Direct
destruction of the cells; thrombosis of the blood
vessels (through the direct influence of the rays on
the endothelium and musculature of the vessels)
and serohemorrhagic inflammation. The latter ends
with the formation of hypertrophic connective tis-
sue. These morphological changes are very simi-
lar to the changes induced in tissues by x-rays.
The analysis of a biological action of any agent
is much simpler in the uncomplicated cellular struc-
ture of a plant or lower animal than in a verte-
brate. A. Richards came to the following conclu-
sion from his studies on the effect of x-rays on the
rate of cell division in the early cleavage of the
eggs of Planorbis. The first effect of exposure to
x-rays upon the rate of cleavage of the eggs of
Planorbis is to stimulate mitotic activity. Follow-
ing the phase of acceleration a phase of depression
sets in ; the end result is a marked retardation in
the development of the egg.
It is quite possible that the action of .r-rays on
plant and animal tissue is identical witli the action
of the rays on metal. To cite an instance: x-rays
produce a marked biological effect on erythrocytes,
and the hemoglobin of the latter contain a solution
of iron. It is known that active secondary rays
are produced in iron by the x-rays penetrating it.
The most marked biological effect of x-rays on
plants and vertebrate animal organism also consists
in inhibition of life functions. Fig. 3. is taken
from Gaus & Lembcke "Roentgentieftherapie" and
represents three plants (edible peas). The largest
one is a control, the upper left plant was radiated
with soft x-rays and the lower left with filtered
hard rays. Both plants are greatly retarded in
their growth. The plant radiated with hard rays
is affected more deeply, and its tip is completely
withered. Fig. 4 from O. Hertwig's article in P.
Lasarus' book on "Radiumtherapie" shows two tad-
poles. The smaller one shows an arrest of devel-
opment produced by radiations.
It is probable that in complex vertebrate tissue
the effect of a small amount of the rays also con-
sists in an acceleration of the cellular functions.
But it is difficult to demonstrate this phenomenon
morphologically. Finally there takes place an in-
hibition of cell life. Different cells react differ-
ently to the rays. For instance, the liver cells are
more susceptible to the rays than the gall-duct cells,
and the tubules of the kidney react stronger than
the glomeruli. Highly interesting is the action of
the rays on the testicle and the ovaries The rays
affect the spermatozoa forming epithelium and the
Graafian follicles without influencing the other
structural parts of the organs. As a result an
azoospermia may occur in a man and a cessation of
menstruation in a woman, by a quantity of the rays
which produces no other abnormality in the organ-
ism.
Morphological Changes Induced in Tumors and
Infectious Granulomata Under the Influence of
Radiations. — It may be stated as a general rule that
tissues of less differentiated, younger cells, cells in
a state of active proliferation, are most deeply in-
fluenced by the rays.
Every tumor or granuloma consists of undiffer-
entiated young cells in a state of active prolifera-
tion, and therefore a strong selective biological and
consequently therapeutic influence of the rays on
these conditions is the most evident. The morpho-
logical changes which take place in the different
types of tumors and in granulomata under the in-
fluence of the rays differ to such an extent that it
may be well to consider them separately.
7. — Microscopical section of a sarcoma after treat-
ment, showing connective tissue but no tumor cells.
Carcinoma. — The first morphological changes
which occur in carcinomatous tissues under the in-
fluence of x-rays are observed in the tumor cells
themselves and are manifested by the vacuolization
of the protoplasm, pycnosis of the nuclei, caryoly-
Dec. 9, 1916]
MEDICAL RECORD.
1019
sis, and complete necrosis of the cell. (.Fig. 5.) All
this is accompanied by a round-cell infiltration
which replaces the destroyed carcinomatous colls.
Somewhat later there begins formation of dense
sclerotic connective tissue poor in blood vessels.
This connective tissue formation may become very
extensive, surround islands of carcinomatous cells,
and assist in the destruction of the latter. The
following case of carcinoma of the sigmoid, ob-
served by the writer, with metastatic dissemination
in the peritoneum which came to autopsy after six
months of continuous x-ray treatment demonstrates
the importance and extent of this connective tissue
formation.
The patient died of acute intestinal obstruction. At
the autopsy there were found in the peritoneal cavity
several loops of the intestines adherent by old adhesions
to the posterior surface of tumor mass in the sigmoid.
The peritoneum, especially in the pelvis, was studded
with numerous white plaques, varying in size from
1 mm. to Vz cm. in diameter; the larger ones were quite
firm to the touch. Microscopical examination of a sec-
tion taken through two loops of the small intestine
which were firmly bound together by old adhesiins
showed that the adhesions consisted of a thick layer of
connective tissue containing occasional nests of de-
generated tumor cells. The peritoneal nodules were
composed of dense connective tissue, with occasional
groups of degenerated tumor cells. In the greater num-
ber of these nodules no tumor cells were found.
Sarcoma. — The morphological changes induced in
sarcoma tissues by x-rays is analogous with those
induced in carcinoma.
The following case of a giant cell sarcoma of the
lower jaw, treated by the writer, illustrates this effect.
A small piece was removed for microscopic examina-
tion before treatment, which showed a sarcoma with
numerous giant cells and actively growing spindle cells.
Following eight weeks of combined radium and x-ray
treatment, another section was taken from the same
region from which the previous one was obtained. The
section showed a very loose connective tissue, relatively
poor in cells, and beneath this a zone of denser con-
nective tissue. No giant cells or any other form of
tumor cells were present. Figs. 6 and 7 show the con-
dition before and after treatment.
Infectious Granulomata, whether tuberculous,
syphilitic, or of any other origin, as well as lym-
phosarcomata, are influenced by the x-rays in an
identical manner. The lymphoid cells are destroyed
and replaced by dense sclerotic fibrous connective
tissue. A case of rhinoscleroma radiated by the
writer shows the characteristic changes. Rhino-
scleroma is an infectious granuloma, characterized
by the presence in the granulation tissue of the so-
called Mikulicz cells. The latter are degenerated
lymphoid cells, enlarged in size, inside of which
may be found frequently the Frisch bacillus, which
is the causative agent. The microscopic examina-
tion after radiation showed that the granulation
tissue was completely replaced by dense connective
tissue. Figs. 8, 9 and 10 show the condition before
and after treatment.
Thus the most generally observed morphological
changes in tumor and granuloma tissue under the
influence of radiation is the extensive formation of
sclerotic connective tissue. Some observers main-
tain that this new connective tissue formation is
the only direct effect of radiation. The destruction
of the tumor cells is in accordance with this opinion
secondary and due to lack of nutrition. This
opinion cannot be accepted as true. In the first
place, as was shown above, the first change noted
in carcinoma is the destruction of the tumor cells
and only subsequently does the connective tissue
form. Moreover, in certain conditions, for in-
stance, rodent ulcer of the skin, the epithelioma
heals and is covered with skin without formation
of connective tissue.
Other investigators assert that the destruction of
the tumor cells is the only direct effect of radiation.
The formation of connective tissue, in accordance
with this view, is secondary to the accumulation of
dead tumor cells and is analogous to formation of
connective tissue around foreign bodies. This as-
sumption is also hardly tenable. In the first place
the amount of connective tissue formation in the
peritoneal nodules of the carcinoma of the sigmoid
reported above was entirely out of proportion to
the number of carcinomatous cells destroyed. More-
over, if such young connective tissue were formed
only by the stimulus of dead tumor cells, then the
x-rays subsequently would dissolve this connective
tissue as easily as it dissolves a keloid, for instance.
But this does not take place and the amount of con-
nective tissue usually increases, with subsequent
radiation.
It must be concluded then that morphological
changes which take place in tumors and granulo-
mata under the influence of x-rays are two-fold.
There occurs an inhibition and ultimate destruction
of the tumor cells with irritation and consequent
proliferation of surrounding connective tissue. The
source of this new connective tissue is not the nor-
mal tissue surrounding the tumor. The postmor-
tem study of carcinoma of the sigmoid reported
above showed that there was no new connective
tissue formed anywhere in the normal organs under
the influence of radiation. The beginning of the
new connective tissue must be looked for either in
the stroma of the tumor, or in the round cell in-
filtration which always closely follows the destruc-
tion of the tumor cells by the rays.
It may be stated that the destruction of the tu-
mor cells is the primary and the formation of new
sclerotic connective tissue a secondary but as im-
portant a phase in the morphological changes
which take place in tumors and granulomata under
the influence of x-rays.
The Technique of X-ray Therapy. — Attempts at
therapy by the aid of the x-rays began immediately
after their discovery, but real progress in the mat-
ter was achieved not more than five years ago. It
was then shown by French investigators and
mainly by Gaus of Freiburg that the soft rays
which constitute the major part of the beam of
rays of an x-ray tube are absorbed by the skin,
and that only the hard rays penetrate into the
deeper tissues and produce there the therapeutic
effect. Two methods have been gradually developed
in order to obtain the hard rays. On one hand
tubes used for therapy are the so-called hard tubes
with a high vacuum, and on the other hand layers
of metal are placed between the tube and the pa-
tient to filter off the softer rays. An additional
filter of leather is placed under the metal to filter
off the soft secondary rays formed in the metal
filter.
Normal skin is highly sensitive to the action of
the x-rays and a small quantity of even hard rays
by far not sufficient to influence the tissues lying
deeper underneath the skin may burn the latter.
To obviate this difficulty another technical method
is added which consists in using a number of small
regions of the skin for the entry of the x-rays.
These "fields" of the skin are so selected that the
pencils of rays penetrating from any of them meet
at the deeper lying tissues to be treated. This so-
1020
MEDICAL RECORD.
[Dec. 9, 1916
called cross fire method increases greatly the quan-
tity of the hard rays which may be employed with-
out injury to the skin, since the combined quantity
of the rays reaching the deep tissue equals the quan-
tity penetrating through each field multiplied by
the number of fields.
Pig. 8. — Microphotograph of a specimen of rhinoscleroma.
Low power, showing granulation tissue.
The maximum quantity of x-rays which can be
directed through the same field of the skin without
injury to the latter is quite well ascertained. A
very important phase of the modern methods of ar-
ray therapy is the great care exercised in measur-
ing accurately the quantity of the x-rays employed.
The measurements at our command are indirect and
are based on the fact that the various chemical ac-
tions of the rays are in direct ratio to their quan-
tity. A solution of barium platinocyanide, which
has normally a green color becomes brown under
the influence of the rays, and the shade depends
upon the quantity of the rays used. A strip of
photographic film wrapped in black paper and con-
sequently impermeable to the rays of the light be-
come darkened under the influence of the x-rays.
The shade of darkening of the strip depends on the
quantity of rays used. On the basis of these photo-
chemical reactions, various apparatus are devised
for measuring the quantities of the x-rays emitted
by a tube in a unit of time. A unit is considered
the quantity of the rays which produces an ery-
thema of the skin.
The next important step in the progress of x-ray
therapy was made by Coolidge through his dis-
covery of the Coolidge x-ray tube. A brief com-
parative description of the old type and the Cool-
idge tubes will show the advantage of the latter.
X-rays originate on the surface of a metal which
is bombarded by the negative electrons of the
cathode rays. The greater the velocity of the
cathode rays the harder, the more penetrating are
the .r-rays. The tubes of the old type have an in-
complete vacuum. A high-potential current passes
in the tube from the anode to the cathode, frees the
electrons of the latter, and propels them toward the
anticathode or target. The bombarding of the elec-
trons induces the formation of the x-rays on the
surface of the target. The target is built of a
heavy metal and becomes overheated under the ac-
tion of the cathode rays. The heat frees the gases
contained in the metal of the target and these in
turn diminish the vacuum of the tube. As a con-
sequence the velocity of the cathode rays also
diminishes and the x-rays become softer. Various
regulating devices are added to the tube in order
to keep the character of the x-rays uniformly hard
for the length of time necessary for therapeutic
purposes. Still the penetration of the rays emitted
by the tube constantly changes. The most effective
old-type tube is the one devised by Gaus of Frei-
burg for therapy. It has a water-cooling chamber
to diminish the heating of the target, a large aux-
iliary vacuum bulb to diminish the influence of the
gases freed from the overheated target on the com-
bined vacuum, and a gas regulator to increase the
amount of gas in the bulbs and diminish the vacuum
when it becomes so high that no x-rays can be
formed.
The fundamental advantage of the Coolidge tube
consists in the fact that it has nearly a complete
vacuum, so that the small amount of gas escaping
from a heated target cannot influence it. Moreover,
the target is built of tungsten which is completely
freed of gas before the tube is finished. In such a
tube with a complete vacuum, a high-potential cur-
rent cannot pass from the anode to the cathode and
free the negative electrons of the latter. The free-
ing of the cathode rays is accomplished in the
Coolidge tube through the heating of the cathode to
a high temperature by the aid of a special storage
battery. The cathode consists of a spiral tungsten
filament supported by a molybdenum sleeve. The
high-potential current propels the freed electrons
to the anode which acts at the same time as a tar-
get. The number of the electrons depend upon the
temperature of the filament of the cathode and their
velocity on the voltage of the primary current.
A priori it would be expected that the Coolidge
tube would not only produce a greater output of
x-rays, but also would generate rays of greater uni-
formity of penetration. Comparative experiments
were done by the writer with the Gaus and the
Coolidge tubes, using a very heavy German coil as
a generator. Both tubes were placed approximately
, . Micropl i rhinoscleroma.
High power, showing granulation tissue; o, Mikulicz cell
filled with Frisch's bacilli.
under similar conditions, i.e. the same voltage of
primary current was sent through the coil, nearly
the same number of milliamperes of high-potential
current was sent through the tube, and the result-
ing x-rays showed the same penetrating power.
Dec. 9, 1916]
MEDICAL RECORD.
1021
To study the distribution of the rays, pieces of
meat of certain thickness were radiated. Test
strips of photographic paper (Kienbock strips)
were placed on the surface of the radiated piece and
at various depths of tissue. Pieces of meat were
used 1, 1.5,, 2, 3, and 4 inches in thickness. The
soft rays were absorbed by a plate of aluminum 3
mm. in thickness and a layer of chamois leather 2
mm. thick placed between the aluminum and the
meat. Fig. 11 shows the records of two experi-
ments: (a) an experiment with 4 inches of meat
and a Gaus tube; (6) an experiment with 4 inches
of meat and a Coolidge tube; (c) shows the Kien-
bock quantimeter and the method of estimation.
The results of numerous experiments may be
summarized as follows: To obtain the same quan-
tity of rays on the surface with a Coolidge tube
takes about one-third of the time that was required
with the old-type tubes. At the depth of 2 inches
of meat the strip shows about one-third the quan-
tity of the rays shown by the surface strip during
the same experiment with an old-type tube and
about one-half by the Coolidge tube. At a depth
of 4 inches there is usually about one-seventh of the
quantity shown on the surface obtained from a Gaus
type, while from a Coolidge tube one obtains at the
same depth usually one-fifth of the quantity shown
on the surface. There is no complete regularity in
the results of the experiments with either tube, but
the Coolidge tube shows a far greater uniformity.
The reason for this superiority shown by the
Coolidge tube is probably due to the following:
The x-rays emitted by a tube are never uniform in
their character and represent all grades of hard-
ness. The methods of measuring the penetration
of the tube reveal only the hardest rays. Appar-
ently the rays are more uniform in the Coolidge
tube and a greater proportion of the pencil of rays
are of the harder quality, and therefore a greater
fraction of these entering the surface reach a cer-
tain depth. Another advantage of the Coolidge tube
consists in the fact that when it is once regulated to
a certain penetration it remains so for an indefinite
period of time.
Therefore, when the same voltage (the same
length of the parallel spark gap) and the same num-
ber of milliamperes of the high-potential is used
in a Coolidge tube then there will also be generated
the same quantity of x-rays in a unit of time, and
the chemical measuring devices will show the same
amounts and need be used only occasionally for
control.
The technique of x-ray therapy employed by the
writer at present is as follows: The Coolidge tube
is used exclusively. The distance between the tar-
get and the skin is 8 inches and the length of the
spark gap is 8V2 inches. A Bauer penetrometer, an
apparatus which measures the hardness of the rays,
as well as the milliammeter are placed so that they
can both be observed constantly through the lead
glass window. The penetration or hardness of the
rays is kept at 10 Bauer and 5 milliamperes are
sent through the tube. Each field of the skin repre-
sents a circle of from 1 to 2 inches in diameter,
depending upon the region treated. The rest of
the skin of the patient is covered with lead rubber
and the operator stands behind a lead lined booth,
within which are placed all the electric controls.
The walls of the treatment room are lined with one-
eighth inch of lead to protect the operator, nurse,
and the patients in the waitng rooms.
The Scope of X-ray Therapy. — It was stated
above that the main physiological function of the
x-rays consists in the inhibition of cell life. Fur-
thermore a quantity of the rays which may be suffi-
cient to inhibit a certain group of cells or a certain
tissue or organ may produce no influence at all on
the rest of the organism. These biological charac-
teristics of the rays clearly indicate the scope of
their therapeutic applicability. In tissue in which
the main function of the cells consists in their pro-
liferation, as in benign or malignant tumors or
granulomata, an agent which kills the cells must of
necessity at first arrest the growth of the tumor,
and subsequently destroy it through the absorption
of the dead cells.
When the cells are endowed with a special func-
tion, as in the parenchymatous organs, then the
death of the cells will destroy or, if not all the cells
are dead, will impede the function of the organ.
The chart presented below shows the diseases
which are treated successfully by the aid of the
x-ray, classified in accordance with the above-men-
tioned biological function of the rays. This classi-
fication of the diseases amenable to x-ray treatment
indicates at the same time clearly the biological
scientific basis for the inclusion of the x-rays in
*v,v ^
■
Fig. 10. — Microphotograph of a specimen of rhino-
scleroma after treatment ; the granulation tissue is re-
placed by dense connective tissue.
our therapeutic armamentarium. Indeed, the
raison d'etre of x-ray therapy is less empiric than
of a number of pharmacological remedies.
Inhibiting Cell Proliferation.
Benign Tumors : Keloid, angioma, verruca,
uterine fibroid, prostatic hypertrophy.
Carcinoma.
Sarcoma.
Lymphoma: Hodgkin's disease, mediastinal
tumor, lymphosarcoma.
Granuloma: Tuberculosis of lymph glands, bones,
joints; rhinoscleroma, inflammatory dermatoses.
Inhibiting Cell Functions.
Ovary: Metropathia, uterine fibroid.
Thyroid: Exophthalmic goiter.
Hypophysis : Acromegaly.
Thymus: Exophthalmic goiter, status lymphati-
cus.
Spleen and bone-marrow: Leucemia.
Below will be given a very brief review of the
value of x-ray therapy in each disease enumerated
in the chart. Good results are claimed by some
1 022
MEDICAL RECORD.
[Dec. 9, 1916
writers, in Addison's disease, sciatica, syringo-
myelia, and several other conditions, but they are
omitted in this presentation and only such patho-
logical conditions are analyzed in which there is
sufficient biological and clinical evidence of the
value of x-ray therapy.
Benign Tumors. — Keloid is readily influenced by
a;-rays. The hard red elevation over the skin dis-
appears and is replaced by a white soft scar. In
view of the fact that the keloid is situated super-
ficially no crossfire method can be employed. The
writer usually gives one full dose of hard filtered
rays and repeats it every three weeks until the ef-
fect is produced.
Prostatic hypertrophy is treated successfully by
.r-ray as well as by radium, when the enlargement
of the organ is due mainly to the hyperplasia of the
glandular tissue. In cases in which the hyper-
trophy is due to an increase of the fibrous con-
nective tissue the results are not so striking, but
even in these cases the improvement of the sub-
jective symptoms is very prompt. In view of the
possibility of an occasional malignant degeneration
of the hypertrophied gland and the splendid results
of surgery, the latter method of treatment is al-
ways preferable in prostatic hypertrophy. On the
other hand, whenever surgery is contraindicated
-ray therapy is the method of choice. Z-radiation
DATE
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11. — Record of two experiments — a, with a Gaus tube; h. with a Coolidge tube: c. shows the Klenbock
quantimeter. The photographic slip is placed alongside a circle with the corresponding shade: the circles show the
previously estimated number of units.
Angioma or nevus responds well to radiations
when it is vascular and elevated over the skin. The
so-called "port wine stains" are more refractory.
X-ray treatment can be assisted by radium. In cer-
tain conditions radium is superior to .r-ray treat-
ment. Angioma and keloid are both influenced more
rapidly by radium than by ./-rays.
Verrucae or warts disappear rapidly after two or
three .r-ray treatments.
Uterine fibroid is placed here because the .r-ray s
produce undoubtedly a direct effect on the cells of
the fibroid tumor and diminish its size. The main
effect, however, is on the ovary and the subject
will, therefore, be considered at greater detail in
the section on inhibition of cell function.
is done through the suprapubic region and the
perineum. The radiation of each field is repeated
every three weeks, and the testicles are protected
against the rays. Radium acts quite as well as the
j'-rays and takes less time. A radium tube is in-
serted in either the rectum or the urethra.
[noma and Sarcoma. — It would lead too far
alield to give here a complete exposition of the
methods and rationale of .r-ray therapy in carci-
noma and sarcoma. Those interested should con-
sult the previous publications of the writer on the
subject. The best method of treatment of malig-
nant tumors is undoubtedly the combination of
eatment and radiotherapy. The gross
tumor should be removed surgically whenever pos-
Dec. 9, 1916]
MEDICAL RECORD.
1023
sible, even when a radical operation cannot be per-
formed, and the remnants of the tumor destroyed
by radiotherapy. The writer has demonstrated
anatomically that small islands of cancer tissue may
be destroyed at a great distance from the skin; i.e.
Fig. 12. — Radiograph of a mediastinal tumor before
treatment.
even a metastasis may be destroyed by arrays when
it is sufficiently small. In view of this the impor-
tance of the postoperative prophylactic radiation
is self evident.
Postoperative treatment should be begun as soon
after the operation as possible and regions should
be selected for treatment in which the metastases
most frequently occurs. For the same reason, i.e.
in order to destroy small islands of tumor tissue at
a distance from the primary tumor as well as to de-
stroy in situ as many as possible of the cancer cells
of the primary tumor every case should receive an
intensive x-ray treatment before the operation.
Such a course of treatment does not take more time
than is needed to prepare the patient for the opera-
tion,
The x-ray treatment of malignant tumors must
be very intensive, a great many fields of entry
should be selected, and the raying of each field re-
peated at least every two weelcs.
Lymphomata. — This class of diseases character-
ized by an enlargement of the lymphatic glands in
various regions of the body responds promptly to
x-ray treatment.
Hodgkin's disease or pseudoleucemia is a disease
which resembles leucemia in many respects, only
usually with a less prominent involvement of the
spleen and no increase in the number of leucocytes
in the blood. The affected lymphatic glands dimin-
ish very rapidly in size under x-ray and radium
treatment, and with it there is a marked improve-
ment in the general condition of the patient. The
opinion seems to prevail that the action of the radia-
tions is only palliative and that ultimately the pa-
tients fail to respond to the treatment. These un-
satisfactory results are most probably due to the
fact that x-ray treatment is attempted only late in
the course of the disease and the treatment is not
pursued with sufficient energy. The radiations
should be given to many regions of the body not less
than once a week for months, and only gradually
should the interval between the treatments be in-
creased. By this method the writer succeeded in
early cases in arresting the disease for long periods.
Mediastinal tumors are most frequently lymph-
omata of the mediastinal lymphatic glands. The
disease usually begins to give clinical symptoms
only in its advanced stage, and therefore the re-
sults of the treatment are only temporary. Never-
theless, a number of cases were reported in which
the x-ray plates show a clinical cure of the condi-
tion. The two radiographs shown in Figs. 12 and
13 picture a case of a mediastinal tumor under
x-ray treatment by the writer. Fig. 12 shows the
tumor before treatment, and Fig. 13 shows the con-
dition practically cleared up nine months later.
Lymphosarcomata, or the round-celled sarcomata
of the lymphatic glands, are not easy to distinguish
from the above described lymphomata, but they
usually tend to break through the glandular cap-
sule and invade the surrounding tissue. Lympho-
sarcomata, while not as easily amenable to treat-
ment as the lymphomata, respond easier than any
other form of sarcoma.
Granulomata. — The therapeutic effect of radia-
tions on infectious granulomata is not due as much
to an influence upon pathogenic microorganisms as
to an inhibitory action on the young cells of the
granulation tissue.
Tuberculosis of the lymphatic glands gives the
most satisfactory results of any form of tuber-
culosis. The clinical condition may be divided into
three groups. Simple enlargement of the lymphatic
glands promptly diminishes under radiation after
an occasional initial enlargement. Ultimately the
glands change into very small hard fibrous nodules
freely movable under the skin. Glands with a cen-
tral focus of suppuration should be treated after an
aspiration of the pus or its evacuation through a
small incision. In suppurating glands with open
sinuses surgical treatment of the latter should ac-
company the radiation. It would lead too far to dis-
cuss here the respective merits of surgery and
radiotherapy in the treatment of tuberculous lymph
glands. It is quite evident that radiotherapy is a
less severe method of treatment than surgery and is
not followed by deforming scars and keloids. More-
over, if subsequently surgical removal should be-
come advisable the preliminary radiation will sim-
plify the operation by diminishing the size of the
glands.
Tuberculosis of the bones, joints, and peritoneum
is favorably influenced by the x-rays. The radiation
should be employed either as an adjuvant to sur-
Fig. 13. — Radiograph of a mediastinal tumor nine
months after the beginning of treatment ; the condition
is cleared up.
gery, or when the latter is contraindicated. In all
classes of surgical tuberculosis the local treatment
with x-rays should be supported by a general radia-
tion of the whole body, either by the direct rays of
the sun (heliotherapy) or by the ultraviolet raya
1024
MEDICAL RECORD.
[Dec. 9, 1916
artificially produced by a quartz-mercury lamp.
Rhinoscleroma is an infectious disease charac-
terized by tumor-like swelling of the mucous mem-
branes of the nasopharynx, the pathology of which
was described above.
The obstruction necessitates surgical removal of
the swelling and the condition rapidly recurs after
the operation. The tumors produce a swelling and
deformity of the nose. Fig. 14 shows a photograph
Of a patient who suffered from rhinoscleroma for
eleven years. She had to be operated upon with
constantly increasing frequency, ultimately every
month. She was treated by the writer with x-rays
and radium and has remained well now for over
two years.
The therapeutic action of the x-rays in infectious
inflammatory dermatoses — psoriasis, eczemata, acne
vulgaris, lupus vulgaris, mycosis fungoides — is very
similar to its action in infectious granulomata.
While all these skin diseases respond readily to
x-ray treatment, all the other methods of treatment
Fig. 14. — Photograph of a rhinoscleroma patient, showing
the characteristic deformity of the nose.
should be tried before radiation is attempted. Only
in lupus vulgaris are the x-rays superior to any
other method of treatment, and in mycosis fungoides
they act like an actual specific. There has been a
great deal of controversy recently in regard to com-
parative merits of the soft and hard rays in the
treatment of skin diseases. The writer finds the
hard filtered x-rays just as efficient in skin lesions
as for deep therapy.
lie hemorrhage and fibroid uterus.
The efficacy therapy in these conditions
has been proven on hundreds of cases. The action
is due mainly to the inhibiting influence of the rays
on the ovaries, causing tl n artificial meno-
pause. .Moreover, as stated above, the x-rays have
undoubtedly a direct effect on the tissue of the
fibroid tumor, destroy most probably its younger
cells, and thus diminish the size of the tumor. In
women near the natural menopause the result is
both prompt and lasting, the bleeding ceases, and
with it the other symptoms. In at least half of the
fibroid cases the tumor itself diminishes occasion-
ally to such an extent that the size of the uterus
becomes nearly normal. In young women the treat-
ment is not nearly as successful, and it is difficult
to obtain a complete menopause. Still the bleeding
decreases so that the menses become normal, and
the size of the tumor is diminished.
In uncomplicated conditions of climacteric
metrorrhagias and fibroids radiotherapy is fully as
efficient and by far less dangerous than the opera-
tive treatment and therefore x-ray therapy is the
method of choice. It is contraindicated in young
healthy women in whom there is a possibility of
performing a conservative myomectomy without re-
moval of the ovaries.
Fibroids complicated by diseases of the adnexa,
or by the coexistence of a carcinoma or a sarcoma
of the uterus demand operative interference. When
the malignancy complicating the fibroid is inoper-
able radiotherapy again becomes the method of
choice.
The possibility that a radiated fibroid uterus may
become subsequently sarcomatous is very slight,
since a true degeneration of a fibroid into a sar-
coma is found in less than % per cent, of the cases.
Thyroid. — Exophthalmic goiter is promptly in-
fluenced by the x-rays in a great percentage of the
cases. Of the symptoms of the disease the pulse
rate is the first to respond most easily to the treat-
ment, next the weight increases, and the sleepless-
ness, and the other nervous symptoms show a great
improvement. The exophthalmus and the goiter
are the last to be influenced and in a certain num-
ber of cases these last two symptoms remain unim-
proved. A preliminary radiation does not make a
subsequent operation more difficult. In view of all
this, no case of exophthalmic goiter should be op-
erated on without an attempt at x-ray therapy.
Thymus. — The thymus is found to be enlarged in
the majority of cases of exophthalmic goiter. In
these cases the symptoms may be due to a great ex-
tent to the enlarged thymus. This organ dimin-
ishes in size very rapidly under x-ray treatment,
therefore cases of exophthalmic goiter accompanied
by an enlarged thymus are readily influenced by
radiation, while the surgical treatment may remain
without effect.
Status lymphaticus is a clinical condition which
is due mainly to the enlargement of the thymus
and may also be very favorably influenced by x-ray
treatment of the gland.
Hypophysis. — In view of the brilliant results ob-
tained by x-ray treatment of the thyroid and the
thymus in exophthalmic goiter it seemed reasonable
a priori to expect that in acromegaly the raying of
the hypophysis may benefit the disease. Indeed,
there are reported in the literature a few cases in
which the x-ray treatment exerted undoubtedly
beneficial effect on the disease.
Spleen and Bone-Marrow. — Leucemia is a disease
in which the characteristic changes are an altera-
tion in the relative proportions of the different
leucocytes of the blood, with an increase in their
number, and the appearance of unusual forms. The
red cells are diminished in number, abnormal forms
appear in the blood, and accompanying these altera-
tions in the blood are changes in the spleen, bone-
marrow, and in the lymphatic glands. In myelo-
genous leucemia the changes are mainly localized
in the spleen and the bone-marrow, and the blood
Dec. 9, 1916]
MEDICAL RECORD.
1025
shows an increase in polymorphonuclear leucocytes
and in myelocites. In lymphatic leucemia all the
lymphatic glands are enlarged as well as the spleen
and there is an increased number of lymphocytes
in the blood. The disease is analogous in many
respects to lymphosarcoma and may be considered
to be a malignant disease of the blood. The readi-
ness with which this disease responds to x-rays is
quite remarkable. The leucocytes after a slight
initial increase promptly diminish in number. The
following observation made by the writer in col-
laboration with Dr. B. Joseph is very interesting
in this connection. While the number of myelocytes
in myelogenous leucemia may decrease to a remark-
able degree after a few x-ray treatments, the in-
creased number of myelocytes found in cases of
skeletal metastases of carcinoma remain uninflu-
enced by radiation. The spleen as well as the
lymphatic glands decrease in size and the general
condition of the patient improves. In regard to the
ultimate result, and the relapses of the disease, the
statement made above in connection with Hodg-
kin's disease may be repeated. The earlier the
treatment is begun, and the more energetically it is
pursued, the longer will the life of the patient be
preserved. The radiations with hard filtered rays
should be given not only over the regions of the
spleen, liver, and the lymphatic glands, but also
over the regions of the long bones. For several
years the treatment should be repeated at stated
intervals. The treatment should be controlled con-
stantly by blood examinations.
Conclusion. — The difference in the technique and
the armamentarium used in radiography and in
x-ray therapeutics is very considerable. Each of
these two modes of the medical application of the
x-rays have extensive fields of usefulness of their
•iwn, and it would be most advantageous for the
progress of both disciplines if they were not united
in the same laboratory. Each worker should de-
velop only one branch of the work. The great suc-
cess of radiotherapy in Germany dates from the
time when the surgeons and gynecologists them-
selves undertook this method of treatment instead
of referring the patients to the radiographers. Cor-
rect radiotherapy implies a thorough understanding
of the pathological and clinical condition of the pa-
tient as well as the technique, dangers, and limita-
tions of the therapeutic measure.
As shown above, the usefulness of x-ray therapy
is limited to a well-defined class of diseases, but in
those it acts very frequently as an actual specific
and always as a very important adjuvant to other
methods of treatment. It behooves as little the
clinician to neglect this method of treatment as the
x-ray therapeutist to become over enthusiastic.
119 West Seventy-first Street.
claims have been put forth. Unfortunately, all of
these have been weighed and found wanting in some
particular, and thus two hapless conclusions are
forced upon us: first, that a reasonably early diag-
nosis of gastric cancer from clinical data alone is
THE WORTH OF AN EARLY X-RAY EXAMI-
NATION IN GASTRIC CANCER.
By GEORGE M. NILES, M.D.,
ATLANTA. GA.
The Roentgen ray as an early diagnostic agent in
suspected or non-suspected cases of gastric cancer
has won a recognized rank.
Many and erudite have been other methods
advanced; and for some of the newer processes,
such as the glycyltryptophan test, the phospho-
tungstic acid reaction of Wolff, the hemolysis test,
and the modified Abderhalden reaction, glowing
Fig. 1. — Malignant infiltration of the pylorus. This patient
has had superficial epitheliomas removed from lip and nose ;
resection advised.
impracticable; second, that when a clinical diagno-
sis of such can be readily made, the patient may
well set his earthly affairs in order, for no form
of therapy is then of permanent service. With
the Roentgen method, however, we have a means
at hand, which, if carefully employed and intelli-
gently interpreted, will prove itself worth while in
detecting early carcinoma.
Another important possibility of a Roentgen ex-
amination is the recognition of a latent, but per-
haps advanced, cancer with few or no special
symptoms.
Apart from pyloric obstruction, the diagnosis of
carcinoma depends upon irregularities in contour
caused by the inroads of the growth. These may
be quite small, like the outline of a piece of coral,
or there may be more or less marked obliteration
of the cavity by the growth, which displaces the
barium, causing a distortion of the normal shadow.
Viewed through the fluoroscopic screen, these in-
roads may suggest peristaltic waves at first sight,
but, on closer observation, it will be noted that they
Fig. 2. — So-called "leather-bottle stomach." In this con-
dition there remains only a rigid tube through which the
nourishment flows out almost immediately ; inoperable con-
dition.
are permanent, that the peristaltic waves sweep
up to these notches, are lost to sight, then reap-
pear on the further side of them. In advanced cases
the major part of the stomach cavity may be com-
pletely obliterated, showing an irregular shadow
1026
MEDICAL RECORD.
[Dec. 9, 1916
that possesses no likeness to a normal gastric con-
tour. Growths invading the anterior or posterior
walls are sometimes so arranged that the barium is
displaced and a clear space observed in the midst
of the shadow. These clear spaces may appear and
Fig. 3. — Annular carcinoma involving the pylorus and
greater curvature of the stomach. Note the "bitten-out" ap-
pearance of the greater curvature ; inoperable condition.
disappear as the peristaltic waves sweep on, and
the gross aspect may sometimes be completely
altered by palpation. Particles of retained food
which have been coated over or admixed with bari-
um may cause confusing shadows, so it is well to
obtain roentgenograms on successive days to guard
against this error.
Adhesions in the vicinity of the stomach, pylorus,
or duodenum may also cause inroads that are diffi-
cult to differentiate from neoplastic growths; and
such problems can only be intelligently solved by
combined palpation under the screen and a liberal
number of roentgenograms.
Spasmodic contractions may counterfeit growths,
calling for gentle massage under the screen, plus
a subsequent examination. Let it be insisted upon
that there is seldom a case in which a single ex-
amination justifies an absolutely positive diagnosis
with its perhaps somber prognosis.
The technique in the Roentgen investigation of
these cases is quite similar to the routine examina-
tion in other lesions of the stomach. The writer
uses buttermilk (about 12 ounces, if that much can
be retained) and barium (about 2'-> ounces). Sev-
eral plates are made at oncp both in the standing
and prone positions. Sometimes plates made in the
»-o
«<0
5^?
Q-h-
o ■*
3
di wing of Kig. 3.
lateral or oblique positions afford valuable informa-
tion. Let this be clearly understood — a single plate
showing a normal filling may carry more diagnos-
tic weight than a dozen which fail to fill.
A few neoplastic growths occur in the cardiac
region of the stomach, usually invading the cardiac
orifice. Such patients generally come for obstruc-
tive symptoms, refereable to the esophagus; and
in many of these it is found that the carcinoma has
already reached the inoperable stage. In the
Fig. 5. — Extensive involvement of pylorus and prepyloric
region. The symptoms appeared suddenly in a very robust
man ; condition inoperable.
writer's experience no carcinomatous invasion of
the stomach is more insidious than that situated
near the cardiac orifice.
Primary carcinoma in the pars media is a rare
entity.
Filling defects at or near the pylorus are annular
in character, lending the appearance of an unduly
elongated pyloric gap. This annular aspect is not
so clearly noted in chronic ulcer. As before men-
tioned, these apparent lesions should be verified by
a number of plates with the patient in varying pos-
tures. Should the annular appearance be cor-
roborated by bitten out "notches," the examiner
maj be nearly sure he is dealing with a growth.
It little matters whether the neoplasm is primary
or a malignant degeneration on the site of an old
ulcer, the potentialities for evil are the same. When
such material conditions are obvious, and are proved
by a painstaking Roentgen investigation, immedi-
ate and radical surgery should be recommended.
Negative findings are of great value only when
the examination has been thorough. A normal-
appearing shadow of the stomach with a smooth
and unserrated contour rules out any neoplasm be-
f?0£«TOIN Iy-1>» Nilcs.
I I
p
Fig. 6. — Artist's drawing of Fig. 5.
yond the microscopic stage. In a few instances un-
der the writer's observation, a careful examination.
Roentgen and otherwise, with unmistakable nega-
tive findings has cured the patient.
In some late cases so much of the stomach struc-
Dec. 9, 1916]
MEDICAL RECORD.
1027
ture may be involved that there seems to be simply
a rigid canal with no peristaltic waves whatever.
The patient can take only a small amount at a
time, thus running out of the stomach almost as
rapidly as it descends through the esophagus. Un-
less the plate is taken expeditiously, the stomach
will have emptied itself so that no shadow will be
discernible. Such a case is shown in Fig. 2.
In conclusion, let it be asserted that when any in-
dividual in middle life rather suddenly develops
indigestion, when this indigestion cannot be satis-
factorily explained by abnormalities of the cir-
culatory system, the kidneys, the blood and blood-
forming organs, or the central nervous system, a
careful roentgenological examination is emphatically
indicated. Otherwise, many guileless patients and
over-optimistic physicians will wake up to a sud-
den realization that the "day of grace" has passed,
and that the malignant process has overspread
•operative bcunds.
922 Candler Building.
COMPLETE TRANSPOSITION OF VISCERA,
WITH REPORT OF TWO .CASES.*
By H. J. HARTZ. M.D.,
PHILADELPHIA. PA.
Of the abnormal positions of the viscera the most
important is the one known as "situs viscerum
inversus" or lateral transposition of the internal
organs; the transposition forming a mirror-image
of the normal. The transposition may be complete
or partial. If restricted to the heart alone the con-
dition is known as dextrocardia. In rarer instances
the change involves only the abdominal organs.
The various theories explaining the development
of the viscera are chiefly of interest to the embry-
ologist and anatomist. Adami' believes that the
most likely explanation is that the main current of
blood to and from the germinal area becomes di-
verted at an early stage of existence and thus
purely mechanical influences lead the vessels of
one side of the organism to receive more blood and
therefore to grow more vigorously than those of
the other. There are numerus other theories re-
lating to this subject but they are too technical to
be discussed in a paper of this kind.
Cases of partial transposition are not as common
as the complete type. Lochte,2 in 1898, was able
to collect but 13 cases of this incomplete variety.
To the clinician transposition of the viscera pre-
sents many interesting problems in differential
diagnosis. Congenital displacements of the heart
to the right must be differentiated from those oc-
curring in disease. The acquired displacement of
the apex beat occurs rarely beyond the right mam-
mary line. It may be caused by the pressure of
a left-sided pleurisy with effusion, a left hydro-
thorax or pneumothorax, a tumor of the left lung
or mediastinal tumors. It may be caused by the
retracting power of chronic fibroid changes in the
right lung and adhesions in the right pleural cavity
which fix the heart in this abnormal position. The
discovery of an enlarged area of dullness in the left
hypochondrium is suggestive of several conditions.
Besides a transposed liver, an enlarged spleen either
of leucemia, malaria, or splenomegaly may be pres-
«nt. The dullness may be caused by an enlarged
movable and prolapsed kidney or perinephritic ab-
scess. Fecal accumulation, effusion in lesser peri-
*Read before Jefferson Hospital Clinical Society, Jan-
uary, 1915.
toneal cavity, a subphrenic abscess, psoas abscess,
cancer of splenic flexure of colon, and tuberculous
peritonitis must also be considered.
In 1865 Gruber' made an exhaustive study of the
literature and collected 79 cases of complete trans-
position of viscera; Klichenmeiser,* in 1883, added to
that series and increased the number to 149. In
1895 Pic1 reported 190 cases, which number repre-
sents all of the cases known in literaturs up to that
year. Arneill," in an elaborate study in 1902 in-
volving communications with leading internists and
anatomists, reported over 40 additional cases.
In this country, cases of transposition in recent
times are much more frequently discovered during
life than on the post-mortem table. Arneill con-
trasts Gruber's series and his own. Of the 79
cases reported by Gruber only five or six were dis-
covered during life. In Arneill's collection, which
numbered 44 cases, 38 were diagnosed during life,
and but six after death.
Case I. — X-ray photograph of patient, standing erect, taken
in anteroposterior position after a bismuth meal. A, stomach
on right side of median line; R. liver on left side of body; C,
heart displaced to right of median line ; D, duodenal cap dis-
placed toward the left.
Gruber in his study arrived at a number of in-
teresting conclusions. There were 49 men, 19
women and 11 in which sex was not mentioned.
The longevity in these individuals did not differ
from those with normal organs. The women were
normally fruitful, one gave birth to 12 children. In
71 of the 79 cases both chest and abdominal organs
were displaced. Of the abdominal organs alone
there were 8 displacements. Lungs were trans-
posed in 35 of 71 cases, the right had two lobes
and the left three lobes.
Case I. — The case that I am
boy 13 years of age, name S. F
of Hebrew parentage. Has one
one brother 11 years old. The
tive. Had measles and chicken
wise has enjoyed perfect health
I was called to the patient's
complaining of pain on left side
reporting is that of a
., white American born
sister 15 years old and
family history is nega-
pox in infancy, other-
home and found him
of chest in midaxillary
1028
MEDICAL RECORD.
[Dec. 9, 1916
line, aggravated on deep inspiration and during cough-
ing; duration one day. Physical examination showed
a well-developed muscular and robust boy. On ex-
amining the bared chest I was surprised at the absence
of the cardiac apex beat from its usual location. The
heart was completely transposed to the right side of
the body with apex in the right mid-clavicular line. The
lungs were normal except for a slight pleural friction
rub in midaxillary line on left side, ascertainable both
on palpation and ausculation. Liver dullness was out-
lined on left side of body and the stomach was trans-
posed to the right of the midline. The right testicle
was at a lower level in the scrotum than the left. The
patient was right handed. In a few days the patient
recovered from his pleurisy. Fluoroscopic and .r-ray
studies were made following ingestion of a bismuth
meal, and verified the physical findings of a complete
transposition of all of the viscera of the chest and
abdomen.
That complete transposition of viscera is not an
infrequent condition is evidenced by the fact that
quite recently (November 22, 1916) I had the good
fortune of discovering a second case of this inter-
esting anatomical anomaly.
Case II. — I was called to the home of a little patiem
that was complaining of a sore throat. The following
history was elicited: The patient D. S., is a boy 12
years of age, American born of Italian parentage.
During childhood had frequent attacks of tonsillitis,
otherwise has epjoyed fair health. The present illness
consists of an acute attack of follicular tonsillitis, super-
imposed on a chronic hyperplasia of tonsils. The boy
is fairly well developed but rather slender for his age.
In view of above history I was anxious to know if
cardiac murmurs existed, and on examining the chest
I located the apex in mid-clavicular line on the right
side, the liver dullness was elicited on left side of body,
the stomach was to right of median line. Fluoroscopic
and x-ray examinations following a bismuth meal
showed a complete transposition of viscera. The plates
were practically identical with those of the case re-
ported above.
REFERENCES.
1. Adami: Principles of Pathology, Philadelphia.
2. Lochte: Beitr. z. path. Anat. u. z. allg. Path. Jena.,
1898, XXIV, 187.
3. Gruber: Archi. f. Anat., Physiol., u. wissensch.
Med. Leipzig, 1865, 558-000.
4. Kuchenmeister: Die Angeborene vollstandige seit-
liche Verlagerung der Eingeweide des Menschen, Leip-
zig, 1883.
5. Pic: Province Med., Lyon, 1895.
6. Arneill: Am. Journal of the Medical Sciences,
1902.
1226 Spruce Strf.ht.
DIVERSIONAL THERAPY IN MENTAL DIS-
EASE.
A PLAN FOR ITS KMPLOYMENT WITH SPECIAL REFER-
ENCE TO SOCIAL CLUBS.
By LEIGH I\ ROBINSON. M.D.
RALEIGH. N. C.
PHYSICIAN IN CHARGE FEMALE DEPARTMENT STATE HOSPITAL.
The treatment of mental disease by diversional
therapy has been recognized for some time to be
the most rational and scientific. The method is one
of substitution and is accomplished by replacing
the focal idea of consciousness. For if a healthy
idea can only occasionally be substituted for an
idea of false reasoning the patient's attitude of
mind and conduct will improve. Considering the
psychology of diversional therapy, let us suppose a
group of patients manifesting different forms of
insanity are attending a moving picture show, we
are impressed how well their attention is held. Sup-
pose another group are attending a dance, and ob-
serve how interested those become who are fond of
dancing and what a good time they have. There
is another group employed in some useful mode of
occupation, we again are impressed with the in-
terest one manifests who is weaving a rug or an-
other occupied in the construction of a table. And
so we could suppose ourselves conducted through-
out an average hospital for the insane and invari-
ably observe that those patients that seem to de-
rive the greatest benefit from their employment
are those most interested in their work and who
accordingly give to it a more undivided attention.
This would bring to mind a well-known fact that
the attention is dependent upon the emotion and
controlled by a motor mechanism which is inhibi-
tory in character. In other words, anything capa-
ble of engaging the attention must first to some
extent stir the emotions. This requires a quality
of attractiveness. Recognizing such principles, di-
versional therapy is employed to render those things
attractive that are not naturally so and in like
manner produce an interest in them.
The different psychoses will be touched upon in
so far as the treatment of them is related to di-
versional therapy. First, manic-depressive insan-
ity ; in the depressed form of this psychosis the
patient has his inhibitory powers of attention in-
creased. Here the mind is obsessed with fixed ideas
that are delusional in character and tend toward
more or less dangerous acts of conduct. In such
cases diversional occupation of the mind will help
to crowd aside the false beliefs. In the other type
characterized by increased psychomotor activity
and flight of ideas, the attention has become greatly
debilitated. Patients suffering from this type may
have the excess energy utilized through occupa-
tion.
Second, in those psychoses characterized by men-
tal enfeeblement and dissociated personality, name-
ly, the precox group, diversional therapy tends to
dissolve the symbolical personality and arrest men-
tal deterioration. The process by which this is ac-
complished is best explained by comparing it to
a boy flying a kite, the boy representing the patient,
the kite his mind soaring afar off in its world of
fantasy and the string diversional therapy which
serves as a means to prevent the mind's complete
withdrawal or at least retard the usual rapid de-
mentia characteristic of this type of insanity.
Third, the use of diversional therapy in the func-
tional group of psychoses yields remarkable results
toward directing the stream of thought into health-
ier channels.
Fourth, there is that large group of dements and
aments who show slow reaction to external stimuli
that may be brought out of their lethargy through
re-education.
In the prescribing of diversions the same care
should be observed as when drugs are used. There
is danger of overtaxing the patient's strength and
causing him to become disinterested through a lack
of variety or too long hours and not enough recrea-
tion. Patients will soon grow weary of "all work
and no play." In view of this fact, care must be
taken to have work and recreation balance well.
In order to schedule new patients correctly, we
follow a regular routine in the keeping on new pa-
tients what we call an "Efficiency Report" which
gives a full report on personal, social, and indus-
trial capacities and incapacities as observed by
Dec. 9, 1916]
MEDICAL RECORD.
1029
nurses and physicians. This report is completed
at the end of the second week subsequent to admis-
sion. A monthly record is kept of the hours pa-
tients are employed and entertained. One record is
kept by those in charge of the department in which
patients work. The nurses on the wards keep three
records, one for the patients who are employed
about the wards, a second in which is kept a total
of the hours each patient on the wards is employed,
a third in which is kept an account of the number
of hours the patients are entertained. These re-
ports give to those in charge a correct account of
the work each patient does in the different depart-
ments. The second report kept by the ward nurses
gives a check upon the i-ecords kept by outside de-
partment heads, who as a rule are careless in keep-
ing correct reports of patients. The third enables
us to balance up productive employment and recre-
ation received by each patient.
It is doubtful if it is a wise plan to give other
rewards than tobacco. At some places, patients are
allowed both smoking and chewing tobacco. Requi-
sition should be made for tobacco in the form of
snuff and plug on approval of physician in charge
for whom it is wanted. It should be given out in
morning daily allowances when the patients are
leaving the wards for their various places of duty.
There is no one thing that gives patients so much
pleasure as the permission to use tobacco, and no
special privilege that will give the work more at-
traction.
Below, I submit a plan for a department of diver-
sional occupation and have tried to observe the
principles of variety and balance between produc-
tive employment and recreation. In the productive
group, there are included the different industries
and the farm upon which an institution's momen-
tum and upkeep partly depend. There is also in-
cluded in this group a number of diversions that
are productive through the manufacture of ma-
terials which are exportable. In the second group,
designated nonproductive, we have in mind the em-
ployment of those patients whose conditions do not
allow them to enjoy the freedom of those who work
in the productive group; that large class of pa-
tients that are more or less disturbed and demand
special attention by the attendants and nurses.
This is the most important group since here the
greatest amount of good by diversional therapy can
be obtained. In this division the patients may be
occupied with raffia, basketry, pottery, and hand
weaving which are all good in holding the atten-
tion of the patients. At the Taunton State Hos-
pital, Miss Cameron, Superintendent of Nurses, uses
a method by which she teaches a class of nurses
a new idea which the nurses each in turn teach to a
group of patients. In the third group designated
recreation the different forms of entertainments
and athletics are included. The scheme of this
plan is as follows:
A. Productive Employment.
1. Industrial: (a) Shops, including sewing
rooms, mending rooms, shoe repair, car-
pentry, laundry, etc.
2. Farm and Garden.
B. Non-Productive Employment.
1. Ward classes.
C. Recreation.
1. Athletics: (a) Gymnasium; (6) Athletic
field, providing tennis courts, ball dia-
monds, football and basket ball.
2. Entertainments, including special lectures.
moving pictures, dances and entertain-
ments by patients.
3. Devotional.
4. Library.
5. Social Clubs.
The department as outlined above, I believe,
should be under the direction of the superintendent
of nurses, as carried out in the Taunton State Hos-
pital at Taunton, Mass. We have accordingly placed
this department under the superintendent of
nurses. Each group is headed by a Supervisor
who is directly responsible to her.
The supervisor of the farm and garden work
parties sends out daily patients as directed by the
medical department to the different places where
their labors are needed. He visits the patients at
such places, looking after them in regard to their
comforts, reporting those to the physician who re-
quire attention. He also makes requisitions for to-
bacco and proportions the same to the attendants
of work parties.
The patients working in the laundry and shops
are under the direction of the department head who
is responsible for them and reports any irregulari-
ties to the assistant physician or superintendent of
nurses. In this department, as in the farm and
garden department, tobacco and snuff is requisi-
tioned for by the supervisor of industrial depart-
ment and dealt out by him to the patients. The
second group of nonproductive employment has al-
ready been described.
The third group, recreation, takes up first ath-
letics, which includes in addition to the gymnasium
all outside athletics. One understanding the prin-
ciples of physical culture should be in charge of
this division. The physical director should provide
during the winter months every evening some form
of entertainment for a part or all the patients.
There should be for every day a regular schedule
of classes, made up of those patients who are in-
cluded in the productive and non-productive groups.
During the summer months special attention should
be directed toward the athletic field, which should
provide tennis courts, ball diamonds, football and
basket ball. The physical director should teach the
patients how to play different games, doing so by
regular classes. Frequent games between patients
should be arranged and games with outside teams
encouraged. It must be remembered that not only
those who attend the classes and take part in the
games derive benefit from the athletic department,
but those who are spectators at the games which
includes a very large number, since all the patients
who can should be permitted to go.
Second, we come to that part of recreation which
includes special entertainments, lectures, moving
pictures, dances, and entertainments given by pa-
tients. Frequent entertainments impromptu in
character should be arranged for the patients ; they
may consist of sleight-of-hand performance and the
like, and if the institution is in a large city a num-
ber of entertainments can be provided by the inhab-
itants, who as a rule will be glad to assist in such
work. Special lectures on interesting subjects and
story telling provide good means for entertainment.
Dances and moving picture shows should come reg-
ularly and frequently.
Third, in this division we come to religious serv-
ices, in which we include such services as conducted
by ministers and others of the pulpit and the sing-
ing of religious songs. These services cannot come
1030
MEDICAL RECORD.
[Dec. 9, 1916
too often if conducted properly. Here we have
three services on Sunday, morning, afternoon, and
evening. The evening service is nothing more than
the singing of hymns, but it enables us to provide all
of the patients with at least weekly attendance. It
is a good routine to request of those in charge of
such services to be careful not to use any discourse
that tends in the slightest degree toward emotion-
alism. The same thought should be borne in mind
in the singing of religious songs, only those hymns
that tend neither to depress nor to excite the emo-
tions should be sung. The books used should have
those songs checked that have been approved by the
medical department.
Fourth. The library should be sufficiently large
for the requirements of both patients and em-
ployees, and should be under the supervision of a li-
brarian who keeps similar records in regard to books
and the loaning of them as in any public library.
The patients, in the attendance of nurses, should be
allowed certain hours to go to the library and select
the books they wish to take. A certain schedule
should be followed in regard to taking patients in
classes to the library where they can read the papers
and magazines provided there.
Fifth. In this division I will describe a plan by
which social clubs organized among patients will
bring remarkable results. A number of state hos-
pitals have organized such clubs and found them
very productive. I have organized among the pa-
tients in the female department a large number of
clubs, namely, reading circles, musical clubs, dra-
matic clubs, card clubs, sewing circles, etc. These
clubs are organized with a limited membership, and
all meet at least once a week. Each club elects its
own officers, consisting of president, vice-president,
and secretary. The officers and members are given
the privilege of conducting the clubs as they desire.
A nurse designated as advising officer meets with
the club and tactfully stimulates its progress. Pa-
tients vote on new members by secret ballot, and
the names of those that are accepted are submitted
to the assistant physician for his approval. Each
member wears a badge which bears the name of
the club, for example : "Monday Afternoon Sewing
Circle." I find the patients are very proud of the
badges, which I believe have a greater stimulating
effect than anything else. One of the parlors of
the administration building is provided for holding
some of the meetings. Refreshments are served at
each meeting in the form of tea, wafers, fruit, or
ice cream. Picnics are voted for occasionally and
because of their beneficial results are granted when-
ever possible. Outsiders are urged to visit the
clubs but I have them obtain final permission from
the president of the club which they wish to visit.
This adds dignity and to the patients increases the
clubs' importance. The visitors are asked to enter
into the work of the meeting exactly the same as
they would do if visiting a club in a community of
normal individuals. Too often persons with best
intentions when visiting mental patients are prone
to show unwanted sympathy and unconsciously ex-
aggerate their own normal condition.
The sewing circles do principally fancy work, and
the members take great pride in learning new
things and teaching the same to new members.
Outside visitors come, and while they are requested
at least to pretend to receive more than they give,
they frequently interest the circles with something
new. The card clubs meet in the evening, play the
usual games and enjoy the refreshments very much.
Every floor and building has a reading circle
named after its respective floor or building. These
circles meet in the evening and read aloud inter-
esting articles in which the advising nurse assists.
Magazines and books are sent to the Hospital by a
number of its friends and are distributed to the
different circles for their use. One of the clubs
has the distinction of having given interesting en-
tertainment every week since its organization eight
months ago. Officers, employees, and outsiders
have been in regular attendance and always report
a good time. The dramatic club gave a play this
Spring for the graduating class of the Training
School, and it was considered by everyone to be
equal to the average amateur play.
Personally, I am very enthusiastic about this
phase of diversion and believe that social clubs tend
to give to the mental patient his former adjustment
more rapidly than any other. Of course, they
should be conducted properly and the principles ad-
hered to which I have brought out above, namely:
First, give patients, as far as possible, full charge
of the clubs which they compose.
Second, keep up an interest by not allowing the
object of the club to diminish in its importance.
Third, serve refreshments at the meetings and if
at all possible grant picnics and special privileges
whenever such are requested.
Fourth, provide badges which not only increase
the interest but create pride in the wearer.
Fifth, encourage officers and outsiders to attend
the meetings frequently, but never allow visitors to
forget that they are objects of the club's hospitality.
NAUSEA AND VOMITING AFTER NITROUS
OXIDE-OXYGEN ANESTHESIA.
By WILLIAM L. SOULE, M.D..
NEW TORK.
ANESTHETIST, CORNELL DIVISION, NEW TORK HOSPITAL.
The opinions of the average medical man on any
unsettled question may be derived from impres-
sions— his own and those of other men — from ex-
perimental evidence, from statistics, or from the
statements of recognized authorities. Though it is
not scientific to rely upon impressions, many con-
clusions are arrived at in this way and sometimes
they are more correct than those based on experi-
mental evidence and statistics. Experiments are
often faulty, statistics are fallacious, and both may
be wrongly interpreted.
The status of gas oxygen anesthesia may be re-
garded as not entirely settled, and, as members of
the medical profession have had varying impres-
sions and experiences in connection with its use,
opinions naturally are divided.
The writer's first experience with nitrous oxide
was obtained in a hospital where a large amount
of tooth-extracting was done under this anesthetic.
The gas was pushed till the appearance of cyanosis
and stertor, then the inhaler was removed and the
extraction rapidly performed. The anesthetic was
considered so safe that we never thought of any
danger and vomiting was very rare. Several years
later the writer saw, for the first time, a major
operation ( prostatectomy ) performed under gas-
oxygen with ether as needed. The cyanosis, which
was exhibited to a considerable extent, was not un-
expected, but the vomiting which followed the with-
drawal of the anesthetic was something of a sur-
prise and gave rise to the question whether ether
Dec. 9, 1916]
MFDICAL RECORD.
1031
alone would not have done as well. Subsequent
experience and conversation with other observers
frequently suggested the same question. It was
disappointing to find that after this form of an-
esthesia patients frequently vomited — especially
women. The vomiting, too, seemed to take place
irrespective of preliminary morphine medication or
the addition of ether or of skill (or lack of skill)
on the part of the anesthetist.
For example, one patient, who received a prelimi-
nary hypodermic of morphine and was under the
anesthetic for a few minutes while the uterus was
curetted, remained apparently unconscious for half
an hour or more after the operation and suffered
from nausea for several hours afterward. Another
patient without preliminary medication took her
anesthetic very satisfactorily for six minutes while
some necrosed bone was removed from the os calcis.
She vomited at the close of the operation and was
more or less nauseated for several hours. No ether
was used in either of these cases. Two patients,
operated upon within a few days of each other,
were of particular interest because of the striking
points of contrast which their cases presented. In
each case a preliminary hypodermic of morphine
Oi gf-) was given.
The first patient was a woman 32 years of age who
was operated upon for varicose veins of both extremi-
ties. Gas-oxygen without ether was given for an hour
and forty-five minutes. During induction of anesthesia
there was moderate cyanosis, but after the first few
minutes the patient's color remained pink and condi-
tions were in every way satisfactory, except that there
was a tendency to vomit whenever the supply of nitrous
oxide was decreased. The operation was completed at
1 P. M. The patient promptly vomited, and nausea and
vomiting continued all the rest of the afternoon. She
stated that these symptoms were much the same as
after ether, but that she preferred the gas-oxygen on
account of the quicker disappearance of her mental con-
fusion. (She had been operated upon for hernia eight
days before, under ether.)
The second patient was a woman of 46 years who un-
derwent a radical operation for carcinoma of the breast.
Gas-oxygen anesthesia was attempted and maintained
for forty-five minutes, with the aid of 2 ounces of
ether. The patient was at all times more or less cya-
nosed. Breathing was irregular and there was a con-
stant tendency to struggle. At the end of forty-five
minutes the nitrous oxide was discontinued and a light
anesthesia kept up for three-quarters of an hour longer
with 4 ounces of ether.
Gas-oxygen anesthesia as usually conducted may
be divided into three classes; first, gas-oxygen an-
esthesia alone; second, gas-oxygen anesthesia as-
sisted by ether; third, ether anesthesia modified
by gas oxygen. The case last described may, on
the whole, be justly called an ether anesthesia com-
plicated by gas-oxygen. The results, however,
were surprisingly satisfactory. The patient was
conscious and talking before being removed from
the table; according to the nurse there was no sub-
sequent vomiting and the patient herself reported
little or no nausea.
Of course these two cases prove nothing. They
are merely examples of two contrasting types fre-
quently met with, the one very susceptible to the
good and bad effects of an anesthetic, the other re-
sistant to both. However, neither of these cases
would have given the casual observer a very favor-
able impression of nitrous-oxide oxygen anesthesia.
A satisfactory anesthesia with this agent pre-
sents much the same features as a correspondingly
satisfactory ether anesthesia. The patient's color
should be pink or only slightly dusky, the pupils
small or medium, the breathing quiet and regular
and the patient sufficiently relaxed to allow the sur-
geon to do his work without too much annoyance
from muscular rigidity.
The conditions usually necessary for such an
anesthesia are somewhat as follows: (1) A reason-
ably tractable patient. (2) A reasonably skillful
anesthetist. (3) A willingness on the part of the
operator to put up with a certain amount of muscu-
lar rigidity or to have the anesthesia deepened by
adding ether rather than by the more dangerous
Preliminary
Quantity of
Duration of
Case.
Age.
Sex.
Operation.
Medication.
Ether Used.
Anesthesia.
Nausea and Vomiting.
1
32
F.
For varicose veins
Magendie 8 minims
None
1% hours
Vomited twice during operation and four or
five times afterward. Nauseated for
several hours.
2
55
F.
Curetting of os calcis
None
None
7
minutes
Very- little vomiting. Slight nausea.
3
20
M.
Resection of rib for empyema
None
None
29
minutes
None.
4
33
F.
Curetting of uterus
None
None
9
minutes
Vomited twice on operating table at close of
5
39
M.
For varicocele
Magendie 7 minims
None
35
minutes
operation. Little subsequent nausea
Retching at close of operation and at least
6
55
F.
Curetting of os calcis
None
None
6
minutes
once subsequently. Moderate nausea.
Moderate vomiting. Nausea for several
hours.
None.
7
58
M.
Prostatectomy
Magendie S minims
1 ounce
20
minutes
8
22
F.
Incision of breast abscess
None
None
10
minutes
Vomited on operating table at close of
9
23
F.
Salpingectomy and appendectomy
Magendie 7 minims
5 drams
45
minutes
operat-uii. (No further record.)
Vomited on operating table at close of oper-
10
61
M.
Removal of osteoma from knee
None
2 drams
25
minutes
t at ion. (No further record.)
Vomiting of mucus at close of operation.
r No subsequent nausea or vomiting.
Vomited bile at close of operation. (No
11
30
M.
joint
Repair of fistula of urinary bladder
Magendie 7 minima
1H ounces
30
minutes
further record.)
12
18
F.
Plastic operation on hand, skin
Magendie 6 minims
1 ounce
1}£ hours
Vomited mucus at close of operation and
grafting
once subsequently. Little nausea.
13
49
F.
For prepatellar bursitis
Magendie 6 minims
4 drams
20
minutes
Vomited two or three times after operation
Moderate nausea.
Vomited once or twice. Little nausea.
14
48
M.
Removal of lipoma of neck
Magendie 8 minims
3 drams
35
minutes
15
28
F.
For hemorrhoids.
Magendie 8 minims
3 drams
35
minutes
None.
16
20
M.
Reduction of fracture of olecranon
Magendie 7 minims
None
10
minutes
None.
17
20
M.
Amputation of foot
Magendie7 minims
4 drams
30
minutes
Little vomiting. Moderate nausea.
18
69
M.
Suture of ruptured quadriceps
femoris
For femoral hernia
Magendie 7 minims
1 dram
45
minutes
None.
19
22
!■
Magendie 6 minims
IJ2 drams
35
minutes
Vomited twice. Little nausea.
20
21
F-
Puncture of breast with exploring
needle
None
20 drops
10
minutes
Vomited bile on withdrawal of anesthetic.
(No further record.)
21
30
F.
Curetting of uterus
None
None
10
minutes
No vomiting. Slight nausea.
22
20
F.
For femoral hernia
Magendie 7 minims
1 dram
35
minutes
None.
23
F.
For removal of buried suture from
abdominal wall
None
None
5
minutes
In the midst of operation vomited a con-
siderable quantity of food taken four
hours before. Moderate subsequent
24
31
F.
Amputation of thigh
Magendie 6 minims
2 drams
25
minutes
nausea.
None.
25
20
F.
Excision of tuberculous cervical
lymph nodes
Magendie 7 minims
None
55
minutes
Vomited once during operation and at least
three times after operation. Moderate
nausea.
1032
MEDICAL RECORD.
[Dec. 9, 1916
method of crowding the nitrous oxide. (4) A suit-
able apparatus. (5) A preliminary subcutaneous
injection of morphine or some other sedative.
If "straight ether" were given under conditions
similar or parallel to the above, would the patient
suffer more subsequent discomfort than after gas-
oxygen. The list presented is one of unselected cases,
taken in the order in which they came to operation.
It would hardly be worth while to make an ex-
haustive analysis of these cases or fair to draw
general conclusions therefrom. It may be noted,
however, that of the seven patients who were free
from nausea and vomiting, five received from a
dram to an ounce of ether, and that of the eighteen
patients who vomited or suffered more or less from
nausea, nine received no ether at all. The record
of nausea and vomiting in twenty-five unselected
ether anesthesias, most of them for minor opera-
tions, should suffer very little by comparison with
that in the list above tabulated. Such a comparison,
however, would be misleading if one were to de-
pend on the written record alone, the reason being
that it is impossible to express with precision the
severity of a patient's vomiting or the degree of his
nausea. The perusal of statistics cannot wholly
take the place of direct personal observation. Such
observation convinces me that, as regards post-
anesthetic nausea and vomiting, gas-oxygen has dis-
tinct advantages, though, doubtless, these are more
or less overrated. A point worthy of notice is that
the vomiting which follows gas-oxyen anesthesia is
assisted by the patient's voluntary efforts and we
do not so often see the cyanosis — often deep and
sometimes alarming — which attends the vomiting
efforts of the not yet conscious ether patient.
Frequently patients are met with who have under-
gone both forms of anesthesia and usually they ex-
press themselves as better pleased with gas-oxygen,
though it must be confessed that they do not seem
wildly enthusiastic in their preference. Indeed,
one of these patients, himself a physician, told the
writer that he was more comfortable after ether for
the reason that his vomiting occurred while he was
unconscious, whereas, after gas-oxygen he "knew
all about it. Since the above cases were tabu-
lated the writer has tested the comparative after-
discomforts of gas-oxygen and ether, making use
of himself as a subject for experiment. The tests
were made a week apart under practically identical
conditions. On each occasion a light breakfast had
been eaten and the anesthetic was given shortly
after midday for twelve minutes by the same pro-
fessional anesthetist. In both instances recovery
from the anesthetic was characterized by absolute
freedom from vomiting but by a tendency to nausea.
In the case of ether this was so pronounced that it
was deemed wise to remain in the recumbent po-
sition for an hour after consciousness returned.
After gas-oxygen the subject was up and about in
a few minutes. In both instances a tendency to
nausea and giddiness persisted through the after-
noon, but a fairly substantial supper was eaten,
enjoyed, and retained.
If a hundred men and a hundred women of the
medical profession, preferably surgeons and anes-
thetists, would repeat these experiments and report
results to (for instance) the American Association
of Anesthetists, valuable first-hand information
would thus be furnished concerning the relative
after-effects of these two forms of anesthesia when
uncomplicated by operative procedures.
411 Manhattan A'kntf
IS AN ANGINA RATHER THAN TONSILLITIS
THE PRECURSOR OF ACUTE
RHEUMATISM?
By JENNIE G. DEENNAN, M.D., CM.,
ROSEBANK, STATEN ISLAND, N. Y.
If one may judge from the statements of some of
the authoritative writers on general medicine the
prevalent belief appears to be that tonsillitis pre-
cedes rheumatism. Thus in Allbutt and Rolleston
it is said: "Tonsillitis is not an infrequent precur-
sor of or concomitant with an attack." In mod-
ern clinical medicine the statement is made that
"American and English physicians for a long time
had already called attention to the frequent occur-
rence of acute rheumatism after an attack of ton-
sillar angina, etc."; Striimpel says: "Not infre-
quently the organs of the threat, particularly, appear
to be the points of entry for the infection (tonsils
and pharyngeal tonsils)."
Now is the throat condition, which so often pre-
cedes an attack of acute rheumatism, a real ton-
sillitis or is it not rather an angina or an inflamma-
tory involvement of the tissues surrounding the ton-
sils due to the infective organism of the following
attack of rheumatism; in other words, is the so-
called tonsillitis, which precedes the rheumatic at-
tack, really a tonsillar condition, or is it not rather
an angina affecting the surrounding tissues and not
the tonsils themselves? The following questions
have presented themselves to my mind : Does the
patient generally suffer so severely during this pre-
cursory attack as he does during a real attack of
tonsillitis from which he recovers without an ac-
companying attack of acute rheumatism? Does he
not frequently suffer rather much more from the
local discomfort than from the systemic symptoms?
or as the Englishman would say, "Doctor, I have
a shockin' sore throat but I am well in myself,"
meaning that the constitutional or systemic symp-
toms do not cause him any discomfort, but that
what discomfort he does suffer comes alone from
the local condition. He has no malaise, no fever,
no headache, no loss of appetite, etc. ; but is in all
respects fit except that his throat is sore. I have
in mind two such cases: one that of a robust young
woman in whom there were no serious after-effects,
and the other that of an elderly man, hitherto pos-
sessing remarkable health and strength for his age,
who, however, later on developed an extremely se-
vere attack of acute rheumatism from which he
has not yet recovered. In the case of the former
aside from the local discomfort she was apparently
well. There was an inflamed condition of the throat,
which caused her great difficulty in swallowing and
the pillars of the fauces were very much inflamed,
the tonsils, however, being only very slightly af-
fected, if at all. Her appetite was good and she made
no change in her ordinary diet, but it was with great
difficulty that she swallowed this food. As she her-
self said, "I am hungry; I must eat; but I do not
know after I have taken the food into my mouth how
I am going to swallow it." Finally the local condi-
tion becoming so uncomfortable, she applied for re-
lief and the physician consulted made an applica-
tion of ichthyol, 10 per cent, in boroglyceride, to the
inflamed area. This was rather a matter of ex-
pediency than of thought in this case, as the ichthyol
was at hand; but still it occurred to him that as
ichthyol is beneficial in reducing the inflammation
of erysipelas and uterine inflammatory conditions.
why not in this one? The result was more than
Dec. 9, 1916]
MEDICAL RECORD.
1033
could have been expected; for almost instantly the
stiffness and the soreness disappeared and in their
place was left a feeling of flabbiness and softness
with no pain. The flabbiness was almost disagree-
able until the tissues regained their normal tone.
From this on there was no return of the condition
and no rheumatic sequela.
In the other case the result was not by any means
so satisfactory; for the patient, an elderly man, as
I have mentioned above, but one exceptionally well
preserved, going to business every day from a com-
muting distance and at intervals taking long busi-
ness trips, complained of a sore throat. He con-
sulted a physician who treated the case lightly, told
the patient to remain at home for a few days, and
gave him a gargle. The condition appeared to be
somewhat relieved and after a few days the patient
returned to his office, but still suffered from some
discomfort in his throat, especially on swallowing.
He made the remark, "it is not my tonsils; it is my
throat." Not being consulted by him, but merely
hearing him make this remark in the ordinary course
of conversation I, in an offhand way, remarked,
"probably you have a rheumatic throat," and thought
no more of the matter until the next day, when he
came down with a very sereve attack of acute rheu-
matism from which he has not yet fully recovered,
having had several severe relapses.
Now, the question in my mind is, were either of
these cases tonsillitis or were they not from the
start rather rheumatic infections, attacking the tis-
sues surrounding the tonsils? I cannot but feel
that had they from the start been treated as rheu-
matic infections they would have sooner yielded
to treatment, and that, in the latter case the acute
attack of articular rheumatism might have been
averted. Will it not always be wise for us so to re-
gard all such conditions of the throat and treat them
accordingly, no matter how slight they may be. That
a tonsillitis may be due to the same organism I do
not wish for one moment to deny; but on the other
hand I wish to draw attention to the fact, that
every sore throat that precedes a rheumatic attack
may not necessarily be a tonsillitis, but may be an
involvement of the peritonsillar tissues by the or-
ganism, which is responsible for the attack.
The localization of the primary attack is accessi-
ble; then why not then and there fight the infection
when it is in its primary stage? In both of these
cases there were no primary systemic symptoms.
Just how beneficial ichthyol may be in this class of
cases is a matter for further investigation. That
it gave relief in this one case I know, but one swal-
low does not make a summer. However, if it is, as
we know, beneficial in erysipelas, why not in a rheu-
matic condition of the throat which may be near of
kin to it in being a streptococcic infection?
In conclusion I would say that I think that it i?
highly desirable that we shall treat all acute in-
flammatory conditions of the throat with an eye to
their being the initiatory lesion in a case of acute
rheumatism. If they are not, no harm will have
been done, and if they are much harm may be pre-
vented. I would like to draw special attention to
the acute inflammatory conditions of the throat
which do not produce constitutional disturbance as
the most dangerous. If the patient has a very se-
vere attack of tonsillitis, which confines him to his
bed because he is too ill to remain out of it, then he
runs a much better chance of not developing rheu-
matism as a sequela, than the patient who does not
feel ill enough to give up, but who is really ill. Un-
fortunately these cases often from being so slight
do not come under the care of a physician until the
rheumatic attack has developed.
Summary.— (a) An angina and not a tonsillitis
may be the precursor of rheumatism. (b) All such
throat lesions should from the first be carefully
treated with an eye to their probable development
into acute rheumatism, (c) The beneficial effect of
ichthyol deserves more consideration.
DIAGNOSIS OF SO-CALLED SCIATICA.
By E. W. BEDFORD, M.D.,
AND
E. O. RAVN, M.D.,
CHICAGO, ILL.
FROM THE NEUROLOGICAL SERVICE (DR. HASSIN) OF COOK
COUNTY HOSPITAL, CHICAGO.
The old teaching that sciatica symptoms are due
to a neuralgia of the sciatic nerve has been prac-
tically abandoned at present. It has been estab-
lished of late by Dejerine' and his pupils that a
great many cases of so-called sciatica are caused
by the involvement of the roots that make up the
sciatic nerve and thus the teaching of so-called
root or radicular sciatica was introduced into neu-
rology. According to Dejerine, radicular sciatica
has the ordinary symptoms of plain sciatica, such
as the Lasegue sign, Valleix painful points, etc.,
but the spontaneous pains are worse than in "tron-
cular," or truncal, sciatica and are aggravated by
coughing, sneezing, and straining of the abdominal
muscles. Occasionally they spread over the crural
nerve which is abnormally sensitive to pressure.
Muscular atrophy is not rare, affecting either all
of the muscles supplied by the sciatic nerve, so-
called total radicular sciatica, or limited to some
muscles only, partial radicular sciatica. The
Achilles reflex is abolished or diminished, the
patellar reflex is present. Sensory disturbances
usually predominate. The differential diagnosis
from truncal sciatica lies in the sensory disturb-
ances since their topography is strictly radicular,
i.e. is confined to the anatomical distribution of the
spinal roots. At the beginning there is hyperes-
thesia to touch, cold, heat, and pain, later hypoes-
thesia, and finally anesthesia. Hyperesthesia fre-
quently occupies the external surface of the leg and
thigh. Anesthesia may be distributed along the
tracts of various lumbar or sacral roots. In the
partial or dissociated form the sensory disorders
frequently affect or pertain to one root only. In
this form there is dissociated atrophic paralysis of
the muscles of the anteroexternal region of the leg,
while those of the posterior surface of the leg and
thigh remain intact. A circumscribed meningitis,
Dejerine states, is the most frequent cause of the
radiculitis and is usually syphilitic. Dejerine's
teaching was confirmed by his pupils and in this
country by A. Gordon," who has published several
cases illustrating Dejerine's teaching of radicular
sciatica.
Some authors, as Bruce," go so far as to place
the cause of sciatica in the lesions of the hip-joint
only. Bruce interprets the symptoms of sciatica as
a referred pain from the diseased hip joint.
Pitfield,* in discussing sacroiliac relaxation as a
cause of sciatica, quotes a prominent neurologist of
the Massachusetts General Hospital whose name he
fails to give, who stated that 90 per cent, of sciatica
cases are due to sacroiliac relaxations and disloca-
tions. Pitfield, like Goldthwait, emphasizes the
close relationship between the sacral plexus and the
1034
MEDICAL RECORD.
[Dec. 9, 1916
sacroiliac synchondrosis. Any disturbance in this
relationship is likely to cause symptoms of pain
along the sciatic nerve. This sacroiliac etiology of
sciatica has been criticized by Lovett.5
Whatever the cause of sciatica may be, it is
nevertheless frequently located outside the nerve
and the roots making up the sciatic nerve. It is
obvious that any lesion that may involve the nerve,
the roots of the nerve, or the sacral plexus will
give symptoms of sciatica. These possible causes
have been sought for in the histories of the Cook
County Hospital for the past four and one-half
years. During this period 400 cases were admitted
under the tentative diagnosis of sciatica. All of
these patients presented symptoms of sciatica as
their chief complaint. It was found that approxi-
mately one-half showed definite and various con-
ditions that were not sciatica at all, but in which
sciatica was merely a symptom. Of these 400
cases admitted as sciatica during 1916, in 75 per
cent, the diagnosis of sciatica was finally modified,
while in 1915 it was rejected in 56 per cent., in 1914
in 40 per cent., in 1913 and 1912 also in 40 per cent.
In other words, the character of sciatica diagnosis
was greatly improved in the past two years, which
can be explained by the fact that in the past two
years much more attention has been paid to the
underlying factors causing sciatica. At present
roentgenograms are made in every case and ortho-
pedic considerations are studied more thoroughly.
It was found that not only one or two but numer-
ous and variable clinical entities presented sciatic
pain as their chief symptom. Of those remaining
cases in which an exhaustive study did not reveal
anything definite, the diagnosis of sciatica or neu-
ritis was made reluctantly. Many of these cases
would probably be classified under sacroiliac dis-
turbances, defective "static balance," etc., by the au-
thorities advocating these respective theories.
Since a classification of this nature is still arbitrary,
these cases, in which examinations were negative,
will not be discussed to any great extent except to
state that 79 per cent, were in men and the average
age was 39 years. The right side was affected in 42
per cent, of these cases, the left side in 41 per cent.,
and both sides in 17 per cent. Since 79 per cent,
occurred in men, most of whom were doing heavy
manual work, it appears plausible that their pains
in the lower extremities may have been manifesta-
tions of some over-exertion.
Of the other 50 per cent in which a correct diag-
nosis could be established, 8 cases proved to be
purely functional (hysteria and neurasthenia). The
rest were organic. In ten cases a diagnosis of lum-
bago or muscular rheumatism was made. Among
other cases to be enumerated below there were three
of chronic nephritis and one of pyelonephritis. This
etiology, however, is rare, though pointed out in the
literature by Lapinsky."
An anatomical classification of other but more
frequent causes of sciatica in our series of cases
will now be presented.
Cerebrospinal cord lesions have been mistaken
for sciatica 13 times; tabes dorsalis, 7 cases; acute
pneumococcus meningitis, 2 cases; cerebrospinal
lues, 1 case; chronic anterior poliomyelitis, 1 case.
In other words, instead of various cerebrospinal
cord lesions, a diagnosis of sciatica was made. To
illustrate at least one instance we will cite the fol-
lowing case:
C. S ., American housewife, age 52, with good habits,
entered the service of Dr. Hassin, complaining of an
acute pain of four months' duration in the back and
down the right thigh and leg, shooting in character,
worse on standing and walking. There was a sense of
constriction about the waist and urination was frequent.
Past history: Rheumatism in right wrist eleven years
ago, pneumonia several times, typhoid fever fifteen
years ago; denies venereal diseases; has had no mis-
carriages; one son is living and well; her husband is
living and well; menstruation is regular. Mother, aunt,
and sister had pulmonary tuberculosis. Physical ex-
amination revealed a well-developed woman with nor-
mal mentality but with Argyll-Robertson pupils and
normal fundi. Positive Kernig and Lasegue signs on
the right side; Achilles absent on the right side but
present on the left; knee jerks and sensibility were
normal; Rhomberg, ataxia, and atrophies were absent.
Wassermann on spinal fluid was strongly positive on
two occasions. Cell count of 5 lymphocytes per cubic
millimeter. Nonne and Noguchi tests were positive.
X-ray examinations were negative. The patient im-
proved markedly under treatment with mercury and
arsenobenzol. This patient did not have sciatica, but
tabes, which was shown by the Argyll-Robertson pupils,
urinary disturbances, lost Achilles reflex, and spinal
fluid findings, and was also confirmed by the results of
the antiluetic treatment.
Diseases of the spinal column: Tuberculosis of
the spinal column was overlooked in two instances;
spondilitis deformans in 11 cases; old fracture of
the spine in 1 case; scoliosis in 2 cases, and kypho-
sis in 1 case. Mild or incipient cases of spondylitis
deformans are more numerous than the other mem-
bers of this group because it is only with the aid
of a Roentgenographic examination that a positive
diagnosis can be made in some cases. To illustrate:
P. T., single, Italian laborer, 34 years old. Com-
plained of pain in the back and left leg of two years'
duration. The present attack began two months ago.
The pain is worse on walking. Past history is negative.
Physical examination revealed moderate tenderness
over the lumbar spines, but the spinal column itself was
not very rigid. There was tenderness along the left
sciatic nerve. The Lasegue sign was positive on ihe
left side. Reflexes and sensibility were normal. There
was no pain on abduction or outward rotation of the
thighs. Examination otherwise was negative. The
x-ray report by Dr. E. Blaine says: "Left transverse
process of fifth lumbar vertebras is large and of butter-
fly outline, which articulates with the upper portion of
the sacrum and ileum — a case of sacrolization. Shad-
ows indicating spondylitis deformans are also present."
The patient left the hospital before any surgical treat-
ment could be carried out, but the case resembles simi-
lar conditions described recently by Shackleton' and
FassetC, who have reported the results after excijion
of these transverse processes.
Conditions of the sacroiliac joint: Tuberculosis
of the sacroiliac synchondrosis was discovered in
5 cases, sacroiliac arthritis in 2 cases, sacroiliac
strain in 5 cases. Dystocia caused symptoms of
sciatica in three instances. A history of trauma or
strain was secured in 24 cases in which sciatica
pain appeared after heavy lifting, contusions to
pelvis or hip, etc.
A. K., American housewife, 28 years old, stated that
for the past twelve years, while washing clothes, etc.,
she had a sharp pain in left hip and difficulty in
straightening up. Four months ago, after dancing une
evening, the pain became worse. At the time of en-
trance pain was present mostly on walking and on ro-
tating the body. The obstetrical history showed that
her first labor was instrumental; her back was weak
after the second labor, which was normal; the history
was otherwise negative. Physical examination: The
patient was very obese; head, chest, and abdomen nor-
mal. Kernig and Lasegue signs were positive on both
sides. Any sudden movement of either th'gh caused
pain in the left hip region, but no pain on abducting the
thighs. On compressing the iliac bones or on direct
pressure there was pain over the left sacroiliac joint.
Pain was present over this region when the patient
raised the right leg while standing on the left leg. Re-
flexes, sensibility tests, and Roentgen examinations
were negative. A diagnosis of sacroiliac strain was
made. After fixation of pelvis and rest in bed patient
improved greatly.
Dec. 9, 1916]
MEDICAL RECORD.
1035
Pelvic lesions comprise the most striking causes
of sciatica symptoms of which we can cite the fol-
lowing conditions: blastomycosis combined with
pelvic abscess, 1 case; retroperitoneal sarcoma, 1
case; carcinoma of pelvic bones secondary to can-
cer of breast, 2 cases; carcinoma of uterus and
pelvis, 1 case; thrombophlebitis of common iliac
vein, 1 case; retroperitoneal abscess, 1 case; ischio-
rectal abscess, 2 cases; fibroid of uterus, 2 cases;
retroversion, 1 case; gonorrheal prostatitis, 1 case.
Of these cases which were all admitted as sciatica,
the most remarkable and unusual are the cases of
blastomycosis and retroperitoneal sarcoma.
P. K., a German laborer, age 32, complained of con-
stant dull, aching pain in right leg of about three weeks'
duration, beginning in the right hip and gradually ex-
tending down the leg, hoarseness and sensation of dry-
ness in the throat, occasional cough, loss of strength and
weight, night sweats, nocturnal urination, and dysuria.
His appetite was good and the bowels were regular.
Patient came to Chicago eight months ago, previous to
which time he had been a farm laborer. The present
illness was first noticed three months before entrance.
Family and venereal histories were negative. He used
tobacco and alcohol moderately. Physical examination
revealed evidences of a pulmonary tuberculosis, al-
though tubercle bacilli were not found in the sputum.
An ulcer the size of a silver quarter was present o l
the right forearm and had been there for one year.
Temperature fluctuated from normal to 101°; pulse 94
to 130, and was weak; respiration 20 to 32. The patient
died after the lapse of a short time in the hospital.
Necropsy by Dr. H. G. Wells demonstrated a pulmonary
and laryngeal tuberculosis, associated with a systemic
oidiomycosis involving especially the lungs, prostrate;,
and sacroiliac synchondrosis. "In the retroperitoneal
tissue of the pelvis there was a fluctuating mass filled
with purulent material extending from the promontory
of the sacrum down through the right obturator fora-
men, the anterior surface of the sacrum was eroded,
and the periosteum was necrotic. A pocket of
eroded bone replaced the right sacroiliac joint. The
nerve trunks of the plexus were eroded. The process
continued through the obturator foramen and about 6 to
8 cm. distally into the thigh, extending upward to the
upper margin of the iliac bone. The left sacroiliac ar-
ticulation was not involved. Microscopic study of the
tissues proved that the case, which clinically and at the
autopsy appeared to be tuberculosis, was one of gen-
eralized oidiomycosis associated with pulmonary and
laryngeal tuberculosis."
A complete report of the case was presented to the
Chicago Pathological Society by Dr. H. G. Wells.
The sciatica symptoms in this case were evidently
due to the involvement of the sacral plexus.
J. D., Swiss teamster, 43 years of age, married, com-
plained of a constant aching pain in the left calf of six
months' duration; the pain has gradually extended to
the left hip in past two months; it keeps the patient
awake at night, but is not aggravated by walking. Ap-
petite is good and the bowels are regular. The history
is otherwise negative. Upon physical examination a
large, firm mass was found on left side of prostate
adjacent to rectum. This mass was not tender and was
not evident on abdominal palpation. There was marked
atrophy of left thigh, which was 10 cm. smaller in cir-
cumference than right thigh. Pain in left hip joint on
manipulation. Tenderness of calf muscles. Steppage
gait with left foot. Reflexes and sensation, urine, and
blood examinations were negative. Wassermann was
positive on spinal fluid, but the latter was otherwise
negative. Roentgen examinations showed bony changes
in the left ischium. A diagnosis of retroperitoneal sar-
coma was made and confirmed by operation which was
done later on to relieve urinary retention and intestinal
obstruction which developed subsequently. The sar-
coma was found in the left side of the true pelvis
pressing upon the rectum and urinary bladder. In this
case a "sciatica" was a symptom of a retroperitoneal
sarcoma.
Hip-joint lesions may be the cause of sciatica
though they are not as frequent in this classifica-
tion as Bruce3 intimates. The following patho-
logical conditions of the hip-joint have been regis-
tered in the hospital records: Tuberculosis of the
hip-joint, 8 cases ; chronic arthritis of the hip-joint,
6 cases; arthritis deformans, 6 cases; acute articu-
lar rheumatism, 3 cases; subacute articular rheu-
matism, 3 cases; chronic articular rheumatism, 3
cases; luetic arthritis of hip, 1 case; gonorrheal
arthritis of the hip, 2 cases; contusion of the hip,
1 case; relaxation of the ligaments of the hip after
an old dislocation, 1 case; old fracture of the neck
of the femur, 2 cases.
Diverse conditions affecting the lower extremi-
ties and causing sciatica manifestations have been
classified in the last group. The records reveal:
Intermittent claudication, 1 case; erythromelalgia,
1 case; metastatic carcinoma of the upper femur
secondary to breast cancer, 1 case; thrombosis of
the femoral vein after typhoid fever, 1 case; acute
periostitis of the femur, 1 case; endothelioma of
the sciatic nerve, 1 case; bullet wound of the sciatic
nerve, 1 case; varicose veins, 3 cases; pes planus,
4 cases.
There were also numerous cases of polyneuritis
which were diagnosed primarily as sciatica. Of
these, 16 were of alcoholic origin, 1 of diabetic, and
1 of typhoid. One case of traumatic neuritis was
recorded. In reference to this group it may be
proper to point out that Quenu" has stated that
sciatica may be due to pressure of varicose veins
upon the sciatic nerve in the neighborhood of the
sacrosciatic foramen.
From the classification of the groups mentioned
above one can see how numerous the causes of so-
called sciatica may be and how imperative it is in
any case of sciatica to attempt to locate the source
of these pains. This is not only absolutely neces-
sary for the sake of a mere diagnosis but, what is
more important, for the purpose of making a cor-
rect prognosis and of instituting proper treatment.
Undoubtedly there are many more etiological fac-
tors instrumental in causing what is commonly
diagnosed as sciatica, but we have attempted to
point out merely those conditions which have oc-
curred in the various services of the Cook County
Hospital in the past four and one-half years.
REFERENCES.
1. Dejerine, J., and Thomas, Andre: "Maladies de la
moelle epiniere," Paris, 1909.
Dejerine, J.: "Semiologie des affections du systeme
nerveux," Paris, 1914, p. 626.
2. Gordon, Alfred: Journal A. M. A., 1910, Vol. LIV,
No. 13.
3. Bruce, Wm. : Sciatica, Aberdeen, 1913.
4. Pitfield: Am. Jour. Med. Sc., 1911, p. 855.
5. Lovett: Journal A. M. A., 1914, Vol. LXII, p. 1615.
6. Lapinsky: Quoted from Oppenheim, Text Book of
Nervous Disease, English translation, 1911, Vol. I, p.
460.
7. Shackleton: Journal A .M. A., Vol. LXV, p. 1600.
8. Fassett: Ibid., Vol. LXV, p. 1775.
9. Quenu: Quotes from Osier's System of Medicine,
1915, Etiology of Sciatica.
Treatment of Severe Hyperemesis Gravidarum. —
Weigh the patient, put her to bed, test urine for acetone,
take blood pressure. If she loses flesh, has acetonuria,
low blood pressure, or fever proceed at once to abortion.
If she is normal, give liquid nourishment in small quan-
tities and often, ice-cold if necessary. Give stomach
lavage for the mental effect. — Jung in Deutsche medizin-
ische Wochenschrift.
Death Rate in Mexico City. — According to the official
bulletin this rate for last March was about 40 per 1,000
inhabitants. The natives suffer at the same period from
respiratory and enteric conditions. Typhus is prevalent
and violent deaths numerous. — Boletin del Coiisejo Su-
perior de Salubridal.
1036
MEDICAL RECORD.
[Dec. 9. 1916
Medical Record.
A Weekly Journal of Medicine and Surgery.
THOMAS L. STEDMAN, A.M., M.D., Editor.
PUBLISHERS
WM. WOOD & CO., 51 FIFTH AVENUE.
See fourth page following reading matter for Rates of Subscription
and Information for Contributors and Subscribers.
New York, December 9, 1916.
THE RELATIONSHIP OF THE DUCTLESS
GLANDS TO DISTURBANCES OF
THE OPTIC NERVE.
Of the ductless glands it is the hypophysis, or
pituitary body, which plays a considerable and sig-
nificant role in the genesis of disorders of func-
tion of the optic nerve. For this reason a brief re-
view of the optic nerve findings in disease (hyper-
trophy or tumor formation) of the hypophyseal
body is very instructive. The mechanical effect of
enlarged hypophysis may result in the production
of heteronymous hemianopsia and the hemianopic
pupillary syndrome. Complete temporal hemi-
anopsia suggests disease of the hypophysis. But
real diagnostic value should also be given to such
findings as heteronymous defects of a quadrant or
octant or even of the color sense alone, as well as
to heteronymous scotomata.
As Schirmer (Journal of Nervous and Mental
Diseases, October, 1916) mentions, injury to the
nerve fibers paralyzes the peripheral fibers first, be-
cause they have the poorest function. It is very-
important to know that the color sense may be dis-
turbed or even lost in many cases before white per-
ception has shown any abnormalities. As a conse-
quence there may be concentric contraction of the
visual fields for color without the fields for white
perception showing any change from the normal
outlines. So great is the power of the nerve fibers
to resist destruction and to recover when the pres-
sure is relieved before actual destruction has taken
place, that in choked disc, in case decompression
has been performed, it is not surprising to find that
there is a period of amblyopia for a week or two or
more, soon to be followed by useful vision. In
these cases, furthermore, it has been discovered
that if the hemianopsia is complete or almost com-
plete the hemianopic pupillary reaction is generally
found present.
Pressure atrophy of the optic nerve may exist,
to be sure, without evidence of hypersecretion or
hyposecretion, as frequently occurs in such condi-
tions as pregnancy, extirpation of the thyroid, in-
fectious diseases, and atrophy of the gonadal sys-
tem. Schirmer observes that the optic nerves may
be affected by the direct chemical action of exces-
sive ductless gland secretion, as in excessive secre-
tion of the thyroid in cases of Graves' disease and
possibly in some cases of pituitary hypersecretion.
In some cases inflammation, in other instances
atrophy may result.
Again we must state that in hypophyseal pres-
sure upon the optic chiasm the color fields may be
distorted or lost before similar changes have taken
place in the white fields, and hence bitemporal
hemichromatopsia may occur early in pituitary-
disease (as in acromegaly). The lesson to be
learned from this point is that one should avoid the
error of pronouncing the fields of vision normal
because the white fields are normal, for, if the color
fields be tested first, the abnormality in this connec-
tion may be noted and early pressure upon the
fibers of the optic nerve thus diagnosed. In all of
our examinations of the disc and the surrounding
structures we should hold well in mind the fact
that from the examination of the eye alone we can-
not and need not make a diagnosis of the etiological
basis of the condition found in the optic disc. Here
the laboratory worker, the neurologist, and the
ophthalmologist should co-operate whole-heartedly
and for the best interests of the patient.
THE TREATMENT OF GONORRHEA BY
ELECTROLYSIS.
Something over two years ago we called attention
to the use of electricity in the abortive treatment
of acute gonorrhea, our remarks at that time being
based upon an article by G. Li Virghi of Naples,
who reported that for about two years he had used
the method which he described in his paper and
that during that time he had treated 92 cases with
100 per cent, of cures. Some of Li Virghi's results
seemed truly remarkable, rapidity of cure being an
outstanding feature in most cases; and in our con-
cluding paragraph we said that if his claims were
verified by other observers a great step forward
would have been made in the treatment of this
treacherous disease.
The verification which we considered to be neces-
sary now seems to have been furnished, for Charles
Russ of London (The Practitioner, September,
1916) reports his results in the treatment by elec-
trolysis of 100 cases of gonorrhea, 69 of which were
of the acute and 31 of the chronic variety. His
confirmation of the value of electrolysis in the treat-
ment of acute gonorrhea is all the more convincing
since it seems certain that these two observers, one
in Naples and the other in London, conceived the
idea of employing electrotherapeutic measures in
the treatment of acute gonorrhea entirely inde-
pendently of each other. Li Virghi's article was
published in Paris, April 15, 1914, but Russ appear*
to have priority of publication, for he published an
article in the Lancet of February 14, 1914, refer-
ring to his research work from 1909 to 1914 on
electrolysis as a means of destroying bacteria and
also detailing the results of his treatment by elec-
trolysis of various types of clinical cases, among
which were two cases of gonorrhea. In the British
Mrdical Journal, June 12, 1915, Russ reported hav-
ing treated 28 cases of gonorrhea by his method;
while in a book entitled, "A New Treatment for
Gonorrhea" (Lewis & Co.. London, 1916) he gives
Dec. !), 1916]
MEDICAL RECORD.
1037
his method in detail and refers to the treatment of
70 cases. With the completion of a series of 100
cases Russ feels that he should again bring the sub-
ject to the attention of the profession, for on the
basis of his experience he considers that his method
marks a distinct advance in the treatment of this
disease. Further confirmation of the value of elec-
trolysis in the treatment of gonorrhea is furnished
by Major E. G. Ffrench in the course of an article
entitled "The Treatment of Venereal Disease in the
Army" (The Practitioner, May, 1916). He states
that some ten cases of gonorrhea have been treated
by Russ' method at the Military Hospital, Roches-
ter Row, S. W., London, and that the treatment
seems worthy of every investigation and will be
very thoroughly tested.
In Russ' series of 69 acute cases the average num-
ber of treatments required was 16, with a minimum
of 5 and a maximum of 34; with 31 chronic cases
the average number of treatments was 20, minimum
14, and maximum 35. In Li Virghi's series of 92
cases there were no complications which he thought
should be attributed to the method, though there
were some which he considered due to forcible in-
jections made by the patients before consulting him.
In Russ' series of 100 cases, acute and chronic, com-
plications occurred in six patients as follows: epi-
didymitis, 4; ophthalmia, 1; arthritis, 1. In the
latter case the patient's doctor had incised a peri-
urethral abscess the day before sending him for
treatment by electrolysis; hence it is a question as
to which is responsible for the metastatic infection.
No cases of stricture have been known to follow
electrolysis in this series.
For details as to the methods of procedure the
reader is referred to the various articles by Li
Virghi and Russ that have already been quoted.
Suffice it to say that there is nothing at all com-
plicated about the treatment, and as the results
were so remarkably good it would seem that the
time has come when electrolytic treatment should
be thoroughly tested in the clinics of some of our
own genitourinary specialists.
TYPHUS FEVER.
Typhus fever, one of the oldest diseases of which
record can be found, was up to two years ago an
almost forgotten malady, at any rate, as an epi-
demic. True, in many countries, in which sanita-
tion was backward, and especially where domestic
hygiene was lacking, typhus was endemic, and, as
First Lieut. Horace C. Hall points out in the Mili-
tary Surgeon, November, 1916, in the Balkans,
Turkey, Persia, Arabia, China, and in Asia gen-
erally typhus has been endemic since the earliest
of folk-lore legends. And within the past three
centuries, along lines of commercial intercourse and
travel, the disease has become largely endemic in
Russia, Poland, Austria, Germany, and Latin
America. But, as said before, there has been no
serious epidemic of typhus fever until war condi-
tions spread the disease through Serbia, and dis-
turbed economic conditions in Mexico disseminated
the infection far and wide in that country. It is a
disease which is spread by neglect of proper sani-
tary precautions and conditions favorable to vermin
also favor the spread of typhus. In fact, it has been
demonstrated that the disease may be transmitted
from man to monkey and therefore presumably
from man to man by means of the common body
louse. While admitting that the body louse does
convey the infection and that the head louse and
bedbug may be regarded as suspicious conveyers,
Hall thinks that it has not been conclusively proven
that vermin are the only means of conveying the
disease. The predisposing causes of typhus are
famine, filth, overcrowding, and conditions favor-
able for the thriving of vermin.
The main means of prevention are to find and
kill the lice and bugs, a difficult task indeed when
dealing with a primitive and dirty people such as
the Mexican peons, the class of individuals among
whom Hall gained his experience.
With regard to treatment it was found that im-
munizing vaccine, so far available, had not been of
any material service. Hall controls the fever with
baths, the delirium with bromides and an iee-cap,
and gives egg albumin in water, even though it has
to be placed in the stomach through a tube passed
through the nose. He gives large broken doses of
calomel, followed by magnesium sulphate and high
enemata which are left in as long as possible. If
the urine is scanty, these enemata are of physiologi-
cal salt solution. He begins the strychnine as a mat-
ter of routine, to combat the muscular weakness
which is certain to follow. An ice-cap is kept on the
patient's head and he is bathed not oftener than
four times within the twenty-four hours. When
the crisis is approaching Hall gives hypodermic
injections of camphor in oil, alternated with spar-
tein sulphate, to tide over the period.
The only specific complication noticed by this ob-
server is that of gangrene of the leg, most com-
monly the left, below the seat of election for ampu-
tation just below the knee. It is a dry gangrene,
extremely painful, and slow to show the line of de-
marcation. In 95 per cent, of such cases it is best
to amputate, as soon as the line of demarcation is
indicated. Hall remarks that in 25 per cent of the
educated, high-strung civilized American patients
he has treated for this disease he has observed a
form of toxic insanity complicating the final out-
come of the cases. This is due, no doubt, to the con-
tinued high fever and severe toxic poisoning. This
insanity is not transitory, that is to say, that while
within a few weeks the reasoning power returns to
nearly normal, there remains a mild delusional in-
sanity for a considerable period.
Sublingual Medication.
One method of administering medicines has, rightly
or wrongly, received very little attention from the
medical profession. This is the practice of placing
a dry tablet containing the drug beneath the tongue
in the sublingual space and having the patient hold
it there without swallowing until the taste disap-
pears. This method is strongly recommended by
Paulson (Practitioner, 1916, XCVII, 389) and is
enthusiastically endorsed by Cooper (Ibid, page
493). These writers are apparently of the opinion
that absorption from the sublingual space takes
1038
MEDICAL RECORD.
[Dec. 9, 1916
place more quickly than from any other portion of
the body, though probably they would admit that
medication injected intravenously would exert its
action more rapidly. It is difficult to get informa-
tion on this question. Most of the standard works
on physiology either fail to mention the mouth as
a place where absorption may occur or else say that
its structure is unsuited for absorption. Indeed,
when one considers that the submaxillary and sub-
lingual glands both empty their secretions into the
sublingual space it is diffieuult to see how absorp-
tion in this area could be very rapid or complete.
It should not be a very difficult matter to investi-
gate this question experimentally both in man and
in animals. Only in this way can we obtain exact
information. The method offers so many advan-
tages that it would be well worth investigation. The
authors claim that it surpasses hypodermic injec-
tion in rapidity and effectiveness and it certainly
does excel in ease and simplicity. The doing away
with the necessity for the sterilization of a hypoder-
mic syringe would be a great help to all of us and
we hope that the method will be thoroughly tried
out and its usefulness or worthlessness fully
demonstrated.
A New Sign of Sciatica.
None of the evidences of sciatica, such as pain
over the nerve, Lasegue's sign, muscular atrophy,
modifications of electrical reactions, scoliosis, ele-
vation of the heel in walking, fibrillary contrac-
tions of the leg muscles, clonus of the glutei, abo-
lition of the Achilles reflex, lessening of the gluteal
fold, etc., is in itself pathognomonic of the disease
in question, and in a given case some of them will
be absent all the time. Hence, a true pathogno-
monic sign would prove of great value in cases
where rapid and certain diagnosis is necessary.
Pisani believes that he has discovered such a sign
in connection with the behavior of the abdominal
reflex on the affected side (Malpighi, July 1-15).
He has found this to be the predominating
symptom in every case thus far examined. It con-
sists in the fact that the reflexes are less pronounced
or absent on the sound side. The superior, median,
and inferior reflexes should all be tested. The pa-
tient lies on his back with his abdominal walls
fully relaxed, and the limbs extended symmetrical-
ly. The predominance of the reflex on the affected
side is not in itself strictly pathognomonic, but is
found in over 80 per cent, of all patients examined;
while the presence of this phenomenon in non-sci-
atic cases means some condition which could never
be confounded with sciatica, so that the sign has
all the force of actual pathognomonic symptoms.
As already stated no negative results have yet ap-
peared.
Cerebrospinal Meningitis in Geneva.
Historians teach us that epidemic cerebrospinal
meningitis is first known to have occurred in the
spring of 1805, when it prevailed to a notable ex-
tent in Geneva. In the following year, Vieusseux,
a Genoese physician, wrote the first account of the
new malady. The number of fatalities inside the
city walls was 33. The first cases occurred outside
the walls, in one of the forlorn suburbs. According
to Mallet there has never been another epidemic of
the disease in Geneva up to the present time (Revue
me'dicale de la Suisse Romande, July 20.) Sporadic
cases occur, but have never shown cumulation, nor
could any case be imputed to contagion. The vital
statistics go back to 1871, and from that year to
1900 but nine cases were reported, all fatal. From
1900 to 1910 there were 25 cases, the increase hav-
ing been associated partly with the diagnostic en-
richment of lumbar puncture. From 1910 to 1916
the number of cases was 21, and 6 of these occurred
last June, while the total for 1915 was 9. In other
words, there has been an incidence of 15 cases in.
the past 18 months. To offset these figures there
were no cases in 1911 and 1913. A further analysis
showed the existence of maxima in 1904, 1908 and
1914-15, periods which correspond to the great
military mobilizations. The great fatality of the
disease has abated since 1910, when serotherapy
was introduced. Evidence has accumulated that
the disease is spread by carriers. It seems extraor-
dinary at first sight that a disease which first ap-
peared in epidemic incidence in a close community,
and which has appeared sporadically in the latter
for at least 45 years, has never since exhibited
epidemicity. The increased incidence of the past
18 months may indicate the approach of an epi-
demic, but Mallet thinks it more likely that it will
be succeeded by a sudden decline.
NftttH of tip? Wssk,
The New York Diagnostic Society, having for
its object the .establishment of institutes for group
diagnosis, was recently organized in New York,
partly, at least, as the result of a suggestion made
by Dr. Charles H. Mayo of Rochester, Minn. Speak-
ing before the Catholic Hospital Society at Mil-
waukee a short time ago Dr. Mayo expressed the
opinion that the one great present day need in hos-
pital advancement was a hospital devoted entirely
to diagnosis. The officers of the society are: Presi-
dent, Dr. M. Joseph Mandelbaum; Vice-Presidents,
Dr. De Witt Stetten and Dr. Otto Hensel; Treas-
urer, Dr. Julius Auerbach; Secretary, Dr. Monroe
Atinstler.
Pasteur Exhibit. — In connection with the meet-
ing of the American Association for the Advance-
ment of Science in New York during Christmas
week preparations are being made for an exhibi-
tion of objects relating to the work of Louis Pas-
teur. Letters, manuscripts, pictures, microscopic
preparations, and other material are desired by the
committee in charge, and it is requested that any
one willing to loan such exhibits communicate with
Prof. C.-E. A. Winslow, American Museum of Na-
tional History, Seventy-seventh Street and Central
Park West, chairman of the subcommittee, or with
Prof. J. G. Hopkins, College of Physicians and Sur-
geons, 437 West Fifty-ninth Street, New York.
War on Heart Disease. — Following the organi-
zation of the Association for the Prevention and
Relief of Heart Disease, the New York Post-Grad-
uate Hospital recently announced the formation of
a special committee to aid the work of its cardiac
department. The committee will assist the visiting
nurses and the social service workers, who now visit
the heart patients in their homes, see that they are
properly cared for and aid them when necessary in
finding work suitable to their physical condition.
New Home for Nurses. — Plans have been filed
with the New York Building Department for the
erection of a seven-story fireproof home for nurses
of the New York Eye, Ear, and Throat Hospital.
The home will be located in the rear of the hospital
building, with a frontage of 125 feet on the north
Dec. 9, 1916]
MEDICAL RECORD.
1039
side of Sixty-third Street. It is estimated that the
cost will be $275,000.
Street Accidents. — During the month of No-
vember, 1916, there occurred 65 deaths in traffic
accidents in New York City, an increase of 19 over
the number for November, 1915. Of these, 42
fatalities were due to automobile accidents, as com-
pared with 18 a year ago. Of those killed, 32 were
children. In the State outside of New York City,
during the month 37 persons were killed by automo-
biles, 4 by trolleys, and 4 by wagons, a total in-
crease of 14 over the figures for last year. In New
Jersey, the figures for the month were 20 persons
killed by automobiles and 4 by trolleys and wagons.
The Safety First campaign needs reviving.
Personals. — Dr. Abraham Jablons of New York
has been commissioned lieutenant-surgeon of the
White Cross Hospital and Relief Association.
Dr. M. Joseph Mandelbaum was the guest of
honor at a dinner given by the New York Diagnos-
tic Society in the Astor Gallery of the Waldorf-
Astoria on Tuesday evening, December 5.
Presentation of Dr. Raymond's Portrait. — On
Monday, December 4, the graduating class of the
Long Island College Hospital presented to the col-
lege a photographic portrait of the late Dr. Joseph
H. Raymond, formerly .secretary of the Faculty
and professor of hygiene. Dr. John D. Rushmore
made the address of acceptance.
Southern Medical Association. — At the annual
meeting of the association held in Atlanta, Ga., on
November 16 and 17, Dr. Duncan Eve, Nashville,
Tenn., was elected President, and Dr. Stewart R.
Roberts, Atlanta, Ga. and Dr. Bransford Lewis, St.
Louis, Mo., first and second Vice-Presidents re-
spectively. Dr. Searle Harris, Birmingham, Ala.,
was re-elected Secretary-Treasurer, and editor of
the Southern Medical Journal. Memphis was se-
lected as the next place of meeting. Announcement
was made at the closing session that the sum of
$10,000 had been subscribed to pay off the indebted-
ness on the Journal.
Penobscot County (Me.) Medical Association. —
The sixty-second annual meeting of this society was
held at Bangor on November 16, when the following
officers were elected: President, Dr. William P.
McNally, Bangor; Vice-President, Dr. J. B. Thomp-
son, Bangor; Secretary-Treasurer, Dr. Harris J.
Milliken, Bangor.
Obituary Notes. — Dr. Charles Louis Beil of
New York, a graduate of Bellevue Hospital Medical
College, New York, in 1898, and a member of the
Medical Society of the State of New York and the
New York County Medical Society, died on Novem-
ber 30, aged 40 years.
Dr. Henry Jonathan Dearborn of Mount Sterl-
ing, 111., a graduate of Rush Medical College, Chi-
cago, in 1888, died at his home on October 29, from
cerebral hemorrhage, aged 51 years.
Dr. Frank Kerrick Green of Louisville, Ky., a
graduate of the Medical Department of the Uni-
versity of Louisville, in 1899, died at Perryville, Ky.,
on October 26, aged 46 years.
Dr. Romeo O. Keiser of Columbus, Ohio, a grad-
uate of Ohio Medical University, Columbus, in 1898,
and of the Cleveland-Pulte Medical College in 1899,
died at his home on November 1, aged 46 years.
Dr. John T. Dunn of Pasadena, Cal., a graduate
of the Medical School of the University of Minne-
sota, Minneapolis, in 1904, died on October 26. aged
37 years.
Dr. John Edwin Walker of Thomaston, Me., a
graduate of the Medical School of Maine, Port-
land, in 1884, and a member of the Maine Medical
Association and the Knox County Medical Society,
died on November 22, aged 58 years. Dr. Walker
was State prison physician of Maine for twenty-six
years.
Dr. William Finder, Jr., of Ballston Spa., N. Y.,
a graduate of Long Island College Hospital, Brook-
lyn, in 1882, and of Columbia University College
of Physicians and Surgeons, New York, in 1883,
died at his home on November 20, aged 61 years.
Dr. Henry Selden Norris of New York, a grad-
uate of New York University Medical College in
1876, and a member of the American Medical Asso-
ciation, the Medical Society of the State of New
York and the New York County Medical Society,
and consulting specialist at Bellevue Hospital, died
at his home on November 19, aged 69 years.
Dr. Abner Hayward of Mount Clemens, Mich., a
graduate of Cleveland University of Medicine and
Surgery in 1866, died at his home on October 28,
from cerebral hemorrhage, aged 86 years.
Dr. David Johnson Culver of Harrisville, N. Y.,
a graduate of the University of Vermont, College
of Medicine, Burlington, in 1881, and a member
of the American Medical Association, the Medical
Society of the State of New York, and the Lewis
County Medical Society, died at his home on Octo-
ber 29, from arteriosclerosis, aged 60 years.
Dr. William McMann of Gardner, 111., a mem-
ber of the Illinois State Medical Society and the
Grundy County Medical Society, died at his home
on October 24, aged 78 years.
Dr. Cecil C. Kimmel of Fort Wayne, Ind., a
graduate of the Indiana Medical College, School of
Medicine, of Purdue University, Indianapolis, in
1907, and a member of the American Medical As-
sociation, the Indiana State Medical Association
and the Allen County Medical Society, died at the
Lutheran Hospital, Fort Wayne, on October 18,
from pneumonia, aged 34 years.
Dr. John B. Armstrong of Chicago, 111., a grad-
uate of the New Orleans School of Medicine in
1869, died at his home on November 8, from heart
disease, aged 69 years.
Dr. Jonathan Henry Woods of Brookline, Mass.,
a graduate of the Long Island College Hospital,
Brooklyn, in 1880, and of Columbia University, Col-
lege of Physicians and Surgeons, New York, in 1881,
and a member of the American Medical Association,
the Massachusetts Medical Society, and the Nor-
folk District Medical Society, died at his home on
November 16, after a short illness, aged 66 years.
Dr. Harry W. Weyant of Philadelphia, a gradu-
ate of the University of Pennsylvania, School of
Medicine, Philadelphia, in 1895, and a member of
the Medical Society of the State of Pennsylvania
and the Philadelphia County Medical Society, died
at his home on November 2, from pneumonia, aged
47 years.
Dr. Hiram M. Winn of Sterling, Okla., a gradu-
ate of the College of Physicians and Surgeons, Keo-
kuk, in 1892, died at his home on October 16, aged
64 years.
Dr. William G. DuBois of Camden, N. J., a grad-
uate of the Hahnemann Medical College and Hos-
pital of Philadelphia in 1880, died at his home on
October 28, aged 59 years.
Dr. Albert Philip Ohlmacher of Detroit,
Mich., a graduate of the Northwestern University
Medical School, Chicago, in 180, and a member of
American Medical Association, the Michigan State
1040
MEDICAL RECORD.
[Dec. 9, 1916
Medical Society, and the Wayne County Medical
Society, died at his home on November 10, aged
51 years.
Dr. Joseph Hammond Huston of Clintondale,
Pa., a graduate of Jefferson Medical College of
Philadelphia in 1866, and a member of the Medi-
cal Society of the State of Pennsylvania and the
Clinton County Medical Society, died in the Lock
Haven Hospital on October 26, from disease of the
bladder, aged 78 years.
Dr. John W. Webster of Siloam Springs, Ark.,
a graduate of Missouri Medical College, St. Louis,
in 1884. and a member of the Arkansas Medical
Society and the Benton County Society, died at his
home on October 21, aged 69 years.
Dr. Elmer G. Myers of Canton, Ohio, a gradu-
ate of Starling Medical College, Columbus, in 1889,
died at his home on November 4, from rheumatic
endocarditis, aged 53 years.
Dr. Edwin A. Lex of Irvington, Ky., a gradu-
ate of the Medical Department of Kentucky Uni-
versity, Louisville, in 1903, died in St. Joseph's In-
firmary, Louisville, on October 26, from typhoid
fever, aged 40 years.
Dr. Peter J. McCahey of Philadelphia, a gradu-
ate of Jefferson Medical College of Philadelphia in
1885, died at his home on October 22, from heart
disease, aged 60 years.
Dr. FENTON D. Drewry of Virgilina, Va., a
graduate of the Medical College of Virginia, Rich-
mond, in 1898, and a member of the Medical So-
ciety of Virginia and the Halifax County Medical
Society, died at the Sara Leigh Hospital, Norfolk,
following an operation for appendicitis, on October
18, aged 39 years.
Dr. Asa M. Stackhouse of Moorestown, N. J., a
graduate of the Hahnemann Medical College and
Hospital of Philadelphia in 1868, died at his home
on October 6, aged 72 years.
Dr. Richard Frederick Winsor of Omaha. Neb.,
a graduate of the University of Illinois, college of
Medicine, Chicago, in 1906, and a member of the
Illinois State Medical Society, the Nebraska State
Medical Association, the Douglas County Medical
Society, and the American Medical Association,
died at his home on October 21, from pneumonia,
aged 36 years.
Dr. Gilman Corson Dolley of Manila, P. I., a
graduate of the Medico-Chirurgical College of
Philadelphia in 1907, a member of the United States
Army and resident physician at the United State?
Leprosarium Culion, Palawan, died in Manila on
October 21, from pneumonia, aged 37 years.
Dr. Andrew L. Marugg of Spechts Ferry, Iowa,
a graduate of the Northwestern University Medi-
cal School, Chicago, in 1898, died in the Mercy
Hospital, Dubuque, Iowa, on October 31 from pneu-
monia, aged 42 years.
Dr. Oliver C. Ormsby of Rexburg. Idaho, a grad-
uate of Rush Medical College, Chicago, in 1870, died
at his home on October 26, from cerebral hemor-
rhage, aged 73 years.
Dr. Marvin Fisher Smith of Hampton, N. H.,
a graduate of Dartmouth Medical School, Han-
over, N. H., in 1883, died at his home on October
31, aged 64 years.
Dr. Wade H. Chase of Rutland, Ohio, a graduate
of the Starling Medical College Columbus, Ohio, in
1897, died at his home on October 8, from carci-
noma, aged 56 years.
Dr. Louis Edward Gott of Falls Church, Va., a
graduate of the University of Maryland, School of
Medicine, Baltimore, in 1861, and a member of the
Medical Society of Virginia and the Fairfax County
Medical Society died in the Georgetown University
Hospital, Washington, on October 29, from pros-
tatic disease, aged 76 years.
Dr. Lewis A. Burck of Frederick, Md., a grad-
uate of Atlantic Medical College Ealtimore, in 1895,
and a member of the Medical and Chirurgical Fac-
ulty of Maryland and the Frederick County Medical
Society, died in the City Hospital of Frederick on
October 16, from cerebral hemorrhage.
Dr. John F. Maddox of Orlando, Fla., a graduate
of the Eclectic Medical College, Cincinnati, in 1877,
died in Edinburg Ind., on October 18, from cerebral
hemorrhage, aged 71 years.
Dr. Henry D. Long of New York, a graduate of
Johns Hopkins University Medical Department,
Baltimore, in 1903, and a member of the American
Medical Association, the New York State and
County Medical Societies, and the New York
Academy of Medicine, died at his home on October
22. from septicemia, aged 40 years.
Dr. William Lee McKibben of Amaranth, Pa.,
a graduate of the University of Pennsylvania,
School of Medicine, Philadelphia, in 1869, died at
his home on October 12, from injuries received by
a fall, aged 79 years.
Dr. Horace William Johnson of Little Rock,
Ark., a graduate of the Northwestern Medical Col-
lege, St. Joseph, in 1886, died in a hospital in Little
Rock on October 14 aged 64 years.
Dr. Merari B. Stevens of Defiance, Ohio, a grad-
uate of the University of Michigan Medical School,
Ann Arbor, in 1869, and a member of the American
Medical Association, the Ohio State Medical Asso-
ciation, and the Defiance County Medical Society,
died at his home on October 19, from heart disease,
aged 73 years.
Dr. P. D. SPIRON of Collinsville, 111., a graduate of
the National Medical University, Chicago, in 1898,
died in his office on November 4, aged 50 years.
Dr. Henry L. Gosling of Washington, D. C, a
graduate of George Washington University Medi-
cal School, Washington, in 1886, died at his home
on November 1, aged 61 years.
Dr. Harriet D. W. Showers of Meridian, Miss.,
a graduate of Cornell University Medical College,
New York, in 1900, died in Brooklyn, N. Y., on No-
vember 29, aged 47 years. Dr. Showers had been
resident physician of the Women's College in
Meridian for eight years.
Dr. John Halsey Benjamin of Riverhead, L. I.,
a graduate of Bellevue Hospital Medical College,
New York, in 1876, and a member of the Medical
Society of the State of New York, the Suffolk
County Medical Society, and the Associated Physi-
cians of Long Island, died on November 26, aged 61
Dr. James O. Green of Long Branch, N. J., a
graduate of Bellevue Hospital Medical College, New
York, in 1866, died recently in Long Branch, aged
76 years.
Dr. George Douglas Ramsay of Newport. R. I.,
a graduate of Tulane University of Louisiana,
School of Medicine, New Orleans, in 1896. and a
member of the American Medical Association, the
Rhode Island Medical Society, the Newport County
Medical Society, and the Medical Reserve Corps,
died at his home on November 27, aged 47 years.
Dr. O. J. Shepardson of Chester, Mass., died in
the Springfield Hospital on November 24, aged 64
years.
Dec. 9, 1916]
MEDICAL RECORD.
1041
(Dbituarg.
ALICE MITCHELL, M.D.
WOODSTOCK, INDIA.
Dr. Alice Mitchell, principal of Woodstock Col-
lege, India, died after an operation for goitre, at
the Augustana Hospital, Chicago, 111., on Tuesday,
November 21, aged 54 years. Dr. Mitchell was
born in Morristown, N. J., and was graduated from
the Woman's Medical College of the New York In-
firmary in 1885. She was appointed an interne in
the Presbyterian Hospital of Chicago, 111., and was
the first woman in this country, if not in the world,
to occupy the position of hospital interne on an
equal standing with men physicians. On the ma-
ternal side she was the granddaughter of Dr.
Charles Alfred Post of New York City, and pos-
sessed by inheritance a strong bent toward sur-
gery. From her father, Rev. Arthur Mitchell, she
inherited the initiative, executive ability, the strong
faith, and zeal for missions which so characterized
her work.
Her experience as a surgeon began at the time of
the Haymarket riots in 1886, when explosive bullets
were a new weapon in warfare, and many victims
of these bombs were brought to the Presbyterian
Hospital. During her term of service as interne
she was admitted by special courtesy of Dr. Mal-
colm Gunn to his clinics at Rush Medical College,
where the pitiable plight of women who were to be
operated on with no member of their own sex pres-
ent excited her sympathies, and she was able to in-
duce the authorities to allow a nurse to accompany
women patients to the clinic operating table — a cus-
tom since generally adopted. In 1895 she sailed for
India as a missionary under the Presbyterian Board
of Foreign Missions, and took the position of resi-
dent physician as well as that of an instructor at
what was then Woodstock School. Besides the de-
velopment of adequate care of the sick and pre-
ventive measures which reduced the sweeping epi-
demics which had formerly so often more or less
disorganized the school work, her judgment and
prompt action at one time checked the spread of
cholera which had broken out in the adjoining vil-
lage and threatened the school when a servant
brought the infection there and died of it. As the
years went on her time was more and more claimed
by the educational and executive side of her work,
although she never gave up her medical activities
entirely, even when she was finally appointed prin-
cipal of what is now Woodstock College.
the service to civil practice have remained in on
active duty in the Medical Reserve Corps. The in-
efficients have long ago been weeded out or re-
signed, and those who have continued on duty (lia-
ble at any time to be relieved from active duty)
have emphatically made good or they would not
have been retained. They are and have been used
interchangeably on any duty with captains or
majors of the Medical Corps, except that their lack
of rank has generally given them the more unde-
sirable stations, and at these stations the most un-
desirable quarters, as they take rank after all other
first lieutenants in the army, and a second lieuten-
ant is a rare bird at the present time.
They are the only officers in the army who re-
ceived no benefit whatever from the recent legisla-
tion. The Dental Corps were jumped over the Med-
ical Reserve Corps and given proper recognition,
promotion, and retirement. The Veterinarians the
same, and the Philippine Scout officers have pro-
motion to captaincies with retirement (these were
former enlisted men, and compared with the Med-
ical Reserve Corps officers their educational re-
quirements were trivial). Even the non-commis-
sioned officers of the Hospital Corps gained two new
grades of hospital sergeant and master hospital
sergeant. The only corps absolutely ignored was
the active list of the Medical Reserve Corps. That
conditions of their service are unsatisfactory is am-
ply testified to by the number of resignations and
requests for inactive assignment among the newer
men ; the older ones with ten or more years of active
service behind them have no practice to return to
and so continue to render the same service for
which their colleagues in the Medical Corps re-
ceive major's rank pay, and prospective retirement.
A bill has been introduced to correct this mani-
fest injustice by commissioning the former con-
tract surgeons who have been active Medical Re-
serve Corns officers since 1908 as captains in the
Medical Corps, but unless the American Medical
Association takes an interest in the matter as did
the Dental Association for the Dental Corps, and
the Veterinary Association for their men, nothing
will come of it, and these trained officers of long
and excellent service will be lost in the new medical
section of the Officers Reserve Corps.
One of Tkem.
MEDICAL RESERVE CORPS, U. S. A.
To the Editor of the Medical Record:
Sir: — In your editorial comment, issue of October
21, 1916 (Vol. 80, No. 17), you take the viewpoint
always taken by the Medical Corps in regard to
the Medical Reserve Corps, which relates to the
large inactive list of those who contemplate service
in time of war only, entirely ignoring the small
body of Medical Reserve Officers who have devoted
their life to the army active service.
For one reason or another, usually the age limit,
they come in as contract surgeons for temporary
service (some were captains and majors during the
Spanish-American War and Philippine Insurrec-
tion with volunteer organizations) and preferring
OUR LONDON LETTER.
(From Our Regular Correspondent.)
medical society president's address— royal so-
ciety OF MEDICINE — OBSTETRICAL SECTION — RE-
NAL CALCULI — ACCIDENTAL HEMORRHAGE — ACUTE
TOXEMIA OF PREGNANCY — CESAREAN SECTION
WITH HYSTERECTOMY.
London, November 4, 1916.
At the opening meeting of the Medical Society of
London's new session, announced in my last, the new
president, Lieut.-Col. D'Arcy Power, F.R.C.S., de-
livered his address, taking as subject "John Ward
and His Diary." This Ward was the vicar of Strat-
ford-on-Avon, whose 16 notebooks are one of the
prized possessions of the Medical Society. From
them Dr. Severn's extracts made in 1839 have so
far been the only authority, so that Mr. Power's
further notes on them will be welcomed by all in-
terested by our earlier contributions. They are
not ordinary diaries, Vut would be rather classed as
commonplace books of an author residing at Oxford
from 1652 to 1660, at which time most of the origi-
nal members of the Royal Society were also there
1042
MEDICAL RECORD.
[Dec. 9, 1916
resident. Ward was intimate with many of them
and seems to have assisted several in their work.
His notes, therefore, may be regarded as of special
interest as those of a resident graduate at a period
of great importance in the university's history.
William Harvey was there working with Dr.
Bathurst on incubation. Dr. Willis was in practice
near Christ Church, with his two assistants (Lower
and Wren). Dr. Wallis, friend of Pepys, was work-
ing at the circulation of the blood. Barlow was
studying oriental languages at the Bodleian. Ward
went to London and studied medicine for a year or
two, but eventually he entered the Church, and in
due course became vicar of Stratford-on-Avon.
At the obstetrical section of the Royal Society
of Medicine some interesting specimens have been
exhibited and three papers read.
A lipoma of the broad ligament was shown by Dr.
Griffith which weighed 13 pounds. At the operation
it was found to be retroperitoneal and extended from
the right broad ligament to the under surface of
the liver. The capsule was incised and the tumor
gradually enucleated from above downward. The
chief vessels were found down in the pelvis, where
the tumor had exposed the right side of the cervix
and uterus. The cavity left was closed by a purse-
string suture and the abdomen closed without drain-
age. Good recovery followed. The tumor was com-
posed of adipose tissue and fibrous tissue-strands.
Only two other specimens of lipoma of the broad
ligament seem to have been recorded.
Dr. Hubert Roberts showed a large calculus of the
ureter, removed by abdominal section. It weighed
275 grains. The patient, female, aged 30, had been
in several hospitals from the age of 17 with symp-
toms which suggested renal calculus or tubercle.
In 1914 patient was pregnant; after delivery she
was not seen until June, 1916, when she was ad-
mitted to hospital. The stone was felt as a mass
to the right of the cervix, painful to the touch, and
fixed. Laparotomy was done and the ureter seen,
much dilated and thickened. It was incised after
temporary clamping, the stone removed, and drain-
age made by an opening in Douglas' pouch
through to the vagina, uninterrupted recovery fol-
lowing.
A large vesical calculus, 3% oz. in weight, was
shown for Mr. Frank Belben. It had formed round
a slate pencil, which the patient, a female of 17,
had introduced into the urethra on account of irri-
tation, and it had slipped into the bladder two years
ago. It was discovered by cystoscopic examination
and removed by suprapubic cystotomy. Another
smaller stone was also found and removed at the
same time. Some difficulty was met with the larger
stone as the bladder had contracted round it and
the pencil had ulcerated into the vesical wall, but
this was overcome, removal completed, and the pa-
tient made a good recovery.
Dr. Hubert Roberts showed an instrument, the
invention of the late Dr. Wallace, for opening Doug-
las' pouch per vaginam, during an abdominal op-
eration.
Dr. Cuthbert Lockyer showed a series of calculi
removed from four patients: (1) a small one from
the upper ureter removed by abdominal section, in-
cising the pelvis of the kidney, pushing the stone up
to the incision, and extracting it. (2) Two calculi
from lower end of ureter of a woman aged 63, who
was under operation for a uterine fibroid and a
solid ovarian tumor. The entire ureter was re-
moved after clamping both ends. A perinephric
abscess formed, which had to be opened and drained,
somewhat prolonging convalescence. (3) A calculus
from a patient from whom previously had been re-
moved the uterus, part of the rectum, and part of
the vagina. It had formed at the rectovaginal
junction in consequence of an uteric fistula and was
removed per vaginam. (4) A large calculus, 5%
inches in circumference, from a case of vesico-
cervico-vaginal fistula following a difficult labor.
It was removed during on operation for closing the
fistula.
Some remarks on this case were made by Dr. H.
Roberts, Mr. D. Drew, and Dr. Griffith, after which
three papers were read: (1) "Concealed Accidental
Hemorrhage with Intraperitoneal Bleeding." by Dr.
McNair; (2) "Acute Toxemia of Pregnancy," with
accidental hemorrhage treated successfully by
cesarean hysterectomy, and (3) "Cesarean Section
with Hysterectomy for Accidental Hemorrhage," by
Drs. Oldfield, Hann, and Fletcher Shaw.
CANADIAN LETTER.
(From Our Special Correspondent. )
POLIOMYELITIS IN CANADA — COLONEL BRUCE'S REPORT
ON CANADIAN HOSPITALS IN ENGLAND — NEW
MILITARY CONVALESCENT HOSPITAL AT WHITBY,
ONTARIO — MEETING OF THE CANADIAN ASSOCIA-
TION FOR THE PREVENTION OF TUBERCULOSIS —
MEETING OF THE SASKATCHEWAN MEDICAL ASSO-
CIATION— A CANADIAN SOCIETY IN PARIS — THE
PROBLEM OF THE TUBERCULOUS SOLDIER— OPEN-
ING OF A CONVALESCENT HOME IN HALIFAX —
PROHIBITION IN MANITOBA — OBITUARY.
Toronto. November 18. IS 16
Poliomyelitis, although not by any means preva-
lent in parts of Canada, is not extinct. New cases
continue to crop up here and there. In Montreal
and in other points in the Province of Quebec there
are several cases. Indeed, the Ontario Board of
Health have taken drastic steps to prevent the dis-
ease from being conveyed into Ontario. Dr. J. W.
S. McCullough, Provincial Officer of Health, has
sent the following notice to the railway companies :
"Please take notice that the Provincial Board of
Health of Ontario requires that all persons under
sixteen years of age coming from points in the
Province of Quebec to points within the Province
of Ontario must have a medical certificate dated
within 24 hours of the time of departure that
they are in good health and have not been ex-
posed to infantile paralysis. In addition to notify-
ing the railway officials, Dr. McCullough has sent
to Montreal Dr. P. J. Moloney, District Officer of
Health, to make an investigation of conditions. If
the situation seems to demand such a procedure,
it is likely that special officers will be appointed to
see that the railway companies are observing the
order. As to the extent of the epidemic, if it may
be termed an epidemic, in Montreal there is no
very definite evidence. Official reports, however,
show but ten cases.
Somewhat interesting testimony has been af-
forded as to the ignorance which prevails with
regard to the manner in which poliomyelitis may be
conveyed. It has been suggested that the disease
was brought into Montreal by the agency of dogs
from New York. This suggestion was rightly
flouted by Dr. C. J. 0. Hastings, Medical Officer of
Health, who said that while the disease might be
transmitted by domestic pets, dogs, and particularly
big dogs, are not, as a rule, greatly petted by small
Dec. 9, 1916]
MEDICAL RECORD.
1043
children. He pointed out that in taking precautions
against the spread of infective poliomyelitis they
were acting not so much on what they knew as on
what they did not know.
Col. Herbert Bruce, Inspector General of the
Canadian Medical Service, in the course of a re-
port he has made recently with respect to the con-
duct of the Canadian hospitals in Great Britain
and the care taken generally of wounded and sick
Canadian soldiers in that country, criticizes the
system in vogue inasmuch as there has been no
medical inspection by the Canadian Army Medical
Service of Canadian Soldiers in Imperial hospitals,
and no efficient medical inspection of Canadian
hospitals. As a consequence of this neglect Ca-
nadian soldiers are retained in hospitals in Great
Britain, many of whom should have been returned
to duty and others should have been returned to
Canada, where they could have been more eco-
nomically and efficiently treated. Other details of
the present system are adversely commented on
with regard to the question of segregation for
Canadian soldiers, a point upon which particular
stress has been laid in the report, opinions appear
to differ considerably. However, after all it is a
matter which rests almost wholly with the Ca-
nadian Government and the military authorities.
If segregation is deemed to be to the best interests
of the soldiers themselves and consequently to those
of the country, then segregation should be intro-
duced and established. New brooms sweep clean
and perhaps new brooms were needed so far as
the management of the Canadian hospitals in Great
Britain were concerned.
The arrangement has practically been concluded
whereby the extensive buildings and their equip-
ment known as Whitby Institution for the Insane
will be turned over to the Canadian Military Hos-
pitals Commission for the treatment and care of
returned soldiers during their period of convales-
cence. By this arrangement, it is understood, the
Whitby Institution, as soon as the buildings already
erected are ready for occupancy, will become the
centralization point within the Province of On-
tario for convalescent soldiers. This is in accord^
ance with the policy of the Military Hospitals Com-
mission to concentrate at a certain selected point
within each province the work of caring for con-
valescent men returned from service overseas.
At the Whitby Institution 1,200 convalescents, or
men suffering fram physical disabilities, total or
partial, excepting, of course, men with tuberculosis,
will be accommodated. The buildings, which are
several in number, are beautifully situated on high
ground overlooking Lake Ontario, and are especially
well adapted in all respects to the purpose for which
they will be used.
Slight reference was made in a previous letter
to the fifteenth annual meeting of the Canadian
Association for the Prevention of Tuberculosis
which was held in the Hotel de Ville, Quebec, on
September 12 and 13, under the presidency of
Senator J. W. Daniel, M.D., of St. John, New
Brunswick. The importance of the meeting, how-
ever, calls for a more extended account of its doings
or rather the fifteenth annual report of the Ex-
ecutive Council is deserving of closer attention.
The report was read by its energetic secretary,
Dr. G. D. Porter of Toronto, to whose efforts, by
the way, the success of the Association is largely
due. Among the many statements of interest in
the report is that in 1908 there were only 250
special beds for patients suffering from tubercu-
losis available in the whole of Canada. In 1911
there were 900, while at the present time there are
2,000 among the various special hospitals and sana-
toria throughout the Dominion. The report goes
on to state that the necessity for this increase,
which is as yet far from sufficient, is most apparent
and as the number of returned soldiers who have
developed tuberculosis at the front are added to
the number already in the country, the need for
further accommodations will be still greater. The
fact must be borne in mind that the strenuous try-
ing life of the trenches, together with the con-
tinual nervous and physical strain of this most mod-
ern warfare, the prolonged exposure, and the effects
of inhaling the German gases will inevitably in
many instances bring on tuberculosis to those pre-
disposed. All these untoward happenings will
lower vitality and leave the system open to the in-
vasion of the germs of tuberculosis, or what is far
more frequent, will arouse and develop latent seeds
of the disease. Colonel Primrose has already re-
ported from the front that in a large percentage
of the cases examined, which proved to be tuber-
culous, it was obvious that an active condition had
been engrafted upon a healed lesion. Consequently,
there is little doubt that the measures of relief for
the tuberculous instituted in Canada in the past
will be most useful in the future when a larger
number of such cases may be looked for.
The ninth annual meeting of the Saskatchewan
Medical Association took place at Regina on July
18 and 19. The meeting was very successful. Dr.
George P. Bawden of Moose Jaw delivered the
presidential address. Dr. Myers of Saskatoon read
an instructive paper entitled "The Returned Dis-
abled Soldier," in which, referring to the problem
of providing for the disabled soldier on his re-
turn to Canada, Dr. Myers expressed the opinion
that the solution of this problem should not be left
entirely to the Military Hospitals Commission, but
that each individual should take his share of the
responsibility. Up to July 13, 1916, 236 disabled
soldiers had returned to Saskatchewan and of these
150 required further medical treatment. Dr. Myers
thought, when feasible, that crippled soldiers should
resume their former employment, and should not be
segregated or gathered in large colonies. Occupa-
tions in the open, such as market gardening and
poultry raising, should be made available for those
suffering from arrested . tuberculosis and nervous
diseases, and small sheep ranches might be estab-
lished on land given by the government, the money
for the purchase of the flock being advanced. He
further suggested that a census be taken of all
employers of labor in the province and of positions
that are or could be made available in the various
services of the government. The paper met with
the approbation of those present at the meeting
and at the business session the following resolu-
tions were passed : "Resolved, that it is the sense
of the association in session that the government
conduct a census of all available positions of em-
ployment within its service and among the em-
ployers of labor in the province, with a view to the
employment of disabled and unfit returned soldiers.
Also that the Saskatchewan Medical Association
feel constrained to offer their services to the gov-
ernment for use in the solution of these problems
in whatever way the government may see fit."
A Canadian society composed of nurses and medi-
cal men has been formed in Paris and meets once a
month for the discussion of scientific and medical
questions. The first meeting took place on Sep-
1044
MEDICAL RECORD.
[Dec. 9, 1916
tember 4, in the great theater of the Sorbonne
under the presidency of Professor Landouzy, the
dean of the Paris Faculty of Medicine.
Reverting to the question of the tuberculous
soldier, it may be said that so far as those of the
Canadian force are concerned, it is regarded by the
Military Hospitals Commission as serious. On
September 15, Dr. Baldwin of Saranac Lake, Drs.
Parfitt and Elliott of Muskoka, and Dr. Byers of
Ste. Agathe, met some of the Commissioners to
discuss the matter. It was reported that there are
at present about 397 soldiers under treatment in
the various sanatoria for tuberculosis throughout
the country. Nearly 60 per cent of these men have
never been overseas. Together with those from
overseas and cases which develop in the camps here
it is computed that in the spring there will be in
the neighborhood of 800 cases to be provided for.
As mentioned before in this letter, the accommoda-
tion for the tuberculous is fairly good in Canada
but not adequate for the many extra cases due to
the war. Therefore, arrangements must be made
at once to provide for the care and treatment of a
large number of tuberculous soldiers.
A convalescent home, known as the Clayton Home,
presented by Mr. W. J. Clayton of Halifax, has been
opened recently in Halifax, N. S. The event is of
particular interest as it is the first institution to
be established in Canada for the definite and sole
purpose of the educational, vocational, and physical
training of disabled soldiers. Statistics got to-
gether by Mr. J. N. MacLean, chief of the license
inspectors in the province of Manitoba, appear to
show that the vigorous enforcement of the Temper-
ance Act there is producing splendid results. Drunk-
enness is said to have been reduced by 80 per cent.
Dr. Gilbert Tweddie of Toronto died on August
23, in the ninetieth year of his age. He was born
in Dumfrieshire in Scotland.
Dr. F. D. W. Bates of Hamilton, a well-known
specialist in diseases of the eye, ear, nose, and
throat, died after a short illness on August 25.
Progress of Mrotral ^rtrnrf.
Boston Medical and Surgical Journal.
November 23, 1916.
1. The Physically Defective. Edward O. Otis
2. Fractures in a Base Hospital. Frederick A. Coller.
3. Speculations Regarding the Pancreas and Metabolism in
Diabetes. Hugh P. Greeley.
4. A Report of Three Cases of Typhus Fever. M. G. Berlin.
1. The Physically Defective.— Edward O. Otis, like
a great many others, wonders whether any of us are
mentally perfect, and suggests that most of us have
a mental bias. Fortunately, the "weakest spot" in the
majority of men does not incapacitate them for a
man's career in the world. Only some marked and
glaring physical deviation from what is considered
the normal places a person in the category of the
physically defective, and this class is what Otis now
considers. Mind will triumph over matter, and when
the will power is intelligently directed and grimly de-
termined it will make a defective body do its bidding.
The men and women, however, who have achieved
marked distinction in spite of acquired or congenital
physical defects are the exception, for besides the
will to succeed, and an exceptional mind, they have
usually enjoyed exceptional opportunities for educa-
tion. Not so with the great mass of the physically de-
fective; but granted that they are of sound mind, much
is to be hoped for in their care. The majority can
be trained to become self-supporting and to employ
the faculties that remain to the best advantage, and
thus discount their handicaps. The legitimate duty of
the State is to provide for the welfare of its people;
and each State must decide for itself in what way and
how far it will and can do this. Two fundamental ob-
jects are the duty of every well-ordered State: First,
to protect its citizens from injurious influences, such
as contagious diseases, by controlling pure food, fac-
tory conditions, and child labor, etc. Second, to afford
an opportunity for development, equality, freedom, and
the pursuit of happiness, which is supposed to belong
to all in this country as a birthright. The public has
largely taken this matter in hand and provided in
many cities and States proper measures for the sup-
ply of these benefits for the defective as well as the
normal individual. While discussing the situation with
reference to all defectives, Otis is especially inter-
ested in the situation with regard to the crippled and
deformed, for whom the States do not appear to have
made equal or adequate provision, although this class
probably largely outnumbers the other two classes.
How many crippled children and adults there are in
the United States no one knows, for no census of them
has ever been taken. Dr. Orr estimates the number
as 259,000, many of them growing up illiterate artd
without training. The State should supply for these
defectives schools and industrial training, whereby they
could be made self-supporting and independent instead
of a burden. There are only five institutions for crip-
pled and deformed children maintained entirely by State
appropriations, one each in Massachusetts, New York,
and Nebraska, and two in Minnesota. Some of the
similar institutions receive public aid but are controlled
and administered by private boards. Otis makes men-
tion of several institutions, especially the Massachu-
setts Hospital School, maintained by an annual State
appropriation of $80,000. The crippled children in the
rural districts need help in this direction, and the
only institutions meeting this demand are the State
institutions of Massachusetts, New York, Minnesota,
and Nebraska. At present only about 5,000 of these
defectives are being cared for. Apparently they do
not make the same appeal to one's sympathies as do
the blind, or deaf and dumb. Contrary to this state
of affairs, more has probably been done for the blind
and deaf than for any other one class of persons. Dr.
Alexander Bell showed that there was a minimum of
64,763 blind persons in the United States, of which
8,000 were under twenty years of age. There are
forty schools for the education of the blind in the
States, with a census of 4,720 individuals; while the
43,812 deaf persons, ninety per cent, of whom became
deaf before their twentieth year, many through acci-
dent and disease, are taken care of in every State
except New Hampshire, Nevada, and Wyoming. Otis
makes a plea for the care of individuals who have been
made physically defective through cardiac, joint, and
other infirmities; that public recognition and provision
be made for them in order that they may be able to
do useful service through efficient and happier lives.
3. Speculations Regarding the Pancreas and Metabo-
lism in Diabetes. — Hugh P. Greeley offers his ideas on
this subject in the nature of a preliminary statement.
In discussing it he says that the work of the pancreas,
or of its internal secretion, is almost as continuous as
the heart-beat, and that almost all the organs of the
body are provided with great reserve power; experi-
mentally, one-eighth of a pancreas, or less, is usually
sufficient to prevent the onset of diabetes. There is
undoubtedly a differing pancreatic function in all of
us, varying in the same way as our mental capacities
vary; our pancreases are "geared" to a certain maxi-
Dee. 9, 1916]
MEDICAL RECORD.
1045
mum metabolic activity and endurance, and the rela-
tion of functional capacity to total metabolism is a
mathematical one. Supposing the normal figures are
represented by 4/4 pancreatic capacity, covering a
metabolic activity of 60 kilos body weight: If the
body weight is increased by 40 kilos, the total metabo-
lism requirement would be increased and the func-
tional capacity relatively reduced 66 per cent. The
amount of reserve power would determine its suffi-
ciency. Failure of compensation would mean diabetes.
In obesity, a similar condition is present, since it may
be one of abnormal metabolic function, and is closely
related to diabetes. An enormous increase in body
weight so increases the total metabolism that the pan-
creas succumbs to the strain and diabetes ensues. In •
an opposite way, influences which reduce ' or retard
metabolic activity benefit diabetes. In speaking of the
relation of age to diabetes, Greeley shows that diabetes
is the severest in infancy and youth and mildest in old
age. The remarkable variations in sugar tolerance in
the same diabetic individual has been suggested to
argue the functional character of the disease. It does
not necessarily follow, however. Severe organic dis-
ease in any organ is capable of the same variation
of function under the sole influence of rest. Herein
lies the benefit of the Allen fasting treatment. Greeley
cites examples of cases of diabetes in connection with
obesity in the adult and the curative effect when the
fat was reduced; while in the case of a child with
diabetes and relatively high' sugar tolerance, with the
gain in weight and on total sugar-free diet came im-
provement in diabetic conditions. He concludes by say-
ing that it remains to be proven whether continuous
successful management results in actual regeneration
of power of the pancreas. The thyroid and liver are
regenerative organs, but the pancreas, up to the pres-
ent time, has seemed not to belong to this group.
New York Medical and Surgical Journal.
November 25. 1916.
1. The After-Treatment of Infantile Paralysis. Reginald H.
Sayre.
2. Epileptogenous Zones in Organic Epilepsy. Alfred Gordon.
3. Injuries to the Spinal Cord Produced by Modern Warfare.
C. Burns Craig.
4. The Treatment of Infantile Paralysis. Henry W. Frauen-
thal.
5. The Treatment of Infantile Paralysis. Frank E. Peckham.
6. The Speedy Cure of Tuberculosis. J. D. Gibson.
7. Health Insurance from the Viewpoint of the Physician.
Ira S. Wile.
8. The Late Dr. Henry L. Eisner. Charles G. Stockton.
1. The After-Treatment of Infantile Paralysis. — Reg-
inald H. Sayre considers that children who recover full
or nearly full function of the muscles after an attack
of infantile paralysis have, nevertheless, been through
a very severe illness, and should be guarded against
too much work, either physical or mental, for several
months, as careful examination will show hyperexcit-
ability of the nervous system in many who at first
glance appear to be normal. Gordon says that the
presence of the reaction of degeneration in the affected
muscles is no indication, as it was once considered, that
treatment should not be continued and persevered for
years after the attack, as he has seen improvement in
these apparently paralyzed muscles long after the sup-
posed ordinary time for such results. Where the co-
operation of the parents can be secured for a sufficient
time, often a matter of years, improvement is often
possible. Various methods of treatment may have to
be resorted to in the same case: medical, electrical,
manipulative, instrumental, and surgical. Strychnine
is distinctly helpful in these cases, and should be given
in increasing doses until some result is produced or
the toleration point reached. Opinions now differ as
to the benefits derived from electrical treatment. Gor-
don has obtained good results from the use of faradism
and galvanism. There is no question but that cold,
blue extremities are rendered warm and pink by the
use of electricity, and subsequent improvement in the
patient which would not have come without its use.
The strength of the current should be just sufficient to
produce muscular contraction; painful applications are
unnecessary, and frighten the patient. Manipulations
of the muscles are absolutely essential in these cases,
but they should never be employed as long as tender-
ness of the peripheral nerves exists, but after the
limbs have become tolerant of movement. Manipula-
tions of the muscles, deep kneadings, rubbings, and su-
perficial strokings are some of the most essential parts
of treatment. The patient should be encouraged to
make voluntary efforts of the paralyzed muscle or
muscles. If the muscles are too weak to respond to
the will, the masseur should put the limb through the
required motions while the child endeavors to make the
limb do the work which the masseur is doing for it.
Very little exercise should be given, in order not to
produce muscle fatigue, and in little children the same
result may be obtained by the use of games. Heat
applications by the electric light oven, and artificial
congestion of the paralyzed extremity by immersion
in a vacuum cup, are beneficial. The question of in-
strumental support comes up in many cases, and while
it is of value in the lower extremities it is of compara-
tively little value in the upper extremities. It should
be light, and should girdle the limb as little as possi-
ble, as the muscles are weak, and a heavy apparatus
weighs them down. Even when the apparatus is em-
ployed other treatment must be continued in order to
restore as much function as possible. It is essential
that these growing bones should be held in as nearly
a normal position as can be done, and deformities pre-
vented, so that the skeleton may be straight. In adapt-
ing an apparatus to the deformed leg the joints of
the apparatus must move in the same axis as the joints
of the leg, otherwise twisting of the foot may result.
Braces should be discarded as soon as the patient is
able to balance and walk without the support. If the
lower extremities and spine are both affected, and the
paralysis persists, the patient is best treated in a wire
cuirass, in which he can be carried about much like an
Indian papoose. He considers the number of cases
which are amenable to surgical treatment is compara-
tively small, but wonderful help can be given these few
cases. Surgery is useful when tissues which are con-
tracted can be elongated, but not otherwise. Subcu-
taneous tenotomy may be employed. The results of
immediate suture of nerves in infantile paralysis has
not been very successful. Bone operations to restore
function must be done only on selected cases, as there
is much to be taken into account, such as expense, time,
and ultimate result in comparison to the relief given
by prolonged treatment and braces. Gordon concludes
as follows, after thoroughly discussing the different
types of deformity which may require bone operation:
"Do not do too much at first; give the patient abso-
lute rest for many weeks. Prevent deformities by op-
posing contracting muscles. Later on use gentle mas-
sage movements, active, passive, and restrictive. En-
deavor to re-establish the path of nerve control to the
muscle. Aid this by electric stimulation in suitable
cases. If necessary, employ support to prevent undue
stretching of muscles or ligaments, or deformity of
bones. Later on, if deformities have developed, do
such surgical operation as may be necessary to put
the skeleton in a position best to support weight, and
to balance the opposing force of muscles so as to pre-
serve equilibrium. By these means many patients who
1046
MEDICAL RECORD.
[Dec. 9, 1916
otherwise would be hopelessly bedridden will be enabled
to go about in comparative comfort."
Journal of the American Medical Association.
Nov* m be r 25, 1916.
1 Further Studies of the Protein Poison. Victor C. Vaughan.
2. A Study of Diarrheas in Boston for 1915. Joseph 1.
3 An Analysis of the Mortality Eoi L915 in the Infant Wel-
fare Stations of Chicago. H. P. Helmholtz and Walter
I [ofl I
4. Chronic Digestive Disorders in Children, with Roentgen-
Ray Findings. Charles Gilmore Kerley and Leon Theo-
dore LeWald ,
.".. Care of Troops on the Mexican Border: Four Months
Medical Experience with an Army of One Hundred
and Fifty Thousand Men. Weston P. Chamberlain.
6. Shinguard Type of Lichen Planus Ocreaformis: A Con-
tnbution to the Rarer Forms of Lichen Planus. David
Lieberthal.
7. Carcinoma of Esophagus with Perforation of Aorta.
Moses Barron.
8. New Method of Injecting Facial Nerve tor Relief of
Facial Spasm. George M. Dorrance.
9. Bilateral Charcot Hips. Occurring Simultaneously. S. J.
Wolfermann.
10. Coagulation Time in Lobar Pneumonia, with Statistics
and an Experimental Study of Its Causes. J. M. An-
ders and George H. Meeker.
11. The Work of the American Medical Association Chemical
Laboratory. W. A. Puckner.
12. Studies in Prophylactic Immunization with Bacillus
Typhi-Exanthematici. Harry Plotz, Peter K. Ohtsky.
and George Baehr.
13. Treatment of Bacillus Pyocancuus Infection. Kenneth
Taylor. _
14. Chenopodium Poisoning : Report of Case. A. F. Coutant.
IB. Perforating Wound of Globe, with Prolapse of Iris: Re-
port of Case. J. Warren White.
2. A Study in Diarrheas in Boston for 1915. —
Joseph I. Grover. (See Medical Record, June 24, 1916,
page 1164.)
4. Chronic Digestive Disorders in Children. — Charles
Gilmore Kerley and Leon Theodore LeWald. (See
Medical Record, June 24, 1916, page 1159.)
5. Care of Troops on the Mexican Border. — Weston
P. Chamberlain gives an account of his four months'
medical experience with an army of one hundred and
fifty thousand men, otherwise the part of the militia
ordered to the Mexican border. He considers that the
mobilization clearly demonstrated many of the weak
features in all branches of our militia system, but he
refers chiefly to the sanitary features, and states some
of the lessons learned from the mobilization, as follows:
1. The physical standards of the regular army should
be strictly applied to the members of the national
guard. 2. All members of the national guard should
be immunized against smallpox, typhoid, and perhaps
the two paratyphoids, at time of enlistment. The for-
mer two procedures should be repeated in three or four
years. The length of time the paratyphoid vaccinatioi
will protect remains to be worked out. 3. The states
should organize sufficient ambulance companies and field
hospitals to bring the allowance of each unit up to at
least four for every authorized division of state troops.
All sanitary equipment should be kept complete, ser-
viceable, and up to date. 4. The medical corps of the
regular army (even when it reaches after four years
the recently authorized allowance of seven per thousand
of strength in the army) will be insufficient to provide
adequately for the needs of any such force as would be
required in a war of the first magnitude. 5. Con-
sequently, adequate medicomilitary training should be
given to the militia sanitary organizations and to the
Medical Reserve Corps. 6. The Medical Reserve Corps
should be greatly increased in size — to 10,000, or per-
haps 20,000. There were approximately 1,600 men in
the corps last summer, and from these it has been
difficult to get 350 for active service. Few wish to
remain long on active duty. 7. Typhoid fever need
no longer be dreaded as a scourge to armies. 8. State
troops can be maintained indefinitely in camps in the
South, and at the same time remain in excellent health,
provided certain simple sanitary precautions are con-
tinuously and rigidly enforced. These precautions will
not be continuously and rigidly enforced unless alert,
and experienced sanitary inspectors are placed in charge
and vested with sufficient powers to enable them to
compel the prompt correction of sanitary defects.
9. Bilateral Charcot Hips, Occurring Simultaneously
— S. J. Wolfermann reports this case because Charcot's
disease in both hips simultaneously is unusual, and to
emphasize further the long period of latency of some
syphilitic infections. The patient, a mechanic, aged
42, married, had always been healthy, and wife had
borne two healthy children. He had had gonorrhea
twenty-five years ago, with a nonsuppurative bubo. In
1891 there was a single hard chancre, and he was
treated with baths; no secondaries were noticed, and
there was no skin or ulcer. During the fall of 1912 he
began to have "rheumatic pains," limited to the areas
below the knees, these pains occurring only at night
and usually along the inner side of the tibia. They
occurred intermittently for about one year, and with-
out any other treatment than the baths he became
apparently well. Two other attacks about six months
apart came on, the second one lasting about a month
and the pain extended up the thighs, with a grating
in the left hip, which symptom now appeared for the
first time. Two months later the left leg felt "asleep"
and became useless. The next month, September, the
darting pains appeared in the right thigh, which be-
came markedly swollen, but not affecting the right hip,
while the right leg became useless. During October he
experienced "a feeling of pressure toward the center
at the waist." After physical examination the diagnosis
formulated itself: "Lightning pains," suggestion of
girdle pain, beginning sphincter weakness, hyper-
esthesia, loss of knee reflexes, Argyll Robertson pupil
and bone destruction without pain or temperature was
assuredly beginning tabes with two Charcot hips.
Wolfermann adds that at this time, after a consider-
able amount of treatment with mercury, iodid, and
arsenic, the grating is practically gone, hyperesthesia
is diminished, and there are no bladder symptoms.
Treatment is continued in view of later attempting to
make new hip joints, if a negative Wassermann reaction
can be obtained.
10. Coagulation Time in Lobar Pneumonia. — J. U
Anders and George H. Meeker state that it is common
knowledge that the time necessary for coagulation to
occur is variable and depends on many conditions, and
that bacteria and their toxins play a role in the coagu-
lation process is undoubted, but their significance is
not definitely known. The subject of the relation of
infection to coagulation has been discussed by several
modern writers, and, on the whole, the weight of
authority is in favor of the view that infectious diseases
retard coagulation. When normal blood coagulates,
"about 0.1 to 0.4 per cent, of its weight separates as
fibrin" (Krehl). In certain diseases, especially thos?
accompanied by inflammatory exudates (as lobar pneu-
monia and pleurisy), a marked pathologic increase up
to 1 per cent, or over may be found. In certain infec-
tions, notably typhoid fever, no increase is observed,
although intravascular clotting is more common in this
disease than in lobar pneumonia, if we except the largt
so-called marantic thrombi found in the great vessels
after death. That the quantity of the fibrin factors has
nothing to do with either extravascular or intravascular
clotting is further shown by the fact that they are pres-
ent in normal amount in hemophilia (Litten, Sahli).
The coagulation time is found to be shortened after
hemorrhage (severe pulmonary hemorrhage, hema-
turia), in carcinoma of the uterus, in abortion, after
transfusion, in endocarditis, in dementia precox, and
Dec. 9, 1916]
MEDICAL RECORD.
1047
after the administration of gelatin. The total number
of observations was 138, and the coagulation time
ranged from one minute to six minutes and twenty-five-
seconds. On the other hand, 100 tests on healthy indi-
viduals showed the coagulation time as distinctly longer
in them than in lobar pneumonia, the mean difference
being one minute and fifty-five seconds. They draw
the following conclusions from their experiments:
1. The coagulation time is somewhat shortened in
lobar pneumonia. 2. The cause or causes of this
abbreviation are not definitely known. 3. The influ-
ence of a meal on the coagulation time is trivial, but
practically constant. 4. The effect of the administra-
tion of calcium salts on the coagulative process must
be quite inconsiderable. 5. The calcium present in
the blood in lobar pneumonia does not exceed the
normal amount.
The Lancet.
November 4, 1916.
1. Possible Function of the Cerebrospinal Fluid. W. D.
Halliburton.
2. Further Cases of Kala-azar in Europeans Successfully
Treated by Intravenous Injections of Tartar Emetic.
Leonard Rogers.
3. Dental Disease in Nursing Women : A Note on the Asso-
ciation Between Oral Sepsis and Deficient Lactation.
Harold Waller.
4. Massage and Medical Electricity in the After-Treatment of
Convalescent Soldiers. Florence Barrie Lambert.
5 I'ltra-Violet Radiation from the Tungsten Arc. W. J.
Turrell.
2. Further Cases of Kala-azar in Europeans Suc-
cessfully Treated by Intravenous Injections of Tartar
Emetic. — Rogers, together with Hume, reported last
February on six cases of kala-azar in Europeans treated
by this method, with recovery in five and death from
phthisis in one, after the kala-azar germ had disap-
peared from the spleen. During the last fourteen
months they have treated eighteen new cases with
remarkable success, and have been able to shorten con-
siderably the time required for effecting a cure by
increasing the doses more rapidly than they ventured
to do at first. Reports on twelve cases are given show-
ing the expected results, and in no case that they have
been able to follow up from four to twelve months has
there been any relapse. With reference to dosage, they
now recommend adults to begin with 4 c.c. of the 2 pei
cent, solution of tartar emetic, to add 2 c.c. at the
- second injection, and, if no toxic symptoms occur, 1 c.c
from that point to 8 or 10 c.c, above which it is not
necessary to go. In patients with dropsy or albumin
in the urine the dose should be increased cautiously, and
in any patient, if toxic symptoms arise, other than
cough, immediately after the injection, the dose should
be reduced until no sickness or nausea occurs. In the
majority of cases the injections have been continued
for from several weeks to two or three months after
the fever had ceased, and only stopped, as a rule, wher
signs of full recovery had appeared, such as increase
in body weight, reduction in size of the spleen, an ap-
proximately normal blood, and when the parasites had
disappeared from the spleen. When it is remembered
that the most reliable data regarding the mortality of
kala-azar under careful and prolonged treatment showed
a mortality of 96 per cent, the results now obtained
by Rogers and Hume are so remarkable that Rogers
suggests that it is difficult to find a parallel case in
which such a deadly and lingering disease has been
brought under complete control by a simple medicinal
remedy. The author further suggests that the use of
tartar emetic appears to be worthy of especial study in
cases of human trypanosomiasis and of sleeping sickness
in Africa.
3. Dental Disease in Nursing Women. — Harold
Waller gives a report of a successful outcome in a
series of his cases in which deficient lactation in nursing
women was due to oral sepsis. This does not mean
that dental sepsis is responsible for all cases in which
the child fails to thrive on the breast milk. But in the
cases to which he has reference dissatisfaction with
the breast feeds and vomiting are among the early
symptoms, and the vomiting is of an intractable type,
occurring at frequent, varying intervals, and is copious
and forcible. The child loses weight, and there is a
persistent blueness of the extremities quite foreign to
one whose diet and digestion are in accord. Where
there is a gain in weight it is unsatisfactory. The
appearance of the mother may suggest ill health, for
she often looks wan and frail, but not in all cases. It
will be found upon inquiry that evidences of metastatic
effects of oral sepsis will be given unsuspectingly. It
is common to be told that the woman is rheumatic and
is subject to recurrent sore throat. Attacks of neu-
ralgia, stiff neck, gumboils, indigestion, vomiting, loss
of weight and strength are complained of. Inspection
ofttimes shows caries of the teeth, broken roots, prob-
ably covered with plates, and discharging sinuses, and
loose teeth with a copious discharge arising from
their alveolar processes. A chronically infected state
of the tonsils must be added to the list. For years
medicine has been resorted to for the debility and
anemia. Cases presenting greater difficulty are those
in which elaborate dental work has been done, cov-
ering up the true condition of the teeth and gums.
The real importance of the question lies in the chance
which treatment offers of effecting a sufficiently rapid
improvement in a woman's health to raise her powers
of lactation from a subnormal to a satisfactory level,
and so avoid the need of artificial feeding for the child.
The prevalence of this condition must be regarded as
a disastrous one, claiming attention on national grounds
of the first importance, in view of the interference it
produces with the course of infant welfare. Waller
found that the results obtained after proper or ever
inadequate attention had been bestowed upon the dental
condition of the mother were (1) the increased rate of
gain in the child's weight and (2) the length of time
over which nursing can be carried should be prolonged.
Also greatly improved health in the mother, with in-
creased flow of good milk; a cessation of dyspeptic
symptoms in the child, with general systemic im-
provement. Three cases are given, one of which
describes the condition of the first-born of a woman of
29 years. The mother appeared healthy, but the baby
at three and a half weeks of age began to waste away
and gave the typical blueness of the extremities. While
the mother's milk was copious, the child continued to
grow worse. After careful dental treatment had beer
instituted in the mother the child's skin improved in
color, the weight, which had been stationary at five
pounds from the third to the tenth week, rose to ten
pounds between the tenth and eighteenth week. The
particular cases illustrative of this condition were
chosen from nearly 200 in which dental sepsis inter-
fered with the power of nursing an infant. Improve-
ment capable of registration was achieved in 80 per
cent., the remainder were nearly all lost sight of and
did not complete the treatment. Waller suggests that
it follows from what has been repoi-ted that the earlier
treatment is obtained the better. It is difficult to sup-
pose that a condition which can influence a child so
profoundly through its parent after birth can fail to
exert effects during intrauterine life. Research into
the association between dental disease and the occur-
rence of miscarriage and the birth of premature infants
of weakly physique might well produce important
results.
1048
MEDICAL RECORD.
[Dec. 9, 1916
British Medical Journal.
November 4, 1916.
1. The Possible Function of the Cerebrospinal Fluid. W. D.
Halliburton.
2. Incidence and Treatment of Entantvba histolytica Infec-
tions at Walton Hospital. Clifford Dobell.
3. Note on Some Examinations and Treatments for Enta-
mirba histolytica Infections. Margaret W. Jepps.
4. A Search for Dysentery Carriers among Soldiers Coming
from Gallipoli and Egypt. J. O. Wakelin Barratt.
5. Note upon a Case of Jaundice from Trinitrotoluol Poison-
ing. Hugh Thursfleld.
6. Hexamine in Acute Anterior Poliomyelitis. N. Fox Ed-
wards.
7. A Simple Aseptic Way of Performing Vaccination. Ech-
lin S. Molyneux.
1. The Possible Function of the Cerebrospinal
Fluid. — W. D. Halliburton, in an address before the
Neurological Section of the Royal Society of Medicine,
gives the normal characteristics, composition, and fate
of this fluid and its pressure. In speaking of the means
of communication between the cerebrospinal fluid and
other parts of the body, or rather the lack of it, he
calls attention to the fact that Dixon and he found
that dyes added to the fluid travel along the course of
certain cranial nerves, especially the olfactory nerve.
Such is not the case with the spinal nerves; no dye
can be detected in their sheaths outside the spinal
canal, and no dye is discernible in the lymph of the
thoracic duct. Clinically the olfactory outlet is im-
portant as it affords an opportunity for the entry of
infective agents. He draws attention to the appar-
ently analogous relation of the cerebrospinal fluid and
lymph, but while the essential feature of a true lymph
is the free interchange between it and the blood in
both directions, this is lacking in cerebrospinal fluid;
at least it appears to be permeable to substances pass-
ing from it to the blood, but impermeable (except for
oxygen) in the direction from the blood to the fluid.
Halliburton says that he has been led to take the follow-
ing view: The nervous mechanism being so sensitive,
so easily influenced by anything unusual, the neurons
must be bathed in an ideal physiological saline solu-
tion to maintain their osmotic equilibrium; the trace
of protein it contains is probably quite sufficient for
nutritive processes. The sugar would serve for a
supply of energy. The choroidal epithelium is really
exercising a protective function by keeping out harm-
ful proteins (toxins, etc.), while some harmless ones
are kept back almost completely; all share the same
process of exclusion. This protective action also ap-
plies in addition to the majority of soluble drugs; this
may operate so as to be detrimental in diseased con-
ditions, but one can hardly expect discrimination on
the part of the epithelial secreting cells. The non-
access of metallic and other poisons to the nervous
elements is such a sine qua non for their health that
during those periods when such substances are given
for the relief of disease or the slaughtering of para-
sites the choroidal cells are unable to change their
habits, and so do not allow the drugs to get through.
Such, Halliburton states, he believes to be the real
significance of this remarkable secretion.
5. Note on a Case of Jaundice from Trinitrotoluol
Poisoning. — Hugh Thursfleld reports a case of a woman
thus poisoned, and calls attention to the fact that only
since the war have we known of the toxicity existing
from the manufacture of explosives belonging to the
group of the nitro-derivatives of benzine and toluene.
Drowsiness, headache, and nausea, varying degrees of
cyanosis, with anemia and jaundice, and in some of the
eases of jaundice a proportion have proved fatal. Such
was the case Thursfleld cited. This young woman,
strong and healthy, had been employed in munition
work for about six months, and four months before
her fatal illness became an examiner in a munition
factory. She examined bags filled with the yellow
powder, hence the atmosphere was powder laden.
She tasted it even in her food. She wore a plate in
the upper jaw and always cleaned it after meals,
but never before eating. One month before her illness
she noticed she was passing dark-colored urine, but
did not feel ill until two weeks later. She complained
of headache and nausea and loss of appetite. She be-
came worse, and was taken to St. Bartholomew's Hos-
pital. She was deeply jaundiced, and the urine was
almost black with pile pigments. Her temperature
was normal, and aside from the jaundice and vomiting
she did not appear to be very ill. Two days later,
however, she became drowsy and vomited excessively,
and in two days, after delirium had set in, she gradu-
ally sank, and died in the evening. Autopsy showed
fatty degeneration of the liver and kidney tissues, with
petechial hemorrhages in the pericardium, viscera, and
parietal pleurae. The history and course of the ill-
ness are those of an acute toxemic jaundice, non-
obstructive in character, but the blood examination
showed a normal condition, with 5,000,000 red cells
per c.mm. and hemoglobin 90 per cent. This was
rather remarkable in view of the fact that trinitrotol-
uol frequently causes anemia. Clinically, the most
striking feature of the case was the suddenness of the
onset of the fatal symptoms, for in less than two
days before her death she seemed to be in good con-
dition, without any serious symptoms pointing to a
grave prognosis. Yet it was obvious at the time of
the autopsy that the toxemia had already robbed her
of any chance of survival.
7. A Simple Aseptic Way of Performing Vaccination.
■ — Echlin S. Molyneux offers a method of vaccination
which he has employed on recruits with good results.
He suggests that while it may appear to seem labori-
ous, with but a little method in handling the individ-
uals, it is not so. He vaccinated 180 men in 231 min-
utes, or well under two minutes each. Each roll of
gauze ten yards long sufficed for from twenty-five to
thirty men, so that the expense was not great. Out
of this number of vaccinations very few inflamed arms
appeared, and the slight inflammation was soon re-
duced by boric-acid solution applications. The technic
is as follows: (1) The patient's arm is first thor-
oughly rubbed by an orderly with methylated spirit
to disinfect the. skin. (2) A tube of calf lymph is
taken and one end broken off; the broken end is held
for a moment in the flame to sterilize it, as it may
touch the patient's skin during the operation. A lighted
match is then applied to the other end of the tube of
lymph, which always contains an air bubble. The heat
of this causes the air to expand, and, if held over the
patient's arm, it blows the lymph on to the arm. (3)
A needle is taken with a point that has been slightly
blunted, and held for a moment in the spirit flame
to sterilize it. The lymph is spread from the drop
on the patient's arm with the sterile needle to as many
points as it is desired to vaccinate, usually four. The
skin is then scratched by the needle sufficiently to
draw a little of the patient's lymph, but not sufficiently
to draw blood. (4) A pad of sterile white gauze is
immediately and firmly strapped on in the following
way: A towel, wrung out in 1 in 40 carbolic, is spread
out on a table, and on it is a roll of sterile gauze ten
yards long. A piece of gauze is cut off and folded
twice or three times and applied to the patient's arm
in such a way that the inside of the gauze comes next
his skin, and no part which has been touched by the
operator's fingers lies near the vaccination wounds.
Then a strip of 1-in. adhesive plaster is wound round
and round the arm over the dressing to keep it secure.
(5) The patient is told on no account to let the dress-
Dec. 9, 1916]
MEDICAL RECORD.
1049
ing get loose, and to have it dressed immediately
should it show signs of slipping. He is ordered light
work not necessitating using his arm, and he is di-
rected to come up in five days. The second and any
subsequent dressings are of boric lint.
La Presse Medicale.
October 26. 1916.
Amebic Dysentery. — Maute has studied this condi-
tion as it occurs in Morocco. At Fez it is endemic.
Without giving the details of his studies, he proceeds
to his results. Intestinal amebiasis is a chronic af-
fection with acute 'exacerbations. The dysenteric cri-
sis is only an episode in the course of the disease.
If after injections of emetine the stools become formed,
this does not mean that the bowel has become steril-
ized. This statement cannot be too strongly empha-
sized. The usual practice is as follows. When the
stools have become normal the emetine injections are
renewed (1 to 3 injections) and the patient kept under
observation for about a fortnight. If there are no
signs of recurrence he is discharged "curea." This
custom is very dangerous, not only for the patient
himself but for those about him. It has recently been
shown that carriers of amebic cysts transmit the dis-
ease. In 8 cases out of 10 so-called emetine cures the
author has found these cysts in the stools. The latter
must be persistently followed up. If finds continue
negative, a provocative test should be made. The au-
thor has succeeded best with iodized water 1:1000 (1
gm. iodine, 2 gms. iodide per liter of water). The
injection should be given in the morning, and two or
three hours later the patient will expel amid some
gripes a certain amount of mucus filled with cells of
all kinds. In rare cases the ameba will be present,
both in the cysts and as free bodies, even in cases
which have seemed to be cured for weeks and in whose
spontaneous stools no parasite can be discovered. From
another angle, amebic dysentery may be overlooked
because of its mild character. In such cases, hepatic
abscesses are more prone to develop than in the more
severe forms; in fact, the abscesses may even seem
to be spontaneous. In an endemic viilieu, every intes-
tinal derangement should be suspected and researches
instituted. At Fez, in addition to the Amoeba histolytica,
the author found the trichomonas and other protozoans,
and intestinal worms (triscephalus, asearis). As these
parasites appear to cause a sort of mixture of infec-
tion or symbrosis which is hostile to a good prognosis,
santonin should be given as a vermifuge. Turpentine
is said to be active against the protozoans. It is
impossible to determine the duration of the evolution
of intestinal amebiasis. In 22 per cent, of cases the
author has seen the cysts disappear by the fifth week,
and in 72 per cent, from the fifth to the tenth week.
In 6 per cent, the disease was especially refractory,
and failed to yield under emetine-arsenic treatment.
Chlorhydrate of emetine is a veritable specific against
the dysenteric crisis. If the diarrhea persists this is
commonly due to the presence of worms or the tricho-
monas. The post-dysenteric management has already
been outlined. Everything depends on a good quality
of emetine. In refractory cases neosalvarsan treatment
may be added.
pathogenicity, Steinert laid down the law that insidi-
ous cases occurred only in rheumatic subjects; in other
words, acute viridans sepsis may only attack subjects
who have not been partially immunized — for we must
look upon the rheumatic subject as enjoying a cer-
tain degree of protection. Another theory not involv-
ing the presence or absence of immune bodies is the
saprophytic, according to which the viridans is essen-
tially harmless but under unknown conditions may be
roused to different types of pathogenicity. These two
theories do not antagonize each other. The saprophytic
view is reasonable and one acute attack of sepsis might
well confer some immunity. Still another theory —
anaphylaxis — might be called upon to explain why a
mild attack of viridans sepsis could be followed by an
acute outburst. Acute viridans sepsis usually takes its
origin from the female genital. Especially fulminat-
ing cases are seen in connection with infected abor-
tion. The viridans has been known to cause erysipelas
and may complicate tetanus and diphtheria. The au-
thor describes a personal case in a man of 37 who had
never suffered a rheumatic attack. About 18 months
before consultation his health began to fail without
apparent cause. Six months later he developed pleurisy
with effusion, which, despite repeated puncture, did not
permanently subside. Later ascites followed and dom-
inated the entire disease picture. The general state
grew progressively worse, and death ensued with the
picture of failing heart and dyspnea. The autopsy finds
are given in great detail. The entire picture was due
to the lesion of the heart, and this is summed up as
follows: An isolated endocarditis limited to the car-
diac wall, and covered with organized fibrin, the valves
being fully intact. In the right ventricle the process
was undergoing resolution, while on the left side, despite
evidences of present acute inflammation, a tendency in
the same direction was noted. The absence of notable
virulence and the consequent slow march of the process
goes hand in hand with the progressive fibrous organ-
ization of the thrombi. Despite the venous stasis in
the viscera the action of the heart was good and could
be likened to that seen in well-compensated organic dis-
ease. The cardiac finds, while unique in this instance,
differed only in degree from those usually encountered,
in which valvular endocarditis occurs. In this case the
inflamed ventricles presented dense adherent masses of
organized fibrin. In various viscera in addition to the
phenomena of stasis were found septic emboli. Save
for the heart the anatomical picture was typical of
sepsis lenta. Clinically the nature of the case was such
that a bacteriological test of the blood was omitted.
There is no intimation as to the source of the infection.
Correspondenz-Blat fur Schweizer Aerzte.
October 28, 1916.
Sepsis Lenta. — Deus refers to Schotmiiller's discovery
in 1903 of the activities of the streptococcus viridans.
The latter, as is known, can cause either acute or in-
sidious sepsis. In order to account for this twofold
La Riforma Medica.
October 23, 1916.
Oxaluria Is Not a Disease of Metabolism. — Fittipaldi
sums up a study of this subject as follows: Oxaluria
as a disease cannot be due to an excess of oxalic acid
or the oxalates in the food. There is no relationship
between oxaluria and diabetes or between oxaluria and
obesity. The coexistence of oxaluria and urticuria is
of no significance in connection with the origin of oxalic
acid. An excess of the latter, isolated from the blood
in oxaluria, does not mean an oxalemia. There is no
connection between oxaluria and gout when oxaluria
appears because of deficiency in tissue respiration;
it means that the sources of the acid have not been
sufficiently oxidized in the blood. Oxaluria is not a
disease of metabolism, but doubtless results from an
enterogenous intoxication due to some specific enzyme
as yet unknown.
1050
MEDICAL RECORD.
[Dec. 9, 1916
Lactic Bacteriotherapy of Wounds. — Colombini, in
writing on the sterilization of wounds, with special
reference to the prophylaxis of tetanus, speaks favor-
ably of the lactic acid bacteriotherapy of wounds as
carried out in the Hospital of the Experimental and
Bacteriological Agrarian Station at Crema. A liquid
previously fermented is employed, consisting of whey
and peptone, containing the products of metabolism
of the lactic acid bacilli. Lactic acid is formed to the
amount of 1 per cent. Owing to temperature conditions,
living cultures cannot be used in wounds. This necessi-
tates the practice of fermenting a substratum with
cultures. Lactic acid is not the only product of bacillary
metabolism. The mixture has striking anti-putrefactive
properties and is able to cleanse an infected wound
thoroughly in a few days. Whatever the theory may
be, the fact remains that infected wounds have later
been shown by the microscope to be sterile. A simple
1 per cent, solution of the acid exhibits no such prop-
erties. There is nothing which points to commer-
cialism, as the liquid is prepared at a Government
Experimental Station for Agriculture, which doubtless
supplies details to any one interested.
Alcoholism in Italy. — M. L. reviews Professor
Bianchi's recent memorial on this subject. Alcoholism
in Italy is a problem in itself. There is an enormous
production of wine, consumed mostly at home. Its use
is a matter of tradition and custom. It is regarded
as food, despite its small nutritive value. The author
marshals the leading arguments advanced as to the
essential harmfulness of alcohol by writers outside of
Italy. In the latter country both acute and chronic
alcohol poisoning are seldom met with. The author
in thirty years of activity in Palermo and Naples has
seldom seen delirium tremens. On the other hand, it
is not impossible that a slow, insidious alcoholic in-
toxication of the Italians has been taking place through
the centuries. This is chiefly in evidence in the great-
est wine growing countries. It is rather a feeling that
this is the case than anything demonstrable. There
seems to be a subnormal efficiency in the worker, due
to lack of endurance or persistency, and there is an
abnormal tendency toward litigation. Alcohol must
play a very small role in acute psychoses, but seems:
in evidence as a casual factor in various affections and
attributes — epilepsy, delinquency, idiocy, arthritism,
obesity, indolence, indifference, excitability, impulsivity,
irascibility, etc. In the Northern countries this prob-
lem of racial characteristics does not exist, and is in
part replaced by that of the excessive use of alcohol
during short periods of time — something unknown in
Italy, as is also the use of industrial alcohol as a
beverage with the dangers of a methylism. The author
from his immense experience with wine drinkers is
able to detect much exaggeration in articles which ema-
nate from the North. The amount taken daily and
the proof of the wine are of great practical significance,
as is also the vocation or absence of one. In other
words, there is a utilizable limit. The alcohol per-
centage of the native wine varies from 10 to 14 (no
other kinds are mentioned) and the use of small
amounts with meals only is regarded as innocuous.
A "small bottle" of wine which contains from 20 to 30
gms. of alcohol answers this requirement. Any-
where from 40 to 70 gms. alcohol daily is regarded
as the limit of safety beyond which a definite action
on the nervous system may be perceptible. A daily
consumption of from 300 to 600 gms. of wine means
the same thing. Aside from defending the minima!
use of wine as not only innocuous, but even perhaps
salutary, Bianchi's conclusions do not. differ essentially
from those of Northern writers.
La Riforma Medica.
October 30, 1916.
Diagnosis of Malignant Tumors of the Liver. — Fer-
ranmni mentions a number of cases occurring in the
past five years in which the diagnosis was made by
necropsy, biopsy after exposure of the liver or borings.
The necropsy in a woman of 63 showed the pressure of
an endothelio-sarcoma. The organ weighed 3,100 grams
and before section presented hardly any evidence of
tumor formation. Upon section numerous tumor
masses were seen. The stomach was normal, but the
left kidney was greatly enlarged from the same disease
process. Very small metastases were found within
the thorax. No primary lesion is mentioned. In a
man aged 55 there was ascites of high degree. Instead
of a paracentesis laparotomy was at once performed,
in order that the liver might be examined. Five liters
of fluid escaped, and the liver was found to be the seat
of numerous nodules. Attempts at aspiration ended
negatively, showing that the latter were solid. There
was a history of very severe, painful crises over the
liver before the appearance of ascites. The latter by
causing dyspnea led the patient to seek relief. The
diagnosis of malignancy having been made, a sys-
tematic search for lymphnode metastases was begun,
with negative results. There was, however, a notable
failure of general health, of the type which suggests
malignancy. The peculiar tint of the cancerous patient
was missing, as was also the yellowish-gray color be-
lieved to be common in sarcomatous patients. The
blood count was not suggestive of malignancy. Hyda-
tids and tertiary syphilis had been excluded. As
between sarcoma and primary cancer the evidence
pointed rather toward the former, chiefly because of
the absence of regional lymphnode metastases, espe-
cially in the left supraclavicular fossa. Sarcoma, so-
called, of the liver comprises perithelioma, endothelioma,
cylindroma, lymphosarcoma, and other subvarieties.
There appears to have been no autopsy on this patient,
as the author leaves the exact diagnosis to be worked
out by clinical evidences. When the liver was inspected
by laparotomy, lymphnodes as large as a walnut were
seen in the omentum and retroperitoneal space. The
evidence, however, leaned toward sarcoma, because of
the absence of external lymphnode metastases and
icterus.
Tuberculous Meningitis Simulating the Prodromic
Period of Multiple Sclerosis. — Cammarata relates the
following case: The patient was a boy aged 3 years,
of good family and personal antecedents. Six months
before consultation he exhibited a tremor of the right
hand, worse in the daytime. Three months later his
rig-lit leg lost its feeling and he walked with a tremulous,
spastic gait. On examination he showed an intention
tremor and could not raise a glass to his lips unlesr.
aided by the left hand. Meningitis could be excluded
completely. Diagnosis, sclerosis en plaques. Some
weeks later he was attacked by fever, headache, and
vomiting, stiff neck, convergent strabismus, terminat-
ing after a few days in convulsions. Lumbar puncture
was now practised. The fluid emerged under strong
pressure and the sediment contained tubercle bacilli.
There was some temporary improvement, but death
followed an exacerbation. Autopsy was refused. The
connection between the early symptoms of sclerosis
and the meningitis was obscure. Sachs describes a"
abortive type of the former, which, however, is ex-
tremely rare at so early an age. By exclusion it is quite
impossible to reach any other diagnosis. Cammarata
suggests that a possible compromise diagnosis would be
a focus of tuberculous meningitis behaving like a patch
of sclerosis.
Dec. 9, 1916]
MEDICAL RECORD.
1051
iBank Reviews.
Pye's Surgical Handicraft: A Manual of Surgical
Manipulations, Minor Surgery, and Other Matters
Connected with the Work of House Surgeons and
Surgical Dressers. Edited and largely rewritten by
W. H. Clayton-Greene, B.A., M.B., B.C.(Camb.),
F.R.C.S. (Eng.). Surgeon to St. Mary's Hospital;
Lecturer on Surgery in the Medical School, etc.
Seventh Edition, Fully Revised, With Some Addi-
tional Matter and Illustrations. Price $4.50 net.
New York: William Wood and Company, 1916.
This has ben a standard work for more than a quarter
of a century and shows no sign of waning popularity.
For this, the seventh, edition the subject matter has
been thoroughly revised and considerable portions prac-
tically rewritten. While originally designed especially
for the instruction of members of house staffs, it has
gradually reached a far wider field of usefulness; and
while still satisfactorily fulfilling its original design
it has been amplified to a degree that renders it a
valuable aid to the general practitioner also. This will
be appreciated by noting the headings of the various
sections. There are 53 chapters embraced in ten sec-
tions, the titles of which are: The arrest of hemor-
rhage; Apparatus for restraint and support (bandages,
splints, etc.) ; Fractures, dislocations, and sprains;
Wounds, ulcers, and burns; Cases requiring prolonged
or mechanical treatment; Minor surgery and kindred
subjects; Special cases connected with the head and
throat; Certain emergencies, surgical and general;
The administration of anesthetics; Miscellaneous.
Under the latter heading there are chapters on the
preparation of patients for operation and their after-
treatment; the making of poultices, fomentations, etc.;
urine testing; a-rays in diagnosis and treatment; and
surgical history taking.
Upon looking through the work we find that there
are many instances where procedures recommended are
quite different from customary methods here yet are
unquestionably good; and that a knowledge of them, as
well as of Ihe more common methods, cannot fail to
add to the efficiency of the reader. On the other hand,
we occasionally find that American methods are far in
advance of those recommended in this work. For ex-
ample, in the chapter on hemorrhage and transfusion
we find the method for continuous saline flow into the
rectum far inferior to the technique of the Murphy
drip; while the discussion of transfusion itself is quite
out of date according to our standards. The discussion
of the truss treatment of hernia is generally poor, while
we consider the advice given regarding the treatment
of undescended testicle to be wrong.
The chapters on surgical emergencies and the treat-
ment of various poisonings contain many valuable sug-
gestions, and the same applies to that on pre- and post-
operative treatment and many others too numerous to
mention specifically. It is certainly not too much to
say that while former editions of this work deserved
popularity, the present revision and extensive rewriting
should add greatly to its prestige.
The Problems of Physiological and Pathological
Chemistry of Metabolism. By Dr. Otto von Furth,
Professor Extraordinary of Applied Medical Chem-
istry in the University of Vienna. Authorized Trans-
lation by Allen J. Smith, Professor of Pathology
and of Comparative Pathology in the University of
Pennsvlvania. Price, $6. Philadelphia and London:
J. B. Lippincott Company, 1916.
In its original form this work of Fiirth's has been
familiar to many workers in biochemical fields as one
of the most satisfying treatises on metabolic chemistry.
The subiect has become so complex in its ramifications
that it is most useful to have a comnrehensive sum-
ming up of the present state of knowledge in this direc-
tion, and the series of lectures here offered in printed
form is designed to give a resume of what may now be
considered as fairly definitely established in regard to
the underlying reactions of vital processes. Even the
most seasoned plodder through scientific literature at
times welcomes a journey that leads over less arid
regions than usual, and the present volume is decidedly
entertaining, as well as instructive, for its lecture char-
acter has enabled the author to adopt a somewhat easier
style than is customary in purely technical works. The
translation is very close, yet its form is admirable, and
it is only rarelv that some twist of phrase has been al-
lowed to remain as a reminder of the svntactic pecu-
liarities of the original. It was certainly the part of
wisdom to choose first the latter of the author's two
volumes for presentation to the English reading pub-
lic, for the former of these, which is devoted to cellular
chemistry, is much more technical and of less appeal to
the general reader. In the present volume, as its title
indicates, the problems of metabolism as a whole are
discussed, both in relation to the normal processes, and
as encountered in various diseases depending on dis-
turbances of the body's chemistry. While in some in-
stances not all of the latest work is included, as for ex-
ample under diabetes and proteid metabolism, for the
lectures on which the book is founded were delivered at
the University of Vienna before 1911, yet there appears
to be little of importance that has been omitted, and the
book will undoubtedly be found of great value by all
who are interested in this fascinating but difficult study.
It is to be. hoped that the translator will extend his
labors also to the production of an English version of
the first volume.
Nervous Disorders of Men. The Modern Psychological
Conception of Their Causes, Effects, and Rational
Treatment. By Bernard Hollander, M.D., Author
of "The Mental Functions of the Brain." Price, $1.25
net. London : Kegan Paul, French, Trubner & Co.,
Ltd.; New York: E. P. Dutton & Co., 1916.
The title of this book is somewhat too general, the au-
thor modifying it in the preface by limiting himself
to functional disorders. It is addressed to the lay
public and to the less well-informed members of the
medical profession. The first part is largely occupied
with an account of "nervousness" somewhat in the vein
of Dr. Stephen Crane or Herbert Kaufman. Various
neuroses, psychoneuroses, and anxiety states are
grouped by the writer under this head. No attempt, of
course, is made to explain phobia, obsessions, etc., by any
of the newer psychological methods. In fact, the
medieval explanation is the one adopted. In a chapter
devoted to the "semi-insane," a brief description is given
of cyclothymia and hypomania. Galvanism and psycho-
therapy constitute the author's therapeutic armamen-
tarium. If the patient has pains in the stomach he
applies the current to the stomach; if he suffers from
any general nervous condition, it is applied to the spine.
Nervous Disorders of Women. The Modern Psycho-
logical Conception of Their Causes, Effects, and Ra-
tional Treatment. By Bernard Hollander, M. D.,
Author of "The Mental Functions of the Brain."
Price, $1.25 net. London: Kegan Paul, French, Trub-
ner & Co., Lt.; New York: E. P. Dutton & Co., 1916.
This book is a companion volume to "Nervous Disorders
of Men," elsewhere reviewed, and many of the chapters
differ from the first book mainly in a change in gender
of the pronoun. Some discussion is given in the intro-
ductory chapter to the difference between the nervous
systems of men and women. There is a chapter of psy-
choanalysis which, while superficial and dealing in gen-
eralities, is quite readable and probably better for the
lay public than much about this subject which is acces-
sible to it.
A Manual of Fire Prevention and Fire Protection
for Hospitals. By Otto R. Eichel, M.D., Director,
Division of Sanitary Supervisors, New York State
Department of Health. Price, $1. New York: John
Wiley & Sons, Inc.; London: Chapman & Hall, Ltd.,
1916.
The preface states that it is the purpose of this manual
to provide in convenient form an outline of the prin-
ciples of fire prevention and protection with indications
for their application in institutions housing the sick.
It is planned for use, not only by superintendents and
boards of managers, but also by inspectors, architects,
builders, and others who have occasion to consider the
fire problem in hospitals. It is to be hoped that the
book will have wide use, and that further study by
those active in hospital management will be stimu-
lated.
Collected Studies from the Bureau of Laboratories,
City of New York. Dr. William H. Park, Director.
Vol. VIII, 1914-1915.
This volume contains sixty-seven reports, of which
twenty-three are not reprints. There are several ex-
tremely valuab'e renorts Tnn'iig tn Ho with dinhtheria,
Schick test and toxin, antitoxin activity, scarlet fever,
poliomyelitis, and meningitis. Along lines of public
hygiene are two good reports, one on public cigar cut-
ters, and the other on the bubble fountain. Numerous
other interests of the Bureau are indicated in the re-
ports, and the volume is a great credit to the workers
who are represented.
1052
MEDICAL RECORD.
[Dec. 9, 1916
MISSISSIPPI VALLEY MEDICAL ASSOCIATION.
Forty-Second Anmtal Meeting, Held at Indianapolis,
Ind., October 10, 11, and 12, 1916.
The President, Dr. Willard J. Stone of Toledo,
Ohio, in the Chair.
Protozoic Enterocolitis in the Middle West. — Dr. Frank
Smithies of Chicago presented the records of the last
100 stool analyses in his clinic at the Augustana Hos-
pital, which indicated that there were 93 instances
where protozoa were observed. The patients' ages
ranged from 7 years to 82 years. The average age
was 39. There were 51 males and 42 females. There
was practically no difference noted in the sex age
figure. Fifty-two patients were of Scandinavian birth
or extraction; the remainder were Americans, Ger-
mans, Irish, Russians, Austrians or English. The geo-
graphic diversity of patients forming this group was
as follows : Illinois 29, Iowa 16, Wisconsin 13, Ne-
braska 8, Michigan 7, Minnesota 6, Indiana 4, South
Dakota 2, Arkansas 2, Ohio 2, Texas 2, Kentucky 1,
and North California 1. Of 93 cases 66 were large
•eaters of fresh garden truck, unwashed fresh raw
fruits and bananas. Diarrhea was complained of in
86 cases. The duration of the diarrhea varied greatly.
Sixty-seven per cent, of the cases had been affected
from one to five years; eight cases had been ill less
than one year, while a like number had been ailing for
more than ten years, the longest period being 43 years.
Constipation occurred in 4 cases. Dyspepsia was prom-
inent in 75 cases. Abdominal pain or discomfort was
a complaint in 89 cases. Loss of weight was noted in
75 cases. The loss varied from 5 pounds to 104 pounds.
The average loss of 17.3 pounds. Loss of strength
was often striking, even though the weight might have
decreased comparatively little. Anemia was usually
evident, although melancholia was frequently observed.
On physical examination these patients generally ap-
peared both starved and toxic. The stools were com-
monly of a greenish-brown or yellow color and of a
puree-like consistency, intermixed with flakes of mucus
and food bits. They might be blood-streaked or foamy.
The reaction was usually definitely alkaline. In his
series there were 40 cases with gastric achylia; 33
cases with subnormal hydrochloric acidity, and 20 cases
with normal or increased gastric HC1- In one instance
of most pronounced acute infection with cerco-
monads and trichomonads the free HC1 was 86. The
gastric motility was normal in 83 cases'. In 10 cases
there was mild stagnation. In 16 instances albuminuria
was noted. His study of specimens of gall bladders
and appendices removed at laparotomy indicated that
in these parts of the gut cysts of protozoa might lurk
for years. Reinfection of the bowel was thus possible.
Treatment of Infected Wounds. — Dr. FREDERICK G.
Dyas of Chicago drew these conclusions: (1) The
application of voluminous dressing to infected wound
surface confines the infective discharges and subjects
the tissues to a bath of pus. (2) Exposure of infected
wound surfaces to the air causes a rapid drying up of
the wound secretion and a desiccation of the tissues by
the evaporating action of the atmospheric air, which
can be increased by playing a current of air from an
electric fan on the exposed area. (3) Infection from
the air is negligible. (4) The open method of treat-
ment tends to convert the moist into the dry type of
gangrene and produces unfavorable conditions for the
growth of anaerobic organisms which are clinically
more virulent than aerobic. (5) The period of infec-
tion is shortened by the use of certain solutions, as a
bath or irrigation, unfavorable to the growth of bac-
teria, which must be discontinued as soon as the signs
of infection subside.
Dr. Henry T. Byford of Chicago said the principle
of drying out the wound was the proper one. To do
that the wound must be drained, not the surface of
the tissue. Convert a wound into a dry, cancellous con-
dition and it would get well. In treating wounds he
began using the old-fashioned method of dry dressing,
for bedsores or where there was a cancellous area which
required some time to come off. He used gauze, but he
did not have the same result as when he used absorbent
cotton. When he began to use absorbent cotton in the
proper way he would have a wound dry up in two or
three days until finally it needed no dressing at all.
But he changed the cotton every hour or two for a
few times. After a few hours it would not have to be
changed so often, say every three or four hours, then
once a day, and then he would leave it on a week or
until the slough came off. It was better to use cotton
for this than gauze because gauze rubbed off the granu-
lation. In fresh wounds that were not infected he
would put on some cotton, change it in a few hours,
and after that there would be less serum, and in a day
or two the wound would dry up so that he would leave
it, and it would heal up dry.
Dr. Daniel N. Eisendrath of Chicago said we must
change our present method of treating infected wounds.
The European War had shown that the battle which
had raged between the upholders of the use of anti-
septics and the upholders of the Wright theory had
been decided in favor of the latter. If we stopped to
think how infections were propagated in wounds, there
were practically only three methods: (1) By con-
tinuity of tissue; (2) by way of "the blood vessels, and
(3) by way of the lymphatics, and the more he saw of
infected wounds the more he was impressed with the
fact that the third method was the most important
one to combat. An infection by way of the blood
vessels only took place in very virulent infection, and
the other (by way of continuity of tissue) could be
combated by means of the principles Dr. Dyas had laid
down. In the lymphatic infection the microorganisms
were carried into the lymphatics and from there into
the systemic circulation. The principle upon which
Dr. Dyas' method depended was first of all to have
free drainage, so that there would be no possible ab-
sorption through the lymphatics; in other words, that
the flow from the lymph vessels carried the organisms
away from them instead of allowing the organisms to
be sealed up in the wound or be forced into it. The
method of treatment which Dr. Dyas had outlined, sup-
plemented by these other practices, to induce constant
lymphatic flow, was one of the most important things
we had to deal with to-day in surgery.
Dr. F. Kreissl of Chicago stated that about forty
years ago Hebra installed in a sanatorium for skin
diseases a so-called permanent water bath for burns of
the second or third degree and for wounds that did not
seem to heal. This bath was arranged so that the
water ran constantly at body temperature, the patient
being suspended on a bed sheet so that he was not
exposed to the pressure of the modern bath. The
patients did very well; there was no bad odor, and
nearly all of them got well. The same method was
applied to the cold water treatment as it was originally
introduced by Winternitz, and he supposed those gen-
tlemen who had been in England and Austria had had
occasion to observe both methods. These gentlemen
advocated it in an empirical way, but the underlying
principle was the same as expressed in Dr. Dyas' very
able paper.
Dr. Walter F. McGaughey of Greencastle, Ind.,
asked whether in the case of an injured hand the
essayist would let a man go without any dressing on it?
Dr. Dyas replied that one man was walking around
in the ward with a piece of ordinary window screen
to keep the flies off. He had used wire screen very
extensively in laparotomies and infected herniotomies.
Secretion of the Mammary (Hands; Its Relationship
to Albuminuria and Eclampsia. — Dr. W. E. GARY of
Louisville drew these conclusions: (1) Eclampsia is
a toxemia arising from the accumulation of material in
the blood of the mother intended for the nourishment
of the fetus in greater quantities than is used by the
fetus and greater than can be eliminated by the ma-
ternal organism through the ordinary channels. (2)
The greater the number of leucocytes in the blood of
the mother the creater the toxemia within certain
bounds, of course, due to individual maternal resistive
ability. (3) The presence of leucocytes in the urine in
large quantities is the first symptom of impending
danger. (4) Leucocyte count of the blood of the
mother may be reduced, albuminuria may be cleared
un by the elimination of leucocytes through the secre-
tion of the mammary gland. (5) When the convulsive
>tatre is reached, damage has already been done to the
kidney and other organs, so that treatment must be
given to overcome this damage. This line of treatment
is suggested: Inflate the glands to start secretion.
Empty the uterus to get rid of the exciting cause.
Eliminate by purgation. Support the kidney elimina-
tion by proctoclysis, as the patient cannot drink water.
Control blood pressure with veratrum viride. By these
Dec. 9, 1916]
MEDICAL RECORD.
1053
measures you can keep your patient alive until full
elimination can be secured through the glands.
Ectopic Pregnancy, Diagnosis and Treatment. — Dr.
Richard R. Smith of Grand Rapids, Mich., said the
treatment of ectopic pregnancy was the removal of the
offending tube with its contents and extravasated blood.
This should be done as soon as suitable arrangements
could be completed, but it was unnecessary to so hasten
matters as to interfere with the operation being prop-
erly performed. In the city he preferred to remove pa-
tients to the hospital; in the country he preferred to
go to them, rather than submit them to a railroad
journey unless the case was one of long standing.
During severe shock the patient might be removed to
the hospital, and then it was merely a matter of judg-
ment as to whether one should watch and wait for a
better physical condition or operate at once. If, after
say a few hours, the patient showed no improvement,
he usually operated; if she did he usually waited six,
twelve, twenty-four, or forty-eight hours. Under gas
or ether anesthesia a median incision was made, a
walling off and scooping out large clots of blood, and a
prompt approach to the tubes. Great gentleness was
attended with safety. The tube should be gently
grasped and gently loosened if it, was adherent. Rough-
ness at this point might easily tear the tube from its
attachments, and the patient lose further blood. The
ovary might ordinarily be preserved, but in old stand-
ing cases with dense adhesions the ovary was apt to
be so torn in getting the tube into the field that its
removal with the tube seemed wiser. It was well to
excise the tube well into the cornu of the uterus, as
with an infected tube covering the denuded surface
might be omitted in critical cases. Attention was then
directed to the opposite tube. What should be done
with it? If it was adherent, a gentle loosening from
adherent structures was good surgery when time per-
* mitted. In young women or in those who had had few
-children, or desired more, the tube, if patulous, should
invariably be saved. He thought it well to talk this
matter over with the patient and her husband before
operation. In older women and those who had already
borne children and felt that they were through with
child-bearing, it was wiser to remove it, for repeated
pregnancies occurred in something like 10 or 15 per
cent, of those women in whom a patulous tube was
left at the first operation, and normal pregnancies oc-
curred in less than half of those already operated
upon for this disease. The removal of the appendix
was usually unwise, but when matters were less press-
ing, and the condition of the patient seemed likely to
give rise to future trouble, it might be removed. Usu-
ally the less we did in the abdomen of a woman with
an ectopic pregnancy the better. The removal of most
of the unattached blood clots was necessary, but the
removal of partially organized and adherent blood
should not be attempted. It was surprising how well
everything cleared up after operation, far better than
in inflammatory cases. No drainage should be insti-
tuted unless, as rarely happened, we were dealing
with an infected case. The closing and suturing of
the abdominal wall should be well done, since post-
operative distention was perhaps .more common than
following an ordinary laparotomy.
Dr. William M. Harsha of Chicago said he would
like to say a word or two about diagnosis. The essay-
ist spoke of the pain usually not reaching throughout
the extent of the abdomen. In some cases he had seen
the pain had been very severe and very extensive, often
reaching up to the sternum. The pain was of that
type which had been called an abdominal crisis and
it was out of all proportion to the lesion that we rec-
ognized as occurring in ectopic pregnancy. Here was
a small tube no larger than a rye straw letting out a
little blood, which was normal to the human tissue,
and that little bit of blood just started a frantic pain.
He had never been able to satisfy himself as to the
cause of the great pain that occurred in tubular rup-
ture, but the extension of the pain, if we assumed that
there was bound to be pain from that little escape of
blood, and the explanation of its general character,
was to his mind found in the so-canea overflow or
reflex; for there was the abdominal brain, It was the
herald of some great danger and the impression of
that pain conveyed to the spinal column and from that
point was reflected and overflowed into the adjacent
segment, and so we got a pain all over the abdomen.
Dr. Daniel N. Eisendrath of Chicago stated there
was one feature in connection with this paper he
would like to emphasize, namely, those cases which
we did not see at the time of rupture or within a few
hours of that time. We were accustomed to see these
cases of ectopic pregnancy either with extreme pallor
or with moderate pallor. The cases to which he re-
ferred were those which we see after twenty-four or
forty-eight hours, when the blood in the peritoneal
cavity gave rise to symptoms of peritonitis, for the
presence of a foreign protein in the peritoneal cavity
would cause the same symptoms as a mild degree of
peritonitis. We had the tympany, the rigidity, the
tenderness on pressure and, above all, there was a
very marked leukocytosis. He had seen several of
these cases that he thought were typical cases of
appendicitis, with a mild form of general peritonitis,
but when we entered the abdominal cavity we found
the extrauterine pregnancy had ruptured two or three
days before.
DR. J. H. Peak of Louisville, Ky., said that the time
when this condition was first noticed was usually de-
pendent upon what was occurring in the tube and how
long pregnancy had existed in the tube. If the preg-
nancy had occurred near the extremity of the tube
there was liability of a tubular abortion, and that
might occur frequently without many symptoms and
the patient might get well because extrusion took place.
Operate then before there was much possibility of
hemorrhage, and the patient would get well. If the
pregnancy took place in the isthmus and further
towards the uterus, when labor took place the hemor-
rhage would be more severe, and the more severe the
hemorrhage the greater the amount of shock and
tenderness and pain, and the quicker a diagnosis could
be made. He had quite a number of specimens in hi?
laboratory in Louisville showing the development in
the various locations in ectopic pregnancy.
Is the Genealogy of the Gonococcus the Same as That
of the Meningococcus? — Dr. Charles E. Barnett of
Fort Wayne, Ind., drew the following conclusions: It
is quite desirable to diagnose the meningococcus com-
plication early, because the period of prognosis will be
calculated for months rather than weeks. The treat-
ment will also be dissimilar. There is no known
method of differentiation except in the treatment of
the case with its own manufactured antibodies (anti-
meningococcus serum), because it has been the writer's
experience to have acute gonorrhea cases react to
meningococcus vaccine. The laboratory findings for
both the meningococcus and Neisser coccus are prac-
tically the same. The almost negative findings in the
rectal examination and the rapid dilatation of the
urethra and bladder following resolution would indi-
cate the inflammatory action superficial rather than
deep in the genital tract. Meningococcus infection of
the genital tract is rare, or else only the most virulent
ones are recognized. The overload of the kidney is
quite manifest during the active stage of bacterial
body elimination. The continued alkalinity of the
urine presents a hazard that requires constant dili-
gence in order to keep it within the bounds of neutral-
ity. The meningococcus in the genital tract simulates
the gonococcus in its action, precisely, with the excep-
tion of showing a marked increase in virulency and
persistency.
DR. E. 0. Smith of Cincinnati stated that he did
not catch from the reading of the paper what was prob-
ably the source of the meningococcic infection. As he
understood, it was a gonococcic infection.
Dr. F. Kreissl of Chicago said that we all saw cases
sometimes where the patient presented himself with
an actue gonorrheal urethritis, and upon microscopical
examination we found the patient had a typical gono-
coccus, and then when the acute condition subsided
suddenly we found on microscopic examination that
other microorganisms had appeared which resembled
these very closely, and if we sent the specimens to a
first-class laboratory man, what did we get? A mixed
report. One day they would report to us a diplococcus
resembling a gonococcus, Gram positive; the next day
it would be Gram negative, and the next day a staphy-
lococcus, and the Lord knows what. If we treated
that case, after a time it seemed that the gonorrhea
disappeared, and we would not find a trace of diplo-
coccus or gonococcus, and yet the patient kept on hav-
ing discharges. The patient was not usually prudent,
and then all at once the discharge stopped, and then,
without provocation, or perhaps with provocation, the
discharge reappeared only to disappear with a few
treatments. If we made a culture of these discharges
we got practically the same answer. He had exam-
ined a great many cases carefully for years, and he
1054
MEDICAL RECORD.
[Dec. 9, 191S
had never yet been able to get a report from the labo-
ratory telling him there was a meningococcus, although
all the others were fairly represented. No matter what
we did for these cases we could not cure them, and he
had come to the point where he told his patients their
condition and that he did not promise them anything.
Uk. P. E. McCown of Indianapolis believed that in
a good many instances from sexual abuses and some
other causes we had a prostatitis arise, ana following
that from some excesses such as drinking the patient
would have a urethral discharge. He had felt in a
number of instances where men had claimed that they
had not been exposed to infection that we were deal-
ing with a staphylococcus, and he believed Dr. Wardle's
work in Chicago had shown conclusively that staphy-
lococcus could be a diplococcus many times. He also
made the statement that it was more susceptible to
leucocytes than the gonococcus itself. He had felt in
dealing with these cases, and he had two at the pres-
ent time, that we were dealing with a staphylococcus
which was growing as a result of a prostatitis, there
being a lowered resistance of the urinary tract which
permitted the staphylococcus to grow. The staphylo-
coccus was in intimate contact with the urethra at all
times. We could perhaps get a staphylococcus growth
there almost any time. These discharges were some-
times very annoying. Patients believed they had gon-
orrhea, and where there had been no exposure they
could not understand the condition. In two instances
these gentlemen accused their wives of infidelity, but
after going into the matter thoroughly he had per-
suaded them that this was not the fact.
Dr. Barnett, in closing, said that Dr. Smith had
asked for the source of the meningococcus. One could
never tell the source. We might have a hematogenous
infection most anywhere. In this case the source was
from the girl, and yet the infection of the other thir-
teen men did not seem to be as virulent as this one.
His idea was that, for instance, this was his first infec-
tion. This man, in fact, had had very little experience
in sexual matters, and the epithelium was quite green,
so in this case we had a greater virulence than where
the field had been traumatized a good deal. He would
say that it came from the girl. In regard to the pros-
tatitis that Dr. McCown had spoken about, the first
infection we got was staphylococcus albus, and then
the whole bacillus, and finally the meningococcus.
Some Clinical Phases of Focal Infection with Especial
Reference to Its Location in the Head and a Plea for
More Accurate Classifications. — Dr. Joseph D. Heitger
of Bedford, Ind., stated that a great field in the treat-
ment of chronic focal infections lay before us, but the
still greater field of prevention of a large percentage
of these cases lay ahead of us. Childhood was the
time to forestall and prevent many of these infections,
and there was no knowing how much of the morbidity
of later life might be prevented by proper attention
to these foci in the head, especially the teeth, tonsils,
sinuses and ears. In order that the profession at
large might obtain the greatest good from these ad-
vances, there must be continual exchange of ideas, not
only between the general practitioner and the special-
ist, but also between the different specialists. The sad-
dest thing about some of these phases of focal infec-
tion was that men were classifying patients, putting
them into this or that group, who were not studying
these patients; who did not understand focal infection
in its broadest sense, or at least they were attempting
to put the focus whore they wanted to place it and
the patient learned by sad experience of the mistake
in diagnosis. Focal infection, when found and prop-
erly diagnosed, offered much that bordered almost on
the miraculous. Its treatment should be judged not
bv the worst that was done by some in falsely inter-
preting its hiding place, but rather by the best that
resulted in those cases which were carefully and ac-
curately diagnosed and classified. A routine method
for their diagnosis and classification could be obtained
and it was to this work that he would invite all to
lend their best efforts.
The Surgical Management of Acute Perforation. Com-
plicating Intraabdominal Infections. — Dr. W. D. Haines
of Cincinnati stated that the type of operative pro-
cedure would depend upon many factors, chief among
which would be the patient's general condition, i. c,
his ability to withstand operation. The length of time
which had elapsed since perforation took place, the
surroundings, the actual findings at operation and the
experience of the operator were important factors for
consideration in planning the operation. Many of these
patients were in such a desperate condition when they
were brought to the operating room that locating and
closing the perforation and providing drainage as
quickly and with as little disturbance to surrounding
structures as was consistent with making a water-
tight joint and placing the drainage would best sub-
serve the interests of the patient. Latterly the ten-
dency on the part of the surgeon had been to liberate
adhesions, resect damaged loops of intestines, provide
drainage by anastomosis and remove all visible pathol-
ogy and while ideal when the patient's condition and
surroundings would permit of extensive operation,,
still by far the greater number of patients suffering
from gastrointestinal perforation were in such physi-
cal condition as to preclude other than the least and
quickest surgery which would reach the goal of closure
and drainage at the primary operation, leaving the
more extensive and technical elements for subsequent
operation. A bad surgical risk before perforation
took place, was not improved by the incident of per-
foration and a live patient with his perforation closed
and peritoneal cavity drained, although the operation
was incomplete, with much pathology in his abdomen,
which might be removed later if occasion demanded,,
was preferable to turning the patient over to the
undertaker after a technically perfect operation.
Much good might be accomplished in the presence of
extensive soiling of the peritoneum by gentle mopping
with dry gauze, conversely much harm might be done
by flushing the peritoneal sac. Perhaps the most that
could be claimed by the followers of this all but obso-
lete and archaic practice of flushing the peritoneal
cavity was that it insured the widest possible distribu-
tion of infectious material, destroyed newly formed
plastic material and materially increased the mor-
tality.
(To be continued.)
NEW YORK ACADEMY OF MEDICINE.
Anniversary Meeting, Held November 16, 1916.
The President, Dr. Walter B. James, in the Chair.
Dr. Walter B. James, in introducing the speaker of
the evening, said that the Academy of Medicine had
been founded in 1847 for the purpose of advancing the
science and art of medicine in the city and the vicinity.
Its halls frequently resounded to scientific discussion
and to essays of highly technical character, but a very
wise provision had been made whereby once every sea-
son someone outside the profession of medicine was
asked to address them. There was a tendency in every
profession to become narrow; one could often learn a
great deal about his profession from those who claimed
to know nothing about it. It had been said that after
a man had reached the age of fifty years he was his
own best physician. If that were true, and if it were
true that a man grew better as he grew older, they had
decided that Mr. Depew was good enough by this time
to be accepted by the profession. He had gone away
beyond the Scriptural three score and ten years and
would tell how he had done it.
The Art of Crowing Older, and the Value of an In-
terest in Public Life. — Mr. Chauncey M. Depew de-
livered this address in which he said, in part, he
feared that if he revealed how often he had had to
rely on a physician th<3 old tradition about a man of
fifty years being his own best physician would disap-
pear. " It was not often he confessed that he felt any
trepidation in speaking in public, but he felt that it was
dangerous to speak before such a highly specialized
group of men. But if age meant experience, and no one
could question but that a man past four score had had
experience, then he was fitted to speak with authority
unless there was some one older to gainsay him. It was
true of all professions that their knowledge depended
largely on experience (with the exception of the theo-
logians) and that was the reason that they grew and
changed and progressed. Seventy-five years ago, say
when he was a boy seven and a half years old, his vil-
lage had any number of old men and women. Every
woman past fifty donned a cap which proclaimed her
antiquity and wore a gray shawl, which advertised the
poverty" of her blood. Every man retired at seventy
and lounged indolently about the house or sat on a nail
keg in the village grocery store and discussed the events
of the day. To-day one could not find a woman wearing
a cap, and, indeed, it was difficult to distinguish the
mother from her daughter. It was equally difficult to
Dec. 9, 1916|
MEDICAL RECORD.
1055
find an elderly statesman on a nail keg, discussing poli-
tics. Modern inventions, the telephone, the cable, and
■easy and luxurious modes of travel had connected a far-
spread world and did much to keep alive mental activity.
Shakespeare, 350 years ago, applauded rapturously the
seven ages of man. He died at the age of fifty-two.
having given the world the greatest literature it had
ever had, and at that time regarded himself as an old
man. In his "Seven Ages of Man" he pictures the boy
in the second age, with his satchel on his arm going
whining to school. There was no such whining boy to-
day; he was now either playing baseball or rooting for
his side. In describing the sixth age of man, Shake-
speare spoke of the old man as of "slippered pantaloon
and shrunken hose'* with his "shrill and piping voice";
to-day that man is at the bar — the legal bar, he meant —
or in the pulpit giving to a listening world the best of
his maturity. He spoke of the seventh age as "sans
teeth, sans taste, sans eyes, sans everything" — now
there was no such age, the dentist provided teeth, the
oculist and optician provided better eyes very often than
nature had given, and the housewife had better look
out if the old gentleman found something on the table
not equal to what he had been accustomed to in the old
days. The ancients apologized for their age, and not
only the ancients, but others. Cicero, at the age of
sixty, wrote "De Senectute," in which he apologized at
length for his old age. No one to-day would expect
an apology from a man over eighty. To-day no one
apologized for his age, but he was exceedingly proud
of it. There were many ancient things of which one
might well be proud. The oath of Hippocrates had
never been improved upon and Hippocrates knew of
many things that were still of value to the medical
profession. Adam Smith of Edinburgh, the greatest
political economist of his day, when an old man wrote
the book entitled "Inquiry in the Nature and Causes of
the Wealth of Nations." That book was responsible for
England's policy of free trade and later for the adop-
tion of a high protective tariff by America.
Mr. Depew declared that he knew of nothing which
had had such a tremendous effect on the world as that
utterance of David in the Ninetieth Psalm, "The days
of our years are three score and ten. or even by reason
of strength four score years, yet is their pride but
labor and sorrow." No one knew how many untimely
deaths this had occasioned. This had been proclaimed
from the pulpit as an inspired saying and men and
women died because they believed it. That psalm has
caused more deaths than the war now raging in Europe.
Dr. White, who formerly lectured in anatomy and
physiology at Yale, said you could get any disease you
wanted if you thought of it hard enough and long
enough, and you could die when you wanted to. He
spoke of having heard men say, "People in my family
never live over seventy years," and they belierved they
could not live beyond that time. Dr. White said there
was such a tradition in his family, so when he reached
the age of seventy he decided to retire and to engage
in a different occupation; he believed that in this way
he could break the record, and he lived to be over four
score. Some preachers believed and preached not only
that man's allotted time was three score and ten years,
but they believed and preached that if the time was ex-
tended to four score years it was as an actual punish-
ment for sin. They took this view without taking into
consideration the life and character of David. David
grew up in poverty, became the leader of the army
and then king of a small tribe. He gradually extended
his power to the borders of Egypt. He had wealth and
power and could enjoy every luxury that money could
buy, and "he lived the life." When we take these facts
into consideration in connection with his condition and
attitude in old age we get a different point of view; the
three score and ten years limit loses its power over us.
The speaker related that his great grandfather lived
to the age of eighty, lamenting the decadence of his
age, and bemoaning the fact that the end of the country
was near and he was glad he would never live to see its
downfall. The reason of this wTas because a Federalist
(Jefferson) had been elected President. Jefferson had
spent some time in Paris and was reported to have
imbibed atheism, French culture, and radicalism. To
turn to the other side of the picture, during his term as
senator, Senator Hoar of Massachusetts, Senator Pet-
tus of Alabama, and Senator Morgan of Alabama, all
of them about eighty, were the leaders of the House,
because of their wonderful grasp of all questions, their
vast knowledge of history and their intellectual vigor
and alertness in debate. Their longevity and their vigor
of mind and body were due to the fact that they felt
their responsibility to one hundred millions of people;
they took very seriously their high office. It had been
his good fortune to have been in Paris at the time that
Michel Chevreuil celebrated the 102nd anniversary of
his birth. He had entered the government service
when eighteen years of age and had been promoted
from time to time until he held a high position in the
scientific world. He gave to France the dyeing process
that assured to her the supremacy in the silk trade.
His birthday was celebrated with great festivities. A
gala performance was given at the opera at which he
received a great ovation which he met with enthusiasm.
He did not leave his box until two o'clock in the morn-
ing. The following morning he reviewed a large army
of troops; in the afternoon he read a highly scientific
paper, and in the evening attended a banquet at which
Mr. Depew had the good fortune to be placed beside him.
He asked Chevreuil how he had attained his one hun-
dred years. The reply was that he had held a govern-
ment position with regular salary and periodical in-
creases, so that he had never had any financial wor-
ries; he had never used alcohol, but drank only the
waters of the Seine (the Seine at that time was a
sewer). While this conversation was going on an old
man on the other side was filling his glass repeatedly
and drinking to the health of every one. This occa-
sioned Chevreuil much anxiety and Mr. Depew asked
who the old gentleman was. Chevreuil replied, "that
is my son." Mr. Depew asked how old the boy was
and received the reply, "seventy-six." This child was
the only real care Chevreuil ever had.
Mr. Depew stated that in his own experience and
observation the fact that had impressed him most was
the absolute control of mind over body. He felt quite
sure that there was something in a man's mind which,
if he could concentrate and control, would place him
where nothing could ever happen to him. When a man
lost control over his mind he lost his best asset for at-
taining longevity. To lose control of one's temper was
absolutely destructive to the possibility of longevity,
because this used up vitality. When a man carried his
business always with him, to church, to the opera, to
his home, it was fatiguing to him and he was making
a great mistake. It was likewise a mistake to retire
from business. The process here was always the same,
unless one retired into another vocation in which he
was as much interested as he had been in his business.
The usual process was to retire to his old home town
and settle down expecting to enjoy life with the same
vigor that he did when he was a boy working in the
village store. It went fairly well the first year; the
second year he grew irritable; the third year he began
taking medicine; the fourth year he took patent medi-
cine, and fifth year one usually saw his obituary
while those younger and better able were enjoying his
estate. The question was, "What could man at this
age turn to?" "Should it be sport or another occupa-
tion?" It was not always possible to engage in an-
other occupation, but sport was always possible. For-
merly elderly men turned to horses and took great
pride and satisfaction in their paces. A man got a
great deal of pleasure in seeing how much speed he
could get out of his horses and in watching the superb
play of muscles and nerve. This was invigorating and
absorbing, but the automobile had destroyed this sport.
After the automobile came golf, and now everyone
was playing golf. Then there was billiards, but here
there was the disadvantage that one must play at the
club, and this meant smoking cigars and drinking a
few cocktails. But a time came when a man could no
longer even play golf or billiards and what was he to
do then? There was always one field left and that
was service; this would last to the end. There was
service for one's country, for the State, for the munici-
pality, for the church, for the hospital, everywhere.
This was the one thing that would last for ever. Pub-
lic life always provided an interest. Every man
should be interested in government, for it was a per-
sonal matter, determining the conditions that governed
his property and the amount of money that he could
accumulate." If the methods of government were not
what they should be this was the fault of the people.
An interest in politics might be aroused just before a
presidential election but it was then forgotten for the
next four years. The primaries had been devised to
overthrow the power of the "political boss." but the
people took no interest in them, so the "boss" ran the
primaries and he was now greater and more powerful
than ever before because he had the sanction of the
1056
MEDICAL RECORD.
[Dec. 9, 1916
people. There was no body of men better fitted to take
a part in politics than the doctors, but they had failed
in this matter of public service. All lawyers took an
interest in politics because there were great prizes to
be won, but not so the doctors; nevertheless there was
no one of whom men were more afraid than they were
of the doctors because of the confidential relation ex-
isting between the doctor and the families in which he
practised. The doctor should bring the w:eight of his
influence to bear at the caucus and at the primaries and
all the way along to the polls. This, however, was not
a subject for anyone to take up as a relief from profes-
sional duty. In government there were always with us
the conservatives and the radicals, the Hamiltons and
the Jeffersons, and just as long as one party was about
equally balanced against the other we would not go
over a precipice nor die of dry rot. Conditions today
were parallel to those of the days of Hamilton and Jef-
ferson; Hamilton stood for strong central government,
Jefferson thought the central government should place
the least restriction possible on the States. From the
combination of these two views Washington produced
the Constitution of the United States, the first constitu-
tion to survive for one hundred years. There was the
same struggle between conservatives and radicals to-
day, though perhaps Jefferson would be astonished at
some of the things his party was doing. So long as
there was this balance of power and people were in-
terested the country would grow and prosper.
But, no doubt, someone was asking, "How about your-
self?" For the benefit of that person he might relate
that at one time, under the stress of affairs, he had
reached a point where it became evident that he must
I.ave relief from the strain, and then he made the plat-
form a way of escaping from busines and freshening up
his mind. On one occasion he had had a very trying
conference and went home completely exhausted. He
had promised to make a speech in the evening. He lay
down and rested, then prepared his speech, and ap-
peared at a banquet at Delmonico's, where he delivered
the speech in due form. He went home at twelve
o'clock, slept well, and appeared at the appointed hour
for further conference. Another man was there who
said he had just seen a column in the newspaper about
the speech Mr. Depew had delivered the night before
and that he was destroying his reputation as a business
man, for no one could see how he could attend to any
business and have time left to prepare and deliver so
many speeches. This man then told that he had played
billiards, smoked, and drank a few cocktails the evening
before and did not retire until two o'clock; he confessed
that he did not feel good for anything. One must in-
sist on regularity of habits, that a man get up early,
and that he give up liquor and tobacco. There was no
need for anybody being a mollycoddle or an insipid
Pollyanna, but he should keep up an interest in all
public questions, do his little charities and acts of kind-
ness, not because he ought to but because he wanted to,
and then he might go to eighty, to ninety, to one hun-
dred years of age, feeling that it was a glorious thing
to have lived in this beautiful life and to have enjoyed
all that there was of it.
clprapwtir limits.
Role of the Endocrine Glands in Mental Disease. —
Serradell in a recent thesis of Toulouse refers first to
the psychic disturbances which accompany menstrua-
tion, and which are characterized by irritability, exult
tion, motor excitability, and also by indifference and
apathy; while in certain cases true psychotic states
are present. After ovariotomy women show apathy,
irritability, sadness, weakening of memory, suicidal
ideas, etc.; also psychoses of confusion or melancholia.
The mental peculiarities and psychoses of the meno-
pause are well known. But nearly all endocrine or-
gans may play some part in mental troubles. In ex-
ophthalmic goiter maniacal states, melancholia and
mental confusion have at times been seen. In acro-
megaly dementia, melancholia, and delirium of persecu-
tion may occur. In adrenal insufficiency the syndrome
may include slowing up of the intellectual faculties,
melancholia, and neurasthenia. Furthermore, in autop-
sies on the insane alterations of the endocrine glands
are often apparent even although certain symptoms may
have been absent. The good results of opotherapy on
the insane represent further documents, the most strik-
ing having been noted in connection with psychic and
somatic infantilism. The glands chiefly given are the
thyroid, ovary, and adrenals. — Journal de Medecine et
de Chirurgie Pratiques.
Hydrotherapy as an Agent in the Treatment of
Convalescents. — Radcliffe offers the various baths
as a curative measure for those suffering from
nervous disorders due to shock, or in cases of
disordered action of the heart, giving defective
circulation. In cases of frost-bite the running
water bath improves the circulation, and the symp-
toms disappear after a few immersions. Sprains
which present a sodden appearance, under this
treatment, become filled with blood and repara-
tion takes place. There are two types of baths —
one for arm and one for leg. The running water
is kept at a temperature of 105° to 115° F., de-
pending on the susceptibility of the patient to heat.
The arm, leg, or foot is placed in this bath for 35
minutes, then light massage and exercises are
given. The pool bath for full immersion, in cases
of heart and nerves, is given in a large tub with
running water at a temperature of 92° F. Immer-
sion lasts for an hour, after which the patient is
made to rest. This bath must be given in a quiet
room, softly lighted. The treatment usually lasts
in all these cases from fourteen to twenty-eight
days. — British Medical Journal.
Treatment of Tonsillitis. — Bush advocates abso-
lute rest in bed even in light cases of this condi-
tion, particularly since the streptococcic type of
tonsillitis seems to be gaining in ascendency, and
is credited as the cause of certain types of rheu-
matism. Aside from the use of the salicylates,
which is strongly advocated, alkaline or astringent
treatment must be given the tonsils. The most
rational treatment is the prompt preparation of an
opsonic autoserum, and administration in proper
doses, thereby affording nature a better oppor-
tunity for the production of those antibodies
without which a cure is impossible. Antitoxins
are nature's treatment for diseases and drugs are
either accessories or mayhap impediments. It
seems unnecessary to state that a brisk, but light
purgative, such as Rochelle salts, should be given
at the onset and low, nourishing diet maintained. —
New York Medical Journal.
Nuts and Fruits in the Diet of Children. — Scott
suggests the dietetic and nutritive value of these
foods for children because they are palatable
and enjoyed. The nutritive value of fruits is
found in the salts they contain, and their thera-
peutic value in their laxative, diuretic, and anti-
scorbutic actions. — New York State Journal of
Medicine.
Determination of Sex. — J. S. Freeborn gives a
record of a series of 1,000 cases as a basis for his
theory of determination of sex, in which a correct
diagnosis was made in 97% per cent, of the cases.
Note is made of the occurrence of date of concep-
tion in the first or second half of the intermen-
strual period. Conception occurred for females
usually 5% days after the last menstruation; for
males, usually 19 days after the last normal men-
struation. He is of the opinion that sex is fixed at
time fertilization occurs; the ovum determining
the sex independent of any inherent quality of
the spermatozoon, and all ova maturing in the
first of the intermenstrual period are female-pro-
ducing ova and the later maturing ones are male-
producing ova. Marital relations should be lim-
ited to the first ten days after the menses for
girls, and to the last ten days of the intermen-
strual period for boys.
Medical Record
A Weekly Journal of Medicine and Surgery
Vol. 90, No. 25.
Whole No. 2406.
New York, December 16, 1916.
$5.00 Per Annum.
Single Copies, ( 5c .
©rtgtnal Arttrks.
COMMENTS UPON THE PERSONALITY, BE-
HAVIOR, AND CONDUCT OF CONVICTS
IN SIBERIAN PRISONS, AS TAKEN
FROM DOSTOEVSKY'S "HOUSE
OF THE DEAD."
By L. PIERCE CLARK, M.D.
NEW YORK.
More than a few workers in psychiatry have wished
there were a psychological dictionary of human be-
havior and conduct, as a normal guide or standard
to life reactions, by which they might, within rela-
tively precise limits, judge the degree of variation
of mentally abnormal and psychotic individuals. It
is precisely the lack of this norm or pattern that
brings out the innate defect of case reports in a
just estimation of the actual beginning of psychotic
reactions. Inasmuch as the new advance in psy-
chiatry, as Hoch justly contends, must be made
in gaining a scientific analysis and evaluation of
ideational or delusional mechanisms, or mental
symptoms of the older psychiatry, in any given
psychosis, the need as above outlined becomes the
more urgent. Had traditional psychology given us
a good account of the emotions, we should not now
find ourselves so destitute and in such great need
for this aid.
In the absence of a normal psychology of the
emotions, one turns to the careful analysis of per-
sonalities and characters made in neurotic and psy-
chotic individuals in the newer studies on these sub-
jects. But often enough these individuals have
already shown exquisite or pronounced departures
from the commonly accepted standards of individual
and social conduct, so that almost any one may
detect the glaring fault. The psychoanalytic move-
ment in handling the neurotics and psychotics has
demonstrated that the future of prevention in men-
tal hygiene must rest largely in the early detection
and correction, if possible, of the earliest abnormal-
ities of these persons. Everywhere attention is be-
ing paid to the study of human behavior and conduct
in the schools, juvenile courts, and in mental clin-
ics. To analyze and give the excellent results al-
ready accomplished in this field would carry us too
far away from the present purpose of this little
essay.
It is not only desirable that the personality, be-
havior, conduct, and emotional reactions shown
therein should be studied in the psychoses, and in
so-called normal individuals, but we need equally
careful studies on the interned criminals.
I venture to say that there are none so dull of
comprehension that they may not find glaring faults
in our prison administration, and that all will admit
our approach to the problem of its correction must
be based not upon a study of the prison inmates
en masse, but upon an exact study of the individual
criminal. Such studies should be made by trained
criminologists in laboratories connected with the
prisons, just as the insane are observed and studied
in psychiatric institutions in our State hospitals.
In search for some careful analyses of the person-
ality of criminals, their behavior and conduct in the
fine relief of a strict standard of discipline and
accountability which close prison surveillance brings
out, I came upon a description of the personalities,
behavior, and conduct of convicts in Siberian pris-
ons, as revealed in a critical study of Dostoevsky's
"House of the Dead," recently translated. In this
work I found many points of interest which I have
judged of sufficient moment for review and com-
ment.
It must be borne in mind that the prison build-
ings were dormitories only, and that all the men
worked, either in the prison yard, or in the region
surrounding the prison. Hence we find no mention
of convict's pallor and certain other phenomena as-
sociated with prison life. Their faces were branded
so they were marked men for life. It is not sur-
prising to learn that prison life teaches the prison-
ers patience, yet, if one may judge correctly, but
few profit from the instruction. We find that the
effects of prison life are to age a man greatly, de-
spite freedom from many causes of death and dis-
ease. The cause for this would seem to be largely
or solely mental — the loss of hope being the greatest
factor. The men in prison never fell asleep readily ;
as they lay thirty on a "bed" it would often take
four hours before all were asleep. Therefore, a
good night's rest was rarely experienced by any of
the prisoners.
As already mentioned, the "branded face" was
a constant reminder throughout life that they were
outcasts. After the sentences expired they lived
near the prison or in some other village as a "set-
tler" and were for the most part considered
"broken men."
It was noted that convicts seldom talked of their
misdeeds or asked questions of others. It was con-
sidered bad form. Those convicts who bragged of
hideous crimes were soon silenced, although not
from indignation. It would seem to have been mo-
tivated from being bored than otherwise.
The chief personal qualities of the convicts were
sullenness, envy, vanity, boastfulness, proneness to
take offense, and great sticklers for form, all rather
childlike traits. They never showed surprise at
anything. The great majority were given to con-
stant slander and backbiting. It was "good form"
to submit to prison regulations and disciplines.
There was often a peculiar personal dignity about
the convicts, although much of it seemed a bit stiff
and overemphasized. There was never a sign of
repentance or remorse; however, they seemed to
1058
MEDICAL RECORD.
[Dec. 16, 1916
feel that they were there by their own fault, and
have many sayings to that effect. But let one fully
agree with them, and they often took offense, which
makes one doubt their sincerity. When reproached
or censured by a non-convict they cursed him ter-
ribly, as though the burdens they bore were quite
enough without additions being assessed thereto.
Often their behavior made one compare them to
a lot of old women, so prevalent were backbiting,
intrigue, slander, envy, and quarreling. Yet they
instinctively respected a strong, dominating fellow
prisoner.
They never by any chance brooded over their
crimes. They even thought their behavior was
ethical, which was no doubt in part due to extreme
vanity. In other ways, too, they often exhibited a
childlike naivete.
It would seem that prison confinement and se-
vere labor develop hatred, a lust for forbidden pleas-
ures, and a "fearful levity"; the hatred always
extends to society. After his punishment the con-
vict feels purged of his crimes, and that in conse-
quence he can begin again with a clean slate. Only
in a prison does a man sometimes own up to most
vicious crimes with a light heart.
As an instance of extreme repression of psychi-
atric interest is the fact that the prisoners almost
universally form the habit of raving and talking
in their sleep. They say, "we are a beaten lot;
our guts have been knocked out, and that is why
we shout at night."
Work as prisoners was hateful, but private work
for which they received some compensation prob-
ably saved them from an increase of viciousness.
It was shown here, as elsewhere, that a man must
be able to work for himself and own property. This
as a rule was not strictly forbidden in the Sibe-
rian prison, and there were cases, like that of a
convict jeweler, in which a man's services were in
demand by the villagers. They sometimes received
alms when going to work. On long winter nights
men worked with hidden tools, learned trades, etc.
The chief proscription was in regard to owning
tools. The graft system, in some respects, was
like that in our own prisons, but no high officials
took part in it.
Now that we have learned that the drug habit
is either contracted or greatly augmented in all
prisons, it is interesting to note that in Siberian
prisons vodka was smuggled into the dormitories
and sold, and some prisoners actually grew rich.
But as money was of no value in prison — to the long-
timers and lifers, at least — the money saved was
nearly always spent in gambling, drunkenness, or
on prostitutes. (This latter condition was rare,
extremely expensive, and involved bribery; the
usual substitutes were common.) Every man pil-
fered from every other man, and was usually
thrashed for it.
The subject of a trade or calling pursued in
prison, almost always in secret, was very diverse.
Nearly every calling was represented, including
money lending, teaching, valet work, trading, etc.,
etc.
Under the system of the prison in question there
was much spare time in winter. The men thus
thrown together were hopelessly bored. There is
something peculiar and trying about life in com-
mon. The most energetic men are bound at last
to "start something," a row, an intrigue, drinking,
card playing — in which latter act a convict often
lost his last shirt. About one-third of the convicts,
however, worked at something, as already stated.
While real fighting was "bad form," men often
"faked" fights for the entertainment of the others.
They would insult, threaten, etc. But if they
seemed about to fight in earnest they were pulled
apart. Real fights are always reported by the
guards, and an investigation follows. Swearing
was not forbidden, and cursing matches were com-
mon. A connoisseur in cursing was respected.
A newcomer was viewed from various angles, one
being in regard to the amount of money he might
possess. They were anxious to get his money for
personal service, tips about prison life, or by theft
or fraud. Newcomers who looked like gentlemen
were regarded with hostility and dislike. This per-
sisted even after the gentlemen had become inured
convicts. While the feeling of the peasant convicts
toward the gentlemen convicts was a deep-seated
hatred, some of it was from jealousy, as the latter
had, as a rule, money, and could buy special privi-
leges.
Convicts like piecework. They work hard until
all is finished and they can then return to the
prison and have time to themselves. As already
stated, the convicts loved to have special work and
own property. When this chance was cut off they
grew depressed, and stopped at nothing to get
money. It never stayed long with them, being
either spent or stolen.
All convicts in the prison described seemed to be
attached to a religious old man whom they called
grandfather. He was free from disagreeable man-
nerisms, seemed childlike, bore everything bravely,
was greatly cast down, but always strove to hide
his melancholy, and would laugh in such a way
as to compel liking. He was communicative, but
never argued. In most ways he was the very oppo-
site of the men in his special church. The convicts
honored him by giving him their money to keep.
"Grandfather," despite his simplicity, devised a
most ingenious hiding place for it, where it was
safe from theft.
It is unnecessary to state that a convict is eager
for freedom. Yet money is seldom saved. When
enough accumulates, his repression breaks forth in
various ways. Some spend their savings in new
clothing, usually of an assorted lot. Their pleasure
in these clothes is quite childlike. They soon go
to pawn, or are sold to others. If holidays were
near at hand, the new clothes came handy. The
clothes might be associated with a feast ending
in a debauch. Very seldom indeed was any one
asked to share it.
When a convict got drunk on vodka he was al-
ways shielded by his fellows — an example of com-
munal action. All Russians, and especially con-
victs, have sympathy with a man who is helpless
or irresponsible from drink. Although great pre-
cautions were always taken to prevent the report
to the governor, usually the inferior custodians had
no mind to interfere.
A talebearer, traitor, or spy among the convicts
is never humiliated or shunned, and such a man
even makes friends. The convict, as a rule, can-
not be made to see anything wrong in treachery.
The prison reaction differs much with the pris-
oner and his crime. Some convicts enjoy prison
life, become criminals in order to be imprisoned.
Many find prison life no worse, or even better, than
their outside existence. For the educated man,
however, if he realizes what his life means, prison
is a torture.
Convicts are not dangerous in the sense that they
attack innocent people. All who come in business
Dec. 16, 1916]
MEDICAL RECORD.
1059
contact with them fear their treachery ; the con-
victs realize this fear and it makes them conceited.
The keepers and higher officials must be firm and
fearless to gain their respect, and must at the
same time trust them. A high official who visits
them unguarded is popular. Had any convict acted
in a threatening manner, others would have sup-
pressed him. Many wardens in our own prisons
can testify to similar experiences. Nevertheless,
one infers that the intense dread universally in-
spired by convicts must have some reason. Aside
from their appearance, numbers, attitude toward
society, etc., which give rise to theoretic insecurity,
the narrator in the book of "The House of the
Dead" knows of but one actual motive which is in
evidence but rarely. The man who is to be flogged
soon is in a state of fearful apprehension, and will
do anything to "change his luck." Such a man
may assault a keeper; it will, at most, cause an
investigation which will defer the punishment for
a short time. In the end the latter will be worse.
The convict has an extraordinary love for physi-
cians, who can sometimes prevent floggings for the
time, although he knows that punishment is com-
ing to him as soon as he leaves the hospital.
Any convict, however sturdy, will put off a flog-
ging. The ordeal seems to be too severe for them
to want it over at once. Some proud ones try to
seem unconcerned before the act, but they deceive
no one. The convicts show humane impulses by
their failure to make comments on such men.
When the convicts are locked up in their sleeping
room with no keepers present, conditions become
"homelike." The lights supposed to be doused were
at once relighted, for each man had a candle and
stick. The workers took up their private labors
already mentioned and others played cards. At
times card playing never ceased until the doors
were unlocked in the morning and never until the
great majority were broke.
As regards class spirit in prison, it was shown
there was a special type, down and out, and devoid
of pride or initiative who were content to wait on
the others, run errands, act as sentinels, etc. For
a few kopecks a night one will act as outside sen-
tinel and nearly freeze. The free-hearted convict,
possessed with money and filled with vodka, is never
generous with these fellows, and always beats them
down to the lowest figure and insists that they
carry out their agreement faithfully.
A convict is sometimes tricked into "changing
names" while en route. By impersonating another
convict he is sure to have much the worst of it,
while the other gets a lighter sentence. The price
paid is usually ridiculously small. Such victims
always remain objects of derision, which is chiefly
because they did not hold out for a large sum of
money.
Toadying and spying have been mentioned before.
Some of these men were actually admired because
of their art in getting around the superintendent
and often deceiving him to their own advantage.
A convict without one kopeck in his pocket was
tenfold more dejected than one who had a few of
them. Had the chance to work for themselves and
the possibility of private gains been eliminated,
these men would either have gone mad, pined away,
or committed some outrage for which death would
have been the penalty. No class of men is so
greedy for money, none spend it so rapidly or fool-
ishly. To possess it they cheat and rob one another ;
they will do anything whatever. Yet despite their
passion for freedom, they never save up against it,
for to be able to spend money, to buy vodka, to
meet with women makes him feel that he is of some
account for a time even in prison. This harmonizes
with the fact that convicts have a tendency to assert
their individuality by bragging, bullying, etc., and
money alone can make this attitude real.
Of great interest are the occasional instances of
running amuck, so to speak, in men who have been
model prisoners for years. Their behavior is de-
moniacal, and they may commit murder or rape;
they get drunk and disorderly, play pranks, etc.
Their "crushed personality" rises and asserts itself
until it reaches a pitch of fury, spite, mental aber-
ration, or fits and convulsions, quite terrible to
contemplate.
Every expression of personality on the part of
a convict is repressed as criminal by the authori-
ties. Dostoevsky calls the explosions or reaction
engendered by continual suppression of his individu-
alistic desires poignant hysterical cravings for self
expression. He believes that a man buried alive
might act in the same irrational manner when he
realized his condition.
Convicts either show scowling brows or over-
jubilant face3. Volunteer entertainers, buffoons,
etc., while they may at times divert the convicts,
are despised and abused. This seems to be due
to their lack of repose and self control. In a word,
it is "bad form," for the convicts wish to be stoical,
reserved, and dignified. Occasionally they tolerated
this sort of man if he would strike back at them.
Convicts look down on peasants, although half of
them are from the peasant class.
When set to a task, convicts are unable to agree
among themselves as to how it should be performed.
An outside foreman seems necessary. Once they
have received their orders, they work with surpris-
ing energy, such as breaking up an old barge and
saving what was worth while. This speed was due,
perhaps, to the piecework concerned. But by work-
ing with speed they saved a half hour a day, though
they worked very hard.
The prisoner's first dream on entering a prison
is always freedom. Hope would seem to be a much
stronger feeling in a convict than in a free man.
He has an unconquerable feeling that he is merely
"on a visit" and must some time return home.
When he first enters there is apparently no differ-
ence between a two-year and a twenty-year sen-
tence. He pictures himself released with all the
qualities of youth unchanged. Even after a long
sentence life is still before him.
If a man is fond of ordinary prison labor (per-
haps only because the exercise is good for him),
the convicts gibe him. Shoveling snow was agree-
able to the convicts and they worked in gangs in
order to quickly release buildings snowed in. Nearly
all became cheerful. Snowballing was frowned on
as undignified.
It is interesting to note that convicts perhaps
unconsciously demand some respect from others and
wish humane treatment. Food and shelter are not
enough. Good men with kind words can do much
with them. But the convict does not wish his offi-
cials to be soft, for then they could not respect them.
They have some pride in their governor and wish
him to be dignified, with decorations which point
to past honors. They like it if he has a "pull."
From him they demand strictness with justice.
One man of the "comedian" type whom the con-
victs call both "foolish and useless," had no use for
1060
MEDICAL RECORD.
[Dec. 16, 1916
the men who despised laughter and because of this
resentment was treated with respect.
The convicts appear to have been religious
throughout, crossing themselves, praying to ikons,
etc., and at Christmas denied themselves in various
ways, by avoiding swearing, etc. While in general
decidedly unfriendly to one another, on Christmas
they at least tried to be friendly, giving Christmas
greetings to those whom they had always disliked.
The intense delight of the convicts in the private
theatricals given during Christmas week was, of
course, natural, relieving the prison monotony.
Nearly all wished to help in some way and only the
best men were in demand. Even the author, as
an educated man, was for once treated with respect
by his enemies. Outside the prison some bluffer
might have secured prestige but in prison the con-
victs are not deceived. Under these conditions jus-
tice becomes a virtue. The best man for the place
will have it whether or not they are on good terms
with him. The author comments that no wise man
can teach these convicts, but often could learn from
them.
At the Christmas entertainment there were not
enough seats for the convicts, but there was no
scramble. It would have been very bad form to
have behaved badly on such an occasion.
The audience at the entertainment was carried
away; their faces softened and even seemed child-
like. Applause was generous. The music and act-
ing seem to have been superior. The play was one
which dealt with a knavish servant, and his pranks
were wildly applauded. The convicts were proud
that they could turn out such an entertainment.
It seems that the convicts never tired of praising
the doctors. They often compared them to fathers.
Some patients in the hospitals were really ill;
others were sent by the doctors "to have a rest."
If there were plenty of spare beds the doctors filled
them with patients who while not really ill were
deserving of sympathy.
Some patients were suffering from the effects of
flogging. Their reception by the inmates depended
on the offense for which punishment was given as
well as the extent of the latter. A very bad man
who had been beaten hard enjoyed more sympathy
than a runaway recruit. No comments of any kind
were made. Orderlies' services were not required.
The convicts who were able took full charge of the
beaten man and better care he could not have had.
The author gave one such man a cup of tea. He
was too dazed to thank him. After having done
all they could the convicts at once ceased to notice
him.
The doctors treated every man with kindness and
spoke friendly words to all. The convicts knew the
physicians were not obliged to do this, and there-
fore appreciated it. They would not have minded
rough treatment. Therefore the doctors were
strictly on the level.
It is surprising to learn that no convict, however
sick, ever had his fetters removed, they died in
them. Even the doctors did not interfere. The
weight was ten pounds and they were so little in
the way that they did not interfere with escapes.
On the other hand, in wasting diseases they became
a burden. The author came to regard them as a
mere badge of degradation.
The "ward doctor" was so kind as to be looked
on as "soft." He could be imposed upon, was also
diffident, blushed easily, etc.
A number of the men who rested up were untried
prisoners — detained in unsanitary quarters. These
men were really much worse off than convicts; as
a rule they were pale, thin, and weak. They had no
disease, but the sympathetic doctor gave them some
imaginary affection, and did not have the heart to
mark them "cured" after a long rest. The head
physician, however, was just and much respected
because he would not stand for malingering.
The men bore no vindictiveness for their beat-
ings, but would goodnaturedly discuss them, the
number of them, those who did the beating. The
men seemed to realize that, having broken laws,
they should be punished. They showed much fatal-
ism here as elsewhere.
It is rather surprising to learn that some floggers
compel a certain affection. They do not play tricks,
such as pretending to let them off and then sud-
denly flog them. The popular kind, while they flog
hard, speak a kind word, or otherwise inspire a
friendly feeling. The man referred to after he left
the prison was always remembered as a "jolly good
fellow," a "father to us."
Time in the prison hospital was passed in telling
stories, looking forward to the doctors' visits, and
in eating. Individual feeding was the custom, and
the man with scurvy fared best of all — beef with
onions or horseradish, vodka now and then. The
special diets did not please all and trading rations
was common. Some had no desire for food and
gave their ration to a neighbor.
Nothing pleased the convicts so much as the ad-
mission of an insane man, but the latter soon got
on their nerves. Insane recruits had to stay there
until other quarters could be secured. Straight
jackets were applied but did not help much.
Convicts who were not very ill disliked medicine,
and at times would not take it. But a very sick
convict liked to be fussed over — bled, cupped, poul-
ticed, etc. Some found cupping painful — men who
had lived through the worst beatings.
"Candle light" was the worst time of the day
for the prisoners. It is a time for thinking, dream-
ing, reminiscences, and speculations as to the fu-
ture, such as what will one do when his time is up.
We note that spring has a peculiar effect upon
the convicts. It arouses desires, cravings and a
yearning melancholy. They are impatient and rest-
less and more apt to quarrel. There is more noise
and shouting at this time of the year.
To "change one's luck" is a characteristic ex-
pression. The convicts, despite the impracticabil-
ity of getting out before their time is up, always
have hopes that luck will change. This wish seems
to concern only the prison that he is actually in.
He might possibly be transferred to another one,
and there are other hazy possibilities.
The convicts took the sacrament once a year and
had a week to prepare for it. No work was done,
and they went to church two or three times a week.
They attended a church in the town, but were not
allowed to pass beyond the background. The con-
victs prayed devoutly, put in their penny in the col-
lection. Reference to the thief on the cross was
looked upon as personal, and all kneeled in a body
at this moment.
When the convicts had time some one subject
usually came up for general discussion. These were
often rumors. However improbable these were, the
convicts showed all the credulity of children — even
when the rumor came through a notorious liar.
One of these rumors actually came true. It re-
ferred to a tour of inspection by a high official.
Dec. 16, 1916]
MEDICAL RECORD.
1061
Convicts delight in discussing officials, rank and
precedence, and who has the most power when a
quarrel comes. They almost quarrel in these argu-
ments, one saying a certain general is superior to
another. These discussions are regarded as more
refined than any others.
There was a regular prison horse and when it
died another would have to be supplied. The con-
victs took the greatest interest in picking the suc-
cessor. They seemed to be buying him for them-
selves, and were as delighted as children. A large
proportion of the men were "horse jockeys," many
lived on horseback when free. Some wonderful
"judging" was seen.
The convicts in general were zoophiles, although
for some reason they disliked dogs, regarding them
as filthy brutes. They utterly ignored them (this
is the peasant idea of dogs) . Pets were not allowed,
but at different times there were goats, geese, etc..
beside the prison horse. Most remarkable was a
wounded eagle who would not make friends. When
finally they let him go, they sympathized with him.
He had never shown the least friendliness. For
awhile he was forgotten in the prison ward but
someone always fed him.
Convicts, especially lifers, including the most
sensible among them, led a strange inward life, a
sort of dream existence accompanied outwardly by
restlessness. The peculiar facial expression of most
convicts, gloomy, sullen, unnatural, was also an in-
dex of this dream life. At times the dream was
almost a delirium. An illogical sense of hope was
part of the mental state. There was also the almost
delusion that they were only on a visit, after all.
Such men must necessarily dream. Such psychic
life is seen outside of prisons only in the psychoses
and psychoneuroses.
Convicts always regarded candid, simple, honest
people as the worst of fools. The ill-humor, the
vanity of the convict would make him antagonistic
to such opposite types. The few really good-na-
tured people among the convicts had to dissemble.
Sometimes a very religious man got comfort from
feeling that he was a martyr.
There was once a complaint by the convicts about
the poor quality of the food. A committee waited
on the superintendent. The "gentlemen" convicts
held aloof. After the strike had ended disastrously,
the beaten convicts made no reproaches to the "gen-
tlemen." Neither did any of them take any action
against the agitation. The whole matter was def-
initely dropped.
The convicts actually loved one of the superin-
tendents, although he did not remain long. They
spoke of him as their father. He seldom passed
a convict without a kind word or humorous remark.
He did nothing to bring about want of respect.
He was a small, cocky kind of person, looked very
dissipated, had no air either of authority or pat-
ronage. The convicts actually smiled when he ad-
dressed them. He looked absolutely fearless and
self-confident.
When a convict actually escaped the men were
tremendously excited. Prison monotony vanished.
All were joyful. These escaped men had actually
"changed their luck." The convicts began to swag-
ger in the presence of the guards. In the interim
the escaped convicts were discussed fully. But in
a few days they were brought back. The convicts
then became angry and depressed and abused the
men because they were taken. From then on they
had no use for the losers, and ignored them.
Something of humanizing value has been ob-
tained in the reform of the Russian exile system,
if various reports are to be believed. Unfortunate-
ly, however, the treatment of the criminal class has
not been as sharply demarkated from that admin-
istered to political offenders as one might wish, as
yet. Much of the punitive, instead of the reform-
ing and constructive upbuilding of personal char-
acter still obtains.
The modern view of reform treatment in our
States' prisons has been on trial among us for sev-
eral years. It remains to be seen if it is not too
late to bring about a great moral regeneration in
the confirmed criminal, one in whom the anti-social
attitude is so definitely formed that new habits of
proper adaptation cannot be instituted. However
this may be, I think that most psychiatrists are
anxious to see what some real studies in this direc-
tion will produce. Undoubtedly a broad and com-
prehensive study of the various types of criminal
behavior and attitude from the first apprehension
and infringement against the law and social order
to that of final incarceration of the old offender in
our States' prisons, will be very useful in determin-
ing the correction of much of the new attitude in
prison reform and point the way even more closely
to sane and safe methods conducive to future
progress.
If one were to propose a scientific method of ap-
proach to the whole problem it might be formulated
as follows:
There should be centers for study of the anti-
social or criminal tendencies in the confirmed group
as in our States' prisons, in the less severe grades
of criminal acts as in our male and female reforma-
tories and in the mildest or most benign offenders
as in the juvenile courts and first offenders. Then
if these careful case-history studies and the en-
vironmental influences in which the criminal acts
had their origin could all be assembled for group
and mass analysis we might have a fairly compre-
hensive understanding of just what types of in-
herent traits in different individuals are likely to
be benign and what are malignant. It would then
be possible to formulate a diagnostic and prognostic
attitude toward the whole problem of criminality,
one of the most pressing issues that confronts so-
ciety to-day.
This hastily sketched scheme would probably
require at least several autonomous research
groups of workers over a period of several
years' study. From time to time, general confer-
ences between the different groups of workers could
be held and thus find where their individual studies
dovetail together, and also find where they could
help each other on methods and material studied.
Research of this character would require the very
best trained men and would probably be rather
costly. It is obvious that from the very nature of
the study it should be done under private grant of
funds.
Since the foregoing article was written, the
Rockefeller Foundation has seen fit to aid in estab-
lishing a psychiatric clinic at Sing Sing Prison.
The same agency has already undertaken similar
research work at the Bedford Reformatory for
Women. Both efforts give promise that we may
soon be in possession of actual clinical data which
will be of the highest value in shaping a more en-
lightened policy in the care and training treatment
of criminals.
128 East Sixtt-fip.st Street.
1062
MEDICAL RECORD.
[Dec. 16, 1916
REMARKS ON ANTERIOR POLIOMYELITIS.
WITH REFERENCE TO THE PRINCIPLES OF TREATMENT
AND THEIR PRACTICAL APPLICATION.*
By ROYAL WHITMAN, M.D.,
NEW YORK.
The present epidemic of anterior poliomyelitis has
been so thoroughly exploited in the newspapers that
it may be the general impression that the disease
is a new one, that its characteristics are not well
understood, and that novel remedies are now to be
employed in its treatment. As a matter of fact, it
differs from the epidemic of 1907 only in the greater
number of cases, in the higher death rate, and in
the larger proportion of complete recoveries.
What is actually new is the general interest that
has been aroused in the subject, which will assure
better opportunities for the scientific study of the
disease that may eventually lead to its prevention,
and which will certainly assure more efficient treat-
ment of its effects than in the past. It is with
this latter phase of the subject that we are at pres-
ent concerned, and the most practical development
toward efficiency is, it seems to me, the enlistment
of the social-service workers ; since they will have
the opportunity to inspect the conditions of the
homes, to send neglected cases to hospitals or
to day nurseries, to instruct the parents as to the
character of the disability, and to supervise the
practical application of the treatment.
This is of the greatest importance for, as has
been suggested, the present epidemic has brought
out as yet no novelty, and the hope for the future
lies in the more efficient and general application of
methods which have been tested in the past. Under
efficient treatment, by far the larger number of the
patients may become, eventually, useful members
of society, and the contrast in the final results be-
tween the patients who have received such treat-
ment, and those who have been neglected is con-
vincing proof of its value.
Anterior poliomyelitis is an acute infectious dis-
ease which involves the central nervous apparatus,
and paralysis and deformity are its consequences.
During the early stages of the disease the pa-
ralysis is usually widespread, because many centers
and conducting tracts are temporarily disabled by
congestion and swelling. Others are damaged in
a greater or lesser degree, and others are destroyed.
At this time, therefore, it is impossible to predict
what the area of permanent paralysis is to be.
When the acute stage has passed, repair begins
and proceeds rapidly at first, indicating that the
congestion has subsided, and that motor impulses
are again transmitted, and in possibly 20 per cent,
of the cases this may go on to complete recovery.
In the majority, however, the response in many of
the muscles is feeble or absent, indicating that
the centers that control them are severely damaged
and that the process of repair will be long delayed.
What is called orthopedic treatment consists pri-
marily in keeping the machinery in condition to
take up its work, if repair of the nerve centers per-
mits, and to adapt by some means the disabled
members to the needs of the individual. In this
treatment the prevention of deformity is of the
first importance, because deformity throws the ma-
chinery out of gear so that it is unable to respond
to the impulses that may be transmitted to it. From
*Read before the New York Conference on Hospital
Social Service at the Academy of Medicine, Novem-
ber I. 1916.
past experience it may be stated that by far the
larger number of patients in all classes of society
become deformed to a greater or lesser degree, and
therefore unnecessarily disabled, deformity being
the inevitable consequence of the disease unless it
is prevented.
The causes of deformity may be classified as:
(1) The force of gravity. (2) Persistent attitudes.
(3) Unbalanced muscular action. (4) Weight bear-
ing and locomotion.
1. The influence of the force of gravity is best
illustrated by the hanging downward of a paralyzed
foot when the patient is sitting or recumbent.
After a time the habitual attitude becomes fixed by
contraction. Thus the hanging foot or what is
called equinus, is the most common of deformities.
2. Certain attitudes are often induced by discom-
fort, or they may be simply accommodative, as the
sitting posture, in which the limbs are bent at the
hips and knees. Thus flexion contraction at these
joints is very common among patients who are un-
able to stand.
3. The muscles in health vary in strength accord-
ing to their function, and are arranged to support
and balance one another. The calf muscle, for in-
stance, is large and strong, because it lifts and
propels the body, while the smaller muscles balance
the foot. Paralysis of the calf muscle causes great
disability with but little immediate tendency to dis-
tortion, because it is opposed by the force of grav-
ity; while paralysis of lateral muscles of compara-
tively slight importance will induce deformity, be-
cause the foot is drawn to one side by those of the
opposite group.
4. Locomotion and weight bearing upon a weak
and unbalanced extremity exaggerate existing de-
formity, and increase the resistance to correction.
Deformity develops, therefore, more rapidly and to
a more extreme degree in early childhood than in
later years.
Prevention of deformity is the most important
part of the treatment from first to last, since if it
is present, it is impossible for normal muscles to
act effectively, and for weak muscles to respond to
impulses and to regain their strength. It develops
insidiously and far more rapidly than is generally
believed. More rapidly in the partly paralyzed
cases than in those of complete paralysis, because
the influences of the force of gravity and accommo-
dative posture are increased by unopposed muscular
action and by retraction of active muscles that are
never as in health stretched to their normal limit.
The first indication of deformity is the evidence
of discomfort when an habitual attitude is changed.
When, for example, a hanging foot is pushed up-
ward. And, in cases in which the muscles of the
front of the leg are paralyzed and the calf muscles
are active, this discomfort is often apparent within
a few days of the paralysis. In fact, much of the
pain supposed to be symptomatic of the disease is
actually induced by tension on contracted tissues.
Preventive treatment consists in moving the
joints of the affected part through their full range
of motion at least twice daily in order that all the
muscles may be extended to the normal limit. Pos-
tures should be alternated, and attitudes that lead
to deformity should be restrained. If, for example,
the trunk muscles are so weak that the body is bent
forward or to one side in the sitting posture, the
child should not be permitted to sit unless it is prop-
erly supported, nor to stand or walk on weak and
uncontrolled limbs.
Dec. 16, 1916]
MEDICAL RECORD.
1063
The secondary part of the treatment is directed
to the preservation of nutrition of the paralyzed
parts. Nutrition depends upon the circulation of
the blood, and the supply of blood is regulated by
the work performed by the muscles. Paralyzed
muscles do not work, consequently, they receive
less blood. Paralyzed limbs become, therefore
eventually shrunken, cold, and discolored ; the ca-
pacity of the blood-vessels having been lessened be-
cause no demand has been made upon them. These
changes are far more noticeable in deformed and
unused limbs than in those which, although equally
disabled, have by treatment been forced to carry
out as far as may be their normal functions.
Massage. — Nutrition may be improved and in
some degree preserved by local treatment. That
which is usually applied is rubbing and friction,
under which warmth and color may be restored to
the paralyzed part. Parents do not understand the
objects of so-called massage, but look upon it as
a direct treatment of the disease, and what they rub
in is of greater importance than the rubbing. Oily
substances are supposed to feed the weak tissues;
actually they only serve to lessen friction, which
in these cases is desirable since only gentle rubbing
should be permitted.
Baths. — Baths, to which in health parents are
unaccustomed, are thought to possess mysterious
virtues, and this belief may be encouraged. A warm
bath in which the child may lie extended stimulates
the circulation and assures the most favorable op-
portunity to demonstrate muscular activity in the
floating limbs, because it is not opposed by fric-
tion and gravity.
Electricity. — The most impressive of all remedial
agents is electricity, because the paralyzed muscles
may, for a time, respond to its stimulation. It has
been employed for many years in the treatment of
all forms of paralysis, but no positive evidence has
been presented that it has any effect other than as
a local stimulant of nutrition. It is far better
adapted to the treatment of older patients than of
young children, who are usually frightened by even
the slight discomfort attending its application.
Muscle Training. — The treatment that is in the
air at present is muscle training. Just as strong
muscles may be made stronger by systematic exer-
cise, so weak muscles may be made stronger by ex-
ercises adapted to their weakness. This is, of
course, self evident. There are very decided limi-
tations to the method. Paralyzed muscles cannot
be trained, and young children are usually poor
subjects either for muscle training or muscle test-
ing. The treatment is of great value in suitable
cases. If properly applied it should lessen the
tendency to deformity and aid the restoration of
power in muscles in which such restoration is pos-
sible. If all the muscles are equally weak any im-
provement in strength is so much gain, particularly
in an upper extremity. If, on the other hand, the
weak muscles are capable of recovering but a frac-
tion of their strength in opposition to the full power
of an opposing group, deformity cannot be pre-
vented in a weight-bearing extremity, except by
mechanical or operative treatment.
Braces. — Braces are used to prevent deformity
and to permit locomotion. If the paralysis is gen-
eral of the trunk and limbs, the child may be
placed on a recumbent frame, on which it may
be carried about, because if permitted to sit, de-
formities of the trunk would develop, which are
progressive and intractable. Or, as a temporary
treatment, a plaster support may be applied, which,
by fixing the spine, assures the rest that favors the
repair of the inflamed spinal cord, and holds the
uncontrolled and often sensitive limbs in proper
position. Plaster supports are of value, also, as
temporary braces during the early stages of the
disease, before the extent of the persistent paralysis
can be determined.
The chief value of braces is as aids in locomo-
tion ; for as soon as the discomfort has subsided a
child will insist on moving about, if this is pos-
sible. Braces are employed to protect the weak
muscles and to lessen the strain upon the joints
which would otherwise induce deformity.
Functional Use. — Functional use, if properly reg-
ulated, is the most powerful of all the stimulants
toward recovery, as contrasted with purely local
treatment. For the muscles and the nerve centers
are interdependent and if a limb is permitted to
become deformed and shrunken from disuse, the
nerve centers, although capable of transmitting im-
pulses, may atrophy for want of practice, while
those upon which constant demands are made should
develop their capacity to the highest degree. Func-
tional use is often impossible without support, and
the character of this support is, therefore, of great-
est importance in treatment, since it must be often
changed in adaptation to the needs of the patient.
Prognosis. — It has been stated that it is impos-
sible to predict the degree of final paralysis in any
case, since improvement may continue for many
years. There are, however, certain very definite
indications on which to base the prognosis. In
favorable cases there is evidence of returning power
in certain muscles throughout the pai'alyzed limb,
indicating repair through a corresponding area of
the cord. The instances of practical recovery after
many years of helplessness are cases of this type,
in which restoration of function has been prevented
by deformity, although the nerve centers have been
repaired. The unfavorable cases are those in
which, in spite of protection, certain groups of
muscles in a definite area show no sign of power,
while in other parts recovery has been partial or
complete.
Operative Treatment. — When the area of perma-
nent paralysis can be accurately determined, usu-
ally after an interval of several years from the
onset of the disease, operative treatment may be
indicated, and this is, from the positive standpoint,
the most effective of all remedies. It consists es-
sentially in transferring active muscles from their
original insertions to points where they may work
to best advantage, and thus to restore the muscular
balance; and in operations on the bones and joints
to assure stability, so that braces may be less bur-
densome or discarded altogether.
Having reviewed the principles of treatment, one
may now consider their practical application.
It may be a general impression that the solution
of the problem is hospital care, but this is as un-
desirable as it is impracticable, since we are deal-
ing with a disability of indefinite duration, and not
with a disease that will run its course in a few
weeks. In many instances the disability is slight
and even in the cases that might be benefited by
hospital care the consent of the parents cannot be
readily obtained, since no definite statement as to
the time of separation, or the outcome of the treat-
ment can be made. A large proportion of the pa-
tients are so young that they need a mother's care,
and in the majority of cases home treatment is to
100-1
MEDICAL RECORD.
[Dec. 16, 1916
be preferred. We may conclude, therefore, that
treatment must be adapted to patients of what is
called the ambulatory class.*
In the present stage of enthusiasm, I am inclined
to think that there is more danger of over treat-
ment than of neglect, and that as far as young
children are concerned, the possible benefits of mas-
sage, electricity, and muscle training in a crowded
clinic are more than offset by exposure, fatigue,
and excitement, not to mention the time consumed
by the mother.
The clinic should be the central point for ob-
servation, supervision, and teaching, while the
mother, properly instructed and aided, if necessary
by the visiting nurses, must be depended upon to
carry out the supplementary treatment. Muscle
training, for example, however difficult in its adap-
tation to many patients, is very simple in its ap-
plication to a single case; although it requires art,
patience, time, and opportunity, qualities and con-
ditions hardly available in a large clinic.
In conclusion, it seems to me that the contribu-
tions of those who are interested in this subject
may be used to best advantage by increasing the
facilities of the hospitals and clinics already
equipped for the work, and by providing a larger
number of social workers and visiting nurses, with
adequate means of transportation, all under central
control, than by establishing new clinics in more
convenient localities, on the supposition that daily
treatment is essential. In other words, that the
best results from the educational, scientific and hu-
manitarian standpoints may be obtained by a con-
centration, rather than by a diffusion of energy.
283 Lexington Avenue.
SOME ASPECTS OF THE TREATMENT OF
INFANTILE PARALYSIS.f
By HAROLD W. WRIGHT, M.D.,
SAN FRANCISCO.
The general principles regarding the treatment of
the effects of anterior poliomyelitis are now quite
generally understood and agreed upon ; but the prac-
tical application of these is often neglected and the
little details of treatment which count for so much
are many times overlooked or but vaguely compre-
hended by both general practitioner and orthopedic
surgeon. Were conditions otherwise we would not
see so many preventable deformities in the clinics
nor so many badly functionating limbs in faulty
apparatus. However, another explanation of the
large number of deformities seen on the streets of
cities and in rural districts may be the still preva-
lent attitude of the laity and also of many general
practitioners toward the treatment of crippling dis-
eases, an attitude characterized by passive pes-
simism. Anyone who has worked in orthopedic
dispensaries can recall numerous instances of pre-
ventable deformity in which the patients had been
told that nothing could be done for them when most
*The Social Service Workers have analyzed for me
200 consecutive cases treated at the Hospital for Rup-
tured and Crippled.
Age: 20 of the patients were under one year; 76
were ( rom 1 to 2 years ; 54 from 2 to 3 years. ( 75 per
cent three years or less.)
Size of family: In 54 instances the patient was
an only child; in fifty-two there was one other; in
forty-three there were two other children in the family.
(72 per cent, of the mothers not overburdened with
children.)
fRead before the San Francisco County Medical So-
ciety, May 2, 1916.
could have been done toward preventing deformity
and thus ultimately securing good function.
Treatment of the Acute Stage. — Have we any
therapy at hand which is in any way efficacious for
preventing the extension of the acute process in the
spinal cord or for hastening the resolution of this
inflammation?
No statistics are available to decide this point.
We can only speculate about it. Theoretically we
can apply the ordinary principles of counter-irrita-
tion, elimination, and supportive treatment to the
initial stage of poliomyelitis; these principles em-
brace such measures as cupping the spine, catharsis,
diuresis and diaphoresis, and special attention to
the proper nutrition of the little patient. Unfor-
tunately, the disease does its damage so quickly and
without premonition that these measures can avail
little in most cases. There is one other principle
which we are accustomed to apply to the subacute
stage of this disorder which is even more in order
during the acute phase; namely, efforts to secure
complete rest of the voluntary and reflex mechan-
ism of the motor part of the central nervous system.
This principle of rest is a cardinal one in the treat-
ment of inflammation in any part of the body ; that
it is not more definitely applied to cases of polio-
myelitis is because of the inaccessibility of the parts
involved. However, it would seem rational to at-
tempt to cut off as much as wt? safely can do the
afferent and efferent stimuli to the anterior horn-
cells and to do this we might make more use than
is generally done of plaster of Paris as a means of
immobilizing the entire body during the very acute
stage, i.e. for the first week, in order to lessen the
irritation of the nerve-cell protoplasm which is
already in an abnormal condition. Other measures
directed to the same end would be the administra-
tion of chloral and bromides in sufficient dosage to
keep the patient quiescent. The body should be well
padded and the limbs placed so as to prevent the
stretching of any muscle, i. e. placed in balance,
before the plaster bandages harden.
We do not know how long the inflammatory re-
action in the spinal cord is of an acute character,
nor how long it will be before the tissues of the
cord become normal or as normal as they ever will
be. We need more data upon this aspect of the
pathology. We therefore need to be conservative in
discontinuing the measures which enforce complete
rest of the central nervous system; certainly they
should be carried out for the first ten days or two
weeks, no matter how small an area of the cord we
may presume to be involved, for all parts of the
nervous system are very intimately connected.
Lumbar puncture is worth while in the beginning
of the disease, especially if there are any meningeal
symptoms ;it may relieve congestion and certainly
can do no harm.
The Subacute Stage. — After the first ten days or
two weeks the therapy of this disease ceases to be
a medical problem and becomes primarily an ortho-
pedic problem. We can now estimate the amount
of damage done to the cord and the nature of the
mechanical defects to be remedied. Our efforts
should be directed first of all and all the time to the
preventing of the stretching of weakened muscles
either by gravity or the pull of their antagonists,
i. e. the maintaining of all muscle forces in equi-
librium. This can be done by plaster splints most
readily and efficiently during the first few weeks of
the subacute stage; the foot and leg should be held
in the position most favorable for later standing
Dec. 16, 1916]
MEDICAL RECORD.
1065
and walking as a general rule, but the factor of
stretch upon weakened muscles must constantly be
borne in mind. In the case of the upper extremity
we must take care that a weakened deltoid or other
muscles which hold the humerus in place are not
stretched by the weight of the arm. The foot
should be in dorsal flexion to ninety degrees with
enough inversion and adduction to maintain the
normal plantar arch ; the knee should have about ten
degrees of flexion, the thigh flexed about ten de-
grees with the hip and abducted and externally ro-
tated about fifteen degrees. When the more unusual
paralysis, such as that of the calf or gluteal muscles,
is present this posture may have to be modified to
avoid stretching these groups. If we are sure that
the lower leg only is affected we may dispense with
the splinting of the thigh, but we cannot be positive
of this at this stage unless we test the muscles very
carefully with the electric current.
During this stage of plaster splinting the appa-
ratus should be so made as to allow of removal daily
for the purpose of gentle massage and bathing;
otherwise the weakened muscles will rapidly atro-
phy. This brings up the subject of braces versus
plaster-of-Paris splints.
When should braces be ordered? The writer be-
lieves that they should be ordered and under con-
struction just as soon as the attendant can deter-
mine the extent of the primary paralysis. By the
term "primary paralysis" is meant the amount of
paralysis resulting after the very acute stage is
past, that is, after the second week from the onset
of the disease until about the twelfth month, to put
it arbitrarily ; the "secondary" paralysis being that
resulting finally after the period of probable re-
cuperation has passed. There is now a tendency on
the part of orthopedic men to regard the period dur-
ing which more recovery of power may occur aa
longer than formerly was thought to be and that it
is to a great extent dependent upon the care of the
case during the first two or three months and also
upon the overcoming of contracture; even as late as
two years after the onset of the disease improve-
ment in power may occur if contractures are over-
come.
Anyone who has seen the atrophic effect upon the
limbs of a little patient who has been encased in
plaster of Paris for many weeks should be reluctant
to use plaster in preference to removable and less
constricting apparatus. Aside from the benefits of
easy removal for purposes of bathing, massage, and
muscle training which braces give, they also permit
the patient to get about without detriment to the
paralyzed part and with benefit to the general health
and the nerve-centers by reason of the stimulation
which comes from voluntary activity. These state-
ments presuppose that the apparatus is made of as
light material as possible and with proper attention
to joints to prevent stretching of weak muscles.
Unfortunately, braces are frequently ordered and
constructed without due supervision on the part of
the attending surgeon and are made much too heavy.
The simpler the brace the better; all unnecessary
leather work and straps should be avoided, as they
add to the weight and also to the expense, which
latter is an important consideration with dispensary
patients. We will not get the results which are
possible in these cases until our orthopedic clinics
are equipped with an experienced mechanic and an
up-to-date workshop.
In connection with the subject of braces, attention
should be called to two conditions sometimes inade-
quately met because the brace is of the wrong type.
The first condition is that of paralysis of the tibialis
anticus muscle alone with good power in the calf
group, common extensors, and the peroneals. Not
infrequently one comes across such patients wear-
ing a steel arch support and they have been told that
this is all that is necessary. But an arch support
cannot take the place of the tibialis anticus, nor will
it prevent pronation and abduction of the foot, with
ultimate breaking down of the arch of the foot from
strain in the abducted position. The tibialis an-
ticus not only helps very much to hold up the plantar
arch, it also adducts the foot at the mediotarsal
joint and dorsally flexes it as the tibio-astragaloid
joint. An arch support can do neither, it can only
invert the foot and so will not prevent the action of
the peroneal and calf groups. What is needed in
such a case is a brace for the lower leg with a bar
on the outside attached to a foot plate and a catch
in the joint to prevent plantar flexion beyond ninety
degrees, full dorsal flexion being allowed as a rule.
Another condition to which a faulty brace is
sometimes applied is that form of paralysis in which
the tensor fascia femoris, as well as the quadriceps
and the lower part of the great adductor are in-
volved, while the sartorius, the gluteii and obturator
muscles which rotate the thigh outward and abduct
it are strong. In such a case a brace going only to
the upper fourth of the thigh or even to the groin
with a padded ring under the ischium is not suffi-
cient to control the comparative overactivity of the
sartorius, the gluteii and the other external rotators
of the thigh; consequently the child walks with leg
abducted and externally rotated, causing a dragging
limp and a list of the pelvis which may ultimately
produce scoliosis. This form of paralysis should be
treated with a long brace having one outside bar or
two lateral bars, the outside one running up as far
as a point between the anterior superior spine and
the trochanter, where it should be movably jointed
with a steel pelvic band and leather strap, the band
having peroneal straps attached to it. When the
back and abdominal muscles are affected this sort
of brace can easily have attached to it a light back
brace, e. g. "Taylor assistant," at the pelvic band.
Electricity and Muscle Training. — How soon
should these measures be instituted? Certainly not
in the acute stage, and in the subacute stage they
should be carried out very cautiously, the duration
of the electrical stimulation or the muscle exercise
being very brief and very gradually increased ac-
cording to the type of response to these stimuli;
this can be observed and estimated by watching the
character of the contraction of the muscle during
the course of the treatment. As soon as the re-
sponse in the muscle-fiber requires more current or
the contraction wave becomes more sluggish or the
patient less keen in the voluntary movements, the
exercise should be discontinued. Lovett advises
such treatment only three times a week. He has
also contrived an apparatus for estimating the
strength of the muscle accurately and regulates the
exercises according to the degree of response thus
measured from day to day.
Electricity has no effect upon the anterior horn-
cells or nerve-trunks so far as we know. It is
simply a convenient means of exercising muscle-
fibers. Electricity and muscle training undoubtedly
have a valuable place in the treatment of infantile
paralysis during the subacute and chronic stages and
should be more often used, especially muscle train-
ing. There is less danger of doing harm by fatigue
1066
MEDICAL RECORD.
[Dec. 16, 1916
of the muscles with muscle training than in the use
of electricity, because a child will usually cease to
react spontaneously at the point of beginning
fatigue, whereas a muscle can be stimulated by the
electrical current beyond this point. Muscle train-
ing also introduces the element of control by the
higher centers and is therefore, I believe, a more
rational and efficient form of stimulation; a good
thing in spastic cases also.
In dispensary work the electrical treatments are
often delegated to a nurse and not supervised by a
competent attendant familiar with the case. Thus
harm rather than good is done, either because of
overstimulation or because of stimulating the wrong
muscles, thus increasing the tendency of deformity,
mechanical treatment being overlooked because the
case is not entirely in the hands of the orthopedic
man.
Fatigue may also be brought about by too much
voluntary activity of the child. Frequent periods
of absolute rest and relaxation should be enforced,
especially in the subacute stage. Anything which
overstimulates and exhausts the nervous system is
detrimental to the recuperation of the local centers
involved in this disease.
Treatment of Deformities. — What has already
been said comprehends the prevention of deformity.
There remains to be considered the correction of de-
formities which have occurred from inadequate
treatment or neglect. Deformity is primarily due to
muscle contractures, and secondarily to ligamentous
strains and bony distortions from postural strain.
To remove the former cause we may resort either
to forcible manipulations with plaster dressings or
to tenotomy and tendon lengthening. It would seem
to the writer that forcible manipulation is bad treat-
ment, and that gradual stretchings are an unneces-
sary waste of time. These procedures involve the
return to plaster-of-Paris dressings for prolonged
periods, thus hindering activity and the nutrition
of muscles and bones which might be properly
exercised in braces. Furthermore, forcible ma-
nipulation produces tear of muscle fiber and tendon,
and this trauma results in connective-tissue forma-
tion which produces a less normal tendon or muscle
than before. On the other hand, tendon lengthen-
ing, or tenotomy by an open operation within the
tendon sheath, has the advantage of promptness in
correction of deformity, requires no more than ten
days of plaster dressing, and results in as good a
tendon and muscle as before. Wherever tendons
can be lengthened within their sheaths this should
be done in preference to closed tenotomy, and it
can always be done with the tendon achilles and
the peroneals; also with the tibialis posticus, which,
by the way, is frequently almost as potent a cause
of deformity as the tendon achilles.
Arthrodeses and Tendon Transplantations. —
Whenever a healthy muscle can be transplanted
wholly or in part without weakening the most im-
portant function of the limb and the period of
possible recovery from paralysis has passed, such
an operation is worth trying, leaving as a second
resource the operation of arthrodesis. Thus a
healthy extensor longus hallucis, if successfully im-
planted beneath the periosteum at the points of
insertion of the paralyzed tibialis anticus, will partly
replace the latter without spoiling the most essen-
tial function of the foot; a peroneus longus tendon
may do the same. A peroneus tertius may be in-
serted in the heel to add power to a weakened calf
group, or the tendon achilles may be split and the
proximal end of the slip can be inserted into the
posterior surface of the tibia beneath the perios-
teum after the method of Gallie, this serving a3
a check ligament to dorsal flexion, in calcaneous
deformity. Several other examples of the appli-
cation of tension transplantation might be men-
tioned.
In deciding upon tendon transplantation, the age
and probable occupation of the patient should be
considered, also whether or not the ligaments have
been so stretched or the bones so distorted that
the transplanted muscle will be unable to hold the
part in the position best for locomotion. This is
apt to be an objection to tendon transplants in long
standing or neglected cases of paralysis, for in
these cases, in spite of the operation, the patient
will require braces.
Arthrodesis has the advantage of doing away
with apparatus, of giving a more stable position to
the weakened limb, and of permanently correcting
a disadvantageous deformity. Its adaptation is
more useful in the foot than in the knee or hip.
An arthrodesis between the head of the astragalus
and the navicular, and between the articular sur-
faces of the calcis and astragalus is a useful pro-
cedure even in cases where a muscle is transplanted
at the same time, e. g. in talipes valgus, for this
operation prevents the lateral mobility of the foot
at the mediotarsal joint, doing away with the chance
of the valgus deformity recurring even if the trans-
plant fails. To overcome a flail ankle joint, the
Whitman operation of astragalectomy is valuable.
At the knee, arthrodesis has been done, particularly
by Hibbs, but has of late been given up. Most
people prefer a movable knee, with a brace, to a
permanently stiff one. Davis of Philadelphia has
done an osteotomy on the lower end of the femur
above the epiphyseal line, setting back the lower
fragment and producing a more stable knee for
weight bearing in cases of quadriceps paralysis.
The field for plastic surgery in infantile paralysis
is still a green one, and full of possibilities. Neu-
roplastic operations are, as yet, in the experimental
stage. The success of these operations depends
upon the improvement in technique of the surgeon;
to attain this, more opportunities for dissection and
animal experiments are greatly needed. But in
spite of surgical advances, the after-care will con-
tinue to be the important element in success, i. e.
close supervision and constant vigilance to prevent
the recurrence of deformity; the treatment of this
disorder will, therefore, continue to be slow, pains-
taking and conservative, as indeed is true of all
orthopedic work, and especially when the nervous
system is involved.
Physicians' Building.
AFTER-CARE OF INFANTILE PARALYSIS
CASES.
By OLIVER H BARTINE,
NEW YORK.
SUPERINTENDENT. HOSPITAL OF THE NEW YORK SOCIETY FOR
THE RELIEF OF RUPTURED AND CRIPPLED; VICE-CHAIRMAN.
NEW YORK COMMITTEE ON AFTER-CARE OF INFANTILE
PARALYSIS CASES.
The after-care problem of the cases of poliomye-
litis that have had their onset during the past sum-
mer has been met in a very able manner by those re-
sponsible for it. By the establishment of the New
York committee upon the after-care and the many
associations cooperating with the orthopedic hos-
Dec. 16, 1916]
MEDICAL RECORD.
1067
pitals and clinics as well as the old-established or-
ganizations (some with specially trained nures, so-
cial workers, and teachers) that have done excellent
service for many years, much benefit will be derived
by the victims of our recent epidemic. Many poor
and afflicted cripples who would otherwise be neg-
lected and delayed in reaching the hospitals will
now be treated and if not cured will at least be so
improved that they may later become useful mem-
bers of society.
It has been a pleasure to see the excellent cooper-
ation between the orthopedic hospitals, general hos-
pitals, and the Department of Health, as well as be-
tween the doctors associated in this work. The sac-
rifices which many hospitals, doctors, nurses, social
workers, committees, and contributors have made in
this cause are great, but great in return is the good
that is being accomplished.
The subject before us presents so many problems,
and there are so many social service activities of
vital importance that to discuss each of them at
length would be impossible within the limits of a
short paper. It therefore seems best to dwell brief-
ly upon a number of issues of fundamental im-
portance.
During the active stages of all epidemics the hos-
pitals, physicians, and health authorities devote
their full time in combating and controlling the dis-
ease. It is not until a later date that they are able
to give the time and attention to a thorough and
comprehensive study of the problem.
In the early stages of this epidemic, having in
mind the inadequate histories of past epidemics of
various diseases, especially that of 1907, I advo-
cated, at a meeting called by the Commissioner of
Health, Dr. Haven Emerson, the founder of the
committee, and later at a meeting called by the
Rockefeller Foundation, in which representative
orthopedic surgeons of the East were present, that
better clinical and social histories of cases of polio-
myelitis occurring in this epidemic be made, not only
in the Indoor department, but also in the outdoor
department. Now that this policy has been adopted
by our committee and the hospitals here as well as
those in other States and communities, it is felt
that within given periods reports upon all or groups
of cases of poliomyelitis will be made, that will as-
tonish the most optimistic and will be invaluable
to those who are scientifically studying the problem.
The medical profession and laity will unquestion-
ably have the most valuable data upon the past epi-
demic and the after-care treatment.
The many policies as adopted by the committee,
if properly carried out, should set a standard and
obviate the inadequate facilities of many institu-
tions, their varied fee systems, and their neglectful
method of caring for dispensary cases, and their
lack of identification of patients roaming from one
hospital to another, thus causing a great amount of
duplication of work and changes perhaps in the
mode of treatment. Possibly the number of patients
attending more than one institution is not so great
as is commonly supposed and it is also possible that
the amount of hospital and dispensary abuse is
greatly over-estimated ; nevertheless, such infor-
mation will be available and the foundation erected
for a central bureau or clearing house for the super-
vision of all dispensary cases in the five boroughs
of New York.
Too little progress, however, is being made to
provide facilities for treatment and care for people
of moderate circumstances. Those who are striving
in this direction have met with many stumbling
blocks. We should give our united support to such
a movement, but by so doing we should not over-
look the private practitioner, at the same time the
private practitioner should not overlook or under-
estimate the wonderful advantages of this move-
ment for the ill and afflicted, many of whom even-
tually become crippled financially and their fam-
ilies impoverished as well as in many cases becom-
ing a burden upon the community.
It is well to caution the many enthusiasts who
are desirous of opening orthopedic clinics and brace-
shops to give the matter very careful consideration
before their establishment, to discuss the problem
with those who are qualified to speak upon the sub-
ject, and also to present their needs and facilities
to the After-Care Committee. Otherwise they may
find ultimately that they are carrying an inadequate
and unnecessarily expensive burden.
From the time of the inception of our committee
I have advocated that a general appeal for funds
should be made by the committee in place of a mul-
tiplicity of appeals that would unquestionably be
confusing to the public. The After-Care Commit-
tee upon recommendation of the Public Health Com-
mittee of the New York Academy of Medicine have
now adopted this plan. It is now believed that the
funds that we hope to raise will be distributed in
a manner that will be most beneficial to the asso-
ciated hospitals and organizations and to the pa-
tients.
To provide fresh air or convalescent home care
and treatment for these children during a number
of summers to come is one of the great problems
that will soon be before us. With present and
added facilities we shall no doubt be able to meet
the situation in an efficient manner. However, we
should not delay in giving this matter serious
thought and consideration, for it may involve a
change of policy in the management of some of the
country homes or institutions.
In an address of mine, made previous to this
epidemic, upon the history of the Hospital for the
Relief of the Ruptured and Crippled, the following
statement was made, and this is equally true to-
day : "The work done in improving the condition
of patients suffering from paralysis is remarkable;
unfortunately in this branch of the work a cure is
rarely possible, but by judicious and skillful treat-
ment the condition of practically every paralyzed
patient can be improved. It is no uncommon sight
to see a child who was carried into the hospital in
a totally helpless condition, or who got about only
with the assistance of crutches, walk out of the
hospital, after some months' treatment, wearing a
light steel brace and able again to take an active
part in the struggle of life."
Children suffering from paralysis under four
years of age, when recommended, are now admitted
to our wards, and our Board of Trustees have also
made a special ruling that cases that cannot be
properly cared for in their own homes can be ad-
mitted to our wards until proper provision is made
for their care.
It is quite essential that hospitals caring for
these cases should have an adequate social service
in an endeavor to follow the patient's progress, to
study his home conditions, and to see that the
physician's directions are followed. Many patients
will not return to a dispensary as often as their
needs require unless encouraged to do so.
Each institution assuming the burden and re-
1068
MEDICAL RECORD.
[Dec. 16, 1916
sponsibility in the care and treatment of infantile
paralysis cases should consider this one of the most
important phases of their work, otherwise the
patient's progressive improvement may be retarded.
It is my belief that the Social Service should be
an integral department of the hospital and, if
thought advisable, there should be an auxiliary
committee for the purpose of advice, consultation,
and other assistance usually rendered by such a
committee.
The present epidemic has added materially to
the work of our Social Service Department. When
the new cases come into the clinic, they are seen by
the registrar, who issues them their cards. They
are then taken to the department especially pre-
pared for them, and are placed in charge of the
Social Service worker. She interviews the parent
and secures the social history and any interesting
data to be had. Then the child is thoroughly ex-
amined by the doctor in charge, who dictates the
notes to a stenographer, who later makes the neces-
sary record on the medical history sheet. After
the doctor prescribes for the child, the social
worker is sure to see that the parent has thoroughly
understood directions. She finds very frequently,
when they speak little English, that these direc-
tions must be repeated several times before they
grasp it. They are also impressed with the impor-
tance of returning upon the dates stated by the
doctor. If they cannot afford the carfare, many
coming from great distances, it is provided. The
patients are visited in their homes, so the worker
may have a good picture of the patient in home
surroundings. Sometimes she finds these little pa-
tients need extra nourishment or warm clothing,
or a pair of orthopedic shoes, which her fund, pro-
vided by a generous committee, permits her to
secure. She also sees that treatments prescribed
by the doctors are followed out.
321 East Fortt-second Street.
THE FALLACY OF INTESTINAL STASIS.*
By MARTIN J. SYNNOTT, A.M.. M.D.,
MONTCLAIR, N.
"Intestinal stasis," so called, was discovered by
Sir Arbuthnot Lane of London. I have watched
Lane operate during each of three visits to Lon-
don. He is a very clever and skillful surgeon, and
a kind, courteous gentleman. But I don't believe
his "short circuiting" operation should be recom-
mended as routine treatment for tuberculosis, gout,
diabetes, etc., as I have heard him advise. I know
he has not the confidence of his colleagues in Eng-
land, and in this country his abdominal opera-
tions for stasis are rapidly falling into disrepute.
A prominent medical authority of Boston regards
Lane as the most dangerous man in the medical
profession to-day, because he is sincere, and sin-
cere men of strong personalities readily secure fol-
lowers for unsound theories.
It must not be forgotten that the stomach and
intestines functionate perfectly well even when the
x-ray shows what appear to be marked abnormali-
ties in position.
So-called remodeling operations on the abdominal
organs for the relief of such .r-ray abnormalities
will. I believe, soon be given up. Attempts at such
remodeling of the human body have not given sat-
*Pi*cussion of a paper on Intestinal Stasis read at a
meetine of the Orange Mountain Medical Society,
September 22, 1916.
isfactory results. Failures have been more numer-
ous than successes, and radical procedures of this
nature are, I think justifiable only in desperate
cases as a last resort where all other remedial meas-
ures have failed and where the patient would pre-
fer death to continued suffering.
At the Massachusetts General Hospital in Boston,
by the way, bismuth residue in the intestines up
to seventy-two hours is considered perfectly nor-
mal, and they have a very active x-ray service
there, keeping four machines going pretty con-
stantly the greater part of the day.
The best thing Lane has done, in my opinion, is
that he has called attention so forcibly to the value
of Russian oil in the treatment of constipation.
The Curtis belt which he recommends is of very
doubtful value. I have had a good deal of experi-
ence with it and prescribed it rather often for a
time after seeing Lane demonstrate it several
years ago in London; but I have long ago lost my
enthusiasm for it, and am not satisfied it has pro-
duced good results in a single case. Women will
not wear it, as it is clumsy and bulky and does
nothing that a properly fitting and properly applied
corset will not do. Men find it uncomfortable and
soon discard it.
As to medical stasis, as ordinarily understood,
I am sure in many, if not the vast majority of cases,
it seldom exists as anything else than constipation.
I have seen this demonstrated over and over again.
Patients diagnosed as "stasis" cases have been
cured by measures adapted to the treatment of or-
dinary chronic constipation. Quite recently a pa-
tient of mine, suffering from a well-marked case
of vagotonia, but also constipated, during a brief
absence of mine from home, was advised by a friend
to consult a prominent surgeon, who after x-ray
and bismuth examinations, told her all her symp-
toms came from intestinal stasis, and that the Lane
operation would cure her. She had made arrange-
ments to have this done when I returned and
promptly persuaded her otherwise, with the result
that she is now well without operation.
The treatment of the symptoms of autointoxi-
cation sometimes met with in severe constipation
should be by diet, exercises, and medical treatment
without recourse to surgery.
We occasionally see stasis cases of the pronounced
neurasthenic type which are undoubtedly chemical
diseases due to autointoxication from internal
glandular starvation, or excess. For some of these
patients, gland extract therapy holds out hope of
benefit.
The study of intestinal stasis is, I think, a phase
of medical evolution brought about by an honest
effort of sincere but mistaken men to solve the
problems of old age, and to find a remedy for
chronic incurable ailments.
Years ago it was the tonsils; when these were
removed the arteriosclerosis would be relieved, the
rheumatism cured, the arthritis deformans checked.
Now we know that the tonsils may be organs of
elimination of bacteria and toxins as well as foci
of infection and that their indiscriminate removal
is not to be advised. As good a man and experi-
enced an observer as the clinical professor of
pathology in one of our largest medical schools
states that the worst cases of chronic rheumatism
and its sequelae he has seen, have occurred in in-
dividuals who had had their ton^il^ removed in
youth; and he unqualifiedly condemns this pro-
cedure as lessening one's immunity to infection.
Dec. 16, 1916]
MEDICAL RECORD.
1069
Next came Metchnikoff with his elixir of life in
the form of the culture of Bacillus bulgaricus,
which was going to cure all human ills. But our
present knowledge tells us that the only positive
benefit derived from it is the production of Eiweiss
milk and lactic acid milk for the treatment of the
infectious diarrheas. Then came Lane. But
Lane's stasis is rapidly becoming passe.
Now it is the blind dental abscess. The chronic
patient, no matter what his history or ailment,
must have his teeth x-rayed. If a shadow is seen,
the tooth, even though apparently sound and giv-
ing no symptoms, must be extracted. An autog-
enous vaccine, usually of the Streptococcus
viridans, which is the fashionable microbe at pres-
ent, is prepared, and the patient inoculated with
this. What could be more simple or scientific!
But this theory loses sight of the fact that most
dentists use very crude technique in making their
cultures, that special media are necessary for the
growth of certain organisms, that the viridans is
often found in healthy mouths, that dental pathol-
ogy is very uncertain; that an encapsulated dental
abscess may do no harm, but breaking into it may
cause a general septicemia (I have recently seen
a case of this kind) ; that bacterial vaccines do not
eliminate toxins; and finally that autogenous vac-
cines have no special advantage over other kinds,
as the most recent immunological research tends to
show that vaccines are not specific in disease, and
that a colon vaccine may be used successfully in
treating typhoid, etc. Thus phylacogens are rapidly
coming into their own.
To quote the German cynical philosopher, in spite
of all our best efforts, life continues to be at best,
a dangerous thing, and very few of us get out of
it alive.
Of course, in what I have said, I do not refer to
surgical stasis caused by some distinctly patho-
logical process such as bands, kinks, adhesions, can-
cer, ulcer, etc. Only surgery can, of course, relieve
a mechanical obstruction.
34 South Fullerton Avende.
THE PRESENT TREATMENT OF DIABETES
MELLITUS*
By HENRY MONROE MOSES. B.S., M.A., M.D.,
BKOOKLTN, NEW YORK.
ASSISTANT ATTENDING PHYSICIAN TO THE KINGS COUNTY HOS-
PITAL AND THE NORWEGIAN HOSPITAL.
In diabetes mellitus we have primarily a disturb-
ance of nutrition in which the ability of the organ-
ism to utilize carbohydrates as it normally does is
more or less impaired while in the more severe
cases there is added to this a disturbance in the
utilization of fats by the body. Treatment is
directed toward the making of the urine sugar-free,
and toward the prevention or control of acidosis.
To treat successfully any case of diabetes we must
give the patient a thorough course of instruction
in the nature of the disease, in the differences in
foods, the carbohydrates, fats, and proteins; some-
thing of the food and the caloric values of these
substances; in the effects of breaking the diet rules,
and in the examination of the urine for sugar. We
must not assume that the patient knows anything
about the condition. He must be told that in
diabetes he fails to get the full benefit of the starch
and sugar eaten, due, we believe to impaired func-
*Read at a meeting- of the Brooklyn Medical Associ-
ation, October 11, 1916.
tion of the pancreas — that it is frequently observed
in people who are obese, or who have gained weight
rapidly, and that it sometimes follows intense or
long-continued nervous excitement. He must know
and realize that faithful treatment accomplishes
wonderful results, but half-hearted treatment avails
little.
Naunyn, who is perhaps the leading authority
on diabetes now living, says: "From my experi-
ence, I consider it highly probable that among the
early strictly treated cases which were originally
considered severe, but later ran a favorable course,
there is many a case for which one must thank
this early strict treatment; while, on the other hand,
there can be no doubt that the cases which run
ultimately a severe course underwent little or no
care."
The patient should be taught that as the urine
becomes sugar-free the power of the body to utilize
carbohydrates improves. If it is not sugar-free,
the patient is only holding his own, or more likely
growing worse. Attention to diet renders the urine
more nearly normal, and this, the patient should
understand, is why so much attention is paid to
his diet.
Dr. Elliott P. Joslin gives his patients cards on
which is a table of the carbohydrate content of
many of the commoner vegetables and fruits, to-
gether with the protein and fat content of some
of the commoner foods. They are advised to obtain
for reference the United States Government bulletin
on Principles of Nutrition and Nutritive Value of
Food, by Atwater, and the bulletin of the Con-
necticut Agricultural Experiment Station on Food
Products.
The diet of a patient is most readily determined
by testing the effects of weighed quantities of vari-
ous foods, and each patient is taught to do this
weighing for himself, and should know the quan-
tities of carbohydrate, protein, and fat he is taking
daily and whether he keeps sugar-free on it. He
knows that he is expected to become sugar-free
during the early part of his treatment, and should
observe and record how this is done, so that if sugar
later reappears in the urine he can follow the same
method and again become sugar-free. For this
reason it is desirable for sugar to return while the
patient is under immediate observation. He is told
to eat too little rather than too much, and that all
food must be eaten slowly. Especial attenion should
be taken in the care of the teeth and gums. Care
should be taken in avoiding injuries to the skin,
and the body should be kept clean with warm baths.
The bowels should move daily, but not be purged.
If diarrhea occurs, the patient is instructed to go
to bed at once, to apply external heat to the body,
and to drink hot water, but not necessarily to stop
food. He should exercise freely at short periods
daily, never get overtired, and avoid athletic con-
tests and all sources of anxiety and worry. He is
told to sleep nine hours or more during the twenty-
four.
The patient is taught to use Benedict's test for
glucose in the urine, so that a daily examination
can be made by him. A notebook is kept in which
he records all questions for the doctor. The patients
under hospital observation are allowed to mingle
freely with one another and to compare conditions
and results. Here they see the improvement in the
more severe cases and are encouraged about their
own condition.
These careful instructions to the patient may
1070
MEDICAL RECORD.
[Dec. 16, 1916
seem too much in detail, but only by getting him
interested can results be obtained. He must realize
that extreme care is essential to recovery. This is
just as important a part of the treatment as any
dietary restrictions.
Can we accomplish anything in the prevention
of diabetes? We know that in some families there
seems to be a tendency to the development of the
disease. We should urge all patients to have an
examination of the urine at least once a year. This
will sometimes allow us to detect the condition early.
All the members of a family of a diabetic patient
should have frequent urinary examinations. An
early diagnosis allows time for much to be done
toward the prevention of the development of the
disease in those susceptible to it. Instruct the indi-
viduals of such a family about the evils of excessive
eating, obesity, mental anxiety, nervous tension,
and excessive physical strain. Every agency which
promotes health and physical development tends to
prevent an outbreak of diabetes in those with a
tendency to the disease.
The employment of drugs as specifics in diabetes
has been common. Many drugs have been used and
benefit has been attributed to the use of these.
Opium, or one of its derivatives, has been used, per-
haps, more than any other drug. It may reduce the
quantity of sugar in the urine in a small amount,
but it has to be given in large doses, and when we
consider the probable duration of life for the indi-
vidual patient under dietetic treatment we are not
justified in giving opium. Aspirin has been used
much, but it eventually disturbs the digestion and
the benefit of its use does not continue after the
drug is stopped. Preparations of the pancreas have
not given the results expected and are not used as
much as formerly. The bacillus bulgaricus has been
advocated, but has been found of no advantage in
treatment. Calcium in the form of the chloride or
lactate has been proposed and used by some of our
own members, who report success in keeping the
patient sugar-free on an unrestricted diet.
The alkalis have been used in diabetes, not for
the glycosuria, but for the threatened coma. In
beginning diabetic coma large doses of alkali, well
diluted, will frequently change the drowsiness and
exaggerated respiration to a more normal condition
and apparently work wonders, but the use of the
alkalis should not continue over a long period of
time. In the ordinary case, however, it is seldom
necessary to use the alkalis, as it is safer, more
agreeable to the patient, and easier to bring about
the disappearance of a slight or moderate acid
intoxication by the omission of fat, followed by fast-
ing, than to attempt to neutralize acid intoxication
with an alkali.
Joslin says in reference to the use of drug medi-
cation : "Drugs may be very beneficial in the course
of treatment of a diabetic case, as in any chronic
ilisease, but this is not because of any specific action
upon the diabetes. Nevertheless, scores of drugs
have been employed with such a purpose. I use
none of them, and I think the same custom is fol-
lowed by those who have had a greater series of
cases. If the patient is properly instructed and his
interest in his own case sufficiently aroused it will
not be necessary to give any drug to retain his
confidence."
The Present Dietetic Treatment. — -The present
dietetic treatment had its beginning at the time
of Rollo, an English army surgeon, who in 1796
limited his diabetic patients to a diet of animal food.
Various modifications have been made at times by
different workers, and our ideas at the present time
are the results of the experiences of these men. Bou-
chardat and Cantani restricted the harmful excess
of protein suggested by Rollo and employed green
vegetables. Naunyn has wielded a powerful influ-
ence in favor of the restriction of protein and also
occasional fast days. A number of years ago he
called attention to the advantages derived from these
fast days and said that one should not fear tem-
porary undernutrition if thereby it were possible
to remove the sugar from the urine. In his severe
cases it not only made the patient sugar-free, but
seemed to increase the carbohydrate tolerance and
diminish the acidosis.
Van Noorden agreed with Naunyn that these days
were never disadvantageous, and writes: "I make
use of these, especially where there is a high aceto-
nuria. It is astonishing how strikingly the acetone
falls on a hunger day. Its effect stretches out for
a number of days later. In numerous severe cases
a hunger day has been instituted every week with
excellent results."
In 1911 Hodgson emphasized the necessity of a
low caloric intake for diabetics, commenting on the
fact that it was not the amount of food that should
be metabolized, but the amount that can be, which
determines the amount necessary.
Guelpa of Paris, in 1909 and 1910, reported a
series of patients treated by several fast days, com-
bined with purgation, and his method has been fol-
lowed by many.
With these clinical observations in mind. Dr.
Frederick M. Allen experimented extensively on
animals, principally dogs, and placed these observa-
tions on a proved experimental basis. His treat-
ment consisted of a vigorous fast with black coffee
and whiskey until sugar-free; then after 24 or 48
hours begin to feed slowly and cautiously. Any
trace of sugar is a signal for a fast day. He pub-
lished his suggestions for treatment in December.
1914, and since then there have been changes in
our ideas of (1) the initial fast, (2) in the necessity
for the use of alcohol, (3) in relation of the protein-
fat diet in the production of acidosis, and (4) in
the use of exercise as a therapeutic agent.
No two cases can be treated exactly alike. Hos-
pital treatment is desired. It is surprising how
benign severe cases of diabetes become when under
constant supervision. Even in hospitals, however,
we have to use constant care to keep some well-
intentioned wardmate from giving a hungry dia-
betic a couple of slices of bread. In long-continued,
untreated, severe cases caution is necessary in the
first few days of treatment. The sudden breaking
of habits of life and diet, together with the excite-
ment of entering a hospital, should make us careful
in the radical elimination of carbohydrate and the
change to an excessive protein-fat diet. The ease
of digestion, as well as the palatability of the
changed diet, must be carefully studied, so as not
to cause too much effort to the system.
In severe, long-standing, complicated, obese, and
elderly cases, as well as in all cases with acidosis,
without otherwise changing habits or diet, omit
the fat. After two days omit the protein, and then
halve the carbohydrates daily until the patient is
taking only ten grams; then fast. In simple cases
begin fasting at once. Fast four days, unless sugar-
free earlier. During the fast the patient is allowed
water freely, tea, coffee, and clear meat broths as-
desired.
Dec. 16, 1916J
xMEDICAL RECORD.
1071
Intermittent Fasting. If glycosuria persists at
the end of four days, give one gram of protein and
one-half gram of carbohydrate per kilo body weight
for two days; then fast again for three days unless
sugar-free. If glycosuria remains, give the protein
as above, with no carbohydrate, for three days, and
then fast one or two days, as necessary. This will
usually clear up the glycosuria.
To learn the carbohydrate tolerance — when the
24-hour urine is free from sugar add 5 grams of
carbohydrate to the diet. Continue to add 5 grams
of carbohydrate daily up to 20 grams; then add 5
grams every other day until glycosuria appears.
Protein Tolerance. When the urine has been
sugar-free for two days add about 20 grams of
protein (3 eggs), and thereafter 15 grams protein
daily in the form of meat until the patient is receiv-
ing at least 1 gram of protein per kilo body weight.
Fat Tolerance. While testing the protein toler-
ance a small quantity of fat is included in eggs and
meat. Add no more fat until the protein reaches
1 gram per kilo body weight, then add 5 to 25 grams
daily until the patient ceases to lose weight or
receives 30 to 40 calories per kilo body weight.
The return of sugar demands fasting for twenty-
four hours, or until sugar-free. Resume the former
diet, except that the carbohydrate is diminished
one-half, until the urine has been sugar-free for
one month, and it should not be increased more than
5 grams a month. Whenever the tolerance is less
than 20 grams carbohydrate fasting should be prac-
tised one day in seven. When the tolerance is
between 20 and 50 grams carbohydrate, upon the
weekly fast day 10 grams carbohydrate and one-
half the usual quantity of protein and fat are
allowed. These, therefore, are not strict fast days
When the tolerance is between 50 and 100 grams
carbohydrate 20 grams of carbohydrate are given
with the one-half quantity of protein and fat. This
outline has to be modified for the individual — the
weight, age, digestion, tastes of the individual, and
duration of the disease have to be considered.
The preparation for fasting is to prevent acidosis,
as it is easier to prevent than to treat. While it is
true that few diabetics develop acidosis on fasting,
it is impossible to predict what will occur. Patients
who have lived in a fairly comfortable condition,
untreated for years, are predisposed to acidosis and
frequently succumb to too active treatment within
a few days of its commencement. The critical period
in the management of diabetes, so far as acid poison-
ing is concerned, is that in which rapid changes in
the diet are being made. All complicated cases,
especially those in which the complication involves
the kidneys, heart, thyroid, the obese, the arteris-
sclerotic, and patients about to undergo an opera-
tion, demand preparatory treatment, which, as we
see, excludes the chief source of acid poisoning —
the fats.
Any occurrence in a patient out of the ordinary
should arouse suspicion, and we should immediately
investigate any of the following symptoms: Ano-
rexia, nausea, vomiting, restlessness, unusual
fatigue, excitement, vertigo, tinnitus aurum,
drowsiness, listlessness, discomfort, painful or deep
breathing. The recognition of these premonitory
symptoms of diabetic coma is of the greatest im-
portance, for it is astonishing how insidiously coma
steals over a patient. The treatment of threatened
coma should be prompt. If this prompt treatment
can be carried out without awakening the suspicion
of the patient it avoids excitement, which is bad
for him. Rest in bed at once is necessary, and
warmth should be furnished to the body. The
bowels should be emptied by an enema.
In threatened coma fasting is efficacious, due,
probably, to sparing the patienfs digestion, thus
preventing vomiting. It also allows the patient
fluids. It improves the tolerance for carbohydrates
and thereby tends to overcome the acidosis.
If the alkalis are to be given at this time, give
them freely and in generous doses at first. Fifty
grams of sodium bicarbonate given within five or
six hours at the approach of threatened coma are
more efficient than double the quantity six hours
later. Alcohol apparently does not reduce the
acidosis and its usefulness seems slight in this
condition. The patient's heart and circulation
should be sustained during this condition with car-
diac medication.
The question of surgery and diabetes is of con-
siderable importance. In the last few years the
mortality following surgical intervention has de-
creased, until now there is less need for conser-
vatism. But whenever delay is not dangerous the
rule still holds to defer surgical interference. Before
undertaking an operation upon a diabetic the sur-
geon should thoroughly understand the dangers with
which the patient has to contend and the elements
which favor surgical success. The dangers are four
— acid intoxication, slow healing of wounds, ex-
haustion, and lack of exercise.
The elements favoring surgical success are:
1. Good medical care before and after the opera-
tion, which should render the urine sugar and acid
free, and keep it so.
2. The method of anesthesia. Every effort
should be made to shorten the period of anesthesia
and to avoid apprehension and excitement on the
part of the patient. Chloroform is contraindicated.
Ether has been used with success, but is dangerous.
Nitrous oxide or nitrous oxide and oxygen appear
to be the best anesthetics. Local anesthesia may be
used, but allows of nervous excitement.
3. The employment of asepsis rather than anti-
sepsis accounts for many improved results.
4. The avoidance of trauma is especially urged
in diabetics. The greatest care should be used in
handling the tissues.
Pregnancy in Diabetics. — A small quantity of
sugar in the urine during pregnancy is not uncom-
mon. As a rule in such cases the sugar permanently
disappears after confinement, although it may recur
with succeeding pregnancies, and untimately a
severe form of diabetes may develop. In pregnant
diabetics there is during the pregnancy an increased
carbohydrate tolerance. Pregnancy is not looked
forward to by the physician or obstetrician with
much pleasure, although recent treatment is more
encouraging in its results.
Joslin, who has followed several cases through
pregnancy, has arrived at the following conclusions :
1. It is necessary to have the patient under
constant supervision through the course of the
pregnancy and for months and years after confine-
ment, because it is not uncommon for the sugar
to return.
2. Treatment should follow exactly the same
methods which are employed in the treatment of
the usual case of diabetes, with special care in
regard to the fat in the diet.
3. Even when sugar appears to a slight extent
in pregnant women it should be carefully watched
and controlled by diet.
1072
MEDICAL RECORD.
[Dec. 16, 1916
4. The advantages of a cesarean section should
be borne in mind.
5. Ether anesthesia is not so safe as gas and
oxygen. If ether should be used, as brief an anes-
thesia and as little ether as possible should be used.
Local anesthesia should be considered.
6. Many statements occurring in the literature
of pregnancy and diabetes must be revised. Preg-
nancy in diabetes does not demand immediate abor-
tion, even if acidosis is present. If pregnant diabetic
cases are suitably managed they will very likely
abort less frequently. Nursing is not contraindicated
following confinement, for the diversion which it
affords the patient may offset the extra demands
thrown upon the metabolism. The next few years
may show that pregnancy may take place in diabetic
patients far more readily than has been supposed.
I wish to take this opportunity to thank Dr.
Elliott P. Joslin for his courtesy to me in allowing
me to see some of his patients during the past sum-
mer. The above treatment follows his present
method of caring for his patients. Acknowledg-
ment is made also of the use of the writings of those
who are doing research and clinical work in diabetes
mellitus.
4 Lefferts Place.
THE R6LE PLAYED BY FEAR IN DISEASES
OF THE STOMACH AND INTESTINES.
By LOUIS HENRY LEVY, MS.. M.D..
NEW HAVEN, CONN.
The relationship of the element of fear to disease
is well recognized and has an important bearing
from the standpoint of diagnosis and proper treat-
ment. Patrick (Jour. Amer. Med. Assn., 1916,
LXVII, 180) has described the role played by fear
in nervous diseases and the case records of almost
every physician contain other instances.
In the consideration of the part played by fear
in the production of disease there must not be con-
fused the symptoms of the various ailments as de-
scribed by the neurasthenic or hysterical individual.
These form a series of cases by themselves in
which the phobia factor is a minor one. The cases
in question are those in which the patient, always
normal and well, seems suddenly to have become
obsessed with the idea that he is the possessor of
some kind of a pathological process. It is because
of the fact that these individuals have always been
free from symptoms that their complaints are care-
fully listened to and a suspicion aroused in the
mind of the physician that there exists some defi-
nite organic cause. It is on this account that the
fears of the patient are often increased, especially
when he has been informed that from the symp-
toms there exists a possibility of the lesion in ques-
tion.
The patient who acquires such a phobia is often
of an intelligent type, one who more than the aver-
age individual is conversant with medical terms and
phrases. As a rule it is an individual who either,
through the perusal of medical literature or in the
course of conversation, becomes acquainted with
some of the symptoms characteristic of organic
conditions. It is the case of a little knowledge pro-
ducing considerable harm.
The public, as a whole, at the present time is
better acquainted with medical matters than it has
been at any previous time. This is due to the
greater publicity given by hygienists and public
health officials to the preventable diseases. Educa-
tion, such as this, of the public is without doubt of
inestimable value and has been the means of de-
creasing the death rate in several of the infectious
diseases. It will also in the near future by the
earlier recognition of symptoms produce almost as
good results in other conditions, such as carcinoma.
However, with the repeated precautions to watch
out for certain symptoms there has been aroused
in many an overcautiousness with the result that
some of the ordinary minor ailments are often mag-
nified to unusual proportions and interpreted
wrongly by the person possessing them.
Another means of creating such a phobia is con-
tact with a patient who has had symptoms of an
incurable or serious condition resulting in death.
Even knowledge of such a patient may result in
producing fear in another person in whom one or
more symptoms may arise. The process of reason-
ing is a simple one. It is well known that the de-
ceased had definite symptoms of a certain kind and
that after a varying period death ensued. Hence
it is assumed that, one or more of the same symp-
toms being present, a similar condition prevails and
may lead to a fatal issue.
As has been stated, the individual is usually one
who has always been well. As a result of indiscre-
tion or exposure an unfamiliar and disagreeable
sensation will arise in some part of the body.
Should this symptom recur or persist for any length
of time the mind becomes focused on it. Attempts
at removal by wrong methods resulting in failure
initiate the fear and should these symptoms simu-
late those of some other case known by the patient,
the fear is strengthened. With the increase of the
fear new symptoms of psychic origin will arise and
the symptom complex will be complete. Sleepless-
ness will result; the appetite will be lost; less food
will be consumed, and following this there will be a
marked decrease in weight — all tending to substan-
tiate in the mind of the patient the fear of the
presence of some malignant or hopeless disease.
Perhaps no field offers a better opportunity for
the display of fear than the gastrointestinal tract.
This is due to the ease with which the different
parts may be disturbed. The slightest divergence
from the regular daily routine of living, particu-
larly in diet, will often produce untoward symptoms
that may persist for several days and form the
basis of an imagined organic lesion. Even the loss
of appetite will predispose to other symptoms re-
sulting in a phobia. Abdominal pains either gastric
or intestinal, if persistent, have been the means of
arousing unnecessary fears. The frequent belch-
ing of large amounts of gas in one who always has
been free from this annoying symptom will give
rise to apprehensions that there is present a serious
gastric condition. Regurgitation of sour fluid,
nausea, vomiting with or without bile, all have
tended, when occurring at frequent intervals, to
arouse fear in the mind of the patient of the pres-
ence of an illness of a serious nature.
With the intestinal tract, the occasional pain in
the atonic intestine often present in constipation,
the rumbling or gurgling sound of gas within the
large intestine, distention of the abdomen in tym-
panites, these also have in many cases resulted in
the phobia that some malignant disease was pres-
ent. The presence of blood in the stools due, as a
rule, to hemorrhoids, has from its unusual occur-
rence filled the mind of the patient with thoughts
of ulcerations and even cancer, especially when as-
sociated with pain.
The treatment of such phobias is not always a
Dec. 16, 1916J
MEDICAL RECORD.
1073
simple one. It is based first of all on the absolute
proof that the condition is a phobia and not a true
pathological condition. On this account it is often
necessary to try every known test. It is only when
these prove negative that the patient's confidence
should be obtained and there should be described to
him the reasons for the absence of any lesion. He
should be convinced absolutely and often conviction
is obtained only after the various tests have all
been demonstrated and clearly explained. The
cause for any abnormal symptom should also be
removed and conditions brought to normal by both
medical treatment and assurances. Each case offers
a problem in itself, and hence the mode of treat-
ment depends mainly on the individuality of the pa-
tient himself.
The following cases are selected from a large
number seen in the private practice of the writer:
Case I. — B. G., female, age 22. The original com-
plaint was belching of gas which had first appeared two
weeks previously, following the overeating of candy and
pastry. Up to this time of her life, she had always
been well and had never had any symptoms of any
illness. With the appearance of the belching she was
reminded of a friend of her family who had died fol-
lowing an operation for perforated gastric ulcer. The
deceased had had as a prominent symptom, belching of
gas. Miss G. became possessed with the idea that she
also had a gastric ulcer. She consulted a physician
who very indiscreetly suggested the possibility of such
a diagnosis. Following this there occurred in rapid
succession a feeling of pressure in the epigastrium
with a burning sensation of the skin over this area.
She also read a household medical advisor on ulcer of
the stomach, and the fear that she had an ulcer became
more firmly fixed in her mind. The constant worry re-
sulted in insomnia. The administration of large doses
of bromide produced a bromide rash which added
further fear. Her bowels which previously had always
been regular became constipated and could be moved
only by the use of very active cathartics. At no time
had she had pain, nausea, or vomiting.
Such was the picture when I was consulted. The
patient had lost 14 pounds in two weeks, and was in a
weakened condition. She came with the main purpose
of having her stomach contents examined. The analysis
following a test breakfast showed a well digested meal
with free acid of 40 and total acidity of 80. Chem-
ically tested there was no blood. The stool was nega-
tive for blood and the urine showed no abnormal sub-
stances. She was put on antacid treatment. Simultane-
ously with the medical treatment there was demonstrated
to the patient in several ways the impossibility of the
presence of ulcer. This required several visits and
patience before she was finally convinced that her
fears were groundless. One month after her last visit
she was married and there has been no recurrence of
symptoms after eighteen months.
" Case II. — D. A., age 42, male. His complaint was
dull pain, irregular in time of occurrence, in the left
hypochondrium radiating around the side to the back.
This pain was independent of the time of eating his
meals and never lasted over fifteen minutes. There
were days when he was free from pain. He was con-
stipated and felt relieved from pain after his bowels
had moved. This was the only symptom at the onset.
The patient first became conscious of these pains eigh-
teen months previously, immediately following the death
of his wife, who had died from carcinoma of the
stomach. The fear that he had carcinoma of the in-
testine became strongly fixed in his mind and he was
insistent that this diagnosis be verified and if neces-
sary operative interference be resorted to. During:
the eighteen months he had made the rounds of several
physicians and also a chiropractor and osteopath. He
had lost weight, was very nervous, and could not sleep
nights. His friends commented on his change in ap-
pearance and also suggested to him the possibility of
carcinoma. This strengthened his fears.
It was at this time that I was consulted. The dura-
tion of the illness without a corresponding increase in
the severity of the symptoms almost at once ruled
against malignancy. In this case, however, before the
patient could be convinced, it was necessary to examine
his stomach contents on different occasions and stool
examinations were also made. The urine was also ex-
amined. X-ray pictures of the left kidney and ureter
and also of the entire gastrointestinal tract were made.
He even insisted on a blood examination which included
a complement fixation test for syphilis and a full blood
count. All of the tests and examinations were nega-
tive. The x-ray photograph of the intestines showed
an unusual acute bend with a slight twist of the gut
at the splenic flexure. The stools had always been very
hard, and it seemed plausible to conclude that the pains
were caused by the hard stools passing over the sharp
bend at the splenic flexure. This diagnosis did not
satisfy the patient, and he visited a consultant in an-
other city. Nothing new was learned and a probable
diagnosis of appendicitis was made and laparotomy
suggested. He visited me again and there was advised
the use of an abdominal belt with a pad fitted over
the splenic area, regulation of the diet and bowels.
These were all tried. The pains gradually disappeared;
the patient gained in weight, and after one year there
were no further pains. With this change, the fear of
carcinoma has entirely disappeared.
Perhaps as good an aid as anything in this case
in removing the fear was the fact that the patient
was accepted by two insurance companies for large
policies after having told them in detail all his
fears concerning the presence of carcinoma.
Case III. — T. S., age 40, male. This patient had
firmly instilled into his mind the fear that there was
something fundamentally wrong with his stomach. This
fear had been present for six years, during which time
he had been treated by several men for various gastric
disturbances. His only symptom was water brash
which occurred at irregular intervals and seemed to
come on when he wanted it to occur. At times, after
severe retching the water brash contained bile. During
the six-year interval every possible test and examina-
tion had been made, including several test meals, x-rav
examinations, stool, urine, and blood examinations, all
of which were negative. For an interval of over three
months his stomach had been washed daily. At no time
had he been placed on a normal diet and his caloric
intake was always less than that required for a man of
his occupation. As a result he lost in weight and this
with the continued treatment strengthened his fear of
some serious gastric condition.
When I first saw him I found him to be a very rest-
less, active, and energetic individual. Physical examina-
tion was entirely negative. The irregularity of the oc-
currence of the water brash and his ability to produce
it at will, together with the absence of other symptoms
ruled against any organic lesion. A test meal exami-
nation showed a slight hyperacidity. The possibility
that his condition was based on fear, and that the water
brash and hyperchlorhydria were part of a nervous
manifestation secondary to the fear, was explained to
him and he was encouraged to increase the amount of
food and gradually to change his diet. When he found
that he could tolerate foods that he had been forbidden
to eat and had not eaten for several years, his fear
gradually subsided until at the end of two months after
treatment, his diet was a regular normal diet. The
water brash had ceased to occur and he had gained 10
pounds in weight. After an interval of eight months
the svmptoms have not recurred and he seems perfectly
well.
Case IV. — E. R., aged 50, female. In this case very
little progress has been made, due mainlv to lack of
intelligence on the part of the patient and her unwill-
ingness to cooperate. Two brothers of the patient had
died of carcinoma of the stomach, and this had upset
her to such an extent that she lost her appetite and
would not eat. The color of her skin, which, normally
had a slight sallow appearance, became more so. Her
change in appearance attracted the attention of her
acquaintances who insisted that she, too, might have
carcinoma, and advised her to consult a physician. The
fear was started in this way, and all attempts to con-
vince her otherwise have resulted in failure. The
usual examinations have been made and all have been
negative. She has firmly fixed in her mind the fear
that she has carcinoma and is going to die as a result
of it. Due to this she will eat but little food and has
become emaciated and weak and there is little doubt
but that the prognosis will be as she has feared. In a
case such as this there has come up the question as to
whether there exists true fear or whether some form of
dementia has not arisen due probably to the death of
1074
MEDICAL RECORD.
[Dec. 16, 1916
the brothers. The idea of the presence of carcinoma is
fixed and nothing seems to be able to remove it. Such a
case is as much in the domain of the psychiatrist as it
is in that of the internist.
1172 Chapel Street.
A PLEA FOR THE PREVENTION AND THE
TREATMENT OF WEAK FEET OCCUR-
RING DURING PREGNANCY AND
THE PUERPERIUM.*
Bv JACOB GROSSMAN', M.D.,
NEW YORK.
Although much has been written about the hy-
giene of pregnancy and the puerperium, in which
proper clothing and belts have been described and
recommended, very' little stress, if any, has been
laid upon proper foot wear. Many authorities in
referring to the subject, simply recommend a low-
heel shoe. Others overlook the topic entirely. It is
true that the weak feet occurring during these
periods do not differ materially from weak feet in
general, still the presence of pregnancy seems to
distract attention from the feet, and one is very apt
to believe that the various symptoms complained of
are the result of pregnancy rather than those of ex-
isting weak feet.
That weak feet may be present for a long time
without producing symptoms has been demonstrated
time and again. It requires in such cases but a
little added strain or perhaps a lowering of the gen-
eral resistance of the patient, such as one would ex-
pect to occur during pregnancy, to produce symp-
toms. The symptoms rarely depend upon the
amount of deformity present. A very slight ever-
sion of the heels and heel cords may produce severe
suffering and on the other hand a severe pes planus
may produce very mild suffering. The relief of
symptoms which occurs in the vast majority of the
former type of cases, by the institution of proper
treatment of the existing weak feet, proves beyond
a doubt that the weak feet are responsible for
these symptoms.
Many pregnant women, on reporting to their
physicians the pain which they experience in the
back, thighs, or legs, are dismissed with the state-
ment that this pain is the result of pressure of the
presenting part of the child upon the nerves and
will disappear after labor. It is true that in a cer-
tain percentage of cases of pregnancy, pressure of
the presenting part may produce various neuralgic
pains referable to the thighs and back, which will
disappear upon the termination of labor. In a vast
majority of cases, these pains are the result of weak
feet. In my observations of a series of 700 cases
of weak feet, there were 400 in whom the pain was
referable to the back and thighs and not to the feet
(Interstate Medical Journal, May, 1916). From
this one can readily appreciate that weak feet can
be present even though the patient does not refer
symptoms to the feet.
The mere recommendation to wear low heels is not
sufficient, as many of these patients are accustomed
to wear high heels and when they attempt to wear
low heels they experience a sensation of falling
backwards. To compensate for this they must as
sume an unnatural and tiresome posture forwards so
ns to balance themselves properly. This type of
patient can wear a high heel with comfort and with-
out serious consequence, provided the heel is square.
*Read at a meeting of the Lebanon Hospital Alumni
.Society, Oct. 3. 1910.
When one considers how important it is for preg-
nant women to obtain proper exercise, among which
walking is the best, one would appreciate the im-
portance of recognizing the presence of weak feet
in these cases, so as to institute proper treatment
and in that way encourage walking and other ex-
ercises. Walking for patients with weak feet is tor-
ture, hence they avoid as much as possible this
beneficial and necessary exercise. As a result of
this, weakness, nervousness, loss of appetite, and
many other conditions may arise from the sedentary
life which they are compelled to live.
Accidents such as falls resulting in fractures,
sprains of the ankle, and miscarriages are not at all
uncommon during pregnancy. These are usually
associated with weak feet, and very often with im-
proper foot wear.
Some of the patients experience very little or no
discomfort during pregnancy and complain of pain
during the puerperium. The following is a brief
history of this type of case.
Mrs L., twenty-four years of age, primipara. Past
history: No complaint referable to weak feet. Present
history: Began four days postpartum, when she experi-
enced a severe cramplike pain referable to the right
calf. This pain was not relieved by local treatment,
such as hot applications, massage, etc. Examination:
Disclosed weak feet. There was no sign of inflam-
mation. Treatment: Strapping, which at first only
partially relieved the pain. Persistent strapping, how-
ever, finally overcame this distressing symptom. Later,
when the patient left her bed, proper shoes were pre-
scribed and to date, almost two years after the onset,
she has been free from pain.
Pathology. — The pathology of the weak foot of
pregnancy does not vary from that of the weak foot
we ordinarily meet with. The early and moder-
ately advanced cases usually show eversion of the
heels and heel cords and a lowering of the arch as
a whole. This eversion varies in degree from a
mild to a very marked rolling out of the heels and
heel cords.
In the advanced cases the head of the astragalus
becomes partially dislocated inwards and down-
wards from the scaphoid and at times it may articu-
late only with the latter at the extreme outer part
of the head ; in consequence, the cartilage disap-
pears from the portion of the bone that is thus ex-
posed and the head forms a marked prominence be-
neath the skin on the inner border of the foot. The
arch of the foot gradually diminishes, until finally
the sole is applied flat to the ground. In well
marked cases, the anterior part of the foot becomes
abducted, and in very severe cases the inner border
of the foot may be convex and the outer concave, so
that the patient walks more on the inner side of the
foot than on the outer.
In very severe cases the peronei tendons may be
dislocated from their groove and lie upon or an-
terior to the external malleolus. In cases of long
standing marked changes also occur in the bones;
the uncovered portion of the head of the astragalus
becomes enlarged, so that it cannot be replaced in
position. Sometimes actual bony ankylosis may
take place. There may be effusion into the sheaths
behind the tendons and in the tarsal joints.
Symptom*. — The symptoms of weak feet rarely
depend upon the amount of deformity present;
cases with just a slight eversion of the heels and
heel cords may suffer severely and on the other hand
cases with a severe pes planus may suffer very
mildly.
The subjective symptoms are: (a) Pain, pres-
ent in the vast majority of cases, usually varies
Dec. 16, 15)16 |
MEDICAL RECORD.
1075
from a severe cramplike shooting pain to a dull
ache. In a number of cases the pain is not re-
ferred to the feet alone, but to points distant, i.e.
back, hip, knees, thighs, and calves. The pain may
be unilateral or bilateral ; in some cases when both
feet are weak, patients complain of unilateral
pain. (6) Another group of symptoms which oc-
cur quite frequently includes weakness, discomfort,
and tired sensation. These are especially evident
after prolonged standing or walking. (c) Many
cases complain of numbness and coldness in the feet.
This is usually the result of the impairment of the
circulation which is commonly associated with weak
feet, (d) As a result of all these symptoms there
may be mental depression, nervous symptoms, and
loss of appetite.
The objective symptoms are: (a) The most con-
stant, one can almost say the diagnostic sign of
weak feet, is eversion of the heels and heel cords.
This may vary from a very mild to a very marked
degree, (o) In some cases, especially in fleshy pa-
tients, there may be a swelling at the outer side of
the ankle, (c) Muscular spasm or rigidity is very
common in the advanced cases. The spasm is due
to the shortened and contracted muscles on the
outer and upper surface of the feet, the result of
the persistent attitude of valgus.
Treatment. — In general we can consider the treat-
ment of weak feet or rather the feet during preg-
nancy and the puerperium under prophylactic and
curative.
A. Prophylactic: (1) Proper footwear. Before
describing in detail the shoe which has proven very
satisfactory in pregnancy and the puerperium, a
brief review of some of the possible conditions
which may arise during these periods would not be
out of place. We know that the circumference of
the legs of many pregnant women vary from one
part of the clay to the other. Women will arise in
the morning with very little or no swelling of the
legs and as the day advances swelling appears. Very
often associated with weak feet is a breaking down
of the anterior arch. At times patients slip and
fall, sustaining sprains and fractures; again they
may trip because their heel catches in carpet, rug
or their dress when they ascend or descend stairs.
The added strain of pregnancy may aggravate an
existing valgus of the feet, or if one is not present,
produce one in a foot which has already been abused
by improper foot wear. A proper shoe to obviate
these conditions and accidents should be constructed
as follows:
(a) There should be an expansion top to com-
pensate for any degree of edema. (6) An eighth
of an inch elevation in the inner border of the
sole and heel to overcome the valgus or prevent
one. (c) A cross bar of an eighth of an inch in the
anterior metatarsal transverse arch to relieve and
prevent metatarsalgia. (d) A cushion rubber lift
in the heel between the top lifts and the under lifts
to give soft and jar-relieving steps when walking.
(e) A special anti-slip finish to the bottom of the
sole and heel so as to prevent slipping and subse-
quent injuries (/) Rounded heel edges to prevent
catching in carpet, rug or dress in ascending or
descending the stairs, (g) Must be built on ana-
tomical principles so that the body weight bearing
is evenly distributed on the feet, (h) The heels
must be of the height most comfortable to the pa-
tient. (0 Should be built so that they can be
worn all day without requiring a change to low7 cut
shoes or slipper*.
The shoes which we prescribe and recommend,
fulfill these requirements and have proven very sat-
isfactory. They are designed for us by Mr. Max
Deutsch of this city.
2. Exercises. Exercises should be practised
twice daily and should not be carried to the extent
of tiring the patient. Walking should be encour-
aged as much as possible.
Tiptoe exercises: The patient places the limbs
in the attitude of moderate inward rotation, raises
the body on the toes to the extreme limit, the legs
being fully extended at the knees, then sinking
slowly, resting the weight on the outer borders of
the feet in marked varus, repeating about twenty
to thirty times. This exercise if practised faith-
fully is all that is required.
B. Curative: The two types of weak feet
which we commonly meet with in pregnancy and
the puerperium are the spastic and the nonspastic.
In the nonspastic passive motion of the foot is
painless and free to the normal limit. In the spas-
tic type passive motion is painful and restricted.
The treatment of the nonspastic type consists of
proper shoes and exercises. As a rule these suf-
fice; at times it is necessary to supplement these
with Whitman's braces.
In the spastic type of weak feet strapping,
shoes, and Whitman's braces are necessary. A
very good method of strapping follows; one end of
a strip of adhesive plaster, about 15 inches long
and 3 inches wide is applied to the outer side of the
ankle just below the external malleolus; the foot is
then adducted as far as possible and the plaster is
drawn tightly beneath the sole up the inner side of
the arch and the leg; it is kept in this position by
one or two plaster strips about the calf. Narrow
strips are then applied about the arch and ankle in
a figure of eight manner. Strapping should be
done twice a week and continued until the spasm
and rigidity have been overcome. When this has
been accomplished the brace and proper shoes
should then be prescribed.
Conclusions: 1. All cases of pregnancy should
be instructed as to the proper care of the feet.
2. Prophylactic measures should be instituted,
regardless of the presence or absence of weak feet.
3. Where neuralgic pains in the limbs, back,
sciatic region, edema about the ankles are com-
plained of, the presence of weak feet should be
eliminated.
4. Only by the institution of prophylactic and
early active treatment can we hope to prevent un-
told suffering in one of the most trying periods in
the woman's life.
1051 Boston Road.
REPORT OX AX OLD CASE OF PAREXCHYMA-
TOUS NEPHRITIS.
By FRANK MACKIE JOHNSON, M D.,
r.. IST< 'V.
In the Medical Record of May 20, 1905, I pub-
lished an article entitled "Cystoscopy and Renal
Lavage," citing the following case:
Mr. E. H-. age 61. History of illness of more than
two years. Principal symptoms had been headache,
nausea, indigestion, weak heart, dropsy, partial inabil-
ity to walk, loss of flesh and strength. Had received
treatment from many physicians and had been told
when he was in some hospital that he had but a short
time to live. Thne was a disfiguring skin eruption on
his face. He had taken large quantities of digitalis and
iron. On examination, a stricture of the urethra was
1076
MEDICAL RECORD.
[Dec. 16, 1916
found. This was dilated. The prostate was enlarged.
Urine examination showed the case to be one of chronic
parenchymatous nephritis, chronic catarrhal cystitis,
and chronic prostatitis. There was a fairly large
amount of albumin present.
The bladder was treated by boracic acid washes and
injections of protargol, mild solutions of silver nitrate,
argyrol, etc., then cystoscopy was performed. The ex-
amination of the left and right urines showed chronic
parenchymatous nephritis. Both kidneys were in about
the same condition. After lavage, % to 1 per cent, of
protargol was injected slowly. In all there were
some eighteen cystoscopies and in the interim bladder
washes of boracic acid, silver nitrate 1/5000, etc.
Salol, alkalies, urotropin, piperazin, et al. constituted
the internal medication. Digitalis I did not use. The
patient showed marked improvement, was able to re-
sume work, had a good appetite and gained sixteen
pounds. His flesh became firmer, right and left urines
showed less albumin, and casts almost disappeared.
Eleven years have passed, and it is now 1916.
During this time he has been up and about, and
feeling quite well. At different times I have given
him bladder and renal lavage. The stricture has
entirely disappeared, so cystoscopy is not difficult.
Soothing diuretics, tonics, urotropin have been more
or less continued.
Four years ago he had a hard attack of grippe.
This caused an added irritation of both bladder
and kidneys, and affected the heart's action. Small
doses of strophantus eliminated this new feature.
He is now 73 years old ; his urine shows more al-
bumin than when I was treating him constantly,
and casts have appeared again. Realizing that his
condition is a serious one, in spite of his assertion
that he feels well, I advised him to resume the
bladder and renal lavage. For some time past I
have obtained remarkably good results in chronic
cystitis, pyelitis, pyelonephritis, etc., from bladder
washes of warmed mild solutions of boracic acid,
followed by injections into the bladder of 2 to 4 c.c.
of colloidal iodine. I gave these treatments every
day, at first, and then three times a week; also
capsules of this iodine internally, one t.i.d. Up
to this time I have believed that the improvement
of condition after lavage was due to the better
drainage rather than to the medicament used. I
am now giving him bladder washes of boracic acid,
followed by injections of the iodine — about 4 c.c.
After lavage of the kidneys I inject this colloidal
iodine very slowly and carefully, a little at a time,
using in all 1 to 2 c.c. Internally, he is taking the
iodine capsules and nothing else.
Both urines have cleared and the albumin has
decreased. Also the good after-effects of the
lavage are more lasting. While I do not expect to
make a cure, I am more than pleased with the
results obtained. And these results have been ob-
tained quickly. It is my firm conviction that if I
had been able to use colloidal iodine years ago my
report of to-day would fully demonstrate that in
iodine we have an agent of real and positive value.
In the light of a newer experience, with cases
that show real improvement and many that have
been cured, I advise the employment of iodine lo-
cally and internally in diseases of the bladder and
kidneys, when lavage can be given. The treatment
should be begun as early as possible.
A few suggestions in the use of this medica-
ment: The iodine used locally should be warmed;
catheters and syringes being dry and sterile. The
bladder and urethra should be made dry so far as
this is possible. Lubricants should contain no
water.
One case, however, does not prove a theory. The
object of this paper is to report a case watched
and treated for eleven years — one looked upon as
incurable; also to emphasize the remarkable re-
sults obtained with colloidal iodine. May I make a
request that some of my readers test the method
mentioned, and give to the profession the result of
their experiences?
43 Tremont Street.
Offenses Involving Moral Turpitude. — In proceedings
to revoke a license to practise medicine as an osteopath
in the State of Washington, it appeared that the de-
fendant was charged with having been convicted of an
offense involving moral turpitude by using the mails
to give notice to cetrain persons named when, how, and
by whom and by what means an abortion could be per-
formed. The Washington Supreme Court held that the
statute providing for revocation of a physician's license
for unprofessional conduct and including conviction of
an offense involving moral turpitude, in which case the
record of conviction shall be conclusive evidence, is a
valid enactment. If conviction of an offense involving
moral turpitude is shown there is no discretion in the
board of medical examiners. The term "moral turpi-
tude" is not so vague and uncertain as to render the
act unreasonable and void. — State Board v. Harrison
(Wash.) 159 Pac. 769.
Identification of X-Ray Photographs.— The admission
of .i-ray plates in evidence rests fundamentally on the
theory that they are the pictorial communication of a
qualified witness wTho uses this method of conveying to
the jury a reproduction of the object of which he is tes-
tifying. This being true the x-ray plates must be made
a part of some qualified witness's testimony, and the
witness should qualify himself by showing that the
process is known to himself to give correct representa-
tions, and that it is a true representation of such ob-
ject.— Bartlesville Zinc Co. v. Fisher, Oklahoma Su-
preme Court, 159 Pac. 476.
Privileged Communications — Mental Capacity. — In a
suit to set aside a will because of the testator's mental
incapacity the California Supreme Court holds that a
hypothetical question to the testator's family physician
calling for an opinion regarding the testator's mental
capacity was correctly excluded under the California
statute providing that a physician cannot, without the
patient's consent, be examined as to information ac-
quired while treating the patient. — In re Ross's Estate,
159 Pac. 603.
Father's Liability for Operation on Partially Eman-
cipated Child. — In an action by a physician and surgeon
to recover for a surgical operation and attendance on
the seventeen-year-old daughter of the defendant, Cox,
it appeared that the latter formerly lived at Chatta-
nooga, but about three years before the occurrence
involved he had removed to the adjoining county of
Bradley. Two of his daughters remained in Chatta-
nooga to earn their own living. This they continued
to do without aid from their father. They were board-
ing at the Y. W. C. A. building when the younger be-
came ill. The plaintiff was called in by the matron,
and, after prescribing for her for a time, decided that
an operation was necessary to remove an ovarian
tumor. The patient's sister telephoned the father that
the doctor advised an operation. The doctor had stated
that the operation would be a slight one, and when
the father inquired whether an incision would have to
be made the daughter replied that it would not, and
that the operation would be a slight one. The father
replied, "Well, then, if it must be done, it must be
done." The daughter responded that her sister would
go for the operation the next day. This assent of the
father over the telephone was not communicated to
the doctor until after the operation. It was held that
there was only a partial emancipation of the sick
daughter, and a promise on the part of the father to
pay for the operation was implied by law. "Emancipa-
tion" of a child is the relinquishment by a parent of
control or authority over the child, conferring on the
latter the right to his or her own earnings and ter-
minating the parent's legal duty to support. It may
be express, as by voluntary agreement of parent and
child, or implied from such acts and conduct as im-
part consent, and it may be conditional or absolute,
complete or partial. — Wallace v. Cox, Tennessee Su-
preme Court, 188 S. W. 611.
Deo. 16, 1916]
MEDICXL RECORD.
1077
Medical Record.
A Weekly Journal of Medicine and Surgery.
THOMAS L. STEDMAN, A.M., M.D., Editor.
PUBLISHERS
WM. WOOD 4. CO., 51 FIFTH AVENUE.
Sec fourth page following reading matter for Rates of Subscription
and Information for Contributors and Subscribers.
New York, December 16, 19 16.
LESSENING THE DIFFICULTY OF CARING
FOR DIPHTHERIA CASES.
Contagious diseases always have been, and proba-
bly always will be, the betes noirs of the general
practitioner. In the first place, there is the diffi-
culty of diagnosis. The average medical school
curriculum, admirably planned and balanced as it
is nowadays, must necessarily, in its crowded four
years, offer scant time to be spent on this par-
ticular subject. Cases may be very scarce in the
hospital connected with the medical school at the
particular time when the student is attending clin-
ics. He goes then into the arena of active practice
often poorly equipped to differentiate diphtheria
from quinsy, chickenpox from smallpox, and scar-
latina from a digestive erythema. In the second
place, there is the difficulty of the family. The diag-
nosis of a contagious disease means excessive in-
convenience to the household and the young prac-
titioner holds his perilous course between the Scylla
of losing the family practice forever with a wrong
diagnosis and the Charybdis of delaying the report
of the case too long, subjecting others to the dis-
ease and perhaps coming himself into serious con-
flict with the health authorities. In the third
place, there is the diplomacy amounting almost to
equivocation necessary if the physician would keep
such cases on his daily visiting list and still retain
the rest of his practice, particularly the children.
In the fourth place, there is the difficulty of pre-
serving quarantine; and in the fifth place, not to
be too prolix, there is the problem of discharging
the case from quarantine, not too soon from the
view-point of the health officer and not too late from
that of the family.
Let us consider briefly a case of diphtheria. In
addition to all the drawbacks just mentioned the
doctor hesitates, in the case of a family in poor cir-
cumstances, to make the diagnosis of diphtheria too
readily on account of the cost of antitoxin. The
family in question may be so poor that such an
expense would be ruinous, especially should the case
turn out not to be diphtheria after all, and yet too
proud to accept the antitoxin from a charitable or-
ganization. Leaving out of consideration such a
situation, however, in diphtheria we have, besides
the ordinary disadvantages of contagious disease,
the presence of what might be called a laboratory
form of the disease. The health regulations of
nearly all cities require the submission of cultures
from the throats of diphtheria cases and one or
more of these must be negative before the case can
be discharged from quarantine. We are all familiar
with the discouraging case which goes along show-
ing plus culture after plus culture long after the
clinical signs of the disease have disappeared.
In Public Health Reports for November 10,
Assistant Surgeon Newton E. Wayson has reported
a study of two diphtheria epidemics, one in Wesl
Virginia and one in Washington, D. C, with especial
reference to the relation between morphology and
virulence, in other words, to see how far a laboratory
diagnosis of diphtheria could be relied upon in en-
deavoring to ascertain whether or not an individual
was actually harboring germs capable of producing
diphtheria. Thirty-seven cases were studied, the
virulence being tested on guinea-pigs of from 200
to 400 grams in weight by injecting with pure broth
culture of the organism, after two days growth al
body temperature.
Not to go too much into detail regarding the vari-
ous laboratory methods used by Dr. Wayson, his
conclusions are well worth reporting. He decided
that a test of virulence by injection into guinea pigs
was a more practicable way of controlling diphtheria
carriers than the method commonly in use in that
it was more reliable and required less time. He
also found that the solid-staining types of the diph-
theria bacillus are usually avirulent, and that
morphology alone is an insufficient index of the
virulence of the organism. It is hardly necessary
to point out the application of these results. They
mean that the method commonly used by health
departments in determining whether or not a case
should be retained in quarantine is longer than is
really necessary and furthermore that a case may
show the organisms in the nose and throat and
still be perfectly harmless. Surely the adoption of
the guinea-pig method would result in pleasing our
patients and their families by avoiding in many
instances long isolation of children who feel perfect-
ly well and who have long since ceased to show an}
clinical signs of diphtheria. Then too we would be
able to deal in a more intelligent manner with so-
called "carriers" when such occur in our practice.
It is always irksome to an individual to be shut up
for periods of time varying from a few days to
many weeks merely because he happens to have
germs in his nasopharynx. With this newer method
we shall be able to tell quickly whether or not such
germs are virulent and if they are not the alleged
carrier can go on his way rejoicing.
FATIGUE, AND ITS EFFECTS ON
EFFICIENCY.
A male or female of the human species, of youthful
or adult age, is capable of working efficiently only
for a certain length of time. Work done when a
person is physically or mentally tired is not effec-
tive, and is often worse than useless. However, the
fact must be taken into account that different
individuals have varying degrees of endurance.
Some can continue to labor effectively for a far
greater length of time than others. It is a ques-
1078
MEDICAL RECORD.
[Dec. 16, 1916
tion largely of mental and physical virility, and also,
to some extent, an acquired habit. But there is a
limit to the power for doing efficient work of every
one, and, speaking generally, long hours of work
are not conducive to good results, from whatever
aspect the matter may be regarded. Physical work
which calls for little or no skill can be persisted
in without detriment to the quality of the work
done for a much longer period than skilled work,
and this result obtains, of course, more surely if
such work is performed in the open air or under
favorable sanitary conditions. Work which for its
effective performance requires concentration of
brain power is doubtless the most severe tax upon
the resources of both mind and body.
According to Professor William Stirling, who
has recently been giving a series of addresses on
the subject, published in the Medical Press of Nov.
6 and 8, fatigue expresses itself in a loss of excita-
bility, a diminished capacity for work or "output."
The sense of fatigue, however, may not run parallel
with the diminution of output. In mental work, de-
cided sensations of fatigue may be experienced
when the objective record shows that increasing
amounts of work are being done. The output may
be falling and there may be absence of the sensa-
tions of fatigue. Overactivity without sufficient
and timely periods of rest leads to fatigue, but fa-
tigue sensations are not to be taken as a direct in-
dex of the nature of fatigue. These sensations are
Nature's warning signals, fatigue itself being a
complex of sensations. Stirling puts fatigue down
as due to two causes: (1) The using up of or-
ganic force or energy, and (2) The wear and tear
of the organs which are overworked. Matter and
energy are used up, restitution does not keep pace
with waste, and there is a run on capital.
Perhaps the most instructive and valuable part
of Stirling's paper is that which deals with indus-
trial fatigue, and he points out the very obvious
truth that in many factories the environment of
the workers leaves much to be desired. It stands
to reason that those who work in an overheated
and moist atmosphere are far more apt to become
fatigued than workers in healthy surroundings. In
fact, such conditions lead to a disinclination or ac-
tual inability to perform effectively active muscular
or mental work. The mental activities, indeed, are
kept at a high pitch and both muscular and nervous
activity are largely governed by the speed of the
machine which the worker has to tend, while the
noise is a most disturbing factor.
In Great Britain, at the present time, the ques-
tion of fatigue in relation to efficiency is promi-
nently brought to the front in regard to the manu-
facture of munitions. It is of the utmost moment
to the successful prosecution of the war that muni-
tions be turned out quickly, and in the endeavor to
effect the object on an immense scale there has been
a tendency to overwork. As said before, a fatigued
person is incapable of doing good work, and good
work is essential, quite as essential as speed, in the
manufacture of munitions. The question of muni-
tion workers has been probed of late and it is
found that hours of even moderate labor incon-
testably lead to fatigue, and consequently to lower-
ing of output. The daily cumulative strain gradu-
ally but surely tells, the mill grinds slowly but
effectively, the machine employed in many cases
setting the pace, and in the "speeding-up" process
the worker must draw more and more on his en-
ergies to keep up with the rhythm of the untiring
machine.
But working at high pressure for some length of
time produces not only fatigue but sickness. As
Miss Hutchins has pointed out in her work, "Women
and the Industrial Revolution," there is a close con-
nection between working overtime, fatigue, and
certain types of nervous diseases. Fatigue both
causes disease directly and predisposes to disease in
general. Stirling quotes Miss Goldmark to the ef-
fect that in the blast furnace industry of the United
States, 88 per cent, of the 31,321 employees are reg-
ularly kept at work seven days a week, and young
boys of fourteen may still be employed all night long
in Pennsylvania.
With respect to the employment of girls and
women, the British Munitions Commission are sat-
isfied that the strain of long hours is serious, and
are of the opinion that work in excess of sixty hours
per week ought to be discontinued as soon as prac-
ticable. It has been proved that youths working
for 70 hours a week turn out less work by 40 per
cent, than when their working time has been re-
duced to 57 hours a week. The problem to be solved
is to insure the maximum of output with the mini-
mum of fatigue. This is from the economic stand-
point. The problem from the public health point ol
view is even more important, for it concerns inti-
mately the health of the race and the welfare of
the nation. Overwork brings an over-fatigue which
induces disease and which tends to the degenera-
tion and deterioration of a population. Moreover,
fatigue is an incentive to the use of alcoholic stim-
ulants, another potent cause of race degeneration.
Thus it would seem that from all standpoints over-
work is a colossal blunder but one into which all
industrial nations have fallen. Proper periods of
rest and repose, especially in the case of the young
and of women, are physiological and economical ne-
cessities, and the country that lavishly and extrava-
gantly uses up her human material with the sole
object of attaining industrial supremacy is doomed
to decay. After all, it is upon a healthy stock that
a nation mainly depends, and therefore it behooves
us to see to it that men and women are not broken
upon the wheel of commercialism.
TOXEMIA OF PREGNANCY.
When toxemia of pregnancy was first described it
was thought to belong to the first seven months of
gestation. In the latter months, and especially at
or soon after labor it would have been hardly pos-
sible to think of any toxic process but eclampsia.
To-day it is recognized that toxemia, in the sense of
an acute lesion of the liver, may appear in close
connection with labor, so that we are justified in
calling it puerperal toxemia. It is also evident that
several quite different conditions may be comprised
under this one term. Neither eclampsia nor tox-
emia in the original comprehension was looked
Dec. 16, 1916]
MEDICAL RECORD.
1079
upon as an infection, but of recent years the pos-
sibility that hepatic toxemia could be due to an
ascending infection of the gall ducts by Bacillus
aeli has received consideration. In its mildest
form it is perhaps expressed as a simple benign
catarrhal jaundice, but in other cases the latter is
a mere symptom of a much graver condition, a
severe lesion of the liver which may be regarded
as the preliminary stage of acute yellow atrophy.
Aside from the rapidly fatal form there is another
in which recovery takes place, yet the patients show
notable symptoms of cholemia. In some cases the
child is born jaundiced. Also of great interest is
the fact that so-called "delayed chloroform poison-
ing" may readily be confused with post partum tox-
emia; so that if much chloroform has been given, a
diagnosis of the latter would be impossible. To
come back to eclampsia, it must be confessed that
it is very difficult to distinguish the rare non-con-
vulsive form from toxemia, and the latter is prob-
ably the better designation.
At the session last June of the Royal Society of
Medicine Phillips described five cases of acute
hepatic toxemia, all he had witnessed in 2,000 con-
finements. All the cases were in primigravidse, and
two ended fatally. In the first, labor was induced
when the patient was near term and toxemia ap-
peared 18 hours after delivery (jaundice, vomiting
of blood, high temperature ) . Death 30 hours later.
Autopsy showed some biliary obstruction suggest-
ing an enteric infection. The precise lesion of the
liver was not determined, but there was beginning
acute yellow atrophy. The second patient became
jaundiced on the second day post partum. She
was almost unconscious — drowsy and apathetic ;
the liver was sensitive to percussion. Tempera-
ture subfebrile. Death occurred in 48 hours, no
autopsy. In the third patient labor was induced in
the thirty-fifth week. During this period the mo-
tions were clay like, and the temperature rose to
102° Fahr. The child was delivered by forceps.
Within 24 hours jaundice appeared with subfebrile
temperature but no evidences of sepsis. Not for
more than two weeks did bile reappear in the stools,
the temperature then becoming normal. The other
cases were similar to the latter. The author re-
gards the evidence of a mild ascending cholangitis
as suggestive. He was in fact so convinced of this
that he treated one patient with autogenous coli
vaccine. In all the recovered cases the urine was
loaded with Bacillus coli. To eliminate the possi-
bility of chloroform poisoning as a factor some
other analgesic should be used in suspicious labors.
such as those in elderly primigravidae, when there is
absence of bile in the stools, etc.
The Height of Specialism.
There is an alleged joke which we have seen in
various vestments in divers of the lay periodicals.
A patient with an injured middle finger is shown
into Dr. X's office. The latter, after a casual glance
at the injured digit, says, "I shall have to refer you
to Dr. Y, in the next block, who specializes in such
cases. My specialty is wounds of the ring finger."
We must confess that this burlesque of the present-
day tendency of the profession is sufficiently near
the truth to register a hit. Many of our conserva-
tive members are of the opinion that we will
eventually carry our refinements to such an extent
that each doctor will become something resembling
a skilled mechanic, proficient enough in the details
pertaining to that little section of the human econ-
omy which he has claimed for his own, but lacking
the broader outlook, the comprehensive grasp of the
organism as a whole, its material and spiritual
needs, which the physician of the old school had.
Too bad that Oliver Wendell Holmes is not living to
express himself in this matter. The appearance of
a large volume" dealing with the umbilicus and
urachus has given us pause. We remember the awe
with which our textbook on anatomy was regarded in
our freshman year at college and it was of approxi-
mately the same proportions as the present tome.
If we are to be governed by the relative importance
of the subjects in question, we shall await a publi-
cation dealing with diseases of the stomach about
the size of the Encyclopedia Britannica and if some
enterprising writer should attempt a work on the
nervous system he could fill about a dozen sections
of bookcases. Seriously, the monumental work of
Dr. Cullen on the umbilicus is excellent and since
the stars ordained that it be written it is fortunate
that it was undertaken by so able a scholar and
surgeon. The subject has been so thoroughly han-
dled as to discourage any one else from treading
the same path for many years to come. Surgeons
having to deal with hernias of this region or with
the annoying infections which prove so difficult to
handle will be grateful to the author for his pains-
taking researches which have been carried on for
twelve years, and for the admirable illustrations
with which he has illuminated his subject.
Hypertrophy of the Prostate and Senile
Involution.
The question of the interdependence of prostatic hy-
pertrophy and senile involution has often been
raised and usually answered in the negative, and
the counter claim is made that the senile prostate
is an atrophic prostate. Leaving out of question the
high incidence of hypertrophy in aged men, we may
discuss the subject of the "youthful" prostatic, and
it may be possible to show that hypertrophy in ad-
vanced age represents only a very slow, insidious
evolution of a disease originating a score of years
earlier. Well developed prostatism may be seen to
occur before the age of 40 — dysuria, tumefaction,
and all. It is a disease of middle life, perhaps of
early middle life, which may not become apparent
until there is some senile involutional change in the
bladder. The disease prevails very largely in the
Anglo-Saxon race, with a history of long latency,
and in hale and hearty old men, and the tumors re-
moved by Freyer and others are often very volumi-
nous. In an article in the Gazette hebdomadaire
des science medicales for September 10, Loumeau
reports two cases of early prostatic hypertrophy.
The first was in a clergyman aged 41, general his-
tory negative. Slow urination at times in boyhood
was attributed to cold, to which he was very sensi-
tive; but seven or eight years ago and again three
*Embryology, Anatomy and Diseases of the Um-
bilicus, together with Diseases of the Urachus. Bv
Thomas Stephen Cullen, M.D. Price, $7.50. Philadel-
phia and London: W. B. Saunders, 1916.
1080
MEDICAL RECORD.
[Dec. 16, 1916
years ago, he noted some aggravation of this symp-
tom until at present he was a marked sufferer from
dysuria. There was no residual urine in the blad-
der, no urethral obstruction, but rectal exploration
showed a bilobar enlargement of the organ which
was also exquisitely sensitive to the sound. The
prostatic urethra was very slightly retracted,
enough to cause severe pain and tenderness, but not
enough to cause obstruction. Here we have a
"young" prostatic in which the hypertrophy must
have appeared at least at the age of 38, and per-
haps even as far back as 33. The second patient
was 44 when first seen. For five years preceding
he had suffered from nocturnal erections not re-
lieved by sexual intercourse — in other words, pri-
apism, for which he had come for relief. There
had been no history of dysuria, and both urethra
and bladder were intact. The priapism was relieved
by treatment, but dysuria at once succeeded it. The
two affections continued to alternate under the
treatment proper for each. As in the first case the
prostatic urethra was sensitive and slightly con-
stricted. Rectal touch revealed a small unilateral
adenoma of the prostate. This second patient
should have been not over 39 years old when his
troubles began. Nothing in the least to suggest
presenile conditions was present.
Eclampsia and Fractured Basis Cranii.
One of the most extraordinary associations of dis-
ease ever recorded recently occurred in Switzerland.
We are familiar enough with types of disease or
injury which go to show that certain individuals
can withstand almost anything, but cases like the
one to be related go even further. The case was re-
ported by Schweizer in the Correspondent Blatt
fur Schweizer Aerzte. The woman after com-
plaining of slight headache, was heard to fall
heavily. A large, powerful woman, she lay uncon-
scious for several hours before reaching the hos-
pital with diagnosis of fracture of the base of the
skull. No fetus could be mapped out as a con-
dition of hydramnios was evidently present. The
os was intact. The possibility of a twin pregnancy
was borne in mind. The full bladder was evacu-
ated and the urine contained albumin and casts. To
account for so severe a fall in a woman who was
simply clearing the breakfast table it was assumed
that it had occurred as part of a general convulsion.
Several tonic-clonic seizures had happened while the
patient was on the examining table. These were
mild, but were soon succeeded by others of greater
severity. The woman had rallied from her coma,
but was confused and restless and high temperature
supervened. Cesarean section was elected because
of the fracture and to give the child or children a
chance of survival. Two children were removed;
they were mature, not asphyctic, and both have
thrived. Despite the difficulties of examination
fetal heart sounds and movements could be per-
ceived. The operation at once terminated the con-
vulsions, and the woman made a good puerperal re-
covery. Mischief in the brain soon became evi-
dent. There were convulsive movements of cortical
origin, almost total aphasia, total alexia, and
agraphia. She was kept in bed a month and slowly
improved, until she was able to leave for home.
Seven and a half months after the injury but a
single sequel persisted, a cloudiness of the vitreous
in the left eye, not noticeable in binocular vision.
It had been an early symptom and was evidently
posttraumatic. On account of the patient's almost
complete recovery much of the case remains ob-
scure. Was there a causal relationship between the
eclampsia and the focal symptoms, aside from the
results of the accident? This is answerable in the
negative. The author believes that in addition to
fracture of the base and its immediate consequences
there was more or less contusion of the brain sub-
stance due to the same violence. The author
finds little help from the literature either of epi-
lepsy or of eclampsia. The pregnant woman is al-
most always recumbent when the first eclamptic
seizure appears. The case must remain largely a
puzzle, but one thing seems certain, viz., cesarean
section has a new indication in eclampsia.
The Milk Supply of London.
The milk supply of London has been unsatisfactory
always, and while some progress has been made in
recent years in remedying its defects, it is still
a very long way from perfect. Some few years ago
one of the Lancet's Commissioners investigated
the matter and pointed out that the milk supply
of London was carelessly handled, that the trans-
portation was defective, that it was often sold in
small stores in which it was subjected to contamin-
ation, and that, on the whole, the system required
complete and thorough revision. It was pointed
out too that the manner in which the milk supply
of New York was handled was superior by far and
that especially was this observed in the means of
transportation, milk cans in America being re-
frigerated, a method unknown in Great Britain.
Again, milk is not carried in sealed bottles in
England, nor is the supervision of the milk in
stores in that country strict. The question had been
tinkered with by the British local Government
Board but no really effective steps have been taken
in the direction of improvement. In the London
Times of September 25 it is stated that the Clean
Milk Society of Great Britain is endeavoring to
arouse the public to the menace of an impure milk
supply. It is demonstrated that, as pointed out by
the Lancet years ago, the milk supply of London
is notoriously dirty from the bacteriological point
of view, and the Society has recommended that the
New York system of transporting milk in refriger-
ated cars and of bottling some of it in sealed bot-
tles should be adopted. The whole of the London
supply is carried in bulk. The charges brought
against the London milk supply are that it is un-
certified, there is no standard of quality, nor care-
ful inspection by means of a score-card system as-
in America. The Society draws attention to the
fact that such negligent methods are bad enough
in times of peace, but in times of war they may be
no less than disastrous when infant life is so-
precious.
Sfatna of th? ©wk
Smallpox Prevalent.— The United States Public
Health Service reports an alarming spread of small-
pox through nineteen States, during the last week,
of November 58 new cases being reported in Con-
necticut, 125 in Cleveland, 87 in North Dakota, 67
in Washington, and 25 each in Virginia and Texas.
The unusually large number of cases in Connecticut
has caused some apprehension in New York City,.
Dec. 16, 1916]
MEDICAL RECORD.
1081
and the Health Department is urging the vaccina-
tion of every one in the city. The last outbreak in
New York occurred in 1902, and past experience
has shown that a return of the disease may be ex-
pected in seven to fourteen years, probably because
of the neglect during the subsidence of the disease
of the precaution of vaccination.
Openings for Psychiatrist. — The Municipal Civil
Service Commission will hold an examination, open
to both men and women, for the position of physi-
cian for the inspection of mentally defective chil-
dren. Applications will be received up to 4 P. M.
on December 16. From the eligible list resulting
the Board of Education will fill a vacancy in the
position of senior physician at a salary of $2,520
per annum, and the Department of Public Chari-
ties three positions of resident physician, at $1,500
per annum and full maintenance, at Randall's Island
Hospital and Schools for Children.
Straus Milk Depots. — The report of the work of
the Nathan Straus pasteurized milk depots states
that during the year 2,000 babies were cared for,
and during the summer 2,500 babies received milk.
Manufacture of Radium. — The Federal Bureau
of Mines, according to the annual report of its di-
rector, manufactured during the year more than
one million dollars' worth of radium. This was ac-
complished through the cooperation of the National
Radium Institute, which furnished capital of $300,-
000 necessary to develop an economical method ol
extracting the radium from the carnotite ores.
Drug Traffic in New York. — At the hearings in
New York last week of the joint legislative com-
mittee appointed last spring to investigate the drug-
forming habit with a view to proposing remedial
legislation, the estimate was made that the number
of drug addicts in the city had increased to 200,000.
The present law, it was asserted, acts as a bulwark
and protection for unscrupulous druggists and
physicians, and the committee was told that there
was urgent need for new laws as well as for addi-
tional institutions where drug users can be prop-
erly treated. It is believed that American manu-
factured drugs are now being sold into Canada and
Mexico and then smuggled back into the United
States.
Bar Narcotic Drugs. — The New England Asso-
ciation of Boards of Pharmacy, in session in Boston
the first week of December, adopted resolutions an-
nouncing a determination to suppress illegal sales
of drugs in stores within its jurisdiction and to
close stores that refused to comply with the State
laws and regulations.
Good Health on Border. — "Above the average"
is the report made by Col. W. D. McCaw, chief sur-
geon of the Southern Department, on the health of
the troops at the border. Five base hospitals — at
San Antonio, El Paso, Brownsville, and Eagle Pass,
Tex., and Nogales, Ariz. — reported less than 2,500
beds occupied, and over 2,000 beds empty. The
army usually, it is said, considers 33 1/3 per cent,
of empty beds a good record.
Sugar Shortage and Infant Mortality. — A dis-
patch from Berlin states that it has been decided
that the increasing mortality among babies in that
city is due to an insufficient allowance of sugar, and
it has been ordered that every child born after De-
cember 1 shall receive an additional half pound of
sugar monthly. The allowance up to this time had
been 750 grams monthly for each child.
Fake Paralysis Cure. — Upon a plea of guilty to
having sold a fake cure for infantile paralysis, a
baker of this city was sentenced recently to serve
thirty days in the penitentiary. When examined
the promised "sure cure" was found to contain the
drugs usually put into the proprietary rheumatism
remedies, and the seller confessed that until the
outbreak of the paralysis epidemic it has been of-
fered as a cure for rheumatism, but that he had
decided he could increase his sales by increasing
his claims.
Christian Science Sanatorium. — In furtherance
of their purpose to maintain a sanatorium where
treatment can be administered according to Chris-
tian Science theories, the Board of Directors of the
Christian Science Church announces that they will
establish a fund for $1,000,000 to be used for build-
ing, equipment, and maintenance. The sanatorium
will be placed in Brookline, Mass., and will be under
the immediate supervision of the Christian Science
Benevolent Association.
Tuberculosis Day. — By proclamation of the
Governor of the State, Sunday, December 10, was
named as Tuberculosis Day in New Jersey. The
Governor requested that public attention be called
at that time to investigations made by the health
authorities for the prevention of the disease.
Fresh Air Work. — The Association for Improv-
ing the Condition of the Poor reports that owing
to increased contributions during the past season
it was able to maintain its fresh air work in New
York despite the increased expenditures for equip-
ment and nursing made necessary by the quaran-
tines against poliomyelitis. From June 1 to Novem-
ber 1 all the fresh air headquarters of the associa-
tion were kept open continuously, including three
not before used. Altogether 52,017 days of outings
were given to 4,428 families.
Personals. — Dr. Carlos Chagas of the Institute
for Experimental Pathology at Rio de Janeiro has
been invited to conduct a course on tropical medi-
cine at Harvard University.
A correspondent of Science states that Dr. H. B.
Fantham of the Liverpool School of Tropical Medi-
cine, who has been serving as chief protozoologist
of the Allied forces at Salonica, has been seriously
ill with amebic dysentery, but is now convalescing,
and is again on duty at Malta.
The University of Illinois, College of Medicine,
Chicago, announces the appointment of Dr. L. V.
Heilbrun as instructor in microscopic anatomy.
Dr. Joseph M. Thuringer of Boston has been ap-
pointed professor of anatomy at the University of
Alabama, School of Medicine, Mobile, and Dr.
Claude W. Mitchell has been made head of the de-
partment of physiology and pharmacology.
The Long Island State Hospital of Brooklyn,
N. Y., has recently changed its name to the Brook-
lyn State Hospital, the change being made to avoid
confusion of the institution with the Long Island
College Hospital. The similarity in the names of
the two hospitals has been the cause of much
trouble heretofore, in the misdirection of patients
as well as of mail, etc.
Home for Nurses. — Announcement has been
made of the gift to the New York Skin and Cancer
Hospital of the four-story building at 338 Second
Avenue, adjoining the hospital, to be used as a home
for the hospital nurses. The giver is Mr. W. C.
Van Antwerp, one of the governors of the hospital,
and the gift is made in memory of his mother. The
house will be remodeled to fit it for a home.
Belgian Contributions. — The Treasurer of the
Committee of American Physicians for the Aid of
1082
MEDICAL RECORD.
[Dec. 16, 1916
the Belgian Profession reports that the receipts
during the quarter ending November 30, 1916, were
$11.40, making the total receipts $7,958.26. The
total disbursements, including 1,625 standard boxes
of food at $2.20, 1,274 boxes at $2.30, and 353 boxes
at $2.28, have amounted to $7,310.04, leaving a bal-
ance on hand of $648.22. Contributions may be sent
to Dr. F. F. Simpson, treasurer, 7048 Jenkins Ar-
cade Building, Pittsburgh, Penn.
Gifts to Charities. — By the will of the late Mrs.
Josephine H. Dickman of New York, the sum of
$5,000 is left to Dr. Benjamin Tenney of Boston, to
be used for such charity or medical purposes as he
may select.
The Goshen Emergency Hospital of Goshen, N. Y.,
receives a bequest of $10,000 by the will of the
late H. W. Van Cortland of that city.
The University of Chicago has received from Mr.
Frederick H. Rawson a gift of $300,000 for the
medical school. The money will be used to erect a
new laboratory building.
By the will of the late Col. VV. G. Vincent, a be-
quest of $60,000 made to his wife, becomes avail-
able after her death for the uses of the School of
Tropical Medicine of Tulane University.
By the will of the late Mr. Jacques Halle of New
York, Mt. Sinai Hospital receives a bequest of
$5,000, while bequests of $2,500 each are made to
the Montefiore Home and the Beth Israel Hospital
Association.
Medical Journal Changes. — We regret to learn
that the Cincinnati Lancet-Clinic has ceased publi-
cation. The Lancet-Clinic was the product of the
consolidation of the Lancet and Observer and the
Clinic, the latter being the first medical weekly is-
sued west of the Alleghenies, and was for many
years a journal of high standing and authority.
The Louisville Monthly Journal of Medicine and
Surgery has become the official organ of the Missis-
sippi Valley Medical Association and has taken the
name of the Mississippi Valley Medical Journal.
The Texas Medical News has died and been rein-
carnated as Medical Insurance and Health Con-
servation.
Medical Society Elections. — Tri-State Medical
Association of Arkansas, Mississippi, and Tennes-
see: Thirty-third annual meeting at Memphis.
Tenn., on November 23. Officers elected : President,
Dr. James W. Gray, Clarksville, Miss.; Vice-presi-
dents, Dr. H. Rogers Hays, North Carrollton, Miss.,
Dr. R. W. Griffin, Tiptonville, Tenn., and Dr. Floyd
Webb, Turrell, Ark.; Secretary, Dr. J. L. Andrews,
Memphis; Treasurer, Dr. J .A. Vaughan, Memphis.
Eastern Medical Society of New York City:
At the annual meeting on December 8, 1916. the
following officers were elected: President, Dr. I.
Seth Hirsch; Vice-Presidents, Drs. H. E. Isaacs
and G. G. Fischlowitz; Recording Secretary, Dr. J.
F. Saphir; Treasurer, Dr. A. A. Hilkowich.
Ohio Valley Medical Association: Annual
meeting at Evansville, Ind., on November 23. Offi-
cers elected: President, Dr. William Shimer, In-
dianapolis, Ind.; Vice-presidents, Dr. J. Rawson
Pennington, Chicago, Dr. W. F. Boggess, Louisville,
Ky., and Dr. Meyer L. Heidingsfeld, Cincinnati,
Ohio; Secretary-Treasurer, Dr. Beniamin L. W.
Floyd.
The Harvey Society. — The fourth lecture of the
scries will be held at the New York Academy of
Medicine on Saturday evening, December 16, 1916,
at 8.30 P. M., by Prof. Henry H. Donaldson of the
Wistar Institute of Anatomy and Biology; subject.
"Growth Changes in the Mammalian Nervous Sys-
tem."
Obituary Notes. — Dr. Ivory Lowe of Canaan,
Me., a graduate of Albany Medical College in 1862,
died at his home on November 26, after a short ill-
ness, aged 80 years.
Dr. Philip Mills Jones of San Francisco, Cal.,
a graduate of Long Island College Hospital, Brook-
lyn, in 1891, and a member of the American Medi-
cal Association, the Medical Society of the State of
California, and the San Francisco County Medical
Society, died suddenly on November 27, aged 46
years. Dr. Jones was secretary of the Medical So-
ciety of the State of California.
Dr. Jacob Brill Peters of Walden, N. Y., a grad-
uate of New York University Medical College in
1885, and a member of the Medical Society of the
State of New York and the Orange County Medical
Society, died at his home after a lingering illness.
on November 23, aged 63 years.
Dr. Ellera J. Whittleton of Webster, N. Y., a
graduate of Cleveland University of Medicine and
Surgery in 1884 and a member of the Monroe
County Homeopathic Medical Society, died at his
home on November 20, after a short illness, aged 57
years.
Dr. Joseph Stafford Horsley of West Point,
Ga., a graduate of the Medical Department of the
University of Georgia, Augusta, in 1870, and a
member of the American Medical Association, the
Medical Association of Georgia, and the Trop
County Medical Society, died on November 17, aged
73 years.
Dr. Frederick James Sanborn of Spencer,
.Mass., a graduate of Bellevue Hospital Medical Col-
lege, New York, in 1883, and a member of the
Massachusetts Medical Society and the Worcester
County Medical Society, died suddenly in his auto-
mobile while making a call, on November 20, aged
55 years.
Dr. Adrian Mathews of Providence, R. I., a
graduate of Jefferson Medical College of Philadel-
phia in 1874, and a member of the American Med-
ical Association, the Rhode Island Medical Society,
and the Providence County Medical Society, died at
his home on November 19, after a long illness, aged
66 years.
Dr. James Albert Breakell of New York, a
graduate of Columbia University, College of Physi-
cians and Surgeons, New York, in 1873, and a mem-
ber of the Medical Society of the State of New
York and the New York County Medical Society,
died at Cross River, N. Y., on November 18, aged
65 years.
Dr. William Williams of Pittsburgh, Kan., a
graduate of the Missouri Medical College, St. Louis,
in 1886, and a member of the American Medical
Association, the Kansas Medical Society, and the
Crawford County Medical Society, died at the home
of his brother in Niangua, Mo., on November 14.
aged 55 years.
Dr. David Byron Todd of San Francisco, Cal., a
graduate of the University of Michigan Medical
School, Ann Arbor, in 1871, died on November 20,
after a brief illness, aged 69 years.
Dr. Norman Howe Liberty of Mineville, N. Y.. a
graduate of Albany Medical College in 1912, and a
member of the Medical Society of the State of New
York and the Essex County Medical Society, was
instantly killed in an automobile accident at Ticon-
deroga, N. Y., on November 13, aged 27 years.
Dr. Claude Bernard Foreman of Kane, 111., a
Dec. 16, 19161
MEDICAL RECORD.
1083
graduate of the Missouri Medical College, St. Louis,
in 1897, and a member of the Illinois State Medical
Society and the Greene County Medical Society,
died in the Springfield, 111., Hospital, on November
27, from appendicitis, aged 40 years.
Dr. William Henry Streng of Richmond, 111., a
graduate of the Chicago College of Medicine and
Surgery, Chicago, in 1907, and a member of the
American Medical Association, the Illinois State
Medical Society, and the McHenry County Medical
Society, was killed instantly in a collision at a grade
crossing in Waukegan, 111., on November 21, aged
38 years.
Dr. Clifton Maupin Faris of Sacramento, Cal..
a graduate of Johns Hopkins University Medical
Department, Baltimore, in 1905, and a member of
the American Medical Association, the Medical So-
ciety of the State of California, and the Sacramento
County Medical Society, died suddenly at his home
on November 16, aged 39 years.
Dr. Alpheus D. Finch of Bellefonte, Ark., a
graduate of the Medical Department of Vander-
bilt University, Nashville, in 1885, died at the home
of his son, near Bellefonte, on November 7, aged
67 years.
Dr. Edward Darrow of Aurora, Minn., a grad-
uate of Rush Medical College, Chicago, in 1901, died
in his office on November 12, from myocarditis, aged
42 years.
Dr. Jessie Valeria Stauffer Smith of Winter-
set, Iowa, a graduate of the College of Physicians
and Surgeon 3, Keokuk, in 1892, and a member of
the Iowa State Medical Society and the Madison
County Medical Society, died on November 12, aged
50 years.
Dr. George P. Munsey of Suncook, N. H., a grad-
uate of Dartmouth Medical School, Hanover, in
1879, died at his home on November 26, aged 61
years.
Dr. C. August W. Schwagmeyer of Cincinnati,
Ohio, a graduate of the Medical College of Ohio,
Cincinnati, in 1870, and a member of the Ohio
State Medical Association and the Hamilton County
Medical Society, died at his home on November 11,
from heart disease, aged 72 years.
Dr. Andrew John Crighton of East Hartford.
Conn., a graduate of the College of Physicians and
Surgeons, Baltimore, in 1891, died at his home on
November 28, aged 52 years.
Dr. James F. Gardner of Capen Bridge. W. Va.,
a graduate of Bellevue Hospital Medical College,
New York, in 1879, was killed in an automobile ac-
cident near Winchester, Va., on November 11, aged
73 years.
Dr. Edwin R. Montgomery of Louisville, Ky.. a
graduate of the Medical Department of the Uni-
versity of Louisville in 1867, died at North Bir-
mingham, Ala., on November 27, aged 69 years.
Dr. Willoughby Walling of Chicago, 111., a
graduate of the Medical Department of the Uni-
versity of Louisville in 1868, and a member of the
Illinois State Medical Society and the Cook County
Medical Society, died at his home on November 28,
aged 68 years.
Dr. DeCou Carpenter Moulding of Chicago,
111., a graduate of Dearborn Medical College. Chi-
cago, in 1906. and of the University of Illinois, Col-
lege of Medicine, Chicago, in 1909, and a member
of the Illinois State Medical Society and the Cook
County Medical Society, died in the Augustana
Hospital, Chicago, on November 21, following an
operation, aged 46 years.
ETHICS OF LETTER WRITING.
To the Editor of the Medical Record:
Sir: — A recent incident gives prominence to the
somewhat stupid custom of physicians in not an-
swering letters that are of minor importance which
come to them. A man was operated on successfully
at a Boston hospital by an eminent surgeon. Later
it occurred to him that he would like to make him
a present as a token of his appreciation. Accord-
ingly he wrote a very pleasant letter of thanks,
without intimations of what he wished to do, ex-
pecting that the doctor would respond in some way
that would promote a further correspondence.
Weeks passed by and no response came, and fear-
ing some mistake, he sent a special delivery letter
of warmly expressed thanks. This brought no an-
swer. The check of a thousand dollars that he in-
tended to give him was then torn up, and a feeling
of indignation and contempt took its place.
While this may be a very unusual incident, it
gives emphasis to the stupid neglect of a great
many physicians to recognize the ordinary cor-
respondence which comes to them. Underrating
the importance of a letter that calls attention to
some fact or brings with it some compliment or
suggests some change or even requests for opinions
on minor matters, is a reflection on the physician's
judgment and ethical sense and always brings with
it suspicion of weakness. Two examples illustrate
this: A physician and teacher of great reputation
rarely writes any letters of thanks for favors and
seldom replies to any correspondence. As a result,
his judgment is discounted in innumerable ways
and his ordinary courtesy is questioned and his per-
sonal reputation has suffered more or less seri-
ously. When remonstrated with for this neglect,
he gave excuses of want of time and so on. The
second example is that of a popular teacher and
practitioner who makes it a rule to answer every
letter, acknowledge every favor, and respond to
every request. As a result, his popularity and es-
teem among the profession are very pronounced.
Every hillside physician, who has written him in a
broken, confused way about some matter has re-
ceived a reply which he treasures as a direct tribute
to himself. Even quack drug men, who write send-
ing him specimens are proud of his recognition in
the simplest form of a letter.
Physicians, of all others, make a fatal mistake in
not adopting the politicians' ethics of answering
every voter who appeals to them in any way. The
physician is a public man and his affability and
courtesy to every one he comes in contact with is
a very large asset in his success. To fear a cor-
respondence that may be used in some way in the
future against him is stupidity. A trained physi-
cian of all others should be able to write clearly and
briefly in such a manner that no complications could
possibly follow. He should show equal courtesy with
the business man or politician who makes cor-
respondence a large lever in his wrork.
T. D. Crothers, M.D.
Hartford, Conn.
Tetanus from Ocular Wounds. — Schneider states that
about sixty cases of this sequence have been recorded
within the past century and adds two personal observa-
tions. Apparently few or none of these occurred as a
result of the war. — La Prcsse Medicale.
1084
MEDICAL RECORD.
[Dec. 16, 1916
OUR LONDON LETTER.
(From Our Regular Correspondent.)
THE HARVEIAN ORATION — BENEFACTORS OF THE ROYAL
COLLEGE OF PHYSICIANS — ENDOWMENT OF RE-
SEARCH— RELATIONS TO ST. BARTHOLOMEW'S HOS-
PITAL— DR. VAUGHAN-HUGHES.
London, November 11, 1916.
Sir T. Barlow's Harveian oration at the Royal Col-
lege of Physicians, which I mentioned last month,
may very well interest you further. It began with
a commemoration of benefactors of the college, the
first president, Linacre, being the real founder, for
it was to a large extent due to his counsel that the
charter was conferred by Henry VIII. But he must
be reckoned further as a pioneer in the revival of
learning and moreover as a physician in the high-
est sense. The early meetings were held in his own
house, which he seems to have presented to the col-
lege during his lifetime. He was followed in his
office by John Cains, who was elected president no
less than nine times and who wrote the "Annals"
with his own hand from 1555 to 1572. He was not
only a great scholar, but the first teacher of anat-
omy in this country, an able naturalist, and writer
on clinical medicine — witness his careful study of
sweating sickness. The next president was Richard
Caldwell, who was elected in 1570 and who jointly
with Lord Lumley endowed the Lumleian lecture-
ship. In 1600 the president was William Gilbert,
the pioneer in the study of magnetism, who has
been called the father of experimental philosophy
in England and the inspirer of Galileo. He be-
queathed to the college his library, globes, scientific
instruments, and natural collections. To him suc-
ceeded Harvey, whose material benefactions to the
college were enormous. In 1651 he had retired,
being 73 years of age, but he still held the Lumleian
lectureship and offered to build and present to the
college a library and museum. In two years these
additions, together with a large convention room,
were completed and conveyed to the college. In
1656 he resigned his lectureship and added further
benefaction to the college in the shape of his patri-
monial estate, the value of which at that time was
£56 a year. He expressed a wish that an annual
feast should be held and an oration delivered in
commemoration of benefactors, for which a fee
should be paid to the orator, and a salary to the
keeper of the museum and library which he had
previously founded and furnished. In his will he
provided for the completion of any part of the build-
ing which might not be finished, and bequeathed his
books, papers, and furniture for the meeting-room
which he had built. Theodore Goulston was con-
temporary for a time with Harvey and became a
censor of the college and endowed the lectureship
named after him which is given by one of the four
youngest fellows. Sir Theodore H. Mayerne was
also a contemporary of Harvey's, who after a dis-
tinguished medical career in France came to Eng-
land, became a fellow of the college to which he
bequeathed his library and was physician to James
I and Charles I.
Baldwin Harney, Jr., was one of Harvey's inti-
mate friends; he served as treasurer of the college
from 1664 to 1666 and gave anatomical lectures at
the college. In 1651 the tenure of the land on which
the college stood being in danger, Harney bought it
and presented it to the college. After the fire of
1666 the college was rebuilt and Harney contributed
to the cost. He also settled an estate in Essex on
the college. The Marquis of Doncaster, one of the
few honorary fellows of the college, was one of Har-
vey's friends and one of his sponsors on election to
the college. Dr. Croone, one of the original fel-
lows of the Royal Society, was censor of the college
in 1679, and one of its most generous benefactors
Mrs. Streatfield's endowment of research fund has
been completed and £10,000 in 2\> per cent, an-
nuities paid into the names of the two colleges as
trustees for the promotion of research in medicine
and surgery.
The relations between Harvey and the governors
of St. Bartholomew's Hospital were cordial and re-
vised regulations proposed by him in 1633 were at
once adopted. These show that he stoutly main-
tained the supremacy of physicians over surgeons
as then was customary. The surgeon was not al-
lowed to perform operations without the consent of
the physician and was required to declare what ex-
ternal remedies he applied in any given case. The
surgeon visited the patients in the wards, but the
physician only did so when a case could not be
brought to the great hall.
Dr. James Vaughan-Hughes has died at the ripe
age of 95 years. He wrote "Twenty Years of Life
in the Victorian Era," in which he recorded his
work with Florence Nightingale when he was at-
tached to the medical staff in the Crimea. For his
work there he was awarded double pay by Lord
Panmure. He had charge for a time of Balaclava
Hospital and attended Florence Nightingale when
she had camp fever. On her recovery he obtained
the loan of Lord Dudley's yacht to take her back to
Scutari. Later he contracted cholera and he at-
tributed his recovery to the attentions of Miss
Nightingale and her nurses. Notwithstanding his
great age, he rode on horseback and drove a car-
riage and pair until a few months ago.
IJrmuTBB at iHrMral irtnirr.
Boston Medical and Surgical Journal.
November 30. 1916.
1. A Clinical Study of the Secretions of the Digestive Trail
Thomas R. Brown.
2. Psychic and Neuropsychic Affections in War. 10. Regis.
3. Drug Addiction and Modern Methods for Its Control. Solo-
mon H. Rubin.
4. Acute Primary "Idiopathic" Phlegmonous Gastritis. Eman-
uel B. Fink.
1. A Clinical Study of the Secretions of the Digestive
Tract. — Thomas R. Brown gives a rather thorough re-
port on this subject and states that the neglect of the
study of the secretory side is most unwise if one wishes
to have a broad conception of the diseased process in
many and varied interesting digestive conditions. From
the studies which he has presented the writer draws
certain conclusions — some physiological, others clinical.
Of the former the demonstration of the lack of influence
of the gastric secretion upon the character of the saliva;
the fact that saliva rich in diastatic ferment is secreted
during the chewing of inert substances, stimulating
neither to the taste or smell; the independence of rennin
and pepsin, the lack of definite quantitative relationship
between the pepsin and the hydrochloric acid of the gas-
tric juice, and that in the absence of the normal mechan-
ism of pancreatic stimulation some other mode of calling
forth the ferment of this gland, probably nervous in
character, is brought into play. From the clinical side,
the large number of conditions met with in which the
absence of hydrochloric acid in the gastric juice is
encountered; the significance of an increase in the
soluble proteid of the gastric contents in the diagnosis
of gastric carcinoma; the importance of recognizing the
Dec. 16, 1916]
MEDICAL RECORD.
1085
group of gastrogenous diarrheas, and the brilliancy of
their treatment with hydrochloric acid; the fact th \t
with a rigorous technique there are low normal limus
to the quantity of diastase found in the stool, and that
an absence of these ferments is very suggestive of can-
cer of the pancreas.
2. Psychic and Neuropsychic Affections in War. —
E. Regis, of Bordeaux, France, strongly urges the estab-
lishment of hospitals for the insane in the army at
sufficient distances from the field of operations. He
has devoted much of his time to the study and diagnosis
of the military psychoses, and finds that in case of
need even special pavilions annexed to ordinary field
hospitals would suffice on condition that their medical
direction was intrusted to specialists. The psycho-
neuroses or psychoses from moral shock, which predom-
inate in great battles, are essentially acute, transitory
and curable in a few days, and no treatment is better
suited to these cases than rest in bed. He divides the
psychoses into two groups, those found in soldiers who
have not been under fire, which are common, and
merely supervening on the occasion of war (dis-
equilibrations, degenerations, alcoholism and general
paralysis). The second group composed of psychic and
neuropsychic affections in men returning from the front
and induced directly by battle. Of the former group
he studied 62 cases, of the latter 88. It is the latter
group of which he gives a detailed account. Among
these, the principal psychic disturbances established by
study of the cases, were hallucinatory oneirism and
mental confusion. While epliepsy is rare, hysteria is
common ; also functional paraplegia or pseudopara-
plegia. He considers that the cause of these conditions
is not results from wounds, but emotional shock re-
ceived in battle or the military life. Even in those
wounded it is the emotional shock which precipitates
the psychosis. Functional paraplegia following battle
must be regarded as the effect of a violent emotional
shock. He concludes that the subjects of neuropsychic
disturbances should be separated from other patients
and placed in a special neurological or neuro-psychiatric
service, in accordance with local organizations, reducing
to a minimum the chances of intermental action, that
is to say, of reciprocal contagion.
New York Medical Journal.
December 2, 1916.
1. Psoriasis as an Hysterical Conversion Symbolization.
Smith Ely Jelliffe. and Elida Evans.
2. Focal Mouth Infections. Their Systemic Effects and Treat-
ment. Robert H. Babcock.
3. Traditional Fallacies About Tuberculosis. Maurice Fish-
berg.
4. Columnar Amniotic Epithelium. Herbert K. Thorns.
5. Oxygenated Milk. Clifford G. Grulee.
6. Ozena. Henry Horn and Ernst Albrecht Victors.
7. Malingering. Paul E. Bowers.
8. Syphilitic and Parasyphilitis Affections of the Urinary
Bladder. A. Straschstein.
9. Epidemic Gastroenteritis. Infantile Paralysis, and Influ-
enza. Bernard Frankel.
3. Traditional Fallacies About Tuberculosis. — Mau-
rice Fishberg believes he is correct when he states that
medical literature is apt to contain fallacies based on
the assumption that because of concomitance of time
and place, two or more phenomena are caused by the
same forces. Tuberculosis seems to have had attached
to it more than the usual number of fallacies, some of
which are not only harmful, but decidedly detrimental
to the individual and his surroundings. For instance,
Fishberg says that in his long experience as physician
for the United Hebrew Charities in New York, he has
never observed a case of tuberculosis transmitted from
one consort to the other. This in spite of the often un-
hygienic surroundings of the patients. They have chil-
dren while sick with tuberculosis and while most of
their offspring become infected, the unaffected consort
remains so indefinitely. J. Petruschky has recently
named "mother immunity" a phenomenon which has
been observed for generations by physicians. A healthy
woman marries a tuberculous man and bears him chil-
dren that succumb to the disease one after another, yet
she is spared and remains in good health. With refer-
ence to children, there is the fallacy of confounding
infection with disease. While extrapulmonary tubercu-
losis is rather common in children of school age, real
pulmonary tuberculosis is rare. Children with
tracheobronchial tuberculosis are not all in danger;
death due to this cause is so rare that it may be disre-
garded when formulating prognosis in the average case.
Nor are these cases a menace to those associating with
them because, as far as is now known, they do not
disseminate the bacilli. It is a fallacy to treat every
sickly underfed child as tuberculous; even when the
tracheobronchial glands are discovered to be enlarged,
there is no reason to prohibit school attendance, or to
institute prolonged and costly treatment, except such
measures as will enhance the nutrition of the child. He
speaks further of the fallacies in connection with diag-
nosis, prognosis, prophylaxis, and treatment.
5. Oxygenated Milk. — Clifford G. Grulee gives an ac-
count of the process of producing oxygenated milk in
the Presbyterian Hospital, Chicago. It was installed
in 1915 by a Danish chemist, N. D. Neilsen, on a plan
following the scheme of Doctor Budde in Copenhagen,
where it was introduced in 1903. This milk takes the
place of certified milk for children and infants, and is
distinctly cheaper. The process is as follows: Good
raw 4 per cent, milk is treated with hydrogen peroxide,
one quart to twenty gallons; it is then heated to 122° —
128° F. for one-half hour, being stirred by a fan in the
reservoir so that it is kept in motion the whole time.
The milk is then withdrawn and bottled hot, and kept
on ice until used. This is a preserved milk without
any preservatives, because at the end of a half hour's
treatment only a trace of the hydrogen peroxide can be
obtained. By this process the milk is made sterile and
therefore all bacteria are inactive, rendering the milk
safe from distribution of pathogenic organisms. The
advantages offered by this process are that fresh milk
can be obtained at any time of the day or night, its
absolute safety, and the fact that it can be kept as
long as two weeks at room temperature without souring
during the summer months, thus insuring greater
safety. Grulee says that theoretically the chemical
change is only a destruction of the catalase enzyme in
the process of splitting the hydrogen peroxide. How-
ever, he found that oxygenated milk cannot be used in
the preparation of buttermilk, as it prohibits the growth
of the necessary bacteria.
Journal of the American Medical Association.
December 2, 1916.
Acute Purulent Infections of the Nose, Throat and Ear:
Our Responsibility to the Public. Hill Hastings.
Syphilitic Psychoses Associated with Manic Depressive
Symptoms and Course. Albert M. Barrett.
Xanthosis and Other Septal Hemorrhages. Chester C.
Cott.
Dermatologieal Dietetics. Ernest Dwight Chipman.
A Consideration of Some Selected Problems in a Tear's
Neurosurgical Service. Ernest Sachs and Sidney I.
Schwab.
Experimental Endocarditis : Its Production with Strepto-
coccus Yiridans of Low Virulence. H. K. Detweiler,
and W. L. Robinson.
An Apparatus Designed for the Use of Partial Vacuum
in Diagnosis and Treatment. Harvey G. Beck.
Tuberculosis of the Mammary Gland. Gatewood.
External Nasal Deformities : Correction by Subcutaneous
Methods. Lee Cohen.
Syphilis of the Stomach : A Case of Hour-Glass Contrac-
tion. R. M. Culler.
Angioma Serpingosum, with Report of a Case. Arthur W.
Stillians.
The Quantitive Effect of Salvarsan on the Wasserman
Reaction of the Blood. John T. King.
Development of Herpes Zoster in a Case of Chorea
Treated with Autogenous Vaccine. Horace Greeley.
1086
MEDICAL RECORD.
[Dec. 16, 1916
4. Dermatological Dietetics. — Ernest Dwight Chip-
man says that nutrition is upkeep and that it essentially
deals with two vital factors, fuel and repair. He gives
the caloric values required by men in various occupa-
tions and walks of life for basal heat production. In
an average man of 156 lb. this will be 70 calories per
hour; extra heat produced by the ingestion of food
causes an increase of about 10 per cent., making a total
of 1848 calories per day. This amount is divided among
the different food constituents, namely, protein, carbo-
hydrate, and fat in required proportion. Because of
its nitrogen content protein is essential to the processes
of growth and repair. In excess of the quantity re-
quired for these purposes it increases the level of heat
production. As to the kind of protein, Voit would have
one-third animal and two-thirds vegetable, though there
seems to be no hard and fast rule respecting this ratio.
Carbohydrates, protecting the albumin of the tissues
from waste better than a similar quantity of fat, are
called albumin sparers. A mixture of absolutely carbo-
hydrates, fats, proteins and salts will not maintain life
for a long time. The experiments of Osborne and
Mendel show that a satisfactory complement exists in a
powder obtained by evaporating milk from which the
protein element has been almost entirely removed. They
found further, in experiments with rats, that when lard
was the sole fat element of the diet growth stopped, but
when butter fat was substituted was resumed. A
minute quantity of some certain substance seems quite
necessary in food. It has been found that a group of
so-called vitamins exists in the vegetable kingdom and
that the members of this group are essential to growth
and nutrition of animal tissue. Deficiency of these sub-
stances causes beriberi. Pellagra is undoubtedly of
analogous origin. The nutritive values of any pro-
tein depend largely on the character and the ex-
tent of the animo-acids it contains. A knowledge
of the basis requirements of nutrition is to be
thoroughly understood in order to apply the princi-
ples of nutrition to the needs of dermatology. A mean
average is necessary in diet lists between the extremes
of generalization and detail. Chipman makes three
divisions of the dermatoses according to their relation-
ship to diet: (1) Those directly dependent on diet;
(2) those in which diet may not be the cause, but in
which it is of capital importance; (:'.) those in which
diet may be an indirect factor. Beyond these three
groups there remain certain morbid states requiring
dietetic care, conditions which are often seen in asso-
ciation with various dermatoses and whose relationships
with these dermatoses may be direct, casual or remote.
The foodstuffs may act either reflexly, directly, indi-
rectly, through insufficiency of certain food elements,
or through excess of certain food stuffs, and through
hypersensitiveness, producing a dermatosis according to
type developed through any one or more of these con-
ditions. Psoriasis can be much helped by placing the
patient on a low protein diet, while eczema will almost
disappear when the carbohydrates and starches are
reduced. Acne can be controlled on a low starch diet.
There are but few specific diets in dermatology, but an
accurate perception of the individual's needs, from the
standpoint of nutrition, is imperative. Much comfort
may often be found in the three simple rules of Brocq:
Eat sparingly; eat slowly; rest after meals.
6. Experimental Endocarditis. — Detweiler and Rob-
inson have followed up a report of earlier work along
this line and in following out the methods advocated
by Rosenow they have elaborated a technic which has
been thoroughly used and has given splendid results.
The method in detail is described, and while recognizing
its disadvantages they also consider the advantages far
outweigh in results. The organisms used in this series
of experiments were obtained from blood in cases of
subacute and chronic infectious endocarditis. All of
the strains belong to the family of Streptococcus viri-
dans. The animal experiments have been confined to
an attempt to produce in rabbits a condition analogous
to that of the patient from whom the organism was ob-
tained. Rabbits from 6 weeks to 2% months old were
used. The majority were Belgian hares. Of all the
animals coming to necropsy, heart lesions were found
in 56.6 per cent. The fact that none of the strains iso-
lated from the blood in cases of endocarditis produced
joint lesions, whereas arthritis was present in four
cases from strains isolated from the mouth and tonsils
seems significant to the writers. It suggests two possi-
bilities: First, that an organism may have in some in-
stances a dual affinity, and depending on environment
and conditions existing in the particular individual in
which they are present, they may attack one organ or
another, or both. Second, that two types were present
in one culture and each type produced its respective
lesion. Pure cultures only of Streptococcus viridans
were sought, and on being obtained, no attempt was
made to grow the organism from one colony only. The
writers venture to suggest that they have established
three important points: (1) The Streptococcus viri-
dans, isolated from the blood in cases of chronic infec-
tious endocarditis, is of very low virulence, probably
lower than any hitherto reported as being recovered
from a similar source. (2) These streptococci are
capable of producing lesions in animals identical to
those found in the patients from whose blood the organ-
isms were obtained. (3) The strains of Streptococcus
viridans isolated from the mouth of normal individuals
are similar to those isolated from the blood of patients
suffering from chronic endocarditis, and are equally
capable of producing heart lesions in the rabbit.
13. Development of Herpes Zoster in a Case of Cho-
rea Treated with Autogenous Vaccine. — Horace Greeley
reports the following case: N. H., boy, aged 8 years,
in otherwise good general health, had been suffering
with chronic twitching of the muscles of the right side
of the face for four years. He had had the usual
hygienic and tonic treatment with iron, etc. As is usual
in such cases, the twitching was almost absent occa-
sionally, as in the morning, and grew worse as the
fatigue of the day accumulated; on some days it was
almost incessant. Knowing that chorea was closely
identified with rheumatism, and that rheumatism, both
acute and chronic, had been demonstrated to be due to
streptococci, and that, more than most conditions, the
beginning chronic form was amenable to vaccine treat-
ment, Greeley determined to try the effect of an auto-
genous streptococcus vaccine. Accordingly, a vaccine
from a tonsillar streptococcus was prepared and given
in nine doses at intervals of a week. The first three
doses were 200 millions, the fourth 300 millions, and
from then on the doses were increased each time 200
millions, until at the ninth dose the patient received
900 millions. On the second and the sixth doses there
was a slight constitutional reaction. The herpetic erup-
tion appeared on the day following the second dose and
comprised fifteen distinct vesicles, which developed on
the skin over and below the extremities of the three
lower ribs on the right side. The eruption showed the
usual symptoms, and was accompanied by a distinct
exacerbation of the chorea lasting for three days.
Since chorea is probably due to a low grade strepto-
coccus infection of the connective tissue sheaths of
motor nerves, or of some area sufficiently contiguous to
them, or to their origin in the central nervous system,
to influence their normal functioning, it is easily under-
Dec. 16, 1916]
MEDICAL RECORD.
1087
stood that a focal reaction, following a dose of specific
vaccine, would cause exacerbation of symptoms, Greeley
is inclined to believe that this is what occurred in this
case.
In the case of other than motor nerves, slight central
irritation could not be supposed to give rise, ordinarily,
to very noticeable manifestations, and it seems probable
that such existed in this case, affecting the vasomotor
nerves distributed to the herpetic area; and further,
that the occurrence of the herpetic eruption involving
the terminations of these nerves is best explained as
being the result of a specific focal reaction at the points
along the nerves presumed to have been the seat of
"rheumatic" inflammation.
The Lancet.
November 11, 1916.
1. Exophthalmic Goitre. Hector Mackenzie.
2. On a Rose-Irrigator for Supplying a Therapeutic Fluid
Continuously and at a Standard Temperature to the
Whole Surface of a Wound. Almroth E. Wright, H. H.
Tanner, and Ralph C. Matson.
3. The Bacteriology of the Feces in Diarrhea of Infants.
W. R. Logan.
4. An Improved Operation for Intrinsic Malignant Disease
of the Larynx. H. Lambert Lack.
T>. The Origin and Prevention of Cerebrospinal Fever. Halli-
day Sutherland.
2. On a Rose-Irrigator for Supplying a Therapeutic
Fluid Continuously and at a Standard Temperature to
the Whole Surface of a Wound. — Wright, Tanner, and
Matson describe this irrigator which apparently fulfils
all the requirements demanded of it. As a rose to the
body of the irrigator, they employed a rubber cap, and
inserted into the perforations a set of tubes. To give
stiffness to these rubber tubes and to carry them around
corners, a copper wire is inserted into each. Tanner
devised the wire arrangement. A drop counter is used
to tell the existence of the flow of stream and to regu-
late the flow, and in the newer arrangement the copper
wires are anchored to a rubber bung or piece of stout
drainage tube or aluminium ring inserted into the bar-
rel of the drop counter or into the irrigating rose. The
irrigator can be made up into three different styles
according to type and condition of wound. A thermos
bottle into which the rose and tubes can be fitted is
used for this purpose as by this means the irrigating
fluid can be kept at an even temperature. For preven-
tion or limitation of the escape of fluid in its passage
from the irrigator to the wound, thick-walled, narrow-
bored rubber tubing is used and the drop counter
chamber is made smaller. The flow is regulated by the
screw clamp, and the size of the drops by the size of
the external diameter of the dropper. The standard
size employed by the writers is one of 4 mm. external
diameter, obtained by inserting the drawn out glass
tube into a hole in the perforated zinc supplied by the
hospitals, filing, and breaking off the point at the level
of the aperture. In a medium sized wound the flow is
adjusted at 90 to 100 drops per minute; larger wounds
require greater flow. In order to irrigate the wound
and at the same time to keep the bed dry the mattress
is cut away from under in the case of a horizontal
wound, and a broad strip of jaconet can be passed under
the limb and the corners can be looped up and tied round
the limb above and below the wound. A type of ham-
mock is thus formed. With this strips of bandage are
employed to drain the wound. In wounds in direct
position the bandages would be employed as direct
drains. In either case they pass out through a hole cut
out in the trough of the jaconet hammock and go
down into a basin under the bed. When the limb can-
not be kept in the horizontal position, or where from
the anatomical relations of the wound the jaconet ham-
mock is inapplicable, we can bank back the fluid, and
effectually prevent leakage into the bed by "irrigation
flanges," built up of cotton-wool covered and fastened
down to the skin by strips of bandage soaked in forma-
lin gelatin.
3. The Bacteriology of the Feces in the Diarrhea of
Infants. — Logan gives the results of his research in this
work as follows: Fourteen cases of diarrhea were all
on artificial diet at the time of onset. The flora of
artificially fed infants differs from that of breast-fed
infants chiefly in a decrease of the acid-tolerant group,
an increase of the normal B. coli group, and in the
appearance of members of the non-lactose-fermenting
group along with some increase of cocci. The flora
of infants suffering from diarrhea shows similar but
more marked changes, and the more severe the diarrhea
the more marked the changes. It is possible that the
acid-tolerant group exerts a beneficent influence in re-
straining the growth in the intestine of the non-lactose-
fermenting group. Bacilli of the non-lactose-ferment-
ing group were obtained from 6 out of 21 (28.5 per
cent.) infants and young children who were free from
diarrhea. Bacilli of this group were isolated from 11
out of 14 cases of diarrhea (78.5 per cent). Bacilli
of Morgan's No. 1 group were isolated from 9 per cent,
of the normal children, and from 35 per cent, of the
cases of diarrhea. True, though non-agglutinable, dys-
entery bacilli were isolated from none of the normal
children, but were obtained from three cases of diarrhea
with blood and mucus (dysentery), or 21 per cent, of
total diarrhea cases. A certain number of cases of
diarrhea of infants are therefore true bacillary dysen-
teries, even in Scotland and in winter time. It is
doubtful whether the overgrowth of non-lactose-fer-
menting bacilli initiates the diarrhea, or whether it is
a secondary and aggravating factor.
5. The Origin and Prevention of Cerebrospinal Fever.
— Halliday Sutherland states that the Diplococcus in-
tracellularis meningitidis of Weichselbaum conforms
to Koch's law for pathogenic organisms. Constantly
found in the tissues and body fluids of the victims of
epidemic cerebrospinal meningitis, the meningococcus
may be isolated in pure culture, is able to reproduce
the disease in monkeys, can be recovered from the
lesions in these animals, and is therefore the causal
organism of cerebrospinal fever. At times when the
disease is not prevalent meningococci have been found
in the throats of 2 per cent, of healthy soldiers. Among
healthy naval ratings, not known to have been exposed
to infection, Sutherland found meningococci in the
throats of two individuals out of a hundred examined,
and the organism has been found recently in a larger
proportion of the civil population not exposed to infec-
tion. The conditions which determine whether or not
infection is spread are as follows: Any organism in the
nasopharynx may be expelled from the mouth during
the act of coughing in small droplets of secretion which
float in the air for from half an hour to four hours,
according to the density and humidity of the atmos-
phere. This would easily explain the method of in-
fection provided the temperature of the air was above
22° C, but on the other hand, meningococci soon perish
at lower temperatures. Now 22° C. corresponds to
71.6° F., and he found that meningococci die in 30 min-
utes when exposed to a temperature of 60° F., while
lower temperatures are more rapidly fatal. It is there-
fore clear that air-borne meningococcal infection can
only occur in a warm atmosphere, and is impossible
in cold air. Epidemics of cerebrospinal fever usually
begin in January or February, and disappear with the
advent of May. But January and February are the two
coldest months of the year. The paradox of a disease
which appears during cold weather, but whose specific
1088
MEDICAL RECORD.
[Dec. 16, 1916
cause can only be carried by warm air is explained by
the fact that cold weather cuts off means of ventilation
and the air indoors becomes warm and saturated. When
the disease is spread in summer, the essential condi-
tion which determines the secondary invasion of the
tissues would be absent. To control the spread of the
infection, Sutherland says that all windows and doors
must be open day and night. A window ventilator
answers the purpose. Pure air is the simplest and
surest means of prevention.
British Medical Journal.
November 11, 1916.
1. Remarks on "Pyrexia" or "Trench Fever." John Muir.
2. A Case of Acute Myeloblasts Leucemia. Rowland Hill.
3. Grafting with Frog Skin. H. W. M. Kendall.
4. The Use of Glycerin and Ichthyol in the Treatment of
Septic Wounds. Thomas W. A Daman.
1. Remarks on "Pyrexia" or "Trench Fever." — John
Muir has based his observations on a twelve months'
experience with a field ambulance on the Franco-
Belgian front. After stating the symptoms, which by
now are well known, he advances the following treat-
ment, which consists mainly of rest and attention to
the bowels, which are usually very constipated. Phen-
acetine, sodium salicylate, and a few other drugs are
used to relieve the shin pains. Pyrexia is cut short by
the use of two powders, each consisting of morphine
acetate gr. %, caffeine citrate gr. 1, phenacetine gr. 8;
one given immediately the patient gets to bed and the
second two hours later. Attention may be focused on
the following points: (1) The nature and mode of
conveyance of the infective agent producing the
numerous cases of "short fever" met with in
our troops are still unknown, and merit further
observation and research. (2) The term "trench
fever" is distinctly misleading, and is not justi-
fied by analysis of the total number cf cases which
occur in the various units of a division and under vary-
ing conditions. Cases occur in considerable numbers
in units situated outside the "trench area," and marked-
ly increased incidence is met under suitable conditions
whilst the troops are far removed from the trenches.
(3) Such inclusive experience can only be gained in a
field ambulance, as all cases are primarily brought
there, and many (about 45 per cent.) are not trans-
ferred to any other medical unit. (4) The name "lice
fever" is also objectionable, since it assumes as a fact
a possible means of conveyance which at present is
merely a hypothesis. (5) The infective agent is proba-
bly a widespread virus borne on the persons of men
concerned (nasopharyngeal?) normally of low viru-
lence. (6) Incidence of the disease depends upon the
condition of the men, whose defense against the in-
fection is specially lowered by exposure and fatigue.
3. Grafting with Frog Skin.— H. W. M. Kendall says
that the idea of grafting granulating surfaces with frog
skin was put into practice by him as far back as 1886-7
in India. He experimented with satisfactory results to
the patients, gratification to himself, and the least pos-
sible inconvenience to the frogs. He has obtained the
same results in France lately. He reports fourteen cases
of successful results. The ideal wound to graft is fiat,
without much suppuration or excessive protuberant
granulations. The rapidity with which the wound com-
mences to heal after the graft has successfully adhered
is in marked contrast to its sluggishness before the
operation. The wound having been gently cleaned with-
out antiseptics and as gently dried, the loose skin on the
inner side of the frog's thigh is carefully pinched up
in a pair of dressing forceps, snipped off with scissors,
spread out and applied by its under surface to the
wound. A strip of gutta-percha tissue smeared with
some mild and soft non-irritating emollient is then
placed over it, fixed in position at its ends by adhesive
plaster, and a dry dressing applied over all. The whole
is gently removed in three days, when the site of the
graft will be noticed as a purplish spot branching out-
wards to the periphery of the wound. A similar dress-
ing is again applied for two days to avoid unnecessary
interference, after which the wound may be dressed
daily, without the gutta-percha tissue, with some simple,
non-irritating ointment, such as boracic, until healing is
completed. The gap in the skin's continuity is by this
process filled up and unsightly or inconvenient con-
traction avoided.
Berliner klinische Wochenschrift.
October 23, 1916.
Bacteriological Diagnosis of Typhoid Fever. — Schmitz,
as a result of study of an epidemic in Jena in 1915,
reaches the following conclusions: Examination of the
stools gave unsatisfactory results; when this method
alone was used during the first five weeks of the dis-
ease the diagnosis was made in but 11.75 per cent. Of
the actual number of tests made only 8.68 per cent,
were positive. Better results were obtained by the
bacteriological blood test — in 30 per cent, the diagnosis
was made. The widal was positive in about 75 per cent.
When all the above methods were used in conjunction
the diagnosis was made in 91 per cent. In this com-
bined series the bacteriological test gave better results
than when used alone. The negative results were prob-
ably attributable to unfavorable culture conditions. In
regard to the stool test this gave 25 per cent positive
results for the first week and then fell off sharply to
one-half, finally dwindling to zero. Early tests of blood
and feces should give much better general results.
Typhoid Fever and Pneumonia. — Doblin describes
some cases. The first was in a robust man who had
been vaccinated five times against typhoid. Three
months after the last inoculation he was taken ill with
diarrhea and subfebrile temperatures. During the
course of these symptoms, which persisted for five
weeks, he passed through an acute bronchitis, which
ran its course in about ten days. In the sixth week the
movements became putrid and bloody; thirst and ema-
ciation appeared, and death resulted from asthenia. The
autopsy showed typhoid, with lesions most marked in
the colon, and perforation. The latter was not clinical-
ly apparent, save as scattered pains. In a second pa-
tient inoculated three times against typhoid the latter
disease set in and pursued its course up to the end
of the third week, when a lobar pneumonia set in.
After eight days this ended by lysis, the lung cleared up
and the typhoid completed its course. A third patient,
also three times vaccinated, developed the same asso-
ciation. The pneumonia appeared in the third week
and ended by crisis in seven days. In both these cases
the pneumonia was a simple complication due to the
typhoid bacillus. Even clinically ordinary lobar pneu-
monia could be excluded. Consolidation appeared and
disappeared abruptly and was less intense; there was no
true hepatization and bronchial sounds were not char-
acteristic of true pneumonia. There was no dyspnea,
cough was not distressing, the sputum not rusty, but
decidedly bloody.
Potato Flour as an Addition to Infant Feeding. —
Muller does not refer to potato starch, but to a flour
made by milling potato flakes. Some time ago maize
preparations were used to eke out in infant feeding,
but after exhaustion of the supply wheat flour and then
"war" flour (wheat and rye) were substituted. The
great drawback was the inability of these flours to mix
harmoniously with milk. Potato starch when mixed
Dec. 16, 1916]
MEDICAL RECORD.
1089
with milk has a starchy consistency and taste. The
author then made use of the milled potato flakes such
as have been used as cattle fodder. The potato, after
steaming, is laid upon hot rollers and thereby dried and
then ground up. When used for fodder the potatoes
are not peeled, but for infant nourishment peeling is
done by machinery. The mineral matter is not leeched
out and in consequence the new product is much better
than potato starch for food. The flour is coarse, slight-
ly brownish and of a pleasant taste. Nurslings take it
well and it mixes well with milk, making good drinks
and porridge. The author hopes to see this product the
center of an industry after the war.
Munchener medizinische Wochenschrift.
October 10, 1916.
Successful Irradiation of Cancer of the Breast in One
Sitting. — Friedrich and Kronig first relate some experi-
ences with irradiation of the uterus and ovary and how
they have been influenced toward the proper dosage for
cancer of the breast. They now declare that the x-ray
surpasses the knife in the treatment of the latter condi-
tion. The erythema dose of the skin has been estab-
lished as 50 discharges of the electrometer system of
the authors' iontoquantimeter. The ovarian dose neces-
sary to bring about amenorrhea in myoma and hemor-
rhagic metropathies has been established at 10 dis-
charges. The sensibility quotient between the ovarian
and cutaneous dose has been fixed at 5. The carcinoma
of the breast dose has been fixed at 40 discharges. The
sensibility quotient between skin dose and mammary
cancer dose is 1.25. Irradiation is contraindicated in
the presence of metastases and cachexia. Thus far the
authors have not determined the prophylactic dose in
respect to recurrence. That x-rays can cause the dis-
appearance of certain cancers in one sitting is a well-
attested fact. There seems no reason a priori why this
result cannot be obtained in an operable cancer of the
breast. The surgeon has always opposed this course,
leaving to the radiographer only the cachectic subject
with inoperable growth. These very subjects may be-
come worse under this treatment. The operable breast
cancer is easily reached by the rays, much more readily
than the cervix uteri. While the authors give us formal
histories we get the impression that after a single ex-
posure the breast cancer undergoes involution.
Difficulties in X-Raying the Gastroenterostomized
Subject. — Freud claims that a correct x-ray diagnosis
of potency of a gastroenterostomy is a mere matter of
chance. The method now current is quite unsuited for
the diagnosis of the presence or absence of a peptic
ulcer of the jejunum, because we can neither determine
the site of the fistula nor map out the loop of the an-
astomosis. We obtain no definite idea as to the relation
of the latter to the deep point of the greater curvature.
Studies of the chemistry and mobility of the stomach
throw no light on the situation. We are in need of a
method which is not only diagnostic but will also enable
us to judge of the suitability of this intervention for
the cure of ulcer. The duodenal sound is a valuable
accessory in these cases. This instrument will inform
us with certainty as to the potency of the anastomosis;
will tell us the size of the latter, its site, its relation
to the deepest point of the greater curvature, the posi-
tion of the loop, presence or absence of adhesions, the
presence of a sensitive area which might mean a recur-
rent ulcer. The procedure is as follows: The sound is
first introduced to the mark 45 in the usual manner,
and the patient then sits or stands while the sound is
swallowed under illumination control. As soon as the
fistula is entered, the sound is allowed to find its way
deeply into the loop until it is arrested; whereupon
vomiting movements appear on further swallowing.
The olive is now drawn backwards into the stomach
and a search made for other possible openings. By
means of the sound bismuth contrast masses are con-
veyed into the anastomosis loop, and the form, capacity,
mobility, etc., of the latter brought out. As soon as the
contrast substance leaves the loop we should be on the
lookout for a bismuth speck which would speak for an
ulcer. In like manner we should examine for the pres-
ence of a niche above the ring of the fistula. Other
important data, notably in reference to sensitive areas,
may be obtained by manipulation of the olive.
Journal de Medecine de Bordeaux.
October, 1916.
Waller's Law and the Theory of Trophism. — Pitres
after an exhaustive review of this subject announces
some conclusions as follows: When any prolongation
whatever of any neuron whatever is severed from the
mother cell the severed portion undergoes the so-called
Wallerian degeneration. This law applies to the periph-
eral protoneurons with two exceptions which are more
apparent than real. First the central segment which
in Waller's law remains intact may undergo certain
changes (chromatolysis) which may be severe enough
to cause the death of the neuron while all its prolonga-
tions degenerate. Second, in the midst of the Wal-
lerian degeneration a few fibres habitually remain in-
tact. These are naturally aberrant or recurrent and
do not have the same origin as the degenerated fibres.
When a motor nerve degenerates the muscles supplied
thereby undergo a characteristic degenerative atrophy.
The regeneration of a peripheral segment of a divided
nerve is brought about by a budding of the central
nerve stump (Waller). Regeneration of the fibres of
a motor nerve may be followed by regeneration of the
fibres of the corresponding muscles. Nervous fibres
of the neuraxis, like those of the peripheral nerves, de-
generate when separated from their mother cells.
Motor fibres degenerate from above downwards; sen-
sory fibres in the reverse direction. The nervous fibres
of the neuraxis cannot regenerate after division. Aside
from degenerative atrophy of the muscles which results
from division of the nerves there is a certain amount
of hypotrophy from disuse, so that simple emaciation is
found side by side with granulofatty (Wallerian) de-
generation of muscle.
Paratyphoid Fever and Bacilluria. — Carles and Mar-
eland state that when the bacteria of an infectious dis-
ease appear in the urine there is reason to suspect
the presence of a renal lesion. In the majority of cases
of typhoid the kidneys remain intact. In bacilluria
we find albuminuria and cylindruria. Again, the bacil-
luria is never limited to the causative germ; staphylo-
cocci, for example, often coexist with the latter. A
sort of latent cystitis may follow the bacilluria. It is
not yet settled whether a paratyphoid bacilluria can
occur under the same circumstances, and the author has
studied cases from this viewpoint. A patient with an
early typhoid syndrome gave a positive blood test
(hemoculture) of the paratyphoid A. Later a drop of
urine was brought away by a catheter and gave the
same positive result. There was also albuminuria.
After defervescence there was extensive elimination of
urine, which contained only B. coli. the kidneys being
intact. A second patient showed mixed infection with
Eberth's bacillus and the paratyphus B. As the urine
contained blood a test for bacilluria was at first in-
conclusive, although positive for the para B. After
the urine had become clear the latter was still present.
The author is not the first to describe paratyphus bacil-
luria, but prior finds have been conflicting. A prac-
1090
MEDICAL RECORD.
[Dec. 16, 1916
tical point involved is the duration of this form of
urinary infection. Cultures cannot always be made
from the urine in these cases and the germs may not
always be virulent. Attempts to sterilize the urine may
fail, and this seems to have been true of the author's
second case.
Le Bulletin Medical.
October 28, 1916.
Wounds of the Abdomen. — Quenu considers 180 cases
of abdominal wounds as reported in eight separate
memoirs on the subject by as many different surgeons.
These are analyzed and criticized from his own per-
sonal experience. One conclusion stands out clearly —
no penetrative wound of the small or large intestine
can ever be left for Nature to cure. Lesions of other
viscera may benefit from surgical intervention; and in
order to determine which viscera are wounded and in
what manner, laparotomy is necessary. An exaggerated
value is imputed to certain diagnostic elements, such as
determination of the trajectory of the projectile, in
which radiography is utilized, and this is true of the
leading clinical symptoms. These all have value, but
are not of critical importance in a rapid summary of
indications for operation. In the 180 cases but three
needless laparotomies were performed; all of the pa-
tients recovering. Is it necessary to operate on every
abdominal wound? Evidently not. The upper segment
of the abdomen, bounded below by a line which touches
both costal arches, may be exempt, although there are
numerous exceptions. This exemption is due to the
fact that projectile wounds received here may belong
rather to the thorax than the abdomen. As for the
abdomen as a whole, not every wound indicates an op-
eration. The question is a most delicate one, for if the
patient appears to be near death a desperate attempt
may be made to save him. On the other hand, if the
patient is in extreme shock, an attempt to operate would
very likely be fatal. A pulseless patient never benefits
by operation. A total absence of pulse, however, must
not be confounded with an extremely rapid pulse, which
perhaps cannot be counted. Such patients may be
snatched from death by operation. A truly pulseless
patient must be treated first and every effort made to
bring back the arterial tension; while with a patient
who still has a pulse no time should be lost in ligating
large blood vessels and removing possible causes of sep-
sis. The technique is comprised under two heads: ex-
ploration of the abdomen and treatment of intestinal
wounds. The median incision is usually the best. In
the exploration the trajectory made by the projectile
comes into consideration, and exerts an influence upon
the position of the patient. If the pelvic organs are
wounded the patient must be in the inclined position.
If the anterior wall of the stomach is perforated the
back of the viscus must be examined by going through
the mesocolon. But, as already stated, the path of the
bullet is not to be overvalued as furnishing special
indications for treatment. Intestinal wounds demand
suture or resection according to the conditions present.
In most cases drainage is indicated. In regard to prog-
nosis something depends on the nature of the projectile.
The mortality from shell fragments, which was 57 per
., is much higher than that from fragments of hand
grenades (42 per cent). Musket or machine gun bul-
lets are considerably more deadly than shrapnel bullets.
Preoperative conditions, which have reference to trans-
portation, and the date of intervention are also power-
ful factors. Recently operation within three hours has
shown a superiority over longer periods. Patients with
very little traumatic shock and otherwise in good con-
dition are practically certain to recover after very early
intervention. The degree of shock, as Crile has shown,
is largely a matter of arterial tension. The low tension
of shock is invariably lowered by laparotomy. Vaquez
has shown that after ordinary laparotomy, a tension of
140 may be lowered to 100. Long experience has
taught the author and his colleagues that operation on a
patient with a tension below 100 is inevitably followed
by death inside of twelve hours. Below 100 the lower
the tension the worse (if possible) the outlook; while
the further above 100 the better in theory the outlook —
although it should be 120 and upward before we can
feel certain of recovery.
Le Bulletin Medical.
November 4, 1916.
The New French Decree Against the Sale of Poisons.
— An outline of the provisions of the decree of Septem-
ber 19, 1916, is begun in the current number of the
Bulletin. The old decree had been in existence since
1846. The successor refers to three separate cate-
gories of poisonous drugs. In the first category, repre-
sented by Table A, we find toxic substances in the ordi-
nary sense of the term. The author enumerates only
those which are used in medicine, and the list includes
all the most violent poisons, such as aconitine and cy-
anides. In the second category, as shown in Table B,
are to be found the various habit forming drugs, which
are relatively few in number. Unusual restrictions and
severe penalties are attendant upon the traffic in these
substances. The third category comprises drugs which
are known simply as dangerous and corresponds to
Table III. The present installment in the Bulletin
deals only with Table A. One notes with some surprise
that codeine, laudanum, and the tincture of opium of
the French Codex are retained in Table A, along with
certain substances of low toxicity. Apparent contra-
dictions in the tables are accounted for by the special
provisions of the decree. All drugs in Table A may be
supplied by pharmacists, physicians, and veterinarians,
by the former, however, only on prescription from the
two latter. Dentists and midwives may furnish their
patients with substances from a special list, upon pre-
scription also. Renewals may be dispensed unless the
writer of the prescription expressly forbids it. There
are special restrictions in connection with prescribing
powerful poisons by the mouth and by hypodermic, con-
sisting in limiting the twenty-four hour dose. If the
figures are exceeded the pharmacist must not fill the
prescription. Those calling for laudanum can be re-
newed only under special provisions. Certain limita-
tions pre-exist in the Codex, which may therefore be
used as a guide in certain renewals. Thus the maxi-
num amount of arsenic to be ingested in twenty-four
hours is stated therein. There is, however, a "joker"
in the new decree w:hich states that a new prescription
is to take the place of a renewal, Le., the old prescrip-
tion is given a new number. It is not considered nec-
essary for the pharmacist to record the name of the
purchaser, as the maker of the prescription, with date,
etc., and special number are held to be sufficient. The
article will be continued.
Fistula in Ano. — Goz has studied ninety-five cases of
this affection in the Munich Surgical Clinic. In 43 per
cent, tuberculosis was in evidence as a factor. Division
of the sphincter caused incontinence only when sev-
eral times repeated. The rule is therefore to divide but
once. Single incision with the thermocautery will cure
67 per cent, of those treated, while repeated incisions
give only 14 per cent of cure. The presence of tubercu-
losis aggravates the prognosis. — Inaugural Dissi rtation,
Tubingen, 1916.
Dec. 16, 1916]
MEDICAL RECORD.
1091
insurant Motrin*.
The Consideration of Rectal and Colonic Dis-
eases in Life Insurance Examinations. — Alfred J.
Zobel states that all important data concerning
the vital organs are obtained by a medical life in-
surance examiner by direct examination and by
precise methods; but, on the other hand, life in-
surance companies evidently do not attach much
importance to the condition of the rectum and
colon — not to mention the rest of the alimentary
canal — for they seem willing to assume that these
organs are free from disease solely from the fa-
vorable answers given by the applicant to routine
printed questions asked by the examiner. That
this is a fallacy, inasmuch as it paves the way to
the acceptance of poor risks, and occasionally to
the rejection of a good one, he demonstrates in
his paper. Applicants almost invariably deny
having or ever having had rectal or colonic dis-
eases.
The writer says that the individual knows
little about his anorectal region, and unless there
is severe pain or itching, alarming bleeding, or
annoying dysentery, he thinks it of little impor-
tance and unworthy of the attention of either
himself or the examiner. The rectal surgeon
often sees individuals who look and feel in the
best of health (outside of "a little attack of pile"),
yet who are found victims of well advanced ma-
lignant disease of the colon or rectum. Unless a
rectal examination be made such a person could
easily pass a life insurance examination. The
examiner should look out for those little fistulous
tracts which cause no pain and discharge but
little secretion, as they are frequently the pri-
mary manifestations of tuberculosis, and may
appear in those who are otherwise healthy. A
severe stricture of the rectum may be present in
a man outwardly perfectly healthy and insurable.
If a history of hemorrhoids is secured, or if they
are found on examination, it should not be forgot-
ten that although their existence does not constitute
a good cause for rejection, they often accompany
liver, spinal cord, genitourinary, and uterine dis-
eases.
If a rectal examination is made the condition of
the genitourinary organs in the male can be in-
vestigated, while in the female accurate informa-
tion can be obtained about the pelvic organs
without subjecting them to a vaginal examination.
At present only information as given by the
woman applicant as to the condition of her pelvic
organs is demanded by the insurance companies.
In conclusion Zobel offers the suggestion that
medical examiners should lay more stress upon
the questions regarding the condition of the bowel
and rectum. A history of discharge, chronic con-
stipation or of diarrhea should be worthy of fur-
ther investigation, and, if there is need, a rectal
examination should be made. That medical ex-
aminer is most efficient who not only secures his
company from poor risks but also saves it business
which otherwise would be lost, and the employment,
in all suspicious cases, of a rectal examination helps
attain efficiency. — Journal of the South Carolina
Medical Association.
Diseases of the Ductless Glands and Internal
Secretions in Relation to Obesity. — In a paper
read before the Assurance Medical Society in Lon-
don, England, on January 5, 1916, Dr. F. Parkes
Webber spoke of the diseases of the ductless
glands and internal secretions in relation to obesity.
The chief syndromes associated with excess of fat,
he said, are Dercum's disease, diffuse symmetrical
lipomatosis of the neck and other regions, and Froh-
lich's pituitary syndrome of adiposity with insuffi-
ciencies of the sexual organs, with which may prob-
ably be allied most cases of "eunuchoid" obesity in
men. A condition which might be legitimately de-
scribed as "precocious obesity" has been occasionally
observed in children in association with new growths
of the type of malignant hypernephroma. A con-
dition of lymphatism associated with excess of
subcutaneous fat might perhaps likewise be in-
cluded under this heading. W. Ebstein has di-
vided ordinary obesity into three stages, viz., the
enviable stage, the comic stage, and the pitiable
stage. It is in the third stage, the pitiable or help-
less stage, that the wretched person loses bodily
strength and activity, cannot take exercise, and
has no longer the will power to resist his com-
plaint. It is in the first stage, that is the stage of
plumpness or embonpoint, the stage admired by
many, that strict moderation in eating and drink-
ing ought to become a habit. Webber is quite sure
that if the relatively early stages of obesity were
more generally regarded in a serious light by life
assurance companies, if slight extra ratings were
more generally insisted on, and if that became uni-
versally known to the lay public, many more can-
didates for the righer grades of obesity would be
inclined to alter their manner of living in time to
avoid arriving at the helpless stage. Of course, it
is not directly from their obesity that most fat
persons die, but from the complications of obesity
or the diseases associated with it.
Albuminuria and Life Insurance. — It seems
scarcely credible that a symptom which is common
to so many diverse conditions, both physiological
and pathological, should so long have succeeded in
masquerading as necessarily connoting renal disease.
And yet it is within the experience of all of us that
people have been, and, alas ! are still being, refused
for life assurance and otherwise condemned as
damaged individuals merely because, from some of
the above-mentioned causes, a little albumin has
been found in their urine. It would be just as
logical — it would, indeed, be more reasonable — if
dyspnea were regarded as necessarily indicating
pulmonary or cardiac disease. Dyspnea is in many
cases very significant of such disease, but inasmuch
as we have all of us become very breathless hun-
dreds of times in the course of our lives, without
any untoward effects, we have acquired some sense
of perspective in the matter. It would be a good
thing if the presence of albumin in the urine could
be manifested by some sign equally gross and
obtrusive. We should then come to realize how
freouent an occurrence it is, and how seldom it
really indicates anything more serious than a mere
passing change of pressure in the blood vessels of
the splanchnic area. — Medical Press and Circular.
Hernia in the Light of an Accident. — Loss of
time due to an operation to relieve a hernia caused
by a fall is held covered in the Iowa case of Berry
v. United Commercial Travelers, L.R.A.1916B, 617,
by a policy of accident insurance against loss of
time on account of bodily injury effected through
external, violent, and accidental means, although
the policy provides that the payments authorized
shall not cover loss resulting from or in conse-
quence of hernia.
1092
MEDICAL RECORD.
[Dec. 16, 1916
Diseases of Occupation and Vocational Hygiene.
Edited by George M. Kober, M.D., LL.D., and Wil-
liam C. Hanson, M.D. Price, ?8 net. Philadelphia:
P. Blakiston's Son & Co., 1916.
Nothing is more significant of the present trend of
preventive medicine than the appearance at this time
of so ambitious a work on this subject. Composed, as
it is, of the articles of some thirty contributors, each
specially expert in his own subject, it offers the most
complete production of its kind which has yet appeared.
The interest in this topic has been growing rapidly in
this country in the past few years, and its progress has
been hastened by the passage of various workmen's
compensation acts. The passage of health insurance
laws, which may be looked for in the near future, will
only strengthen the stimulus which now urges the em-
ployer to throw every possible safeguard about the life
and health of his employees. A branch of medicine
which is showing such intense activity demands a text-
book which is prepared with great care and breadth of
view and exceptional completeness. Such a book is
found in the volume under discussion. Practically every
possibility of disease of occupation is considered, and the
means of prophylaxis pointed out. In addition there
is a large section on governmental study and legislation
and a short chapter on statistics which is deserving of
special attention.
University of Iowa Monographs. Studies in Medi-
cine. Prof. Henry Albert, Editor. Volume I,
Number 1. Iowa City, Iowa: Published by the Uni-
versity, June, 1916.
This monograph is made up of ten reprints of articles
which have appeared in widely read medical journals
during 1915-16, with a single non-medical exception.
The articles are almost all of high class; but as the
reading physician or surgeon will have already read
them, it is unnecessary to make a recapitulation. Taken
as a whole, they speak well for the activities of the
University.
A Practical Medical Dictionary of Words Used in
Medicine with their Derivation and Pronunciation,
Including Dental, Veterinary, Chemical, Botanical,
Electrical, Life Insurance and other Special Terms;
Anatomical Tables of the Titles in General Use and
those Sanctioned by the Basle Anatomical Conven-
tion ; Pharmaceutical Preparations, Official in the
United States and British Pharmacopoeias and Con-
tained in the National Formulary; Chemical and
Therapeutic Information as to Mineral Springs of
America; and Comprehensive List of Synonyms. By
Thomas Lathrop Stedman, A.M., M.D., Editor of
"Twentieth Century Practice of Medicine," of the
"Reference Handbook of the Medical Sciences," and
of the Medical Record. Fourth Revised Edition.
Illustrated. Price, $5 net. New York: William
Wood & Company, 1916.
It will be superfluous to say much regarding a diction-
ary which has gone through four editions and which is
consequently so well known to the profession as is Sted-
man's medical dictionary. Whatever sins of commis-
sion or omission have been perpetrated in former edi-
tions, they have not been committed or omitted in this
edition. That is to say, that the author has benefited
by intelligent criticism, and that the revision has been
thorough. Medical terms and titles are coined with
such rapidity that it is difficult for a dictionary to keep
pace with them. For example, in this issue no fewer
than 2,000 new words have been added, the majority
of which have been born in the last two years. In this
edition, too, all the terms of the Basle Anatomical
Nomenclature are indicated even when they do not
differ from the vernacular. Like the former editions
this one is an excellent specimen of the publishers' care
and of the printers' and binders' art.
La Fievre Typhoide et les Fievres ParatyphoIdes
(Symptomatologie, fitiologie, Prophylaxis). Par H.
Vincent, Medecin-Inspecteur de l'Armee, et L. Mu-
RATET, Chef des Travaux a la Faculte de Medecine de
Bordeaux. Prix 4 fr. Paris: Masson et Cie., 1916.
This book is one of the first numbers of a series of epit-
omes of war medicine and surgery which is being issued
at the present time. The volumes are light and of con-
venient size and are designed for the use of medical
officers on active service. They are admirably adapted
to this purpose, if this volume is any criterion, and
should find a wide acceptance. This book on typhoid
and paratyphoid fevers contains in very condensed form
practically all our present information on the subject.
The first part has to do with the etiology, symptomatol-
ogy, diagnosis, and treatment, while in the second part is
an extensive discussion of the epidemiology and prophy-
laxis. There is no attempt to discuss the pathology of
these diseases. The authors apparently have more faith
in the value of the diazo reaction than is generally found
in this country, and have had much success with the
use of vaccines as a form of treatment. It is on the
whole a very excellent presentation of the subject and
valuable at this time, when medical men are beginning
to realize that paratyphoid fever is much more common
than has hitherto been supposed.
Localization by X-Rays and Stereoscopy. By Sir
James Mackenzie Davidson, M.B., CM., Aberd.,
Consulting Medical Officer, Roentgen Ray Depart-
ment, Royal London Ophthalmic Hospital, and x-Ray
Department, Charing Cross Hospital; Fellow, Physi-
cal Society; President, Radiology Section, Seventeenth
International Congress of Medicine. Price, $3. New
York: Paul B. Hoeber, 1916.
This book is a personal one, the results of 20 years' ex-
perience, including, of course, the finds of two years of
warfare on a huge scale. It is based wholly on work
with the older tubes. The Coolidge tube is briefly men-
tioned and the author is silent on the other gasless
tubes. There are but 70 pages of text, with nearly as
many illustrations, 35 being stereoscopic plates. Such
a book can hardly be given an analytical review, but
should be of great interest to all radiologists.
Les Sequelles Osteoarticuliculaires des Plaies de
Guerre. Par A. Broca. Price, 4 francs. Paris:
Masson & Cie., Editeurs, 1916.
This volume is one of a large series of small mono-
graphs, the outgrowth of the present war. They are
doubtless meant to serve the surgeon at the front and
at the same time to form a document of the lessons of
the war after the latter has expired. The author has
recently published a beautiful work on amputations
and excisions, noticed at the time in these columns, and
the present manual deals with such subjects as vicious
callus, traumatic osteomyelitis, ankylotes, and the ques-
tion of pensions. From the nature of the 112 illustra-
tions it appears that the work belongs largely under
surgical pathology.
Principles of Diagnosis and Treatment in Heart
Affections. By Sir James Mackenzie, M.D.,
F.R.S., F.R.C.P., LL.D., Ab. & Ed., F.R.C.P.I. (Hon.),
Physician to the London Hospital (in charge of the
Cardiac Department), Consulting Physician to the
Victoria Hospital, Burnley. Price, $2.50. London:
Henry Froude; Hodder and Stoughton; New York:
Oxford University Press, American Branch, 1916.
Any book on the heart from the pen of Sir James Mac-
kenzie is sure to be welcomed, for not only is what he
says authoritative, but it is said in such a way as to
hold the attention of the reader and combine for him
pleasure with study. The present work was prepared
for a post-graduate lecture course at the Cardiac De-
partment of the London Hospital, but the war pre-
vented its delivery. No change was made in the form of
presentation, when publication was decided upon, ex-
cept to divide the book into chapters; the style is there-
fore colloquial — which is an advantage rather than a
drawback. The book is one for the general practi-
tioner rather than the heart specialist or the labora-
tory experimentalist, and only cursory mention is made
of such expensive and usually unnecessary apparatus
as the electrocardiagraph. The reader who has been
brought up to believe in the many and great dangers of
disease of the heart will receive frequent shocks in com-
ing across such statements as that the author has never
seen the so-called "athlete's heart" which he charac-
terizes as an absurd bogey, and that dilatation can never
be produced in a healthy heart as a result of over-
strain; he also warns against Nauheim "and all other
forms of cure over which there is a trail of commercial-
ism"; he speaks slightingly of the value of blood pres-
sure estimations in diagnosis, prognosis, or as a guide
to treatment and doubts whether we shall ever find
them of any considerable help in our work; and his
scepticism as to the utility of a few protein or purin
free diet is patent. With all due respect to this ac-
knowledged authority on cardiac diseases, we regard
him as a safer guide in the diagnosis than in the treat-
ment of these affections.
Dec. 16, 1916]
MEDICAL RECORD.
1093
MISSISSIPPI VALLEY MEDICAL ASSOCIATION.
Forty-second Annual Meeting, Held at Indianapolis,
hid., October 10, 11, and 12, 1916.
The President, Dr. Willard J. Stone of Toledo,
Ohio, in the Chair.
(Continued from page 1054.)
Blood Chemical Analyses in Reference to Diagnosis
and Treatment. — Dr. K. B. H. Gradwohl of St. Louis
said that chronic kidney degeneration was accompanied
by the accumulation of all three constituents — uric acid,
urea nitrogen and creatinin. The normal finding in
respect to uric acid was 1 to 2, 5 milligrams per 100
c. c. of blood; of urea nitrogen, from 12 to 15 milli-
grams, and of creatinin of from 1 to 2.5 milligrams.
An undue accumulation of all three constituents was a
remarkably valuable method of estimation of true kid-
ney function. Values for urea nitrogen in conditions
of uremic nephritis had been known to reach as high
as 300 milligrams, and of creatinin as much as 30
milligrams. These high values indicated grave uremia.
His experience had shown the tremendous accumula-
tion of these constituents in bad cases of nephritis,
even where the urinary findings were scant so far
as albumin and casts were concerned. He had been
able in all his work to confirm the contention of My-
ers and Lough that the presence of over 5 milligrams
of creatinin in 10 c. c. of blood indicated an absolutely
fatal prognosis. The combination of nephritis with
diabetes mellitus had possibly long been recognized,
but too often was disregarded. The estimation of
blood sugar in diabetes should be accompanied by an
estimation of the other non-protein nitrogenous blood
constituents to determine the condition of the kidney.
If blood chemical analyses were made more often in
grave diabetic states it would be shown that some of
these so-called cases of diabetic coma were really in
a state of extreme uremia due to this complicating
nephritis. Many cases of diabetes mellitus had died
of uremia and were called diabetic coma and treated
as such. By personal experience he was able to con-
firm the data already obtained on the undue accumu-
lation of these non-protein nitrogenous constituents of
blood in gout, the nephritides and deranged renal con-
ditions. He had used the blood sugar methods of Bene-
dict and Lewis and could vouch for their inestimable
benefits in the diagnosis and treatment of diabetes
mellitus. He could also recommend the Van Slyke
method of estimation of the combining power of blood
plasma. Another field of usefulness of these tests
which was now opening up was the preoperative sur-
vey of surgical cases, the estimation of operation risks,
and the manner in which kidneys were functionating
after operative interference. This should prove of
great help to the operating surgeon.
The Clinical Value and Methods of Blood Analyses in
Medical Diagnosis. — Dr. G. W. McCaskey of Fort
Wayne first asked attention very briefly to the subject
of acidosis as determined by dialysis, removal of car-
bonic acid from the dialysate by aeration and the de-
termination of the hydrogen ion content by the indi-
cator method according to the technic of Merriott. The
determination of the hydrogen ion concentration of the
fresh blood containing as it did variable amounts of
CO,, did not give us any definite information in regard
to the actual existence of acidosis. The existence of
acidosis could only be assumed when there was a dimi-
nution of the reserve alkali of the blood which was
made up of the bicarbonates, alkaline protein com-
pounds and alkali phosphates. Under normal condi-
tions this reserve was very constant. The total hydro-
gen ion concentration might be constant with varying
amounts of reserve alkali by fluctuation of the CO,
content. A certain very slight degree of acidosis, al-
most infinitesimal in amount, was physiologically re-
quired for stimulation of the respiratory centers, and
this was really the information given by determining
the total hydrogen ion concentration of perfectly fresh
blood. This had, at present, very little clinical value.
If, however, we dialyzed the oxalated blood, or per-
haps, better still, the serum and completely removed
the CO, by aeration, the hydrogen ion concentration
then became a very accurate measure of the alkali
reserve and varying grades of acidosis might be accu-
rately determined. It was no longer necessary to make
a clinical guess as to the existence of an acidosis. A
normal alkali reserve under average conditions of diet
was found to vary but little and was expressed by the
logarithm 8.5 with a variation of 8.4 up to 8.55. These
various grades of acidosis in adults were found espe-
cially in diabetes and in some cases of nephritis, but of
course they were much more common in children in
which the tendency to acidosis was much more marked.
It was largely a question of the quantity of acid prod-
ucts of metabolism and whether they were volatile
like carbonic acid or non-volatile like oxybutyric, sul-
phuric, etc. The latter acids actually combined with
the reserve alkali of the blood permanently fixing it,
producing genuine and demonstrable acidosis with the
svmptoms of which we had long been familiar. The
sugar content of the blood had a very definite clinical
significance. Under physiologic conditions it was 0.1
per cent, or less. This was the threshold beyond which
renal excretion occurred with normal kidneys. With
a rise in this threshold considerably above 0.1 per
cent., which occurred in some cases of diabetes and
nephritis, the quantity of sugar in the blood might be
greatly increased, producing tissue irritation and vari-
ous functional perversions, but without glycosuria.
Hence the importance of estimating the sugar content
of the blood in all doubtful cases. In addition to the
determinations of the alkali reserve and sugar of the
blood, and perhaps, more important than either, the
estimation of the creatinin, urea and uric acid content
of the blood demanded our attention. Creatinin, the
determination of which in the blood had just been out-
lined, was first given clinical significance by Folin as
the most constant exponent of nitrogen tissue metabol-
ism. Recently Lyers had studied its blood retention
in nephritis. A considerable increase undoubtedly oc-
curred in the severer grades of nephritis, but in the
quantities usually present it was so easily excreted by
the kidneys that its retention undoubtedly marked
severe impairment of the kidney function. His own
observation led him to conclude that the quantity nor-
mally present was nearly always less than one milli-
gram per 100 c. c. of blood. Six mgm. had been his
most common result. In seven fatal cases of nephritis
and a considerable number of non-fatal cases he had
never found the very high values reported by Myers.
As a result of his own clinical studies he was forced to
conclude that 1.5 to 2 mgms. of creatinin per 100 c. c.
of blood indicated pathological retentions from in-
creased renal block. The quantity of urea in the blood,
as was well known, was influenced within certain pretty
well defined limits, by the proteid intake. Widal's esti-
mate was 20 mgms. per 100 c. c. in health. It undoubt-
edly varied both ways from this amount, but on ordi-
nary diet, 30 to 35 milligrams might be regarded as
the highest normal limit. Recent studies by Chase and
Myers seemed to indicate that in variations of the
uric acid content of the blood we had an earlier and
more delicate index of impairment of renal function.
Of the three principal end products of metabolism there
was apparently more difficulty in excretion, and com-
paratively slight impairment in the functional capac-
ity of the kidneys led to an increased quantity remain-
ing in the blood. The estimation of the chlorides in
the blood did not seem to hold out as much promise
as in the case of the nitrogenous constituents and sugar.
The chlorides apparently had a habit of playing hide
and seek between the tissues and the blood, influenced
by physiological and pathological conditions which
were at present obscure.
Dr. H. K. Langdon of Indianapolis stated that body
metabolism in general found expression in the urine
in some manner, but this expression was frequently
only an end reaction, and was subject to gTeat varia-
tion, due not only to the complexity of kidney function,
but also to many extrarenal factors. It was reason-
able to suppose that the blood would give us a more
intimate knowledge of the changes in metabolism
brought about by certain internal diseases. The phe-
nolsulphonephthalein test, as it was most generally
interpreted, was a test for the entire eliminative power
of the kidney as a whole, but the kidney was a very
complex machine and the physiological functions of
the component parts were affected in different degrees
by different diseased conditions. It was not right,
therefore, to place too much dependence on this one
test, or any one test for kidney function, or upon one
test for any obscure condition. This tendency was
well illustrated by the attitude of many medical men
towards the Wassermann test for syphilis. It seemed
to be the general idea that a blood Wassermann was
1094
MEDICAL RECORD.
[Dec. 16, 1916
sufficient, when the collected data up to the present
time showed that the examination of the spinal fluid
was of greater value than the blood Wassermann, not
only in late but in early syphilis. Ambard's coefficient
had a precise expression of the elimination of urea by
the kidney for ordinary clinical purposes, was prob-
ably not as accurate or as practical as the estimation
of blood urea. McClean had modified Ambard's calcu-
lation in an effort to simplify it and to make the quo-
tient rise and fall with kidney efficiency. This method
had its place in selected cases. In a series of cases
he used Bertrand's method of blood sugar estimation,
but titration against a standard solution of potassium
permanganate did not give a well defined end point,
and he found his results very unreliable. The method
of Benedict and Lewis was much more accurate.
DR. G. W. McCaskey of Fort Wayne stated that
the advantage of the Marriott method was this: Re-
cently he had a case in the hospital that he thought
showed some intoxication acidosis. His assistant and
he went to the hospital with a little collodion sac and
a test tube in the vest pocket. They drew the blood
and had a little saline diluting solution put in the
collodion sac and dropped it into the solution. This
must be done immediately in order to get the first
reading when the CO, was present. While they were
doing something else they took the blood out and threw
the sac away. The reading was 7.6. They then went
to the office with the test tube in their vest pocket,
took a bulb with a capillary pipette and blew air
through this for three minutes, and in that time it had
lost a little carbonic acid while going to the office, a
distance of several squares. But while Dumping this
air through for three minutes it changed from 7.6 to
8.6, the very highest limit. So that if anything the
patient had a hyperalka'.inity rather than an acidosis.
This was an illustration of the rapidity and ease with
which this could be used. In regard to the high limit
of creatinin in fatal cases of nephritis, he had seen a
patient die of typical nephritis with a ohthalein esti-
mate of only 2.5 milligrams creatinin per c. c. He
had seen that happen. • It was undoubtedly an excep-
tion.
Fractures of the Hip.— Dr. P. M. Hickey of Detroit
said that in considering the practical benefit to be de-
rived from roentgen studies, such as were presented in
the paper, he would feel that its importance primarily
lay in the establishment of an accurate diagnosis. The
mechanics of fractures had not assumed its proper
place. While the cardinal symptoms of fracture — first,
disability, and second, localized area of tenderness —
might serve to establish the presence or absence of
a fracture, still the question of the treatment would
of necessity be based largely on an accurate recogni-
tion of the type of fracture and the position of the
broken parts. If the roentgenogram told us exactly
the part of the bone which was broken, and our knowl-
edge of antaomy told us which way the fragments were
displaced by muscular pull, the art of the surgeon
would be much helped in solving the problem of proper
measures for the mechanical reposition and retention
of the displaced fragments.
Diagnosis and Operative Treatment of Vesical Diver-
ticula.— Dr. Filipp Kreissel of Chicago stated that di-
verticula of any appreciable size and situated c'ose to
the lower part of the ureter would eventually displace
the same or by pressure give rise to dilatation of the
renal pelvis, resulting in hydronephrosis, eventually
atrophy of the parenchyma, and if infection should
supervene pyelitis, pyelonephritis and kidney abscess.
Rupture of the overdistended sac, extra or intraperi-
toneally, with serious or fatal consequences had also
been recorded. Since it was of more importance to
ascei-tain the presence of a diverticulum than to settle
the question whether all or some were congenital or
secondary, a consideration of the gravity of these
lesions should make an early diagnosis imperative and
early treatment desirable. By an earlv recognition of
the anomaly most, if not all, of the enumerated com-
plications might be prevented and the opportunity
given to render a radical operation more simple before
infection and inflammation had resulted in dense ad-
hesions between the sac and important pelvic and
abdominal structures. Furthermore, better functional
results might be expected from an early operation,
since the breaking down of dense or extensive adhe-
sions was always followed by the formation of new,
unyielding tissue which interfered with the free mo-
bility of the bladder wall. In the early stage frequent
and fractionary urination should at least arouse sus-
picion, but we would not be justified in diagnosing a
diverticulum from this one point alone since polla-
kiuria was also a symptom of lesions of spinal or cere-
bral origin. With conservative and pa.liative operative
procedures, such as drainage of the sac, enlarging the
diverticular opening, curetting or cauterizing its wall,
nothing could be accomplished. Better and more last-
ing results would follow radical surgery of the sac.
The available records of the reported cases clearly
proved this contention. In all the radical operations,
about twenty altogether, including two of his own
cases, there were three cases of death, one due to
sepsis after a transperitoneal operation, and two which
occurred some time after the operation and were due
to secondary advanced lesions in the corresponding
kidney. In the other cases the results were h'ghly
satisfactory, some being completely relieved from all
symptoms, others retaining the tendency of voiding in
several phases.
(7*o be continued.)
NEW YORK ACADEMY OF MEDICINE.
Stated Meeting, Held November 2, 1916.
The President, Dr. Walter B. James, in the Chair.
This meeting was arranged with the cooperation of the
Section on Genitourinary Diseases.
The Relation of Chronic Infections of the Genitouri-
nary Tract to Obscure Internal Disorders. — Dr. Hugh
Hampton Young of Baltimore presented this communi-
cation, in which he stated that this subject of focal in-
fection was one of great importance, but he lealized
that it would be difficult to bring together accurate
comprehensive data to show the important role played
by the genitourinary tract. He briefly reviewed some of
the more salient features of the literature on this sub.ect
and said the first question that came up was "What
are the 'obscure internal disorders' which are related
to focal infections?" Billings gave a rather terrifying
list in recent publications which included acute rheu-
matism, arthritis deformans, gonorrheal arthritis, ma-
lignant endocarditis, myositis, myocarditis, septicemia,
nephritis, various visceral degenerations, thyroiditis,
pancreatitis, peptic, gastric, and duodenal ulcer, chole-
cystitis, various cardiovascular degenerations, arterio-
sclerosis, and chronic neuritis. Wright had added the
following: Secondary anemia, urticaria, furunculosis,
eczema, diabetes, purpura hemorrhagica, asthma,
chronic catarrh, and nervous breakdown, and Maier
cited cases of anorexia, tachycardia, and asthenia, as
due to chronic infections. McCrae, giving cases seen
in the writer's clinic, laid stress on the disproportionate
general symptoms which accompanied lesions of the
verumontanum, prostate, and seminal vesicles. In 1006
they (Young, Geraghty, and Stevens) called attention
to various obscure referred pains which occurred as a
result of chronic inflammatory infiltrations in and about
the prostate, e aculatory ducts, and seminal vesicles.
Previous diagnoses of lumbago, renal and intestinal
colic, neuralgia, neuritis, and sciatica had been made,
but were dissipated by the cure of the prostatic disease.
Dr. Young then took up seriatum the various genito-
urinary regions subject to infection, and pointed out the
anatomical peculiarities which might re ider certain
locations natural points for the localization and per-
sistence of infectious processes. A g ance at the anat-
omy and pathology of the kidney would seem to indicate
at once that many opportunities for absorption from
localized infectious processes were present. In the
glomerulus was found a distended sac with constricted
neck and uphill drainage, and likewise in the urinary
tubule imperfect drainage in the narrow ascending
tubule should infection occur. In parenchymatous and
perinephritic infections the chances of absorption and
resultant general sepsis were even greater. From the
renal pelvis and calyces the drainage was ordinarily
good and in simple pyelitis little absorption was seen,
but inflammatory infiltrations, anatomical abnormal-
ities, and calculus interfered with drainage in many
cases and pelvic dilatation, hydronephrosis, destruction
of renal cortex, and perirenal inflammation followed,
producing typical conditions for systemic invasion with
toxins and bacteria. One should therefore expect to find
in our clinical material and in the literature an abun-
dance of evidence of systemic disease from focal infec-
tions in the kidney and pelvis. But strange to say such
was not the case. Rheumatism and arthritis were cer-
tainly very rare as a complication, their own clinical
Dec. 16, 1916]
MEDICAL RECORD.
1095
records showing nine, and a hurried survey of 4000 au-
topsy records revealed no case with a combination of
arthritis and chronic renal suppuration. Many in-
stances, however, of chronic myocarditis and occasion-
ally of endocarditis were found. A careful search of
the literature revealed very little information on this
subject. Billings said "pyelitis of whatever type, even
when there is only moderate obstruction of the drainage
of the kidney pelvis, may produce myositis, arthritis,
neuritis, etc.," but he gave nothing more on the subject
and cited no case histories. Other writers and also the
more recent text-books on pathology, bacteriology, and
surgery threw no light on the subject. All investigators
were agreed that streptococci were very rarely found in
chronic urinary infections (cystitis and pyelitis) and this
might explain why arthritis, rheumatism, and endocardi-
tis so rarely accompanied renal suppurations; apparent-
ly the latter were specifically due to streptococci and
gonococci, both of which were found with great rarity
in focal renal infections. In the acute suppurative ne-
phritis of Brewer the foci of infection of which were
generally due to the staphylococcus, endocarditis often
existed, but both were acute local manifestations of a
blood infection and did not properly belong to the sub-
ject under discussion. Changes similar to those in the
upper end of the ureter which led to urinary obstruc-
tion, pyelitis, nephritis, etc., might exist almost any-
where along the course of the ureter with similar re-
sults. A review of the statistics of cultures from 800
cases of metastatic arthritis studied by Murphy and
Kreuscher, and recently presented here, again furnished
conclusive evidence that arthritis was a coccus disease.
Their demonstration that the disease was periarticular
confirmed other work in which the joint fluid had been
usually found sterile. The terminal portion of the
ureter was frequently obstructed by calculi, strictures,
tumors, and congenital defects, and so one often found
it transformed into a dilated flabby tube filled with
stagnant infected urine, surely propitious for produc-
ing back-pressure effects and general toxemias. Here
again the literature and clinical material afforded little
help, no citations of definite systemic infections being
given which could be attributed to pyoureters being
found. It was not to be expected that much absorption
would occur from ordinary cases of cystitis. Some-
times the mucous membrane of the bladder was so re-
sistant that an infection might persist for months with-
out causing inflammation. When obstruction was pres-
ent however, drainage was interfered with, residual
urine developed, the bladder became trabeculated,
pouches and diverticula formed, and excellent oppor-
tunities for infection, deep-seated inflammation, ulcer-
ation, septic absorption, and general infection occurred.
Here again the absence of streptococci was probably
the reason one rarely encountered rheumatism or ar-
thritic complications. But the bacilli of the colon group
which preponderated here as the infective agent were
far from harmless. The course followed by the B. coli
infections of the bladder were seen regularly in en-
larged prostate cases. After a few catheterizations the
bacilli were generally found in the urine, and after a
time, as a rule, a mild cystitis and urethritis resulted
with varying systemic manifestations — fever, malaise,
and occasionally chill and evidence of severe toxemia.
After a short period — three to ten days — a tolerance
for the chronic infection was established and the pa-
tient might go on catheterizing himself for the rest
of his days with only occasional attacks of sepsis.
If, however, regular catheterization was not afforded
and considerable residual urine was persistently pres-
ent, the pressure effects produced results of a serious
nature upon the whole organism. Just as the bacilli got
into the circulation from the intestinal tract when the
latter was in a condition of stasis due to chronic con-
stipation, so might the same organisms infect and
poison the body in chronic urinary obstruction. A
more potent effect was probably produced upon the
kidneys and through them the heart, blood vessels, and
other vital structures by infection combined with back
pressure. The clinical picture was a common one: a
pale anemic, asthenic patient, with lack of appetite, at
times nausea and severe digestive disturbances, and
with evidence of myocarditis, arteriosclerosis, hyperten-
sion, and chronic renal insufficiency. The catheter
showed residual urine of poor quality, the phthalein
test revealed marked impairment of the kidney func-
tion, and uremic and cardiac crises during the course
of palliative treatment emphasized clearly the desper-
ate condition of the patient. Such cases not infre-
quently showed little or no urinary symptoms, and went
along untreated for months or years, the patient being
treated for the above-mentioned conditions, while the
back-pressure and colon-bacillus infection went merrily
on. The proof of the urological etiology of these grave
internal disorders was the way in which they dis-
appeared when the back pressure of infected urine was
relieved by systematic catheterization, drainage, or pros-
tatectomy. Distinguished internists who had directed
the treatment of certain severe cases, had been astound-
ed to see patients who were apparently in extremis
gradually become rational as uremia disappeared and
vascular, myocardial, and endocardial conditions im-
proved so astonishingly that ultimately a radical peri-
neal prostatectomy was carried out almost without risk.
The remarkable recuperative power of the kidneys was
shown by the scores of cases in which the phthalein
test and blood urea indicated that only a trace of func-
tional capacity was left on entrance to the hospital, but
which under catheter drainage so rapidly improved that
often within a month a fairly normal function was ob-
tained and operation successfully performed. Coming
to the urethra it was found that the various glandular
structures surrounding and draining into the urethra,
all with narrow ducts, furnished a most fertile field for
the development of chronic infections. This was the
most complex glandular system in the body, and as one
or all of these structures were infected in thousands of
cases of gonorrhea one could appreciate the dangerous
status of these patients not only to society but also to
themselves. The medical profession was even yet rather
ignorant or indifferent to the fact that the patient
should never be declared cured of his gonorrhea simply
because the discharge had ceased and shreds were no
longer present in the urine. The examination of the
secretion from the prostate and seminal vesicles was so
easy and so decisive that it should never be neglected
before discharging an acute or chronic gonorrheal case
as cured. The remote lesions caused by the extension
of a gonococcus infection were manifold. Almost every
tissue and structure of the body had yielded its cases
of gonococcus infection. Although fulminating in onset
many of these very severe infections, even endocarditis
and general septicemia, were sometimes not fatal, but
the deforming effects were generally terrible in their
results. One of the most interesting phases of chronic
gonorrheal inflammation was the general disappearance
of the gonococcus and its frequent supplacement by
other bacteria, particularly the streptococcus. This
had been particularly demonstrated in chronic seminal
vesiculitis. It had been shown that the gonococcus dis-
appeared with increasing rapidity as the years went
by. In a bacteriological study of chronic prostatitis
the writer and his associates (Geraghty and Stevens)
found the streptococcus present in 16 per cent, of the
cases. Staphylococcus albus, in 16 per cent.; no colon
bacilli and no gonococci were found in any case, though
50 per cent, came within three years of the gonorrheal
infection. There was apparently definite proof that the
pyogenic cocci and not the gonococcus or colon bacillus
was responsible for chronic infections of the prostate
and seminal vesicles, and also for the arthritis and
rheumatic conditions which so frequently accompanied
them. Clinical cases in great numbers were on record
to prove the varied lesions remote and serious in char-
acter which owed their existence to infection of the
seminal vesicles and probably also to infections of the
prostate and other adnexa. From the experiments of
Thaon, Posner, Kohn, Comus, and Gley. Leguen, and
Gaillardot there seemed to be little doubt that the pros-
tate had an internal secretion. The active principle
had not been isolated nor its exact physiological proper-
ties established, but evidence pointed to its being toxic
when injected into animals and that it affected the blood
pressure and to some extent the heart. Certain in-
vestigators had noticed an anticoagulative action, and
this might be responsible for some of the rather trouble-
some hemorrhages that sometimes occurred from the
prostate. Not infrequently the prostate was seriously
inflamed in conjunction with the seminal vesicle, and it
might be responsible alone for remote rheumatic and
cardiac lesions. It should unquestionably be incised
and drained along with the seminal vesicle in such cases.
Likewise infection often occurred in hypertrophy of
the prostate, invading, as a rule, the normal layer of
prostatic tissue behind and external to the hyper-
trophied lobes. Several of the writer's cases associated
with joint and heart disorders had rapidly improved
after perineal prostatectomy in which this portion of
the prostate was drained by the preliminary capsular
incision. In some prostatectomies he had exposed and
1096
MEDICAL RECORD.
[Dec. 16, 1916
drained the seminal vesicles and believed that this
should be done more frequently as a vesiculitis was not
seldom present.
The verumontanum, composed as it was of glandular
and cavernous tissue and containing the utricle, ejaeu-
latory ducts, and highly complex nerve supply, was
one of the most common focal causes of remote dis-
orders. Not only were there chronic inflammatory
conditions accompanied by disproportionately severe
sexual and urinary symptoms, but the most remarkable
referred symptoms frequently occurred. In a study of
358 cases of chronic prostatitis the writer found that
referred pains of varied character were present in a
large percentage of the cases. The most common loca-
tion was the back, 64 cases, then came the perineum 35,
suprapubic region 22, hips 10, thighs 12, knee 4, leg 4,
simulating sciatica 5, kidney region 8, and simulating
renal colic 10. The widespread character was thus
evident. In an excellent paper on the remote effects of
lesions of the prostate and deep urethra, McCrae cited
several cases in which symptoms had been referred to
the heart, palpitation, rapidity of rate, attacks in which
with precordial distress there was tachycardia, and at-
tacks simulating angina pectoris. The seminal tract was
likewise a frequent focus of infection both for tuber-
culosis and other suppurative processes. The demon-
stration that the entire seminal tract might be removed
without injury of the prostate, urethra, bladder or
testicle had brought another region into the radically
curative field of surgery.
Dr. Young completed his address by showing lantern
slides of anatomical peculiarities that predisposed to
focal infection and systemic absorption, and of the
pathological changes which led to toxemia or sepsis, and
described several surgical measures by which they might
be eradicated.
Dr. Thomas McCrae of Philadelphia stated that it
might be said that pelvic inflammatory disease in the
male was now coming into its own. They had heard a
great deal of pelvic inflammatory disease in the female,
but pelvic inflammatory disease in the other sex was
probably just as important. From the standpoint of
internal medicine there were several ways to approach
this subject. First he would emphasize the importance
of keeping it in mind. If a patient came with symp-
toms of disturbance of sexual functions or symptoms
of genitourinary disease of course attention was di-
rected to the genitourinary tract, but if there was
nothing in the symptoms of the patient to suggest dis-
ease or disturbance of the genitourinary tract, it was
not so easy to discover the etiological factor. It was
only by keeping the genitourinary system in mind as a
possible source that one would avoid the most serious
errors. Disease of the prostate, verumontanum, and
seminal vesicles might be responsible for a general
nervous disturbance. As an instance of this the case
of a young man about whom the speaker had been con-
sulted by the head of large corporation might be cited.
This young man did well for a time, and then began to
slip back and to become inefficient. The head of the
corporation stated that if the man did not do better he
would have to discharge him. In consultation the man
was very frank and realized that he had lost his grip
on things. He said he could not work as formerly, he
was beginning to be the victim of fear and anxiety
and realized that in transacting his business he did not
make a good impression. The man did not drink, and
there were no localized hints at all as to his condition.
In the examination it was found that he had a general
prostatitis and inflammation of the verumontanum,
which had given no symptoms of any account. He was
treated merely for this local condition, and by the end
of three months there was a tremendous change for the
better. This man had gained his health and efficiency.
According to the statement of the head of the corpora-
tion who brought him to me for consultation he was
as efficient as ever. Often in cardiac conditions which
were called functional one would find the cause in the
genitourinary system. These might be designated as
anxiety or fear neurosis. Dr. McCrae said he did not
want to give the impression that all nervous diseases
in the male were due to prostatic disease, but as to the
influence of the prostate on the heart too much could
not be said. If one believed there was an internal secre-
tion it would be easy to understand and would go far
to explain the psychic phenomena associated with dis-
turbances of the prostate. Furthermore, the point
should be emphasized that many of these cases gave no
local symptoms, and much work had to be done to find
the far distant cause. Again, it was easy to recognize
a local cause if one took the trouble to make an ex-
amination
Dr. Edward L. Keyes said that any paper written by
Dr. Young was so complete that it rarely admitted of
discussion. He wished first to confess that he did not
get the results that Dr. Young did by excising the
tuberculous seminal vesicles. In some cases he had
been fortunate, but as a rule he left the seminal vesicles
alone. Dr. Young had stated that rheumatism was
unusual in cases of infection of the kidney. One in-
stance had come under his observation, however, in
which rheumatism was the only systemic condition due
to a renal stone. This patient was cured of his rheu-
matism by removal of the stone. Dr. Young did not
make any reference to the acute pyelitis of infancy in
which the symptoms were often so remote from the
urin?.ry tract. Two striking points in reference to the
pyelitis of infancy were the fact that the symptoms of
chronic infections were usually referred to the digestive
tract, while acute infections in infancy were often
hyperacute. Repeated chills in infancy could only mean
malaria or acute inflammation of the kidney. Atten-
tion had been called to the great variety of conditions
that might be traced to infections of the genitourinary
tract. The speaker had seen several cases that were
distinctly of the cerebral type, and it was only in the
course of a routine examination that the urinary origin
of the symptoms was discovered, and relief was pro-
cured by drainage.
Dr. Walter A. Bastedo said that the important point
emphasized by the speaker was that in searching for
the cause of obscure internal trouble one should not only
look over the teeth, tonsils, and abdominal organs, but
should also investigate the genitourinary organs. Dr.
Young had referred repeatedly to Dr. Eugene Fuller's
work in demonstrating infection of the seminal vesicles.
It might be of interest to know that Dr. Larkin, at Dr.
Fuller's request, had removed the prostate and seminal
vesicles from about 35 consecutive male cases brought
to autoposy, and that in a large number of these there
was an infection, usually of the streptococcic variety.
In regard to the prostatic cases with retention in which
there was a low phthalein output, high filtrate nitrogen,
and high blood pressure, so that there seemed definite
kidney disease, but which, following proper drainage,
lost their kidney picture, the speaker asked Dr. Young
if he thought the kidney disturbance could be attributed
to infection. Would it not rather be due to the damming
up of the urine, for though the germs could still be
found in the urine, the kidneys were relieved? There
was another influence not always thought of, and that
was the effect of venous back pressure on the kidney.
In the laboratory if one clamped off the renal vein only
a little bit the urine flowed slow-er or even ceased, and
this indicated that a comparatively small venous back
pressure might cause urinary stagnation in the kidney
and ureter, and thus favor urinary infection. This
would suggest that urinary infection might be due to
disturbances of the circulation. In regard to the
psychic state with the anxieties and phobias, a distinc-
tion must be made between the genital and the urinary
disturbances. In the strictly bladder and ureter and
kidney troubles we did not have these phobias, but in
the affections of the genital tract they were very com-
mon ; and as they occurred whether the condition was
an infection or not, it would seem that these psychic
disturbances were genital or sexual. In these cases
whatever would remove the sex tension would tend to
relieve the psychic symptoms, whether it was removal
of the prostate, or draining the seminal vesicles, or
straightening out the uterus, or functional relief.
The speaker had had cases of supposed ulcer
of the stomach or duodenum, and cases with cardiac
irregularities, in whom the psychic sex disturbance
was apparently the underlying fault. For example, in
the cases supposed to be ulcer one could find no blood
in the stools or stomach contents, and no positive string
test, though a high hydrochloric acidity; and if one
put these patients to bed on an ulcer cure, though they
improved for a short period they would soon get very
restless, and if they were then kept in bed would have
a return of their symptoms. These cases occurred in
persons out of wedlock, and after a few days treatment
for hyperchlorhydria, one did well to get them into
vigorous activity such as horseback ridine, or golf, or
send them into the woods for a hunt. It did not seem to
the speaker that these were cases of genitourinary in-
fection, but simply psychic disturbances related to the
sexual organs whether there was an infection or not.
In closing Dr. Bastedo said he did not think these
Dec. 16, 1916]
MEDICAL RECORD.
1097
psychic patients should always be sent to the genito-
urinary specialist, but that often they might with ad-
vantage be sent to any physician who was also a
philosopher.
Dr. J. Bentley Squier said that though this work
was very interesting, much remained to be learned
clinically and Dr. Young had shown that this was also
his opinion. The genitourinary tract might be divided
into the upper and the lower tract. Most of the infec-
tions of the upper tract had been found to be ascending
infections. The lymphatics were so arranged that in-
fection from any part of the abdomen might reach the
kidney though this route. When medical men took up
the study of neurasthenia they got into the habit of
thinking that sex neurasthenia was at the bottom of
all neurasthenia and as due to some lesion of the
prostate, or seminal vesicles, or elsewhere in the genito-
urinary tract. But one might also include disturbances
of the internal secretions, first of the adrenals and then
of the hormones, which would result in lowering the
threshold of the nervous system. If this source of irri-
tation were relieved the patient would be cured. This
was a very fascinating theory and might be taken for
what it was worth. It should be remembered that focal
infection might occur anywhere from the top of the
head to the soles of the feet, or from the mouth to the
anus. As a result one might have heart disease, or
rheumatism, or many other conditions, and any pro-
cedure from the removal of the teeth to a curettage of
the uterus might be undertaken for the purpose of cur-
ing the condition. So that one might say that where
a patient had a condition that might be due to focal
infection, the broader the physician was the more likely
was he to be correct in discovering the primary source
of the trouble and the more successful would he be in
dealing with a focus of infection. If a man followed
a specialty that might embrace a focus of infection in
its field, he was prone to find such a focus there.
Dr. Reginald H. Sayre said he agreed with what
Dr. Squier had said regarding the importance of finding
where the particular focus of infection was that was
making the trouble. It might be possible to cure a
patient by pulling a tooth or draining a seminal vesicle,
but if this result was to be attained it must be done
early. A joint was not cured in this way after an
arthritis was established. When that stage was reached
the joint should be given rest and protection. Dr. Sayre
stated that he had seen many cases in which the teeth
had been pulled or the tonsils extirpated, or a vesicu-
lectomy performed and the infected joint grew worse,
because nothing had been done to protect it; it did not
get better until it was treated locally. One should not
forget the importance of rest and protection to an in-
flamed part as well as the removal of the focus of the
disease.
Dr. Emanuel Libman said that while he appreciated
that focal infections were of great importance in caus-
ing various forms of disease and that their role had
been for a time underestimated, at the present time
there was a tendency to blame conditions upon local
foci that were not due to such a cause. This was par-
ticularly true with relationship to the question of chronic
appendicitis causing various forms of infections. The
chronic appendices generally showed more or less com-
plete obliteration. The lesion consisted of a production
of fibrous tissue and it did not appear clear how such a
focus should be the origin of any infections. It was
only rarely nowadays that appendicitis cases in which
pus was present, were allowed to become chronic. The
only general effect that one could imagine could come
from a chronic appendicitis would be by whatever in-
toxication was caused by stasis in the ileum and by
reflex action especially on the pylorus. It was im-
portant to be careful in one's use of the term "rheuma-
tism." The term rheumatism should be used in the old
clinical sense and in no other way. The disease which
we called rheumatic fever was characterized by the
tendency to recur, by the lack of suppuration in any
joints, by the tendency to the development of peri-
carditis, chorea, and verrucous endocarditis with
Aschoff bodies present in the heart muscle. The only
primary focus that was considered as existing in rheu-
matism was a preliminary tonsillitis. Therefore, if
any local focus was present aside from a tonsilitis, the
case could not be properly grouped as rheumatic. Cases
of joints infected with hemolytic or non-hemolytic
streptococci should be called "streptococcus arhtritis"and
not rheumatism. Up to the present time it had not been
definitely proven that streptococci caused rheumatism.
If these cases could all be proven to be due to strepto-
cocci, then the term rheumatism could be dropped and
the name streptococcus arthritis used to replace it. It
was better, however, for the present, to use the term
rheumatism for this special group of cases as described
above and try to find out what they were due to. The
speaker believed that Dr. Rosenow's theory of mutation
of the streptococcus and pneumococcus must be ac-
cepted. At the Mount Sinai Laboratory they had for
many years believed in such mutation, as evidenced by
the publication of the work by Drs. Buerger and Rytten-
berg in 1907. The speaker took part in those studies at
that time, and since then Dr. Aschner and he made
studies from time to time, and would in the near future
publish some further examples of mutation. It was
much more common to see a pneumococcus take on
streptococcus features in the body than the other way
around. The speaker agreed with Dr. Bastedo in re-
gard to his statements concerning the importance of
sexual tension as an etiological factor. To show how
far in error one might go in blaming conditions on a
focal infection, the speaker was now trying to prevent
a woman from having her tonsils and teeth removed for
headaches which she herself had confided to him are
due to such tension.
Dr. Young, in closing the discussion, said he wanted
Dr. Bastedo to realize that he did not want everybody
sent to the genitourinary surgeon, but he wanted the
general practitioner educated so that he would realize
the importance of a rectal examination and that he
might know that it was possible to get a portion of the
seminal vesicle and make an examination under the
microscope which would give him definite information.
In regard to the back pressure and infection, there was
no question but that back pressure led to a deterioration
of the kidney; it lowered the functional capacity and
increased the output of urea, etc., and thus made the
secondary changes more rapid in the heart and arteries.
The neurological and psychical disturbances were not
necessarily due to the focal infection but to the results
produced by the focal infection or possibly by a cicatrix.
In a chronic vesiculitis there might be a cicatricial con-
tracture and from it pressure that caused a neurosis.
The neuroses coming from that small area were widely
separated and of great importance.
£>tate Hfofctral Utrntsing fSoarda.
STATE BOARD EXAMINATION QUESTIONS.
College of Physicians and Surgeons of Ontario.
Final Examinations, May, 1916.
medicine.
Answer five questions only.
1. Describe the clinical course of an average case of
acute lobar pneumonia terminating favorably, giving the
usual physical signs noted over affected lung at various
stages of progress.
2. Discuss the causation, symptoms, differential diag-
nosis and treatment of catarrhal jaundice.
3. Describe the causation, symptoms, differential diag-
nosis and treatment of epidemic cerebro-spinal menin-
gitis.
4. (a) Give the causation, diagnosis, course and
treatment of tinea tonsurans (ringworm of the scalp).
(6) Give the diagnostic features and detail treatment
of scabies.
5. What are the most common types of growth in
brain or brain membranes causing symptoms of cerebral
tumor? Discuss the general symptoms of such growths,
and give localizing features of a growth in any selected
area of cerebrum.
6. A business man, 48 years old, of sedentary habits,
with good appetite and using alcohol and tobacco mod-
erately, consults you for frequent headaches and
tendency to be forgetful. On examination you find a
high tension pulse, systolic blood pressure of 190 mm.,
while urine shows a trace of albumin and a few hyaline
casts. Describe further examinations you would think
necessary, and discuss diagnosis, prognosis, and treat-
ment.
SURGERY.
1. (a) Describe the symptoms of fracture of the
spine at lower dorsal region. (6) Give treatment,
(c) Give indication for operation, (d) Describe the
operation.
2. (a) In what diseases of the kidneys do you con-
sider its removal advisable? (6) Give differential diag-
1098
MEDICAL RECORD.
[Dec. 16, 1916
nosis between any two of these diseases, (c) Describe
the operation for removal.
3. (a) Give symptoms of ulcer of the stomach. (6)
From what other diseases must it be differentiated?
(c) Under what conditions is operation necessary? (d)
Describe the operation.
4. (a) Describe the symptoms of a strangulated
hernia (inguinal). (6) Give methods of treatment.
(c) Describe the operation when the intestine is
gangrenous.
5. (a) Describe the symptoms of a fracture of the
middle of the femur. (6) Give treatment in detail in
an adult.
OBSTETRICS AND GYNECOLOGY.
1. Cystitis: give causes, course and treatment.
2. Describe the operation for (a) a recent laceration
of the perineum, (b) an old laceration, and (c) mention
the most important features of each case.
3. What conditions are often mistaken for pregnancy?
How would you establish a diagnosis?
4. Define accidental hemorrhage and give its prog-
nosis and treatment.
5. Give (a) the characters and duration of normal
lochia, (6) causes of suppression, (c) causes of pro-
longed continuance.
ANSWERS.
MEDICINE.
1. Acute lobar pneumonia "begins with a severe and
usually protracted chill, followed by a rapid rise of tem-
perature, 103° to 104° P., a strong, full, but rapid pulse,
soon showing evidence of embarrassed cardiac action.
There are also present pain near the nipple, aggravated
by piessure, breathing, or coughing; shortness of
breath, the number of respirations increasing to 40, 50,
or more a minute; disturbance of the ratio between
pulse and respiration; and cough, at first short, ringing,
and harsh, followed by a scanty, frothy, mucoid expecto-
ration. The sputum soon becomes transparent, viscid,
and tenacious, changing about the second day to the fa-
miliar rusty sputum. The quantity is increased and a
yellow color is assumed as the disease advances. The
prostration is pronounced. The face is flushed, espe-
cially over the malar bones. The lips are more or less
blue and herpes may be observed. Epistaxis, headache,
sleep.essness, and gastric disturbances are common. The
tongue is coated, the appetite is impaired, and there is
constipation. Delirium is sometimes present. The urine
is small in amount, highly coloied, deficient in chlorides,
and often slightly albuminous. The blood shows evi-
dences of leucocytosis. The fever usually reaches its
maximum within twenty-four hours and continues high,
with diurnal remissions, until the fifth, seventh, ninth,
or eleventh day, when a crisis occurs, and within twen-
ty-four hours all the symptoms are lessened, the fever
absent, and convalescence is established. Occasionally,
the termination is by lysis.
"Physical signs over the affected lung : Palpation dur-
ing the first stage shows the vocal fremitus to be more
distinct than normal. In the second stage, the vocal
fremitus is markedly exaggerated, except in case of oc-
clusion of the bronchi by secretion. In the first stage,
the percussion note is slightly impaired at times, having
a hollow or tympanitic quality. In the second stage
there is dullness over the affected parts, with an in-
creased sense of resistance. In the first stage there is
a feeble vesicular murmur, associated with the true
vesicular (crackling) rale, heard at the end of inspira-
tion only. In the second stage there is harsh, high-
pitched, bronchial respiration, at times resembling a
to-and-fro metallic sound, except when the bronchi are
filled with secretion. Bronchophony is present and at
times pectoriloquy may be heard. In the third stage,
the bieathing changes from bronchial to bronchovesicu-
lar and the crepitant rale returns. As resolution pro-
ceeds, the breath sounds are associated with large and
small moist and bubbling rales." — (Hughes' Practi
Medicine.)
2. Catarrhal JAUNDICE. "Causes. — Extension of gas-
trointestinal inflammation is the most common cause.
Atmospheric changes, passive congestion of the liver,
and the infectious fevers are less frequent factors.
"Symptoms. — The affect inn begins with epigastric
distress, coated tongue, impaired appetite, nausea, with
perhaps vomiting, looseness of the bowels, and slight
feverishness. In from three to live days the eyes be-
come yellow, and jaundice gradually appears
over the whole body; the feverishness disap-
pears, the skin becomes harsh, dry, and itchy,
the bowels constipated, the stools whitish or
clay-colored, accompanied with much flatus and col-
icky pains; the urine heavy and dark, loaded with
urates and containing biliary elements. When the
jaundice is complete, the surface is cold, the heart's ac-
tion slow, the mind torpid and greatly depressed, and
there is pain or tenderness on pressure over the hepatic
region. The symptoms subside within a few days after
the jaundice appears, but the depression, discoloration,
and condition of the bowels persist for one or two
weeks."
"Differential Diagnosis.— When jaundice is induced
by obstruction to the outflow of bile other than that pro-
duced by inflammation, such as arises from stricture of
the common duct, tumors of the abdominal viscera, for-
eign bodies such as gall-stones and parasites, fecal ac-
cumulations, spasms of the bile ducts due to emotion,
etc., the symptoms of these different affections will be
found associated with the icteroid manifestations. Non-
obstructive or hematogenous jaundice is unassociated
with inflammatory changes in the bile ducts, and arises
from disintegration of the blood or hemolysis. It dif-
fers from catarrhal jaundice in its history, the absence
of clay-colored stools, and less staining of the urine.
"Treatment. — The patient should be placed at rest in
bed and the diet restricted to milk and lime-water,
broths, eggs, lean meats, etc., care being taken to elim-
inate all starchy, fatty, or saccharine substances. Cal-
omel, gr. Vi, with sodium bicarbonate, gr. iij, should be
then given every two hours until twelve doses are taken,
followed by Hunyadi water. Sodium phosphate, 3j,
may also be given, well diluted, every four hours. The
dry, itching skin may be relieved by diaphoresis, a hot
bath containing potassium carbonate night and morn-
ing, or a weak carbolic acid solution. If insomnia is
present potassium bromide, gr. xxx, may be adminis-
tered. Diuretics are indicated if the urine continues
scanty, preference being given to the alkaline waters,
potassium bitartrate lemonade, and spirit of nitrous
ether, ngx to xx. In cases in which the constipation per-
sists, aloes, podophyllum, colocynth, and other chola-
gogues should be employed. Irrigation of the colon
once daily with cold water, gradually increasing the
temperature, is often very effective." — (Hughes' Prac-
tice of Medicine.)
3. Cerebrospinal Meningitis. Causation. — The dis-
ease is caused by the Diplococcus intracellulars menin-
gitidis; other microorganisms are also supposed to be
capable of causing the disease. Predisposing causes
are bad hygiene, overcrowding, foul air, poor food. The
diplococcus is believed to gain entrance to the body
through the nasal mucous membrane, and the infection
leaves the body through the same channel. "Carriers"
may transmit the disease through their nasal discharge.
Symptoms: Sudden onset, with headache, vomiting,
rigors, stiffness of neck and back producing opisthoto-
nos, pulse full and rapid, temperature about 102° P.,
photophobia, delirium; Kernig's sign is present, and the
diplococci may be found in the cerebrospinal fluid after
lumbar puncture; the tache cerebrale may be observed,
and leucocytosis is present. The diagnosis is made
from the symptoms, chiefly the presence of Kernig's
sign and the diplococci in the cerebrospinal fluid. In
typhoid fever the onset is gradual, the temperature is
characteristic, the opisthotonos and Kernig's sign are
absent, there are no diplococci in the cerebrospinal
fluid, and Widal's reaction may be present. Tuber-
culous meningitis is not epidemic, is not of sudden on-
set, and a primary focus of tuberculosis may generally
be detected elsewhere. Treatment : Isolation in an airy
room, rest in bed. nourishing diet, ice bags to the nape
of the neck, morphine for the pain, bromides for the
restlessness, lumbar puncture to relieve the symptoms,
and the injection of Flexner's serum. Stimulation may
be necessary.
4. Tinea tonsurans (ringworm of the scalp) is a con-
tagious affection due to the trichophyton fungus which
invades the hair and hair follicles. It generally occurs
in children, and is characterized by small circumscribed
patches of baldness in which the hair is diseased and
often broken off close to the scalp. Vesicles, pustules,
and scales are observed. The patches spread and may
be as large as a silver dollar. Itching is a constant
symptom. The diagnosis is made certain by the pres-
ence of the fungus; a hair should be extracted, im-
mersed in liquor potassa?, and then examined under the
microscope. Vigorous and persistent local treatment is
Dec. 16, 1916]
MEDICAL RECORD.
1099
required. The hair of the affected part should be cut
close, and the head washed daily with soap and hot
water, or an ointment of oleate of mercury, or of sul-
phur should be applied twice a day. Treatment must
be continued as long as the fungus is present.
Scabies. — The diagnostic features are the presence of
the itch mite (acarus scabiei) and its burrows. The
eruption is multiform and generally on the flexor sur-
faces of the body, and the itching is intense and is worse
at night. Treatment consists of a hot bath, followed by
the application of sulphur ointment (one dram to the
ounce of petrolatum) every night for a week; the bed
linen and underclothes should be sterilized. After the
interval of one week treatment must be undertaken
again for a week.
5. The common types of cerebral growths are the tu-
bercle, gumma, sarcoma, carcinoma, and cysts. The
general symptoms are those of apoplexy: There may
be prodromal symptoms such as vertigo, pain in the
head, or impairment of memory; but as a rule the at-
tack is sudden with vertigo and unconsciousness; there
may be retention or incontinence of urine, the urine has
a high specific gravity and may contain albumin; hemi-
plegia generally ensues; the tongue protrudes toward
the affected side; aphasia (either motor or sensory)
may be present; the face is flushed, breathing is ster-
torous; the body temperature is first subnormal and
then elevated; the pulse is slow and full; in severe cases
the pulse becomes weak, and the respirations become
of the Cheyne-Stokes type; the reflexes are abolished.
If the tumor is in the prefrontal region, there may be
no symptoms at all, or mental enfeeblement, disturb-
ances of smell and vision, motor agraphia and aphasia.
6. A complete physical examination should be made,
noting especially the condition of the heart, arterial
walls, and abdominal organs; the diastolic blood pres-
sure should also be obtained; the urine should be ex-
amined, noting the specific gravity, 24 hours quantity,
presence of sugar and indican, and the amount of urea
excreted; the patient should be questioned about the
amount of rest, exercise, and recreation (including va-
cation) which he takes; the eyes should be examined
by a competent oculist and any errors of refraction
should be corrected ; a Wassermann test should be made.
The diagnosis lies between nervous fatigue, eye-
strain, simple hypertension, gastrointestinal autointoxi-
cation, arteriosclerosis, chronic interstitial nephritis,
and syphilis. Prognosis. If the condition is dependent
upon causes which may be removed, the prognosis is
fairly good so long as there are not marked changes
in the bloodvessels. With organic arterial changes
there is danger that these symptoms may be precursors
of cerebral hemorrhage or thrombosis, in which case the
outlook for future health and usefulness is bad, and for
life doubtful. Treatment. The indications are: — For
gastrointestinal autointoxication, the diet must be regu-
lated, the total amount limited, and the quantity of pro-
teids restricted; laxatives, especially salines, should be
given. For nervous fatigue, more sleep, or a vacation
may be required. Syphilis requires cautious treatment
with mercury, arsenic and potassium iodide. Arterio-
sclerosis requires a restricted diet (as just given for
autointoxication), also potassium iodide (10 grains,
three times a day) for a long period, nitroglycerin (gr.
1/100 to 1 50) may be tried, and if no bad effects are
noticeable in heart, circulation or urine, it may be used
as required; sodium nitrite may be used instead; the
patient should avoid overeating, constipation, and ex-
posure to chills, and he should limit his business activi-
ties (at least for a time) ; alcohol and tobacco should
be limited to the smallest amount compatible with
physical comfort, and beer and heavy wines should be
avoided. Moderate exercise as walking, golf, etc.,
should prove beneficial. Chronic interstial nephritis re-
quires the same treatment as just outlined for arterio-
sclerosis, but in addition it might be advisable to avoid
red meats.
SURGERY.
1. In fracture of the spine in the lower dorsal re-
gion, there will be paralysis of the muscles of the lower
limbs, with total anesthesia of legs and gluteal and
perineal regions ; there may be paralysis of the bladder
or retention of urine with overflow, according as the
vesical center is or is not involved; there will be incon-
tinence of the feces, ine extent of the paralysis and
anesthesia depend on the lesion to the cord; if only
one side of the cord is affected, only one limb will be
paralyzed and anesthetic. The parts immediately above
the lesion are hypersensitive, and there is a zone of pain
around the body ("girdle pain"). Bedsores arise on
very slight irritation, cystitis usually comes on from
septic infection, the temperature and pulse are variable
(according to the amount of toxic absorption). "The
treatment naturally varies with the character of the
case. The patient is carefully placed on a prepared
bed, the greatest gentleness being used in handling and
lifting him, for fear of increasing the damage to the
cord. The bed must be firm though not hard; perhaps
the best type to employ is a horsehair mattress placed
over fracture boards; nothing more soft or yielding is
permissible. Spring beds and wire-wove mattresses are
most undesirable. A water-bed is required in the later
stages, but should not be used at first, as it is scarcely
firm enough. The shock resulting from the accident is
treated in the usual way by warmth and, if need be, by
stimulants; but it must be remembered that anesthetic
regions of the body can be easily blistered or burnt by
hot-water bottles, unless carefully guarded by flannels.
When reaction has occurred, a more thorough examina-
tion of the patient can be made, and the subsequent
course of action decided on. In many cases, as soon as
the patient is laid flat on a bed, the displacement reme-
dies itself, especially if the spine has been comminuted,
and then the treatment must be symptomatic, as also
after reduction or operation, where the paraplegia per-
sists or is only slowly recovered from. He is kept in
bed, absolutely flat, and with the head low; perhaps
some form of mechanical support — e. g., a plaster of
Paris or leather jacket — may be considered advisable;
but its application is always a matter of difficulty, and
in the early stages it does but little good. Food is reg-
ularly administered, and at first must be light and
readily assimilable. The chief care of the attendants
must be directed to the skin, bladder, and bowels." —
(Rose and Carless' Manual of Surgery.)
Indications for operation (laminectomy). — When the
cord is not completely severed; in fractures of the
arches alone when the cord is pressed upon; when the
paraplegia comes on slowly, after an interval. When
there is complete local destruction of the cord no opera-
tion should be done.
Laminectomy. — "The patient is placed either prone or
lying on his left side with a pillow supporting the chest,
and the spinous processes of the vertebrae to be dealt
with are exposed by raising a rectangular flap of skin
and fascia. When there are signs of fracture of the
neural arches, the center of the flap should lie over the
broken vertebra?. When there are no signs of fracture,
the site of the incision is determined by the spinal
symptoms. The muscles, along with the periosteum,
are separated from the spines and laminae, and the
hemorrhage, which is often very free, is arrested by
pressure and forceps. The interspinous ligaments are
then divided with scissors, and the spines snipped off at
their bases with bone pliers. The ligamenta subflava
are next divided close to the bone and the lamina? sawn
across and levered out, or cut away with rongeur for-
ceps. The fatty tissue outside the dura is separated,
and any veins that are torn are tied. The extra-dural
space is now examined by pushing aside the dura with
the enclosed cord, and any blood clots or fragments of
bone which may be present are removed. If it is neces-
sary to open the dura, it should be securely sutured
again to prevent leakage of cerebrospinal fluid. The
divided muscles are brought together with catgut
sutures, but, as there is usually a good deal of oozing
for some hours after the operation, a drainage tube
should be inserted down to the gap in the bone, and left
in position for forty-eight hours. Special care must be
taken to avoid soiling of the dressings by discharges
from the paralyzed bowel and bladder." — (Thomson
and Miles' Surgery.)
2. Removal of the kidney may be advisable in exten-
sive tuberculous disease of the kidneys, calculous pyo-
nephrosis, hydronephrosis, malignant disease, and rup-
ture of ureter or kidney if complications are present.
In any case, before deciding to remove one kidney it
must be positively ascertained that the patient has an-
other kidney capable of performing its functions.
Tuberculosis of the kidney shows polyuria, acid urine
which may contain pus or blood, the sediment may con-
tain tubercle bacilli. If no tubercle bacilli are found
microscopically, some of the sediment injected into a
guinea pig will cause tuberculosis in that animal. Cys-
toscopy examination with catheterization of ureters
will show which kidney is affected, and tuberculous ul-
cers in the bladder may also be detected close to the
ureteral orifice.
1100
MEDICAL RECORD.
[Dec. 16, 1916
Malignant disease of the kidney gives hematuria,
pain in loin and thigh, and emaciation. A tumor
may be palpable. Cystoscopic examination gives none
of the features noted above, and there are no tubercle
bacilli in the urine.
Nephrectomy. — "The abdominal operation is chiefly
utilized when the organ is much enlarged, on account
of the readier access obtained, especially to the pedicle.
The peritoneum is likely to be opened, and may be ex-
posed to septic contamination, when the pelvis and the
upper part of the ureters are distended with decompos-
ing pus, as is frequently the case; but this is easily pre-
vented. Drainage is obtained for the cavity left after
the removal of the organ by a counter opening made
through the loin. One great advantage is that the
other kidney can be first examined, if required, and its
condition ascertained. As to the technique, theie is fre-
quently no necessity to open the peritoneal cavity, since
the kidney is almost always enlarged, but an opening
is often made, intentionally or accidentally. The
colon and peritoneum are peeled off the organ and dis-
placed inwards; it is then freed from its adhesion to
surrounding tissues, the surgeon endeavoring to keep
outside its true capsule, but inside the layer of con-
densed perinephric tissue. Special precautions must be
adopted in dealing with the deep aspect of the tumor,
particularly on the right side, where it is occasionally
adherent to the inferior vena cava. The mass is now
lifted from its bed, and its pedicle, consisting of the
ureter and renal vessels, isolated. These latter are se-
cured separately by ligature and divided, a clamp being
applied to the distal ends. The ureter is dealt with in
the same way, small pieces of gauze being packed around
so as to receive any secretion which may escape; the
exposed mucous membrane in the portion which is left
is carefully touched over with pure carbolic acid. The
kidney thus freed is removed, and the wound in the ab-
dominal parietes closed in the usual way, provision for
drainage having been previously made either through
the loin or from the front. Considerable shock is often
experienced from this operation and the death rate is
somewhat high. Occasionally the perinephric adhesions
are so firm and extensive that the only practicable
plan of removing the organ is to enucleate it from with-
in the capsule as far as the hilum; the capsule is then
torn or cut through so as to expose the pelvis and renal
vessels, which are secured." — (Rose and Carless' Man-
ual of Surgery.)
3. Ulcer of the stomach. Symptoms. — Pain, which
is intermittent in character, localized in the stomach,
and coming on soon after a meal; vomiting, which also
occurs soon after eating, and often relieves the pain;
hematemesis is common; examination of the gastric
contents shows an excess of free hydrochloric acid.
It is to be differentiated from cancer of the stomach,
duodenal ulcer, gastralgia, gastritis, pylorospasm, hy-
persecretion, cholecystitis, cholelithiasis, and renal cal-
culus.
Operation is indicated when the hemorrhage is copi-
ous and recurrent, when medicinal treatment has been
given a fair trial and no cure has been made, when
after apparent cure a relapse has occurred, when per-
foration occurs, when adhesions about the stomach in-
terfere with the proper performance of its functions.
Posterior gastroenterostomy. — "The abdomen is opened
by a vertical incision to the right of the middle line
above the umbilicus. The stomach, transverse colon,
and omentum are drawn out of the wound and turned
upward, and an opening is made in the mesocolon near
its root, so as to expose the posterior surface of the
stomach; a portion of stomach at the lowest part of
the greater curvature is selected for the anastomosis.
The upper part of the jejunum is then found by passing
the fingers along the under surface of the mesocolon
immediately to the left of the spine, and the highest
available portion of it brought into contact with the
stomach in such a way that the loop of bowel selected
runs from right to left (Mayo). An anastomosis is
then made between the stomach and jejunum, an
ellipse of mucous membrane being excised from each
viscus. The edges of the opening in the mesocolon are
then stitched over the line of junction, so as to bury
it and prevent any hernial protrusion through the gap.
r being cleansed, the viscera are replaced in the
abdomen, and the wound in the parietes closed. When
the patient has recovered from the anesthetic he is
propped up in bed with pillows." — (Thomson and Miles'
Sllf:
4. Symptoms of strangulated licniia: General. —
"Severe pain comes on suddenly after some effort, at
first referred to the umbilicus, and subsequently to the
site of the hernia. This is accompanied by some shock.
The pulse is weak, and, though slow at first, becomes
rapid; the skin is cold and clammy; vomiting occurs,
and soon becomes frequent and fecal-smelling. Consti-
pation is complete, though both feces and flatus may
be passed at first from the lower bowel. The patient
generally becomes exhausted from the vomiting and in-
ability to take food. When gangrene occurs the tem-
perature becomes subnormal, the pulse very rapid and
weak, and the patient dies of toxemia from the general
peritonitis which follows gangrene. Local. — A tumor
forms at one of the hernial sites; or more often the
patient has been the subject of a hernia, which he now
finds to be irreducible, tense, tender, and without im-
pulse on coughing. If allowed to persist the sac and
coverings become gangrenous."
Treatment is taxis or operation. "Operative treat-
ment should be undertaken at once when gentle taxis
has failed. An incision is made over the sac, which is
then opened. There is usually fluid in the sac, so there
is no danger of wounding the gut. The fluid is washed
away, then the cause of strangulation is made out,
and a hernia knife guided up to it by a finger or broad
hernia director. The constriction is nicked in one or
two places and the gut is drawn down so that the site
of strangulation may be examined. Omentum is liga-
tured and removed. If the patient is profoundly col-
lapsed and will not bear a prolonged operation, an
artificial anus is established by dividing the constriction
outside the sac, so as not to open the peritoneal cavity.
The loop of bowel is then opened to give free exit to the
feces. Most of the cases which have to be treated in
this way are so bad before treatment is commenced that
a fatal termination must be expected. If the patient
can possibly stand it, immediate resection gives the best
chance, and with Murphy's button or a bobbin much
time can be saved. A radical cure is advisable after the
strangulation has been relieved, unless the patient's
condition contraindicates it. Liquid food is given at the
end of twenty-four hours, and the bowels need not be
disturbed for five or six days, when castor oil may be
given." — (Aids to Surgery.)
5. Symptoms of fracture of the middle of the femur.
— History of injury; disability; pain on movement;
preternatural mobility; crepitus; shortening of the
limb, deformity (simple overriding of fragments, or
angular deformity). The lower fragment is drawn
upward and inward, and may be either in front of or
behind the upper fragment; the ends of the fragments
can be felt by the surgeon. The thigh and leg are
slightly flexed and, generally, everted.
Treatment: "The limb is carefully washed and, if
hairy, shaved. Two long strips of strapping, three
inches wide, fixed below to a square piece of board V*
to % inch thick (slightly wider than the ankle opposite
the "two malleoli), which is known as the stirrup, are
heated and pressed against the lower third of the frac-
tured limb. They are here secured by short, thin pieces
of strapping 1 to lyi inches in width, passed in a
figure of 8 around the limb above the malleoli and end-
ing just below the fracture; the knee may be left un-
covered. It is necessary to see that the pull of the ex-
tension is exerted on the femur and not on the knee.
Large pads of wool should be introduced between the
malleoli and the sides of the strapping, to prevent the
skin over these processes becoming chafed. A cord is
fixed to the stirrup and passes over a pulley at the end
of the bed, and is there secured to a tin can which is
filled with shot up to the required weight. If now the
foot of the bed is raised on blocks, extension and
counterextension are obtained, the patient's body acting
as a counter-extending weight. When the fracture has
been manipulated into a good position under an anes-
thetic (it is always necessary to control the fracture
with some splints before the anesthetic is given), the
extension apparatus is applied, and Liston's splint is
bandaged to the limb. A proper splint of this kind
should extend from the axilla to below the foot, and it
is secured to the patient in three places: (1) round the
thorax, (2) round the limb at seat of fracture, and
(R) to the leg and ankle. In securing the thorax it
is necessary to take the first turn of the bandage round
the splint from within outward, and then round the
back of the patient's thorax, the direction of the band-
age in this way preventing the natural tendency of the
splint to rotate forward. Several turns should be taken
round the thorax in order to retain it in position. The
remaining bandages should be secured from without
inward, in order to check the tendency of the foot and
Dec. 16, 1916]
MEDICAL RECORD.
1101
leg to roll outward. In order to prevent the rotation
of the limb a method devised by Cheyne and Burghard
may be adopted. This consists in securing the limb at
the level of the popliteal space to a short splint, 8 by
4 inches, by means of a plaster of Paris bandage. The
presence of this splint effectually prevents any rotation,
either inward or outward. Special care must be taken
to see that the malleoli and the skin over the heel are
not subjected to any great pressure. If the fracture is
put up in this way it must be kept up for six to eight
weeks, and the amount of weight applied to the limb
must be varied according to the age of the patient and
the tendency to deformity. Roughly half a pound a
year will be found to answer most purposes, but if
there is much spasm the amount can be increased up to
20 pounds. At the end of six weeks, during which
period the limb should have been regularly massaged —
this can usually be done without disturbing the exten-
sion— the patient should be got up, and some form of
retentive apparatus applied. A Thomas's splint is a
very valuable form of apparatus, since it enables the
patient to get about, and allows of active movements
being undertaken, while he himself can hobble about on
crutches. If such treatment is not considered advis-
able, he should be kept in splints for eight weeks, and
then a'lowed to lie in bed without any apparatus on at
all, while the limb is regularly massaged, and he should
be encouraged to get up for a short time on crutches,
graduallv exercising the limb, until at the end of about
ten weeks he is walking on it as before."— ( Pye's
Surgical Handicraft). Some surgeons advise imme-
dj.o+p ^o,-at;m, nnd cut down on to the fractured bone
and, after reduction, fix the fragments by two or three
Lane's plates.
OBSTETRICS AND GYNECOLOGY.
1. Cystitis. — Causes: Retention of urine, tumors,
foreign bodies, calculus, ammoniacal urine, various
pathogenic bacteria producing (for example) gonor-
rhea, tuberculosis of genitourinary tract, pus in the
urine. Symptoms: Frequent urination, with tenesmus
and a burning sensation in the urethra; later on pain
in the bladder, hematuria, and the urine contains pus
and epithelial cells. Chills, fever, rapid pulse, and
headache may also be present. A feeling of weight or
pain in the pelvis is noticed. Treatment: Rest in bed;
the imbibition of plenty of milk and water, and the
avoidance of all highly seasoned food; laxatives; diu-
retics; sitz-bath; irrigation of the bladder with an anti-
septic solution ; hot fomentation and vaginal douches
are often helpful; sometimes intravesical medication is
necessary.
2. (a) Operation for recent laceration of the peri-
neum.— "The parts are cleansed and a pledget of sterile
cotton or gauze pushed up the vagina to stop any flow
from the uterus obscuring the wound. The sutures
(preferably of aseptic silk) are passed with a mod-
erately curved needle about 2 inches long as follows:
Beginning at the posterior end of the laceration (that
nearer the anus) , the needle enters the skin near the
edge of the wound and follows a circular course until
its point appears at the very bottom of the laceration
(a finger of the other hand in the rectum guarding
against its penetrating that canal) ; it then enters the
opposite side of the laceration at the bottom of the
wound and comes out of the skin opposite its point of
entrance, having followed a similar circular course to
that pursued on the other side where it first went in.
The ends are loosely tied or secured by catch-forceps,
until the requisite number of sutures are passed in a
similar manner (half an inch apart), when the wound
is again cleansed, the vaginal plug removed, and the
sutures tied tightly enough to coapt the parts without
injurious constriction, the order of succession in tying
being that in which the sutures were passed.
In "complete" lacerations — those of the third degree
—through the sphincter ani to the rectum, the opera-
tion is more difficult. The rectal tear is first stitched
with catgut sutures (a short, curved needle being used)
and going through the rectal wall only. The sutures
are tied on the inside, so that the knots are on the
mucus membrane of the bowel. They begin from above
and come down to the sphincter ani, the cut ends of
which are drawn out with a tenaculum while the su-
tures penetrate them. These catgut sutures need not
be removed; they will digest in the tissues and dis-
appear of themselves. The posterior wall of the va-
gina is next sutured with fine silk, from above down-
ward toward the hymen. Finally, skin sutures through
the perineum itself, including muscles of the pelvic floor
(as just described for lacerations of the first and sec-
ond degrees) complete the operation. The silk sutures
may be removed in about a week. Antiseptic dressings
are applied as after an ordinary labor, extra care being
taken to keep the wound aseptically clean by daily irri-
gation with the creolin solution." — (King's Obstetrics.)
(6) Operation for old laceration of the perineum. —
"Lateral tears are best repaired by the Emmett opera-
tion. With the patient in the lithotomy position, guide
sutures or tenacula are passed through the apex of
the rectocele and through each labium majus at the
lowest carnucute myrtiformes. By drawing on the lat-
eral suture and pulling the central suture downward
and to the opposite side, the lateral sulcus appears as
a triangle with the apex up in the vagina. This tri-
angle is denuded of mucous membrane by cutting off
long strips by means of forceps and scissors, or by dis-
secting the mucous membrane off in one piece. The
triangle on the opposite side is treated in the same
manner, and the denudation completed by removing
the mucous membrane between the bases of the triangles
and be'ow the central suture. Each lateral triangle is
closed by interrupted sutures of chromicized catgut or
silkworm gut, the latter being shotted. The needle,
which should be curved, is entered near the margin of
the wound on the outer side, passed deeply to catch the
fibers of the levator ani, and brought out at the bottom
of the sulcus, at a point nearer the operator; it is then
reinserted at the bottom of the sulcus, and passed up-
ward and backward in the rectocele, to emerge opposite
the point of the original insertion. The opposite tri-
angle is treated in the same manner, which leaves a
small raw area externally to be closed. The upper or
"crown stitch" passes through the skin of the perineum
below the lateral guide suture, then through the rec-
tocele below the central guide suture, and finally
through the tissues below the opposite guide stitch. As
many sutures as may be necessary are inserted below
this. If silkworm gut is used, the stitches should be
removed on the tenth day. The external genitals are
irrigated with weak bichloride of mercury solution after
each urination; catheterization should, if possible, be
avoided. The bowels are moved on the second day. In-
ternal douches are not needed unless there be infaction.
The patient should be kept in bed two weeks, and heavy
work and sexual intercourse forbidden for three
months." — (Stewart's Surgery.)
(c) The chief difference between the two operations,
is that in the recent condition denudation is unnecessary
(except for the possible trimming off of any ragged
edges of the wound).
3. The conditions which may be mistaken for preg-
nancy are, uterine fibroid, ascites, ovarian cyst (or
other tumor) , fat, pseudocyesis, and subinvolution of
the uterus.
Pregnancy. — Positive signs of pregnancy: Hearing
the fetal heart sound; (2) active movement of the
fetus; (3) ballottement; (4) outlining the fetus in
whole or part by palpation; and (5) the umbilical or
funic souffle. Doubtful signs of pregnancy : (1) Pro-
gressive enlargement of the uterus; (2) Hegar's sign;
(3) Braxton Hick's sign; (4) uterine murmur; (5) ces-
sation of menstruation; (6) changes in the breasts;
(7) discoloration of the vagina and cervix; (8) pig-
mentation and striae; (9) morning sickness.
Further, in pregnancy the tumor is hard and does
not fluctuate, it is situated in the median line, the
cervix is soft, the rate of growth of the tumor and the
general condition of the patient's health may help in
arriving at a diagnosis.
Uterine fibroid. — Menstruation is irregular and some-
times very profuse; absence of the signs of pregnancy:
the tumor is nodular, firm, irregular in outline, and
while generally placed somewhat centrally is not in the
median line, and is not symmetrical; the rate of growth
is irregular, being, as a rule, slow, but sometimes ex-
tending over years.
Ascites. — Absence of the signs of pregnancy; the ab-
domen is distended, but the shape varies with the posi-
tion of the patient; on lying down there is bulging at
the sides, the tumor fluctuates, and percussion shows
dullness in the flanks, with resonance in the median
line, but the dullness varies with the position of the
patient.
Ovarian cyst. — Absence of the chief signs of preg-
nancy; there may be the characteristic facies. the tu-
mor is soft, fluctuating, is more to one side, and does
not show fetal signs.
Fat. — Absence of signs of pregnancy, also of fibroid,
or ascites.
1102
MEDICAL RECORD.
[Dec. 16, 1916
Psendocyesis. — The uterus is not enlarged, and the
administration of a general anesthetic causes the col-
lapse of the "tumor."
Subinvolution of uterus.- — The uterus does not in-
crease in size, there is a leucorrhea, there is generally
pain in the back or ovarian region, there is a history of
irregular (and profuse) menstruation, and the signs of
pregnancy are absent.
4. Accidental hemorrhage is the hemorrhage which oc-
curs when a normally situated placenta separates (par-
tially or completely) from its uterine attachment. The
prognosis depends upon the recognition of the condition.
If there is an external flow of blood, and the condition
is recognized and treated promptly, the prognosis is
guardedly favorable; if there is no external flow of
blood, but the hemorrhage is concealed, the prognosis is
very grave, for the diagnosis may not be made suffi-
ciently early to allow of adequate treatment. In this
form, the maternal mortality is at least 50 per cent.,
and the fetal death rate is 90 per cent. Treatment:
"The chief indication is to evacuate the uterus as
speedily as possible, so that the uterine muscle will con-
tract and close the bleeding sinuses. If the bleeding
is slight no immediate intervention may be required ex-
cept to rupture the membranes. The patient should be
kept under close observation, and in bed. Chloride of
calcium, gr. xx every three hours, is useful by promot-
ing coagulability of the blood. A very tight abdominal
binder and an icebag upon the lower abdomen may help.
Generally in either variety of hemorrhage the cervix
should be dilated manually. After full dilatation the
delivery is rapidly completed by forceps or version, or
in dead or nonviable fetus by embryotomy. Firm com-
pression of the uterus is maintained manually by a
skilled assistant during delivery. • Precautions should
be taken against postpartum hemorrhage. When the
cervix resists manual dilatation and immediate delivery
is urgently demanded, vaginal cesarean section may be
performed. The effects of blood loss are combated as
in other hemorrhages." — (Polak's Manual of Ob-
stet rics.)
5. In the first four or five days the discharge is
bloody in character, and is called the lochia rubra; it
consists of placental tissue, decidua, blood, epithelial
cells, mucus, and microorganisms. For the next two or
three days the discharge is serosanguinolent, and is
called the lochia serosa; then for two or three weeks or
until the endometrium is regenerated, the discharge be-
comes creamy, and contains fat. cholesterin, epithelial
cells and leucocytes; during this period it is called lochia
alba. The discharge has a peculiar fleshy smell, some-
thing like fresh blood. Ordinarily the lochia continues
for from two and a half to five weeks. Suppression of
lochia may be due to infection or to obstruction of the
outflow. Prolonged continuance of the lochia may be
due to subinvolution of the uterus, posterior displace-
ments of the uterus, and retained secundines; the condi-
tion is more common in multipara? than in primiparae.
Diazo and Urochromogen Reaction. — Zucker and Ruge
regard the urochromogen reaction as more simple
in typhoid than the diazo reaction. Dilute 10 c.c.
filtered urine with water until it is colorless. Divide in
two test glasses and add to one 5 drops of potassium
permanganate solution 1 to 1,000, shake well and allow
it to stand for a minute. Then compare with the other
glass by daylight. The original glass should then give
a canary yellow color. — Miinchener medizinische Wo
enschrift.
Simulation of Albuminuria by the Injection of White
of Egg into the Bladder. — Hollande, Lepeytre and Gate
state that simulators have mixed white of egg with
their urine and have even injected it into the bladder in
order to obtain exemption from military service. It is
no simple matter to detect this fraud if the albumin is
added in small quantities. A solution of equal parts of
formol and crystalli/.able acetic acid should throw down
egg albumin in the presence of pathological albumin;
and 24 hours after the injection egg albumin will have
disappeared from the urine, while in the meantime it
steadily diminishes. The microscopic examination
should be negative. But tests that are trustworthy
in vitro may fail in the urine. Maurel's reagent, like
that above mentioned, precipitates egg albumin, but
also aceto-soluble albumin and albumose, these redis-
solving when the tube is shaken. The fact that the
authors have attempted to obtain specific precipitine
reactions and anaphylactic reactions suggests that they
are not entirely satisfied with inorganic tests. — Lyon
Medical.
Solvent for the Preservation of Eye Drops. —
Harman recommends solvent in which to preserve
eye drops :
Distilled water 1 pint
Methyl salicylate 2 grains
Oil of gaultheria 2 minims
Tincture of iodine 2 minims
The mixture is thoroughly shaken, poured into a
bottle, and allowed to stand for twenty-four hours,
when it may be used. Since aqueous solutions are
somewhat wasteful, this may be thickened with
gum arabic until it is so sticky that it will hang
as a round drop from a lachrymal probe. Atro-
pine, homatropine, and cocaine have the same
therapeutic action in this gummy as in aqueous
solution, and its use will effect a considerable re-
duction in cost when expensive eye medicines have
to be employed. — Birmingham Medical Review.
Kerosene Treatment in Laryngeal Conditions. —
T. M. Clayton advises the employment of kerosene
in cases of laryngeal diphtheria — together with
antitoxin — spasmodic croup, and so-called mem-
braneous croup in young children. The dosage is
thirty minims every four hours for three doses,
then ten-mimim doses three or four hours daily
until normal breathing has been established. The
unpleasant taste of the kerosene may be dis-
guised by sarsaparilla. — British Medical Journal.
Relief for Itching. — The following prescription,
while an old one, can be relied upon to give decided
relief in cases of itching from various causes:
R Menthol gr. vi
Methyl salicylate gr. xxx
Oxide of zinc 5iij
Lanoline ."ij
Vaseline 5iij
This ointment may be applied over the affected area.
— Bulletin general de therapeutique.
A Bladder Sedative. — This prescription is of-
fered as a remedy in the majority of forms of
bladder irritability, except where there is strong
alkaline decomposition:
If Potass, citrat grs. x-xx
Sodii bromidi grs. x-xx
Tr. belladonnas tm v-xv
Tr. hyoscyami Trj> xx-xl
Infus. buchu (recentis) . . .ad gi
Misce. Ft. mist.
Sig. : Two tablespoonfuls in water every'
four or six hours.
For Cleanliness and Curative Properties in
Otitis Media. — Coble, as well as others, uses car-
bolic acid, 40 to 60 minims, to one quart of water,
with which he irrigates the affected ear. When the
perforation is very large or the discharge has a foul
odor, the accompanying prescription gives good re-
sults:
|{ Boracic acid grs. xx
Ethyl alcohol ,-,j
The canal must be thoroughly cleansed with
boric acid solution, dried, then a diluted solution of
the above medicine dropped into the canal and al-
lowed to remain until all smarting disappears. To
accomplish this the patient should be made to lie
down on the well ear, or if both ears are affected
flat on the back. A solution of one to three is of
sufficient strength with which to begin the treat-
ment, and the strength can be gradually increased
until the original prescription can be employed. —
Indianapolis Medical Journal.
Medical Record
A Weekly Journal of Medicine and Surgery
Vol. 90, No. 26.
Whole No. 2407.
New York, December 23. 1916.
$5.00 Per Annum.
Single Copies, 15c.
Original Arttrlra.
INOPERABLE PERIPHERAL GANGRENE.
By \V GILMAN THOMPSON, M.D..
NEW FORK.
From time to time one meets with cases of periph-
eral gangrene, resulting from various diseases,
which, for certain reasons, do not admit of opera-
tive treatment, nor, in fact, do they invariably de-
mand it. These reasons may be the advanced age
of the patient, a state of extreme debility, a pre-
carious cardio-vascular condition, the hopelessness
of the causative disease, or perhaps the refusal of
the patient to undergo operation. In such instances
the physician must do the best he can to mitigate
the evil, and one meets sometimes with surprising
results through natural healing or spontaneous am-
putation.
The writers of a generation past paid much more
attention to peripheral or symptomatic gangrene
than do more recent authors, from which it may
fairly be concluded that its ocurrence was, on the
whole, more common in that period.
Present-day writers of medical text books usu-
ally omit the topic entirely, or, in enumerating the
complications of some important disease, state
merely that "gangrene may occur," leaving its site,
extent, and gravity wholly to the imagination. One
of the most widely read of modern text books re-
fers only casually to gangrene in diabetes as some-
times involving the lung, without mention of its
not infrequent peripheral occurrence. Gangrene of
the lung, it should be recalled, is less often due to
obstructive processes than the consequence of bac-
terial infection, and hence differs radically from
the type of peripheral gangrene which is the sub-
ject of the present discussion. The peripheral gan-
grene of diabetes is usually due to an arteriosclero-
sis, and is, therefore, most often met with in cases
of long duration in patients in middle or advanced
life, in whom the symptoms of diabetes have prev-
iously been comparatively mild.
Gangrene of the superficial regions of the body
appears frequently to have been observed in the
severe, acute contagions, and infections, many of
which to-day are well known to run a much milder
course, as a rule. In such instances it more often
involved large areas of the skin, and sometimes the
vulva or scrotum, rather than an entire foot or leg,
as may be the case with senile or diabetic gangrene.
In those cases, doubtless, the condition of the blood
and enfeebled heart action were as important factors
in its production as embolic processes, endarteritis.
or thrombosis. Numerous examples of gangrene
of this type have been recorded as accompanying
malignant scarlatina and variola, mumps, typhus,
*A paper read before fbe Practitioners' Society, Nov.
:: 191(5.
diphtheria, and even varicella (varicella escharot-
ica). A number of cases of gangrene of the vulva
in measles, and of the penis and scrotum in cholera,
have been recorded, and Reynolds early attributed
the gangrene sometimes observed in erysipelas, in
part at least, to pressure from the effused serum
upon the local vessels and tissues. Among the more
unusual causes of gangrene, Osier has described a
case of multiple gangrenous areas of the skin of
the hands and feet in aestivo-autumnal fever. He
also cites a similar condition of superficial gan-
grene observed in typhoid fever after the use of
ice bags, and I have met with another case in
which quite extensive gangrene of the skin resulted
from a too long continued use of the abdominal
ice-water coil. Gangrene of the leg has been known
to follow typhoid fever, and in one case, that of a
boy, the lesion necessitated amputation of the foot.
Gangrene is also recorded in leucemia.
Exceptionally, gangrene may result from the con-
striction produced by scar tissue. MacCallum has
reported an interesting case of this sort. The
patient was an old man who acquired infected axil-
lary glands. The scar tissue which resulted so con-
stricted the axillary artery as to give rise to a dry
gangrene of the hand.
In another group of cases the origin of the gan-
grene is to be looked for in trophic nerve lesions,
as in those sometimes accompanying cerebrospinal
meningitis, transverse myelitis, Raynaud's disease,
and severe herpes zoster. Cases of distinctly em-
bolic origin are met with chiefly in the lower limbs.
I have lately observed a fatal case of gangrene of
the leg, which extended up the thigh, in a young
man having ulcerative endocarditis; and a number
of similar cases have been reported. They would
doubtless be more common were it not that the
emboli usually reach the brain or some important
abdominal viscus before the popliteal vessels.
Quite different are the diabetic cases, in which
the development of the gangrene is liable to be
quite slow; and often preceded by several days of
pain. Most of these cases occur in patients over
50 years of age, but exceptionally the patient may
be under twenty. Although the toes, feet, and legs
afford the commonest site of the destructive process,
it may appear in the buttocks, back, external geni-
talia, or fingers, where it sometimes follows trauma.
During the past five years, in the Cornell Division
of Bellevue Hospital, there have been observed 38
cases of peripheral gangrene due to medical, in dis-
tinction from traumatic or visceral, causes. Of
these, 19, or one-half, were ascribed to arterio-
sclerosis, many of which were definitely of syph-
ilitic origin. Eleven more cases complicated dia-
betes, four accompanied chronic valvular disease of
the heart, but only one was assigned to myocarditis.
There were two cases with chronic nephritis, and
one each with erysipelas, tuberculosis, and hemi-
1104
MEDICAL RF.CORD.
[Dec. 23, 1916
plegia. Several of these cases presented features
of individual interest. One of those due to chronic
endocarditis was probably of embolic origin, for
the usual sequence of the gangrenous areas was
reversed. Gangrenous areas appeared first in the
calves, then over the dorsal surface of both feet,
and finally the plantar surfaces and toes became
involved. Another case of this type exhibited an
aortic stenosis, with a seven months' history of
gangrene of the great toe, resulting in spontaneous
amputation. A third case was possibly embolic,
owing to its very sudden onset and rapid course,
although the patient gave no evidence of valvular
heart disease, but only of myocarditis. He was
in fair health at the age of 74, when, while sitting
smoking by his fireside, he suddenly lost all power
of motion in both legs. Dry gangrene of both feet
rapidly supervened, and spread up the legs to the
knees, and the man died one month after the onset
of symptoms.
The symptom of intermittent claudication some-
times precedes for several days, or even weeks,
the advent of gangrene. It was observed in sev-
eral cases of the Bellevue series.
One of the diabetic patients was a woman 75
years of age. She had attacks of intermittent
claudication in both legs, which finally were followed
by complete loss of power. Becoming bedridden,
deep gangrene appeared in the buttocks and on
other parts of the body not subject to pressure.
With two exceptions, all of the diabetic cases
occurred in patients above 48 years of age, two
being 75 years old. In one case only was the onset
attributable to local injury. Several of the patients
on entering the hospital gave a history of previous
amputation for gangrene of a toe or foot, but the
operation had exerted no control over the spread
of the lesion, and was, in this type of case, of
doubtful utility. In one case the lesion extended
rapidly to the thigh, and in six cases to the leg.
In two diabetic cases only was the gangrene "dry."
One of these patients was a man 75 years of age,
the other was 48, and the latter case was excep-
tional, for, in addition to a progressive gangrene
which finaly required amputation at the upper third
of the tibia, following serial amputations of the
toes of both feet, the process involved several fin-
gers on each hand. The man had an obliterating
endarteritis in addition to diabetes.
Another case of gangrene from endarteritis obli-
terans was that of a painter only 35 years of age.
He did not have diabetes, but a syphilitic osteomy-
elitis, which resulted in gangrene of the entire
right foot. In these cases of obliterating endarteri-
tis (or the thromboangeitis of Burger) the lumen
of the artery is choked by vascular granular tissue,
the intima is plicated, but not so thickened as in
senile arteriosclerosis, and the condition is of toxic
or infectious origin.
My attention was first drawn to the medical treat-
ment of peripheral gangrene early in my medical expe-
rience by the case of a man :;."> ye irs of age who en-
tered the New York Hospital with an obliterating
endarteritis of syphilitic origin. He presented on ad-
mission a commencing gangrene of the toes of the right
foot which soon extended throughout the entire foot.
The visiting surgeons declined to amputate, and the
foot was treated by the old fashioned method of apply-
ing opium poultices and various soothing lotions to re-
lieve pain, with the effect that the process rapidly ex-
tended until at the end of a fortnight it reached the
knee, where a well marked line of demarcation ap-
peared. Meanwhile the sloughing of all the soft parts
produced so unbearable a stench that the process of
dressing the leg made the patient's retention in the
ward a serious problem, at least for the other patients.
I then applied the method of constant dry heat which
I have used ever since in like emergencies. A Bun-
sen burner was placed on the floor and a stream of air
heated to about 150° F. was directed upon the leg
through a small caliber stove pipe. Under this con-
stant dry heat the limb was soon mummified, prac-
tically all odor disappeared, pain was greatly lessened,
and spontaneous amputation took place at the knee
joint, the leg being finally suspended by a couple of
lateral ligaments which were snipped off with a pair
of scissors. The skin healed over the stump and the
patient was enabled to leave the hospital, hopping about
with a crutch.
A more recent case was that of a colored woman who
entered Bellevue Hospital with sloughing gangrene of
both feet, which on one side reached half way up the
leg, the condition being a complication of advanced dia-
betes. The case was a hopeless one and the odor was
so unbearable that the woman had to be placed in iso-
lation. Dry heat, similarly applied, soon controlled the
odor and greatly relieved the patient's pain.
A third case was so unusual in several aspects that
a more detailed reference to it is given. The patient
was a woman, who previous to her death in her 88th
year had an interesting cardiovascular history. With
a small frame, poor thoracic expansion, and a uniform-
ly rapid and small volume pulse, her physique sug-
gested a condition of aortic atresia. Late in life, with
a senile arteriosclerosis, a definite murmur of aortic
stenosis appeared. She remained fairly active, how-
ever, until four years prior to her death, when she de-
veloped a very rapid and intermittent pulse, a low
grade of fever of irregular type, extreme prostration
and emaciation. Like many aged persons, she had
completely neglected the care of the teeth and the mouth
was in such a foul state that it seemed probable that
her condition was due to septic infection from this
source. A dentist was put in charge, and by almost
daily treatments, combined with constant antiseptic-
care of the mouth on the part of her nurses, after
more than two months of fever, the symptoms sub-
sided, the pulse became regular under the use of stim-
ulants and a fair measure of strength returned.
Eighteen months later the patient had an attack of
bronchopneumonia and for several days death seemed
imminent. She, however, again recovered, when she
was seized with intense pain in the right foot and leg
Fearing the development of gangrene, the nurses were
cautioned to keep the limb warm and watch carefully
for local cyanosis. Five days later purplish spots ap-
peared over the ankle and dorsum of the foot, followed
by blebs and excoriations, and by the end of the sec-
ond month it was evident that the entire foot was
doomed. The sloughs were treated with aristol, potas-
sium permanganate, aluminum acetate, and a variety
of other applications, but the odor became unbearable
— so much so, in fact, that it permeated the entire
house, and more than once caused the nurses to vomit
after attempting to dress the foot. The patient's house
being in the country, there was no gas with which to
supply a draft of heated air, but there was abundant
electric current. I obtained an electric toaster and an
electric fan and enclosed them in an asbestos tube
which led from the toaster to the foot. The fan fur-
nished a constant current of air. which was super-
heated in passing over the toaster, and directed across
the foot day and night. (See the illustration.) The
relief of pain which ensued was remarkable and
the patient's incessant moaning and restlessness
ceased. By 'his means the superficial tissues were
soon mummified, but every few days a deep slough
would open up and the nauseous stench returned,
I then resorted to 95 per cent, alcohol, and keep-
ing the entire foot saturated with it, the odor was
again controlled, as well as extension of the gangrene.
for previous to these two methods of treatment edema,
with purplish mottling of the skin, spread half way up
the leg, so that it was feared at one time that the
process would I -tend to the knee. Then followed a
es of "amputations." first of the toes, then of the
metatarsal bones and finally of the astragalus (which
proved very refractory), all bones being removed with
a pair of dressing scissors. The entire time from the
' of the gangrene until the complete removal of
'he foot was 11 months. Immediately thereafter a
healing process began and. aided by liberal application
Is im of Peru, at the end of four months more
stump wis a: completely covered with normal skin
Dec. 23, 1916 J
MKDICAL RECORD.
1105
as if a primary operation had been performed, which
the family had refused, and which the patient's cardiac
condition and advanced age might otherwise have pre-
cluded. An interesting feature of the ease was that
owing to the patient's senile childishness and extraor-
dinary care on the part of the nurses never to allow her
to see her foot, she never discovered that she had lost it
and could not understand why she was not permitted
to get out of bed ! After the stump was healed the pa-
tient gained considerably in strength, digestion im-
proved, and her mental state was that of a happy, good
natured child. In this condition she lived for seven
months, and finally succumbed to a second attack of
bronchopneumonia.
The case is of interest from the point of view of
the slow development of the gangrene ( through
fourteen months), the complete recovery in a pa-
tient eighty-eight years of age, and the apparent
control of the process by the methods employed.
When the gangrene threatens to involve an oppo-
site limb, as it did in many of the cases above cited,
every effort should be made to avert it. The heart
force should be strengthened by digitalis, and if
blood pressure be high, such as to cause the heart
undue exertion, vaso dilators should be given. Mas-
sage should carefully and systematically be prac-
ticed, and the limb should be kept warm, and re-
lieved as much as possible from the effect of gravi-
tation, and particularly from pressure or trauma.
In cases of parietal thrombosis with only partial
cardial disease, and, in the aged, with arteriosclero-
sis. The difficulty is to determine how far back in
the circulation the obstruction may exist. With
partial pop! 'teal obstruction, for example, the gan-
grene, beginning in the toes or dorsum of the foot,
may extend very rapidly, or, if the obstruction be
not too great, the gangrene may remain limited,
and be impossible of differentiation from an ob-
struction localized much nearer the gangrene, with
little tendency to cause extension of the process.
Some years ago I saw a man of 70 years, in average
general health, who presented a gangrene of the
entire fifth toe and the contiguous surface of the
fourth toe. The fifth toe became so superficially
black and shriveled that I urged amputation. This
he refused, and I was surprised to find at the end
of a couple of months that the toes became en-
tirely normal, and they so remained until the pa-
tient's death from pneumonia several years later.
A middle-aged woman with myocarditis and attacks
of fibrillation developed several large areas of su-
perficial gangrene over the heel and dorsum of the
foot. Sloughing ensued, and there was every rea-
son to fear very extensive destruction of the foot,
if not of the entire leg; but with local warmth and
the energetic use of cardiac stimulants complete re-
covery from the lesion resulted, and there has been
no return during more than two years past. Cases
Asbestos _cqv?S- ■
Home-made apparatus for treatment of gangrene by hot air. The air current, directed by the electric fan, is heated
passing over the electric toaster. A sheet of asbestos covers the apparatus.
occlusion of the vessels, much may be accomplished
apparently by these measures.
Pain in gangrene involving only portions of the
general surface of the body is usually absent or
inconsiderable, amounting to nothing more than the
inconvenience of a superficial ulcer. Quite other-
wise is it with gangrene of the extremities, par-
ticularly of the feet. In such cases it may antedate
any other evidence of the lesion by a week or ten
days, and may be regarded as due to a neuritis un-
til the changes in temperature and color of the
surface or sensory disturbances appear. It may
to some extent be relieved by applications of a hot
lead-and-opium wash, a menthol-and-camphor lini-
ment, or similar topical remedy. As the lesion pro-
gresses, however, the pain, in many cases, especially
in senile gangrene, often becomes unbearable. It
is constant and wearing, prevents sleep, and causes
great restlessness, so that it must he relieved by
morphine. After sloughing appears, however, the
hot air treatment often gives remarkable relief. Fol-
lowing spontaneous amputation, and while healing
of the stump is in progress, the symptom usually
disappears.
I have learned to be chary of a too positive prog-
nosis in certain cases of peripheral gangrene, par-
ticularly those occurring in connection with myo-
of peripheral gangrene from embolism derived from
septic endocarditis are often extensive, and have a
uniformly bad prognosis.
In several of the Bellevue diabetic series the de-
velopment of gangrene preceded death from coma
by only two or three weeks, but in one case, which
involved the great toes and part of one foot, there
was a history of 18 months' duration. Another
patient, a man 57 years of age, gave a history of
onset of gangrene of the foot, with temporary bet-
terment which preceded by four years his death
from coma.
Another exceptional case was that of a tailor 43
years of age who, ten years previously, had suffered
amputation of the metatarsi of one foot for dia-
betic gangrene, after which he remained well and
able to work for three years, when the opposite
toes became involved, and he had several other mi-
nor amputations previous to admission to the hos-
pital. Hence, in the diabetic, gangrene is not neces-
sarily an immediate precursor of death.
In senile peripheral gangrene there is always dan-
ger of a pneumonia supervening, or possibly of a
gangrenous focus developing in the lung, as in the
case of a man 97 years of age who entered the hos-
pital with a superficial gangrene extending over the
anterior surface of the left leg and from the middle
hog
MEDICAL RECORD.
[Dec. 23, 1916
of the foot to the knee. The toes were not involved,
and the process did not have time to extend beyond
the subcutaneous tissues before the patient died
of pneumonia.
Much interest and importance attaches to the
question whether to advise operation or not in the
types of peripheral gangrene above described, and
it is impossible to formulate definite rules. The
matter, however, is often decided by the patient,
who refuses amputation and prefers to take his
chance with the spontaneous outcome of the lesion.
It is customary, in this event, to resort to wet dress-
ings with such solutions as those of aluminum ace-
tate, weak alcohol (10 per cent.), potassium per-
manganate, iodoform, iodine, "red wash," etc., but
in my experience much more satisfactory results
are obtained by the dry treatment with superheated
air, reinforced, when the odor becomes unbearable,
by absolute alcohol rather than by the weaker solu-
tions.
61 WEtir Fort - rREET.
THE MEDICAL CORPS OF THE ARMY AS A
CAREER.
By LLEWELLYN P. WILLIAMSON. M I >
MAJO CORPS, U. S. ARMY.
Every medical student during his college years
gives serious thought to his career after gradua-
tion. Most men hope to put in one or two years
immediately following graduation as internes in
a large hospital, for, in the present status of medi-
cine, the practical training thus obtained is inval-
uable in the first few years of practice. To the
average student, therefore, the college work and
hospital training are taken as a matter of course
and are simply preparation for what he is to do in
the after years.
And what is he to do? Will he enter practice in-
dependently or will he associate himself with some
established practitioner? Will he make his start
in a large city or in a country town? Will he at-
tempt to take up a specialty at once or will he start
in general practice? Or, finally, will he go into one
of the Government services?
Many circumstances will necessarily have an in-
fluence on the final answer to this question. Per-
sonal inclination, personal obligations, finai
liable openings, or opportunities must be taken
into account; and the advantages and disadvan-
tages of the various careers open to a medical man
must be weighed carefully and fitted to the condi-
tions affecting the individual.
In all the affairs of life the question of finances
must enter largely and the medical profession is
no exception. To the graduate with ample means
the matter of finance is not a vital question. After
upleting his hospital course he could, in normal
times, pursue a course of postgraduate study in
Europe and can do so very advantageously now in
our own country. Later he can select a location
best suited to his inclinations and await his time
practice to come to him.
The average graduate, however, must consider
the financial side of the question. The cost of ob-
taining a medical education, and of establishing
oneself in practice is great and while in many in-
stances the eventual return on the original invest-
ment is large, in the majority of cases it is ex-
tremely moderate. The practice of medicine is an
honorable profession and for the man who loves it
an intensely interesting profession, but for the
average man who makes it his life work it has
never proved a very profitable profession.
In making plans for a start in practice the loca-
tion naturally will receive much thought. The large
city is, of course, first considered for it is there
that the greatest prominence in the profession and
the greatest monetary rewards are usually attained.
These are, however, slow in coming and a period
of from five to ten years of generous outlay and
niggardly income is the usual experience of the
young doctor locating in a large city.
For the man whose financial resources are small
or who has expended a large part of them in getting
his medical education, a large city is therefore
practically prohibited unless he can form an alli-
ance with an older practitioner who is in a position
to start him in practice. Even such a position re-
quires many years of hard work both in private
practice and hospital work for which there is little
remuneration except the valuable experience gained.
Usually the man of limited means is compelled to
start his practice in the smaller cities or country
towns. Here he begins to make a "living wage'-
more quickly, but the chance for anything more
than a comfortable living is small. Professionally,
too, the advantages occurring to him are never so
great as in the large cities.
No matter in what locality the graduate starts he
will be subject to keen competition both fair and
unfair. In the year 1906 there were in the United
States 122,167 registered physicians, a proportion
of 1 to every 695 of the then population. In 1910
there are 146,613 physicians, a proportion to the
present population of 1 to 691. Thus it can be seen
that, while the time required and the cost to obtain
a medical education has markedly increased, the
proportion of doctors to the population has not
diminished, and the average estimated income for
all physicians in the United States is to-day $1,200
each per annum. In addition to the fair competi-
tion to be expected from this surplus of doctors,
the fee splitter, the osteopath, the chiropractic, the
optometrist, and the Christian Scienist are all de-
velopments of recent years and make marked in-
roads on the practice of the conscientious physician.
In addition to the worries of competition there
are many demands on the physician's time and ener-
gies for charitable work, which frequently it is to
his ultimate advantage not to refuse. And much
time must also be devoted to making friendships
both professional and otherwise from which, event-
ually, practice may be gained. Not until after the
average physician has practised many years is he
able to avail himself of vacations and the periods
of study at medical centers which are so necessary
now in the rapid growth of medical science.
Having considered the prospects for practice in
civil life, what may the medical man expect if he
decides on the army as a career? What are his
prospects financially and professionally? And
what will the army give him in the general scheme
of life?
Financially, he can never get the great rewards
which come to some successful physicians in civil
life. On the contrary, however, from the time he is
commissioned he is assured a comfortable living,
his pay, and emoluments gradually increasing as
the years go by. An attractive feature to the army
service is that the pay of a medical officer and
allowances by which his pay is supplemented go on
as long as he conscientiously performs his duties.
Dec. 23, 1916]
MKDICAL RECORD.
1107
and there is no loss of income because of illness or
an occasional vacation.
If, through illness, an officer is compelled to re-
linquish his work, he is put on the retired list and,
while his income is decreased somewhat, it will still
be sufficient to afford him a living. At the age of
64 all officers are placed on the retired list with
three-fourths of the pay they were receiving at
the time they reached retiring age. This pay will
provide an ample competence as long as the officer
lives. The question of "putting aside something
for a rainy day" does not enter so intimately into
the medical officer's calculations therefore as it does
in the life of the civil practitioner.
What are his prospects professionally? In the
old days the position of the army doctor was simi-
lar to that of the village physician. He was, in
effect, a family doctor. In those days the army
was stationed in frontier posts and each post was
a village in itself with the ranch people and farmers
outside forming an available clientele for additional
income for the army doctor. He had to care for all
the various illnesses occurring among the male and
female inhabitants of the post and also was usually
called to attend to similar ailments among the popu-
lation of the surrounding country.
At the present time conditions in the army and
consequently conditions in the army medical service
are very different. The old frontier post is gone
and now the army is beginning to be organized in
divisions and brigades and stationed in large posts.
The result is that the practice of medicine in the
army has taken on the aspects of the practice of
medicine in cities. At every post there is a large
hospital perfectly equipped with all the medical,
surgical, and laboratory appliances now necessary
for the modern practice of medicine. Because of
the number of troops stationed at each post and
the families of the officers and men also living there,
the source from which medical material comes is
large and varied. At every post hospital cases of
all kinds may be constantly found and medicine
and surgery in all its branches finds ample scope in
which to employ its talents. In addition to the
post hospitals there are large general hospitals at
Washington, San Francisco, Hot Springs, Ark., Fort
Bayard, N. M., Manila, Hawaii, and Panama.
The service at these hospitals is organized just
as is the service at large civil hospitals. Medical
officers according to their special qualifications, are
detailed as internists, surgeons, laboratory workers,
neurologists, oculists, aurists, and for other special
services. The material upon which they may demon-
strate their ability is ample. As noted above the
government equips these hospitals with all the latest
devices in medicine and surgery, and a complete
library embracing all the latest medical books and
journals is maintained at each post. Every op-
portunity and every facility is given the medical
officer for research work and development and espe-
cially is this so in laboratory work. There has re-
cently been organized in the Medical Corps a Re-
search Division, composed of men possessing special
ability and training in laboratory work, who will
be given every opportunity for original work.
The opportunities for professional work and the
standard of that work existing among members of
the medical corps to-day is shown by what that
corps has accomplished in recent years. It is well
known how yellow fever was made to disappear from
Havana and how the building of the Panama Canal
was made possible by General Gorgas, an army
surgeon. It is not perhaps so well known that
typhoid, long the scourge of armies, has been en-
tirely banished from our army by the work of
Major Russell of the medical corps. Before the
taking over by the United States of Porto Rico in
1898 smallpox and hookworm were the scourges of
that island. Both have been completely abolished
by the work of army medical officers. A similar
tale may be told of the Philippines where smallpox
and beriberi, the curses of those islands, no longer
exist. These are but a few instances of the work
possible for army medical officers. As a body they
have big work provided for them and they always
do it well.
An especially important branch of the medical
officers' work is hygiene, sanitation, and preventive
medicine, and in this work it is believed that the
medical officers of the American army excel those
of all other armies. In a recent letter from an army
officer abroad, the following statement was made:
"I have seen the field sanitation of most of the arm-
ies in Europe and I also had the pleasure of visiting
the maneuver division of the American Army at
San Antonio, Tex., in 1911. From what I saw there
and from what I see here I am of the opinion that
the American army beats the world in field sani-
tation."
In order that medical officers may keep abreast
of what is being done in civil life they are en-
couraged in every way to associate with the leading
practitioners in the vicinity of their stations and
are ipso facto members of the American Medical
Association. In addition to this they are usually
given honorary membership in local societies wher-
ever they may be stationed.
To give selected medical officers opportunity to
see the work of the leading civilian physicians and
surgeons, they are frequently detailed as attending
surgeons in the large cities where they will have all
the clinical advantages offered by the large civil
hospitals.
So much for the purely medical side of the army
doctor's life. In addition to this he must be a medi-
cal officer. That is he must be specially trained
in the application of modern medical and surgical
science to the needs of the military establishment.
To this end he must be well-versed in military cus-
toms and the administration of the various sanitary
units which go to make up the organized medical
service of the modern army. The reason for the
maintenance of this organized service in all armies
is the preservation of the available fighting strength
by the prevention of disease; and the cure and
prompt return to duty of as many wounded as pos-
sible. To attain this end the medical officer has
different and even greater responsibilities than his
civilian brother.
What is the social side of the medical officer's
life? What comforts may he expect and what hard-
ships may he have to undergo?
In the first place he is a commissioned officer with
the rights, privileges, and responsibilities that all
other officers assume. He is in command of the
enlisted force of the medical department and his
life, character, and deportment must be such as to
inspire confidence, respect, and affection from the
men under his command and from his brother offi-
cers. In time of peace he must remember that he
may at any time be called upon to undergo the
physical hardships of a campaign and for that rea-
son he must at all times, by means of exercise and
the proper rules of living, keep himself in good
1108
MEDICAL RECORD.
[Dec. 23, 1916
physical condition. This fact is recognized in arm-
ies and ample opportunity is afforded for exercise
of various kinds such as tennis, golf, walking,
riding, etc.
While on duty at a post he is furnished a com-
fortable house commensurate with his rank and his
needs, and an allowance is made for heat and light.
The commissary store of the Quartermaster Depart-
ment furnishes necessary food supplies for the en-
listed men and these may be purchased by officers
at government rates by which a considerable saving
may be effected in "the high cost of living." When
on duty in cities where no army quarters are avail-
able, he is given commutation for quarters in ac-
cordance to his rank and is permitted to rent where
he pleases. Trie general social life of an army post
is that which one finds in any community of edu-
cated, well-bred people. One may enter into it as
much or as little as he pleases, as military life does
not mean the restriction of personal liberty.
The above is a brief outline of what the medical
officer may expect in time of peace.
What may he expect if war occurs? In war the
medical officer's place may be with the troops on
the firing line, in the mobile medical organizations
directly behind the firing line, or in the base and
general hospitals well to the rear. In accepting a
position in the medical corps he obligates himself
to go wherever his services are needed. This may
mean that he will have to spend weeks or months
in camp and days on the march; that he may have
to stand in the trenches beside the machine gun or
that he may have to stand at an operating table in
an improvised hospital day and night until exhaust-
ed ; that he may have to sleep under a tent and live
on the simple fare of the soldier. In other words
that he may have to face war in all its stern reali-
ties. If he is not prepared to do this he should not
enter the medical corps.
The following in detail are the requirements and
the rewards of the medical officer:
Applicants must be between the ages of 22 and
32 years, must be graduates of recognized medical
colleges and have had at least one year's hospital
training. After passing a preliminary physical
and mental examination they are commissioned in
the medical section of the Reserve Officers Corps
and ordered to Washington for a term of instruc-
tion at the Army Medical School. The coui-se at
this school is an excellent one and embraces the
professional, medical, and military duties of the
medical officer with a special laboratory course
covering the essentials of field sanitation and hy-
giene. While attending this course they receive
the pay of a first lieutenant, $166.66 per month and
an allowance for house rent, heat, and light amount-
ing to approximately $45 per month more. This will
provide all the living expenses ordinarily necessary
for a sojourn in Washington.
Upon completion of the school course, candidates
are given a final examination and, if successful, are
commissioned in the Medical Corps with the rank
of first lieutenant. After five years' service, upon
passing another examination, they are promoted to
the grade of captain. Further promotion to the
grades of major, lieutenant-colonel, and colonel are
made by seniority. With the great increase in the
regular army during the next four years, as now
provided by law, promotion above the grade of cap-
tain promises to be fairly rapid.
The pay for the respective grades is: Lieuten-
ant, $2,000 per annum; captain. $2,400; major,
$3,000; lieutenant-colonel, $3,500; colonel, $4,000.
($150 per year is allowed a captain or lieutenant if
he owns one horse, and $200 if he owns two horses.
Forage is furnished for the horses.)
This is the flat pay, and the lower grades are
increased 10 per cent for each five years of service
up to twenty years. Thus a captain promoted after
five years' service would receive in place of $2,400,
10 per cent, increase or $2,640 (if he owned two
horses his pay would be $2,840) ; and a major after
fifteen years service would receive $3,900. The ulti-
mate pay in the higher grades is: Major, $4,000;
lieutenant-colonel, $4,500; colonel, $5,000.
In addition to the flat and longevity pay each
officer is allowed a house or when at a station where
no public quarters are available, "commutation for
quarters." This commutation amounts to $36 per
month for lieutenants ; $48 for captains, $60 for
majors, $72 for lieutenant-colonels, and $84 for
colonels. Where heat and light are not furnished in
kind, an additional money allowance is made to cover
the cost of same.
When their services can be spared, all officers are
allowed one month's leave every year on full pay.
Or the leave may be allowed to accumulate and they
may be granted four months' leave at one time. Un-
der exceptional circumstances officers may be
granted a longer leave on half pay.
Having considered all the facts relative to the
medical officer's life in detail, we are now prepared
to answer the questions the graduate asked himself
when he contemplated taking the army medical serv-
ice as a career.
What may he expect financially? He will receive
a moderate amount of pay but this pay is a certainty
and he will receive it regularly sick or well as long
as he lives. It will be sufficient to enable him to live
comfortably and is in reality much more than a
similar amount would be in civil life for the reason
that he has no house rent and no office rent to pay
nor does he have to buy the instruments, dressings,
surgical material, and apparatus, as well as the
books and periodicals which make so great a drain
on the resources of the civilian doctor. Nor does
he have to lay by a certain amount "for a rainy
day." His retired pay attends to that. Considering
all these facts the pay of the medical officer com-
pares favorably with the average income from pri-
vate practice.
What may he expect professionally? If he so
elects he will nearly always have plenty of time
and material for practising and advancing himself
in his chosen profession; and time and opportunity
for original study in any line he may choose.
What may he expect in his social life? He will
always be able to live comfortably and will be asso-
ciated with educated people both in his own pro-
fession and among the officers of the line and their
families generally. He will be saved the annoyance
and petty worries incident to competition and the
seeking of practice in civil life. And he will have
time to travel if he so desires without feeling that
he is neglecting his practice.
Such then is the usual life of the army medical
officers. As a whole the army is proud of them and
the profession at large has given frequent instances
of the regard and esteem in which they are held by
their civilian brothers. Taking it all in all, it is
believed that the Medical Corps of the Army offers
a most attractive career to the earnest young doctor
who is interested in his profession and does not
vearn for large financial returns.
I
Dec. 23, 1916J
MEDICAL RECORD.
1109
RETROSPECTIONS, MEDICAL AND OTHER-
WISE.
By A. D. ROCKWELL. A.M., M.D.,
FLUSHING. N. Y.
NEUROLOGIST EMERITUS TO THE FLUSHING HOSPITAL AND
DISPENSARY.
In glancing over the earlier issues of the Medical
Record I find that it was in the year 1866, just half
a century ago, that I wrote my first article in rela-
tion to "Electricity in Medicine," and in the flood
of following years, nearly two generations have
come and gone. As I find myself, after all these
years, very much out of the race of active workers,
yet sound in mind and body, with abundant leisure
for the things I find most agreeable to do, it oc-
curs to me that a few observations, personal and
otherwise, and especially along the lines of my life
work, might be fittingly given.
Since those days of crude appliances and crude
and limited workmanship, electrotherapeutics has
developed into a magnificent field of actualities, and
still wider possibilities. Why the profession at
large yet fails adequately to appreciate its value I
will not attempt to say. One drawback, however,
as I think all must agree, is that there has been by
far too much special pleading, with all the hurtful
influence on the professional mind that such en-
thusiasm implies.
Truly, it is the day of young men. The old
clergyman is not very much wanted, neither is the
old doctor, and so it comforts me to recall the reply
of the ancient warrior to the boasting young brave
that "the seventies have all the twenties and forties
in them." The years during and immediately fol-
lowing the civil war did not hold much of scientific
or original advancement in affairs medical. The
surgery in the field was hasty and crude and pre-
ventive medicine practically unknown. It was be-
fore the birth of antisepsis and for lack of it men
then died like sheep. There were not wanting, how-
ever, some keenly observant students, and among
others, Weir Mitchel did useful and original work in
the study of gunshot wounds.
The conflict over, a million young men were seek-
ing a career, and many chose the profession of medi-
cine. Two lecture seasons with no preliminary ex-
amination was the prescribed course, and in eigh-
teen months young soldiers found themselves trans-
formed into young medicos. My own medical train-
ing was little better, since I had graduated during
the war and my experience as a surgeon through
two severe campaigns, while extensive and varied
enough, was of but little practical value. I recall
with pleasure, however, that the most immediately
useful asset in the field that my brief course at
Bellevue gave me, was the private instruction in
bandaging by the now venerable Dr. Stephen Smith,
whose long life has been a pattern of efficient work.
And very much I stood in need of further instruc-
tion, as the following incident illustrates:
On returning to civil life I put out my sign in
Harlem, then a growing village, and while awaiting
patients attended a third course of lectures at the
College of Physicians and Surgeons, then located at
Twenty-third Street and Fourth Avenue. I had
never witnessed a case of parturition. When, there-
fore, my friend, the late Dr. E. Darwin Hudson,
himself, later an expert, asked me if I would assist
in taking charge of a case in one of the poorer
purlieus of the city, I readily consented. Hudson
was in the graduating class and to its members the
professor, the late Dr. T. G. Thomas, occasionally
assigned cases of this kind. Hudson, too, had never
seen a case and in some trepidation he turned to
me for aid. I was a graduate of some years ; I had
been an army surgeon. Surely here was a young
man with large experience and one upon whom to
lean in an emergency. It did not occur to him, and I
did not refer to the fact that with an army in the
field there was scant need for the services of an
obstetrician. We found the suffering woman on
the top floor of an old tenement, and entirely unat-
tended. The only furniture of the room was a
rickety bed, one end of which broke down during
the accouchement, a wash bowl half filled with dirty
water, and an old chair. I made the usual prelimi-
nary examination which afforded me no information,
but I looked wise, and so far as I could see or feel
pronounced everything ship shape. The hours
passed drearily and wearily away and seeing no
signs of an immediate ending, we withdrew for
awhile to the old Earle's Hotel in Grand Street for
rest and refreshment. Returning in the course of
an hour and making another examination, I be-
came puzzled and ill at ease. Feeling the great re-
sponsibility, Hudson went off in all haste to the
residence of Dr. Thomas to report and for instruc-
tions. In due time he came back with word from
the professor that everything was probably all right
and suggested "patient waiting." In the early
hours of the morning, a new soul was ushered into
this waiting world. We washed and with the few
rags found dressed the babe and went our way.
What of the life and career of that boy? If still
living he would be fifty years of age. Born in ab-
ject poverty, even in filth and disgrace, like another
Oliver Twist, what chance had he? A victim of
inexorable fate if he lived, let us hope that kind
nature soon took him to herself.
During my brief but not altogether uninteresting
experience as a general practitioner, I was called
one day to see a woman evidently suffering from an
inflammation of the brain or its meninges. All her
life she had been a deeply religious woman and of
exemplary character, and yet in her ravings she in-
dulged in language both profane and obscene, rare-
ly equaled by the most depraved natures. To me it
is still a mystery how such a perversion found
lodgment and outward expression in one whose
nature was gentle and whose training and associa-
tions had been unexceptionable. During the evening
a friend came in to see her. His name was William
Miller, Dr. Miller by courtesy. I had already heard
of him as a so-called electrician and knew that he
received considerable patronage from some of th.p
best men in the profession, among others Dr. Wil-
lard Parker. I found him a simple hearted old man
of about 65 or 70, who had a great opinion of the
value of electricity in the treatment of disease, and
in the case at hand, with modesty and hesitation he
expressed the opinion that a good strong application
of electricity might do good. I was amused by
many of his absurdities of statement, but was im-
pressed by his evident honesty and by his large,
yet crude and ill-digested experience, and naturally
desired to know more of his methods in a field at
that date so little cultivated by the profession.
Fifty years ago it was a gala time for quacks of
every description. Quacks for the ear, eye, and nose,
as well as electrical quacks abounded, but this old
man was good and honest and, as much as any one
I ever knew, gave a quid pro quo for the little fee
he received.
1110
MKDICAL RECORD.
[Dec. 23, 1916
I accepted his invitation to come to his office at
914 Broadway to study his cases and see him work.
I saw evidences of the good results that followed his
stereoptyped and simple method of application, for
his sole apparatus consisted of an ordinary induction
coil constructed by himself, which, however, yielded
a current of remarkable quality. He was intelli-
gent, but unlearned. He knew nothing of electro-
physiology and kindred departments, little of dis-
ease, pathology, or practical therapeutics. So far
as conerns scientific electrotherapeutics, he existed
as an example of profound ignorance, associated
with perfect honesty of intention. He never enun-
ciated an idea, neither had he any conception of the
principles on which he worked or through which he
wrought cures. He was, however, so thoroughly the
master of the methods he invariably used that the
truth of the saying that it is not so much the
method that does good as the way it is employed,
never seemed so clear as when comparing his effec-
tive manipulations with awkward slipshod methods.
In many of his cases, unquestionably, the excellent
results that followed were greatly aided by his
powerful and skilful manipulating processes, which
for all practical purposes was an expert and thor-
ough massage.
About this time I renewed a former acquaintance
with Dr. George M. Beard and he was greatly in-
terested in my account of this old man with his
novel methods and quaint ways, and together we
both visited him again and again. Here, indeed,
was something new and worth investigating.
During all my medical training I do not recall
that electricity was ever mentioned in connection
with therapeutics or even surgery. All other physi-
cal agents, water, air, exercise, heat, and cold re-
ceived due attention, but Nature's most subtle, all
pervasive, and most powerful principle remained ab-
solutely neglected in this country excepting by dis-
honest empirics and a few eminently worthy but
ignorant irregulars, like our good friend "Dr. Mil-
ler." Abroad, as we learned later, a number of
able men of science had given the subject careful
study, but as yet their investigations had made lit-
tle impression here. It seems that already Beard
with his usual curiosity in regard to every strange
and misunderstood or ill understood thing, had in
the past been somewhat interested in the subject.
While still a student at Yale, he had in his own
person, experienced some benefit from the use of
the crude induction coil. He was therefore quite
ready to cooperate with me in my proposed in-
vestigations. After two years of working and wait-
ing, I was beginning to get a foothold in Harlem
and it required some little resolution to burn my
bridges, as it were, and enter a new untried and
unpopular field. Even that great and liberal
minded man, Austin Flint, advised me not to meddle
with it, but to leave it in the hands of the quacks
where it belonged, while my equally good friend,
Dr. Willard Parker, gave me similar advice. And
then again, as young men will do, I had just become
engaged and needed more than ever to get firmly
established. To be sure, the income for the year
had been somewhat under $1,000, yet it seemed to
me fairly satisfactory and a precursor of future
gains. And still again, it was somewhat uncon-
ventional and perhaps a little risky to become in
any way associated with one who, however honest,
was in the eyes of the profession little better than
a quack.
After due reflection and consultation with Beard
I removed my sign in Harlem as a general prac-
titioner and rented a room in the same building
with the office of Miller. In this way I had the
advantage of studying his cases and at the same
time getting some of the overflow. The profits
were not very large, for Miller received the munifi-
cent fee of one dollar, and I could not well charge
more. When it is remembered, however, that his
daily patients numbered between twenty and thirty,
it is seen that he enjoyed a comfortable yearly in-
come. An amusing incident occurred in connection
with this subject of fees. In the beginning of his
irregular practice he charged but fifty cents a
visit. Miller was a school teacher originally, and
being of a mechanical turn of mind, became inter-
ested in the subject of induction coils. He began to
treat people of his acquaintance for some of their
ailments. By degrees his practice grew, so that he
made a business of it, and finally acquired a wide
clientele. I suggested that he raise his fee to
two dollars and pointed out the fact that one of his
old patients about to come to him again just then
was well to do, and a good one to begin on. With
some hesitancy the old gentleman consented. She,
upon whom the experiment was to be tried, came
at the appointed time, received her treatment and
handed the doctor the usual fee. With some embar-
rassment he said that he had raised his fee to two
dollars. The richly attired patient surveyed him
curiously for a moment and thrusting the bill into
his hand said, "Go 'long, take your money." The
doctor took it and that was the last attempt to raise
his fee. Most of my practice, however, was un-
remunerative, excepting as it added little by little
to the sum of my, or I should say our, experience.
Beard, to be sure, did not have his sign up, but
he was as deeply interested as was I, and might
be called a silent partner. He was at this time con-
nected with the Demilt Dispensary, and it was his
function to send as many of the charity patients
as possible to 914 Broadway for electrical treat-
ment, and experimentation. And to this day it ex-
cites a smile as I again see Dr. Beard with his
grave face yet keen sense of humor, ushering into
the little office half a dozen more or less of the
unwashed. In one way we earned all the experience
that came to us, since it was no pleasant job to go
over the bodies of these unfortunates, especially in
very warm weather. It was a crude experience,
but we saw all manner of cases and of course kept
a detailed account of each.
Dr. Miller was getting old and seriously thought
of abandoning his work, and suggested that we give
him notes for a certain sum, for the good will of
the business. I suggested that he stay away from
the office some day, and let me manage the patients
that came. Alas for human expectations! On
reaching the office that morning, I found half a
dozen patients in waiting. The situation was ex-
plained, but without exception, one by one, they all
departed leaving me alone, and of the more than
twenty callers that day, not more than one or per-
haps two cared or dared to trust themselves in my
hands. That settled in my mind the question of
the feasibility of buying a practice.
By this time, our experience had become such
that we decided to give it to the world and selected
the Medical Record through which we hoped our
views might be disseminated. The result was a
series of five articles, running through a period of
two or three months, under the title of "The Medi-
cal Use of Electricity." We had great hopes, for
Dec. 23, 1916]
MEDICAL RECORD.
llll
we felt very sure that nothing quite like these
papers had ever before appeared, but the results
exceeded our expectations. The London Lancet re-
published each article as it appeared, and in Ger-
many also they were reproduced. When finally
William Wood & Co. issued the combined articles
in book form, its reception was in the main highly
complimentary. There were, however, a few dis-
cordant notes. Among these, the Edinburgh Medi-
cal Review was both humorous and unappreciative.
In making applications of the faradic current to
sensitive parts, we explained the method of apply-
ing it through one's own person. No artificial
electrode could equal the hand in flexibility and
power of adaptation to inequalities of surface and
in treating delicate women and children and in ap-
plications to the head, forehead, eyes, face, and
sensitive motor points, the use of the hand was in-
valuable. In making use of this method we had
observed that the muscles of our own arms had
perceptibly increased in size and strength. In
commenting on this statement, the Review went on
to say, "Notwithstanding this alarming condition
of affairs (the enlargement of the biceps) in con-
sideration of the fact that the Atlantic ocean rolls
between them and us we shall not hesitate to ex-
press our opinion."
About this time we wrote another joint article
and sent it to Albany for the coming session of the
State Medical Society. On the committee was Dr.
S. of Brooklyn. Reading the title of the paper he
quickly exclaimed, "What, are these men regular?"
and if it had not been for minds more hospitable, it
probably would have been rejected. Soon after, we
conceived the idea of presenting the subject in
Brooklyn. I mentioned the matter to that great
and liberal minded man, Prof. Austin Flint, Sr.,
professor of the practice of medicine at Bellevue.
"Certainly," he said, "I think you should do so;
it is a subject of which the profession knows little
or nothing, and I will give you a letter to my
friend, Dr. S." Armed with this letter in which
I was called "his young friend," I found Dr. S. in
his office and handed it to him. He received me
coldly and, having read it, gave it back, with the
remark that he had little to do with that sort of
thing, and said I had better call on Dr. R., as it
was more in his line. To Dr. R. I went, and was
well received. He expressed great willingness to
give me an opportunity and said he would present
the matter to the society and would communicate
further with me. When he did broach the subject
it was immediately met by opposition and the
chief opponent was Dr. S. His objections were that
the question of electricity in medicine was one in
which they could have no interest, since it was
little less than quackery ; that the young man's chief
aim was to drum up practice, and finally they needed
no information from him.
Years after I did read a paper before this society
by invitation. By this time the esteemed and in
many ways excellent Dr. S. had long been in heaven
and so missed the opportunity of hearing it. Pa-
tients now began to come to us in greater number,
referred mainly by members of the profession who
had read our contributions, had faith in our in-
tegrity, and saw the reasonableness of our con-
tention.
About this time Dr. Beard received an independ-
ent commission from Scribner the publisher, to re-
write a great volume on Domestic Medicine en-
titled the "Home Physician." He entered upon the
task with his customary enthusiasm and dogged in-
dustry and in an incredibly short space of time it
was completed. Some would have placed at least
a part of the fairly generous sum received in the
bank for a rainy day, but this was against the
principles of Beard, from which he never deviated
to the day of his death. For him money was a
thing not to be hoarded, but to be spent, and he
therefore immediately announced his intention to
go abroad. For certain very good reasons I ob-
jected but he persisted, saying, with much truth,
that in visiting men of science abroad and especially
those interested in the work in which we were en-
gaged, he would garner much material that would
be of service in the writing of the more compre-
hensive treatise that we were contemplating and
later on accomplished. He was gone three months.
When he bade me good-bye, I was treating a pa-
tient. When he returned and unexpectedly entered
the office, that identical patient was seated on the
stool, undergoing treatment. With uplifted hands
and feigned astonishment, Beard exclaimed, "For
the Lord's sake, have you been treating that man
all this time?"
Beard brought back some valuable information,
but of the $800 he took with him he had but fifty
cents left, and none coming to him. The compli-
cations that ensued and how he managed to sur-
mount them is another story.
Dr. Beard was a truly unique and attractive per-
sonality, but his name is now little more than a
memory, and to allow my pen to linger for a while
upon his gifts and graces would be an agreeable
task. He coined the term Neurasthenia, and his
classic monograph on the congeries of symptoms
to which he gave a local habitation and a name was
the basis of all subsequent literature on that sub-
ject. To his keen and discriminating examination,
hypnotism yielded some of its mysteries, and he
exposed the fallacies and unreliability of the aver-
age human testimony as few have done. His con-
tributions to the subject of seasickness were
original and of positive value, and he who reads
his forgotten treatise on "American Nervousness"
will find in it much truth stamped with his own indi-
viduality. His monographs on the "Legal Responsi-
bility of Old Age" and the "Relation of Old Age
to Work" still interest me, as do others of his many
contributions outside the realm of actual medicine.
He died at the age of 42, and as was said of the
poet Burns, so almost may it be said of him. "The
plan of a mighty edifice had been sketched, some
columns, porticos, firm masses of building stand
completed; the rest more or less clearly indicated
with many a far-stretching tendency, which only
studious and friendly eyes can now trace towards
the purposed termination. For the work is broken
off in the middle, almost in the beginning, and
rises among us, beautiful and sad, at once unfin-
ished and a ruin."
It may be all a fancy, but the great physicians
of those days seem to loom up larger than those of
this generation. There were the consultants,
Alonzo Clark and Austin Flint, brainy and big
physically, and who in relation to their fellows
seemed in a way to stand apart. Among the sur-
geons were Parker, Sands, Van Buren, and Wood,
and the gynecologists, Sims, Emmet, and Thomas,
constituted a trio of surpassing excellence and
originality.
The distinctive impression made by these men
and a few others in this city and throughout the
country may be accounted for in part by paucity of
numbers. In the field of literature it is the same,
1112
MEDICAL RECORD.
[Dec. 23, 1916
and the rule applies also to our estimate of great
commanders in all wars previous to the unspeakable
one now waging. So wonderfully has medical and
surgical proficiency progressed that now the "woods
are full" of men whose knowledge and skill are
equal to every emergency.
But let us not forget the original minds that,
preceding us, made possible the triumphs of the
present. How in gynecology, as a single example,
did the discoveries of a Sims revolutionize it! His
statue stands in Bryant Park, unnoticed by the hur-
rying crowd, but the women of the world have cause
to bless his name forever.
370 Sanford Avenue.
EXTRAUTERINE PREGNANCY.
Br E. MACD. STANTON. M.D.. F.A.C.S..
SCHENECTADY, N. V.
Compared with most of the other intraabdominal
diseases treated by the surgeon, the problems pre-
sented by extrauterine pregnancy are relatively sim-
ple. For this reason we find that the first surgeon
to deal with this disease — Lawson Taite — was able
to master its essentials and place its surgical treat-
ment on a foundation which has not been essen-
tially altered since his time.
Because the problems of diagnosis and treatment
are relatively simple, this disease should be to-day
probably the best diagnosed and best treated of
the intraabdominal surgical conditions. That this
is not always the case, however, is indicated by the
fact that my records show that just one-half of
the patients referred to me with extrauterine preg-
nancy had been previously treated for from a
week to several months under a mistaken diagno-
sis, and seventeen per cent, of them had been pre-
viously curetted for supposed abortions. In all but
one of the orginally incorrectly diagnosed cases the
essential points were present in the history which
should have led to at least a presumptive diagnosis
when the patient first consulted her physician. In
the one exception an attempted criminal abortion so
beclouded the history as to make a diagnosis be-
fore the tragic stage quite unlikely.
That the disease is not so rare as to give the
general practitioner an excuse for failing to bear
it in mind is shown by the fact that nearly two
per cent, of my laparotomies have been performed
for this condition. With such a record as to diag-
nosis in a community like Schenectady, filled by a
group of practitioners whose diagnostic skill I know
to be fully equal to, if not above, the average, 1
am led to believe that certain of the main points
concerning the diagnosis and treatment of this dis-
ease will once more bear reiterating.
Etiology. — Up to the present time no really sat-
isfactory hypothesis has been advanced to account
for the fixation and development of the ovum in the
extrauterine position. It seems futile to offer theo-
ries for these abnormal cases when we know almost
nothing of the forces which carry the fertilized
ovum to the uterus and fix it in its normal habitat.
Most writers have emphasized the fact that a
large percentage of ectopic cases give a history of
a preceding period of sterility often accompanied
by symptoms referable to a pelvic inflammatory dis-
ease. This same fact was noted in a considerable
proportion of my own cases, but it is by no means
an absolute rule, and its importance should not be
overestimated. Williams' states that in seventy-
nine cases studied by him the average period elaps-
ing between an intrauterine pregnancy and the sub-
sequent extrauterine pregnancy was three years and
nine months, or but little more than the average
to be expected between normal pregnancies.
Diagnosis. — In considering the diagnosis of ex-
trauterine pregnancy it is well to follow the plan
of grouping the symptoms into those of the "tragic"
and "non-tragic" stages.
The classical case of extrauterine pregnancy in
the "tragic" stage of the disease should be diag-
nosed almost at sight — a woman, an abdominal pain,
and sudden pallor or collapse, are the three factors
necessary for an almost positive diagnosis. The
other data, such as suspected pregnancy, irregular
flowing, the absence of a history pointing to a per-
forative ulcer, etc., may be obtained while prepar-
ing to carry out the steps necessary to bring the
patient to the operating room in the best possible
condition. A bimanual examination is not neces-
sary, and, as a rule, one should not be made until
the patient has reached the operating room.
It must be borne in mind, however, that the tragic
stage is seldom the one first encountered even by
the consulting surgeon, and the general practitioner
really sees very few cases for the first time in
this stage of the disease. Harris1 has reported a
series of one hundred and thirty cases in which
more than ninety per cent, of the patients first pre-
sented themselves for examination before the tragic
stage. My experience is in accord with that of
Harris, in that all but two of my patients con-
sulted a physician for trouble due to the extrauter-
ine pregnancy at a period previous to the onset of
the tragic symptoms.
The Non-tragic Stage. — In the non-tragic stage
the diagnosis is not forced upon one as it is in
the tragic cases, and yet in nearly every instance
the data necessary for an almost positive diagno-
sis may be elicited from the history alone. Addi-
tional data may often be obtained from the physi-
cal examination, but if the objective findings are
not of a very positive character, either for oi
against the diagnosis, they are liable to prove mis
leading, and should be rated as of secondary im-
portance to the data obtained from the history.
The two symptoms of paramount importance in
the early diagnosis of ectopic pregnancy are pain
and irregularity of menstruation. Harris says:
"When any woman, after puberty and before the
menopause, who has menstruated regularly and
painlessly, goes 4, 5, 6, 8, 10, 15, or 18 days over
the time at which menstruation is due, sees blood
from the vagina differing in quality, color, quan-
tity or continuance from her usual menstrual flow,
and has pains, generally severe, on one side of the
pelvis or the other, or possibly in the hypogastric
region, ectopic gestation may be presumed."
In my series, without exception, it was pain which
first caused the patient to seek medical advice. In
each case, either the first or some of the following
pains were typical or highly suggestive as to char-
acter if not as to location. Usually, but not always,
they were quite severe. There may have been dull
pains and laborlike pains, and pains such as the
patient has during her menstrual periods, but some
time in each of my cases at least one or several pains
were experienced which were sharp and quick in
character, and quite unlike those ordinarily en-
countered in other pelvic conditions. "Sudden,"
"stabbing," "knifelike" are terms often used by the
patients in describing these pains.
As a rule, the pain is located in the pelvis, but.
Dec. 23, 1916]
MEDICAL RECORD.
1113
curiously enough, it may be referred by the patient
to the back, rectum, epigastrium, or kidney region,
so that it may require close questioning to locate
the trouble in the pelvis. As a rule, nausea rarely
accompanies pain of pelvic origin, but in my histo-
ries I find frequent mention of nausea, or even
vomiting, in relation to the sudden pains of extrau-
terine pregnancy. Fainting is usually a symptom
of the tragic stage, yet more or less faintness is
frequently mentioned in my histories, even without
marked evidence of internal hemorrhage.
Irregular Flowing.— The expression, "a typical
menstruation of ectopic gestation," although a mis-
nomer, is a useful one in so far as it directs atten-
tion to the appearance of blood, in time or charac-
ter of flow out of rhythm with the normal men-
strual cycle of the individual. In two of my his-
tories the record as to menstruation is incomplete.
In each of the other cases there is a definite record
of irregularity. In some a period had been missed
but bleeding varying from a slight show to rather
severe hemorrhage came on just before or soon
after the onset of pains. In several cases both the
pains and show began soon after an apparently nor-
mal period.
It has been shown that the continued uterine
hemorrhage so frequently encountered in these
cases usually commences with the death of the
fetus and continues while placental tissue remains
in contact with the tube, the physiological factors
responsible for its continuance being essentially the
same as in an ordinary incomplete abortion. Even
in those rare cases when the life of the fetus con-
tinues, more or less uterine bleeding at irregular
intervals is the rule.
The really important point to be always borne in
mind is that pelvic pain plus an unusual uterine
bleeding spells ectopic pregnancy, in a very con-
siderable proportion of cases. Whenever this com-
bination of symptoms is present it becomes the
imperative duty of the practitioner to rule out the
possibility of extrauterine pregnancy before pro-
ceeding to entertain any other possible diagnosis.
Additional diagnostic data may be obtained from
many sources. In the pretragic stage there is
seldom any elevation of temperature commensurate
with the amount of acute trouble evidently present
in the pelvis. On the other hand, I have myself
several times erred or come near erring because I
did find a temperature of from 100~ to 101° or
even higher, and we should always remember that
intraperitoneal hemorrhage is usually followed by
a fever of the surgical type.
Treatment. — In no other field of abdominal sur-
gery were the advantages of operative treatment so
promptly recognized. The excision of the appen-
dage bearing the gestation sac is usually a very
simple procedure, and except for the acute anemia
and shock encountered in the tragic stage these
patients are usually excellent operative risks. A
good deal has been written about the advisability
of delaying operation in cases of profound collapse.
I am a firm believer in delay if the patient is in
such collapse as to be obviously unable to stand any
operation, but I do believe the fact should be very
strongly emphasized that extrauterine pregnancy
patients in the "tragic" stage of the disease stand
anesthesia and operation better than any other
cases presenting like blood pressure and pulse find-
ings. The man reduced to an apparently similar
state of collapse or shock by a traumatism such as
a crushed leg is in no way comparable as an opera-
tive risk to the woman suffering from a ruptured
ectopic, and the same may be said of the shock
and collapse accompanying perforations and intra-
abdominal infections.
Nine of my patients were operated upon during
the acute tragic stage in the presence of acute
anemia and a rapid pulse. One I kept in a partial
Trendelenburg position for about two hours before
operation because she was quite pulseless when ad-
mitted to the hospital. Every one of my tragic
cases actually improved from the time they began
to take the ether until they left the operating table.
The operations were complete in from seven to ten
minutes. No time was spent in removing clots
other than those which presented in the wound and
pelvis during the manipulations necessary to ex-
cise the gestation sac. All of these tragic stage
patients made uneventful recoveries. I know of no
other pathological condition capable of producing
the degree of "shock" present in these nine patients,
for which I could operate in the presence of the
shock without expecting a mortality of from 30
to 60 per cent.
When operating in the non-tragic stage, proced-
ures other than the simple excision of the affected
appendage may be safely undertaken. First as re-
gards the removal of blood and clots, I believe
that the peritoneal cavity should be left reasonably
clean, but this does not mean that the intestines
should be much handled and endothelial surfaces
injured by sponging in over-careful attempts to
rid the peritoneal cavity of blood. If the loops of
intestines are not displaced and are left to normal
relationship one to another the remaining blood
will do no harm other than to cause a few gas
pains during the first days after operation.
There has been considerable discussion concern-
ing the danger of a second ectopic in the opposite
side if both tubes are not excised. Statistics on
this question vary so much as to make them of
little value from a percentage viewpoint. They do
show, however, that if the opposite tube is not re-
moved the woman who has had one ectopic preg-
nancy stands a fairly good chance of having subse-
quent normal pregnancies and a rather remote
chance of a second ectopic pregnancy. In my own
work I have not felt it justifiable to remove the
opposite tube because of the danger of a second
ectopic, yet for one reason or another (usually be-
cause of obvious disease of the other tube) I have
excised both tubes in eleven out of twenty-three
operative cases.
Hysterectomy. — Recently, at least one surgeon of
prominence has advocated removing the uterus in
these cases. Such a procedure may yield interest-
ing pathological data but otherwise the arguments
in favor of hysterectomy are in kind like advocat-
ing excision of the toes for fear they might some
day be frozen.
Drainage. — Unless there is oozing from granu-
lating surfaces at the placental site it is seldom
advisable to drain these cases even though con-
siderable blood be left behind. In my series drain-
age was used only twice, each time because I feared
oozing from a raw granulating surface.
Late Cases with Living Fetuses. — The above re-
marks concerning the simplicity of the operation
have concerned the ordinary case interrupted in the
vast majority of instances before the third month
of the pregnancy. Occasionally an extrauterine
pregnancy may proceed with a living fetus to a
much later stage of pregnancy, or even to term.
1114
MEDICAL RECORD.
[Dec. 23, 1916
In these cases, if the fetus be still alive, the prob-
lem of dealing with the broadly attached placenta
without encountering terrific hemorrhage is very
difficult. Unless one can be certain of being able to
control the blood supply to the placenta in these
cases it is best to remove the fetus and leave the
placenta until it has had time to become separated
from the maternal circulation. The older surgeons
encountered a fair number of these cases but better
diagnosis and prompt operations have made them
so rare to-day as to have little influence on the
subject as a whole.
Transfusion. — In patients suffering from the ef-
fects of acute hemorrhage, blood transfusion, using
a properly selected donor, gives practically perfect
results. Many cases of ruptured ectopic preg-
nancy offer ideal indications for transfusion. How-
ever, because of the possible dangers of anaphylaxis
and the fact that insufficient time is usually avail-
able for the various laboratory tests of compata-
bility, transfusion should be resorted to only when
it is evidently so necessary as to make the risks
incidental to the transfusion itself of but minor
relative importance.
In my own work I have never had to transfuse
an ectopic patient but in a number of cases of
hemorrhage from other causes we have during the
past year used the indirect 0.2 per cent, citrate
method of Lewisohn."
The technique of this method is so simple that
it can be carried out by anyone capable of giving an
intravenous transfusion of physiological salt solu-
tion and in our experience it has given perfect re-
sults. If the citrate solution and other apparatus
necessary for giving one of these transfusions is
not kept constantly on hand in the hospital, immedi-
ate arrangements should be made to prepare an out-
fit and provide a donor to be used if necessary at
the time when the ambulance is called for an ectopic
patient encountered in the tragic stage of the
disease.
Prognosis. — There are no reliable statistics pur-
porting to show the mortality in ectopic pregnancy
cases before the days of surgical intervention. In
those days the diagnosed cases mostly ended fatally
or were first diagnosed at autopsy. The fact, how-
ever, that the disease was then looked upon chiefly
as a rare pathological curiosity occasionally en-
countered by those doing coroner's autopsies would
lead one to believe that a large proportion of those
cases now operated upon as ectopics eventually re-
covered. Our present knowledge concerning the
frequency of termination by tubal abortion would
also tend to support this view.
To-day the advisability of operation is universally
recognized and with average surgical skill the prog-
nosis depends almost entirely upon the condition of
the patient when she reaches the operating room.
Surgeons are agreed that except in the worst of
the tragic cases the mortality after operation is al-
most nil, and the after results are most satisfactory.
In my twenty-three operated cases there was no
mortality and there were no postoperative complica-
tions worthy of note. The one case dying under
my care is reported as follows :
Female, age 30, referred by Dr. Murray. This pa-
tient had been ill three weeks with what I diagnosed as
pelvic peritonitis. The temperature had ranged from
99° to 101°, and the predominating symptoms when I
saw her were those of peritoneal irritation involving
the small intestines. She was sent to the hospital with
the intention of operating the following day, but by
morning her condition was seen to be improving so
markedly that the operation was deferred. Finally it
was decided to operate the fifth day following her ad-
mission, but at 3 A.M. on the morning she was to be
operated upon the patient woke out of sleep, raised up
in bed, fell back gasping for breath, and died at 3:20
A.M.
Autopsy showed an extrauterine pregnancy with the
tube adherent above the pelvic brim, the hemorrhagic
mass being surrounded by loops of small intestines.
Death in this case was due to an error in diagnosis
which was, however, partially justifiable owing to the
abnormal position of the tube. The clinical picture
which had held my attention was always referable to
the involvement of the small intestines in what I took
to be an inflammatory process. Nevertheless, when the
history of this case is reviewed with the idea of extra-
uterine pregnancy in mind the essential points for the
correct diagnosis are found to have been recorded by
myself at my first examination ; namely, abdominal pain
promptly followed by irregular flowing which was still
present when I first examined the patient.
Cases Incorrectly Diagnosed as Extrauterine
Pregnancies.- — I have operated upon one patient
under a positive diagnosis of ectopic pregnancy who
turned out to have had a sudden rupture of a cocoa-
nut-sized ovarian cyst. Two other patients I oper-
ated upon because of early pregnancy, severe pains,
and what I took to be a mass at one side of the
uterus. In both I found intrautreine pregnancies
with the early uterine enlargement confined chiefly
to one side of the uterus. Irregular flowing was
not mentioned in the history of either case.
REFERENCES.
1. Williams, P. F. — Extra Uterine Pregnancy and Its
Subsequent History, an Analysis of 147 cases. — Am. J.
Obst., N. Y., LXVII, 1165-1170, discussion 1177.
2. Harris, P. A. — Early Diagnosis of Tubal Preg-
nancy. J. A. M. A., 1907,' XLIV, 1103-1110.
3. Lewisohn, R.- — Blood Transfusion by the Citrate
Method. Surg. Gyn. & Obst,, 1915, XXI, 37.
Illuminating Company Building.
HELIOPHOBIA.
A MENACE TO THE COMMUNITY.
Bt F. ROBBINS. M.D.,
NEW YORK.
The obligation of the physician to set an example
to the community is greater to-day than hereto-
fore, because his personal transgressions against
the laws of hygiene are apt to become common prop-
erty in these days of general admission to medical
societies and libraries. The physician who shuts
out precious sunlight for hours from a reading
room because for five minutes a ray has danced
across his page, sets a pernicious example to the
ever-present majority of the ignorant. Praesente
medico nihil nocet is a sentence perhaps not intelli-
gible to all readers, but the principle still survives
in a community which is fast losing all reverence
for the medical profession.
God said: Let there be light. The devil whis-
pered to men, and blinds were invented. (Accord-
ing to the Century Dictionary, a blind is anything
which obstructs sight, intercepts the view, or keeps
out light; the associated meanings of the adjective
are very suggestive: Not possessing or proceeding
from intelligence; destitute of intellectual, moral,
or spiritual sight.) It would be comical, were it
not so serious a matter, that "blinds" is the term
selected for the contrivances which begrudge the
light to the other occupants of a room, in "favor"
of the one or two who may be incommoded (not
actually harmed) by the visiting sunlight. It is
the old confusion between cause and effect. For the
reassurance of those who honestly fear harm to
their own eyes, and therefore feel justified in de-
Dec. 23, 1916]
MEDICAL RECORD.
1115
priving others of their share of the sun, be it said
that one of the most efficient treatments of
trachoma is — sunlight. In the experience of Gron-
holm, a single exposure of the affected eyes to
sun-radiation according to Finsen's method, during
ten minutes, was sometimes sufficient for a cure.
Very favorable results were obtained by Hunsel, in
eighty cases of trachoma, by combining copper-
sulphate treatment with daily exposure of the eyes
to sunlight.
According to the Bulletin of the American Asso-
ciation for the Conservation of Vision, at least
half of the educated class in the United States are
afflicted with serious defects of vision, and the
conspicuous reason for the present condition is the
practically universal ignorance regarding the eyes,
their care, and the way in which they should be
used. It is of tremendous national importance, says
Douglas C. McMurtrie, that the American people
shall be endowed with good eyesight.
The greatest good to the greatest number in-
volves full utilization of our none-too-abundant light
from heaven. For those whose subjective sensa-
tions lead them to the unjustifiable exclusion of
the sun's good light from places destined for the
accommodation of others" who believe in the preser-
vation of sight through light, the individual adop-
tion of smoked glasses (Schutzbrillen of the Ger-
mans) is recommended as the simplest and fairest
solution of the glare-problem. The word "glare"
is one recently adopted by the engineering profes-
sion from general usage, meaning discomfort or
depression of the visual function, associated with
strong light sensation. In his discussion of physio-
logical points bearing on glare, Cobb points out the
fact that detailed knowledge on this subject is
scarce, and also that under practical conditions, the
actual reduction of visual acuity by this feature of
glare is not so great as to cause in itself serious
embarrassment of vision.
The optic nerve is made to be stimulated by light.
Normal eyes are rendered extremely sensitive to
light through prolonged sojourn in the dark; the
more so, the more carefully the light is kept away
from the eye. In order to protect for minutes a
pair of abnormally sensitive eyes, the heliophobe
will cheerfully proceed to darken for hours an en-
tire room, and incidentally to cultivate millions of
bacteria. Safely encased in the impenetrable armor
of egotism, he thoughtlessly jeopardizes the sight
and health of his fellows, lowering blinds right and
left for his personal gratification, without ever
remembering on his departure to readmit the light
of day. Once pulled down, a window blind remains
down by common consent and indifference, in the
great freemasonry of laziness. Libraries are not
the only offenders, however, and public institutions
such as post offices are open to criticism, if shut-
tered from the sunlight. The Fifty-first Street
station in this city scrupulously excludes the sun
from its southern windows, and gratuitously serves
the public with a choice allotment of germs from
all sources. Elevated railroad companies, while
chary of giving full value in form of a seat for the
nickel, generously provide shutters and blinds,
which the conductor considers it a sacred duty tc
pull down on the sunny side of the train, ostensibly
to protect the eyes of the reading public — (too bad
anti-vibrators are not furnished at the same time!)
— but really to provide a culture-medium for the
vegetable and animal parasites which lurk and
multiply in the shadows. Public health would be
the gainer, were the exclusion of sunlight (a most
efficient germicide) from public conveyances de-
clared a misdemeanor.
The commercial spirit of the age manifests itself
very plainly in the disregard and waste of sunlight.
Although the sun still shines for all, unless pre-
vented by skyscrapers or blind-pullers, the forma-
tion of a sun trust in years to come may serve as
an eye-opener. Many patrons of window blinds
have never heard of the heliotherapy of tubercu-
losis, nor do they realize that the scientific ex-
ploitation of sunlight may yet be developed into a
close competitor of radium and the z-ray. Millions
are expended for radium-treatment of cancerous
skin-growths before the purposeful application of
direct sunlight has been given even half a trial.
Rain water warmed by the sun was credited with
cardinal virtues for the tubbing of delicate babes
in the old-fashioned nursery. The up-to-date
boudoir is beginning to be interested in "radium-
ized" water, for Milady's, or perhaps for Fido's
bath. Mundus vult decipi, ergo decipiatur. Revel
in radium, if you will, but do not rob your neighbor
of the sun!
What is the basis of this irrational attitude
towards sunlight, and of the fear of its effect upon
the eye? Answers of habitual blindpullers vary
from the naive, "It hurts my eyes," to a more
sophisticated reference to the "injurious" ultra
violet rays. Let us see. According to available
measurements, the rays which reach us from the
sun correspond to wave lengths of about 50,000 to
about 100 uu. Wave lengths of about 810 uu to
about 380 au. belong to the visible spectrum. In-
visible rays of more than 810 au are designated as
ultra red rays, while rays of less than 380 u.u are
usually described as ultra violet rays. It has been
shown that rays of shorter wave length than 38 nn.
are practically entirely absorbed in the cornea, so
that these rays cannot possibly exert an injurious
effect upon the lens and retina, but at most only
upon the superficial portions of the eye, the cornea
and conjunctiva. These short wave lengths are
essentially responsible for the phenomenon of snow
blindness, the changes of which are usually re-
stricted to the conjunctiva. Concerning the in-
jurious action of short wave rays on the endo-
thelium of the cornea and on the crystalline lens,
the interposition of an ordinary glass plate, such
as window-glass, between the source of light and
the eye suffices to prevent an injurious action on
the endothelium. (Hess.) The contents of sun-
light— even less so than those of artificial light —
in ultra violet rays are not sufficient to cause eye-
trouble. Persons who work daily in a strong arti-
ficial light, as in electric concerns, for example,
suffer very rarely from ocular disturbances, except
through negligence or accident. Under ordinary
conditions of daily life, the ultra violet rays do not
enter into consideration at all, in the protection of
the eye against an alleged excess of light. At a
low sea level, ordinary daylight contains very small
amounts of ultra violet rays, which are absorbed
to a considerable degree by the deeper air-layers.
Moreover, as emphasized by Fuchs, the ultra violet
rays are not perceived by the retina, and therefore
cannot produce unpleasant sensations of any kind.
The dazzling sensation caused by a glare of light is
derived only from the visible rays of the spectrum,
the same rays which are injurious to the eye in
diseased conditions of the retina and chorioid. In
all such cases, ordinary smoked glasses will protect
1116
MEDICAL RECORD.
[Dec. 23, 1916
the wearer against all fancied or real danger, with-
out interfering with the right and health of others.
In the presence of hyperirritability of the retina,
even a small amount of bright daylight may elicit
unpleasant sensations, and this is frequently the
case in neurasthenic and hysterical individuals.
Fuchs compares this intolerance of light with the
equally common hypersusceptibility to noise, in
nervous patients. People of this description are
apt to complain not only of more or less brilliant
daylight, but also of unpleasant sensations pro-
duced by bright or shining objects, for example,
by the white paper, when reading or writing. In
illustration, Fuchs mentions the case of an over-
worked and highly neurasthenic business man, who
finally came to shield his eyes with his hand when
signing his name, in order to avoid being dazzled
by the white paper. In all probability, he had also
contracted the delightful habit of lowering all blinds
within his reach. Shrinking from bright daylight
or sunshine is a very common sign of neurasthenia..
The victims of drug habits, especially morphine,
often insist upon the most rigid exclusion of sun-
light from their shadow-realm.
The light of day has never been shown to have
an injurious influence upon the eye, in health or
even in disease, and it is an antiquated notion to
hold strong sunlight responsible for certain forms
of eye trouble. Such views were current in the
eighties, and should long have been outgrown even
by the laity. On the ground of biological considera-
tions, as pointed out by Hess, it is difficult to con-
ceive that a living structure, phylogenetically de-
veloped under the permanent action of daylight,
should have simultaneously acquired the peculiar-
property of sustaining damage through this same
daylight. In a lecture held at the international
Medical Congress, London, 1913, Hess conclusively
refuted the view that photophobia is transmitted by
the nerves of the cornea and iris, for he showed thai
tight compression of the eyes, even in total dark-
ness, after all light has been excluded, often relieves
the disturbances in diseased conditions of the
cornea and iris. As tight compression of the eye-
lids has the same effect also in the presence of
light, the widespread misconception has arisen that
the reason for this compression is photophobia.
This misconception flourished on the adaptation of
the eye to the darkness, through the partial closing
of the lids, with the result that it becomes more
sensitive to light. This fear of light is secondary,
however, being caused by the palpebral closure, and
is not related to the corneal affection as such. This
arbitrary closing of the eyelids, and the resulting
photophobia, is entirely analogous to the wilful
drawing down of window blinds.
Darkness or a dim light plays a peculiar part in
the psychology of the sufferers from heliophobia.
The significance of darkness in nervous psycho-
pathology was investigated by Abraham, who
finds that this light-fear manifests itself in form
of intolerance for daylight, more particularly sun-
light. Psychoneurotics of this type are easily
"dazzled," feeling their sight confused by brilliance
of light. Some complain of more or less severe
pain in the eyes on brief exposure to moderate day-
light or artificial light, and resort to all sorts of
measures for protection against it. Besides show-
ing an exaggerated sensitiveness toward illumina-
tion, these persons react to light stimuli with a true
phobia of the neurotic fear type. The subconscious
content of the fear complex is threatened blindness.
All psychoneurotics of this group suffer from helio-
phobia. A heliophobic patient under Abraham's ob-
servation hung threefold curtains before his bed-
room windows, so that not a ray of light could enter
in the morning. Psychoanalysis finally showed that
the patient identified with the sun the watchful
eye of his father, whose control he was anxious to
escape. It would lead too far to enter into a con-
sideration of the sun as a phallus-symbol. Let us
plead, in the last words of Goethe, for "more light,"
and with a modern poet, Rhys Carpenter,
"Because we dare behold the sun,
With eyes unshaken, unafraid!"
BIBLIOGRAPHY.
Cobb, Percy W. : Physiological points bearing on
glare, Scientific American (N. Y. Section of Illuminat-
ing Engineering Society, Jan. 12, 1911), April, 1911;
p. 1.
McMurtrie, Douglas C: Concerning Eyesight. Bul-
letin of the Am. Assoc, for the Conservation of Vision,
1911.
Carpenter, Rhys: The Sun Thief, and other poems.
London, 1914. (H. Milford, Pub.).
Abraham, K.: Ueber Einschriinkungen und Urn-
wandlungen der Schaulust bei den Neurotikern. Yahr-
buch der Psycho-Analyse, VI., 1914. pp. 25.
Fuchs, E.: Ueber Lichtecheu. Wiener klinische
Wchschrft. 25. No. 1, 1912. pp. 33.
Hess, C. : Ueber Schadigungen des Auges durch
Licht. Archiv. fur Augenheilkunde, 75, 1913, pp. 127.
: Versuche iiber die Einwirkung ultra-
violetten Lichtes auf die Linse; ibid. 55, 1907. pp. 185.
Heiberg and Gronholm: Histologische Untersuchun-
gen iiber die Eimvirkune: des Finsenlichtes. Archiv fiir
Ophthalmologic, 80, 1911. p. 47.
Gronholm: Finsentherapie bei Trachom, ibid. p. 1.
van Hunsel, J. H. F. E.: Proeve van trachoombe-
handeling met zonlicht. Geneesk. Tijds. voor Neder-
Inndsch-lndie. Batavia, 1911, Vol. LI, p. 753.
11 West Forty-fifth Street.
TONSILLECTOMY UNDER NOVOCAINE.
By P. M. LEWIS, M.D.,
NEW YORK.
[OUSE SURGEON, NEW YORK THROAT, NOSE, AND LUNG HOSriTAl..
This article is written in order to relate a little ex-
perience regarding tonsillectomy as I found it in
my own case. We often hear that there is no bet-
ter way to learn than by veritable experience and
so it is. We can apprehend and appreciate to a cer-
tain degree the subjective and objective symptoms
of others, but when those symptoms are personal
we can more thoroughly orientate ourselves to the
real condition of things.
Having had several attacks of follicular tonsil-
litis in previous years and having lately seen so
many pernicious maladies arising from pathologi-
cal tonsils I resolved that it was very pertinent to
have mine removed since they had several times
proven themselves subject to infection. One at-
tack of tonsillitis or the slightest focus of infec-
tion should be conclusive evidence in favor of their
extirpation. The tonsils have been shown capable
of being the host of many and varied forms of or-
ganisms from the non-pathogenic to those of the
most virulent types. One cannot scrutinize too
closely for some focus of infection. Frequently in
removing an apparently healthy tonsil, products of
inflammation will exude while manipulating the
tonsil during the operation. The prominence or
non-prominence of the tonsil offers no index as to
the amount of hypertrophy or diseased condition.
Some of the largest tonsils with marked patho-
logical lesions are the so-called buried ones and may
present a normal healthy surface as viewed intact.
Dec. 23, 1916]
MEDICAL RECORD.
1117
When indicated, tonsillectomy should be done
during childhood. At this period of life the tissues
that will be cut and traumatized during the opera-
tion heal readily and the inconvenience to the pa-
tient lasts only a day or so; whereas in the case
of an adult the tissues are highly fibrous, necessi-
tating more trauma during the operation, the heal-
ing process is slow and the patient is quite con-
scious of a real sore throat for longer than a week.
I am sure that most operators are aware of the fact
that as age advances the period of convalescence
from tonsillectomy increases.
Novocaine in tonsil work is advocated only in the
case of adults and then the operator should use
some discretion and satisfy his own mind that the
patient is not of a highly nervous type and one
that will give him a considerable amount of trouble
during the operation. The patient should be given
his choice between a local and general anesthetic
and told the advantages and disadvantages of each.
Some patients have a horror of being put to sleep
and will welcome the suggestion of a local anes-
thetic. A patient's mental condition on a subject
of this nature should not be ignored and where there
is an alternative the mental equilibrium of the pa-
tient should not be perturbed.
The following are some of the advantages of
tonsillectomy under novocaine: (1) If it be a clini-
cal patient it is not necessary for him to remain in
a hospital ; he can go home alone and the probability
of a hemorrhage is not nearly so great as in the
Street*s syringe for injecting the tonsils
case of a general anesthetic. The expense of an
operating room, the necessity of an anesthetist and
an assistant are eliminated. (2) The hemorrhage
during the operation is insignificant and the post-
operative hemorrhage is always slight. (3) The
patient is in the upright position, which is the ideal
position for the operator. (4) From personal ex-
perience I can give the assurance that the patient
does not experience any pain. This may not be
true in every case when the operator has failed to
anesthetize the tissues properly. (5) The patient
can hold the mouth open and it is not necessary to
use a mouth gag or tongue depressor nor does one
have to traumatize the tissues by sponging, for if
there is any bleeding the patient can expectorate it.
Technique. — It is not the purpose of this paper
to describe the technique of tonsillectomy, since that
can be found in any standard text on the subject.
It is only desired to describe the method of ad-
ministering the anesthetic and the after treatment.
The tissues surrounding the field of operation should
have a thorough application of a 4 per cent, solu-
tion of cocaine and in a few minutes an applica-
tion of a 10 per cent, solution of cocaine over the
same area. The initial 4 per cent, cocaine is toler-
ated much better by the patient than if a stronger
solution be used. The cocaine is used to allay the
reflexes of the fauces and the pharynx. If this is
not done the manipulation of the instruments dur-
ing the operation, touching highly irritable tissues,
will produce very annoying reflexes causing the pa-
tient to gag and retch even against his strongest
voluntary efforts to resist. Then, too, when the
lies are partly cocainized, making the puncture
to inject the novocaine will cause but little if any
pain.
For the injection of novocaine, Street's syringe is
conveniently used. The suitable size of the instru-
ment with the needle curved at an angle of about
45 deg. to the long axis of the syringe add much to
the advantageous use of it. In addition the guard
around the needle extending to within a certain
distance of the point will prevent the needle from
making too deep a puncture. With everything
prepared a 2 per cent, solution of novocaine with a
few drops of adrenalin added is injected into each
tonsil. The first injection is made in the most
prominent part of the tonsil. While injecting the
solution the tonsil is seen to swell and in a few
moments become somewhat blanched. Novocaine be-
ing such an efficient anesthetic, and because of the
great vascularity of the tonsil tissues the drug be-
ing so rapidly absorbed and disseminated through-
out the area, probably the initial injection would be
sufficient for the operation ; but to be sure the ante-
rior and posterior pillars and the edges of the tonsil
should be injected. With this procedure one can
always feel satisfied that the tissues are thoroughly
anesthetized and can assure the patient that the
operation will not be painful. Novocaine is being
used frequently in our clinics for tonsillectomy with
unique results.
Cocaine should never be in-
jected into the tonsils, for it is
very toxic, the tissues in that
area rapidly absorb it, and sev-
eral fatalities have been caused
by its use.
Postoperative Treatment. —
The following applies to tonsil-
lectomy performed under a gen-
eral anesthetic as well as
local, especially in adults. In the case of a
local anesthetic the patient will feel quite nor-
mal after the operation until the effects of the
anesthetic have abated, which is from one to three
hours. After this the throat will be extremely sore.
The patient should not remain up any undue length
of time. There is a decided hyperactivity of all the
salivary glands. In addition to this phenomenon
there is some bleeding, and with this accumulation
of foreign material in the mouth there will invari-
ably follow frequent attempts at deglutition. Even
if the saliva and blood are expectorated deglutition
will follow unless prevented by strong voluntary
efforts. From the standpoint of hemorrhage deglu-
tition is a most serious factor. With each degluti-
tory action, the levator palati, the tensor palati, and
the palatopharyngei (posterior half arches) mus-
cles in contracting to close the posterior nares will
pull upon the tissues that have been cut during the
operation, break up nature's barrier, and bleeding
will start anew. The patient should be advised not
to swallow any more than is absolutely necessary
for the first twelve or eighteen hours following the
operation. This advice is very difficult to follow.
To aid the patient in this he should have y8 to %
grain morphine hypodermically. It is not the cus-
tom to follow tonsillectomy with morphine, but
there is nothing to be gained by withholding it and
it is of paramount importance for the patient to
have it if for no other purpose than indirectly t©
prevent hemorrhage. It will make the patient more
1118
MEDICAL RECORD.
[Dec. 23, 1916
comfortable, decrease the attempts at swallowing,
and in this way guard against hemorrhage. Only
one dose should be given and then only after the
effects of the novocaine have subsided. When given,
the patient should be told that he is getting some-
thing to prevent hemorrhage, which statement will
be true and he will rarely know any better. Adults
seldom have adenoids, but when present they should
not be removed during the tonsil operation if it is
done under a local anesthetic, for the bleeding from
the adenoids will inconvenience the patient more
than that from the tonsillectomy. Then the mu-
cous membrane on the posterior tips of the turbi-
nates may be abraded or enlarged posterior tips may
even be cut off if the LaForce adenotome is used
and the bleeding will persist for several hours. The
adenoids can just as easily be removed at some other
time.
After the danger from hemorrhage has passed,
the patient should be advised to swallow the saliva
that collects in the mouth and not to expectorate it.
The procedure is quite difficult to the patient, but
it must be done to keep the tissues of the back of
the mouth and pharynx moist. At this period the
tissues have a tendency to become dry and if they
are not kept moist by swallowing the saliva they will
remain dry and painful. The patient should know-
about these things and it will add much to his com-
fort. A weak saline solution used as a gargle will
stimulate the secretions, aid in keeping the tissues
moist, and be very soothing to the patient.
THE TUBERCULIN DISPENSARY.
By RICHARD COLE NEWTON, M.D.,
MONTCLA1R, N. J.
LATE CAPTAIN AND ASSISTANT SURGEON, I'. s. ARMY; 1, \TE
PRESIDENT N. J. STATE BOARD OF HEALTH I CONSULTING
PHYSICIAN TO NEW MOUNTAINSIDE HOSPITAL.
The principal reason that we are making so little
headway toward the stamping out of human tuber-
culosis is that there are so many unlocated incipient
cases. Before we shall make real progress in this
direction, the popular conception of the extent and
true history of the disease must be entirely changed.
The tuberculin diagnostic test must be generally
adopted and some method must be devised by which
practically all children and all adults whose sys-
tems are below par, without an obvious cause, must
be subjected to the test; and those found to be in-
fected must be treated, and that too, if possible,
before positive symptoms can be demonstrated in
the lungs or in any part of the body. When a posi-
tive diagnosis of tuberculosis can be made by physi-
cal examination of the chest, the case is no longer
incipient, and the golden moment for beginning
treatment has passed.
It may be a long time before wholesale tests with
tuberculin will be made upon human beings as they
are now made upon cattle. We have not yet reached
that stage of civilization when human life shall re-
ceive as much consideration as property. Cattle
must be tested for various diseases, including tuber-
culosis, and are carefully protected from infection
by legal enactment. If they become infected and
are therefore a menace to other cattle they must
be instantly slaughtered if necessary to prevent
the spread of contagion.
With man, conditions, of course, are different,
and it is by no means entirely due to indifference
that it is so difficult to bring incipient cases of
human tuberculosis promptly under treatment.
There are several reasons for this, the principal one
being the widespread ignorance of the true nature
of tuberculin, and the consequent fear that harm
may result from its use. Nor can we justly assert
that there are no grounds for this fear, if one may
judge the present by the past.
Ever since Koch proclaimed tuberculin as a rem-
edy for tuberculosis its use has been more or less
a series of experiments which have been largely
unavoidable owing to the peculiar nature of the
remedy, and the natural history of the disease,
neither of which have, as yet, been fully explained,
although, fortunately, recent researches in bio-
chemistry, immunity, and susceptibility have thrown
so much light upon these intricate subjects that
clinicians are moving forward in the treatment
of tuberculosis with supreme confidence in the ulti-
mate outcome of the warfare against this insidious
enemy.
It has been absolutely demonstrated that tuber-
culin, in moderate doses, has no effect on non-tuber-
culous human beings, any more than it has upon
healthy cattle. Furthermore, it is not a poison,
and when properly used does no harm to tubercu-
lous subjects in any stage of the disease. It is, in
reality, a measure of their susceptibility, and in
properly graduated doses calls forth the protective
agents of the body in increasing numbers until the
patient becomes completely immune to the tuber-
culin, which contains the most active agent of the
tubercle bacilli. (The bacilli, however, from which
the tuberculin has been extracted, have all been
killed by heat and the product has been filtered
through porcelain before being put upon the mar-
ket. It has also been accurately standardized.)
The tuberculin calls forth an artificial immunity
in the body, which strengthens and reinforces the
natural immunity which is possessed in some meas-
ure by every one, and in this way affords an es-
cape from the infection of tuberculosis.
When these fundamental facts shall be generally
understood the further information must be dis-
seminated that practically every one is tuberculous
at some time in his life, that tuberculosis is by
no means highly contagious, since practically no
one has ever contracted tuberculosis in any of the
well-conducted tuberculosis sanatoria, where proper
precautions are always observed regarding the care
of the sputum and the excretions of the patients.
There is, therefore, no reason why tuberculous
patients should be treated like the lepers of whom
we read in Scripture. These unfortunates were
probably not a menace to their neighbors, since
leprosy is probably not contagious, and they de-
served far more considerate treatment than they
received. The fear of being shunned by one's
neighbors and of being isolated from one's family
and friends keeps many sickly persons from sub-
mitting to an examination to learn whether or not
they may be tuberculous. So people buy the nos-
trums they see so flauntingly advertised as "sure
cures" for consumption, and hope against hope that
they will throw off their colds "when the warm
weather comes," and when they are finally brought
under treatment the golden opportunity is gone to
check the disease before it has made such substan
tial progress that it can be detected by the physical
signs in the lungs.
We require all immigrants to be vaccinated be-
fore admission to this country. We send back across
the ocean cases of trachoma, feeblemindedness, or
marked bodily sickness, yet we allow many cases
i
Dec. 23, 1916]
MEDICAL RECORD.
1119
of incipient phthisis, which cannot be detected with
certainty unless all immigrants are properly tested
with tuberculin, to settle among us. A matter of
such importance should receive instant attention
from those in authority.
Probably the establishment of properly equipped
tuberculin dispensaries similar to those established
abroad, especially in England, and, I presume, in
Germany, will be the first practical step that we
can take toward making sure that large numbers
of people shall be tested for tuberculosis. Whether
legal enactments will be necessary before people
generally will submit themselves and their children
to the tubercuin test it is too early to state.
Efforts have already been made to introduce rou-
tine tuberculin tests for tuberculosis into the
schools, and this should be done without delay. The
economic saving to the individual as well as to the
State, if tuberculosis can be arrested in its earliest
stage, is simply incalculable. The tuberculin dis-
pensaries abroad report that they cure one hundred
per cent, of the incipient cases they treat. Suther-
land, an English writer, declares that eighty per
cent, of all cases of tuberculosis can be treated with-
out interfering with their occupations. In 1913
there were forty tuberculin dispensaries in Eng-
land. Probably there are more now, and probably
soon there will be a large number in America where
rich and poor may go, if they choose, and learn all
about their condition, so far as their liability to
die of the great white plague is concerned; where
young doctors may be taught the intricate and
painstaking methods that the expert clinician must
employ to immunize his patient against tuberculo-
sis. In a properly equipped tuberculin dispensary,
cultures can be made and z-ray pictures taken, and
every appliance to aid the diagnosis and complete
the cure of tuberculosis shall be in constant use
and manipulated by the skillful hands of experts.
These dispensaries shall be centers of teaching a
well as of treatment. They must employ a certain
number of competent nurses and health inspectors
to do follow-up work to instruct those under treat-
ment that they must observe the rules of hygiene,
must avoid bad air and bad company, alcohol, inju-
rious food, and so forth, if they wish to get the
full benefit of the treatment and to more surely
escape from their deadly infection.
While such work will be expensive, it will, in the
end, prove to be the greatest measure of economy
which any town, city, or country can practise. It
would take a skilled statistician and economist to
figure out the probable gain in material wenlth
alone, not to mention the actual saving of human
life and the prevention of untold suffering, misery,
and destitution. And, inasmuch as by a well-known
law of sanitation, if one disease is expelled from
a community the death rate from other diseases
will be materially lessened, our general death and
morbidity rate will be greatly diminished by a gen-
eral use of tuberculin.
Doctor Bonime of New York has developed a
method of administering tuberculin which it is
firmly believed surpasses in accuracy and safety
any other yet brought forward. It has the great
advantage of fully enlisting the patient's interest
and attention, and the results have surpassed any-
thing before seen in America. If the patient shall
come under treatment sufficiently early, and will
follow instructions with reasonable fidelity, a cure
can safely be promised him without interference
with his occupation or ordinary mode of life.
If some of our noble-minded philanthropists
would institute a string of tuberculin dispensaries
in the United States like the well-known Rocke-
feller hook-worm dispensaries of the South, only
somewhat more elaborate (since they must be more
permanent, and fitted to handle a more complicated
disease), the economic and sanitary advantage
would be incalculable. They would need to be under
some central control, and should employ only truly
scientific and competent men, who should, like the
employees of any corporation, be retained only so
long as their work was satisfactory.
To assume that some such plan will be put into
operation in a comparatively short time does not
seem in the least unreasonable. To the writer's
mind, it is impossible to conceive of any means
by which money could be so economically and profit-
ably invested.
11' Church Street.
OPERATIONS ON THE UTERUS AND THE
VAGINA, WITHOUT AN ANESTHETIC.
By HENHY ALBERT WADE. M.D., F.A.C.S.,
BROOKLYN, N. Y.
VISITING SURGEON TO THE BETHANY DEACONESS HOSPITAL;
VISITING GYNECOLOGIST TO THE WILLIAMSBURGH HOSPITAL.
There are certain areas in the genital tract in
women poorly supplied with sensory nerves. The
extent and location of these areas vary somewhat
in different individuals, and in some women such
areas are nonexistent. We have taken advantage
of this relative anesthesia in certain portions of the
genital tract, and are able in many cases to do
reparative and corrective work on the uterus and
the vagina without an anesthetic. After the op-
eration has been completed the patient is able to
return to her home without assistance, and only
infrequently is she confined to her bed subsequently.
These areas of relative anesthesia are: the mu-
cous membrane lining the fundal and the cervi-
cal portions of the uterus, that covering the cervical
portion of the uterus, and that lining the anterior
and posterior walls of the vagina. The lateral walls
of the vagina are much more sensitive. The areas
of relative anesthesia in the anterior and the pos-
terior walls of the vagina extend from about one-
quarter of an inch from the junction of the cervix
to the vagina above to one-eighth of an inch from
the mucocutaneous junction at the outlet of the
vagina. The degree of relative anesthesia of the
interior of the fundal and the cervical portions of
the uterus may be determined by the introduction
within the cavity of the uterus of a uterine sound.
The degree and the extent of anesthesia of the an-
terior and the posterior walls of the vagina may be
determined by grasping the mucous membrane at
different points with a mouse-toothed forceps. The
age of the patient has a direct bearing upon the
relative degree of anesthesia, the older the patient
the less sensitive the lining of the genital tract.
The surgeon should ascertain by the application of
these tests that the field of operation is not sensi-
tive before operating without an anesthetic.
The following conditions may frequently be re-
lieved by operation without the aid of a general or
a local anesthetic: Endometritis of the fundal or
the cervical portion ; lacerations of the cervical por-
tion of the uterus, requiring either a repair or an
amputation of the cervix ; procidentia of the uterus
due either to an hypertrophy of the cervix or to
an increase in the caliber of the vagina; acute
1120
MEDICAL RECORD.
[Dec. 23, 191(5
flexions of the body of the uterus upon its cervix;
cystocele; rectocele.
The patient is never informed as to the exact
time the operation is to take place, or that the work
is to be done without an anesthetic. After having
determined that the field of operation is not sensi-
tive, the patient is directed to call at the office at
some appointed time, and after having loosened her
clothes about her waist, she is placed upon the table
in the dorsal position. The external genitals are
then washed with soap and warm water, and the
hair shaven over the mons veneris and the labia ma-
jora. She is then given a douche of physiological
salt solution or of some mild antiseptic solution. The
patient is then dismissed. At the time of her next
visit the procedure varies, depending upon what
portion of the genital tract requires operation, but
in all cases no actual cutting or suturing is at-
tempted until after the patient has made several
visits to the office, and has become accustomed to
being placed upon the table in the dorsal position,
and has become accustomed to the manipulation of
instruments about the lower genital tract.
In cases giving symptoms that we ascribe to an
endometritis, the caliber of the cervical canal is en-
larged by incising its walls with a knife, and the
interior of the uterus is thoroughly painted with a
50 per cent, solution of tincture of iodine in alcohol.
The application of the iodine to the endometrium
is repeated from three to four times upon alternate
days. The patient generally has some uterine
cramps lasting from one to two hours after each
application. In two cases of endometritis, at the
request of the family physician, the uterus was
curetted, using a sharp curette, with but little pain
at the time of the curettement and with no un-
toward symptoms subsequently. We have treated
eleven women by this method — nine with repeated
applications of tincture of iodine to the en-
dometrium, and two with curettement, followed by
an application of tincture of iodine to the en-
dometrium. The results have been fairly satisfac-
tory, no better and no worse than the results ob-
tained when the work was done with the patient
under a general anesthetic.
The repair or the amputation of the cervix with-
out an anesthetic is not difficult provided the uterus
is movable and the vaginal canal is not contracted
so that the cervix may be brought down to the
entroitus. The late Dr. Alexander Skene in his
work on "Gynecology," edition of 1890, refers to
two cases of the repair of lacerations of the cervix,
the operations having been performed in his office,
with no subsequent ill results. Dr. H. J. Boldt has
described a method of repairing the recently torn
cervix in a paper entitled "Intermediate Trachelor-
rhaphy; Its Use as a Prophylactic Against the Per-
nicious Effects Sometimes Caused by Lacerations
of the Cervix" (Journal of the A. M. A., October
30, 1915). We have repaired 16 old lacerations of
the cervix and amputated one. cervix that was stel-
lately torn. We have repaired 6 freshly torn cer-
vices and amputated one cervix that had been pre-
viously torn at a former labor and had received
ther damage at the time of the patient's last
confinement, seven weeks before the operation ;
there being but little of the cervical tissues re-
maining, the cervix was amputated without dis-
comfort to the patient and with a good result. Of
16 repairs of old lacerations of the cervix. 12 re-
sulted satisfactorily after the first attempt at re-
pair. Of the 5 that were reoperated upon. 4 were
satisfactory and one case resulted poorly. Of the
6 freshly torn cervices, the repair of 4 was satis-
factory, one fair, and one poor; the latter, upon re-
operation, gave a good result. In 2 cases we had
postoperative bleeding, in one case a ligature
slipped while the patient was still in the office, and
in another case, five days after the operation, there
was a brisk bleeding from the point of repair,
probably from premature absorption of the catgut
used. In both of these cases, much to our surprise,
the repair turned out fairly well. These 2 cases
emphasized to us the necessity of extreme care-
fulness in obtaining perfect hemostasis in opera-
tions upon the pelvic organs in women, where the
patients are not subsequently confined to their beds.
The anterior vaginal wall has been repaired with-
out an anesthetic in 4 cases. In one case the re-
pair was satisfactory. Two women consented to
be reoperated upon, and after the second operation
the result was satisfactory.
The posterior vaginal wall was repaired in 6 cases.
The result was satisfactory in 5 cases. The one
failure was reoperated upon twice, and after the
third operation the result was fair.
Stem pessaries were introduced into the cavity
of the uterus in 6 cases of infantile uterus with
acute flexions of the body of the uterus upon its
cervix. The caliber of the cervical canal was en-
larged, and the angle of flexion was obliterated by
incision with a scalpel, and without discomfort to
the patient. The introduction of the stem was then
quite simple and accomplished without pain.
The cases reported in this paper number but 51,
operated upon during the past 14 months. Our ex-
perience, therefore, is quite limited, but we have
been impressed with the following facts:
The large number of women who will submit to
these operations upon the lower genital tract with-
out an anesthetic, and the willingness with which
they consent to a second operation, after a few
weeks' interval, in those cases where the result of
the first operation has not been satisfactory. For
this reason the end results in these operations done
without an anesthetic compare favorably with the
operations performed with the aid of anesthesia,
when, if the result of the operation is not satisfac-
tory, it is very difficult to obtain the consent of the
patient to be reoperated upon.
Economically, this method of operating without an
anesthetic has a decided value. Women with torn
cervices frequently have not the means to leave
their families and remain within the confines of a
hospital for some days, and so allow the condition
to persist until they have become chronic invalids,
or until cells of a malignant character have become
engrafted upon the seat of the old tear in the cer-
vix, and in either case these women are not able
to do their duty to their families and to society.
The operator should have had an extended ex-
perience in gynecological surgery with the patient
under an anesthetic before attempting to operate
without the aid of anesthesia.
From a review of our cases and the results ob-
tained, we feel encouraged to continue in suitable
cases these operations without an anesthetic upon
the genital tract of women.
:nue.
The "Four Masters" in French Psychiatry. — Accord-
ing: to Pupre the most illustrious psychiatrists in
France form a continuous succession, including: the re-
lationship of master and pupil. These men are Pi^rl.
Esquirol, Baillarger, and Mag-nan (just deceased).
Dec. 23, 1916]
MEDICAL RECORD.
1121
THE BACTERIAL ETIOLOGY OF POISON-OAK
DERMATITIS (RHUS POISONING).
By LOWELL, C. FROST, M.D.,
LOS ANGELES, CAL.
There are few diseases at once more painfully an-
noying to the patient and more "unsatisfactory"
to the physician than the dermatitis caused by
contact with or proximity to the poisonous plants
of the Rhus family. Like "rheumatism" and "ec-
zema," this is an ailment for which there is a host
of remedies claimed to be specific. This means un-
questionably that in all these diseases our knowl-
edge of the etiology has been inadequate as a basis
for our therapeutics. It is the purpose of this
paper to suggest a new line of approach to the
problem in hand. It will be of advantage before
presenting a new theory to review very briefly the
essential points of the one which at present is
vaguely, but generally, held.
It is remarkable and unfortunate that an afflic-
tion so widely spread throughout the country, and
so exploited by the manufacturers of worthless
"cures," should be so slighted in our standard text-
books. McCrea's five-volume edition of Osier's "Sys-
tem of Medicine" does not mention the subject in
the text or the index, and some other supposedly
authoritative works dismiss it with a few words of
inherited tradition. Sollmann, in his "Pharmacol-
ogy," makes an attempt to treat it scientifically.
His view of the etiology may be taken as represent-
ing at its best the general opinion. According to
this, all species of Rhus secrete in the lacteals of
the leaves a fixed oil of extreme toxicity, and this
is conveyed to the fine hairs on the leaf surface
(Schwalbe, 1902). This fixed oil was isolated by
Pfaff as toxicodendrol. This, after contact with
the skin, remains latent from one to nine days,
usually four or five days (Sollmann), and then sets
up by purely chemical irritation a dermatitis which
goes through all the characteristic stages to vesicu-
lation and pustulation.
I wish to cite several cases of dermatitis caused
by Rhus toxicodendron, poison-oak, and to report
on the results of laboratory experiments with cer-
tain bacteria found on the leaves of this plant. On
these cases and experiments I have based my rea-
sons for believing that this dermatitis is not pri-
marily the result of cutaneous irritation by a chem-
ical poison; and that it is primarily a systemic
infectious disease of the exanthematous type, caused
by invasion by a definite bacterial organism. That
the oily, active principle of the plant is irritating
to the skin I do not doubt, but I believe that its
toxic power is greatly exaggerated, and that the
dermatitis should be ascribed almost wholly to
other agents. These cases, selected from a large
number which I have observed and collected during
the past two years, are chosen as illustrating most
clearly the points which I wish to emphasize. They
are, however, strictly typical cases, selected as such,
and not primarily for the purpose of bolstering up
any hypothesis. My experience has been limited to
the Western variety of the Rhus family, Rhus diver-
ziloba, commnoly called poison-oak. From all I
can learn of the Eastern varieties, Rhus toxicoden-
dron, poison-ivy, and Rhus venenata, poison sumach,
their effects have an etiology closely related to that
of the variety here considered.
Case I. — S. B. N., a healthy young American in the
plumber's trade, had not been out of the city for three
month?, when he was called to San Francisco on busi-
ness. He took a day-train, and had reached the summit
of one of the mountain passes when he found that
owing to a fire in the tunnel, the passengers were com-
pelled to walk around the mountain, about a quarter of
a mile, and re-entrain on the other side. The newly-
made path was broad and well beaten and contained no
shrubs nor roots. He noticed, however, that there was
a luxuriant growth of poison-oak along almost the
whole length of the path, the nearest of it being about
fifteen feet from him, as he walked along. He did not
come into contact with it, nor did anyone else in the
party, with whom he might afterward have had con-
tact. The wind was strong, and blew from the direction
of the poison-oak toward him. He was perspiring
freely at the time. After taking the train, which he
did immediately on reaching it, he proceeded to San
Francisco and remained in that city for two weeks with-
out going into the country. There was thus no possi-
bility of any other exposure to the infection than that
afforded by the proximity described above, and contact,
direct or indirect, is absolutely excluded. He had dis-
missed the incident from his mind when five days later
a few typical vesicles appeared on the skin of the thigh
just above the popliteal space. These were accom-
panied by itching and burning, with some local redness
and swelling. Having suffered from one attack of
poison-oak as a child, Mr. N. recognized these symp-
toms and called a physician; he also realized the futility
and danger of scratching, and forebore carefully. De-
spite this and the conscientious use of grindeiia and
sugar of lead lotions, the characteristic exanthem
rapidly spread, and in twenty-four hours had covered
the posterior aspect of the thigh, the deltoid area of
both arms, and the right side of the neck and face —
which, it may be remarked, was the side farthest from
the poison-oak and not struck by the wind at the time
of exposure. The disease followed the usual course, the
lotions having no influence except for a slight subjective
cooling effect.
Case II. — R. E. S., a Mexican-American ranch laborer,
aged 62. S. lived in the Ojai Valley, Southern Cali-
fornia, where there is an abundant growth of poison-
oak, and owing to the fact that he seemed to possess
complete immunity to its poison, he had for years often
been hired to "grub out" the plant from the neighbor-
hood of homes whose owners were susceptible. This
\york he always did with bare hands. On several occa-
sions he ate the leaves of the plant to win wagers, but
did not make a regular practice of this. He had never
had any symptom of poisoning from this source, and
had always been of rugged health. In the spring of
1915 he suffered a severe attack of pneumonia which
left him much broken in health, and with a chronic
bronchitis — possibly tuberculous. When he had recov-
ered sufficiently to be again active, in June, he was hired
to grub out some poison-oak bushes for a neighbor.
As usual, he did this bare-handed. On the third day
after this he developed an area of the characteristic
exanthem on the neck, and in the course of two days
it appeared on the backs of the hands, arms, and be-
tween the shoulder blades. The attack was only of
moderate severity, the self -administered treatment con-
sisting of local applications of carron oil, which seemed
to be very effective in controlling the itching and burn-
ing.
Case III. — O. A. H, a healthy young American
twenty-eight years old, became a member of the U. S.
Forestry Service in 1914. He had never suffered from
poison-oak nor from poison ivy. Having only recently
come to California from the East he was quite un-
familiar with the Western variety of the Rhus — poison-
oak. While on his first trip of inspection in July, 1914,
he pulled up and carried in his hand for several min-
utes a spray of the handsome crimson and green foliage.
His more experienced companion on seeing it acquainted
him with its true nature, and as soon as possible —
about an hour later — had him wash and scrub with a
strongly alkaline laundry soap, in accordance with the
official recommendation for such cases as given by the
Bureau of Forestry. The parts so treated remained free
from any signs of poisoning, but three days later the
typical exanthem appeared on the outer aspect of the
calves of both legs, with the usual symptoms. He had
been extremely careful not to touch any portion of his
body with his hands after contact with the plant, and
had thoroughly disinfected his boots and puttees with
the strong .-cap solution; he had changed his clothes as
soon as possible after his exposure, and had taken every
precaution against any indirect contagion. In the mat-
ter of treatment he used only the soap solution, going
1122
MEDICAL RECORD.
[Dec. 23, 1916
over the entire body with it twice daily, being careful
to apply it to the affected area last, and to use a fresh
cloth each time. The exanthem did not appear on any
other area. The treatment seemed to relieve the dis-
comfort very effectively, but did not shorten the course
of the disease as manifested by the local signs.
Cases IV and V. — Albert S. and his mother, Mrs. J.
H. S., aged respectively twelve and thirty-four years,
both of good physique and active habit, were walking
through the woods one day in September, 1914, when
the boy ran to the roadside and picked a branch of
pretty leaves. Mrs. S., knowing the plant to be poison-
oak, snatched it from him with her own bare hands.
When told what it is was, the boy impetuously ran back
to the bush, picked several of the leaves, chewed, and
swallowed them, explaining that his "scout-master"
had told him that "this was the way the Indians used
to cure themselves when they had touched poison-oak."
On their return home a physician was called, who ad-
vised a cathartic and the washing of the boy's hands
with baking soda. Mrs. S. had forgotten or did not
mention her own exposure. On the second day Mrs. S.
developed the typical exanthem which covered her face
and both hands. It ran the usual course. On the eighth
day the boy, who had been kept strictly at home mean-
while, showed a patch of the same eruption on his left
upper arm, and the next morning another patch ap-
peared on the right hand. There was some itching and
burning, with the .usual redness and swelling, but these
areas did not increase in size, and subsided in less than
four days, treated only with the baking soda lotion. His
lips and mouth at no time showed any irritation, and
he had no internal symptoms.
Case VI. — Mary H., American, aged 13. This young
girl displayed a hypersensitivity to Rhus toxicodendron
which resulted in what was almost a chronic infection.
Her earliest attack was in 1908 at the age of six years,
following the free handling of the plant; details of this
attack are not available. It was said to have been very
severe, however, and to have covered almost all of her
body. After her recovery from this it was found that
whenever she became overheated an eruption of the
same type appeared on isolated and different areas, ac-
companied by the same signs locally and the same
symptoms. Since that time she has had to date (1916)
over twenty attacks, most often following an exposure
from mere proximity to the plant by wind-blown in-
fection, three times from an accidental contact, and five
or six times when there was no known cause. The
diagnosis has been made by competent medical authority
in each case. The attacks have been decreasing in
severity for the past three years, but scars on her neck
and forehead which resemble those of a severe chicken-
pox exanthem are said to have been made by former
eruptions of the poison-oak. Although less severe, the
attacks now last longer. Her parents tell me that the
eruption appears from two to six days after exposure,
in those instances in which there was definite knowledge
of this. They have found that a saturated solution of
washing soda (sodium carbonate) does more to relieve
the distress than any other remedy, although they have
tried all the standard "cures." Nothing seems to
shorten or abort the attack, according to their report.
Case VII. — A. B., a Mexican youth of 17 years, of
somewhat deficient mentality, while walking in the
country found a shrub of poison-oak, picked some of
it, chewed the leaves, and brought home a bouquet of
the remainder. No signs until the seventh day, when
he had a slight chill. The temperature was unrecorded.
The next day his face became greatly swollen, with
characteristic vesicles and general symptoms. His
hands, arms, and genitals were also in the same con-
dition. During the first week he suffered several at-
tacks of nausea and vomiting, accompanied by indefi-
nite, but persistent gastric pain. Recovery was unevent-
ful, and was complete in eighteen days, apparently un-
hastened by the liberal use of many and various ad-
vertised "sure cures." No kidney irritation was ob-
served at any time.
The following are the points to note in the re-
view of these cases:
1. The incubation period. The average time in
the cases cited was four and a half days. Minimum,
one day; maximum, eight days. Sollmann* says
"The active principle is the same for all species.
It has a considerable latent period, from one to nine
days, usually four or five days. This does not seem
to be influenced by the dose." (Italics mine.) I
submit that it is hard to conceive of a chemical der-
mic irritant whose effects remain absolutely latent
for four, five, or nine days; and it is almost im-
possible to conceive of such an irritant whose "la-
tent period" is "uninfluenced by the dose." The
bacterial hypothesis which I am proposing in this
paper is confirmed by these same observations.
2. Complete natural immunity is shown by cer-
tain individuals. Cf. Case II. Sollmann says (op.
tit.) : "Only certain individuals seem to be suscep-
tible, while others may handle or masticate all por-
tions of the plant with absolute impunity." Fox
states:- "While some may handle this vine with
impunity, others are not only poisoned by its slight-
est touch, but even by its proximity." Can we con-
ceive of a chemical irritant which respects indi-
vidual immunities? Sollmann continues: "The
reason for this is very obscure, but it may be re-
membered that certain animals are immune to can-
tharides." In this connection it is sufficient to note
that the immunity referred to is relative, not abso-
lute, and that only certain animal species are even
relatively immune to cantharides. No human be-
ing has any immunity to any chemical irritant of
such a high grade of toxicity. On the other hand,
the bacterial hypothesis has in its confirmation
the analogies of many other bacterial infections.
3. This immunity may be lost through a lowering
of the physical resistance, or a hypersensitivity
may be established. Cf. Cases II and VI. The
reasoning in the last paragraph applies here with
equal force.
4. Exposure may be strictly limited to proximity
to the plant, as in Case I. In this regard, Sollmann
says: "In susceptible individuals, an extremely
small amount of the poisonous principle (1/1000
mg.) is sufficient to cause a violent dermatitis. In
this way the poisoning may be spread by contagion,
i.e. sufficient may be passed from the clothing or
hands of one person to another to cause poisoning.
This is, perhaps, the only instance of contagion by
a chemic poison." (Italics mine.) Again: "The
toxic principle ... is ... a fixed oil (toxicoden-
drol.) The authenticated cases of poisoning at a
distance, which would seem to speak for its volatil-
ity, can probably be explained by the oil being car-
ried by dust, pollen, etc." I will leave the reader
to balance the chemic-poison hypothesis with the
bacterial, keeping in mind the details of Case I.
Either the fixed oil — carried by pollen or dust — or
bacteria must necessarily have been the windblown
agent. I have examined the region near to the lo-
cality where the exposure took place, and find that
there were no pollen-bearing plants in flower at
that time. And just how would flying dust parti-
cles pick up a charge of the poisonous fixed oil?
5. The first appearance of the exanthem is often
on an area untouched directly by the plant, and
protected from subsequent indirect contagion or
windblown virus. Cf. Case III. This would in
itself seem to necessitate the hypothesis of a gen-
eral infection with local manifestations, and this
hypothesis is, I believe, supported by every other
recorded observation in such cases.
The following notes on Rhus poisoning, by
Ilirschler in the Reference Handbook of the Medical
Sciences, 3d Ed., Vol. VI, p. 510, are of interest as
noting the occurrence of signs and symptoms indi-
*Sollmann: Pharmacology.
et seq.
Ed. of 1906, page 709
*Fox, George Henry:
Article "Dermatitis."
"Diseases of the Skin,"
Dec. 23, 1916]
MEDICAL RECORD.
1123
cative of a general infection, and as recognizing the
existence of cases of infection without contact with
the plant, and of the existence of individual immu-
nities and susceptibilities : "There are individuals,
too, who from childhood have never been subject
to plant poisoning, but with change of climate or
methods of living are suddenly rendered susceptible.
Some general symptoms may arise during the prog-
ress of the eruption. Nervous symptoms from the
suffering are common, and rather rarely there is
a chill followed by a fever of 101° to 102° F., with
rapid pulse and prostration. Many persons who
have had at one time or another an attack of se-
verity have found that in passing through the
woods, or anywhere in proximity to the plant, they
may have a recurrence of the attack, even though
the plant has not been touched. The writer has
personally verified this, but finds that as the years
pass, and there has been no new contact with the
ivy, the peculiar susceptibility to the air-laden poi-
son [sic] becomes almost nil."
Duncan, in an article in the Neiv York Medical
Journal, Nov. 14, 1916, ingeniously erects from the
combined principles of anaphylaxis and homeopathy
a new theory of treatment which he calls autother-
apy, and illustrates his thesis by the autotherapeu-
tic treatment of ivy poisoning. This consists of
the traditional eating of the leaves when in dan-
gerous contact with the plant. He states that he
has long employed this method of treatment, the
implication being that it has been succcessful. He
also states that "in Fairmount Park, Philadelphia,
a few years ago, and in Bronx Park, it was the cus-
tom to instruct park hands, when hiring them, to
chew a few leaves of the poison-ivy plant when
clearing away the vines, as a preventive." From
the viewpoint of bacterial etiology, this treatment
would be the equivalent of the administering of
tuberculin per os, since the bacteria would be de-
stroyed in the gastric juice and their endotoxins
liberated and absorbed, to stimulate the formation
of specific antibodies in the tissues.
Owing to the lack of special equipment, the re-
sults of my approach toward the problem from the
laboratory side are incomplete. They are, however,
very suggestive.
Bacterial cultures made in August, 1915, from
the fresh green leaves and from the older red ones
of the Rhus toxicodendron show several types of
cocci and bacilli. Only one type of bacteria was
apparently constant on all the leaves examined.
This type was found to be most abundant on the
under side of the leaves collected from several
sources, and was a short, thick bacillus, rather
variable in its dimensions, but usually found to be
about two microns in width and three to four mi-
crons long. It was of strictly aerobic growth, and
produced spores, one highly refractive spore ap-
pearing in each bacillus in old colonies which had
been subjected to drying in the air for several days.
The same spore-Dearing form was predominant on
the reddish overmature leaves. The growth was
not good on agar, gelatin, or bouillon, but was
abundant on potato at room temperature. These
bacilli stained well with methylene blue and with
gentian violet, the spore-bearing forms showing up
well with Neisser's double stain or with very weak
carbol-fuchsin.
The culturing of these bacilli lessened whatever
virulence they possessed originally, for inoculation
by inunction of the pure culture into the skin pro-
duced, after 48 hours, only a slight redness, with-
out itching or burning, and followed by no further
symptoms.
With the facilities at my command I was unable
to determine whether or not the bacilli form any
soluble toxin, or whether an antitoxin could be
produced by suitable means. Nor could I carry out
the experiments obviously needed to determine the
possibility of producing an active immunity through
the use of a bacterin made from these organisms.
No animal experiments were undertaken.
These are lines along which I believe brilliant
and very practical results may be attained by prop-
erly qualified and equipped laboratory technicians.
*; L22 Hollywood Boulevard.
Expert Opinion as to Cause of Injury — Physical
Examination of Injured Porson. — In an action for in-
jury to a girl of about 17, while a passenger on the
defendant's street car, in a head-on collision, it ap-
peared that after the accident her menstruation be-
came irregular and obstructed. Complaint was made
by the defendant that physicians were allowed to testify
that in their opinion the plaintiff's injuries, as testi-
fied to, could, and probably did, produce the obstructed
menstruation, and that this was an invasion of the
jury's province. The court held that, while it was true
that the ultimate facts respecting the extent of the
alleged injuries and damages, and what caused them,
were for the jury, it was also true that, in case the
injuries which are suffered by an individual, as in
this ease, where the extent thereof cannot be observed
in the ordinary way, and it is shown that certain in-
visible organs of the body are affected, a physician
who testifies as an expert may give his opinion con-
cerning the effect that a certain injury on the body
may produce upon such organs. Certainly the jurors,
merely laymen, and wholly inexperienced in such mat-
ters, could only guess at what effect certain injuries
to the body might have on certain sexual organs of
an injured female. While it may be true that a physi-
cian may not absolutely know, or be able to say with
positiveness (since it is largely a matter of diagnosis),
just what may have caused the ailment, yet, as an
expert, he may give his opinion. It is for the jury to
say what, if any, effect they will give to such evidence.
The defendant's counsel at the trial asked the court
to make an order that the plaintiff be required to sub-
mit to a physical examination to be made by certain
physicians selected by the defendant, and in the pres-
ence of the plaintiff's physician and of her father.
The court declined to make the order on the ground
that it was powerless to do so, in view of its former
ruling in Larsen v. Salt Lake City, 34 (Utah), 318.
This is a point on which the decisions are in conflict. —
Sharp v. Ogden Rapid Transit Co., Utah Supreme
Court, 160 Pac. 438.
Medical Evidence as to Effect of Eating Tainted
Meat. — Action was brought against a retailer of meat
for damages for sickness alleged to have been caused
by eating unwholesome dried beef sold by the de-
fendant. It was alleged that the plaintiff ate of the
meat soon after purchasing it, and that it caused him
to become ill, to be thrown into fits and spasms; that
his digestive system had become so impaired as to
render his life a burden to himself and his family; that
he had lost control of his excretory organs, and that
his health had become permanently impaired. It was
urged by the defendant that the trial court erred in
admitting the testimony of two physicians, who ex-
pressed the opinion that the plaintiff's sickness was
caused by eating the meat, because their opinion was
based partly upon the history of the case as detailed
to them by the plaintiff. It was asserted that this
should have been excluded as hearsay. But neither of
the physicians repeated what the plaintiff had said.
It was obvious that no intelligent examination could
have been made, nor any intelligent opinion expressed,
without taking into consideration both the subjective
and the objective symptoms. The evidence was held
not objectionable as being hearsay. — Fleisher v. Car-
stens Packing Co., Washington Supreme Court, 160
Pac. 14.
1124
MEDICAL RECORD.
[Dec. 23, 1916
Medical Record.
A Weekly Journal of Medicine and Surgery.
THOMAS L. STEDMAN, A.M., M.D., Editor.
PUBLISHERS
WM. WOOD &. CO., Si FIFTH AVENUE.
See fourth page following reading matter for Rates of Subscription
and Information for Contributors and Subscribers.
New York, December 23, 1916.
THE ETIOLOGY OF SCARLET FEVER.
Nothing definite is known of the cause of scarlet
fever, though a vast amount of work has been done
on that disease and much of the bacteriology of its
complications is reasonably settled. The part played
by the streptococcus, though of the greatest impor-
tance, especially so far as the complications are
concerned, has generally been considered to be that
of a secondary invader. Mallory and Medlar {Jour.
of Med. Research, 1916, xxxv., 209) searched for
a possible organism in sections made from the
pharynx of patients dying early in severe attacks,
making use of stored material from autopsies per-
formed some years ago. They describe the almost
constant finding of a slender Gram-positive bacillus
in the mucous membrane at the edges of the ulcers
or erosions, which they believe to be the primary
lesion of the disease. These organisms were found
almost constantly early in the disease and were
absent in sections made from autopsies where
scarlet fever was not present. They were able to
study no very acute cases because of the mildness
of the disease in Boston during the past year, but
made cultures from those cases which did come
under their observation. Cultures of an organism
resembling, in morphology and staining properties,
the one seen in tissue sections were obtained in
five instances from cases early in the disease.
The writers have named this organism B. scarla-
tinas and think that it is reasonable to infer that it
is the cause of scarlet fever. In uncomplicated
fulminating cases this causative agent is present
in large numbers in the lesions in the respiratory
tract, but dies out quickly in the milder cases. Their
arguments in favor of the idea that this organism
is the cause of scarlet fever are that it was found
abundantly and extensively distributed in five case-.
Moreover, it was found only in children who had
had scarlet fever. Control examinations of tissues
from over five hundred cases, mostly from the con-
tagious department, failed to show it. It has nol
been encountered as a pathogenic secondary invader
in other fatal diseases.
organism studied by Mallory and Mi
seems to be a diphtheroid, or a member of thai
group, and in this fact lies much of the objer
that will be made to the acceptance of it as
B. scarl- The diphtheroid group have been
blamed at one time or another as the causative
agent of a number of unrelated conditions, such as
Hodgkin's disease and typhus fever, and often with
much more evidence than is presented by these au-
thors. But the diphtheroids are a ubiquitous family
and seem always to intrude where they may cause
the most difficulty to us, with our gross methods of
differentiation. These authors, of course, do not
pretend that they have discovered the cause of scar-
let fever, and present this theory only as what seems
to be a logical inference from the work which they
report. Nevertheless, it would seem wise to remem-
ber that in the diphtheroid bacilli we have a group
of organisms which have caused much confusion in
the past and are evidently to continue their annoy-
ing habit in the future.
AMBIDEXTERITY.
The European War has brought the subject of am-
bidexterity into prominence. A very large number
of men have been and are being maimed by the loss
of the right hand or arm. The movement for ren-
dering men incapacitated as the results of wounds
able to follow their former or other trades and call-
ings was initiated in France, and great success has
attended such training. In Great Britain also dis-
abled soldiers are being trained with care and in-
telligence to follow trades or work most suitable to
them. A loss of the right arm prevents a man in
nearly every instance from pursuing his previous
employment; indeed, for a time, at least, until he
can be trained to use the left hand or is fitted with
some prosthetic apparatus from doing any manual
work. From almost time immemorial man has been
a right-handed animal. The first man was, prob-
ably, "bidexter" or "ambidexter," as it can scarcely
be imagined that he emerged into life with an in-
herited instinctive right-handedness. There have
always been, during all ages of which any history
or tradition has been handed down, ambidextrous
individuals and sometimes a race has possessed, pos-
sibly by training, two handed dexterity; thus the
inhabitants of the Balearic Isles who gained great
fame in the far off times in which they lived by
their ambidextrous manner of slinging. Also we
find mention in the Old Testament of the 700 Ben-
jamite slingers, who were able to demonstrate in
the most practical way how useful it was in a battle,
and especially in a battle in which man and not ma-
chinery counted most, to be able to hurl the missiles
from the sling with one or the other arm equally
well. There were doubtless more left handed or
ambidextrous persons in the old times than now,
Plato. Aristotle, and other of the ancient writers
frequently referring to ambidexterity ; although the
Japanese of the present day are reputed to be, in a
large measure, a left-handed people. But among
Europeans and Americans an ambidextrous man or
woman is a rara avis.
Without dwelling upon the apparently overwhelm-
ing advantages of two handedness, it may be in-
teresting to notice one objection which is frequently
urged against ambidexterity. This relates to the
mental or physiological effects. Some medical men
have voiced the fear that the extra labor thus im-
posed upon the brain would endanger the intel-
Dec. 23, 1916]
MEDICAL RECORD.
1125
lectual and mental standard of the individual. The
supporters of ambidexterity, however, contend that
ambidextral instruction does not entail extra work
on the brain, but rather distributes the work to be
done over a double area of brain matter. Instead,
therefore, of one side or hemisphere of the brain
having all the work to do and the other lobe be-
coming atrophied through disuse, both sides are
-alternately or simultaneously and symmetrically en-
gaged, exercised, and developed, and ultimately in
adult life each half takes its own proper share of
the daily task; thus each lobe is proportionately
benefited by this division of labor. So far as many
of the victims of the war are concerned, it would
certainly seem that ambidexterity would have been
a blessing. A man who can use both hands in his
work is much less helpless when he is disabled than
one who can use only his right hand. When a man
has been bereft of his right arm and has to earn
his living, the question is raised in the vocational
homes whether to fit him with an artificial hand
and teach him to use this or to train him in the
use of his left hand. A great deal of success has
been attained already in the training of disabled
soldiers in the use of the left hand, and unless
the objections brought against this can be sus-
tained by more conclusive evidence than any that
has yet been brought forward, it would seem to be
decidedly preferable in the majority of cases to
train the left hand than to make the cripple depend-
ent upon an artificial hand.
As was said above, the movement for the training
of soldiers crippled by loss of the right hand or arm
were initiated in France. In the Revue Scientifique
it is stated that Mile. Josefa Joteyko of the College
de France, who has studied thoroughly neuromus-
cular physiology, has planned a scientific method for
the education of the left hand in cripples where the
right hand has been maimed or lost. The theory is
that since the body is bilaterally symmetrical, the
left hand should be trained to carry out the move-
ments of the right hand in an inverse direction, or
what might be termed "mirror movements." It was
found, however, that an amount of work performed
by the left hand, that usually done by the right
hand, produced a greater strain on the heart.
Therefore, all cripples using the left hand for right-
hand work should undergo a periodic examination
of the heart, and the extensive use of the left hand
should be limited to certain trades or professions,
and the work should be changed when it is found
that too great a strain is being thrown upon the
heart.
It would undoubtedly have been greatly to the ad-
vantage of those who have lost their right arms if
they had previously been ambidextrous, and there
is no proof that either heart or brain suffers un-
duly from two-handedness ; the Japanese, if it is
true that they are largely ambidextrous, do not
seem to have suffered thereby, for they are as hardy
and as mentally alert a race as any on earth.
The arguments in support of the training of the
left hand are stronger than the objections which
have been brought against such training, and the
wounds of war appear to have supplied a powerful
plea in favor of ambidexterity.
COMPTOCORMIA.
This term, which means literally flexed trunk, has
been applied to a static deformity resulting from the
accidents of modern warfare. The point of flexion
is at the level of the first lumbar vertebra. The sub-
ject exactly resembles a normal man whose spine
is in a state of physiological flexion. The profile
shows nothing abnormal. There is a compensatory
extension of the head in the interest of vision, and
the abdominal muscles are contracted. The patient
is not much inconvenienced, and walks with a cane.
Upon examination, one is surprised to find perfect
suppleness of the vertebral column, with normal
mobility of the spine. The condition is evidently
a purely functional one, which could readily be
simulated.
The condition seems to have been first noted by
Souques in patients in the Salpetriere. Mme. Ro-
sanoff-Saloff has studied sixteen cases, and an ab-
stract of her work is found in the Journal de Mede-
cine et de chirurgie pratiques for September 25.
Ordinary methods of diagnosis failed to reveal any
indication of organic disease. The deformity af-
fected both wounded and unwounded soldiers, the
latter being much more numerous. In fact, but
two of them had been wounded, and in one case the
injury was remote from the point of flexion. Of
the unwounded men, the great majority had suf-
fered from shell shock, and suffered violence at
the dorsolumbar spine. As a rule, they remained
unconscious for a considerable period. Bruises over
the spine were mentioned by the victims, but on
examination neither wound nor fracture was in
evidence save in the exceptions mentioned. Lum-
bar pain had invariably been present at the outset,
and in certain cases had persisted for months,
slowly abating thereafter. The pain is described as
severe and incessant, aggravated by the slightest
movement. During this period the sufferers remain
in bed, in the attitude least uncomfortable, until the
lessening of the pain permits them to rise in the
flexed position. All treatment is unavailing. Spi-
nal puncture now shows that if any abnormalities
had been present originally their consequences must
have totally disappeared. The muscles, which were
for a long time immobilized by suffering, may now
show contractures, which, however, may be re-
garded in part as psychogenic. The treatment may
be briefly summarized as "plaster jacket and sug-
gestion." A general anesthetic is indicated in some
of the cases in which the jacket is to be applied.
Once the corset has relieved the patient, the latter
must be handled with a certain strictness of dis-
cipline. He is not allowed to receive visits or write
letters, and is made to suffer other privations until
it is time to remove the corset. When this is done
he must be told firmly that his recovery is com-
plete. In this manner Souques succeeded in curing
all of the patients.
CURING SCARS BY ELECTRICITY.
There are some who think that the present aeon
will be known to posterity as the electrical age. At
any rate that potent force is coming to play a
larger and larger part in industry, in war, and a
1126
MEDICAL RECORD.
[Dec. 23, 1916
not insignificant part in medicine. Textbooks on
electrotherapeutics are gradually becoming bulkier,
so that we may look forward to the day not so far
distant when no physician will think of hanging
out his shingle without a battery in his office. The
European War has greatly increased our knowledge
of the practical application of electricity, particu-
larly in regard to the detection of the location of
bullets and other foreign bodies in the tissues and
the examination of parts of the body which have
suffered some nerve injury to determine diagnosis
and prognosis. Lately we have seen a new appli-
cation of electricity in the treatment of painful or
adherent scars.
In La Presse Medicale for August 3, Drs. Chiray
and Bourguignon report their experience in treat-
ing scars which have become contracted or adherent
by ionization with potassium iodide. These doctors
have been neurologists to one of the French mili-
tary divisions and so have had ample material with
which to work. Their method was to apply to the
scar a negative electrode, its covering soaked in a
1 per cent, solution of potassium iodide. The posi-
tive electrode was wet with distilled water and ap-
plied to the other side of the limb. Zinc or tin elec-
trodes were used and were covered with asbestos.
They were about two feet square, the current was
generally 10 milliamperes, and each seance was one i
hour long. The stages of the treatment were as
follows: The scar at first became paler, then thin-
ner and not so indurated, while the skin itself felt
more pliable. Finally, the scar became separated
from the underlying tissues and could be easily
moved over them. Treatments were given every
day at the beginning, and the first improvement be-
came evident usually a few weeks after starting
them, rarely as early as the eighth or tenth day, but
often not for five or six weeks. Chiray and Bour-
guignon believe that the treatment should be kept
up for at least three or four months.
The above is a valuable addition to the medical
lessons taught us by the war and will undoubtedly
be noted by American surgeons. It is impossible in
the event of war to treat all wounds secundum
artem, and it is inevitable that in some cases scars
should result which by their contraction cause dis-
comfort and hinder motility. The ionization method
seems to offer an effectual way of dealing with such
unpleasant conditions.
Health of the Navy.
One of the most encouraging signs of the times is
the awakening of the civilized world to the im-
portance of personal health and sanitation. While
every effort is now being made by means of lectures
and practical instruction to enlighten the general
public on matters of health and hygiene, the Gov-
ernment through the Army and Navy has lost no
time in carrying out plans for the development of
hygiene of the highest type. In his annual report
for the fiscal year the Secretary of the Navy says
that the chief object of concern to the Surgeon Gen-
eral and the Medical Corps of the Navy is the mat-
ter of health and sanitation and the clean living
of the personnel essential to efficient service. Few
people outside of the Navy realize how carefully
guarded as to health conditions these young men
are. When a comparison is drawn between the men
who enter commercial or other walks of life and
those in the Navy, the secretary expresses wonder
that more young men do not choose the sea for a
life occupation; it is probably, he thinks, due to a
knowledge only of its apparent hardships, and an
ignorance of its advantages for a healthy life. Mor-
tality statistics show that eight out of every thou-
sand men on land die from the ordinary risks of dis-
ease and accidents annually during what should be
their healthiest years; while last year only 4.48 per
1,000 of the naval personnel were lost by death.
This is in itself significant. Tuberculosis gave but
11 per cent, to the death roll, while during the
same period in civilian life 30 per cent, of total
deaths between fifteen and sixty years were due to
this disease. This, however, is of course an unfair
comparison, for the sailor is a picked man and no
one with incipient tuberculosis would be accepted
for the service. The report, indeed, states that dur-
ing the past year of the 106,392 men who applied
for enlistment in the navy, only 30.18 per cent,
were accepted. The present rigidity of physical re-
quirements not only insures a high standard of
health among the men, but helps to lighten the pen-
sion load of the country in the coming years. The
work in sanitation which was carried out in Pan-
ama and Porto Rico by the Government has also
been begun for the people in Hayti and Santo Do-
mingo. That the Government is fairly alive to the
advantages of health among the men to whom its
first line of defense is entrusted is shown by the
increase in appropriations for the medical depart-
ment from $682,000 last year to $1,187,728 for the
current year.
The Brain and Life of Ruben Dario.
The brain of the Spanish poet, Dario, bequeathed
to Dr. J. J. Martinez, has been found to weigh 1850
gms., which places it in the same rank with the
brain of Dupuytren, Cuvier, and Abercrombie. The
cortex and convolutions showed superior develop-
ment. Dario was precocious, a boy poet, dominated
by his emotions. He was, in fact, highly neuro-
pathic and had night terrors in early childhood. He
frequently abused alcohol, which often caused de-
lusions of grandeur. He slept poorly. His memory
was prodigious. His character showed great weak-
ness. He was always in love. He beheld visions
not only at night but in the daytime, and at times
seemed to have telepathic and clairvoyant powers.
Dr. Galceran Granes in the Gaceta Medica Catalana
for October 31 sums up Dario as follows: He was
incomplete or "not all there," was unbalanced, a
Bohemian. He could be summed up as intensive,
imaginative, with a prodigious memory. His re-
tention and constructive imagination are apparent
in his poetry, but these do not constitute genius or
originality, as apposed to formalism. While he al-
ways suggested genius, this was apparently domi-
nated by the formalistic. Nevertheless, he was
chiefly independent of outside influences. Appar-
ently the extremely contradictory attributes pos-
sessed by him are the most certain evidence of lack
of balance. Nearly every statement made about
him must at once be qualified. The main lesson is
that an unbalanced person who is a genius may pos-
sess a brain equal in size and with convolutions
apparently as well formed as that of a genius who
is well poised.
Dec. 23, 1916]
MEDICAL RECORD.
1127
Lumbar Puncture of the Fetus During Podalic
Version.
It would hardly suggest itself a priori that the
withdrawal of a few cubic centimeters of cerebro-
spinal fluid from the fetus would materially facili-
tate the moulding of the head; yet Professor Costa,
director of the Royal School of Obstetrics at
Novara, employs this resource systematically in his
clinic (II Policlinico, 1916, XXIII, Medical Section,
p. 1212). In addition to his clinical work he has
made experiments along these lines. He claims that
not only is there a greater compressibility of the
head, but a lessened compression of the nerve cen-
ters, especially of the respiratory and cardiac cen-
ters. After the trunk has been partly delivered, the
spine of the child is flexed by an assistant and the
needle inserted between the fourth and fifth lum-
bar vertebrae. Aspiration is contraindicated, for as
the fetal head passes through the pelvis the fluid
escapes spontaneously. The use of this resource
tends to cause an increased dependence on podalic
version whenever there is any difficulty whatever in
the passage of the head through the inlet, or when
there is incomplete dilatation of the cervix. From
another viewpoint, in any podalic version, irrespec-
tive of indication, lumbar puncture will render less
difficult the birth of the head.
£feroa of tip? Wtsk.
American Congress on Internal Medicine. — The
first scientific session of the American Congress on
Internal Medicine, which was chartered only last
year, will be held at the Hotel Astor, New York, on
December 28 and 29, under the presidency of Dr.
Reynold W. Wilcox, who will address the members
on "The Domain of Internal Medicine and the Pur-
port of the Congress." On the first day of the con-
gress there will be a discussion on the ductless
glands in cardiovascular diseases and dementia
precox, and on the second a symposium on duodenal
ulcer. Following the congress a convocation of the
American College of Physicians will be held, at
which time candidates for fellowship in the college
will be elected. All communications and inquiries
relative to these meetings should be addressed to
the secretary general, Dr. Heinrich Stern, 250 West
Seventy-third Street, New York.
Symposium on Cancer. — In connection with the
convocation in New York the last part of this
month of the American Association for the Ad-
vancement of Science, a symposium on cancer will
be held at a meeting at the American Museum of
Natural History, Columbus Avenue and Seventy-
seventh Street, at 2.30 P. M., on Friday, December
29. The American Society for the Control of Can-
cer has been asked to co-operate in bringing to pub-
lic attention this important meeting, the program
for which has been arranged by Prof. E. 0. Jor-
dan and Prof. C.-E. A. Winslow. The speakers
and the title of their addresses are as follows:
Prof G. N. Calkins of Columbia University, "The
Stimulating Effects of Protoplasmic Substances on
Cell Division." Prof. Leo Loeb of Washington Uni-
versity, St. Louis, "Tissue Growth and Tumor
Growth." Dr. Joseph C. Bloodgood of Johns Hop-
kins University, "Cancer in the Human Being."
In addition, Dr. James Ewing will summarize the
latest experience and conclusions regarding the use
of radium in the treatment of cancer, and Mr. Cur-
tis E. Lakeman, executive secretary of the Ameri-
can Society for the Control of Cancer, will tell of
the past and present efforts to combat this disease
through the education of the public. The meeting
will be open to the general public as well as to the
medical profession.
Navy Hospital Ship. — The projected navy hos-
pital ship, construction of which has been author-
ized, will be the first vessel designed and built for
this purpose by any nation, it is said. Every con-
venience of an up-to-date shore hospital has been
provided, and provision will be made for 300 pa-
tients in peace times and 500 in war. The ship will
carry special stabilizers to minimize rolling and
pitching, and will be equipped with laboratories, a
complete x-ray plant, and a full shore-going hospital
outfit, including ambulances.
Leprosy in Newark. — A case of leprosy has been
reported from the Newark City Hospital. The pa-
tient, a Syrian rug peddler of Springfield Mass., is
being held in the isolation ward. He has been in
this country two and a half years.
Ban on Heroin. — All physicians of the United
States Public Health Service have recently been
ordered not to dispense any heroin for any purpose
hereafter, and to return to headquarters any quan-
tities of the drug they may have on hand. This
action has been taken in the hope of counteracting
the increasing use of heroin throughout the country.
It is pointed out that less dangerous agents possess
as powerful medical qualities, and that the sooner
physicians realize this the easier it will be to curb
the constant increase in the number of habitual
heroin users.
Nurses' Home Dedicated. — The Central Club for
Nurses, New York, dedicated its new building at
132 East Forty-fifth Street, on December 10. The
membership of the club already numbers more than
800, representing 250 nursing schools, and although
the building has just been completed it is already
overcrowded.
Centenarian Dead. — John M. Phipps of Shen-
andoah, la., died suddenly at his home on Decem-
ber 10, aged 105 years.
"Anesthesia Rag." — A dispatch from Chicago to
the New York Sun introduces the "anesthesia rag,"
with the following explanation: "The operating
room at Columbus Hospital was equipped with a
phonograph by order of the surgeons when a patient
failed to succumb to the anesthestic. A popular
air was started. The patient was soothed into ac-
cepting the anesthetic and his appendix was fox
trotted out without a misstep. The method will be
used regularly."
Site for Tuberculosis Hospital. — The Nassau
County (N. Y.) Board of Supervisors on December
13 voted to purchase a 100-acre farm at Bethpage,
L. I., to be used as the site for a tuberculosis hos-
pital for the county. At a referendum election
some months ago the people of the county approved
of the appropriation of $100,000 for the site and
the hospital.
Civil Service Examination. — The United States
Civil Service Commission will hold an examination
on January 3, 1917, open to men only, for the pur-
pose of filling vacancies in the position of deputy
collector, inspector, and agent under the anti-nar-
cotic act. There are at present about seventy-five
vacancies in this position in the Internal Revenue
Service, Treasury Department, at $1,600 a year,
with actual traveling expenses and subsistence while
away from post of duty on official business. Gradu-
ation in pharmacy or medicine from a recognized
1128
MEDICAL RECORD.
[Dec. 23, 1916
institution, or the possession of a State license
to practice pharmacy, is a prerequisite for consider-
ation for this position. Further details may be ob-
tained on application to the United States Civil
Service Commission, Washington, D. C.
Personals. — Dr. F. E. Harrington of the United
States Public Health Service has been assigned by
Surgeon General Blue for a year's health work in
Jefferson County, Alabama.
Dr. C. Frederic Jellinghaus announces the re-
moval of his office to 572 Park Avenue, New York.
Dr. Millard Knowlton, chief of the Bureau of
Education and Publicity of the New Jersey State
Department of Health, has tendered his resigna-
tion, to take effect on January 15. Dr. Knowlton
plans to continue his studies in public health in
Harvard University and the Massachusetts Insti-
tute of Technology.
Dr. E. R. Hildreth, resident physician at the
Presbyterian Mission Hospital, San Juan, Porto
Rico, who has been in the United States on fur-
lough, sailed from New York on December 15 to
resume his work.
Dr. Henry A. Bernstein has been elected Ob-
stetrician and Associate Gynecologist, to the Beth
David Hospital, New York City.
General Gorgas Returns. — The International
Health Board Commission of the Rockefeller Foun-
dation, headed by Gen. W. C. Gorgas, U. S. A.,
which has been carrying on a study of yellow fever
and other contagious diseases of the tropics, re-
turned to New York on December 11. In addition
to General Gorgas the party comprised Dr. Henry
R. Carter of the U. S. Public Health Service, Dr.
C. C. Lyster, Dr. Eugene R. Whitmore, and Dr.
William R. Wrightson. Dr. Juan Guiteras, also a
member of the commission, stopped off at Barbados
to investigate yellow fever conditions there. The
report of the commission will be made public shortly
through the Rockefeller Foundation.
Enforced Health Insurance Opposed. — The di-
rectors of the Board and Trade Transportation of
New York, anticipating the reintroduction in the
Legislature of the bill for compulsory State health
insurance, put themselves on record recently as op-
posed to such "arbitrary and unsound legislation."
The bill is considered too arbitrary because the lia-
bility of various classes of workingmen to illness or
disease varies, because much depends upon the
workingman's habits, intelligence, and sobriety, and
because the responsibility of employers varies so
greatly.
Gifts to Charities.— By the will of Mrs. Mary
Warden Harkness of New York, who died recently,
bequests are made to a number of charitable and
educational institutions. Among the gifts to medi-
cal institutions are the following: $10,000 to St.
Bartholomew's Church, New York, for the purposes
of its clinic; $100,000 to the Morristown Memorial
Hospital, Morristown, N. J., for endowment; $100,-
000 to the Flagler Hospital, St. Augustine, Fla., for
endowment; $100,000 to the Germantown Dis-
pensary and Hospital, Germantown, Pa., for en-
dowment; $50,000 to St. John's Guild. New York, as
endowment for its fresh-air work; $100,000 to the
Babies' Hospital, New York, for endowment; $100,-
000 to St. Mary's Hospital, New York, for endow-
ment.
By the will of the late Joshua L. Bailey of Phila-
delphia bequests are made as follows: Pennsyl-
vania Hospital $5,000; Bryn Mawr Hospital, Phila-
delphia Hospital for Women, Frederick Douglass
Hospital, Lying-in Hospital, Friends' Hospital for
the Insane, Oncologic Hospital, each $2,000.
To Treat Occupational Diseases. — The Medical
Board of the Union Hospital, Borough of the Bronx,
New York, at a recent meeting voted to establish
a division of occupational diseases with Dr. Fred-
eric W. Loughran as attending physician in charge.
Patients treated in this division will, before their
discharge, be instructed in methods of lessening or
preventing the dangers that surround them while
at work; and, should opportunity offer, employers
will be advised as to the value of industrial hygiene.
Gift to Long Island College Hospital. — It has
recently been announced that the late Dr. John A.
McCorkle of Brooklyn, before his death, set aside, in
trust for the Long Island College Hospital, bonds
of the value of $50,000, thus forming one of the
largest gifts ever made to a medical institution by
a physician in active practice. As the bonds became
payable to the college upon Dr. McCorkle's death,
the gift did not become known at the time his will
was read. A committee of citizens of Brooklyn
has now undertaken to raise an equal amount as a
memorial to Dr. McCorkle.
New West Side Hospital. — Plans are being pre-
pared for the erection of a new hospital to be known
as the St. Nicholas Hospital, on the upper West
Side of New York, a part of the city where hospital
provision has not kept pace with increase in popu-
lation. A site running through the block between
St. Nicholas and Edgecomb Avenues at 148th Street
has been donated to the incorporators of the hos-
pital, and a large portion of the building fund has
already been subscribed, it is stated. The first
building, which will be erected as a unit so that
others of a similar type may be added, will be a five-
story building with accommodations for sixty pa-
tients. The State Board of Charities now has the
application for a charter for the hospital under con-
sideration, and the plans for the buildings and gen-
eral scope of the hospital will also be submitted to
the Hospital Committee of the New York College of
Surgeons. The chief of the medical division, it is
announced, will be Dr. Harlow Brooks, and the sur-
gical division will be under the charge of Drs. Seth
M. Milliken and John T. Moorhead.
Medical Society Elections. — Androscoggin
County (Me.) Medical Association: The annual
meeting of this society was held in Lewiston on
December 5, when the following officers were
elected: President, Dr. S. E. Sawyer, Lewiston;
Vice-President, Dr. E. B. Buker, Auburn; Secre-
tary-Treasurer, Dr. L. F. Hall.
Kennebec County (Me.) Medical Society: At
the annual meeting held on December 7, in Au-
gusta, the following officers were elected: Presi-
dent, Dr. O. C. S. Davies, Augusta; Vice-President,
Dr. A. U. Desjardins, Waterville; Secretary, Dr.
S. J. Beach, Augusta: Treasurer, Dr. Stephen E.
Vosburgh, Augusta.
Southwestern Minnesota Medical Associa-
tion: The annual meeting of this association was
held in Mankato on December 4, officers being
elected as follows: President, Dr. A. F. Schmitt,
Mankato; Vice -Presidents, Dr. W. F. C. Heise,
Winona, and Dr. A. Olson, Nicollet; Secretary, Dr.
W. T. Adams, Elgin; Treasurer. Dr. G. F. Merritt,
St Peter.
Obituary Notes. — Dr. SiLAS A. Boam of Topeka,
Kan., a graduate of the University of Birmingham.
England, in 1870, died at his home on November
15, from heart disease, aged 70 years.
Dec. 23, 1916]
MEDICAL RECORD.
1129
Prof. Hugo Munsterberg, whose sudden death oc-
curred in Boston on December 16, at the age of 53
years, was a graduate in medicine from the Uni-
versity of Heidelberg in 1887. Five years later he
came to this country to take up the work of pro-
fessor of psychology and director of the psychologi-
cal laboratory at Harvard University, which he con-
tinued until his death. He did no work in medicine,
although the field of psychotherapy attracted his
interest, but as a psychologist he received the wid-
est recognition.
Dr. John McGuffin of Hastings, Mich., a grad-
uate of the Detroit College of Medicine and Sur-
gery in 1900, died at his home on November 7, aged
42 years.
Dr. Riland Dillard Berry of Springfield, 111.,
a graduate of the Medical College of Ohio, Cincin-
nati, in 1879, and a member of the American Medi-
cal Association, the Illinois State Medical Society,
and the Sangamon County Medical Society, died in
St. John's Hospital, Springfield, on November 3,
from cerebral hemorrhage, aged 61 years.
Dr. Isaac H. Mayer of Willow Street, Pa., a
graduate of the Jefferson Medical College of Phila-
delphia in 1859, died at his home on November 13,
aged 73 years.
Dr. Verne Ernest Winston of Keystone, S. D.,
a graduate of the University of Illinois, College of
Medicine, Chicago, in 1903, died in the Methodist
Deaconess Hospital, Rapid City, S. D., on November
12, following an operation for appendicitis, aged
37 years.
Dr. Robert E. Cunningham of Castile, La., a
graduate of the Medical Department of the Uni-
versity of the South, Sewanee, Tenn., in 1902, died
suddenly at his home on November 11, aged 44
years.
Dr. Joshua H. Gheesling of Greensboro, Ga., a
graduate of the Medical Department of the Uni-
versity of Georgia, Augusta, in 1879, and a mem-
ber of the American Medical Association, the Medi-
cal Association of Georgia, and the Greene County
Medical Society, died in the Grady Hospital, At-
lanta, on November 20, following an operation, aged
60 years.
Dr. John Frank Kane of Minooka, Pa., a grad-
uate of Georgetown University, School of Medicine,
Washington, D. C, in 1911, and a member of the
Medical Society of the State of Pennsylvania, and
the Lackawanna County Medical Society, died in the
Mary Kellar Memorial Hospital, South Scranton,
Pa., on November 20, following an operation, aged
32 years.
Dr. James M. Evans of Clarksburg, Ohio, a
graduate of Starling Medical College, Columbus, in
1850, died at his home on November 15, aged 91
years.
Dr. Thomas W. Smith of Kiefer, Okla., a gradu-
ate of the Hospital College of Medicine, Louisville,
Ky., in 1900, and a member of the American Medical
Association, the Oklahoma State Medical Associa-
tion, and the Creek County Medical Society, died in
a hospital in Tusla, Okla., on November 10, aged
42 years.
Dr. George W. Parr of Geuda Springs, Kan., a
graduate of the School of Medicine of the Western
Reserve University, Cleveland, in 1868, and of
Bellevue Hospital Medical College, New York, in
1876, died at his home on November 19, from pneu-
monia, aged 75 years.
Dr. Charles Gray Cole of Binghamton, N. Y.,
a graduate of the Albany Medical College in 1897,
and a member of the American Medical Association,
the Medical Society of the State of New York, the
Broome County Medical Society, and the Bingham-
ton Academy of Medicine, died at his home on Os-
tober 27, from pneumonia, aged 51 years.
Dr. Samuel Erskine McClymonds of College
Springs, la., a graduate of Miami Medical College,
Cincinnati, in 1877, died at his home on November
17, aged 64 years.
Dr. Jesse M. Ledbetter of Shreveport, La., a
graduate of Charity Hospital Medical College, New
Orleans, in 1876, died at his home on November 9,
aged 62 years.
Dr. Robert L. Walker of Carnegie, Pa., a grad-
uate of the School of Medicine of the University of
Pennsylvania, Philadelphia, in 1866, and a member
of the Medical Society of the State of Pennsylvania,
and the Allegheny County Medical Society, died at
his home on November 19, from pleuro-pneumonia,
aged 78 years.
Dr. George E. Nickel of Belle Vernon, Pa., a
graduate of the Physio-Medical Institute, Cincin-
nati, in 1881, died at his home on November 13, aged
57 years.
Dr. Onas Smith of Ash Grove, Mo., a graduate
of the St. Louis College of Physicians and Surgeons
in 1904, died at his home on November 15, follow-
ing an operation, aged 33 years.
Dr. Andrew James Park of Oak Park, III., a
graduate of the Medical School of Harvard Univer-
sity, Boston, in 1852, died on November 25, from
senile debility, aged 90 years.
Dr. Oliver Herman Heidt of Detroit, Mich., a
graduate of the University of Michigan Medical
School, Ann Arbor, in 1915, died in Harper Hos-
pital, Detroit, on November 23, aged 26 years.
Dr. John A. Warner of Clarksville, Mich., a
graduate of Saginaw Valley Medical College. Sagi-
naw, Mich., in 1901, and of the Detroit College of
Medicine and Surgery in 1908, died in Chicago on
November 5, aged 51 years.
Dr. Edwin Hunt Robinson of Robinson Springs,
Ala., a graduate of Memphis Medical College in
1849, died at his home on November 22, aged 89
years.
Dr. David Claytor of Bedford, Va., a veteran of
the Confederate Army, died at his home on Novem-
ber 17, aged 84 years.
(RattSBpimtents.
OUR LONDON LETTER.
(From Our Regular Correspondent.)
SANITATION OF CAMPS — WIND OF THE BULLET-
FUNCTIONS OF THE CEREBROSPINAL FLUID.
London, Nov. 18, 1916.
The Epidemiological Section of the Royal Society
of Medicine has had under consideration the sani-
tation of camps introduced by Capt. C. G. Moor,
who after describing the organization of a sanitary
section dwelt upon certain aspects of sanitary work
at a base: as to water supply, he would cooperate
with the civil authorities and so secure double
sterilization, as the men's water bottles would be
systematically dealt with at the same time. In dis-
posing of horse manure, the plan he considered most
satisfactory was to lay down a tram line to the yard
at a gauge of 18 in. and a weight of rails of 12 lb.
to 18 lb. Sleepers should be not more than 2 ft.
apart and properly packed. By this plan manure
1130
MEDICAL RECORD.
[Dec. 23, 1916
could be removed a mile or a mile and a half from
the camp. To burn the manure a cross-trench in-
cinerator was best. To keep down flies when burn-
ing or close packing was not practicable, a good
plan was to run fowls on the dumps, as they de-
voured great numbers of larva?; to keep them from
latrines close-fitting lids to the buckets were essen-
tial and also care to ensure these lids were replaced
instantly after use. Very efficacious fly wires might
be made of the wires of hay bales by smearing them
with a mixture of two parts of powdered resin and
one of castor oil, melted and applied hot. Various
devices employed by the sanitary sections in the
field were illustrated by Major Fremlin, commander
of the City Sanitary Company. Lieutenant-Colonel
Copeman insisted on the importance of close pack-
ing manure as stifling the fly pest at its source,
and spoke of excellent results of chemical treat-
ment of sullage water. Mr. Bacot, entomologist of
the Lister Institute, pointed out the danger of ap-
plying results obtained with fly sprays at ordinary
temperatures to tropical or subtropical conditions.
Lieutenant-Colonel Kenwood hoped that many of the
simple and effective devices invented under the
stress of war conditions would be utilized in civil
public health work in rural districts. Captain Hart-
ley related his experience with a sanitary section
at the front and showed the danger of allowing
wastage in the sanitary ranks to be replaced by un-
trained men.
The question of the effects of the "wind of the
bullet" has been again brought forward in view of
the war. The problem is whether the displacement
of air alone can cause serious or even mortal in-
juries, without the man being touched by the pro-
jectile. You will remember that Baron Larrey
maintained that all the stories of men being killed
or wounded in such a way were due to a false inter-
pretation of the facts. Nevertheless, it is certain
that soldiers have been rendered deaf by the explo-
sion of a shell near them. Further, one French
soldier was found dead in a field after exposure to
such danger, although no splinter seemed to have
touched him. This has naturally revived the ques-
tion of the wind of the bullet. There does not ap-
pear to be any record of soldiers being actually
killed without being touched by a solid piece of the
projectile. There is, however, a great difference
between the shells of to-day and those of former
years. This is due to greater speed as well as the
greater power of the explosive element, and results
in more men being knocked out. Shells bursting
near them may cause concussion of the brain or
spine with violent headaches or deafness. In a case
recorded by Professor Symonds a soldier walking
on one side of the road was knocked down by a shell
bursting on the other side, making him insensible
for several days. He tells, too, of cases in which the
bullet traversed the skin and caused a burning
wound an inch in length. Symonds has had no case
due to the wind of the bullet, but if such occurred
they would be treated in the field hospitals.
Professor Halliburton's address at the Neurolog-
ical Section of the Royal Society of Medicine was
devoted to the "Possible Functions of the Cerebro-
spinal Fluid," a subject which he opened with a
statement of the present state of knowledge as to
the character, composition, and fate of the fluid.
Under normal conditions it is clear, like pure water,
of low specific gravity, contains in solution inor-
ganic salts similar to those in the blood with a trace
of coagulable protein and some reducing substance
which has now been determined to be glucose; it
is practically free from formed elements. Under
some abnormal states the protein may be greatly
increased or other substances added to it, such as
cholesterol, choline, or a similar substance. Cellu-
lar structures may also be added and the differentia-
tion of these is a valuable aid to diagnosis. Para-
sites of different sorts are found in other cases.
The fluid is formed primarily by the secreting cells
which so prominently cover the choroid plexuses
in the cerebral ventricles, so that this structure was
well named by Mott, the choroid gland. The fluid is
normally present at a certain pressure which is
not the result of arterial pressure transmitted pas-
sively. This pressure may, indeed, be influenced by
either the arterial or the venous, but does not
depend on these, and often varies quite independ-
ently of them. The true cerebrospinal pressure,
said Professor Halliburton, is the result of the
secretory pressure of the choroid epithelium cells;
in other words, the craniospinal contents can no
longer be regarded as a fixed quantity without
power to expand or contract in volume. Three
groups of substances promote the flow and increase
the pressure independently of those which affect it
secondarily by altering blood pressure; first group,
excess of carbon dioxide (or lack of oxygen) in the
blood, as in asphyxia or drugs which interfere with
respiration ; second group, volatile anesthetics,
which may act by interfering with or altering
respiration or the physical conditions of secretion;
third group, this is specific and consists of an ex-
tract of the choroid gland, or of the brain ; the
former is the more powerful. The chemical nature
of the hormone in this extract is uncertain, but it
is probably some product of nervous metabolism,
which, arising in the brain, passes to the choroids,
accumulates in them, and stimulates the secreting
cells to activity ; it cannot be discovered in the nor-
mal secretion, but in general paralysis and brain
softening — conditions in which catabolic processes
are excessive — it can be recognized (by physio-
logical tests) in the fluid itself. The plexuses have
abundant nerves, but there is no evidence that they
are secretory; probably they are not. This fluid
is without doubt being formed continually. Then,
what becomes of it? Neutral fluids disappear in a
few minutes, if introduced into the cranio-vertebral
cavity, and the course taken by them, and presum-
ably by the normal fluid also, can be traced by chem-
ical tests or by the physiological action. By such
methods it has been proved that the exit is through
the bloodstream. The speed with which such sub-
stances appear in the blood is very remarkable,
especially if introduced into the subcerebellar re-
gion ; e.g. adrenalin, nicotine, or atropine will show
typical physiological action in a few seconds, almost
as rapidly as if injected into the venous circulation.
On the other hand, those substances not readily dif-
fusible (e.g. commercial peptone) do not produce
their effects when introduced into the cerebrospinal
fluid, so that the old theory of valved orifices lead-
ing to the large veins at the base of the brain must
be abandoned. Diffusion is most rapid in the sub-
cerebellar district, but is extremely slow in the
spinal, especially the lower spinal region, and prob-
ably occurs in the venous sinuses by the micro-
scopic arachnoid villi — possibly also by transfer-
ence through the thin walls of the blood vessels
within the central nervous system. Diffusion in the
opposite direction does not occur except in a negligi-
ble degree in the case of alcohol and a few drugs.
Dec. 23, 1916]
MEDICAL RECORD.
1131
#rngrpHH of JHeMral &rimr?.
Boston Medical and Surgical Journal.
December 7. 1916.
1. Preparedness for Health. Haven Emerson.
2. Spinal Fluid Sugar. J. B. Rieger. S. M. and H. C. Solomon.
3. An Outline of the Elements and Treatment of Stammering.
Anne Bradstreet Stedman.
4. Fatty Degenerative Changes in the Purkinje Cell Belt of
the Cerebellum in Exhaustive Infective Psychoses. Eg-
bert W. Fell.
5. The Yerkes-Bridges Point Scale as Applied to Candidates
for Employment at the Psychopathic Hospital. C. S.
Rossy.
6. The Intensive Group of Social Service Cases. Mary C.
Jarrett.
7. An Expedient for the Radical Cure of Some Retroversions.
Edward Reynolds.
S. Ether Anesthesia. H. H. Amsden.
1. Preparedness for Health. — Haven Emerson, Com-
missioner of Health, New York City, makes a strong
plea for preparedness for health along three avenues:
The prevention of communicable diseases; the correc-
tion of habits which determine or contribute to prema-
ture death, and the prevention of industrial hazards.
With relation to the registration laws for births and
deaths — to our shame, be it said — we, who claim to be
a civilized nation, have still so cheap a notion as to life
and death that we are without a national registration
law or uniform State laws demanding the reporting of
births and deaths. Only 66 per cent, of the population
of the United States lives in States where the regis-
tration of deaths is compulsory, and less than 31 per
cent, live where registration of births is required.
Emerson states that while there are the thousands killed
in Europe in battle, more people are killed by preventa-
ble disease annually in this country than the annual
loss of any nation in the present war. He refers to the
yearly death rate in New York City, which has fallen
from 29 per thousand to 14 per thousand of population,
and that out of 75,000 deaths a year, 31,700 were from
causes which are largely, if not wholly, preventable.
We still lose 13,866 children under a year of age. But
in reviewing the results obtained by the half-century
experiences of the Department of Health, we find that
if the death rate of 1866 had prevailed in 1915, we
should have lost in New York City last year 88,000 peo-
ple who are now living. The best results are shown in
the infant mortality rate, which has fallen from 242 per
thousand living births in 1891 to 98 per thousand births
in 1915, and in the past five years from 170 to 98 per
thousand births. Whereas only 80 per cent, of the
babies born in 1898 lived through their first year, now
more than 90 per cent, survive. He compares the work
in the examination of food handlers done by the physi-
cians of the Health Department and the results ob-
tained by the same number of private physicians em-
ployed for the same purpose. The results showed that
the departmental physicians discovered 3.7 times as
many cases of pulmonary tuberculosis as the private
physicians. He further states that whether by organi-
zation, by endowment, or by State employment, there
must come a change in the basis of medical practice.
While reviewing some of the brilliant results obtained
through the efforts of the Department of Health, he
also shows wherein weakness lies, and the urgent need
for public and scientific cooperative medical service
promptly summoned and consistently obeyed ; the quick
and efficient handling of contagious and communicable
diseases, which make heavy inroads on lives; educa-
tion in the right ways of living, from the training of
the expectant mother, through the schooling of her
child, and until the new home is started in the next gen-
eration; union of effort by the State, the employer, and
the employee, to prevent wastage from occupational
disease. Upon these principles of action must our so-
cial program for national service be built. It is not a
conflict with the popular clamor for a military and
naval preparedness that Emerson suggests, not a hin-
drance to commercial preparedness for greater na-
tional wealth, but a warning of the futility of both of
these without the assurance that the first need and
greatest asset of a nation, its health, should take the
leading place in men's thoughts. There is nothing so
democratic as disease, no bond so strong as the appeal
of suffering fellowmen.
3. An Outline of the Elements and Treatment of
Stammering. — Anne B. Stedman says that with the
cases of structural defect, stammering is of purely men-
tal origin; otherwise the expression in faulty speech
of the neurotic temperament. Therapy must therefore
be based on this fact. Two methods are used: One,
used by physicians, aims to cure by working from the
inside out, that is by giving all the attention to the
frame of mind when speaking; the second, employed by
teachers not of the medical profession, endeavors to
treat from the outside in by the use of vocal exercises
without regard to the mental element. Now the stam-
merer can produce perfectly normal consonants and
vowels when unembarrassed, and practical treatment of
the habit, vocal exercises, etc., are only half the battle.
The treatment must go deeper until it reaches the fear
— the emotional disturbance that occurs under trying
circumstances between the thought and its expression.
It is here that the training of a neurologist is required,
as stammering is as truly the province of the neurolo-
gist as any other nervous affection. The layman in
teaching this condition narrows his field and must de-
pend on the personal touch. Often, to tell a child who
is constantly bracing himself for difficulties, that he
need not do the things he dreads, is followed by sur-
prise, gradual relaxation, and a new perspective, which
is a great help to normal speech. In a public clinic
this plan cannot be carried out, so class treatment must
be resorted to, which is of inestimable benefit in many
ways, but aside from benefit to the stammerer it shows
to the teacher the weak spot in the patient's progress,
and then improvement, though frequently hard won, is
no longer superficial. Elemental speech exercises, prin-
ciples of singing, elocution, and phonetics, breath con-
trol, and relaxation are methods all employed. These
cannot be followed out alone at home, no matter how
conscientious the pupil; the newly acquired mode of
speech must be used constantly until it becomes me-
chanical. In the majority of the patients, character
plays an important part in recovery. Will, persever-
ance, and ambition make up the final third when a pa-
tient has been brought two-thirds of the way toward
normal speech. Besides the above mentioned aids, a
change has to be brought about in the patient's attitude
of mind; something has to relax, to let go before the
force of ambition can even be appealed to. Character —
moral force, that is — is not synonymous with mental
makeup, and it is the stammerer's mental makeup, for
which he cannot be held responsible, which is at the
bottom of his trouble. Cure the habit, but cure the mind
as well.
7. An Expedient for the Radical Cure of Some Re-
troversions.— Edward Reynolds makes special reference
to the cases of women who between pregnancies suffer
from retroversion, yet for whom an operation is not in-
dicated, but the wearing of a pessary between preg-
nancies becomes necessary. He gives his treatment as
follows: All that is necessary to secure effective puer-
peral involution of the supporting structures, and a
cure of the retroversion, is so to arrange the puerperium
that the supporting structures undergo involution, and
complete involution, while the uterus is held in an ex-
treme forward position. Under these circumstances
1132
MEDICAL RECORD.
[Dec. 23, 1916
the supporting structures will almost invariably shorten
and resume firmness to a degree which will hold the
uterus permanently in a normal position. At a period
in the puerperium at which the uterus is too large to
be capable of retroverting, i.e. between the tenth and
fifteenth day of the puerperium, the uterus should be
thrown into strong anteversion bimanually, and a care-
fully fitted, hard rubber pessary should be made to
hold it there. Such a pessary will usually be larger
than the stock sizes and must often be specially pro-
cured. Very hot vaginal douches should then be admin-
istered twice daily. From two to four quarts should
be used, and the injection should last from fifteen to
twenty minutes. It should be given with a fountain
syringe and under a fall of not more than twelve to
fifteen inches in order to avoid forcing fluid through the
open os. In this position of the uterus and under the
influence of the hot douches involution is usually very
rapid. In most cases it will be found that within a
week the original pessary will have become too large
and too highly curved for the contracting vagina. A
second and smaller, but equally well fitting, pessary
should then be adjusted, and the douches continued.
This will usually need to be replaced by one of lesser
size in from ten days to a fortnight, and after a few
weeks this must again be reduced. The hot douches
should be continued until the uterus is but little above
the normal size and firmness, but should then be inter-
mitted, as too long a continuance of the douches some
times results in hyperinvolution, which might cause sub-
sequent dysmenorrhea.
of an attack of gonorrhea, the physician is, and must be
dependent upon the microscope for definite information
as to the progress of his patient. In conclusion, Wyeth
quotes from Dr. George Luys, of Paris, who says in his
"Traite de la blennorrhagie": "Our therapy is nowadays
so perfect that it is not permissible for a medical man
to allow a case of gonorrheal urethritis to go on with-
out curing it. Modern science has made such conquests
that we can say without exaggeration that there is no
inflammation of the urethra which cannot be cured com-
pletely by appropriate treatment. But it should not be
forgotten that this result is obtained only by means of
prolonged and painstaking observation and that urethro-
scopy alone enables us to diagnose the local lesions
with accuracy, and to apply the sovereign remedy cor-
rectly. Without the control of his eye it is impossible
for the medical man to select the best and most effica-
cious treatment."
New York Medical Journal.
December 9, 1916.
1. Gonorrhea a Curable Scourge. George A. Wyeth.
2. Hay Fever. William Scheppegrell.
3. Surgical Immunity. W. Wayne Babcoek.
4. The Psyehopathology of Noise. A. A. Brill.
5. Profound Secondary Anemia Due to Ulcerated Internal
Hemorrhoids. J. P. Saphir.
6. Internal Hemorrhoids. Arthur A. Landsman.
7. Hard Water and Health. Frank Leslie Rector.
8. Parenchymatous Glossitis. Max Lubman.
1. Gonorrhea a Curable Scourge. — George A. Wyeth
states that the modern means at the command of the
physician are so definite and precise that it is inex-
cusable for a case of gonorrhea to remain uncured. He
does not suggest that it is a simple or easy thing to
fight the gonococcus, but painstaking care in diagnosis
and definite location of the lesion are now possible.
Until a short time ago both profession and laity joined
in considering gonorrhea an unimportant affection,
while the seriousness of syphilis was early recognized.
He considers it gratifying that certain of the daily pa-
pers are lending their columns to the fighting of this
dread disease, for only by education can headway
against it be made. Gonorrhea is a preventable dis-
ease, as has been amply proved in the U. S. Navy. Gon-
orrhea can be aborted in the majority of cases if seen
within twenty-four hours after a purulent discharge
has begun, except in primary cases. While it is not
the object of his paper to give detailed treatment, gen-
eral principles may be outlined as follows: First, defi
nitely to locate the seat of infection and treat it locally
by irrigations and applications. Here, too, mild solu-
tions of protargol have served us well. Wyeth wishes
to emphasize the importance of the systematic use of
the microscope in treating this disease; first from a di-
agnostic standpoint. Surely no one can say positively
of any given case of urethral discharge that the cause
is gonorrheal unless gonococci are demonstrated. More
than once has it been his pleasing experience to con-
vince a patient who thought himself infected with
gonorrhea, that his belief lacked foundation. Since
there can be no hard and fast rule as to the duration
Journal of the American Medical Association.
D< ■■< mber 9, 1916.
1. Spinal Fluid Findings Characteristic of Cord Compression.
James B. Ayer and Henry R. Viets.
2. Municipal Health Administration. Ernest C. Levy.
3. A Further Report on Thromboplastin Solution as a Hemo-
static. Alfred F. Hess.
I. Itching as a Symptom. Philip Kilroy.
5. The Problem of Diphtheria Carriers. Sophie Habinoff.
6. District Health Organization. C. St. Clair Drake.
7. Thyroid Disease in Relation to Rhinology and Laryngol-
ogy. B. R. Shurly.
8. Autogenous Colon Vaccines in the Study. Diagnosis and
Therapy of Chronic Intestinal Toxemia. G. Reese Sat-
terlee.
9. A New Development in Sanatorium Treatment. Daniel E
Drake.
10. Institutional Typhoid Epidemic Combated by Vaccina-
tion. Philip B. Newcomb.
11. Streptococcus Infection as a Cause of Spontaneous Abor-
tion. Arthur H. Curtis.
12 The Treatment of Certain Diseases of the Skin by the
Intravenous Injection of a Foreign Proteid. M. F. Eng-
man and R. A. McGarry.
13. Cerebellar Localization: An Experimental Study by a
New Method. I. Leon Meyers.
3. A Further Report on Thromboplastin Solution as
a Hemostatic. — Alfred F. Hess refers to his report given
about a year ago from the Research Laboratory, De-
partment of Health, New York City, and a little later
another report on the same subject from Cronin, both
published in The Journal A. M. A., on the experimental
work done with thromboplastin as a hemostatic. Dur
ing the past year Hess has continued his clinical ex-
periments at the Research Laboratory, Department of
Health, New York City, along this line together with
laboratory tests to determine more fully the various
properties of thromboplastin. Since an account of the
first report was given in these columns, it is only neces-
sary to give now his later results. Thromboplastin so-
lution has been supplied to several of the maternity
hospitals of New York City, where it has been employed
locally in cases of melena neonatorum, in bleeding from
the cord, skin, mouth, vagina, etc., and also as a dress-
ing where there was undue hemorrhage following cir-
cumcision. Thromboplastin should be applied directly
to the bleeding ai-ea; clots should first be removed. Hess
reports the following results from his latest investiga-
tions: Tissue juice made from brain (thromboplastin
solution) has proved itself of practical value in con-
trolling hemorrhage wherever it can reach the site of
bleeding. In cases of true hemophilia it may be re-
garded almost as a specific hemostatic. It is to be
recommended for local use in the bleeding of the new-
born, in nasal hemorrhage, and in the parenchymatous
bleeding associated with various operations, etc.
Where local applications fail, it should be injected into
the site of hemorrhage, as in bleeding from the gums
following tooth extraction. This method can readily
be resorted to, as thromboplastin solution loses but lit-
tle of its potency as the result of dilution and cursory
boiling. Further clinical experience is necessary before
Dec. 23, 1916]
MEDICAL RECORD.
1133
its value can be determined as a hemostatic in con-
nection with hemorrhage of the gastrointestinal tract.
However, it is innocuous when given by mouth in con-
siderable dosage, and would seem to be indicated in
bleeding from the stomach and from the upper intestine.
In addition to its hemostatic action, this tissue extract
has been found to possess healing properties, actively
stimulating granulation tissue and hastening epitheliza-
tion. It is therefore applicable as a dressing for torpid
ulcers and for sluggish wounds.
5. The Problem of Diphtheria Carriers. — Sophie Ra-
binoff found in her investigations during an outbreak of
diphtheria in an institution caring for 400 children in
New York City that in the group of eighty diphtheria
carriers which were studied, it was found that a certain
number became negative, irrespective of the treatment
employed. No better results were obtained with iodized
phenol or with Fullers' earth, than with the silver prep-
arations or other antiseptics. Indeed, those cases which
were not treated in any way did equally as well. An
exception must be made only as regards the results ob-
tained with Fullers' earth in adults, which were fairly
satisfactory. The real problem of the carrier lies in
the ultimate group in which the bacteria persist in
spite of all local treatment. The presence of a foreign
body in the nose may provide a favorable environment
for the growth of the diphtheria bacilli. Removal of
tonsils and adenoids seems to offer a safe and rapid
method of eliminating diphtheria bacilli from the nose
and throat of carriers, and should finally be resorted to
where other methods have failed.
11. Streptococcus Infection as a Cause of Spontane-
ous Abortion. — Arthur H. Curtis states that the object
of his report is to produce evidence which will be help-
ful in the solution of the problem of definite cause or
causes of spontaneous abortion from infection. It is al-
ready known that the Treponema pallidum is directly re-
sponsible for the death of the fetus in the later months.
From thorough experimental and clinical work carried
on in the Pathological Laboratory and Gynecological
Service of St. Luke's Hospital, Chicago, he offers the
following report as a summation of his work thus far:
From the urine of a patient who gave spontaneous birth
to a stillborn child were obtained large numbers of
streptococci. Two pregnant rabbits were intravenous-
ly inoculated with cultures of this organism. Death of
the fetuses followed. One mother appeared to be in
normal health, the other became seriously sick some
days after the death of the fetuses. Pure cultures of
the streptococcus were obtained from the kidneys and
from the uterine contents of both animals. From a spon-
taneous stillbirth were obtained pure cultures of a
Gram-positive streptococcus. A series of three preg-
nant rabbits was intravenously injected with washed
cultures of this organism. In each instance there was
premature labor or death of the embryos with absorp-
tion. Serious maternal illness was not evident. At
necropsy, pure cultures of the streptococcus were re-
covered from the uterine cavity. Whether organisms
other than the streptococcus possess the power of in-
terrupting the course of pregnancy does not materially
influence these results. These facts remain: Strepto-
cocci can be isolated from women who give spontaneous
birth to stillborn children : streptococci have been ob-
tained in pure culture from the placenta and from the
stillborn fetus; intravenous injection of pregnant rab-
bits with cultures of these streptococci is followed by
fetal death; the streptococcus can be isolated in pure
culture from the fetus and from the uterine cavity of
the mother rabbit. The streptococcus encountered in
these cases appears to be peculiarly adapted to infec-
tion of the genitourinary tract. Several closely re-
lated, probably identical strains, have been isolated
from patients with uterine, tubal, and kidney infec-
tions. Possessed of certain variability in cultural char-
acteristics, these strains have much in common. We
may have here to do with a type of streptococcus espe-
cially modified by, and with especial affinity for, growth
in the genitourinary tract; it is characterized by per-
sistence of infection, low virulence, and richness of
growth on artificial mediums.
The Lancet.
November 18, 1916.
1. An Inquiry into the Natural History of Septic Wounds.
Section III. Kenneth Goadby.
2. A Note on the Value of Vaccine Therapy in the Treatment
of Gunshot Wounds, Viewed from a Surgical Aspect.
R. H. Jocelyn Swan.
3. The Psychology of Malingering and Functional Neuroses
in Peace arid War. Thomas Lumsden.
t. The Angle of the Dropping Pipette and Accuracy in Ag-
glutination Technique. R. P. Garrow.
1. An Inquiry into the Natural History of Septic
Wounds. — Kenneth Goadby gives an exhaustive account
in the third section of his report, covering tissue reac-
tions. The first two sections previously published con-
tained certain facts relating to sinus formation and sin-
uses and vaccine therapy. His conclusions from this last
extensive work are drawn as follows: (1) That the en-
ergy dissipated in the tissues from projectiles produces
changes in a wider area than that immediately lacerated
by the projectile itself. (2) That the cellular activity
promoting repair in the affected areas proceeds con-
comitantly with degenerative processes; with the de-
generative processes are associated anaerobic bacteria,
B. perfringens, B. malignant edema, and possibly B.
Hibler IX type. (3) That there is direct histological
evidence of tissue digestion, in addition to necrotic
changes due to traumatism or coagulation owing to in-
terference with circulation. Evidences of degenerative
tissue changes are found in tissue removed from wounds
at long periods after the original infection of the wound.
(4) That acid production by anaerobic bacteria of the
perfringens class is an important factor in the deter-
mination of clinical gas gangrene. (5) That the gen-
eral blood reaction in the direction of leucocytosis is
more related to infection with the pathogenic cocci than
the anaerobic bacilli. In the three sections of the pres-
ent report an attempt has been made to correlate cer-
tain facts obtained in the course of an inquiry as yet un-
completed. The bacteriological data as to the organisms
occurring in the depth of the sinus have been confirmed
by direct examination of the tissue concerned. The bac-
teriological evidence of sequestered organisms in the
sinus walls of "flare" cases also receives striking con-
firmation from the histological examination. The evi-
dence adduced confirms the opinion previously expressed
that the organisms remaining in the tissue retain their
activity and potentiality for disease. Theoretically
there is further evidence that the use of vaccine therapy
of appropriate antigen is of advantage in combating
the infections. No drainage in the ordinary sense of
the term can easily affect the contorted intricacies of a
sinus passing first of all into bony tissue and thereafter
radiating in several directions; it is in this type of
wound, or rather sequelse to a wound, that the bacteria
are found lodged in the tissues, partially shut off from
the action of the living cells. Operative interference
sets them free; they may, and do, reinfect the surround-
ing areas, and to raise the patient's resistance to such
disability is clearly a therapeutic step of supreme im-
portance.
2. The Value of Vaccine Therapy in the Treatment
of Septic Gunshot Wounds. — R. H. Jocelyn Swan has
continued his studies of vaccine therapy with reference
to septic gunshot wounds with Goadby, the writer of
1134
MEDICAL RECORD.
[Dec. 23, 1916
the foregoing article. Swan says that while the future
course of vaccines naturally depends upon the examina-
tion revealed in the individual wound, he directs that
every case of septic wounds arriving from overseas shall
receive an initial dose of a mixed polyvalent vaccine
of proteus and streptococcus until the true bacteriology
of the wound can be worked out and before any surgical
measure, other than freely incising the wound to se-
cure adequate drainage, is adopted. It is only in a com-
paratively few cases that a mixed infection containing
the above named organisms will not be found, and he
impresses upon readers the importance of making an ex-
amination of both the superficial and deeper aspects of
the wound, for he has found frequently that the deeper
part of the wound only will give the true indication of
anaerobic activity. In selected cases operative inter-
ference of some sort is necessary as an urgent measure
before vaccine therapy can be given, and these are the
cases that are so frequently followed by pyrexia 102° —
103° F. for from twenty-four to forty-eight hours,
whereas similar cases in which vaccines have been used
usually show no pyrexia even when anaerobic gas-form-
ing organisms were proved to be present in the depth of
the wound. Since radiographic examination is always
necessary for knowledge of hidden bone and tissue con-
dition and the presence of metal fragments, it is this
time that is so valuable in an attempt to immunize
patients against the proteus and streptococcal infec-
tion, and should be done in all cases. Swan has found
the greatest value of vaccine therapy in the treatment
of complicated septic fractures of long bones and of
fractures which open into joint cavities. In the treat-
ment of septic compound fractures is made a routine
practice of giving a preliminary dose of polyvalent vac-
cine (proteus and mixed streptococci), and then after
two or three days freely open the wound to secure ade-
quate drainage, approximating the fragments and only
removing those fragments which are undoubtedly com-
pletely separated, at the same time taking advantage
of the opening of the wound to obtain further bacterio-
logical examination. Extension apparatus of various
types or splints suitable to the individual fracture are
applied, but should the resulting position of the frag-
ments prove on further radiographic examination to be
unsatisfactory, he has no hesitation, after a further few
doses of specific vaccine, in securing the bone frag-
ments in apposition by means of silver wire or even bone
plates in the presence of sepsis, and can now look back
on a series of cases in which not only have limbs been
saved, but bones in good alignment and functional use.
Further, the result as regards sinus formation and ne-
crosis of fragments of bone in the seat of fracture has
been more appreciably lessened in those cases in which
vaccines have been used than in those in which exactly
similar surgical measures were employed without the
assistance of vaccines. In the treatment of septic gun-
shot fractures which involve a large joint, vaccine
therapy holds an important place. In these cases he
has obtained a freely movable and serviceable limb, and
a much better result than after excising a fixed joint
after the wounds have healed, when the tissues around
the joint are so matted by the long-continued suppura-
tion. Another feature is the freedom from secondary
hemorrhage in cases treated with a polyvalent proteus
and streptococcal vaccine. Whereas before its use sec-
ondary hemorrhage was not uncommon in septic
wounds, no case under his care has occurred where vac-
cines have been employed. It seems probable that the
control of the proteus and streptococcal infection arrests
the digestive action in the tissues of the anaerobic co-
existing infection. He cannot venture to discuss the
bacteriological problems involved, but is convinced of
the great use of vaccines as a supplementary treatment
to surgical measures in septic wounds, and is satisfied
that the routine employment of a polyvalent vaccine of
proteus and streptococcus is of value in inhibiting the
tissue-necrosis caused by anaerobic bacilli, which are so
commonly associated with these organisms in gunshot-
wound infection.
British Medical Journal.
November 18, 1916.
1. An Investigation Concerning the Disinfection of Meningo-
coccus Carriers. M. H. Gordon and Martin Flack.
2. An Experimental Study of the Cultural Requirements of
the Meningococcus. H. M. Gordon, T. G. M. Hine,
and Martin Flack.
3. Epidemic Cerebrospinal Meningitis : Its Bacteriology and
Pathology. W. J. Denehy.
4. Observations on the Treatment of Cerebrospinal Fever. C.
Worster-Drought.
1. An Investigation Concerning the Disinfection of
Meningococcus Carriers. — Gordon and Flack state that
in all outbreaks of cerebrospinal fever where bacterio-
logical investigations have been made, carriers have
been found greatly to outnumber the cases; even then
the extent of the carriers of the true organism has been
somewhat overestimated. By application of the agglu-
tination test, based upon a study of meningococci iso-
lated from the cerebrospinal fluid of over 200 of the
actual cases, and applied throughout in a strictly quan-
titative fashion with suitable controls, the number of
persons who would otherwise be identified as carriers
merely because they harbor in their nasopharynx an
organism resembling the meningococcus is reduced by
as much as 30 to 40 per cent. But even with this pre-
caution, the number of carriers considerably exceeds
the number of cases. Thus from contacts of sixteen
cases ninety-two carriers were found in a recent out-
break. Dry warm weather with sunshine apparently
has some beneficial influence in enabling carriers to be-
come free, and cold, damp, sunless weather the opposite.
How far this apparent influence of the weather is due
to its effect on the secretion of the nasal mucus, re-
mains to be seen. Now the meningococcus is one of
the least resistant of all pathogenic bacteria to disin-
fectants, and it is rapidly destroyed by some of the
mildest of these bactericidal agents in concentrations
easily tolerated by the mucous membrane of the naso-
pharynx. Theoretically, therefore, the meningococcus
should be destroyed in the nasopharynx with ease if
only it could be reached there by a suitable disinfectant.
The means employed for applying disinfectants locally
has consisted up to the present chiefly of hand sprays
and douches. It seems needless to mention that these
means have not proved successful, especially in the
treatment of chronic carriers, for all the organisms
could not be reached on the nasal mucous membrane.
The object of these experiments was to find a disin-
fectant and to apply it to the nasal membrane in the
form of a vapor, reaching the necessary parts in a fine
shower of droplets. Experiments have been made with
a considerable number of disinfectants, but the ones
of which chief use has been made so far are chloramine
1 to 2 per cent., or zinc sulphate 1.2 per cent. Eusol
was tried, but was found more irritating and less ef-
ficient for the present purpose than the substances
named. The cubic capacity of the room in which the
carriers have been subjected to treatment with the spray
has been reduced, by means of a canvas ceiling, to 750
cubic feet. One liter of the solution of disinfectant is
sprayed into this area in the course of fifteen to twenty
minutes. The carriers remain in the room during the
whole of that time, inhaling the air through their nos-
trils. Thirteen men were subjected to the treatment
with chloramine. ten of whom were found free of the
organism after from four to thirteen days. Three re-
Dec. 23, 1916]
MEDICAL RECORD.
1135
maining showed either neurotic symptoms or failed to
inhale properly. As a result of more extensive work
than can be given here, Gordon and Flack consider that
these observations have led us to belive that, in the case
•of carriers of the meningococcus, prognosis with regard
to the duration of their future period of carrying varies
largely with the degree to which their nasopharyngeal
secretion is infected by the meningococcus. In our ex-
perience, the majority of carriers whose nasopharynx
yields only a few colonies of the meningococcus clear up
•quickly. In the case of these persons good results fol-
low local treatment either by direct application of a 1
per cent, solution of chloramine, or by subjecting them
to inhalation of a steam spray charged with zinc sul-
phate. On the other hand, carriers whose nasopharyn-
geal secretion yields a copious growth, or a practically
pure culture of the meningococcus, are often far more
difficult to cure. The results on these persons with zinc
salts were disappointing, but they served to emphasize
the success of those obtained with chloramine, which,
though still somewhat few in number, are more than
encouraging, and would appear to indicate that a large
proportion of these chronic carriers can be definitely
freed of the meningococcus by this form of treatment
in a comparatively short space of time. We would add
that while these observations on meningococcus carriers
were in progress, several cases of chronic nasal or post-
nasal catarrh have been submitted to disinfectant treat-
ment by the automatic steam spray. As in all of these
persons improvement has resulted, we offer the sug-
gestion that this method is worthy of trial on a larger
scale for the treatment of such cases.
Miinchener medizinische Wochenschrift.
October 17. 191C.
Diagnosis of Weil's Disease. — Professor Biiumler
takes up this subject in detail, describing one case at
great length and speculating on its nature. The re-
semblance to yellow fever is marked and a correspond-
ing cause is suggested. In the former the blood is in-
fectious for the first three days, while in Weil's disease
infection may be conveyed by the first day to animals.
The guinea pig shows the same disease as man. In
Weil's disease the period of infectiousness of the blood
may extend to the tenth day. Uhlenhuth and Fromme
have isolated a delicate, slender spirochete from the
blood and tissues of infected guinea pigs. Krumbein
and Frieling have shown that the flea can convey the
disease from man to the dog. Rare among the civilian
population Weil's disease appears with epidemic inci-
dence in the troops. In the author's 50 years of hospital
and consultation practice he has seen but one case of
Weil's disease, as described by Weil. Of many cases of
icterus gravis seen by him not one could have been con-
founded with the former, with a solitary exception,
which was seen 22 years ago. During the first 3 days
the resemblance to Weil's disease was striking, but the
temperature persisted and the icterus and renal symp-
toms were unusually severe; it was four months be-
fore the patient recovered. He still lives and is earn-
ing his living. All this history speaks strongly against
icterus gravis which Baumler regards as a sepsis pro-
ceeding from some infection of the liver or gall-ducts.
Had the guinea pig test been available at that period
such a condition could have been readily excluded. The
case history is now reproduced from the hospital record
of 1894.
Lung Tuberculosis or Lung Syphilis? — Wilmars de-
scribes 8 cases in which this question had to be de-
cided. All were regarded eventually as examples of
pure lues, but the author quotes others in which both
diseases were associated. Patients with pure pulmonary
lues may be admitted into tuberculosis sanatoria where
they do not belong. A positive Wassermann reaction
cannot exclude tuberculosis in such cases. Absence of
tubercle bacilli in extensive pulmonary disease in as-
sociation with syphilitic history or stigmata of that
disease means that intensive syphilis therapy should
be practised. Of great value in diagnosis is the pres-
ence or absence of fever. A patient may have emacia-
tion, night sweats, cough, and bloody sputum, but if he
has no temperature syphilis should be suspected. Tu-
berculin as a diagnostic test is mentioned in but one
case. These patients often do surprisingly well on
potassium iodide. In cases of association of both dis-
eases the presence of tubercle bacilli and positive Was-
sermann will often make the diagnosis, but in closed
tuberculosis the bacillus may not be found. While the
author has found a positive Wassermann in all of his
mixed cases, others have not been so fortunate. He
would place all subjects with tubercle bacilli and fever
in the sanatoria and would keep all others out. He
closes by quoting from a well-known syphilographer
to the effect that in many cases an autopsy alone can
explain the true mechanism, i.e. to what extent is one
disease determined by the other?
Case of Pulmonary "Calculi." — Helbig describes a
case of this clinically rarest of affections, which is termed
in German Steinhitsten because stones are coughed up
by the victim. Autopsy finds are not included, for these
are not so infrequent; but of clinical cases few have
ever been placed on record. In the most recent, reported
by Bickel and Grunmach, the stones were no larger
than a pea. The author's patient was a woman of 58,
healthy until recent years, when she began to suffer
with symptoms suggesting influenza. During the first
attack no "stones" were coughed up, but during a sec-
ond visitation she began to expel small "stones." She
has never since been entirely free from cough. A third
attack of "influenza" one year after the preceding led
to paroxysms of coughing, with dyspnea, and finally in
expulsion of what she termed a "bone." About 8
months later a fourth attack culminated in a like man-
ner, while at the end of another two weeks a fifth seiz-
ure brought the patient for the first time under medical
care. She brought with her four of the "stones," two
of which were as large as hazel nuts. An x--ray showed
two circumscribed shadows in the lung which doubt-
less represented unexpelled "stones." Miscroscopic sec-
tion showed the presence of bone corpuscles and la-
mella? in all the foreign bodies. This surprising find
really furnished an explanation of the whole disease
process which must have been tuberculous. The pa-
tient had developed latent calcified foci of the disease,
which in turn had led by pi'ocesses known to patho-
logists to a metaplasia of osseous tissue as a result of
constant irritation of the fibrous capsule of the focus.
The "stones" expelled were in reality osseous tissue.
While a "stone cough" may be a reality, the present
case should be termed "bone cough."
Cause and Transmission of Volhynia Fever. — Accord-
ing to Topfer the five day or Volhynia fever has not yet
been proved to be due to a parasite, although the cir-
culating blood of the patient can convey the disease.
The author inoculated guinea pigs intraperitoneally with
human blood and obtained a fever curve identical with
that caused under the same conditions by typhus.
Transmission by the body louse is therefore the most
probable cause and the author has studied the insects
from that viewpoint. As a result he found organisms
which were readily distinguished from the supposed ex-
citing cause of typhus despite considerable resemblance.
Notwithstanding the clinical differences between the
two fevers, it is not improbable that clinical typhus
1136
MEDICAL RECORD.
[Dec. 23, 1916
may really be at times the result of mixed infection.
From analogy the cause of isolated five-day fever should
be a protozoan (recurrent character as seen in relaps-
ing fever); but it seems that this view must now be
abandoned.
Acute Urethritis Due to the Streptobacillus L'rethra?
of Pfeiffer.- — According to Engwer this microorganism,
first described by Pfeiffer in 1904, may exert a patho-
genic action, but only in cases of prior acute gonorrhea
or actual gleet. With a soil thus prepared the strepto-
bacillus, naturally a saprophyte, can cause a special
form of urethritis. If chronic gonorrhea is already
present a symbiosis results. The streptobacillus can
then cause a genuine bacterial urethritis with increased
secretion and exacerbation of the clinical behavior.
Retransfusion in Abdominal Hemorrhage. — Accord-
ing to Kreuter attempts were first made about two
years ago to restore to the circulation the blood lost in
internal hemorrhages. The subject had a good experi-
mental basis and quite recently the author attempted
its application to a wounded soldier who suffered from
profuse intraabdominal hemorrhage following projec-
tile wounds of the liver, spine, and one kidney. Lapar-
otomy was at once performed, and while much blood
escaped in clots, the fluid portion was allowed to ab-
sorb in sterile compresses and was also washed out
with saline infusion. The soaked compresses were
squeezed and the escaping blood was passed through a
filter into the irrigation-blood. In this manner a liter
of clot-free blood was quickly obtained. The lower ab-
domen and pelvis contained an abundance of thick clots
and the total loss of blood was estimated at from 2*4
to 3 liters. With patient moribund blood was trans-
fused into an elbow vein, 15 minutes of time being re-
quired for the operation, in addition to 20 minutes
required for laparotomy, etc. The abdomen was cleansed
and closed during the transfusion. The immediate ef-
fect was marvelous, but another hemorrhage followed
from the wounded kidney and death soon occurred.
Leeches in the Larynx. — Harting, who is serving in
the Balkan campaign, had among his first Turkish
patients three with "worms in the throat." He was
unable to converse with these soldiers, and his first
diagnosis was ascarides in the pharynx as a result of
vomiting. Cathartics were ordered. Next day the men
were spitting blood and the diagnosis was changed.
The laryngoscope showed in each patient a dark blue
mass below the vocal cords. The men were told to gag,
which act raised the larynx and enabled the author to
grasp and extract the parasites. The grateful patients
nearly smothered the doctor with hugs. The soldiers
had recently drunk from a puddle of water while suffer-
ing greatly from thirst.
La Presse Medicale.
Wo r '! ber 2, 1916.
Acute Azotemic Nephritis in the Troops. — Ameuille
states that in civil practice acute nephritis a frigore
is of rare occurrence. Since the outbreak of the war it
has become so common that up to the end of June,
l'.U"), 1,062 cases had been recorded in the French ex-
peditionary force, and we know now that it is abnor-
mally frequent throughout the entire army. It appears
to increase in frequency as the war is prolonged, and
is now known to be independent of atmospheric con-
ditions, while still of the type of nephritis from ex-
posure— anasarca, massive albuminuria, uremic symp-
toms mild in character. But there are other cases
without edema but with a variety of symptoms point-
ing to the kidneys. Such cases the author terms acute
azotemic nephritis. Concerning the latter surprisingly
little is known. Hogarth has recently noted its occur-
rence in the English troops under the name of acute
nephritis without edema. We see fever, hematuria,
albuminuria, and evidences of infection. The blood
hows nitrogen retention. The affection may begin as
a simple fever and devoid of symptomatology. Typhoid
would perhaps be first thought of, but the occasional
presence of remissions opposes this possibility. More-
over the temperature rises suddenly and not gradually,
with oscillations more marked. The vomiting which
may set in is too marked and persistent for an ordi-
nary infection. Headache may be persistent and vio-
lent. Certain cases begin with an angina or other local
manifestation. The diagnosis may be grippe or bilious
attack or merely a general feverish cold with muscular
soreness and stiffness. Then it will be noted that the
urine is scanty and perhaps bloody. The diagnosis of
acute nephritis is evident through the presence of
formed elements of blood in the centrifugalized sedi-
ment. Mere presence of albumin means nothing in
febrile and hematuric cases. A blood test for urea is
alone of value in prognosis, and if the proportion in-
creases a fatal outcome is assured. In nearly every
case seen cough and expectoration were noted and
sonorous rales heard over the chest. The liver is some-
times sensitive to palpation and slight icterus may oc-
cur. Acute nephritis with icterus has been seen by a
number of observers. Severe headache and meningism
point to increase of nitrogen in the blood. In some
cases convulsions have been mistaken for epilepsy. In
one such case the amount of urea per liter of blood was
2.55 gms. The course of the disease varies greatly. It
may be short and fatal, short and benign, and may be
long, usually with complete recovery, but often with
some persistence of ill health. When both fever and
albuminuria are absent we have only the blood to guide
us. The purely azotemic type attacks the patient
"brutally" and he may not recover from its impetus.
The onset of the edematous type is less brutal but more
profound; life is not so much menaced for nitrogen
retention is less and quite constant. Still the dropsical
and nondropsical forms are manifestations of one dis-
ease— "war nephritis." When a subject dies from acute
azotemia signs of an old renal lesion may be found,
with the superaddition of acute intestinal nephritis.
Practically the histology of the kidneys is the same in
both diseases. Something about prolonged trench life
damages the resisting power of the kidneys and the
active cause is doubtless microorganisms in every in-
stance, although this point has not been demonstrated
beyond doubt.
Revue Medicale de la Suisse Romande.
October 20, 1916.
Infrequency of Extrapulmonary Tuberculosis Under
Tropica] Sunlight. — Sleiner speaks only of Java, where
he has practised for 20 years. Pulmonary tuberculosis
is common enough, alike in the aborigines and various
foreigners. No race or class has any immunity. But
it is most rare to encounter white swelling of the knee,
hip disease, scrofulous glands, scrofulous ophthalmia,
etc. These conditions are the very ones which benefit
by heliotherapy in the North. The Javanese live in al-
most perpetual sunshine, for in the rainy season the
rain seldom appears before 4 p. m. Only the Euro-
peans are protected from the solar light and heat, but
these are lightly clad and partly exposed to solar rays:
much more in fact than during the European summer,
especially in childhood. The country is by no means
salubrious, and typhoid, cholera, dysentery, ankylosto-
miasis, and malaria flouish. The bubonic plague has
of late years become familiar. Cleanliness is hardly
understood. The natives expectorate everywhere.
Dec. 23, 19 1G]
MEDICAL RECORD.
1137
Bathing is common but only as a refreshment. Food
is ample — rice, fish, and legumes with not a little meat.
The Europeans and Chinese seem alone in the use of
alcohol. There is no milk industry. Cows' milk seems
plentiful but is little used as a beverage, save by Euro-
pean children. It is by no means good milk, but can
hardly contribute to the spread of pulmonary tuber-
culosis because of the absence of extrapulmonary forms
which are usually associated with a possible bovine
transmission. Whether or not the so-called scrofula is
directly related to eventual pulmonary tuberculosis,
every child (and nearly all are believed to have latent
tuberculosis) ought to have the benefit of heliotherapy.
During the warm months the skin should be exposed
as much as possible to the sun — at least 50 per cent, of
the surface. The Javanese certainly gets plenty of
fresh air, both because he is outdoors so much and be-
cause the loosely built houses are ventilated auto-
matically. The inside air, however, is smoky and other-
wise disagreeable. The frequency of pulmonary tu-
berculosis in Java may perhaps be accounted for by
the lack of sanitary knowledge and by conditions like
malaria and ankylostomiasis which tend to lower the
general resistance.
Le Progres Medical.
October 20, 1916.
"Cesarean Section" Due to Shell Explosion. — Saint,
Goehlinger, and Poire relate the case of a woman who
lived in a town on the British front which was under
daily bombardment. She was 33, and 6 months' preg-
nant when a fragment of shell exploded in the street,
injuring her abdomen. When first seen there was a
marked peritoneal defence toward the right. The uterus
was anteverted and its highest point was two fingers
breadth above the navel. Attempts to palpate the fetus
failed because of pain and defensive reaction. The
shell fragment had passed through the abdominal
cavity, the points of entrance and exit being close to-
gether. The woman bled freely from the vagina, and
a wound 5 cm. long was found in the fundus uteri.
Amniotic fluid and meconium were found in the lesser
pelvis. The fetus was seen to lie in the left occipital
position, presenting a slight shell wound in the lumbar
region. The authors made a hysterotomy incision which
conformed to the external wound and extracted the
fetus and placenta, as in the ordinary cesarean opera-
tion. The premature fetus was left alone, as dead, but
began to cry from exposure to the cool air. In the
meantime the uterus had been sutured after careful
hemostasis, the other visceri having been found intact.
The infant, a female, weighing but 950 gms. and already
wounded by the projectile, succumbed, perhaps for want
of proper care, in a few hours. The mother made a
good recovery; doubtless the presence of the fetus saved
her own life by preventing injury of the intestines.
The case is perhaps unique and the infant may be re-
garded as the "youngest victim of the war."
Cerebrospinal Commotion from Shell Shock. — Bon-
homme and Nordmann mention three kinds of disorder
which result from this form of shock. 1. Troubles of
character. The subject becomes irritable, will not tol-
erate the slightest contradiction, is surprised to find
himself angry without apparent cause. He is impres-
sionable in other ways, weeps when visited by a friend,
and may not be able to converse until after some time.
A bold man becomes timid, begs his relatives to obtain
certain simple privileges from the physician which
would readily have been granted. Subjects are de-
pressed, seek solitude, finally become melancholic. 2.
Troubles of intellect. Ideation is slow and even at
times incoherent: it is difficult to maintain a conversa-
tion. The confusion which followed the injury has sub-
sided but cerebral activity is lessened throughout. The
subjects, usually of a higher social plane than the aver-
age soldier, realize their condition keenly, think of sui-
cide. Amnesia is common with inability to fix atten-
tion. There can be no improvement until this symptom
vanishes. 3. Somatic disturbances. Headache is very
common, with vertigo and insomnia with hypnagogue
hallucinations. The body tires readily, as well as the
mind. Attempts at work lead to tremor, pains in the
limbs, etc. Sexual desire is usually abolished. Horror
of noise is often present. To sum up the picture cor-
responds with that of Erichsen's "railway spine" and
post traumatic neurosis of civil practice. There is
nothing pathognomonic about shell shock as compared
with physical shock from severe shell injury, which is
of course largely psychical. After a number of weeks
the patient while "convalescent" still suffers a good
deal and his state may remain stationary. The patients
classed as "improved" may recover completely in time.
These represent averages, for there are some rapid
recoveries, while some patients may not even show im-
provement for many months. The so-called stationary
case may after a variable time, perhaps several years,
proceed to recovery.
Le Progres Medical.
November 5, 1916.
Glandular and Humoral Repercussion in Shock. —
Loeper and Verpy state that these manifestations are
as yet but little known while by no means rare. The
majority of "commotionists" treated by the authors
were asthenic and for a few days incapable of any ef-
fort. Another symptom is absolute anorexia. Not
much urine is voided and constipation is the rule. Low-
ered blood pressure is seen in two-thirds. The entire
picture can be explained by adrenal insufficiency, and
if adrenalin is given the picture tends to disappear.
The adrenals may be thus affected through a nervous
mechanism or perhaps by direct violence over the loins,
in which case renal hematuria should coexist. The
anorexia may be attributed to various anomalies of
gastric secretion arising in part through the vagus.
The pancreas may also be affected through the effects
of shock on the central nervous system, while the dis-
turbed nitrogen coefficient in the urine is characteristic
of hepatic disturbance. The blood is profoundly modi-
fied in these shock cases, although the individual varia-
tion may not be marked. Bloodsugar is abnormally
low after the day of the injury. To sum up, the diges-
tive organs, adrenals and blood all suffer from the
rudeness of the central nervous shock.
A New Adjuvant Remedy for Tetanus. — Lopez reports
a cured case of tetanus in which the substance diallyl-
malonylurea was used to replace chloral. The case was
one of delayed outbreak and serum along with chloral
showed no power whatever over the convulsions. The
new remedy was substituted for chloral and notable im-
provement followed with prompt recovery. The amount
of serum given was but 240 ccm. The new substance
is known to be a hypnotic and nerve sedative. It may
be able to replace chloral and is free from some of the
latter's drawbacks.
Posttyphoid Ocular Paralyses. — According to Gines-
tous, not over six or seven cases of this complication
are on record. The common motor nerve is the one
chiefly involved. In two cases the sixth nerve was af-
fected. In one of the latter the complication appeared
during the course of the disease. The author pushed
the mixed treatment in his case, which proved to be
incurable. — Le Cad
1138
MEDICAL RECORD.
[Dec. 23, 1916
Slunk Epumiia.
A Practical Treatise on Disorders of the Sexual
Function in the Male and Female. By Max
Huhner, M.D., Chief of Clinic, Genitourinary De-
partment, Mount Sinai Hospital Dispensary, New
York City; formerly Attending Genitourinary Sur-
geon, Bellevue Hospital, Outpatient Department and
Assistant Gynecologist, Mount Sinai Hospital Dis-
pensary, New York City; Member, American Urologi-
cal Association, American Medical Association, New
York Urological Association, Fellow of the New York
Academy of Medicine, etc.; Author, "Sterility in the
Male and Female and Its Treatment," etc. Price, $3.
net. Philadelphia: F. A. Davis Co.; London: Stanley
Phillips, 1916.
Dr. HUHNER's book gives the impression of the repub-
lication of a number of papers on this subject which he
has cemented together and put in a permanent form.
Thus cases are reported and the same statement ap-
pears often in various parts of the book, giving a some-
what monotonous effect. The author succeeds in finding
a physical basis for nearly all the sexual ills that flesh
is heir to; usually it is a congestion of the posterior
urethra, or prostatic trouble. He dismisses psycho-
analysis briefly: "The ardent disciples of Freud, in
their enthusiasm, are apt to be entirely too narrow in
their interpretations." He further states that the cases
he reports are sent to him only after the psychoanalysts
have failed to help them.
The conservative, orthodox viewpoint is the one taken
all through the present volume. The chapters on mas-
turbation are especially good. It is difficult to see, how-
ever, why a chapter on enuresis was included in a vol-
ume with this title.
A Text-Book of Pathology. By W. G. MacCallum,
Professor of Pathology in the College of Physicians
and Surgeons, Columbia University, New York. With
575 illustrations, chiefly from drawings by Alfred
Feinberg. Price, $7.50 net. Philadelphia and Lon-
don: W. B. Saunders Company, 1916.
The appearance of a new text-book by a teacher of wide
experience is always of interest, chiefly in the personal
reaction of the writer toward his subject and in the
perspective which he brings, rather than in any especial
contribution by which the total matter of the particular
phase of the science under consideration may be ex-
panded; for, alter all, no one volume can contain all the
facts which have been amassed, and the real originality
of the book must lie in the style, classification, and nec-
essary elimination of the less important subjects. So
in this admirable but rather portly volume we have
an interesting contribution to this aspect of literary
psychology. The writer, with engaging frankness, states
in his preface that he has freely and willingly omitted
many subjects ordinarily included in the conventional
text-book of pathology, that he has tried to make the
etiological influences the basis of his classification, and
that without making any claim for novelty, he has
wished to feature, so to speak, the concept of injury
as covering all activities, whether parasitic or chemical,
which induce in the animal body the reactive phenomena
ordinarily designated as disease. That, in our present
somewhat dense ignorance of a number of conditions,
this procedure leads to grave difficulties is to be ex-
pected, and the rebellious subject of tumors, of the
cause of which we certainly have not the slightest
inkling, is perforce promptly excluded from the classi-
fication and treated in a separate section. Even in
other subjects, the etiological treatment leaves gaps;
for example, if paresis and tabes are to be considered
as due to the Spirochmta pallida alone, the query in-
stantly arises as to the infrequency of these diseases in
the negro and, also, in the white female, though syphilis
affects black and white of both sexes in approximately
equal numbers. Some etiological factor is missing, evi-
dently, though the student may gain the idea that the
spirochete is alone to blame. In consequence of this
method of classification the reader may, also, find it dif-
ficult even with the aid of the index to complete his
knowledge of certain processes. Appendicitis is in-
cluded under inflammatory processes induced by bac-
teria ; but, unless he possesses more than the average
stock of erudition observable in his genus, the student
will not realize that mention of the possible correlation
between inflammatory lesions of the organ and the
presence of oxyuris in the appendical mucosa is to be
looked for in the index under the name of the parasite
and not under the caption "appendix" or "appendi-
citis."
But these slight defects are matters of small moment
in comparison to the real and positive value of the text
taken as a whole. The style is so clear and admirable
that the author's hope, expressed in the preface, of
making a continuous story of the facts of general
pathology, is excellently realized. Among the most
valuable chapters are those on the blood-forming or-
gans and on the diseases due to injuries of the organs
of internal secretion. In the first, the lesions of the
bone marrow are illustrated by a beautiful series of
plates, some of them in color, while in the second the
various clinical aspects of hyper- and hypoactivity of
the hypophysis are brought out with unusual clearness,
assisted by striking photographs of cases, many of them
from Cushing's monograph.
The volume is brought to a close by a long and ad-
mirable chapter on tumors with many illustrations and
a final summary of the modern views on etiology. The
temptation to impose a new classification of neoplasms
on a long-suffering scientific public is happily resisted
by the writer, and as a consequence the old familiar
designations now hallowed by long use are still em-
ployed.
Les Blessures de l'Abdomen. Par J. Abadie (d'Oran),
Correspondent National de la Societe de Chirurgie.
Avec Preface du Dr. J. L. Faure. Une volume de
240 pages avec 67 figures originales et 4 planches,
hors texte. Price, 4 francs. Paris: Masson et Cie.,
1916.
This volume is intended to be timely above all. Con-
cerning abdominal wounds there are more differences
of opinion than when other localities are involved. We
cannot reconcile the results of expectancy with those of
operation, because cures are seen under non-operative
management. Palliative as well as radical operations
have a field. Three objects are always kept in view,
viz., the doctrine, or determination of the method of
choice for the individual case; the organization, which
makes it possible to treat the case properly, and, final-
ly, the technique.
Medical and Surgical Reports of the Episcopal
Hospital, Philadelphia. Volume III. Edited by
Astley P. C. Ashhurst, M.D. Published through
the generosity of a friend of the hospital. Octavo of
356 pages. Philadelphia: Press of William J. Dor-
nan, 1915.
This volume consists of collected papers by members of
the attending staff, the papers being based on work
done in the Episcopal Hospital during the years 1914-
1915. Many of the articles have been published in med-
ical journals and are reprinted so that the hospital
shall receive credit for all articles based upon material
it has furnished. There are twenty-five contributors who
have furnished thirty-eight papers representing work
in the following departments: Medical, Surgical, Ortho-
pedic, Ophthalmic, Aural and Laryngeal, Obstetric,
Dermatological, and Dental. Many of the papers are
profusely illustrated and practically all reflect much
credit upon the institution with which their authors are
connected.
A Manual of Otology for Students and Practi-
tioners. By Charles Edwin Perkins, M.D.,
F.A.C.S., Professor of Clinical Otology in New York
University and Bellevue Hospital Medical College;
Associate Aural Surgeon to St. Luke's Hospital; As-
sociate Aural Surgeon to New York Eye and Ear
Infirmary; Fellow of the American Otological So-
ciety, New York Otological Society, New York Acad-
emy of Medicine, etc. Illustrated with 120 engrav-
ings. Price. §3 net. Philadelphia and New York:
Lea & Febiger, 1916.
A thorough knowledge of the ear from the anatomi-
cal, physiological, and pathological standpoint is noto-
riously very difficult of attainment. By which is meant
that to learn how to properly treat diseases and affec-
tions of the ear is by no means easy. It follows then
that this branch of medical study is a difficult part of
the student's curriculum. The aim of Dr. Perkins's
manual is to lighten these difficulties for medical and
post-graduate students and to supply data which will
enable those who thoroughly master them to become
capable aurists. This aim appears to have been accom-
plished in a satisfactory manner. The chapters of the
suppurative diseases of the labyrinth may be especially
recommended.
Dec. 23, 1916J
MEDICAL RECORD.
1139
during i&tvatts.
THE PRACTITIONERS' SOCIETY OF NEW YORK.
Two Hundred and Eighty-first Regular Meeting, !!■ Id
November 3, 1916.
Dk. John S. Thacher, President, in the Chair.
Rhinoplasty. — Dr. Robert Abbe showed a man on whom
he had made an unusually presentable nose by a novel
plastic operation The entire nose, except the edges of
the nostrils and tip, had been destroyed by cancer, which
involved the septum and sides so that they required ex-
tensive removal. To make a nose by the usual flap from
the forehead would have left a deep saddle-nose defect,
so that a central support was required. This Dr. Abbe
made by undermining a triangle of skin from each
cheek, its base at each side of the nose. The nutrition
of these flaps came from the cellular tissue and peri-
osteal base, inasmuch as thu skin was cut through su-
perficially clear up to the nasal defect, but deeply on
the cheeks. These flaps were turned over the nasal
defects so that their points crossed each other and they
were stitched together side by side where the bridge
was needed. The flaps had their skin side inward and
wet side up. On this bridge was now laid a forehead
flap wet side down carefully stitched to the tip of the
nose and cheeks. Thiersch's skin grafts then covered
the forehead defects. In two weeks the redundant skin
at the root of the nose was carefully cut out and the
shape of the nose was symmetrically balanced. The pa-
tient breathed freely through both nostrils on account
of the skin lining where the cheek flaps were inverted.
Each cheek presented a fine horizontal scar. There was
every reason to believe there would be no sagging of
the bridge.
Inoperable Peripheral Gangrene. — Dr. W. GlLMAN
Thompson read this paper (see page 1103.)
Dr. G. E. Brewer said that in many cases of periph-
eral gangrene the general condition was so poor that
amputation beyond the probable extent of the gangrene
was extremely risky. In many cases small local ampu-
tations were imperative whatever the patient's con-
dition and these had to keep pace with the extension of
the gangrene. He was greatly interested in the hot-air
treatment. He had used the hot air in treating burns,
but not in treating gangrene. The relief of pain and the
elimination of the odor were strong recommendations
for the procedure as outlined by Dr. Thompson.
Dr. Wm. H. Park said that he had had two experi-
ences in gangrene which were interesting. In a case of
typhoid fever, two subcutaneous injections of horse
serum for the control of intestinal hemorrhage had been
followed by gangrene and sloughing of the surround-
ing connective tissue and the overlying skin. The areas
were as large as one's hand but, while serious, did not
interfere with the course of the disease. In a case of
scarlet fever, gangrene and sloughing had followed a
subcutaneous injection of serum. No permanent harm
had resulted. Dr. Park was of the opinion that some
other elements than pressure entered into the causation
of the gangrene in both cases.
Dr. J. A. Fordyce said that gangrene was not in-
frequently encountered in syphilitic endarteritis. This
gangrene might be very extensive. A confusing point
in these cases was that they not infrequently showed a
negative Wassermann reaction. It was very unsafe to
regard them as nonsyphilitic on this alone. In all such
cases a provocative dose of salvarsan should be given.
This frequently changed a negative reaction to a posi-
tive one and made the diagnosis certain. In all cases
of doubt autosyphilitic treatment should be instituted.
Dr. L. A. Conner said that in cases of gangrene
associated with diabetes a determined effort should be
made to reduce the patient's blood content of sugar to
as nearly normal as possible. Under normal procedures
this end could usually be attained with a fair degree of
promptness and the eases of gangrene in diabetes which
he had seen had been greatly helped. He strongly ad-
vised conservative measures in the treatment of these
cases and considered medical care more helpful than
surgery.
Dr. Robert Abbe said that one of the chief advan-
tages of the hot-air treatment of these cases was
purification of the atmosphere. This was a very im-
portant feature of the treatment. At times pro
amputation must be insisted upon. He had used spina!
anesthenia in these cases with great satisfaction and
had o')tained quick convalescence. He had seen one case
of apparently severe gangrene make a spontaneous
recovery. The surface of the great toe had been blue
black, but only a shedding of the cuticle had occurred.
Dr. M. Allen Starr asked if hot air had been em-
ployed in the treatment of Raynaud's disease.
Dr. C. L. Dana said that he had used dry heat for
a good many years and had obtained good results with
il in Raynaud's disease.
Dr. Oilman Thompson, in reply to a question of
Dr. Thacher's, said that the best temperature he re-
garded as about 150° F. He considered the free circu-
lation of the hot air as most important to produce
evaporation. The current of hot air should be fairly
strong. Where the employment of hot air had been im-
practicable he had used 95 per cent, alcohol with satis-
factory results, this being far better than the weak
solutions usually employed.
Tonsillectomy in Poliomyelitis. — Dr. J. C. Roper pre
sented this communication. In the recent epidemic of
poliomyelitis the New York Hospital had opened a
special branch hospital for the treatment of this disease.
At this hospital the bacteriology of the disease had been
studied by Dr. E. C. Rosenow of the Mayo Clinic,
Rochester, Minn. From pus expressed from the tonsils
of the patients during life, Dr. Rosenow had isolated
a streptococcus which produced paralysis in small ani-
mals and monkeys. Tonsils removed at autopsy had re-
vealed small foci of purulent material from which same
organism was isolated with the same result. This or-
ganism Dr. Rosenow considered identical with that re-
covered from the spinal cord by Flexner and Noguchi.
Many cases of poliomyelitis showed a tendency to pro-
gress as regarded paralysis. After the acute symptoms
had subsided in these cases, extreme irritability per-
sisted accompanied by a slight fever and apparently at
times an extension of the paralysis. In these cases, on
the basis of Dr. Rosenow's work, the possibility was
assumed that the process was being kent up by reinfec-
tion from some source, probably the tonsils. Tonsil-
lectomy was performed in twelve cases and foci were
found in many of the tonsils removed. No acute cases
were operated upon. In the case showing the most
marked improvement, operation had been performed on
the 21st day of the disease. The tonsils contained three
typical foci. Operation on all of the other cases had
been performed from the 23rd to the 35th day of the
disease. Several seemed distinctly benefited. Because
of the number of deaths occurring after the first week
(50 per cent, in this series) if Dr. Rosenow's work was
confirmed we would seem justified in cases of delayed
recovery in removing the tonsils as possible infecting
foci. No untoward results were observed.
Dr. W. H. Park said he did not feel that much prog-
ress had been made during the past six months in the
knowledge of the disease. Personally, he could not yet
accept the possibility of the process of the disease being
kept up by repeated infections from a tonsillar focus.
Rather he regarded it as akin to rabies and cerebro-
spinal meningitis in being a single infection of the cen-
tral nervous system. There was no question but that
Dr. Rosenow was a skilful and enthusiastic worker, but
Dr. Park doubted if he had established the identity of
the streptococcus isolated from the tonsils with the
Flexner and Noguchi organism recovered from the
spinal cord. At the Department of Health laboratories,
they had gotten the small forms from eighteen of nine-
teen cases but had seen no transmutations to large
forms. It was probable that infection occurred through
the intestinal tract as well as through the nasopharynx
and tonsils. Possibly something of interest and import-
ance would be developed during the next six months
from the work now being carried on at the laboratori^
of the Department of Health.
.MISSISSIPPI VALLEY MEDICAL ASSOCIATION.
Forty-second Annua! Mi Held at Indianapolis,
October 10, 11, and 12, 1016.
The President, Dr. Willard J. Stone of Toledh.
Ohio, in the Chair.
{Concluded from page 1094)
Operative Treatment of Tuberculous Spine. — Dr.
Henry B. Thomas of Chicago stated that the Hibbs
technique had the following advantages: it copied na-
ture in her preparation for the fixation of the verte-
1140
MEDICAL RECORD.
[Dec. 23, 1916
bras. It required operation only in the posterior region
of the spine itself, making unnecessary the removal
of bone from the leg. The technique, though difficult
at first, became simple with repetition. It immediately
reduced the kyphotic deformity by the length of the
spinous process, usually one-half to one inch. Anky-
losing the articular processes greatly aided in the
fixation. Welding the opposed lamina? was an addi-
tional link in the chain of ankylosis. The most import-
ant suggestion regarding the after-treatment concerned
the mechanical fixation after the patient was kept in
bed for six weeks; either a cast or a brace was worn
for from six to ten months, with constant observations
of the position and progress.
Dr. John Ridlon of Chicago said that in these
operations of Hibbs and Albee for the treatment of
tuberculosis of the spine, he still used braces. It was
claimed that it shortened the duration of the sickness.
Perhaps it did, but sometimes it certainly did not, be-
cause all these cases were not perfect restorations, de-
spite Albee. Some of the patients died as the result
of the operation, some of the grafts came out, some
of the grafts broke, and a great many of them that
were put in were put into spines already ankylosed
through the course of time and by the grace of God.
These were the best results that were to be had when
a graft was put into a spine that was already per-
fectly solid. There was no doubt that in selected cases
this operation had a place, and he was of the opinion
that the Hibbs operation was a little more appealing
to one's judgment of what was right than the Albee.
On the other hand, he had seen many of these opera-
tions, he had assisted in some, he had done none him-
self, and he never would.
Dr. Charles Davison of Chicago stated that any
procedure which would shorten the duration of any-
thing so serious as Potts' disease should be entitled
at least to consideration. The probabilities were that
the real benefit could only be decided by a large series
of cases collected for many years. He had been very
much interested in Dr. Thomas' work at the Cook
County Hospital, and he had the honor to see some
of the cases of Albee, which he did, collected through
quite a period of time. The thing that he was most
interested in was what happened to the transplant.
He made experiments also along other lines and along
lines of bone grafting. With a transplant taken from
the same individual and opposed to the same kind of
bone, for instance a contact of the tibia, to a con-
tact bone of the spine, if it was done in an esthetic
manner, if there was absolute immobilization of the
transplant, we got a primary union similar to the
primary union of one of the soft parts. For the time
being at least the transplant left a succulent pabulum
between it and the host when it went on and became
an integral part of the bony framework. As long
as it had function it would remain; when the func-
tion ceased it would deteriorate to a certain extent.
In the Hibbs method of bony repair it seemed to be
different. The bone was taken from the same neigh-
borhood, but instead of being kept in a mass it was
largely minced or broken up in particles. Some of the
pieces might be intact so that they would heal promptly
and become a part, but largely the bone was broken
up, the bony cells were liberated, the lining of the bone
cell was given up, and we got a new growth of bone
there much like a callous. That continued to immobil-
ize as it became osseous as long as there was function;
when function ceased it gradually absorbed and went
to the compensation between strength and bone.
Dr. John D. Trawick of Louisville said that he had
seen Dr. Thomas operate and he must say he was
just a little enthusiastic about the method of his
operation. He should be very glad if he would dis-
cuss the question of the anesthetic for these little
patients. Was the risk of the anesthetic the ordinary
risk that was to be expected in any capital operation
for a child? Was there a choice of anesthetics, and
if there were any particular points he could bring out
in his closing discussion bearing relativelv on the mor-
tality as it pertained to the anesthetic, he should be
very <_;lad to have his view.
Dr. W. P.. OWEN of Louisville thought we made a
great mistake in using the word "cured" for these
cases. In tuberculosis of the spine, or pulmonary
tuberculosis, no matter what area of the body might be
involved, we made a mistake to use the word "cured."
The first reports were really almost too good to be
true. He thought they had proven not to be true;
that is, they had nol lasted. Two hundred and fifty
operations for bone transplant with one hundred per
cent, cure was hard to swallow at one time. He had
had a good many of these cases and did not feel the
operation itself was a serious one. The shock that
resulted from it was very slight. In many cases an
opiate was not necessary. He did not think it made
any difference what anesthetic was used, so long as
we were using the best that was known for any surgi-
cal procedure. As to the two operations that Dr.
Thomas discussed, while he had had very little expe-
rience with the Hibbs opei'ation, it seemed to him very
simple and in some respects a more feasible procedure,
although he should think there would be one objection,
and that was the point that was first claimed as a
point in its favor — the flexibility of the spine pro-
duced by the Hibbs rather than the autogenous splint.
If we allowed motion in the spine the cure was not so
apt to take place. One splint would nrobably be re-
tained in place more satisfactorily than several splints,
and in the breaking down of the spinous process that
was what it meant — it was made up of a number of
pieces of bone.
Doctor Thomas, in closing, said that in regard to
the anesthetic, he thought Dr. Trawick probably asked
the question because he saw a fatal result he had.
He had had two deaths on the table. He thought both
of them were from the anesthetic, or the way the
anesthetic was given. At one of the cases he lost Dr.
Trawick was present, and he had made it a rule ever
since to attempt to do no operation on the spine un-
less he had a professional anesthetist. He wanted no
intern to give the anesthetic for him when he operated
on tuberculous spines. There was no trouble, the chil-
dren got along nicely, especially if we kept them in
the hospital for a few days beforehand and got ac-
quainted with them, so they went to the table without
fright. They did nicely so far as the anesthetic went.
Tumors of the Breast. — Dr. J. Garland Sherrill of
Louisville considered proper palpation the most val-
uable of all the means at our command for determining
the character of a mammary tumor. If not properly
employed, however, it might be worth less. Very little
could be learned by pinching the breast between the
fingers; the proper plan was to place the palm of the
hand fiat on the breast and gently press the gland
against the chest wall. This would reveal any abnor-
mal mass, show whether it was indurated or not, de-
termine its mobility over the chest wall or pectoral
muscle, also its mobility under or attachment to the
skin; its outline elasticity, and whether or not it was
encapsulated. The observer would also note the amount
of pain produced by pressure and manipulation. By
gently sliding the breast over the pectoral muscles
with the palmar surface of the examining finger its
attachment could be readily made out, and dimpling
of the skin with slight fixation occurring early in can-
cer could be detected. Palpation also enabled one to
determine the enlargement of the axillary and cervi-
cal glands. Recently a case came under his observa-
tion where the patient had a malignant tumor of con-
siderable size in the breast, which could scarcely be
detected by flat palpation over the breast; but was
readily made out by lateral compression. He had also
seen a case where there was a malignant growth of
supernumerary glandular tissue lying some distance
above a normal mammary gland. Certain character-
istics were present in benign enlargements whether of
cystic or solid type. They occurred at any age, more
often in the young. They grew slowly or not at all.
They were usually encapsulated and never infiltrated
the surrounding tissues; they were mobile, showed no
glandular enlargement and were usually painless, but
in certain neuralgic patients might be quite painful.
They occurred in unmarried and nulliparous women
especially. Malignant growths usually developed after
thirty, but sometimes as early as eighteen years of
age. They were likely to grow slowly but constantly
if carcinomatous; fast but spasmodically if sarcoma-
tous. They were encapsulated, with the possible excep-
tion of certain eases of sarcoma. They became at-
tached to the skin and fascia quite early. Early glan-
dular involvement was shown in carcinoma. Pain was
a late symptom, but always present in the later stages.
These growths usually occurred in parous women.
An irregular outline and induration gradually merging
into surrounding tissue is characteristic of scirrhus.
It was not always easy to differentiate between
adenoma, adenocystoma, cystoma, and a cysto-sarcorr.a;
and adenocysto-carcinoma of the proliferating type was
. Iways difficult to distinguish from the above types.
Dec. 23, 1916J
MEDICAL RECORD.
1141
There was also a border line condition where patho-
logically the tissue was benign in one portion and
malignant in another, seen in cases of chronic cystic
mastitis of Koenig. In such cases histological exam-
ination at operation was imperative to determine the
best line of operative procedure. In rare instances
abscess and suppurative cysts of the breast had been
mistaken for a malignant growth. In order to verily
the clinical diagnosis every mammary tumor should
be subjected to microscopic examination.
New Methods of Pyloroplasty for Congenital Pyloric
Stenosis. — Dr. Alfred A. Strauss of Chicago drew the
following conclusions: "The advantages of pyloro-
plasty over posterior gastroenterostomy are (1) The
incision required is very small, in contradistinction to
that necessary in performing posterior gastroenteros-
tomy, large enough to deliver the partially distended
stomach, transverse colon, and then to find the right
loop of jejunum. (2) Those who have performed gas-
troenterostomies in these infants will appreciate the
saving of a tremendous amount of shock thus secured.
(3) The methods of operative procedure described
cover every form of pathologic condition so far found
in congenital pyloric stenosis. (4) The operations re-
construct a pathologic pylorus to a more normal
pylorus, particularly as to its lumen ana enormous
thickness of musculature. Finally, the normal an-
atomical relation of the stomach to bowel is preserved
by the pylorus remaining the normal connecting tube
between stomach and duodenum. The developing liver
and pancreas in the infant, which we know from ex-
periments in physiology are stimulated reflexly by food
passing through the duodenum, must certainly be con-
sidered in a more normal condition here than with a
closed-off pylorus, as occurs after a posterior gastro-
enterostomy. Moreover the duration of the operation
is one-third the time taken by posterior gastroen-
terostomy. The most important fact regarding this
operative procedure is that these children come back
from the operating room with no more shock than
from the smallest minor operation. The projectile
vomiting has ceased, no peristaltic waves are seen,
they take their nourishment, and do not appear ill at
all, as one would expect from an abdominal opera-
tion."
Surgical Treatment of Internal Hemorrhoids Under
Local Anesthesia. — Dr. Louis J. Hirschman of Detroit
stated that the technic was very simple and was
efficacious for the following reasons : " ( 1 ) The
anesthesia was complete and satisfactory. (2) There
was no necessity of damaging the sphincter by dilat-
ing or divulsing it by mechanical means. (3) By
the everting forceps the use of specula which only ob-
structed the view was obviated. (4) The method of
placing the ligature at the junction of pile and healthy
mucosa by shutting off the blood supply from the
branches of the superior hemorrhoidal vessels ren-
dered the operation almost bloodless. The only hemor-
rhage with which one met came from the power por-
tion of the wound which was largely supplied by the
inferior hemorrhoidal vessels and was of no conse-
quence. (5) By tying the ligature with a long and
short end the long end of the ligature was used as a
suture and when tied to the short end and at the top
of the wound brought the edges together so that
good hemostasis was assured. (6) By excising the
hemorrhoid and removing all diseased tissue below
the mucosa level and down to the sphincter all of the
pathology was eradicated and recurrence was impos-
sible. The clamp-and-cautery or clamp-and-suture
operations were so often followed by recurrence be-
cause only the top of the hemorrhoid was removed.
All under the bits of the clamp was left behind and
that very often was the major part of the hemorrhoid.
By the open operation and the excision, nothing could
be left behind and all of the hemorrhoid was ac-
counted for. If the average surgeon who used a
clamp would before he sewed or seared remove the
clamp, opening the wound, thus discovering what he
left behind, the author was sure there would be no
more clamp operations performed for the removal of
hemorrhoids. (7) Postoperative anesthesia was so
satisfactory when quinine and urea were employed
that the patient was able to be up and around after
the first day or two, and many of them refused to stay
in bed at all. (8) The lateral position prevented any
sacroiliac strain which was often caused by the litho-
tomy position."
Fat as a Hemostatic in Renal and Prostatic Surgery.
— Dr. Irvin S. Koll of Chicago said that the clinical
experience at this time was sufficiently extensive to
warrant the conclusion that the method could be con-
sidered of practical value. Ihe fat was preferably
obtained from a dog, under strict aseptic precautions.
Placed in an airtight, sterile container, in salt solution,
on ice, it could be kept indefinitely. Should it not be
possible to obtain it from a dog, the fat could be
taken from the patient at the time of operation.
There was usually sufficient perirenal fat for the kid-
ney work, but the patients were often not sufficiently
adipose to obtain enough fat from the site of the in-
cision in suprapubic prostatectomy. Following the
enucleation of the prostate, the bleeding was checked
either by hot water irrigation or tamponing the cavity
tightly for a few moments with gauze. The cavity-
was then well fitted with fat, and several interrupted
catgut sutures were tied over the edges of the cut
mucous membrane of the bladder to hold the fat in
place; enough of an opening was left for drainage.
The fat would slough out in two or three days after
it had served the purpose for which it was intended.
The efficiency of this method of hemostasis was in-
dicated by the cessation of the oozing, as noted by
the rapid clearing of the urine. When doing a
pyelotomy, two sutures were placed longitudinally at
either side of the pelvis before it was incised. After
removal of the calculus and exploration Dy the finger,
a piece of fat — preferably perirenal — was placed over
the incision and the opposite ends of the two sutures
were tied over the fat. This made a perfect closure
and required no further suturing. Should it be nec-
essary to cut into the cortex of the kidney for the
removal of the stone — the cavity thus left was plugged
with a piece of fat, another piece was placed over
the incision, the sutures were then run through this
plug and tied over the other piece. Lacerations were
repaired by using a large piece of fat and including it
in the suture. This prevented tearing through the
kidney at the same time it held the fat in place. The
rapid clearing of the urine and recovery of 19 supra-
pubic prostatectomies, together with the satisfactory
use of the above method in 20 kidney operations, the
writer felt, should place the use of fai as a hemostatic
in renal and prostatic surgery upon a sound surgical
basis.
Tumors of the Kidney and Stone. — Drs. H. H. Martin
and H. O. Mertz of LaPorte, Ind., from their studies,
concluded: "(1) Epithelial tumors of the kidney are
most frequently associated with renal calculi. That
of these, the relative proportion of association is
greater in epithelial tumors of the kidney pelvis. (2)
Cystic tumors, associated with renal stone are next
in frequency. (3) The coexistence of renal calculi and
mesotheliomatous and sarcomatous tumors is rare. (4)
There does exist a definite and constant relation be-
tween the stone and epithelial tumors of the same kid-
ney. The stone in the majority of cases, fifty-six tier
cent, in epithelial tumors of the parenchyma and sixty-
two per cent, in epithelial tumors of the pelvis and
ureter, being the primary lesion, "which because of
its irritation, direct and consequent, is the principal
etiological factor in the production of the neoplasm."
(5) In cystic tumors of the kidney, in the true poly-
cystic degeneration the calculus is invariablv secondary,
or but chance, while in a large cyst it not infrequently
is one of the etiological factors. (6) In mesothelio-
matous tumors the stone is always secondary, or but
chance occurrence, while of the sarcomatous neoplasms
we have collected two cases with an uncertain relation-
ship existing, while in the third case the stone was
secondary. (7) That in the coexistence of stone and
neoplasm in the kidney of a child must be extremely
rare. In our searches we have found no such associa-
tion."
High-Frequency Electricity in Treatment of Uterine
Fibroids and of Prostatic Enlargements. — Dr. Nathan
Rosewater of Cleveland summarized as follows: "(1)
High frequency currents applied through glass vacuum
electrodes upon the mucosa of the vagina and rectum
are not painful, irritating, nor seemingly harmful in
moderate doses over long periods of time. (2) High
frequency currents given as described do not tend to
cause sterility, but on the contrary several cases of
pregnancy occurred after treatment in married women
who had been sterile over periods of eight to eleven
years. (3) In cases of acute specific prostatitis, im-
mediate cessation of painful symptoms and rapid cure
without recurrence, occurred in the cases treated. (4)
In the cases of enlarged prostate of the senile, with-
out inflammatory conditions a slower but equally posi-
1142
MEDICAL RECORD.
[Dec. 23, 1916
tive improvement was observed. The first noticeable
passage of urine — after two years absolute cessation
except with catheter — was after one month's treat-
ment, bi-weekly, and the next six weeks later, fol-
lowed by others soon after. (5) In cases of ever,
extremely large uterine fibroids an extra prolonged
treatment weekly, or even once a month was followed
by decided reduction in size and in restitution to nor-
mal function. It is uncertain how many treatments
should be given, over what period of time they should
be repeated; but most of those who stopped treat-
ment subsequently submitted to operation; none died
subsequently of malignancy. (6) Case 6 was not
given iodides, ergot or other medication nor was she
bandaged, yet her fibroid was materially reduced in
size, and normal function returned, so that the high
frequency current stands credited with mass reduction
and uterine tonicity. In case 5, function was improved
long before mass reduction was noticeable and leaves
it uncertain as to what aid was given by the bandage,
the iodides or the ergot, singly or combined with the
electricity. The reverse is also true; the use of the
bandage in appropriate cases, together with the iodides
and ergot, is not incompatible with a successful re-
sult in the treatment of uterine fibroids. (7) High
frequency electricity applied in the rectum and vagina
for tuberculous peritonitis is not incompatible with
a successful recovery after laparotomy, reserving
laparotomy for those cases that show no improvement
without it."
Value of the Cystoscope in the Differential Diagnosis
of Abdominal Lesions. — Dr. Courtney W. Shropshire
of Birmingham, Ala., stated that the very best results
in the differential diagnosis of abdominal lesions were
obtained by the combined efforts of the surgeon, cysto-
scopist, Roentgenologist, and laboratory technician. It
was impossible in a great many cases to say without
the aid of the cystoscope whether an existing lesion
was within the abdominal cavity or represented some
pathological condition of the urinary tract. It was
therefore his belief that a cystoscopic and radiographic
examination should be made in every case which bor-
dered on uncertainty. For it was only in this way
that we would avoid serious errors in diagnosis and
increased risk to our patients. Chute of Boston re-
ported some time ago a case of renal calculus causing
marked intestinal symptoms, referable to the splenic
flexure of the colon. The patient was advised that
laparotomy was necessary, but for some trivial reason
refused operation. During a similar attack some time
later an examination of the urine revealed the presence
of pus and blood. These findings were followed by a
cystoscopic and Roentgenographs examination. A large
calculus was discovered in the left kidney. Following
an operation relief was immediate, and the patient had
had no further symptoms. The fact which impressed
him more than any other in this instance was the fail-
ure to make a cystoscopic examination in this very ob-
scure condition — for neither the symptoms nor the
radiographic examination of the intestinal tract was
of great value — and it was not uncommon for lesions
of the left kidney to produce symptoms simulating ob-
struction at the splenic flexure of the colon. Symptoms
somewhat similar to the above occurred in a patient
whom he saw in consultation at one of the local in-
firmaries. There was intense abdominal pain, which
was general, accompanied by marked tenderness to
pressure along the lower border of the ribs on the left
side. The patient's bowels had not moved since the
beginning of the attack, three days previous, and there
was intermittent vomiting, a distended abdomen, and a
temperature of 102°. After considerable effort on the
part of the surgeon the patient's bowels moved. Ex-
amination of the feces for blood was negative, and noth-
ing of value could be learned by means of radiographic
examination. After the bowels had been emptied he
was very comfortable and remained so for several days.
His pain then returned, and the original symptoms
again developed. At this time we were called to make
an examination of the urinary tract. A cystoscope was
easily introduced, bladder negative, right ureteral open-
ing negative, left ureteral opening very much congested.
Catheter passed t" right pelvis with difficulty, left
catheter was introduced, meeting with some resistance
about 5 c. above ureteral opening, but it was gradu-
ally forced higher by gentle manipulation. Urine
dripped from left ureter continuously and rapidly until
150 c.c. were collected. Functional test with phthalein
as follows: Right, appearance 3 minutes; 30 minutes
48 per cent.; left, appearance, 10, 30, 10 per cent.
Thorium was injected into the left pelvis and the radio-
graphic examination showed a large irregular shadow
■ tiding- from the kidney region downward to the
brim of the pelvis. Diagnosis, hydronephrosis on left
kidney. The surgeon who operated on this patient
made an incision anteriorly, removing the left kidney
with great difficulty. On examination, we found a large
hydronephrotic kidney, the kidney substance proper
being reduced to a mere shell. This sac was filled with
a gelatinous substance. The patient died on the third
day following operation. No autopsy was held. In
concluding his paper he said that: (1) Too much re-
liance should not be placed upon pain or even tender-
ness to pressure in vague abdominal lesions. (2)
Lesions of the left kidney often produced symptoms
referable to the intestinal tract. (3) Renal colic was
caused by an overdistention of the renal pelvis, and
that an obstruction in the lower third would often cause
symptoms referable to the kidney region. (4) A cysto-
scopic and radiographic examination were an absolute
necessity in the differential diagnosis of abdominal
lesions.
Treatment of Fractures of the Long Bones. — Dr. !■ .
H. Corrigan of Cleveland said that reduction under
anesthesia should be the procedure unless strongly con-
traindicated by age or infirmity. Immobilization, using
immobilization only in the sense of maintenance of re-
duction. Complete immobilization with splints was not
possible nor was it necessary; if reduction was main-
tained slight motion between the fragments did no
harm, and it was even held, by some authorities, that
it was in a sense physiologic and an important factor
in stimulating osteogenesis. The form of immobiliza-
tion apparatus was not important, but there was a very
decided trend toward the made-to-measure splint, of
plaster Paris, silicate of soda, etc., rather than the
ready-made splints turned out by the manufacturers to
fit all fancies. The principle of extension and early
■ eduction were the ones upon which he wishes especially
to lay stress because extension had never been given
the attention in this country that it deserved. The
work of Bardenhauer of Cologne, which was well known
and largely accepted, in Europe, had been very little
mentioned in this country, and it was his belief that
the greatest advance in fracture treatment would come
from a wider study of the principles of extension laid
down by him. In order to facilitate the early applies
tion of extending force to the limb, he had devised
an extension bandage or sleeve woven in such a fashion
that when pulled upon from below it became smaller
and gripped the limb. The advantage of this extension
bandage was primarily that it did away with the dis-
agreeable and annoying features of adhesive plaster.
Moreover, it was easily and quickly applied, easily re-
moved and was sterilizable.
Technique of Nephrectomy for Renal Tubercul. inl-
and Other Infections of the Kidney. — Dr. Paul Monroe
Pilcher of Brooklyn, N. Y., said that, leaving out
many of the points upon which most surgeons agreed,
such as a sufficiently large incision to expose the kid-
ney region, resection of the ribs, if necessary, and re-
moval of much of the perinephritic fat, he wished to
direct attention to three points: (1) The adhesions of
the kidney to the surrounding tissues. (2) The treat-
ment of the pedicle. (3) The treatment of the ureter
1. In studying the specimens which he had removed.
it had been repeatedly noted that at those points where
the active tubercular lesions came to the surface of the
kidney, the surrounding tissue always threw out a de-
fensive line of plastic material forming adhesions cov-
ering this point. This was especially true at the upper
pole of the kidney. He respected these protective
barriers thrown out by nature by carefully ligating the
adhesions and cutting the adhesions between ligatures
leaving a considerable portion attached to the kidney
itself. As soon as the capsule beneath the point of
attachment of these adhesions was lifted up active
tuberculous foci were almost invariably discovered.
It was his contention, then, that the stripping up of
these adhesions in removing the kidney was a source
of danger, for if the kidney surface be left unprotected
during the manipulation of nephrectomy it was very
easy for caseous material to be squeezed into the wound,
and' infection take place. He had found it of advantage
as a rule to attack the upper pole, for it was here the
adhesions were strongest, and while it took some time
to tie and cut these adhesions, still the result was a
freely movable upper pole which allowed us more
quickly to approach the vessels which were in the
supei ior half of the pedicle.
Dec. 23, 1916]
MEDICAL RECORD.
1143
2. If the upper pole had been freed it was usually
possible to pass the finger down beneath the pedicle
and by careful dissection to expose the elements of the
pedicle. There was very little danger of rupturing the
pedicle if too much strain had not been put upon it.
By a certain blunt dissection and the use of gauze the
fat which made up the chief bulk of the tuberculous
pedicle could be stripped down and the artery usually
became plainly evident. Then in most cases "the ureter
was found and easily differentiated. Having controlled
the pedicle by the finger beneath it to hold it up, a
ligature carrier was passed between the vessels and the
ureter, and a chronic gut ligature was applied to the
vessels before they were cut. Then a second ligature
was applied to the vessels near the kidney itself, a
clamp applied near the ligature which controlled the
vessels and the vessels were then divided. Before doing
further, a second ligature was placed around the ves-
sels and, if possible, the artery and the vein were also
tied separately. It was needless to say that this was
not always possible. Having freed the kidney from its
restraining vessels it was lifted up, and it was very
simple then to strip the tissues away from the ureter
for a very considerable distance, usually allowing us
to control 4 or 5 inches of the ureter without much
difficulty. Up to this point it would be noted that
the wound had been entirely protected from infection,
first by not disturbing the adhesions protecting the
active tuberculosis near the surface, and, second, by not
having exposed anything which communicated with the
pelvis of the kidney or the interior of the ureter. He
then allowed the kidney with its ureter still attached
to hang out from the lower end of the wound and pro-
ceeded to close the wound from which the kidney had
been removed, draining together all of the deeper tis-
sues and bringing together the fascia and the muscles
in their proper relations and entirely closing the wound,
suturing the skin, leaving the kidney still attached by
its ureter coming out at the lower angle of the wound.
3. The final step: Suture was passed through the skin
just above the ureter, and this was used as a ligature
to tie off the ureter. Then the needle of a hypodermic
syringe containing 95 per cent, phenol was inserted into
the upper portion of the ureter and 10 to 15 drops of
phenol was injected into the ureter. Then the upper
portion of the ureter was clamped and was cut between
ligature and clamp. The stump was cauterized and dry
dressings applied. His experience since he had em-
ployed this technique had been more uniformly satis-
factory than it had been with any other method.
Roentgen Examination of Fractured Skulls. — Dr.
William H. Stewart of New York City said that the
frequency with which fracture of the skull was mis-
taken for various other conditions, especially in cases
of coma, called for any method which would make a
rapid and positive diagnosis. This, with many other
difficulties which were encountered in the correct in-
terpretation of this lesion, rendered the routine Roent-
gen examination of the skull of the greatest importance
in all head injuries. It offered an actual visual demon-
stration of the presence or absence of fracture, its loca-
tion, character and extent. It was a noteworthy fact
that each succeeding collection of statistics of the rela-
tive frequency of fractures gave this lesion an increas-
ing percentage; thus Guilt gave 1.45 per cent., von
Bruns 3.4 per cent., and Chudosky 3.8 per cent. These
figures, he believed, in view of the more accurate diag-
nosis with the Roentgen ray, were altogether too low.
If a systematic Roentgenographic examination were
properly made of all injuries, either direct or indirect,
of the head, he felt confident that the relative frequency
of fractures of the skull would show a much larger
percentage. He based this statement on the number
of cases in which the diagnosis could only be made
by means of the Roentgen examination, especially when
the patient had no symptoms, either objective or sub-
jective, only a history of a fall. In one of the institu-
tions he was connected with 250 cases of head injuries
had been examined since Jan. 1. 1915, forty-five of which
were positive for fractures — about 20 per cent. Pa-
tients were often in a comatose or irritable condition
when referred to the Roentgenologist; therefore, ex-
treme patience and perseverance were required. It
must be borne in mind that the minimum amount of dis-
turbance and movement was the rule. In the examina-
tion of these cases the head must be absolutely fixed
and all respiratory movement overcome. If the ob-
jective symptoms, such as bleeding from the ear, nose,
or mouth, laceration of the scalp, hematoma, or
paralysis were present, they were a clue as to the
possible site of the fracture, and attention was natu-
rally directed toward that area. This must not mis-
lead one, however, for every examination should cover
the frontal, both parieto-temporals, occipital and basilar
regions. Having obtained satisfactory Roentgenograms,
it was necessary for us to have the experience and
anatomical knowledge to make the correct interpreta-
tion. In the reading of Roentgenograms of the base of
the skull, beginning behind, we saw the foramen mag-
num and within the odontoid process of the axis. Just
forward from this opening on either side the mastoids
were distinctly reproduced with the associated shadows
of the petrous portion of the temporal bones. Anterior
to this was a clear view of the middle fossa. If we
had not produced too much extension of the chin the
anterior fossa could be seen well in front of the over-
lying shadow of the lower jaw. Fractures of the
zygomatic arch with the amount of displacement were
usually beautifully shown in these base plates. In the
interpretation of the frontal, lateral and occipital
regions we had to remember the normal radiating lines
cast by the grooves on the inner table of the skull
which accommodated the meningeal blood vessels. These
grooves spread out fan-shaped from an anterior point
backward. The shadows cast by the diploic spaces, be-
tween the inner and outer tables of the skull, were lines
extending vertically upward from a point at the base,
directly in variance to the shadows representing the
meningeal grooves. Fractures usually showed as light,
sharply cut lines of varying width, depending upon the
amount of separation; they might be vertical, hori-
zontal, or curved, but were seldom directed in the same
manner as the blood vessel grooves.
Roentgen Studies in Bone Pathology with Special
Reference to Spontaneous Fractures. — Dr. Leon T. Le
Wald of New York City, stated that in two cases
the spontaneous fracture occurred in the femur, one
in the middle of the shaft and in the other at the
junction of the shaft with the neck. In neither case
could complete reduction be accomplished, but as the
final outcome proved, this appeared to be a desirable
rather than an unfortunate outcome, as the general
alignment was better than the corresponding bone on
the other side in each instance. This would almost
make it appear as if the spontaneous fracture were an
attempt on the part of nature to straighten the extreme
deformity which one saw in these cases. Rapid and
complete union of the fragment occurred in both cases.
In his series of pathological fractures, bone cyst merited
most careful consideration, for without careful Roent-
gen examination an ordinary fracture would have been
diagnosed, and inadequate treatment would have been
instituted. In two cases a perfect result was obtained,
in one by open operation and curettage, in the other a
similar procedure supplemented by a bone graft. A
rare form of bone cyst was encountered in the skull
of a young woman. This was successfully dealt with
by removal. Without Roentgen examination, which
showed the absolute limitation of the process, sarcoma
would have been thought of, and either no operation or
a very extensive one might have been the method of
treatment. In the past, without doubt, many cases of
bone cysts had been dealt with too radically even by
amputation of an extremity under the supposition that
one was dealing with a sarcoma. Spontaneous frac-
ture might give the first clue to a primary or secondary
new growth in bone. Roentgen examination of the
part involved might immediately establish the diagnosis.
Clinical examination based upon the Roentgen findings
might then locate a primary growth at some remote
part of the body, such as the kidney or prostate gland.
Syphilis of the bones might not be suspected until a
spontaneous fracture followed by Roentgen examina-
tion and a Wassermann test established the diagnosis
and pointed the way to a cure, not only of the bone
condition but of other unsuspected syphilitic lesions.
Radiation Treatment of Cancer of the Cervix. — Fla-
tau removes the mass with scissors and curette until
no cancer tissue remains. Radium is used at the op-
eration surface, while with the ^'-rays an attempt is
made to head off metastases by raying all lymphatic
areas. The entire pelvis is next irradiated. Recently
(1913-1916) eight out of nineteen inoperable cases have
been improved or arrested. Of six recurrences, two
have shown improvement or cure. Of twenty-four be-
ginning cases, twelve have been cured and seven im-
proved. Of the forty-nine cases treated, twenty are
dead and in fourteen the disease is arrested (pro-
visional cure). — ZevJralblntt fur Gynakologie.
1144
MEDICAL RECORD.
[Dec. 23, 1916
Mxstsilwxg.
Mortality Statistics for 1915. — A preliminary an-
nouncement with reference to mortality in 1915,
issued by the Bureau of the Census, shows that
nearly one-third of the 909,155 deaths reported for
that year in the "registration area," which con-
tained approximately 67 per cent, of the popula-
tion of the entire United States, were due to three
causes — heart diseases, tuberculosis, and pneu-
monia— and nearly two-thirds to twelve causes —
the three just named and Bright's disease and
nephritis, cancer, apoplexy, diarrhea and enteritis,
arterial diseases, diabetes, influenza, diphtheria,
and typhoid fever. The deaths from heart disease
numbered 105,200, or 156.2 per 100,000 of popula-
tion; this is a marked increase as compared with
1900, when the death rate was only 123.1 per 100,-
000. The increase has not been continuous, but
has fluctuated from year to year. Tuberculosis in
its various forms claimed 98,194 victims in 1915,
of whom 85,993 died of tuberculosis of the lungs.
The decline in the death rate from this disease has
been continuous from year to year since 1904 and
has amounted to over 25 per cent., from 200.7 per
100,000 in 1904, to 145.8 in 1915. Tuberculosis in
all its forms, however, still causes more deaths an-
nually than any other form of bodily illness except
heart disease, and about 46 per cent, more than all
external causes — accidents, homicides, and sui-
cides— combined. Pneumonia, including broncho-
pneumonia, caused 89,326 deaths, or 132.7 per 100,-
000. This rate, although lower than for most of
the years from 1900 to 1911, is higher than for
1912, 1913, and 1914. The rate for 1914, 127 per
100,000, is the lowest on record. The death rate
from pneumonia, like that from tuberculosis, has
shown a marked decline since 1900, when it was
180.5 per 100,000. The fluctuations in the rate
from year to year have, however, been continuous.
The only other death rate higher than 100 per
100,000 during 1915 was that for Bright's disease
and nephritis, 104.7, the total number of deaths due
to these maladies being 64,480 and 6,020, respec-
tively. The mortality rate from these two causes
increased from 89 per 100.000 in 1900 to 103.4 in
1905, fluctuated more or less between 1905 and
1912, and has shown little change since that time.
Next as a cause of mortality come cancer and
other malignant tumors, which caused 54,584
deaths in 1915. The death rate from cancer has
risen from 63 per 100,000 in 1900 to 81.1 in 1915,
and the increase has been almost continuous. It
is quite possible, however, that at least a part of
this increase is due to more correct diagnoses and
greater care in making reports. Of the deaths
from this cause in 1915. nearly 39 per cent.. 21,221,
were due to cancer of the stomach and liver. Apo-
plexy caused 53,397 deaths, or 79.3 per 100,000
Diarrhea and enteritis caused 48,325 deaths or
71.7 per 100,000; this rate has declined almosl
steadily since 1900 when it was 133.2. Arterial
diseases caused 15,685 deaths, or 23..°, per 100.000:
diabetes, 11,775 deaths, or 17.5 per 100,000; and
influenza. 10.7G8 deaths, or 16 per 100,000. The
rate for diabetes has risen almost continuously
since 1900, when it was 9.7 per 100.000. Of the
lesser causes of death, the rate for diphtheria and
croup was 15.7 per 100,000, for typhoid fever, 12.4
per 100,000, for whooping cough, measles, and scar-
let fever, 8.1, 5.4, and 3.6 respectively.
That the "safety first" campaign has borne good
fruit is shown by the figures for accidental deaths.
For 1913, 54,011 deaths were reported as due to
accident; for 1914 the number was reduced to
51,770, and for 1915 to 51,406; and during this
period there was not only an increase in popula-
tion of the registration area but an increase in the
area itself. The rate, therefore, fell from 85.3 in
1913, to 78.5 in 1914, and to 76.3 in 1915. The
number of suicides reported during the year was
11,216, or 16.7 per 100,000; the suicide rate has
varied but little during the past ten years.
Sonkfl fimtwd.
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it is under no obligation to notice or review any publica-
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not b" of interest to its readers.
Les Blessures de L'Abdomen. Par J. Abadie
(d'Oran). Preface de J. L. Faure. Avec 69 figures
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Nervous and Mental Disease Monograph Series
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By Prof. Sigmund Freud, LL.D., Vienna. Authorized
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duction by James J. Putnam, M.D. Published by Nerv-
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Second Revised and Enlarged Edition. 117 pages.
Price, $2.00.
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Whole No. 2408.
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©rixjinal Arttrks.
SENSITIZED TYPHOID BACTERIA.
(TYPHOID SERO-BACTERINS.)
By A. L,. GAEBAT, M.D..
NEW YORK.
ASSISTANT PATHOLOGIST AND ADJUNCT VISITING PHYSICIAN.
GERMAN HOSPITAL.
Sensitization of antigens is becoming a recognized
important procedure. Sensitization means the mix-
ing of an antigen (bacteria, red-blood cells, proteins,
etc.) with its specific antibodies. These antibodies
are supplied by the serum of an animal that has been
previously immunized with the particular antigen.
If, for example, a rabbit or goat receives injections
of typhoid bacteria, the usual antibodies (agglu-
tinins, bacteriolysins, bacteriotropins (opsonins),
complement fixation bodies, etc.) appear in its
serum. If an emulsion of typhoid bacilli be mixed
with this immune serum, the bacteria become sen-
sitized; that is, during the process of sensitization
the bacteria unite with the specific immune bodies
present in the serum.
Several important general rules pertaining to sen-
sitization must be mentioned right here. (1) It is
not sufficient merely to mix the bacteria and the
corresponding immune serum; it is essential that
the bacteria and their antibodies unite, before we
can say that they have become sensitized. Thus it
is important, primarily, to have an excess of immune
serum and, secondarily, to expose the bacteria to
the action of the immune serum for a sufficient
length of time in order to obtain complete and thor-
ough union. Otherwise incomplete sensitization oc-
curs which manifests itself on animal injection
by a production of antibodies stimulated by those
bacteria which had remained unsensitized. (2) The
immune serum used for sensitizing the bacteria
should be free from complement. This is accom-
plished by heating the serum, if fresh, for half an
hour at 56° C. before adding it to the emulsion of
the bacteria, or if the serum has been kept for a long
period, the complement will have been destroyed.
(3) The immune serum may be obtained from an
animal of the same or different species, e. g. the
typhoid bacteria may have been isolated from the
human being and the immune serum for sensitiza-
tion obtained from a convalescent typhoid individ-
ual. As a general rule, such a procedure is not prac-
ticable; so that the serum for sensitizing is usually
obtained from an animal (goat or horse or rabbit)
that has been immunized by successively increasing
quantities of the respective bacteria, in this way ob-
taining a strongly immune serum. (4) Finally,
sensitized bacilli may be dead or living, depending
on whether the bacteria have or have not been killed
previous to being mixed with the immune serum.
Results of Injection of Sensitized Bacteria. — Let
us first take up animal experiments and see what
happens after injections of sensitized bacteria (Gar-
bat and Meyer) .* It is of interest to compare these
findings with those obtained by immunization with
the same dosage of non-sensitized bacteria. A de-
scription of an actual experiment in rabbits will
contrast these clearly. Virulent strains of typhoid
bacteria are grown upon agar for 24 hours at 37° C.
The growth thus obtained is washed off and sus-
pended in normal saline. The bacteria are killed by
exposing the emulsion to 60° C. in a water bath on
two successive days. The entire amount is divided
equally. One-half is mixed with an excess of a
highly immune, inactive typhoid serum obtained
from a horse; the mixture is allowed to sensitize in
the incubator at 37° C. for 24 hours, then washed
carefully in saline, suspended in saline, and injected
intravenously. The other half is simply washed the
same way, suspended in an equal amount of saline,
and also injected intravenously. Certain differences
in the two animals are evident:
A. Temperature. — The temperature of the sen-
sitized rabbit begins to rise about one hour after the
injection and rises 2 or 3° above the normal tem-
perature. The maximum degree is reached in about
4 to 6 hours. The fever does not remain high, but
falls rapidly in 2 to 4 hours. This quick response
to sensitized bacteria was recently proven also by
Schottstaedt.2 The temperature of the non-sensiti-
zed rabbits rises slowly ; it does not, however, reach
the same height as did the rabbit injected with
non-sensitized bacteria. It returns to normal only
after 24 to 36 hours.
This difference in the temperature is observed
regularly, and not only after the first, but also after
all subsequent injections. As will be seen later on,
it is dependent upon the rapid destruction of the
sensitized bacilli. This phenomenon proves to us an
important characteristic of sensitized bacteria, i. e.,
that their action is rapid, almost immediate, and of
quick response. Any immunity that their action
may produce is necessarily more quickly attained.
B. The General Condition of the Animals. —
When the maximum temperature has been reached,
the sensitized rabbits are much more active and
sprightly than the non-sensitized animals, which
seem greatly depressed and show signs of serious
illness; they sit still and often have diarrhea. They
remain in this condition for about 36 hours, while
the sensitized rabbits are completely restored to ac-
tivity after 8 or 10 hours.
When the rabbits received repeated injections at
intervals of 8 days and at each time the dose of the
antigen was doubled, the non-sensitized rabbits died
almost without exception after the third injection.
Their temperature dropped far below normal; severe
diarrhea continued until death. Post mortem ex-
amination showed merely a severe inflammation of
the small intestine. This result confirms the con-
1146
MEDICAL RECORD.
[Dec. 30, 1916
elusions arrived at by Kraus and Stenitzer, regard-
ing bacterial anaphylaxis. The sensitized rabbits,
on the other hand, reacted more favorably to the
third injection, so that it would seem that sensitiza-
tion reduces the danger of anaphylaxis. The recent
work of Jobling supports this finding. Of 7 non-
sensitized animals 6 died. Of 7 sensitized animals
2 died.
The above description of the reaction from the in-
jection elicits a second important point in favor of
the sensitized bacteria, namely, the slighter disturb-
ance after inoculation.
C. Antibody Content of Serum. — The typhoid
antibodies are agglutinins, precipitins, complement
fixation bodies, bacteriolysins, and bacteriotropins
or opsonins. After one or two injections of sensiti-
zed typhoid bacteria, rabbits do not develop any ag-
glutinins or complement fixation bodies. On the
other hand, the rabbits immunized with non-sensi-
tized bacteria get up a high power of agglutination
and complement fixation. After a third and subse-
quent injection of sensitized bacteria some agglu-
tinins and complement fixatives appear, but far
fewer in number than in the sera from rabbits im-
munized with non-sensitized bacteria.
That no agglutinins were produced by the injec-
tion of the sensitized bacteria, was by some attrib-
uted to the possible development of antiagglutinins,
but this is disproven by mixing the non-agglutinat-
ing serum in equal parts with a strongly aggluti-
nating one and finding that the power of agglutina-
tion is not decreased any more than can be account-
ed for by the dilution. The absence of agglutinins
or complement fixation bodies is very well explained
in the light of Ehrlich's theory of saturation of the
antigen with its antibodies. The classical experi-
ments of Neisser and Lubowski3 showed that killed
agglutinated typhoid bacilli produced no antibodies.
The fact that some degree of agglutination appears
after the third or subsequent injection of sensitized
bacteria may be due either to the difficulty of com-
plete saturation of such large quantities of bacteria
or to a separation between the agglutinin and its
bacillus in the blood stream, setting some of the
bacilli free and unsensitized and thus capable of
stimulating agglutinins. This is hardly ever the
case after the first or second injection, if the bac-
teria have been properly sensitized.
The question that next arises is: Do rabbits
that have been immunized with sensitized bacteria,
and that have developed no agglutinins or comple-
ment fixation bodies, possess any typhoid antibod-
ies at all? Most emphatically, yes. The serum
from these rabbits, when examined by Neufeld's
method of phagocytosis in the test tube, or Pfeif-
fer's method in the peritoneal cavity of the guinea
pig, shows a very high degree of opsonic or bacte-
riotropic activity. The examination of the perito-
neal exudate shows marked phagocytosis. On the
other hand, similar experiments undertaken with
the serum from rabbits that had been immunized
with non-sensitized bacteria, show a much lesser
opsonic activity in vitro and a strong bacteriolytic
(not phagocytic) action in the peritoneal cavity of
mice and guinea pigs. Furthermore, and even more
important, is the fact that the serum from rabbits
immunized with sensitized bacteria, and containing
no agglutinin or complement fixation bodies, is
capable of saving mice that had been injected with
lethal doses of live typhoid bacteria. This curative
property was either entirely absent, or present to
a much lesser degree, in the sera of rabbits injected
with non-sensitized bacteria. Thus, in summariz- .
ing this question of immune bodies, it may be said
that injections of sensitized bacteria produce hardly
any agglutinins, precipitins, or complement fixation
bodies, a moderate number of bacteriolysins, but
large numbers of bacteriotropins and curative bod-
ies for mice; while unsensitized bacteria produce
large numbers of agglutinins, precipitins, comple-
ment fixation bodies, and bacteriolysins, but few
bacteriotropins and curative bodies for mice.
In studying the literature on this subject, I have
found that some observers, Negre,' Ardin Delteil,
Negre et Raynaud,5 report some degree of agglutina-
tion after the injection of sensitized typhoid bacte-
ria, although only about one-tenth as strong as after
non-sensitized. More recently, Lieberman and AceT
found identically the same titer of agglutinin and
bacteriolysin in rabbits after injection of sensi
tized as of non-sensitized bacteria. They do not,
however, state their method of sensitization, so that
I am almost convinced that their procedure was
faulty. On the other hand, Pfeiffer and Friedber-
ger7 corroborated my results. They found no pre-
cipitation action, an agglutination action of only
1 :20, and an especially low bacteriolytic action after
injection of sensitized typhoid and cholera bacte-
ria. Their conclusion, however, is erroneous when
they say that sensitized typhoid bacteria had no
antigenic value; they omitted to test the opsonic
value of the serum or its action in animals.
A recent article by Schottstaedt" also shows low
agglutinating and bactericidal power of the serum
in rabbits after injection of sensitized typhoid bac-
teria. It is wrong to conclude therefrom, as this
author does, that "the height of the immunity curve
after sensitized vaccines is only about one-quarter
as potent, or that sensitized vaccines are less po-
tent than non-sensitized typhoid vaccines." From
merely agglutination or bactericidal action, such
comparison is not permissible. Bacteriotropic or
opsonic experiments in vivo and in vitro, or cura-
tive action in animals, will refute such statement.
High agglutination or bactericidal action should not
be expected after injections of sensitized typhoid
bacteria. In man, the systematic study of anti-
bodies after the prophylactic injection of sensi-
tized typhoid bacteria has been carried out most
carefully by Broughton Alcock," working under Bez-
redka's supervision. They found no agglutination
or complement fixation in the individuals after two
inoculations of sensitized living bacteria, while the
power of phagocytosis was very high (6 bacilli per
phagocyte in dil. 1:192). These results correspond
fully with my animal experiments.
I have dwelt in detail upon this subject of anti-
bodies because the general relationship between im-
munity and the detection of antibodies is still a
problem for discussion. We all know that immu-
nity can last long after the disappearance of known
specific serum properties; then, too, we have often
found that the serum from patients who died con-
tained many antibodies, while those that recovered
had very few. Leishman* considers an increase
in phagocytic activity as the most important im-
munity. Klein10 attaches more importance to pha-
gocytosis than to agglutination and bacteriolysis.
Most recently, Bull" has shown that agglutination
does enter as the primary stage in the destruction
of the bacillus typhosus and other bacteria.
Virulence and Toxicity of Sensitized Typhoid Ba-
cilli.— Next in importance to the question of anti-
bodies is the question of the virulence and toxicity
Dec. 30, 1916]
MEDICAL RECORD
1147
of sensitized typhoid bacilli. I already mentioned,
under the heading of general reactions, that rab-
bits immunized intravenously with progressively
increasing doses of sensitized bacteria withstood
the inoculation much better than those inoculated
with non-sensitized bacteria. Of seven rabbits
thus immunized with dead non-sensitized bacilli,
six died after the third injection, with symptoms
of anaphylaxis; while of seven rabbits immunized
with dead sensitized bacteria only two died. No
explanation for this was offered, but Jobling1* has
since found that bacteria treated with serum do
not absorb the antitrypsin ferments of the blood,
the disappearance of which is associated with the
phenomenon of anaphylaxis.
Guinea pigs inoculated intraperitoneal^ with le-
thal doses of dead sensitized bacilli remained alive,
while the animals injected with the same dose of
non-sensitized bacilli succumbed within ten hours,
with severe symptoms of intoxication. Two hours
after the injection, the rectal temperature of these
non-sensitized guinea pigs was so low that it could
not be estimated by the thermometer. The tem-
perature of the animals treated with the sensi-
tized bacilli rose slightly. Stained specimens of
the peritoneal exudate from the sensitized guinea
pig showed, two hours after the injection of the
sensitized bacteria, no intact bacteria and an excess
of leucocytes, for the greater part vacuolated. Later
on, macrophages appeared, which took up the leu-
cocytes, all this being strong evidence of positive
chemotaxis. The peritoneal exudate from the non-
sensitized guinea pig showed many broken up ba-
cilli, but only few leucocytes.
Already in 1902, Bezredka" had found that the
sensitized vaccine of typhoid and cholera bacteria
(killed by heating one hour at 60° C.) when in-
jected intraperitoneally in guinea pigs, was less
toxic than the unsensitized vaccine. My above-
mentioned experiments confirm this absolutely.
More recently, Cecil" repeated these experiments,
and, in addition, used live, sensitized bacilli. He
also came to the same conclusion, namely: (1) Sen-
sitized, living typhoid bacilli, when injected intra-
venously in rabbits and guinea pigs, are less viru-
lent than non-sensitized living typhoid bacilli. (2)
Sensitized typhoid bacilli, killed by heat, are in a
similar way less virulent than non-sensitized, killed
typhoid bacilli. (3) The most probable explanation
for this difference is that sensitized typhoid bacilli
undergo phagocytosis and bacteriolysis more rap-
idly than the non-sensitized bacilli.
Mode of Action of Sensitized Bacilli. — We may
now discuss the mode of action of sensitized bacilli.
Pfeiffer and his workers showed that the typhoid,
as well as the cholera bacillus, belongs to a class
of microorganisms whose poisonous substances are
contained within the body of the bacillus, and are
not easily given off into the surrounding medium
in which they grow, as is the case, for example,
with the diphtheria bacillus. This central sub-
stance was named the endotoxin, and was for a long
time considered highly poisonous to the animal
body. For example, death has been reported in
the literature (DrigalskP) as having been caused
by the sudden liberation of these endotoxins in ty-
phoid fever after the use of a highly bacteriolytic
serum. The term endotoxin had always been con-
sidered a misnoma, as it did not fulfill the require-
ments of a true toxin ; i.e. it was devoid of anti-
genic properties, and its toxicity did not follow the
rule of multiple proportions.
With this view in mind, associated with the ani-
mal and test-tube experiments mentioned in this
paper, it seems permissible to the author to pro-
pose as a working basis the following explanation
for the action of the sensitized bacteria: The ty-
phoid bacillus consists of two parts: an inner, cen-
tral or nuclear substance, the endotoxin, and an
outer or enveloping protoplasmic substance or memr
brane. Injection of the whole bacilli stimulates
antibodies first referable to the outer capsule, the
usual bacteriolytic, agglutinating and complement
fixation antibodies. After the production of these
bodies they combine in vivo with the typhoid bac-
teria, i.e., sensitize them in the circulation, and,
with the aid of the complement of the blood, bacte-
riolysis occurs, resulting in the liberation of the cen-
tral substance or endotoxin. This endotoxin is now
capable of producing its own antibodies, the anti-
endotoxins. When sensitized bacteria are injected
the outer capsule is already saturated with its anti-
bodies (agglutinins, bacteriolysins, complement fix-
ation bodies, etc.) ; thus, none of these antibodies,
or only a few of them, are formed; antibodies are,
however, produced referable to the endotoxin, be-
cause as soon as the sensitized bacteria reached
the circulation bacteriolysis at once occurred; the
bacteria were immediately broken up by the aid
of the complement, and the endotoxins were liber-
ated and allowed to stimulate their antibodies.
These antiendotoxins, as they may be termed for
purposes of designation, -are strongly bacteriotro-
pic or phagocytic in nature. This has already been
proven above by the examination of the serum of
man and animals after inoculation with sensitized
bacteria. Thus sensitization may be considered a
biological means for the liberation of endotoxin.
For years attempts have been made to liberate the
typhoid endotoxins by physical and chemical meth-
ods of extraction or maceration of the bacteria.
The methods of M. Hahn, MacFayden, Bezredka,
Kraus and Stenitzer, Meyer and Bergell, are well
known. Liidke's adoption of the Gottstein and
Matthes' method by ferment digestion has the same
object in view. Sensitization accomplishes this
end, in a manner more closely resembling that of
nature. The endotoxin should not be looked upon
in the light of the only poisonous element of the
typhoid bacillus, because it has been shown above
that rabbits and guinea pigs are not killed by the
sudden liberation of large quantities of endotoxin
after inoculation with multilethal doses of sensi-
tized bacteria, while animals inoculated with same
doses of the whole bacteria succumbed with marked
symptoms of intoxication. Thus the outer portion
of the typhoid bacillus must also have its poison-
ous constituents, if not even more so than the endo-
toxin.
I am fully aware that the theory of endotoxins
had exposed itself to criticism during the recent
split products and ferment period of Vaughan, but
as some of this latter work has been shaken in its
foundations by the works of Jobling, Bronfenbren-
ner,10 and still more recently by the experiments of
Novy, the endotoxin theory seems as yet to be the
best working hypothesis for immunization with sen-
sitized vaccines. I am glad to see that Nichols," in
a recent paper on sensitized vaccines, has ar-
rived at a similar conclusion. Vaughan's explana-
tion for the action of sensitized vaccines, as ex-
pressed by him in the very short but lucid paper of
Stewart18 seems to me, after all, to agree funda-
mental^ with the view advocated above, but he
1148
MEDICAL RECORD.
[Dec. 30, 1916
expresses it in terms of protein split products, in-
etead of Ehrlich's nomenclature.
A few words should be allotted to Theobald
Smith's" consideration of the mode of action of
eensitized bacteria. He draws the analogy between
bacteria saturated with their antibodies and toxin-
antitoxin mixtures. Definite active immunity is
produced with neutral toxin-antitoxin mixtures.
A single such injection surpasses in effectiveness
many doses of pure toxin. The mixture penetrates
quite generally through the body, whereas the pure
toxin is chiefly held at or near the place of injec-
tion. This diffusion tends to cause maximum anti-
body formation over a wide territory by a relatively
very small amount of free or perhaps dissociable
toxin in the toxin-antitoxin mixtures. Theobald
Smith is inclined to believe that a similar phenome-
non of diffusion occurs with sensitized bacteria.
Naturally, this idea is purely theoretic.
Preparation of the Sensitized Vaccine. — Before
taking up the practical application of sensitized
bacteria in man, certain problems in the prepara-
tion of the sensitized vaccine merit a little addi-
tional discussion.
First, and most important, is the question of live
versus dead sensitized bacteria and the posible dan-
gers associated with the use of the former. As a
rule, if there are several methods for producing
immunity, that one should be chosen which ap-
proaches most closely the way that nature employs
in producing that same immunity, provided that
there are no harmful effects. In general, living
virus has proven itself superior to a heated
one in calling forth immunity. The less artificial
manipulation of a vaccine during its preparation
the better; thus we can destroy the entire efficiency
of a vaccine by too prolonged or too high exposure
to heat. From a study of antibodies, Schottstaedt
found that vaccines killed by heat seem to be less
active than those killed by the addition of phenol
only. However, the possible infectious power of a
living sensitized vaccine, or its liability to produce
a typhoid carrier state, has kept many physicians
from the use of the live virus. This is erroneous.
Both of these factors are dependent upon the
proper sensitization of the vaccine. An emulsion
of live bacteria, but which have been thoroughly
and completely sensitized, i.e. all bacteria saturated
with antibodies, can do no harm, because, as has
been so often said in this paper, when injected even
in a massive dose the sensitized bacteria are quickly
destroyed at the site of injection or in the circu-
lation with the aid of the complement there exist-
ing; no live bacteria remain to cause a typhoid
carrier state. Certainly, if the vaccine is not com-
pletely sensitized so that there are a great num-
ber of live bacteria ununited with their antibodies,
these bacteria will not be destroyed when they are
injected, but may multiply, and thus cause a typhoid
infection. Even in this instance the almost immedi-
ate immunity produced by those bacteria which had
been sensitized may destroy the unsensitized ones
if they are not too numerous. The fact that cul-
tures made from live sensitized bacteria show a
profuse growth should not lead one to believe that
the same thing will happen in animals or human
beings when inoculated with living sensitized ba-
cilli. Naturally, when live sensitized bacteria are
cultured they will grow; they have remained alive
and have not been destroyed, as they would be in
a living body, by the help of complement. This is
further proven by mixing living sensitized bacte-
ria in one test tube with fresh normal horse serum,
and in another tube with heated horse serum (the
heating has destroyed the complement). Both mix-
tures are allowed to remain at 37° C. for one hour,
and then cultures are made from each. After 24
hours' incubation a profuse growth will be noted
from the test tube which contained living bacteria
plus heated serum, while no growth occurs from
the mixture of living bacteria plus fresh, non-
heated serum. The latter contained sufficient com-
plement to allow bacteriolysis, or destruction of the
bacteria, even in the test tube. (Rowland.20) These
experiments are in accord with my theory expressed
above for the freedom from danger in sensitized
bacteria, and disprove the statements made by
many that sensitized bacteria are inocuous because
they are easily and rapidly taken up by the pha-
gocytes. In this test-tube experiment there were
no leucocytes, so that phagocytosis was no element.
The important factor is the bacteriolysis which
takes place almost immediately with sensitized bac-
teria. The property of increased phagocytosis comes
into play later by stimulation from the liberated
endotoxin. The immediate bacteriolysis in the pres-
ence of complement explains also the important
question relative to producing a typhoid carrier.
For several years after Bezredka first advised
the method of the live sensitized bacteria he was
met by opposition on the grounds that a typhoid-
carrier state might possibly thus be produced, with
the gall bladder as the central supply. (Editorial
Jour. Am. Med. Ass'n, Vol. LXI, No. 20, p. 1914.)
Bezredka" and others had reported on over thou-
sands and thousands of cases without a single mis-
hap of this kind. At the same time, this skepticism
prevailed — unrighteously so. In rabbits, no gall-
bladder lesions are produced after subcutaneous and
intravenous injections of sensitized bacteria. If
the sensitized vaccine were accidentally taken by
mouth, as is possible from contaminated water or
food, it may be inferred that disease would be pro-
duced, because under ordinary circumstances there
would be no complement available in the gastro-
intestinal tract for the completion of the bacterio-
lytic phenomenon. For the same reason, when sen-
sitized vaccine is injected directly into the gall blad-
der of rabbits a purulent cholecystitis will be pro-
duced, and typhoid bacilli can be recovered from
the pus as well as from the stools. In this in-
stance the bile is simply a good medium for the
multiplication of the typhoid bacilli. There is in-
sufficient complement for the destruction of the
bacteria. Even after rabbits have been immunized
with Bezredka's vaccine, subcutaneously or intra-
venously, an active purulent cholecystitis from
which typhoid bacilli can be recovered may be pro-
duced by direct gall-bladder inoculations with the
live sensitized virus (Nichols"). This is to be ex-
pected; because the fact that rabbits have been
immunized does not mean that their bile has de-
veloped typhoid protective bodies, or contains more
complement. It is the complement and associated
bacteriolysis which are the deciding factors in the
inertness of the live sensitized vaccine, but the
latter must be completely and properly sensitized.
Typhoid infections, or typhoid carriers from the
live sensitized vaccine, are thus entirely prevent-
able if these immune reactions are kept in mind.
Most of the sensitized vaccines on the market at
present are made up of dead bacteria. At this stage
of their use this may be a wise step, for it prevents
any possible trouble that might arise from an im-
Dec. 30, 1916]
MEDICAL RECORD.
1149
properly prepared live vaccine. With the great
number of unreliable commercial firms or laborato-
ries which have entered into this field, such poorly
prepared vaccines would be more than probable.
This would be a great hindrance to the further de-
velopment of the live virus type of vaccine.
It may be of interest to dwell for a few moments
upon the question of what strain of typhoid bacillus
should be employed in the preparation of the sen-
sitized vaccine. As you know, both the English and
American armies have made up their non-sensitized
typhoid vaccine from a single strain of the typhoid
bacillus (known as the Rawling strain), which was
obtained from the spleen of a soldier who died of
typhoid in England in 1900. It was selected origi-
nally by Leishman for experimental use in pre-
paring vaccines, not on account of its low toxicity
or superior immunizing properties, but because it
gave a remarkably even emulsion when washed off
agar with salt solution (Leishman, Harrison, Small-
man, and Tullock32). Recent examination (Nich-
ols") has shown this strain to be still definitely
pathogenic for rabbits, in that it produces a typhoid
cholecystitis when injected into the gall bladder of
rabbits. It is relatively avirulent, as in general
the recently isolated strains are more virulent;
finally, it is distinctly toxic, and its efficacy is
believed to depend upon this toxicity. Naturally,
this same strain can be used in preparing the sen-
sitized vaccine, and the serum for sensitization ob-
tained from a horse that has been highly immunized
against this Rawling strain. It has always been
an open question which type of typhoid bacterium
is most suitable for a vaccine (Broughton-Alcock*).
Thus, Leishman, Russel, and Vincent have recom-
mended a strain of feeble virulence; Wassermann
has proposed a strain that calls forth the greatest
response in antibodies; Bezredka has obtained con-
tradicting results in trying the virulence of several
strains upon animals. Thus, a strain taken from
a carrier killed guinea pigs in one-sixth the quan-
tity found necessary of a strain taken from a
man after death from typhoid fever. The in-
jection of the latter gave rise to an attack of
typhoid in a chimpanzee, while an injection of the
former had but a slight transitory effect on an-
other chimpanzee infected. The clinical evidence,
as furnished by the very convincing results in the
English and American armies, favors the use of
the Rawling strain in the preparation of the vac-
cine. The writer, however, has always been strongly
of the opinion that a polyvalent typhoid vaccine,
non-sensitized as well as sensitized, is the ideal
preparation. In the prophylactic inoculation of my
patients in private practice, and of the nurses and
doctors at the German Hospital of New York, a
polyvalent vaccine from eight different typhoid
strains, isolated from the blood of different patients
at the hospital, has been used. It would be rational
to include also the two types of paratyphoid in the
vaccine. This was primarily carried out by Ka-
beshima23 in the Japanese navy. More recently, Vin-
cent," Widal,21 and Chantemesse16 speak favorably
of this plan. Also in the treatment of typhoid fever
with sensitized bacteria have I employed a polyva-
lent vaccine. Naturally, the polyvalent emulsion of
bacteria has to be sensitized with a serum that has
been produced by immunization with all of the dif-
ferent strains, in order that the very important
factor of complete sensitization is assured. The
failure in immunization, as has been reported in
several civil communities after the use of the army
vaccine, may possibly be accounted for by the lack
of the poly valency; i.e. antibodies, stimulated by
the Rawling strain, were inert against the type of
the typhoid bacillus causing the infection. This
seems plausible when one considers the experimen-
tal evidences by Teague and Torrey," Raskin,* and
Garbat," who showed that various strains of the
same bacteria differ from one another in their spe-
cific antibodies, both agglutinins and complement
fixation antibodies. Furthermore, the different ac-
tion observed in sugar media of dextrose and man-
nite with the various strains of the typhoid bacillus
proves slight individual peculiarities, and should be
considered in favor of the polyvalency for both pro-
phylactic and therapeutic vaccines. As for auto-
genous sensitized vaccine in the treatment of ty-
phoid fever, this is somewhat impracticable. First
of all, its preparation entails 4 or 5 days, and sec-
ondly, it is questionable whether the same patients'
serum which it would be advisable to use in order
to be certain of absolute sensitization contains suffi-
cient antibodies. Immunizing an animal with this
particular strain, and then using this serum for sen-
sitization, would cause entirely too much delay. I
have treated three typhoid fever patients with auto-
genous sensitized vaccines, but found no better re-
sponse than from the use of a stock polyvalent
sensitized vaccine.
It may be interesting from a laboratory worker's
standpoint to say a few words about the different
methods for standardization or enumeration of the
vaccines. As a pupil of Sir Almroth Wright, I have
followed his classic method of a comparative count
between red-blood cells and bacteria in a stained
smear made from a dilution of equal parts of the
bacterial emulsion and red-blod cells. Sensitized
bacteria are somewhat swollen, but are regular in
outline and stain well. At the same time, I have
found it simpler, in order to get an even smear,
to standardize the bacterial emulsion before sensi-
tization, as it was somewhat difficult after sensitiza-
tion to break up the agglutinated clumps. One notes
the total quantity of the original saline emulsion, a
sample of which is used for enumeration, before
the addition of the immune sensitizing serum ; then,
after sensitization and washing of the sensitized
bacteria are completed, saline is added in a quan-
tity equal to the original volume noted. In this
way the standardization of the wnsensitized emul-
sion holds true for the sensitized one. Bezredka
suspends a quantity of bacteria grown upon the
gelose surface of a Roux bottle, sensitized and
washed, in 100 c.c. of saline; 1/10 c.c. of this emul-
sion is supposed to contain 500 million bacteria.
Broughton-Alcock finds that if there are 500 mil-
lion sensitized bacteria to 1 c.c, and this is diluted
1 :40, 1/10 c.c. of this dilution will just fix 1/10 c.c.
of guinea pig's complement titrated to just dis-
solve 1 c.c. of 5 per cent, sheep's blood. Dilu-
tions can be thus arranged so as to come up to
this standard. He further found that a 24-hours'
growth on an ordinary agar slant approximates
about 50,000 million bacteria. A Roux bottle is
about 16 times as great.
Some observers (Schottstaedt2) employ the hemo-
cytometer method, using the Helber blood-platelet
counter, while others (Ichikawa30) employ arbitrary
dilutions and dosage; thus the growth from ora
agar slant is sensitized and suspended in 10 c.c. of
saline, and of this V2 c.c. is taken as the dose. All
these methods probably have their wide margins
of error, but give good results with each worker.
1150
MEDICAL RECORD
[Dec. 30, 1916
The last method of arbitrary dilution is simplest,
but indefinite as to actual numbers. It seems to me
that the original Wright method, with the above-
described modification, aims at an accurate deter-
mination, and in the hands of one accustomed to
it renders comparatively favorable estimations.
With these introductory experimental findings we
are in a position now to discuss the administration
of sensitized typhoid vaccines for prophylactic and
therapeutic purposes. It may be of help to first
compare its action with the ordinary vaccines. The
inoculation of the ordinary dead typhoid bacteria
as a prophylactic measure is now well recognized.
The results in the American and English armies
have been exceedingly satisfactory. The efficiency
of this vaccine is easily explained on the basis of
the biological indications to be met. The injection
of the dead bacteria into a normal individual is
usually followed by the production in great num-
bers of the various antibodies mentioned above:
bacteriolysins, agglutinins, bacteriotropins, and oc-
casionally complement fixation bodies. Some of
these immune agents are probably capable of de-
stroying the typhoid bacilli. If the inoculated indi-
vidual is exposed to infection, that is, if live bac-
teria find their way into his body, they are readily
destroyed, and will not multiply. Naturally, if the
army of invaders is excessive, or the defense too
slight, infection will arise in spite of the prophy-
lactic measure. Fortunately, such instances are ex-
ceptional. The immunity is, therefore, explained
on a bacteriolytic, and to a less degree on a bacterio-
tropic or opsonic basis. From clinical experiences
it has been shown that immunity persists even after
these immune bodies cannot be demonstrated any
longer.
The prophylaxis attained by the injection of Bez-
redka's sensitized typhoid vaccine, living or dead,
cannot, if sensitization is complete, be explained
on identically the same principles, for as soon as
the sensitized bacteria enter the normal system
they combine with the complement of the blood and
are broken up. The agglutinating and bacteriolytic
antibodies and the complement fixation bodies are,
therefore, either not produced at all or only in
very small quantities ; consequently, the reliance for
protection must be placed on the phagocytic activ-
ity, stimulated by the liberated central substance
of the broken-up bacteria, the so-called endotoxin.
Thus the prophylactic immunity with sensitized
vaccine is of a bacteriotropic character, while that
with the non-sensitized vaccine is mainly of a bac-
teriolytic nature. Which one is superior cannot
et be definitely stated. Thus far, many thou-
sands of cases have been inoculated by the sensi-
tized method, but sufficient data are lacking for
comparison with the Wright method. Metchnikoff
and Bezredka11 have the laboratory experiments in
their favor. Possibly this unfortunate war may
furnish us more statistics, as members of the
French army have been vaccinated with the sensi-
tized virus. We know, however, that the reaction
from the sensitized vaccine inoculation is much
milder, and the immunity starts more rapidly; pos-
sibly the future will prove that it is also more last-
ing and secure. The doses employed are similar
to the non-sensitized, i.e., 500 millions, 1000 mil.
1000 mil. at intervals of about seven days, or 1000
mil. 2000 mil. at intervals of 10-12 days. The in-
oculations are usually given subcutaneously.
It may be in place here to consider a problem
which has suggested itself to me, but which I have
thus far been unable to carry out. If the injection
of ordinary vaccine causes mainly a bacteriolytic
reaction, and the administration of sensitized vac-
cine mainly a bacteriotropic response, would it not
be advisable in prophylactic immunization to inocu-
late individuals with both sensitized and non-sensi-
tized vaccines? In this way a combined form of
immunity would be attained. As experimental ba-
sis for this suggestion I have shown that if the
serum from rabbits immunized with non-sensitized
bacteria is mixed in equal quantity with the serum
from rabbits immunized with sensitized bacteria,
this mixed serum was more curative for mice in-
fected with typhoid bacteria than equal quantities
of either serum alone. Naturally, it will be neces-
sary to establish the best method for such mixed
immunization: whether the two vaccines should be
administered separately, and at different times, or
whether they should be given at the same time, as
would be accomplished also by an incompletely sen-
sitized vaccine.
In the therapy of typhoid fever the use of the
ordinary non-sensitized vaccines has not met with
as favorable results as for purposes of prophylaxis.
Up to the present time thousands of cases have
been treated, but the beneficial effects in the ma-
jority of instances are not sufficiently marked to
warrant the employment of vaccines as a routine
procedure.
Recently, series of cases treated by intravenoits
injections of non-sensitized vaccine have been re-
ported; occasionally a striking crisis in the course
of the disease was observed. There are other re-
ports, however, in which the effects have been dis-
tinctly harmful (or even fatal).
When the biologic basis for the possible thera-
peutic value of ordinary vaccines in typhoid fever
is asked, the explanation is much more difficult and
hypothetical than in the question of prophylaxis.
Several factors are to be kept in mind: First,
typhoid fever is a self-limited disease, running a
typical clinical course, and probably associated with
definite phases of immunity to account for its char-
acteristic picture and self-limitation. Second, the
number of bacteria existing in a typhoid patient
is very great; they circulate everywhere, and stimu-
late the tissue cells continually, resulting in the
formation of agglutinins, bacteriolysins, bacterio-
tropins, complement fixatives, etc. These antibodies
are apparently produced very slowly, and are either
not of sufficient number or are of a nature suitable
to overcome the infection quickly. It usually takes
four weeks or more to ultimately accomplish this.
The reason for this prolonged period may possibly
be ascribed to the structure of the typhoid bacillus.
As we said above, this bacterium belongs to a class
of microorganisms whose central substance, the
so-called endotoxin, is liberated only after the bacil-
lus has been broken up. This central substance
also stimuates antibodies (antiendotoxins for pur-
pose of designation) which are bacteriotropic in
action and probaby important elements in the cura-
tive process of typhoid fever.
Were it permissible to divide the phases of ty-
phoid fever from an immunological point of view,
as is usually done from the clinical aspect, one would
assume that the first stage consists of the multi-
plication of the invaded typhoid bacilli. Then, as
a defensive reaction, the tissue cells stimulate the
formation of antibodies (bacteriolysins. agglutin-
ins, and but few bacteriotropins^ The next phase
sees the numerous bacteriolysins attack the bacte-
Dec. 30, 1916]
MEDICAL RECORD.
1151
ria, sensitize them, and with the aid of the com-
plement the micro-organisms are broken up and
their endotoxins liberated. The latter, thus freed,
further stimulate the tissue cells, with the result
that other protective bodies (antiendotoxins) are
produced in sufficient numbers to prevent any harm-
ful effects and finally to overcome the infection.
Naturally, these very schematic stages are not
sharply limited, and do not fall within definite pe-
riods of time. Sluggishness, or absence of the
proper reaction on the part of the tissue cells at
any stage, is followed by a protraction of the dis-
ease, or even death; death by infection, if the bac-
teria multiply and are not broken up, due to in-
sufficient response by the bacteriolysins, or death
by intoxication if marked bacteriolysis has oc-
curred, or has occurred so quickly that the liberated
endotoxins are not in turn neutralized by sufficient
antiendotoxins.
Keeping this explanation in mind, one can readily
observe that the injection of ordinary vaccines in
typhoid fever aims at nothing more than what the
body is already doing with all its power, namely,
the production of antibodies for the breaking up
of the bacteria, the liberation of their endotoxins,
and the ultimate manufacture of antiendotoxins.
There may be cases in which the body cells are
inactive, and are stimulated to activity and produc-
tion of antibodies only after the inoculation of the
vaccine. Here the ordinary bacterins are of un-
doubted aid.
As a general rule, however, it is best to relieve
the sick body as much as possible of any active
reaction, uring an infection the tissue cells are
less responsive than during health, especially if the
disease be a severe and prolonged one. That is
why an efficient serum (passive immunity) would
be the ideal form of specific therapy. Sensitized
vaccines possibly hold a position between serum
therapy and ordinary bacterin treatment. In the
first place, they save the system from the strain
of producing the primary antibodies for the de-
struction of the bacteria, since the bacteria are
already laden with these bacteriolysins, agglutinins,
etc., artificially supplied; and second, this provision
hastens the stage of liberation of the endotoxins
and the consequent almost immediate stimulation
of the antiendotoxins, an important step in the
recovery from the disease. With this explanation
one readily sees the more rational basis for the
employment of sensitized vaccine in the typhoid
fever therapy.
As early as 1911-12 I treated a series of 17 ty-
phoid cases with a vaccine killed by heating,
sensitized with immune serum from convalescent
patients, and given subcutaneously in doses of 200
to 500 million every 5 or 6 days. While the disease
terminated by crisis in only a small percentage of
cases, the impression was gained that the general
course of the disease was milder. With my present
knowledge of sensitized vaccines, I would unhesi-
tatingly advise more frequent inoculations.
Ichikawa30 reported a series of 87 cases treated
with live sensitized vaccine administered intrave-
nously. Ten platinum loopfuls of typhoid cultures
were sensitized with 10 c.c. of immune convalescent
serum for 5 or 6 hours in incubator, and the sedi-
ment, after being washed three times, was suspended
in 100 c.c. of saline. Of this, % c.c, diluted with
saline, was injected intravenously. He also treated
23 cases subcutaneously. Usually, one or two in-
jections, when given intravenously, were sufficient
to bring the temperature down to normal on the
morning following the intravenous administration.
A chill and increase in temperature usually occurred
before the drop.
Boinet reported a series of 15 cases in 1913" and
a series of 53 cases in 1914.32 He used Bezredka's
vaccine subcutaneously in increasing doses of 1, 2,
3 and 4 c.c. on 4 to 6 consecutive days. Usually, 3 to
6 injections were given, and the temperature came
down to normal.
Szecsy33 treated 112 cases with a live (not older
than 12 days) vaccine, sensitized with immune
horse's serum, and injected subcutaneously in doses
of 1, 2, 3 and 4 c.c. on four consecutive days. Each
c.c. contained 1/10 platinum loop of growth from
an agar slant.
Fritz Meyer3' treated 26 cases intravenously in
a manner similar to Ichikawa, and came to similarly
favorable conclusions.
The literature of typhoid fever therapy by means
of sensitized vaccines intravenously is increasing
very rapidly on account of the war. The above few
reports are taken as examples of the distinctly
encouraging results. Other reports are by Biedl,*"
Eggerth,36 Sladek and Kotlousky,3' Boral," Hol-
ler,39 Lang, Luksch and Wilhelm."
With the subcutaneous method of Boinet or
Szecsy, sharp reactions were not the usual termina-
tion, but the disease ended by lysis. On the whole,
the impression was gained that the inoculation ren-
dered the general course of the disease milder and
shorter and the complications and relapses fewer.
I would be inclined to adopt the intravenous method
of treatment even though the reaction following the
inoculation is sometimes severe.
The fundamental work of Gay on sensitized ty-
phoid vaccine has not been overlooked. His recent
very complete contribution" holds forth distinct
promise for the vaccine therapy of typhoid fever.
The preparation employed by Gay is, however, a
modified sensitized vaccine; one from which the
endotoxin is extracted, thus differing in principle
from the usual sensitized vaccine under discussion.
We are still on the very lowest step of the ladder
of sensitized vaccines as a therapeutic measure in
typhoid fever. Experience must teach us the ac-
curacy of the dosage, the frequency of inoculations,
the mode of inoculation, the contraindications, etc.,
etc. Only then shall we know definitely the value
of this form of treatment.
I wish to warn you, however, how guarded one
should be about the results of any form of specific
therapy in a disease like typhoid fever. Normally,
all types of illness may exist. Clinicians have fre-
quently observed that during some typhoid seasons
the patients will present mild infections without
any special treatment whatever. One could attribute
beneficial effects to vaccine treatment with certainty
only if rapid improvement or crisis in the course
of the disease would set in soon after the inocu-
lation. Such acute changes can be expected more
often by treatment with a specific serum than with
a vaccine, for by the former (passive immuniza-
tion) antibodies are injected ready for neutraliz-
ing the poison ; while in the latter instance the anti-
bodies must first be manufactured by the tissue
cells. This ever-existing factor in vaccine therapy
makes it absolutely necessary to start the treatment
in typhoid fever as early in the course of the dis-
ease as possible, at a time when the reactive power
of the individual is still responsive and unimpaired
bv the infection.
1152
MEDICAL RECORD.
[Dec. 30, 1916
REFERENCES.
1. Garbat and Meyer: Zeitschr. f. exp. Pathol, u.
Therap., Bd. 8, 1910.
2. Schottstaedt: Journal A. M. A., Vol. LXV, No. 20,
1915, p. 1713.
3. Neisser and Lubowski: Centralblatt f. Bakt., Vol.
XXX, 1901.
4. Negre: Compt. rendus de la Soc. de Biol., Feb-
ruary 28, 1913.
5. Ardin Delteil, Negre et Raynaud: Compt. rendus
de la Soc. de Biol, No. 74, 1913, p. 371.
6. Liebermann and Acel: Deut. med. Wochenschr.,
August 12, 1915.
7. Pfeiffer and Friedberger: Centralblatt f. Bakt.,
November, 1910, p. 344.
8. Alcock: Lancet, August 24, 1912, p. 504.
9. Leishman: Harben Lectures, 1910.
10. Klein: Johns Hopkins Hos. Bulletin, 1907, p. 261.
11. Bull: Jour. Exp. Med., Vol. XXII, No. 4, 1915.
12. Jobling: Ibid., Vol. XX, 1914, p. 37.
13. Bezredka: Ann. de l'lnst. Pasteur, No. 16, 1902,
p. 918.
14. Cecil: Jour. Infect. Dis., Vol. XVI, No. 1, 1915.
15. Drigalski: Centralblatt f. Bakt., Bd., XLII.
16. Bronfenbrenner: Jour.. Exp. Med., Vol. XXII, No.
6, 1915, p. 792.
17. Nichols: Ibid., Vol. XXII, No. 6, 1915.
18. Stewart: N. Y. Med. Jour., February 14, 1914, p.
323.
19. Smith, Theobald: Jour. A. M. A., January 24,
1913.
20. Roland: Jour, of Hygiene, London, December,
1914, p. 207.
21. Bezredka: Ann. del PInst. Pasteur, August, 1913,
pp. 598-619.
22. Leishman, Harrison, Smallman, Tullock: Journal
of Hygiene, Vol. V, 1905, p. 381.
23. Kabeshima: Centralblatt f. Bakt., Vol. LXXIV,
No. 1, 1914, p. 294.
24. Vincent: Bull, de l'Acad. de Med., Vol. LXXIV,
No. 33, 1915.
25. Widal: Ibid., Vol. LXXIV, No. 32, 1915.
26. Chantemesse: Ibid., Vol. LXXIV, No. 35, 1915.
27. Teague and Torrey: Journ. Med. Research, 1907,
p. 223.
28. Raskin: Centralblatt f. Bakt., H. 4, Bd. XLVIII,
p. 508.
29. Garbat: Am. Jour. Med. Sc, July, 1914, p. 84.
30. Ichikawa : Zeitschr. f. Immunitatsf '., No. 23, 1914,
p. 32.
31. Boinet: Comptes rendus de la Soc. de Biol., March
14, 1913.
32. : Ann. de l'lnst. Pasteur, 1914, pp. 540 and
597.
33. Szecsy: Deut. med. Wochenschr., No. 33, 1915.
34. Meyer: Berliner klin. Wochenschr., Vol. LII, 1915,
p. 677.
35. Biedl: Wiener klin. Wochenschr., Vol. XXXVIII,
1915, p. 125.
36. Eggerth: Ibid., p. 126.
37. Sladek and Kotlowsky: Ibid., p. 389.
38. Boral: Ibid., p. 415.
39. Holler: Med. Klinik, Vol. XI, 1915, pp. 639 and
668.
40. Lang, Luksch, and Wilhelm: Wiener klin. Woch-
enschr.. Vol. XXVIII, 1915, p. 756.
41. Gay: Archives of Int. Med., February, 1916, p.
303.
71 East Ninety-first Street.
DIATHERMIA IN THE TREATMENT OF TRI-
FACIAL NEURALGIA.*
By HEINRICH F. WOLF, M.D.,
NEW YORK.
CHIEF OF THE DEPARTMENT OF PHYSICAL THERAPY, MOUNT
8INAI HOSPITAL AND DISPENSARY.
I have used the diathermia treatment in cases of
trifacial neuralgia for more than two years. Look-
ing over the literature I have found that Nagel-
Schmidt has published his results of this treatment
with diathermia and Dr. Q. C. Geyser has published
in American Medicine, 1913, Vol. 8, page 606, a re-
*Read before the Society for the Promotion of Physi-
cal Therapy, New York, May 11, 1916.
port on one case which he treated in the same way.
I am publishing my experience firstly on account
of the good results I have obtained in many cases,
and secondly because this experience has taught me
which type of cases are amenable to treatment.
First a few words concerning diathermia. Dia-
thermia, or thermopenetration, is a method which
consists in heating the tissue by means of the high-
frequency current. The ordinary high-frequency
current cannot be used properly for this purpose,
as the tension is too high and the irritation too
marked by the sparking. It would take too long,
however, to go into the detail of the technique and
I have to refer to other publications.
The conservative treatment of trifacial neuralgia
of the more severe kind has been considered a hope-
less one. The fact that frequent remissions occur
in the severity of the pain, especially when the dis-
ease is only of recent date, has induced a great
many physicians to exaggerate the value of certain
methods such as galvanic electricity or the static
breeze, but we can say with a large degree of cer-
tainty that a fully developed ticdouloureux has rare-
ly if ever yielded to conservative treatment, and we
know that even injections of alcohol have failed in
a large percentage of cases, or have given only tem-
porary relief.
Under such circumstances it might be of value to
report the results, which I have had in the treat-
ment of severe cases of trifacial neuralgia with
diathermia.
Case I. — February 10, 1915. A. F., aged about 40
years, has suffered from severe attacks of neuralgia, in
the right supraorbital region, for a number of years.
The present attack started ten days ago. The pain was
continuous, and did not respond to medical treatment of
any kind. The patient had not slept for ten days. This
pain disappeared after the first treatment and the pa-
tient slept for one hour, after which the pain returned,
but in a lesser degree. After six treatments, the pa-
tient was entirely free from pain.
Case II. — D. L., about 35 years old, suffered for nine
years from typical ticdouloureux, the attacks occurring
every few minutes, especially in the infraorbital region
of the upper jaw. There was typical paresthesia in the
mouth. The attacks were rare in the beginning, grad-
ually getting more frequent and of longer duration.
The patient was injected twelve times and operated
upon on Feb. 10, canal being opened and injected. He
did not improve, and was about to be operated upon
again, but the day before the operation was to take
place I was sent for to see him. At that time he was
having attacks every five to ten minutes, and was sleep-
ing badly. We commenced daily treatments, and about
ten days later the patient had attacks only twice a day;
he slept well, but had pain when eating or talking.
After twelve treatments the pain had entirely gone, and
the patient was presented in the Yorkville Medical So-
ciety. About six weeks later the patient had a recur-
rence and received three more treatments. I am not
able to ascertain whether he was permanently cured.
Case III.— Mrs. E. B., aged 72, had pain in the left
side, especially the lower jaw, very severe during the
last six months; her nights were sleepless on account
of the pain. The duration of the attacks was from
thirty minutes to three hours. Alcohol injections were
given six weeks previous to this treatment, but without
result. The first treatment was given on March 14,
1915. On the following day she reported herself a great
deal better, having had but one severe and one light at-
tack. On the 16th there were some very light attacks,
but no severe ones. On March 22 she had attacks the
whole of the afternoon and from one to two and from
five to six on the following morning. There was a burn-
ing sensation in the mouth. On March 24 there were
light attacks from 7 p.m. to 1 A.M., and on March 25
stronger attacks at 5 a.m. No treatment was given for
three days. March 28, somewhat severe and pro-
longed attacks. March 29, light attacks only in the
morning and evening. The patient disappeared for a
time and later was admitted to the Mount Sinai Hos-
pital according to prearranged plans (having been put
Dec. 30, 1916]
MEDICAL RECORD.
1153
on the waiting list). She was then found to be so
much better that it was not necessary to give her sur-
gical treatment.
Case IV. — Mrs. D. F. (recommended by Dr. Abra-
hamson) had had pain for six months in the middle
and lower branches, the attacks being very frequent,
with hardly any painless intervals; she could not sleep.
There was tenderness at the supramaxillary and infra-
maxillary foramina. We commenced treatment March
23, 1915. On the following day the condition was the
same. On March 25 she was slightly better, and on
the following day was much better. Treatment was
then discontinued, on account of an intercurrent dis-
ease. The patient returned after two weeks in greatly
improved condition. She received in all ten treatments,
and is now apparently cured.
Case V. — Mrs. S. S., 51 years (Dr. Abrahamson),
had had pain for eight years, without known cause, in
the right infraorbital region; it formerly occurred in
attacks, but latterly pain has been constant. Eating
and drinking cause excruciating pain. She sleeps
sometimes four or five hours, lying down seeming to re-
lieve the pain. After four treatments the patient was
greatly improved, having only slight pain in the morn-
ing. She was treated for a month with varying effect.
There was a recurrence during the summer and the pa-
tient received a few more treatments. The ultimate
result is doubtful, as the x-ray picture shows a bony
tumor in the neighborhood of the nerve at the base of
the skull. This patient, who had been treated by Dr.
Abrahamson for years, has not reported for treatment
at his clinic since.
Case VI. — Mr. M. (Dr. I. Strauss), has had severe
pain in the upper branch for one month, the attacks
occurring every ten minutes. Improvement com-
menced after first treatment. The day following the sec-
ond treatment the patient had only three attacks. Dis-
charged after four treatments.
Case VII.— Mrs. W. N. (Dr. I. Strauss), had had
light attacks of neuralgia for a number of years. The
pain disappeared after three treatments.
CASE VIII.— Mr. N., 38 years old (Dr. I. Strauss),
has had very severe pain during the last seven years,
the pain being continuous, with severe exacerbations
about twice a day. Two injections did not give any
relief; he cannot eat or talk without pain. The patient
received about twenty applications without any appre-
ciative relief and discontinued the treatment.
CASE IX. — Miss W. (Dr. W. J. Maloney), had been
ill for seven years, the pain being practically continu-
ous, with remissions during the night. A number of al-
cohol injections were given by prominent neurologists
without effect. The treatment brought relief for about
an hour, but owing to the patient having to leave the
city, it wTas discontinued after eight sessions. No con-
clusion could be drawn from this case on account of the
limited number of treatments, but I have included it to
make my record complete.
Case X. — Mr. M., referred to me by Dr. Carr. The
patient has a long history of suffering. During the past
six years he has had attacks of the most severe type of
trifacial neuralgia on the left side in the middle and
lower branches, alternating with free intervals, which
are becoming steadily shorter and the attacks always
longer. Patient always describes them as spasms. At
the beginning of the war he was in Munich to receive
alcohol injections, but left the country immediately be-
fore the treatment was commenced. His last attack has
continued steadily for six months. X-ray examinations
revealed caries of the alveolar process, which was op-
erated upon by Dr. Carr. In spite of the operation, the
pain continued and the resection of the ganglion Gas-
seri was contemplated. As a last resort diathermia was
used, which completely relieved the pain after ten days.
The patient was presented before the Neurological sec-
tion of the Academy of Medicine, where I expressed my
doubt whether the relief of the pain was due to the
usual remission or to the treatment. A few days later
the patient again began to have slight pain, which, how-
ever, has practically disappeared after a few more
treatments. The character of the pain changed, it be-
ing more a sensation of soreness, without spasm. The
patient returned four months later with an unusually
severe attack which, according to his previous experi-
ence, should have lasted four or five months. He had
about 200 spasms (as the patient describes it) in one
night, and seemed to be in a desperate condition. After
four treatments the pain entirely disappeared. The
wound in the upper jaw has not yet healed.
Case XI. — Mr. Sch. has had a very severe form of
trifacial neuralgia of the upper and middle branches
for twelve years, alternating with remissions. In the
beginning there was swelling of the face. Two teeth
were extracted and the pain disappeared. Two years
later the pain returned and lasted six weeks. The at-
tacks were slight. Again two years later there was
another attack which lasted a few months. Three
weeks ago the pain returned with unusual severity. It
began at four a.m. and lasted for twelve hours. It
was so severe that the patient actually crawled on the
floor. An alcohol injection was given without effect.
Diathermia treatment was then commenced, with splen-
did results. The patient was enabled to resume his
work after one week, even though he still has slight
attacks off and on. The x-ray picture was negative.
Case XII. — Mrs. G. L., has had neuralgia in the up-
per and middle branches for three years, especially se-
vere during the last six months, without intermissions;
the exacerbations occur periodically. Received injection
in Mount Sinai Hospital with no result, and was then
referred to me. After four treatments patient was so
much relieved that she could bear the pain very easily.
The treatment has been continued with excellent re-
sult.
Case XIII.— Mrs. T., 50 years of age. The patient's
history, as told by herself, is as follows: She had a se-
vere attack of typhoid twenty-six years ago, and has
never been quite well since. About twenty years ago
pain developed in the right side of the face (always in
the lower jaw) . In the beginning the pain was very
severe, and she had attacks of thirty minutes' duration,
at intervals of two to four hours. This occurred about
once a year and lasted for about three or four weeks at
a time. The attacks became gradually worse until the
pain became practically continuous throughout the time
mentioned. It has been very bad for ten years. About
nine years ago she was treated with injections, but she
was unable to tell me what the substance was; it could
not have been alcohol, as the injections were given
daily with small needles. The attacks then became
lighter and less frequent, and she gradually became bet-
ter. The condition remained much the same for nine
years, but since last September the patient has had very
frequent attacks — in fact, the pain has been nearly con-
tinuous, with very little sleep at night. We com-
menced treatment three weeks ago, and improvement
began three days later, there being no attacks some-
times for two or three hours, even when talking. The
patient was able to sleep some nights for six or seven
hours without interruption. The attacks are now
usually very short, lasting only a few seconds, and the
pain is quite mild. The treatment will be continued.
Two days ago she complained of chills which start dur-
ing the night, followed by attack of heat, and sometimes
without the latter. Upon investigating I discovered
that she had suffered with malaria fifteen years ago,
five years after the beginning of the present trouble.
I have had no opportunity in this short time to ex-
amine her blood for malaria Plasmodia, but I am aware
of the possibility of their presence. The fact that the
attacks began long before the malaria started is not
quite sufficient to exclude the connection, as the malaria
might have been unrecognized.
Though not belonging to this class, I should like
to report a case that was brought to me by Dr. M.
Mrs. M. suffered from a sudden attack of neuralgia
in the middle branch of the trigeminus. Diathermia
treatment stopped the pain after ten minutes and
there has been no recurrence.
If we try to analyze the records of these cases
we note that those patients who were sick only for
a short time were relieved permanently and quickly.
Patients who complained of genuine tic douloureaux,
with free intervals, reacted well. Old people, in
whom the disease seems to be due to arteriosclerotic
changes in the vasa nervorum, seem to be greatly
relieved by this treatment. Trifacial neuralgia in
adults, which causes continuous pain with exacerba-
tions, with paresthesia in the mouth, and which are
evidently due to degenerative changes in the ganglia,
seem to be refractory to the treatment. The diffi-
culty with these cases is that through the long
duration of disease the nervous system has been
to such an extent deranged that it is difficult to
1154
MEDICAL RECORD.
[Dec. 30, 1916
induce them to take the treatment for any length
of time. They are too quickly discouraged and
become unmanageable. Injections of alcohol into
the nerve seem to spoil the chances of recovery, as
Nagelschmidt has already pointed out; but it has
occurred to me this conclusion may not be correct,
as the injections are given only in very severe cases
of long standing, which yield neither to injections
nor to any other form of treatment, except dissec-
tion of the ganglion Gasseri.
In one very interesting case the Gasserian gan-
glion was resected by Dr.Elsberg, and the occurrence
of complete anesthesia proved that the operation
was successful, but the patient still complained of
considerable pain. The condition was improved by
diathermia.
So far as the technique is concerned, I wish to
point out that we have to try to apply the electrodes
in such a way that the affected ganglion shall be
located between the two. The best way is to apply
one at the back of the neck, at the base of the skull,
and the other over the eye, which is first covered
with a thick layer of cotton saturated with salt
solution, or on the upper jaw.
We seldom use more than 1000 milliamperes and
generally only 700. The duration of each treatment
is from thirty minutes to one hour.
In conclusion I wish to say that diathermia is a
very valuable agent in the management of trifacial
neuralgia, and it should always be tried before less
conservative treatments, such as alcohol injections
or section of the nerves or the ganglion, are re-
sorted to.
None of the patients mentioned as improved or
cured have returned to the physicians who recom-
mended them or to me, which may be regarded as
proof that the improvement continued.
161 West Eighty-sixth Street.
EMPLOYMENT OF PERSONS IN THE AR-
RESTED STAGE OF TUBERCULOSIS.*
By JAMES S. FORD, 11. D..
WALLINGFORD, CONN.
ASSISTANT PHYSICIAN, GAYLORD FARM SANATORIUM.
One of the most important questions that the tu-
berculosis worker has to face is what employment
the arrested cases may safely take up. This ques-
tion has been argued for a great many years and
even to-day there is not unanimity of opinion.
The advice given years ago that all arrested
cases must seek outdoor employment, irrespective
of what that might be, is still given by many men
in general practice. There has been in the last few
years a decided trend among those engaged in the
treatment of tuberculosis to send their patients back
to their former ocupations provided, of course, they
were not harmful. From an economic point of view
this question is of vital interest, bearing as it does
upon the income of the family thus determining
what living and housing conditions will be avail-
able. Considerations that must enter into the ad-
vice given the arrested cases are whether the place
of employment is going to be in a crowded city or
in a small town and whether it will be in a poorly
lighted and poorly ventilated building, or in the
modern steel and concrete type furnishing a maxi-
mum amount of fresh air, sunlight, and efficient
ventilation.
All too often these factors are not thought of
*Read before the Third Annual North Atlantic Tuber-
culosis Conference, Newark, N. J., October 21, 1916.
and what may be perfectly safe employment under
ordinary conditions becomes most harmful under
conditions of overcrowding and poor sanitation.
Furthermore, employment that may be safe and
healthful in a well-ventilated shop becomes a men-
ace to the discharged patient when attempted in a
tenement home. A great deal of stress is put upon
the danger of various occupations but very fre-
quently litle or no attention is paid to the housing
and living conditions of the individual. We have
discovered time and again that the working condi-
tions of many of our former patients were all that
could be asked for but that their housing conditions
left very much to be desired. Under such cir-
cumstances the employment cannot justly be blamed
for a relapse and yet I dare say that but little at-
tention is given to this other important factor I have
mentioned in determining the cause of the break-
down. It is supreme folly to treat a man six
months to a year in a sanatorium, then send him
back to a shop or office where everything is ideal
from a hygienic standpoint and have him live in a
home where conditions are most unhealthful. Such
a patient is almost certain to relapse and his oc-
cupation will have nothing whatever to do with
it. The time and money sent in obtaining an ar-
rest of the tuberculous process is entirely wasted.
The question has frequently been brought for-
ward as to what occupations are harmful to the ar-
rested case and while there are, no doubt, a few
that would fall into this classification, I am con-
vinced that very often the personal habits of the
individual are the predisposing factors in the re-
lapse for which the employment bears the burden
of blame.
We hear a great deal of the so-called dusty oc-
cupations predisposing to tuberculosis and being
absolutely unsafe for patients to resume. However,
in the modern factories with their various appli-
ances and exhausts to carry off irritating dust, the
element of danger to the returned worker seems to
be reduced to a minimum. On going over our rec-
ords we find that we have had a great many more
housewives as patients than representatives of all
the dusty trades put together and very little objec-
tion is raised against the housewife, whose disease
has become arrested, returning home to resume her
household duties. Surely no work is more wear-
ing or has longer hours than the keeping up of a
well-regulated household. Standing in front of a
hot stove preparing meals is certainly enervating
and the exposure that so frequently occurs going
out into the cold from a hot kitchen is a decided fac-
tor that predisposes to "catching cold" with a con-
sequent lighting up of the arrested process.
In sending patients back to work a most impor-
tant injunction to be given them is that they con-
tinue to obtain a maximum of rest. If you can
thoroughly impress this advice upon discharged
patients — that every hour not spent working must
be spent resting for the first year, at least, follow-
ing the restoration of their health — employment
will be found not to be such a factor in relapse.
The decision as to sending a patient back to work
is often a difficult one to arrive at and this especially
is true when the individual is an unskilled hand.
The first advice he frequently receives from mis-
guided relatives and his family doctor is that he
must seek an outside job and too often do we hear
that much-talked-about, but never-realized "light
work on a farm." I have no hesitancy in saying
that the patient taking an outdoor job where he will
Dec. 30, 1916]
MEDICAL RECORD.
1155
be exposed to the elements, runs a fifty per cent,
greater risk of relapse than does the man who takes
inside employment. The farm colony idea, so en-
thusiastically championed by Forster, Sloan and
others, is not practical, due to the difficulty in inter-
esting the average patient in farming. I have no
argument whatever with the advocates of this form
of employment when used for therapeutic purposes
and when the workers are under the care of a well-
trained physician. However, to have these patients
take up farming after leaving the sanatorium,
thrown as they will be upon their own resources and
free from any medical supervision, is fraught with
danger. The hours of work on a farm are long,
there is exposure to all kinds of weather, the worry
is great and very often, especially in the beginning,
the financial return is small. With this last factor
in mind you must realize that the housing and living
conditions are bound to suffer. This myth of light
work should have been exploded long before this, for
the only thing light about the occupation of farming
is the pay.
It is a big mistake to take your patient from an
indoor position and urge upon him the taking of an
outdoor occupation. The field in this regard is
limited to canvassers, collectors, teamsters, trolley
and railroad jobs, chauffeurs, watchmen, foremen
of construction gangs, and timekeepers. The last
three might be considered suitable employment for
the arrested case, being exposed to the elements less
than any of the others mentioned, but the hours
would in all likelihood be long, the pay small, less
desirable housing be obtained and poor living con-
ditions ensue. Then, added to this, would be the
anxiety over the possibility of not making good in
the new employment, the bringing into play of pre-
viously unused muscles, with consequent marked
fatigue, and the worry that would go with the di-
minished income.
The most logical plan is to send the patients back
to their old occupations, for here the mental strain
is decidedly less, they would be assured of a larger
income than would be the case were they to engage
in a new field and they could enjoy better housing
and living. Furthermore, they would be working
with and for people who in all likelihood would make
things as easy as possible for them.
An ideal arrangement is to send the arrested cases
back to their old employment, beginning with part
time work and keeping them under medical super-
vision. We have been able to have that plan adopted
by a few of the manufacturing companies of our
state and it solves the question of employment for
the discharged patient as no other plan does. The
returned worker reports back to us for periodical
examinations and his working hours are increased
only on our recommendation. In this way the in-
dividual is able to try out his strength and by gradu-
ally adding to his working time suffers no bad ef-
fects.
There can be no doubt that indoor work for the
discharged tuberculosis patient is much to be pre-
ferred. On going over the records of Gaylord Farm
for the past twelve years we discovered that of the
patients who had returned to indoor employment,
but 20 per cent, had relapsed; that of those who
had returned to outdoor employment, thirty-nine per
cent, had relapsed ; and that of those who previous
to their illness had indoor positions but after dis-
charge had taken up outdoor work, forty-two per
cent, have had a setback. The work indoors as a
rule is not as strenuous as outdoor occupation and
most of it can be done sitting down, which is a de-
cided factor in the prevention of undue fatigue.
I want to mention an occupation that I believe of-
fers much to many of our discharged young women
patients — that of the trained tuberculosis nurse.
Many of the patients who would have to return to
employment where long hours prevail, or to board-
ing places where living and housing are not up to
the requirements that the discharged patient should
have, will find here a means of prolonging their life,
of earning a good livelihood under favorable auspices
and have the satisfaction of doing a good work.
There is undoubtedly a distinct field in sanatoria
for the trained tuberculosis nurse. However, I do
not believe, as some do, that she has a place in pub-
lic health work. Aside from the fact that her train-
ing is not general I feel that such work is much too
strenuous and wearing for any one with even a
slight amount of tuberculosis.
The problem of employment is rather easily solved
when you are dealing only with the incipient cases.
By far the great majority of these can safely re-
turn to their original occupation and by living a
God-fearing life for a year or so will be as good
physically as any healthy man. Of two hundred and
thirty-six incipient cases discharged from our sana-
torium, two to twelve years ago, one hundred and
ninety-three, or eighty-two per cent, are alive, well
and at work.
The problem of employment is not so easily solved
for some of your moderately and far advanced cases.
For these people part time work, not of too labori-
ous a character, should be obtained; and no doubt
through the agencies of employment bureaus, pri-
vate, municipal and state and through the organized
charities associations such work could be found.
The moderately advanced and far advanced cases
present a tremendous economic problem as the per-
centage of these cases that can keep at occupations
of any kind suffers markedly when compared with
the incipient group. Of six hundred and ninety-
seven moderately advanced cases discharged in the
past twelve years, three hundred and seventeen,
forty-five per cent., are alive and at work, while of
one hundred and seventy-nine far advanced cases
discharged in the same length of time but thirty-
three, eighteen per cent., are working.
There is one other factor that will help solve this
much mooted problem of employment of these ar-
rested cases and that is an early diagnosis of their
disease. I have shown you how large a percentage
of our incipient cases have been able to return to
their own work and I feel sure that these figures
can be duplicated elsewhere throughout the country.
In addition to this the preaching of improved home
hygiene and better living will have a most beneficial
influence. The well-known work of The Home Hos-
pital in New York City has shown us what improved
housing will do for many cases of tuberculosis. If
then we could have these model tenements built in
the large cities where these arrested cases could live
and have manufacturers appreciate the enormous
value of fresh air, sunlight and efficient ventilation
in their plants, I feel sure that the question of em-
ployment of arrested cases would not prove the bug-
aboo that it now so frequently is.
Myelo-erythrccytoma Mediastinicum. — Moreschi
under this term describes tumors of the mediastinum
which consist of rapidly proliferating and infiltrating:
erythroblasts and megaloblasts and occur with the blood
state erythroleucemia. In more familiar language the
tumor was a lymphosarcoma. — // Policlinico.
1156
MEDICAL RECORD.
[Dec. 30, 1916
HEMATURIA AND PYURIA.
By S. WILLIAM SCHAPIRA, M.D.,
NEW YORK.
PROFESSOR OF GENITO-URINARY SURGERY, FORDHAM UNIVERSITY
SCHOOL OF MEDICINE; VISITING GENITO-URINARY SURGEON,
SEA-VIEW AND SYDENHAM HOSPITALS.
AND
JOSEPH WITTENBERG, M.D.,
BROOKLYN.
INSTRUCTOR OF GENITO-URINARY SURGERY, FORDHAM "NTjrERSITS
SCHOOL OF MEDICINE ; ATTENDING GENITO-URINARY SURGEON,
BEDFORD DISPENSARY AND HOSPITAL,
BROOKLYN. N. V.
Hematuria occurs with bleeding from any cause m
or into any part of the urinary tract. The causes
are local and general.
Under local causes we have: (a) Traumatism of
the kidney, bladder, or urethra, by external violence,
by calculus, by injury with instruments, or by the
scratching with crystals in concentrated urine.
(b) Inflammation or congestion, which occurs with
infectious diseases, from exposure or with the elimi-
nation of irritating drugs like cantharides or tur-
pentine, (c) Ulceration: simple or tubercular, oc-
casionally leuetic. (d) Rupture of dilated veins, in
the papillse of the kidney in the ureter or in the
bladder, (e) Tumor. (/) Parasites, as bilharzia or
filiaria. These are very rare in this climate, (g)
Under the head of congestion, we should include the
congestion resulting from the complete emptying
of an overdistended bladder. The support which is
given to the congested vessels in the bladder wall
is suddenly removed and they bleed slightly.
General causes include dyscrasia of the blood
which we find with : (a) the specific infectious dis-
eases, (b) Hemophilia, purpura, and leueemia, (c)
Phosphorus poisoning.
Essential hematuria comes under the heading of
those resulting from general causes, but the fact
is that in the majority of cases of what we call es-
sential hematuria careful examination of the kidney
shows that the condition is not idiopathic at all, the
kidney showing some interstitial change or change
in the blood-vessels, commonly dilatation of the
vein, at the apex of a pyramid.
Peculiar cases of family hematuria have been ob-
served where no other symptoms were present in
life and no lesions were found in the kidneys post
mortem.
The amount of blood in the urine varies from a
few blood cells, to what appears to be almost pure
blood. The term hematuria, as commonly used, im-
plies that sufficient blood is present to be noticed
microscopically.
Diagnosis of Hematuria. — Hematuria must be
distinguished from coloring of the urine after in-
gestion of certain substances, especially rhubarb
and senna, or dyes in candy. The microscope is the
simplest and best means to exclude them all.
Diagnosis of the seat of the hemmorhage and of
its cause is made by: (1) the history of the case
and the symptoms; (2) the time of appearance of
the blood, whether at the beginning or the end of
urination; (3) the appearance of the urine and by
its constituents, and (4) physical examination.
For example, a history of attacks of renal colic,
made worse by jarring, will point to renal calculus.
Hematuria appearing and stopping without apparent
cause, and scanty in amount makes us think of
tuberculosis of the kidneys or of the bladder. A pro-
fuse hematuria appearing and stopping without
apparent cause, immediately suggests a tumor. The
presence of a stab or a gunshot wound or signs of
other severe trauma at the region of the kidney or
bladder with the hematuria clearly point to injury
of the kidney, just as a profuse purulent discharge
from the urethra, with pain or urination accom-
panying the hematuria, shows a urethritis.
The time of the appearance of the blood is of as-
sistance. Blood appearing with the first part of the
stream shows the hemorrhage comes from the
urethra. Terminal hematuria means that capillaries
at the posterior urethra or at the trigone have been
injured by the spasm of the muscles in squeezing
out the last few drops of urine. Urine that is well
mixed with blood shows hemorrhage above the in-
ternal sphincter or in the posterior urethra with the
blood draining back into the bladder.
The appearance of the urine, its color, clots, mix-
ture with pus, etc., teaches much. In blood which
has long been in contact with acid urine, the oxy-
hemaglobin is changed into methemaglobin ; the
blood is therefore dark. In alkaline urine, the blood
regains its light color. Dark colored blood in the
urine is therefore apt to come from the kidney, the
urine being usually acid and the mixture of the
blood with the urine being long and intimate. When
the bleeding is from the bladder, the condition
causing the hemorrhage is apt to be accompanied
by alkaline urine : also all the blood not having been
in contact with the urine for a long time is therefore
apt to be light in color whatever the reaction of the
urine. Blood clots in the form of ureteral casts,
show hemorrhage above the bladder; blod clots
formed in the urethra are broader than ureteral
casts. Blood clots of irregular shape show that coag-
ulation takes place in the bladder, but they do not
show the source of the blood — whether the kidney,
the ureter, the bladder, or the posterior urethra.
Differentiation is made between hemorrhage from
the bladder and that from the posterior urethra, by
washing the bladder clear, and filling it with clear
salt solution. If the bleeding is from the bladder, all
the solution is soon colored; if from the posterior
urethra, whatever part of the fluid is withdrawn
through the catheter is clear, and that part passed
by the patient is colored, especially the last part,
from expression of any blood present in the pos-
terior urethra, with the last drops of urine.
Other contents of the urine may point to the
cause or to the location of the lesion. We may find:
(a) tumor fragments or cells, (6) concretions of
stone or numerous crystals, (c) renal casts and
abundant epithelial cells from the various parts of
the urinary tract, (d) albumin, which is always
present with hematuria, being derived from the
blood serum. If however the albumin is out of pro-
portion to the amount of blood the kidneys are
probably involved.
The cystoscope is the last and the most certain
means of determining whether the bleeding is from
the bladder or from the kidney, and, if the latter,
from which kidney. If from the bladder, it will
also show the cause; if from the kidney, the ureter
catheter passed into the renal pelvis may bring away
a piece of tumor or withdraw tuberculous urine, or
if coated with wax, may show the scratches made by
a calculus.
Pyuria. — Pyuria results from some purulent in-
flammation along the course of the urinary tract: or
the emptying of pus from some neighboring focus
into the urinary tract. The suppuration results
from some infection, simple or tuberculous, or which
complicates a calculus, tumor, or stricture.
Dec. 30, 1916]
MEDICAL RECORD.
1157
We must first make sure that turbidity of the
urine is due to pus; once satisfied as to that, we
look for the site of the suppurating focus and for its
cause.
We will review the things from which we must
differentiate pus and the simple methods used.
The cloudiness produced by urates, disappears on
warming the urine; phosphates clear up on the
addition of a little acid ; carbonates clear up by the
same method with the evolution of some carbonic
acid gas; chyluria clears up on shaking the urine
with ether; mucus precipitates on the addition of
a little acetic acid, and redissolves by adding an ex-
cess of the acid after the urine is first diluted with
an equal volume of water.
The haze of bacteriuria is not affected by heat nor
by chemicals and the germs are not precipitated by
the centrifuge unless alcohol is first added to the
urine. The urine is opalescent and often has a foul
odor.
A simple chemical test for pus is adding a solu-
tion of a caustic alkali to the urine and twirling the
glass ; the pus is coagulated into slimy ropy masses.
If the sediment is allowed to settle, the fluid above
decanted and a solution of caustic alkali added, the
coagulum produced will adhere to the bottom of
the glass if that is turned upside down.
We make a diagnosis of the site of the suppura-
tive lesion and its cause by the history of the case,
by the symptoms present, and by the physical ex-
animation as mentioned in the section on hematuria.
Of these we will mention only a few points that are
so characteristic of certain pathological conditions
as immediately to suggest these conditions.
Intermittent pyuria, where the urine is perfectly
clear at certain times and suddenly becomes full of
pus, then clear again, shows a condition in which
there is a temporary obstruction to the escape of
pus from a suppurating cavity. A strongly sug-
gestive accompanying symptom is that the patient
presents septic symptoms when the urine is clear,
that is when the pus is retained, and these septic
symptoms promptly subside with the removal of the
obstruction and the discharge of the pus in the
urine. The usual condition in which this is present
is a pyonephrosis complicating a calculus or a pro-
lapsed kidney, where the ureter is at times obstruct-
ed by the calculus or by a kink from displacement
of the kidney. An inflamed diverticulum of the
bladder may give the same symptoms as will occa-
sionally a seminal vesiculitis, the pus being poured
into the bladder at intervals.
We will consider the characteristics of the urine
more particularly and the direct examination of the
urinary tract. Pus showing in the first glass and
not in the second means that the source of the pus
is in the anterior urethra. A turbid first and second
urine show either an acute posterior urethritis (that
is habitually accompanied by an acute anterior
urethritis) where the discharge is profuse enough
to flow back into the bladder, or a purulent process
above the vesical sphincter.
Renal pus is characterized by settling on the bot-
tom of the glass in a flat layer like heavy sand. The
fluid above is slightly cloudy from a little pus and
bacteria. Since chronic renal irritation, of which
this pus is an indication, is usually accompanied by
a polyuria, the urine is of low specific gravity. Py-
uria of renal tuberculosis shows a light color, often
like that of lemonade or lighter; while calculous
pyuria is apt to be dark from blood.
Bladder pus is mixed with considerable mucus,
so that it floats well and becomes somewhat viscid
on standing. Pus from the urethra is also light
and fluffy, but is mixed with less mucus, and there-
fore settles more readily. In neither cystitis nor
urethritis is polyuria present; the specific gravity
is therefore not low, as with pyuria of renal origin.
Alkaline pyuria was formerly thought to be of
visical origin and acid purulent urine from the kid-
neys. We now know that the reaction of the urine
depends on the causative germ. Infection by the
B. coli, tubercle bacillus, gonococcus and B. typhosus
is accompanied by acid urine, while infection by the
staphylococcus, streptococcus or B. proteus results
in decomposition of the urea with the formation of
ammonia. It is true though, that infection by the
ammoniagenic germs is much more common in the
bladder than in the kidney, in which it is quite un-
common.
Cystoscopic examination and ureter catheteriza-
tion is the last refinement in the diagnosis of the
source of pus in the urine when that is above the
internal sphincter.
The condition of the bladder wall and the pres-
ence or absence of diverticula are seen. The efflux
from the ureteral mouths is seen to be turbid or
clear. When the pus from a kidney is too scanty
to be noticed in this way, ureteral catheterization
will secure the urine from each kidney separately
for careful examination. In rare instances where
some neighboring suppurating mass empties into the
ureter, the catheter, if passed into the renal pelvis,
will withdraw clear urine, while the urine as it
comes from the ureteral mouth is contaminated.
The causes of the suppuration may be judged at
times by the other urinary findings. Concretions
of urinary salts, pieces of tumor, considerable
epithelium from the bladder, from the renal pelvis,
or from the urinary tubules are good guiding signs.
A trace of albumin is due to the pus itself; consid-
erable albumin points to disease of the kidneys.
1847 Madison Avenue. New York.
591 Willoughby Avenue, Brooklyn.
RHINAL PREMONSTRATION OF TUBER-
CULOSIS.
Bt J. A. HAGEMANN, M.D.,
PITTSBURGH, PA.
OTO-RHINO-LARYNGOLOGIST TO THE PITTSBURGH HOSPITAL.
Predilection to determinate channels of exit from
the human body is evidenced by a number of sub-
stances which have medicinal applicableness. Some
of these display the idiosyncrasy of producing con-
siderable disturbance at their respective areas of
departure. One need but recall the hydragogue
action of elaterium, or the renal and vesical irrita-
tion from cantharides or turpentine. Other cor-
roborative examples readily come to mind, and the
truism is merely cited as an anticipatory substan-
tiation of the postulate to be presented. The parts
played by the toxins which have their origin in the
secluded pockets in pyorrhea alveolaris and the
elusive tonsillar crypts in the etiology of arthritis,
neuritis, etc., have lately been so extensively ex-
ploited that a review of them here would be su-
pererogatory, and reference is made thereto only
in collateral confirmation of the concept which in-
spired the writing of this paper. Reflection on the
foregoing commonly accepted knowledge excites as-
tonishment that analogous excretory irritations en-
countered in patients not having ingested any ma-
terial which might precipitate such symptoms
1158
MEDICAL RECORD.
[Dec. 30, 1916
should so persistently have been classed as primary
maladies. When, for example, percolation of end-
products from some remotely situated pathological
process occurs within the nose, we may have a clin-
ical picture of coryza similar to that excited by
chilling of the surface, or by bacterial invasion. As
no nose is sterile, a culture will almost certainly
reveal a "mixed infection." But we are not justi-
fied in reasoning post hoc, ergo propter hoc. The
mere presence of this or that infective agency does
not authenticate that it is the instigator of the then
present activity. Bacterial guests may simply be
neighbors who "dropped in" without being impli-
cated in the disturbance. Hypothetically, the nasal
mucous membrane might be assumed to be a sort of
safety valve, serving as an indicator of some inter-
nal bullition, and in the present discussion consid-
eration will be limited to derangement of nasal
functions conjecturally due to incontiguous tuber-
cular sources. Generically speaking, it may be con-
ceded that a secretion is a substance which is of
further use to the economy, whereas an excretion
is but eliminated debris. Accordantly, the normal
moisture investing the nasal mucous membrane may
be considered a secretion, because it undoubtedly
has efficacy.
When the excretory functions are ordinarily per-
formed, no inconvenience is experienced, but when
adventitious elements must be disposed of there
may be afflictive harassment at the area of emerg-
ence. Sometimes the burden becomes too onerous,
yet excites no particular irritation and vicarious
elimination is essayed. Such elimination may be
superposed upon a secretory surface. For exam-
ple, it is familiar that the kidneys expel iodine to a
certain degree. When their capacity is taxed, the
burden of eliminating the surplusage, or at least
chemical products of such surplusage, is allotted to
the Schneiderian membrane with coincident dis-
tressing hydrorrhea. It is a familiar observation
that the arytenoids become unduly tumid during
the progress of some cases of pulmonary or lar-
yngeal tuberculosis, but the contingence that a sus-
tained coryza might portend a possible concealed
tuberculous nidus appears to have been largely dis-
regarded. A unique physiognomy characterizes the
victims of early covert tuberculous invasion. In a
minor degree there is resemblance to the facies of
hay-fever, yet the lacrymation characteristic of that
distressing ailment is not present. On the con-
trary, one often notes a lactescent tint of the sclera,
suggestive of low percentage of hemaglobin. The
skin of the upper lip and about the angles of the
mouth sometimes assumes a faint purplish tint
analogous to that observed in some women during
the early months of pregnancy. While only similar
in type, and less in degree, that comparison conveys
a more graphic conception than a lengthy descrip-
tion might. A peculiar psychological propensity is
often noted. The patient aims to minimize the de-
fective resonance due to tumescence of the nasal
mucous membrane, and develops a habit of gently
and rather surreptitiously mopping the moisture
from the nose with the kerchief.
It is improbable that any considerable quantity
of toxic material is poured into the blood or lymph
streams during the early invasive or the latent
tuberculous stage. Yet during such periods one
encounters the peculiar coryza alluded to. It ap-
pears plausible that such toxic products as are
formed have a predilection to escape from the body
by way sal mucous membrane, and that the
secreting surface smarts under the unaccustomed
burden.
Of course, these traits are often encountered in
flagrant cases of tuberculosis, but are then usually
so overshadowed by more salient signs that their
import becomes insignificant and negligible. Some-
times the focal center of infection is ensconced in
such manner or place as to exact an exhaustive
search on the part of the physician. Painstaking
indagation of the thoracic organs may at first fail
to elicit any evidence of tuberculous involvement
there, yet, in heedless or neglected patients, in
process of time unmistakable indications of the
bacillary invasion will crop out. One may feel com-
paratively safe in assuming that in the majority of
cases a circle whose radius extends three inches
from the thyroid notch will encompass the focal
area of the tuberculous infective process giving rise
to the nasal outburst. Waldeyer's ring, comprising
a circle of lymphoid tissue beginning at the lingual
tonsil, and in its upward passage following the
course of the posterior pillar, and traversing the
small lymphoid mass sometimes called the tubular
tonsil, then the pharyngeal tonsil via Rosenmueller's
fossa, and thence in reverse order down the other
side to the opposite lingual tonsil, is a fertile field
for tuberculous processes. Whether borne there by
the blood current or deposited there by the respira-
tory perflation may not be determinable, but the
clinical features are uniform. The patients are
relatively healthy. Their cardinal complaint is the
discomfort brought about by the hyperplasia of the
lymphoid tissue comprised in Waldeyer's ring.
Children so afflicted are commonly considered
"scrofulous." Small tonsils, which are secluded be-
tween the anterior and posterior pharyngeal pillars,
are sometimes so elusive that only a most painstak-
ing search will prove them accomplices in the path-
ological process.
A patient's statement that "the tonsils have been
removed" should not be accepted without challenge.
There may be remnants whose undestroyed crypts
constitute serviceable propagation depots. Deep
palpation along the sides of the neck will probably
reveal strings of very small glands, some of them
quite sensitive, merged in the cervical fascia. The
engorgement of the glands is presumably due to the
absorption of products sent forth by the bacilli
which have lodgment at one or several points in the
lymphoid tissue constituting Waldeyer's ring. The
characterizing, unyielding coryza preponderates to
such degree that other symptoms appear subordi-
nate and minor signs may be overlooked. Taking
all these matters into consideration, they would
seem to warrant the hypothesis that intractable ex-
cretory irritation of the "nasal mucous membrane
presents strong presumptive evidence of some
tuberculous activation.
The gratifying results attained by judicious
treatment of early tuberculosis are too familiar, and
the methods of ministration are so well grounded
that their recital here appears uncalled-for.
Cure or Arrest of Hydrocephalus. — Eunika relates the
case of a child aged 14 months which sustained a fall
from which there followed perforation of a hydro-
cephalus with bulky effusion under the skin. As a re-
sult of three punctures from 500 to 700 cm. of this effu-
sion wcr< I'll" and the balance was absorbed. The
disease, if not cured, was at least arrested. — Zentral-
blatt fur Chirurgie.
Dec. 30, 1916]
MEDICAL RECORD.
1159
Medical Record.
A Weekly Journal of Medicine and Surgery.
THOMAS L. STEDMAN, A.M., M.D., Editor.
PUBLISHERS
WM. WOOD &. CO., 51 FIFTH AVENUE.
See fourth page following reading matter for Rates of Subscription
and Information for Contributors and Subscribers.
New York, December 30, 1916.
DEEP BREATHING.
Since deep breathing is a popular health meas-
ure, advocated also by many physicians, a scien-
tific consideration of the subject by a competent
medical observer should be welcome. In the
Berliner klinische Wochenschrift for October 2,
Professor Arnold Hiller writes on the action of
deep breathing on certain important somatic func-
tions. The author gives a resume of the sci-
entific literature of the subject since 1890. Deep
breathing has been recommended chiefly for asth-
matics and young candidates for tuberculosis,
especially children. Aside from these uses the ex-
ercises are employed to promote euphoria and effi-
ciency. In 1890 the author was recommending sea
bathing because it was naturally calculated to ven-
tilate the lungs through the combination of high at-
mospheric pressure and the sea breezes. The first
component to receive his attention was diaphragma-
tic breathing, which in superficial breathers is the
only form in use. As the diaphragm descends
with forced inspiration it compresses the soft, plas-
tic tissue of the liver and increases the passage of
blood through that organ. At the same time it in-
creases the secretion and excretion of bile. Any
condition like gallstone disease which is aggravated
by stagnation in the liver may in theory be pre-
vented by deep diaphragmatic breathing. The
stomach, when filled with food, may likewise be fa-
vorably influenced by the same factor; because the
movement of the stomach-contents through the py-
lorus is facilitated. The influence exerted on other
abdominal viscera, such as the spleen and kidneys, is
problematical.
Costal breathing is concerned chiefly with the up-
per portion of the chest and promotes the circulation
of blood in the lungs and heart, because as the chest
expands the blood in the great veins is forced to-
ward the heart ; while at the same time the circula-
tion of the brain is somewhat depleted when for any
reason that organ is congested. Under favorable
conditions a deep inspiration with expansion of the
chest may be seen to empty the distended veins on
the backs of the hands. As similar conservative ac-
tion may be demonstrated in cases of varicose veins
and hemorrhoids. So far as any alleged danger of
emphysema of the lungs is concerned, the author
has seen the latter condition disappear under deep
breathing. To return to the heart the author in-
sists that deep breathing causes a physiological hy-
pertrophy of the right side, in which the muscula-
ture is apt to be relatively weak.
The subject of the respiratory exchanges, which
naturally is one of vast importance, is left by
the author to the last. An increased intake of
oxygen naturally stimulates metabolism. Increased
combustion of carbohydrates may cause a notable
reduction in weight, while all products of in-
complete catabolism become fully oxidized. Deep
breathing is therefore the most scientific resource
for the prevention of uric acid disease. Much de-
pends upon a correct technique. One must begin
with diaphragmatic breathing, which naturally pre-
cedes rib breathing. The inspiratory movements are
now slowly increased until all the muscles involved
in rib breathing gradually participate. One begins
with three daily periods of 15 or 20 minutes each.
The position of the breather is immaterial, and he
may do his forced breathing while standing or
walking. The author makes one assertion which
should be modified slightly. It is true that continu-
ous deep breathing will cause an increase in the vol-
ume of the radial pulse, but in some individuals a
very deep breath appears to arrest the pulse because
of the compression of the subclavian artery by the
fully inflated apex of the lung. Hence inspirations
should be limited to a certain number per minute.
SUBFEBRILE TEMPERATURE AND
FEBRICULA.
Slight hyperthermia may represent the initial
phase of a serious process; of a benign type of a
disease which usually pursues a serious course; or
of a condition essentially mild. Fifty years ago the
term "slow fever" was used for a protracted
febricula, but such terms disappeared with the gen-
eral use of the clinical thermometer. If the latter
instrument were in more familiar use we should
doubtless find that many an individual who is feel-
ing below par is running a subfebrile evening tem-
perature. If the medical man recognizes such a case
he" orders the patient to bed until the temperature
becomes normal. But when, as is often the case,
rest does not help and the patient rebels at the rest
cure, the practitioner is constrained to let the pa-
tient go about his business, and the temperature be-
comes normal in time. Febricula is most common in
childhood, when many affections react with sub-
febrile temperature, or actual fever. This may be
associated with slight colds, gastrointestinal dis-
turbances, a single inflamed tonsillar crypt, etc. In
adults the same conditions may or may not cause
febricula.
In La Riforma Medica for September 18, Profes-
sor Rossi considers a number of conditions which
cause mild hyperthemia of a sustained type. The
first patient suffered from Graves's disease. The
symptoms were numerous but very vague, and at
first no diagnosis was made. A subfebrile tempera-
ture at times became febrile. The entire range was
37° to 38° C. (98.6° to 100.4° Fahr.). Lowering of
temperature had no prognostic significance. The
theory in such cases is that hyperthyroidism can
affect the heat centers. In another case a febricula
1160
MEDICAL RECORD.
[Dec. 30, 1916
was brought with difficulty into relationship with
lues. In an elderly man with a slight febrile move-
ment pointing to an enterocolitis the cause was
found to be pseudoleucemia. In certain cases of can-
cer and sarcoma, usually of the viscera, rise of tem-
perature may be present. The febricula of tuber-
culosis requires no discussion. A temperature up to
100° Fahr. in a child of 4 years was found to have
been due to basilar meningitis.
There are, however, quite different types of
febricula. Rossi mentions the case of a woman who
was sent to a sanatorium for general failure of
health. A subfebrile temperature led to the diag-
nosis of tuberculosis, which was, however, negatived
by other tests. No cause could be found for the
temperature rise nor for the general state. Subse-
quent developments appeared to show that all the
symptoms were psychogenic. Rossi also gives in
great detail other cases which were finally found to
be examples of nervous or hysterical hyperthemia.
For all of these cases he makes use of the term
dysthermia — whether neurotic or endocrinic or
mixed origin. There is no doubt that this neuro-
endocrine mechanism may be sometimes involved in
the first-mentioned cases of febricula — notably in
cases of exophthalmic goiter.
THE FRENCH TREATMENT OF BURNS.
The daily press and certain medical reports from
the European fighting front have frequently men-
tioned a new and successful treatment of burns by
French surgeons. Since the special dressing was
known by a coined word and since its composition
was not definitely stated, the profession has been
awaiting an official description. In the first place
it is not very new, since its employment goes back
to 1904. It has been in use in the present war
almost from the outset, but has only recently come
into anything like general employment. It consists
of a mixture of paraffin and resin, and while no
chemical change is set up it possesses peculiar phys-
ical properties which make it available for the
treatment of burns.
In the Archives de medecine et de pharmacie
militaires for August Dr. Barthe de Sanfort re-
ported over 300 burns in soldiers treated with the
remedy, which is described in detail. The name
"ambrine," with which it was christened, comes
from its amber hue, and seems to be purely descrip-
tive. This surgeon states that he first devised the
formula in 1904. Toussaint used it in 1907 in the
Military Hospital at Lille, while another colleague,
Michaux, has also had long experience with it. Re-
cently Kirmisson presented some patients before the
Societe de Chirurgie in which the remarkably
favorable action was well demonstrated.
The substance is a solid which fuses at about
50° C. and may be sterilized by boiling without in-
jury. It is applied hot (at 70° 0.-158° F.), caus-
ing no pain whatever, and even after 24 hours is
still warmer than the body. The favorable action is
due in part to local hyperthermia. Occurring as it
does in cakes of paraffin consistency it is broken up
into bits of various size, heated to 125° C. (257° F.)
and then cooled to 70° C. (158° F.), the tempera-
ture of application. Its use is not confined to burns
for it is excellent in freezes and is even superior in
the treatment of certain wounds. It is first applied
in very small quantities with formation of a thin
pellicle. Over this is placed a very thin layer of
cotton, which is followed by more of the remedy.
This simple dressing is painless and inexpensive.
It is removed in 24 hours and comes away en masse
and without pain. It is true that considerable pus,
often of foul odor, is found beneath. This, together
with loose sloughs, is carefully wiped off and the
surface dried with a hot air douche. The dressing
is then reapplied. In no type of burn is it contra-
indicated. In general, rapid healing takes place
with superior end results.
Lead Poisoning from Imbedded Bullets.
Interest in this possibility has been revived dur-
ing the present war. Nothing seems more assured
than that bullets in the tissues do not, in the vast
majority of cases, cause even the mildest form of
plumbism. The question is, have they ever caused
this condition beyond doubt. Lewin and Kiister
long ago answered this question in the affirmative
and in more recent years Dennig and also Neu have
analyzed a very large number of observations and
have found the sequence less uncommon than one
might otherwise believe. It is necessary to follow
cases up, because plumbism may not appear until
many years after the injury. At a session last June
of the Verein der Aerzte in Halle a. S. (Mueiuiit ,<< 
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